reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter I - FINANCIAL REQUIREMENTS › Section 11.801 - Accounting Guidance

Current through Reg. 49, No. 28; July 12, 2024
To the extent that the accounting guidance given in §
										7.18
					 of this title (relating to National Association of Insurance Commissioners
					 Accounting Practices and Procedures Manual) does not conflict with the
					 provisions of this chapter, an HMO must follow that guidance. In the event of a
					 conflict between the provisions of this chapter and §
										7.18
					 of this title, the HMO must follow the provisions of this
					 chapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter I - FINANCIAL REQUIREMENTS › Section 11.802 - Minimum Net Worth

Current through Reg. 49, No. 28; July 12, 2024
(a) An applicant
				  for a certificate of authority to operate an HMO must have unencumbered assets
				  that satisfy the requirements of Insurance Code §
										843.403
				  (concerning Minimum Net Worth).
(b)
				  For the purpose of calculating assets to satisfy the minimum net worth
				  requirements of Insurance Code §
										843.403, lawful
				  money of the United States of America includes deposits in an institution that
				  is a member of the Federal Deposit Insurance Corporation. Demand deposits,
				  savings deposits, or time deposits, of the type that are federally insured in
				  solvent banks, savings and loan associations, and their branches, which are
				  organized under the laws of the United States of America or under the laws of
				  any state of the United States of America may not exceed the greater of:
(1) the amount of federal deposit insurance
				  coverage pertaining to the deposit; or
(2) 10 percent of the issuing financial
				  institution's equity, provided that the institution's equity is in excess of
				  $25 million.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter I - FINANCIAL REQUIREMENTS › Section 11.805 - Other Assets

Current through Reg. 49, No. 28; July 12, 2024
(a) Other assets an
				  HMO may find necessary in its operations include, but are not limited to, the
				  following:
(1) uncollected premiums or
				  subscriptions with an adequate provision for uncollectable premiums or
				  subscriptions;
(2) advances of
				  capitation or other fees expected to be paid for the next month to medical and
				  other health care service providers under contract with the HMO, provided that
				  no termination of the contract may take place before the end of the period for
				  which advances were paid;
(3) the
				  following items, provided that a detailed inventory is maintained with each
				  item marked by any identifying number and the proof of cost maintained:
(A) furniture, labor-saving devices,
				  machines, and all other office equipment used in the administration of the
				  HMO;
(B) furniture, medical
				  equipment, and vehicles used in connection with the direct provision of health
				  care services; and
(C) electronic
				  machines, constituting a data processing system or systems and operating
				  systems software used directly for the provision of medical services and the
				  administration of the HMO;
(4) inventories of necessary pharmaceutical
				  and surgical supplies used directly in the treatment of medical conditions, it
				  being the duty of the HMO to sufficiently prove the value of the
				  inventories;
(5) real estate and
				  leasehold estates, including buildings and improvements, and leasehold
				  improvements on rented space, for the accommodation of the HMO's current or
				  expected business operations used in the provision or support of health care
				  services, including space for rent to any physician or provider under contract
				  with the HMO, which property will be used in the provision of health care
				  services to members of the HMO by that physician or provider; and
(6) claims overpayments, with the right of
				  offset supported by a contractual agreement, which are specifically
				  identifiable payments, may be admitted to the extent a liability to that
				  physician or provider exists.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter I - FINANCIAL REQUIREMENTS › Section 11.806 - Investment Management by Affiliate Companies

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to compliance with Insurance Code
				  Chapter 843 (concerning Health Maintenance Organizations), this chapter, and
				  other applicable insurance laws and regulations of this state, a domestic HMO,
				  which is a member of a holding company system with assets in an aggregate
				  amount in excess of $1 billion and a tangible net worth of at least $100
				  million and having affiliates licensed in this state may authorize an
				  affiliated corporation that, if other than the ultimate holding company, is
				  solvent with at least $10 million tangible net worth and whose performance and
				  obligations under a written agreement with the HMO are guaranteed by the
				  ultimate holding company to invest, hold, and administer as agent or nominee on
				  behalf of the domestic HMO bonds, notes, or other evidences of indebtedness
				  that are authorized and permissible investments under Insurance Code Chapter
				  843 and other applicable insurance laws and regulations of this state that
				  apply to HMOs, and which mature within one year of the date of acquisition. The
				  securities must be invested, held, and administered under a written agreement
				  authorized by the board of directors of the HMO or an authorized committee, and
				  submitted to the commissioner for prior approval. Approval must be based on
				  satisfactory evidence that the agreement will facilitate the operations of the
				  domestic HMO and will not unreasonably diminish the service to or protection of
				  the domestic HMO's enrollees within this state.
(b) The agreement must:
(1) specify in which office location it will
				  maintain records adequate to identify and verify the securities (or
				  proportionate interest therein) belonging to the HMO; and
(2) allow the commissioner or the
				  commissioner's designee to examine all records relating to those securities
				  held subject to the agreement and must agree to furnish these records at the
				  principal office of the HMO within 10 business days of a request by the
				  commissioner or any of the department's commissioned examiners.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter I - FINANCIAL REQUIREMENTS › Section 11.807 - Fiduciary Responsibility

