reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter H - EXAMINATIONS › Section 10.200 - Fee for Examination of a Certified Workers' Compensation Health Care Network

Current through Reg. 49, No. 28; July 12, 2024
(a) As provided in
				  Insurance Code §
										1305.251,
				  concerning Examination of Network, a network must pay to the department an
				  examination fee set by the Commissioner for expenses directly attributable to
				  an examination of the network conducted pursuant to Insurance Code §
										1305.251
				  or §
										1305.252,
				  concerning Examination of Provider or Third Party.
(b) The examination fee includes the actual
				  salary and expenses of the examiners directly attributable to the examination.
(1) The actual salary of an examiner is
				  determined by dividing the annual salary of the examiner by the total number of
				  working days in a year, then dividing that amount by the number of hours in a
				  working day. The actual salary included in an examination fee is the part of
				  the annual salary attributable to each hour the examiner examines the
				  network.
(2) The expenses included
				  in an examination fee are those actually incurred by the examiner and directly
				  attributable to the examination, including the actual cost of:
(A) transportation;
(B) lodging;
(C) meals;
(D) subsistence expenses;
(E) parking fees; and
(F) department overhead expenses.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter A - GENERAL PROVISIONS › Section 11.1 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) Severability.
				  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. To this
				  end, all provisions of this chapter are severable.
(b) Effect of rules. The sections in this
				  chapter are prescribed to govern the performance of appropriate statutory and
				  regulatory functions and are not to be construed as limitations on the exercise
				  of statutory authority by the commissioner of insurance.
(c) Effective date. This chapter is effective
				  on August 1, 2017. Actions taken before the effective date of this chapter are
				  governed by the regulations in effect on the date the action was taken, and the
				  former regulations are continued in effect for that purpose.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter B - NAME APPLICATION PROCEDURE › Section 11.101 - How to Obtain Forms

Current through Reg. 49, No. 28; July 12, 2024
A name application form and other HMO forms may be obtained
					 by contacting the Company Licensing and Registration Office, Mail Code 103-CL,
					 Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104, or
					 from the department's website at www.tdi.texas.gov.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter B - NAME APPLICATION PROCEDURE › Section 11.102 - Information Required

Current through Reg. 49, No. 28; July 12, 2024
The name application form may be submitted with or at any
					 time before submitting the application for certificate of authority, together
					 with a $100 filing fee.
(1) The name,
				  address, and title or relationship to the proposed HMO of each organizer must
				  be shown on the name application form, along with the same information about
				  any affiliated organization.
(2) An
				  organization applying for a certificate of authority as an HMO or an existing
				  HMO is prohibited from using the following words in its name, contracts, or
				  literature: "insurance," "casualty," "surety," or "mutual."
(3) A name application form may be accepted
				  by the commissioner before the proposed HMO's basic organizational document is
				  filed with the Texas secretary of state. Applicants must use the same exact
				  name when filing with the commissioner and the secretary of state.
(4) A certificate of authority will not be
				  granted until the name has been accepted.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter B - NAME APPLICATION PROCEDURE › Section 11.104 - Criteria

Current through Reg. 49, No. 28; July 12, 2024
The commissioner will review requests for reservation of
					 names in the manner provided for the review of corporate names under Chapter 7,
					 Subchapter G, of this title (relating to Review of Corporate
					 Names).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter B - NAME APPLICATION PROCEDURE › Section 11.105 - Use of the Term "HMO," Service Marks, Trademarks, and Assumed Name

Current through Reg. 49, No. 28; July 12, 2024
(a) While in the process of planning or
				  development, the term "HMO" may be used as a part of the proposed HMO's name as
				  long as the developmental status of the proposed HMO is made clear in all
				  dealings with employers, individuals, prospective contract holders, news media,
				  and others.
(b) A trademark,
				  service mark, or assumed name must be filed with and approved by the
				  commissioner before use.
(c) After
				  the commissioner issues a certificate of authority, the HMO must use the name
				  as it appears on the certificate of authority on all advertising and forms
				  distributed to the public.
(d)
				  After the commissioner issues a certificate of authority, the HMO must file any
				  new trademark or service mark, or any changes to an existing trademark or
				  service mark, with the commissioner.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter B - NAME APPLICATION PROCEDURE › Section 11.106 - Time Limits; Extension Requirements

