CHAPTER 1272. DELEGATION OF CERTAIN FUNCTIONS BY HEALTH MAINTENANCE ORGANIZATION
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE C. MANAGED CARE
CHAPTER 1272. DELEGATION OF CERTAIN FUNCTIONS BY HEALTH
MAINTENANCE ORGANIZATION
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1272.001. DEFINITIONS. (a) In this chapter:
(1) "Delegated entity" means an entity, other than a health
maintenance organization authorized to engage in business under
Chapter 843, that by itself, or through subcontracts with one or
more entities, undertakes to arrange for or provide medical care
or health care to an enrollee in exchange for a predetermined
payment on a prospective basis and that accepts responsibility
for performing on behalf of the health maintenance organization a
function regulated by this chapter, Chapter 222, 251, or 258, as
applicable to a health maintenance organization, Chapter 843 or
1271, Section 1367.053, Subchapter A, Chapter 1452, or Subchapter
B, Chapter 1507. The term does not include:
(A) an individual physician; or
(B) a group of employed physicians, practicing medicine under
one federal tax identification number, whose total claims paid to
providers not employed by the group constitute less than 20
percent of the group's total collected revenue computed on a
calendar year basis.
(2) "Delegated network" means a delegated entity that assumes
total financial risk for more than one of the following
categories of health care services: medical care, hospital or
other institutional services, or prescription drugs, as defined
by Section 551.003, Occupations Code. The term does not include a
delegated entity that shares risk for a category of services with
a health maintenance organization.
(3) "Delegated third party" means a third party other than a
delegated entity that contracts with a delegated entity, either
directly or through another third party, to:
(A) accept responsibility for performing a function regulated by
this chapter, Chapter 222, 251, or 258, as applicable to a health
maintenance organization, Chapter 843 or 1271, Section 1367.053,
Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507; or
(B) receive, handle, or administer funds, if the receipt,
handling, or administration is directly or indirectly related to
a function regulated by this chapter, Chapter 222, 251, or 258,
as applicable to a health maintenance organization, Chapter 843
or 1271, Section 1367.053, Subchapter A, Chapter 1452, or
Subchapter B, Chapter 1507.
(4) "Delegation agreement" means an agreement by which a health
maintenance organization assigns the responsibility for a
function regulated by this chapter, Chapter 222, 251, or 258, as
applicable to a health maintenance organization, Chapter 843 or
1271, Section 1367.053, Subchapter A, Chapter 1452, or Subchapter
B, Chapter 1507.
(5) "Limited provider network" means a subnetwork within a
health maintenance organization delivery network in which
contractual relationships exist between physicians, certain
providers, independent physician associations, or physician
groups that limits an enrollee's access to physicians and
providers to those physicians and providers in the subnetwork.
(b) In this chapter, terms defined by Section 843.002 have the
meanings assigned by that section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.074(e), eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 3B.02701, eff. September 1, 2007.
Sec. 1272.002. COMPLIANCE OF LIMITED PROVIDER NETWORK OR
DELEGATED ENTITY WITH CERTAIN LEGAL REQUIREMENTS. A limited
provider network or delegated entity shall comply with each
statutory or regulatory requirement that relates to a function
assumed by or carried out by the network or entity under this
chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER B. DELEGATION AGREEMENTS
Sec. 1272.051. APPLICABILITY OF SUBCHAPTER. This subchapter
does not apply to a group model health maintenance organization,
as defined by Section 843.111.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.052. DELEGATION AGREEMENT REQUIRED. (a) A health
maintenance organization that delegates a function required by
this chapter, Chapter 843, 1271, or 1367, Subchapter A, Chapter
1452, or Subchapter B, Chapter 1507, shall execute a written
delegation agreement with the entity to which the function is
delegated.
(b) The health maintenance organization shall file the
delegation agreement with the department not later than the 30th
day after the date the agreement is executed.
(c) The parties to the delegation agreement shall determine
which party bears the expense of complying with a requirement of
this subchapter, including the cost of an examination required by
the department under Subchapter B, Chapter 401, if applicable.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.074(f), eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 2G.002, eff. April 1, 2009.
