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INSURANCE CODE - NOT CODIFIED
CHAPTER 20A. HEALTH MAINTENANCE ORGANIZATION ACT
Art. 20A.01A. Citation of This Law
Article repealed effective April 1, 2005.
This Act may be cited as Chapter 20A, Insurance Code, and the sections contained in this Act may be cited as articles of Chapter 20A, Insurance Code. Added by Acts 2001, 77th Leg., ch. 1419, Sec. 13, eff. June 1, 2003. Art. 20A.01B. Applicability of Definitions
Article repealed effective April 1, 2005.
In this Act, terms defined by Section 843.002, Insurance Code, have the meanings assigned by that section. Added by Acts 2001, 77th Leg., ch. 1419, Sec. 13, eff. June 1, 2003. Art. 20A.09. Evidence of Coverage and Charges
Article repealed effective April 1, 2005.
Text of article as amended by Acts 1997, 75th Leg., ch. 837, Sec. 4.01, Acts 1997, 75th Leg., ch. 905, Sec. 1, Acts 1997, 75th Leg., ch. 1023, Sec. 4 (a) Every enrollee residing in this state is entitled to evidence of coverage under a health care plan. If the enrollee obtains coverage under a health care plan through an insurance policy or a contract issued by a group hospital service corporation, whether by option or otherwise, the insurer or the group hospital service corporation shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage. By agreement between the insurer, group hospital service corporation, or health maintenance organization and the subscriber, or the person entitled to receive the policy, contract, or evidence of coverage, the evidence of coverage required by this section may be delivered by electronic transfer. (b) No evidence of coverage, or amendment thereto, shall be issued or delivered to any person in this state until a copy of the form of evidence of coverage, or amendment thereto, has been filed with and approved by the commissioner. (c) An evidence of coverage may not contain provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, which encourage misrepresentation, or which are untrue, misleading, or deceptive as defined in Section 14 of this Act. (d) Each evidence of coverage must contain provisions regarding the requirements adopted under Subsections (e)-(i) of this section. (e) Each evidence or coverage must contain a clear and complete statement, if a contract, or a reasonably complete facsimile, if a certificate, of: (1) the medical, health care services, limited health care services, or single health care service and the issuance of other benefits, if any, to which the enrollee is entitled under the health care plan, limited health care service plan, or single health care service plan; (2) any limitation on the services, kinds of services, benefits, or kinds of benefits to be provided, including any deductible or co-payment feature; (3) where and in what manner information is available as to how services may be obtained; and (4) a clear and understandable description of the health maintenance organization's methods for resolving enrollee complaints, including the enrollee's right to appeal denials of an adverse determination, as that term is defined by Section 12A of this Act, to an independent review organization and the procedures for making an appeal to an independent review organization. Any subsequent changes may be evidenced in a separate document issued to the enrollee. (f) If medically necessary covered services are not available through network physicians or providers, the health maintenance organization, on the request of a network physician or provider, within a reasonable period, shall allow referral to a non-network physician or provider and shall fully reimburse the non-network physician or provider at the usual and customary or an agreed rate. The evidence of coverage must provide for a review by a specialist of the same specialty or a similar specialty as the type of physician or provider to whom a referral is requested before the health maintenance organization may deny a referral. (g) An enrollee with a chronic, disabling, or life-threatening illness may apply to the health maintenance organization's medical director to use a nonprimary care physician specialist as the enrollee's primary care physician. An application made by an enrollee under this subsection must include information specified by the health maintenance organization, including certification of the medical need, and must be signed by the enrollee and the nonprimary care physician specialist interested in serving as the enrollee's primary care physician. To be eligible to serve as the enrollee's primary care physician, the specialist must: (1) meet the health maintenance organization's requirements for primary care physician participation; and (2) be willing to accept the coordination of all of the enrollee's health care needs. (h) If the request for special consideration described by Subsection (g) is denied, an enrollee may appeal the decision through the health maintenance organization's established complaint and appeals process. (i) The effective date of the designation of a nonprimary care physician specialist as an enrollee's primary care physician, as provided by Subsection (g) of this section, may not be applied retroactively. The health maintenance organization may not reduce the amount of compensation owed to the original primary care physician for services provided before the date of the new designation. (j) Any form of the evidence of coverage or group contract to be used in this state, and any amendments thereto, are subject to the filing and approval requirements of Subsection (l) of this section, unless it is subject to the jurisdiction of the commissioner under the laws governing health insurance or group hospital service corporations, in which event the filing and approval provisions of such law shall apply. To the extent, however, that such provisions do not apply to the requirements of Subsections (c)-(i) of this section, the requirements of those subsections apply.
Text of subsec. (k) as added by Acts 1997, 75th Leg., ch. 837, Sec. 4.01
(k) Continuation of Coverage and Conversion. (A) A health maintenance organization shall provide a group continuation privilege as required by this subsection. Any enrollee whose coverage under the group contract has been terminated for any reason except involuntary termination for cause, and who has been continuously insured under the group contract and under any group contract providing similar services and benefits which it replaces for at least three consecutive months immediately prior to termination shall be entitled to such privilege as outlined below. Involuntary termination for cause does not include termination for any health-related cause. Health maintenance organization contracts subject to this section shall provide continuation of group coverage for enrollees subject to the eligibility provisions below: (1) Continuation of group coverage must be requested in writing within 31 days following the later of: (aa) the date the group coverage would otherwise terminate; or (bb) the date the enrollee is given notice of the right of continuation by either the employer or the group contract holder. (2) An enrollee electing continuation must pay to the group contract holder or employer on a monthly basis, in advance, the amount of contribution required by the contract holder or employer, plus two percent of the group rate for the coverage being continued under the group contract, on the due date of each payment. (3) The enrollee's written election of continuation, together with the first contribution required to establish contributions on a monthly basis, in advance, must be given to the contract holder or employer within 31 days following the later of: (aa) the date the group coverage would otherwise terminate; or (bb) the date the enrollee is given notice of the right of continuation by either the employer or the group contract holder. (4) Continuation may not terminate until the earliest of: (aa) six months after the date the election is made; (bb) the date on which failure to make timely payments would terminate coverage; (cc) the date on which the covered person is covered for similar services and benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or any other plan or program; or (dd) the date on which the group coverage terminates in its entirety. (5) Not less than 30 days before the end of the six months after the date the enrollee elects continuation of the contract, the health maintenance organization shall notify the enrollee that he/she may be eligible for coverage under the Texas Health Insurance Risk Pool, as provided under Article 3.77, Insurance Code, and the health maintenance organization shall provide the address for applying to such pool to the enrollee. (B) A health maintenance organization may offer to each enrollee a conversion contract. Such conversion contract shall be issued without evidence of insurability if written application for and payment of the first premium is made not later than the 31st day after the date of termination. The conversion contract shall meet the minimum standards for services and benefits for conversion contracts. The commissioner shall issue rules and regulations to establish minimum standards for services and benefits under contracts issued pursuant to this subdivision. (C) The premium for a conversion contract issued under this Act shall be determined in accordance with the health maintenance organization's premium rates for coverage that were provided under the group contract or plan. The premium may be based on geographic location of each person to be covered and the type of conversion contract and coverage provided. The premium for the same coverage under a conversion contract may not exceed 200 percent of the premium determined in accordance with this subdivision. The premium must be based on the type of conversion contract and the coverage provided by contract.
Text of subsec. (k) as redesignated from subsec. (b) by Acts 1997, 75th Leg., ch. 905, Sec. 1
(k) The formula or method for calculating the schedule of charges for enrollee coverage for medical services or health care services must be filed with the commissioner before it is used in conjunction with any health care plan. The formula or method must be established in accordance with actuarial principles for the various categories of enrollees. The charges resulting from the application of the formula or method may not be altered for an individual enrollee based on the status of that enrollee's health. The formula or method must produce charges that are not excessive, inadequate, or unfairly discriminatory, and benefits must be reasonable with respect to the rates produced by the formula or method. A statement by a qualified actuary that certifies the appropriateness of the formula or method must accompany the filing together with supporting information considered adequate by the commissioner.
