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Health Maintenance Organization (HMO) FAQs

Health Maintenance Organizations

Complaints

Referrals

Health Maintenance Organizations

Q. Does Texas have any health maintenance organization (HMO) "Prompt Pay"-related requirements?
A. Yes. Texas statutes require an HMO to pay the claims of physicians/providers promptly.

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Q. What is an HMO Certificate of Authority and how do I become an HMO?
A. A "Certificate of Authority" (COA) is the term used to refer to the department's authorization of a person to operate an HMO in Texas. A person who desires to operate an HMO in Texas must submit an application to the department that complies with the requirements under Texas Insurance Code (TIC)§843.078, and which includes the documentation requested by the Commissioner of Insurance under 28 Texas Administrative Code (TAC) §11.204. For more information, visit the Company Licensing and Registration offers HMO page at www.tdi.texas.gov/licensing/company/clhmo.html

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Q. What laws apply to an HMO in Texas?
A. HMOs are authorized and regulated under TIC Chapter 843. The HMO rules are designated under 28 TAC Chapter 11. However, there are other laws and rules that also apply to a Texas-licensed HMO, including, but not limited to TIC Ch.544, TIC Ch. 1271, TIC Ch. 1272, TIC Ch. 1367, and TIC Ch. 1452.

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Q. Are there any required provisions for an HMO-provider contract in Texas?
A.
Yes. A complete listing of Texas' required HMO-physician/provider contractual provisions may be found at 28 TAC §11.901.

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Q. Does the State of Texas regulate the fees that a Texas-licensed HMO pays to the physicians and providers in the HMO's delivery network?
A.
No. TDI does not set or limit the fees that an HMO pays to its contracted physicians and providers.

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Q. Is a Texas-licensed HMO allowed to delegate functions to other entities?
A.
Yes. A Texas-licensed HMO is allowed to delegate certain functions to other entities. TIC Chapter 1272, and the rules under 28 TAC §11.2601-11.2612 regulate the delegation of certain functions from an HMO to a delegated entity. In addition, other laws, such as TIC Chapter 4151, and any rules adopted there under, may apply.

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Complaints

Q. What information do you need to submit with a complaint?
A.
When submitting a complaint, you may either complete the TDI complaint form that may be found on our website at http://www.tdi.texas.gov/consumer/complfrm.html or write the complaint out in a letter format. The complaint should include the name and contact information for the enrollee, the enrollee identification number, the name of the HMO, the reason for the complaint, and all supporting documentation. Supporting documentation may include a copy of the enrollee's ID card, a copy of the claim form, documentation of collection attempts, explanations of benefits (EOBs), and any correspondence between the HMO and the enrollee.

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Q. What is the difference between a fully insured plan and a self-funded plan?
A.
The most common type of fully insured plan is a health benefit plan in which an employer contracts with an HMO/carrier to pay health care claims based on the benefits purchased for a monthly premium. Covered employees may be responsible for deductibles and/or copayments, as applicable. Fully insured plans could also be offered by an association.

A self-funded plan is a health benefit plan offered and funded by an employer or employee organization to pay for claims incurred by enrollees or employees.

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Q. Who handles Medicaid, Medicare, TRICARE (formerly known as CHAMPUS), and CHIP complaints?
A.
Medicaid complaints are handled by the Texas Health and Human Services Commission.
Traditional Medicaid complaints can be sent to:
HHSC Claims Administration and Contract Management
Texas Health and Human Services Commission
Operations Oversight-Mail Code 91-X
P.O. Box 204077
Austin, TX 78720-4077
Phone: (512) 249-3744

Medicaid Star or Star-Plus Plans complaints can be sent to:
Complaint Coordinator
Health Plan Management
Texas Health and Human Services Commission
Managed Care Operations-Mail Code H-320
PO Box 85200
Austin, TX 78708
Phone: 1-877-787-8999 (Toll-Free)
TDD: 1-888-425-6889 (Toll-Free) For the deaf or hearing impaired

Medicare complaints are handled by the Centers for Medicaid and Medicare Services. Medicare complaints can be sent to:
Centers for Medicare and Medicaid Services
Dallas Regional Office
1301 Young Street, Room 833
Dallas, TX 75202
Phone: (214) 767-4463

TRICARE complaints for the South Region, which includes Texas, are handled by Humana. TRICARE complaints can be sent to:
Regional Grievance Coordinator
Humana Military Healthcare Services
8123 Datapoint Drive, Suite 400
San Antonio, TX 78229

For mental health concerns, send your grievance to:
Grievance Specialist
ValueOptions
PO Box 551188
Jacksonville, FL 32255-1188

CHIP complaints concerning enrollment or eligibility issues are handled by the Health and Human Services Commission. These types of CHIP complaints can be sent to:
Health and Human Services Commission
Attention: Complaint Department
PO Box 149024
Austin, TX 78714-9024
Phone: 1-800-647-6558

CHIP complaints concerning claims issues are handled by the Texas Department of Insurance. These types of CHIP complaints can be sent to:
Mail:
Consumer Protection, Mail Code 111-1A
PO Box 149091
Austin, TX 78714-9091
Phone: 1-800-252-3439 or (512) 463-6515
Fax: 512-490-1007
Online at: http://www.tdi.texas.gov/consumer/complfrm.html
Email: ConsumerProtection@tdi.texas.gov
In person or by delivery service:
Texas Department of Insurance
Consumer Protection (111-1A)
333 Guadalupe St.
Austin, Texas 78701

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Q. Does TDI accept anonymous complaints?
A.
Yes. When a complaint is received from someone who does not wish to provide his or her contact information, the complaints are still accepted and investigated.

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Q. Does the law prohibit an HMO from retaliating against an enrollee or provider for filing a complaint?
A.
Yes. Under TIC §843.281 and 28 TAC §11.901(2), an HMO is prohibited from engaging in retaliatory action against a group contract holder, an enrollee, a person acting on behalf of a group contract holder or enrollee, or a physician/provider for filing a complaint against the HMO or for appealing a decision of the HMO.

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Q. What is an Access plan?
A.
An Access Plan is an action plan filed with the department for approval by the commissioner as received from an HMO. The plan establishes arrangements for healthcare in previously approved or proposed service areas in which the HMO does not have an adequate number of contracted physicians, providers, or facilities. For access plan requirements see 28 TAC §11.1607.

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Referrals

Q. What are referrals? What is the difference between referrals for in-network and out-of-network care?
A.
Referrals - In-Network - A directive or request from a primary care physician and/or treating doctor that allows the patient to receive care from a specialist or other contracted provider within the geographical service area.
Referrals - Out-of-Network - A directive or request from a physician or provider for health care services to be provided outside the geographical service area when care is not available within the network.

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Q. If medically necessary covered services are not available through network physicians and providers, who pays for Out-of-Network services?
A.
If medically necessary covered services are not available through contracted HMO network providers, the HMO, upon request from a network provider, must allow a referral to a non-network physician or provider. The HMO must reimburse the non-network physician or provider at an agreed rate or usual and customary rate.

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Q, Can an HMO deny a referral request for Out-of-Network services?
A.
Yes, if the HMO has documented that an in-network provider is available to provide the requested services.

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Last updated: 09/16/2016

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