Current through Reg. 49, No. 28; July 12, 2024
Any director, member of a committee, officer, or any
					 representative of a domestic HMO, who is charged with the duty of handling or
					 investing its funds, may not intentionally:
(1) deposit or invest the funds, except in
				  the corporate name of the HMO or in the name of the nominee of the HMO as may
				  be allowed elsewhere in this subchapter; or
(2) take or receive to his or her own use any
				  fee, brokerage, or commission, on account of a loan made by or on behalf of the
				  HMO, except that reasonable interest may be received on amounts loaned to the
				  HMO.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter I - FINANCIAL REQUIREMENTS › Section 11.808 - Liabilities

Current through Reg. 49, No. 28; July 12, 2024
(a) Each HMO must account for liabilities as
				  provided for in §
										11.801 of
				  this title (relating to Accounting Guidance), and must segregate its
				  liabilities into classifications of "covered" or "uncovered." Agreements to
				  loan money or to make future capital or surplus contributions do not, in
				  themselves, cause liabilities to be covered. Any guarantee of future
				  contributions to surplus that are directed and based on the payment of a debt
				  will allow that debt to be reflected as a covered liability. A liability, for
				  which provision is made other than by the assets of the HMO, may qualify as a
				  covered liability if the amount owed is:
(1)
				  based on a physician or provider contract with a hold-harmless clause as
				  provided in §
											11.901
				  of this title (relating to Required and Prohibited Provisions);
(2) subordinated in writing to the uncovered
				  health care liabilities of the HMO; or
(3) unconditionally guaranteed and the
				  guarantee is without monetary limit, as specified in §
											11.810
				  of this title (relating to Guarantee from a Sponsoring Organization), by a
				  sponsoring organization that has a tangible net worth of at least $10 million
				  in excess of all amounts that the sponsoring organization has
				  guaranteed.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter I - FINANCIAL REQUIREMENTS › Section 11.810 - Guarantee from a Sponsoring Organization

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  The following items must be incorporated into a guarantee from a sponsoring
				  organization for the HMO to report expenses and liabilities as covered:
(1) the guarantee must be approved by a board
				  resolution of the sponsoring organization;
(2) the sponsoring organization must have a
				  tangible net worth of at least $10 million for each guarantee issued;
(3) the sponsoring organization must agree to
				  file audited financial statements annually with the department's Financial
				  Analysis Section within 180 days of the end of the sponsoring organization's
				  fiscal year;
(4) the guarantee must
				  be unconditional and may not be monetarily limited;
(5) the guarantee, at a minimum, must cover
				  otherwise "uncovered" health care expenses and liabilities, including any
				  present or future contingencies that may arise from the delivery of health
				  care. If the HMO is offering Medicaid products, all expenses and liabilities
				  must be covered;
(6) the guarantee
				  must not be limited in duration;
(7) the guarantee must provide for
				  six-months' advance notice to the department before its cancellation;
				  and
(8) the guarantee must be
				  notarized and signed by the president and another officer of the sponsoring
				  organization.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter I - FINANCIAL REQUIREMENTS › Section 11.811 - Action under Insurance Code Section 843.157 and Insurance Code Section 843.461

