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Texas Administrative Code (Last Updated: March 27,2024) |
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TITLE 28. INSURANCE |
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PART 1. TEXAS DEPARTMENT OF INSURANCE |
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CHAPTER 11. HEALTH MAINTENANCE ORGANIZATIONS |
| SUBCHAPTER A. GENERAL PROVISIONS |
| § 11.1. General Provisions |
| § 11.2. Definitions |
| SUBCHAPTER B. NAME APPLICATION PROCEDURE |
| § 11.101. How to Obtain Forms |
| § 11.102. Information Required |
| § 11.104. Criteria |
| § 11.105. Use of the Term "HMO," Service Marks, Trademarks, and Assumed Name |
| § 11.106. Time Limits; Extension Requirements |
| § 11.107. Effect of Filing for or Receiving Certificate of Authority |
| § 11.108. Effect of Withdrawing Application for Certificate of Authority |
| § 11.109. Situations in Which Name Applications Will Cease |
| SUBCHAPTER C. APPLICATION FOR CERTIFICATE OF AUTHORITY |
| § 11.201. Filing Fee |
| § 11.202. Binding, Indexing, and Numbering Requirements |
| § 11.203. Revisions During Review Process |
| § 11.204. Contents |
| § 11.205. Additional Documents to be Available for Review |
| § 11.206. Review of Application; Examination |
| § 11.207. Withdrawal of an Application |
| SUBCHAPTER D. REGULATORY REQUIREMENTS FOR AN HMO AFTER ISSUANCE OF CERTIFICATE OF AUTHORITY |
| § 11.301. Filing Requirements |
| § 11.302. Service Area Expansion or Reduction Applications |
| § 11.303. Examination |
| SUBCHAPTER F. EVIDENCE OF COVERAGE |
| § 11.501. Contents of the Evidence of Coverage |
| § 11.502. Filing Requirements for Evidence of Coverage Filed as Part of an Application for a Certificate of Authority |
| § 11.503. Filing Requirements for Evidence of Coverage after Receipt of Certificate of Authority |
| § 11.504. Disapproval of an Evidence of Coverage |
| § 11.505. Specifications for Evidence of Coverage Including Insert Pages and Matrix Filings |
| § 11.506. Mandatory Contractual Provisions: Group, Individual, and Conversion Agreement and Group Certificate |
| § 11.507. Additional Mandatory Contractual Provisions: Conversion and Individual Agreements |
| § 11.508. Basic Health Care Services and Mandatory Benefit Standards: Group, Individual, and Conversion Agreements |
| § 11.509. Additional Mandatory Benefit Standards: Individual and Group Agreements |
| § 11.511. Optional Provisions |
| § 11.512. Optional Benefits |
| SUBCHAPTER G. ADVERTISING AND SALES MATERIAL |
| § 11.602. HMOs Subject to Insurance Code Chapters 541, 542, and 547, and Related Rules |
| § 11.603. Filings |
| SUBCHAPTER H. SCHEDULE OF CHARGES |
| § 11.701. Schedule of Charges Must be Filed Before Use |
| § 11.702. Actuarial Certification |
| § 11.703. Filings and Supporting Documentation |
| § 11.704. Conversion Rates |
| SUBCHAPTER I. FINANCIAL REQUIREMENTS |
| § 11.801. Accounting Guidance |
| § 11.802. Minimum Net Worth |
| § 11.803. Statutory Deposit Requirements |
| § 11.804. Invested Assets |
| § 11.805. Other Assets |
| § 11.806. Investment Management by Affiliate Companies |
| § 11.807. Fiduciary Responsibility |
| § 11.808. Liabilities |
| § 11.810. Guarantee from a Sponsoring Organization |
| § 11.811. Action under Insurance Code §843.157 and Insurance Code §843.461 |
| SUBCHAPTER J. PHYSICIAN AND PROVIDER CONTRACTS AND ARRANGEMENTS |
| § 11.900. Nonprimary Care Physician Specialists as Primary Care Physician |
| § 11.901. Required and Prohibited Provisions |
| § 11.902. Prohibited Actions |
| § 11.903. Physician or Provider Communication |
| § 11.904. Provision of Services Related to Immunizations and Vaccinations |
| SUBCHAPTER K. REQUIRED FORMS |
| § 11.1001. Required Forms |
| SUBCHAPTER M. ACQUISITION, CONTROL, OR MERGER OF A DOMESTIC HMO |