Text of subsec. (l) as added by Acts 1997, 75th Leg., ch. 837, Sec. 4.01
(l) Individual Health Care Plan. A health maintenance organization may provide an individual health care plan as required by this subsection. (A) For purposes of this subsection, an "individual health care plan" means: (1) a health care plan providing health care services for individuals and their dependents; (2) a health care plan in which an enrollee pays the premium and is not being covered under the contract pursuant to continuation of services and benefits provisions applicable under federal or state law; and (3) a plan in which the evidence of coverage meets the requirements of Section 2(a) of this Act. (B) A health maintenance organization may limit its enrollees to those who live, reside, or work within the service area for such network plan. (C) Renewability of Coverage. An individual health care plan or a conversion contract providing health care services shall be renewable with respect to an enrollee at the option of the enrollee, and may be nonrenewed based only on one or more of the following reasons: (1) failure to pay premiums or contributions in accordance with the terms of the plan or the issuer has not received timely premium payments; (2) fraud or intentional misrepresentation; (3) the health maintenance organization is ceasing to offer coverage in the individual market in accordance with rules established by the commissioner; (4) enrollee no longer resides, lives, or works in the area in which the health maintenance organization is authorized to provide coverage, but only if such coverage is terminated under this paragraph uniformly without regard to any health-status-related factor of covered enrollees; or (5) in accordance with applicable federal law and regulations. (D) The commissioner may adopt rules necessary to implement this subsection and to meet the minimum requirements of federal law and regulations.
Text of subsec. (l) as redesignated from subsec. (c) by Acts 1997, 75th Leg., ch. 905, Sec. 1
(l) The commissioner shall, within a reasonable period, approve any form of the evidence of coverage or group contract, or amendment thereto, if the requirements of this section are met. After notice and hearing, the commissioner may withdraw previous approval of any form, if the commissioner determines that it violates or does not comply with this Act or a rule adopted by the commissioner. It shall be unlawful to issue such form until approved. If the commissioner disapproves such form, the commissioner shall notify the filer. In the notice, the commissioner shall specify the reason for the disapproval. A hearing shall be granted within 30 days after a request in writing by the person filing. If the commissioner does not disapprove any form within 30 days after the filing of such form it shall be considered approved; provided that the commissioner may by written notice extend the period for approval or disapproval of any filing for such further time, not exceeding an additional 30 days, as necessary for proper consideration of the filing. (m) The commissioner may require the submission of whatever relevant information he or she deems necessary in determining whether to approve or disapprove a filing made pursuant to this section. (n) Articles 3.51-9 and 3.74, Insurance Code, and Section 1(F)(5), Chapter 397, Acts of the 54th Legislature, Regular Session, 1955 (Article 3.70-1(F)(5), Vernon's Texas Insurance Code), apply to health maintenance organizations other than those health maintenance organizations offering only a single health care service plan. (o) Evidence of coverage does not constitute a health insurance policy as that term is defined by the Insurance Code. (p) Article 3.72 of the Insurance Code applies to health maintenance organizations to the extent that such article is not in conflict with this Act and to the extent that the residential treatment center or crisis stabilization unit is located within the service area of the health maintenance organization and subject to such inspection and review as required by this Act or the rules hereunder. (q) Article 21.55, Insurance Code, applies to out-of-area or emergency claims for which benefits are not assigned or payment is not made directly to the physician or provider. (r) Redesignated as V.A.T.S. Insurance Code, art. 20A.09H by Acts 2001, 77th Leg., ch. 396, Sec. 5. Acts 1975, 64th Leg., p. 519, ch. 214, Sec. 9, eff. Dec. 1, 1975. Amended by Acts 1979, 66th Leg., p. 1451, ch. 638, Sec. 4, eff. June 13, 1979; Acts 1981, 67th Leg., p. 198, ch. 91, Sec. 2, eff. Jan. 1, 1982; Acts 1981, 67th Leg., 1st C.S., p. 64, ch. 7, Sec. 2, eff. Nov. 10, 1981. Subsecs. (a), (e), (f) amended and Subsec. (g) added by Acts 1985, 69th Leg., ch. 906, Sec. 5, eff. Aug. 26, 1985; Subsecs. (a) to (c) amended by Acts 1987, 70th Leg., ch. 567, Sec. 6, eff. Sept. 1, 1987; Subsec. (h) added by Acts 1987, 70th Leg., ch. 1091, Sec. 3, eff. Sept. 1, 1987; Acts 1987, 70th Leg., ch. 1096, art. I, Sec. 1.02, eff. Sept. 1, 1987; Subsec. (j) added by Acts 1989, 71st Leg., ch. 155, Sec. 3, eff. Sept. 1, 1989; Subsec. (i) added by Acts 1991, 72nd Leg., ch. 242, Sec. 11.04, eff. Sept. 1, 1991; Subsec. (a) amended by Acts 1997, 75th Leg., ch. 1023, Sec. 4, eff. Sept. 1, 1997; Subsecs. (k) and (l) added by Acts 1997, 75th Leg., ch. 837, Sec. 4.01, eff. July 1, 1997; amended by Acts 1997, 75th Leg., ch. 905, Sec. 1, eff. Sept. 1, 1997; Subsec. (r) redesignated as V.A.T.S. Insurance Code, art. 20A.09H by Acts 2001, 77th Leg., ch. 396, Sec. 5, eff. Sept. 1, 2001; Subsec. (a) amended by Acts 2003, 78th Leg., ch. 260, Sec. 1, eff. Sept. 1, 2003; Subsec. (a) amended by Acts 2003, 78th Leg., ch. 261, Sec. 1, eff. Sept. 1, 2003. For text of article as amended by Acts 1997, 75th Leg., ch. 163, Sec. 5, Acts 1997, 75th Leg., ch. 837, Sec. 4.01, Acts 1997, 75th Leg., ch. 1023, Sec. 4, Acts 1997, 75th Leg., ch. 1026, Sec. 7, see art. 20A.09, post. Art. 20A.09. Evidence of Coverage and Charges
Article repealed effective April 1, 2005.