Current through Reg. 49, No. 28; July 12, 2024
(a) In addition to
				  any other actions available under the Insurance Code, the commissioner may take
				  action against an HMO under §843.157 (concerning Rehabilitation,
				  Liquidation, Supervision, or Conservation of Health Maintenance Organizations)
				  and Insurance Code §
										843.461
				  (concerning Enforcement Actions). In evaluating the conditions in this section,
				  the commissioner will evaluate all relevant circumstances concerning the HMO's
				  operation. The evaluation of the information relating to these conditions is a
				  part of the examination process. The conditions listed in this section do not
				  conclusively indicate that action must be taken. One or more of the conditions
				  can exist in an HMO that is in satisfactory condition; however, one or more of
				  these conditions has often been found in an HMO that was unable to perform its
				  obligations to enrollees, creditors, or the general public, or has required the
				  commissioner to initiate regulatory action to protect enrollees, creditors, and
				  the general public.
(b) The
				  commissioner may take action under this section, if the commissioner finds that
				  one or more of the conditions listed below or in §
										8.3
				  of this title (relating to Hazardous Conditions and Remedy of Hazardous
				  Conditions) exist:
(1) an HMO's federal
				  qualification designation, or NCQA accreditation, or both, are revoked or
				  discontinued;
(2) an HMO's reported
				  claims in process exceed 12 percent of annualized medical and hospital expenses
				  (12 percent is approximately a 45-day backlog);
(3) an HMO fails to comply with Insurance
				  Code Chapter 843 (concerning Health Maintenance Organizations), this chapter,
				  or other applicable insurance laws and regulations of this state;
(4) an HMO has an inadequate provider
				  network;
(5) an HMO contracts with
				  a management or administrative company on a capitated or percentage of premium
				  basis and the administrative or management company refuses to submit financial
				  statements to the HMO;
(6) a
				  physician or provider that is under contract, directly or indirectly, with an
				  HMO, has a pattern of balance billing; or
(7) an HMO does not have the minimum net
				  worth required by Insurance Code §
											843.403
				  (concerning Minimum Net Worth) and §
											11.802 of this
				  title (relating to Minimum Net Worth).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter J - PHYSICIAN AND PROVIDER CONTRACTS AND ARRANGEMENTS › Section 11.900 - Nonprimary Care Physician Specialist as Primary Care Physician

Current through Reg. 49, No. 28; July 12, 2024
(a) An HMO must allow an enrollee with
				  chronic, disabling, or life threatening illnesses to apply to the HMO's medical
				  director to use a nonprimary care physician specialist as a primary care
				  physician, provided that:
(1) the enrollee
				  makes a request for special consideration that includes:
(A) a certification by the nonprimary care
				  physician specialist of the medical need for the enrollee to use the nonprimary
				  care physician specialist as a primary care physician;
(B) a statement signed by the nonprimary care
				  physician specialist that the specialist is willing to accept responsibility
				  for the coordination of all of the enrollee's health care needs; and
(C) the signature of the enrollee;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter J - PHYSICIAN AND PROVIDER CONTRACTS AND ARRANGEMENTS › Section 11.901 - Required and Prohibited Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Physician and provider contracts, subcontracts, and arrangements must include
				  provisions regarding a hold-harmless clause as described in Insurance Code
				  § 843.361 of this title (concerning Enrollees Held Harmless).
(1) A hold-harmless clause is a provision in
				  a physician or health care provider agreement that obligates the physician or
				  provider to look only to the HMO and not its enrollees for payment for covered
				  services (except as described in the evidence of coverage issued to the
				  enrollee).
(2) In compliance with
				  Insurance Code §
											843.002 (concerning
				  Definitions) relating to an "uncovered expense," if a physician or health care
				  provider agreement contains a hold-harmless clause, then the costs of the
				  services will not be considered uncovered health care expenses in determining
				  amounts of deposits necessary for insolvency protection under Insurance Code
				  §
											843.405
				  (concerning Deposit with Comptroller).
(3) The following is an example of an
				  approvable hold-harmless clause: "(Physician or Provider) hereby agrees that in
				  no event, including, but not limited to nonpayment by the HMO, HMO insolvency,
				  or breach of this agreement, may (Physician or Provider) bill, charge, collect
				  a deposit from, seek compensation, remuneration, or reimbursement from, or have
				  any recourse against subscriber, enrollee, or persons other than the HMO acting
				  on their behalf for services provided under this agreement. This provision does
				  not prohibit collection of supplemental charges or copayments made in
				  compliance with the terms of (applicable agreement) between HMO and subscriber
				  or enrollee. (Physician or Provider) further agrees that:
(A) this provision will survive the
				  termination of this agreement regardless of the cause giving rise to
				  termination and must be construed to be for the benefit of the HMO subscriber
				  or enrollee; and
(B) this provision
				  supersedes any oral or written contrary agreement now existing or hereafter
				  entered into between (Physician or Provider) and subscriber, enrollee, or
				  persons acting on their behalf. Any modification, addition, or deletion to the
				  provisions of this clause will be effective on a date no earlier than 15 days
				  after the commissioner has received written notice of the proposed
				  changes."
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter J - PHYSICIAN AND PROVIDER CONTRACTS AND ARRANGEMENTS › Section 11.902 - Prohibited Actions

