(a) The commissioner may require additional information
from the HCC or any participant in the HCC as reasonably necessary
to make any determination required by Insurance Code Chapter 848,
this subchapter, and applicable insurance laws and regulations of
this state.
(b) The commissioner may require any or all of the
additional information set forth in subsection (c) of this section.
An HCC or HCC participant is not required to create the items listed
in subsection (c) of this section unless and except as the commissioner
requires the items to be provided under this section. Once created,
the documents must be maintained by the HCC or participant for at
least five years.
(c) Additional information the commissioner may require
includes the following:
(1) underlying documentation or data supporting any
information, reports, or memoranda submitted to the department under
the Insurance Code or this title;
(2) contact information for current participants or
employees of the HCC, and last known contact information for former
participants or employees;
(3) interviews by the department with individuals affiliated
with the HCC or HCC participants;
(4) any participant's agendas, minutes, recordings,
summaries, handouts, or presentations to the HCC;
(5) documents relating to past, current, or planned
fees, risk-sharing, fee schedules, fee conversion factors, withholds,
capitation, pricing plans, pricing strategies, or other forms of payment;
(6) documents relating to planned additions to the
participation in the HCC or expansions of participants in the HCC;
(7) de-identified information regarding utilization
of services by the HCC's patients or participants, including both
medical and financial information;
(8) current bylaws, rules, or regulations of an HCC
participant's professional staff or any of its departments or subunits;
(9) questionnaires submitted by participants to applicable
professional associations in connection with annual surveys of association
members, and to any other association, accreditation agency, or government
agency, in connection with any annual or other periodic survey of
the participant;
(10) reports prepared by accreditation agencies in
connection with accreditation of the HCC or any HCC participant;
(11) revenue-and-cost reports, profitability reports,
and other financial reports;
(12) internal or external reports relating to quality
of care at any health care service location in each service area by
the HCC or its participants, including:
(A) data or reports submitted to or received from or
by quality rating organizations;
(B) quality-of-care initiatives;
(C) quality assurance or quality improvement systems;
and
(D) the effect of changes in health care service location
quality on patient volume and revenue;
(13) financial reports regularly prepared by or for
the HCC applicant on any periodic basis relating to any arranged health
care service;
(14) memoranda, excluding engineering and architectural
plans and blueprints, relating to plans of the HCC applicant, or any
participant, for the construction of new facilities, the closing of
any existing facilities, or an expansion, a conversion, or a modification
of current facilities;
(15) memoranda relating to plans of, or steps undertaken
by the HCC applicant or any participant for any acquisition, divestiture,
joint venture, alliance, or merger involving any participant in the
service area other than the application for certificate of authority
of the applicant;
(16) memoranda analyzing or discussing the effect of
any merger, joint venture, acquisition, or consolidation of HCCs in
the applicant's service area, including the HCC's application if approved,
on the HCC's prices, costs, margins, service quality, or any other
aspect of competitive performance, including:
(A) memoranda comparing the actual cost savings or
other benefits of the transactions to those previously projected;
and
(B) memoranda discussing how the benefits were or might
be achieved;
(17) a description relating to the consolidation or
realignment of any medical and health care services arranged by or
through the applicant whether completed, in progress, or planned among
the participants;
(18) the names and addresses of all contracting physicians,
in Excel-compatible format;
(19) documents created or used by, for, or on behalf
of the applicant for the purpose of soliciting physicians or health
care providers to join the applicant as an employee or participant,
promoting continued participation in the applicant, or otherwise offering,
promoting, or advertising the applicant's services or activities on
behalf of physicians or health care providers, and all documents supplied
by the HCC to newly recruited physicians or health care providers;
(20) contracts between the HCC applicant or any of
its participants and any private payor, all attachments to the contracts,
and all documents relating to the contracts, including:
(A) documents sufficient to show the name, contact
person, and telephone number of each health plan contracting with
the applicant for physician services;
(B) documents relating to fees, fee schedules, fee
conversion factors, withholds, capitation, pricing plans, pricing
strategies, or other forms of payment;
(C) documents discussing actual or potential negotiations,
offers, or responses to any contract, fee schedule, or risk-sharing
arrangement with a third-party payor;
(D) copies of internal memoranda relating to:
(i) the development or negotiation of contracts with
payors or participants, and internal HCC decisions regarding negotiating
positions;
(ii) competition to obtain contracts;
(iii) decisions to terminate contracts;
(iv) draft, contingent, or expired contracts, including
contracts not entered into, not yet finalized or in force, or no longer
in force; and
(v) contract amendments or modifications; and
(E) the beginning date and termination date, as applicable,
for each contract;
(21) documents relating to plans, interests, or steps
undertaken by the HCC applicant for any acquisition, divestiture,
joint venture, alliance, collaboration, license, or merger with any
HCC or other health care provider, including:
(A) any notes or minutes taken; or
(B) reports, memoranda, or correspondence regarding
meetings between the HCC applicant and any other HCC or other health
care provider;
(22) documents reflecting:
(A) actual or planned lease, management contract, or
other agreement for the HCC applicant to operate a facility in the
service area that is, or will be, owned in whole or in part by another
individual or entity; and
(B) formal or informal commercial or operational relationships
or affiliations that have existed, exist, or are planned between or
among any facilities, or facilities and any physician organizations
in the service area, including purchases by the HCC applicant of services
from other facilities or from physician organizations, and vice versa;
(23) for each participant, summaries and interpretations
of contract terms and methodologies used to determine the payment
due to the participant under a contract with a payor in effect at
any time during the previous three years for each treatment, office
visit, or other medical or health care service provided or delivered
in the service area;
(24) a list and description by Current Procedural Technology
code, if available, of each medical or health care service arranged
by or through the applicant in the HCC's service area, and for each
code listed, a statement of:
(A) the number of procedures performed;
(B) the amount of revenue received by the applicant;
(C) the ZIP code for each patient receiving the procedure
or service; and
(D) the location of the office where the procedure
or service was performed; and
(25) documents reflecting participants' contribution
margins or identifying or quantifying fixed or variable costs for
the provision of any health care service in the service area.
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