Current through Reg. 49, No. 28; July 12, 2024
Names reserved for use by a proposed HMO are subject to the
					 following time limits and extension requirements:
(1) A requested name is reserved for 365 days
				  from the date the name is accepted by the commissioner.
(2) Before the end of this 365-day period, a
				  proposed HMO that has not submitted an application for a certificate of
				  authority may request that the name reservation be extended for an additional
				  365 days by submitting the following:
(A) a
				  letter of request for extension; and
(B) a statement explaining the current status
				  of the proposed HMO and the estimated date on which an application for a
				  certificate of authority will be filed.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter B - NAME APPLICATION PROCEDURE › Section 11.107 - Effect of Filing for or Receiving Certificate of Authority

Current through Reg. 49, No. 28; July 12, 2024
Once a proposed HMO has filed an application for a
					 certificate of authority, the name application no longer must be extended. If
					 the commissioner denies a certificate of authority, then the name application
					 is canceled on the date the denial order becomes final. If a certificate of
					 authority is granted, then the name is reserved for use by the HMO as long as
					 the certificate of authority is in effect.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter B - NAME APPLICATION PROCEDURE › Section 11.108 - Effect of Withdrawing Application for Certificate of Authority

Current through Reg. 49, No. 28; July 12, 2024
If an application is filed and then withdrawn or delayed at
					 the request of a proposed HMO, then at the time of the withdrawal or request
					 for delay, the proposed HMO must request that the name continue to be reserved
					 and estimate the date on which the application will be refiled. If a 365-day
					 name application period expires during the withdrawal period, then the
					 requirements of §
										11.106(2)
					 of this title (relating to Time Limits; Extension Requirements) must be met in
					 order for the name application to be continued.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter B - NAME APPLICATION PROCEDURE › Section 11.109 - Situations in Which Name Applications Will Cease

Current through Reg. 49, No. 28; July 12, 2024
A name will cease to be reserved when:
(1) a proposed HMO fails to request extension
				  before the end of a 365-day name application period;
(2) the commissioner denies an application
				  for a certificate of authority; or
(3) the commissioner revokes or cancels a
				  certificate of authority.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter C - APPLICATION FOR CERTIFICATE OF AUTHORITY › Section 11.201 - Filing Fee

Current through Reg. 49, No. 28; July 12, 2024
A filing fee required by Insurance Code §
										843.154 (concerning Fees),
					 as determined by §
										7.1301
					 of this title (relating to Regulatory Fees), must accompany an application for
					 a certificate of authority, unless the filing is made electronically through
					 the NAIC's System for Electronic Rate and Form Filing, in which case the fees
					 may not be attached to the filing. For filings made electronically, the
					 department will send an invoice for the fees, and the HMO must pay, as provided
					 in §
										7.1302
					 of this title (relating to Billing System). The fee is
					 nonrefundable.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter C - APPLICATION FOR CERTIFICATE OF AUTHORITY › Section 11.202 - Binding, Indexing, and Numbering Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A proposed HMO may submit an application
				  for a certificate of authority in electronic format, by electronic file
				  transmission or in a data storage format acceptable to the department, or by
				  paper.
(b) If an HMO submits an
				  application in paper format, the applicant must submit three separate copies of
				  the application in separate three-ring binders, so that pages may be easily
				  replaced when necessary. Paper applications must include dividers with
				  identifying subject tabs preceding each separate exhibit.
(c) Applications submitted in an electronic
				  format must include separate file folders with names identifying each
				  exhibit.
(d) Each application must
				  contain a table of contents.
(e)
				  All pages must be clearly legible and numbered.
(f) An HMO should not use identical items in
				  more than one section of the application. Instead of using the same information
				  in more than one place, an application must refer to the file or page on which
				  the required form or list may be found.
(g) An original application becomes the
				  charter file once the applicant submits all required revisions and the
				  commissioner approves the application.
(h) The application is subject to Government
				  Code Chapter 552 (concerning Public Information).
(i) Each item in the application must be
				  identified by a unique number as more fully described in §
										11.301(2)
				  of this title (relating to Filing Requirements).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter C - APPLICATION FOR CERTIFICATE OF AUTHORITY › Section 11.203 - Revisions During Review Process