Current through Reg. 49, No. 28; July 12, 2024
An HMO may not:
(1) require a physician to use a hospitalist
				  for a hospitalized patient by contract under Insurance Code §
										843.320
				  (concerning Use of Hospitalist);
(2) refuse to contract with a nurse first
				  assistant to be part of a provider network or refuse to reimburse a nurse first
				  assistant under Insurance Code §
										843.3045
				  (concerning Nurse First Assistant);
(3) require a physician to use the services
				  of a nurse first assistant as defined by Occupations Code §
										301.354
				  (concerning Nurse First Assistants; Assisting at Surgery by Other
				  Nurses);
(4) refuse to contract
				  with a podiatrist licensed by the Texas State Board of Podiatric Medical
				  Examiners who joins the professional practice of a contracted physician or
				  provider under Insurance Code §
										843.319
				  (concerning Certain Required Contracts);
(5) refuse a request to identify a physician
				  assistant or advanced practice registered nurse as a provider in the HMO's
				  network under Insurance Code §
										843.312
				  (concerning Physician Assistants and Advanced Practice Nurses);
(6) employ an optometrist or therapeutic
				  optometrist to provide a vision care product or service, pay an optometrist or
				  therapeutic optometrist for a service not provided, or restrict or limit an
				  optometrist's or therapeutic optometrist's choice of sources or suppliers of
				  services or materials under Insurance Code §
										1451.156
				  (concerning Prohibited Conduct); or
(7) contract with a dentist to limit the fee
				  the dentist may charge for a service that is not a covered service under
				  Insurance Code §
										843.3115.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter J - PHYSICIAN AND PROVIDER CONTRACTS AND ARRANGEMENTS › Section 11.903 - Physician or Provider Communication

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  An HMO may not, as a condition of a contract with a physician or provider, or
				  in any other manner, prohibit, attempt to prohibit, or discourage a physician
				  or provider from discussing with or communicating to a current, prospective, or
				  former patient, or a party designated by a patient, with respect to:
(1) information or opinions regarding the
				  patient's health care, including the patient's medical condition or treatment
				  options, or the availability of facilities both in-network and out-of-network
				  for the treatment of a patient's medical condition;
(2) information or opinions regarding the
				  provisions, terms, requirements, or services of the health care plan as they
				  relate to the medical needs of the patient;
(3) the fact that the physician's or
				  provider's contract with the HMO has terminated or that the physician or
				  provider will otherwise no longer be providing medical care or health care
				  services under the health care plan; or
(4) the fact that, if medically necessary
				  covered services are not available through network physicians or providers, the
				  HMO must, on the request of a network physician or provider and within time
				  appropriate to the circumstances relating to the delivery of the services and
				  the condition of the patient, but in no event to exceed five business days
				  after receipt of reasonably requested documentation, allow referral to a
				  non-network physician or provider.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter J - PHYSICIAN AND PROVIDER CONTRACTS AND ARRANGEMENTS › Section 11.904 - Provision of Services Related to Immunizations and Vaccinations

Current through Reg. 49, No. 28; July 12, 2024
(a) In compliance with Insurance Code Chapter
				  1353 (concerning Immunization or Vaccination Protocols Under Managed Care
				  Plans), an HMO may not require a physician to issue an immunization or
				  vaccination protocol for an immunization or vaccination to be administered to
				  an enrollee by a pharmacist.
(b) No
				  contract between an HMO and a pharmacy or pharmacist may prohibit a pharmacist
				  from administering immunizations or vaccinations if the immunizations or
				  vaccinations are administered in compliance with the Texas Pharmacy Act,
				  Occupations Code, Title 3, Subtitle J, Chapters 551-569 (concerning Pharmacy
				  and Pharmacists), and related rules.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter K - REQUIRED FORMS › Section 11.1001 - Required Forms

Current through Reg. 49, No. 28; July 12, 2024
The following forms are to be used in conjunction with the
					 rules adopted under this chapter. Copies of these forms may be obtained by
					 contacting the Company Licensing and Registration Office, Mail Code 103-CL,
					 Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104, or
					 from the department's website at www.tdi.texas.gov. Each HMO or other person or
					 entity must use the form or forms required by this title as appropriate to its
					 particular activities. The forms are listed as follows:
(1) Name Application Form, (rev.
				  03/14);
(2) Application for a
				  Certificate of Authority to do business in the State of Texas, (rev.
				  09/04);
(3) State of Texas Officers
				  and Directors Page, TDI Form FIN306, (rev. 06/10);
(4) State of Texas Biographical Affidavit,
				  NAIC UCAA Form 11, (rev. 04/13);
(5) HMO Certification and Transmittal Form,
				  TDI Form LHL 259, (rev. 07/14);
(6)
				  Reconciliation of Benefits to Schedule of Charges Form, TDI Form LHL 654, (rev.
				  01/13);
(7) Statutory Deposit
				  Transaction Form, Form No. FIN407 (rev.11/15); and
(8) Declaration of Trust Form, Form No.
				  FIN453 (rev.11/15).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter M - ACQUISITION, CONTROL, OR MERGER OF A DOMESTIC HMO › Section 11.1201 - Acquisition, Control, or Merger of a Domestic HMO

