After the commissioner issues an HMO's certificate of authority,
the HMO is required to file with the commissioner, either for approval
before effect or for information only, any items specified in §11.204
of this title (relating to Contents) that the HMO has deleted, amended,
or revised as outlined in paragraphs (4) and (5) of this section and
any items specified in §11.302 of this title (relating to Service
Area Expansion or Reduction Applications). These requirements include
filing changes made necessary by federal or state law or regulations.
All requirements in this section apply to both electronic and paper
filings unless stated otherwise.
(1) Completeness and format of filings.
(A) The department will not accept a filing for review
until the filing is complete. An application to modify an approved
application for a certificate of authority that requires the commissioner's
approval under Insurance Code §843.080 (concerning Modification
or Amendment of Application Information) or Insurance Code Chapter
1271, Subchapter C, (concerning Commissioner Approval) is considered
complete when all information required by this section; §11.302;
and Chapter 11, Subchapter T, of this title (relating to Quality of
Care) that is applicable and reasonably necessary for the department
to make a final determination has been filed.
(B) Unless otherwise required by this chapter or the
Insurance Code, an HMO may submit a filing electronically through
the NAIC's System for Electronic Rate and Form Filing or through any
other method acceptable to the department.
(C) Unless otherwise required by this chapter or the
Insurance Code, paper filings must:
(i) be submitted on 8-1/2- by 11-inch paper;
(ii) not be submitted in bound booklets;
(iii) be legible;
(iv) be in typewritten, computer generated, or printer's
proof format; and
(v) except for maps, not contain any color highlighting
unless accompanied by a clean copy without highlighting.
(D) As provided in this section, an HMO may submit
some filings as provided in §7.201 of this title (relating to
Forms Filings).
(E) As provided in this section, an HMO may submit
some filings as provided in §11.203(a) of this title (relating
to Revisions During Review Process).
(2) Identifying form numbers required. Each item required
to be filed by paragraphs (4) and (5) of this section must be identified
by a printed unique form number, adequate to distinguish it from other
items. The identifying form numbers must be composed of a total of
no more than 40 letters, numbers, symbols, or spaces.
(A) The identifying form number must appear in the
lower left-hand corner of the page. In the case of a multiple-page
document, the identifying form number must only appear on the lower
left-hand corner of the first page, and page numbers should appear
on subsequent pages.
(B) If an item is to be replaced or revised after issuance
of a certificate of authority, a new identifying form number must
be assigned.
(i) A change in address or phone number on a form will
not require a new identifying form number.
(ii) A new edition date added to the original identifying
form number is an acceptable way of revising the number so that it
is identifiable from any previously approved item; for example, if
"G-100" was the originally approved number, then the revision may
be numbered "G-100 12/79."
(iii) Changing the case of the suffix is not considered
to be a change in the number; for example, "ED" and "ed," or "REV"
and "rev" are the same for form numbering purposes.
(3) Attachments for filings. Filings required by paragraphs
(4)(A) and (B) and (5)(A) and (B) of this section must be accompanied
by the following:
(A) an HMO certification and transmittal form for each
new, revised, or replaced item;
(B) the supporting documentation considered necessary
by the commissioner to review the filing and, for filings submitted
on paper, a cover letter which includes the following:
(i) company name;
(ii) form numbers that are being submitted; and
(iii) a paragraph that describes the type of filing
being submitted, along with any additional information that would
aid in processing the filing, including the reasons for submitting
the filing; and
(C) the applicable filing fee as determined by §7.1301
of this title (relating to Regulatory Fees), unless the filing is
made electronically through the NAIC's System for Electronic Rate
and Form Filing, in which case the fees should not be attached to
the filing. For filings made electronically, the department will send
an invoice for the fees, and the HMO must pay, as provided in §7.1302
of this title (relating to Billing System).
(4) Filings requiring approval. After issuance of a
certificate of authority, each HMO must file with the commissioner,
using the method specified below, a written request to implement or
modify the following operations or documents and receive the commissioner's
approval before putting the modifications into effect:
(A) electronically through the NAIC's System for Electronic
Rate and Form Filing:
(i) evidence of coverage filings, as described in §11.501
of this title (relating to Contents of the Evidence of Coverage);
(ii) a description and a map of the service area, with
key and scale, which must identify the county or counties or portions
of counties to be served;
(iii) the written description of health care plan terms
and conditions made available to any current or prospective group
contract holder and current or prospective enrollee of the HMO, including
the member handbook for all plans other than Children's Health Insurance
Program (CHIP) plans in compliance with the requirements of Insurance
Code §843.201 (concerning Disclosure of Information About Health
Care Plan Terms) and §11.1600 of this title (relating to Information
to Prospective and Current Contract Holders and Enrollees); and
(iv) any material change in the HMO's emergency care
procedures;
(B) on paper or electronically through the NAIC's System
for Electronic Rate and Form Filing or any other method acceptable
to the department:
(i) any material change in network configuration; and
(ii) if a material change in the network configuration
results in the HMO's inability to comply with the network adequacy
standards described in §11.1607 of this title (relating to Accessibility
and Availability Requirements), an access plan that complies with
that section;
(C) as provided in §7.201 of this title:
(i) the form of all contracts described in §11.204(14)(A),
(C), (D), and (E) of this title, including any amendments to those
contracts and prior notification of the cancellation of any management
contracts in §11.204(14)(E) of this title;
(ii) the form of all contracts or subcontracts between
affiliated physician and provider groups with the individual members
of the groups providing health care services to the HMO's enrollees
described in §11.204(14)(B) of this title, including any amendments
to those contracts;
(iii) any new or revised loan agreements or amendments
documenting loans made by the HMO to any affiliated person or to any
medical or other health care physician or provider, whether providing
services currently, previously, or potentially in the future; and
any guarantees of any affiliated person's, physician's, or provider's
obligations to any third party;
(iv) any agreement by which an affiliate agrees to
handle an HMO's investments under §11.806 of this title (relating
to Investment Management by Affiliate Corporation);
(v) any change in the physical address of the books
and records described in §11.205 of this title (relating to Additional
Documents to be Available for Review);
(vi) any change to any of the requirements for guarantees
under §11.810 of this title (relating to Guarantee from a Sponsoring
Organization);
(vii) any insurance contracts or amendments, guarantees,
or other protection against insolvency, including the stop-loss or
reinsurance agreements, if changing the carrier or description of
coverage, between the HMO and affiliates, as described in §11.204(16)
of this title; and
(viii) modifications to any type of affiliate compensation
arrangements, such as compensation based on fee-for-service arrangements,
risk-sharing arrangements, or capitated risk arrangements, made to
physicians and providers in exchange for the provision of, or the
arrangement to provide health care services to, enrollees, including
any financial incentives for physicians and providers;
Cont'd... |
