(a) This section pertains to a managed care organization (MCO) which the Health and Human Services Commission (HHSC) determines has failed to comply with the terms of a contract to provide health care services or dental services to members enrolled in the MCO.
(b) HHSC is responsible for identifying and investigating contract deficiencies and violations, and taking corrective action to remedy contract deficiencies and violations of an MCO. Corrective actions may include assessment of liquidated damages, contract termination, and/or any other sanction or remedy available under the terms and conditions of the contract or state and federal law and regulations.
(c) If HHSC finds that performance issues, problems, or deficiencies exist with an MCO, as those issues pertain or relate to certain deliverable services, HHSC may investigate a claim of contract violation and determine whether a contract violation has occurred or currently exists.
(d) If HHSC determines that a contract violation has occurred or currently exists, HHSC will decide on the appropriate contract sanction or remedy to be imposed.
(e) If required by contract, HHSC will give written notice to the MCO, describing the contract violation, the contract sanction or remedy to be imposed, the method by which reimbursement (if applicable) to HHSC will be made, and the time frame for resolution of the issue.
(f) When a contract violation has been determined and a sanction or remedy imposed, HHSC will post the following information on HHSC's Internet website:
  (1) the name and address of the MCO;
  (2) a description of the contractual obligation the MCO failed to meet;
  (3) the date of determination of noncompliance;
  (4) the date the sanction or remedy was imposed;
  (5) the maximum sanction or remedy that may be imposed under the contract for the violation; and
  (6) the actual sanction or remedy imposed against the MCO.
(g) HHSC will post and maintain the records required by this section on HHSC's Internet website in English and Spanish. HHSC will update the list of records on the website at least quarterly.
(h) The information posted on the website will be displayed for twelve months (12) from the date of posting, or for twelve months after completion of the contract sanction or remedy, whichever is later.
(i) HHSC will not post information on HHSC's Internet website that relates to a sanction or remedy while the sanction or remedy is the subject of an administrative appeal or judicial review. Nothing in this subsection creates or enlarges a right to an administrative appeal or judicial review of a contract sanction or remedy.
(j) For purposes of this section, a contract sanction or remedy includes assessment or imposition of one or more of the following:
  (1) assessment of a penalty;
  (2) assessment of liquidated damages or other monetary remedies;
  (3) imposition of a corrective action plan;
  (4) debarment;
  (5) involuntary suspension of a contract or portion of a contract; and/or
  (6) involuntary termination of a contract or portion of a contract.
(k) For purposes of this section, a sanction is not considered to include:
  (1) a vendor hold or similar temporary delay in payment; or
  (2) an agreed temporary remedial measure intended to facilitate contract compliance.

Source Note: The provisions of this §353.5 adopted to be effective May 1, 2007, 32 TexReg 2275; amended to be effective March 1, 2012, 37 TexReg 1283