Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter R - APPROVED NONPROFIT HEALTH CORPORATIONS
Section 11.1702 - Requirements for Issuance of Certificate of Authority to an ANHC

Universal Citation: 28 TX Admin Code § 11.1702

Current through Reg. 50, No. 13; March 28, 2025

(a) Before obtaining a certificate of authority under Insurance Code Chapter 844 (concerning Certification of Certain Nonprofit Health Corporations), an applicant ANHC must:

(1) comply with each requirement for the issuance of a certificate of authority imposed on an HMO under Insurance Code Chapter 843 (concerning Health Maintenance Organizations) and Insurance Code Chapter 1271 (concerning Benefits Provided by Health Maintenance Evidence of Coverage; Charges), this chapter, and other applicable insurance laws and regulations of this state; and

(2) demonstrate by appropriate documentation that the applicant ANHC has established and maintains accreditation by the:
(A) NCQA; or

(B) Joint Commission on Accreditation of Health Care Organizations network accreditation program.

(b) The commissioner may grant a provisional certificate of authority to an applicant ANHC under Insurance Code Chapter 844, if the:

(1) applicant ANHC complies with each requirement for the issuance of a certificate of authority imposed on an HMO under Insurance Code Chapters 843 and 1271, this chapter, and other applicable insurance laws and regulations of this state;

(2) applicant ANHC demonstrates that it has applied for accreditation;

(3) applicant ANHC is diligently pursuing accreditation as determined by the commissioner; and

(4) accrediting organization has not denied the accreditation.

(c) An ANHC with a certificate of authority or a provisional certificate of authority must comply with all the appropriate requirements that an HMO must comply with under Insurance Code Chapter 843 and 1271, this chapter, and other applicable insurance laws and regulations of this state in order to maintain a certificate of authority.

(d) This subchapter does not apply to an activity exempt from regulation under Insurance Code Chapters 843 and 844, including an ANHC that contracts to arrange for or provide only medical care as defined in Insurance Code § 843.002 (concerning Definitions).

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