| (a) After the issuance of a certificate of authority,
each HCC must file certain information with the commissioner, either
for approval prior to effectuation or for information only, as provided
in this section.
(b) In accord with Insurance Code §848.060(e),
an HCC must report to the department a material change in the size,
composition, or control of the HCC.
(c) An HCC must make the filings outlined in paragraphs
(2) and (3) of this subsection and in §13.423 of this title (relating
to Service Area Change Applications). These requirements include filing
changes necessitated by federal or state law or regulations.
(1) Complete filings required. The department will
not accept a filing for review until the filing is complete.
(2) Filings requiring approval. After the issuance
of a certificate of authority, an HCC must file for approval with
the commissioner a written request to implement or modify the following
operations or documents and receive the commissioner's approval prior
to effectuating those modifications:
(A) a description and a map of the service area, with
key and scale, that identifies the county, counties, or portions of
counties to be served;
(B) any material change in size, composition, or control
of the HCC;
(C) proposed dividends for any calendar year that if
declared and paid will, individually and in the aggregate, have a
distribution value equal to or exceeding the greater of:
(i) 10 percent of the HCC's net asset value for the
prior year; or
(ii) 10 percent of the HCC's net income for the prior
year;
(D) any new or revised loan agreements evidencing loans
made by the HCC to any affiliated individual or entity or to any physician
or health care provider, whether providing services currently, previously,
or potentially in the future; and any guarantees of any affiliated
individual's or entity's or of any physician's or health care provider's
obligations to any third party;
(E) a copy of any proposed material amendment to basic
organizational documents; however, if the approved amendment must
be filed with the secretary of state, an original or a certified copy
of the document with the original file mark of the secretary of state
must be filed with the commissioner;
(F) a copy of any material amendments to bylaws of
the HCC, with a notarized certification bearing the original or electronic
signature of the corporate secretary of the HCC that it is a true,
accurate, and complete copy of the original;
(G) any name, or assumed name, on a form, as specified
in §13.404 of this title (relating to Use of the Term "HCC;"
Service Mark; Trademarks; d/b/a);
(H) original or renewal service contracts and management
agreements, the terms of which must comply with Insurance Code §823.101
as if the HCC were an insurer; and
(I) any proposed new or revised payment methodology
for use in any contract between the HCC 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.
(3) Filings for information. Material filed under this
paragraph is not to be considered approved, but may be subject to
review for compliance with Texas law and consistency with other HCC
documents. On or before 30 days after the effective date of a change,
an HCC must file with the commissioner, for information only, deletions
and modifications to the following previously approved or filed operations
and documents:
(A) the list of officers and directors, a biographical
data sheet for each individual listed on the officers and directors
page, and biographical affidavit forms in §13.413(c)(6)(A) and
(B) of this title (relating to Contents of the Application);
(B) any change in the physical address of the books
and records described in §13.415 of this title (relating to Documents
to be Available for Quality of Care and Financial Examinations);
(C) any new trademark or service mark or any changes
to an existing trademark or service mark;
(D) a copy of the form of any new contract or subcontracts
or any substantive changes to previously filed copies of forms of
all contracts described in §13.413(d)(3) and (e)(5) of this title,
not including management agreements or proposed new or revised payment
methodologies filed for approval, with amended contract forms accompanied
by an additional copy of the contract form that reflects the revisions
made;
(E) notice of the cancellation of any management contracts
described in §13.413(e)(5)(D) of this title;
(F) any insurance contracts or amendments to those
contracts, guarantees, or other protection against insolvency, including
the stop-loss or reinsurance agreements, if changing the insurer or
description of coverage, as described in §13.413(d)(4)(A) of
this title;
(G) any change in the affiliate chart as described
in §13.413(c)(7) of this title;
(H) modifications to any 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
providers. The HCC must maintain the confidentiality of these compensation
arrangements;
(I) any material change in network configuration; and
(J) a description of the quality assurance and quality
improvement program, as set forth in §13.481 and §13.482
of this title (relating to Quality Improvement Structure for HCCs
and Quality Assurance and Quality Improvement, respectively).
(4) Approval period. Any modification for which commissioner's
approval is required is considered approved unless disapproved within
60 days from the date the filing is determined by the department to
be complete. The commissioner may postpone the action for a period
not to exceed 60 days, as necessary for proper consideration. The
commissioner will notify the HCC by letter of any postponement. The
commissioner, after notice and opportunity for hearing, may withdraw
approval of a filing made under paragraph (2) of this subsection or
reject any informational filing made under paragraph (3) of this subsection.
(5) Filing review procedure. Within 20 days from the
department's receipt of an initial filing for commissioner's approval
under this section, the department will determine whether the filing
is complete or incomplete for purposes of acceptance for review and,
if found to be incomplete, the department will issue a written notice
in paper or electronic form to the HCC of its incomplete filing.
(A) Incomplete filing. The written notice of an incomplete
filing will state that the filing is not complete and has not been
accepted for review. In addition, the notice will specify the information,
documentation, and corrections necessary to make the filing complete
for purposes of this section. If a filing is resubmitted in whole
or in part and is still incomplete, an additional written notice will
be issued. The notice will specify the corrections or information
necessary for completeness and state that the 60-day period for official
action will not begin until the date the department determines the
filing to be complete. If a filing is not resubmitted within 30 days
of the date of the written notice of incompleteness, the department
will consider the filing withdrawn and will close it.
(B) Processing of complete filing. The department will
in writing approve or disapprove a complete filing within the period
of time set forth in paragraph (4) of this subsection, beginning on
the date the filing is determined to be complete. The HCC may waive
in writing the deemed approval time line set forth in paragraph (4)
of this subsection.
(C) Conversion to renewal review. If the filing by
the HCC under this subsection is sufficiently material, the department
may require the HCC to file an application for renewal before the
date required by Insurance Code §848.060(a).
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