Texas Insurance Code Title 8, Chapter 1272 - Delegation Of Certain Functions By Health Maintenance Organization
SUBCHAPTER A GENERAL PROVISIONS
- Texas Section 1272.001 - Definitions
(a) In this chapter: (1) "Delegated entity" means an entity, other than a health maintenance organization authorized to engage in business under Chapter 843, that...
SUBCHAPTER B DELEGATION AGREEMENTS
- Texas Section 1272.002 - Compliance Of Limited Provider Network Or Delegated Entity With Certain Legal Requirements
A limited provider network or delegated entity shall comply with each statutory or regulatory requirement that relates to a function assumed by or carried out...
- Texas Section 1272.051 - Applicability Of Subchapter
This subchapter does not apply to a group model health maintenance organization, as defined by Section 843.111. Added by Acts 2003, 78th Leg., ch. 1274,...
- Texas Section 1272.052 - Delegation Agreement Required
(a) A health maintenance organization that delegates a function required by this chapter, Chapter 843, 1271, or 1367, Subchapter A, Chapter 1452, or Subchapter B,...
- Texas Section 1272.053 - Monitoring Plan
A delegation agreement required by Section 1272.052 must establish a monitoring plan that: (1) allows the health maintenance organization to monitor compliance with the minimum...
- Texas Section 1272.054 - Requirements For Termination Without Cause
A delegation agreement required by Section 1272.052 must provide that the agreement cannot be terminated without cause by the delegated entity or the health maintenance...
- Texas Section 1272.055 - Collection Of Payments
A delegation agreement required by Section 1272.052 must prohibit the delegated entity and the physicians and providers with whom the entity has contracted from billing...
- Texas Section 1272.056 - Compliance With Statutory And Regulatory Requirements
A delegation agreement required by Section 1272.052 must provide that: (1) the agreement does not limit in any way the health maintenance organization's authority or...
- Texas Section 1272.057 - Examination By Commissioner
A delegation agreement required by Section 1272.052 must require the delegated entity to permit the commissioner to examine at any time any information the commissioner...
- Texas Section 1272.058 - Information Relating To Delegated Third Party
A delegation agreement required by Section 1272.052 must require the delegated entity to provide the license number of a delegated third party performing a function...
- Texas Section 1272.059 - Contracts With Delegated Third Party
A delegation agreement required by Section 1272.052 must provide that: (1) any agreement under which the delegated entity directly or indirectly delegates a function required...
- Texas Section 1272.060 - Utilization Review
A delegation agreement required by Section 1272.052 must provide that: (1) enrollees shall receive notification at the time of enrollment of which entity is responsible...
- Texas Section 1272.061 - Rights And Duties Of Delegated Entity And Health Maintenance Organization
A delegation agreement required by Section 1272.052 must provide that the delegated entity acknowledges and agrees that: (1) the health maintenance organization: (A) is required...
- Texas Section 1272.062 - Information To Be Provided By Delegated Entity To Health Maintenance Organization
(a) A delegation agreement required by Section 1272.052 must provide that: (1) except as provided by Subsection (b), the delegated entity shall make available to...
- Texas Section 1272.063 - Enrollee Complaints
(a) A delegation agreement required by Section 1272.052 must provide that: (1) if the delegated entity receives a complaint that does not involve emergency care,...
SUBCHAPTER C INFORMATION REPORTING TO DELEGATED ENTITY
- Texas Section 1272.064 - Rules
The commissioner may adopt rules as necessary to implement this subchapter. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
- Texas Section 1272.101 - Applicability Of Subchapter
This subchapter does not apply to a group model health maintenance organization, as defined by Section 843.111. Added by Acts 2003, 78th Leg., ch. 1274,...
- Texas Section 1272.102 - Reporting Required
(a) The commissioner shall determine the information a health maintenance organization shall provide to a delegated entity with which the health maintenance organization has entered...
SUBCHAPTER D RESERVE REQUIREMENTS
- Texas Section 1272.103 - Rules
The commissioner may adopt rules as necessary to implement this subchapter. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
- Texas Section 1272.151 - Applicability Of Subchapter
This subchapter does not apply to a group model health maintenance organization, as defined by Section 843.111. Added by Acts 2003, 78th Leg., ch. 1274,...
