reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter C. Authority to Engage in Business › Section 843.082. Requirements for Approval of Application

Sec. 843.082.  REQUIREMENTS FOR APPROVAL OF APPLICATION.  The commissioner shall issue a certificate of authority on payment of the application fee prescribed by Section 843.154(c) if the commissioner is satisfied that:
(1)  with respect to health care services to be provided, the applicant:
(A)  has demonstrated the willingness and potential ability to ensure that the health care services will be provided in a manner to:
(i)  ensure both availability and accessibility of adequate personnel and facilities;  and
(ii)  enhance availability, accessibility, quality of care, and continuity of services;
(B)  has arrangements, established in accordance with rules adopted by the commissioner, for a continuing quality of health care assurance program concerning health care processes and outcomes;  and
(C)  has a procedure, that is in accordance with rules adopted by the commissioner, to develop, compile, evaluate, and report statistics relating to the cost of operation, the pattern of utilization of services, and availability and accessibility of services;
(2)  the person responsible for the conduct of the affairs of the applicant is competent, is trustworthy, and has a good reputation;
(3)  the health care plan, limited health care service plan, or single health care service plan is an appropriate mechanism through which the health maintenance organization will effectively provide or arrange for the provision of basic health care services, limited health care services, or a single health care service on a prepaid basis, through insurance or otherwise, except to the extent of reasonable requirements for copayments;
(4)  the health maintenance organization is fully responsible and may reasonably be expected to meet its obligations to enrollees and prospective enrollees, after considering:
(A)  the financial soundness of the health care plan's arrangement for health care services and the schedule of charges used in connection with the arrangement;
(B)  the adequacy of working capital;
(C)  any agreement with an insurer, a group hospital service corporation, a political subdivision of government, or any other organization for insuring the payment of the cost of health care services or providing for automatic applicability of an alternative coverage in the event the plan is discontinued;
(D)  any agreement that provides for the provision of health care services;  and
(E)  any deposit of cash or securities submitted in accordance with Section 843.405 as a guarantee that the obligations will be performed;  and
(5)  the proposed plan of operation, as shown by the information submitted under Section 843.078 and, if applicable, Section 843.079, or by independent investigation, does not violate state law.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter C. Authority to Engage in Business › Section 843.083. Denial of Certificate of Authority

Sec. 843.083.  DENIAL OF CERTIFICATE OF AUTHORITY.  (a)  If the commissioner certifies that the health maintenance organization's proposed plan of operation does not meet the requirements of Section 843.082, the commissioner may not issue a certificate of authority.
(b)  The commissioner shall notify the applicant that the plan is deficient and specify the deficiencies.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter C. Authority to Engage in Business › Section 843.084. Duration of Certificate of Authority

Sec. 843.084.  DURATION OF CERTIFICATE OF AUTHORITY.  A certificate of authority continues in effect:
(1)  while the certificate holder meets the requirements of this chapter and:
(A)  Section 1367.053;
(B)  Subchapter A, Chapter 1452;
(C)  Subchapter B, Chapter 1507;
(D)  Chapters 222, 251, and 258, as applicable to a health maintenance organization; and
(E)  Chapters 1271 and 1272; or
(2)  until the commissioner suspends or revokes the certificate or the commissioner terminates the certificate at the request of the certificate holder.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.037, eff. April 1, 2009.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter C. Authority to Engage in Business › Section 843.085. Change in Control: Commissioner Approval

Sec. 843.085.  CHANGE IN CONTROL:  COMMISSIONER APPROVAL.  Any change in control, as defined by Chapter 823, of a health maintenance organization is subject to the approval of the commissioner.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter D. General Powers and Duties of Health Maintenance Organizations › Section 843.102. Health Maintenance Organization Quality Assurance

