reglab/statecodes huggingface dataset:
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 3 - EXAMINATIONS; REGULATORY REQUIREMENTS FOR AN HCC AFTER ISSUANCE OF CERTIFICATE OF AUTHORITY; AND ADVERTISING AND SALES MATERIAL › Section 13.423 - Service Area Change Applications

Current through Reg. 49, No. 28; July 12, 2024
(a) An
					 HCC must file an application for approval with the department before the HCC
					 may expand or reduce an existing service area or add a new service
					 area.
(b) If any of the following
					 items are changed by a proposed service area expansion or reduction, the new
					 item or any amendments to an existing item must be submitted for approval or
					 filed for information, as specified in §
											13.422
					 of this title (relating to Filing Requirements That Apply After Issuance of
					 Certificate of Authority):
(1) a description
					 and a map with key and scale, showing both the currently approved service area
					 and the proposed new service area as required by §
												13.413(e)(1)
					 of this title (relating to Contents of the Application);
(2) a form of any new contracts or amendment
					 of any existing contracts in the new area, as described in §
												13.413(e)(5)
					 of this title;
(3) network
					 configuration information, as required by §
												13.413(e)(2)
					 of this title;
(4) a brief
					 narrative description of the administrative arrangements and organizational
					 charts as described in §
												13.413(c)(7)
					 of this title and any other information the HCC considers to be
					 pertinent;
(5) biographical data
					 sheets for any new management staff assigned to the new area;
(6) copies of leases, loans, agreements, and
					 contracts to be used in the proposed new area, including information described
					 in §
												13.422(c)(2)(D)
					 of this title;
(7) separate and
					 combined sources of financing and financial projections as described in
					 §13.413(d)(1) - (3) of this title; and
(8) any new or amended reinsurance
					 agreements, insurance, or other protection against insolvency, as specified in
					 §
												13.413(d)(4)
					 of this title.
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 3 - EXAMINATIONS; REGULATORY REQUIREMENTS FOR AN HCC AFTER ISSUANCE OF CERTIFICATE OF AUTHORITY; AND ADVERTISING AND SALES MATERIAL › Section 13.424 - Certificate of Authority Renewal Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Not later than 180 days before its
					 certificate anniversary date, the HCC must file with the commissioner an
					 application to renew its certificate.
(b) The filing must include:
(1) the Original/Renewal Application for
					 Certificate of Authority to do the Business of a Health Care Collaborative
					 (HCC) in the State of Texas form; and
(2) the financial statements for the HCC, as
					 of the close of the preceding calendar year.
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 3 - EXAMINATIONS; REGULATORY REQUIREMENTS FOR AN HCC AFTER ISSUANCE OF CERTIFICATE OF AUTHORITY; AND ADVERTISING AND SALES MATERIAL › Section 13.425 - Compensation Arrangements

Current through Reg. 49, No. 28; July 12, 2024
(a) An HCC must
					 comply with Insurance Code §
											848.053,
					 including requirements relating to committee membership, charges, fees,
					 distributions, or other compensation assessed for services provided by HCC
					 participants, and to the sharing of the data among nonparticipating physicians
					 and health care providers.
(b) An
					 HCC must establish and enforce procedures to maintain the confidentiality of
					 charge, fee, and payment data and information between HCC participants and any
					 individual or entity outside of the HCC, including information to be
					 transmitted to the department.
(c)
					 A participant in an HCC is prohibited from using charge, fee, and payment data
					 collected by the HCC in any negotiation of charges, fees, or payments if the
					 HCC is not a party to the negotiation.
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 3 - EXAMINATIONS; REGULATORY REQUIREMENTS FOR AN HCC AFTER ISSUANCE OF CERTIFICATE OF AUTHORITY; AND ADVERTISING AND SALES MATERIAL › Section 13.426 - Confidentiality

