| (a) In addition to any other actions available under
the Insurance Code, the commissioner may take action against an HMO
under §843.157 (concerning Rehabilitation, Liquidation, Supervision,
or Conservation of Health Maintenance Organizations) and Insurance
Code §843.461 (concerning Enforcement Actions). In evaluating
the conditions in this section, the commissioner will evaluate all
relevant circumstances concerning the HMO's operation. The evaluation
of the information relating to these conditions is a part of the examination
process. The conditions listed in this section do not conclusively
indicate that action must be taken. One or more of the conditions
can exist in an HMO that is in satisfactory condition; however, one
or more of these conditions has often been found in an HMO that was
unable to perform its obligations to enrollees, creditors, or the
general public, or has required the commissioner to initiate regulatory
action to protect enrollees, creditors, and the general public.
(b) The commissioner may take action under this section,
if the commissioner finds that one or more of the conditions listed
below or in §8.3 of this title (relating to Hazardous Conditions
and Remedy of Hazardous Conditions) exist:
(1) an HMO's federal qualification designation, or
NCQA accreditation, or both, are revoked or discontinued;
(2) an HMO's reported claims in process exceed 12 percent
of annualized medical and hospital expenses (12 percent is approximately
a 45-day backlog);
(3) an HMO fails to comply with Insurance Code Chapter
843 (concerning Health Maintenance Organizations), this chapter, or
other applicable insurance laws and regulations of this state;
(4) an HMO has an inadequate provider network;
(5) an HMO contracts with a management or administrative
company on a capitated or percentage of premium basis and the administrative
or management company refuses to submit financial statements to the
HMO;
(6) a physician or provider that is under contract,
directly or indirectly, with an HMO, has a pattern of balance billing;
or
(7) an HMO does not have the minimum net worth required
by Insurance Code §843.403 (concerning Minimum Net Worth) and §11.802
of this title (relating to Minimum Net Worth).
(c) This section does not affect the commissioner's
authority to take or order any other appropriate action under the
commissioner's authority in the Insurance Code.
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