reglab/statecodes huggingface dataset:
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 11.1806 - Additional Information That May be Requested from an MCO Participating in Medicaid

Current through Reg. 49, No. 28; July 12, 2024
(a) Whenever
				  requested by the department, an MCO participating in Medicaid must file with
				  the department a complete set of financial exhibits pertaining to the state
				  Medicaid program, in the format of the Managed Care Financial Statistical
				  Report, as may be modified or amended by the Texas Health and Human Services
				  Commission. When a request is received, the MCO must then file a Managed Care
				  Financial Statistical Report reflecting the state Medicaid program operations
				  for each contract year in the same format as the monthly Managed Care Financial
				  Statistical Report. These reports must comply with the instructions issued by
				  the Texas Health and Human Services Commission.
(b) For any new or modified request to the
				  Texas Health and Human Services Commission for participation in the Medicaid
				  managed care program, all financial projections, including enrollment
				  projections, from the effective or renewal date of a Medicaid contract that are
				  submitted to the Texas Health and Human Services Commission, must also be
				  submitted to the department. The MCO must submit the same financial
				  projections, including a cash flow statement, submitted to the Texas Health and
				  Human Services Commission with the request to participate in the Medicaid
				  program. This information must be submitted with the application for a
				  certificate of authority if the MCO is not already a licensed MCO. If the MCO
				  is a licensed operation, then the financial projections must be sent with the
				  application for service area expansion.
(c) The MCO must notify the department of any
				  similar financial or statistical reports required by other contracting state
				  agencies and must submit copies of these reports to the department when
				  requested by the department.
(d)
				  Information submitted under this section must be sent to the Financial Analysis
				  Section, Mail Code 303-1A, Texas Department of Insurance, P.O. Box 149104,
				  Austin, Texas 78714-9104.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter T - QUALITY OF CARE › Section 11.1901 - Quality Improvement Structure for Basic, Single Service, and Limited Service HMOs

Current through Reg. 49, No. 28; July 12, 2024
(a) Basic, single
				  service, and limited service HMOs must develop and maintain an ongoing QI
				  program designed to objectively and systematically monitor and evaluate the
				  quality and appropriateness of care and services and to pursue opportunities
				  for improvement. Unless the HMO has no enrollees, the QI program should include
				  the active involvement of one or more enrollee(s) who are not employees of the
				  HMO.
(b) The HMO governing body is
				  ultimately responsible for the QI program. The governing body must:
(1) appoint a quality improvement committee
				  (QIC) that must include practicing physicians and individual providers, and may
				  include one or more enrollee(s) from throughout the HMO's service area, none of
				  whom may be employees of the HMO;
(2) approve the QI program;
(3) approve an annual QI plan;
(4) meet at least annually 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 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter T - QUALITY OF CARE › Section 11.1902 - Quality Improvement Program for Basic, Single Service, and Limited Service HMOs

Current through Reg. 49, No. 28; July 12, 2024
The QI program for basic, single service, and limited
					 service HMOs must be continuous and comprehensive, addressing both the quality
					 of clinical care and the quality of services. The HMO must dedicate adequate
					 resources, such as personnel and information systems, to the QI program.
(1) Written description. The QI program must
				  include a written description of the QI program that outlines program
				  organizational structure, functional responsibilities, and meeting
				  frequency.
(2) Work plan. The QI
				  program must include an annual QI work plan designed to reflect the type of
				  services and the population served by the HMO in terms of age groups, disease
				  categories, and special risk status. The work plan must:
(A) include objective and measurable goals,
				  planned activities to accomplish the goals, time frames for implementation,
				  responsible individuals, and evaluation methodology; and
(B) address each program area, including:
(i) network adequacy, which includes
				  availability and accessibility of care, including assessment of open and closed
				  physician and individual provider panels;
(ii) continuity of health care and related
				  services;
(iii) clinical
				  studies;
(iv) the adoption and
				  periodic updating of clinical practice guidelines or clinical care standards,
				  which the QI program must ensure:
(I) are
				  approved by participating physicians and individual providers;
(II) are communicated to physicians and
				  individual providers; and
(III)
				  include preventive health services;
(v) enrollee, physician, and individual
				  provider satisfaction;
(vi) the
				  complaint and appeals process, complaint data, and identification and removal
				  of communication barriers that may impede enrollees, physicians, and providers
				  from effectively making complaints against the HMO;
(vii) preventive health care through health
				  promotion and outreach activities;
(viii) claims payment processes;
(ix) contract monitoring, including
				  delegation oversight and compliance with filing requirements;
(x) utilization review processes;
(xi) credentialing;
(xii) member services; and
(xiii) pharmacy services, including drug
				  utilization.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter V - STANDARDS FOR COMMUNITY MENTAL HEALTH CENTERS › Section 11.2101 - Community Health Maintenance Organization

