Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter U - ARRANGEMENTS BETWEEN INDEMNITY CARRIERS AND HMOS FOR POINT-OF-SERVICE COVERAGE › Section 21.2902 - Arrangements between Indemnity Carriers and HMOs to Provide Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) Written agreement between the HMO and the
				  indemnity carrier. A POS plan offered under this subchapter must be evidenced
				  by a written agreement between the HMO and indemnity carrier that must be filed
				  with the department as a plan document and must provide the following:
(1) the identity of each entity, including
				  the HMO, the indemnity carrier, or any third-party administrator (TPA) that
				  will administer the coverages offered under the POS plan;
(2) all duties of the HMO and indemnity
				  carrier to each other relating to the POS plan issued under this
				  subchapter;
(3) all costs allocable
				  to the HMO or the indemnity carrier relating to the POS plan;
(4) the HMO's network of providers and, if
				  the POS indemnity coverage includes preferred provider benefits, as allowed by
				  Insurance Code Chapter 1301 and applicable rules, the indemnity carrier's list
				  of preferred providers, which may not be identical; and
(5) the respective premium rates for the POS
				  HMO coverage and for the POS indemnity coverage must be derived separately by
				  the HMO and the indemnity carrier and must be separately identified in each POS
				  plan contract; however, the agreement may provide that for a POS plan offered
				  by the entities under this subchapter:
(A) the
				  HMO, the indemnity carrier or a TPA may collect the premiums for both
				  coverages;
(B) the purchaser may
				  issue one payment for both coverages; and
(C) the entity delegated to collect the
				  premium will then disburse the appropriate premium to the other party or
				  parties;
(6) premium
				  rates charged by the HMO must be based on the actuarial value of the POS HMO
				  coverage and may be different from the premium rates charged by the indemnity
				  carrier, which must be based on the actuarial value of the POS indemnity
				  coverage offered by the indemnity carrier;
(7) the HMO and indemnity carrier must
				  maintain separate books and records for the POS plan, including but not limited
				  to information regarding premiums, lists of covered persons, claim payment
				  data, complaint records, maintenance tax records, and all other books and
				  records required to be maintained by law or rule;
(8) neither entity may use the other to
				  perform functions or duties that are its own responsibility by law or rule,
				  including but not limited to making all reports and filings required by law or
				  rule;
(9) the entities may delegate
				  those functions or duties permitted by law or rule to be delegated to another
				  party to perform, including but not limited to contracting with providers,
				  administering claims, and conducting grievance procedures, provided that the
				  delegating entity remains responsible for ensuring that all delegated functions
				  are conducted in compliance with all applicable laws and rules;
(10) the agreement between the indemnity
				  carrier and the HMO may not be canceled or terminated until the coverage for
				  each enrollee in a POS plan issued by both the indemnity carrier and HMO is
				  terminated or canceled according to the provisions of this subchapter;
				  and
(11) the arrangements to be
				  made in the event of insolvency, loss of certification or any other
				  circumstances affecting the ability of the indemnity carrier, the HMO, or both
				  to comply with this subchapter.