Text of article as amended by Acts 1997, 75th Leg., ch. 163, Sec. 5, Acts 1997, 75th Leg., ch. 837, Sec. 4.01, Acts 1997, 75th Leg., ch. 1023, Sec. 4, Acts 1997, 75th Leg., ch. 1026, Sec. 7 (a)(1) Every enrollee residing in this state is entitled to evidence of coverage under a health care plan. If the enrollee obtains coverage under a health care plan through an insurance policy or a contract issued by a group hospital service corporation, whether by option or otherwise, the insurer or the group hospital service corporation shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage. (2) No evidence of coverage, or amendment thereto, shall be issued or delivered to any person in this state until a copy of the form of evidence of coverage, or amendment thereto, has been filed with and approved by the commissioner. (3) An evidence of coverage shall contain: (A) no provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, which encourage misrepresentation, or which are untrue, misleading, or deceptive as defined in Section 14 of this Act; (B) a clear and complete statement, if a contract, or a reasonably complete facsimile, if a certificate, of: (i) the medical, health care services, limited health care services, or single health care service and the issuance of other benefits, if any, to which the enrollee is entitled under the health care plan, limited health care service plan, or single health care service plan; (ii) any limitation on the services, kinds of services, benefits, or kinds of benefits to be provided, including any deductible or co-payment feature; (iii) where and in what manner information is available as to how services may be obtained; and (iv) a clear and understandable description of the health maintenance organization's methods for resolving enrollee complaints, including the enrollee's right to appeal denials of an adverse determination, as that term is defined by Section 12A of this Act, to an independent review organization and the procedures for making an appeal to an independent review organization. Any subsequent changes may be evidenced in a separate document issued to the enrollee; (C) a provision that, if medically necessary covered services are not available through network physicians or providers, the health maintenance organization must, on the request of a network physician or provider, within a reasonable time period allow referral to a non-network physician or provider and shall fully reimburse the non-network physician or provider at the usual and customary or an agreed rate; each contract must further provide for a review by a specialist of the same, or a similar, specialty as the physician or provider to whom a referral is requested before the health maintenance organization may deny a referral; (D) a provision to allow enrollees with chronic, disabling, or life-threatening illnesses to apply to the health maintenance organization's medical director to utilize a nonprimary care physician specialist as a primary care physician, provided that: (i) the request includes information specified by the health maintenance organization, including certification of medical need, and is signed by the enrollee and the nonprimary care physician specialist interested in serving as the primary care physician; (ii) the nonprimary care physician specialist meets the health maintenance organization's requirements for primary care physician participation; and (iii) the nonprimary care physician specialist is willing to accept the coordination of all of the enrollee's health care needs; (E) a provision that if the request for special consideration specified in Paragraph (D) of this subdivision is denied, an enrollee may appeal the decision through the health maintenance organization's established complaint and appeals process; and (F) a provision that the effective date of the new designation of a nonprimary care physician specialist as set out in Paragraph (D) of this subdivision shall not be retroactive; the health maintenance organization may not reduce the amount of compensation owed to the original primary care physician prior to the date of the new designation. (4) If an evidence of coverage provides benefits for rehabilitation services and therapies, the provision of those services and therapies that, in the opinion of a physician, are medically necessary may not be denied, limited, or terminated if they meet or exceed treatment goals for the enrollee. For a physically disabled person, treatment goals may include maintenance of functioning or prevention of or slowing of further deterioration. (5) Any form of the evidence of coverage or group contract to be used in this state, and any amendments thereto, are subject to the filing and approval requirements of Subsection (c) of this section, unless it is subject to the jurisdiction of the commissioner under the laws governing health insurance or group hospital service corporations, in which event the filing and approval provisions of such law shall apply. To the extent, however, that such provisions do not apply to the requirements of Subdivision (3) of this subsection, the requirements of Subdivision (3) shall be applicable. (b) The formula or method for calculating the schedule of charges for enrollee coverage for medical services or health care services must be filed with the commissioner before it is used in conjunction with any health care plan. The formula or method must be established in accordance with actuarial principles for the various categories of enrollees. The charges resulting from the application of the formula or method may not be altered for an individual enrollee based on the status of that enrollee's health. The formula or method must produce charges that are not excessive, inadequate, or unfairly discriminatory, and benefits must be reasonable with respect to the rates produced by the formula or method. A statement by a qualified actuary that certifies the appropriateness of the formula or method must accompany the filing together with supporting information considered adequate by the commissioner. (c) The commissioner shall, within a reasonable period, approve any form of the evidence of coverage or group contract, or amendment thereto, if the requirements of this section are met. After notice and opportunity for hearing, the commissioner may withdraw previous approval of any form, if the commissioner determines that it violates or does not comply with this Act or a rule adopted by the commissioner. It shall be unlawful to issue such form until approved. If the commissioner disapproves such form, the commissioner shall notify the filer. In the notice, the commissioner shall specify the reason for the disapproval. A hearing shall be granted within 30 days after a request in writing by the person filing. If the commissioner does not disapprove any form within 30 days after the filing of such form it shall be considered approved; provided that the commissioner may by written notice extend the period for approval or disapproval of any filing for such further time, not exceeding an additional 30 days, as necessary for proper consideration of the filing. (d) The commissioner may require the submission of whatever relevant information he or she deems necessary in determining whether to approve or disapprove a filing made pursuant to this section. (e) Article 3.74 of the Texas Insurance Code applies to health maintenance organizations other than those health maintenance organizations offering only a single health care service plan. (f) Article 3.51-9 of the Texas Insurance Code applies to health maintenance organizations other than those health maintenance organizations offering only a single health care service plan. (g) Evidence of coverage does not constitute a health insurance policy as that term is defined by the Insurance Code. (h) Article 3.70-1(F)(5) of the Insurance Code applies to health maintenance organizations other than those health maintenance organizations offering only a single health care service plan. (i) Article 3.72 of the Insurance Code applies to health maintenance organizations to the extent that such article is not in conflict with this Act and to the extent that the residential treatment center or crisis stabilization unit is located within the service area of the health maintenance organization and subject to such inspection and review as required by this Act or the rules hereunder. (j) Redesignated as V.A.T.S. Insurance Code, art. 20A.09Z, by Acts 2001, 77th Leg., ch. 1419, Sec. 14.
Text of subsec. (k) as added by Acts 1997, 75th Leg., ch. 837, Sec. 4.01
(k) Continuation of Coverage and Conversion. (A) A health maintenance organization shall provide a group continuation privilege as required by this subsection. Any enrollee whose coverage under the group contract has been terminated for any reason except involuntary termination for cause, and who has been continuously insured under the group contract and under any group contract providing similar services and benefits which it replaces for at least three consecutive months immediately prior to termination shall be entitled to such privilege as outlined below. Involuntary termination for cause does not include termination for any health-related cause. Health maintenance organization contracts subject to this section shall provide continuation of group coverage for enrollees subject to the eligibility provisions below: (1) Continuation of group coverage must be requested in writing within 31 days following the later of: (aa) the date the group coverage would otherwise terminate; or (bb) the date the enrollee is given notice of the right of continuation by either the employer or the group contract holder. (2) An enrollee electing continuation must pay to the group contract holder or employer on a monthly basis, in advance, the amount of contribution required by the contract holder or employer, plus two percent of the group rate for the coverage being continued under the group contract, on the due date of each payment. (3) The enrollee's written election of continuation, together with the first contribution required to establish contributions on a monthly basis, in advance, must be given to the contract holder or employer within 31 days following the later of: (aa) the date the group coverage would otherwise terminate; or (bb) the date the enrollee is given notice of the right of continuation by either the employer or the group contract holder. (4) Continuation may not terminate until the earliest of: (aa) six months after the date the election is made; (bb) the date on which failure to make timely payments would terminate coverage; (cc) the date on which the covered person is covered for similar services and benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or any other plan or program; or (dd) the date on which the group coverage terminates in its entirety. (5) Not less than 30 days before the end of the six months after the date the enrollee elects continuation of the contract, the health maintenance organization shall notify the enrollee that he/she may be eligible for coverage under the Texas Health Insurance Risk Pool, as provided under Article 3.77, Insurance Code, and the health maintenance organization shall provide the address for applying to such pool to the enrollee. (B) A health maintenance organization may offer to each enrollee a conversion contract. Such conversion contract shall be issued without evidence of insurability if written application for and payment of the first premium is made not later than the 31st day after the date of termination. The conversion contract shall meet the minimum standards for services and benefits for conversion contracts. The commissioner shall issue rules and regulations to establish minimum standards for services and benefits under contracts issued pursuant to this subdivision. (C) The premium for a conversion contract issued under this Act shall be determined in accordance with the health maintenance organization's premium rates for coverage that were provided under the group contract or plan. The premium may be based on geographic location of each person to be covered and the type of conversion contract and coverage provided. The premium for the same coverage under a conversion contract may not exceed 200 percent of the premium determined in accordance with this subdivision. The premium must be based on the type of conversion contract and the coverage provided by contract. (k) Redesignated as V.A.T.S. Insurance Code, art. 20A.09H by Acts 2001, 77th Leg., ch. 396, Sec. 5.