Sec. 843.102.  HEALTH MAINTENANCE ORGANIZATION QUALITY ASSURANCE.  (a)  A health maintenance organization shall establish procedures to ensure that health care services are provided to enrollees under reasonable standards of quality of care that are consistent with prevailing professionally recognized standards of medical practice.  The procedures must include mechanisms to ensure availability, accessibility, quality, and continuity of care.
(b)  A health maintenance organization shall operate a continuing internal quality assurance program to monitor and evaluate its health care services, including primary and specialist physician services and ancillary and preventive health care services, in all institutional and noninstitutional settings.
(c)  The commissioner by rule may establish minimum standards and requirements for the quality assurance programs, including standards for ensuring availability, accessibility, quality, and continuity of care.
(d)  A health maintenance organization shall record formal proceedings of quality assurance program activities and maintain documentation in a confidential manner.  The health maintenance organization shall make the quality assurance program minutes available to the commissioner.
(e)  A health maintenance organization shall establish and maintain a physician review panel to assist in:
(1)  reviewing medical guidelines or criteria;  and
(2)  determining prescription drugs to be covered by the health maintenance organization, if the health maintenance organization offers a prescription drug benefit.
(f)  A health maintenance organization shall ensure the use and maintenance of an adequate patient record system to facilitate documentation and retrieval of clinical information for the health maintenance organization's evaluation of continuity and coordination of patient care and assessment of the quality of health and medical care provided to enrollees.
(g)  The clinical records of enrollees shall be available to the commissioner for examination and review to determine compliance.  The records are confidential and privileged and are not subject to the public information law, Chapter 552, Government Code, or to subpoena, except to the extent necessary to enable the commissioner to enforce this section.
(h)  A health maintenance organization shall establish a mechanism for the periodic reporting of quality assurance program activities to its governing body, providers, and appropriate health maintenance organization staff.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter D. General Powers and Duties of Health Maintenance Organizations › Section 843.103. Acquisition and Operation of Facilities; Certain Loans; Commissioner Approval of Affiliate Transactions

Sec. 843.103.  ACQUISITION AND OPERATION OF FACILITIES;  CERTAIN LOANS;  COMMISSIONER APPROVAL OF AFFILIATE TRANSACTIONS.  (a)  A health maintenance organization may:
(1)  purchase, lease, construct, renovate, operate, or maintain hospitals or medical facilities and ancillary equipment and other property reasonably required for the principal office of the health maintenance organization or for another purpose necessary in engaging in the business of the health maintenance organization;  and
(2)  make loans to a medical group, under an independent contract with the group to further its program, or corporations under its control, to acquire or construct medical facilities and hospitals, or to further a program providing health care services to enrollees.
(b)  If the exercise of a power granted under Subsection (a) involves an affiliate, as described by Section 823.003, the health maintenance organization before exercising that power shall file notice and adequate supporting information with the commissioner for approval.
(c)  The commissioner shall disapprove the exercise of a power described by Subsection (a) that would in the commissioner's opinion:
(1)  substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations;  or
(2)  impair the interests of the public or the health maintenance organization's enrollees or creditors in this state.
(d)  If the commissioner does not disapprove the exercise of a power described by Subsection (a) before the 31st day after the date notice is filed under this section, the exercise of the power is considered approved.  The commissioner may, by official order, delay action as necessary for proper consideration for not more than an additional 30 days.
(e)  The commissioner may adopt rules exempting from the filing requirements of Subsection (b) an activity that has a de minimis effect.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter D. General Powers and Duties of Health Maintenance Organizations › Section 843.104. Contracts for Certain Administrative Functions

Sec. 843.104.  CONTRACTS FOR CERTAIN ADMINISTRATIVE FUNCTIONS.  A health maintenance organization may contract with any person to perform functions such as marketing, enrollment, and administration on behalf of the health maintenance organization.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter D. General Powers and Duties of Health Maintenance Organizations › Section 843.105. Management and Exclusive Agency Contracts

