Part 1.
TEXAS DEPARTMENT OF INSURANCE
Chapter 11.
HEALTH MAINTENANCE ORGANIZATIONS
The Commissioner of Insurance adopts amendments to §§11.1,
11.2, 11.101, 11.201 - 11.206, 11.301 - 11.303, 11.502 - 11.506, 11.508, 11.509,
11.512, 11.602, 11.603, 11.801 - 11.803, 11.806, 11.810, 11.901, 11.904, 11.1001,
11.1301 - 11.1306, 11.1401 - 11.1404, 11.1500, 11.1600 - 11.1602, 11.1604
- 11.1607, 11.1702 - 11.1704, 11.1801 - 11.1806, 11.1901, 11.1902, 11.2101
- 11.2103, 11.2200, 11.2201, 11.2203, 11.2204, 11.2303, 11.2311, 11.2314,
11.2402, 11.2405, 11.2501 - 11.2503, 11.2601, and 11.2602, and new §§11.902,
11.2207, 11.2208, and 11.2406, concerning regulation of health maintenance
organizations (HMOs). Sections 11.2, 11.205, 11.303, 11.506, 11.901, 11.1600,
11.1601, 11.1605, 11.1607, 11.1806, 11.1902, 11.2207 and 11.2208 are adopted
with changes to the proposed text as published in the November 12, 2004 issue
of the
Texas Register
(29 TexReg 10357). Sections
11.1, 11.101, 11.201 - 11.204, 11.206, 11.301, 11.302, 11.502 - 11.505, 11.508,
11.509, 11.512, 11.602, 11.603, 11.801 - 11.803, 11.806, 11.810, 11.902, 11.904,
11.1001, 11.1301 - 11.1306, 11.1401 - 11.1404, 11.1500, 11.1602, 11.1604,
11.1606, 11.1702 - 11.1704, 11.1801 - 11.1805, 11.1901, 11.2101 - 11.2103,
11.2200, 11.2201, 11.2203, 11.2204, 11.2303, 11.2311, 11.2314, 11.2402, 11.2405,
11.2406, 11.2501 - 11.2503, 11.2601, and 11.2602 are adopted without changes.
These amendments and new sections are necessary to implement statutory
changes from prior legislative sessions and to update procedures and requirements
to conform to certain nationally recognized standards. In addition, because
these sections have not undergone comprehensive revision for a number of years,
the department believes it is necessary to streamline and consolidate requirements
to reflect more accurately acceptable HMO practices and TDI’s policies
and procedures, and to clarify statutory requirements. The department also
believes rule revision is necessary to respond to regulatory concerns that
have arisen since the last revision.
The commissioner held a public hearing on the proposed sections on December
9, 2004. Subsequently, the department received comments regarding changes
within these proposed sections. In response to comments, the department has
changed several of the proposed sections as published; however, none of the
changes introduce new subject matter or affect additional persons than those
subject to the proposal as originally published.
The department is not adopting the proposed language concerning payment
for out-of-network services at §§11.506(10)(D), 11.1600(b)(11)(D),
and 11.1607(i)(4) in order to appropriately defer the issue pending possible
action in the current legislative session. However, the department has adopted
a notice requirement at §11.1600(b)(11)(D) that requires an HMO to notify
an enrollee to contact the HMO upon receipt of a bill from any provider. The
originally proposed language related to the issue of payment for services
received by enrollees outside of an HMO’s provider network due to emergencies
or the unavailability of a network provider. Comments received by the department,
both written and at the hearing, placed a great deal of emphasis on this issue
and generally focused on two possible effects of the proposed language. First,
commenters were concerned that the proposal would have a negative effect on
an HMO's ability to contract with certain types of specialty providers. These
commenters noted current difficulties for HMOs attempting to contract with
certain types of providers due to a variety of factors. Commenters specifically
identified arrangements between hospitals and providers that make certain
providers the exclusive provider of that type in a hospital. If a hospital
operating under such an arrangement is a network facility, the commenters
feel that the providers working within the hospital have little incentive
to contract with an HMO because any steerage that commonly results from a
provider’s contract with an HMO already exists due to the hospital’s
exclusive arrangement with the provider. The commenters opined that the proposal
would make it even more difficult to contract with these providers for a rate
other than the provider’s full billed charges.
Other commenters representing HMOs expressed concern that their ongoing
efforts to negotiate with out-of-network providers for payment of necessary
out-of-network services would be hindered by the proposed language because
it would operate as a disincentive to accept an amount lower than the billed
charge. These commenters are describing situations in which they are not seeking
to contract with the provider in order to bring the provider into the HMO’s
network, but rather are attempting to negotiate a price for services rendered
by an out-of-network provider due to an emergency or the unavailability of
a network provider.
The causes of the contracting and negotiating issues identified by commenters
merit further consideration to determine adequate and appropriate solutions.
Health care coverage through a managed care carrier depends upon a network
of providers who have, in general, contracted with the managed care carrier
for discounts in return for steerage of patients. The HMO model of managed
care is especially reliant upon a provider network, as enrollees are not allowed
to receive covered services from out-of-network providers unless it becomes
necessary due to an emergency or the unavailability of a network provider
for a specific service. If HMOs are unable to contract with providers for
discounts, the cost model on which HMOs are based most likely fails or requires
significant premium increases from current levels. Comments received in this
rulemaking process have highlighted the increasing difficulty that HMOs are
having in contracting with certain specialty providers that provide hospital-based
services. This trend results in an increased likelihood that enrollees will
receive out-of-network services in a network facility, which hampers the ability
of an HMO to exercise cost control.
The inability of HMOs and providers to agree on a usual and customary or
other acceptable payment amount for necessary out-of-network services essentially
places enrollees in a position of paying a greater amount than would have
been required were services available from a network provider. The reported
difficulties that HMOs are experiencing in attempting to contract with hospital-based
specialty providers should not result in a shifting of costs to enrollees
under the current statutory scheme. The proposal expresses the department’s
interpretation of the HMO Act, which prohibits enrollees from exposure to
additional costs for necessary out-of-network services, despite the reported
increased frequency of such services.
One aspect of the current statutory scheme appears to receive improper
emphasis as a remedy for the difficulties associated with contracting with
facility-based providers. With respect to the issue of enrollees that are
forced to receive services outside the network, the HMO commenters look to
the language in Article 20A.09(f) to limit an HMO’s responsibility to
a usual and customary amount as determined by the HMO. The amount determined
by the HMO is often lower than the provider’s billed charges, which
may result in the provider looking to the enrollee for the balance. Use of
Article 20A.09(f) as a solution for reported current difficulties in contracting
with certain types of providers is not consistent with certain protections
afforded enrollees in the HMO Act, such as requirements related to network
adequacy. The commenters’ interpretations create an exception to the
network adequacy requirements that circumvents the rule and would allow enrollees
to be routinely exposed to additional costs for services that should be available
through network providers. Enrollees receiving these out-of-network services
are rarely aware of the contracting status of the provider and have no opportunity
to ensure that services are not received from out-of-network providers. The
department understands Article 20A.09(f) to apply more appropriately to unusual
situations in which the HMO’s network would not likely have the type
of specialist necessary.
The issue of who is appropriately responsible for the costs of necessary
out-of-network services is at the heart of the subject of balance billing.
Although the department believes that the HMO Act requires enrollees to be
protected from additional cost exposure for unavoidable out-of-network services,
the evolving state of the market may yield cost consequences that the legislature
could not have anticipated when the HMO Act was originally enacted. Deference
to the legislature on this issue is therefore both appropriate and timely.
Payment for out-of-network services and balance billing have recently become
the focus of legislative interest, as evidenced by the interim charge to the
Senate State Affairs Committee to study payments by insurers and HMOs for
out-of-network services. The Committee’s report includes several recommendations
for further study and consideration, stating "the issue begs for legislative
action, [but] the degree of action should be fully vetted and debated." Because
of the possibility of legislative attention to this matter, the department
is not adopting the proposed language relating to payment of necessary out-of-network
services. Should the legislature decline to take any action, the department
may revisit the issue.
Despite the department’s decision to defer additional action on this
issue, the adopted rule includes a notice requirement so that enrollees receive
proper guidance regarding steps to take when they receive a bill from any
provider. Of all the parties involved in the issue of out-of-network payments,
enrollees have the least ability to exercise control over circumstances that
result in out-of-network services. Consequently, the department has adopted
a notice requirement at §11.1600(b)(11)(D) that requires an HMO to notify
an enrollee to contact the HMO upon receipt of a bill from any provider.
In response to comments, the department has made the following changes
to the language as proposed: The definition of "consumer choice health benefit
plan" has been revised to restore original language regarding applicable rules.
The definition of "copayment" in §11.2(b)(17) is changed to include the
language: "which may be expressed in terms of a dollar amount or a percentage
of the contracted rate." The department changed the definition of "premium"
in §11.2(b)(33) by replacing the reference to "small and large employer
and eligible employees" with the term "contract holder" to take into account
individual coverage. In §11.303(d)(1) and (3), the department restored
the words "or their designee" after "key management staff," in two places
to clarify that a key manager’s designee may attend the entrance and
exit conferences in the event a given key manager is not available. The department
deleted the phrase "on HMO’s behalf" in §11.901(a)(1)(C) because
physicians and providers do not collect copayments on behalf of the HMO. The
department revised the notice in §11.1600(b)(11)(D) to require HMOs to
include a notice in the plan description advising enrollees to notify the
HMO of any bill received from any provider. The department added language
to §11.1600(f) requiring that internet provider directory information
be easily accessible from the home page of the site. In §11.1607(g)(1)(B),
the department changed back the availability requirement for urgent behavioral
health care from 48 hours to 24 hours. The department changed the time frames
concerning the annual reports in §11.1806(a) to be consistent with the
time frames set by the Health and Human Services Commission. In §11.1902(4)(C)(iv)
the department added language to clarify that the only individual providers
for which site visits are required are individual behavioral health providers,
as well as clarify that the provision applies to the relocation and opening
of additional office sites of certain providers. The department added language
in §11.2208(c) to clarify that the requirement for contracting with an
inpatient facility applies only to single service HMOs that provide inpatient
care. In addition to the foregoing changes, the department changed the reference
in §11.1600(f) from "this paragraph" to "subsection (b)(11)" and the
reference in §11.508(d) from "this section" to "this subchapter" to correct
inaccurate cite references, and included a reference to Insurance Code §843.102
in §§11.204(14) and 11.301(5)(N) to more accurately reflect applicable
statutory authority. The department also changed the former names of the state
agencies in §11.506(10)(F)(ii) to the name of the appropriate existing
state agency. The department made other changes for purposes of consistency
and clarity, as well as to correct clerical and typographical errors. The
department also withdrew the proposed amendments to §11.809 (29 TexReg
11945, December 24, 2004), and instead proposed comprehensive amendments to
the section in a separate proposal that was published in the same issue of
the
Texas Register
.
The amendment to §11.1 revises the section’s title. Amendments
to §11.2(b) add a new definition for clinical director, revise the existing
titles of the definitions of consumer choice plan, referral specialists, and
state-mandated plan, and revise the text of the existing definitions of agent,
consumer choice plan, copayment, premium, and state-mandated plan.
Amendments to §11.101 update the contact information for obtaining
forms.
The amendments to §§11.202(a), 11.203(a) and 11.204 reduce the
number of additional copies required at the time of application for a certificate
of authority and for revised filings to expedite review and eliminate filing
of unnecessary copies. The amendment to §11.202(f) reflects a requirement
for one original application, and deletes an original signature requirement
to accommodate electronic filings. The amendments to §11.204(13)(B) and §11.205(a)(7)
clarify that the contracts between the HMO and delegated entities and/or delegated
networks be provided as part of the application process and that such agreements
be available during qualifying examinations. The amendment to §11.204(14)
clarifies the required quality improvement plan description. The amendments
to §11.204(18) add a requirement that the HMO provide network configuration
information, including maps demonstrating the location and distribution of
the physician and provider network within the service area upon initial filing
of an application for a certificate of authority. Amendments to §§11.205(a)(6),
11.302(b)(3), and 11.303(c)(7) incorporate the requirement for this network
configuration information. The amendments are adopted to ensure full compliance
with §843.078(k), which requires network configuration information to
demonstrate network adequacy. The maps, by indicating where particular providers
are located, are much more demonstrative of network sufficiency and accessibility
than written descriptions. In addition, the amendments also require that the
HMO provide lists of physicians and individual and institutional providers,
along with license type and specialization, and information concerning whether
such physicians or individual providers are accepting new patients. The license
type and specialization information allows TDI to more readily distinguish
primary care physicians from specialists in determining network adequacy to
support all types of covered services.
Section 11.204(23) clarifies that the applicant must demonstrate appropriate
operational structure and adequate management and staff to operate an HMO
and fully comply with all statutory and regulatory requirements applicable
to the HMO and any contracting entities. The amendments to §11.205 clarify
that referenced documents must be available for review at the HMO’s
Texas office at the time of examination, but may be physically maintained
at a different site; add language about qualifications of management and staff;
clarify complaints and appeals policies; and set out prescribed categories
of complaints to facilitate analysis and provide for uniform categorization.
These complaint categories require greater detail in, and expand on, the four
categories of complaints HMOs are currently required to maintain. These complaint
categories are also referenced in Subchapter D (§11.303(c)(4)). TDI believes
these amendments are necessary to facilitate review of complaints during examinations
and to allow TDI and the industry to more specifically monitor problems and
concerns in the face of marketplace changes that could impact enrollees. Recognizing
that these changes may require additional time to implement, TDI solicited
and received commenters’ input on appropriate compliance dates. Based
on the comments received, TDI has specified January 1, 2006, as the date by
which HMOs shall comply with these requirements. The amendments also clarify
and simplify the reference to health information systems records, clarify
the reference to network configuration documents, and consolidate the categories
of executed agreements to be available during examination. The amendments
to §11.205 also change the requirement that the entire physician or provider
contract be made available for review during examination; because of confidentiality
concerns, the provision requires that only the first page and signature page
be made available.
Section 11.205(a)(14), concerning claims systems, determines the HMO’s
capacity to comply with all applicable statutes and rules addressing claims
payment. The amendment to §11.205(a)(16) requires the HMO, at the time
of the qualifying examination, to demonstrate compliance with applicable laws,
including audits or examination reports by other entities, which will provide
TDI a more complete picture of the applicant and help the agency to pinpoint
any areas requiring particular attention prior to licensing.
To make departmental review and storage of documents more efficient, the
amendments to §11.301 add requirements for filings; clarify that, consistent
with insurance form filing requirements, each form must have a printed unique
form number; reduce the number of required form filings; and add the requirement
that the HMO include a cover letter with such filings. The amendments to §11.301
also add references to delegated entities and delegated networks and clarify
that a filing must include a reconciliation of benefits to schedule of charges
form. The amendments to §§11.301(5)(G) and 11.303(c)(8)(C) clarify
that contracts between the HMO and delegated entities and/or delegated networks
are included in the documents that an HMO must file pursuant to Insurance
Code Article 20A.18C and 28 TAC §11.2611 for examinations, and subsequent
to issuance of the certificate of authority. The amendments to §11.302
clarify that, consistent with §§843.080 and 843.078(h), a request
for any modification of the service area, including a reduction, must be filed
with and approved by the department. The amendments to §§11.302
and 11.303 also require the filing of network configuration information. The
amendments to §11.303 clarify that: the department may conduct complaint
examinations in addition to other types of examinations; quality of care examinations,
except those made pursuant to Insurance Code Article 1.15, may take place
off-site; examinations may be conducted by examination teams rather than single
examiners; and examination teams may conduct interviews of key management
staff or their designee in connection with such examinations. Amendments to §11.303
also identify the documents that should be available for review during examinations
to include those documents that have been deleted from §11.205(a) as
more appropriate for review after issuance of a certificate of authority.
The amendments change the timeframe for correcting serious deficiencies from
10 business days to 12 calendar days.
To expedite review and eliminate the filing of unnecessary copies, the
department reduced the number of copies of documents an HMO must file relating
to an evidence of coverage in §§11.502 and 11.503. Section 11.503
is changed to correct mail codes and clarify procedures for notifying HMOs
of approval or disapproval. Section 11.505 clarifies that each form will have
a different number, and expands the categories of variable language that can
be included in form filings to include optional benefits and provisions. This
flexibility will increase efficiency in form filings and facilitate greater
speed to market. Section 11.506 clarifies the statutory directive in Article
20A.09(a)(1) that every enrollee residing in this state is entitled to an
evidence of coverage, implements HB 1798 and HB 1800 (78th Legislature), which
permit an HMO to deliver plan evidences of coverage electronically, and removes
the reference to "standard language" because TDI reviews all forms for compliance.
The amendments to that section also clarify that cancellation of an enrollee
in a group cannot be based on health status related factors, consistent with
the requirements of the federal Health Insurance Portability and Accountability
Act of 1996 (HIPAA), P.L. 104-191.
The amendment to §11.506(2)(A) deletes the word "nominal" as an inaccurate
description of a 50% copayment. Section 11.506(3)(A) is amended to conform
to Insurance Code Articles 26.23 and 26.86 and to HIPAA. Section 11.506(3)(B)
deletes the 60-day timeframe for prior notice to the group because there are
no circumstances under which the 60-day notice would apply. Section 11.506(6)(C)
clarifies that conversion coverage is an option; the continuation provision
is mandatory. Section 11.506(9)(E) conforms to Insurance Code Article 20A.09H
(Children and Grandchildren), which refers to "enrollee." Section 11.506(16)
implements HB 508 (78th Legislature) by increasing from 30 to 60 the number
of days prior notice an HMO is required to give regarding a group plan premium
rate increase. Section 11.506(19) increases the age for dependent coverage
for a child from 21 to 25 years as required by HB 1446 (78th Legislature).
Throughout §11.506(23) the reference to an enrollee’s choice of
an obstetrician is changed from "designated" to "selected." Amended §11.506(25)
refers to Article 21.52J rather than listing its requirements.
Amendments to §11.901(a)(1) add provisions from Subchapter L, §11.1102.
The repeal of Subchapter L is published elsewhere in this issue of the
Amendments to §11.901(a)(12) add new language required by SB 781 (76th
Legislature), as it amended Insurance Code Article 20A.18A (now §843.311(3))
relating to podiatrists. Amendments to §11.901(a)(13) add language from
SB 418 (78th Legislature), which added Insurance Code Article 21.52Z, §2
relating to electronic health care transactions. Amendments to §11.902(a)
add language from HB 606 (77th Legislature) that added new §18D to Insurance
Code Article 20A (now §843.320) relating to hospitalists. Amendments
to §11.902(b) and (c) add language from HB 803 (77th Legislature) that
added subsection (o) to Insurance Code Article 20A.14 (now §843.3045)
relating to nurse first assistants. Amendments to §11.902(d) add language
from HB 1163 (78th Legislature) that added Insurance Code §843.319 (Certain
Required Contracts) relating to podiatrists. Section 11.902(e) adds language
that implements Insurance Code §843.312 relating to physician assistants
and advance practice nurses. Where appropriate, the amendments refer to the
statute rather than restating particular statutory requirements.
Amendments to §11.1001 update the contact information for obtaining
forms and update form numbers.
The amendment to §11.1302(a)(1) clarifies that leaving the HMO, rather
than leaving a particular plan within the HMO, triggers termination of appointment
to the Solvency Surveillance Committee (SSC). The amendment to §11.1302(b)
clarifies what constitutes a quorum. It also clarifies the circumstances requiring
a majority vote of the total committee membership. The amendment to §11.1302(c)
changes the maximum interval between SSC meetings by providing for a regular
annual meeting, rather than quarterly, as presently required. This change
will provide greater scheduling flexibility for better responsiveness to specific
concerns regarding an HMO, while eliminating requirements for meetings that
were not always necessary. The amendments to §11.1302(d) harmonize the
subsection with the Open Meetings Act, remove the provision allowing meetings
by telephone conference call, incorporate provisions concerning emergency
meetings, and add a provision permitting a majority of members to call a special
meeting. The amendment to §11.1302(e) adds the Open Meetings Act reference
for notice requirements. The amendment to §11.1302(f) makes clear that
SSC meetings are generally open, and adds language setting out circumstances
under which a closed meeting may be held. The amendment to §11.1304(a)
clarifies that the written record of SSC proceedings is subject to pertinent
confidentiality laws.
The amendment to §11.1403 updates the toll-free telephone number and
the agency organizational reference. The amendment to §11.1404(a) deleting
certain language relating to Article 21.52B reflects the decision in Texas
Pharmacy Assoc. v. Prudential Ins. Co. of America, 105 F.3d 1035 (5th Cir.
1997). The department is aware that there is uncertainty regarding the enforceability
of Article 21.52B following the decision in Texas Pharmacy Assoc. and the
subsequent U.S. Supreme Court case concerning Employee Retirement Income Security
Act preemption and a Kentucky any willing provider statute similar to Article
21.52B. See Kentucky Association of Health Plans v. Miller, 123 S.Ct. 1471
(2003). Should the statute be determined to be enforceable without additional
legislative action, the absence of this language from the rule will not prevent
the department from enforcing Article 21.52B.
The amendments to §11.1500 incorporate in substance the federal standards
for the term "similarly situated." The amendments to §11.1600(a) and
(b) implement HB 1800 (78th Legislature), which allows HMOs to provide plan
descriptions electronically to enrollees and contract holders. Amendments
to this section also consolidate notice requirements regarding current and
prospective female enrollees’ choice of an obstetrician-gynecologist
(OB-GYN) and clarify that female enrollees may select an OB-GYN without the
requirement for formal designation. Because the OB-GYN notice requirements
in §11.1600 and §11.1608 are similar, the §11.1608 requirements
have been repealed. The adoption of the repeal of §11.1608 is published
elsewhere in this issue of the
Texas Register
.
