reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 7 - CORPORATE AND FINANCIAL REGULATION › Subchapter S - MULTIPLE-EMPLOYER WELFARE ARRANGEMENTS REQUIREMENTS FOR OBTAINING AND MAINTAINING CERTIFICATE OF AUTHORIZATION › Section 7.1911 - Name Eligibility and Proof of Existence

Current through Reg. 49, No. 28; July 12, 2024
(a) No multiple-employer welfare arrangement
				  licensed under this subchapter shall take any name which is the same as or
				  closely resembles the name of any other multiple-employer welfare arrangement
				  possessing a certificate of authority and doing business in this state. A
				  multiple-employer welfare arrangement must complete a name application form to
				  transact business under its own name and shall not adopt any assumed name,
				  except that a multiple-employer welfare arrangement by amending its articles
				  may change its name or take a new name with the approval of the
				  commissioner.
(b) Whenever it shall
				  be necessary in any legal proceeding to prove the existence of a
				  multiple-employer welfare arrangement, a certified copy of the
				  multiple-employer welfare arrangement's certificate of authority shall be prima
				  facie evidence of the existence of the multiple-employer welfare
				  arrangement.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 7 - CORPORATE AND FINANCIAL REGULATION › Subchapter S - MULTIPLE-EMPLOYER WELFARE ARRANGEMENTS REQUIREMENTS FOR OBTAINING AND MAINTAINING CERTIFICATE OF AUTHORIZATION › Section 7.1912 - Filings by Multiple-Employer Welfare Arrangements; Report of Cash Reserves; Approval by Commissioner; Additional Actuarial Review

Current through Reg. 49, No. 28; July 12, 2024
(a) Each multiple-employer welfare
				  arrangement transacting business in this state shall file annually with the
				  commissioner statements and reports described in paragraphs (1) and (2) of this
				  subsection, as follow:
(1) within 90 days of
				  the end of the MEWA's fiscal year, financial statements audited by a certified
				  public accountant; and
(2) within
				  90 days of the end of the MEWA's fiscal year, an actuarial opinion prepared and
				  certified by an actuary who is not an employee of the multiple-employer welfare
				  arrangement and who is a fellow of the Society of Actuaries, a member of the
				  American Academy of Actuaries, or an enrolled actuary under the Employee
				  Retirement Income Security Act of 1974 (29 United
				  States Code §1241 and §
											1242).
				  The actuarial opinion shall include:
(A) a
				  description of the actuarial soundness of the multiple-employer welfare
				  arrangement, including any recommended actions that the multiple-employer
				  welfare arrangement should take to improve its actuarial soundness;
(B) the recommended amount of cash reserves
				  the multiple-employer welfare arrangement should maintain which shall not be
				  less than the greater of 20% of the total contributions in the preceding plan
				  year or 20% of the total estimated contributions for the current plan
				  year;
(C) a calculation of cash
				  reserves with proper actuarial regard for known claims, paid and outstanding, a
				  history of incurred by not reported claims, claims handling expenses, unearned
				  premium, an estimate for bad debts, a trend factor, and a margin for error;
				  and
(D) the recommended level of
				  specific and aggregate stop-loss insurance the multiple-employer welfare
				  arrangement should maintain.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 7 - CORPORATE AND FINANCIAL REGULATION › Subchapter S - MULTIPLE-EMPLOYER WELFARE ARRANGEMENTS REQUIREMENTS FOR OBTAINING AND MAINTAINING CERTIFICATE OF AUTHORIZATION › Section 7.1913 - Examination of Multiple-Employer Welfare Arrangements

Current through Reg. 49, No. 28; July 12, 2024
(a) The commissioner or any person appointed
				  by the commissioner shall have the power to examine the affairs and conduct of
				  any multiple-employer welfare arrangement and for such purposes shall have free
				  access to all the books, records, and documents that relate to the business of
				  the plan and may examine under oath its trustees or directors, officers,
				  agents, and employees in relation to the affairs, transactions, and condition
				  of the multiple-employer welfare arrangement. Examinations of a
				  multiple-employer welfare arrangement shall be made in the same manner and with
				  the same frequency that applies to domestic and foreign insurers licensed to
				  transact the business of insurance in this state.
(b) Expenses of examination shall be paid by
				  each multiple-employer welfare arrangement in the same manner and to the same
				  extent as is provided for domestic insurance companies in the Insurance Code,
				  Article 1.16.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 7 - CORPORATE AND FINANCIAL REGULATION › Subchapter S - MULTIPLE-EMPLOYER WELFARE ARRANGEMENTS REQUIREMENTS FOR OBTAINING AND MAINTAINING CERTIFICATE OF AUTHORIZATION › Section 7.1914 - Duties and Compensation of Trustees, Officers, or Directors

