SUBCHAPTER A GENERAL PROVISIONS
- Texas Section 843.001 - Short Title
This chapter may be cited as the Texas Health Maintenance Organization Act. Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1,
- Texas Section 843.002 - Definitions
In this chapter: (1) "Adverse determination" means a determination by a health maintenance organization or a utilization review agent that health care services provided or...
- Texas Section 843.003 - Powers Of Insurers And Group Hospital Service Corporations
(a) An insurer authorized to engage in the business of insurance in this state under Chapter 822, 841, or 883, an accident insurance company, health...
- Texas Section 843.004 - Governing Body Of Health Maintenance Organization
The governing body of a health maintenance organization may include physicians, providers, or other individuals, or any combination of physicians, providers, and other individuals. Added...
- Texas Section 843.005 - Use Of Insurance-related Terms By Health Maintenance Organization
A health maintenance organization that is not authorized as an insurer may not use in its name, contracts, or literature the word "insurance," "casualty," "surety,"...
- Texas Section 843.006 - Public Documents
(a) Except as provided by Subsection (b), each application, filing, and report required under this chapter, Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter...
- Texas Section 843.007 - Confidentiality Of Medical And Health Information
(a) Any information relating to the diagnosis, treatment, or health of an enrollee or applicant obtained by a health maintenance organization from the enrollee or...
- Texas Section 843.008 - Costs Of Administering Health Maintenance Organization Laws
Money collected under this chapter and Chapters 222, 251, and 258, as applicable to a health maintenance organization, must be sufficient to administer this chapter...
- Texas Section 843.009 - Appeals; Judicial Review
(a) A person who is affected by a rule, ruling, or decision of the department or the commissioner is entitled to have the rule, ruling,...
SUBCHAPTER B APPLICABILITY OF AND CONSTRUCTION WITH OTHER LAWS
- Texas Section 843.010 - Applicability Of Certain Provisions To Governmental Health Benefit Plans
Sections 843.306(f) and 843.363(a)(4) do not apply to coverage under: (1) the child health plan program under Chapter 62, Health and Safety Code, or the...
- Texas Section 843.051 - Applicability Of Insurance And Group Hospital Service Corporation Laws
(a) Except to the extent that the commissioner determines that the nature of health maintenance organizations, health care plans, or evidences of coverage renders a...
- Texas Section 843.052 - Laws Relating To Solicitation Or Advertising
(a) Solicitation of enrollees by a health maintenance organization or its representative or agent does not violate a law relating to solicitation or advertising by...
- Texas Section 843.053 - Laws Relating To Restraint Of Trade
(a) A health maintenance organization that contracts with a health facility or enters into an independent contractual arrangement with physicians or providers practicing individually or...
- Texas Section 843.054 - Laws Requiring Certificate Of Need For Health Care Facility Or Service
(a) A health maintenance organization is not exempt from any statute that provides for the regulation and certification of need of health care facility construction,...
- Texas Section 843.055 - Laws Relating To Practice Of Medicine
(a) This chapter does not authorize the practice of medicine as defined by state law. (b) This chapter does not repeal, modify, or amend Section...
SUBCHAPTER C AUTHORITY TO ENGAGE IN BUSINESS
- Texas Section 843.056 - Inapplicability Of Bankruptcy Law
By applying for and receiving a certificate of authority to engage in business in this state, a health maintenance organization agrees and admits that it...
- Texas Section 843.071 - Certificate Of Authority Required; Use Of "Health Maintenance Organization" Or "Hmo"
(a) A person may not organize or operate a health maintenance organization in this state, or sell or offer to sell or solicit offers to...
- Texas Section 843.072 - Authorization Required To Act As Health Maintenance Organization
(a) A person, including a physician or provider, may not perform any act of a health maintenance organization except in accordance with the specific authorization...
- Texas Section 843.073 - Certificate Of Authority Requirement: Applicability To Physicians And Providers
(a) A person is not required to obtain a certificate of authority under this chapter to the extent that the person is: (1) a physician...
