(a) An original application or renewal application
will be processed pursuant to Insurance Code §§848.056 -
848.060 and §848.153.
(b) The department will conduct an examination as specified
in §13.421(a) of this title (relating to Examination; Fee for
Expenses) in conjunction with each application. If a hearing is held
in connection with an application, then the examination(s) will occur
prior to the date of the hearing.
(c) Application review will include a determination
of compliance with Insurance Code §848.057. The review of pro-competitive
benefits of the proposed or existing HCC in relation to anticompetitive
effects of market power increase will be in accord with established
antitrust principles of market power analysis.
(d) The commissioner has sole discretion to impose
restrictions on an HCC applicant's certificate of authority that are
deemed necessary to preserve competition. Examples of these restrictions
include the following:
(1) prohibiting the HCC applicant from including "anti-steering,"
"guaranteed inclusion," "product participation," "price parity," or
similar contractual clauses or provisions in its contracts with a
private payor;
(2) prohibiting the HCC applicant from tying sales,
explicitly or implicitly through pricing policies, of the HCC's services
to a private payor's purchase of other services from physicians or
health care providers outside of the HCC (and vice versa), including
providers affiliated with HCC participants;
(3) prohibiting contracting with HCC participants on
a basis that prevents or discourages them from contracting outside
the HCC, either individually or through other HCCs or provider networks;
(4) prohibiting restrictions on a private payor's ability
to provide its health plan enrollees with cost, quality, efficiency,
and performance information used by the HCC to aid enrollees in evaluating
and selecting physicians and health care providers in the health plan;
(5) prohibiting sharing with or among the HCC's participants
any competitively sensitive pricing or other data that could be used
to set prices or other terms for services that the participants provide
outside the HCC; and
(6) restricting the HCC's certificate of authority
to certain geographic areas or health care services.
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