Sec. 1272.053. MONITORING PLAN. A delegation agreement required
by Section 1272.052 must establish a monitoring plan that:
(1) allows the health maintenance organization to monitor
compliance with the minimum solvency requirements established
under Subchapter D, if applicable; and
(2) 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 entity to
physicians and providers on a monthly basis; and
(C) a summary of complaints from physicians, providers, and
enrollees regarding delays in payment or nonpayment of claims,
including the status of each complaint, on a monthly basis.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.054. REQUIREMENTS FOR TERMINATION WITHOUT CAUSE. A
delegation agreement required by Section 1272.052 must provide
that the agreement cannot be terminated without cause by the
delegated entity or the health maintenance organization unless
the party terminating the agreement provides written notice
before the 90th day before the termination date.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.055. COLLECTION OF PAYMENTS. A delegation agreement
required by Section 1272.052 must prohibit the delegated entity
and the physicians and providers with whom the entity has
contracted from billing or attempting to collect from an enrollee
under any circumstance, including the insolvency of the health
maintenance organization or entity, payments for covered services
other than authorized copayments and deductibles.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.056. COMPLIANCE WITH STATUTORY AND REGULATORY
REQUIREMENTS. A delegation agreement required by Section
1272.052 must provide that:
(1) the agreement does not limit in any way the health
maintenance organization's authority or responsibility, including
financial responsibility, to comply with each statutory or
regulatory requirement; and
(2) the delegated entity shall comply with each statutory or
regulatory requirement relating to a function assumed by or
carried out by the entity.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.057. EXAMINATION BY COMMISSIONER. A delegation
agreement required by Section 1272.052 must require the delegated
entity to permit the commissioner to examine at any time any
information the commissioner reasonably believes is relevant to:
(1) the financial solvency of the entity; or
(2) the ability of the entity to meet the entity's
responsibilities in connection with any function delegated to the
entity by the health maintenance organization.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.058. INFORMATION RELATING TO DELEGATED THIRD PARTY. A
delegation agreement required by Section 1272.052 must require
the delegated entity to provide the license number of a delegated
third party performing a function that requires:
(1) a license as a third-party administrator under Chapter 4151
or utilization review agent under Chapter 4201; or
(2) another license under this code or another insurance law of
this state.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 2G.003, eff. April 1, 2009.
Sec. 1272.059. CONTRACTS WITH DELEGATED THIRD PARTY. A
delegation agreement required by Section 1272.052 must provide
that:
(1) any agreement under which the delegated entity directly or
indirectly delegates a function required by this chapter, Chapter
843, 1271, or 1367, Subchapter A, Chapter 1452, or Subchapter B,
Chapter 1507, including the handling of funds, if applicable, to
a delegated third party must be in writing; and
(2) the delegated entity, in contracting with a delegated third
party directly or through a third party, shall require the
delegated third party to comply with the requirements of Section
1272.057 and any rules adopted by the commissioner implementing
that section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.074(g), eff. September 1, 2005.
Sec. 1272.060. UTILIZATION REVIEW. A delegation agreement
required by Section 1272.052 must provide that:
(1) enrollees shall receive notification at the time of
enrollment of which entity is responsible for performing
utilization review;
(2) the delegated entity or third party performing utilization
review shall perform that review in accordance with Chapter 4201;
and
(3) the delegated entity or third party shall forward
utilization review decisions made by the entity or third party to
the health maintenance organization on a monthly basis.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 2G.004, eff. April 1, 2009.
