Part 1.
TEXAS DEPARTMENT OF INSURANCE
Chapter 11.
HEALTH MAINTENANCE ORGANIZATIONS
The Texas Department of Insurance proposes amendments to §11.2
concerning definitions relating to health maintenance organization (HMO) telehealth
services and telemedicine medical services and physician and provider credentialing; §11.1607
concerning accessibility and availability requirements for HMOs providing
telemedicine medical services and telehealth services; and §§11.1901-11.1902
concerning quality improvement programs operated by HMOs, including credentialing
and recredentialing of physicians and providers. The amendments to §11.2
provide definitions necessary to implement Senate Bill 544 (Acts 2001, 77th
Leg., ch. 1369, §2, eff. Sept. 1, 2001), which enacted Insurance Code
Article 20A.39 relating to credentialing of physicians and providers and Senate
Bill 789 (Acts 2001, 77th Leg. ch. 1255, §§5-9, eff. June 15, 2001)
which amended the Insurance Code Article 21.53F relating to telemedicine and
telehealth services. The amendments to §11.1607 are necessary to clarify
the applicability of subsections (i)-(k) to both telehealth services and telemedicine
medical services as a result of the enactment of Senate Bill 789. The amendments
to §§11.1901 and 11.1902 are necessary to reorganize, clarify, and
eliminate redundancy in the current requirements and procedures in these sections,
for quality improvement programs operated by HMOs. Section 11.1903, relating
to the operation and responsibilities of an HMO quality improvement committee,
is proposed for repeal; the proposed repeal is published elsewhere in this
issue of the
Texas Register
. Additionally,
the amendments to §11.1902(4) and (5) propose standards necessary to
implement Senate Bill 544 which specifies guidelines and standards for rules
adopted under the Insurance Code Article 20A.37 that regulate implementation
and maintenance of HMO credentialing, the process for selecting and retaining
affiliated physicians and providers. Article 20A.37 requires each HMO to have
an ongoing internal quality assurance program to monitor and evaluate its
health care services in all institutional and noninstitutional contexts and
authorizes the Commissioner to establish, by rule, minimum standards and requirements
for these programs, including, but not limited to, standards for assuring
availability, accessibility, quality and continuity of care.
The proposed amendments to §11.2 clarify that credentialing is the
process of collecting, assessing, and validating qualifications and other
relevant information pertaining to a physician or provider to determine eligibility
to deliver health care services. They also delete the reference to "dentist"
in the definition of credentialing and clarify, in the definition of dentist,
that a dentist is an individual provider. These changes are consistent with
other proposed clarification changes in §§11.1901-11.1902 to include
dentists as individual providers in the proposed rules. The proposed amendments
also add definitions for individual provider, institutional provider, recredentialing,
telehealth service and telemedicine medical services and delete the definition
of credentials because it is not necessary.
The proposed amendments to §11.1607(i)-(k) clarify that the current
requirements and criteria that apply to an HMO's provision of telemedicine
shall also apply to telehealth services, including that each evidence of coverage
delivered or issued for delivery by an HMO may provide enrollees the option
to access covered health care services through a telehealth service or a telemedicine
medical service. The proposed amendments also change the term "telemedicine"
to "telemedicine medical services" for consistency with the Insurance Code
Article 21.53F as enacted by Senate Bill 789.
In accordance with Senate Bill 544, amendments to §11.1902(4) and
(5) propose standards for credentialing and recredentialing of physicians
and providers that are in compliance with the standards in the Insurance Code
Article 20A.39 and with standards of the National Committee for Quality Assurance
(NCQA), to the extent that the NCQA standards do not conflict with other laws
of this state. The NCQA is an independent nonprofit organization that uses
performance measures to assess and accredit managed care organizations, including
HMOs. The amendments propose standards for credentialing policies and procedures
for physicians, individual providers, and institutional providers, including
initial and recredentialing primary source verification; the credentialing
application; initial and recredentialing sanction information; initial credentialing
site visits; performance monitoring; ongoing monitoring of sanctions and complaints;
notification to appropriate authorities of actions taken against a physician
or provider and physician and provider appeal rights; initial and ongoing
assessment of institutional providers; and delegation of credentialing; and
uniform requirements and guidelines for HMOs conducting site visits for cause.
Throughout the proposed amendments to §§11.1901-11.1902, two
changes are proposed for clarification and simplification with no substantive
changes to the current rules: (i) deletion of references to the term "dentists"
because the proposed definitions of both of the terms "dentist" and "individual
provider," as well as the definition of "provider" in the Insurance Code Article
20A.02(t), result in dentists being included as "individual providers" in
the proposed rules; and (ii) specification of "individual providers" and "institutional
providers" as appropriate. Also, wherever the current provisions of §11.1903
are incorporated into §§11.1901-11.1902, or current provisions of §§11.1901-11.1902
are reorganized, the current wording is revised in some instances for purposes
of clarification and deletion of redundancy and to reflect the Department's
interpretation of current rules.
The proposed amendments to §11.1901 incorporate the various provisions
of §§11.1902(8)(B) and 11.1903 relating to the responsibilities
of the HMO governing body to receive and review reports on the quality improvement
program, including the delegation of quality improvement activities and the
use of multidisciplinary teams by the quality improvement committee.
The proposed amendments to §11.1902 clarify that the HMO shall dedicate
adequate resources to the quality improvement program, incorporate current §11.1902(2)(C)
and clarify that the HMO shall continuously update and monitor the quality
improvement program.
The proposed amendments to §11.1902(2) clarify that an annual quality
improvement work plan shall include a schedule of activities designed to reflect
the population served by the HMO in terms of age groups, disease categories,
and special risk status; that an annual quality improvement work plan shall
include goals, objectives, and planned projects or activities identified from
the previous year, as well as for the current year; time frames for implementation;
individuals responsible; and coordination of functions; and what the HMO must
include in the annual quality improvement work plan to monitor quality improvement,
including objective and measurable quality indicators, process or outcome
performance measurements, and data appropriate to the goals and objectives
of the activity.
The proposed amendments to §11.1902(2)(C) clarify that the annual
quality improvement work plan shall include ongoing or periodic assessment
of both quality of care and quality of service in planned projects and specifies
what is to be assessed, including network adequacy; continuity of health care
and related services; clinical studies; the adoption and annual updating of
clinical practice guidelines or clinical care standards; enrollee, physician,
and individual provider satisfaction; the complaint and appeal process and
complaint data and identification and removal of communication barriers which
may impede effective making of complaints against the HMO; preventive health
care through promotion and outreach activities; the claims payment processes;
contract monitoring, and utilization review processes. Proposed §11.1902(2)(C)(viii)
relating to claims payment processes and §11.1902(2)(C)(ix) relating
to contract monitoring are included to clarify the general requirement in
current §§11.1901-11.1903 regarding a comprehensive quality improvement
program and to assess compliance with the Insurance Code Article 20A.18B and
28 TAC §§21.2801-21.2820, which provide guidelines and requirements
for the prompt payment of physicians and providers, and the Insurance Code
Article 20A.18C related to the delegation of certain functions by HMOs and
the monitoring of these delegated functions.
Proposed §11.1902(2)(D) incorporates current §11.1903(G)(i)-(ii)
and clarifies that the annual quality improvement work plan shall include
ongoing or periodic analysis and evaluation of both quality of clinical care
and quality of service in planned projects specified in §11.1902(2)(C).
The proposed amendments to §11.1902(3) incorporate current §11.1903(2)(H)(i)-(ii)
and clarify that there shall be an annual written evaluation report on the
quality improvement program that includes completed activities, trending of
clinical and service indicators, analysis of program performance, conclusions,
and demonstrated improvements in care and services.
Most of the proposed amendments to §11.1902(4) are for the purpose
of bringing current physician and provider HMO credentialing standards into
compliance with the standards in the Insurance Code Article 20A.39 and with
NCQA standards, to the extent that the NCQA standards do not conflict with
other laws of this state. In compliance with NCQA standards (CR 1.8), proposed §11.1902(4)(A)
requires that HMO policies and procedures clearly indicate the physician or
provider responsible for the credentialing program. The proposed amendments
to §11.1902(4)(B) are for clarification and readability purposes and,
consistent with the NCQA standards (CR 1), require written criteria for credentialing
of physicians and providers and written procedures for verification. Current §11.1902(5)(A)(ii),
relating to annual evaluation of credentialing policies and procedures, is
deleted because it is not consistent with NCQA standards.