Sec. 843.105.  MANAGEMENT AND EXCLUSIVE AGENCY CONTRACTS.  (a)  A health maintenance organization may not enter into a management contract or exclusive agency contract unless the proposed contract is first filed with and approved by the commissioner.
(b)  The commissioner must approve or disapprove the contract not later than the 30th day after the date the contract is filed or within a reasonable extended period that the commissioner specifies by notice given within the 30-day period.
(c)  The commissioner shall disapprove the proposed contract if the commissioner determines that the contract:
(1)  subjects the health maintenance organization to excessive charges;
(2)  extends for an unreasonable time;
(3)  does not contain fair and adequate standards of performance;
(4)  authorizes persons to manage the health maintenance organization who are not sufficiently trustworthy, competent, experienced, and free from conflict of interest to manage the health maintenance organization with due regard for the interests of the health maintenance organization's enrollees or creditors or the public;  or
(5)  contains provisions that impair the interests of the public in this state or the health maintenance organization's enrollees or creditors.
(d)  The commissioner shall disapprove a proposed management contract unless the commissioner determines that the management contractor has in force in its own name a fidelity bond on its officers and employees in the amount of at least $100,000 or another amount prescribed by the commissioner.
(e)  The fidelity bond must be issued by an insurer that holds a certificate of authority in this state.  If, after notice and hearing, the commissioner determines that a fidelity bond is not available from an insurer that holds a certificate of authority in this state, the management contractor may obtain a fidelity bond procured by a surplus lines agent resident in this state in compliance with Chapter 981.
(f)  The fidelity bond must obligate the surety to pay any loss of money or other property that the health maintenance organization sustains because of an act of fraud or dishonesty by an employee or officer of the management contractor during the period that the management contract is in effect.
(g)  Instead of a fidelity bond, the management contractor may deposit with the comptroller cash or securities acceptable to the commissioner.  The deposit must be maintained in the amount and is subject to the same conditions required for a fidelity bond under this section.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter D. General Powers and Duties of Health Maintenance Organizations › Section 843.106. Insurance, Reinsurance, Indemnity, and Reimbursement

Sec. 843.106.  INSURANCE, REINSURANCE, INDEMNITY, AND REIMBURSEMENT.  A health maintenance organization may contract with an insurer or group hospital service corporation authorized to engage in business in this state to provide insurance, reinsurance, indemnification, or reimbursement against the cost of health care and medical care services provided by the health maintenance organization.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter D. General Powers and Duties of Health Maintenance Organizations › Section 843.107. Indemnity Benefits; Point-of-Service Provisions

Sec. 843.107.  INDEMNITY BENEFITS;  POINT-OF-SERVICE PROVISIONS.  A health maintenance organization may offer:
(1)  indemnity benefits covering out-of-area emergency care;
(2)  indemnity benefits, in addition to those relating to out-of-area and emergency care, provided through an insurer or group hospital service corporation;
(3)  a point-of-service plan under Subchapter A, Chapter 1273; or
(4)  a point-of-service rider under Section 843.108.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.038, eff. April 1, 2009.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter D. General Powers and Duties of Health Maintenance Organizations › Section 843.108. Point-of-Service Rider

Sec. 843.108.  POINT-OF-SERVICE RIDER.  (a)  In this section, "point-of-service rider" means a rider under which indemnity benefits for the cost of health care services are provided by a health maintenance organization in conjunction with corresponding benefits arranged for or provided by a health maintenance organization.
(b)  A health maintenance organization may offer a point-of-service rider for out-of-network coverage without obtaining a separate certificate of authority as an insurer if the expenses incurred under the point-of-service rider do not exceed 10 percent of the total medical and hospital expenses incurred for all health plan products sold by the health maintenance organization.  If the expenses exceed that level, the health maintenance organization may not issue new point-of-service riders until the expenses fall below that level or until the health maintenance organization obtains a certificate of authority as an insurer.
(c)  Indemnity benefits for services provided under a point-of-service rider may be limited to those services defined in the evidence of coverage and may be subject to different cost-sharing provisions.  The cost-sharing provisions for indemnity benefits may be higher than the cost-sharing provisions for in-network health maintenance organization coverage.  For enrollees in a limited provider network, higher cost-sharing may be imposed only when benefits or services are obtained outside the health maintenance organization delivery network.
(d)  A health maintenance organization that issues a point-of-service rider under this section must meet additional net worth requirements prescribed by the commissioner.  The commissioner shall base the net worth requirements on the actuarial relation of the amount of insurance risk assumed through the point-of-service rider to the amount of solvency and reserve requirements otherwise required of the health maintenance organization.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter D. General Powers and Duties of Health Maintenance Organizations › Section 843.109. Payment by Governmental or Private Entity

Sec. 843.109.  PAYMENT BY GOVERNMENTAL OR PRIVATE ENTITY.  A health maintenance organization may accept from a governmental or private entity payments for all or part of the cost of services provided or arranged for by the health maintenance organization.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter D. General Powers and Duties of Health Maintenance Organizations › Section 843.110. Corporation, Partnership, or Association Powers

Sec. 843.110.  CORPORATION, PARTNERSHIP, OR ASSOCIATION POWERS.  A health maintenance organization has all powers of a partnership, association, or corporation, including a professional association or corporation, as appropriate under the organizational documents of the health maintenance organization, that are not in conflict with this chapter or other applicable law.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter D. General Powers and Duties of Health Maintenance Organizations › Section 843.111. Group Model Health Maintenance Organizations