Current through Reg. 49, No. 28; July 12, 2024
(a) An HCC must establish and administer
					 procedures and internal controls to safeguard and ensure against the sharing of
					 any confidential information with or among participants.
(b) The requirements of this section include
					 establishing and enforcing collection, custodial, retrieval, and transmittal
					 procedures to ensure that information that the HCC or its participants must
					 maintain as confidential is protected as confidential both as to entities and
					 individuals outside the HCC, and between or among participants. The
					 requirements of this section apply to confidential information that:
(1) the HCC maintains as custodian;
					 or
(2) the HCC or any of its
					 participants submit to the department under Insurance Code §
												848.057
					 or to the attorney general under Insurance Code §
												848.059.
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 3 - EXAMINATIONS; REGULATORY REQUIREMENTS FOR AN HCC AFTER ISSUANCE OF CERTIFICATE OF AUTHORITY; AND ADVERTISING AND SALES MATERIAL › Section 13.429 - HCCs Subject to Insurance Code Chapters 541 and 542 and Related Rules

Current through Reg. 49, No. 28; July 12, 2024
HCCs must comply with Insurance Code Chapters 541 and
						542, and rules promulgated by the department pursuant to Insurance Code
						Chapters 541 and 542, as applicable, in the same manner as insurance companies
						or HMOs.
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 4 - FINANCIAL REQUIREMENTS › Section 13.431 - Reserves and Working Capital Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) An HCC must maintain working capital
					 composed of current assets with a ratio of current assets to current
					 liabilities of 1.25:1, based on the greater of the prior year's actual
					 liabilities or the projected liabilities for the subsequent year, subject to
					 the following requirements, as applicable:
(1) an HCC consisting of physicians and one
					 or more facilities must maintain unencumbered net equity of not less than
					 $200,000; and
(2) an HCC must base
					 its ratio of assets to liabilities on the projected liabilities for the
					 subsequent year if the HCC has not been certified for more than one
					 year.
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 4 - FINANCIAL REQUIREMENTS › Section 13.432 - Fiduciary Responsibility

Current through Reg. 49, No. 28; July 12, 2024
A director, member of a committee, officer, or
						representative of an HCC who is charged with the duty of handling or investing
						its funds is prohibited from intentionally:
(1) depositing or investing the funds, except
					 in the corporate name of the HCC or in the name of a nominee of the HCC as may
					 be allowed elsewhere in this subchapter; or
(2) taking or receiving to his or her own use
					 any fee, brokerage, or commission for, or on account of, a loan made by or on
					 behalf of the HCC, except that the individuals referenced in this section may
					 receive reasonable interest on amounts loaned to the HCC.
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 5 - HCC CONTRACT ARRANGEMENTS › Section 13.441 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) An HCC's
					 contracts with physicians and health care providers must not impede application
					 of provisions in Insurance Code Chapters 843 (Health Maintenance Organizations)
					 and 1301 (Preferred Provider Benefit Plans), and in Chapter 11 of this title
					 (relating to Health Maintenance Organizations) and Chapter 3, Subchapter X of
					 this title (relating to Preferred and Exclusive Provider Plans), that impose
					 requirements concerning relations with physicians or health care
					 providers.
(b) An HCC is prohibited
					 from using a financial incentive or making a payment to a physician or health
					 care provider if the incentive or payment acts directly or indirectly as an
					 inducement to limit medically necessary services.
(c) If an HCC participant's market share as
					 calculated under §
											13.414
					 of this title (relating to Limited Exemption from Certain Information Filing
					 Requirements) exceeds 50 percent in a PSA for any service that no other HCC
					 participant provides to patients in that PSA, the participant furnishing the
					 service is a dominant provider for purposes of this subchapter. An HCC with a
					 dominant provider is prohibited, in the PSA in which the dominant provider
					 furnishes those services, from:
(1) requiring
					 a private payor to contract exclusively with the HCC; or
(2) otherwise restricting a private payor's
					 ability to contract or deal with other HCCs, networks, physicians, or health
					 care providers.
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 6 - CHANGE OF CONTROL BY ACQUISITION OF OR MERGER WITH HCC › Section 13.451 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, for purposes of this
						division, have the following meanings unless the context clearly indicates
						otherwise.
(1) Control--The
					 possession, direct or indirect, of the power to direct or cause the direction
					 of the management and policies of an individual or entity, whether through the
					 ownership of voting securities, by contract other than a commercial contract
					 for goods or nonmanagement services, or otherwise, unless the power is the
					 result of an official position with or corporation office held by an
					 individual.
(2) Voting
					 security--Any security presently entitling its owner or holder to vote in the
					 direction or management of the affairs of an individual or entity, or any
					 instrument presently convertible by its owner or holder into a voting security,
					 or the right to acquire a voting security.
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 6 - CHANGE OF CONTROL BY ACQUISITION OF OR MERGER WITH HCC › Section 13.452 - Determination of Control

