| (a) A regional or local health care program may apply to participate through the development and implementation of a regional or local health care program with benefit, operational and administrative provisions that meet or exceed the standards specified in this section. (b) A regional or local health care program participating in the Healthy Texas Program under this section must provide benefits and service levels for participating enrollees that meet or exceed those that are established by the commissioner for the benefit categories set forth in paragraphs (1) - (9) of this subsection. Such compliance must be certified by an authorized representative of the governing body of the regional or local health care program on a form and in the manner prescribed by the commissioner for the following categories of benefits and service levels: (1) an annual maximum benefit requirement per enrollee; (2) an annual maximum financial requirement prerequisite to payment of eligible claims of participating enrollees; (3) cost-sharing maximum requirements for benefits or services covered by or through a regional or local health care program; (4) an annual out-of-pocket maximum requirement; (5) hospital inpatient and outpatient benefits; (6) radiology and diagnostic tests; (7) emergency care; (8) maternity coverage with a limited copay for the initial prenatal visit; and (9) immunization coverage at 100 percent of cost. (c) A small employer participating in a regional or local health care program applying to participate in the Healthy Texas Program under this section must: (1) meet the small employer participation provisions of §26.521(a), (b), (d), (e)(1) and (g) - (k) of this subchapter (relating to Small Employer Participation); (2) have eligible employees that elect to participate in the Healthy Texas Program at a rate equal to or greater than 60 percent; and (3) contribute an amount of premium or program health care costs for employees which, when combined with any amount obtained from any other eligible source as provided in the Health and Safety Code §75.055, amounts to at least 50 percent of the premium or program health care costs for each employee covered under the health care program. (d) A regional or local health care program participating in the Healthy Texas Program under this section must meet the claims eligibility provisions of §26.562 of this subchapter (relating to Eligibility of Claims Paid for Reimbursement from the Fund), the response provisions to information requests under §26.563(b) of this subchapter (relating to Fund Administration), and the data filing requirements of §26.564 of this subchapter (relating to Data Filing Requirements) that apply to a health benefit plan issuer participating in the Healthy Texas Program. (e) A regional or local health care program participating in the Healthy Texas Program under this section shall, within 90 days of the end of its fiscal year, file the documents described in paragraphs (1) - (3) of this subsection with the commissioner in a form and manner prescribed by the commissioner: (1) financial statements audited by a certified public accountant; (2) an actuarial opinion prepared and signed by a qualified actuary who is a member of the American Academy of Actuaries. The actuarial opinion must opine on the adequacy of reserves in support of the program benefits and must include the amount of any additional reserves needed in order to render an unqualified opinion. A determination of adequacy must include a determination that a good and sufficient provision is made for all unpaid claims and other actuarial liabilities in support of the program benefits. In no event can the total reserves held be less than 20 percent of the total contributions in the preceding program operating year or less than 20 percent of the total estimated contributions for the current program operating year. Reserves must be maintained in cash or federally guaranteed obligations of less than five-year maturity that have fixed principal amounts; and (3) a report prepared and certified by the governing board or program operator. The certified report shall include a summary and description of the financial soundness of the regional or local health care program, including any actions the program is recommended to take or intends to implement to improve or to enhance the financial soundness of the program. |
