CHAPTER 847. HEALTH CARE QUALITY ASSURANCE - Texas Statutes

INSURANCE CODE

TITLE 6. ORGANIZATION OF INSURERS AND RELATED ENTITIES

SUBTITLE C. LIFE, HEALTH, AND ACCIDENT INSURERS AND RELATED

ENTITIES

CHAPTER 847. HEALTH CARE QUALITY ASSURANCE

Sec. 847.001. SHORT TITLE. This chapter may be cited as the

Health Care Quality Assurance Act.

Added by Acts 2005, 79th Leg., Ch.

789, Sec. 1, eff. June 17, 2005.

Sec. 847.002. LEGISLATIVE FINDINGS; PURPOSES. The legislature

finds that to ensure enrollees high quality care, many health

benefit plan issuers voluntarily undergo a rigorous accreditation

process conducted by nationally recognized accreditation

organizations. To maintain accreditation, these health benefit

plan issuers are subject to continuing review of their processes

and standards. The legislature recognizes that many of these

processes and standards are also reviewed by state agencies,

resulting in increased agency costs and increased health benefit

plan administrative costs. The purpose of this chapter is to

allow appropriate recognition of accreditation by nationally

recognized accreditation organizations and to foster coordination

among state agencies in order to:

(1) help make health benefit plan coverage more affordable for

consumers; and

(2) eliminate duplication of effort by both health benefit plan

issuers and state agencies.

Added by Acts 2005, 79th Leg., Ch.

789, Sec. 1, eff. June 17, 2005.

Sec. 847.003. DEFINITIONS. In this chapter:

(1) "Commission" means the Health and Human Services Commission.

(2) "Health benefit plan" means an individual, group, blanket,

or franchise insurance policy, a certificate issued under a group

policy, a group hospital service contract, or an individual or

group subscriber contract or evidence of coverage issued by a

health maintenance organization that provides benefits for health

care services. The term does not include:

(A) accident-only or disability income insurance coverage or a

combination of accident-only and disability income insurance

coverage;

(B) credit-only insurance coverage;

(C) disability insurance coverage;

(D) Medicare services under a federal contract;

(E) Medicare supplement and Medicare Select benefit plans

regulated in accordance with federal law;

(F) long-term care coverage or benefits, nursing home care

coverage or benefits, home health care coverage or benefits,

community-based care coverage or benefits, or any combination of

those coverages or benefits;

(G) workers' compensation insurance coverage or similar

insurance coverage;

(H) coverage provided through a jointly managed trust authorized

under 29 U.S.C. Section 141 et seq. that contains a plan of

benefits for employees that is negotiated in a collective

bargaining agreement governing wages, hours, and working

conditions of the employees that is authorized under 29 U.S.C.

Section 157;

(I) hospital indemnity or other fixed indemnity insurance

coverage;

(J) reinsurance contracts issued on a stop-loss, quota-share, or

similar basis;

(K) short-term major medical contracts;

(L) liability insurance coverage, including general liability

insurance coverage and automobile liability insurance coverage,

and coverage issued as a supplement to liability insurance

coverage, including automobile medical payment insurance

coverage;

(M) coverage for on-site medical clinics;

(N) coverage that provides other limited benefits specified by

federal regulations;

(O) coverage that provides limited scope dental or vision

benefits; or

(P) other coverage that:

(i) is similar to the coverage described by this subdivision

under which benefits for medical care are secondary or incidental

to other coverage benefits; and

(ii) is specified by federal regulations.

(3) "National accreditation organization" means:

(A) the Accreditation Association for Ambulatory Health Care;

(B) the Joint Commission on Accreditation of Healthcare

Organizations;

(C) the National Committee for Quality Assurance;

(D) the American Accreditation HealthCare Commission ("URAC");

or

(E) any other national accreditation entity recognized by rules

jointly adopted by the commissioner of insurance and the

executive commissioner of the commission.

Added by Acts 2005, 79th Leg., Ch.

789, Sec. 1, eff. June 17, 2005.

Sec. 847.004. APPLICABILITY OF CHAPTER. This chapter applies

only to an entity that issues a health benefit plan and that

holds a license or certificate of authority issued by the

commissioner and provides benefits for medical or surgical

expenses incurred as a result of a health condition, accident, or

sickness, including:

(1) an insurance company;

(2) a group hospital service corporation operating under Chapter

842;

(3) a health maintenance organization operating under Chapter

843;

(4) an approved nonprofit health corporation that holds a

certificate of authority issued by the commissioner under Chapter

844;

(5) a multiple employer welfare arrangement that holds a

certificate of authority under Chapter 846;

(6) a stipulated premium company operating under Chapter 884;

(7) a fraternal benefit society operating under Chapter 885; or

(8) a reciprocal exchange operating under Chapter 942.

Added by Acts 2005, 79th Leg., Ch.

789, Sec. 1, eff. June 17, 2005.