Current through Reg. 49, No. 28; July 12, 2024
For purposes of this division:
(1) control is presumed to exist if any
					 individual or entity, directly or indirectly, owns, controls, holds with the
					 power to vote or holds irrevocable proxies representing, 10 percent or more of
					 the voting securities or authority of any other individual or entity;
(2) this presumption may be rebutted by a
					 showing made in the manner provided by Insurance Code §
											823.010
					 that control does not exist in fact; and
(3) the commissioner may determine, after
					 furnishing all interested parties notice and opportunity for hearing and making
					 specific findings of fact to support the determination, that control exists in
					 fact where an individual or entity exercises directly or indirectly, either
					 alone or pursuant to an agreement with one or more other individuals or
					 entities, such a controlling influence over the management or policies of an
					 authorized HCC as to be deemed to control the HCC.
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 6 - CHANGE OF CONTROL BY ACQUISITION OF OR MERGER WITH HCC › Section 13.453 - Filing Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Unless an
					 individual or entity has filed with the department the items as set forth in
					 subsection (b) of this section, the individual or entity is prohibited from:
(1) acquiring an ownership interest in an
					 entity that holds a certificate of authority as an HCC if the individual or
					 entity is, or after the acquisition would be, directly or indirectly in control
					 of the certificate holder; or
(2)
					 otherwise acquiring control of or exercising any control over the certificate
					 holder.
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 6 - CHANGE OF CONTROL BY ACQUISITION OF OR MERGER WITH HCC › Section 13.454 - Commissioner Action

Current through Reg. 49, No. 28; July 12, 2024
(a) A proposed
					 acquisition of control will be disapproved if, after notice and opportunity for
					 hearing, the commissioner determines that:
(1) immediately following the change of
					 control, the certificate holder would not be able to satisfy the requirements
					 for the issuance of a certificate of authority;
(2) the competence, trustworthiness,
					 experience, and integrity of the individuals who would control the operation of
					 the certificate holder are such that it would not be in the interest of health
					 care services consumers in this state to permit the acquisition of control;
					 or
(3) the acquisition of control
					 would violate this code or another law of this state, any law of another state,
					 or of the United States.
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 6 - CHANGE OF CONTROL BY ACQUISITION OF OR MERGER WITH HCC › Section 13.455 - Change of Control with Increased Market Share

Current through Reg. 49, No. 28; July 12, 2024
For any change in control of an authorized HCC that
						results in an increase to its market share in any PSA as provided in §
											13.414
						of this title (relating to Limited Exemption from Certain Information Filing
						Requirements), the department may require that the HCC file an application for
						renewal before the date required by Insurance Code §
											848.060(a).
						An HCC may, in connection with a filing under this division, submit an
						application for renewal of certificate of authority.
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 8 - OTHER REQUIREMENTS › Section 13.471 - Notification of Change in Payment Arrangements

Current through Reg. 49, No. 28; July 12, 2024
An HCC must notify all affected payors in writing of a
						material change in the payment arrangement for physicians, health care
						providers, or both within 30 days of any change in the type of payment
						arrangement for any type of service (for example, from capitation to
						fee-for-service, from fee-for-service to capitation). The notification of the
						change must include a description of the payment arrangement that has been
						changed and a description of the new payment arrangement.
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 8 - OTHER REQUIREMENTS › Section 13.472 - Requirements for Certain Delegation Contracts