- Texas Section 843.074 - Certificate Of Authority Requirement: Applicability To Medical School And Medical And Dental Unit
A medical school or medical and dental unit, as defined or described by Section 61.003, 61.501, or 74.601, Education Code, is not required to obtain...
- Texas Section 843.075 - Certificate Of Authority For Single Health Care Service Plan
The commissioner may issue a certificate of authority to a health maintenance organization organized and operated solely to provide a single health care service plan....
- Texas Section 843.076 - Application
(a) Any person may apply to the commissioner for and obtain a certificate of authority to organize and operate a health maintenance organization. (b) An...
- Texas Section 843.077 - Eligibility Of Foreign Corporation
A foreign corporation may qualify for a certificate of authority under this chapter, including a certificate of authority for a single health care service plan,...
- Texas Section 843.078 - Contents Of Application
(a) An application for a certificate of authority must include: (1) a copy of the applicant's basic organizational document, if any, such as the articles...
- Texas Section 843.079 - Contents Of Application: Limited Health Care Service Plan
In addition to the items required under Section 843.078, an application for a certificate of authority for a limited health care service plan must include...
- Texas Section 843.080 - Modification Or Amendment Of Application Information
(a) The commissioner may adopt reasonable rules that the commissioner considers necessary for the proper administration of this chapter to require a health maintenance organization,...
- Texas Section 843.082 - Requirements For Approval Of Application
The commissioner shall issue a certificate of authority on payment of the application fee prescribed by Section 843.154(c) if the commissioner is satisfied that: (1)...
- Texas Section 843.083 - Denial Of Certificate Of Authority
(a) If the commissioner certifies that the health maintenance organization's proposed plan of operation does not meet the requirements of Section 843.082, the commissioner may...
- Texas Section 843.084 - Duration Of Certificate Of Authority
A certificate of authority continues in effect: (1) while the certificate holder meets the requirements of this chapter and: (A) Section 1367.053; (B) Subchapter A,...
SUBCHAPTER D GENERAL POWERS AND DUTIES OF HEALTH MAINTENANCE ORGANIZATIONS
- Texas Section 843.085 - Change In Control: Commissioner Approval
Any change in control, as defined by Chapter 823, of a health maintenance organization is subject to the approval of the commissioner. Added by Acts...
- Texas Section 843.101 - Providing Or Arranging For Care
(a) A health maintenance organization may provide or arrange for medical care services only through: (1) other health maintenance organizations; or (2) physicians or groups...
- Texas Section 843.102 - Health Maintenance Organization Quality Assurance
(a) A health maintenance organization shall establish procedures to ensure that health care services are provided to enrollees under reasonable standards of quality of care...
- Texas Section 843.103 - Acquisition And Operation Of Facilities; Certain Loans; Commissioner Approval Of Affiliate Transactions
(a) A health maintenance organization may: (1) purchase, lease, construct, renovate, operate, or maintain hospitals or medical facilities and ancillary equipment and other property reasonably...
- Texas Section 843.104 - Contracts For Certain Administrative Functions
A health maintenance organization may contract with any person to perform functions such as marketing, enrollment, and administration on behalf of the health maintenance organization....
- Texas Section 843.105 - Management And Exclusive Agency Contracts
(a) A health maintenance organization may not enter into a management contract or exclusive agency contract unless the proposed contract is first filed with and...
- Texas Section 843.106 - Insurance, Reinsurance, Indemnity, And Reimbursement
A health maintenance organization may contract with an insurer or group hospital service corporation authorized to engage in business in this state to provide insurance,...
- Texas Section 843.107 - Indemnity Benefits; Point-of-service Provisions
A health maintenance organization may offer: (1) indemnity benefits covering out-of-area emergency care; (2) indemnity benefits, in addition to those relating to out-of-area and emergency...
- Texas Section 843.108 - Point-of-service Rider
(a) In this section, "point-of-service rider" means a rider under which indemnity benefits for the cost of health care services are provided by a health...
- Texas Section 843.109 - Payment By Governmental Or Private Entity
A health maintenance organization may accept from a governmental or private entity payments for all or part of the cost of services provided or arranged...