Current through Reg. 49, No. 28; July 12, 2024
A Community Health Maintenance Organization (CHMO) is an
					 entity created by one or more community centers under Health and Safety Code
					 §
										534.001 (concerning
					 Establishment), and authorized by the department to provide a plan for limited
					 health care services as defined in Insurance Code §
										843.002(18)
					 (concerning Definitions).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter V - STANDARDS FOR COMMUNITY MENTAL HEALTH CENTERS › Section 11.2102 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) Each CHMO must
				  comply with all requirements for a limited health care service plan specified
				  in this subchapter.
(b) Each CHMO
				  must provide coverage for work in progress and must clearly specify that the
				  enrollee must agree to have the work completed by a participating physician or
				  provider in the HMO delivery network, as defined under Insurance Code §
										843.002(15)
				  (concerning Definitions), or as otherwise arranged by the limited service
				  HMO.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter V - STANDARDS FOR COMMUNITY MENTAL HEALTH CENTERS › Section 11.2103 - Requirements for Issuance of Certificate of Authority to a CHMO

Current through Reg. 49, No. 28; July 12, 2024
(a) Before obtaining a certificate of
				  authority, an applicant CHMO must comply with each requirement for the issuance
				  of a certificate of authority imposed on a limited health care service plan
				  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.
(b) A CHMO with a certificate of authority
				  must comply with all the appropriate requirements that a limited health care
				  service plan must comply with under Insurance Code Chapters 843 and 1271, this
				  chapter, and other applicable insurance laws and regulations of this state to
				  maintain a certificate of authority. A CHMO is subject to the same statutes and
				  rules as a limited service HMO and considered a limited service HMO for
				  purposes of regulation and regulatory enforcement.
(c) Nothing in this subchapter prevents one
				  or more community centers from forming a nonprofit corporation under
				  Occupations Code §
										162.001
				  (concerning Certification by Board) to provide services on a risk-sharing or
				  capitated basis as permitted under Insurance Code Chapter 844 (concerning
				  Certification of Certain Nonprofit Health Corporations).
(d) This subchapter does not apply to an
				  activity exempt from regulation under Insurance Code §
										843.051
				  (concerning Applicability of Insurance and Group Hospital Service Corporation
				  Laws), §843.053 (concerning Laws Relating to Restraint of Trade),
				  §843.073 (concerning Certificate of Authority Requirement; Applicability
				  to Physicians and Providers), or §843.318 (concerning Certain Contracts of
				  Participating Physicians or Provider Not Prohibited).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter V - STANDARDS FOR COMMUNITY MENTAL HEALTH CENTERS › Section 11.2104 - Minimum Standards for Community Health Centers