Current through Reg. 49, No. 28; July 12, 2024
An HMO is subject to the requirements of Insurance Code
					 Chapter 823 (concerning Insurance Holding Company Systems); Insurance Code
					 Chapter 824 (concerning Merger and Consolidation of Stock Insurance
					 Corporations); and Chapter 7, Subchapter B, of this title (relating to
					 Insurance Holding Company Systems).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter O - ADMINISTRATIVE PROCEDURES › Section 11.1401 - Commissioner's Authority to Require Additional Information

Current through Reg. 49, No. 28; July 12, 2024
The commissioner may require additional information as
					 needed to make any determination required by Insurance Code Chapter 843
					 (concerning Health Maintenance Organizations) and Insurance Code Chapter 1271
					 (concerning Benefits Provided by Health Maintenance Evidence of Coverage;
					 Charges), this chapter, and other applicable insurance laws and regulations of
					 this state.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter O - ADMINISTRATIVE PROCEDURES › Section 11.1402 - Notification to Physicians and Providers

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  An HMO that provides coverage for health care services or medical care through
				  one or more physicians or providers is required by Insurance Code §
										843.305
				  (concerning Annual Application Period for Physician and Providers to Contract)
				  to provide a 20-calendar day period each calendar year during which any
				  provider or physician in the geographic service area may apply to participate
				  in each of the HMO's networks providing health care services or medical care
				  under the terms and conditions established by the HMO for the provision of the
				  services and the designation of the physicians and providers. Section 843.305
				  may not be construed to:
(1) require that an
				  HMO use a particular type of provider or physician in its operation;
(2) require that an HMO accept a physician or
				  provider of a category or type that does not meet the practice standards and
				  qualifications established by the HMO; or
(3) require that an HMO contract directly
				  with the physicians or providers.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter O - ADMINISTRATIVE PROCEDURES › Section 11.1403 - Requirement for Notifying Enrollees of Toll-Free Telephone Number for Complaints about Psychiatric or Chemical Dependency Services of Private Psychiatric Hospitals, General Hospitals, and Chemical Dependency Treatment Centers

Current through Reg. 49, No. 28; July 12, 2024
(a) HMOs must include the following notice in
				  information provided to new subscribers:
Attached Graphic
(b) The entire notice must be in
				  at least 10-point type. If the newsletter or other mailing is in larger than
				  10-point type, the notice must be in the same type as the rest of the
				  newsletter or mailing. Paragraphs 1 - 4 of the English notice and paragraphs 1
				  - 4 of the Spanish notice must be in boldface type. Paragraphs 1 and 2 of the
				  English and Spanish notices must be in capital letters. A final print of the
				  mailing must be submitted to the Life and Health Lines Office of the Texas
				  Department of Insurance for filing within 30 days following distribution to
				  enrollees.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter O - ADMINISTRATIVE PROCEDURES › Section 11.1404 - Pharmacy Application and Recertification

Current through Reg. 49, No. 28; July 12, 2024
(a) An HMO may not require any pharmacy or
				  pharmacist participating or applying to participate as a contracted provider in
				  an HMO delivery network to:
(1) provide
				  financial statements to the HMO; or
(2) deposit with the HMO any monies or other
				  form of consideration, except for reasonable application and recertification
				  fees.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter P - PROHIBITED PRACTICES › Section 11.1500 - Discrimination Based on Health Status-Related Factors

Current through Reg. 49, No. 28; July 12, 2024
An HMO may not require an enrollee in a group health plan
					 to pay a premium or contribution that is different from the premium or
					 contribution for a similarly situated enrollee based on a health status-related
					 factor. For purposes of this section, the term "similarly situated" has the
					 meaning assigned to it in 45 CFR § 146.121 (concerning Prohibiting
					 Discrimination Against Participants and Beneficiaries Based on a Health
					 Factor). An HMO may not establish policies or procedures that are based on
					 health status-related factors for the eligibility of any individual to enroll
					 under a group plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Q - OTHER REQUIREMENTS › Section 11.1601 - Enrollee Identification Cards