Text of subsec. (l) as added by Acts 1997, 75th Leg., ch. 837, Sec. 4.01
(l) Individual Health Care Plan. A health maintenance organization may provide an individual health care plan as required by this subsection. (A) For purposes of this subsection, an "individual health care plan" means: (1) a health care plan providing health care services for individuals and their dependents; (2) a health care plan in which an enrollee pays the premium and is not being covered under the contract pursuant to continuation of services and benefits provisions applicable under federal or state law; and (3) a plan in which the evidence of coverage meets the requirements of Section 2(a) of this Act. (B) A health maintenance organization may limit its enrollees to those who live, reside, or work within the service area for such network plan. (C) Renewability of Coverage. An individual health care plan or a conversion contract providing health care services shall be renewable with respect to an enrollee at the option of the enrollee, and may be nonrenewed based only on one or more of the following reasons: (1) failure to pay premiums or contributions in accordance with the terms of the plan or the issuer has not received timely premium payments; (2) fraud or intentional misrepresentation; (3) the health maintenance organization is ceasing to offer coverage in the individual market in accordance with rules established by the commissioner; (4) enrollee no longer resides, lives, or works in the area in which the health maintenance organization is authorized to provide coverage, but only if such coverage is terminated under this paragraph uniformly without regard to any health-status-related factor of covered enrollees; or (5) in accordance with applicable federal law and regulations. (D) The commissioner may adopt rules necessary to implement this subsection and to meet the minimum requirements of federal law and regulations.
Text of subsec. (l) as added by Acts 1997, 75th Leg., ch. 1026, Sec. 7
(l) A health maintenance organization that offers a basic health care plan shall provide or arrange for the provision of basic health care services to its enrollees as needed and without limitations as to time and cost other than limitations prescribed by rule of the commissioner. (m) Nothing in this Act shall require a health maintenance organization, physician, or provider to recommend, offer advice concerning, pay for, provide, assist in, perform, arrange, or participate in providing or performing any health care service that violates its religious convictions. A health maintenance organization that limits or denies health care services under this subsection shall set forth such limitations in the evidence of coverage as required by Section 9(a)(3) of this Act. (n) The commissioner may adopt minimum standards relating to basic health care services. Acts 1975, 64th Leg., p. 519, ch. 214, Sec. 9, eff. Dec. 1, 1975. Amended by Acts 1979, 66th Leg., p. 1451, ch. 638, Sec. 4, eff. June 13, 1979; Acts 1981, 67th Leg., p. 198, ch. 91, Sec. 2, eff. Jan. 1, 1982; Acts 1981, 67th Leg., 1st C.S., p. 64, ch. 7, Sec. 2, eff. Nov. 10, 1981. Subsecs. (a), (e), (f) amended and Subsec. (g) added by Acts 1985, 69th Leg., ch. 906, Sec. 5, eff. Aug. 26, 1985; Subsecs. (a) to (c) amended by Acts 1987, 70th Leg., ch. 567, Sec. 6, eff. Sept. 1, 1987; Subsec. (h) added by Acts 1987, 70th Leg., ch. 1091, Sec. 3, eff. Sept. 1, 1987; Acts 1987, 70th Leg., ch. 1096, art. I, Sec. 1.02, eff. Sept. 1, 1987; Subsec. (j) added by Acts 1989, 71st Leg., ch. 155, Sec. 3, eff. Sept. 1, 1989; Subsec. (i) added by Acts 1991, 72nd Leg., ch. 242, Sec. 11.04, eff. Sept. 1, 1991; Subsec. (a) amended by Acts 1997, 75th Leg., ch. 1023, Sec. 4, eff. Sept. 1, 1997; Subsec. (a)(3) amended by Acts 1997, 75th Leg., ch. 163, Sec. 5, eff. Sept. 1, 1997; Subsecs. (k) and (l) added by Acts 1997, 75th Leg., ch. 837, Sec. 4.01, eff. July 1, 1997; amended by Acts 1997, 75th Leg., ch. 1026, Sec. 7, eff. Sept. 1, 1997; Subsec. (k) redesignated as V.A.T.S. Insurance Code, art. 20A.09H by Acts 2001, 77th Leg., ch. 396, Sec. 5, eff. Sept. 1, 2001; Subsec. (j) redesignated as V.A.T.S. Insurance Code, art. 20A.09Z by Acts 2001, 77th Leg., ch. 1419, Sec. 14, eff. June 1, 2003. For text of article as amended by Acts 1997, 75th Leg., ch. 837, Sec. 4.01, Acts 1997, 75th Leg., ch. 905, Sec. 1, Acts 1997, 75th Leg., ch. 1023, Sec. 4 Art. 20A.09B. Periodic health evaluations required
Article repealed effective April 1, 2005.
(a) The basic health care services provided under an evidence of coverage must include periodic health evaluations for each adult enrollee. (b) The services provided under this section must include a health risk assessment at least once every three years and, for a female enrollee, an annual well-woman examination provided in accordance with Article 21.53D of this code, as added by Chapter 912, Acts of the 75th Legislature, Regular Session, 1997. (c) This section does not apply to an evidence of coverage for a limited health care service plan or a single health care service plan. Added by Acts 2001, 77th Leg., ch. 1369, Sec. 1, eff. Sept. 1, 2001. Art. 20A.09E. Well-Child Care From Birth
Article repealed effective April 1, 2005.
(a) In this Act, "well-child care from birth" has the meaning used under Section 1302, Public Health Service Act (42 U.S.C. Section 300e-1), and its subsequent amendments, and includes newborn screening required by the Texas Department of Health. (b) Each health maintenance organization shall ensure that each health care plan provided by the organization includes well-child care from birth that complies with the federal requirements adopted under Chapter XI, Public Health Service Act (42 U.S.C. Section 300e et seq.), and its subsequent amendments, and the rules adopted by the Texas Department of Health to implement those requirements. Added by Acts 1999, 76th Leg., ch. 1438, Sec. 1, eff. Aug. 30, 1999. Art. 20A.09F. Immunizations of Children
Article repealed effective April 1, 2005.
In addition to an immunization required under Section 3(a), Article 21.53F, Insurance Code, each health maintenance organization shall include in each health care plan provided by the organization coverage for immunization against rotovirus and any other immunization required for a child by statute or rule. Added by Acts 1999, 76th Leg., ch. 1438, Sec. 1, eff. Sept. 1, 1999. Art. 20A.09H. Dependent Grandchildren
Article repealed effective April 1, 2005.
Text of article as redesignated by Acts 2001, 77th Leg., ch. 396, Sec. 5
(a) A health maintenance organization may provide benefits under a health care plan to a dependent grandchild of an enrollee when the dependent grandchild is less than 21 years old and living with and in the household of the enrollee. (b) For purposes of this section, a grandchild of an enrollee is a dependent, regardless of whether the enrollee treats the grandchild as a dependent for federal income tax purposes. Added by Acts 1997, 75th Leg., ch. 837, Sec. 4.01, eff. July 1, 1997. Redesignated from V.A.T.S. Insurance Code, art. 20A.09, subsec. (k) and amended by Acts 2001, 77th Leg., ch. 396, Sec. 5, eff. Sept. 1, 2001. For text of article as redesignated by Acts 2001, 77th Leg., ch. 1027, Sec. 7, see article 20A.09H, post. Art. 20A.09H. Children and Grandchildren
Article repealed effective April 1, 2005.
