Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter E - HEALTH CARE COLLABORATIVES › Division 7 - ADMINISTRATIVE PROCEDURES › Section 13.461 - Commissioner's Authority to Require Additional Information

Current through Reg. 49, No. 28; July 12, 2024
(a) The commissioner may require additional
					 information from the HCC or any participant in the HCC as reasonably necessary
					 to make any determination required by Insurance Code Chapter 848, this
					 subchapter, and applicable insurance laws and regulations of this
					 state.
(b) The commissioner may
					 require any or all of the additional information set forth in subsection (c) of
					 this section. An HCC or HCC participant is not required to create the items
					 listed in subsection (c) of this section unless and except as the commissioner
					 requires the items to be provided under this section. Once created, the
					 documents must be maintained by the HCC or participant for at least five
					 years.
(c) Additional information
					 the commissioner may require includes the following:
(1) underlying documentation or data
					 supporting any information, reports, or memoranda submitted to the department
					 under the Insurance Code or this title;
(2) contact information for current
					 participants or employees of the HCC, and last known contact information for
					 former participants or employees;
(3) interviews by the department with
					 individuals affiliated with the HCC or HCC participants;
(4) any participant's agendas, minutes,
					 recordings, summaries, handouts, or presentations to the HCC;
(5) documents relating to past, current, or
					 planned fees, risk-sharing, fee schedules, fee conversion factors, withholds,
					 capitation, pricing plans, pricing strategies, or other forms of
					 payment;
(6) documents relating to
					 planned additions to the participation in the HCC or expansions of participants
					 in the HCC;
(7) de-identified
					 information regarding utilization of services by the HCC's patients or
					 participants, including both medical and financial information;
(8) current bylaws, rules, or regulations of
					 an HCC participant's professional staff or any of its departments or
					 subunits;
(9) questionnaires
					 submitted by participants to applicable professional associations in connection
					 with annual surveys of association members, and to any other association,
					 accreditation agency, or government agency, in connection with any annual or
					 other periodic survey of the participant;
(10) reports prepared by accreditation
					 agencies in connection with accreditation of the HCC or any HCC
					 participant;
(11) revenue-and-cost
					 reports, profitability reports, and other financial reports;
(12) internal or external reports relating to
					 quality of care at any health care service location in each service area by the
					 HCC or its participants, including:
(A) data
					 or reports submitted to or received from or by quality rating
					 organizations;
(B) quality-of-care
					 initiatives;
(C) quality assurance
					 or quality improvement systems; and
(D) the effect of changes in health care
					 service location quality on patient volume and revenue;
(13) financial reports regularly prepared by
					 or for the HCC applicant on any periodic basis relating to any arranged health
					 care service;
(14) memoranda,
					 excluding engineering and architectural plans and blueprints, relating to plans
					 of the HCC applicant, or any participant, for the construction of new
					 facilities, the closing of any existing facilities, or an expansion, a
					 conversion, or a modification of current facilities;
(15) memoranda relating to plans of, or steps
					 undertaken by the HCC applicant or any participant for any acquisition,
					 divestiture, joint venture, alliance, or merger involving any participant in
					 the service area other than the application for certificate of authority of the
					 applicant;
(16) memoranda analyzing
					 or discussing the effect of any merger, joint venture, acquisition, or
					 consolidation of HCCs in the applicant's service area, including the HCC's
					 application if approved, on the HCC's prices, costs, margins, service quality,
					 or any other aspect of competitive performance, including:
(A) memoranda comparing the actual cost
					 savings or other benefits of the transactions to those previously projected;
					 and
(B) memoranda discussing how
					 the benefits were or might be achieved;
(17) a description relating to the
					 consolidation or realignment of any medical and health care services arranged
					 by or through the applicant whether completed, in progress, or planned among
					 the participants;
(18) the names
					 and addresses of all contracting physicians, in Excel-compatible
					 format;
(19) documents created or
					 used by, for, or on behalf of the applicant for the purpose of soliciting
					 physicians or health care providers to join the applicant as an employee or
					 participant, promoting continued participation in the applicant, or otherwise
					 offering, promoting, or advertising the applicant's services or activities on
					 behalf of physicians or health care providers, and all documents supplied by
					 the HCC to newly recruited physicians or health care providers;
(20) contracts between the HCC applicant or
					 any of its participants and any private payor, all attachments to the
					 contracts, and all documents relating to the contracts, including:
(A) documents sufficient to show the name,
					 contact person, and telephone number of each health plan contracting with the
					 applicant for physician services;
(B) documents relating to fees, fee
					 schedules, fee conversion factors, withholds, capitation, pricing plans,
					 pricing strategies, or other forms of payment;
(C) documents discussing actual or potential
					 negotiations, offers, or responses to any contract, fee schedule, or
					 risk-sharing arrangement with a third-party payor;
(D) copies of internal memoranda relating to:
(i) the development or negotiation of
					 contracts with payors or participants, and internal HCC decisions regarding
					 negotiating positions;
(ii)
					 competition to obtain contracts;
(iii) decisions to terminate
					 contracts;
(iv) draft, contingent,
					 or expired contracts, including contracts not entered into, not yet finalized
					 or in force, or no longer in force; and
(v) contract amendments or modifications;
					 and
(E) the beginning
					 date and termination date, as applicable, for each contract;
(21) documents relating to plans,
					 interests, or steps undertaken by the HCC applicant for any acquisition,
					 divestiture, joint venture, alliance, collaboration, license, or merger with
					 any HCC or other health care provider, including:
(A) any notes or minutes taken; or
(B) reports, memoranda, or correspondence
					 regarding meetings between the HCC applicant and any other HCC or other health
					 care provider;
(22)
					 documents reflecting:
(A) actual or planned
					 lease, management contract, or other agreement for the HCC applicant to operate
					 a facility in the service area that is, or will be, owned in whole or in part
					 by another individual or entity; and
(B) formal or informal commercial or
					 operational relationships or affiliations that have existed, exist, or are
					 planned between or among any facilities, or facilities and any physician
					 organizations in the service area, including purchases by the HCC applicant of
					 services from other facilities or from physician organizations, and vice
					 versa;
(23) for each
					 participant, summaries and interpretations of contract terms and methodologies
					 used to determine the payment due to the participant under a contract with a
					 payor in effect at any time during the previous three years for each treatment,
					 office visit, or other medical or health care service provided or delivered in
					 the service area;
(24) a list and
					 description by Current Procedural Technology code, if available, of each
					 medical or health care service arranged by or through the applicant in the
					 HCC's service area, and for each code listed, a statement of:
(A) the number of procedures
					 performed;
(B) the amount of
					 revenue received by the applicant;
(C) the ZIP code for each patient receiving
					 the procedure or service; and
(D)
					 the location of the office where the procedure or service was performed;
					 and
(25) documents
					 reflecting participants' contribution margins or identifying or quantifying
					 fixed or variable costs for the provision of any health care service in the
					 service area.