The amendments also remove unnecessarily restrictive requirements for the
provider directory that are not required by statute. Section 11.1600(b)(11)
adds language requiring notice advising enrollees to contact the HMO if they
receive a bill from any physician or provider. The amendment to §11.1600(c)
reiterates that HMOs are prohibited from making untrue or misleading statements
to either current or prospective enrollees. The amendment to §11.1600(d)
clarifies that an HMO may use its handbook to satisfy the plan description
requirements if it discloses information adequately and in accordance with §11.1600.
The amendment to §11.1600(e) requires the plan description to include
a disclosure that the enrollee may receive care from a physician other than
a primary care physician while in an inpatient facility. While this disclosure
is already required in the Evidence of Coverage under §11.506(26), to
ensure awareness of this critical provision, the department has added this
requirement to the plan description. Section 11.1600(f) implements SB 494
(78th Legislature), which requires HMOs with an internet site to maintain
a list of physicians and providers and to provide the same information that
is required in a paper directory, and adds language requiring that the internet
notices related to an HMO’s current list of physicians and providers
be easily accessible from the home page of the HMO’s site.
Section 11.1601(b) implements SB 418 (78th Legislature) regarding identification
cards that must comply with §21.2820. Section 11.1601(c) implements Insurance
Code Article 21.53L regarding standards for prescription drug identification
cards. Section 11.1600(d) implements SB 473 (78th Legislature), which restricts
the use of social security numbers on identification cards. Section 11.1605(b),
(c), (d) and (e) consolidates all pharmacy services requirements and implements
HB 2382 (77th Legislature) enacting Insurance Code Article 21.52L, which relates
to health benefit plan coverage for prescription contraceptive drugs and devices.
Amendments to §11.1606(b) and (c), concerning an HMO’s chief
executive officer, operations officer and clinical director (formerly "medical
director"), change the emphasis from full-time status and residence in the
service area to detailed functional and practical requirements of the positions.
The change reflects the department’s understanding that executives can
be responsible for operations in several states or several different service
areas on less than a full-time basis in this state. The amendments to §11.1607
consolidate accessibility and availability requirements from Subchapter U, §11.2001
et. seq. The adoption of the repeal of the remaining provisions of Subchapter
U is published elsewhere in this issue of the
Texas
Register
. These provisions are repealed because some have been moved
to other sections of this rule, and some were changed to comply with certain
national and industry standards, as detailed herein. Subsections (a) - (h)
of §11.1607, concerning accessibility and availability requirements,
add standards for availability of medical care consistent with national industry
standards. In accordance with the most recent National Committee on Quality
Assurance (NCQA) and industry standards, §11.1607(g) changes the availability
requirements for routine behavioral health care from three weeks to two weeks.
Also consistent with industry standards, the requirements for availability
of routine dental care were changed from three weeks to eight weeks, and the
availability of preventive dental health services was changed from two or
three months to four months. Section 11.1607(h) clarifies that an HMO must
have a network that encompasses the entire service area, and that access radii
are to be measured from providers to the boundaries of the service area, not
from current enrollees to providers. This is to clarify the expectation that
an HMO have a network that encompasses its entire service area, not just the
current enrollee population or area in which the plan is marketing.
Section 11.1607(j) clarifies that certain health care services, such as
transplants or treatment for cancer, burns, or cardiac disease, may be provided
outside the service area; however, an HMO may not require an enrollee to travel
outside of the service area to receive such services unless it provides the
enrollee with a written explanation of the benefits and detriments of in-area
and out-of-area options.
Section 11.1801(c) has been deleted as it is fully executed. Amendments
to §11.1802 prescribe a more comprehensive method for assessing the minimum
capital or net worth requirements of a Medicaid managed care organization
(MCO) and refer to amounts established by statute for required minimum capital
and surplus, rather than stating specific amounts in the rule. Obsolete language
that was superseded by §11.809 is deleted from paragraph §11.1802(a)(2)
and replaced by Risk Based Capital (RBC) requirements as the method, developed
in coordination with the National Association of Insurance Commissioners (NAIC),
for assessing capital adequacy. The method will be phased in over three years.
All HMOs, including those that are MCOs, must already comply with the RBC
formula currently required in §11.809. Insurance Code Article 1.61 requires
TDI, in conjunction with the Texas Health and Human Services Commission (HHSC),
to establish fiscal solvency standards for MCOs, and these amendments are
meant to ensure that MCOs that contract with the state operate in a fiscally
sound manner. The amendment to §11.1803(b) clarifies that the deposit
is used to protect the interests of the enrollees.
Section 11.1804 allows a reduction in the special statutory deposit required
for MCOs, taking into account certain guarantees from sponsoring organizations.
The amendment clarifies that the reduction relates only to the amount of the
statutory deposit held under §11.1803 and does not relate to other requirements
or unrelated non-Medicaid business. Section 11.1806(a) removes the automatic
requirement for filing certain financial information with TDI and instead
requires the information be filed only upon the department’s request,
and changes the time frames concerning the annual reports to be consistent
with the time frames set by HHSC. Section 11.1806(b) clarifies that, concurrently
with filing a Medicaid participation request with HHSC, Medicaid MCO candidates
must file with TDI the financial projections related to that request; it also
deletes the term "RFA" because it is not commonly used. Section 11.1806(c)
clarifies that an MCO must notify TDI of any financial or statistical reports
filed with other state agencies, but is not required to file such reports
with TDI except upon TDI’s request.
The amendments to the titles of §§11.1901 and 11.1902 clarify
that the sections apply to both basic and limited service HMOs. The amendment
to §11.1901(c)(1)(B) clarifies that the subcommittee is responsible for
reporting to the quality improvement committee (QIC), which in turn is responsible
for reporting to the governing body. Amendments throughout §11.1902 implement
Insurance Code Article 21.58D, as amended by HB 1095 (78th Legislature), relating
to standardized forms for verification of certain credentials including those
for advanced practice nurses and physician assistants; fully update credentialing
requirements to comply with NCQA standards as required by Insurance Code Article
20A.39; and add requirements relating to initial credentialing site visits
and tracking the opening of new offices to comply with NCQA requirements applicable
to primary care physicians and individual primary care providers, obstetrician-gynecologists,
primary care dentists, and high-volume behavioral health physicians or individual
behavioral health providers. Although the NCQA standards do not specifically
address primary care dentists, the department, pursuant to the direction of
Article 20A.39, has applied those standards to dentists to ensure consistent
quality in all areas of health care.
The amendments to §11.1902(2) more accurately state criteria the work
plan must meet. The amendments to §11.1902(2)(B) expand updating intervals
for those clinical guidelines that change more or less frequently, allow practicing
physicians and providers to have input into clinical practice guidelines,
and in accord with NCQA requirements, delete the requirement that practice
guidelines be communicated to providers in a particular way. The amendment
to §11.1902(2)(B) adds clauses (xi) through (xiii) to include program
areas that are essential to any quality improvement (QI) work plan. The amendments
to §11.1902(4)(B) add a reference to the provider directory to indicate
which physicians and providers must be credentialed, and clarify that hospital-based
physicians and providers, if they are not listed in the provider directory,
and opticians would not be required to be credentialed by the HMO. Section
11.1902(4)(B)(ii) adds language to comply with NCQA standards concerning physician
and practitioner rights. Section 11.1902(4)(B) requires appropriate, timely
notice to applicants concerning credentialing and recredentialing to comply
with NCQA standards and adds a specific timetable associated with NCQA-required
monitoring of certain sanctions. The amendment to §11.1902(4)(B)(viii)
provides additional discrimination prohibitions to be included in HMO credentialing
and recredentialing procedures to ensure compliance with NCQA requirements
and other applicable law. The amendment to §11.1902(4)(C)(iv) clarifies
that site visits apply only to certain physicians and providers, more clearly
states that the HMO may conduct a single visit to accomplish on-site visit
requirements for multiple providers, and adds language requiring the HMO to
have a process to track the relocation of and opening of additional office
sites for primary care physicians and individual primary care providers, obstetrician-gynecologists,
primary care dentists, and high-volume behavioral health physicians or individual
behavioral health providers. Section 11.1902(4)(D) provides that the items
to be gathered at the time of recredentialing and the recredentialing timeframes
are the same as for an original credentialing. The amendment to §11.1902(4)(F)
deletes reference to clause (v) because site visits for evaluation are no
longer required at the time of recredentialing. Section 11.1902(7) restates
the provisions for the delegation of credentialing functions from former §11.1902(4)(B)(vi).
Section 11.2207 is adapted from revised Subchapter T to add specific QI
requirements for single service HMOs, to clarify that the same QI standards
apply to all HMOs. In addition, the amendments incorporate the single health
care services availability and accessibility requirements from Subchapter
U, §11.2006, so that all requirements relating to single service HMOs
are contained in one subchapter.
Amendments to §11.2314 add the words "opportunity for" to clarify
that under §843.461(a)(1) only notice and an opportunity for a hearing
must be available before the commissioner may suspend or revoke a certificate
of authority.
Section 11.2406 specifies the statutory and regulatory standards for a
limited service HMO providing long-term care services and benefits.
Amendments to the subchapters, including Subchapters G, I, R, Z and AA,
make editorial or grammatical changes for ease of reading or for clarity;
update references to statutory authority; change specific references to more
general references to avoid constant updating and revisions; add consistent
abbreviations; eliminate redundant or unnecessary wording; and reflect accurate
terminology.
§11.2(b)(17): Some commenters suggest that the department clarify
that a copayment may be expressed either in terms of a dollar amount or a
percentage.
Agency Response: The department agrees to add the language "which may be
expressed in terms of a dollar amount or a percentage of the contracted rate,"
to reflect the position the department has historically taken.
§11.2(b)(33): A commenter believes the modifications to the definition
of "premium" do not take into account individual coverage because the definition
refers to only large and small employers and large and small employer carriers.
Agency Response: The department agrees and has changed the rule to encompass
individual as well as employer coverage.
§11.204(18): A commenter agrees with language requiring HMOs to submit
lists of various physicians, specialties, and individual and institutional
providers and whether or not they are accepting new patients. The commenter
also recommends that the HMOs be required to submit lists of any specialty
groups the HMO was unsuccessful in bringing into their network because having
this information during the application process would allow a more comprehensive
representation of the network’s adequacy or inadequacy.
Agency Response: The department declines to make the requested change.
The HMO Division determines network adequacy based on an HMO’s contracted
physicians and providers, not on non-contracted physicians and providers.
The list of contracted physicians and providers, along with maps showing their
locations, are evaluated against TDI access requirements to ascertain whether
an adequate number of physicians and providers with the appropriate skill
levels are available to provide the covered services. If deficiencies are
noted in the network, the HMO will be required to submit an access plan for
approval unless the network deficiencies are so severe that they cannot be
adequately addressed by an access plan. In such case, the network will not
be approved.
§11.204(23): A commenter feels the requirement for a description of
the management structure and personnel to demonstrate an applicant’s
capacity to meet the needs of providers and enrollees, and to meet the requirements
of regulatory and contracting entities, is vague and may exceed the agency’s
statutory authority.
Agency Response: The department disagrees. This provision is not new but
rather clarifies and expands the previous language in §11.204(23) that
required applicants for an HMO certificate of authority to provide information
demonstrating their ability to comply with statutory requirements. Further, §843.078(n)
provides that an application for a certificate of authority must include "any
other information that the commissioner requires to make the determinations
required by this chapter and Chapter 20A" of the Insurance Code.
§§11.204, 11.205, 11.506, 11.901, 11.1600, 11.1601, and 11.1607:
Some commenters strongly support the department’s position and encourages
adoption of these sections.
Agency Response: The department appreciates the comments.
§11.205: A commenter understands the department’s rationale
for requiring greater detail regarding complaints to facilitate monitoring
problems and concerns that may impact enrollees. However, some commenters
believe the proposed changes to the complaint categories will necessitate
change to complaint and appeal policies and procedures and the current complaint
log format. These commenters feel that substantial lead time will be required
to design enhancements, re-program and test impacted databases and systems,
and train coordinators. One commenter suggests an effective date of enhanced
categories be January 1, 2006 or later. Another proposed nine months lead
time. A commenter also asked the department for additional guidance on the
use of these categories, as one complaint could fall into more than one category.
Agency Response: The department agrees with the need for a delayed compliance
date. Therefore, the department has determined that compliance with this provision
is required as of January 1, 2006. The department recognizes that a single
complaint may fall under multiple categories, and expects that reporting will
distinguish clearly between number of complaints and number of categories.
For example, a report of complaints might state that there were a certain
number of complaints within a time period, but the total number of complaints
within the complaint categories during the same time period may be larger
due to the multiple categories that apply.
§11.303(c): A commenter requests adding "or applicable sample documents"
to this subsection for out of state HMOs because having all provider contracts
in this state should not be necessary.
Agency Response: The department declines to make this change to subsection
(c) since it reflects current department procedures. A form contract is not
an adequate substitute for a copy of an executed contract because it does
not contain evidence of actual agreements in effect.
§11.303(c)(5): A commenter asks whether enrollee disenrollment logs
and provider termination logs are information that an HMO is currently required
to maintain. If not, the commenter says that the regulations should elaborate
on the form of these logs.
Agency Response: The rules do not require that provider termination logs
be provided. The requirement for enrollee disenrollment and termination logs
is not new, as former 28 TAC §11.205(a)(5) required HMOs to maintain
such logs.
§11.303(d)(1) and (3): A commenter suggests that the rule be revised
to clarify that a key manager’s designee may attend the entrance and
exit conferences in the event a given key manager is not available.
Agency Response: The department agrees and will restore the words "or their
designee."
§11.303(d)(5): A commenter states that the department has modified
the timeline in the event the exam team cites serious deficiencies. The commenter
states that an HMO is required to provide the exam team with a signed plan
to correct deficiencies within one business day, instead of the previous 10
business days, and to submit a plan of corrective action within 10 days
instead of the previous 30 days, in accordance with the severity of the deficiency.
The commenter says that one business day to provide TDI with a signed plan
to correct deficiencies is extremely onerous, especially when there is no
definition of what a "serious" deficiency is. The commenter recommends returning
to the original language.
Agency Response: The department declines to make this change. The commenter
may not be distinguishing between the requirements for "serious deficiency"
and "potentially serious deficiency," which, in the previous rules, had different
time frames. The proposed and adopted rule eliminates the category of "potentially
serious deficiency" but continues to give the HMO one business day to submit
a plan to correct serious deficiencies. However, the proposed and adopted
version allows 12 calendar days (rather than 10 business days) to correct
the deficiencies. In most cases, however, this will result in identical time
frames. One example of a serious deficiency is an HMO with an unlicensed medical
director or no medical director.
§11.505(f): A commenter suggests that to provide plans with additional
flexibility in filing of EOCs with ranges of benefits, exclusions, and other
provisions, the phrase "is limited to" be replaced with "such as."
Agency Response: The department disagrees. The adopted rule expands the
types of variable information that can be included in an EOC, but the department
declines to make the list open-ended at this time. However, the department
is receptive to suggestions regarding variability that may be appropriate
for consideration in future rulemaking.
§11.506(2)(A): Some commenters suggest that the department delete
the reference to the 200% of total premium limit on copayments, as this maximum
came from federal minimum requirements for HMOs, and SB 541 (78th Legislature)
deleted the reference to federal minimum qualifications. A commenter believes
that doing so will allow for increased cost sharing and more flexibility in
HMO products. To be comparable to other benefits provided in the market, a
commenter suggests "the department place limitation the same as for PPOs,
which do not allow a cost differential less than 30% co-insurance for an insured
and the insurer must pay 70%."
Agency Response: The "federal minimum requirements" the commenter references
are found in the Public Health Service Act (42 U.S.C. Section 300e et seq.).
SB 541 deleted only the requirement that the basic health care services an
HMO must provide include at least the services designated as basic health
services under Section 1302, Title XIII, Public Health Service Act (42 U.S.C.
Section 300e-1(1)). The bill made no other change to the application of the
Public Health Service Act in Texas law. SB 541 does address the commenter’s
concern by authorizing an HMO to offer plans generally not subject to limitations
or restrictions on deductibles, coinsurance, copayments, or any annual or
lifetime maximum benefit amounts. An HMO may thus offer a consumer choice
health benefit plan that is not subject to the §11.506(2)(A) limit on
copayments, and the increased cost sharing and flexibility in HMO products
the commenter seeks are already available pursuant to SB 541. The department
thus declines to make this change.
§11.506(2)(B): A commenter suggests that consumer choice plans specifically
be exempted from the general prohibition against deductibles.
Agency Response: The department declines to make this change. While this
adoption revises the definition of consumer choice health benefit plans, generally
it does not seek to identify provisions that may be exempt from regulation
under, or otherwise subject to, SB 541. The regulations specifically applicable
to consumer choice plans are located at Subchapter AA, Chapter 21 of this
title.
§11.506(9)(E)
Comment: A commenter states that there are two Articles 20A.09H dealing
with grandchildren, and that it would be helpful to clarify which controls.
Agency Response: The caption of the applicable statute ("Children and Grandchildren")
was included in the rule to distinguish between the two articles.
Comment: A commenter suggests that rather than changing the term from "subscriber"
to "enrollee" with regard to grandchild coverage, the phrase "or subscriber's
spouse" be added after "subscriber."
Agency Response: The department declines to make this change, since Article
20A.09H uses the term "enrollee."
§11.506(23)(F): A commenter suggests inserting "which does not allow
open access to participating obstetricians/gynecologists" after "An HMO" in
the first line.
Agency Response: The department disagrees, as there should be no instance
where an HMO does not allow open access. In the interest of standardization,
the HMO must include the space on the enrollment form for selection.
§11.901(a)(1)(A) and (C): A commenter suggests that this language
confine the hold harmless provisions in these sections to services that are
covered under the HMO plan. The commenter also observes that subparagraph
(C) incorrectly states that providers can collect supplemental charges or
copayments on behalf of the HMO. Providers collect copayments on their own
behalf, not on behalf of the HMO.
Agency Response: The department disagrees that the first suggested change
is necessary, as the rule already states that it applies to covered services.
The department agrees to delete language concerning the collection of copayments
"on HMO’s behalf."
§11.901(a)(5): A commenter says that this section could arguably eliminate
the ability of HMOs to terminate the provider on less than 90 days’
notice for the reasons stated in §843.306 (imminent harm, fraud, etc.).
The commenter doubts that was the intent, but expressed concern that the section
does not clearly permit such terminations. The commenter stressed health plans’
need to terminate a provider immediately for such good cause.
Agency Response: The department understands the commenter’s concerns.
However, the exceptions for cases of imminent harm to a patient; action by
a licensing board, or other governmental agency; and provider fraud or malfeasance
are referenced in the rule by citation to §843.306 and do not need to
be restated.
§11.902: A commenter requests that this section be revised to clarify
that nurse first assistants must comply with the terms established by the
HMO for participation in the network including, but not limited to, meeting
credentialing standards and network need.
Agency Response: The department declines to make this change, as this provision
mirrors the statute.
§11.1600(a): A commenter requests inserting "with the contract holder"
after "By agreement" in the last sentence.
Agency Response: The department declines to make the requested change,
as Article 20A.09(a) says the agreement may be between the HMO and the subscriber,
or the person entitled to receive the evidence of coverage.
§11.1600(b)(11): A commenter agrees with the language, but suggests
that the HMO also be required to provide a list of any non-contracted specialists
in the service area that are pertinent to the provision of medical benefits
to enrollees; this would provide a more comprehensive representation of the
network and provide enrollees a better understanding of the circumstances
under which a non-network physician or provider may be involved in their care.
Agency Response: The department declines to make the requested change.
While the department understands the commenter’s interest in enrollees
having a better understanding of the circumstances under which a non-network
physician or provider may be involved in their care, the department disagrees
that providing enrollees with a list of all non-contracted specialists in
a service area would accomplish that goal. The enrollee may obtain the same
information that the commenter suggests be available by reviewing the list
of contracted physicians and providers that the HMO is required to provide.
The enrollees can assume that any physician or provider not on the list is
not in the network. In addition, a list of all non-network physicians and
providers may confuse enrollees and be difficult for HMOs to assemble and
maintain.
§11.1600(b)(11)(E): A commenter states that HMO and health plan internet
sites are often quite large and difficult to navigate, and suggests that internet
notice must be "conspicuous," "prominent," and "no deeper than one page below
the HMO main home page." Other commenters applaud the enrollee notice in this
section, and feel that it ensures that enrollees have more information to
make healthcare decisions, but request that the information be more easily
accessed on the website, and suggest no more than three "clicks" to get to
the information.
Agency Response: The department agrees that clarification would be useful,
and has added clarifying language in §11.1600(f), which refers to the
entire provider directory, rather than in (b)(11)(E), which is limited to
the notice provisions that must be included in the provider directory.
§11.1600(d): A commenter notes that the plan description still requires
the HMO to hand out paper provider directories but, along with another commenter,
believes that web site directories are more accurate and up-to-date than paper
directories. Consequently, the commenters believe, the department should allow
HMOs to direct members to the HMO website for provider lists and to provide
written hard copy directories upon request. A commenter believes Insurance
Code §843.2015 gives the department the authority to allow carriers to
provide such directories in this manner and points out that allowing carriers
to do so will save costs.
Agency Response: The proposal does not require issuance of a paper directory.
Section 11.1600(d) concerns only situations where an HMO seeks to provide
plan descriptions and provider directories along with the handbook. Subsections
(a) and (b), which address an HMO’s publication of a plan description,
allows an HMO to furnish a plan description, including a provider directory,
electronically upon agreement. Pursuant to TIC §843.2015, electronic
distribution includes publishing the directory on the HMO’s internet
site. The electronic option may not work for all enrollees or potential enrollees,
as internet access is not universal. Moreover, some electronic directories
pull up only one provider at a time or a limited provider list at one time
based upon search criteria such as ZIP code, which lists providers available
in a certain ZIP code. Accordingly, while electronic distribution is permitted,
if the enrollee does not agree to accept an electronic version, the HMO must
furnish a paper copy of the plan description or directory.