Sec. 843.111.  GROUP MODEL HEALTH MAINTENANCE ORGANIZATIONS.  (a)  In this section, "group model health maintenance organization" means a health maintenance organization that provides the majority of its professional services through a single group medical practice that is formally affiliated with the medical school component of a state-supported public college or university in this state.
(b)  Unless this section and a power specified in Section 843.101, 843.103, 843.104, 843.106, 843.107, 843.109, or 843.110 are specifically amended by law, a law, without regard to the time of enactment, may not be construed to prohibit or restrict a group model health maintenance organization from:
(1)  selectively contracting with or declining to contract with a provider as the group model health maintenance organization considers necessary;
(2)  contracting for or declining to contract for an individual health care service or full range of health care services as the group model health maintenance organization considers necessary, if the service or services may be legally provided by the contracting provider;  or
(3)  requiring enrolled members of the group model health maintenance organization who wish to obtain the services covered by the group model health maintenance organization to use the providers specified by the group model health maintenance organization.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter D. General Powers and Duties of Health Maintenance Organizations › Section 843.113. Specified Powers Not Exclusive

Sec. 843.113.  SPECIFIED POWERS NOT EXCLUSIVE.  The powers of a health maintenance organization are not limited to the powers specified by this subchapter.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter E. Regulation of Health Maintenance Organizations › Section 843.151. Rules

Sec. 843.151.  RULES.  The commissioner may adopt reasonable rules as necessary and proper to:
(1)  implement this chapter and Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapters 222, 251, and 258, as applicable to a health maintenance organization, and Chapters 1271 and 1272, including rules to:
(A)  prescribe authorized investments for a health maintenance organization for all investments not otherwise addressed in this chapter;
(B)  ensure that enrollees have adequate access to health care services; and
(C)  establish minimum physician-to-patient ratios, mileage requirements for primary and specialty care, maximum travel time, and maximum waiting time for obtaining an appointment; and
(2)  meet the requirements of federal law and regulations.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.039, eff. April 1, 2009.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter E. Regulation of Health Maintenance Organizations › Section 843.152. Subpoena Authority

Sec. 843.152.  SUBPOENA AUTHORITY.  In implementing this chapter and the following provisions, the commissioner may exercise subpoena authority in accordance with Subchapter C, Chapter 36:
(1)  Section 1367.053;
(2)  Subchapter A, Chapter 1452;
(3)  Subchapter B, Chapter 1507;
(4)  Chapters 222, 251, and 258, as applicable to a health maintenance organization; and
(5)  Chapters 1271 and 1272.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.040, eff. April 1, 2009.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter E. Regulation of Health Maintenance Organizations › Section 843.153. Authority to Contract

Sec. 843.153.  AUTHORITY TO CONTRACT.  In performing duties under this chapter and the following provisions, the commissioner may contract with a state agency or, after notice and opportunity for hearing, with a qualified person to make recommendations concerning determinations to be made by the commissioner:
(1)  Section 1367.053;
(2)  Subchapter A, Chapter 1452;
(3)  Subchapter B, Chapter 1507;
(4)  Chapters 222, 251, and 258, as applicable to a health maintenance organization; and
(5)  Chapters 1271 and 1272.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.041, eff. April 1, 2009.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter E. Regulation of Health Maintenance Organizations › Section 843.154. Fees

Sec. 843.154.  FEES.  (a)  The commissioner shall, within the limits prescribed by this section, prescribe the fees to be charged under this section.
(b)  Except for fees collected under Subsections (e) and (f), fees collected under this section shall be deposited to the credit of the Texas Department of Insurance operating account.
(b-1)  A fee collected under Subsection (e) or (f) shall be deposited to the credit of the account described by Section 401.156(a).
(c)  A health maintenance organization shall pay to the commissioner a fee in an amount not to exceed:
(1)  $18,000 for filing and review of its original application for a certificate of authority;
(2)  $200 for filing of an evidence of coverage that requires approval;  and
(3)  $100 for a filing that is required by rule but does not require approval.
(d)  A health maintenance organization shall pay to the comptroller a fee in an amount not to exceed $500 for filing of an annual report under Section 843.155.
(e)  A health maintenance organization shall pay to the commissioner a fee, in an amount certified by the commissioner to be just and reasonable, for the expenses of all examinations of health maintenance organizations made on behalf of the state by the commissioner or under the commissioner's authority.
(f)  A health maintenance organization shall pay to the commissioner a fee in an amount assessed by the commissioner and paid in accordance with rules adopted by the commissioner for the expenses of an examination under Section 843.156(a) that:
(1)  are incurred by the commissioner or under the commissioner's authority;  and
(2)  are directly attributable to that examination, including the actual salaries and expenses of the examiners directly attributable to that examination, as determined under rules adopted by the commissioner.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 659 (S.B. 1291), Sec. 5, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter E. Regulation of Health Maintenance Organizations › Section 843.157. Rehabilitation, Liquidation, Supervision, or Conservation of Health Maintenance Organization