Current through Reg. 49, No. 28; July 12, 2024
(a) The trustees or directors of a
				  multiple-employer welfare arrangement shall give the attention and exercise the
				  vigilance, diligence, care, and skill that prudent persons use in like or
				  similar circumstances. Trustees or directors shall be responsible for all
				  operations of the multiple-employer welfare arrangement and shall take all
				  necessary precautions to safeguard the assets of the multiple-employer welfare
				  arrangement.
(b) The board of
				  trustees or directors shall select such officers as designated in the articles
				  or bylaws or trust agreement and may appoint agents as deemed necessary for the
				  transaction of the business of the multiple-employer welfare arrangement. All
				  officers and agents shall respectively have such authority and perform such
				  duties in the management of the property and affairs of the multiple-employer
				  welfare arrangement as may be delegated by the board of trustees or directors.
				  Any officer or agent may be removed by the board of trustees or directors
				  whenever in their judgment the business interests of the multiple-employer
				  welfare arrangement will be served by the removal. The board of trustees or
				  directors shall secure the fidelity of any or all such officers or agents who
				  handle the funds of the multiple-employer welfare arrangement by bond or
				  otherwise.
(c) Trustees or
				  directors shall serve without compensation from the multiple-employer welfare
				  arrangement except for actual and necessary expenses. A multiple-employer
				  welfare arrangement shall not pay any salary, compensation, or emolument to any
				  officer of the multiple-employer welfare arrangement unless the payment is
				  first authorized by a majority vote of the board of trustees or directors of
				  the multiple-employer welfare arrangement.
(d) An officer, employee, or agent of a
				  multiple-employer welfare arrangement shall not be compensated unreasonably.
				  The compensation of any officer or employee of a multiple-employer welfare
				  arrangement shall not be calculated directly or indirectly as a percentage of
				  money or premium collected. The compensation of any agent shall not exceed 5.0%
				  of the money or premium collected.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 7 - CORPORATE AND FINANCIAL REGULATION › Subchapter S - MULTIPLE-EMPLOYER WELFARE ARRANGEMENTS REQUIREMENTS FOR OBTAINING AND MAINTAINING CERTIFICATE OF AUTHORIZATION › Section 7.1915 - Suspension, Revocation, or Limitation of Certificate of Authority and Other Remedies

Current through Reg. 49, No. 28; July 12, 2024
In addition to any requirements or remedies set out in the
					 Insurance Code, Article 3.95-13, the commissioner may suspend, revoke, or limit
					 the certificate of authority of a multiple-employer welfare arrangement if the
					 commissioner finds, after notice and hearing, that the multiple-employer
					 welfare arrangement does not meet the requirements of the Insurance Code,
					 Chapter 3, Subchapter I, and these sections.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 7 - CORPORATE AND FINANCIAL REGULATION › Subchapter T - PERMISSIBLE PAYMENTS TO INSURERS, AGENTS AND SPONSORING ORGANIZATIONS › Section 7.2001 - Solicitation of Voluntary Contributions by Sponsoring Organizations

Current through Reg. 49, No. 28; July 12, 2024
Sponsoring organizations governed by Insurance Code,
					 Article 21.35-B, may solicit voluntary contributions with a membership renewal
					 solicitation when the membership renewal solicitation is separate from an
					 insurance billing.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 8 - EARLY WARNING SYSTEM FOR INSURERS IN HAZARDOUS CONDITION › Subchapter A - HAZARDOUS CONDITION › Section 8.1 - Authority, Scope, and Purpose

