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You are here: Home . rules . 2007 . 0413-059

SUBCHAPTER GG. Health Care Quality Assurance Presumed Compliance

28 TAC §§21.4101 - 21.4106

1. INTRODUCTION. The Commissioner of Insurance adopts new Subchapter GG, §§21.4101 - 21.4106, concerning health care quality assurance presumed compliance for certain entities that offer health benefit plans. New §§21.4101 - 21.4106 are adopted with changes to the proposed text as published in the December 29, 2006, issue of the Texas Register (31 TexReg 10517).

2. REASONED JUSTIFICATION. These new sections are necessary to implement §1 of Senate Bill 155, enacted by the 79th Legislature, Regular Session, which added Chapter 847, the Health Care Quality Assurance Act (Act), to the Insurance Code effective June 17, 2005. Chapter 847 applies to entities that: issue a health benefit plan, as defined in the Insurance Code §847.003(2); hold a license or certificate of authority issued by the Commissioner; and provide benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including those entities specified in the Insurance Code §847.004. The purpose of the rule and the Act is to provide standards for the appropriate recognition of accreditation by national accreditation organizations that accredit health benefit plan issuers. These standards will facilitate increased affordability of health benefit plan coverage for consumers and eliminate duplication of effort by both health benefit plan issuers and state agencies.

The Department posted an informal draft of the new sections on its internet website from November 20 through December 6, 2006, and invited public input. Subsequently, the Department published the proposed new sections in the Texas Register on December 29, 2006.

The Department received one comment on the proposal, and has made a few nonsubstantive changes for clarification to the text of the rule as adopted, as a result of this comment. Additionally, the Department is adopting these new sections with other nonsubstantive changes to the proposal for purposes of clarification and consistency, and where necessary, the Department has corrected punctuation errors, out-of-date cross-references, and grammatical errors. For example, references to "Internet," have been changed to lower case for consistency with current usage. None of these changes, however, materially alter issues raised in the proposed rule, introduce new subject matter, or affect persons other than those previously on notice. The adopted sections should be read in conjunction with the Insurance Code Chapter 847, and other statutes and rules as applicable. The changes to the proposed text are:

Section 21.4101: For clarification, in the first sentence of §21.4101(a), the Department has added the words "codified as" between the phrase "Health Care Quality Assurance Act (Act)," and the phrase "the Insurance Code Chapter 847." In §21.4101(b)(3), the Department, for consistency with the statutory language in the Insurance Code §847.004, has added the word "incurred" between the words "surgical expenses" and the words "as a result of" to read: ". . . medical or surgical expenses incurred as a result of a health condition, accident, or sickness, . . . ."

Section 21.4102: The Department has substituted the term "accreditation" for the term "accrediting" in the definition of national accreditation organization in §21.4102(6) for consistency with references to national accreditation organization throughout the sections as adopted and Chapter 847. In §21.4102(8), which defines the term utilization review agent, the Department has changed the reference to the obsolete citation to Article 21.58A §2(21) to the current correct citation §4201.002(14), effective April 1, 2007, as a result of the enactment of the nonsubstantive revision of the Insurance Code by the 79th Legislature, Regular Session, HB 2017.

Section 21.4103: The Department has added the term "nonconditional" before the term "accreditation" in two places in §21.4103(e): in the catchline and in the second sentence for consistency with other references to the defined term nonconditional accreditation in this section and throughout the rule as adopted and Chapter 847. Also, in §21.4103(e), the Department, for purposes of clarification, has changed the proposed language to read: ". . . the health benefit plan issuer shall report this change in accreditation status to the department not later than the 30th day following the date [in lieu "of notification by"] the national accreditation organization notifies the health benefit plan issuer of the loss of nonconditional accreditation status."

Section 21.4104: The Department has substituted slight variations of the phrase "health benefit plan issuer(s) with nonconditional accreditation" for the phrase "accredited health benefit plan issuer(s)" in the catchline and the first sentence of §21.4104(a) for clarification that health benefit plans must have nonconditional accreditation. This change is also necessary for consistency with the terminology in the statute and with the definition of the term nonconditional accreditation in §21.4102(6). In §21.4104(a) and (b), the Department has substituted the phrase "state statutory and regulatory requirements" for the phrase "department requirements" for consistency with Chapter 847. In §21.4104(a)(1), the Department has added the word "national" before "accreditation organization" for consistency with other references to "national accreditation organization" throughout the sections as adopted and Chapter 847. The Department has substituted the phrase "health benefit plan issuer(s) without nonconditional accreditation" for the phrase "nonaccredited health benefit plan issuers" in two instances in §21.4104(b) as adopted, for clarification and for consistency with the terminology in the statute and with the definition and use of the term nonconditional accreditation in other parts of the rule as proposed; the term "nonaccredited" is not used in Chapter 847 of the Insurance Code and is not defined in the rule as proposed.

