SECTION 13.414. Limited Exemption from Certain Information Filing Requirements

(a) This section specifies circumstances under which an applicant is not required to provide the information specified in §13.413(i) of this title (relating to Contents of the Application) in filing an original or renewal application for certificate of authority.

(b) An applicant is not required to provide the information specified in §13.413(i) of this title if:

(1) for each PSA in which two or more individual or group participants provide common services, the applicant's market share is 35 percent or less; and

(2) no contract between the HCC and any participating hospital restricts the HCC or hospital from contracting with other HCCs, networks, hospitals, physicians, physician groups, health care providers, or private payors.

(c) Notwithstanding the provisions of subsection (b) of this section, an HCC that has a contract with a physician or health care provider in a rural county as defined by the U.S. Census Bureau and that does not restrict that physician's or health care provider's ability to contract or deal with other HCCs, networks, physicians, or health care providers is not required to provide the information specified in §13.413(i) of this title, if the inclusion of the physician or health care provider alone causes the HCC's share of any common service to exceed 35 percent.

(d) Notwithstanding the provisions of subsection (b) of this section, an HCC that includes a rural hospital but does not restrict the hospital from contracting with other HCCs, networks, physicians, or health care providers is not required to provide the information specified in §13.413(i) of this title, if the inclusion of the rural hospital alone causes the HCC's share of any common service to exceed 35 percent.

(e) For purposes of this section, an HCC's market share is determined by aggregating the market shares of its participants, calculated as follows:

(1) for physicians or individual health care providers within a particular health care specialty, by dividing the number of physicians or individual health care providers in the specialty within the HCC by the total number of physicians or health care providers providing each of the common services within that health care specialty within a participating physician's or health care provider's PSA;

(2) for outpatient services at a facility, by dividing the number of physicians or health care providers participating in the HCC within each PSA by the total number of physicians or health care providers within each PSA that provide each common service;

(3) for hospital inpatient services, by dividing the number of staffed hospital beds by particular medical specialty within the hospital or group of hospitals as reported to the Texas Department of State Health Services, for each common service area, by the total number of staffed hospital beds by medical specialty within each participating hospital's PSA; and

(4) if an HCC's participants can be classified as falling within more than one of the categories set forth in paragraphs (1) - (3) of this subsection, calculations must be made for all of the categories within which the participants in the HCC provide services.

(f) Notwithstanding the definition of PSA in §13.402 of this title (relating to Definitions), a participant may calculate market share through reference to the HCC's PSA for a health care specialty rather than the participant's PSA if the participant demonstrates to the commissioner's satisfaction that analysis of competition within the HCC's PSA provides a more accurate measure of competition relating to the participant in the context of the HCC than the analysis of competition within the participant's PSA.

(g) Notwithstanding this section, on receipt of the original or renewal application, the commissioner has discretion to require an applicant to provide any or all of the information specified in §13.413(i) of this title or §13.461 of this title (relating to Commissioner's Authority to Require Additional Information), or both, when the commissioner deems the information reasonably necessary to conduct the review required under Insurance Code Chapter 848.

Source Note: The provisions of this §13.414 adopted to be effective March 31, 2013, 38 TexReg 2100