Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter AA - DELEGATED ENTITIES
Section 11.2605 - Delegation Agreements - Information to Be Provided by HMO to Delegated Entity
Universal Citation: 28 TX Admin Code § 11.2605
Current through Reg. 50, No. 13; March 28, 2025
(a) An HMO must provide to each delegated entity with which the HMO has a delegation agreement, at least monthly unless otherwise stated in the agreement and provided in standard electronic format agreed to by the parties, the following information:
(1) the name and either the date of birth or
social security number of each enrollee of the HMO who is eligible or assigned
to receive health care from the delegated entity, including the enrollees added
and terminated since the previous reporting period;
(2) the age, sex, evidence of coverage, and
any riders to that evidence of coverage, and, if applicable, the name of the
employer, for the enrollees of the HMO who are eligible or assigned to receive
health care from the delegated entity;
(3) a summary of the number and amount of
claims paid by the HMO on behalf of the delegated entity during the previous
reporting period; provided that an HMO is not prevented from providing, on
request, additional nonproprietary information regarding the claims if the HMO
pays any claims for the delegated entity;
(4) a summary of the number and amount of
pharmacy prescriptions paid for each enrollee for which the delegated entity
has taken partial risk during the previous reporting period, provided that an
HMO is not prevented from providing, on request, additional nonproprietary
information regarding the claims, if the HMO pays any claims for the delegated
entity;
(5) information that is
needed by the delegated entity to file claims for reinsurance, coordination of
benefits, and subrogation; and
(6)
patient complaint data that relates to the delegated entity.
(b) An HMO must provide to each delegated entity with which the HMO has a delegation agreement the following information, as applicable, provided in standard electronic format agreed to by the parties at least quarterly unless otherwise stated in the agreement:
(1) detailed risk-pool data, reported
quarterly and on settlement, sufficient to allow the delegated entity to
adequately monitor its position in the risk pool; and
(2) the percent of premium attributable to
hospital or facility costs, if hospital or facility costs impact the delegated
entity's costs and, if there are changes in hospital or facility contracts with
the HMO, the projected impact of those changes on the percent of premium
attributable to hospital and facility costs within 30 days of the
changes.
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