Current through Reg. 49, No. 28; July 12, 2024
Each evidence of coverage providing limited mental health
					 care services by a CHMO must provide benefits as described in Chapter 11,
					 Subchapter Y, of this title (relating to Limited Service HMOs) as minimum
					 covered services for mental illness and chemical dependency.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter W - SINGLE SERVICE HMOS › Section 11.2200 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the meaning indicated below unless the context clearly
					 indicates otherwise:
(1) ADA--The
				  American Dental Association.
(2)
				  CDT--The current dental terminology manual developed and revised periodically
				  by the ADA.
(3) ADA code/dental
				  procedure description--Numerical codes and corresponding descriptions specified
				  in the CDT to describe bona fide dental procedures.
(4) Comparable facility--The location where
				  emergency dental services are rendered, including, but not limited to, the
				  office of a licensed dentist, a dental clinic, hospital, freestanding emergency
				  clinic, urgent care clinic, or other facility.
(5) Emergency dental services--Under a single
				  service plan providing dental care services and benefits, emergency dental
				  services are limited to procedures administered in a comparable facility, to
				  evaluate and stabilize dental conditions of a recent onset and severity
				  accompanied by excessive bleeding, severe pain, or acute infection that would
				  lead a prudent layperson possessing an average knowledge of dentistry to
				  believe that immediate care is needed.
(6) Insurer--An insurance company, a group
				  hospital service corporation operating under Insurance Code Chapter 842
				  (concerning Group Hospital Service Corporations), a fraternal benefit society
				  operating under Insurance Code Chapter 885 (concerning Fraternal Benefit
				  Societies), or a stipulated premium insurance company operating under Insurance
				  Code Chapter 884 (concerning Stipulated Premium Insurance Companies).
(7) Point-of-service group disclosure
				  statement--A written statement containing information about dental benefits
				  that the HMO must provide to:
(A) an
				  employer, an association, or other private group arrangement to whom the HMO
				  must offer a dental point-of-service plan; and
(B) any prospective enrollees in a dental
				  point-of-service plan, if the employer, association, or private group
				  arrangement accepts the dental point-of-service plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter W - SINGLE SERVICE HMOS › Section 11.2201 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) Each single
				  service HMO must provide uniquely described services with any corresponding
				  copayments for each covered service and benefit and must provide a single
				  health care service plan as defined in Insurance Code §
										843.002 (concerning
				  Definitions). Each single service HMO must comply with all requirements for a
				  single health care service plan specified in this subchapter.
(b) Each single service HMO schedule of
				  enrollee copayments must specify an appropriate description of covered services
				  and benefits, as required by §
										11.506
				  of this title (relating to Mandatory Contractual Provisions: Group, Individual,
				  and Conversion Agreement and Group Certificate), and may specify recognized
				  procedures or other information used for the purpose of maintaining a
				  statistical reporting system.
(c)
				  Each single service HMO evidence of coverage must include a glossary of
				  terminology, including the terms used in the evidence of coverage required by
				  §
										11.501
				  of this title (relating to Contents of the Evidence of Coverage). The glossary
				  must be included in the information to prospective and current group contract
				  holders and enrollees, as required by Insurance Code §
										843.201
				  (concerning Disclosure of Information About Health Care Plan Terms).
(d) In the event of a conflict between the
				  provisions of this subchapter and other provisions of this chapter, this
				  subchapter prevails with regard to single service HMOs. It is not considered a
				  conflict if a topic that is not addressed in this subchapter appears elsewhere
				  in this chapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter W - SINGLE SERVICE HMOS › Section 11.2202 - Limitations and Exclusions

Current through Reg. 49, No. 28; July 12, 2024
Single service HMOs are prohibited from:
(1) excluding services required for
				  preexisting conditions that would otherwise be covered under the plan;
				  and
(2) establishing waiting
				  periods for coverage of preexisting conditions.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter W - SINGLE SERVICE HMOS › Section 11.2203 - Minimum Standards - Dental Care Services and Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) Each single service HMO evidence of
				  coverage that uses any dental procedure codes must use the codes as specified
				  in the current version of the CDT and certify that the codes referenced in its
				  evidence of coverage are as specified in the current version of the
				  CDT.
(b) Each single service HMO
				  evidence of coverage providing coverage for dental care services must provide
				  benefits for covered dental treatment in progress and may, if clearly
				  disclosed, require the enrollee to have the treatment completed by a
				  participating provider in the HMO delivery network, as defined in Insurance
				  Code §
										843.002 (concerning
				  Definitions), or as otherwise arranged by the single service HMO.
(c) Each single service HMO evidence of
				  coverage providing coverage for dental care services and benefits must provide
				  services for the purposes of preventing, alleviating, curing, or healing dental
				  disease, including dental caries and periodontal disease. The services may
				  include an infection control (sterilization) fee. Single service HMOs providing
				  coverage for dental care services must provide coverage for the following
				  primary and preventive services provided by a general dentist or hygienist, as
				  applicable:
(1) office visit during and after
				  regularly scheduled hours;
(2) oral
				  evaluations;
(3) X-rays;
(4) bitewings;
(5) panoramic film;
(6) dental prophylaxis (adult and
				  child);
(7) topical fluoride
				  treatment for children;
(8) dental
				  sealants for children;
(9) amalgam
				  fillings (one, two, three, and four or more surfaces, primary and permanent,
				  including polishing);
(10) anterior
				  resin fillings (one, two, three, and four or more surfaces, or involving
				  incisal angle, primary and permanent, including polishing);
(11) simple oral extractions;
(12) surgical incision and drainage of
				  abscess, intraoral soft tissue; and
(13) palliative (emergency) treatment of
				  dental pain, provided that the enrollee may obtain emergency treatment of
				  dental pain in a comparable facility.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter W - SINGLE SERVICE HMOS › Section 11.2204 - Minimum Standards - Vision Care Services and Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) Each single service HMO evidence of
				  coverage providing vision care services and benefits must provide the following
				  as covered primary and preventive vision services:
(1) comprehensive eye examination to include
				  medical history;
(2) visual
				  acuities, with and without correction (distance and near);
(3) cover test at 20 feet and at 16
				  inches;
(4) versions;
(5) external examination of the eye lids,
				  cornea, conjunctiva, pupillary reaction (neurological integrity), and muscle
				  function;
(6) binocular
				  measurements for far and near;
(7)
				  internal eye examination (ophthalmoscopy);
(8) autorefraction/refraction (far point and
				  near point);
(9) tonometry
				  (reasonable attempt or equivalent testing if contraindicated);
(10) retinoscopy;
(11) biomicroscopy;
(12) intraocular pressure glaucoma
				  test;
(13) slit lamp examination;
				  and
(14) urgent care.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter W - SINGLE SERVICE HMOS › Section 11.2205 - Prohibited Practices