Sec. 1272.061. RIGHTS AND DUTIES OF DELEGATED ENTITY AND HEALTH
MAINTENANCE ORGANIZATION. A delegation agreement required by
Section 1272.052 must provide that the delegated entity
acknowledges and agrees that:
(1) the health maintenance organization:
(A) is 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;
(B) is directly accountable for compliance with those standards;
and
(C) is not precluded from contractually requesting that the
delegated entity provide proof of financial viability;
(2) the role of another delegated entity with which the
delegated entity 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
entity's performance; and
(3) if the delegated entity fails to meet monitoring standards
established to ensure that functions delegated or assigned to the
entity under the delegation agreement are in full compliance with
all statutory and regulatory requirements, the health maintenance
organization may cancel delegation of any or all delegated
functions.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.062. INFORMATION TO BE PROVIDED BY DELEGATED ENTITY TO
HEALTH MAINTENANCE ORGANIZATION. (a) A delegation agreement
required by Section 1272.052 must provide that:
(1) except as provided by Subsection (b), the delegated entity
shall make available to the health maintenance organization
samples of contracts with physicians and providers to ensure
compliance with the contractual requirements described by
Sections 1272.054 and 1272.055; and
(2) the delegated entity shall provide to the health maintenance
organization, in a format usable for audit purposes and not more
frequently than quarterly unless otherwise specified in the
delegation 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 describing the methods, including capitation,
fee-for-service, or other risk arrangements, that the delegated
entity used to pay the entity's physicians and providers, and
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 to enable the health maintenance organization to
file claims for reinsurance, coordination of benefits, and
subrogation, if required by the delegation agreement; 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 an individual physician or provider with whom
the 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.
(b) A delegation agreement may not require a delegated entity to
make available to the health maintenance organization contractual
provisions relating to financial arrangements with the entity's
physicians and providers.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.063. ENROLLEE COMPLAINTS. (a) A delegation agreement
required by Section 1272.052 must provide that:
(1) if the delegated entity receives a complaint that does not
involve emergency care, the entity shall report the complaint to
the health maintenance organization not later than the second
business day after the date the entity receives the complaint;
and
(2) if the delegated entity receives a complaint involving
emergency care, the entity shall immediately forward the
complaint to the health maintenance organization.
(b) Subsection (a) does not prohibit a delegated entity from
attempting to resolve a complaint.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.064. RULES. The commissioner may adopt rules as
necessary to implement this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER C. INFORMATION REPORTING TO DELEGATED ENTITY
Sec. 1272.101. APPLICABILITY OF SUBCHAPTER. This subchapter
does not apply to a group model health maintenance organization,
as defined by Section 843.111.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.102. REPORTING REQUIRED. (a) The commissioner shall
determine the information a health maintenance organization shall
provide to a delegated entity with which the health maintenance
organization has entered into a delegation agreement.
(b) The information must include:
(1) for each enrollee who is eligible or assigned to receive
services from the delegated entity:
(A) the enrollee's name, birth date or social security number,
age, and sex;
(B) the benefit plan and any riders to that plan that are
applicable to the enrollee; and
(C) the enrollee's employer;
(2) the name and birth date or social security number of each
enrollee added or terminated since the health maintenance
organization last provided the information;
(3) if the health maintenance organization pays any claims on
behalf of the delegated entity, a summary of the number and
amount of:
(A) claims paid during the previous reporting period; and
(B) pharmacy prescriptions paid for each enrollee during the
previous reporting period for which the delegated entity has
taken partial risk;
(4) information that enables the delegated entity to file claims
for reinsurance, coordination of benefits, and subrogation;
(5) patient complaint data that relates to the delegated entity;
(6) detailed risk-pool data, reported quarterly and on
settlement;
(7) if hospital or facility costs impact the delegated entity's
costs, the percent of premium attributable to hospital or
facility costs, reported quarterly; and
(8) 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 during the 30-day period following those
changes.
(c) Notwithstanding Subsection (b)(3), a delegated entity may,
on request, receive additional nonproprietary information
regarding claims paid by a health maintenance organization on
behalf of the entity.
(d) A health maintenance organization shall provide information
required under Subsections (b)(1)-(5) in standard electronic
format at least monthly unless the delegation agreement provides
otherwise.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.103. RULES. The commissioner may adopt rules as
necessary to implement this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER D. RESERVE REQUIREMENTS
Sec. 1272.151. APPLICABILITY OF SUBCHAPTER. This subchapter
does not apply to a group model health maintenance organization,
as defined by Section 843.111.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.152. GENERAL RESERVE REQUIREMENTS. (a) A delegated
network shall maintain reserves adequate for the liabilities and
risks assumed by the network, as computed in accordance with
accepted standards, practices, and procedures relating to the
liabilities and risks for which the reserves are maintained,
including known and unknown components and anticipated expenses
of providing benefits or services.
