Sec. 843.078. CONTENTS OF APPLICATION. (a) An application for a certificate of authority must include:
(1) a copy of the applicant's basic organizational document, if any, such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents;
(2) all amendments to the applicant's basic organizational document; and
(3) a copy of the bylaws, rules and regulations, or similar documents, if any, regulating the conduct of the applicant's internal affairs.
(b) An application for a certificate of authority must include a list of the names, addresses, and official positions of the persons responsible for the conduct of the applicant's affairs, including:
(1) each member of the board of directors, board of trustees, executive committee, or other governing body or committee;
(2) the principal officer, if the applicant is a corporation; and
(3) each partner or member, if the applicant is a partnership or association.
(c) An application for a certificate of authority must include a copy of any independent contract or other contract made or to be made between the applicant and any physician, provider, or person listed under Subsection (b).
(d) An application for a certificate of authority must include:
(1) a copy of the form of evidence of coverage to be issued to an enrollee;
(2) a copy of the form of the group contract, if any, to be issued to an employer, union, trustee, or other organization; and
(3) a written description of health care plan terms made available to any current or prospective group contract holder or current or prospective enrollee of the health maintenance organization in accordance with Section 843.201.
(e) An application for a certificate of authority must include a financial statement that is current on the date of the application and that includes:
(1) the sources and application of funds;
(2) projected financial statements during the initial period of operations;
(3) a balance sheet reflecting the condition of the applicant on the date operations are expected to start;
(4) a statement of revenue and expenses with expected member months; and
(5) a cash flow statement that states any capital expenditures, purchase and sale of investments, and deposits with the state.
(f) An application for a certificate of authority must include the schedule of charges to be used during the first 12 months of operation.
(g) An application for a certificate of authority must include a statement acknowledging that lawful process in a legal action or proceeding against the health maintenance organization on a cause of action arising in this state is valid if served in accordance with Chapter 804.
(h) An application for a certificate of authority must include a statement reasonably describing the service area or areas to be served by the applicant.
(i) An application for a certificate of authority must include a description of the complaint procedures the applicant will use.
(j) An application for a certificate of authority must include a description of the procedures and programs to be implemented by the applicant to meet the quality of health care requirements of this chapter and:
(1) Section 1367.053;
(2) Subchapter A, Chapter 1452;
(3) Subchapter B, Chapter 1507; and
(k) An application for a certificate of authority must include network configuration information, including an explanation of the adequacy of the physician and other provider network configuration. The information provided must:
(1) include the names of physicians, specialty physicians, and other providers by zip code or zip code map; and
(2) indicate whether each physician or other provider is accepting new patients from the health maintenance organization.
(l) An application for a certificate of authority must include a written description of the types of compensation arrangements, such as compensation based on fee-for-service arrangements, risk-sharing arrangements, or capitated risk arrangements, made or to be made with physicians and providers in exchange for the provision of or an arrangement to provide health care services to enrollees, including any financial incentives for physicians and providers. The compensation arrangements are confidential and are not subject to the public information law, Chapter 552, Government Code.
(m) An application for a certificate of authority must include documentation demonstrating that the applicant will comply with Section 1271.005(c).
(n) An application for a certificate of authority must include any other information that the commissioner requires to make the determinations required by this chapter and:
(1) Section 1367.053;
(2) Subchapter A, Chapter 1452;
(3) Subchapter B, Chapter 1507;
(4) Chapters 222, 251, and 258, as applicable to a health maintenance organization; and
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.036, eff. April 1, 2009.