Current through Reg. 49, No. 28; July 12, 2024
(a) Under an
				  individual plan, a single service HMO may not limit or otherwise interfere with
				  an enrollee's right to terminate his or her membership in the plan before the
				  end of the enrollment year.
(b) A
				  single service HMO may not limit coverage for emergency services under a single
				  health care service plan.
(c) A
				  single service HMO may not charge an emergency fee in addition to a copayment
				  for emergency services.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter W - SINGLE SERVICE HMOS › Section 11.2206 - Mandatory Disclosure Statements; Certification of Compliance

Current through Reg. 49, No. 28; July 12, 2024
(a) Each point-of-service group enrollment
				  application and, if the employer, association, or private group arrangement
				  elects to offer the point-of-service option, each enrollment form, must include
				  a disclosure statement written in a readable and understandable format that
				  includes the following information:
(1) a
				  statement that the dental indemnity benefits are provided through an insurer
				  and that the dental care services are offered or arranged by the HMO;
(2) the name of the insurer and the name of
				  the HMO offering the benefits; and
(3) an explanation that, in order to receive
				  benefits:
(A) under the HMO, an enrollee must
				  use only network providers, except for emergency dental care, and pay the
				  copayments specified in the evidence of coverage;
(B) under the indemnity plan, an enrollee may
				  use any provider but before receiving reimbursement, the enrollee must meet the
				  required deductible and is responsible for the coinsurance amount specified in
				  the policy or certificate.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter W - SINGLE SERVICE HMOS › Section 11.2208 - Single Service Accessibility and Availability

Current through Reg. 49, No. 28; July 12, 2024
A single service HMO that chooses to offer a particular
					 service to an enrolled population must comply with §
										11.1607
					 of this title (relating to Accessibility and Availability Requirements). Any
					 single service must be provided directly by the HMO or by
					 contract.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Y - LIMITED SERVICE HMOS › Section 11.2402 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) A limited
				  service HMO must develop and maintain an ongoing quality improvement structure
				  and program that complies with Chapter 11, Subchapter T, of this title
				  (relating to Quality of Care).
(b)
				  Each limited service HMO must provide uniquely described services with any
				  corresponding copayments for each covered service and benefit, and provide a
				  limited health care service plan as defined in Insurance Code §
										843.002 (concerning
				  Definitions). Each limited service HMO must comply with all requirements for a
				  limited health care service plan specified in this subchapter.
(c) Each limited service HMO schedule of
				  enrollee copayments must specify an appropriate description of covered services
				  and benefits, as required by §
										11.506
				  of this title (relating to Mandatory Contractual Provisions: Group, Individual,
				  and Conversion Agreement and Group Certificate), and may specify recognized
				  procedure codes or other information used for maintaining a statistical
				  reporting system.
(d) Each limited
				  service HMO evidence of coverage must include a glossary of terms, including
				  the terms used in the evidence of coverage required by §
										11.501
				  of this title (relating to Contents of the Evidence of Coverage). The glossary
				  must be included in the information to prospective and current group contract
				  holders and enrollees, as required by Insurance Code §
										843.201
				  (concerning Disclosure of Information about Health Care Plan Terms).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Y - LIMITED SERVICE HMOS › Section 11.2403 - Prohibited Practices