Current §11.1902(5)(A)(iii) is redesignated as §11.1902(4)(B)(ii)
and §11.1902(4)(B)(iii) and amended to clarify who is required and not
required to be credentialed. In accordance with NCQA standards (CR 1.1), the
only substantive change to the current rule is that pharmacists have been
added to those who are not required to be credentialed. Both the current rule
and the proposed rule require all dentists to be credentialed, including those
who provide dental care only under a dental plan or rider. Insurance Code
Articles 20A.03(c) and 20A.37 authorize the Department to regulate dental
HMOs, including credentialing of contracted dentists, and the NCQA standards
in this instance conflicts with the other laws of this state. Under the Insurance
Code Article 20A.39(a), rules adopted by the Commissioner that relate to an
HMO's credentialing of physicians and providers are not required to comply
with NCQA standards if those standards conflict with other laws of this state.
Both the current rule and the proposed rule require advanced practice nurses
(APNs) and physicians' assistants (PAs) to be credentialed. The NCQA standards
do not specifically include or exclude APNs and PAs from credentialing requirements.
However, APNs and PAs meet the NCQA definition of practitioners who have an
independent relationship with the managed care organization. Additionally,
under the Insurance Code Article 20A.02(t), APNs and PAs are considered "providers."
The Insurance Code Article 20A.14(j) provides that if an APN or PA is statutorily
authorized to provide care by a physician participating in an HMO's provider
network, the HMO may not refuse to contract with an APN or PA to be included
in the HMO's provider network, refuse to reimburse the APN or PA for covered
services, or otherwise discriminate against the APN or PA solely because the
APN or PA is not identified as a practitioner under the Insurance Code Article
21.52, §3.
Current §11.1902(4)(A)(v) is deleted because the six months verification
time limit is incorporated into the proposed rules where appropriate and the
two-year site visit verification time limit is not consistent with NCQA standards.
Current §11.1902(5)(A)(vii), which requires recredentialing of physicians
and individual providers every two years and requires HMOs to maintain documentation
of current state licensure, is deleted because the requirements do not comply
with NCQA standards or with the Insurance Code Article 20A.39(d). Proposed §11.1902(4)(B)(vi),
consistent with NCQA standards (CR 10), specifies procedures for monitoring
physician and provider performance between periods of recredentialing.
Current §11.1902(5)(A)(viii) is redesignated as §11.1902(4)(B)(vii)
and proposed to be amended to comply with NCQA standards (CR 13) on delegation
of credentialing, including required annual audits and exceptions and the
requirement that the HMO maintain the right to approve credentialing, suspension,
and termination of physicians and providers. The proposed amendments to §11.1902(5)(B)(vii)
also clarify that credentialing files maintained by other entities to whom
the HMO has delegated credentialing functions be made available to the Department
for examination upon request, which is in accordance with the Insurance Code
Article 20A.17(b)(4).
Current §11.1902(5)(A)(x) is redesignated as §11.1902(4)(B)(ix)
and amended for clarity and compliance with NCQA standards (CR 11) on HMO
procedures for notifying appropriate authorities when a physician's or provider's
affiliation is suspended or terminated due to quality of care concerns.
Current §11.1902(5)(B)(i) is redesignated as §11.1902(4)(C)(i)
and amended to require that physicians complete the standardized credentialing
application adopted in 28 TAC §21.3201; the proposal for §21.3201
is published elsewhere in this issue of the
Texas
Register
. Proposed amendments to §11.1902(4)(C)(i) also provide
that HMOs are not precluded from using the standardized credentialing application
form specified in §21.3201 for individual providers and provide, in compliance
with NCQA standards (CR 4), that the completion date on the credentialing
application shall be within 180 calendar days prior to the date the credentialing
committee deems a physician or individual provider eligible for initial credentialing.
Current §11.1902(5)(B)(ii)(I) is redesignated as §11.1902(4)(C)(ii)(I)
and amended to provide that, in compliance with NCQA standards (CR 3.1), the
license and sanctions must be verified within 180 calendar days prior to the
date the credentialing committee deems a physician or individual provider
eligible for initial credentialing and the license must be in effect at the
time of the credentialing decision.
Current §11.1902(5)B)(ii)(II), relating to requirements for clinical
privileges, is deleted because it does not comply with NCQA standards. Current §11.1902(5)(B)(ii)(III),
relating to education and training, is redesignated as §11.1902(4)(C)(ii)(II)
and amended to provide, consistent with NCQA standards (CR 3.3), that if a
specialty board verifies education and training, evidence of board certification
shall also serve as a primary source verification of education and training.
Current §11.1902(5)(B)(ii)(IV), relating to board certification, is redesignated
as §11.1902(4)(C)(ii)(III) and amended to provide, in compliance with
NCQA standards (CR 3.4), that the source used must be the most recent available.
Current §11.1902(5)(B)(iii)(III), relating to Drug Enforcement Agency
and Department of Public Safety Controlled Substances permits, is included
in proposed §11.1902(4)(C)(ii)(IV) and amended to comply with NCQA standards
(CR 3.2).
In accordance with NCQA standards (CR 3.6), amendments are proposed to §11.1902(4)(C)(iii)(I)
to require professional liability claims history to be verified within 180
days prior to the date of the credentialing decision and to be obtained from
the professional liability carrier or the National Practitioner Data Bank.
In accordance with NCQA standards (CR 5.3), amendments are proposed to §11.1902(4)(C)(iii)(II)
to require information on previous sanction activity by Medicare and Medicaid
to be verified within 180 days prior to the date of the credentialing decision
and to specify seven possible sources, including the National Practitioner
Data Bank.
Current §11.1902(5)(B)(iv) is redesignated as §11.1902(4)(C)(iv)
and amended, in accordance with NCQA standards (CR 6), to require initial
credentialing site visits to each obstetrician-gynecologist and high-volume
individual behavioral health provider and to allow one site visit in specified
instances of group practice situations. Current §11.1902(5)(B)(v) is
redesignated as §11.1902(4)(C)(v) and amended, in accordance with the
Insurance Code Article 20A.39(c), to require that site visit evaluations consist
of appointment availability. Proposed amendments to §11.1902(4)(C)(v)
also provide that if a physician or individual provider offers services such
as radiology or laboratory services that require certification or licensure
in accordance with the Insurance Code Article 20A.39(b), the current certification
or licensure must be available for review at the initial credentialing site
visit. In accordance with NCQA standards (CR 6), proposed amendments to §11.1902(4)(C)(v)
require corrective action plans and follow-up site visits every six months
until the site meets the HMO's standards.
Current §11.1902(5)(C) is redesignated as §11.1902(4)(D) and
amended, in accordance with the Insurance Code Article 20A.39(d)(1), to require
HMOs to recredential physicians and individual providers at least once every
three years. Proposed amendments to §11.1902(4)(D), in accordance with
NCQA standards (CR 9), require HMOs to consider performance indicators for
primary care and high-volume individual behavioral health care providers in
recredentialing decision making. Proposed amendments to §11.1902(5)(D)(i)-(ii),
in accordance with NCQA standards (CR 7), require reverification from specified
primary sources and in accordance with the verification time limit for the
initial credentialing process in proposed §11.1902(4)(C), and delete
the current §11.1902(5)(C)(iii) requirements for recredentialing site
visits for primary care physicians and high-volume physicians and providers
and multi-practitioners every two years.
Current §11.1902(5)(D) is redesignated as §11.1902(4)(E) and
amended in §11.1902(4)(E)(i)-(v), in accordance with NCQA standards (CR
12), to specify the credentialing process for institutional providers, including
on-site evaluation of the institutional provider against the HMO's written
standards if the provider is not accredited by the HMO-required national accrediting
body. Recredentialing of institutional providers at least every three years,
is addressed in proposed §11.1902(4)(F). Proposed §11.1902(4)(F)
also provides, in accordance with NCQA standards (CR 12.5), that the recredentialing
process shall update information obtained for initial credentialing.