- Texas Section 843.110 - Corporation, Partnership, Or Association Powers
A health maintenance organization has all powers of a partnership, association, or corporation, including a professional association or corporation, as appropriate under the organizational documents...
- Texas Section 843.111 - Group Model Health Maintenance Organizations
(a) In this section, "group model health maintenance organization" means a health maintenance organization that provides the majority of its professional services through a single...
- Texas Section 843.112 - Dental Point-of-service Option
(a) In this section: (1) "Point-of-service option" means a plan provided through a contractual arrangement under which: (A) indemnity benefits for the cost of dental...
SUBCHAPTER E REGULATION OF HEALTH MAINTENANCE ORGANIZATIONS
- Texas Section 843.113 - Specified Powers Not Exclusive
The powers of a health maintenance organization are not limited to the powers specified by this subchapter. Added by Acts 2001, 77th Leg., ch. 1419,...
- Texas Section 843.151 - Rules
The commissioner may adopt reasonable rules as necessary and proper to: (1) implement this chapter and Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter...
- Texas Section 843.152 - Subpoena Authority
In implementing this chapter and the following provisions, the commissioner may exercise subpoena authority in accordance with Subchapter C, Chapter 36: (1) Section 1367.053; (2)...
- Texas Section 843.153 - Authority To Contract
In performing duties under this chapter and the following provisions, the commissioner may contract with a state agency or, after notice and opportunity for hearing,...
- Texas Section 843.154 - Fees
(a) The commissioner shall, within the limits prescribed by this section, prescribe the fees to be charged under this section. (b) Except for fees collected...
- Texas Section 843.155 - Annual Report
(a) Not later than March 1 of each year, a health maintenance organization shall file with the commissioner a report covering the preceding calendar year....
- Texas Section 843.156 - Examinations
(a) The commissioner may examine the quality of health care services and the affairs of any health maintenance organization or applicant for a certificate of...
SUBCHAPTER F RELATIONS WITH ENROLLEES AND GROUP CONTRACT HOLDERS
- Texas Section 843.157 - Rehabilitation, Liquidation, Supervision, Or Conservation Of Health Maintenance Organization
(a) The rehabilitation, liquidation, supervision, or conservation of a health maintenance organization shall be treated as the rehabilitation, liquidation, supervision, or conservation of an insurer...
- Texas Section 843.201 - Disclosure Of Information About Health Care Plan Terms
(a) A health maintenance organization shall provide an accurate written or electronic description of health care plan terms, including restrictions or limitations related to a...
- Texas Section 843.2015 - Information Available Through Internet Site
(a) A health maintenance organization that maintains an Internet site shall list on the Internet site the physicians and providers, including, if appropriate, mental health...
- Texas Section 843.202 - Disclosure Of Information To Medicare Recipients
(a) Before a prospective enrollee is enrolled in a health care plan offered to Medicare recipients by a Medicare-contracting health maintenance organization, the health maintenance...
- Texas Section 843.203 - Selection Of Primary Care Physician Or Provider
(a) Each plan application form shall prominently include a space in which the enrollee at the time of application or enrollment shall select a primary...
- Texas Section 843.204 - Untrue Or Misleading Information
(a) A health maintenance organization or a representative of a health maintenance organization may not: (1) use or distribute or knowingly permit the use or...
- Texas Section 843.205 - Member's Handbook; Information About Complaints And Appeals
(a) In this section, "major population" means a group constituting 10 percent or more of the enrolled population of the health maintenance organization. (b) A...
- Texas Section 843.206 - Notice Of Change In Payment Arrangements
A health maintenance organization shall notify a group contract holder within 30 days of any substantive change to the payment arrangements between the health maintenance...
- Texas Section 843.207 - Notice Of Change In Operations
A health maintenance organization shall provide to its enrollees reasonable notice of any material adverse change in the operation of the health maintenance organization that...
- Texas Section 843.2071 - Notice Of Increase In Charge For Coverage
(a) Not less than 60 days before the date on which an increase in a charge for coverage under this chapter takes effect, a health...
- Texas Section 843.208 - Cancellation Or Nonrenewal Of Coverage
A health maintenance organization may cancel or refuse to renew the coverage of an enrollee only for: (1) failure to pay the charges for the...