Current through Reg. 49, No. 28; July 12, 2024
This subchapter of the rules and regulations of the State
					 Board of Insurance is promulgated and adopted pursuant to the authority
					 provided in the Insurance Code, Articles 1.32, 3.55-1, and 21.28-A. The
					 sections in this subchapter apply to any person, organization, association, or
					 company (authorized or unauthorized, admitted or nonadmitted) acting as an
					 insurer, or as principal or agent of an insurer, including stock companies,
					 reciprocals or interinsurance exchanges, Lloyd's associations, fraternal
					 benefit societies, stipulated premium companies, title insurance companies, and
					 mutual companies of all kinds, including statewide mutual assessment
					 corporations, local mutual aid associations, burial associations, county mutual
					 insurance companies, and farm mutual insurance companies. The purpose of these
					 rules and regulations is to enumerate conditions which may indicate an insurer
					 is in hazardous condition and which may be a basis for the commissioner of
					 insurance to initiate an action against an insurer under the Insurance Code,
					 Articles 1.32, 3.55-1. or 21.28-A. In evaluating any of these conditions, all
					 circumstances concerning the insurer's operation must be evaluated in making an
					 ultimate conclusion that an insurer is in hazardous condition. The evaluation
					 of the information relating to these conditions is part of the examination
					 process. The conditions enumerated in this subchapter do not conclusively
					 indicate that an insurance company is in hazardous conditions. One or more of
					 the conditions can exist in an insurance company which is in satisfactory
					 condition; however, one or more of these conditions has often been found in an
					 insurance company which was unable to perform its obligations to policyholders,
					 claimants, creditors, or shareholders, or has required the commissioner of
					 insurance to initiate regulatory action to protect policyholders, claimants,
					 creditors, and shareholders.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 8 - EARLY WARNING SYSTEM FOR INSURERS IN HAZARDOUS CONDITION › Subchapter A - HAZARDOUS CONDITION › Section 8.2 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, shall have the following meanings, unless the context clearly
					 indicates otherwise.
(1)
				  Agency--Commissioner of insurance and all divisions, departments, and employees
				  of the commissioner of insurance or of the State Board of Insurance.
(2) Insurer--Any person, organization,
				  association, or company (authorized or unauthorized, admitted or nonadmitted)
				  acting as an insurer, or as principal or agent of an insurer, including stock
				  companies, reciprocals or interinsurance exchanges, Lloyds associations,
				  fraternal benefit societies, stipulated premium companies, title insurance
				  companies, and mutual companies of all kinds, including statewide mutual
				  assessment corporations, local mutual aid associations, burial associations,
				  county mutual insurance companies, and farm mutual insurance
				  companies.
(3) Surplus--The
				  remainder of statutorily admitted assets less statutorily required liabilities.
				  The term also includes mortuary fund and expense fund combined of statewide
				  mutual assessment companies, burial associations, and mutual aid
				  associations.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 8 - EARLY WARNING SYSTEM FOR INSURERS IN HAZARDOUS CONDITION › Subchapter A - HAZARDOUS CONDITION › Section 9.1 - Basic Manual of Rules, Rates and Forms for the Writing of Title Insurance in the State of Texas

Current through Reg. 49, No. 28; July 12, 2024
The Texas Department of Insurance adopts by reference the
Basic Manual of Rules, Rates and Forms for the Writing of Title
					 Insurance in the State of Texas
(Basic Manual) as amended, effective
					 February 1, 2021. The Basic Manual is available from the Texas Department of
					 Insurance, Mail Code 104-PC, P.O. Box 149104, Austin, TX 78711-2040. The Basic
					 Manual is also available on the TDI website at www.tdi.texas.gov, and by email
					 from ChiefClerk@tdi.texas.gov.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 8 - EARLY WARNING SYSTEM FOR INSURERS IN HAZARDOUS CONDITION › Subchapter A - HAZARDOUS CONDITION › Section 9.2 - Texas Disclosure

Current through Reg. 49, No. 28; July 12, 2024
The Texas Department of Insurance adopts by reference Form
					 T-64 and Procedural Rule P-73 as part of the
Basic Manual of Rules,
					 Rates and Forms for the Writing of Title Insurance in the State of
					 Texas
as amended, effective August 1, 2015. The documents are
					 available from the Office of the Chief Clerk, Mail Code 113-2A, Texas
					 Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. The
					 documents are also available on the TDI website at
					 www.tdi.texas.gov.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 9 - TITLE INSURANCE › Subchapter A - BASIC MANUAL OF RULES, RATES AND FORMS FOR THE WRITING OF TITLE INSURANCE IN THE STATE OF TEXAS › Section 9.1 - Basic Manual of Rules, Rates and Forms for the Writing of Title Insurance in the State of Texas

Current through Reg. 49, No. 28; July 12, 2024
The Texas Department of Insurance adopts by reference the
					 Basic Manual of Rules, Rates and Forms for the Writing of Title Insurance in
					 the State of Texas (Basic Manual) as amended, effective February 1, 2021. The
					 Basic Manual is available from the Texas Department of Insurance, Mail Code
					 104-PC, P.O. Box 149104, Austin, TX 78711-2040. The Basic Manual is also
					 available on the TDI website at www.tdi.texas.gov, and by email from
					 ChiefClerk@tdi.texas.gov.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 9 - TITLE INSURANCE › Subchapter A - BASIC MANUAL OF RULES, RATES AND FORMS FOR THE WRITING OF TITLE INSURANCE IN THE STATE OF TEXAS › Section 9.2 - Texas Disclosure