Proposed §11.1902(4)(G), in accordance with the Insurance Code Article
20A.39(a), provides that if the NCQA standards change and there is a difference
between the Department's promulgated standards and the NCQA standards, that
the NCQA standards shall prevail to the extent those standards do not conflict
with the other laws of this state.
Proposed §11.1902(5)(A), in accordance with NCQA standards (CR 6.7),
requires the HMO to have procedures for detecting deficiencies subsequent
to the initial site visit and to reevaluate the site and institute actions
for improvement when the HMO identifies new deficiencies. Proposed §11.1902(5)(B),
in accordance with the Insurance Code Article 20A.39(e), specifies the requirements
and guidelines for HMOs conducting site visits for cause.
These amendments are proposed to be effective July 1, 2002, with the standardized
credentialing application form for physicians required in §11.1902(4)(C)(i)
to be used for initial credentialing or recredentialing that occurs on or
after July 1, 2002.
Kimberly Stokes, Senior Associate Commissioner, Life/Health/Licensing,
has determined that during the first five years the proposed amendments will
be in effect, there will be no fiscal impact on state or local government
as a result of enforcing or administering the proposed amendments. There will
be no measurable effect on local employment or the local economy as a result
of administering or enforcing the proposed amendments.
Ms. Stokes has determined that for each year of the first five years the
amendments are in effect, the public benefits anticipated as a result of the
adoption of the amendments to §11.1607(i)-(k) are updated rules consistent
with the Insurance Code Article 21.53F as amended by Senate Bill 789, clarification
of the information to be provided to the enrollee on the evidence of coverage
regarding the enrollee's ability to access covered telehealth services and
telemedicine medical services, and promotion of awareness of the telemedicine
medical services and telehealth services coverage that may be provided by
the HMO. The public benefits anticipated as a result of the adoption of the
proposed amendments to §11.1901 and §11.1902 are clarified and better
organized operational procedures and standards for HMO governing bodies and
quality improvement programs, which are easier to understand and follow. These
amendments can also assist HMOs in earlier identification of potential problem
areas, such as network adequacy, continuity of care, and claims payments,
thereby enabling the HMO to address such problems before they become major
and adversely affect the care provided to enrollees. The additional public
benefits anticipated as a result of the adoption of the amendments to §11.1902(4)
and (5)(A) are Department standards for credentialing of physicians and providers
that are consistent with NCQA standards. This will result in greater efficiency
and lower administrative costs for those HMOs that are NCQA accredited because
they will be required to comply with only one set of credentialing standards.
This will also result in lower administrative costs for all HMOs because credentialing
of physicians and individual providers will be required every three years,
instead of every two years as required under the current rules, and because
site visits for primary care physicians and high-volume physicians and providers
will no longer be required at recredentialing. These lower administrative
costs may also help keep premium costs down because costs to operate the HMOs
are used in determining the premium charged to enrollees. In addition, while
the proposed rules require HMOs to have a method of verifying licensure and
sanctions during the three years between recredentialing, the HMOs will no
longer be required to verify licensure prior to or on the expiration date
of the license. As a result, each HMO will be able to design a credentialing
process that best fits its organizational and economic needs. Also, the three-year
recredentialing cycle for physicians and individual providers and the required
use of the standardized credentialing application for physicians and the permissive
use of this application for individual providers will result in a more efficient
and less time-consuming credentialing process. The public benefits anticipated
as a result of the adoption of proposed §11.1902(5)(B) are updated rules
consistent with the Insurance Code Article 20A.39(e); specification of uniform
requirements and guidelines for HMOs conducting site visits for cause; and
earlier identification and correction of quality of care problems, including
those related to patient safety, accessibility, and appointment availability.
Any economic costs required to comply with the proposed amendments to §11.1607(i)-(k),
are the direct result of the legislative enactment of Senate Bill 789. Any
economic costs required to comply with the proposed amendments to §11.1902(4)
and §11.1902(5) are the direct result of the legislative enactment of
Senate Bill 544, and the directive in the Insurance Code Article 20A.39(a)
that the rules adopted by the Commissioner under the Insurance Code Article
20A.37 that relate to an HMO's process for selecting and retaining affiliated
physicians and providers comply with NCQA standards, to the extent those standards
do not conflict with other laws of this state, and with the standards enacted
in the Insurance Code Article 20A.39. There are no additional costs anticipated
to persons or entities who are required to comply with the proposed amendments
to §11.2 and to §§11.1901-11.1902(1)-(3) and (6) that reorganize,
clarify, and delete redundancy in current §§11.1901-11.1903.
Ms. Stokes has determined that there is no adverse economic effect on any
HMO that qualifies as a small business or micro-business under the Government
Code §2006.001, as a result of the proposed amendments. All of the economic
costs to any small business or micro-business HMO required to comply with
the proposed amendments to §11.1607(i)-(k) are the direct result of the
legislative enactment of Senate Bill 789; in addition, the provision of covered
health care services through a telehealth service or a telemedicine medical
service is at the option of the HMO and such costs are included in the premium
costs paid by the enrollees. The determining factors in the costs that would
be incurred by an HMO in complying with the proposed amendments to §11.1607(i)-(k)
are whether the HMO opts to provide the telehealth or telemedicine medical
services and are not related to the size of the HMO. All of the economic costs
to any small business or micro-business HMO required to comply with the proposed
amendments to §11.1902(4) and (5)(A) are the direct result of the legislative
enactment of Senate Bill 544, and its directive that the rules adopted by
the Commissioner under the Insurance Code Article 20A.37 that relate to an
HMO's process for selecting and retaining affiliated physicians and providers
comply with NCQA standards, to the extent those standards do not conflict
with other laws of this state, and with the standards enacted in the Insurance
Code Article 20A.39. The determining factors in the costs that would be incurred
by an HMO in complying with the proposed amendments to §11.1902(4) and
(5)(A) are not related to the size of the entity, but rather to the implementation
and maintenance of the HMO's quality improvement program, including the credentialing
and recredentialing of physicians and providers, which all HMOs, regardless
of size, are required by the Insurance Code Article 20A.37 to implement and
maintain. All of the economic costs required to comply with proposed §11.1902(5)(B)
are the direct result of the legislative enactment of Insurance Code Article
20A.39(e) in Senate Bill 544. The determining factors in the costs that would
be incurred by an HMO in complying with the proposed amendments to §11.1902(5)(B)
are not related to the size of the HMO, but rather to the number of physician
and provider offices for which site visits for cause are required. Therefore,
the size of the HMO has no bearing upon the applicability of any of the proposed
amendments. Because of this; the intent of Senate Bill 544 to bring Texas
standards for credentialing physicians and providers into compliance with
the NCQA standards; the intent of the Insurance Code Article 20A.39(e) that
all HMOs, regardless of size, not be precluded from conducting a site visit
to the office of any physician or provider at any time for cause; and the
intent of the Insurance Code Article 20A.37 that all HMOs, regardless of size,
implement and maintain a quality assurance program, it is neither legal nor
feasible to exempt small business or micro-business HMOs from the requirements
of the proposed amendments. Additionally, because the provision of telehealth
services and telemedicine medical services is at the option of the HMO, it
is not necessary to exempt small business or micro-business HMOs from the
requirements of the proposed amendments to §11.1607(i)-(k).
To be considered, written comments on the proposal must be submitted no
later than 5:00 p.m. on May 27, 2002 to Lynda H. Nesenholtz, General Counsel
and Chief Clerk, Mail Code 113-1C, Texas Department of Insurance, P.O. Box
149104, Austin, Texas 78714-9104. An additional copy of the comment must be
simultaneously submitted to Margaret Lazaretti, Director of Project Development,
Life/Health/Licensing, Mail Code 107-2A, Texas Department of Insurance, P.O.
Box 149104, Austin, Texas 78714-9104. A request for a public hearing must
be submitted separately to the Office of Chief Clerk.
