Current through Reg. 50, No. 13; March 28, 2025
(a) The governing
body of an HMO, as described in Insurance Code §
843.004 (concerning
Governing Body of Health Maintenance Organization), has ultimate responsibility
for the development, approval, implementation, and enforcement of
administrative, operational, personnel, and patient care policies and
procedures related to the HMO's operation.
(b) The HMO must have a chief executive
officer or operations officer who is accountable for the administration of the
health plan, including:
(1) developing
corporate strategy;
(2) overseeing
marketing programs;
(3) overseeing
medical management functions; and
(4) ensuring compliance with all applicable
statutes and rules pertaining to the operations of the HMO.
(c) The HMO must have a full-time
clinical director who:
(1) is licensed in
Texas or otherwise authorized to practice in this state in the field of
services offered by the HMO, for example:
(A)
a basic HMO must have a physician;
(B) a dental HMO must have a dentist or
physician;
(C) a vision HMO must
have an optometrist or physician; and
(D) a limited services HMO must have a
physician;
(2) resides
in the state of Texas;
(3) is
available at all times to address complaints, clinical issues, utilization
review, and any quality of care issues on behalf of the HMO;
(4) demonstrates active involvement in all
quality management activities; and
(5) will be subject to the HMO's
credentialing requirements and must be credentialed in compliance with NCQA or
American Accreditation HealthCare Commission, Inc., standards.
(d) The HMO may establish one or
more service areas within Texas; each defined service area must:
(1) demonstrate to the department the ability
to provide continuity, accessibility, availability, and quality of
services;
(2) specify the counties,
or any portions of counties, included in the service area;
(3) provide a complete physician and provider
listing for all enrollees residing, living, or working in the service area, as
provided in §
11.1600 of this title (relating to
Information to Prospective and Current Contract Holders and Enrollees);
and
(4) maintain separate cost
center accounting for each service area to facilitate the reporting of
divisional operations as required for HMO financial reporting.
