| (a) This section pertains to a managed care organization
(MCO) which the Health and Human Services Commission (HHSC) determines
has failed to comply with the terms of a contract to provide health
care services or dental services to members enrolled in the MCO.
(b) HHSC is responsible for identifying and investigating
contract deficiencies and violations, and taking corrective action
to remedy contract deficiencies and violations of an MCO. Corrective
actions may include assessment of liquidated damages, contract termination,
and/or any other sanction or remedy available under the terms and
conditions of the contract or state and federal law and regulations.
(c) If HHSC finds that performance issues, problems,
or deficiencies exist with an MCO, as those issues pertain or relate
to certain deliverable services, HHSC may investigate a claim of contract
violation and determine whether a contract violation has occurred
or currently exists.
(d) If HHSC determines that a contract violation has
occurred or currently exists, HHSC will decide on the appropriate
contract sanction or remedy to be imposed.
(e) If required by contract, HHSC will give written
notice to the MCO, describing the contract violation, the contract
sanction or remedy to be imposed, the method by which reimbursement
(if applicable) to HHSC will be made, and the time frame for resolution
of the issue.
(f) When a contract violation has been determined and
a sanction or remedy imposed, HHSC will post the following information
on HHSC's Internet website:
(1) the name and address of the MCO;
(2) a description of the contractual obligation the
MCO failed to meet;
(3) the date of determination of noncompliance;
(4) the date the sanction or remedy was imposed;
(5) the maximum sanction or remedy that may be imposed
under the contract for the violation; and
(6) the actual sanction or remedy imposed against the
MCO.
(g) HHSC will post and maintain the records required
by this section on HHSC's Internet website in English and Spanish.
HHSC will update the list of records on the website at least quarterly.
(h) The information posted on the website will be displayed
for twelve months (12) from the date of posting, or for twelve months
after completion of the contract sanction or remedy, whichever is
later.
(i) HHSC will not post information on HHSC's Internet
website that relates to a sanction or remedy while the sanction or
remedy is the subject of an administrative appeal or judicial review.
Nothing in this subsection creates or enlarges a right to an administrative
appeal or judicial review of a contract sanction or remedy.
(j) For purposes of this section, a contract sanction
or remedy includes assessment or imposition of one or more of the
following:
(1) assessment of a penalty;
(2) assessment of liquidated damages or other monetary
remedies;
(3) imposition of a corrective action plan;
(4) debarment;
(5) involuntary suspension of a contract or portion
of a contract; and/or
(6) involuntary termination of a contract or portion
of a contract.
(k) For purposes of this section, a sanction is not
considered to include:
(1) a vendor hold or similar temporary delay in payment;
or
(2) an agreed temporary remedial measure intended to
facilitate contract compliance.
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