Subchapter A. GENERAL PROVISIONS
28 TAC §11.2
The amendments are proposed pursuant to the Insurance Code
Articles 20A.39, 20A.37, 21.58D, and §36.001. Article 20A.39(a) requires
the rules adopted under Article 20A.37 that relate to implementation and maintenance
by an HMO of a process for selecting and retaining affiliated physicians and
providers to comply with the provisions of new Article 20A.39 and the standards
promulgated by the National Committee for Quality Assurance, to the extent
that those standards do not conflict with other laws of this state. Article
20A.37(b) requires each HMO to have an ongoing internal quality assurance
program to monitor and evaluate its health care services in all institutional
and noninstitutional contexts and authorizes the Commissioner to establish,
by rule, minimum standards and requirements for these programs, including,
but not limited to, standards for assuring availability, accessibility, quality
and continuity of care. Article 21.58D requires the Commissioner by rule to
adopt a standardized form for the verification of the credentials of a physician
and to require HMOs operating under the Insurance Code Chapter 20A to use
the form. Section 36.001 provides that the Commissioner of Insurance may adopt
rules to execute the duties and functions of the Texas Department of Insurance
only as authorized by statute.
The following articles are affected by the proposal: Insurance Code Articles
21.53F and 20A.39, 20A.37, 21.58D
§11.2.Definitions.
(a)
(No change.)
(b)
The following words and terms, when used in this chapter,
shall have the following meanings unless the context clearly indicates otherwise.
(1) - (13)
(No change.)
(14)
Credentialing--The
process of collecting, assessing,
and validating
[
(15)
[
[
(16)
[
(A)
offers services, facilities, and beds for use for more
than 24 hours for two or more unrelated individuals requiring diagnosis, treatment,
or care for illness, injury, deformity, abnormality, or pregnancy; and
(B)
regularly maintains, at a minimum, clinical laboratory
services, diagnostic X-ray services, treatment facilities including surgery
or obstetrical care or both, and other definitive medical or surgical treatment
of similar extent.
(17)
[
(18)
[
(A)
health status;
(B)
medical condition (including both physical and mental illnesses);
(C)
claims experience;
(D)
receipt of health care;
(E)
medical history;
(F)
genetic information;
(G)
evidence of insurability (including conditions arising
out of acts of domestic violence, including family violence as defined by
the Insurance Code Article 21.21-5); or
(H)
disability.
(19)
Individual provider--Any person,
other than a physician or institutional provider, who is licensed or otherwise
authorized to provide a health care service. Includes, but is not limited
to, licensed doctor of chiropractic, dentist, registered nurse, advanced practice
nurse, physician assistant, pharmacist, optometrist, registered optician,
and acupuncturist.
(20)
Institutional provider--A
provider that is not an individual. Includes any medical or health related
service facility caring for the sick or injured or providing care or supplies
for other coverage which may be provided by the HMO. Includes but is not limited
to:
(A)
General hospitals,
(B)
Psychiatric hospitals,
(C)
Special hospitals,
(D)
Nursing homes,
(E)
Skilled nursing facilities,
(F)
Home health agencies,
(G)
Rehabilitation facilities,
(H)
Dialysis centers,
(I)
Free-standing surgical centers,
(J)
Diagnostic imaging centers,
(K)
Laboratories,
(L)
Hospice facilities,
(M)
Infusion services centers,
(N)
Residential treatment centers,
(O)
Community mental health centers,
(P)
Urgent care centers, and
(Q)
Pharmacies.
(21)
[
(22)
[
(23)
[
(24)
[
(25)
[
(26)
[
(27)
[
(28)
[
(29)
[
(30)
[
(31)
[
(32)
[
(33)
[
(34)
[
(35)
Recredentialing--The periodic
process by which:
(A)
qualifications of physicians and providers are
reassessed;
(B)
performance indicators, including utilization
and quality indicators, are evaluated; and
(C)
continued eligibility to provide services is
determined.
(36)
[
(37)
[
(38)
[
(39)
[
(40)
[
(41)
[
(42)
[
(A)
offers services, facilities and beds for use for more than
24 hours for two or more unrelated individuals who are regularly admitted,
treated and discharged and who require services more intensive than room,
board, personal services, and general nursing care;
(B)
has clinical laboratory facilities, diagnostic X-ray facilities,
treatment facilities or other definitive medical treatment;
(C)
has a medical staff in regular attendance; and
(D)
maintains records of the clinical work performed for each
patient.
(43)
[
(44)
[
(45)
[
(46)
Telehealth service--As defined
in Section 57.042, Utilities Code.
(47)
[
(48)
[
(49)
[
(50)
[
(51)
[
(52)
[
(53)
[
(54)
[
(55)
[
(56)
[
(57)
[
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State on April 15, 2002.
TRD-200202330
Lynda Nesenholtz
General Counsel and Chief Clerk
Texas Department of Insurance
Earliest possible date of adoption: May 26, 2002
For further information, please call: (512) 463-6327
28 TAC §11.1607
The amendments are proposed pursuant to the Insurance Code
Articles 20A.39, 20A.37, 21.58D, and §36.001. Article 20A.39(a) requires
the rules adopted under Article 20A.37 that relate to implementation and maintenance
by an HMO of a process for selecting and retaining affiliated physicians and
providers to comply with the provisions of new Article 20A.39 and the standards
promulgated by the National Committee for Quality Assurance, to the extent
that those standards do not conflict with other laws of this state. Article
20A.37(b) requires each HMO to have an ongoing internal quality assurance
program to monitor and evaluate its health care services in all institutional
and noninstitutional contexts and authorizes the Commissioner to establish,
by rule, minimum standards and requirements for these programs, including,
but not limited to, standards for assuring availability, accessibility, quality
and continuity of care. Article 21.58D requires the Commissioner by rule to
adopt a standardized form for the verification of the credentials of a physician
and to require HMOs operating under the Insurance Code Chapter 20A to use
the form. Section 36.001 provides that the Commissioner of Insurance may adopt
rules to execute the duties and functions of the Texas Department of Insurance
only as authorized by statute.
The following articles are affected by the proposal: Insurance Code Articles
21.53F and 20A.39, 20A.37, 21.58D
§11.1607.Accessibility and Availability Requirements.
(a)-(h)
(No change.)
(i)
Each evidence of coverage or certificate delivered or issued
for delivery by an HMO may provide enrollees the option to access covered
health care services through
a telehealth service or a
telemedicine
medical service
.
(j)
Before providing
telehealth services or
telemedicine
medical
services to an enrollee, an HMO shall provide the enrollee with
the option to select a physician or provider within the HMO delivery network
to provide the covered health care services, or to elect to receive
telehealth
services
or
telemedicine
medical
services.
(k)
In order to provide covered health care services to any
enrollee by
a telehealth service or a
telemedicine
medical
service
, an HMO shall satisfy the criteria specified under subsection
(a) of this section.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed
with the Office of the Secretary of State on April 15, 2002.
TRD-200202329
Lynda Nesenholtz
General Counsel and Chief Clerk
Texas Department of Insurance
Earliest possible date of adoption: May 26, 2002
For further information, please call: (512) 463-6327
28 TAC §11.1901, §11.1902
The amendments are proposed pursuant to the Insurance Code
Articles 20A.39, 20A.37, 21.58D, and §36.001. Article 20A.39(a) requires
the rules adopted under Article 20A.37 that relate to implementation and maintenance
by an HMO of a process for selecting and retaining affiliated physicians and
providers to comply with the provisions of new Article 20A.39 and the standards
promulgated by the National Committee for Quality Assurance, to the extent
that those standards do not conflict with other laws of this state. Article
20A.37(b) requires each HMO to have an ongoing internal quality assurance
program to monitor and evaluate its health care services in all institutional
and noninstitutional contexts and authorizes the Commissioner to establish,
by rule, minimum standards and requirements for these programs, including,
but not limited to, standards for assuring availability, accessibility, quality
and continuity of care. Article 21.58D requires the Commissioner by rule to
adopt a standardized form for the verification of the credentials of a physician
and to require HMOs operating under the Insurance Code Chapter 20A to use
the form. Section 36.001 provides that the Commissioner of Insurance may adopt
rules to execute the duties and functions of the Texas Department of Insurance
only as authorized by statute.
The following articles are affected by the proposal: Insurance Code Articles
21.53F and 20A.39, 20A.37, 21.58D
§11.1901.Quality Improvement Structure .
