Current through Reg. 50, No. 13; March 28, 2025
The application for a certificate of authority must contain
the following, in this order:
(1) a
completed name application form along with any certificate of reservation of
corporate name issued by the secretary of state;
(2) a completed certificate of authority
application form;
(3) the basic
organizational documents and all amendments, complete with the original
incorporation certificate with charter number and seal indicating certification
by the secretary of state, if applicable;
(4) the bylaws, rules, or any similar
document regulating the conduct of the internal affairs of the
applicant;
(5) information about
officers, directors, and staff, including:
(A)
a completed officers and directors page;
(B) NAIC UCAA biographical data forms for all
persons who are to be responsible for the day-to-day conduct of the applicant's
affairs, including all members of the board of directors, board of trustees,
executive committee or other governing body or committee, the principal
officers, and controlling shareholders of the applicant if the applicant is a
corporation, or all partners or members if the applicant is a partnership or
association; and
(C) a complete set
of fingerprints for each person to whom the fingerprint requirements of Chapter
1 of this title (relating to General Administration) apply;
(6) organizational information, as
follows:
(A) a chart or list clearly
identifying the relationships between the applicant and any affiliates, and a
list of any currently outstanding loans or contracts to provide services
between the applicant and the affiliates;
(B) a chart showing the internal
organizational structure of the applicant's management and administrative
staff; and
(C) a chart showing
contractual arrangements of the HMO's delivery network;
(7) a fidelity bond or deposit for officers
and employees that must be:
(A) an original or
copy of a bond complying with Insurance Code §
843.402 (concerning
Officers' and Employees' Bond), which must not contain a deductible;
or
(B) a cash deposit held under
Insurance Code §
843.402 or as provided
by Insurance Code §
423.004 (concerning
Statutory Deposits with Department) in the same amount and subject to the same
conditions as the bond described in this paragraph;
(8) information relating to out-of-state
licensure and service of legal process for all applicants must be submitted by
using the attorney for service form; provided that:
(A) if the applicant is domiciled in another
jurisdiction, an agent for service of legal process must be appointed in
compliance with Insurance Code Chapter 804 (concerning Service of Process)
using Form FIN 312 (rev. 04/00), and the applicant must furnish a copy of the
certificate of authority from the domiciliary jurisdiction's licensing
authority; and
(B) the applicant
must furnish a statement acknowledging that all lawful process in any legal
action or proceeding against the HMO on a cause of action arising in this state
is valid if served as provided in Insurance Code Chapter 804;
(9) the evidence of coverage to be
issued to enrollees and any group agreement that is to be issued to employers,
unions, trustees, or other organizations as described in Chapter 11, Subchapter
F, of this title (relating to Evidence of Coverage);
(10) financial information, consisting of the
following:
(A) a financial statement that
includes a balance sheet reflecting the required net worth, assets, and any
liabilities;
(B) if the applicant
is newly formed, a balance sheet reflecting the HMO's proposed initial
funding;
(C) projected financial
statements using the NAIC UCAA ProForma Financial Statements for Health
Companies, commencing with the proposed beginning of operations and containing
at least two full calendar year projections, and including the identity and
credentials of the person preparing the projections; and
(D) the most recent audited financial
statements of the HMO's immediate parent company, the ultimate holding company
parent, and any sponsoring organization;
(11) the schedule of charges, excluding any
charges for Medicaid products, with an actuarial certification and supporting
documentation meeting the qualifications specified in §
11.702 of this title (relating to
Actuarial Certification),
(12) if
the applicant proposes to write Medicaid products, an actuarial certification
and supporting documentation meeting the qualifications specified in §
11.702 of this title, and noting
whether the proposed rates are the maximum rates allowed by the contracting
state agency, if rates less than the maximum rates allowed are being proposed
or if the contracting state agency rates are not available;
(13) a description and a map of the
applicant's proposed service area, with key and scale, which must identify the
county or counties, or portions of counties, to be served; provided that all
copies of the map must be in color, if the HMO submits a map on paper and in
color;
(14) the form of any
contract or monitoring plan between the applicant and:
(A) any person listed on the officers and
directors page;
(B) any physician,
medical group, association of physicians, or any other provider, and the form
of any subcontract between those entities and any physician, medical group,
association of physicians, or any other provider to provide health care
services, provided that contracts, including subcontracts between physician and
provider groups with the individual members of the groups providing health care
services to the HMO's enrollees, must include a hold-harmless provision and
comply with all other provisions of §
11.901 of this title (relating to
Required and Prohibited Provisions);
(C) any affiliated exclusive agent or
agency;
(D) any affiliated person
who will perform marketing, administrative, data processing services, or claims
processing services;
(E) any
affiliated person who will perform management services, together with a deposit
or the original or a copy of a bond with no deductible meeting the requirements
of Insurance Code §
843.105 (concerning
Management and Exclusive Agency Contracts);
(F) an ANHC that agrees to arrange for or
provide health care services, other than medical care or services ancillary to
the practice of medicine, or a provider HMO that agrees to arrange for or
provide health care services on a risk-sharing or capitated risk arrangement on
behalf of a primary HMO as part of the primary HMO delivery network; together
with a monitoring plan, as required by §
11.1604 of this title (relating to
Requirements for Certain Contracts Between Primary HMOs and ANHCs and Between
Primary HMOs and Provider HMOs);
(G) any insurer or group hospital service
corporation to offer indemnity benefits under a point-of-service contract;
and
(H) any delegated entity or
delegated network, as those terms are described in Insurance Code Chapter 1272
(concerning Delegation of Certain Functions by Health Maintenance
Organization);
(15) a
description of the quality improvement program and work plan that includes a
process for medical peer review required by Insurance Code §
843.082 (concerning
Requirements for Approval of Application) and §843.102 (concerning Health
Maintenance Organization Quality Assurance); provided that arrangements for
sharing pertinent medical records between physicians, providers, or both,
contracting or subcontracting under paragraph (14)(B) of this section with the
HMO and ensuring the confidentiality of the records must be
explained;
(16) insurance,
guarantees, and other protection against insolvency:
(A) any affiliated reinsurance agreement and
any other affiliated agreement described in Insurance Code §
843.082(4)(C),
covering excess of loss, stop-loss, catastrophes, or any combination thereof,
which must provide that the Commissioner and HMO will be notified no less than
60 days before termination or reduction of coverage by the insurer;
(B) any conversion policy or policies that
will be offered by an insurer to an HMO enrollee in the event of the
applicant's insolvency;
(C) any
other arrangements offering protection against insolvency, including
guarantees, as specified in §
11.808 of this title (relating to
Liabilities) and §
11.810 of this title (relating to
Guarantee from a Sponsoring Organization);
(17) authorization for bank disclosure to the
Commissioner of the applicant's initial funding;
(18) the written description of health care
plan terms and conditions made available by:
(A) an HMO other than an HMO offering a
Children's Health Insurance Program (CHIP) plan to any current or prospective
group contract holder and current or prospective enrollee of the applicant
under Insurance Code §§
843.201 (concerning
Disclosure of Information About Health Care Plan Terms), 843.078 (concerning
Contents of Application), and 843.079 (concerning Contents of Application;
Limited Health Care Service Plan), and §
11.1600 of this title (relating to
Information to Prospective and Current Contract Holders and
Enrollees);
(B) an HMO offering a
CHIP plan in the form of the member handbook, for information only, together
with a certification from the HMO that the handbook has been approved by the
Texas Health and Human Services Commission and a copy of the document approving
the handbook;
(19)
network configuration information for each of the HMO's physician or provider
networks, including limited provider networks, along with:
(A) maps for each product type demonstrating
the location and distribution of the physician, dentist, and provider network
within the proposed service area by county, with each specialty represented in
one map that includes the radii mileage requirements described in §
11.1607 of this title (relating to
Accessibility and Availability Requirements);
(B) lists for each product type of
credentialed and contracted physicians, dentists, and individual providers, in
an Excel-compatible format, specifying:
(iv) the municipality in
which the facility is located or county in which the facility is located if the
facility is in the unincorporated area of the county;
