SECTION 21.4103. Presumed Compliance

(a) Health benefit plan issuer presumed compliance. Pursuant to the Insurance Code §847.005(a), a health benefit plan issuer shall be presumed to be in compliance with state statutory and regulatory requirements if:

(1) a national accreditation organization has issued the health benefit plan issuer nonconditional accreditation applicable to its operations within the state of Texas; and

(2) the national accreditation organization's accreditation requirements are the same, substantially similar to, or more stringent than the department's statutory and regulatory requirements.

(b) Examination. Pursuant to the Insurance Code §847.007(a), in conducting an examination of a health benefit plan issuer, the commissioner:

(1) shall accept the accreditation report submitted by the health benefit plan issuer as evidence of the health benefit plan issuer's compliance with the processes and standards for which the issuer has received nonconditional accreditation; and

(2) may adopt relevant findings from a health benefit plan issuer's accreditation report in the examination report if the accreditation report complies with applicable state and federal requirements regarding the nondisclosure of proprietary and confidential information and personal health information.

(c) Exceptions. Pursuant to the Insurance Code §847.007(b), this section does not:

(1) apply to any process or standard of a health benefit plan issuer that is not covered as part of the health benefit plan issuer's accreditation; or

(2) set minimum quality standards.

(d) Submission of report. Pursuant to the Insurance Code §847.006(a), at the department's request, the health benefit plan issuer seeking presumed compliance pursuant to subsection (b) of this section must provide to the department a complete copy of the accreditation report issued by the national accreditation organization.

(e) Loss of nonconditional accreditation. If a health benefit plan issuer loses nonconditional accreditation, the health benefit plan issuer shall report this change in accreditation status to the department not later than the 30th day following the date the national accreditation organization notifies the health benefit plan issuer of the loss of nonconditional accreditation status. A health benefit plan issuer will be subject to immediate examination by the department if it loses its nonconditional accreditation status.

Source Note: The provisions of this §21.4103 adopted to be effective May 3, 2007, 32 TexReg 2364