Current through Reg. 49, No. 28; July 12, 2024
(a) Revisions
				  during the review of an application for a certificate of authority must be
				  addressed to: Company Licensing and Registration Office, Mail Code 103-CL,
				  Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104, or
				  submitted electronically as instructed by the department. The applicant must
				  include a transmittal letter and any revision specified in this
				  subchapter.
(b) Each revision to
				  the basic organizational documents, bylaws, or officers and employees bond must
				  be accompanied by a notarized certification of the corporate secretary or
				  corporate president of the applicant that the revision submitted is true,
				  accurate, and complete, and, if the item is a copy, by a notarized
				  certification that the copy is a true, accurate, and complete copy of the
				  original.
(c) If an electronic file
				  or page is to be revised or replaced, the modified document must be submitted
				  with the changed item or information clearly designated.
(d) Staff will conduct a review of the
				  application and notify the applicant of the need for revisions necessary to
				  meet the requirements of Insurance Code Chapter 843 (concerning Health
				  Maintenance Organizations), this chapter, and other applicable insurance laws
				  and regulations of this state. If the applicant does not make the necessary
				  revisions, the department will deny the application.
(e) If the time required for the revisions
				  will exceed the time limits set out in §
										1.809
				  of this title (relating to HMO Certificate of Authority), the applicant must
				  request additional time within which to make the revisions. The applicant must
				  specifically set out the length of time requested, which may not exceed 90
				  days. The commissioner may grant or deny the request for an extension of time
				  at the commissioner's discretion under §
										1.809
				  of this title.
(f) The applicant
				  may request additional extensions, but must set out in writing the need for the
				  additional time for each requested extension. A request must provide sufficient
				  detail for the commissioner to determine if good cause for the extension
				  exists. The commissioner may grant or deny any additional request for an
				  extension of time at the commissioner's discretion.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter C - APPLICATION FOR CERTIFICATE OF AUTHORITY › Section 11.204 - Contents

Current through Reg. 49, No. 28; July 12, 2024
The application for a certificate of authority must contain
					 the following, in this order:
(1) a
				  completed name application form along with any certificate of reservation of
				  corporate name issued by the secretary of state;
(2) a completed certificate of authority
				  application form;
(3) the basic
				  organizational documents and all amendments, complete with the original
				  incorporation certificate with charter number and seal indicating certification
				  by the secretary of state, if applicable;
(4) the bylaws, rules, or any similar
				  document regulating the conduct of the internal affairs of the
				  applicant;
(5) information about
				  officers, directors, and staff, including:
(A)
				  a completed officers and directors page;
(B) NAIC UCAA biographical data forms for all
				  persons who are to be responsible for the day-to-day conduct of the applicant's
				  affairs, including all members of the board of directors, board of trustees,
				  executive committee or other governing body or committee, the principal
				  officers, and controlling shareholders of the applicant if the applicant is a
				  corporation, or all partners or members if the applicant is a partnership or
				  association; and
(C) a complete set
				  of fingerprints for each person to whom the fingerprint requirements of Chapter
				  1 of this title (relating to General Administration) apply;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter C - APPLICATION FOR CERTIFICATE OF AUTHORITY › Section 11.205 - Additional Documents to be Available for Review

Current through Reg. 49, No. 28; July 12, 2024
(a) The following documents must be made
				  available for review at the applicant's office in Texas or another location
				  within Texas agreed to by the department and on request during the application
				  process:
(1) administrative: policy and
				  procedure manuals;
(2) health
				  information systems: policies and procedures for accessing enrollee health
				  records and a plan to provide for confidentiality of those records complying
				  with applicable law;
(3) executed
				  agreements, including:
(A) management
				  services agreements;
(B)
				  administrative services agreements; and
(C) delegation agreements;
(4) executed physician and
				  provider contracts: a copy of the first page, including the form number, and
				  signature page;
(5) executed
				  subcontracts: a copy of the first page, including the form number, and
				  signature page of all contracts with subcontracting physicians and
				  providers;
(6) manuals: current
				  physician manual and current provider manual provided to each contracting
				  physician or provider, which must contain details of the provisions that govern
				  the physicians and providers;
(7)
				  credentialing files: as specified in §
											11.1902(4)
				  of this title (relating to Quality Improvement Program for Basic, Single
				  Service, and Limited Service HMOs);
(8) reporting system: the statistical
				  reporting system developed and maintained by the applicant that allows for
				  compiling, developing, evaluating, and reporting statistics relating to the
				  cost of operation, the pattern of utilization of services, and the
				  accessibility and availability of services;
(9) claims systems: policies and procedures
				  that demonstrate the capacity to pay claims timely and to comply with all
				  applicable statutes and rules;
(10)
				  financial records: financial information, including statements, ledgers,
				  checkbooks, inventory records, evidence of expenditures, investments, and
				  debts; and
(11) any other records:
				  demonstrating compliance with applicable statutes and rules, including audits
				  or examination reports by other entities, including governmental authorities or
				  accrediting agencies.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter C - APPLICATION FOR CERTIFICATE OF AUTHORITY › Section 11.206 - Review of Application; Examination