Current through Reg. 49, No. 28; July 12, 2024
An HCC that delegates responsibility by contract with a
						delegated entity, delegated network, or delegated third party, as those terms
						are defined in Insurance Code §
											1272.001 through
						reference to contracts with HMOs, must:
(1) submit to the department a monitoring
					 plan setting out how the HCC will ensure that all delegated HCC functions are
					 implemented in a manner consistent with full compliance by the HCC with all
					 regulatory requirements of the department;
(2) conduct an on-site or desk audit of the
					 delegated entity, delegated network, or delegated third party no less
					 frequently than annually, or more frequently on indication of material
					 noncompliance, to obtain information necessary to verify compliance with all
					 regulatory requirements of the department. Written documentation of each audit
					 required by this paragraph must be made available to the department on request;
					 and
(3) take prompt action to
					 correct any failure by the delegated entity, delegated network, or delegated
					 third party to comply with regulatory requirements of the department relating
					 to any matters delegated by the HCC and necessary to ensure the HCC's
					 compliance with the regulatory requirements.
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 8 - OTHER REQUIREMENTS › Section 13.473 - Organization of an HCC

Current through Reg. 49, No. 28; July 12, 2024
(a) The governing
					 body, which must comply with the requirements described in Insurance Code
					 §
											848.052,
					 must have ultimate responsibility for the development, approval,
					 implementation, and enforcement of administrative, operational, personnel, and
					 patient care policies and procedures related to the operation of the
					 HCC.
(b) The HCC must have a
					 clinical director who:
(1) is currently
					 licensed in Texas or otherwise authorized to practice in this state in the
					 field of services offered by the HCC;
(2) resides in Texas;
(3) is available at all times to address
					 complaints, clinical issues, utilization review, and any quality-of-care issues
					 on behalf of the HCC;
(4)
					 demonstrates active involvement in all quality management activities;
					 and
(5) is subject to the HCC's
					 credentialing requirements, as appropriate.
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 8 - OTHER REQUIREMENTS › Section 13.474 - Requirements for HMO or Insurer Delegation of Functions to HCCs

Current through Reg. 49, No. 28; July 12, 2024
(a) An HMO's delegation of functions to an
					 HCC is subject to the requirements of Insurance Code Chapter 1272 and Chapter
					 11, Subchapter AA of this title (relating to Delegated Entities).
(b) An insurer's delegation of functions to
					 an HCC is subject to the requirements of Insurance Code Chapter 1272 and
					 Chapter 11, Subchapter AA of this title as if the insurer were an
					 HMO.
(c) If a provision of this
					 subchapter imposes a compliance requirement that is greater than or in conflict
					 with those contained in Insurance Code Chapter 1272 or Chapter 11, Subchapter
					 AA of this title, the requirement of this subchapter governs.
(d) A delegation agreement between an HMO or
					 insurer and an HCC must mandate that the HMO or insurer disclose in all
					 provider listings distributed to insureds or enrollees those providers
					 participating in the HCC within the HMO's or insurer's approved service
					 area.
(e) If an insurer contracts
					 for services with an HCC on a basis other than fee-for-service, the insurer
					 must disclose the nature of its payment arrangement with the HCC in either the
					 insurance policy and certificates or in any provider listing distributed to
					 insureds.
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 9 - QUALITY AND COST OF HEALTH CARE SERVICES › Section 13.481 - Quality Improvement Structure for HCCs

Current through Reg. 49, No. 28; July 12, 2024
(a) An HCC must develop and maintain an
					 ongoing quality improvement (QI) program designed to objectively and
					 systematically monitor and evaluate the quality and appropriateness of health
					 care services that it arranges for or offers, and to pursue opportunities for
					 improvement. Unless the HCC has no patients, the QI program must include the
					 active involvement of one or more patient(s) who are not employees of the
					 HCC.
(b) The governing body is
					 ultimately responsible for the QI program. The governing body must:
(1) appoint a quality improvement committee
					 (QIC) that includes the clinical director, practicing physicians, and, if
					 applicable, other individual health care providers;
(2) approve the QI program;
(3) approve an annual QI plan;
(4) meet no less than semiannually to receive
					 and review reports of the QIC or group of committees and take action when
					 appropriate; and
(5) review the
					 annual written report on the QI program.
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 9 - QUALITY AND COST OF HEALTH CARE SERVICES › Section 13.482 - Quality Assurance and Quality Improvement