§11.1605(b): A commenter suggests adding language to permit an HMO
to contract with a mail order pharmacy vendor who is located outside of Texas
and who may not be licensed in Texas (unless a pharmacy providing mail order
services to Texas residents must be licensed under Texas State Board of Pharmacy
requirements).
Agency Response: The department declines to make the requested change,
as the Texas Pharmacy Act, Texas Occupations Code Subtitle J, requires a pharmacy
vendor who ships medications into Texas through mail order arrangements to
become licensed as a Class E Pharmacy.
§11.1606(b): A commenter believes that the department should not dictate
the responsibilities of the Chief Operating Officer (COO) or Chief Executive
Officer (CEO) other than general oversight and responsibility for the operations
of the HMO, and notes that the list contained in this section doesn’t
fit all organizational structures. Another commenter asks that the CEO or
COO definition not include responsibility for "marketing operations" and "medical
management" because medical management decisions should be made by doctors,
and recommends that the CEO or COO be responsible instead for "the general
oversight of the plan."
Agency Response: The department disagrees and does not believe the recommended
change is necessary. If in a particular organizational structure, an executive
at an equal or higher level than the CEO or COO oversees portions of the functions,
and informs the CEO or COO of the status of the functions on a regular basis,
the department would take this structure into account during an examination.
Oversight of medical management functions does not imply that the CEO/COO
makes medical management decisions; rather, the CEO/COO oversees the administrative
functions of the medical management department such as staffing, equipment
and other resources, and ensuring compliance with all applicable statutes
and rules pertaining to the operations of the HMO.
§11.1606(c) and (d): A commenter supports the revised requirements
for clinical director as more flexible and more reflective of the current
operations of national health plans.
Agency Response: The department appreciates the comment.
§11.1606(c)(1): A commenter feels this provision should state, "shall
be currently licensed in the United States or otherwise authorized to practice
in the United States…"
Agency Response: The department declines to change the existing requirement
because a clinical director, as a health care professional, must logically
be a physician or provider. Texas Insurance Code, at §843.002(22), defines
"physician" as "an individual licensed to practice medicine in this state."
Likewise, §843.002(24) defines "provider" as "a person, other than a
physician, who is licensed or otherwise authorized to provide a health care
service in this state."
§11.1607(g): Some commenters support changing the availability of
routine behavioral health care from three to two weeks. Another commenter
is concerned about this change, and asks about the disposition of the provisions
in 28 TAC §11.2001. The commenter says that change from three weeks to
two weeks for appointment times for behavioral health providers is particularly
troublesome in a Medicaid context, where it is difficult to find qualified
providers willing to accept patients for that program at rates that are competitive,
given HHSC's capitation rates to HMOs.
Agency Response: The change from three weeks to two weeks is consistent
with NCQA requirements. The department clarifies that the referenced provision
was formerly located at §11.2001, Subchapter U, which is being repealed
simultaneously with this adoption order. Regarding Medicaid patients, the
department notes that HHSC has authority over the Medicaid product, except
as specifically provided for in the Texas Insurance Code and other applicable
laws, and therefore the provision does not apply other than by reference,
if any, in the HHSC contract with the HMO.
§11.1607(g)(1)(B): Some commenters oppose changing the availability
requirements for urgent behavioral health care from 24 hours to 48 hours from
time of request. They feel the change would be dangerous to patients who need
urgent treatment and that unnecessary delays will cause the patient’s
health to deteriorate and lead to the need for more and more expensive services.
Agency Response: The department agrees that urgent behavioral health care
should be available on a timely basis and is retaining the 24 hour requirement.
§11.1607(h): A commenter feels the language change to "travel distances
from any point in the service area to a point of service…" would require
a change to current software mapping programs, which measure distances from
where actual enrollees live or work. Another commenter requests confirmation
of its understanding that the mileage requirements of the rule refer to the
given mileage radius rather than actual road mileage.
Agency Response: While changes to current software programs may be required
to meet the clarified standard, the department believes the change was necessary
to ensure that HMOs have networks that encompasses the entire service area.
In addition, the department notes that a variety of software or manual methods
of demonstrating compliance is available. The department clarifies that the
mileage requirements are measured as radii from provider and physician locations
within the HMO service area. This change should better demonstrate access
to the particular type of provider throughout the service area.
§11.1607(j): A commenter feels the requirement to provide an enrollee
with a written explanation of the out-of-area options seems onerous. The commenter
says that HMOs arrange for access to providers based on the medically appropriate
services needed by the member, and questions how often an HMO would "force"
an enrollee to go outside the service area when in-area services are available.
The criteria for going outside would be based on the need for the higher skill
level.
Agency Response: Treatments or services that require a "higher level of
skill or specialty" may be rare. However, these services may still be needed
in such instances and the requirement should not be onerous or burdensome
for HMOs. The rule allows HMOs the flexibility to provide quality care in
a cost-effective manner, while balancing the need for appropriate notice to
enrollees. The department is familiar with one situation in which an HMO contracted
with a network of "centers of excellence" for transplant services. In some
service areas, the contracted facility was located outside the service area,
although another transplant facility was also located within the service area.
In this instance, the HMO filed an access plan to demonstrate that the in-area
facility did not meet the quality standards for the particular transplant
services, or else was inaccessible because it did not enter into a contract.
In the event that an enrollee had required the transplant services in this
instance but wished to stay in the service area, the department expects that
the HMO will give the enrollee written information regarding the benefits
and detriments of the in-area and out-of-area facilities, allowing the enrollee
to make the decision after full disclosure. The HMO has the option of authorizing
out-of-network services in such a situation, and may even negotiate a single-member
contract with the in-area facility.
§11.1806(a): A commenter suggests that the requirement that the second
(final) Medicaid Financial Statistical Report be accompanied by a CPA opinion
creates issues of timing (for the report to be prepared, and then audited,
before submission) and expense (the audit fees). The 30-day period between
270 and 300 days after the contract period is not only insufficient for this
new requirement, but also is not consistent with the Medicaid requirement
that the report reflect data through the 334th day and be submitted by the
365th day.
Agency Response: This provision was not changed from that originally adopted
in 1998, which was consistent with the requirements of the Texas Department
of Health at that time. Upon consultation with the Health and Human Services
Commission (HHSC), who has changed the requirement to the time period the
commenter referenced, this section was changed to the time frames of the annual
reports as set by HHSC.
§11.1902(4)(B)(i): A commenter states that this section requires each
provider of a Group/Independent Physician Association to be individually credentialed
by the HMO but does not make allowance for delegation, although delegation
is listed in many areas.
Agency Response: The provision distinguishes between individual credentialing
of members of a group, as opposed to a group credentialing process. To the
extent that an HMO delegates credentialing, the same requirements would apply
to the delegate. However, as set forth in 28 TAC §11.2601, the HMO remains
ultimately responsible for compliance with all applicable laws, including
credentialing requirements.
§11.1902(4)(B)(v): A commenter states that clause (v) should be changed
so that applicants must be notified only if the credentialing or recredentialing
decision is adverse. The commenter says that every plan has network management
procedures for welcoming new providers upon initial credentialing and that
it would be redundant and burdensome to require separate notification of a
positive decision. For recredentialing, the process for providers successfully
recredentialed is seamless so that notification of a positive recredentialing
decision would serve no useful purpose. The commenter also says that NCQA
has eliminated this requirement for notification of positive actions and only
requires notification of adverse actions.
Agency Response: The department declines to make the change because the
language is consistent with NCQA standard CR1 (2004).
§11.1902(4)(C)(iv)
Comment: A commenter is concerned about the use of the term "individual
provider" and asks that the department clarify that site visits are required
only for primary care providers, OB/GYNs and high-volume specialists.
Agency Response: To clarify, the department will add the words "behavioral
health" when referring to "individual provider," where appropriate.
Comment: A commenter urges deletion of the language requiring HMOs to have
a process to track the opening of new physician and individual provider offices,
and to perform a site visit of each new office site of the stated physicians
and providers. The commenter says that the language implies that the plan
would have an obligation to continuously monitor the status of new office
openings, which would be extremely costly and burdensome. The commenter suggests
alternative language that says opening of a new provider office is considered
a material change in a provider's participation status that must be reported
to the HMO, which will perform a site visit when so informed.
Agency Response: The site visit requirement is only applicable to relocation
and opening of additional sites for primary care physicians, OB/GYNs, and
high-volume behavioral health physicians or individual behavioral health providers.
Because HMOs are already required to maintain a current provider directory,
tracking should impose no additional burden. To clarify, the section has been
changed as follows: "The HMO shall have a process to track the relocation
and the opening of additional office sites for primary care providers, obstetrician-gynecologists,
primary care dentists, and high-volume behavioral health physicians or individual
behavioral health providers."
§11.1902(7)(A)(iv): A commenter states that the language of this clause
is not consistent with NCQA standards. The commenter could find no requirements
for a procedure for termination of the delegation agreement for non-performance
in the standards for NCQA accreditation.
Agency Response: The language is consistent with current NCQA standard
CR12 (2004). A written delegation agreement is required for the delegation
of any function required by the HMO Act, including credentialing, under Article
20A.18C. One of the required provisions of such agreement is an acknowledgment
and agreement by the delegated entity that if it fails to meet standards established
to ensure that delegated functions are in full compliance with all statutory
and regulatory requirements, the HMO may cancel delegation of any or all delegated
functions.
§11.1902(7)(B) and (C)(iii): A commenter says it did not find any
requirements for semi-annual reports received from the delegated entities
in the standards for NCQA accreditation.
Agency Response: This requirement is consistent with NCQA standard CR12
(2004).
§11.2201(c): One commenter says that some single service HMOs only
contract with full service HMOs and therefore would never produce an evidence
of coverage (EOC). The commenter accordingly recommends adding the words "if
applicable" after the term "evidence of coverage."
Agency Response: The department disagrees that this is necessary, since
the provision applies only to an HMO that issues an EOC.
§11.2207(d)(2)(B)(xiii): A commenter recommends adding "as applicable"
after "pharmacy," as not all single service HMOs cover this benefit.
Agency Response: The department disagrees that the suggested phrase is
necessary, as the language would only be applicable to those HMOs that offer
pharmacy benefits.
§11.2207(d)(4)(G): A commenter disagrees with linking department rules
to NCQA requirements for categories of health plans that are not accredited
by NCQA, and suggests that the language in this subparagraph be revised to
exempt categories of health plans that NCQA does not accredit, i.e., stand-alone
dental plans.
Agency Response: The department disagrees, as this requirement comes from
Insurance Code Article 20A.39, which applies to all HMOs without exception.
§11.2208(b): A commenter asks that this subsection clarify the exclusion
of non-emergency conditions (such as routine eye care and dental checkups).
Agency Response: The department does not believe this change is necessary.
Sections 11.2203 and 11.2204 specifically address minimum standards for dental
care and vision care services and benefits, and §11.2208(b) already requires
an HMO to make services available only "as appropriate."
§11.2208(c): A commenter says that this requirement could severely
limit the business of health plans that hold the contract with ambulatory
surgical centers and hospitals and not with single service HMOs. Presently
none of the commenter’s business with full service HMOs carve out both
provider and hospital services.
Agency Response: To clarify that this section applies only to single service
HMOs that provide inpatient care, the department has changed the subsection
as follows: "If a service offered by a single health care service HMO requires
inpatient status…."
Payment for Out-Of-Network Services
§11.506(10)(D) and §11.1607(i)(4): A commenter generally supports
the rules as published, and believes the amendments to these sections are
necessary to ensure that enrollees receive covered services by paying only
the deductibles and copayments stated in their contracts. The commenter agrees
that this language does not address an HMO’s ability to negotiate rates;
instead the amendments clarify that HMOs must provide care on a pre-paid basis
in accordance with accessibility and availability standards of the statute.
Agency Response: The department appreciates the comment. However, as previously
noted, the department acknowledges concerns that the proposed language may
have some effect on an HMO’s ability to negotiate with certain providers
which may not have been anticipated at the time of the original enactment
of the HMO Act. As a result of the possibility of legislative action, the
department is not adopting the proposed language concerning payment for necessary
out-of-network services at §§11.506(10)(D), 11.1600(b)(11)(D), and
11.1607(i)(4) in order to appropriately defer the issue during the current
legislative session.
§11.506(10)(D) and §11.1600(b)(11): A commenter feels that these
sections should be changed to include not only the term "network" but also
"network facilities," as contained in §11.1607(i)(4), to maintain consistency
and clarify the intent that enrollees are protected from paying amounts that
may be balance billed whether benefits are received from a network provider
or a non-contracted physician.
Agency Response: The department is not adopting the proposed language relating
to payment of necessary out-of-network services. However, the department disagrees
that this change would be necessary because it is generally understood that
a network would include any providers who contract with the HMO, including
facilities. "Provider" is defined in Insurance Code §843.002(24) as "a
person, other than a physician, who is licensed or otherwise authorized to
provide a health care service in this state, including . . . a pharmacy, hospital
or other institution or organization."
§11.506 and 11.1607: Some commenters feel that the term "usual and
customary," as stated in Texas Insurance Code Article 20A.09Y, refers to the
fee a particular physician charges for a particular service. The commenters
believe that defining the term in this manner is necessary to protect the
enrollee from balance billing, as there will undoubtedly be a difference between
the amount the plan is willing to pay and the physician’s actual charge.
A commenter believes this position is supported by Insurance Code Article
21.60 which, when referring to the amount the plan is willing to pay, does
not use the phrase "usual and customary." Another commenter feels that to
allow plans to define "usual and customary" as their contracted rate confuses
the issue and violates the statute.
Another commenter notes that the language of the 1997 Patient Protection
Act relating to ER providers came from the department’s rules and asserts
that the "usual and customary" language was included to address those instances
when the HMO and provider could not agree on a rate. A commenter notes that §11.204(20),
concerning contents of an application, continues to require that the HMO demonstrate
that it will pay for emergency care services rendered by non-network providers
at either a negotiated rate or the "usual and customary" rate. The commenter
asserts that "usual and customary" rates are established as a means of providing
fair and reasonable compensation for services rendered while protecting health
plans and members from "price gouging."
Agency Response: The different approaches from the commenters on this issue
demonstrate the complexity involved in payment for necessary out-of-network
services. Defining "usual and customary" would likely have more far-reaching
effects on other elements of the health care industry than ensuring enrollees
are protected from additional charges for out-of-network services. As a result
of the possibility of legislative action on the issue of payment for necessary
out-of-network services, the department is not adopting the proposed language
relating to payment of necessary out-of-network services and declines to define
"usual and customary" as suggested.
§11.506(10)(D): Some commenters oppose the requirement that an HMO
ensure enrollees are indemnified or otherwise held harmless if they receive
out-of-network emergency care services. Some commenters state that this issue
is currently not addressed by statute and, as one commenter notes, there is
presently no Texas law to prohibit non-contracted providers from balance billing
patients. The commenters believe that the rules exceed the department’s
statutory authority in Article 20A.09Y, which allows HMOs to pay for emergency
services through a negotiated rate or, in the event the HMO cannot negotiate
a rate, a usual and customary rate.
Agency Response: While the commenters are correct that there is no law
preventing out-of-network providers from balance billing an enrollee, the
proper focus for these rules is the department’s authority over HMOs
and their payment obligations for necessary out-of-network services. Some
HMOs indicate they rely upon the term "usual and customary" in the statute
in order to pay an amount that is sometimes less than what a provider is willing
to accept. This, in turn, creates the potential for additional cost exposure
to enrollees, which is inconsistent with other provisions of the statute.
As a result of the possibility of legislative action, the department is not
adopting the proposed language concerning payment for necessary out-of-network
services in §§11.506(10)(D), 11.1600(b)(11)(D), and 11.1607(i)(4)
to appropriately defer the issue during the current legislative session.
§11.506(10)(D)(ii): Some commenters are concerned that emergency care
providers may terminate existing contracts in order to maximize their revenue
by forcing payment of billed charges by HMOs. A commenter suggests that, as
applied to consumer choice plans that have copayments that are a percentage
of the billed charges, this requirement could actually result in additional
out-of-pocket liability for enrollees.
Agency Response: As discussed previously, the department received comments
regarding the effects the proposed language may have on an HMO’s future
ability to negotiate with providers, including emergency providers, to create
a network. The department also recognizes that creating a network of contracted
providers is crucial to the concept of managed care, including consumer choice
plans offered by an HMO. Because of the potential effects that the proposed
language may have on HMOs’ ability to create networks of contracted
providers, as well as legislative interest in the issue of payment for necessary
out-of-network services, the department is not adopting the proposed language.
§11.506(10)(D): Some commenters request that this provision be removed
because the current statutory framework allows HMOs to negotiate with non-contracted
emergency service providers for a rate lower than billed charges. If the provision
remains, it will essentially remove the incentive for emergency care providers
to negotiate and, as one commenter notes, may embolden already aggressive
emergency care providers into absolute refusal to negotiate rates. Without
rate negotiation, providers will be free to set exorbitant charges, which
will only serve to make health plan coverage more unaffordable in Texas. They
note that currently if their negotiations are unsuccessful most HMOs will
make certain that their enrollees are held harmless.
Agency Response: As discussed previously, the department received comments
regarding the possible effects the proposed language may have on an HMO’s
ability to negotiate with out-of-network emergency providers and the potential
associated costs. Because of this, as well as legislative interest in the
issue of payment for necessary out-of-network services, the department is
not adopting the proposed language.
§§11.506, 11.1600 and 11.1607
Comment: A commenter notes that balance billing is a nationwide problem
but, along with others, does not believe the rule amendments are the appropriate
way to address the problem. Some commenters believe the rule seeks to treat
the problem of network adequacy, especially with facility-based providers,
with a solution that guarantees to increase the network adequacy problem.
Because the amendments take away the HMO’s ability to negotiate with
providers, the commenters assert, the rule amendments make the term "usual
and customary" effectively the same as billed charges. The commenters assert
that if HMOs are required to fully indemnify members for use of out-of-network
providers rather than to be able to negotiate or pay a reasonable and customary
fee, providers will leave HMO networks so that they can be paid full billed
charges. This result is contrary to the requirement that HMOs provide adequate
networks. A commenter asserts that facility-based providers have no incentive
to contract with health plans under current laws and believes the proposed
amendments further encourage providers to not contract with HMOs or to leave
the networks. A commenter notes that those that stay in network will be able
to exact increased contract rates because of the threat of going out-of-network.
The result is an upward pressure on contract pricing that must inevitably
be passed on to employers and employees, as well as any state plan that does
not have a mandatory fee schedule and automatic hold harmless requirement,
i.e., CHIP and others. The commenter believes that the rules are inconsistent
with the cost-saving purpose of HMOs, and will result in an extreme cost increase
to employers in the form of rate increases, which will result in higher costs
ultimately paid by enrollees. Thus, the commenter concludes, the rules threaten
the very existence of the fully-insured HMO market in Texas, and limit insurance
availability, resulting in an increase in the number of uninsured in Texas.
Some commenters recommend that the department not address the issue, as often
non-contracted providers will negotiate and many times the carrier will pay
billed charges if necessary to hold the member harmless.
Agency Response: The department recognizes the concern that the proposed
language may hinder contract negotiation efforts, but the absence of protections
for enrollees seeking services in a network facility highlights a potential
network adequacy problem that the commenter is not addressing. The cost-saving
aspect of HMOs, as mentioned by the commenters, depends upon the ability to
contract with providers for discounted fees. However, another aspect essential
to HMOs, to deliver covered services to enrollees without additional costs
other than applicable copayments and deductibles, depends upon the ability
of enrollees to access covered services in a network facility. This issue
was a subject of the Senate Committee on State Affairs Interim Report and,
as stated in the report, "begs for legislative action." Due to the upcoming
legislative session and the expressed interest in the subject, the department
is not adopting the proposed language.
Comment: Some commenters take issue with the statements in the preamble
of the proposed rules which indicate that the revisions requiring indemnification
of health plan members who obtain out-of-network services are necessary to
comply with existing statutory requirements and are basically a restatement
of Insurance Code Article 20A.09(f). The commenters feel that Article 20A.09(f)
clearly states that an HMO may pay either an agreed rate or, absent an agreement,
may pay a usual and customary rate. A commenter notes that the language of
the 1997 Patient Protection Act came from the department’s rules and
was included to address the fact that insurance companies may not be able
to reach an agreement with providers on a rate. Some commenters feel that
the regulation would make the statutory reference to "usual and customary"
meaningless as it essentially mandates the payment of full billed charges.
The commenters further note that the requirement of a hold harmless provision
found in Subchapter K, §843.361 of the Insurance Code only applies to
contracted providers and would be rendered meaningless if the department’s
interpretation is correct. Under the department’s interpretation, there
would be no need for the hold harmless provision because all health care costs
other than copayments would be borne by the HMO, regardless of whether there
was a provider network contract. Rules of statutory construction do not support
this result. Thus, the commenters assert that the rule not only exceeds statutory
authority but actually conflicts with existing statutes.
Agency Response: The commenter is correct that the hold harmless language
found in §843.361 specifically relates to contracted providers. The provision
is made a part of the provider contract and is an important enrollee protection
in the HMO Act. When enrollees must receive services outside the provider
network due to the unavailability of services through a network provider,
the statute continues to protect enrollees by requiring HMOs to "fully" reimburse
the out-of-network provider. Although unrelated to the requirement in §843.361,
the department views this directive as a requirement that enrollees be held
harmless when forced to receive services outside of the network. This provision,
combined with the §843.361 requirement for a contractual hold harmless
provision for contracted providers, protects enrollees from additional costs
when attempting to access covered services.
The department disagrees with the commenters’ characterization of
the statute and its requirements concerning out-of-network payments by HMOs.
Paying a provider at the HMO’s usual and customary amount and thereby
subjecting the enrollee to additional costs is inconsistent with the statutory
directive to "fully" reimburse the provider. A fundamental concept of a managed
care plan is that enrollees are protected from additional costs in exchange
for giving up the ability to choose a provider outside the HMO’s network.