- Texas Section 843.209 - Identification Card
An identification card or other similar document issued by a health maintenance organization to an enrollee must: (1) indicate that the health maintenance organization is...
- Texas Section 843.210 - Terms Of Enrollee Eligibility
(a) A contract between a health maintenance organization and a group contract holder must provide that: (1) in addition to any other premiums for which...
SUBCHAPTER G DISPUTE RESOLUTION
- Texas Section 843.211 - Applicability Of Subchapter To Entities Contracting With Health Maintenance Organization
This subchapter applies to a person to whom a health maintenance organization contracts to: (1) process or pay claims; (2) obtain the services of physicians...
- Texas Section 843.251 - Complaint System Required; Commissioner Rules And Examination
(a) A health maintenance organization shall implement and maintain a complaint system that provides reasonable procedures to resolve an oral or written complaint initiated by...
- Texas Section 843.252 - Complaint Initiation And Initial Response; Deadlines For Response And Resolution
(a) If a complainant notifies a health maintenance organization of a complaint, the health maintenance organization, not later than the fifth business day after the...
- Texas Section 843.253 - Complaint Investigation And Resolution
(a) A health maintenance organization shall investigate each complaint received in accordance with the health maintenance organization's policies and in compliance with this chapter. (b)...
- Texas Section 843.254 - Appeal To Complaint Appeal Panel; Deadlines
(a) A health maintenance organization shall provide an appeals process for a complainant who is not satisfied with the resolution of the complaint. The appeals...
- Texas Section 843.255 - Composition Of Complaint Appeal Panel
(a) A health maintenance organization shall appoint members to a complaint appeal panel to advise the health maintenance organization on the resolution of a disputed...
- Texas Section 843.256 - Information Provided To Complainant Relating To Complaint Appeal Panel
Not later than the fifth business day before the date a complaint appeal panel is scheduled to meet, unless the complainant agrees otherwise, the health...
- Texas Section 843.257 - Rights Of Complainant At Complaint Appeal Panel Meeting
A complainant, or a designated representative if the enrollee is a minor or is disabled, is entitled to: (1) appear in person before the complaint...
- Texas Section 843.258 - Appeal Involving Ongoing Emergency Or Continued Hospitalization
(a) The investigation and resolution of an appeal of a complaint relating to an ongoing emergency or denial of continued hospitalization shall be concluded: (1)...
- Texas Section 843.259 - Notice Of Decision On Appeal
(a) A health maintenance organization shall include in a notice of the final decision on an appeal a statement of the specific medical determination, clinical...
- Texas Section 843.260 - Record Of Complaints
(a) A health maintenance organization shall maintain a complaint and appeal log regarding each complaint. The log must identify those complaints relating to limited provider...
- Texas Section 843.261 - Special Provisions For Appeals Of Adverse Determinations
(a) A health maintenance organization shall implement and maintain an internal appeal system that: (1) provides reasonable procedures for the resolution of an oral or...
SUBCHAPTER H GENERAL PROVISIONS REGARDING COMPLAINTS
- Texas Section 843.262 - Certain Decisions Binding
(a) If an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record appeals an adverse determination as provided under...
- Texas Section 843.281 - Retaliatory Action Prohibited
(a) A health maintenance organization may not engage in retaliatory action, including refusal to renew or cancellation of coverage, against a group contract holder or...
- Texas Section 843.282 - Submitting Complaints To Department
(a) Any person, including a person who has attempted to resolve a complaint through a health maintenance organization's complaint system process and is dissatisfied with...
SUBCHAPTER I RELATIONS WITH PHYSICIANS AND PROVIDERS
- Texas Section 843.283 - Posting Of Information On Complaint Process Required
A contract between a health maintenance organization and a physician or provider must require the physician or provider to post, in the office of the...
- Texas Section 843.301 - Practice Of Medicine Not Affected
This chapter, Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapters 222, 251, and 258, as applicable to a health maintenance organization, and...