(a)
The HMO shall develop and maintain an ongoing quality improvement
program designed to objectively and systematically monitor and evaluate the
quality and appropriateness of care and
services
[
(b)
The HMO governing body is ultimately responsible for the
overall quality improvement program. The HMO governing body shall:
(1)
appoint
a
[
(2)
approve the quality improvement program;
(3)
approve an annual quality improvement plan; [
(4)
meet no less than annually to
receive and review
reports of the quality improvement committee or group of committees and take
action when appropriate
; and
[
(5)
review the annual written report
on the quality improvement program.
(c)
The quality improvement committee
shall develop and evaluate the overall effectiveness of the quality improvement
program.
(1)
The quality improvement committee may delegate
quality improvement activities to other committees that may, if applicable,
include practicing physicians, individual providers, and enrollees from throughout
the service area.
(A)
All committees shall collaborate and coordinate
efforts to improve the quality, availability, and accessibility of health
care services to be furnished by the HMO to its enrollees.
(B)
All committees shall meet and regularly report
findings, recommendations, and resolutions in writing through the quality
improvement committee to the HMO governing body.
(C)
If the quality improvement committee delegates
any quality improvement activity to any subcommittee, then the quality improvement
committee must establish a method of oversight of each subcommittee.
(2)
The quality improvement committee shall use
multidisciplinary teams, when indicated, to accomplish quality improvement
program goals.
§11.1902.Quality Improvement Program.
The quality improvement program shall be continuous and comprehensive,
including both the quality of clinical care and the quality of service [
(1)
Written description. There shall be a written description
of the quality improvement program that outlines program organizational structure,
functional responsibility and design.
(2)
Work plan. There shall be an annual quality improvement
work plan[
(A)
Goals
, objectives, [
(B)
Use of quality indicators, performance measurements,
and quality improvement data collection to monitor quality improvement.
(i)
Quality indicators must be
objective, measurable, and include performance goals for each indicator.
(ii)
Performance measures must
be process or outcome measures.
(iii)
Data collected must be appropriate to
the goals and objectives of the activity.
[
(C)
Ongoing or periodic assessment of both quality of
clinical care and quality of service in planned projects, specifically:
[
(i)
Network adequacy, which includes
availability and accessibility of care, including assessment of open/closed
physician and individual provider panels;
(ii)
Continuity of health care
and related services;
(iii)
Clinical studies, which shall
specify methodologies to be used to accomplish them;
(iv)
The adoption and annual updating
of clinical practice guidelines or clinical care standards, compatible with
current principles of health care; the quality improvement program shall assure
the practice guidelines:
(I)
are approved by participating physicians and
individual providers;
(II)
are included in physician and provider manuals;
and
(III)
include preventive health services.
(v)
Enrollee, physician, and individual
provider satisfaction;
(vi)
The complaint and appeal process,
complaint data, and identification and removal of communication barriers which
may impede enrollees, physicians, and providers from effectively making complaints
against the HMO;
(vii)
Preventive health care through
health promotion and outreach activities:
(I)
The HMO shall inform and educate physicians
and providers about using the health management and outreach programs for
the enrollees assigned to them.
(II)
Outreach may be accomplished through, but not
limited to, written educational materials, community-based programs and presentations,
health promotion fairs, and monetary contributions to community-based organizations
and health related initiatives of other programs.
(viii)
Claims payment processes;
(ix)
Contract monitoring, including
delegation oversight and compliance with filing requirements; and
(x)
Utilization review processes.
(D)
Ongoing or periodic analysis
and evaluation of both quality of clinical care and quality of service planned
projects specified in subparagraph (C) of this paragraph, which shall include:
(i)
Evidence that results of evaluation are used
to improve clinical care and services; and
(ii)
A systematic method of tracking areas identified
for improvement to assure that appropriate action is taken to effect the needed
improvement.
(3)
Evaluation
[
[
[
[
(4)
[
[
(A)
The HMO's policies and procedures shall clearly indicate
the physician or individual provider directly responsible for the credentialing
program and shall include a description of his or her participation.
(B)
HMOs shall develop written criteria for credentialing
of physicians and providers
and
[
(i)
[
[
[
(ii)
Credentialing
[
(I)
individual
providers who furnish
services only under the direct supervision of a physician or
another
individual
provider
except as specified in clause (i) of this subparagraph
;
(II)
hospital-based physicians or
individual
providers [
(III)
students
[
(IV)
pharmacists.
(iii)
[
[
(iv)
[
(v)
[
(I)
Medicare and Medicaid sanctions;
(II)
Information from state licensing
boards regarding sanctions or licensure limitations; and
(III)
Complaints.
[
(vi)
[
(vii)
[
(viii)
[
(C)
[
(i)
Physicians
[
(ii)
The following shall be verified from primary sources and
evidence of verification shall be
included in
the
credentialing
files:
(I)
A current [
(II)
[
[
(III)
[
(IV)
Valid Drug Enforcement Agency
(DEA) or Department of Public Safety (DPS) Controlled Substances Registration
Certificate, if applicable. These must be in effect at the time of the credentialing
decision and may be verified by any one of the following means:
(-a-)
copy of the DEA or DPS certificate;
(-b-)
visual inspection of the original certificate;
(-c-)
confirmation with DEA or DPS;
(-d-)
entry in the National Technical Information
Service database; or
(-e-)
entry in the American Medical Association
Physician Master File.
(iii)
The following shall
be verified within 180 calendar
days prior to the date of the credentialing decision and shall
also
be included in the
physician's
[
(I)
Past five years of
[
(II)
Information on previous sanction activity by Medicare
and Medicaid[
(-a-)
National Practitioner Data
Bank;
(-b-)
Cumulative Sanctions Report
available over the internet;
(-c-)
Medicare and Medicaid Sanctions
and Reinstatement Report distributed to federally contracting HMOs;
(-d-)
state Medicaid agency or
intermediary and the Medicare intermediary;
(-e-)
Federation of State Medical
Boards;
(-f-)
Federal Employees Health
Benefits Program department record published by the Office of Personnel Management,
Office of the Inspector General;
(-g-)
entry in the American Medical
Association Physician Master File.
[
[
[
(iv)
The HMO shall perform a site visit to the offices of each
primary care physician,
obstetrician-gynecologist,
[
(v)
Site visits shall [
(D)
[
(i)
Reverification of the following
[
(I)
Licensure
and information on sanctions or limitations
on licensure;
(II)
[
[
(-a-)
if the physician or
individual provider
[
(-b-)
if the physician or individual provider
indicates
[
(III)
Drug Enforcement Agency (DEA)
or Department of Public Safety (DPS) Controlled Substances Registration Certificate,
if applicable. These may be reverified by any one of the following means:
(-a-)
copy of the DEA or DPS certificate;
(-b-)
visual inspection of the original certificate;
(-c-)
confirmation with DEA or DPS;
(-d-)
entry in the National Technical Information
Service database; or
(-e-)
entry in the American Medical Association
Physician Master File.
(ii)
Updated history of professional liability claims,
and
[
[
(E)
[
(i)
Evidence
[
(ii)
Evidence
[
(iii)
Evidence of other applicable state or federal requirements,
e.g., Bureau of Radiation Control certification for diagnostic imaging centers,
Texas Mental Health and Mental Retardation certification for community mental
health centers, CLIA (Clinical Laboratory Improvement Amendments of 1988)
certification for laboratories;
[
(iv)
Evidence of accreditation by a national accrediting
body, as applicable; the HMO shall determine which national accrediting bodies
are appropriate for different types of institutional providers. The HMO's
written policy and procedures must state which national accrediting bodies
it accepts;
[
(v)
Evidence of on-site evaluation of the institutional
provider against the HMO's written standards for participation if the provider
is not accredited by the national accrediting body required by the HMO.
[
(F)
The HMO procedures shall provide
for recredentialing of institutional providers at least every three years
through a process that updates information obtained for initial credentialing
as set forth in subparagraph (E)(i)-(v) of this paragraph.
(G)
Under Insurance Code Article
20A.39, the standards adopted in this paragraph must comply with the standards
promulgated by the National Committee for Quality Assurance (NCQA) to the
extent that those standards do not conflict with other laws of the state.
Therefore, if the NCQA standards change and there is a difference between
the standards specified in this paragraph and the NCQA standards, the NCQA
standards shall prevail to the extent that those standards do not conflict
with the other laws of this state.
