SECTION 11.811. Action under Insurance Code §843.157 and Insurance Code §843.461

(a) In addition to any other actions available under the Insurance Code, the commissioner may take action against an HMO under §843.157 (concerning Rehabilitation, Liquidation, Supervision, or Conservation of Health Maintenance Organizations) and Insurance Code §843.461 (concerning Enforcement Actions). In evaluating the conditions in this section, the commissioner will evaluate all relevant circumstances concerning the HMO's operation. The evaluation of the information relating to these conditions is a part of the examination process. The conditions listed in this section do not conclusively indicate that action must be taken. One or more of the conditions can exist in an HMO that is in satisfactory condition; however, one or more of these conditions has often been found in an HMO that was unable to perform its obligations to enrollees, creditors, or the general public, or has required the commissioner to initiate regulatory action to protect enrollees, creditors, and the general public.

(b) The commissioner may take action under this section, if the commissioner finds that one or more of the conditions listed below or in §8.3 of this title (relating to Hazardous Conditions and Remedy of Hazardous Conditions) exist:

(1) an HMO's federal qualification designation, or NCQA accreditation, or both, are revoked or discontinued;

(2) an HMO's reported claims in process exceed 12 percent of annualized medical and hospital expenses (12 percent is approximately a 45-day backlog);

(3) an HMO fails to comply with Insurance Code Chapter 843 (concerning Health Maintenance Organizations), this chapter, or other applicable insurance laws and regulations of this state;

(4) an HMO has an inadequate provider network;

(5) an HMO contracts with a management or administrative company on a capitated or percentage of premium basis and the administrative or management company refuses to submit financial statements to the HMO;

(6) a physician or provider that is under contract, directly or indirectly, with an HMO, has a pattern of balance billing; or

(7) an HMO does not have the minimum net worth required by Insurance Code §843.403 (concerning Minimum Net Worth) and §11.802 of this title (relating to Minimum Net Worth).

(c) This section does not affect the commissioner's authority to take or order any other appropriate action under the commissioner's authority in the Insurance Code.

Source Note: The provisions of this §11.811 adopted to be effective August 1, 2017, 42 TexReg 2169