SECTION 13.416. Review of Original or Renewal Application; Commissioner Discretion

(a) An original application or renewal application will be processed pursuant to Insurance Code §§848.056 - 848.060 and §848.153.

(b) The department will conduct an examination as specified in §13.421(a) of this title (relating to Examination; Fee for Expenses) in conjunction with each application. If a hearing is held in connection with an application, then the examination(s) will occur prior to the date of the hearing.

(c) Application review will include a determination of compliance with Insurance Code §848.057. The review of pro-competitive benefits of the proposed or existing HCC in relation to anticompetitive effects of market power increase will be in accord with established antitrust principles of market power analysis.

(d) The commissioner has sole discretion to impose restrictions on an HCC applicant's certificate of authority that are deemed necessary to preserve competition. Examples of these restrictions include the following:

(1) prohibiting the HCC applicant from including "anti-steering," "guaranteed inclusion," "product participation," "price parity," or similar contractual clauses or provisions in its contracts with a private payor;

(2) prohibiting the HCC applicant from tying sales, explicitly or implicitly through pricing policies, of the HCC's services to a private payor's purchase of other services from physicians or health care providers outside of the HCC (and vice versa), including providers affiliated with HCC participants;

(3) prohibiting contracting with HCC participants on a basis that prevents or discourages them from contracting outside the HCC, either individually or through other HCCs or provider networks;

(4) prohibiting restrictions on a private payor's ability to provide its health plan enrollees with cost, quality, efficiency, and performance information used by the HCC to aid enrollees in evaluating and selecting physicians and health care providers in the health plan;

(5) prohibiting sharing with or among the HCC's participants any competitively sensitive pricing or other data that could be used to set prices or other terms for services that the participants provide outside the HCC; and

(6) restricting the HCC's certificate of authority to certain geographic areas or health care services.

Source Note: The provisions of this §13.416 adopted to be effective March 31, 2013, 38 TexReg 2100