Current through Reg. 49, No. 28; July 12, 2024
The Texas Department of Insurance adopts by reference Form
					 T-64 and Procedural Rule P-73 as part of the Basic Manual of Rules, Rates and
					 Forms for the Writing of Title Insurance in the State of Texas as amended,
					 effective August 1, 2015. The documents are available from the Office of the
					 Chief Clerk, Mail Code 113-2A, Texas Department of Insurance, P.O. Box 149104,
					 Austin, Texas 78714-9104. The documents are also available on the TDI website
					 at www.tdi.texas.gov.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 9 - TITLE INSURANCE › Subchapter C - TEXAS TITLE INSURANCE STATISTICAL PLAN › Section 9.401 - Texas Title Insurance Statistical Plan

Current through Reg. 49, No. 28; July 12, 2024
The Texas Department of Insurance adopts by reference the
					 rules in the Texas Title Insurance Statistical Plan as amended effective April
					 1, 2020. This document is published by and is available from the Texas
					 Department of Insurance, Mail Code 105-5D, P.O. Box 149014, Austin, Texas
					 78714-9104. This document is also available on the TDI website at
					 www.tdi.texas.gov.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter A - GENERAL PROVISIONS AND DEFINITIONS › Section 10.1 - Purpose and Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) This chapter
				  implements provisions of the Workers' Compensation Health Care Network Act,
				  Insurance Code Chapter 1305, concerning Workers' Compensation Health Care
				  Networks, and provides standards for the certification, administration,
				  evaluation, and enforcement of the delivery of health care services to injured
				  employees by networks contracting with or established by:
(1) workers' compensation insurance
				  carriers;
(2) employers certified
				  to self-insure under Labor Code Chapter 407, concerning Self-Insurance
				  Regulation;
(3) groups of employers
				  certified to self-insure under Labor Code Chapter 407A, concerning Group
				  Self-Insurance Coverage; and
(4)
				  except as described in subsection (d) of this section, governmental entities
				  that self-insure, either individually or collectively, under:
(A) Labor Code Chapter 501, concerning
				  Workers' Compensation Insurance Coverage for State Employees, Including
				  Employees Under the Direction or Control of the Board of Regents of Texas Tech
				  University;
(B) Labor Code Chapter
				  502, concerning Workers' Compensation Insurance Coverage for Employees of the
				  Texas A&M University System and Employees of Institutions of the Texas
				  A&M University System;
(C)
				  Labor Code Chapter 503, concerning Workers' Compensation Insurance Coverage for
				  Employees of the University of Texas System and Employees of Institutions of
				  the University of Texas System;
(D)
				  Labor Code Chapter 504, concerning Workers' Compensation Insurance Coverage for
				  Employees of Political Subdivisions; and
(E) Labor Code Chapter 505, concerning
				  Workers' Compensation Insurance Coverage for Employees of Texas Department of
				  Transportation.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter A - GENERAL PROVISIONS AND DEFINITIONS › Section 10.3 - Contact Information

Current through Reg. 49, No. 28; July 12, 2024
Current email addresses, mailing addresses, and telephone
					 numbers for the Division of Workers' Compensation and MCQA are available on the
					 department's website. This contact information should be used when an email
					 address, mailing address, or telephone number is referenced in a section in
					 this chapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter B - CERTIFICATION › Section 10.20 - Certification Required

Current through Reg. 49, No. 28; July 12, 2024
Except as provided by Labor Code §
										504.053(b)(2),
					 concerning Election:
(1) A person may
				  not operate or perform any act of a workers' compensation health care network
				  in this state:
(A) unless the person holds a
				  certificate issued under Insurance Code Chapter 1305, concerning Workers'
				  Compensation Health Care Networks, and this chapter; or
(B) except in accordance with the specific
				  authorization of Insurance Code Chapter 1305 or this chapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter B - CERTIFICATION › Section 10.21 - Certificate Application

Current through Reg. 49, No. 28; July 12, 2024
(a) A person who
				  seeks a certificate to operate as a workers' compensation health care network
				  must file an application on the forms prescribed under this subchapter,
				  accompanied by a non-refundable fee of $5,000.
(b) The applicant, an officer, or other
				  authorized representative of the applicant must verify the application by
				  attesting to the truth and accuracy of the information in the
				  application.
(c) Prescribed forms
				  for a certificate application may be obtained from:
(1) the department's website; or
(2) the MCQA mailing address.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter B - CERTIFICATION › Section 10.22 - Contents of Application