The commenters’ interpretation would undermine that concept. Additionally,
the HMO Act requires that an HMO maintain an adequate network. This requirement
would be rendered meaningless if the inability of HMOs and providers to agree
on a usual and customary or other acceptable payment amount for necessary
out-of-network services subjected enrollees to additional costs when they
are forced to go outside of the network for covered services. Moreover, the
use of Article 20A.09(f) to solve reported current difficulties in contracting
with certain types of providers is not consistent with certain protections
afforded enrollees in the HMO Act, such as requirements related to network
adequacy. The commenters’ interpretations create an exception to the
network adequacy requirements that circumvents the rule and would allow enrollees
to be routinely exposed to additional costs for services that should be available
through network providers. The HMOs’ reported difficulty contracting
with facility-based providers and the resulting possibility of out-of-network
services is an issue that has become more prominent since the legislature
originally enacted this provision. Due to potential legislative action, as
evidenced by the Senate Committee on State Affairs Interim Report, the department
is not adopting the proposed language concerning payment for necessary out-of-network
services at §§11.506(10)(D), 11.1600(b)(11)(D), and 11.1607(i)(4)
to appropriately defer the issue during the current legislative session.
Comment: A commenter believes the legislature should address the balance
billing problem and has asked the legislature to do so.
Agency Response: The department acknowledges that the legislature has expressed
its intent to address this issue, and therefore is not adopting these provisions
pending such action.
Comment: Some commenters feel that physicians will always have an incentive
to contract with HMOs who negotiate in good faith, and thus will continue
to contract with HMOs. A commenter disagrees that the steerage of patients
is the only incentive for a physician to contract, as other incentives exist,
including: application of prompt pay to contracted providers; facility-based
physicians who want to maintain a relationship with a hospital; and a hospital
preferring a group who will contract over one who does not.
Agency Response: The department notes that many factors may influence providers’
decisions to contract with HMOs, including those mentioned by the commenter,
but acknowledges the concerns regarding the potential effect of the proposed
provisions on negotiations between HMOs and providers for discounted rates.
The department recognizes the challenge concerning the fundamental HMO concept
of providing covered services through a closed network of providers and the
HMOs’ stated inability to contract to provide those services. Given
the expressed legislative interest in addressing this issue, the department
is not adopting the proposed language concerning payment for necessary out-of-network
services at §§11.506(10)(D), 11.1600(b)(11)(D), and 11.1607(i)(4)
to appropriately defer the issue during the current legislative session.
Comment: One commenter estimates costs for a health plan under existing
market participation to be about $15 million (using 2003 figures) and says
costs will go up as providers leave the network. These costs will ultimately
be borne by the enrollee. Another commenter estimates that 95,000 of its members
will be affected and that paying billed charges would cost an additional $8.87
million. The amount will go up as providers leave the network. The commenter
is concerned that there is no limit to billed charges and has seen one as
high as 1800 percent of Medicare in 2002. The same commenter says the average
for billed charges in West Texas in 2002 was 300 percent of Medicare and now
it is 400 percent.
Agency Response: The department acknowledges the concerns regarding potential
cost effects the proposed language may have on an HMO’s ability to contract
or negotiate with providers. Given these concerns and the competing consideration
of enrollee protection, as well as the expressed legislative interest in addressing
this issue, the department is not adopting the proposed language concerning
payment for necessary out-of-network services at §§11.506(10)(D),
11.1600(b)(11)(D), and 11.1607(i)(4) to appropriately defer the issue during
the current legislative session.
Comment: Some commenters assert that the proposed provisions are contrary
to previous positions taken by the department.
Agency Response: Regardless of the department’s previous statements
on this issue, the proposal sought to clarify an HMO’s out-of-network
payment obligations consistent with existing statutory requirements through
the rulemaking process. As a result of the considerations regarding HMOs’
ability to negotiate and contract with providers and a clear legislative interest
in this subject, the department is not adopting the proposed language concerning
payment for necessary out-of-network services at §§11.506(10)(D),
11.1600(b)(11)(D), and 11.1607(i)(4) to appropriately defer the issue during
the current legislative session.
Comment: A commenter states that they currently have over 53,000 CHIP members
and if the proposed rules go into effect, they will have to request a premium
increase from HHSC, which will probably hurt their ability to increase CHIP
membership. The commenter notes that they had paid billed charges in the past
but recognized that doing so took away their ability to negotiate. They then
changed to paying a usual and customary rate based on Medicaid, which increased
their ability to contract and saved $2.7 million for the plan and HHSC. If
a non-contracted provider balance bills a member, they try to reach agreement,
but if they are unsuccessful they will sometimes pay billed charges to protect
the member. Because they pay non-contracted providers at a usual and customary
rate, they have the ability to negotiate with providers. To take this ability
away will cost more than $2.7 million. The commenter believes things are working
now and has received few complaints on this issue. A commenter believes the
proposed rule amendments will have a huge impact on HHSC, and will be asking
for a premium increase if the amendments are adopted.
Agency Response: The proposed language sought to clarify the issue of payment
of necessary out-of-network services due to some confusion regarding HMOs’
responsibilities for payment of such services. The department is aware of
the competing considerations concerning costs and enrollee protections, as
well as the expressed legislative interest in addressing them. As a result,
the department is not adopting the proposed language concerning payment for
necessary out-of-network services at §§11.506(10)(D), 11.1600(b)(11)(D),
and 11.1607(i)(4) to appropriately defer the issue during the current legislative
session.
Comment: Some commenters note that if an HMO is meeting its statutory duty
to maintain an adequate network, payment to non-network physicians is not
an issue. One commenter believes that adequate provider networks actually
decrease health care costs and promote continuity of care and health management,
and reduce hassles for the patient, health plan, and provider. Thus, these
commenters believe the department is correct in stating that the root of the
balance billing issue is the failure of HMOs to have an adequate network and
provide the basic health care services they promise to provide on a prepaid
basis. The commenters believe HMOs should be held to their obligations. A
commenter notes that only HMOs that continue to fail to meet their obligations
will see increased costs, which are "currently borne on the backs of patients
and non-network physicians- both of whom are innocent parties." A commenter
also feels that the cost of an inadequate network is a risk an HMO takes when
it applies for a certificate of authority to offer HMO services in Texas.
Some commenters applaud the department’s efforts to protect patients
by monitoring network adequacy and ensuring patients do not incur additional
financial liability as a result of accessing care when a contracted provider
is unavailable. The commenters note that the proposal merely states current
state law, and thank the department for its continued efforts in resolving
issues that plague insurance.
Agency Response: The proposal sought to clarify an HMO’s out-of-network
payment obligations consistent with existing statutory requirements through
the rulemaking process. The department recognizes that HMOs are reporting
difficulties in contracting with certain facility-based providers, which impacts
network adequacy and makes balance billing or increased costs to HMOs more
likely. For the reasons stated previously, the department is not adopting
the proposed language concerning payment for necessary out-of-network services
at §§11.506(10)(D), 11.1600(b)(11)(D), and 11.1607(i)(4) to appropriately
defer the issue during the current legislative session.
Comment: Some commenters express concern about reimbursement of non-network
providers at "usual and customary" in absence of an agreed-to rate. One commenter
notes that the term "usual and customary" is "all over the board." Some commenters
state that some health plans have used this as an opportunity to cap out-of-network
expenses without regard to actual billed charges or market rates for the services.
Although the Attorney General has made clear that a non-network physician
may balance bill for the services not covered by the health plan, it is unreasonable
for a health plan to determine a "usual and customary" amount from another
negotiated discount. A commenter encourages patients to use mechanisms already
in place through the Texas State Board of Medical Examiners (TSBME) for review
to address excessive billing. Under current antitrust law, physicians cannot
survey other area physician’s charges to determine appropriateness.
A commenter discusses testimony at the hearing regarding overcharging and
improper billing and notes that there are ample tools available to combat
the very few who improperly bill. Current law states that it is illegal pursuant
to Article 21.79F to charge a higher price based solely on the fact that an
insurer will pay all or part of the price, and TSBME can enforce the Texas
Medical Practice Act relating to improper billing.
Agency Response: The department encourages the use of all legal means to
ensure that health care charges are reasonable and proper. However, as the
comments reveal, the issue of "usual and customary" has been the subject of
varying interpretations. The conflicting comments received on this issue demonstrate
the complexity involved in payment for necessary out-of-network services.
Defining "usual and customary" would likely have more far-reaching effects
on elements of the health care industry other than protecting enrollees from
additional charges for out-of-network services. Comments received from HMOs
indicate that routine payment of out-of-network providers’ billed charges,
even if not excessive, will have a substantial impact on costs and, as a result,
on premiums. The department acknowledges the considerations concerning costs,
as well as the need for enrollee protections when forced to seek out-of-network
services. Due to these competing considerations and the possibility of legislative
action on the issue of payment of out-of-network services, the department
is not adopting the proposed language relating to payment of necessary out-of-network
services and declines to define "usual and customary."
Comment: A commenter is dismayed at some testimony at the hearing and feels
that testimony of several health plan representatives that the proposed rule
will increase premiums is untrue. The commenter asserts that TDI policy has
for years provided that non-contracted providers may bill patients and notes
that an AG opinion on this subject was issued over a year and a half ago.
Consequently, the HMOs’ argument that costs for treatment by non-contracted
physicians has not already been included in premiums is not credible. The
commenter believes that costs for treatment by out-of-network providers should
already be included in HMO premiums due to the inevitability of such treatment.
Agency Response: The department notes that comments concerning the proposed
language highlight existing confusion regarding the issue and competing considerations
concerning costs and enrollee protections. Due to these considerations, and
the expressed legislative interest in addressing them, the department is not
adopting the proposed language concerning payment for necessary out-of-network
services at §§11.506(10)(D), 11.1600(b)(11)(D), and 11.1607(i)(4)
to appropriately defer the issue during the current legislative session.
Comment: A commenter disagrees with the proposed rules requiring "indemnification"
of all costs of out-of-network care incurred by enrollees. Some commenters
believe the statutory and regulatory basis relied on in implementing the indemnification
requirement is unsupportable. The department relies on the fact that HMO insurance
is purchased on a "prepaid basis" to suggest a requirement that all costs
other than copayments are the responsibility of the health plan. It would
follow that if all costs other than copayments are borne by the health plan,
the health plans must indemnify the costs of out-of-network services that
are incurred by the member. A commenter believes that the use of the phrase
"prepaid basis" in the relevant statutory sections was never intended to provide
a requirement of indemnification. Rather, the commenter states, it was intended
to distinguish a prepaid plan from a plan that indemnified for medical costs
as is made clear by Insurance Code §843.002(12), which defines a "health
care plan" as a plan "that consists in part of providing or arranging for
health care services on a prepaid basis through insurance or otherwise, as
distinguished from indemnifying for the cost of health care services." The
commenter believes the department is acting outside its rulemaking authority
in promulgating the particular provisions relating to indemnification of out-of-network
costs.
Agency Response: A fundamental element of an HMO’s health plan is
the requirement that an enrollee receive covered services from network providers
that have agreed to hold enrollees harmless for such services. This entitles
enrollees to receive basic health care services from network providers without
being subject to any costs beyond applicable copayments and deductibles. However,
if an enrollee is forced, due to the unavailability of a network provider,
to receive services from an out-of-network provider and is subject to additional
costs, this basic principle fails. The proposal placed enrollees in the same
position they would have been had they been treated by a network provider
and used the term "indemnify" to ensure this outcome. The department is aware
of the competing considerations concerning costs and enrollee protections
and the expressed legislative interest in addressing them. Therefore, the
department is not adopting the proposed language concerning payment for necessary
out-of-network services at §§11.506(10)(D), 11.1600(b)(11)(D), and
11.1607(i)(4) to appropriately defer the issue during the current legislative
session.
Comment: A commenter contends that the out-of-network and balance billing
rules do not apply to Children’s Health Insurance Program (CHIP) HMOs
by operation of Texas Health and Safety Code §62.152(3), which exempts
the CHIP program from state insurance laws that require "the use of a particular
policy or contract form or of particular language in a policy or contract
form." TDI’s proposed rules would require specific language in the evidence
of coverage and notices to HMO enrollees. The commenter believes that these
rules do not apply to CHIP by virtue of the program’s statutory exemption
and requests that the rules state that they are not applicable to CHIP HMOs.
Agency Response: The department declines to adopt the suggested exclusion
for CHIP HMOs. Although the department is not making the proposed changes
relating to payment for necessary out-of-network services in §§11.506(10)(D),
11.1600(b)(11)(D) and 11.1607(i)(4), the insurance laws and rules of this
state, in general, apply to CHIP, except as otherwise provided in the Insurance
Code and Texas Health and Safety Code §62.152. The department points
out that the current CHIP/Medicaid RFP requires that "[t]he Member will not
be responsible for any payment for Medically Necessary Covered Services, other
than HHSC-specified co-payments for CHIP Members, where applicable."
Comment: A commenter feels language should be adopted like that contained
in rules implementing the prompt payment provisions of SB 418 at 28 TAC §21.2826,
and suggests: "These rules are not applicable to Medicaid and CHIP provided
by an HMO or preferred provider carrier to persons enrolled in the medical
assistance program established under Chapter 32, Human Resources Code, or
the child health plan established under Chapter 62, Health & Safety Code."
Agency Response: The department adopted §21.2826 pursuant to Insurance
Code Article 21.30, which requires the Commissioner of Insurance to exempt
Medicaid if, after consulting with the Commissioner of Health and Human Services,
he determines that the provisions of SB 418 would have a negative fiscal impact
on the Medicaid program. Because the Commissioner of Health and Human Services
indicated that the bill would have a negative fiscal impact, the Commissioner
of Insurance adopted §21.2826, which exempts both traditional Medicaid
and Medicaid HMO plans from the provisions of SB 418. While federal law, Health
and Safety Code §62.152, and certain provisions of the Insurance Code
provide certain exemptions to CHIP and Medicaid coverages, the department
does not believe the law authorizes the requested blanket exemption.
Comment: A commenter states that, given the Texas Health and Human Services
Commission’s exclusive authority to administer Texas Medicaid contracts,
the rules should not be applicable to HMOs with whom HHSC contracts because
it could result in forcing such HMOs to cover the cost of billed charges,
rather than an amount substantially less than billed charges, as the commenter
understands is current practice. The commenter requests that the department’s
rules explicitly not apply to Medicaid HMOs. Another commenter expresses concern
that the rules are in conflict with HHSC’s plan to limit reimbursement.
Agency Response: The department agrees that HHSC has authority over the
Medicaid product, except as specifically provided in the Insurance Code, and
therefore the provision does not apply other than by reference, if any, in
the HHSC contract with the HMO.
§11.1600(b)(11)(D): A commenter supports this proposal but recommends
requiring the HMO to inform the enrollee of the possibility that professional
and ancillary services delivered in a contracted hospital or facility might
be provided by non-network physicians or providers. This would give enrollees
a better understanding as to when they might receive a bill for services provided
by a non-network physician or provider and better understanding of their recourse
under the indemnification requirements of the HMO.
Agency Response: The department agrees that a notice is appropriate, but
declines to require the recommended notice. While the department recognizes
the importance of informed decision-making, it notes that patients may not
always be in a position to make informed choices about which doctors may provide
services in a hospital setting, nor may they be able to require that the hospital
honor the enrollee’s choice of doctors. Instead, the department is adopting
a notice requirement that HMOs inform enrollees to contact the HMO whenever
they receive a bill from a provider, whether contracted or non-contracted.
For With Changes: Office of Public Insurance Counsel, Texas Medical Association,
Texas Hospital Association, Dallas County Medical Society, Texas Medical Group
Management Association, Harris County Medical Society, Against: Texas Association
of Health Plans, Scott & White Health Plan, Texas Society of Psychiatric
Physicians, Texas Health and Human Services Commission, Cigna Health Care,
Humana, Inc., Community First Health Plans, Inc., Texas Association of Business,
Unicare, Firstcare HMO, Texas Children’s Health Plan, and Pacificare.
Subchapter A. GENERAL PROVISIONS
28 TAC §11.1, §11.2
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
§11.2.Definitions.
(a)
The definitions found in the Texas Health Maintenance Organization
Act, Texas Insurance Code §843.002, are incorporated into this chapter.
(b)
The following words and terms, when used in this chapter,
shall have the following meanings unless the context clearly indicates otherwise.
(1)
Act--The Texas Health Maintenance Organization Act, codified
as the Texas Insurance Code Chapters 20A and 843.
(2)
Admitted assets--All assets as defined by statutory accounting
principles, as permitted and valued in accordance with §11.803 of this
title (relating to Investments, Loans, and Other Assets).
(3)
Adverse determination--A determination upon utilization
review that the health care services furnished or adopted to be furnished
to a patient are not medically necessary or not appropriate.
(4)
Affiliate--A person that directly, or indirectly through
one or more intermediaries, controls, or is controlled by, or is under common
control with, the person specified.
(5)
Agent--A person who may act as an agent for the sale of
a health benefit plan under a license issued under Insurance Code Chapter
21.
(6)
ANHC or approved nonprofit health corporation--A nonprofit
health corporation certified under §162.001 of the Occupations Code.
(7)
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 Article 1.11 and §§802.001, 802.003 and 843.155.
(8)
Authorized control level--The number determined under the
RBC formula in accordance with the RBC instructions.
(9)
Basic health care service--Health care services which an
enrolled population might reasonably require to maintain good health, as prescribed
in §§11.508 and 11.509 of this title (relating to Mandatory Benefit
Standards: Group, Individual and Conversion Agreements, and Additional Mandatory
Benefit Standards: Group Agreement Only).
(10)
Clinical director--Health professional who meets the following
criteria:
(A)
is appropriately licensed;
(B)
is an employee of, or party to a contract with, a health
maintenance organization; and
(C)
is responsible for clinical oversight of the utilization
review program, the credentialing of professional staff, and quality improvement
functions.
(11)
Code--The Texas Insurance Code.
(12)
Consumer choice health benefit plan--A health benefit
plan authorized by Insurance Code Article 3.80 or Article 20A.09N, and as
described in Subchapter AA of Chapter 21 of this title (relating to Consumer
Choice Health Benefit Plans).
(13)
Contract holder--An individual, association, employer,
trust or organization to which an individual or group contract for health
care services has been issued.
(14)
Control--As defined in Insurance Code §§823.005
and 823.151.
(15)
Controlled HMO--An HMO controlled directly or indirectly
by a holding company.
(16)
Controlled person--Any person, other than an HMO, who
is controlled directly or indirectly by a holding company.
(17)
Copayment--A charge, which may be expressed in terms of
a dollar amount or a percentage of the contracted rate, in addition to premium
to an enrollee for a service which is not fully prepaid.
(18)
Credentialing--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.
(19)
Dentist--An individual provider licensed to practice dentistry
by the Texas State Board of Dental Examiners.
(20)
General hospital--A licensed establishment that:
(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.
(21)
HMO--A health maintenance organization as defined in Insurance
Code §843.002(14).
(22)
Health status related factor--Any of the following in
relation to an individual:
(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
Insurance Code Article 21.21-5); or
(H)
disability.
(23)
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.
(24)
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.
(25)
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.
(26)
Limited service HMO--An HMO which has been issued a certificate
of authority to issue a limited health care service plan as defined in Insurance
Code §843.002.
(27)
NAIC--National Association of Insurance Commissioners.
(28)
Out of area benefits--Benefits that the HMO covers when
its enrollees are outside the geographical limits of the HMO service area.
(29)
Pathology services--Services provided by a licensed laboratory
which has the capability of evaluating tissue specimens for diagnoses in histopathology,
oral pathology, or cytology.
(30)
Pharmaceutical services--Services, including dispensing
prescription drugs, under the Pharmacy Act, Occupations Code, Subtitle J,
that are ordinarily and customarily rendered by a pharmacy or pharmacist.
(31)
Pharmacist--An individual provider licensed to practice
pharmacy under the Pharmacy Act, Occupations Code, Subtitle J.
(32)
Pharmacy--A facility licensed under the Pharmacy Act,
Occupations Code, Subtitle J.
(33)
Premium--All amounts payable by a contract holder as a
condition of receiving coverage from a carrier, including any fees or other
contributions associated with a health benefit plan.
(34)
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.
(35)
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.
(36)
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.
(37)
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.
(38)
Qualified HMO--An HMO which has been federally approved
under Title XIII of the Public Health Service Act, Public Law 93-222, as amended.
(39)
Quality improvement (QI)--A system to continuously examine,
monitor and revise processes and systems that support and improve administrative
and clinical functions.
(40)
RBC--Risk-based capital.
(41)
RBC formula--NAIC risk-based capital formula.
(42)
RBC Report--Health Risk-Based Capital Report including
Overview and Instructions for Companies published by the NAIC and adopted
by reference in §11.809 of this title (relating to Risk-Based Capital
for HMOs and Insurers Filing the NAIC Health Blank).
(43)
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.
(44)
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.
(45)
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.
(46)
Schedule of charges--Specific rates or premiums to be
charged for enrollee and dependent coverages.
(47)
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).
(48)
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 §843.002.
(49)
Special hospital--A licensed establishment that:
(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.
(50)
Specialists--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.
(51)
State-mandated health benefit plan--As defined in §21.3502
of this title (relating to Definitions).
(52)
Statutory surplus--Admitted assets minus accrued uncovered
liabilities.
(53)
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.
(54)
Subsidiary--An affiliate controlled by a specified person
directly or indirectly through one or more intermediaries.
(55)
Telehealth service--As defined in Section 57.042, Utilities
Code.
(56)
Telemedicine medical service--As defined in Section 57.042,
Utilities Code.
(57)
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.
(58)
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 his or her health.
(59)
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.
(60)
Voting security--As defined in Insurance Code §823.007,
including any security convertible into or evidencing a right to acquire such
security.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed with the Office of
the Secretary of State on February 4, 2005.
TRD-200500519
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §11.101
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500520
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.201 - 11.206
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
§11.205.Documents To Be Available for Qualifying Examinations.