Sec. 843.157.  REHABILITATION, LIQUIDATION, SUPERVISION, OR CONSERVATION OF HEALTH MAINTENANCE ORGANIZATION.  (a)  The rehabilitation, liquidation, supervision, or conservation of a health maintenance organization shall be treated as the rehabilitation, liquidation, supervision, or conservation of an insurer and be conducted under the supervision of the commissioner under Chapter 441 or 443, as appropriate.
(b)  The commissioner may also order the rehabilitation, liquidation, supervision, or conservation of a health maintenance organization if in the commissioner's opinion the continued operation of the health maintenance organization would be hazardous to the enrollees or to the people of this state.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.044, eff. April 1, 2009.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.201. Disclosure of Information About Health Care Plan Terms

Sec. 843.201.  DISCLOSURE OF INFORMATION ABOUT HEALTH CARE PLAN TERMS.  (a)  A health maintenance organization shall provide an accurate written or electronic description of health care plan terms, including restrictions or limitations related to a limited provider network or delegated network within a health care plan, to allow a current or prospective group contract holder or current or prospective enrollee to make comparisons and informed decisions before selecting among health care plans.  The written or electronic description must:
(1)  be in readable and understandable format prescribed by the commissioner;  and
(2)  include a current list of physicians and providers, including a delineation of any limited provider network or delegated network.
(b)  A health maintenance organization may satisfy the requirement imposed under Subsection (a) through the member handbook provided under Section 843.205 if:
(1)  the handbook's contents are substantially similar to and provide the same level of disclosure as the written or electronic description prescribed by the commissioner;  and
(2)  the current list of physicians and providers is also provided.
(c)  If an enrollee designates a primary care physician who practices in a limited provider network or delegated entity, not later than the 30th day after the date of the enrollee's enrollment, the health maintenance organization shall provide the information required under this section to the enrollee with the enrollee's identification card or in a mailing separate from other information.
(d)  A health maintenance organization shall provide to an enrollee on request information on:
(1)  whether a physician or other health care provider is a participating provider in the health maintenance organization's network;
(2)  whether proposed health care services are covered by the health plan; and
(3)  what the enrollee's personal responsibility will be for payment of applicable copayment or deductible amounts.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 261, Sec. 2, eff. Sept. 1, 2003;  Acts 2003, 78th Leg., ch. 1276, Sec. 10A.208(a), eff. Sept. 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 12, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.2015. Information Available Through Internet Site

Sec. 843.2015.  INFORMATION AVAILABLE THROUGH INTERNET SITE.  (a)  A health maintenance organization that maintains an Internet site shall list on the Internet site the physicians and providers, including, if appropriate, mental health providers and substance abuse treatment providers, that may be used by enrollees in accordance with the terms of the enrollee's health care plan.  The listing must identify those physicians and providers who continue to be available to provide services to new patients or clients.
(b)  The health maintenance organization shall update at least quarterly an Internet site subject to this section.
(c)  The commissioner may adopt rules as necessary to implement this section.  The rules may govern the form and content of the information required to be provided under Subsection (a).
Acts 2003, 78th Leg., ch. 1177, Sec. 3, eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.202. Disclosure of Information to Medicare Recipients

Sec. 843.202.  DISCLOSURE OF INFORMATION TO MEDICARE RECIPIENTS.  (a)  Before a prospective enrollee is enrolled in a health care plan offered to Medicare recipients by a Medicare-contracting health maintenance organization, the health maintenance organization must provide the prospective enrollee with a disclosure form adopted by the commissioner under Subsection (b).
(b)  The commissioner shall adopt a disclosure form informing a prospective enrollee in a Medicare-contracting health maintenance organization of:
(1)  the effect of enrollment in the health maintenance organization on the prospective enrollee's opportunity to purchase Medicare supplement insurance;  and
(2)  any differences in the benefits and costs between the health care plan offered to Medicare recipients and Medicare supplement insurance.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.203. Selection of Primary Care Physician or Provider