Text of article as redesignated by Acts 2001, 77th Leg., ch. 1027, Sec. 7
(a) If children are eligible for coverage under the terms of an evidence of coverage, any limiting age applicable to an unmarried child of an enrollee, including an unmarried grandchild of an enrollee, is 25 years of age. The limiting age applicable to a child must be stated in the evidence of coverage. (b) A health maintenance organization may provide benefits under a health care plan to a dependent grandchild of an enrollee who is living with and in the household of the enrollee. Added by Acts 1997, 75th Leg., ch. 837, Sec. 4.01, eff. July 1, 1997. Redesignated from V.A.T.S. Insurance Code, art. 20A.09, subsec. (k) and amended by Acts 2001, 77th Leg., ch. 1027, Sec. 7. For text of article as redesignated by Acts 2001, 77th Leg., ch. 396, Sec. 5, see article 20A.09H, ante. Art. 20A.09N. Choice of Benefits Plan (a) The legislature recognizes the need for individuals and employers in this state to have the opportunity to choose health maintenance organization plans that are more affordable and flexible than existing market health care plans offered by health maintenance organizations. The legislature, therefore, seeks to increase the availability of health care plans by allowing health maintenance organizations authorized to operate health maintenance organizations in this state to issue group or individual evidences of coverage that, in whole or in part, do not offer or provide mandated health benefits. (b) In this section, "standard health benefit plan" means a group or individual evidence of coverage that, in whole or in part, does not offer or provide state-mandated health benefits, but that provides creditable coverage as defined by Article 26.035(a) of this code or Section 1(H)(4)(b), Chapter 397, Acts of the 54th Legislature, Regular Session, 1955 (Article 3.70-1, Vernon's Texas Insurance Code). (c) For purposes of this section, "state-mandated health benefits" means coverage required under the Insurance Code or other laws of this state to be provided in an evidence of coverage that: (1) includes coverage for specific health care services or benefits; (2) places limitations or restrictions on deductibles, coinsurance, copayments, or any annual or lifetime maximum benefit amounts, including limitations provided in Section 9(l) of this Act, as added by Chapter 1026, Acts of the 75th Legislature, Regular Session, 1997; or (3) includes a specific category of licensed health care practitioner from whom an enrollee is entitled to receive care. (d) For purposes of this section, "state-mandated health benefits" does not include coverage that is mandated by federal law or standard provisions or rights required under the Insurance Code or other law of this state to be provided in an evidence of coverage that are unrelated to specific health illnesses, injuries, or conditions of an insured, including provisions related to: (1) continuation of coverage under Section 3B, Article 3.51-6, Insurance Code; (2) termination of coverage under Articles 3.70-1A, 26.23, and 26.86, Insurance Code; (3) preexisting conditions under Section 1(H), Chapter 397, Acts of the 54th Legislature, Regular Session, 1955 (Article 3.70-1, Vernon's Texas Insurance Code), and Articles 26.49 and 26.90, Insurance Code; (4) coverage of children, including newborn or adopted children, under: (A) Subchapter J, Chapter 3, Insurance Code; (B) Article 21.24-2, Insurance Code; (C) Article 26.21(n), Insurance Code; (D) Article 26.21A, Insurance Code; and (E) Article 26.84, Insurance Code; (5) services of providers under Section 843.304 of this code; (6) coverage for serious mental health illness under Article 3.51-14, Insurance Code, if the standard health benefit plan is issued to a large employer as defined in Article 26.02, Insurance Code; and (7) coverage for cancer screenings under the following articles of this code: (A) Article 3.70-2(H), as added by Chapter 1091, Acts of the 70th Legislature, Regular Session, 1987; (B) Article 21.53F, as added by Chapter 1287, Acts of the 75th Legislature, Regular Session, 1997; and (C) Article 21.53S. (e) A health maintenance organization authorized to issue an evidence of coverage in this state may offer one or more standard health benefit plans. (f)(1) Each written application for enrollment in a standard health benefit plan must contain the following language at the beginning of the document in bold type: "You have the option to choose this Consumer Choice of Benefits Health Maintenance Organization health care plan that, either in whole or in part, does not provide state-mandated health benefits normally required in evidences of coverage in Texas. This standard health benefit plan may provide a more affordable health plan for you although, at the same time, it may provide you with fewer health plan benefits than those normally included as state-mandated health benefits in Texas. If you choose this standard health benefit plan, please consult with your insurance agent to discover which state-mandated health benefits are excluded in this evidence of coverage." (2) Each standard health benefit plan must contain the following language at the beginning of the document in bold type: "This Consumer Choice of Benefits Health Maintenance Organization health care plan, either in whole or in part, does not provide state-mandated health benefits normally required in evidences of coverage in Texas. This standard health benefit plan may provide a more affordable health plan for you although, at the same time, it may provide you with fewer health plan benefits than those normally included as state-mandated health benefits in Texas. Please consult with your insurance agent to discover which state-mandated health benefits are excluded in this evidence of coverage." (g) A health maintenance organization providing a standard health benefit plan must provide a proposed contract holder or a contract holder with a written disclosure statement that: (1) acknowledges that the standard health benefit plan being purchased does not provide some or all state-mandated health benefits; (2) lists those state-mandated health benefits not included in the standard health benefit plan; and (3) if the standard health benefit plan is issued to an individual certificate holder, provides a notice that purchase of the plan may limit the certificate holder's future coverage options in the event the certificate holder's health changes and needed benefits are not available under the standard health benefit plan. (h) Each applicant for initial enrollment and each contract holder on renewal must sign the disclosure statement provided by the health maintenance organization under Subsection (g) of this section and return the statement to the health maintenance organization. Under a group evidence of coverage, the term "applicant" means the employer. (i) A health maintenance organization must: (1) retain the signed disclosure statement in the organization's records; and (2) on request from the commissioner, provide the signed disclosure statement to the department. (j) The commissioner shall adopt rules as necessary to implement this section. (k) A health maintenance organization that offers one or more standard health benefit plans under this section must also offer at least one evidence of coverage that provides state-mandated health benefits and that is otherwise authorized by the Insurance Code. (l) A health maintenance organization shall file for informational purposes the rates to be used with a standard health benefit plan. Nothing in this section shall be construed as granting the commissioner any power or authority to determine, fix, prescribe, or promulgate the rates to be charged for any evidence of coverage. Added by Acts 2003, 78th Leg., ch. 1179, Sec. 2, eff. Sept. 1, 2003. Art. 20A.09Y. Emergency Care Services
Article repealed effective April 1, 2005.
A health maintenance organization shall pay for emergency care services performed by non-network physicians or providers at the negotiated or usual and customary rate and that the health care plan contains, without regard to whether the physician or provider furnishing the services has a contractual or other arrangement with the entity to provide items or services to covered individuals, the following provisions and procedures for coverage of emergency care services: (1) any medical screening examination or other evaluation required by state or federal law that is necessary to determine whether an emergency medical condition exists will be provided to covered enrollees in a hospital emergency facility or comparable facility; (2) necessary emergency care services will be provided to covered enrollees, including the treatment and stabilization of an emergency medical condition; and (3) services originated in a hospital emergency facility or comparable facility following treatment or stabilization of an emergency medical condition will be provided to covered enrollees as approved by the health maintenance organization, provided that the health maintenance organization is required to approve or deny coverage of poststabilization care as requested by a treating 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 case to exceed one hour from the time of the request; the health maintenance organization must respond to inquiries from the treating physician or provider in compliance with this provision in the health maintenance organization's plan. Added by Acts 2001, 77th Leg., ch. 1419, Sec. 13, eff. June 1, 2003. Art. 20A.09Z. Prompt Payment of Claims
Article repealed effective April 1, 2005.
Text of article effective June 1, 2003
A health maintenance organization shall comply with Article 21.55 of the Insurance Code with respect to prompt payment to enrollees. Added by Acts 1989, 71st Leg., ch. 155, Sec. 3, eff. Sept. 1, 1989. Redesignated from V.A.T.S. Insurance Code, art. 20A.09, subsec. (j) and amended by Acts 2001, 77th Leg., ch. 1419, Sec. 14, eff. June 1, 2003. Art. 20A.18C. Delegation of certain functions
Article repealed effective April 1, 2005.