Current through Reg. 49, No. 28; July 12, 2024
(a) If an
				  HMO issues identification (ID) cards to enrollees, the HMO must issue the ID
				  cards within 30 calendar days of receiving notice of the enrollee's selection
				  of a primary care physician. The enrollee ID card will include, at a minimum,
				  all necessary information to allow an enrollee to access all services under the
				  certificate or evidence of coverage that require presentation of the
				  card.
(b) All ID cards an HMO
				  issues must comply with the requirements of Insurance Code §
										843.209
				  (concerning Identification Card) and §1693.002 (concerning Identification
				  Card and Required Information) and §
										21.2820 of
				  this title (relating to Identification Cards).
(c) If an evidence of coverage provides
				  benefits for prescription drugs, an HMO must issue an ID card in compliance
				  with Insurance Code §
										1369.153
				  (concerning Information Required on Identification Card) and §4151.152
				  (concerning Identification Cards) and §§
										21.3002-
				  21.3004
				  of this title (relating to Definitions; Pharmacy Identification Cards, Standard
				  Identification Cards, and Issuance of Standard Identification Cards).
(d) All ID cards issued by an HMO must comply
				  with the requirements of Business and Commerce Code §
										501.001
				  (concerning Certain Uses of Social Security Number Prohibited) and
				  §501.002 (concerning Certain Uses of Social Security Number Prohibited;
				  Remedies), which restrict the display of social security numbers on ID
				  cards.
(e) An ID card or other
				  similar document issued by a qualified health plan issuer to an enrollee of a
				  qualified health plan purchased through an exchange must display on the card or
				  document in a location of the issuer's choice the acronym "QHP."
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Q - OTHER REQUIREMENTS › Section 11.1602 - Enrollment Form and Access to Certain Information

Current through Reg. 49, No. 28; July 12, 2024
(a) An HMO must include on its enrollment
				  form a space in which an enrollee may indicate:
(1) the enrollee's primary language;
				  and
(2) whether the enrollee has a
				  disability affecting the enrollee's ability to communicate or read.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Q - OTHER REQUIREMENTS › Section 11.1603 - Notification of Change in Payment Arrangements

Current through Reg. 49, No. 28; July 12, 2024
An HMO must provide written notification to affected group
					 contract holders of a substantive change in the payment arrangement for
					 physicians and providers within 30 days of any change in the type of payment
					 arrangement; for example, a change from capitation to fee for service, or from
					 fee for service to capitation, for any type of service. The notification of the
					 change must include a description of the changed payment arrangement and a
					 description of the new payment arrangement.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Q - OTHER REQUIREMENTS › Section 11.1604 - Requirements for Certain Contracts Between Primary HMOs and ANHCs and Between Primary HMOs and Provider HMOs

Current through Reg. 49, No. 28; July 12, 2024
A primary HMO that enters into a contract with an ANHC in
					 which the ANHC agrees to arrange for or provide health care services other than
					 medical care or services ancillary to the practice of medicine, or with a
					 provider HMO in which the provider HMO agrees to arrange for or provide health
					 care services on a risk-sharing or capitated risk arrangement on behalf of the
					 primary HMO as part of the primary HMO delivery network must:
(1) submit a monitoring plan to the
				  department setting out:
(A) how the primary
				  HMO will ensure that the ANHC or provider HMO has an effective administrative
				  system for providing timely and accurate reimbursement to all physicians and
				  providers under contract with the ANHC or provider HMO; and
(B) how the primary HMO will ensure that all
				  HMO functions delegated or assigned under contract with the ANHC or provider
				  HMO are consistent with full compliance by the primary HMO with all department
				  regulatory requirements;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Q - OTHER REQUIREMENTS › Section 11.1605 - Pharmaceutical Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Prescription
				  drug coverage that includes copayments must do so for both generic drugs and
				  name-brand drugs. If the negotiated or usual and customary cost of the drug is
				  less than the copayment, the enrollee may only be required to pay the lower
				  cost. The copayments may be the same, or if different, must be applied as
				  follows:
(1) if the prescription is for a
				  generic drug, the enrollee may be required to pay no more than the generic
				  copayment;
(2) if the prescription
				  is for a name-brand drug, the enrollee may be required to pay no more than the
				  name-brand copayment if:
(A) the prescription
				  is written "dispense as written"; or
(B) there is no generic equivalent for the
				  prescribed drug;
(3) if
				  the prescription is written "product selection permitted" and the enrollee
				  elects to receive a name-brand drug when a generic equivalent is available,
				  then the enrollee may be required to pay no more than the generic copayment
				  plus the difference between the cost of the generic drug and the cost of the
				  name-brand drug; and
(4) if the
				  enrollee's prescription benefit requires the use of generic-equivalent drugs
				  (required generic) and the enrollee receives a name-brand drug when a generic
				  equivalent is available, then the enrollee may be required to pay no more than
				  the generic copayment plus the difference between the cost of the generic drug
				  and the cost of the name-brand drug, even when the prescription is written
				  "dispense as written."
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Q - OTHER REQUIREMENTS › Section 11.1606 - Organization of an HMO

