28 Tex. Admin. Code § 13.441 - General Provisions
(a) An HCC's
contracts with physicians and health care providers must not impede application
of provisions in Insurance Code Chapters 843 (Health Maintenance Organizations)
and 1301 (Preferred Provider Benefit Plans), and in Chapter 11 of this title
(relating to Health Maintenance Organizations) and Chapter 3, Subchapter X of
this title (relating to Preferred and Exclusive Provider Plans), that impose
requirements concerning relations with physicians or health care
providers.
(b) An HCC is prohibited
from using a financial incentive or making a payment to a physician or health
care provider if the incentive or payment acts directly or indirectly as an
inducement to limit medically necessary services.
(c) If an HCC participant's market share as
calculated under §
13.414 of this title (relating to
Limited Exemption from Certain Information Filing Requirements) exceeds 50
percent in a PSA for any service that no other HCC participant provides to
patients in that PSA, the participant furnishing the service is a dominant
provider for purposes of this subchapter. An HCC with a dominant provider is
prohibited, in the PSA in which the dominant provider furnishes those services,
from:
(1) requiring a private payor to
contract exclusively with the HCC; or
(2) otherwise restricting a private payor's
ability to contract or deal with other HCCs, networks, physicians, or health
care providers.
Notes
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