Current through Reg. 49, No. 28; July 12, 2024
(a) An HCC must establish, implement, and
					 administer a continuous quality assurance and quality improvement program that
					 includes defined policies and processes to:
(1) promote evidence-based medicine and best
					 practices;
(2) secure patient
					 engagement;
(3) promote
					 coordination of care across a continuum of care; and
(4) measure and report the quality of health
					 care services and the impact on cost.
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 9 - QUALITY AND COST OF HEALTH CARE SERVICES › Section 13.483 - Credentialing

Current through Reg. 49, No. 28; July 12, 2024
An HCC must implement a documented process for selection
						and retention of contracted participants. The credentialing process must comply
						with the standards promulgated by the National Committee for Quality Assurance,
						URAC, the Joint Commission on Accreditation of Hospital Organizations, or the
						Accreditation Association for Ambulatory Health Care, as appropriate, to the
						extent that those standards are applicable and do not conflict with other laws
						of this state.
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 10 - COMPLAINT SYSTEMS; RIGHTS OF PHYSICIANS; LIMITATIONS ON PARTICIPATION › Section 13.491 - Complaint Systems

Current through Reg. 49, No. 28; July 12, 2024
(a) Each HCC must
					 implement and maintain a complaint system that complies with Insurance Code
					 §
											848.107 and
					 this division that provides reasonable procedures for resolving an oral or
					 written complaint initiated by a complainant concerning the HCC or health care
					 services arranged by, or offered through, the HCC.
(b) For purposes of this subchapter, a
					 complaint is any oral or written expression of dissatisfaction by a complainant
					 to an HCC regarding any aspect of the HCC's operation.
(c) The HCC's complaint system must address a
					 complaint initiated:
(1) by or on behalf of a
					 patient who sought or received health care services by a participant;
					 or
(2) by a participant.
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 10 - COMPLAINT SYSTEMS; RIGHTS OF PHYSICIANS; LIMITATIONS ON PARTICIPATION › Section 13.492 - Complaints; Deadlines for Response and Resolution

Current through Reg. 49, No. 28; July 12, 2024
(a) Not later than seven calendar days after
					 receipt of an oral or written complaint, the HCC must:
(1) acknowledge receipt of the complaint in
					 writing;
(2) acknowledge the date
					 of receipt; and
(3) provide a
					 description of the HCC's complaint procedures, its appeal process for
					 complaints filed by patients, and deadlines associated with each.
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 10 - COMPLAINT SYSTEMS; RIGHTS OF PHYSICIANS; LIMITATIONS ON PARTICIPATION › Section 13.493 - Rights of Physicians

Current through Reg. 49, No. 28; July 12, 2024
Before a complaint against a physician under Insurance
						Code §
											848.107 is
						resolved, or before a physician's association with an HCC is involuntarily
						terminated, the HCC must provide the physician an opportunity to dispute the
						complaint or termination through a process that includes:
(1) written notice of the complaint or basis
					 of the termination;
(2) opportunity
					 for hearing not earlier than the 30th day after the physician receives notice
					 under paragraph (1) of this section;
(3) the right to provide information at the
					 hearing; and
(4) a written decision
					 that includes specific facts and reasons for the decision.
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 10 - COMPLAINT SYSTEMS; RIGHTS OF PHYSICIANS; LIMITATIONS ON PARTICIPATION › Section 13.494 - Limitations and Prohibition

Current through Reg. 49, No. 28; July 12, 2024
(a) An HCC may
					 limit a physician or physician group from participating in the HCC only if the
					 limitation is based on an established development plan approved by the HCC
					 board of directors. The HCC must provide each applicant physician or group with
					 a copy of the development plan.
(b)
					 An HCC is prohibited from taking a retaliatory or adverse action against a
					 physician or health care provider that files a complaint with a regulatory
					 authority regarding the action of an HCC.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 1 - PURPOSE AND DEFINITIONS › Section 13.510 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to augment and
						implement the regulation of an employee health benefit plan that is not fully
						insured and is sponsored by a PEO as permitted by Texas Labor Code Chapter 91,
						concerning Professional Employer Organizations.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 1 - PURPOSE AND DEFINITIONS › Section 13.511 - Regulated PEOs; Approval Required