Current through Reg. 49, No. 28; July 12, 2024
A limited service HMO may not:
(1) exclude services required for preexisting
				  conditions which would otherwise be covered under the plan;
(2) establish waiting periods for coverage of
				  preexisting conditions;
(3) impose
				  a lifetime coverage maximum for any covered service or benefit;
(4) limit or otherwise interfere with an
				  enrollee's right to terminate his or her membership in the plan before the end
				  of the enrollment year;
(5) limit
				  coverage for emergency services under a limited health care service
				  plan;
(6) charge an emergency fee
				  in addition to a copayment for emergency services; or
(7) count medication-related services and
				  services provided by telephone toward the annual outpatient visit total for
				  either serious or nonserious mental illness.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Y - LIMITED SERVICE HMOS › Section 11.2405 - Minimum Standards - Mental Health and Chemical Dependency Services and Benefits

Current through Reg. 49, No. 28; July 12, 2024
Each limited service HMO evidence of coverage providing
					 coverage for mental health and chemical dependency services and benefits
					 must:
(1) cover, in compliance with
				  the limited service HMO's standards of medical necessity, court-ordered mental
				  health and chemical dependency treatment and may, if clearly disclosed, require
				  the enrollee to have the treatment completed by a participating physician or
				  provider in the HMO delivery network, as defined in Insurance Code §
										843.002 (concerning
				  Definitions), or as otherwise arranged by the limited service HMO;
(2) comply with Chapter 21, Subchapter P, of
				  this title (relating to Mental Health Parity)
(3) provide primary mental health and
				  chemical dependency services and benefits, including:
(A) for treatment of serious mental illness,
				  as defined in Insurance Code Chapter 1355, Subchapter A, (concerning Group
				  Health Benefit Plan Coverage for Certain Serious Mental Illnesses and Other
				  Disorders), up to 45 inpatient days per year and up to 60 outpatient visits per
				  year, which include assessment or screening, treatment planning, and crisis
				  services;
(B) for treatment of
				  nonserious mental illness, up to 30 inpatient days per year and up to 30
				  outpatient visits per year, which include screening and assessment, treatment
				  planning, and crisis services;
(C)
				  treatment of chemical dependency in compliance with the levels of care and
				  clinical criteria specified in Chapter 3, Subchapter HH, of this title
				  (relating to Standards for Reasonable Cost Control and Utilization Review for
				  Chemical Dependency Treatment Centers); and
(D) any other services necessary and
				  appropriate to treat mental health and chemical dependency services or required
				  by the Insurance Code, Health and Safety Code, and other applicable laws and
				  regulations of this state; and
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Y - LIMITED SERVICE HMOS › Section 11.2406 - Minimum Standards - Long Term Care Services and Benefits

Current through Reg. 49, No. 28; July 12, 2024
Each limited service HMO evidence of coverage providing
					 long-term care services and benefits must comply with Insurance Code Chapter
					 1651 (concerning Long-Term Care Benefit Plans) and Chapter 3, Subchapter Y, of
					 this title (relating to Standards for Long-Term Care Insurance, Non-Partnership
					 and Partnership Long-Term Care Insurance Coverage Under Individual and Group
					 Policies and Annuity Contracts, and Life Insurance Policies That Provide
					 Long-Term Care Benefits Within the Policy).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Z - POINT-OF-SERVICE RIDERS › Section 11.2502 - Issuance of Point-of-Service Riders

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Financial requirements. An HMO that issues a point-of-service rider is subject
				  to 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).
(b)
				  Termination, cancellation, and renewability. An HMO must comply with all state
				  and federal laws and rules applicable to termination, cancellation, and
				  renewability of a point-of-service rider plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter Z - POINT-OF-SERVICE RIDERS › Section 11.2503 - Coverage Relating to Point-of-Service Rider Plans