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  An application for a certificate of authority will be processed in compliance
				  with §
										1.809
				  of this title (relating to HMO Certificate of Authority).
(b) After completion of the department's
				  review of documents, the department may perform quality of care and financial
				  examinations. If a hearing is held in compliance with §
										1.809
				  of this title, then the examinations must occur before the date of the hearing.
				  The commissioner may request a copy of the most recent financial examination
				  report issued by the domiciliary regulator of an applicant that is a foreign
				  HMO, instead of conducting a financial examination.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter C - APPLICATION FOR CERTIFICATE OF AUTHORITY › Section 11.207 - Withdrawal of an Application

Current through Reg. 49, No. 28; July 12, 2024
(a) On written
				  notice to the department, an applicant may request withdrawal of an application
				  for a certificate of authority from consideration by the department.
(b) The department may close an application
				  if the department determines that the applicant has failed to respond in a
				  timely manner to requests made by the department for additional information or
				  if the application is incomplete.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter D - REGULATORY REQUIREMENTS FOR AN HMO AFTER ISSUANCE OF CERTIFICATE OF AUTHORITY › Section 11.301 - Filing Requirements

Current through Reg. 49, No. 28; July 12, 2024
After the commissioner issues an HMO's certificate of
					 authority, the HMO is required to file with the commissioner, either for
					 approval before effect or for information only, any items specified in §
										11.204 of
					 this title (relating to Contents) that the HMO has deleted, amended, or revised
					 as outlined in paragraphs (4) and (5) of this section and any items specified
					 in §
										11.302
					 of this title (relating to Service Area Expansion or Reduction Applications).
					 These requirements include filing changes made necessary by federal or state
					 law or regulations. All requirements in this section apply to both electronic
					 and paper filings unless stated otherwise.
(1) Completeness and format of filings.
(A) The department will not accept a filing
				  for review until the filing is complete. An application to modify an approved
				  application for a certificate of authority that requires the commissioner's
				  approval under Insurance Code §
											843.080
				  (concerning Modification or Amendment of Application Information) or Insurance
				  Code Chapter 1271, Subchapter C, (concerning Commissioner Approval) is
				  considered complete when all information required by this section;
				  §11.302; and Chapter 11, Subchapter T, of this title (relating to Quality
				  of Care) that is applicable and reasonably necessary for the department to make
				  a final determination has been filed.
(B) Unless otherwise required by this chapter
				  or the Insurance Code, an HMO may submit a filing electronically through the
				  NAIC's System for Electronic Rate and Form Filing or through any other method
				  acceptable to the department.
(C)
				  Unless otherwise required by this chapter or the Insurance Code, paper filings
				  must:
(i) be submitted on 8-1/2- by 11-inch
				  paper;
(ii) not be submitted in
				  bound booklets;
(iii) be
				  legible;
(iv) be in typewritten,
				  computer generated, or printer's proof format; and
(v) except for maps, not contain any color
				  highlighting unless accompanied by a clean copy without highlighting.
(D) As provided in this section,
				  an HMO may submit some filings as provided in §
											7.201 of
				  this title (relating to Forms Filings).
(E) As provided in this section, an HMO may
				  submit some filings as provided in §
											11.203(a)
				  of this title (relating to Revisions During Review Process).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter D - REGULATORY REQUIREMENTS FOR AN HMO AFTER ISSUANCE OF CERTIFICATE OF AUTHORITY › Section 11.302 - Service Area Expansion or Reduction Applications

