SECTION 13.441. General Provisions

(a) An HCC's contracts with physicians and health care providers must not impede application of provisions in Insurance Code Chapters 843 (Health Maintenance Organizations) and 1301 (Preferred Provider Benefit Plans), and in Chapter 11 of this title (relating to Health Maintenance Organizations) and Chapter 3, Subchapter X of this title (relating to Preferred and Exclusive Provider Plans), that impose requirements concerning relations with physicians or health care providers.

(b) An HCC is prohibited from using a financial incentive or making a payment to a physician or health care provider if the incentive or payment acts directly or indirectly as an inducement to limit medically necessary services.

(c) If an HCC participant's market share as calculated under §13.414 of this title (relating to Limited Exemption from Certain Information Filing Requirements) exceeds 50 percent in a PSA for any service that no other HCC participant provides to patients in that PSA, the participant furnishing the service is a dominant provider for purposes of this subchapter. An HCC with a dominant provider is prohibited, in the PSA in which the dominant provider furnishes those services, from:

(1) requiring a private payor to contract exclusively with the HCC; or

(2) otherwise restricting a private payor's ability to contract or deal with other HCCs, networks, physicians, or health care providers.

Source Note: The provisions of this §13.441 adopted to be effective March 31, 2013, 38 TexReg 2100