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 PEOs subject to this subchapter. This subchapter applies to a PEO sponsoring a
					 self-funded employee health benefit plan if:
(1) its primary business location is in this
					 state; or
(2) a majority of the
					 eligible employees of at least one of its clients are employed in this state;
					 or
(3) the primary business
					 location of at least one of its clients is in this state, where no other state
					 contains a majority of that employer's eligible employees.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 1 - PURPOSE AND DEFINITIONS › Section 13.512 - ERISA's Applicability; Severability of Subchapter's Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter applies to an approved
					 PEO and its plan and trust to the extent permitted by the Employee Retirement
					 Income Security Act of 1974 (ERISA),
					 29 U.S.C.
					 §§1001 -
					 1191c.
(b) If a court of competent jurisdiction
					 holds that any provision of this subchapter or its application to any person or
					 circumstance is invalid for any reason, the invalidity does not affect other
					 provisions or applications of this subchapter that can be given effect without
					 the invalid provision or application. To this end, the provisions of this
					 subchapter are severable.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 1 - PURPOSE AND DEFINITIONS › Section 13.513 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
						subchapter, have the following meanings, unless the context clearly indicates
						otherwise:
(1) Affiliate--A person is
					 defined as an affiliate under §
											7.202(a)(2)
					 of this title (relating to Definitions).
(2) Approved PEO--A PEO that has received a
					 certificate of approval from TDI to sponsor a plan.
(3) Cash--Currency and demand deposits with
					 banks and other financial institutions.
(4) Client--A person who enters into a
					 professional employer services agreement with a licensed PEO.
(5) Coemployment relationship--A contractual
					 relationship between a client and a PEO that involves the sharing of employment
					 responsibilities with or allocation of employment responsibilities to covered
					 employees in compliance with the professional employer services agreement and
					 Labor Code Chapter 91, concerning Professional Employment
					 Organizations.
(6)
					 Commissioner--The commissioner of insurance.
(7) Contracting regulated entity--An entity
					 regulated by TDI that has contracted with an approved PEO to accept
					 responsibility for the performance of any requirement of this
					 subchapter.
(8) Controlling
					 person--A person that directly or indirectly and alone or under an agreement
					 with one or more other persons, exercises such a controlling influence over the
					 management or policies of the PEO that it is necessary or appropriate in the
					 public interest or for the protection of the PEO's covered employees that the
					 person be considered to control the PEO. A person is presumed to be a
					 controlling person if:
(A) the person or a
					 person and members of the person's immediate family directly or indirectly,
					 own, control, or hold with the power to vote 10 percent or more of the voting
					 securities or authority of the PEO; or
(B) the person holds proxies representing 10
					 percent or more of the voting securities or authority of the PEO, but is not a
					 corporate officer or director of the PEO.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 2 - APPLICABILITY OF INSURANCE CODE AND ADMINISTRATIVE CODE PROVISIONS › Section 13.520 - Applicability of Insurance Code Provisions to an Approved PEO, Plan, or Trust

Current through Reg. 49, No. 28; July 12, 2024
Under Labor Code §
											91.0411,
						this division lists Insurance Code and Administrative Code provisions that are
						necessary to augment and implement the regulation of a plan that is not fully
						insured.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 2 - APPLICABILITY OF INSURANCE CODE AND ADMINISTRATIVE CODE PROVISIONS › Section 13.521 - Applicable Insurance Code and Administrative Code Terms

Current through Reg. 49, No. 28; July 12, 2024
For purposes of this subchapter and for purposes of
						regulation by TDI:
(1) PEO as large
					 employer. An approved PEO is a large employer as defined in Insurance Code
					 Chapter 1501, concerning the Health Insurance Portability and Availability Act,
					 unless a provision in this subchapter clearly indicates otherwise.
(2) PEO plan as large employer health benefit
					 plan. An approved PEO's plan is a large employer health benefit plan as defined
					 in Insurance Code Chapter 1501 unless a provision in this subchapter clearly
					 indicates otherwise.
(3) Provisions
					 applicable to both small and large employer plans. An Insurance Code or
					 Administrative Code provision that refers to both small and large employer
					 health benefit plans or their issuers applies to an approved PEO as a large
					 employer health benefit plan issuer and to its plan as a large employer health
					 benefit plan unless a provision in this subchapter clearly indicates
					 otherwise.
(4) Plan document is
					 group policy. An approved PEO's plan document is a group policy unless a
					 provision in this subchapter clearly indicates otherwise.
(5) Certificate of coverage is certificate of
					 insurance. An approved PEO's certificate of coverage is a certificate of
					 insurance. An approved PEO's certificate of coverage must comply with ERISA,
					 29 U.S.C.
					 §1022 (Summary plan
					 description).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 3 - CERTIFICATE OF APPROVAL › Section 13.530 - Certificate of Approval Required