(5)
Site visits for cause.
(A)
The HMO shall have procedures for detecting
deficiencies subsequent to the initial site visit. When the HMO identifies
new deficiencies, the HMO shall reevaluate the site and institute actions
for improvement.
(B)
An HMO may conduct a site visit to the office
of any physician or provider at any time for cause. The site visit to evaluate
the complaint or other precipitating event shall be conducted by appropriate
personnel and may include, but not be limited to, an evaluation of any facilities
or services relating to the complaint or event and an evaluation of medical
records, equipment, space, accessibility, appointment availability, or confidentiality
practices, as appropriate.
(6)
Peer Review. The quality improvement program shall provide
for an effective peer review procedure for physicians[
[
[
[
[
[
[
[
[
[
[
[
This agency hereby certifies that the proposal
has been reviewed by legal counsel and found to be within the agency's legal
authority to adopt.
Filed
with the Office of the Secretary of State on April 15, 2002.
TRD-200202331
Lynda Nesenholtz
General Counsel and Chief Clerk
Texas Department of Insurance
Earliest possible date of adoption: May 26, 2002
For further information, please call: (512) 463-6327
28 TAC §11.1903
(Editor's note: The text of the following section proposed for
repeal will not be published. The section may be examined in the offices of
the Texas Department of Insurance or in the Texas Register office, Room 245,
James Earl Rudder Building, 1019 Brazos Street, Austin.)
The Texas Department of Insurance proposes repeal
of §11.1903 concerning quality improvement committees of health maintenance
organizations (HMOs). Repeal of this section is necessary to eliminate redundant
provisions and to incorporate provisions of this section into the proposed
amendments to §§11.1901-11.1902 which are published elsewhere in
this issue of the
Texas Register
.
Kimberly Stokes, Senior Associate Commissioner, Life/Health/Licensing,
has determined that during the first five years the proposed repeal is in
effect, there will be no fiscal impact on state or local government as a result
of enforcing or administering the proposed repeal. There will be no measurable
effect on local employment or the local economy as a result of the proposal.
Ms. Stokes has also determined that for each year of the first five years
the repeal of the section is in effect, the public benefit anticipated as
a result of administration and enforcement of the repealed section will be
easier-to-understand and better-organized operational guidelines and standards
for HMO quality improvement committees, governing bodies, and quality improvement
programs. There is no anticipated economic cost to persons who are required
to comply with the proposed repeal. There is no anticipated difference in
cost of compliance between small and large businesses.
To be considered, written comments on the proposal must be submitted no
later than 5:00 p.m. on May 28, 2002 to Lynda H. Nesenholtz, General Counsel
and Chief Clerk, Mail Code 113-1C, Texas Department of Insurance, P.O. Box
149104, Austin, Texas 78714-9104. An additional copy of the comment must be
simultaneously submitted to Margaret Lazaretti, Director of Project Development,
Life/Health/Licensing, Mail Code 107-2A, Texas Department of Insurance, P.O.
Box 149104, Austin, Texas 78714-9104. A request for a public hearing must
be submitted separately to the Office of Chief Clerk.
Repeal of §11.1903 is proposed pursuant to the Insurance
Code Article 20A.37 and §36.001. Article 20A.37(b) requires each HMO
to have an ongoing internal quality assurance program to monitor and evaluate
its health care services in all institutional and noninstitutional contexts
and authorizes the Commissioner to establish, by rule, minimum standards and
requirements for these programs, including, but not limited to, standards
for assuring availability, accessibility, quality and continuity of care.
Section 36.001 provides that the Commissioner of Insurance may adopt rules
to execute the duties and functions of the Texas Department of Insurance only
as authorized by statute.
The proposed repeal affects regulation pursuant to the following statutes:
Insurance Code Article 20A.37
§11.1903.Quality Improvement Committee.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State on April 15, 2002.
TRD-200202328
Lynda Nesenholtz
General Counsel and Chief Clerk
Texas Department of Insurance
Earliest possible date of adoption: May 26, 2002
For further information, please call: (512) 463-6327
Subchapter X. CREDENTIALING OF PHYSICIANS
review of
] qualifications and other relevant
information pertaining to a physician[
, dentist,
] or provider
to determine eligibility to deliver health care services
[
who seeks
a contract with an HMO
].
Credentials--Certificates, diplomas, licenses or
other written documentation which verifies proof of training, education, and
experience in a field of expertise.
]
(16)
]
Dentist--An individual
provider
licensed to practice dentistry by the Texas State Board of Dental Examiners.
(17)
] General hospital--A licensed
establishment that:
(18)
] HMO--A health maintenance
organization as defined in Insurance Code Article 20A.02(n).
(19)
] Health status related factor--Any
of the following in relation to an individual:
(20)
] Limited provider network--A
subnetwork within an HMO delivery network in which contractual relationships
exist between physicians, certain providers, independent physician associations
and/or physician groups which limit the enrollees' access to only the physicians
and providers in the subnetwork.
(21)
] Limited service HMO--An HMO
which has been issued a certificate of authority to issue a limited service
health care plan as defined in the Insurance Code Article 20A.02(l).
(22)
] Out of area benefits--Benefits
that the HMO covers when its enrollees are outside the geographical limits
of the HMO service area.
(23)
] Pathology services--Services
provided by a licensed laboratory which has the capability of evaluating tissue
specimens for diagnoses in histopathology, oral pathology, or cytology.
(24)
] Pharmaceutical services--Services,
including dispensing prescription drugs, as defined in the Pharmacy Act, Texas
Civil Statutes, Article 4542a-1, §5 that are ordinarily and customarily
rendered by a pharmacy or pharmacist.
(25)
] Pharmacist--An individual
provider
licensed to practice pharmacy under the Pharmacy Act, Texas
Civil Statutes, Article 4542a-1.
(26)
] Pharmacy--A facility licensed
under the Pharmacy Act, Texas Civil Statutes, Article 4542a-1 §29.
(27)
] Premium--The prospectively
determined rate that is paid by or on behalf of an enrollee for specified
health services.
(28)
] Primary care physician or
primary care provider--A physician or individual provider who is responsible
for providing initial and primary care to patients, maintaining the continuity
of patient care, and initiating referral for care.
(29)
] Primary HMO--An HMO that
contracts directly with, and issues an evidence of coverage to, individuals
or organizations to arrange for or provide a basic, limited, or single health
care service plan to enrollees on a prepaid basis.
(30)
] Provider HMO--An HMO that
contracts directly with a primary HMO to provide or arrange to provide health
care services on behalf of the primary HMO within the primary HMO's defined
service area.
(31)
] Psychiatric hospital--A licensed
hospital which offers inpatient services, including treatment, facilities
and beds for use beyond 24 hours, for the primary purpose of providing psychiatric
assessment and diagnostic services and psychiatric inpatient care and treatment
for mental illness. Such services must be more intensive than room, board,
personal services, and general medical and nursing care. Although substance
abuse services may be offered, a majority of beds must be dedicated to the
treatment of mental illness in adults and/or children.
(32)
] Qualified HMO--An HMO which
has been federally approved under Title XIII of the Public Health Service
Act, Public Law 93-222, as amended.
(33)
] Quality improvement--A system
to continuously examine, monitor and revise processes and systems that support
and improve administrative and clinical functions.
(34)
] Reference laboratory--A licensed
laboratory that accepts specimens for testing from outside sources and depends
on referrals from other laboratories or entities. HMOs may contract with a
reference laboratory to provide clinical diagnostic services to their enrollees.
(35)
] Reference laboratory specimen
procurement services--The operation utilized by the reference laboratory to
pick up the lab specimens from the client offices or referring labs, etc.
for delivery to the reference laboratory for testing and reporting.
(36)
] Referral specialists (other
than primary care)--Physicians or
individual
providers who set
themselves apart from the primary care physician or primary care provider
through specialized training and education in a health care discipline.
(37)
] Schedule of charges--Specific
rates or premiums to be charged for enrollee and dependent coverages.
(38)
] Service area--A geographic
area within which direct service benefits are available and accessible to
HMO enrollees who live, reside or work within that geographic area and which
complies with §11.1606 of this title (relating to Organization of an
HMO).