Sec. 843.203.  SELECTION OF PRIMARY CARE PHYSICIAN OR PROVIDER.  (a)  Each plan application form shall prominently include a space in which the enrollee at the time of application or enrollment shall select a primary care physician or primary care provider.
(b)  An enrollee shall at all times have the right to select or change a primary care physician or primary care provider within the health maintenance organization network of available primary care physicians and primary care providers, except that a health maintenance organization may limit an enrollee's request to change physicians or providers to not more than four changes in a 12-month period.
(c)  For purposes of this subchapter, an applicant physician, as defined by Chapter 1452, may not be considered to be an available primary care physician or primary care provider within the  health maintenance organization delivery network for selection by an enrollee.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 1203 (H.B. 1594), Sec. 2, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.204. Untrue or Misleading Information

Sec. 843.204.  UNTRUE OR MISLEADING INFORMATION.  (a)  A health maintenance organization or a representative of a health maintenance organization may not:
(1)  use or distribute or knowingly permit the use or distribution of prospective enrollee information that is untrue or misleading;  or
(2)  use or knowingly permit the use of:
(A)  advertising that is untrue or misleading;
(B)  solicitation that is untrue or misleading;  or
(C)  any form of evidence of coverage that is deceptive.
(b)  In this chapter, Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapters 222, 251, and 258, as applicable to a health maintenance organization, and Chapters 1271 and 1272, a statement or item of information is:
(1)  considered to be untrue if the statement or item does not conform to fact in any respect that is or may be significant to an enrollee of, or person considering enrollment in, a health care plan; and
(2)  considered to be misleading, whether or not the statement or item is literally untrue, if, in the total context in which the statement is made or the item is communicated, the statement or item may be reasonably understood by a reasonable person who does not possess special knowledge regarding health care coverage as indicating:
(A)  the inclusion of a benefit or advantage that does not exist and that is of possible significance to an enrollee of, or person considering enrollment in, a health care plan; or
(B)  the absence of an exclusion, limitation, or disadvantage that does exist and that is of possible significance to an enrollee of, or person considering enrollment in, a health care plan.
(c)  In this chapter, Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapters 222, 251, and 258, as applicable to a health maintenance organization, and Chapters 1271 and 1272, an evidence of coverage is considered to be deceptive if the evidence of coverage, taken as a whole and with consideration given to typography and format as well as language, would cause a reasonable person who does not possess special knowledge regarding health care plans and evidences of coverage for health care plans to expect charges or benefits, services, or other advantages that the evidence of coverage does not provide or that the health care plan issuing the evidence of coverage does not regularly make available for enrollees covered under the evidence of coverage.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.045, eff. April 1, 2009.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.205. Member's Handbook; Information About Complaints and Appeals

Sec. 843.205.  MEMBER'S HANDBOOK;  INFORMATION ABOUT COMPLAINTS AND APPEALS.  (a)  In this section, "major population" means a group constituting 10 percent or more of the enrolled population of the health maintenance organization.
(b)  A health maintenance organization shall establish procedures to:
(1)  provide to an enrollee a member handbook and materials relating to the complaint and appeals process in the languages of the major populations of the enrolled population;  and
(2)  provide access to a member handbook and the complaint and appeals process to an enrollee who has a disability that affects the enrollee's ability to communicate or read.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.206. Notice of Change in Payment Arrangements

Sec. 843.206.  NOTICE OF CHANGE IN PAYMENT ARRANGEMENTS.  A health maintenance organization shall notify a group contract holder within 30 days of any substantive change to the payment arrangements between the health maintenance organization and physicians or providers.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.207. Notice of Change in Operations

Sec. 843.207.  NOTICE OF CHANGE IN OPERATIONS.  A health maintenance organization shall provide to its enrollees reasonable notice of any material adverse change in the operation of the health maintenance organization that will directly affect the enrollees.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.2071. Notice of Increase in Charge for Coverage