(viii) Texas license number;
(x) name of the HMO contracted facility,
including hospital(s), in which the physician or individual provider has
privileges;
(xi) date of last
credentialing or recredentialing; and
(xii) an indication of whether they are
accepting new patients;
(C) lists for each product type of
credentialed and contracted facilities, including hospitals, in an
Excel-compatible format, specifying:
(iii) the municipality in
which the facility is located or county in which the facility is located if the
facility is in the unincorporated area of the county;
(viii) name of national accrediting body, if
applicable; and
(ix) date of last
credentialing or recredentialing;
(D) for each facility listed under
subparagraph (C) of this paragraph:
(i) create
separate headings under the facility name for radiologists, anesthesiologists,
pathologists, emergency department physicians, neonatologists, and assistant
surgeons;
(ii) under each heading
described by clause (i) of this subparagraph, list each preferred
facility-based physician practicing in the specialty corresponding with that
heading;
(iii) for the facility and
each facility-based physician described by clause (ii) of this subparagraph,
clearly indicate each health benefit plan issued by the HMO that may provide
coverage for the services provided by that facility, physician, or
facility-based physician group;
(iv) for each facility-based physician
described by clause (ii) of this subparagraph, include the name, street
address, telephone number, and any physician group in which the facility-based
physician practices;
(v) include
the facility in a listing of all facilities and indicate each health benefit
plan issued by the HMO that may provide coverage for the services provided by
the facility; and
(vi) the list
must list each facility-based physician individually and, if a physician
belongs to a physician group, also as part of the physician group;
(20) a written
description of the types of compensation arrangements, such as compensation
based on fee-for-service arrangements, risk-sharing arrangements, or capitated
risk arrangements, made or to be made with physicians and providers in exchange
for the provision of or the arrangement to provide health care services to
enrollees, including any financial incentives for physicians and providers;
provided that such compensation arrangements are confidential under Insurance
Code §
843.078(l)
and not subject to Government Code Chapter 552 (concerning Public
Information);
(21) documentation
demonstrating that the applicant will pay for emergency care services performed
by non-network physicians or providers as provided by Insurance Code §
1271.155 (concerning
Emergency Care);
(22) a description
of the procedures by which:
(A) a member
handbook and materials relating to the complaint and appeal process and the
independent review process will be provided to enrollees in languages other
than English, in compliance with Insurance Code §
843.205 (concerning
Member's Handbook; Information About Complaints and Appeals); and
(B) access to a member handbook and materials
relating to the complaint and appeal process and the independent review process
will be provided to an enrollee who has a disability affecting communication or
reading, in compliance with Insurance Code §
843.205;
(23) notification of the physical address in
Texas of all books and records described in §
11.205 of this title (relating to
Additional Documents to be Available for Review);
(24) a description of the HMO's information
systems, management structure, and personnel that demonstrates the applicant's
capacity to meet the needs of enrollees and contracted physicians and
providers, and to meet the requirements of regulatory and contracting
entities;
(25) a written
description of the utilization management and utilization review
program;
(26) the URA name and
certificate or registration number if the applicant performs utilization review
under Insurance Code Chapter 4201 (concerning Utilization Review Agents) and
Chapter 19, Subchapter R, of this title (relating to Utilization Reviews for
Health Care Provided Under a Health Benefit Plan or Health Insurance Policy),
or the URA name and certificate number of the certified URA that will perform
utilization review on behalf of the applicant if the applicant delegates
utilization review;
(27) complaint
and appeal procedures, templates of letters, and logs, including the complaint
log, which must categorize each complaint using the following categories and
noting all that are applicable to the complaint:
(A) quality of care or services;
(B) accessibility and availability of
services;
(C) utilization review or
management;
(D) complaint
procedures;
(E) physician and
provider contracts;
(F) group
subscriber contracts;
(G)
individual subscriber contracts;
(I) claims processing; and
(28) documentation of claim systems and
procedures that demonstrates the HMO's ability to pay claims timely and comply
with applicable claim payment statutes and rules.