Current through Reg. 49, No. 28; July 12, 2024
A PEO may not sponsor a plan in Texas unless the PEO has
						received a certificate of approval issued under this subchapter and is
						operating its plan and trust as required by this subchapter. If a PEO receives
						and maintains a certificate of approval under this subchapter, it will not be
						considered an unauthorized insurer for purposes of Insurance Code Chapter 101,
						concerning Unauthorized Insurance.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 3 - CERTIFICATE OF APPROVAL › Section 13.531 - Forms and Fees

Current through Reg. 49, No. 28; July 12, 2024
(a) Form of
					 application. A PEO must apply for a certificate of approval by providing the
					 information required by this division.
(b) Application fee. Each application for a
					 certificate of approval must be accompanied by a nonrefundable application fee
					 of $5,050.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 3 - CERTIFICATE OF APPROVAL › Section 13.532 - Application Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Organizational information. An applicant must provide the following information
					 and documentation about its structure and operations:
(1) its name, federal employer identification
					 number, location, and a means for contacting its representative for purposes of
					 the application;
(2) the physical
					 location of the plan and trust's books and records, and its means of
					 maintaining the books and records;
(3) the name of the applicant's ultimate
					 controlling person or persons;
(4)
					 the documents or instruments describing the rights and obligations between the
					 applicant and its clients, including but not limited to all forms of its
					 professional employer services agreement;
(5) a description of the applicant's basic
					 organizational structure, including organizational charts or lists that show:
(A) the relationships and contracts between
					 the applicant and any affiliates of the applicant that affect the plan;
					 and
(B) the internal organizational
					 structure of the applicant's management and administrative staff;
(6) disclosure of any suit or
					 judgment filed in a matter involving dishonesty, breach of trust, or a
					 financial dispute within the last 10 years against the applicant, an ultimate
					 controlling person, or any other persons from whom biographical information is
					 provided under paragraph (10) of this subsection;
(7) a copy of its most recent TDLR
					 license;
(8) a financial statement
					 of the applicant covering a period ending not more than 180 days prior to the
					 date of the application, that is prepared using generally accepted accounting
					 principles of the United States and includes:
(A) a balance sheet that reflects a solvent
					 financial position;
(B) an income
					 statement;
(C) a cash flow
					 statement; and
(D) the sources and
					 uses of all funds;
(9)
					 evidence that the applicant has engaged or will engage a sufficient number of
					 competent persons to:
(A) administer the
					 plan; and
(B) provide claims
					 adjusting and underwriting services to the plan;
(10) evidence of the PEO's fidelity coverage
					 that complies with §
												13.542 of
					 this title (relating to PEO's Fidelity Coverage); and
(11) for all plans sponsored by the
					 applicant, whether operating in Texas or in any other state, a list of and
					 access to all reports for the last three years created and filed with the
					 United States Department of Labor in compliance with Employee Retirement Income
					 Security Act of 1974 (ERISA),
					 29 U.S.C.
					 §§1021(g),
					 concerning Reporting by Certain Arrangements; 1023, concerning Annual Reports;
					 and 1024, concerning Filing and Furnishing of Information.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 3 - CERTIFICATE OF APPROVAL › Section 13.533 - Actuarial Opinion Requirements

Current through Reg. 49, No. 28; July 12, 2024
The independent actuarial opinion submitted with the
						application must:
(1) describe the
					 extent to which projected plan contributions:
(A) are not excessive;
(B) are not unfairly
					 discriminatory;
(C) are adequate to
					 pay all of the plan's:
(i) benefit
					 payments;
(ii) administrative
					 expenses;
(iii) other operational
					 expenses; and
(D) are
					 sufficient to maintain the required reserves and surplus to be held in trust
					 for the plan's participants; and
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 3 - CERTIFICATE OF APPROVAL › Section 13.534 - Application Review, Approval, and Denial