Current through Reg. 49, No. 28; July 12, 2024
(a) An HMO may not consider an in-plan
				  covered service to be a benefit provided under the point-of-service
				  rider.
(b) An HMO may not require
				  an enrollee to use either the point-of-service rider benefits or in-plan
				  covered services first.
(c) An HMO
				  that includes limited provider networks:
(1)
				  may not limit the access, under the point-of-service rider, of an enrollee
				  whose in-plan covered services are restricted to the limited provider network,
				  to either participating physicians and providers or nonparticipating physicians
				  and providers;
(2) may not impose
				  cost-sharing arrangements for an enrollee whose in-plan covered services are
				  restricted to a limited provider network, and who, through the point-of-service
				  rider, accesses a participating physician or provider outside the limited
				  provider network, that differ from the cost-sharing arrangements for in-plan
				  covered services obtained by the enrollee from a physician or provider in the
				  limited provider network; and
(3)
				  may provide for cost-sharing arrangements for benefits obtained from
				  nonparticipating physicians and providers that are different from the cost
				  sharing arrangements for in-plan covered services, provided that coinsurance
				  required under a point-of-service rider must never exceed 50 percent of the
				  total amount to be covered.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter AA - DELEGATED ENTITIES › Section 11.2601 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) A delegating
				  HMO must:
(1) identify all responsibilities
				  relating to the function being delegated;
(2) create an agreement that enables the HMO
				  and department to monitor both the delegated entity's financial solvency and
				  performance or subsequent delegation of all delegated functions; and
(3) retain ultimate responsibility for
				  ensuring that all delegated functions are performed in compliance with
				  applicable statutes and rules.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter AA - DELEGATED ENTITIES › Section 11.2602 - 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) Delegated entity--An
				  entity, other than an HMO authorized to do business under Insurance Code
				  Chapter 843 (concerning Health Maintenance Organizations) and Chapter 1272
				  (concerning to Delegation of Certain Functions by Health Maintenance
				  Organization) and other applicable insurance laws and regulations of this
				  state, that by itself, or through subcontracts with one or more entities,
				  undertakes to arrange for or to provide medical care or health care to an
				  enrollee in exchange for a predetermined payment on a prospective basis and
				  that accepts responsibility to perform on behalf of the HMO any function
				  regulated by Insurance Code Chapter 843 and Chapter 1272 and other applicable
				  insurance laws and regulations of this state. The term does not include an
				  individual physician or a group of employed physicians practicing medicine
				  under one federal tax identification number and whose total claims paid to
				  physicians and providers not employed by the group is less than 20 percent of
				  the total collected revenue of the group calculated on a calendar-year
				  basis.
(2) Delegated network--Any
				  delegated entity that assumes total financial risk for more than one of the
				  following categories of health care services: medical care, hospital or other
				  institutional services, or prescription drugs, as defined by Occupations Code
				  §
										551.003 (concerning
				  Definitions). The term does not include a delegated entity that shares risk for
				  a category of services with an HMO.
(3) Delegated third party--A third party
				  other than a delegated entity that contracts with a delegated entity, either
				  directly or through another third party, to:
(A) accept responsibility to perform any
				  function regulated by Insurance Code Chapter 843 and Chapter 1272 and other
				  applicable insurance laws and regulations of this state; or
(B) receive, handle, or administer funds, if
				  the receipt, handling, or administration of the funds is directly or indirectly
				  related to a function regulated by Insurance Code Chapter 843 and Chapter 1272
				  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 AA - DELEGATED ENTITIES › Section 11.2603 - Requirements for Delegation by HMOs

Current through Reg. 49, No. 28; July 12, 2024
(a) Any
				  delegation of any function under Insurance Code Chapter 843 (concerning Health
				  Maintenance Organizations) and Chapter 1272 (concerning Delegation of Certain
				  Functions by Health Maintenance Organization), and other applicable insurance
				  laws and regulations of this state by an HMO must comply with this
				  subchapter.
(b) Oversight by the
				  department does not relieve an HMO of responsibility for monitoring and
				  oversight of its delegated entities.
(c) Before entering into, renewing, or
				  amending a delegation agreement, an HMO must make a reasonable effort to
				  evaluate the delegated entity's current and prospective ability to perform the
				  functions to be delegated, including, but not limited to, the solvency and
				  financial operations of the delegated entity and the projected financial
				  effects of the agreement on the delegated entity.
(d) An HMO that delegates functions to a
				  delegated entity must have a written contingency plan to resume any and all
				  delegated functions, including, as applicable:
(1) quality of care;
(2) continuity of care, including a plan for
				  transferring enrollees to new physicians and providers in the event of
				  termination of the delegation agreement; and
(3) processing, adjudication, and payment of
				  claims.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter AA - DELEGATED ENTITIES › Section 11.2605 - Delegation Agreements - Information to Be Provided by HMO to Delegated Entity