(b) Except as provided by Sections 1272.153 and 1272.154, a
delegated network shall maintain reserves as described by
Subsection (c) only with respect to the portion of services
assumed under the delegation agreement that is outside the scope
of the network's license for medical care or hospital or other
institutional services, as applicable.
(c) A delegated network shall maintain financial reserves equal
to the greater of:
(1) 80 percent of the amount of liabilities and risks for which
reserves must be maintained under this subchapter and that have
been incurred but not paid by the network; or
(2) an amount equal to two months of the premium amount assumed
by the network for services with respect to which reserves must
be maintained under this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.153. RESERVE REQUIREMENTS FOR MEDICAL CARE AND
HOSPITAL OR INSTITUTIONAL SERVICES. A delegated network that
assumes under a delegation agreement both medical care and
hospital or institutional services shall maintain reserves
adequate to cover the liabilities and risks associated with
medical care or hospital or institutional services, whichever
category of services is allocated the largest portion of the
premium by the health maintenance organization.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.154. RESERVE REQUIREMENTS FOR PRESCRIPTION DRUGS. A
delegated network that assumes financial risk for medical care or
hospital or institutional services and for prescription drugs, as
defined by Section 551. 003, Occupations Code, shall maintain, in
addition to any other reserves required under this subchapter,
reserves adequate to cover the liabilities and risks associated
with the prescription drug benefits.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.155. FORM OF RESERVES. The reserves required under
this subchapter must be:
(1) secured by and consist only of United States legal tender or
bonds of the United States or this state;
(2) held at a financial institution in this state that is
chartered by the United States or this state; and
(3) held in trust for, for the benefit of, or to provide health
care services to enrollees under the delegation agreement.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.156. ESCROW ACCOUNT. (a) A delegated network
required to maintain reserves under this subchapter shall
establish an escrow account to pay claims and deposit the
reserves into the escrow account on:
(1) notification of the network's intent to terminate or refuse
to renew a contract under which the network assumed liabilities
and risks from a health maintenance organization; or
(2) modification of a contract under which the network assumed
liabilities and risks from a health maintenance organization if
the modified contract eliminates those liabilities and risks.
(b) The delegated network shall notify the commissioner on
establishing an escrow account under this section.
(c) On the 271st day after the date the reserves are deposited
into the escrow account, the delegated network is entitled to the
release of funds remaining in escrow. Funds released from the
escrow account shall be distributed to each individual who
contributed to the reserves deposited into the account in
proportion to the individual's total contribution.
(d) The commissioner shall take any action necessary to ensure
the release of funds remaining in escrow after the date specified
by Subsection (c).
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER E. COMPLIANCE
Sec. 1272.201. APPLICABILITY OF SUBCHAPTER. This subchapter
does not apply to a group model health maintenance organization,
as defined by Section 843.111.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.202. NOTICE OF NONCOMPLIANCE OR HAZARDOUS OPERATING
CONDITION. (a) If a health maintenance organization becomes
aware of information that indicates a delegated entity with which
the health maintenance organization has entered into a delegation
agreement is not operating in accordance with the agreement or is
operating in a condition that renders continuing the entity's
business hazardous to the enrollees, the health maintenance
organization shall in writing:
(1) notify the entity of those findings; and
(2) request a written explanation and documentation supporting
that explanation of the entity's apparent noncompliance or the
existence of the hazardous condition.
(b) A health maintenance organization shall provide to the
commissioner a copy of each notice and request submitted to a
delegated entity under this section and each response or other
documentation the health maintenance organization receives or
generates in response to the notice and request.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.203. RESPONSE TO NOTICE. A delegated entity shall
respond in writing to a request from a health maintenance
organization under Section 1272.202 not later than the 30th day
after the date the entity receives the request.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.204. COOPERATION OF HEALTH MAINTENANCE ORGANIZATION.