Sec. 843.2071.  NOTICE OF INCREASE IN CHARGE FOR COVERAGE.  (a)  Not less than 60 days before the date on which an increase in a charge for coverage under this chapter takes effect, a health maintenance organization shall:
(1)  give to each enrollee under an individual evidence of coverage written notice of the effective date of the increase; and
(2)  provide the enrollee a table that clearly lists:
(A)  the actual dollar amount of the charge for coverage on the date of the notice;
(B)  the actual dollar amount of the charge for coverage after the charge increase; and
(C)  the percentage change between the amounts described by Paragraphs (A) and (B).
(b)  The notice required by this section must be based on coverage in effect on the date of the notice.
(c)  This section may not be construed to prevent a health maintenance organization, at the request of an enrollee, from negotiating a change in benefits or rates after delivery of the notice required by this section.
(d)  A health maintenance organization may not require an enrollee entitled to notice under this section to respond to the health maintenance organization to renew the coverage or take other action relating to the renewal or extension of the coverage before the 45th day after the date the notice described by Subsection (a) is given.
(e)  The notice required by this section must include:
(1)  contact information for the department, including information concerning how to file a complaint with the department;
(2)  contact information for the Texas Consumer Health Assistance Program, including information concerning how to request from the program consumer protection information or assistance with filing a complaint; and
(3)  the addresses of Internet websites that provide consumer information related to rate increase justifications, including the websites of the department and the United States Department of Health and Human Services.
Added by Acts 2011, 82nd Leg., R.S., Ch. 1147 (H.B. 1951), Sec. 3.001, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.208. Cancellation or Nonrenewal of Coverage

Sec. 843.208.  CANCELLATION OR NONRENEWAL OF COVERAGE.  A health maintenance organization may cancel or refuse to renew the coverage of an enrollee only for:
(1)  failure to pay the charges for the coverage;  or
(2)  another reason prescribed by rules adopted by the commissioner.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.209. Identification Card

Sec. 843.209.  IDENTIFICATION CARD.  An identification card or other similar document issued by a health maintenance organization to an enrollee must:
(1)  indicate that the health maintenance organization is regulated under this code and subject to the provisions of Subchapter J;  and
(2)  display:
(A)  the first date on which the enrollee became enrolled;  or
(B)  a toll-free number a physician or provider may use to obtain that date.
Added by Acts 2003, 78th Leg., ch. 214, Sec. 4, eff. June 17, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.210. Terms of Enrollee Eligibility

Sec. 843.210.  TERMS OF ENROLLEE ELIGIBILITY.  (a)  A contract between a health maintenance organization and a group contract holder must provide that:
(1)  in addition to any other premiums for which the group contract holder is liable, the group contract holder is liable for an enrollee's premiums from the time the enrollee is no longer part of the group eligible for coverage under the contract until the end of the month in which the contract holder notifies the health maintenance organization that the enrollee is no longer part of the group eligible for coverage by the contract; and
(2)  the enrollee remains covered by the contract until the end of that period.
(b)  Each health maintenance organization that enters into a contract described by Subsection (a) shall notify the group contract holder periodically as provided by this section that the contract holder is liable for premiums on an enrollee who is no longer part of the group eligible for coverage under the contract until the health maintenance organization receives notification of termination of the enrollee's eligibility for that coverage.
(c)  If the health maintenance organization charges the group contract holder on a monthly basis for the coverage premiums, the health maintenance organization shall include the notice required by Subsection (b) in each monthly statement sent to the group contract holder.  If the health maintenance organization charges the group contract holder on other than a monthly basis for the premiums, the health maintenance organization shall notify the group contract holder periodically in the manner prescribed by the commissioner by rule.
(d)  The notice required by Subsection (b) must include a description of methods preferred by the health maintenance organization for notification by a group contract holder of an enrollee's termination from coverage eligibility.
Added by Acts 2005, 79th Leg., Ch. 669 (S.B. 51), Sec. 2, eff. September 1, 2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 1217 (S.B. 1143), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter F. Relations With Enrollees and Group Contract Holders › Section 843.211. Applicability of Subchapter to Entities Contracting With Health Maintenance Organization

Sec. 843.211.  APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH HEALTH MAINTENANCE ORGANIZATION.  This subchapter applies to a person to whom a health maintenance organization contracts to:
(1)  process or pay claims;
(2)  obtain the services of physicians or other providers to provide health care services to enrollees; or
(3)  issue verifications or preauthorizations.
Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 13, eff. September 1, 2007.