SECTION 11.1606. Organization of an HMO

(a) The governing body of an HMO, as described in Insurance Code §843.004 (concerning Governing Body of Health Maintenance Organization), has ultimate responsibility for the development, approval, implementation, and enforcement of administrative, operational, personnel, and patient care policies and procedures related to the HMO's operation.

(b) The HMO must have a chief executive officer or operations officer who is accountable for the administration of the health plan, including:

(1) developing corporate strategy;

(2) overseeing marketing programs;

(3) overseeing medical management functions; and

(4) ensuring compliance with all applicable statutes and rules pertaining to the operations of the HMO.

(c) The HMO must have a full-time clinical director who:

(1) is licensed in Texas or otherwise authorized to practice in this state in the field of services offered by the HMO, for example:

(A) a basic HMO must have a physician;

(B) a dental HMO must have a dentist or physician;

(C) a vision HMO must have an optometrist or physician; and

(D) a limited services HMO must have a physician;

(2) resides in the state of Texas;

(3) is available at all times to address complaints, clinical issues, utilization review, and any quality of care issues on behalf of the HMO;

(4) demonstrates active involvement in all quality management activities; and

(5) will be subject to the HMO's credentialing requirements and must be credentialed in compliance with NCQA or American Accreditation HealthCare Commission, Inc., standards.

(d) The HMO may establish one or more service areas within Texas; each defined service area must:

(1) demonstrate to the department the ability to provide continuity, accessibility, availability, and quality of services;

(2) specify the counties, or any portions of counties, included in the service area;

(3) provide a complete physician and provider listing for all enrollees residing, living, or working in the service area, as provided in §11.1600 of this title (relating to Information to Prospective and Current Contract Holders and Enrollees); and

(4) maintain separate cost center accounting for each service area to facilitate the reporting of divisional operations as required for HMO financial reporting.

Source Note: The provisions of this §11.1606 adopted to be effective August 1, 2017, 42 TexReg 2169