(39)
] Single service HMO--An HMO
which has been issued a certificate of authority to issue a single health
care service plan as defined in the Insurance Code Article 20A.02(y).
(40)
] Special hospital--A licensed
establishment that:
(41)
] Statutory surplus--Admitted
assets minus accrued uncovered liabilities.
(42)
] Subscriber--If conversion
or individual coverage, the individual who is the contract holder and is responsible
for payment of premiums to the HMO; or if group coverage, the individual who
is the certificate holder and whose employment or other membership status,
except for family dependency, is the basis for eligibility for enrollment
in the HMO.
(43)
] Subsidiary--An affiliate
controlled by a specified person directly or indirectly through one or more
intermediaries.
(44)
] Telemedicine
medical
service
--As defined in
Section 57.042, Utilities Code
[
the Insurance Code Article 21.53F
].
(45)
] Urgent care--Health care
services provided in a situation other than an emergency which are typically
provided in a setting such as a physician or
individual
provider's
office or urgent care center, as a result of an acute injury or illness that
is severe or painful enough to lead a prudent layperson, possessing an average
knowledge of medicine and health, to believe that his or her condition, illness,
or injury is of such a nature that failure to obtain treatment within a reasonable
period of time would result in serious deterioration of the condition
of
[
or
] his or her health.
(46)
] Utilization review--A system
for prospective or concurrent review of the medical necessity and appropriateness
of health care services being provided or proposed to be provided to an individual
within this state. Utilization review shall not include elective requests
for clarification of coverage.
(47)
] Voting security--As defined
in the Insurance Code Article 21.49-1, including any security convertible
into or evidencing a right to acquire such security.
(48)
] NAIC--National Association
of Insurance Commissioners.
(49)
] Annual financial statement--The
annual statement to be used by HMOs, as promulgated by the NAIC and as adopted
by the commissioner under Insurance Code Articles 1.11 and 20A.10.
(50)
] RBC--Risk-based capital.
(51)
] RBC formula--NAIC risk-based
capital formula.
(52)
] Authorized control level--The
number determined under the RBC formula in accordance with the RBC instructions.
(53)
] RBC Report--1999 NAIC Managed
Care Organizations Risk-Based Capital Report including Overview and Instructions
for Companies published by the NAIC.
(54)
] Total adjusted capital--An
HMO's statutory capital and surplus/total net worth as determined in accordance
with the statutory accounting applicable to the annual financial statements
required to be filed pursuant to the Insurance Code, and such other items,
if any, as the RBC instructions provide.
Subchapter Q. OTHER REQUIREMENTS
Subchapter T. QUALITY OF CARE
service
provided to enrollees,
] and to pursue opportunities for improvement.
the formal
] quality improvement
committee
that
[
which
] shall include practicing physicians,
[
dentists,
]
individual
[
other
] providers
and at least one enrollee from throughout the HMO's service area. For purposes
of this section, the enrollee appointed to the committee may not be an employee
of the HMO;
and
]
.
]
requiring updates as needed
]. The HMO shall dedicate
adequate
resources such as personnel, analytic capabilities, and data resources to
the
quality improvement
program [
that are adequate to meet
the needs of the program
].
The HMO shall continuously update and
monitor the quality improvement program.
, or schedule of activities,
] that includes
a schedule
of activities designed to reflect the population served by the HMO in terms
of age groups, disease categories, and special risk status. The work plan
shall include
but [
is
] not
be
limited to the following:
scope,
] and planned
projects or activities
identified from the previous year, as well as
for the
current
year
;
time frames for implementation;
responsible individuals; and coordination of functions.
[
;
]
planned monitoring of
previously identified issues, including tracking of issues over time; and
]
planned evaluation and modification, if necessary, of the quality improvement
program.
]
Monitoring and evaluation
].
There shall be an annual written report on the quality improvement program,
which includes completed activities, trending of clinical and service indicators,
analysis of program performance, conclusions, and demonstrated improvements
in care and services.
[
The program monitoring and evaluation of
clinical issues shall reflect the population served by the HMO in terms of
age groups, disease categories, and special risk status. Monitoring and evaluation
of clinical issues shall include:
]
(A)
care and services provided
in institutional settings;]
(B)
care and services provided
in noninstitutional settings, including, but not limited, to practitioner
offices and home and community support services agencies; and]
(C)
primary care and major specialty
services, including but not limited to mental health, cancer, burn or cardiac
centers.]
Identifying special needs. The quality improvement
program shall identify enrollees with special needs such as disabilities and
chronic conditions in order to assist the HMO in facilitating the development
and implementation of appropriate courses of care to assure that health care
services are available and accessible.
]
(5)
]
Credentialing. An HMO shall implement a documented
process for selection and retention of
contracted physicians and
[
affiliated
] providers, which includes the following elements,
as applicable:
appropriate to the nature
of the services to be furnished to enrollees. HMOs shall also develop
]
written procedures for verifications.
The governing body shall approve the policies and
procedures.
]
(ii)
The policies and procedures
shall be evaluated by practicing physicians and providers on at least an annual
basis.]
(iii)
]
Credentialing
is
[
shall
be
] required for all physicians and [
other
] providers,
including
[
who are permitted to practice independently under state
law. Except for
] advanced practice nurses, [
and
] physicians'
assistants
, and physicians and individual providers who are hospital-based
and listed in the provider directory. Physicians or providers who are members
of a contracting group, such as an independent physician association or medical
group, shall be credentialed individually.
credentialing
] is not required for:
who provide services incident to hospital services
],
except as specified in clause (i) of this subparagraph;
[
unless those physicians or providers are separately identified in enrollee
materials as available to enrollees.
]
Students
],
residents, or fellows
; or
[
do not require credentialing. Physicians
or providers who are members of a contracting group shall be credentialed
individually.
]
(iv)
] The initial credentialing
process, including application, verification of information, and a site visit
(if applicable), must be completed before the effective date of the initial
contract with the physician or provider.
(v)
Information collected pursuant
to subparagraphs (B)(ii) and (iii) of this paragraph must be no more than
six months old on the date on which the physician, dentist, or provider is
determined to be eligible for contract by a peer review or credentialing committee
, with the exception of information relating to the site visit and medical
record review, which shall be no more than two years old.]
(vi)
] An HMO shall have written
policies and procedures for suspending or terminating affiliation with a contracting
physician or provider, including an appeals process, pursuant to the Insurance
Code Article 20A.18A(b).
(vii)
]
The HMO shall have a
procedure for the ongoing monitoring of physician and provider performance
between periods of recredentialing and shall take appropriate action when
occurrences of poor quality are identified. Monitoring shall include, but
not be limited to:
The HMO shall
have written procedures for recredentialing at least every two years through
a process that updates information obtained in initial credentialing and considers
performance indicators. The HMO shall maintain documentation of current state
licensure and required permits to practice.
]
(viii)
] If the HMO delegates [
the
] credentialing functions to other entities, it shall have
a process for developing
[
written procedures for
] delegation
criteria and for performing
[
of credentialing functions to other
entities which include, but are not limited to, criteria for delegation,
]
pre-delegation
and annual audits
[
audit procedure and criteria
],
a
delegation agreement,
a
monitoring plan,
and a procedure for termination of the delegation agreement for non-performance.
If the HMO delegates credentialing functions to an entity accredited by the
National Committee for Quality Assurance, the annual audit of that entity
is not required; however, evidence of this accreditation shall be made available
to the department for review. The HMO shall maintain documentation of
[
Documentation of
] pre-delegation
and annual audits
[
evaluations performed
], executed delegation agreements, reports
received from the delegated entities, current rosters or copies of signed
contracts
with
[
of
] physicians and providers who are
affected by the delegation agreement, and
ongoing
[
continuing
] monitoring
and shall make this documentation
[
evaluations
shall be maintained by the HMO and made
] available to the department
for review. Credentialing files
maintained by
[
at
] the
other entities to whom the HMO has delegated credentialing functions
[
delegated entity
] shall be made available to the department for
examination upon request.
In all cases, the HMO shall maintain the right
to approve credentialing, suspension, and termination of physicians and providers.
(ix)
] The HMO's procedures shall
ensure that selection and retention criteria do not discriminate against physicians
or providers who serve high-risk populations or who specialize in the treatment
of costly conditions.