Current through Reg. 49, No. 28; July 12, 2024
(a) An HMO must
				  provide to each delegated entity with which the HMO has a delegation agreement,
				  at least monthly unless otherwise stated in the agreement and provided in
				  standard electronic format agreed to by the parties, the following information:
(1) the name and either the date of birth or
				  social security number of each enrollee of the HMO who is eligible or assigned
				  to receive health care from the delegated entity, including the enrollees added
				  and terminated since the previous reporting period;
(2) the age, sex, evidence of coverage, and
				  any riders to that evidence of coverage, and, if applicable, the name of the
				  employer, for the enrollees of the HMO who are eligible or assigned to receive
				  health care from the delegated entity;
(3) a summary of the number and amount of
				  claims paid by the HMO on behalf of the delegated entity during the previous
				  reporting period; provided that an HMO is not prevented from providing, on
				  request, additional nonproprietary information regarding the claims if the HMO
				  pays any claims for the delegated entity;
(4) a summary of the number and amount of
				  pharmacy prescriptions paid for each enrollee for which the delegated entity
				  has taken partial risk during the previous reporting period, provided that an
				  HMO is not prevented from providing, on request, additional nonproprietary
				  information regarding the claims, if the HMO pays any claims for the delegated
				  entity;
(5) information that is
				  needed by the delegated entity to file claims for reinsurance, coordination of
				  benefits, and subrogation; and
(6)
				  patient complaint data that relates to the delegated entity.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter AA - DELEGATED ENTITIES › Section 11.2606 - Reporting Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) On receipt
				  of a financial statement indicating that a delegated entity or delegated third
				  party has an amount of total liabilities greater than its total assets, the HMO
				  must immediately forward a copy of the financial statement to the
				  department.
(b) An HMO that becomes
				  aware of any information, including the information described in subsection (a)
				  of this section, that suggests or indicates that the delegated entity or
				  delegated third party is not operating in compliance with its written agreement
				  or is operating in a condition that may render the continuance of its business
				  hazardous to the enrollees, must immediately:
(1) notify the delegated entity in writing of
				  those findings; and
(2) request, in
				  writing, a written explanation with supporting documentation of:
(A) the delegated entity's or delegated third
				  party's apparent noncompliance with the written agreement; or
(B) the existence of the condition that
				  apparently renders the continuance of the delegated entity's or delegated third
				  party's business hazardous to the enrollees.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter AA - DELEGATED ENTITIES › Section 11.2607 - Examinations of Delegated Entities

Current through Reg. 49, No. 28; July 12, 2024
(a) On
				  receipt of complaints, a notice under §
										11.2606 of
				  this title (relating to Reporting Requirements), or as otherwise permitted
				  under the Insurance Code or related rules, the department may examine any
				  matter relating to the financial solvency of the delegated entity or delegated
				  third party or the delegated entity's ability to meet its responsibilities
				  under the delegation agreement.
(b)
				  The department may request documents, perform on-site examinations, and require
				  any other action of the delegated entity and any delegated third party that the
				  department determines necessary to perform an examination under this
				  section.
(c) A delegated entity's
				  failure to comply with a request under subsection (b) of this section may
				  result in either or both:
(1) notification to
				  the HMO that the delegated entity is subject to penalties under the delegation
				  agreement; or
(2) entry of an order
				  by the commissioner to resume or redelegate any functions delegated to the
				  delegated entity or terminate the agreement in its entirety.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter AA - DELEGATED ENTITIES › Section 11.2608 - Department May Order Corrective Action

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  The department may require at any time that a delegated entity take corrective
				  action to comply with the department's statutory and regulatory requirements
				  that:
(1) relates to any matters delegated by
				  the HMO to the delegated entity;
(2) is necessary to ensure the HMO's
				  compliance with statutory and regulatory requirements; or
(3) relates to the financial solvency and
				  operations of the delegated entity.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter AA - DELEGATED ENTITIES › Section 11.2609 - Reserve Requirements for Delegated Networks

Current through Reg. 49, No. 28; July 12, 2024
In addition to any other requirements set forth in this
					 subchapter, an HMO that contracts with a delegated network must ensure that the
					 delegated network complies with Insurance Code Chapter 1272, Subchapter D,
					 (concerning Reserve Requirements). The HMO's agreement with the delegated
					 network must include a provision:
(1)
				  that records related to the requirements of Insurance Code Chapter 1272,
				  Subchapter D, must be accessible at all times to the HMO;
(2) requiring all financial records and
				  related information necessary to show the delegated network's compliance with
				  the requirements of Insurance Code Chapter 1272, Subchapter D;
(3) making the records described in paragraph
				  (1) of this section available to the department on request; and
(4) that records be kept providing evidence
				  that the HMO has adequately monitored the delegated network for compliance with
				  the requirements of Insurance Code Chapter 1272, Subchapter D.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter AA - DELEGATED ENTITIES › Section 11.2610 - Penalties for Noncompliance