Current through Reg. 49, No. 28; July 12, 2024
(a) An HMO must file an application with the
				  department for approval before the HMO may expand an existing service area,
				  reduce an existing service area, or add a new service area.
(b) For the purposes of an application to
				  expand an existing service area, reduce an existing service area, or add a new
				  service area, an HMO must file the following items:
(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 §
											11.204(13)
				  of this title (relating to Contents);
(2) network configuration information, as
				  required by §
											11.204(19)
				  of this title;
(3) combined
				  financial projections as described in §
											11.204(10)(B)
				  of this title, including a breakdown of the income statement for existing
				  business, and the effect of the proposed service area expansion or reduction;
				  and
(4) if any of the items
				  specified in §
											11.301 of
				  this title (relating to Filing Requirements) are changed by a service area
				  expansion or reduction application, the new item or any amendments to an
				  existing item must be filed for approval or filed for information, as outlined
				  in §
											11.301(4) and
				  (5) of this title.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter F - EVIDENCE OF COVERAGE › Section 11.501 - Contents of the Evidence of Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) An
				  evidence of coverage or an amendment to an evidence of coverage may not be
				  issued, delivered, or used in Texas unless it has been filed for review and has
				  received the approval of the commissioner. The following forms are always
				  considered to be part of the evidence of coverage:
(1) group agreement;
(2) certificate issued to each subscriber who
				  is enrolled through a group (the same form may be used as both the group
				  agreement and the group certificate);
(3) conversion and individual
				  agreements;
(4) group, conversion,
				  and individual applications for coverage;
(5) group subscriber enrollment
				  form;
(6) riders, endorsements,
				  amendments, and letters of agreement;
(7) matrix filings;
(8) schedule of benefits; and
(9) any other form attached to or made a part
				  of the evidence of coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter F - EVIDENCE OF COVERAGE › Section 11.502 - Filing Requirements for Evidence of Coverage Filed as Part of an Application for a Certificate of Authority

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  The filing and formatting requirements of §
										11.301(1)(B) and
				  (2)(A) of this title (relating to Filing
				  Requirements) apply to an evidence of coverage, when filed as part of the
				  application for a certificate of authority.
(b) During the review period, an applicant
				  must submit each new page or form reflecting any revisions.
(c) No later than the 10th calendar day after
				  approval or issuance of a certificate of authority, an HMO must file a clean,
				  final version of the evidence of coverage with revisions and a copy of the
				  original version of the evidence of coverage showing the new or revised text as
				  redlined. The submission must include:
(1) an
				  explanation that the evidence of coverage was submitted as part of the
				  application for a certificate of authority and is being submitted in compliance
				  with this subsection;
(2) a
				  certification that the forms are without deviation and are the exact final
				  evidence of coverage versions that resulted in approval of the certificate of
				  authority application; and
(3) the
				  final version of an approved service area description and map as attached to
				  the evidence of coverage, with key and scale, which must identify the county or
				  counties or portions of counties to be served.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter F - EVIDENCE OF COVERAGE › Section 11.503 - Filing Requirements for Evidence of Coverage after Receipt of Certificate of Authority

Current through Reg. 49, No. 28; July 12, 2024
(a) After receipt
				  of a certificate of authority, no evidence of coverage filing may be amended or
				  altered in any manner, and no new evidence of coverage filing may be used,
				  unless the proposed new or revised evidence of coverage filing has been filed
				  for review and has received the approval of the commissioner. The evidence of
				  coverage must be filed as provided in §
										11.301 of
				  this title (relating to Filing Requirements).
(b) The department will notify the HMO of the
				  department's action in compliance with §
										1.704
				  of this title (relating to Summary Procedure; Notice).
(c) The department will base its approval or
				  disapproval on the content of drafts submitted to the department. Filings must
				  comply with the specifications described in §
										11.505
				  of this title (relating to Specifications for the Evidence of Coverage and
				  Matrix Filings). Any discrepancy in content between the final document to be
				  issued and the approved draft is grounds for revocation of the certificate of
				  authority.
(d) The review period
				  for an evidence of coverage filing begins on the date an acceptable, typed
				  draft of the form is received.
(e)
				  The review period may be extended on 30-days written notice of extension to the
				  HMO before the expiration of the initial review period.
(f) At the end of the review period, the
				  evidence of coverage filing is considered approved unless it has already been
				  withdrawn, affirmatively approved, or disapproved by the
				  commissioner.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter F - EVIDENCE OF COVERAGE › Section 11.504 - Disapproval of an Evidence of Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) If
				  the department disapproves any portion of an evidence of coverage, the
				  department will specify the reason for the disapproval. The department may
				  disapprove any form or withdraw any previous approval if a form:
(1) fails to meet the requirements of
				  Insurance Code Chapter 1271 (concerning Benefits Provided by Health Maintenance
				  Evidence of Coverage; Charges), this chapter, or other applicable statutes and
				  regulations;
(2) does not properly
				  describe the services and benefits;
(3) contains any statements that are unclear,
				  untrue, unjust, unfair, inequitable, misleading, or deceptive or that violate
				  Insurance Code Chapters 541 (concerning Unfair Methods of Competition and
				  Unfair or Deceptive Acts or Practices), 542 (concerning Processing and
				  Settlement of Claims), 543 (concerning Prohibited Practices Related to Policy
				  or Certificate of Membership), 544 (concerning Prohibited Discrimination), or
				  547 (concerning False Advertising by Unauthorized Insurers), or any other
				  applicable law or regulations;
(4)
				  provides services or benefits that are too restrictive to achieve the purpose
				  for which the form was designed;
(5) fails to attain a reasonable degree of
				  readability, simplicity, and conciseness;
(6) provides services or benefits or contains
				  other provisions that would endanger the solvency of the issuing HMO;
				  or
(7) is contrary to the law or
				  policy of this state.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter F - EVIDENCE OF COVERAGE › Section 11.505 - Specifications for Evidence of Coverage Including Insert Pages and Matrix Filings

