(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.
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