SECTION 13.461. Commissioner's Authority to Require Additional Information

(a) The commissioner may require additional information from the HCC or any participant in the HCC as reasonably necessary to make any determination required by Insurance Code Chapter 848, this subchapter, and applicable insurance laws and regulations of this state.

(b) The commissioner may require any or all of the additional information set forth in subsection (c) of this section. An HCC or HCC participant is not required to create the items listed in subsection (c) of this section unless and except as the commissioner requires the items to be provided under this section. Once created, the documents must be maintained by the HCC or participant for at least five years.

(c) Additional information the commissioner may require includes the following:

(1) underlying documentation or data supporting any information, reports, or memoranda submitted to the department under the Insurance Code or this title;

(2) contact information for current participants or employees of the HCC, and last known contact information for former participants or employees;

(3) interviews by the department with individuals affiliated with the HCC or HCC participants;

(4) any participant's agendas, minutes, recordings, summaries, handouts, or presentations to the HCC;

(5) documents relating to past, current, or planned fees, risk-sharing, fee schedules, fee conversion factors, withholds, capitation, pricing plans, pricing strategies, or other forms of payment;

(6) documents relating to planned additions to the participation in the HCC or expansions of participants in the HCC;

(7) de-identified information regarding utilization of services by the HCC's patients or participants, including both medical and financial information;

(8) current bylaws, rules, or regulations of an HCC participant's professional staff or any of its departments or subunits;

(9) questionnaires submitted by participants to applicable professional associations in connection with annual surveys of association members, and to any other association, accreditation agency, or government agency, in connection with any annual or other periodic survey of the participant;

(10) reports prepared by accreditation agencies in connection with accreditation of the HCC or any HCC participant;

(11) revenue-and-cost reports, profitability reports, and other financial reports;

(12) internal or external reports relating to quality of care at any health care service location in each service area by the HCC or its participants, including:

(A) data or reports submitted to or received from or by quality rating organizations;

(B) quality-of-care initiatives;

(C) quality assurance or quality improvement systems; and

(D) the effect of changes in health care service location quality on patient volume and revenue;

(13) financial reports regularly prepared by or for the HCC applicant on any periodic basis relating to any arranged health care service;

(14) memoranda, excluding engineering and architectural plans and blueprints, relating to plans of the HCC applicant, or any participant, for the construction of new facilities, the closing of any existing facilities, or an expansion, a conversion, or a modification of current facilities;

(15) memoranda relating to plans of, or steps undertaken by the HCC applicant or any participant for any acquisition, divestiture, joint venture, alliance, or merger involving any participant in the service area other than the application for certificate of authority of the applicant;

(16) memoranda analyzing or discussing the effect of any merger, joint venture, acquisition, or consolidation of HCCs in the applicant's service area, including the HCC's application if approved, on the HCC's prices, costs, margins, service quality, or any other aspect of competitive performance, including:

(A) memoranda comparing the actual cost savings or other benefits of the transactions to those previously projected; and

(B) memoranda discussing how the benefits were or might be achieved;

(17) a description relating to the consolidation or realignment of any medical and health care services arranged by or through the applicant whether completed, in progress, or planned among the participants;

(18) the names and addresses of all contracting physicians, in Excel-compatible format;

(19) documents created or used by, for, or on behalf of the applicant for the purpose of soliciting physicians or health care providers to join the applicant as an employee or participant, promoting continued participation in the applicant, or otherwise offering, promoting, or advertising the applicant's services or activities on behalf of physicians or health care providers, and all documents supplied by the HCC to newly recruited physicians or health care providers;

(20) contracts between the HCC applicant or any of its participants and any private payor, all attachments to the contracts, and all documents relating to the contracts, including:

(A) documents sufficient to show the name, contact person, and telephone number of each health plan contracting with the applicant for physician services;

(B) documents relating to fees, fee schedules, fee conversion factors, withholds, capitation, pricing plans, pricing strategies, or other forms of payment;

(C) documents discussing actual or potential negotiations, offers, or responses to any contract, fee schedule, or risk-sharing arrangement with a third-party payor;

(D) copies of internal memoranda relating to:

(i) the development or negotiation of contracts with payors or participants, and internal HCC decisions regarding negotiating positions;

(ii) competition to obtain contracts;

(iii) decisions to terminate contracts;

(iv) draft, contingent, or expired contracts, including contracts not entered into, not yet finalized or in force, or no longer in force; and

(v) contract amendments or modifications; and

(E) the beginning date and termination date, as applicable, for each contract;

(21) documents relating to plans, interests, or steps undertaken by the HCC applicant for any acquisition, divestiture, joint venture, alliance, collaboration, license, or merger with any HCC or other health care provider, including:

(A) any notes or minutes taken; or

(B) reports, memoranda, or correspondence regarding meetings between the HCC applicant and any other HCC or other health care provider;

(22) documents reflecting:

(A) actual or planned lease, management contract, or other agreement for the HCC applicant to operate a facility in the service area that is, or will be, owned in whole or in part by another individual or entity; and

(B) formal or informal commercial or operational relationships or affiliations that have existed, exist, or are planned between or among any facilities, or facilities and any physician organizations in the service area, including purchases by the HCC applicant of services from other facilities or from physician organizations, and vice versa;

(23) for each participant, summaries and interpretations of contract terms and methodologies used to determine the payment due to the participant under a contract with a payor in effect at any time during the previous three years for each treatment, office visit, or other medical or health care service provided or delivered in the service area;

(24) a list and description by Current Procedural Technology code, if available, of each medical or health care service arranged by or through the applicant in the HCC's service area, and for each code listed, a statement of:

(A) the number of procedures performed;

(B) the amount of revenue received by the applicant;

(C) the ZIP code for each patient receiving the procedure or service; and

(D) the location of the office where the procedure or service was performed; and

(25) documents reflecting participants' contribution margins or identifying or quantifying fixed or variable costs for the provision of any health care service in the service area.

Source Note: The provisions of this §13.461 adopted to be effective March 31, 2013, 38 TexReg 2100