Current through Reg. 49, No. 28; July 12, 2024
(a) The filing and
				  formatting requirements of §
										11.301 of
				  this title (relating to Filing Requirements) apply to an evidence of
				  coverage.
(b) The style,
				  arrangement, and overall appearance of documents must give no undue prominence
				  to any portion of the text. The text of the group, individual, and conversion
				  agreements, the certificate, and all amendments include all printed matter
				  except:
(1) the HMO's name, address, website
				  address, and phone number;
(2) the
				  name or title of the form;
(3) the
				  captions and subcaptions; and
(4)
				  any brief introduction to or description of the evidence of coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter F - EVIDENCE OF COVERAGE › Section 11.506 - Mandatory Contractual Provisions: Group, Individual, and Conversion Agreement and Group Certificate

Current through Reg. 49, No. 28; July 12, 2024
(a) Each enrollee
				  residing in Texas is entitled to an evidence of coverage under a health care
				  plan. An HMO may deliver the evidence of coverage electronically but must
				  provide a paper copy on request.
(b) Each group, individual, and conversion
				  contract and group certificate must contain the following provisions:
(1) Face page. Where applicable, the name,
				  address, website address, and phone number of the HMO must appear. The
				  toll-free number referred to in Insurance Code §
											521.102
				  (concerning Health Maintenance Organization or Insurer Toll-Free Number for
				  Information and Complaints) must appear on the face page.
(A) The face page of an agreement is the
				  first page that contains any written material.
(B) If the agreements or certificates are in
				  booklet form, the first page inside the cover is considered the face
				  page.
(C) The HMO must provide the
				  information regarding the toll-free number referred to in Insurance Code
				  Chapter 521, Subchapter C, (concerning Health Maintenance Organization or
				  Insurer Toll-Free Number for Information and Complaints), in compliance with
				  §
												1.601
				  of this title (relating to Notice of Toll-Free Telephone Numbers and
				  Information and Complaint Procedures).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter F - EVIDENCE OF COVERAGE › Section 11.507 - Additional Mandatory Contractual Provisions: Conversion and Individual Agreements

Current through Reg. 49, No. 28; July 12, 2024
Conversion and individual agreements must contain the
					 following additional mandatory provisions:
(1) Reinstatement. A provision clearly
				  setting forth the requirements for reinstatement and disclosing how
				  reinstatement changes or affects the rights and coverages originally provided.
				  New evidence of insurability may be required.
(2) Ten days to examine agreement. A
				  provision stating that the contract holder may return the contract within 10
				  days of receiving it and have the premium paid refunded if, after examination
				  of the contract, the contract holder is not satisfied with it for any reason.
				  If the contract holder returns the contract to the issuing HMO or to the agent
				  through whom it was purchased, then the contract is considered void from the
				  beginning and the parties are in the same position as if no contract had been
				  issued. If services are rendered or claims paid by the HMO during the 10 days,
				  the subscriber is responsible for repaying the HMO for the services or
				  claims.
(3) Consideration. The
				  original consideration, including premiums, application fee, and any other
				  amounts to be paid for coverage, must be expressed in the agreement or in the
				  application.
(4) Continuance of
				  coverage due to change in marital status. A provision stating that if a person
				  loses coverage due to a change in marital status, that person will be issued
				  coverage in compliance with §
										21.407 of
				  this title (relating to Continuance of Coverage).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter F - EVIDENCE OF COVERAGE › Section 11.509 - Additional Mandatory Benefit Standards: Individual and Group Agreements