- Texas Section 1272.152 - General Reserve Requirements
(a) A delegated network shall maintain reserves adequate for the liabilities and risks assumed by the network, as computed in accordance with accepted standards, practices,...
- Texas Section 1272.153 - Reserve Requirements For Medical Care And Hospital Or Institutional Services
A delegated network that assumes under a delegation agreement both medical care and hospital or institutional services shall maintain reserves adequate to cover the liabilities...
- Texas Section 1272.154 - Reserve Requirements For Prescription Drugs
A delegated network that assumes financial risk for medical care or hospital or institutional services and for prescription drugs, as defined by Section 551. 003,...
- Texas Section 1272.155 - Form Of Reserves
The reserves required under this subchapter must be: (1) secured by and consist only of United States legal tender or bonds of the United States...
SUBCHAPTER E COMPLIANCE
- Texas Section 1272.156 - Escrow Account
(a) A delegated network required to maintain reserves under this subchapter shall establish an escrow account to pay claims and deposit the reserves into the...
- Texas Section 1272.201 - Applicability Of Subchapter
This subchapter does not apply to a group model health maintenance organization, as defined by Section 843.111. Added by Acts 2003, 78th Leg., ch. 1274,...
- Texas Section 1272.202 - Notice Of Noncompliance Or Hazardous Operating Condition
(a) If a health maintenance organization becomes aware of information that indicates a delegated entity with which the health maintenance organization has entered into a...
- Texas Section 1272.203 - Response To Notice
A delegated entity shall respond in writing to a request from a health maintenance organization under Section 1272.202 not later than the 30th day after...
- Texas Section 1272.204 - Cooperation Of Health Maintenance Organization
A health maintenance organization shall cooperate with a delegated entity to correct a failure by the entity to comply with the department's regulatory requirements relating...
- Texas Section 1272.205 - Examination By Department; Report
(a) On receipt of a notice under Section 1272.202 or if complaints are filed with the department, the department may conduct an examination regarding: (1)...
- Texas Section 1272.206 - Response To Department Report; Corrective Plan
The delegated entity and health maintenance organization shall respond to the department's report under Section 1272.205(b) and submit a corrective plan to the department not...
- Texas Section 1272.207 - Request For Corrective Action
The department may request at any time that a delegated entity take corrective action to comply with the department's statutory and regulatory requirements that: (1)...
- Texas Section 1272.208 - Authority Of Commissioner To Issue Order
(a) Regardless of whether a delegated entity complies with a request for corrective action under Section 1272.207, the commissioner may order a health maintenance organization...
- Texas Section 1272.209 - Public Documents
(a) Except as provided by Subsection (b), a report required under Section 1272.205(b) or corrective plan required under Section 1272.206 is a public document. (b)...
- Texas Section 1272.210 - Record Of Complaints; Report
(a) The department shall: (1) maintain enrollee and provider complaints in a manner that identifies complaints made about limited provider networks and delegated entities; and...
SUBCHAPTER F PENALTIES
- Texas Section 1272.211 - Rules
The commissioner may adopt rules as necessary to implement this subchapter. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
- Texas Section 1272.251 - Applicability Of Subchapter
This subchapter does not apply to a group model health maintenance organization, as defined by Section 843.111. Added by Acts 2003, 78th Leg., ch. 1274,...
- Texas Section 1272.252 - Suspension Or Revocation Of License Of Third-party Administrator Or Utilization Review Agent
Notwithstanding any other provision of this code or another insurance law of this state, the commissioner may suspend or revoke the license of a third-party...
- Texas Section 1272.253 - Sanctions And Penalties Against Health Maintenance Organization
The commissioner may impose sanctions or penalties under Chapters 82, 83, and 84 on a health maintenance organization that does not provide in a timely...
- Texas Section 1272.254 - Contractual Penalties Required
A health maintenance organization by contract shall establish penalties for a delegated entity that does not provide in a timely manner information required under a...
SUBCHAPTER G PROVISION OF SERVICES BY LIMITED PROVIDER NETWORK OR DELEGATED ENTITY
- Texas Section 1272.255 - Rules
The commissioner may adopt rules as necessary to implement this subchapter. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
- Texas Section 1272.301 - Access To Out-of-network Services
(a) A contract between a health maintenance organization and a limited provider network or delegated entity must provide that: (1) if medically necessary covered services...
- Texas Section 1272.302 - Continuity Of Care
(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...
Last modified: September 28, 2016