(a) A health maintenance organization that delegates any function required by this Act shall execute a written agreement with each delegated entity. The health maintenance organization shall file the written agreement with the Texas Department of Insurance not later than the 30th day after the date the agreement is executed. The parties to each agreement shall determine the party that will bear the expense of compliance with any requirement of this subsection, including the cost of any examinations required by the department under Article 1.15, Insurance Code, if applicable. The written agreement must contain: (1) a monitoring plan that allows the health maintenance organization to monitor compliance with the minimum solvency requirements established under Section 18D of this Act, if applicable, and that includes: (A) a description of financial practices that will ensure that the delegated entity tracks and reports liabilities that have been incurred but not reported; (B) a summary of the total amount paid by the delegated entity to physicians and providers on a monthly basis; and (C) a summary of complaints from physicians, enrollees, and providers regarding delays in payments of claims or nonpayment of claims, including the status of each complaint, on a monthly basis; (2) a provision that the agreement cannot be terminated without cause by the delegated entity or the health maintenance organization without written notice provided before the 90th day preceding the termination date; (3) a provision that prohibits the delegated entity and the physicians and providers with whom it has contracted from billing or attempting to collect from an enrollee under any circumstance, including the insolvency of the health maintenance organization or delegated entity, payments for covered services other than authorized copayments and deductibles; (4) a provision that the delegation agreement may not be construed to limit in any way the health maintenance organization's authority or responsibility, including financial responsibility, to comply with all statutory and regulatory requirements; (5) a provision that requires the delegated entity to comply with all statutory and regulatory requirements relating to any function, duty, responsibility, or delegation assumed by or carried out by the delegated entity; (6) a provision that requires the delegated entity to permit the commissioner to examine at any time any information the commissioner reasonably believes is relevant to: (A) the financial solvency of the delegated entity; or (B) the ability of the delegated entity to meet the entity's responsibilities in connection with any function delegated to the entity by the health maintenance organization; (7) a provision that requires the delegated entity to provide the license number of any delegated third party performing any function that requires a license as a third party administrator under Article 21.07-6, Insurance Code, or a license as a utilization review agent under Article 21.58A, Insurance Code, or that requires any other license under the Insurance Code or another insurance law of this state; (8) a provision that requires that: (A) enrollees will receive notification at the time of enrollment which entity has responsibility for performing utilization review; (B) the delegated entity or third party performing utilization review shall do so in accordance with Article 21.58A, Insurance Code; and (C) utilization review decisions made by the delegated entity or a third party shall be forwarded to the health maintenance organization on a monthly basis; (9) a provision that requires that any agreement in which the delegated entity directly or indirectly delegates any function required by this Act, including the handling of funds, if applicable, to a delegated third party be in writing; (10) a provision that requires the delegated entity, in contracting with a delegated third party directly or through a third party, to require the delegated third party to comply with the requirements of Subdivision (6) of this subsection and any rules adopted by the commissioner implementing that subdivision; (11) an acknowledgment and agreement by the delegated entity that: (A) the health maintenance organization is: (i) required to establish, operate, and maintain a health care delivery system, quality assurance system, provider credentialing system, and other systems and programs that meet statutory and regulatory standards; (ii) directly accountable for compliance with those standards; and (iii) not precluded from contractually requesting that the delegated entity provide proof of financial viability; (B) the role of any delegated entity with which it subcontracts through a delegated third party is limited to performing certain delegated functions of the health maintenance organization, using standards that are approved by the health maintenance organization and that are in compliance with applicable statutes and rules and subject to the health maintenance organization's oversight and monitoring of the delegated entity's performance; and (C) if the delegated entity fails to meet monitoring standards established to ensure that functions delegated or assigned to the entity under the delegation contract are in full compliance with all statutory and regulatory requirements, the health maintenance organization may cancel delegation of any or all delegated functions; (12) a provision that requires the delegated entity to make available to the health maintenance organization samples of contracts with physicians and providers to ensure compliance with the contractual requirements described by Subdivisions (2) and (3) of this subsection, except that the agreement may not require that the delegated entity make available to the health maintenance organization contractual provisions relating to financial arrangements with the delegated entity's physicians and providers; (13) a provision that requires the delegated entity to provide the health maintenance organization, in a usable format necessary for audit purposes and at most quarterly unless otherwise specified in the agreement, the data necessary for the health maintenance organization to comply with the department's reporting requirements with respect to any delegated functions performed under the delegation agreement, including: (A) a summary: (i) describing the methods, including capitation, fee-for-service, or other risk arrangements, that the delegated entity used to pay its physicians and providers; and (ii) including the percentage of physicians and providers paid for each payment category; (B) the period that claims and debts for medical services owed by the delegated entity have been pending and the aggregate dollar amount of those claims and debts; (C) information that will enable the health maintenance organization to file claims for reinsurance, coordination of benefits, and subrogation, if required by the health maintenance organization's contract with the delegated entity; and (D) documentation, except for information, documents, and deliberations related to peer review that are confidential or privileged under Subchapter A, Chapter 160, Occupations Code, that relates to: (i) a regulatory agency's inquiry or investigation of the delegated entity or of an individual physician or provider with whom the delegated entity contracts that relates to an enrollee of the health maintenance organization; and (ii) the final resolution of a regulatory agency's inquiry or investigation; and (14) a provision relating to enrollee complaints that requires the delegated entity to ensure that upon receipt of a complaint, as defined by this Act, the delegated entity shall report the complaint to the health maintenance organization within two business days, except that in a case in which a complaint involves emergency care, as defined in this Act, the delegated entity shall forward the complaint immediately to the health maintenance organization, and provided that nothing in this subdivision prohibits the delegated entity from attempting to resolve a complaint. (b) The commissioner shall determine the information that a health maintenance organization shall provide to each delegated entity with which the health maintenance organization has a delegation agreement. The information must include the following information, provided in standard electronic format at least monthly unless otherwise stated in the agreement: (1) the names and dates of birth or social security numbers of the enrollees of the health maintenance organization who are eligible or assigned to receive services from the delegated entity, including the enrollees added and terminated since the previous reporting period; (2) the age, sex, benefit plan and any riders to that benefit plan, and employer for the enrollees of the health maintenance organization who are eligible or assigned to receive services from the delegated entity; (3) if the health maintenance organization pays any claims for the delegated entity, a summary of the number and amount of claims paid by the health maintenance organization on behalf of the delegated entity during the previous reporting period, provided that a delegated entity is not precluded from receiving, upon request, additional nonproprietary information regarding such claims; (4) if the health maintenance organization pays any claims for the delegated entity, a summary of the number and amount of pharmacy prescriptions paid for each enrollee for which the delegated entity has taken partial risk during the previous reporting period, provided that a delegated entity is not precluded from receiving, upon request, additional nonproprietary information regarding such claims; (5) information that enables the delegated entity to file claims for reinsurance, coordination of benefits, and subrogation; and (6) patient complaint data that relates to the delegated entity. (c) In addition to the information required by Subsection (b) of this section, a health maintenance organization shall provide to a delegated entity: (1) detailed risk-pool data, reported quarterly and on settlement; and (2) the percent of premium attributable to hospital or facility costs, if hospital or facility costs impact the delegated entity's costs, reported quarterly, and, if there are changes in hospital or facility contracts with the health maintenance organization, the projected impact of those changes on the percent of premium attributable to hospital and facility costs within 30 days of such changes. (d) A health maintenance organization that becomes aware of any information that indicates the delegated entity is not operating in accordance with its written agreement or is operating in a condition that renders the continuance of its business hazardous to the enrollees, shall: (1) notify the delegated entity in writing of those findings; (2) request, in writing, a written explanation, with documentation supporting the explanation, of: (A) the delegated entity's apparent noncompliance with the written agreement; or (B) the existence of the condition that apparently renders the continuance of the delegated entity's business hazardous to the enrollees; and (3) provide the commissioner with copies of all notices and requests submitted to the delegated entity and the responses and other documentation the health maintenance organization generates or receives in response to the notices and requests. (e) A delegated entity shall respond to a request from a health maintenance organization under Subsection (d) of this section in writing not later than the 30th day after the date the request is received. (f) The health maintenance organization shall cooperate with the delegated entity to correct any failure by the delegated entity to comply with the regulatory requirements of the department relating to any matters: (1) delegated to the delegated entity by the health maintenance organization; or (2) necessary for the health maintenance organization to ensure compliance with statutory or regulatory