| (a) Order of contents. The application must include
the items in the order listed in this section.
(b) Original and copies. An applicant filing a nonelectronic
application must submit two additional copies of the application along
with the original application.
(c) General contents. An application must include:
(1) a declaration executed under oath or affirmation
by an officer or other authorized representative of the HCC certifying
that the collection of any confidential information for purposes of
satisfying filing requirements of this subchapter was made in accord
with the confidentiality requirements of §13.426 of this title
(relating to Confidentiality);
(2) a completed application for certificate of authority;
(3) the basic organizational documents and any amendments
to them, complete with the original incorporation certificate with
charter number and seal indicating certification by the secretary
of state, if applicable;
(4) the bylaws, rules, or any similar documents regulating
the conduct of the internal affairs of the applicant, certified by
an officer or other authorized representative of the applicant HCC;
(5) a plan of operation for the HCC, including an overview,
history, types of health care service offered, and operations provisions
that include pro-competitive strategies of the HCC;
(6) information about officers, directors, and staff:
(A) a completed officers and directors page; and
(B) biographical data forms for all individuals who
are to be responsible for the day-to-day conduct of the affairs of
the applicant;
(7) separate organizational charts or lists, as described
in subparagraphs (A) - (C) of this paragraph:
(A) charts clearly identifying the contractual relationships
involved in the applicant's health care delivery system and between
the applicant and any affiliates, and a list of contracts to provide
services between the applicant and the affiliates;
(B) a chart showing the internal organizational structure
of the applicant's management and administrative staff; and
(C) for the purposes of this paragraph, the information
provided must clearly identify any relationship between the HCC and
any affiliate or other organization if a common individual or entity
directly or indirectly controls 10 percent or more of both the HCC
and the affiliate or other organization;
(8) notice of the physical address in Texas of all
books and records described in §13.415 of this title (relating
to Documents to be Available for Quality of Care and Financial Examinations);
and
(9) a description of the information systems, management
structure, and personnel that demonstrates the applicant's capacity
to meet the needs of patients and participants and to meet the requirements
of regulatory and contracting entities.
(d) Financial information. An application must include
financial and financially-related information consisting of the following:
(1) projected financial statements, including a balance
sheet, income statement, and cash flow statement. Additionally:
(A) the projected data must be provided for two consecutive
annual reporting periods;
(B) the financial statements must include the identity
and credentials of the individual making the projections; and
(C) the projected data must reflect compliance with §13.431
of this title (relating to Reserves and Working Capital Requirements);
(2) a balance sheet reflecting actual assets and liabilities,
and net assets sufficient to comply with §13.431 of this title;
(3) the form, including any proposed payment methodology,
of any contract between the applicant and any payor that addresses
the applicant arranging for medical and health care services for the
payor in exchange for payments in cash or in kind as provided in Insurance
Code Chapter 848;
(4) if applicable, insurance or other protection, or
both, against insolvency and:
(A) any reinsurance agreement and any other agreement
described in Insurance Code §848.102 covering the cost of a potential
significant event or catastrophe; and
(B) any other arrangements offering protection against
insolvency;
(5) proof of the applicant's maintenance of a fidelity
bond or similar officer and employee antifraud protection as provided
in §13.473(d) of this title (relating to Organization of an HCC);
and
(6) authorization for disclosure to the commissioner
of the financial records of the applicant and affiliates to confirm
assets.
(e) Provider and service area information. An application
must include:
(1) a description and a map of the service area, with
key and scale, that identifies the county or counties, or portions
of the county or counties, to be served. If the original map is in
color, all copies also must be in color;
(2) network configuration information, including maps
demonstrating the location and distribution of the participants by
physician type and provider type within the proposed service area
by county, counties, or ZIP code(s); lists of participants in Excel-compatible
format, including business address, county, license type and specialization,
hospital admission privileges, and an indication of whether they are
accepting new patients;
(3) the identity of any integrated practice group or
independent practice association to which any participant belongs,
including the group's name, business address, type of legal organization,
and approximate number of members;
(4) for each participating facility:
(A) the facility's name and business address;
(B) a description of the services provided by the facility;
and
(C) a statement as to whether the facility's agreement
with the HCC allows the facility to contract or affiliate with other
HCCs;
(5) the form of any contract or monitoring plan between
the applicant and:
(A) any individual listed on the officers and directors
page;
(B) any delegated entity, delegated network, or delegated
third party as described in Insurance Code Chapter 1272; or any other
physician or health care provider, plus the form of any subcontract
between those individuals or entities and any physician or health
care provider to provide health care services. All contracts must
include a hold-harmless provision that complies with Insurance Code §843.361
and §1301.060, as applicable, for the protection of patients
covered by health benefit plans;
(C) any exclusive agent or agency; or
(D) any individual or entity who will perform management,
marketing, administrative, data processing, or claims processing services;
and
(6) a written description of the types of compensation
arrangements, such as compensation based on fee-for-service arrangements,
risk-sharing arrangements, prepaid funding arrangements, or capitated
risk arrangements, made or to be made with physicians and health care
providers in exchange for the provision of, or the arrangement to
provide, health care services to patients, including any financial
incentives for physicians and health care providers.
(f) Quality assurance and quality improvement information.
An application must include a detailed description of the policies
and processes contained in the quality assurance and quality improvement
program required by §13.482 of this title (relating to Quality
Assurance and Quality Improvement).
(g) Accreditation disclosure. If an HCC has attained
accreditation from a nationally recognized accrediting body such as
the National Committee for Quality Assurance, URAC, or the Accreditation
Association for Ambulatory Health Care, the HCC must disclose:
(1) the name of the accrediting body;
(2) the date accreditation was granted;
(3) the accreditation level;
(4) current accreditation status; and
(5) a copy of the accreditation report.
(h) Antitrust analysis information required of all
applicants. An application must include:
(1) for each participant in the HCC, disclosure of
any known past or pending investigation, or administrative or judicial
proceeding, in which it is alleged that the participant has engaged
in any form of price-fixing or other antitrust violation, or health
care fraud or abuse, including any governmental or private investigations,
lawsuits, and any judgments, fines, or penalties relating to those
allegations;
(2) identification of each common service provided
by participants, grouped by:
(A) specific Medicare specialty code for each specialty
of any participating physician or health care provider;
Cont'd... |