Sec. 847.005. PRESUMED COMPLIANCE WITH CERTAIN STATUTORY AND

REGULATORY REQUIREMENTS. (a) A health benefit plan issuer is

presumed to be in compliance with state statutory and regulatory

requirements if:

(1) the health benefit plan issuer has received nonconditional

accreditation by a national accreditation organization; and

(2) the national accreditation organization's accreditation

requirements are the same, substantially similar to, or more

stringent than the department's statutory or regulatory

requirements.

(b) A health benefit plan issuer that offers a Medicare

Advantage coordinated care plan under a contract with the federal

Centers for Medicare and Medicaid Services is presumed to be in

compliance with any state statutory and regulatory requirements

that are the same, substantially similar to, or more stringent

than the requirements for Medicare Advantage coordinated care

plans, as determined by the commissioner.

(c) If the department determines that a health benefit plan

issuer is in compliance with a state statutory or regulatory

requirement, the commission may presume that a Medicaid or state

child health plan program managed care plan offered by a health

benefit plan issuer under contract with the commission is in

compliance with any contractual Medicaid or state child health

plan program managed care plan requirement that is the same as,

substantially similar to, or more stringent than the state

statutory or regulatory requirement, as determined by the

commission.

(d) The commissioner may take appropriate action, including

imposition of sanctions under Chapter 82, against a health

benefit plan issuer who is presumed under Subsection (a), (b), or

(c) to be in compliance with state statutory and regulatory

requirements but does not maintain compliance with the same,

substantially similar, or more stringent requirements applicable

to the issuer under Subsection (a), (b), or (c).

(e) The department shall monitor and analyze periodically as

prescribed by rule by the commissioner updates and amendments

made to national accreditation standards as necessary to ensure

that those standards remain the same, substantially similar to,

or more stringent than the department's statutory or regulatory

requirements.

Added by Acts 2005, 79th Leg., Ch.

789, Sec. 1, eff. June 17, 2005.

Sec. 847.006. FILING OF ACCREDITATION REPORT; CONFIDENTIALITY

REQUIREMENTS. (a) The commissioner may require a health benefit

plan issuer to submit to the commissioner the accreditation

report issued by the national accreditation organization.

(b) An accreditation report submitted under Subsection (a) is

proprietary and confidential information under Chapter 552,

Government Code, and is not subject to subpoena. The

commissioner shall limit the disclosure of the accreditation

report to those department employees who need the accreditation

report to perform the duties of their job. A department employee

may not further disclose the accreditation report.

(c) The national accreditation organization recommendations

summary results are not proprietary information and are subject

to public disclosure under Chapter 552, Government Code.

Added by Acts 2005, 79th Leg., Ch.

789, Sec. 1, eff. June 17, 2005.

Sec. 847.007. DUTIES OF COMMISSIONER OF INSURANCE. (a) In

conducting an examination of a health benefit plan issuer, the

commissioner:

(1) shall accept the accreditation report submitted by the

health benefit plan issuer as a prima facie demonstration of the

issuer's compliance with the processes and standards for which

the issuer has received accreditation; and

(2) may adopt relevant findings in a health benefit plan

issuer's accreditation report in the examination report if the

accreditation report complies with applicable state and federal

requirements regarding the nondisclosure of proprietary and

confidential information and personal health information.

(b) Subsection (a) does not apply to any process or standard of

a health benefit plan issuer that is not covered as part of the

issuer's accreditation. This section does not set minimum

quality standards but operates only as a replacement of duplicate

requirements.

(c) The commissioner may by rule determine the application of

compliance with national accreditation requirements by a

delegated entity, delegated third party, or utilization review

agent to compliance by the health benefit plan issuer that

contracts with the delegated entity, delegated third party, or

agent.

Added by Acts 2005, 79th Leg., Ch.

789, Sec. 1, eff. June 17, 2005.

Sec. 847.008. COMMISSION DUTIES. (a) The commission may

require the commissioner to submit to the commission the

documents reviewed by the department that substantiate the

compliance of the health benefit plan issuer with applicable

state statutory and regulatory requirements.

(b) Documents submitted under Subsection (a) are proprietary and

confidential information under Chapter 552, Government Code, and

are not subject to subpoena. The commission shall limit

disclosure of the documents to commission employees who need the

documentation to perform the duties of their job. A commission

employee may not further disclose the compliance documents.

Added by Acts 2005, 79th Leg., Ch.

789, Sec. 1, eff. June 17, 2005.

Sec. 847.009. MEMORANDUM OF UNDERSTANDING. The commissioner and

the commission must enter into a memorandum of understanding to

specify the responsibilities of the department and the commission

under this chapter.

Added by Acts 2005, 79th Leg., Ch.

789, Sec. 1, eff. June 17, 2005.

Sec. 847.010. ENFORCEMENT. This chapter may not be construed to

prohibit the commissioner or the commission from enforcing laws

or rules relating to:

(1) the operation of a health benefit plan; or

(2) violation of a contract.

Added by Acts 2005, 79th Leg., Ch.

789, Sec. 1, eff. June 17, 2005.