- Texas Section 843.302 - Disclosure Of Application Procedures And Qualification Requirements To Physician Or Provider
A health maintenance organization shall, on request, make available and disclose to a physician or provider written application procedures and qualification requirements for contracting with...
- Texas Section 843.303 - Denial Of Initial Contract To Physician Or Provider
(a) A health maintenance organization that denies a contract to a physician or provider who initially applies to contract with the health maintenance organization to...
- Texas Section 843.304 - Exclusion Of Provider Based On Type Of License Prohibited
(a) A provider licensed or otherwise authorized to practice in this state may not be denied the opportunity to participate in providing health care services...
- Texas Section 843.3041 - Acupuncturist Services
(a) A health maintenance organization that includes acupuncture in the services covered by the organization's health care plan may not refuse to provide reimbursement for...
- Texas Section 843.3045 - Nurse First Assistant
A health maintenance organization may not refuse to contract with a nurse first assistant, as defined by Section 301.1525, Occupations Code, to be included in...
- Texas Section 843.305 - Annual Application Period For Physicians And Providers To Contract
(a) This section applies only to a health maintenance organization that provides coverage for health care services through: (1) one or more physicians or providers...
- Texas Section 843.306 - Termination Of Participation; Advisory Review Panel
(a) Before terminating a contract with a physician or provider, a health maintenance organization shall provide to the physician or provider a written explanation of...
- Texas Section 843.307 - Expedited Review Process On Termination Or Deselection
On request by the physician or provider, a physician or provider whose participation in a health care plan is being terminated or who is deselected...
- Texas Section 843.308 - Notification Of Patients Of Deselected Physician Or Provider
(a) Except as provided by Subsection (b), if a physician or provider is deselected for a reason other than the request of the physician or...
- Texas Section 843.309 - Contracts With Physicians Or Providers: Notice To Certain Enrollees Of Termination Of Physician Or Provider Participation In Plan
A contract between a health maintenance organization and a physician or provider must provide that reasonable advance notice shall be given to an enrollee of...
- Texas Section 843.310 - Contracts With Physicians Or Providers: Certain Indemnity Clauses Prohibited
A contract between a health maintenance organization and a physician or provider may not contain a clause purporting to indemnify the health maintenance organization for...
- Texas Section 843.311 - Contracts With Podiatrists
A contract between a health maintenance organization and a podiatrist licensed by the Texas State Board of Podiatric Medical Examiners must provide that: (1) the...
- Texas Section 843.3115 - Contracts With Dentists
(a) In this section, "covered service" means a dental care service for which reimbursement is available under an enrollee's health care plan contract, or for...
- Texas Section 843.312 - Physician Assistants And Advanced Practice Nurses
(a) A health maintenance organization may not refuse a request by a physician participating in the health maintenance organization delivery network and a physician assistant...
- Texas Section 843.313 - Economic Profiling
(a) A health maintenance organization that conducts or uses economic profiling of physicians or providers participating in the health maintenance organization delivery network shall make...
- Texas Section 843.314 - Inducement To Limit Medically Necessary Services Prohibited
(a) A health maintenance organization may not use a financial incentive or make a payment to a physician or provider if the incentive or payment...
- Texas Section 843.315 - Payment Of Capitation; Assignment Of Primary Care Physician Or Provider
(a) This section applies to a health maintenance organization that to any extent uses capitation as a method of compensation. (b) A health maintenance organization...
- Texas Section 843.316 - Alternative Capitation System
As an alternative to the procedures prescribed by Section 843.315, a health maintenance organization may request approval from the department of a capitation payment system...
- Texas Section 843.317 - Exclusion Of Physician Or Provider Based On Affiliation With Health Maintenance Organization Prohibited
A physician, health care provider, group of physicians or health care providers, or health care facility or institution may not exclude a physician or provider...
- Texas Section 843.318 - Certain Contracts Of Participating Physician Or Provider Not Prohibited
(a) This chapter and this code do not prohibit a physician or provider who is participating in a health maintenance organization delivery network, whether by...
- Texas Section 843.319 - Certain Required Contracts
Notwithstanding Section 843.304, a health maintenance organization may not deny a contract to a podiatrist licensed by the Texas State Board of Podiatric Medical Examiners...