(a)
The following documents must be available for review at
the HMO's office located within the State of Texas:
(1)
administrative: policy and procedure manuals; physician
and provider manuals; enrollee materials; organizational charts; key personnel
information, e.g., resumes and job descriptions; and other items as requested;
(2)
quality improvement: program description and work plan
as required by §11.1902 of this title (relating to Quality Improvement
Program for Basic and Limited Services HMOs);
(3)
utilization management: program description, policies and
procedures, criteria used to determine medical necessity, and examples of
adverse determination letters, adverse determination logs, and IRO logs;
(4)
complaints and appeals: policies and procedures, examples
of letters and examples of complaint and appeal logs. On or after January
1, 2006, each complaint shall be categorized as one or more of the following
types of complaint:
(A)
quality of care or services;
(B)
accessibility/availability of services;
(C)
utilization review or management;
(D)
complaint procedures;
(E)
physician and provider contracts;
(F)
group subscriber contracts;
(G)
individual subscriber contracts;
(H)
marketing;
(I)
claims processing; and
(J)
miscellaneous;
(5)
health information systems: policies and procedures for
accessing enrollee health records and a plan to provide for confidentiality
of those records in accordance with applicable law;
(6)
network configuration information, as outlined in §11.204(18)
of this title (relating to Contents) demonstrating adequacy of the physician,
dentist and provider network;
(7)
executed agreements, including:
(A)
management services agreements;
(B)
administrative services agreements; and
(C)
delegation agreements;
(8)
executed physician and provider contracts: copy of the
first page, including the form number, and signature page of individual provider
contracts and group provider contracts;
(9)
executed subcontracts: copy of the first page, including
the form number, and signature page of all contracts with subcontracting physicians
and providers;
(10)
current physician manual and current provider manual which
shall be provided to each contracting physician and other provider. The manuals
shall contain details of the requirements by which the physicians and providers
will be governed;
(11)
credentialing files: as specified in §11.1902(4)
of this title (relating to Quality Improvement Program for Basic and Limited
Services HMOs) and §11.2207(d)(4) of this title (relating to Quality
Improvement Structure and Program for Single Service HMOs);
(12)
a copy of all printed materials to be presented to prospective
enrollees, an enrollee handbook, and an evidence of coverage;
(13)
the statistical reporting system developed and maintained
by the HMO which allows for compiling, developing, evaluating, and reporting
statistics relating to the cost of operation, the pattern of utilization of
services, and the accessibility and availability of services;
(14)
claims systems: policies and procedures that demonstrate
the capacity to pay claims timely and to comply with all applicable statutes
and rules;
(15)
financial records: including statements, ledgers, checkbooks,
inventory records, evidence of expenditures, investments and debts; and
(16)
any other records demonstrating compliance with applicable
statutes and rules, including audits or examination reports by other entities,
including governmental authorities or accrediting agencies.
(b)
The following documents may be maintained outside the State
of Texas if the HMO has received prior approval by the commissioner pursuant
to Insurance Code §803.003:
(1)
financial records, including ledgers;
(2)
checkbooks;
(3)
inventory records;
(4)
evidence of expenditures, investments, and debts; and
(5)
the minutes of the HMO organizational meetings which indicate
the type and date of each meeting, and the officer or officers who are responsible
for the handling of the funds of the applicant; the minutes of meetings of
the HMO board of directors; management committee meeting minutes.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500521
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.301 - 11.303
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
§11.303.Examination.
(a)
The department has authority to conduct examinations of
HMOs under Insurance Code §§843.251 and 843.156. Such examinations
may be conducted to determine the financial condition ("financial exams"),
quality of health care services ("quality of care exams"), or compliance with
laws affecting the conduct of business ("market conduct exams" or "complaint
exams").
(b)
On-site financial, market conduct examinations, complaint
or quality of care exams shall be conducted pursuant to Insurance Code Article
1.15 and §7.83 of this title (relating to Appeal of Examination Reports).
(c)
The following documents must be available for review at
the HMO's office located within the State of Texas:
(1)
administrative: policy and procedure manuals; physician
and provider manuals; enrollee materials; organizational charts; key personnel
information, e.g., resumes and job descriptions; and other items as requested;
(2)
quality improvement: program description, work plans, program
evaluations, committee and subcommittee meeting minutes;
(3)
utilization management: program description, policies and
procedures, criteria used to determine medical necessity, and templates of
adverse determination letters; adverse determination logs, including all levels
of appeal; and utilization management files;
(4)
complaints and appeals: policies and procedures and templates
of letters; and complaint and appeal logs, including documentation and details
of actions taken. On or after January 1, 2006, all complaints shall be categorized
according to §11.205(a)(4)(A) - (J) of this title (relating to Documents
to be Available for Qualifying Examinations); and complaint and appeal files;
(5)
satisfaction surveys: enrollee, physician and provider
satisfaction surveys, enrollee disenrollment and termination logs;
(6)
health information systems: policies and procedures for
accessing enrollee health records and a plan to provide for confidentiality
of those records;
(7)
network configuration information as required by §11.204(18)
of this title (relating to Contents) demonstrating adequacy of the physician,
dentist and provider network;
(8)
executed agreements: including:
(A)
management services agreements;
(B)
administrative services agreements; and
(C)
delegation agreements.
(9)
executed physician and provider contracts: copy of the
first page, including form number, and signature page of individual provider
contracts and group provider contracts;
(10)
executed subcontracts: copy of the first page, including
the form number, and signature page of all contracts with subcontracting physicians
and providers;
(11)
credentialing: credentialing policies and procedures and
credentialing files;
(12)
reports: any reports submitted by the HMO to a governmental
entity;
(13)
claims systems: policies and procedures and systems/processes
that demonstrate timely claims payments, and reports that substantiate compliance
with all applicable statutes and rules regarding claims payment to physicians,
providers and enrollees;
(14)
financial records: including statements, ledgers, checkbooks,
inventory records, evidence of expenditures, investments and debts; and
(15)
other: any other records demonstrating compliance with
applicable statutes and rules.
(d)
Quality of care examinations shall be conducted pursuant
to the following protocol:
(1)
Entrance conference. The examination team or assigned examiner
shall hold an entrance conference with the HMO's key management staff or their
designee before beginning the examination.
(2)
Interviews. Examination team members or the examiner shall
conduct interviews with key management staff or their designated personnel.
(3)
Exit conference. Upon completion of the examination, the
examination team or examiner shall hold an exit conference with the HMO's
key management staff or their designee.
(4)
Written report of examination. The examination team or
examiner shall prepare a written report of the examination. The department
shall provide the HMO with the written report, and if any deficiencies are
cited, then the department shall issue a letter outlining the timeframes for
the corrective action plan and corrective actions.
(5)
Serious deficiencies cited and plan of correction. If the
examination team or examiner cites serious deficiencies, the HMO shall provide
the examination team or examiner with a signed plan to correct deficiencies
within one business day of written notice of deficiencies. The HMO's plan
of correction shall allow up to 12 days for correction of the deficiencies
in accordance with severity of the deficiencies.
(6)
Plan of correction. Except as provided in paragraph (5)
of this subsection, if the examination team or examiner cites deficiencies,
then the HMO shall provide a signed plan of correction to the department no
later than 30 days from receipt of the written examination report. The HMO's
plan must provide for correction of these deficiencies no later than 90 days
from the receipt of the written examination report.
(7)
Verification of correction. The department shall verify
the correction of deficiencies by submitted documentation or by on-site examination.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500522
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.502 - 11.506, 11.508, 11.509, 11.512
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
§11.506.Mandatory Contractual Provisions: Group, Individual and Conversion Agreement and Group Certificate.
Each enrollee residing in this state is entitled to an evidence of
coverage under a health care plan. By agreement between the issuer of the
evidence of coverage and the enrollee, the evidence of coverage approved under
this subchapter and required by this section may be delivered electronically.
Each group, individual and conversion contract and group certificate must
contain the following provisions.
(1)
Name, address, and phone number of the HMO--The toll-free
number referred to in Insurance Code Article 21.71, where applicable, must
appear on the face page.
(A)
The face page of an agreement is the first page that contains
any written material.
(B)
If the agreements or certificates are in booklet form the
first page inside the cover is considered the face page.
(C)
The HMO must provide the information regarding the toll-free
number referred to in Article 21.71 in accordance with §1.601 of this
title (relating to Notice of Toll-Free Telephone Numbers and Information and
Complaint Procedures).
(2)
Benefits--A schedule of all health care services that are
available to enrollees under the basic, limited, or single health care service
plan, including any copayments or deductibles and a description of where and
how to obtain services. An HMO may use a variable copayment or deductible
schedule. The copayment schedule must clearly indicate the benefit to which
it applies.
(A)
Copayments. An HMO may require copayments to supplement
payment for health care services. Each HMO may establish one or more copayment
options. A basic service HMO may not impose copayment charges that exceed
fifty percent of the total cost of providing any single service to its enrollees,
nor in the aggregate more than twenty percent of the total cost to the HMO
of providing all basic health care services. A basic service HMO may not impose
copayment charges on any enrollee in any calendar year, when the copayments
made by the enrollee in that calendar year total two hundred percent of the
total annual premium cost which is required to be paid by or on behalf of
that enrollee. This limitation applies only if the enrollee demonstrates that
copayments in that amount have been paid in that year. The HMO shall state
the copayment in the group, individual or conversion agreement and group certificate.
(B)
Deductibles. A deductible shall be for a specific dollar
amount of the cost of the basic, limited, or single health care service. An
HMO shall charge a deductible only for services performed out of the HMO's
service area or for services performed by a physician or provider who is not
in the HMO's delivery network.
(C)
Immunizations. An HMO shall not charge a copayment or deductible
for immunizations as described in Insurance Code Article 21.53F for a child
from birth through the date the child is six years of age, except that a small
employer health benefit plan, as defined by Insurance Code Chapter 26, that
covers such immunizations may charge a copayment or deductible.
(3)
Cancellation and non-renewal--A statement specifying the
following grounds for cancellation and non-renewal of coverage and the minimum
notice period that will apply.
(A)
An HMO may cancel a subscriber in a group and subscriber's
enrolled dependents under circumstances described in clauses (i)- (vii) of
this subparagraph, so long as the circumstances do not include health status
related factors:
(i)
For nonpayment of amounts due under the contract, coverage
may be cancelled after not less than 30 days written notice, except no written
notice will be required for failure to pay premium.
(ii)
In the case of fraud or intentional misrepresentation
of a material fact, except as described in paragraph (14) of this section,
coverage may be cancelled after not less than 15 days written notice.
(iii)
In the case of fraud in the use of services or facilities,
coverage may be cancelled after not less than 15 days written notice.
(iv)
For failure to meet eligibility requirements other than
the requirement that the subscriber reside, live, or work in the service area,
coverage may be cancelled immediately, subject to continuation of coverage
and conversion privilege provisions, if applicable.
(v)
In the case of misconduct detrimental to safe plan operations
and the delivery of services, coverage may be cancelled immediately.
(vi)
For failure of the enrollee and a plan physician to establish
a satisfactory patient-physician relationship if it is shown that the HMO
has, in good faith, provided the enrollee with the opportunity to select an
alternative plan physician, the enrollee is notified in writing at least 30
days in advance that the HMO considers the patient-physician relationship
to be unsatisfactory and specifies the changes that are necessary in order
to avoid termination, and the enrollee has failed to make such changes, coverage
may be cancelled at the end of the 30 days.
(vii)
Where the subscriber neither resides, lives, or works
in the service area of the HMO, or area for which the HMO is authorized to
do business, but only if the HMO terminates coverage uniformly without regard
to any health status-related factor of enrollees, coverage may be cancelled
after 30 days written notice. An HMO shall not cancel coverage for a child
who is the subject of a medical support order because the child does not reside,
live or work in the service area.
(B)
An HMO may cancel a group under circumstances described
in clauses (i)- (vi) of this subparagraph:
(i)
For nonpayment of premium, all coverage may be cancelled
at the end of the grace period as described in paragraph (13) of this section.
(ii)
In the case of fraud on the part of the group, coverage
may be cancelled after 15 days written notice.
(iii)
For employer groups, violation of participation or contribution
rules, coverage may be cancelled in accordance with §26.8(h) and §26.303(j)
of this title (relating to Guaranteed Issue; Contribution and Participation
Requirements and Coverage Requirements).
(iv)
For employer groups, in accordance with §26.16 and §26.309
of this title (relating to Refusal To Renew and Application To Reenter Small
Employer Market and Refusal To Renew and Application To Reenter Large Employer
Market), coverage may be cancelled upon discontinuance of:
(I)
each of its small or large employer coverages; or
(II)
a particular type of small or large employer coverage.
(v)
Where no enrollee resides, lives, or works in the service
area of the HMO, or area for which the HMO is authorized to do business, but
only if the coverage is terminated uniformly without regard to any health
status-related factor of enrollees, the HMO may cancel the coverage after
30 days written notice.
(vi)
If membership of an employer in an association ceases,
and if coverage is terminated uniformly without regard to the health status
of an enrollee, the HMO may cancel the coverage after 30 days written notice.
(C)
In the case of a material change by the HMO to any provisions
required to be disclosed to contract holders or enrollees pursuant to this
chapter or other law, a group or individual contract holder may cancel the
contract after not less than 30 days written notice to the HMO.
(D)
An HMO may cancel an individual contract under circumstances
described in clauses (i)- (vi) of this subparagraph.
(i)
For nonpayment of premiums in accordance with the terms
of the contract, including any timeliness provisions, coverage may be cancelled
without written notice, subject to paragraph (13) of this section.
(ii)
In the case of fraud or intentional material misrepresentation,
except as described in paragraph (14) of this section, the HMO may cancel
coverage after not less than 15 days written notice.
(iii)
In the case of fraud in the use of services or facilities,
the HMO may cancel coverage after not less than 15 days written notice.
(iv)
Where the subscriber neither resides, lives, or works
in the service area of the HMO, or area for which the HMO is authorized to
do business, but only if coverage is terminated uniformly without regard to
any health status-related factor of enrollees, coverage may be cancelled after
30 days written notice. An HMO shall not cancel the coverage for a child who
is the subject of a medical support order because the child does not reside,
live or work in the service area.
(v)
In case of termination by discontinuance of a particular
type of individual coverage by the HMO in that service area, but only if coverage
is discontinued uniformly without regard to health status-related factors
of enrollees and dependents of enrollees who may become eligible for coverage,
the HMO may cancel coverage after 90 days written notice, in which case the
HMO must offer to each enrollee on a guaranteed-issue basis any other individual
basic health care coverage offered by the HMO in that service area.
(vi)
In case of termination by discontinuance of all individual
basic health care coverage by the HMO in that service area, but only if coverage
is discontinued uniformly without regard to health status-related factors
of enrollees and dependents of enrollees who may become eligible for coverage,
the HMO may cancel coverage after 180 days written notice to the commissioner
and the enrollees, in which case the HMO may not re-enter the individual market
in that service area for five years beginning on the date of discontinuance
at the last coverage not renewed.
(4)
Claim payment procedure--A provision that sets forth the
procedure for paying claims, including any time frame for payment of claims
which must be in accordance with Insurance Code Articles 21.55 and 20A.09Z
and the applicable rules.
(5)
Complaint and appeal procedures--A description of the HMO's
complaint and appeal process available to complainants.
(6)
Continuation of coverage--Group agreements must contain
a provision providing for mandatory continuation of coverage for enrollees
who were continuously covered under a group certificate for three months prior
to termination of the group coverage, or newborn or newly adopted children
of enrollees with three months prior continuous coverage, that is no less
favorable than provided by Insurance Code Article 20A.09(k).
(A)
An enrollee shall have the option to continue coverage
as provided for by Insurance Code Article 20A.09(k), upon completion of any
continuation of coverage provided under The Consolidated Omnibus Budget Reconciliation
Act of 1985 (COBRA) (Public Law Number 99-272, 100 stat. 222) and any amendments
thereto.
(B)
A dependent, upon completion of any continuation of coverage
provided under Insurance Code Article 3.51-6 §3B, shall have the privilege
to continue coverage for the 6 months prescribed by Insurance Code Article
20A.09(k).
(C)
If an HMO offers conversion coverage, it must be offered
to the enrollee not less than 30 days prior to the expiration of the COBRA
or Article 3.51-6 §3B continuation coverage period.
(D)
A basic service HMO shall notify the enrollee not less
than 30 days before the end of the six months from the date continuation under
Article 20A.09(k) was elected that the enrollee may be eligible for coverage
under the Texas Health Insurance Risk Pool, as provided under Insurance Code
Article 3.77, and shall provide the address and toll-free number of the pool.
(7)
Definitions--A provision defining any words in the evidence
of coverage which have other than the usual meaning. Definitions must be in
alphabetical order.
(8)
Effective date--A statement of the effective date requirements
of various kinds of enrollees.
(9)
Eligibility--A statement of the eligibility requirements
for membership, including:
(A)
that the subscriber must reside, live or work in the service
area and the legal residence of any enrolled dependents must be the same as
the subscriber, or the subscriber must reside, live or work in the service
area and the residence of any enrolled dependents must be:
(i)
in the service area with the person having temporary or
permanent conservatorship or guardianship of such dependents, including adoptees
or children who have become the subject of a suit for adoption by the enrollee,
where the subscriber has legal responsibility for the health care of such
dependents;
(ii)
in the service area under other circumstances where the
subscriber is legally responsible for the health care of such dependents;
(iii)
in the service area with the subscriber's spouse; or
(iv)
anywhere in the United States for a child whose coverage
under a plan is required by a medical support order.
(B)
the conditions under which dependent enrollees may be added
to those originally covered;
(C)
any limiting age for subscriber and dependents;
(D)
a clear statement regarding the coverage of newborn children:
(i)
No evidence of coverage may contain any provision excluding
or limiting coverage for a newborn child of the subscriber or the subscriber's
spouse.
(ii)
Congenital defects must be treated the same as any other
illness or injury for which coverage is provided.
(iii)
The HMO may require that the subscriber notify the HMO
during the initial 31 days after the birth of the child and pay any premium
required to continue coverage for the newborn child.
(iv)
An HMO shall not require that a newborn child receive
health care services only from network physicians or providers after the birth
if the newborn child is born outside the HMO service area due to an emergency,
or born in a non-network facility to a mother who does not have HMO coverage.
The HMO may require that the newborn be transferred to a network facility
at the HMO's expense and, if applicable, to a network provider when such transfer
is medically appropriate as determined by the newborn's treating physician.
(v)
A newborn child of the subscriber or subscriber's spouse
is entitled to coverage during the initial 31 days following birth. The HMO
shall allow an enrollee 31 days after the birth of the child to notify the
HMO, either verbally or in writing, of the addition of the newborn as a covered
dependent.
(E)
a clear statement regarding the coverage of the enrollee’s
grandchildren up to the age of 25 under the conditions under which such coverage
is required by Insurance Code Article 3.70-2, subsection (L) and Article 20A.09H
(Children and Grandchildren).
(10)
Emergency services--A description of how to obtain services
in emergency situations including:
(A)
what to do in case of an emergency occurring outside or
inside the service area;
(B)
a statement of any restrictions or limitations on out-of-area
services;
(C)
a statement that the HMO will provide for any medical screening
examination or other evaluation required by state or federal law that is necessary
to determine whether an emergency medical condition exists in a hospital emergency
facility or comparable facility;
(D)
a statement that necessary emergency care services will
be provided, including the treatment and stabilization of an emergency medical
condition; and
(E)
a statement that where stabilization of an emergency condition
originated in a hospital emergency facility or comparable facility, as defined
in subparagraph (F) of this paragraph, treatment subject to such stabilization
shall be provided to enrollees as approved by the HMO, provided that the HMO
is required to approve or deny coverage of poststabilization care as requested
by a treating physician or provider. An HMO shall approve or deny such treatment
within the time appropriate to the circumstances relating to the delivery
of the services and the condition of the patient, but in no case shall approval
or denial exceed one hour from the time of the request.
(F)
For purposes of this paragraph, "comparable facility" includes
the following:
(i)
any stationary or mobile facility, including, but not limited
to, Level V Trauma Facilities and Rural Health Clinics which have licensed
and/or certified personnel and equipment to provide Advanced Cardiac Life
Support (ACLS) consistent with American Heart Association (AHA) and American
Trauma Society (ATS) standards of care;
(ii)
for purposes of emergency care related to mental illness,
a mental health facility that can provide 24-hour residential and psychiatric
services and that is:
(I)
a facility operated by the Texas Department of State Health
Services;
(II)
a private mental hospital licensed by the Texas Department
of State Health Services;
(III)
a community center as defined by the Texas Health and
Safety Code, §534.001;
(IV)
a facility operated by a community center or other entity
the Texas Department of State Health Services designates to provide mental
health services;
(V)
an identifiable part of a general hospital in which diagnosis,
treatment, and care for persons with mental illness is provided and that is
licensed by the Texas Department of State Health Services; or
(VI)
a hospital operated by a federal agency.
(11)
Entire contract, amendments--A provision stating that
the form, applications, if any, and any attachments constitute the entire
contract between the parties and that, to be valid, any change in the form
must be approved by an officer of the HMO and attached to the affected form
and that no agent has the authority to change the form or waive any of the
provisions.
(12)
Exclusions and limitations--A provision setting forth
any exclusions and limitations on basic, limited, or single health care services.
(13)
Grace period--A provision for a grace period of at least
30 days for the payment of any premium falling due after the first premium
during which the coverage remains in effect. A charge may be added to the
premium by the HMO for late payment received within the grace period. If payment
is not received within the 30 days, coverage may be cancelled after the 30th
day and the terminated members may be held liable for the cost of services
received during the grace period, if this requirement is disclosed in the
agreement.
(14)
Incontestability:
(A)
All statements made by the subscriber on the enrollment
application shall be considered representations and not warranties. The statements
are considered to be truthful and are made to the best of the subscriber's
knowledge and belief. A statement may not be used in a contest to void, cancel
or non-renew an enrollee's coverage or reduce benefits unless:
(i)
it is in a written enrollment application signed by the
subscriber; and
(ii)
a signed copy of the enrollment application is or has
been furnished to the subscriber or the subscriber's personal representative.