Current through Reg. 49, No. 28; July 12, 2024
(a) Commissioner's review. The commissioner
					 will review the applicant's submission and other pertinent information,
					 including information from TDLR, to ensure the applicant's compliance with
					 applicable statutes and regulations, and:
(1)
					 conduct any investigation that the commissioner considers necessary to
					 determine whether the applicant has obtained an appropriate license or has
					 delegated to contracting regulated entities, adequate facilities, resources,
					 and competent personnel, as determined by the commissioner, to administer the
					 plan and trust;
(2) examine under
					 oath any person interested in or connected with the applicant or its plan or
					 trust; or
(3) perform an
					 examination to confirm compliance with applicable Texas statutes and rules,
					 including funding of the trust.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 4 - CONDUCT OF APPROVED PEO › Section 13.540 - Governance and Operation of Approved PEO

Current through Reg. 49, No. 28; July 12, 2024
(a) Management of approved PEO. An approved
					 PEO must be managed by competent and trustworthy individuals. An individual
					 responsible for risk management, financial reporting, underwriting, claims, or
					 investment functions of the plan and trust must be eligible for licensure based
					 on the guidelines established in Chapter 1, Subchapter D of this title
					 (relating to Effect of Criminal Conduct) and hold any necessary licenses as
					 required by the Insurance Code.
(b)
					 Initial plan administration. An approved PEO must contract with a third party
					 administrator to perform the day-to-day operations of the plan until the plan's
					 trustees have contracted with a third party administrator to perform the
					 day-to-day operations of the plan as provided in §
											13.555
					 of this title (relating to Trustees' Responsibility and Authority).
(c) Location of books and records. An
					 approved PEO may request to maintain the plan and trust's books and records
					 outside this state in compliance with Insurance Code Chapter 803.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 4 - CONDUCT OF APPROVED PEO › Section 13.541 - Stop-Loss Insurance

Current through Reg. 49, No. 28; July 12, 2024
An approved PEO must contract for stop-loss insurance in
						the name of and on behalf of the plan and trust that complies with §
											13.567 of
						this title (relating to Stop-Loss Insurance), until the trustees have
						contracted for stop-loss insurance as provided in §
											13.555
						of this subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 4 - CONDUCT OF APPROVED PEO › Section 13.542 - PEO's Fidelity Coverage

Current through Reg. 49, No. 28; July 12, 2024
An approved PEO must maintain a fidelity bond or a
						zero-deductible crime policy that complies with the requirements of §
											13.568
						of this title (relating to Standards for Fidelity Coverage). The fidelity bond
						or zero-deductible crime policy must cover each person responsible for handling
						or administering plan assets, including: the approved PEO; its directors,
						officers, and employees; or any other individual responsible for servicing the
						plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter F - PROFESSIONAL EMPLOYER ORGANIZATIONS SPONSORING SELF-FUNDED EMPLOYEE HEALTH BENEFIT PLANS › Division 4 - CONDUCT OF APPROVED PEO › Section 13.543 - Approved PEO's Conduct with Respect to the Plan and Trust

Current through Reg. 49, No. 28; July 12, 2024
(a) Assessed contributions. Contributions
					 assessed by the approved PEO from clients for coverage for their participants
					 must be sufficient to fund at least 100 percent of the plan and trust's
					 aggregate stop-loss retention, as provided in Division 6 of this subchapter,
					 plus all other expenses of the plan and trust.
(b) Payments to the trust. An approved PEO
					 must transfer to the trust all payments from clients or participants that
					 represent or that are intended as contributions to the trust as soon as those
					 amounts can reasonably be segregated from the approved PEO's general assets,
					 but no later than 15 days after receipt. These payments are plan
					 assets.
(c) Reimbursement from plan
					 assets. An approved PEO may be reimbursed by the trust for its reasonable
					 expenses incurred to:
(1) establish and
					 initially administer the plan and trust; and
(2) comply with this subchapter, including
					 contracting for stop-loss insurance and fidelity coverage.