(x)
] The
HMO
[
HMO's procedures
] shall
have
[
include
] a procedure
for notifying licensing [
or disciplinary bodies
] or other appropriate
authorities when a
physician's
[
practitioner's
] or provider's
affiliation is suspended or terminated due to quality
of care concerns
[
deficiencies
].
(B)
] Initial credentialing process
for physicians and individual providers shall include, but not be limited
to, the following:
The applicant
] shall
complete
the standardized credentialing
[
an
] application
[
for affiliation. The application
]
adopted in §21.3201
of this title (relating to the Texas Standardized Credentialing Application
for Physicians) and individual providers shall complete an application which
includes
[
shall include
] a work history covering at least
five years, [
and
] a statement by the applicant regarding any limitations
in ability to perform the functions of the position, history of loss of license
and/or felony convictions; and history of loss or limitation of privileges,
sanctions or other disciplinary activity
, current professional liability
insurance coverage information, and information on whether the individual
provider will accept new patients from the HMO. This does not preclude an
HMO from using the standardized credentialing application form specified in §21.3201
of this title for credentialing of individual providers. The completion date
on the application shall be within 180 calendar days prior to the date the
credentialing committee deems a physician or individual provider eligible
for initial credentialing
[
The application shall also include whether
the physician will accept new patients from the HMO
].
valid
] license to practice in the
State of Texas
and information on sanctions or limitations on licensure
. The primary source for verification shall be the state licensing agency
or board for Texas
, and the license and sanctions must be verified within
180 calendar days prior to the date the credentialing committee deems a physician
or individual provider eligible for initial credentialing. The license must
be in effect at the time of the credentialing decision
.
If applicable, clinical privileges in good standing
at the hospital designated by the physician or dentist as the primary network
admitting facility. The primary source for verification shall be the hospital.
]
(III)
]
Education and training, including evidence
of graduation from the appropriate professional school and completion of a
residency or specialty training, if applicable. Primary source verification
shall be sought from the appropriate schools
and
[
,
]
training facilities or the American Medical Association's MasterFile. If the
state licensing board
,
[
or
] agency
, or specialty
board
verifies education and training with the
physician's
[
physician
] or
individual
provider's schools and facilities,
evidence of current state licensure
or board certification
shall
also serve as primary source verification of education and training.
(IV)
] Board certification, if
the physician or
individual
provider
indicates
[
states
] that he/she is board certified on the application. Primary source
verification may be obtained from the American Board of Medical Specialties
Compendium, the American Osteopathic Association, the American Medical Association
MasterFile, or from the specialty boards
, and the source used must be
the most recent available.
physician
] or individual
provider's credentialing file:
Malpractice
]
history
of professional liability claims that resulted in settlements
or judgments paid by or on behalf of the physician or individual provider,
which may be obtained
from the
professional liability carrier or
the
National Practitioner Data Bank;
;
]
which may be obtained from one of the following:
(III)
Copy of a valid Drug Enforcement
Agency (DEA) and Department of Public Safety Controlled Substance permit,
if applicable;]
(IV)
Evidence of current, adequate
malpractice insurance meeting the HMO's requirements;]
(V)
Information about sanctions
or limitations on licensure from the applicable state licensing agency or
board].
or
]
primary care dentist,
and high-volume individual behavioral health provider
as part of the initial credentialing process. In addition, the HMO
shall have written procedures for determining [
the
] high-volume
[
physicians and
]
individual behavioral health
[
non-institutional
] providers. If physicians or
individual
providers are part of a group practice which shares the same office, one visit
to the site may be used for
all physicians or individual providers in
the group practice, as well as for new physicians or individual providers
who subsequently join the group practice. The site visit assessment shall
be made available to the department for review
[
all physicians
and providers in that office as long as medical records for each physician
or provider are sampled
].
be conducted by clinical personnel
(or teams including clinical personnel), and shall
] consist of an evaluation
of the site's accessibility, appearance,
appointment availability,
and space, [
and of the adequacy of equipment,
] using standards
approved
[
developed
] by the HMO.
If a physician or individual
provider offers services that require certification or licensure, such as
laboratory or radiology services, the physician or individual provider shall
have the current certification or licensure available for review at the site
visit.
In addition, as a result of the site visits, it shall be determined
whether the site conforms to the HMO's standards for [
medical or dental
] record
organization, documentation,
[
keeping practices
] and confidentiality
practices
[
requirements
].
Should the site not conform to the HMO's standards, the HMO shall require
a corrective action plan and perform a follow-up site visit every six months
until the site complies with the standards.
(C)
]
The HMO shall have written
procedures for recredentialing physicians and individual providers at least
every three years through a process that updates information obtained in initial
credentialing, including professional liability coverage. The process shall
also consider performance indicators for primary care and high-volume individual
behavioral health care providers, including enrollee complaints and information
from quality improvement activities
. Recredentialing procedures [
for physicians and individual providers
] shall include, but not be limited
to, the following processes:
The following
shall be reverified
] from
the
primary sources
and in
accordance with the same verification time limit as for the initial credentialing
process specified in subparagraph (C) of this paragraph
:
Clinical privileges;
]
(III)
]
Board certification: [
only
]
dentist
] was due to be recertified
;
or
states
] that he or she has become board certified
since the last time he or she was credentialed or recredentialed
; and
[
.
]
The HMO shall requery the National Practitioner Data Bank
and obtain updated
] sanction
and
[
or
] restriction
information from [
licensing agencies,
] Medicare[
,
] and
Medicaid
in accordance with the verification sources and time limits
specified in subparagraph (C)(iii) of this paragraph.
(iii)
Site visits conducted by
clinical personnel (or teams including clinical personnel) shall be repeated
for primary care physicians and high-volume physicians and providers. Multi-practitioner
sites should be visited every two years. Medical record audits, including
evaluation of the quality of encounter notes, shall be performed within the
two years prior to recredentialing.]
(D)
]
The credentialing
[
Credentialing
] process for institutional providers shall include[
, but not be limited to,
] the following:
The HMO procedure shall require
evidence
] of state licensure
;
[
, and of compliance with
any other applicable state or federal requirements.
]
The HMO procedure may require
evidence
] of Medicare certification
;
[
, as applicable,
or accreditation by the Joint Commission on Accreditation of Healthcare Organizations
or another national accrediting body. The HMO shall maintain evidence of current
licensure and Medicare certification or national accreditation in the provider's
credentialing file at all times.
]
If the provider is not Medicare
certified or accredited by a national accrediting body, the HMO shall establish
written standards for participation, and maintain evidence of evaluation of
the provider against those standards in the provider's credentials file.
]
The HMO shall maintain evidence of current licensure
and Medicare certification in the provider's credentialing files at all times.
]
The HMO procedures shall provide for recredentialing of institutional
providers at least every three years.
]
, dentists,
]
and
individual
[
other
] providers.
(7)
Measurements, data collection,
and analysis. The HMO shall track quality improvement by using measurements,
quality improvement data collection and analysis.]
(A)
To monitor and evaluate aspects of care and
services identified, the HMO shall use quality indicators that are objective,
measurable, and based on current knowledge and clinical experience.]
(B)
The HMO shall have performance goals for each
indicator.]
(8)
Methods and frequency of data
collection. The HMO shall establish methods and frequency of data collection
for each indicator.]
(A)
Quality improvement activities include the
collection of data.]
(B)
Data collected through monitoring and evaluation
activities shall be analyzed.]
(i)
Appropriate clinicians shall evaluate data
on clinical performance of practitioners.]
(ii)
Multidisciplinary teams shall be used, where
indicated, to analyze and address quality improvement issues.]
(9)
Health promotion.]
(A)
The HMO shall facilitate preventive health
care through health promotion activities. Health promotion activities include
outreach to enrollees to encourage appropriate use of services and educating
enrollees in preventive health care measures. Outreach may be accomplished
through but not limited to written educational materials, community based
programs, health promotion fairs, verbal communication, and monetary contributions
made to community based organizations and health related initiatives of other
programs.]
(B)
The HMO shall inform and educate physicians
and, if applicable, providers such as dentists and physical therapists about
using the health management and outreach programs for the enrollees assigned
to them.]
Chapter 21.
TRADE PRACTICES