Current through Reg. 49, No. 28; July 12, 2024
Each certificate application must include:
(1) a description or a copy of the
				  applicant's basic organizational structure documents and other related
				  documents, including organizational charts or lists that show:
(A) the relationships and contracts between
				  the applicant and any affiliates of the applicant; and
(B) the internal organizational structure of
				  the applicant's management and administrative staff;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter B - CERTIFICATION › Section 10.23 - Action on Application

Current through Reg. 49, No. 28; July 12, 2024
The Commissioner will approve or disapprove an application
					 for certification of a network in accordance with Insurance Code §
										1305.054,
					 concerning Action on Application; Renewal of Certification.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter B - CERTIFICATION › Section 10.24 - Network Financial Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) On at least
				  a calendar year basis, each network must prepare financial statements in
				  accordance with generally accepted accounting principles, which mustinclude:
(1) a balance sheet;
(2) an income statement;
(3) a cash flow statement;
(4) a statement of equity; and
(5) a supplemental description of the
				  network's basic organizational structure, general business relationships, and
				  management.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter B - CERTIFICATION › Section 10.25 - Filing Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A network
				  must file with the department as soon as practicable but not later than 30 days
				  prior to implementation, a written request for approval and must receive
				  department approval before implementation of changes to the following:
(1) management contracts and information
				  regarding fidelity bonds as described in Insurance Code §
											1305.102,
				  concerning Management Contracts, and §
											10.40 of
				  this title (relating to Management Contracts), including information regarding
				  cancellation of fidelity bonds, new fidelity bonds, or amendments to fidelity
				  bonds;
(2) the physical location of
				  the network's books and records as described in §
											10.22(12)
				  of this title (relating to Contents of Application); and
(3) material modification of network
				  configuration in accordance with §
											10.27
				  of this title (relating to Modifications to Network Configuration).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter B - CERTIFICATION › Section 10.26 - Modifications to Service Area

Current through Reg. 49, No. 28; July 12, 2024
(a) A network
				  must file a modification request with and receive approval from the department
				  before the network may expand, eliminate, or reduce an existing service area,
				  or add a new service area. An officer or other authorized representative of the
				  network must verify the modification request by attesting to the truth and
				  accuracy of the information in the modification request.
(b) A modification request for a service area
				  modification must include:
(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 under §
											10.22(9)
				  of this title (relating to Contents of Application);
(2) network configuration information, as
				  required under §
											10.22(11)
				  of this title; and
(3) separate and
				  consolidated projections as described in §
											10.22(13)
				  of this title for the existing network, the proposed new service area, and the
				  proposed network.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter B - CERTIFICATION › Section 10.27 - Modifications to Network Configuration

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  network must file a modification request with and receive approval from the
				  department before the network makes a material modification to its network
				  configuration. The modification request must be filed not later than 30 days
				  prior to implementation of the material modification.
(b) A modification request for a modification
				  to network configuration must include:
(1) a
				  description and a map of the network's service area or areas, with key and
				  scale, that identifies each county, ZIP code, partial ZIP code, or part of a
				  county to be served as required by §
											10.22 of
				  this title (relating to Contents of Application);
(2) network configuration information, as
				  required by §
											10.22(11)
				  of this title; and
(3) if the
				  modification involves adding or modifying telehealth service, telemedicine
				  medical service, or teledentistry dental service, an explanation of how the
				  network would update its provider directory, and any statements or restrictions
				  on services that can be provided via telehealth service, telemedicine medical
				  service, or teledentistry dental service.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter C - CONTRACTING › Section 10.40 - Management Contracts

Current through Reg. 49, No. 28; July 12, 2024
(a) A network may
				  not enter into a contract with another entity for management services, or
				  modify a previously approved management contract, unless the proposed contract
				  or modification is first filed with the department and approved by the
				  Commissioner in accordance with Insurance Code §
										1305.102,
				  concerning Management Contracts.
(b) For purposes of this chapter, management
				  services include management control and decision-making, and contracting on
				  behalf of the network under a delegation of management authority, power of
				  attorney, or other arrangement.
(c)
				  If a person is serving as both a management contractor or a third party to
				  which the network delegates a function and as an agent of the health care
				  provider, the contract between the management contractor or third party and the
				  health care provider must comply with Insurance Code §
										1305.153,
				  concerning Provider Reimbursement.
(d) A management contractor or a third party
				  that is also serving as an agent for one or more health care providers in the
				  certified network must meet the disclosure requirements with the certified
				  network under Insurance Code §
										1305.153.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter D - NETWORK REQUIREMENTS › Section 10.60 - Notice of Network Requirements; Employee Information