Current through Reg. 49, No. 28; July 12, 2024
(a) The governing
				  body of an HMO, as described in Insurance Code §
										843.004
				  (concerning Governing Body of Health Maintenance Organization), has ultimate
				  responsibility for the development, approval, implementation, and enforcement
				  of administrative, operational, personnel, and patient care policies and
				  procedures related to the HMO's operation.
(b) The HMO must have a chief executive
				  officer or operations officer who is accountable for the administration of the
				  health plan, including:
(1) developing
				  corporate strategy;
(2) overseeing
				  marketing programs;
(3) overseeing
				  medical management functions; and
(4) ensuring compliance with all applicable
				  statutes and rules pertaining to the operations of the HMO.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Q - OTHER REQUIREMENTS › Section 11.1607 - Accessibility and Availability Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Each health benefit plan delivered or
				  issued for delivery by an HMO must include an HMO delivery network that is
				  adequate and complies with Insurance Code §
										843.082
				  (concerning Requirements for Approval of Application).
(b) There must be a sufficient number of
				  primary care physicians and specialists with hospital admitting privileges to
				  participating facilities who are available and accessible 24 hours per day,
				  seven days per week, within the HMO's service area to meet the health care
				  needs of the HMO's enrollees.
(c)
				  An HMO must make general, special, and psychiatric hospital care available and
				  accessible 24 hours per day, seven days per week, within the HMO's service
				  area.
(d) If an HMO limits
				  enrollees' access to a limited provider network, it must ensure that the
				  limited provider network complies with all requirements of this
				  section.
(e) An HMO must make
				  emergency care available and accessible 24 hours per day, seven days per week,
				  without restrictions on where the services are rendered.
(f) All covered services that are offered by
				  an HMO must be sufficient in number and location to be readily available and
				  accessible within the service area to all enrollees.
(g) An HMO must arrange for covered health
				  care services, including referrals to specialists, to be accessible to
				  enrollees on a timely basis on request and consistent with these guidelines:
(1) urgent care must be available within 24
				  hours for medical, dental, and behavioral health conditions;
(2) routine care must be available within:
(A) three weeks for medical
				  conditions;
(B) eight weeks for
				  dental conditions; and
(C) two
				  weeks for behavioral health conditions.
(3) Preventive health services must be
				  available within:
(A) two months for a
				  child;
(B) three months for an
				  adult; and
(C) four months for
				  dental services.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Q - OTHER REQUIREMENTS › Section 11.1610 - Annual Network Adequacy Report