requirements. (g) On receipt of a notice under Subsection (d) of this section, or if complaints are filed with the Texas Department of Insurance, the department may examine the matters contained in the notice as well as any other matter relating to the financial solvency of the delegated entity or the delegated entity's ability to meet its responsibilities in connection with any function delegated to the entity by the health maintenance organization. (h) Except as provided by this subsection, the Texas Department of Insurance, on completion of the department's examination, shall report to the delegated entity and the health maintenance organization the results of the department's examination and any action the department determines is necessary to ensure that the health maintenance organization meets its responsibilities under this Act, the Insurance Code, any other insurance laws of this state, and rules adopted by the commissioner, and that the delegated entity can meet its responsibilities in connection with any function delegated to the entity by the health maintenance organization. The department may not report to the health maintenance organization any information regarding fee schedules, prices, cost of care, or other information not relevant to the monitoring plan. (i) The delegated entity and the health maintenance organization shall respond to the department's report and submit a corrective plan to the Texas Department of Insurance not later than the 30th day after the date of receipt of the department's report. (j) Reports and corrective plans required under Subsection (h) or (i) of this section shall be treated as public documents, except that health care provider fee schedules, prices, costs of care, or other information not relevant to the monitoring plan and any other information that is considered confidential by law shall be considered confidential. (k) The department may request at any time that a delegated entity take corrective action to comply with the department's statutory and regulatory requirements that: (1) relate to any matters delegated by the health maintenance organization to the delegated entity; or (2) are necessary to ensure the health maintenance organization's compliance with statutory and regulatory requirements. (l) Regardless of whether a delegated entity complies with a request for corrective action, the commissioner may order the health maintenance organization to take any action the commissioner determines is necessary to ensure that the health maintenance organization is in compliance with this Act, including: (1) reassuming the functions delegated to the delegated entity, including claims payments for services previously rendered to enrollees of the health maintenance organization; (2) temporarily or permanently ceasing assignment of new enrollees to the delegated entity; (3) temporarily or permanently transferring enrollees to alternative delivery systems to receive services; or (4) terminating the health maintenance organization's contract with the delegated entity. (m) The Texas Department of Insurance shall maintain enrollee and provider complaints in a manner that identifies complaints made about limited provider networks and delegated entities. The department shall periodically issue a report on the complaints received by the department that includes a list of complaints by category, by action taken on the complaint, and by entity or network name and type. The department shall make the report available to the public and shall include information to assist the public in evaluating the information contained in the report. (n) Notwithstanding any other provision of this Act, the Insurance Code, or any other insurance law of this state, the commissioner may suspend or revoke the license of any third party administrator or utilization review agent that fails to comply with this section. (o) The commissioner may impose sanctions or penalties under Chapters 82, 83, and 84, Insurance Code, against a health maintenance organization that does not provide timely information required by Subsections (b) and (c) of this section. (p) A health maintenance organization shall by contract establish penalties for delegated entities that do not provide timely information required under a monitoring plan as required by Subsection (a)(1) of this section. (q) This section does not apply to a group model health maintenance organization, as defined by Section 6A of this Act. (r) The commissioner may adopt rules as necessary to implement this section. Added by Acts 1999, 76th Leg., ch. 621, Sec. 2, eff. Sept. 1, 1999. Amended by Acts 2001, 77th Leg., ch. 550, Sec. 4, eff. Sept. 1, 2001. Art. 20A.18D. Reserve Requirements for Delegated Network
Article repealed effective April 1, 2005.
(a) A delegated network shall establish and maintain reserves that are adequate for the liabilities and risks assumed by the delegated network, as computed in accordance with accepted standards, practices, and procedures relating to the liabilities and risks reserved for, including known and unknown components and anticipated expenses of providing benefits or services. (b) Except as provided by Subsections (c) and (d), the delegated network shall establish and maintain reserves as described by Subsection (e)(1) or (2) only with respect to the portion of services assumed under the delegation agreement that are not within the scope of the network's license for medical care or hospital or other institutional services, as applicable. (c) If the scope of services assumed under the delegation agreement includes both medical care and hospital or institutional services, the delegated network shall establish and maintain reserves that are adequate to cover the liabilities and risks associated with medical care or with hospital or institutional services, whichever type of services has been allocated the largest portion of the premium by the health maintenance organization. (d) If the delegated network assumes financial risk for medical care or hospital or institutional services and for prescription drugs, as defined by Section 551.003, Occupations Code, the network shall establish and maintain reserves that are adequate to cover the liabilities and risks associated with the prescription drug benefits, in addition to any other reserves required under this section. (e) A delegated network shall maintain financial reserves equal to the greater of: (1) 80 percent of the risk and liabilities that must be reserved under this section and that have been incurred but not paid by the delegated network; or (2) two months of premium amount assumed by the delegated network for services that must be reserved under this section. (f) The reserves required under this section must be secured by and only consist of legal tender of the United States or bonds of the United States or this state. The reserves must be held at a financial institution in this state that is chartered by the United States or this state. The reserves must be held in trust for, for the benefit of, or to provide health care services to, enrollees of the health maintenance organization under the agreement between the health maintenance organization and the delegated network. (g)(1) A delegated network required to establish and maintain reserves under this section shall establish an escrow account for the payment of claims and deposit such reserves into the escrow account upon providing notice of its intent to terminate or non-renew a contract through which the delegated network assumed liabilities and risks from a health maintenance organization. Upon the establishment of the escrow account, the delegated network shall notify the commissioner. (2) A delegated network required to establish and maintain reserves under this section shall establish an escrow account for the payment of claims and deposit such reserves into the escrow account upon the modification of a contract through which the delegated network assumed liabilities and risks from a health maintenance organization if the modified contract eliminates the liabilities and risks previously assumed by the delegated network. Upon the establishment of the escrow account, the delegated network shall notify the commissioner. (3) Two hundred seventy days after the date the reserves are deposited into the escrow account, the delegated network shall be entitled to the release of the remaining amounts held in escrow. (4) The amounts released from the escrow account shall be distributed to those individuals who contributed to the reserves deposited into escrow in proportion to the individuals' total contribution. (5) The commissioner shall, and has the authority to, take any action necessary to ensure the release of any amounts remaining in escrow in excess of the 270-day time period in Subsection (g)(3). (h) This section does not apply to a group model health maintenance organization, as defined by Section 6A of this Act. Added by Acts 2001, 77th Leg., ch. 550, Sec. 5, eff. Sept. 1, 2001. Art. 20A.18E. Certain Physician and Provider Contracts; Continuity of Care for Certain Enrollees
Article repealed effective April 1, 2005.
(a) In this section, "special circumstance" means a condition for which the treating physician or provider reasonably believes that discontinuing care by the treating physician or provider could cause harm to the patient. (b) Each contract between a health maintenance organization and a limited provider network or delegated entity must require that each contract between the network or entity and a physician or provider provide that: (1) reasonable advance notice be given to an enrollee of the impending termination from the limited provider network or delegated entity of a physician or provider who is currently treating the enrollee; and (2) the termination of the physician or provider contract, except for reason of medical competence or professional behavior, does not release the limited provider network or delegated entity from the obligation to reimburse a physician or provider who is treating an enrollee of special circumstance, such as a person who has a disability, acute condition, or life-threatening illness or is past the 24th week of pregnancy, at a rate that is not less than the contract rate for that enrollee's care in exchange for continuity of ongoing treatment of an enrollee then receiving medically necessary treatment in accordance with the dictates of medical prudence. (c) A special circumstance shall be identified by the treating physician or provider, who must request that the enrollee be permitted to continue treatment under the physician's or provider's care and agree not to seek payment from the patient of any amounts for which the enrollee would not be responsible if the physician or provider were still in the limited provider network or delegated entity. (d) Contracts between a limited provider network or delegated entity and physicians or providers shall provide procedures for resolving disputes regarding the necessity for continued treatment by a physician or provider. (e) This section does not extend the obligation of a limited provider network or delegated entity to reimburse a terminated physician or provider for ongoing treatment of an enrollee beyond the 90th day after the effective date of the termination, or beyond nine months in the case of an enrollee who at the time of the termination has been diagnosed with a terminal illness. However, the obligation of the limited provider network or delegated entity to reimburse the terminated physician or provider or, if applicable, the enrollee for services to an enrollee who at the time of the termination is past the 24th week of pregnancy, extends through delivery of the child, immediate postpartum care, and the follow-up checkup within the first six weeks of delivery. Added by Acts 2001, 77th Leg., ch. 550, Sec. 5, eff. Sept. 1, 2001. Art. 20A.18F. Out-of-Network Services of Limited Provider Network or Delegated Entity
Article repealed effective April 1, 2005.