Current through Reg. 49, No. 28; July 12, 2024
(a) An insurance carrier that establishes or
				  contracts with a network must deliver to the employer, and the employer or
				  carrier, as applicable under subsection (g) of this section, must deliver to
				  the employer's employees in the manner and at the times prescribed by Insurance
				  Code §
										1305.005,
				  concerning Participation in Network; Notice of Network Requirements:
(1) the notice of network requirements and
				  employee information required by Insurance Code §
											1305.005
				  and §
											1305.451,
				  concerning Employee Information; Responsibilities of Employee, and this
				  section; and
(2) the employee
				  acknowledgment form described by Insurance Code §
											1305.005
				  and this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter D - NETWORK REQUIREMENTS › Section 10.62 - Dispute Resolution for Employee Requirements Related to In-Network Care

Current through Reg. 49, No. 28; July 12, 2024
(a) If an employee asserts that he or she
				  does not currently live in the network's service area, the employee may request
				  a review by contacting the insurance carrier and providing evidence to support
				  the employee's assertion.
(b) An
				  insurance carrier must review the employee's request for review, including any
				  evidence provided by the injured employee and any evidence collected by the
				  insurance carrier, and make a determination regarding whether the employee
				  lives within the network's service area or lives within the service area of any
				  other workers' compensation network contracted with or established by the
				  insurance carrier (alternate network). If an insurance carrier makes a
				  determination that the employee lives within the service area of an alternate
				  network, the insurance carrier must provide the employee with the notice of
				  network requirements as described under §
										10.60
				  of this title (relating to Notice of Network Requirements; Employee
				  Information) for the alternate network. Upon receipt of the notice of network
				  requirements, the employee must select a treating doctor from the list of the
				  alternate network's treating doctors in the network's service area.
(c) Not later than seven calendar days after
				  the date the insurance carrier receives notice of the injured employee's
				  request for review, the insurance carrier must notify the employee, in writing,
				  of the carrier's determination. This notice must include a brief description of
				  the evidence the carrier considered when making the determination, a copy of
				  the carrier's determination, and a description of how an employee may file a
				  complaint regarding this issue with the department. The insurance carrier must
				  also send a copy of the carrier's determination to the employee's
				  employer.
(d) If an employee
				  disagrees with the insurance carrier's determination, the employee may file a
				  complaint with the department in accordance with §
										10.122
				  of this title (relating to Submitting Complaints to the Department). To be
				  considered complete, the employee's complaint must include:
(1) the employee's contact information,
				  including the employee's name, current physical address, and telephone
				  number;
(2) a copy of the insurance
				  carrier's determination; and
(3)
				  any evidence the employee provided to the insurance carrier for
				  consideration.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter D - NETWORK REQUIREMENTS › Section 10.63 - Plain Language Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) The notice
				  of network requirements and employee information form and acknowledgment form
				  required by Insurance Code §
										1305.451,
				  concerning Employee Information; Responsibilities of Employee, and §
										10.60
				  of this title (relating to Notice of Network Requirements; Employee
				  Information) must be written in plain language and comply with the following
				  requirements:
(1) the text must achieve a
				  minimum level of readability that may not be more difficult than the equivalent
				  of a ninth grade reading level as measured by the Flesch reading ease test, a
				  test referenced in the list of standardized tests contained in §
											3.3092(c)(1)
				  of this title (relating to Format, Content, and Readability for Outline of
				  Coverage), or other standardized test as approved by the department;
(2) the form must be printed in not less than
				  12-point type;
(3) the form must be
				  appropriately divided and captioned in a meaningful sequence such that each
				  section contains an underlined, boldfaced, or otherwise conspicuous title or
				  caption at the beginning of the section that indicates the nature of the
				  subject matter included in or covered by the section; and
(4) the form must be written in a clear and
				  coherent manner and wherever practical, words with common and everyday meanings
				  must be used to facilitate readability.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter E - NETWORK OPERATIONS › Section 10.80 - Accessibility and Availability Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  All services specified by this section must be provided by a provider who holds
				  a current appropriate Texas license, unless the provider is exempt from license
				  requirements.
(b) The network must
				  ensure that the network's provider panel includes:
(1) an adequate number of contracted treating
				  doctors and specialists, who must be available and accessible to employees 24
				  hours a day, seven days a week, within the network's service area;
(2) sufficient numbers and types of health
				  care providers to ensure choice, access, and quality of care to injured
				  employees;
(3) an adequate number
				  of treating doctors and specialists who have admitting privileges at one or
				  more network hospitals located within the network's service area to make any
				  necessary hospital admissions;
(4)
				  hospital services that are available and accessible 24 hours a day, seven days
				  a week, within the network's service area. The network must provide for the
				  necessary hospital services by contracting with general, special, and
				  psychiatric hospitals, as applicable;
(5) physical and occupational therapy
				  services and chiropractic services that are available and accessible within the
				  network's service area;
(6)
				  emergency care that is available and accessible 24 hours a day, seven days a
				  week, without restrictions as to where the services are rendered; and
(7) an adequate number of doctors who are
				  qualified to provide maximum medical improvement and impairment rating services
				  as required under Labor Code §
											408.023,
				  concerning List of Approved Doctors; Duties of Treating
				  Doctors.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter E - NETWORK OPERATIONS › Section 10.82 - Credentialing

