28 Tex. Admin. Code § 13.473 - Organization of an HCC

(a) The governing body, which must comply with the requirements described in Insurance Code § 848.052, must have ultimate responsibility for the development, approval, implementation, and enforcement of administrative, operational, personnel, and patient care policies and procedures related to the operation of the HCC.

(b) The HCC must have a clinical director who:

(1) is currently licensed in Texas or otherwise authorized to practice in this state in the field of services offered by the HCC;

(2) resides in Texas;

(3) is available at all times to address complaints, clinical issues, utilization review, and any quality-of-care issues on behalf of the HCC;

(4) demonstrates active involvement in all quality management activities; and

(5) is subject to the HCC's credentialing requirements, as appropriate.

(c) The HCC may establish one or more service areas within Texas. For each defined service area, the HCC must:

(1) provide a delivery network that is adequate and complies with Insurance Code Chapter 848, and demonstrate to the department the ability to provide continuity, accessibility, availability, and quality of services that the HCC has contracted or will contract to provide within the HCC's service area, including the following, as applicable:

(A) participants that are sufficient in number, size, and geographic distribution to be capable of furnishing the contracted health care services, taking into account the number of potential patients, their characteristics, and their medical and health care needs, including the following:

(i) current utilization of covered health care services within the prescribed geographic distances outlined in this section; and

(ii) projected utilization of covered health care services;

(B) an adequate number of participants available and accessible to patients 24 hours a day, seven days a week;

(C) sufficient numbers and classes of participants to ensure choice, access, and quality of care;

(D) an adequate number of participating physicians who have admitting privileges at one or more participating hospitals to make any necessary hospital admissions;

(E) emergency care that is available and accessible 24 hours a day, seven days a week;

(F) services sufficiently available and accessible as necessary to ensure that the distance from any point in the HCC's designated service area to a point of service is not greater than:

(i) 30 miles in nonrural areas and 60 miles in rural areas for primary care and general hospital care; and

(ii) 75 miles for specialty care and specialty hospitals;

(G) urgent care available and accessible within 24 hours for health and behavioral health conditions;

(H) routine care available and accessible:

(i) within three weeks for health conditions; and

(ii) within two weeks for behavioral health conditions;

(I) preventive health services available and accessible:

(i) within two months for a child, or earlier if necessary for compliance with nationally recognized recommendations for specific preventive care services; and

(ii) within three months for an adult;

(2) specify the counties and ZIP codes, or any portions of any counties, included in the service area; and

(3) maintain separate cost center accounting for each service area to facilitate the reporting of divisional operations as required for HCC financial reporting.

(d) The HCC must maintain in force in its own name a fidelity bond on its officers and employees.

(1) The fidelity bond must be in an amount of at least $100,000, or another amount prescribed by the commissioner, and issued by an insurer that holds a certificate of authority in this state.

(2) The fidelity bond must obligate the surety to pay any loss of money or other property the HCC sustains because of an act of fraud or dishonesty by an employee or officer of the HCC, acting alone or in concert with others, while employed or serving as an officer of the HCC.

(3) Subject to the same coverage amount and conditions required for a fidelity bond under this subsection, an HCC may, instead of obtaining a fidelity bond:

(A) obtain and maintain in force in its own name insurance coverage in a form and amount acceptable to the commissioner; or

(B) deposit with the Texas Comptroller of Public Accounts readily marketable liquid securities acceptable to the commissioner.

Notes

28 Tex. Admin. Code § 13.473

The provisions of this §13.473 adopted to be effective March 31, 2013, 38 TexReg 2100