(a) Each contract between a health maintenance organization and a limited provider network or delegated entity must provide that if medically necessary covered services are not available through network physicians or providers, the limited provider network or delegated entity must, on request of a network physician or provider, 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-upon rate. (b) The referral shall be allowed within the time appropriate to the circumstances relating to the delivery of the services and the condition of the patient, but not later than the fifth business day after the date any reasonably requested documentation is received by the limited provider network or delegated entity. (c) The enrollee may not be required to change the enrollee's primary care physician or specialist providers to receive medically necessary covered services that are not available within the limited provider network or delegated entity. (d) Each contract must also 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 limited provider network or delegated entity may deny a referral. (e) A denial of out-of-network services under this section is subject to appeal under Article 21.58A, Insurance Code. Added by Acts 2001, 77th Leg., ch. 550, Sec. 5, eff. Sept. 1, 2001. Art. 20A.18G. Compliance of Limited Provider Network or Delegated Entity with Certain Requirements
Article repealed effective April 1, 2005.
A limited provider network or delegated entity shall comply with all statutory and regulatory requirements relating to any function, duty, responsibility, or delegation assumed by or carried out by the limited provider network or delegated entity under this Act. Added by Acts 2001, 77th Leg., ch. 550, Sec. 5, eff. Sept. 1, 2001. Art. 20A.33. Taxation
Article repealed effective April 1, 2005.
(a) Each health maintenance organization shall on or before the first day of March of each year file its annual statement showing the gross amount of revenues collected during the year ending December 31 preceding, and each such health maintenance organization shall pay an annual tax for the gross amounts of revenues collected for the issuance of health maintenance certificates or contracts at the rate provided by Article 4.11, Insurance Code, as amended. For the purposes of computing and collecting the tax herein provided, a health maintenance organization is an "insurance organization" within the terms of Article 4.11, Insurance Code, as amended. (b) Repealed by Acts 1993, 73rd Leg., ch. 685, Sec. 3.29(6), eff. Sept. 1, 1993. (c) Each health maintenance organization covered by Subsection (a) of this section shall be subject to Articles 4.13, 4.14, and 4.15, Insurance Code. (d) The commissioner shall annually determine the rate of assessment of a per capita maintenance tax to be paid on an annual or semiannual basis, on the correctly reported gross revenues for the issuance of health maintenance certificates or contracts collected by all authorized health maintenance organizations issuing such coverages in this state. The rate of assessment may not exceed $2 for each enrollee. The rate of assessment may differ between basic health care plans, limited health care service plans, and single health care service plans and shall equitably reflect any differences in regulatory resources attributable to each type of plan. The comptroller shall collect the maintenance tax. For purposes of this section, the amount of maintenance tax assessed may not be computed on enrollees who as individual certificate holders or their dependents are covered by a master group policy paid for by revenues received from the United States for insurance contracted for by the United States in accordance with or in furtherance of Title XVIII of the federal Social Security Act (42 U.S.C. Section 1395c et seq.) and its subsequent amendments. (e) The tax required by this section is in addition to all other taxes now imposed or that may be subsequently imposed and that are not in conflict with this section. (f) The commissioner, after taking into account the unexpended funds produced by this tax, if any, shall adjust the rate of assessment each year to produce the amount of funds that it estimates will be necessary to pay all the expenses of regulating health maintenance organizations during the succeeding year. In making an estimate under this subsection, the commissioner shall take into account the requirement that the general revenue fund be reimbursed under Article 4.19, Insurance Code. (g) The taxes collected shall be deposited in the State Treasury to the credit of the general revenue fund to be reallocated to the Texas Department of Insurance operating fund and shall be spent as authorized by legislative appropriation on warrants issued by the comptroller pursuant to duly certified requisitions of the commissioner. Amounts reallocated to the Texas Department of Insurance operating fund under this subsection may be transferred to the general revenue fund in accordance with Article 4.19, Insurance Code. (h) The comptroller may collect the tax assessed under this section on a semiannual or other periodic basis from those health maintenance organizations whose tax liability under this section for the previous year was $2,000 or more. (i) The commissioner shall advise the comptroller of the applicable rate of assessment no later than the date 45 days prior to the due date of the tax return for the period for which such taxes are due. If the commissioner has not advised the comptroller of the applicable rate by such date, the applicable rate shall be the rate applied in the previous tax period. If the commissioner advises the comptroller of the applicable rate of assessment after taxes have been assessed pursuant to this subsection, the comptroller shall: (1) advise each taxpayer in writing of the amount of any additional taxes due; or (2) refund any excess taxes paid. Acts 1975, 64th Leg., p. 530, ch. 214, Sec. 33, eff. Dec. 1, 1975. Amended by Acts 1979, 66th Leg., p. 1456, ch. 638, Sec. 14, eff. June 13, 1979; Acts 1981, 67th Leg., p. 1784, ch. 389, Sec. 37(c), eff. Jan. 1, 1982. Subsec. (a) amended by Acts 1983, 68th Leg., p. 3938, ch. 622, Sec. 30, eff. Sept. 1, 1983; Acts 1985, 69th Leg., ch. 304, Sec. 2, eff. Aug. 26, 1985. Amended by Acts 1987, 70th Leg., ch. 249, Sec. 8, eff. Aug. 31, 1987; Subsec. (a) amended by Acts 1989, 71st Leg., ch. 237, Sec. 2, eff. Aug. 28, 1989; Subsec. (d) amended by Acts 1989, 71st Leg., ch. 284, Sec. 6, eff. Sept. 1, 1989; Subsec. (b) repealed by Acts 1993, 73rd Leg., ch. 685, Sec. 3.29(6), eff. Sept. 1, 1993; Subsec. (d) amended and subsecs. (e) to (i) added by Acts 1993, 73rd Leg., ch. 685, Sec. 3.20, eff. Sept. 1, 1993; Subsec. (d) amended by Acts 1997, 75th Leg., ch. 1023, Sec. 10, eff. Sept. 1, 1997; amended by Acts 1997, 75th Leg., ch. 1040, Sec. 73, eff. Sept. 1, 1997; Subsec. (d) amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.121(a), eff. Sept. 1, 2003. Art. 20A.39. Credentialing of Physicians and Providers
Article repealed effective April 1, 2005.
(a) Rules adopted by the commissioner under Section 37 of this Act that relate to implementation and maintenance by a health maintenance organization of a process for selecting and retaining affiliated physicians and providers must comply with: (1) this section; and (2) standards promulgated by the National Committee for Quality Assurance, to the extent those standards do not conflict with other laws of this state. (b) The commissioner shall require a health maintenance organization to verify that a physician's license to practice medicine and any other certificate the physician is required to hold, including a certificate issued by the Department of Public Safety of the State of Texas or the federal Drug Enforcement Agency or a certificate issued under the Medicare program, is valid as of the date of initial credentialing and on the date of each recredentialing. (c) The commissioner shall require a health maintenance organization that conducts a site visit for the purpose of initial credentialing to evaluate during the visit a site's accessibility, appearance, space, medical or dental recordkeeping practices, availability of appointments, and confidentiality procedures. The commissioner may not require the health maintenance organization to evaluate the appropriateness of equipment during the site visit. (d) The commissioner may not require that a health maintenance organization: (1) formally recredential physicians or providers more frequently than once in any three-year period; (2) verify the validity of a license or certificate held by a physician other than as of the date of initial credentialing or recredentialing of the physician; (3) use clinical personnel to perform a site visit for initial credentialing of a physician or provider unless clinical review is needed during the site visit; or (4) require a site visit be performed for recredentialing of a physician or provider. (e) This section does not preclude a health maintenance organization from performing a site visit of a physician or provider at any time for cause, including a complaint made by a member or another external complaint made to the health maintenance organization. Added by Acts 2001, 77th Leg., ch. 1369, Sec. 2, eff. Sept. 1, 2001.



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