A health maintenance organization shall cooperate with a
delegated entity to correct a failure by the entity to comply
with the department's regulatory requirements relating to:
(1) a function delegated to the entity by the health maintenance
organization; or
(2) a matter necessary for the health maintenance organization
to ensure compliance with each statutory or regulatory
requirement.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.205. EXAMINATION BY DEPARTMENT; REPORT. (a) On
receipt of a notice under Section 1272.202 or if complaints are
filed with the department, the department may conduct an
examination regarding:
(1) any matter contained in the notice; and
(2) any other matter relating to the financial solvency of the
delegated entity or the entity's ability to meet the entity's
responsibilities in connection with a function delegated to the
entity by the health maintenance organization.
(b) Except as provided by Subsection (c), the department, on
completion of an examination under this section, shall report to
the delegated entity and the health maintenance organization:
(1) the results of the examination; and
(2) any action the department determines is necessary to ensure
that:
(A) the health maintenance organization meets the health
maintenance organization's responsibilities under this code, any
other insurance laws of this state, and rules adopted by the
commissioner; and
(B) the entity is able to meet the entity's responsibilities in
connection with a function delegated to the entity by the health
maintenance organization.
(c) The department may not report to the health maintenance
organization information relating to fee schedules, prices, or
cost of care or other information not relevant to the monitoring
plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.206. RESPONSE TO DEPARTMENT REPORT; CORRECTIVE PLAN.
The delegated entity and health maintenance organization shall
respond to the department's report under Section 1272.205(b) and
submit a corrective plan to the department not later than the
30th day after the date of receipt of the report.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.207. REQUEST FOR CORRECTIVE ACTION. 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 a function delegated by the health maintenance
organization to the entity; or
(2) are necessary to ensure the health maintenance
organization's compliance with each statutory or regulatory
requirement.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.208. AUTHORITY OF COMMISSIONER TO ISSUE ORDER. (a)
Regardless of whether a delegated entity complies with a request
for corrective action under Section 1272.207, the commissioner
may order a health maintenance organization with which the entity
has entered into a delegation agreement to take any action the
commissioner determines is necessary to ensure that the health
maintenance organization is complying with this chapter, Chapter
843, 1271, or 1367, Subchapter A, Chapter 1452, or Subchapter B,
Chapter 1507.
(b) Actions the commissioner may order a health maintenance
organization to take under this section include:
(1) reassuming the functions delegated to the delegated entity,
including claims payments for services previously provided to
enrollees;
(2) temporarily or permanently ceasing assignment of new
enrollees to the entity;
(3) temporarily or permanently transferring enrollees to
alternative delivery systems to receive services; or
(4) terminating the delegation agreement with the entity.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.074(h), eff. September 1, 2005.
Sec. 1272.209. PUBLIC DOCUMENTS. (a) Except as provided by
Subsection (b), a report required under Section 1272.205(b) or
corrective plan required under Section 1272.206 is a public
document.
(b) Health care provider fee schedules, prices, costs of care,
or other information that is not relevant to the monitoring plan
or is confidential by law is not a public document under this
section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.210. RECORD OF COMPLAINTS; REPORT. (a) The
department shall:
(1) maintain enrollee and provider complaints in a manner that
identifies complaints made about limited provider networks and
delegated entities; and
(2) periodically issue a report on the complaints that includes
a list of complaints organized by:
(A) category;
(B) action taken on the complaint; and
(C) entity or network name and type.
(b) The department shall make available to the public the report
and information to assist the public in evaluating the
information contained in the report.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.211. RULES. The commissioner may adopt rules as
necessary to implement this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER F. PENALTIES
Sec. 1272.251. APPLICABILITY OF SUBCHAPTER. This subchapter
does not apply to a group model health maintenance organization,
as defined by Section 843.111.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.252. SUSPENSION OR REVOCATION OF LICENSE OF
THIRD-PARTY ADMINISTRATOR OR UTILIZATION REVIEW AGENT.