Current through Reg. 49, No. 28; July 12, 2024
(a) Networks must have a documented process
				  for selection and retention of preferred providers sufficient to ensure that
				  preferred providers are adequately credentialed. At a minimum, a network's
				  credentialing standards must meet the standards promulgated by the National
				  Committee for Quality Assurance (NCQA) or URAC to the extent that those
				  standards do not conflict with other laws of this state. Networks will be
				  presumed to be in compliance with statutory and regulatory requirements
				  regarding credentialing if they have received nonconditional accreditation or
				  certification by the NCQA, The Joint Commission, URAC, or the Accreditation
				  Association for Ambulatory Health Care; maintain evidence of that accreditation
				  or certification; and provide it to the department on request.
(b) The requirements of §
										10.41
				  of this title (relating to Network-Carrier Contracts) apply to delegation of
				  credentialing.
(c) Delegation of
				  credentialing.
(1) If the network delegates
				  credentialing functions to other entities, it must have:
(A) a process for developing delegation
				  criteria and for performing pre-delegation and annual audits;
(B) a delegation agreement;
(C) a monitoring plan; and
(D) a procedure for termination of the
				  delegation agreement for non-performance.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter E - NETWORK OPERATIONS › Section 10.83 - Guidelines and Protocols

Current through Reg. 49, No. 28; July 12, 2024
(a) Each network
				  must adopt treatment guidelines, return-to-work guidelines, and individual
				  treatment protocols, which must be evidence-based, scientifically valid,
				  outcome-focused, and be designed to reduce inappropriate or unnecessary health
				  care while safeguarding access to necessary care.
(b) An insurance carrier or network may not
				  deny treatment for a compensable injury solely because its treatment guidelines
				  do not specifically address the treatment or injury.
(c) A network must, through its quality
				  improvement program under §
										10.81
				  of this title (relating to Quality Improvement Program), assure that all
				  treatment guidelines, return-to-work guidelines, and individual treatment
				  protocols are made accessible to all network providers. The network must
				  contractually require providers to follow treatment guidelines, return-to-work
				  guidelines, and individual treatment protocols pursuant to §
										10.42(b)(2)
				  of this title (relating to Network Contracts with Providers).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter E - NETWORK OPERATIONS › Section 10.84 - Treating Doctor

Current through Reg. 49, No. 28; July 12, 2024
In addition to the duties and requirements placed upon
					 treating doctors under Insurance Code Chapter 1305, concerning Workers'
					 Compensation Health Care Networks, and this chapter, a doctor designated as a
					 treating doctor by a network must comply with Labor Code §§
										408.0041(c) and
					 (g), concerning Designated Doctor
					 Examination; 408.025(c), concerning Reports and Records Required from Health
					 Care Providers; 408.023(l) - (p), concerning List of Approved Doctors; Duties
					 of Treating Doctors; and rules adopted by the Commissioner of Workers'
					 Compensation.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter E - NETWORK OPERATIONS › Section 10.85 - Selection of Treating Doctor; Change of Treating Doctor

Current through Reg. 49, No. 28; July 12, 2024
(a) Selection of treating doctor. An injured
				  employee who lives within the service area is entitled to the employee's
				  initial choice of a treating doctor from the list provided by the network of
				  all treating doctors under contract with the network who provide services
				  within the service area in which the injured employee lives in accordance with
				  Insurance Code §
										1305.104(a),
				  concerning Selection of Treating Doctor.
(b) Change of treating doctor. An injured
				  employee who is dissatisfied with the employee's initial choice of treating
				  doctor or with an alternate treating doctor may select an alternate or
				  subsequent treating doctor in accordance with Insurance Code §
										1305.104(b) -
				  (e).
(c) Use of specialist as treating doctor. An
				  injured employee with a chronic, life-threatening injury or chronic pain
				  related to a compensable injury may apply to the network's medical director to
				  use a specialist that is in the same network as the injured employee's treating
				  doctor in accordance with Insurance Code §
										1305.104(f) -
				  (i).
(d) Request for an HMO primary care physician
				  or provider as the employee's treating doctor. An injured employee required to
				  receive health care services within a network may select as the employee's
				  treating doctor a doctor who the employee selected, prior to injury, as the
				  employee's primary care physician or provider under Chapter 843, as the terms
				  "physician" and "provider" are defined in that chapter. The network must grant
				  an employee's request for an HMO primary care physician or provider to serve as
				  the employee's treating doctor if the physician or provider agrees to abide by
				  the terms of the network's contract and comply with Insurance Code Chapter
				  1305, Subchapters D - I, and rules adopted under those subchapters, as
				  applicable to treating doctors.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter E - NETWORK OPERATIONS › Section 10.86 - Telephone Access