(B)
An individual contract may only be contested because of
fraud or intentional misrepresentation of material fact made on the enrollment
application. A group certificate may only be contested because of fraud or
intentional misrepresentation of material fact on the enrollment application.
For small employer coverage, the misrepresentation shall be other than a misrepresentation
related to health status.
(C)
For a group contract or certificate, the HMO may increase
its premium to the appropriate level if the HMO determines that the subscriber
made a material misrepresentation of health status on the application. The
HMO must provide the contract holder 31 days prior written notice of any premium
rate change.
(15)
Out-of-network services--Each contract between an HMO
and a contract holder must provide that if medically necessary covered services
are not available through network physicians or providers, the HMO must, upon
the request of a network physician or provider, within the time appropriate
to the circumstances relating to the delivery of the services and the condition
of the patient, but in no event to exceed five business days after receipt
of reasonably requested documentation, allow a referral to a non-network physician
or provider and shall fully reimburse the non-network provider at the usual
and customary or an agreed rate.
(A)
For purposes of determining whether medically necessary
covered services are available through network physicians or providers, the
HMO shall offer its entire network, rather than limited provider networks
within the HMO delivery network.
(B)
The HMO shall not require the enrollee to change his or
her primary care physician or specialist providers to receive medically necessary
covered services that are not available within the limited provider network.
(C)
Each contract must further provide for a review by a specialist
of the same or similar specialty as the type of physician or provider to whom
a referral is requested before the HMO may deny a referral.
(16)
Schedule of charges--A statement that discloses the HMO's
right to change the rate charged with 60 days written notice pursuant to Insurance
Code Article 3.51-10.
(17)
Service area--A description and a map of the service area,
with key and scale, which shall identify the county, or counties, or portions
thereof, to be served indicating primary care physicians, hospitals, and emergency
care sites. A ZIP code map and a provider list may be used to meet the requirement.
(18)
Termination due to attaining limiting age--A provision
that a child's attainment of a limiting age does not operate to terminate
the coverage of the child while that child is incapable of self-sustaining
employment due to mental retardation or physical disability, and chiefly dependent
upon the subscriber for support and maintenance. The HMO may require the subscriber
to furnish proof of such incapacity and dependency within 31 days of the child's
attainment of the limiting age and subsequently as required, but not more
frequently than annually following the child's attainment of such limiting
age.
(19)
Termination due to student dependent's change in status--Each
group agreement and certificate that conditions dependent coverage for a child
twenty-five years of age or older on the child's being a full-time student
at an educational institution shall contain a provision in accordance with
Insurance Code Article 21.24-2.
(20)
Conformity with state law--A provision that if the agreement
or certificate contains any provision not in conformity with the Act or other
applicable laws it shall not be rendered invalid but shall be construed and
applied as if it were in full compliance with the Act and other applicable
laws.
(21)
Conformity with Medicare supplement minimum standards
and long-term care minimum standards--Each group, individual and conversion
agreement and group certificate must comply with Chapter 3, Subchapter T of
this title (relating to Minimum Standards for Medicare Supplement Policies),
referred to in this paragraph as Medicare supplement rules, and Chapter 3,
Subchapter Y of this title (relating to Standards for Long-Term Care Insurance
Coverage Under Individual and Group Policies), referred to in this paragraph
as long-term care rules, where applicable. If there is a conflict between
the Medicare supplement rules and/or the long-term care rules and the HMO
rules, the Medicare supplement rules or long-term care rules shall govern
to the exclusion of the conflicting provisions of the HMO rules. Where there
is no conflict, an HMO shall follow both the Medicare supplement rules and/or
the long-term care rules and the HMO rules where applicable.
(22)
Nonprimary care physician specialist as primary care physician--A
provision that allows enrollees with chronic, disabling, or life threatening
illnesses to apply to the HMO's medical director to utilize a nonprimary care
physician specialist as a primary care physician as set forth in Insurance
Code Article 20A.09(g).
(23)
Selected obstetrician or gynecologist--Individual, conversion
and group agreements and certificates, except small employer plans as defined
by Insurance Code Chapter 26, must contain a provision that permits an enrollee
to select, in addition to a primary care physician, an obstetrician or gynecologist
to provide health care services within the scope of the professional specialty
practice of a properly credentialed obstetrician or gynecologist, and subject
to the provisions of Insurance Code Article 21.53D. An HMO shall not preclude
an enrollee from selecting a family physician, internal medicine physician,
or other qualified physician to provide obstetrical or gynecological care.
(A)
An HMO shall permit an enrollee who selects an obstetrician
or gynecologist direct access to the health care services of the selected
obstetrician or gynecologist without a referral by the enrollee’s primary
care physician or prior authorization or precertification from the HMO.
(B)
The access to health care services of an obstetrician or
gynecologist, includes:
(i)
one well-woman examination per year;
(ii)
care related to pregnancy;
(iii)
care for all active gynecological conditions; and
(iv)
diagnosis, treatment, and referral to a specialist within
the HMO’s network for any disease or condition within the scope of the
selected professional practice of a properly credentialed obstetrician or
gynecologist, including treatment of medical conditions concerning breasts.
(C)
An HMO may require an enrollee who selects an obstetrician
or gynecologist to select the obstetrician or gynecologist from within the
limited provider network to which the enrollee’s primary care physician
belongs.
(D)
An HMO may require a selected obstetrician or gynecologist
to forward information concerning the medical care of the patient to the primary
care physician. However, the HMO shall not impose any penalty, financial or
otherwise, upon the obstetrician or gynecologist by the HMO for failure to
provide this information if the obstetrician or gynecologist has made a reasonable
and good faith effort to provide the information to the primary care physician.
(E)
An HMO may limit an enrollee in the plan to self-referral
to one participating obstetrician and gynecologist for both gynecological
care and obstetrical care. Such limitation shall not affect the right of the
enrollee to select the physician who provides that care.
(F)
An HMO shall include in its enrollment form a space in
which an enrollee may select an obstetrician or gynecologist as set forth
in Insurance Code Article 21.53D. The enrollment form must specify that the
enrollee is not required to select an obstetrician or gynecologist, but may
instead receive obstetrical or gynecological services from her primary care
physician or primary care provider. Such enrollee shall have the right at
all times to select or change a selected obstetrician or gynecologist. An
HMO may limit an enrollee’s request to change an obstetrician or gynecologist
to no more than four changes in any 12-month period.
(G)
An enrollee that elects to receive obstetrical or gynecological
services from a primary care physician (i.e., a family physician, internal
medicine physician, or other qualified physician) shall adhere to the HMO's
standard referral protocol when accessing other specialty obstetrical or gynecological
services.
(24)
Diagnosis of Alzheimer's disease--An HMO that provides
for the treatment of Alzheimer's disease must provide that a clinical diagnosis
of Alzheimer's disease by a physician licensed in this state pursuant to the
Insurance Code Article 3.78 shall satisfy any requirement for demonstrable
proof of organic disease.
(25)
Drug Formulary--A group agreement and certificate, except
small employer plans as defined by Insurance Code Chapter 26, that covers
prescription drugs and uses one or more formularies must comply with Insurance
Code Article 21.52J and Chapter 21, Subchapter V of this title (relating to
Pharmacy Benefits).
(26)
Inpatient care by non-primary care physician--If an HMO
or limited provider network provides for an enrollee's care by a physician
other than the enrollee's primary care physician while the enrollee is in
an inpatient facility (e.g., hospital or skilled nursing facility), a provision
that upon admission to the inpatient facility a physician other than the primary
care physician may direct and oversee the enrollee's care.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500523
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §11.602, §11.603
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500524
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.801 - 11.803, 11.806, 11.810
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500525
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.901, 11.902, 11.904
The amendments and new section are adopted pursuant to Insurance
Code §§843.080, 843.082, 843.083, 843.102, 843.151, and 843.404;
Articles 20A.09N, 20A.18C, 20A.39, 21.53D (Obstetrical care), 21.53F (Children’s
benefits), 21.53F (Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001.
Section 843.080 provides that the commissioner may promulgate reasonable rules
that the commissioner considers necessary for the proper administration of
Chapter 843 to require a health maintenance organization, after receiving
its certificate of authority, to submit modifications or amendments to the
operations or documents described in §§843.078 and 843.079 to the
commissioner, for the commissioner's approval or only to provide information,
before implementing the modification or amendment or to require the health
maintenance organization to indicate the modifications to the commissioner
at the time of the next site visit or examination. Section 843.082 sets out
the determinations the commissioner must make prior to granting a certificate
of authority to an HMO. Section 843.083 sets out the notification and deficiency
specification requirements for plan applications whose defects preclude issuance
of a certificate of authority. Section 843.102 provides that the commissioner
by rule may establish minimum standards and requirements for the quality assurance
programs of HMOs, including standards for ensuring availability, accessibility,
quality and continuity of care. Section 843.151 provides that the commissioner
may adopt reasonable rules as necessary and proper to implement Chapters 843
and 20A, including rules to prescribe authorized investments for a health
maintenance organization for all investments not otherwise addressed in Chapter
843; to ensure that enrollees have adequate access to health care services;
to establish minimum physician-to-patient ratios, mileage requirements for
primary and specialty care, maximum travel time, and maximum waiting time
for obtaining an appointment; and to meet the requirements of federal law
and regulations. Section 843.404 provides that the commissioner may adopt
rules or may by rule establish guidelines requiring a health maintenance organization
to maintain a specified net worth based on the nature and kind of risks the
health maintenance organization underwrites or reinsures; the premium volume
of risks the health maintenance organization underwrites or reinsures; the
composition, quality, duration, or liquidity of the health maintenance organization's
investment portfolio; fluctuations in the market value of securities the health
maintenance organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
§11.901.Required Provisions.
(a)
Physician and provider contracts and arrangements shall
include provisions:
(1)
regarding a hold harmless clause as described in Insurance
Code §843.361:
(A)
A hold harmless clause is a provision, as required by Insurance
Code §843.361, in a physician or health care provider agreement that
obligates the physician or provider to look only to the HMO and not its enrollees
for payment for covered services (except as described in the evidence of coverage
issued to the enrollee).
(B)
In accordance with Insurance Code §843.002 relating
to an "uncovered expense," if a physician or health care provider agreement
contains a hold harmless clause, then the costs of the services will not be
considered uncovered health care expenses in determining amounts of deposits
necessary for insolvency protection under Insurance Code §843.405.
(C)
The following language is an example of an approvable hold-harmless
clause: (Physician/Provider) hereby agrees that in no event, including, but
not limited to non-payment by the HMO, HMO insolvency, or breach of this agreement,
shall (physician/provider) bill, charge, collect a deposit from, seek compensation,
remuneration, or reimbursement from, or have any recourse against subscriber,
enrollee, or persons other than HMO acting on their behalf for services provided
pursuant to this agreement. This provision shall not prohibit collection of
supplemental charges or copayments made in accordance with the terms of (applicable
agreement) between HMO and subscriber/enrollee. (Physician/Provider) further
agrees that:
(i)
this provision shall survive the termination of this agreement
regardless of the cause giving rise to termination and shall be construed
to be for the benefit of the HMO subscriber/enrollee; and
(ii)
this provision supersedes any oral or written contrary
agreement now existing or hereafter entered into between (physician/provider)
and subscriber, enrollee, or persons acting on their behalf. Any modification,
addition, or deletion to the provisions of this clause shall be effective
on a date no earlier than 15 days after the commissioner has received written
notice of such proposed changes;
(2)
regarding retaliation as described in Insurance Code §843.281;
(3)
regarding continuity of treatment, if applicable, as described
in Insurance Code §843.309 and §843.362;
(4)
regarding written notification to enrollees receiving care
from a physician or provider of the HMO’s termination of that physician
or provider in accordance with Insurance Code §843.308 and §843.309;
(5)
regarding written notification of termination to a physician
or provider in accordance with Insurance Code §843.306 and §843.307:
(A)
the HMO must provide notice of termination by the HMO to
the physician or provider at least 90 days prior to the effective date of
the termination;
(B)
not later than 30 days following receipt of the written
notification of termination, a physician or provider may request a review
by the HMO’s advisory review panel;
(C)
within 60 days following receipt of the provider’s
request for review, the advisory review panel must make its formal recommendation
and the HMO must communicate its decision to the physician or provider;
(6)
regarding posting of complaints notice in physician/provider
offices as described in Insurance Code §843.283. A representative notice
that complies with this requirement may be obtained from the HMO Division,
Mail Code 103-6A, Texas Department of Insurance, P.O. Box 149104, Austin,
Texas 78714-9104;
(7)
regarding indemnification of the HMO as described in Insurance
Code §843.310;
(8)
regarding prompt payment of claims as described in Insurance
Code Article 20A.09Z and all applicable statutes and rules pertaining to prompt
payment of clean claims, including Insurance Code Chapter 843, Subchapter
J (Payment of Claims to Physicians and Providers) and Chapter 21, Subchapter
T of this title (relating to Submission of Clean Claims) with respect to the
payment to the physician or provider for covered services that are rendered
to enrollees;
(9)
regarding capitation, if applicable, as described in Insurance
Code §843.315 and §843.316;
(10)
regarding selection of a primary physician or provider,
if applicable, as described in Insurance Code §843.315;
(11)
entitling the physician or provider upon request to all
information necessary to determine that the physician or provider is being
compensated in accordance with the contract. A physician or provider may make
the request for information by any reasonable and verifiable means. The information
must include a level of detail sufficient to enable a reasonable person with
sufficient training, experience and competence in claims processing to determine
the payment to be made according to the terms of the contract for covered
services that are rendered to enrollees. The HMO may provide the required
information by any reasonable method through which the physician or provider
can access the information, including e-mail, computer disks, paper or access
to an electronic database. Amendments, revisions or substitutions of any information
provided pursuant to this paragraph must be made in accordance with subparagraph
(D) of this paragraph. The HMO shall provide the fee schedules and other required
information by the 30th day after the date the HMO receives the physician's
or provider's request.
(A)
This information must include a physician-specific or provider-specific
summary and explanation of all payment and reimbursement methodologies that
will be used to pay claims submitted by a physician or provider. At a minimum,
the information must include:
(i)
a fee schedule, including, if applicable, CPT, HCPCS, CDT,
ICD-9-CM codes and modifiers:
(I)
by which the HMO will calculate and pay all claims for
covered services submitted by or on behalf of the contracting physician or
provider; or
(II)
that pertains to the range of health care services reasonably
expected to be delivered under the contract by that contracting physician
or provider on a routine basis along with a toll-free number or electronic
address through which the contracting physician or provider may request the
fee schedules applicable to any covered services that the physician or provider
intends to provide to an enrollee and any other information required by this
paragraph, that pertains to the service for which the fee schedule is being
requested if the HMO has not previously provided that information to the physician
or provider;
(ii)
all applicable coding methodologies;
(iii)
all applicable bundling processes, which must be consistent
with nationally recognized and generally accepted bundling edits and logic;
(iv)
all applicable downcoding policies;
(v)
a description of any other applicable policy or procedure
the HMO may use that affects the payment of specific claims submitted by or
on behalf of the contracting physician or provider, including recoupment;
(vi)
any addenda, schedules, exhibits or policies used by the
HMO in carrying out the payment of claims submitted by or on behalf of the
contracting physician or provider that are necessary to provide a reasonable
understanding of the information provided pursuant to this paragraph; and
(vii)
the published, product name and version of any software
the HMO uses to determine bundling and unbundling of claims.
(B)
In the case of a reference to source information as the
basis for fee computation that is outside the control of the HMO, such as
state Medicaid or federal Medicare fee schedules, the information the HMO
provides shall clearly identify the source and explain the procedure by which
the physician or provider may readily access the source electronically, telephonically,
or as otherwise agreed to by the parties.
(C)
Nothing in this paragraph shall be construed to require
an HMO to provide specific information that would violate any applicable copyright
law or licensing agreement. However, the HMO must supply, in lieu of any information
withheld on the basis of copyright law or licensing agreement, a summary of
the information that will allow a reasonable person with sufficient training,
experience and competence in claims processing to determine the payment to
be made according to the terms of the contract for covered services that are
rendered to enrollees as required by subparagraph (A) of this paragraph.
(D)
No amendment, revision, or substitution of any of the claims
payment procedures or any of the information required to be provided by this
paragraph shall be effective as to the contracting physician or provider,
unless the HMO provides at least 90 calendar days written notice to the contracting
physician or provider identifying with specificity the amendment, revision
or substitution. An HMO may not make retroactive changes to claims payment
procedures or any of the information required to be provided by this paragraph.
Where a contract specifies mutual agreement of the parties as the sole mechanism
for requiring amendment, revision or substitution of the information required
by this paragraph, the written notice specified in this section does not supersede
the requirement for mutual agreement.
(E)
Failure to comply with this paragraph constitutes a violation
of Insurance Code Chapters 843 and 20A (Texas Health Maintenance Organization
Act).
(F)
Upon receipt of a request, the HMO must provide the information
required by subparagraphs (A) - (D) of this paragraph to the contracting physician
or provider by the 30th day after the date the HMO receives the contracting
physician's or provider's request.
(G)
A physician or provider that receives information under
this paragraph:
(i)
may not use or disclose the information for any purpose
other than:
(I)
the physician’s or provider’s practice management,
(II)
billing activities,
(III)
other business operations, or
(IV)
communications with a governmental agency involved in
the regulation of health care or insurance;
(ii)
may not use this information to knowingly submit a claim
for payment that does not accurately represent the level, type or amount of
services that were actually provided to an enrollee or to misrepresent any
aspect of the services; and
(iii)
may not rely upon information provided pursuant to this
paragraph about a service as a representation that an enrollee is covered
for that service under the terms of the enrollee’s evidence of coverage.
(H)
A physician or provider that receives information under
this paragraph may terminate the contract on or before the 30th day after
the date the physician or provider receives the information without penalty
or discrimination in participation in other health care products or plans.
The contract between the HMO and physician or provider shall provide for reasonable
advance notice to enrollees being treated by the physician or provider prior
to the termination consistent with Insurance Code §843.309.
(I)
The provisions of this paragraph may not be waived, voided,
or nullified by contract;
(12)
providing that a podiatrist, practicing within the scope
of the law regulating podiatry, is permitted to furnish x-rays and nonprefabricated
orthotics covered by the evidence of coverage; and
(13)
regarding electronic health care transactions as set forth
in §21.3701 of this title (relating to Electronic Health Care Transactions)
if the contract requires electronic submission of any information described
by that section.
(b)
An HMO may require a contracting physician or provider
to retain in the contracting physician or provider's records updated information
concerning a patient's other health benefit plan coverage.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500526
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §11.1001
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500527
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.1301 - 11.1306
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500528
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.1401 - 11.1404
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500529
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §11.1500
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500530
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.1600 - 11.1602, 11.1604 - 11.1607
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
§11.1600.Information to Prospective and Current Contract Holders and Enrollees.
(a)
An HMO shall provide an accurate written description of
health care plan terms and conditions to allow any prospective contract holder
or enrollee or current contract holder or enrollee to make comparisons and
informed decisions before selecting among health care plans. By agreement,
the HMO may deliver the required description of health care plan terms required
by this section electronically.
(b)
The written or electronic plan description must be in a
readable and understandable format that meets the requirements of §3.602
of this title (relating to Plain Language Requirements), by category, and
must include a clear, complete and accurate description of these items in
the following order:
(1)
a statement that the entity providing the coverage is an
HMO;
(2)
a toll-free number, unless exempted by statute or rule,
and address for obtaining additional information, including provider information;
(3)
all covered services and benefits, including a description
of the options (if any) for prescription drug coverage, both generic and brand
name;
(4)
emergency care services and benefits, including coverage
for out-of-area emergency care services and information on access to after-hours
care;
(5)
out-of-area services and benefits (if any);
(6)
an explanation of enrollee financial responsibility for
payment of premiums, copayments, deductibles, and any other out-of-pocket
expenses for noncovered or out-of-plan services, and an explanation that network
physicians and providers have agreed to look only to the HMO and not to its
enrollees for payment of covered services, except as set forth in this description
of the plan;
(7)
any limitations or exclusions, including the existence
of any drug formulary limitations;
(8)
any prior authorization requirements, including limitations
or restrictions thereon, and a summary of procedures to obtain approval for,
referrals to providers other than primary care physicians or dentists, and
other review requirements, including preauthorization review, concurrent review,
post service review, and post payment review, and the consequences resulting
from the failure to obtain any required authorizations;
(9)
provision for continuity of treatment in the event of the
termination of a primary care physician or dentist;
(10)
a summary of the complaint and appeal procedures of the
HMO, a statement of the availability of the independent review process, and
a statement that the HMO is prohibited from retaliating against a group contract
holder or enrollee because the group contract holder or enrollee has filed
a complaint against the HMO or appealed a decision of the HMO, and is prohibited
from retaliating against a physician or provider because the physician or
provider has, on behalf of an enrollee, reasonably filed a complaint against
the HMO or appealed a decision of the HMO;
(11)
a current list of physicians and providers, including
behavioral health providers and substance abuse treatment providers, if applicable,
updated on at least a quarterly basis. The list shall include the information
necessary to fully inform prospective or current enrollees about the network,
including names and locations of physicians and providers, a statement of
limitations of accessibility and referrals to specialists, including any limitations
imposed by a limited provider network, and a disclosure of which physicians
and providers will not accept new enrollees or participate in closed provider
networks serving only certain enrollees.
(A)
If an HMO limits enrollees' access to a limited provider
network, it shall provide to prospective and current group contract holders
and enrollees a notice in substantially the following form: "Choosing Your
Physician--Now that you have chosen XYZ Health Plan, your next choice will
be deciding who will provide the majority of your health care services. Your
Primary Care Physician or Primary Care Provider (PCP) will be the one you
call when you need medical advice, when you are sick and when you need preventive
care such as immunizations. Your PCP is also part of a "network" or association
of health professionals who work together to provide a full range of health
care services. That means when you choose your PCP, you are also choosing
a network and in most instances you are not allowed to receive services from
any physician or health care professional, including your obstetrician-gynecologist
(OB-GYN), that is not also part of your PCP's network. You will not be able
to select any physician or health care professional outside of your PCP's
network, even though that physician or health care provider is listed with
your health plan. The network to which your PCP belongs will provide or arrange
for all of your care, so make sure that your PCP's network includes the specialists
and hospitals that you prefer."