Notwithstanding any other provision of this code or another
insurance law of this state, the commissioner may suspend or
revoke the license of a third-party administrator or utilization
review agent that fails to comply with Subchapter B, C, or E.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.253. SANCTIONS AND PENALTIES AGAINST HEALTH
MAINTENANCE ORGANIZATION. The commissioner may impose sanctions
or penalties under Chapters 82, 83, and 84 on a health
maintenance organization that does not provide in a timely manner
information required by Subchapter C.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.254. CONTRACTUAL PENALTIES REQUIRED. A health
maintenance organization by contract shall establish penalties
for a delegated entity that does not provide in a timely manner
information required under a monitoring plan established under
Section 1272.053.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1272.255. RULES. The commissioner may adopt rules as
necessary to implement this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER G. PROVISION OF SERVICES BY LIMITED PROVIDER NETWORK
OR DELEGATED ENTITY
Sec. 1272.301. ACCESS TO OUT-OF-NETWORK SERVICES. (a) A
contract between a health maintenance organization and a limited
provider network or delegated entity must provide that:
(1) if medically necessary covered services are not available
through network physicians or providers, the limited provider
network or delegated entity, on the request of a network
physician or provider, shall:
(A) allow a referral to a non-network physician or provider; and
(B) fully reimburse the non-network physician or provider at the
usual and customary rate or an agreed rate; and
(2) before the limited provider network or delegated entity may
deny a referral to a non-network physician or provider, a
specialist of the same or similar specialty as the type of
physician or provider to whom the referral is requested must
conduct a review of the request.
(b) The limited provider network or delegated entity shall allow
the referral within the time appropriate to the circumstances
relating to the delivery of the services and the condition of the
enrollee who is a patient, but not later than the fifth business
day after the date the network or entity receives any reasonably
requested documentation.
(c) An 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 through the delegated
entity.
(d) A denial of out-of-network services under this section is
subject to appeal under Chapter 4201.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 2G.005, eff. April 1, 2009.
Sec. 1272.302. CONTINUITY OF CARE. (a) In this section,
"special circumstance" means a condition regarding which a
treating physician or provider reasonably believes that
discontinuing care by that physician or provider could cause harm
to an enrollee who is a patient. Examples of an enrollee who has
a special circumstance include an enrollee with a disability,
acute condition, or life-threatening illness and an enrollee who
is past the 24th week of pregnancy.
(b) A 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 must:
(1) require that reasonable advance notice be given to an
enrollee of an impending termination from the network or entity
of a physician or provider who is currently treating the
enrollee; and
(2) provide that the termination of the physician's or
provider's contract, except for reason of medical competence or
professional behavior, does not release the network or entity
from the obligation to reimburse the physician or provider for
treatment of an enrollee who has a special circumstance at a rate
that is not less than the contract rate for that enrollee's care
in exchange for continuity of ongoing treatment of the enrollee
then receiving medically necessary treatment in accordance with
the dictates of medical prudence.
(c) The treating physician or provider shall identify a special
circumstance. That physician or provider must:
(1) request that the enrollee be permitted to continue treatment
under the physician's or provider's care; and
(2) agree not to seek payment from the enrollee who is a patient
of any amount for which the enrollee would not be responsible if
the physician or provider continued to be included in the limited
provider network or delegated entity.
(d) Except as provided by Subsection (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 after:
(1) the 90th day after the effective date of the termination; or
(2) if the enrollee has been diagnosed with a terminal illness
at the time of termination, the expiration of the nine-month
period after the effective date of the termination.
(e) If an enrollee is past the 24th week of pregnancy at the
time of termination, the obligation of the limited provider
network or delegated entity to reimburse the terminated physician
or provider or, if applicable, the enrollee extends through
delivery of the child, immediate postpartum care, and a follow-up
checkup within the six-week period after delivery.
(f) A contract between a limited provider network or delegated
entity and a physician or provider must provide procedures for
resolving disputes regarding the necessity for continued
treatment by a physician or provider.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.