- Texas Section 843.320 - Use Of Hospitalist
(a) In this section, "hospitalist" means a physician who: (1) serves as physician of record at a hospital for a hospitalized patient of another physician;...
- Texas Section 843.321 - Availability Of Coding Guidelines
(a) A contract between a health maintenance organization and a physician or provider must provide that: (1) the physician or provider may request a description...
SUBCHAPTER J PAYMENT OF CLAIMS TO PHYSICIANS AND PROVIDERS
- Texas Section 843.323 - Contract Provisions Prohibiting Rejection Of Batched Claims
(a) If requested by a participating physician or provider, a health maintenance organization shall include a provision in the physician's or provider's contract providing that...
- Texas Section 843.336 - Definition
(a) In this subchapter, "clean claim" means a claim that complies with this section. (b) A nonelectronic claim by a physician or provider, other than...
- Texas Section 843.337 - Time For Submission Of Claim; Duplicate Claims; Acknowledgment Of Receipt Of Claim
(a) A physician or provider must submit a claim to a health maintenance organization not later than the 95th day after the date the physician...
- Texas Section 843.338 - Deadline For Action On Clean Claims
Except as provided by Sections 843.3385 and 843.339, not later than the 45th day after the date on which a health maintenance organization receives a...
- Texas Section 843.3385 - Additional Information
(a) If a health maintenance organization needs additional information from a treating participating physician or provider to determine payment, the health maintenance organization, not later...
- Texas Section 843.339 - Deadline For Action On Prescription Claims; Payment
(a) A health maintenance organization, or a pharmacy benefit manager that administers pharmacy claims for the health maintenance organization, that affirmatively adjudicates a pharmacy claim...
- Texas Section 843.340 - Audited Claims
(a) Except as provided by Section 843.3385, if a health maintenance organization intends to audit a claim submitted by a participating physician or provider, the...
- Texas Section 843.3405 - Investigation And Determination Of Payment
The investigation and determination of payment, including any coordination of other payments, does not extend the period for determining whether a claim is payable under...
- Texas Section 843.341 - Claims Processing Procedures
(a) A health maintenance organization shall provide a participating physician or provider with copies of all applicable utilization review policies and claim processing policies or...
- Texas Section 843.342 - Violation Of Certain Claims Payment Provisions; Penalties
(a) Except as provided by this section, if a clean claim submitted to a health maintenance organization is payable and the health maintenance organization does...
- Texas Section 843.343 - Attorney's Fees
A physician or provider may recover reasonable attorney's fees and court costs in an action to recover payment under this subchapter. Added by Acts 2001,...
- Texas Section 843.344 - Applicability Of Subchapter To Entities Contracting With Health Maintenance Organization
This subchapter applies to a person, including a pharmacy benefit manager, with whom a health maintenance organization contracts to: (1) process or pay claims; (2)...
- Texas Section 843.345 - Exception
This subchapter does not apply to a capitated payment required to be made to a physician or provider under an agreement to provide health care...
- Texas Section 843.346 - Payment Of Claims
Except as provided by this subchapter, a health maintenance organization shall pay a physician or provider for health care services and benefits provided to an...
- Texas Section 843.347 - Verification
(a) In this section, "verification" means a reliable representation by a health maintenance organization to a physician or provider that the health maintenance organization will...
- Texas Section 843.348 - Preauthorization Of Health Care Services
(a) In this section, "preauthorization" means a determination by a health maintenance organization that health care services proposed to be provided to a patient are...
- Texas Section 843.349 - Coordination Of Payment
(a) A health maintenance organization may require a physician or provider to retain in the physician's or provider's records updated information concerning other health benefit...
- Texas Section 843.350 - Overpayment
(a) A health maintenance organization may recover an overpayment to a physician or provider if: (1) not later than the 180th day after the date...
- Texas Section 843.351 - Services Provided By Certain Physicians And Providers
The provisions of this subchapter relating to prompt payment by a health maintenance organization of a physician or provider and to verification of health care...