Current through Reg. 49, No. 28; July 12, 2024
(a) Failure of
				  any party to any agreement under this subchapter to comply with any requirement
				  of this subchapter may result in an order from the commissioner that the HMO
				  must terminate the delegation agreement and resume or redelegate any or all
				  delegated functions as well as the imposition of penalties provided under the
				  Insurance Code and related rules.
(b) Any action by an HMO relating to a
				  delegation agreement that does not comply with this subchapter or takes place
				  under a provision of a delegation agreement not in compliance with this
				  subchapter constitutes a violation under this subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter AA - DELEGATED ENTITIES › Section 11.2611 - Filing of Delegation Agreements

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  An HMO must file the written executed agreement described in this subchapter
				  and any subsequently executed amendments to the agreement with the department
				  as required under §
										11.301 of
				  this title (relating to Filing Requirements).
(b) Every agreement must include as an
				  attachment a completed Delegated Entity Data form, form SN014, (rev.
				  02/16).
(c) Every agreement must
				  include, as an attachment, a table of contents that allows the department to
				  track the agreement's compliance with the requirements of §
										11.2604
				  of this title (relating to Delegation Agreements - General Requirements and
				  Information to be Provided to HMO) and §
										11.2605
				  of this title (relating to Delegation Agreements - Information to be Provided
				  by HMO to Delegated Entity).
(d) On
				  notification from the department of a deficiency in a delegation agreement or
				  filing required under this subchapter, the HMO must respond within 10 business
				  days with a proposed correction for the defect.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter A - GENERAL PROVISIONS › Section 12.2 - Severability Clause

Current through Reg. 49, No. 28; July 12, 2024
If a court of competent jurisdiction holds that any
					 provision of this chapter or its application to any person or circumstance is
					 invalid for any reason, the invalidity does not affect other provisions or
					 applications of this chapter that can be given effect without the invalid
					 provision or application, and to this end the provisions of this chapter are
					 severable.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter A - GENERAL PROVISIONS › Section 12.3 - Effect of Chapter

Current through Reg. 49, No. 28; July 12, 2024
This chapter governs the performance of appropriate
					 statutory and regulatory functions and is not to be construed as limiting the
					 exercise of statutory authority by the commissioner of
					 insurance.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter A - GENERAL PROVISIONS › Section 12.4 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) All independent review organizations
				  (IROs) performing independent reviews of adverse determinations made by
				  utilization review agents, health insurance carriers, health maintenance
				  organizations, and managed care entities must comply with this chapter. IROs
				  performing independent reviews of adverse determinations made by certified
				  workers' compensation health care networks and workers' compensation insurance
				  carriers must comply with this chapter, subject to §
										12.6
				  of this title (relating to Independent Review of Adverse Determinations of
				  Health Care Provided Under Labor Code Title 5 or Insurance Code Chapter
				  1305).
(b) All IROs performing
				  independent reviews of adverse determinations regarding preauthorization
				  exemptions made under Insurance Code Chapter 4201, Subchapter N, concerning
				  Exemption From Preauthorization Requirements for Physicians and Providers
				  Providing Certain Health Care Services, must comply with § 12.601 of this
				  title (relating to Preauthorization Exemptions).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter A - GENERAL PROVISIONS › Section 12.5 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this chapter,
					 will have the following meanings unless the context clearly indicates
					 otherwise.
(1) Adverse
				  determination--A determination by a utilization review agent made on behalf of
				  any payor that the health care services provided or proposed to be provided to
				  a patient are not medically necessary or appropriate, or are experimental or
				  investigational.
(2) Affiliate--A
				  person who, directly or indirectly, through one or more intermediaries,
				  controls, is controlled by, or is under common control with the person
				  specified.
(3) Best
				  evidence--Evidence based on:
(A) randomized
				  clinical trials;
(B) if randomized
				  clinical trials are not available, cohort studies or case-control
				  studies;
(C) if subparagraphs (A)
				  and (B)of this paragraph are not available, case-series; or
(D) if subparagraphs (A), (B), and (C) of
				  this paragraph are not available, expert opinion.