Current through Reg. 49, No. 28; July 12, 2024
Individual and group agreements must contain the following
					 additional mandatory provisions as applicable:
(1) Certificate. Group agreements must
				  include provisions that the contract holder must be provided with subscriber
				  certificates to be delivered to each subscriber, the certificate is a part of
				  the group contract as if fully incorporated, and any direct conflict between
				  the group agreement and the certificate will be resolved according to the terms
				  most favorable to the subscriber. If the same form is used as both the group
				  contract and the certificate, a copy of the group contract must be delivered to
				  each subscriber.
(2) New enrollees.
				  Group agreements must include a provision specifying the conditions under which
				  new enrollees may be added to those originally covered, including effective
				  date requirements. For coverage issued to employers, group agreements must
				  include a provision for special enrollment under 45 C.F.R. § 146.117
				  (concerning Special Enrollment Periods).
(3) Agreements must comply with the benefit,
				  offer, coverage, and notice requirements contained in Insurance Code Title 8,
				  Subtitle E, (concerning Benefits Payable Under Health Coverages), as
				  applicable.
(4) Inability to
				  undergo dental treatment. Group agreements, except for contracts issued to
				  small employer plans and consumer choice health benefit plans, may not exclude
				  from coverage under the plan an enrollee who is unable to undergo dental
				  treatment in an office setting or under local anesthesia due to a documented
				  physical, mental, or medical reason as determined by the enrollee's physician
				  or the dentist providing the dental care. This benefit does not require an HMO
				  to provide dental services if dental services are not otherwise scheduled or
				  provided as part of the benefits covered by the agreement.
(5) Agreements, including consumer choice
				  health benefit plan agreements, providing coverage for children under 18 must
				  define reconstructive surgery for craniofacial abnormalities as provided by
				  Insurance Code §
										1367.153
				  (concerning Reconstructive Surgery for Craniofacial Abnormalities; Definition
				  Required).
(6) Group agreements,
				  including consumer choice health benefit plan agreements, must cover formulas
				  necessary to treat phenylketonuria or a heritable disease to the same extent
				  that the agreement provides coverage for drugs that are available only on the
				  orders of a physician, as required by Insurance Code Chapter 1359 (concerning
				  Formulas for Individuals With Phenylketonuria or Other Heritable
				  Diseases).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter F - EVIDENCE OF COVERAGE › Section 11.511 - Optional Provisions

Current through Reg. 49, No. 28; July 12, 2024
Evidences of coverage may contain optional provisions,
					 including, but not limited to, the following:
(1) Coordination of benefits. Plans may
				  contain a provision that the value of any benefits or services provided by the
				  HMO may be coordinated with any other type of insurance plan or coverage under
				  governmental programs so no more than 100 percent of eligible expenses incurred
				  is paid. The coordination of benefits provision applies to the plan when an
				  enrollee has health care coverage under more than one plan. This provision will
				  only apply for the duration of the enrollee's coverage in a plan.
(A) If benefits are covered by more than one
				  plan, any plan or plans that do not have a coordination of benefits provision
				  are primary.
(B) Group plans issued
				  or renewed on or before March 25, 2014, may not coordinate benefits with any
				  type of individual or conversion plan.
(C) Group plans issued or renewed on or after
				  March 25, 2014, may coordinate benefits with other plans subject to the
				  requirements of Insurance Code Chapter 1203 (concerning Coordination of
				  Benefits Provisions) and Chapter 3, Subchapter V, of this title (relating to
				  Coordination of Benefits).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter F - EVIDENCE OF COVERAGE › Section 11.512 - Optional Benefits

Current through Reg. 49, No. 28; July 12, 2024
An HMO may provide health services to its enrollees in
					 addition to the services required in §
										11.508
					 of this title (relating to Basic Health Care Services and Mandatory Benefit
					 Standards: Group, Individual and Conversion Agreements). An HMO may limit these
					 optional health services as to time and cost. Evidences of coverage may contain
					 optional benefits, including:
(1)
				  corrective appliances and artificial aids;
(2) cosmetic surgery;
(3) care for military service-connected
				  disabilities for which the enrollee is legally entitled to services and for
				  which facilities are reasonably available to the enrollee;
(4) care for conditions that state or local
				  law requires be treated in a public facility;
(5) dental services, except as otherwise
				  required;
(6) vision
				  care;
(7) custodial or domiciliary
				  care;
(8) experimental and
				  investigational medical, surgical, or other experimental or investigational
				  health care procedures, unless approved as a basic health care service by the
				  policymaking body of the HMO, provided that:
(A) a denial of a request for experimental or
				  investigational services is an adverse determination; and
(B) an HMO must comply with Chapter 19,
				  Subchapter R, of this title (relating to Utilization Reviews for Health Care
				  Provided Under a Health Benefit Plan or Health Insurance Policy) if the HMO
				  denies requested services because the HMO determines that the requested
				  services are experimental and investigational;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter G - ADVERTISING AND SALES MATERIAL › Section 11.602 - HMOs Subject to Insurance Code Chapters 541, 542, and 547, and Related Rules