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  An HMO must file a network adequacy report with the department on or before
				  August 15 of each year and before marketing any plan in a new service area
				  after August 15, 2017. The network adequacy report must specify:
(1) the trade name of each HMO plan in which
				  enrollees currently participate;
(2) the applicable service area of each plan;
				  and
(3) whether the HMO service
				  delivery network supporting each plan meets the requirements in §
											11.1607
				  of this title (relating to Accessibility and Availability
				  Requirements).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Q - OTHER REQUIREMENTS › Section 11.1611 - Out-of-Network Claims; Non-Network Physicians and Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) When services are rendered to an enrollee
				  by a non-network facility-based physician in a network facility, or in
				  circumstances where an enrollee is not given the choice of a network physician
				  or provider, the HMO must fully reimburse the non-network facility-based
				  physician or provider at the usual and customary rate as described in
				  subsection (e) of this section or at an agreed rate.
(b) In circumstances where an enrollee
				  receives emergency care in a non-network facility, the HMO must fully reimburse
				  a non-network physician or provider for emergency care services at the usual
				  and customary rate as described in subsection (e) of this section or at an
				  agreed rate until the enrollee can reasonably be expected to transfer to a
				  network physician or provider.
(c)
				  If medically necessary covered services, other than emergency care, are not
				  available through a network physician or provider on the request of a network
				  physician or provider, the HMO must:
(1)
				  approve a referral to a non-network physician or provider within the time
				  appropriate to the circumstances relating to the delivery of the services and
				  the condition of the patient, but in no event to exceed five business days
				  after receipt of reasonably requested documentation; and
(2) provide for a review by a physician or
				  provider with expertise in the same specialty as or a specialty similar to the
				  type of health care physician or provider to whom a referral is requested under
				  paragraph (1) of this subsection before the HMO may deny the
				  referral.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Q - OTHER REQUIREMENTS › Section 11.1612 - Mandatory Disclosure Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Online directory. An HMO must develop and maintain a directory of contracting
				  physicians and health care providers, display the directory on a public
				  Internet website maintained by the HMO, and ensure that a direct electronic
				  link to the directory is conspicuously displayed on the electronic summary of
				  benefits and coverage of each plan issued by the HMO. The directory must:
(1) include the name, address, telephone
				  number, and specialty, if any, of each physician and provider;
(2) clearly indicate each health benefit plan
				  issued by the HMO that may provide coverage for services provided by each
				  physician or provider included in the directory;
(3) be electronically searchable by physician
				  or health care provider name and location;
(4) be publicly accessible without the
				  necessity of providing a password, a username, or personally identifiable
				  information; and
(5) be reviewed on
				  an ongoing basis and corrected or updated, if necessary, not less than once
				  each month.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter R - APPROVED NONPROFIT HEALTH CORPORATIONS › Section 11.1702 - Requirements for Issuance of Certificate of Authority to an ANHC

Current through Reg. 49, No. 28; July 12, 2024
(a) Before obtaining a certificate of
				  authority under Insurance Code Chapter 844 (concerning Certification of Certain
				  Nonprofit Health Corporations), an applicant ANHC must:
(1) comply with each requirement for the
				  issuance of a certificate of authority imposed on an HMO under Insurance Code
				  Chapter 843 (concerning Health Maintenance Organizations) and Insurance Code
				  Chapter 1271 (concerning Benefits Provided by Health Maintenance Evidence of
				  Coverage; Charges), this chapter, and other applicable insurance laws and
				  regulations of this state; and
(2)
				  demonstrate by appropriate documentation that the applicant ANHC has
				  established and maintains accreditation by the:
(A) NCQA; or
(B) Joint Commission on Accreditation of
				  Health Care Organizations network accreditation program.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter R - APPROVED NONPROFIT HEALTH CORPORATIONS › Section 11.1703 - Requirements for Agents of an ANHC Certificate of Authority Holder

Current through Reg. 49, No. 28; July 12, 2024
Any agent for an ANHC with a certificate of authority or a
					 provisional certificate of authority will be considered an HMO agent and must
					 comply with the applicable requirements of Insurance Code Chapter 4054
					 (concerning Life, Accident, and Health Agents) and Chapter 19 of this title
					 (relating to Agents' Licensing).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter R - APPROVED NONPROFIT HEALTH CORPORATIONS › Section 11.1704 - Statutes and Rules Applicable to ANHC with a Certificate of Authority

Current through Reg. 49, No. 28; July 12, 2024
An ANHC with a certificate of authority or provisional
					 certificate of authority under Insurance Code Chapter 844 (concerning
					 Certification of Certain Nonprofit Health Corporations) and this subchapter is
					 subject to the same statutes and rules as an HMO and is considered an HMO for
					 purposes of regulation and regulatory enforcement.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter S - SOLVENCY STANDARDS FOR MANAGED CARE ORGANIZATIONS PARTICIPATING IN MEDICAID OR CHILDREN'S HEALTH INSURANCE PROGRAM › Section 11.1801 - Entities Covered

Current through Reg. 49, No. 28; July 12, 2024
(a) As used in this
				  subchapter, a managed care organization is an entity holding a certificate of
				  authority to operate as an HMO under Insurance Code Chapter 843 (concerning
				  Health Maintenance Organizations) and Insurance Code Chapter 1271 (concerning
				  Benefits Provided by Health Maintenance Evidence of Coverage; Charges), or as
				  an ANHC under Insurance Code Chapter 844 (concerning Certification of Certain
				  Nonprofit Health Corporations).
(b)
				  Any managed care organization or other entity providing the services specified
				  in
				  42 United States Code §
											1396b(m)(2)(A) and
				  participating in the State Medicaid Program or Children's Health Insurance
				  Program (CHIP) (MCO) must comply with the requirements of Insurance Code §
										843.403
				  (concerning Minimum Net Worth) and §
										7.402
				  of this title (relating to Risk-Based Capital and Surplus Requirements for
				  Insurers and HMOs).