(a) This section specifies circumstances under which
an applicant is not required to provide the information specified
in §13.413(i) of this title (relating to Contents of the Application)
in filing an original or renewal application for certificate of authority.
(b) An applicant is not required to provide the information
specified in §13.413(i) of this title if:
(1) for each PSA in which two or more individual or
group participants provide common services, the applicant's market
share is 35 percent or less; and
(2) no contract between the HCC and any participating
hospital restricts the HCC or hospital from contracting with other
HCCs, networks, hospitals, physicians, physician groups, health care
providers, or private payors.
(c) Notwithstanding the provisions of subsection (b)
of this section, an HCC that has a contract with a physician or health
care provider in a rural county as defined by the U.S. Census Bureau
and that does not restrict that physician's or health care provider's
ability to contract or deal with other HCCs, networks, physicians,
or health care providers is not required to provide the information
specified in §13.413(i) of this title, if the inclusion of the
physician or health care provider alone causes the HCC's share of
any common service to exceed 35 percent.
(d) Notwithstanding the provisions of subsection (b)
of this section, an HCC that includes a rural hospital but does not
restrict the hospital from contracting with other HCCs, networks,
physicians, or health care providers is not required to provide the
information specified in §13.413(i) of this title, if the inclusion
of the rural hospital alone causes the HCC's share of any common service
to exceed 35 percent.
(e) For purposes of this section, an HCC's market share
is determined by aggregating the market shares of its participants,
calculated as follows:
(1) for physicians or individual health care providers
within a particular health care specialty, by dividing the number
of physicians or individual health care providers in the specialty
within the HCC by the total number of physicians or health care providers
providing each of the common services within that health care specialty
within a participating physician's or health care provider's PSA;
(2) for outpatient services at a facility, by dividing
the number of physicians or health care providers participating in
the HCC within each PSA by the total number of physicians or health
care providers within each PSA that provide each common service;
(3) for hospital inpatient services, by dividing the
number of staffed hospital beds by particular medical specialty within
the hospital or group of hospitals as reported to the Texas Department
of State Health Services, for each common service area, by the total
number of staffed hospital beds by medical specialty within each participating
hospital's PSA; and
(4) if an HCC's participants can be classified as falling
within more than one of the categories set forth in paragraphs (1)
- (3) of this subsection, calculations must be made for all of the
categories within which the participants in the HCC provide services.
(f) Notwithstanding the definition of PSA in §13.402
of this title (relating to Definitions), a participant may calculate
market share through reference to the HCC's PSA for a health care
specialty rather than the participant's PSA if the participant demonstrates
to the commissioner's satisfaction that analysis of competition within
the HCC's PSA provides a more accurate measure of competition relating
to the participant in the context of the HCC than the analysis of
competition within the participant's PSA.
(g) Notwithstanding this section, on receipt of the
original or renewal application, the commissioner has discretion to
require an applicant to provide any or all of the information specified
in §13.413(i) of this title or §13.461 of this title (relating
to Commissioner's Authority to Require Additional Information), or
both, when the commissioner deems the information reasonably necessary
to conduct the review required under Insurance Code Chapter 848.
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