(B)
If an HMO does not limit an enrollee’s selection
of an obstetrician or gynecologist to the limited provider network to which
that enrollee’s primary care physician or provider belongs, it shall
provide to current or prospective enrollees a notice in compliance with Insurance
Code Article 21.53D in substantially the following form: "ATTENTION FEMALE
ENROLLEES: You have the right to select an OB-GYN to whom you have access
without first obtaining a referral from your PCP. (Name of HMO) has opted
not to limit your selection of an OB-GYN to your PCP's network. You are not
required to select an OB-GYN. You may elect to receive your OB-GYN services
from your PCP."
(C)
An HMO shall clearly differentiate limited provider networks
and open networks within its service area by providing a separate listing
of its limited provider networks and an alphabetical listing of all the physicians
and providers, including specialists, available in the limited provider network.
An HMO shall include an index of the alphabetical listing of all physicians
and providers, including behavioral health providers and substance abuse treatment
providers, if applicable, within the HMO's service area, and shall indicate
the limited provider network(s) to which the physician or provider belongs,
and the page number where the physician or provider's name can be found.
(D)
An HMO shall provide notice to enrollees informing them
to contact the HMO upon receipt of a bill for covered services from any physician
or provider. The notice shall inform enrollees of the method(s) for contacting
the HMO for this purpose.
(E)
An HMO that maintains an internet site shall include on
its internet site the information as required in subparagraphs (A) - (D) of
this paragraph.
(12)
the service area.
(c)
No HMO, or representatives thereof, may cause or knowingly
permit the use or distribution of enrollee information which is untrue or
misleading.
(d)
An HMO may utilize its handbook to satisfy the requirements
of this section if the information contained in the handbook is substantially
similar to and provides the same level of disclosure as the written or electronic
description prescribed by the commissioner and contains all the information
required under subsection (b) of this section.
(e)
If an HMO or limited provider network provides for an enrollee's
care by a physician other than the enrollee's primary care physician while
the enrollee is in an inpatient facility (e.g., hospital or skilled nursing
facility), the plan description must disclose that upon admission to the inpatient
facility, a physician other than the primary care physician may direct and
oversee the enrollee's care.
(f)
An HMO that maintains an internet site shall list the information
as required by subsection (b)(11) of this section and Insurance Code §843.2015
on its internet site. Such information shall be easily accessible from the
home page of the site.
§11.1601.Enrollee Identification Cards.
(a)
If an HMO issues identification (ID) cards to enrollees,
the HMO shall issue the ID cards within 30 calendar days of receiving notice
of the enrollee’s selection of a primary care physician. The enrollee
ID card will include, at a minimum, all necessary information to allow an
enrollee to access all services under the certificate or evidence of coverage
which require presentation of the card.
(b)
All ID cards an HMO issues shall comply with the requirements
of §21.2820 of this title (relating to Identification Cards).
(c)
If an evidence of coverage provides benefits for prescription
drugs, an HMO shall issue an ID card in compliance with §§21.3002
- 21.3004 of this title (relating to Definitions; Pharmacy Identification
Cards, and Issuance of Standard Identification Cards).
(d)
All ID cards issued by an HMO shall comply with the requirements
of Business and Commerce Code Section 35.58, which restricts the display of
social security numbers on ID cards.
§11.1605.Pharmaceutical Services.
(a)
Should an HMO provide prescription drug coverage, such
coverage shall be subject to copayments for both generic drugs and name brand
drugs. If the negotiated or usual or customary cost of the drug is less than
the copayment, the enrollee shall pay the lower cost. The copayments may be
the same, or if different, shall be applied as follows:
(1)
if the prescription is for a generic drug, the enrollee
shall pay no more than the generic copayment;
(2)
if the prescription is for a name brand drug, the enrollee
shall pay no more than the name brand copayment if:
(A)
the prescription is written "Dispense as written"; or
(B)
there is no generic equivalent for the prescribed drug;
(3)
if the prescription is written "product selection permitted"
and the enrollee elects to receive a name brand drug when a generic equivalent
is available, the enrollee shall pay no more than the generic copayment plus
the difference between the cost of the generic drug and the cost of the name
brand drug.
(4)
if the enrollee’s prescription benefit requires the
use of generic equivalent drugs ("required generic") and the enrollee receives
a name brand drug when a generic equivalent is available, the enrollee shall
pay no more than the generic copayment plus the difference between the cost
of the generic drug and the cost of the name brand drug, even when the prescription
is written "dispense as written."
(b)
Pharmacy services, if offered, shall be available and accessible
within the service area for the enrolled population through pharmacies licensed
by the Texas State Board of Pharmacy. The HMO shall offer such pharmacy services
directly or through contracts.
(c)
An HMO that provides coverage for prescription drugs under
an individual or group health benefit plan shall comply with the requirements
of Insurance Code Article 21.53M, and §21.3010 and §21.3011 of this
title (relating to Definitions; Coverage of Off-Label Drugs and Minimum Standards
of Coverage for Off-Label Drug Use).
(d)
An HMO that provides coverage for prescription drugs or
devices under an individual or group state-mandated health benefit plan shall
comply with the requirements of Insurance Code Article 21.52L (Health Benefit
Plan Coverage for Prescription Contraceptive Drugs and Devices and Related
Services).
(e)
An HMO that provides coverage for prescription drugs under
a group state-mandated health benefit plan and that utilizes one or more drug
formularies to specify which prescription drugs the plan will cover shall
comply with the requirements of Insurance Code Article 21.52J and §§21.3020
- 21.3023 of this title (relating to Definitions; Prescription Drug Formulary,
Required Disclosure of Drug Formulary, Continuation of Benefits, and Nonformulary
Prescription Drugs; Adverse Determination).
§11.1607.Accessibility and Availability Requirements.
(a)
Each health benefit plan delivered or issued for delivery
by an HMO must include an HMO delivery network which is adequate and complies
with Insurance Code §843.082.
(b)
There shall be a sufficient number of primary care physicians
and specialists with hospital admitting privileges to participating facilities
who are available and accessible 24 hours per day, seven days per week, within
the HMO’s service area to meet the health care needs of the HMO’s
enrollees.
(c)
An HMO shall make general, special, and psychiatric hospital
care available and accessible 24 hours per day, seven days per week, within
the HMO's service area.
(d)
If an HMO limits enrollees' access to a limited provider
network, it must ensure that such limited provider network complies with the
provisions of this section.
(e)
An HMO shall make emergency care available and accessible
24 hours per day, seven days per week, without restrictions as to where the
services are rendered.
(f)
All covered services that are offered by the HMO shall
be sufficient in number and location to be readily available and accessible
within the service area to all enrollees.
(g)
HMOs must arrange for covered health care services, including
referrals to specialists, to be accessible to enrollees on a timely basis
upon request and consistent with guidelines set out in paragraphs (1) - (3)
of this subsection:
(1)
Urgent care shall be available:
(A)
within 24 hours for medical and dental conditions; and
(B)
within 24 hours for behavioral health conditions.
(2)
Routine care shall be available:
(A)
within three weeks for medical conditions;
(B)
within eight weeks for dental conditions; and
(C)
within two weeks for behavioral health conditions.
(3)
Preventive health services shall be available:
(A)
within two months for a child;
(B)
within three months for an adult; and
(C)
within four months for dental services.
(h)
An HMO is required to provide an adequate network for its
entire service area. All covered services must be accessible and available
so that travel distances from any point in its service area to a point of
service are no greater than:
(1)
30 miles for primary care and general hospital care; and
(2)
75 miles for specialty care.
(i)
If any covered health care service or a participating physician
and provider is not available to an enrollee within the mileage radii specified
in subsection (h)(1) and (2) of this section because physicians and providers
are not located within such mileage radii, or if the HMO is unable to obtain
contracts after good faith attempts, or physicians and providers meeting the
minimum quality of care and credentialing requirements of the HMO are not
located within the mileage radii, the HMO shall submit an access plan to the
department for approval, at least 30 days before implementation in accordance
with the filing requirements in §11.301 of this title (relating to Filing
Requirements). The access plan shall include the following:
(1)
the geographic area identified by county, city, ZIP code,
mileage, or other identifying data in which services and/or physicians and
providers are not available;
(2)
for each geographic area identified as not having covered
health care services and/or physicians or providers available, the reason
or reasons that covered health care services and/or physicians and providers
cannot be made available;
(3)
a map, with key and scale, which identifies the areas in
which such covered health care services and/or physicians and providers are
not available;
(4)
the HMO's plan for making covered health care services
and/or physicians and providers available to enrollees in each geographic
area identified;
(5)
the names and addresses of the participating physicians
and providers and a listing of the covered health care services to be provided
through the HMO delivery network to meet the medical needs of the enrollees
covered under the HMO's plan required under paragraph (4) of this subsection;
(6)
the names and address of other physicians and providers
and a listing of the specialties for any other health care services or physicians
and providers to be made available in the geographic area in addition to those
physicians and providers participating in the HMO delivery network listed
under paragraph (5) of this subsection;
(7)
the procedures to be followed by the HMO to assure that
primary care physicians, general hospitals, specialists, special hospitals,
psychiatric hospitals, diagnostic and therapeutic services, or single or limited
health care service providers and all other mandated health care services
are made available and accessible to enrollees in the geographic areas identified
as being areas in which such covered health care services and/or physicians
and providers are not available and accessible, and any plans of the HMO for
attempting to develop an HMO delivery network through which covered health
care services are available and accessible to enrollees in these geographic
areas in the future; and
(8)
any other information which is necessary to assess the
HMO's plan.
(j)
The HMO may make arrangements with physicians or providers
outside the service area for enrollees to receive a higher level of skill
or specialty than the level which is available within the HMO service area
such as, but not limited to, transplants, treatment of cancer, burns, and
cardiac diseases. An HMO may not require an enrollee to travel out of the
service area to receive such services, unless the HMO provides the enrollee
with a written explanation of the benefits and detriments of in-area and out-of-area
options.
(k)
The HMO shall not be required to expand services outside
its service area to accommodate enrollees who live outside the service area,
but work within the service area.
(l)
In accordance with Insurance Code Article 21.53F (Telemedicine),
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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500531
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.1702 - 11.1704
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500532
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.1801 - 11.1806
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
§11.1806.Additional Information That May be Requested From an MCO Participating in Medicaid.
(a)
Whenever requested by the department, the MCO shall file
a complete set of financial exhibits pertaining to the state Medicaid program,
in the format of the Managed Care Financial Statistical Report, as may be
modified or amended by the Texas Health and Human Services Commission. When
a request is received, the MCO shall then file, on two separate occasions,
an original Managed Care Financial Statistical Report reflecting the state
Medicaid program operations for each contract year in the same format as the
monthly Managed Care Financial Statistical Report. These reports shall be
in accordance with the instructions promulgated by the Health and Human Services
Commission.
(b)
For any new or modified request to the Texas Health and
Human Services Commission for participation in the Medicaid managed care program,
all financial projections, including enrollment projections, from the effective
or renewal date of a Medicaid contract that are submitted to the Texas Health
and Human Services Commission are also required to be submitted to the Texas
Department of Insurance. The MCO shall submit the same financial projections,
including a cash flow statement, submitted to the Texas Health and Human Services
Commission with the request to participate in the Medicaid program. This information
shall be submitted with the certificate of authority if the MCO is not already
a licensed MCO. If the MCO is a licensed operation, then the financial projections
must be sent with the next financial statement due to the department.
(c)
The MCO shall notify the department of any similar financial
or statistical reports required by other contracting state agencies and shall
submit copies of these reports, when requested by the department.
(d)
Information submitted pursuant to this section shall be
sent to the Texas Department of Insurance, Financial Analysis & Examinations,
Mail Code 303-1A, P.O. Box 149104, Austin, Texas 78714-9104.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500533
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §11.1901, §11.1902
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
§11.1902.Quality Improvement Program for Basic and Limited Services HMOs.
The QI program for basic and limited services HMOs shall be continuous
and comprehensive, addressing both the quality of clinical care and the quality
of services. The HMO shall dedicate adequate resources, such as personnel
and information systems, to the QI program.
(1)
Written description. The QI program shall include a written
description of the QI program that outlines program organizational structure,
functional responsibilities, and meeting frequency.
(2)
Work plan. The QI program shall include an annual QI work
plan designed to reflect the type of services and the population served by
the HMO in terms of age groups, disease categories, and special risk status.
The work plan shall include:
(A)
Objective and measurable goals; planned activities to accomplish
the goals; time frames for implementation; responsible individuals; and evaluation
methodology.
(B)
The work plan shall address each program area, including:
(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;
(iv)
The adoption and periodic updating of clinical practice
guidelines or clinical care standards; the QI program shall assure the practice
guidelines:
(I)
are approved by participating physicians and individual
providers;
(II)
are communicated to physicians and individual providers;
and
(III)
include preventive health services;
(v)
Enrollee, physician, and individual provider satisfaction;
(vi)
The complaint and appeals process, complaint data, and
identification and removal of communication barriers that may impede enrollees,
physicians, and providers from effectively making complaints against the HMO;
(vii)
Preventive health care through health promotion and outreach
activities;
(viii)
Claims payment processes;
(ix)
Contract monitoring, including delegation oversight and
compliance with filing requirements;
(x)
Utilization review processes;
(xi)
Credentialing;
(xii)
Member services; and
(xiii)
Pharmacy services, including drug utilization.
(3)
Evaluation. The QI program shall include an annual written
report on the QI program, which includes completed activities, trending of
clinical and service goals, analysis of program performance, and conclusions.
(4)
Credentialing. An HMO shall implement a documented process
for selection and retention of contracted physicians and providers, which
includes the following elements, as applicable:
(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 written procedures for verifications.
(i)
The HMO shall credential all physicians and providers,
including advanced practice nurses, and physician assistants, if they are
listed in the provider directory. An HMO shall credential each physician or
individual provider who is a member of a contracting group, such as an independent
physician association or medical group.
(ii)
Policies and procedures must include the following physicians’
and providers’ rights:
(I)
the right to review information submitted to support the
credentialing application;
(II)
the right to correct erroneous information;
(III)
the right, upon request, to be informed of the status
of the credentialing or recredentialing application; and
(IV)
the right to be notified of these rights.
(iii)
An HMO is not required to credential:
(I)
hospital-based physicians or individual providers, including
advanced practice nurses and physician assistants unless listed in the provider
directory;
(II)
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;
(III)
students, residents, or fellows;
(IV)
pharmacists; or
(V)
opticians.
(iv)
An HMO must complete the initial credentialing process,
including application, verification of information, and a site visit (if applicable),
before the effective date of the initial contract with the physician or provider.
(v)
Policies and procedures shall include a provision that
applicants be notified of the credentialing or recredentialing decision no
later than 60 calendar days after the credentialing committee’s decision.
(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 Insurance Code §§843.306
- 843.309.
(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 it identifies occurrences of poor quality.
Monitoring shall include:
(I)
Medicare and Medicaid sanctions: the HMO must determine
the publication schedule or release dates applicable to its physician and
provider community; the HMO is responsible for reviewing the information within
30 calendar days of its release;
(II)
Information from state licensing boards regarding sanctions
or licensure limitations; and
(III)
Complaints.
(viii)
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. Procedures shall also include a provision that credentialing and
recredentialing decisions are not based solely on an applicant’s race,
ethnic/national identity, gender, age, sexual orientation or the types of
procedures or types of patients.
(ix)
The HMO shall have a procedure for notifying licensing
or other appropriate authorities when a physician's or provider's affiliation
is suspended or terminated due to quality of care concerns.
(C)
Initial credentialing process for physicians and individual
providers shall include the following:
(i)
Physicians, advanced practice nurses and physician assistants
shall complete the standardized credentialing application adopted in §21.3201
of this title (relating to the Texas Standardized Credentialing Application
for Physicians, Advanced Practice Nurses and Physician Assistants) and individual
providers shall complete an application which includes a work history covering
at least five years, 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, lack of current illegal drug use,
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.
(ii)
The HMO shall verify the following from primary sources
and shall include evidence of verification in the credentialing files:
(I)
A current 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.
(II)
Education and training, including evidence of graduation
from an 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
MasterFile. If the state licensing board, agency, or specialty board verifies
education and training with the physician’s 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.
(III)
Board certification, if the physician or individual provider
indicates that he/she is board certified on the application. The HMO may obtain
primary source verification from the American Board of Medical Specialties
Compendium, the American Osteopathic Association, the American Medical Association
MasterFile, or from the specialty boards, and the HMO must use the most recent
available source.
(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 the
HMO may verify them 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 MasterFile.
(iii)
The HMO shall verify within 180 calendar days prior to
the date of the credentialing decision and shall include in the physician's
or individual provider's credentialing file the following:
(I)
Past five-year history of professional liability claims
that resulted in settlements or judgments paid by or on behalf of the physician
or individual provider, which the HMO may obtain from the professional liability
carrier or the National Practitioner Data Bank;
(II)
Information on previous sanction activity by Medicare
and Medicaid which the HMO may obtain from one of the following:
(-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; or
(-g-)
entry in the American Medical Association Physician MasterFile.
(iv)
The HMO shall perform a site visit to the offices of each
primary care physician or individual primary care provider, obstetrician-gynecologist,
primary care dentist, and high-volume behavioral health physician or individual
behavioral health provider as part of the initial credentialing process. In
addition, the HMO shall have written procedures for determining high-volume
behavioral health physicians or individual behavioral health providers. If
physicians or individual providers are part of a group practice that shares
the same office, the HMO may perform one visit to the site 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 HMO
shall make the site visit assessment available to the department for review.
The HMO shall have a process to track the relocation of and the opening of
additional office sites for primary care physicians and individual primary
care providers, obstetrician-gynecologists, primary care dentists, and high-volume
behavioral health physicians or individual behavioral health providers as
they open.
(v)
Site visits shall consist of an evaluation of the site's
accessibility, appearance, appointment availability, and space, using standards
approved 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, the HMO shall determine whether the site conforms to the
HMO’s standards for record organization, documentation, and confidentiality
practices. 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.
(D)
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.
(i)
Recredentialing will include a current and signed attestation
that must be completed within 180 days prior to the date the credentialing
committee deems a physician or individual provider eligible for recredentialing
with the following factors:
(I)
reasons for any inability to perform the essential functions
of the position, with or without accommodation;
(II)
lack of current illegal drug use;
(III)
history of loss or limitation of privileges or disciplinary
activity;
(IV)
current professional liability insurance coverage; and
(V)
correctness and completeness of the application.
(ii)
Recredentialing procedures must be completed within 180
days prior to the date the credentialing committee deems a physician or individual
provider eligible for recredentialing and shall include the following processes:
(I)
Reverification of the following from the primary sources:
(-a-)
Licensure and information on sanctions or limitations
on licensure;
(-b-)
Board certification:
(-1-)
if the physician or individual provider was due to be
recertified; or
(-2-)
if the physician or individual provider indicates that
he or she has become board certified since the last time he or she was credentialed
or recredentialed; and
(-c-)
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:
(-1-)
copy of the DEA or DPS certificate;
(-2-)
visual inspection of the original certificate;
(-3-)
confirmation with DEA or DPS;
(-4-)
entry in the National Technical Information Service database;
or
(-5-)
entry in the American Medical Association Physician MasterFile.
(II)
Review of updated history of professional liability claims
in accordance with the verification sources and time limits specified in subparagraph
(C)(iii) of this paragraph.
(E)
The credentialing process for institutional providers shall
include the following:
(i)
Evidence of state licensure;
(ii)
Evidence of Medicare certification;
(iii)
Evidence of other applicable state or federal requirements,
e.g., Bureau of Radiation Control certification for diagnostic imaging centers,
certification for community mental health centers from the Texas Department
of Mental Health and Mental Retardation or its successor agency, 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 policies and procedures must state which national accrediting bodies
it accepts; and
(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) - (iv) 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 HMO shall conduct the site visit to
evaluate the complaint or other precipitating event, which may include an
evaluation of any facilities or services related 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 QI program shall provide for a peer review
procedure for physicians and individual providers, as required in the Medical
Practice Act, Chapters 151-164, Occupations Code. The HMO shall designate
a credentialing committee that uses a peer review process to make recommendations
regarding credentialing decisions.
(7)
Delegation of Credentialing.
(A)
If the HMO delegates credentialing functions to other entities,
it shall have:
(i)
a process for developing delegation criteria and for performing
pre-delegation and annual audits;
(ii)
a delegation agreement;
(iii)
a monitoring plan; and
(iv)
a procedure for termination of the delegation agreement
for non-performance.
(B)
If the HMO delegates credentialing functions to an entity
accredited by the NCQA, the annual audit of that entity is not required for
the function(s) listed in the NCQA accreditation; however, evidence of this
accreditation shall be made available to the department for review.
(C)
The HMO shall maintain:
(i)
documentation of pre-delegation and annual audits;
(ii)
executed delegation agreements;
(iii)
semi-annual reports received from the delegated entities;
(iv)
evidence of evaluation of the reports;
(v)
current rosters or copies of signed contracts with physicians
and individual providers who are affected by the delegation agreement; and
(vi)
documentation of ongoing monitoring and shall make it
available to the department for review.
(D)
Credentialing files maintained by the other entities to
which the HMO has delegated credentialing functions shall be made available
to the department for examination upon request.
(E)
In all cases, the HMO shall maintain the right to approve
credentialing, suspension, and termination of physicians and providers.