- Texas Section 843.352 - Conflict With Other Law
To the extent of any conflict between this subchapter and Subchapter C, Chapter 1204, this subchapter controls. Added by Acts 2003, 78th Leg., ch. 214,...
- Texas Section 843.353 - Waiver Prohibited
Except as provided by Sections 843.336(f) and 843.337(c), the provisions of this subchapter may not be waived, voided, or nullified by contract. Added by Acts...
SUBCHAPTER K RELATIONS BETWEEN ENROLLEE AND PHYSICIAN OR PROVIDER
- Texas Section 843.354 - Legislative Declaration
It is the intent of the legislature that the requirements contained in this subchapter regarding payment of claims to providers who are pharmacists or pharmacies...
- Texas Section 843.361 - Enrollees Held Harmless
A contract or other agreement between a health maintenance organization and a physician or provider must specify that the physician or provider will hold an...
- Texas Section 843.362 - Continuity Of Care; Obligation Of Health Maintenance Organization
(a) In this section, "special circumstance" means a condition regarding which a treating physician or provider reasonably believes that discontinuing care by that physician or...
SUBCHAPTER L FINANCIAL REGULATION OF HEALTH MAINTENANCE ORGANIZATIONS
- Texas Section 843.363 - Protected Physician Or Provider Communications With Patients
(a) A health maintenance organization may not, as a condition of a contract with a physician, dentist, or provider, or in any other manner, prohibit,...
- Texas Section 843.401 - Fiduciary Responsibility
A director, officer, member, employee, or partner of a health maintenance organization who receives, collects, disburses, or invests funds in connection with the activities of...
- Texas Section 843.402 - Officers' And Employees' Bond
(a) A health maintenance organization shall maintain in force in its own name a fidelity bond on its officers and employees in an amount of...
- Texas Section 843.403 - Minimum Net Worth
(a) A health maintenance organization authorized to provide basic health care services shall maintain a minimum net worth of $1.5 million. (b) A health maintenance...
- Texas Section 843.404 - Additional Net Worth Requirements
(a) The commissioner may adopt rules or by rule establish guidelines requiring a health maintenance organization to maintain a specified net worth based on: (1)...
- Texas Section 843.405 - Deposit With Comptroller
(a) Unless otherwise provided by this section, a health maintenance organization shall deposit with the comptroller cash or securities, or any combination of cash, securities,...
- Texas Section 843.406 - Hazardous Financial Condition
(a) If the financial condition of a health maintenance organization indicates that the continued operation of the health maintenance organization could be hazardous to its...
- Texas Section 843.407 - Receivership And Delinquency Proceedings
(a) In addition to all other remedies available by law, if the commissioner believes that a health maintenance organization or another person is insolvent or...
- Texas Section 843.408 - Insolvency And Allocation To Other Health Maintenance Organizations
(a) If a health maintenance organization becomes insolvent, the commissioner shall equitably allocate the insolvent health maintenance organization's group contracts and nongroup enrollees among all...
- Texas Section 843.409 - Examination Expenses
(a) A credit against the amount of premium taxes to be paid by a health maintenance organization in a taxable year may not be allowed...
SUBCHAPTER N ENFORCEMENT
- Texas Section 843.410 - Assessments
(a) To provide funds for the administrative expenses of the commissioner regarding rehabilitation, liquidation, supervision, conservatorship, or seizure of a health maintenance organization in this...
- Texas Section 843.461 - Enforcement Actions
(a) After notice and opportunity for a hearing, the commissioner may: (1) suspend or revoke a certificate of authority issued to a health maintenance organization...
- Texas Section 843.462 - Operations During Suspension Or After Revocation Of Certificate Of Authority
(a) During the period a certificate of authority of a health maintenance organization is suspended, the health maintenance organization may not: (1) enroll additional enrollees...
- Texas Section 843.463 - Injunctions
If the commissioner believes that a health maintenance organization or another person is violating or has violated this chapter or a rule adopted under this...
- Texas Section 843.464 - Criminal Penalty
(a) A person, including an agent or officer of a health maintenance organization, commits an offense if the person: (1) wilfully violates this chapter or...