CHAPTER 847. HEALTH CARE QUALITY ASSURANCE
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.