This agency hereby certifies that the adoption
has been reviewed by legal counsel and found to be a valid exercise of the
agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500534
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.2101 - 11.2103
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500535
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.2200, 11.2201, 11.2203, 11.2204, 11.2207, 11.2208
The amendments and new sections are adopted pursuant to Insurance
Code §§843.080, 843.082, 843.083, 843.102, 843.151, and 843.404;
Articles 20A.09N, 20A.18C, 20A.39, 21.53D (Obstetrical care), 21.53F (Children’s
benefits), 21.53F (Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001.
Section 843.080 provides that the commissioner may promulgate reasonable rules
that the commissioner considers necessary for the proper administration of
Chapter 843 to require a health maintenance organization, after receiving
its certificate of authority, to submit modifications or amendments to the
operations or documents described in §§843.078 and 843.079 to the
commissioner, for the commissioner's approval or only to provide information,
before implementing the modification or amendment or to require the health
maintenance organization to indicate the modifications to the commissioner
at the time of the next site visit or examination. Section 843.082 sets out
the determinations the commissioner must make prior to granting a certificate
of authority to an HMO. Section 843.083 sets out the notification and deficiency
specification requirements for plan applications whose defects preclude issuance
of a certificate of authority. Section 843.102 provides that the commissioner
by rule may establish minimum standards and requirements for the quality assurance
programs of HMOs, including standards for ensuring availability, accessibility,
quality and continuity of care. Section 843.151 provides that the commissioner
may adopt reasonable rules as necessary and proper to implement Chapters 843
and 20A, including rules to prescribe authorized investments for a health
maintenance organization for all investments not otherwise addressed in Chapter
843; to ensure that enrollees have adequate access to health care services;
to establish minimum physician-to-patient ratios, mileage requirements for
primary and specialty care, maximum travel time, and maximum waiting time
for obtaining an appointment; and to meet the requirements of federal law
and regulations. Section 843.404 provides that the commissioner may adopt
rules or may by rule establish guidelines requiring a health maintenance organization
to maintain a specified net worth based on the nature and kind of risks the
health maintenance organization underwrites or reinsures; the premium volume
of risks the health maintenance organization underwrites or reinsures; the
composition, quality, duration, or liquidity of the health maintenance organization's
investment portfolio; fluctuations in the market value of securities the health
maintenance organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
§11.2207.Quality Improvement Structure and Program for Single Service HMOs.
(a)
A single service HMO shall develop and maintain an ongoing
quality improvement (QI) program designed to objectively and systematically
monitor and evaluate the quality and appropriateness of care and services
and to pursue opportunities for improvement.
(b)
The governing body is ultimately responsible for the QI
program. The governing body shall:
(1)
appoint a QI committee (QIC) that shall include practicing
physicians, individual 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;
(2)
approve the QI program;
(3)
approve an annual QI plan;
(4)
meet no less than annually to receive and review reports
of the QIC or group of committees and take action when appropriate; and
(5)
review the annual written report on the QI program.
(c)
The QIC shall evaluate the overall effectiveness of the
QI program.
(1)
The QIC may delegate QI activities to other committees
that may, if applicable, include practicing physicians and individual providers,
and enrollees from the service area.
(A)
All committees shall collaborate and coordinate efforts
to improve the quality, availability, and accessibility of health care services
.
(B)
All committees shall meet regularly and report the findings
of each meeting, including any recommendations, in writing to the QIC.
(C)
If the QIC delegates any QI activity to any subcommittee,
then the QIC must establish a method to oversee each subcommittee.
(2)
The QIC shall use multidisciplinary teams, when indicated,
to accomplish QI program goals.
(d)
The QI program for single service HMOs shall be continuous
and comprehensive, addressing both the quality of clinical care and the quality
of services. The HMO shall dedicate adequate resources, such as personnel
and information systems, to the QI program.
(1)
Written description. The QI program shall include a written
description of the QI program that outlines program organizational structure,
functional responsibilities, and meeting frequency.
(2)
Work plan. The QI program shall include an annual QI work
plan designed to reflect the type of services and the population served by
the HMO in terms of age groups, disease categories, and special risk status,
as applicable. The work plan shall include:
(A)
Objective and measurable goals; planned activities to accomplish
the goals; time frames for implementation; responsible individuals; and evaluation
methodology.
(B)
The work plan shall address each program area, including:
(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, as applicable;
(iii)
Clinical studies;
(iv)
The adoption and use of current professionally-recognized
clinical practice guidelines, or, in the absence of current professionally-recognized
clinical practice guidelines for particular practice areas or conditions,
those developed by the health plan that:
(I)
are approved by participating physicians and individual
providers;
(II)
are communicated to physicians and individual providers;
and
(III)
include preventive health services.
(v)
Enrollee, physician, and individual provider satisfaction;
(vi)
The complaint and appeal process, complaint data, and
identification and removal of communication barriers that may impede enrollees,
physicians and providers from effectively making complaints against the HMO;
(vii)
Preventive health care through health promotion and outreach
activities:
(viii)
Claims payment processes, as applicable;
(ix)
Contract monitoring, including delegation oversight and
compliance with filing requirements;
(x)
Utilization review processes, as applicable;
(xi)
Credentialing;
(xii)
Member services; and;
(xiii)
Pharmacy services, including drug utilization.
(3)
Evaluation. The QI program shall include an annual report
on the QI program, which includes completed activities, trending of clinical
and service goals, analysis of program performance, and conclusions.
(4)
Credentialing. An HMO shall implement a documented process
for selection and retention of contracted physicians and providers, which
includes the following elements, as applicable:
(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 written procedures for verifications.
(i)
The HMO shall credential all physicians and providers including
advanced practice nurses and physician assistants, if they are listed in the
provider directory. An HMO shall credential each physician and individual
provider who is a member of a contracting group, such as an independent practice
association or medical group.
(ii)
Policies and procedures must include the following physicians’
and providers’ rights:
(I)
the right to review information submitted to support the
credentialing application;
(II)
the right to correct erroneous information;
(III)
the right, upon request, to be informed of the status
of the credentialing or recredentialing application; and
(IV)
the right to be notified of these rights.
(iii)
An HMO is not required to credential:
(I)
hospital-based physicians or individual providers, including
advanced practice nurses and physician assistants unless listed in the provider
directory;
(II)
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;
(III)
students, residents, or fellows;
(IV)
pharmacists; or
(V)
opticians.
(iv)
An HMO must complete the initial credentialing process,
including application, verification of information, and a site visit (if applicable),
before the effective date of the initial contract with the physician or provider.
(v)
Policies and procedures shall include a provision that
applicants be notified of the credentialing or recredentialing decision no
later than 60 calendar days after the credentialing committee’s decision.
(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 Insurance Code §§843.306
- 843.309.
(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 it identifies occurrences of poor quality.
Monitoring shall include:
(I)
Medicare and Medicaid sanctions: the HMO must determine
the publication schedule or release dates applicable to its physician and
provider community; the HMO is responsible for reviewing the information within
30 calendar days of its release;
(II)
Information from state licensing boards regarding sanctions
or licensure limitations; and
(III)
Complaints.
(viii)
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.
Procedures shall also include a provision that credentialing and recredentialing
decisions are not based solely on an applicant’s race, ethnic/national
identity, gender, age, sexual orientation, or the types of procedures or types
of patients.
(ix)
The HMO shall have a procedure for notifying licensing
or other appropriate authorities when a physician’s or provider's affiliation
is suspended or terminated due to quality of care concerns.
(C)
Initial credentialing process for physicians and individual
providers shall include the following:
(i)
Physicians, advanced practice nurses and physician assistants
shall complete the standardized credentialing application adopted in §21.3201
of this title (relating to the Texas Standardized Credentialing Application
for Physicians, Advanced Practice Nurses and Physician Assistants) and individual
providers shall complete an application which includes a work history covering
at least five years, 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, lack of current illegal drug use,
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.
(ii)
The HMO shall verify the following from primary sources
and shall include evidence of verification in the credentialing files:
(I)
A current 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.
(II)
Education and training, including evidence of graduation
from an 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
MasterFile. If the state licensing board, agency, or specialty board verifies
education and training with the physician’s 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.
(III)
Board certification, if the physician or individual provider
indicates that he/she is board certified on the application. The HMO may obtain
primary source verification from the American Board of Medical Specialties
Compendium, the American Osteopathic Association, the American Medical Association
MasterFile, or from the specialty boards, and the HMO must use the most recent
available source.
(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 the
HMO may verify them 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 MasterFile.
(iii)
The HMO shall verify within 180 calendar days prior to
the date of the credentialing decision and shall include in the physician’s
or individual provider's credentialing file the following:
(I)
Past five-year history of professional liability claims
that resulted in settlements or judgments paid by or on behalf of the physician
or individual provider, which the HMO may obtain from the professional liability
carrier or the National Practitioner Data Bank;
(II)
Information on previous sanction activity by Medicare
and Medicaid which the HMO may obtain from one of the following:
(-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 MasterFile.
(iv)
The HMO shall perform a site visit to the offices of each
primary care physician or individual provider, obstetrician-gynecologist,
primary care dentist, and high-volume behavioral health physician or individual
provider as part of the initial credentialing process. In addition, the HMO
shall have written procedures for determining high-volume behavioral health
physicians and individual providers. If physicians or individual providers
are part of a group practice that shares the same office, the HMO may perform
one visit to the site 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 HMO shall make the site visit assessment available
to the department for review. The HMO shall have a process to track the opening
of new physician or individual provider offices. The HMO shall perform a site
visit of each new office site of primary care physicians and individual providers,
obstetrician-gynecologists, primary care dentists, and high-volume behavioral
health physicians or individual providers as they open.
(v)
Site visits shall consist of an evaluation of the site's
accessibility, appearance, appointment availability, and space, using standards
approved 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, the HMO shall determine whether the site conforms to the
HMO's standards for record organization, documentation, and confidentiality
practices. 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.
(D)
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.
(i)
Recredentialing will include a current and signed attestation
that must be completed within 180 days prior to the date the credentialing
committee deems a physician or individual provider eligible for recredentialing
with the following factors:
(I)
reasons for any inability to perform the essential functions
of the position, with or without accommodation;
(II)
lack of current illegal drug use;
(III)
history of loss or limitation of privileges or disciplinary
activity;
(IV)
current professional liability insurance coverage; and
(V)
correctness and completeness of the application.
(ii)
Recredentialing procedures must be completed within 180
days prior to the date the credentialing committee deems a physician or individual
provider eligible for recredentialing and shall include the following processes:
(I)
Reverification of the following from the primary sources:
(-a-)
Licensure and information on sanctions or limitations
on licensure;
(-b-)
Board certification:
(-1-)
if the physician or individual provider was due to be
recertified; or
(-2-)
if the physician or individual provider indicates that
he or she has become board certified since the last time he or she was credentialed
or recredentialed; and
(-c-)
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:
(-1-)
copy of the DEA or DPS certificate;
(-2-)
visual inspection of the original certificate;
(-3-)
confirmation with DEA or DPS;
(-4-)
entry in the National Technical Information Service database;
or
(-5-)
entry in the American Medical Association Physician MasterFile.
(II)
Review of updated history of professional liability claims,
and sanction and restriction information from Medicare and Medicaid in accordance
with the verification sources and time limits specified in subparagraph (C)(iii)
of this paragraph.
(E)
The credentialing process for institutional providers shall
include the following:
(i)
Evidence of state licensure;
(ii)
Evidence of Medicare certification;
(iii)
Evidence of other applicable state or federal requirements,
e.g., Bureau of Radiation Control certification for diagnostic imaging centers,
certification for community mental health centers from Texas Mental Health
and Mental Retardation or its successor agency, 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 policies 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’s 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) - (iv) 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 HMO shall conduct the site visit to
evaluate the complaint or other precipitating event, which may include an
evaluation of any facilities or services related 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 QI program shall provide for a peer review
procedure for physicians and individual providers, as required in the Medical
Practice Act, Chapters 151-164, Occupations Code. The HMO shall designate
a credentialing committee that uses a peer review process to make recommendations
regarding credentialing decisions.
(7)
Delegation of Credentialing.
(A)
If the HMO delegates credentialing functions to other entities,
it shall have:
(i)
a process for developing delegation criteria and for performing
pre-delegation and annual audits;
(ii)
a delegation agreement;
(iii)
a monitoring plan; and
(iv)
a procedure for termination of the delegation agreement
for non-performance.
(B)
If the HMO delegates credentialing functions to an entity
accredited by the NCQA, the annual audit of that entity is not required for
the function(s) listed in the NCQA accreditation; however, evidence of this
accreditation shall be made available to the department for review.
(C)
The HMO shall maintain:
(i)
documentation of pre-delegation and annual audits;
(ii)
executed delegation agreements;
(iii)
semi-annual reports received from the delegated entities;
(iv)
evidence of evaluation of the reports;
(v)
current rosters or copies of signed contracts with physicians
and individual providers who are affected by the delegation agreement; and
(vi)
documentation of ongoing monitoring and shall make it
available to the department for review.
(D)
Credentialing files maintained by the other entities to
which the HMO has delegated credentialing functions shall be made available
to the department for examination upon request.
(E)
In all cases, the HMO shall maintain the right to approve
credentialing, suspension, and termination of physicians and providers.
§11.2208.Single Health Care Services Accessibility and Availability.
(a)
A single health care service HMO that chooses to offer
to an enrolled population a particular service shall comply with §11.1607(a)
and (e) - (j) of this title (relating to Accessibility and Availability Requirements).
Any single health care service shall be offered directly by the HMO or by
contract.
(b)
A sufficient number of participating single health care
physicians or dentists or other individual providers with appropriate hospital
or inpatient facility admitting privileges shall be available and accessible
24 hours per day, seven days per week, within the HMO’s service area,
to ensure availability and accessibility of care, including inpatient admissions
and care, as appropriate.
(c)
If a service offered by a single health care service HMO
requires inpatient status for the management of a single health care condition
the HMO shall provide for the appropriate inpatient facility according to
the need by contracting with one or more general, or special hospitals; or
home and community support services agencies for outpatient services.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500536
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.2303, 11.2311, 11.2314
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500537
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.2402, 11.2405, 11.2406
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500538
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §§11.2501 - 11.2503
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500539
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
28 TAC §11.2601, §11.2602
The amendments are adopted pursuant to Insurance Code §§843.080,
843.082, 843.083, 843.102, 843.151, and 843.404; Articles 20A.09N, 20A.18C,
20A.39, 21.53D (Obstetrical care), 21.53F (Children’s benefits), 21.53F
(Telemedicine), 21.53K, 21.53L, 21.53M, 21.58D, 26.04, and §36.001. Section
843.080 provides that the commissioner may promulgate reasonable rules that
the commissioner considers necessary for the proper administration of Chapter
843 to require a health maintenance organization, after receiving its certificate
of authority, to submit modifications or amendments to the operations or documents
described in §§843.078 and 843.079 to the commissioner, for the
commissioner's approval or only to provide information, before implementing
the modification or amendment or to require the health maintenance organization
to indicate the modifications to the commissioner at the time of the next
site visit or examination. Section 843.082 sets out the determinations the
commissioner must make prior to granting a certificate of authority to an
HMO. Section 843.083 sets out the notification and deficiency specification
requirements for plan applications whose defects preclude issuance of a certificate
of authority. Section 843.102 provides that the commissioner by rule may establish
minimum standards and requirements for the quality assurance programs of HMOs,
including standards for ensuring availability, accessibility, quality and
continuity of care. Section 843.151 provides that the commissioner may adopt
reasonable rules as necessary and proper to implement Chapters 843 and 20A,
including rules to prescribe authorized investments for a health maintenance
organization for all investments not otherwise addressed in Chapter 843; to
ensure that enrollees have adequate access to health care services; to establish
minimum physician-to-patient ratios, mileage requirements for primary and
specialty care, maximum travel time, and maximum waiting time for obtaining
an appointment; and to meet the requirements of federal law and regulations.
Section 843.404 provides that the commissioner may adopt rules or may by rule
establish guidelines requiring a health maintenance organization to maintain
a specified net worth based on the nature and kind of risks the health maintenance
organization underwrites or reinsures; the premium volume of risks the health
maintenance organization underwrites or reinsures; the composition, quality,
duration, or liquidity of the health maintenance organization's investment
portfolio; fluctuations in the market value of securities the health maintenance
organization holds; the adequacy of the health maintenance organization's
reserves; the number of individuals enrolled by the health maintenance organization;
or other business risks. Article 20A.09N(j) provides the commissioner shall
adopt rules as necessary to implement provisions of HMO choice of benefits
plans. Article 20A.18C(r) provides that the commissioner shall adopt reasonable
rules to implement the article as it relates to delegation of certain functions
by an HMO. Article 20A.39(a) provides that rules adopted by the commissioner
under §843.102 that relate to implementation and maintenance by an HMO
of a process for selecting and retaining affiliated physicians and providers
to comply with provisions of Article 20A.39 and standards promulgated by the
National Committee for Quality Assurance, to the extent those standards do
not conflict with other laws of this state. Article 21.53D, §6, provides
the commissioner shall adopt rules as necessary to implement obstetrical/gynecological
care provisions. Article 21.53F, addressing children’s benefits, provides
in Section 7 the commissioner may adopt rules as necessary to implement children’s
benefits provisions in the article. Article 21.53F, addressing telemedicine,
provides in Section 6 the commissioner may adopt rules necessary to implement
the article. Article 21.53K, §2, provides the commissioner may adopt
rules to implement the article. Article 21.53L, §4, provides that the
commissioner shall adopt necessary rules to implement pharmacy benefit card
provisions of the article. Article 21.53M, §4, provides the commissioner
may adopt rules to implement the off-label drug coverage provisions of the
article. Article 21.58D provides the commissioner shall by rule adopt a standardized
form for verification of credentials of professionals named in the statute
and shall consider any credentialing application form widely used in the state
or by the department. Article 26.04 provides that the commissioner shall adopt
rules as necessary to implement Insurance Code Chapter 26 and to meet the
minimum requirements of federal law and regulations which, for large and small
employer health carriers, are contained in HIPAA. Section 36.001 provides
that the Commissioner of Insurance may adopt any rules necessary and appropriate
to implement the powers and duties of the Texas Department of Insurance under
the Insurance Code and other laws of this state.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on February 4, 2005.
TRD-200500540
Brenda Caldwell
Special Regulatory Counsel
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
The Commissioner of Insurance adopts the repeal of Subchapter L, §11.1101
and §11.1102, concerning standard language for mandatory and other provisions;
Subchapter Q, §11.1608, concerning other requirements; and Subchapter
U, §§11.2001 - 11.2006, concerning services. The repeal of these
sections is adopted without changes to the proposal published in the November
12, 2004, issue of the
Texas Register
(29
TexReg 10419).
The repeal of Subchapters L and U is necessary to streamline and improve
the regulatory efficiency of Chapter 11. The provisions of Subchapters L and
U have either been transferred to other subchapters and published elsewhere
in this issue of the
Texas Register
, or deleted
as unnecessary. The repeal of §11.1608 is necessary because many of its
notice provisions are now included in adopted §11.1600(b)(11), published
elsewhere in this issue of the
Texas Register
.
The purpose and objective of the repeal is to allow for the streamlining
and adoption of amendments to Chapter 11. The repealed sections have either
been incorporated into other provisions in Chapter 11 or deleted as unnecessary.
No comments were received.
Subchapter L. STANDARD LANGUAGE FOR MANDATORY AND OTHER PROVISIONS
28 TAC §11.1101, §11.1102
The repeal of the sections is adopted pursuant to the Insurance
Code §§843.102, 843.151, and 36.001. Section 843.102 provides that
the commissioner by rule may establish minimum standards and requirements
for the quality assurance programs of HMOs, including standards for ensuring
availability, accessibility, quality and continuity of care. Section 843.151
provides the commissioner may adopt reasonable rules as necessary and proper
to fully implement Insurance Code Chapters 843 and 20A, as well as the requirements
of federal law and regulations. Section 36.001 provides that the Commissioner
of Insurance may adopt any rules necessary and appropriate to implement the
powers and duties of the Texas Department of Insurance under the Insurance
Code and other laws of this state. Subchapter L. Standard Language for Mandatory
and Other Provisions
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the
Office of the Secretary of State on February 4, 2005.
TRD-200500543
Gene C. Jarmon
General Counsel and Chief Clerk
Texas Department of Insurance
Effective date: February 24, 2005
Proposal publication date: November 12, 2004
For further information, please call: (512) 463-6327
Subchapter B. NAME APPLICATION PROCEDURE
Subchapter C. APPLICATION FOR CERTIFICATE OF AUTHORITY
Subchapter D. REGULATORY REQUIREMENTS FOR AN HMO SUBSEQUENT TO ISSUANCE OF CERTIFICATE OF AUTHORITY
Subchapter F. EVIDENCE OF COVERAGE
Subchapter G. ADVERTISING AND SALES MATERIAL
Subchapter I. FINANCIAL REQUIREMENTS
Subchapter J. PHYSICIAN AND PROVIDER CONTRACTS AND ARRANGEMENTS
Subchapter K. REQUIRED FORMS
Subchapter N. HMO SOLVENCY SURVEILLANCE COMMITTEE PLAN OF OPERATION
Subchapter O. ADMINISTRATIVE PROCEDURES
Subchapter P. PROHIBITED PRACTICES
Subchapter Q. OTHER REQUIREMENTS
Subchapter R. APPROVED NONPROFIT HEALTH CORPORATIONS
Subchapter S. SOLVENCY STANDARDS FOR MANAGED CARE ORGANIZATIONS PARTICIPATING IN MEDICAID
Subchapter T. QUALITY OF CARE
Subchapter V. STANDARDS FOR COMMUNITY MENTAL HEALTH CENTERS
Subchapter W. SINGLE SERVICE HMOS
Subchapter X. PROVIDER SPONSORED ORGANIZATIONS
Subchapter Y. LIMITED SERVICE HMOS
Subchapter Z. POINT-OF-SERVICE RIDERS
Subchapter AA. DELEGATED ENTITIES
Chapter 11.
HEALTH MAINTENANCE ORGANIZATIONS
Subchapter Q. OTHER REQUIREMENTS