Current through Reg. 49, No. 28; July 12, 2024
Each network must establish and maintain telephone access
					 logs for calls received other than during regular business hours that
					 accurately record the following:
(1)
				  the date the network received the telephone call;
(2) detailed information necessary for the
				  network to respond to the telephone call;
(3) the date the network responded to the
				  telephone call; and
(4) identifying
				  information for the telephone call.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter F - UTILIZATION REVIEW › Section 10.100 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
In addition to the requirements under this subchapter, the
					 requirements of Insurance Code Chapter 4201, concerning Utilization Review
					 Agents, apply to utilization review conducted in relation to a workers'
					 compensation health care network. In the event Chapter 4201 conflicts with this
					 chapter and Insurance Code Chapter 1305, concerning Workers' Compensation
					 Health Care Networks, this chapter and Insurance Code Chapter 1305
					 control.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter F - UTILIZATION REVIEW › Section 10.104 - Independent Review of Adverse Determination

Current through Reg. 49, No. 28; July 12, 2024
(a) Requirements for independent review of an
				  adverse determination are governed by Insurance Code Chapter 1305, concerning
				  Workers' Compensation Health Care Networks, and department and Division of
				  Workers' Compensation rules, including Chapter 10, Subchapter F, of this title
				  (relating to Utilization Review), Chapter 12 of this title (relating to
				  Independent Review Organizations), Chapter 19 of this title (relating to
				  Licensing and Regulation of Insurance Professionals), and §
										133.308
				  of this title (relating to MDR of Medical Necessity Disputes).
(b) The person who performs utilization
				  review; denies a referral request because the referral is not medically
				  necessary; or denies a request for deviation from treatment guidelines,
				  individual treatment protocols, or screening criteria must:
(1) permit the employee, person acting on
				  behalf of the employee, or the employee's requesting provider to seek review of
				  the referral denial or reconsideration denial within the period prescribed by
				  subsection (c) of this section by an independent review organization assigned
				  in accordance with Insurance Code Chapter 4202, concerning Independent Review
				  Organizations, and department and Division of Workers' Compensation rules;
				  and
(2) provide to the appropriate
				  independent review organization the information and documents listed in §
											133.308(k)
				  of this title (relating to MDR of Medical Necessity Disputes) and the response
				  letter described by Insurance Code §
											1305.354(a)(4),
				  concerning Reconsideration of Adverse Determination, not later than the third
				  business day after the date the person receives notification of the assignment
				  of the request to an independent review organization.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter G - COMPLAINTS › Section 10.120 - Complaint System Required

Current through Reg. 49, No. 28; July 12, 2024
(a) Each network
				  must implement and maintain a complaint system compliant with Insurance Code
				  Chapter 1305, Subchapter I, concerning Complaint Resolution, and this
				  subchapter that provides reasonable procedures for resolving an oral or written
				  complaint.
(b) For purposes of this
				  subchapter, a complaint relating to a fee dispute is a complaint from a
				  provider regarding failure to pay a claim in accordance with the contract
				  between the network and provider.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter G - COMPLAINTS › Section 10.121 - Complaints; Deadlines for Response and Resolution

Current through Reg. 49, No. 28; July 12, 2024
(a) Not later than seven calendar days after
				  receipt of an oral or written complaint, a network must:
(1) acknowledge receipt of the complaint in
				  writing;
(2) acknowledge the date
				  of receipt; and
(3) provide a
				  description of the network's complaint procedures and deadlines.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter G - COMPLAINTS › Section 10.122 - Submitting Complaints to the Department

Current through Reg. 49, No. 28; July 12, 2024
(a) Any person, including a person who has
				  attempted to resolve a complaint through a network's complaint system process
				  or attempted to resolve a dispute regarding whether the employee lives within
				  the network's service area through the insurance carrier, who is dissatisfied
				  with resolution of the complaint, may submit a complaint to the
				  department.
(b) The department's
				  complaint form may be obtained from the department's website.