| § 11.1201. Acquisition, Control, or Merger of a Domestic HMO |
| SUBCHAPTER O. ADMINISTRATIVE PROCEDURES |
| § 11.1401. Commissioner's Authority to Require Additional Information |
| § 11.1402. Notification to Physicians and Providers |
| § 11.1404. Pharmacy Application and Recertification |
| SUBCHAPTER P. PROHIBITED PRACTICES |
| § 11.1500. Discrimination Based on Health Status-Related Factors |
| SUBCHAPTER Q. OTHER REQUIREMENTS |
| § 11.1600. Information to Prospective and Current Contract Holders and Enrollees |
| § 11.1601. Enrollee Identification Cards |
| § 11.1602. Enrollment Form and Access to Certain Information |
| § 11.1603. Notification of Change in Payment Arrangements |
| § 11.1604. Requirements for Certain Contracts Between Primary HMOs and ANHCs and Between Primary HMOs and Provider HMOs |
| § 11.1605. Pharmaceutical Services |
| § 11.1606. Organization of an HMO |
| § 11.1607. Accessibility and Availability Requirements |
| § 11.1610. Annual Network Adequacy Report |
| § 11.1611. Out-of-Network Claims; Non-Network Physicians and Providers |
| § 11.1612. Mandatory Disclosure Requirements |
| SUBCHAPTER R. APPROVED NONPROFIT HEALTH CORPORATIONS |
| § 11.1702. Requirements for Issuance of Certificate of Authority to an ANHC |
| § 11.1703. Requirements for Agents of an ANHC Certificate of Authority Holder |
| § 11.1704. Statutes and Rules Applicable to ANHC with a Certificate of Authority |
| SUBCHAPTER S. SOLVENCY STANDARDS FOR MANAGED CARE ORGANIZATIONS PARTICIPATING IN MEDICAID OR CHILDREN'S HEALTH INSURANCE PROGRAM |
| § 11.1801. Entities Covered |
| § 11.1806. Additional Information That May be Requested from an MCO Participating in Medicaid |
| SUBCHAPTER T. QUALITY OF CARE |
| § 11.1901. Quality Improvement Structure for Basic, Single Service, and Limited Service HMOs |
| § 11.1902. Quality Improvement Program for Basic, Single Service, and Limited Service HMOs |
| SUBCHAPTER V. STANDARDS FOR COMMUNITY MENTAL HEALTH CENTERS |
| § 11.2101. Community Health Maintenance Organization |
| § 11.2102. General Provisions |
| § 11.2103. Requirements for Issuance of Certificate of Authority to a CHMO |
| § 11.2104. Minimum Standards for Community Health Centers |
| SUBCHAPTER W. SINGLE SERVICE HMOS |
| § 11.2200. Definitions |
| § 11.2201. General Provisions |
| § 11.2202. Limitations and Exclusions |
| § 11.2203. Minimum Standards - Dental Care Services and Benefits |
| § 11.2204. Minimum Standards - Vision Care Services and Benefits |
| § 11.2205. Prohibited Practices |
| § 11.2206. Mandatory Disclosure Statements; Certification of Compliance |
| § 11.2208. Single Service Accessibility and Availability |
| SUBCHAPTER Y. LIMITED SERVICE HMOS |
| § 11.2401. Definitions |
| § 11.2402. General Provisions |
| § 11.2403. Prohibited Practices |
| § 11.2405. Minimum Standards - Mental Health and Chemical Dependency Services and Benefits |
| § 11.2406. Minimum Standards- Long-Term Care Services and Benefits |
| SUBCHAPTER Z. POINT-OF-SERVICE RIDERS |
| § 11.2501. Definitions |
| § 11.2502. Issuance of Point-of-Service Riders |
| § 11.2503. Coverage Relating to Point-of-Service Rider Plans |
| SUBCHAPTER AA. DELEGATED ENTITIES |
| § 11.2601. General Provisions |
| § 11.2602. Definitions |
| § 11.2603. Requirements for Delegation by HMOs |
| § 11.2604. Delegation Agreements - General Requirements and Information to be Provided to HMO |
| § 11.2605. Delegation Agreements - Information to be Provided by HMO to Delegated Entity |
| § 11.2606. Reporting Requirements |
| § 11.2607. Examinations of Delegated Entities |
| § 11.2608. Department May Order Corrective Action |
| § 11.2609. Reserve Requirements for Delegated Networks |
| § 11.2610. Penalties for Noncompliance |
| § 11.2611. Filing of Delegation Agreements |