Current through Reg. 49, No. 28; July 12, 2024
HMOs must comply with Insurance Code Chapters 541
					 (concerning Unfair Methods of Competition and Unfair or Deceptive Acts or
					 Practices), 542 (concerning Processing and Settlement of Claims), and 547
					 (concerning False Advertising by Unauthorized Insurers) and related rules, to
					 the extent these rules may be applied to HMOs in the same manner as insurance
					 companies.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter G - ADVERTISING AND SALES MATERIAL › Section 11.603 - Filings

Current through Reg. 49, No. 28; July 12, 2024
Any HMO licensed to do business in Texas that offers
					 coverage to Medicare beneficiaries under the provisions of Subchapter XVIII of
					 42 United States Code, Health Insurance for the Aged and Disabled, must file
					 with the department a copy of each advertisement related to the coverage that
					 is produced by the HMO or its agents and is an invitation to inquire or
					 invitation to contract as defined in §
										21.113
					 of this title (relating to Rules Pertaining Specifically to Accident and Health
					 Insurance Advertising and Health Maintenance Organization Advertising) no later
					 than 45 days before its use. Material must be filed in compliance with §
										21.120 of this
					 title (relating to Filing for Review). Material filed under this paragraph is
					 not to be considered approved but may be subject to review for compliance with
					 Texas law and consistency with other documents.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter H - SCHEDULE OF CHARGES › Section 11.701 - Schedule of Charges Must be Filed Before Use

Current through Reg. 49, No. 28; July 12, 2024
(a) No schedule of charges, formula, or
				  method for calculating the schedule of charges may be used until a copy of the
				  formula or method for calculating the schedule of charges with supporting
				  documentation has been filed with the commissioner, as required by §
										11.703
				  of this title (relating to Filings and Supporting Documentation).
(b) The schedule of charges must include all
				  charges made for group, conversion, or individual coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter H - SCHEDULE OF CHARGES › Section 11.702 - Actuarial Certification

Current through Reg. 49, No. 28; July 12, 2024
Each formula or method for calculating the schedule of
					 charges must be accompanied by the certification of a qualified actuary that,
					 based on reasonable assumptions, the formula is appropriate to produce rates
					 that are not excessive, inadequate, or unfairly discriminatory. An actuary is
					 considered qualified if he or she is a member in good standing of both the
					 American Academy of Actuaries and the Society of Actuaries.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter H - SCHEDULE OF CHARGES › Section 11.703 - Filings and Supporting Documentation

Current through Reg. 49, No. 28; July 12, 2024
An HMO must submit schedule of charges information with the
					 certificate of authority application in compliance with §
										11.204(11) and
					 (12) of this title (relating to Contents).
					 After the commissioner issues a certificate of authority, the HMO must file
					 rates and supporting documentation before use as follows:
(1) rates for a new product:
(A) evidences of coverage to which the rates
				  apply;
(B) for individual and small
				  group plans, a new rate sheet including rates for each plan and each
				  combination of rating factors used by the HMO; and
(C) actuarial memorandum:
(i) a brief description of benefits and
				  general marketing method;
(ii) a
				  brief description of how rates were determined, including a general description
				  and source of each assumption used;
(iii) a list of retention components,
				  including, but not limited to, expenses, taxes, fees, and profit expressed as a
				  percent of premium, dollars per policy, or dollars per unit of
				  benefit;
(iv) the target loss
				  ratio, including a brief description of how it was calculated and all
				  components used in its calculation;
(v) a description of the experience used in
				  developing the HMO's rates, including the level of credibility and
				  appropriateness of experience data, and justification for the use of proposed
				  manual rates if the HMO's own experience is not credible;
(vi) the assumptions and support used in
				  developing rates, including, but not limited to, adjustments for trend,
				  morbidity, lapses, risk-mitigating programs, and changes in benefits;
(vii) any other data used to support the
				  proposed rate; and
(viii) an
				  actuarial certification required by §
												11.702 of
				  this title (relating to Actuarial Certification);
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter H - SCHEDULE OF CHARGES › Section 11.704 - Conversion Rates

Current through Reg. 49, No. 28; July 12, 2024
(a) Charges for any
				  individual's coverage may not be based on the individual's health
				  status.
(b) The charge by an HMO
				  for individual coverage that has been converted from group coverage may not
				  exceed 200 percent of the rate that the individual would be charged for
				  comparable group coverage.