Section 21.4105: In §21.4105(a), the Department has substituted the phrase "statutory and regulatory requirements of the department" for the term "requirements" and has added the phrase "department statutory and regulatory" before the term "requirements" for clarification and consistency with the Insurance Code §847.005(e). In §21.4105(c), for clarification, the Department has changed the proposed language to read: "[t]he presumed compliance table listing the summary of the comparison of national accreditation standards and department statutory and regulatory requirements may be obtained [in lieu of "is available"] from: . . . ."

Section 21.4106: The Department has determined that subsection (c), relating to the confidentiality and release of an examination report that contains confidential information from an accreditation report, is unnecessary and, for purposes of clarification, has deleted the proposed subsection. The confidentiality provisions are addressed in Insurance Code §§843.006(b), 847.006(b), and 847.007(a)(2). Section 843.006(b) provides that examination reports are confidential, but may be released if the Commissioner is of the opinion that such release is in the public interest. Insurance Code §847.006(b) provides that accreditation reports submitted under §847.006(a) are proprietary and confidential information under Government Code Chapter 552, and are not subject to subpoena. Insurance Code §847.007(a)(2) authorizes the Commissioner, in conducting an examination of a health benefit plan issuer, to adopt relevant findings from a health benefit plan issuer's accreditation report into 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. Therefore, subsection (c) related to the confidentiality of examination reports, is unnecessary because relevant provisions within Government Code 552 and Insurance Code Chapters 843 and 847 already prohibit the release of such information.

3. HOW THE SECTIONS WILL FUNCTION. Section 21.4101 states the purpose and the scope of the subchapter. Section 21.4102 defines relevant terms, including accreditation report, nonconditional accreditation, and summary results. Section 21.4103(a) sets forth the requirements by which a health benefit plan issuer that has nonconditional accreditation shall be presumed in compliance with state statutory and regulatory requirements. Section 21.4103(b) requires that in conducting an examination

of a health benefit plan issuer, the Commissioner shall accept the accreditation report submitted by the health benefit plan issuer as evidence of compliance with the processes and standards for which the health benefit plan issuer has received nonconditional accreditation. Section 21.4103(c) sets forth exceptions to the presumed compliance section. Section 21.4103(d) requires health benefit plan issuers seeking presumed compliance to provide to the Department a complete copy of their accreditation report. Section 21.4103(e) provides that if a health benefit plan issuer loses nonconditional accreditation status, it must report this change in status to the Department not later than the 30th day following the date the national accreditation organization notifies the health benefit plan issuer. Section 21.4104 addresses presumed compliance of functions that are delegated by health benefit plan issuers. Section 21.4105 addresses Department monitoring and analysis of national accreditation organization standards. Section 21.4106(a) sets forth the confidentiality requirements for accreditation reports, and subsection (b) sets forth the confidentiality requirements for summary results.

4. SUMMARY OF COMMENTS AND AGENCY'S RESPONSE.

General: A commenter supports the proposed rule as published and states the belief that it supports the intent of Senate Bill 155. According to the commenter, it awards nonconditional accreditation status only and if a plan cannot meet its requirements and obtain a status of Excellent, Commendable, Accredited, or Provisional, the plan is not considered accredited and is given a Denied status. The commenter recommends that the Department provide interpretative guidance specific to defining the level of accreditation that is required to meet the intent of nonconditional accreditation. The commenter recommends this additional guidance be included in the table of standards that the Department will post on its internet website.

Agency Response: The Department disagrees with the commenter that the requested additional guidance concerning the specific level of accreditation required to meet nonconditional accreditation, as defined in §21.4102(6), can be included in the Department's table of standards to be provided on its internet website. Instead, as authorized by the Insurance Code §847.005(e), the table summarizes the Department's comparison of national accreditation organization standards with the Department's statutory and regulatory requirements. While the Department is not making any changes to the proposed text of the rule in response to the concern raised by the commenter, the Department, in considering the comment, has identified sections of the rule as proposed concerning nonconditional accreditation that require clarification.

In the §21.4103(e) catchline and in the second sentence of §21.4103(e), the Department has inserted the term "nonconditional" to modify the term "accreditation" so that subsection (e) contains the more accurate and defined term nonconditional accreditation for consistency with the first sentence in subsection (e) as proposed and to clarify when a health benefit plan issuer will be subject to immediate examination by the Department upon loss of its nonconditional accreditation status. As proposed, §21.4104(b) referred to "nonaccredited health benefit plans" without defining or explaining the term "nonaccredited." Therefore, the reference to "nonaccredited health plan issuers" in §21.4104(b), as adopted, is changed to "health benefit plan issuers without nonconditional accreditation." This change is made for consistency in terminology with the statute and with the definition and use of the term nonconditional accreditation in other parts of the rule as proposed. The reason for the distinction in the requirements relating to delegations by health benefit plan issuers in subsections (a) and (b) of §21.4104 is that, pursuant to Insurance Code §847.005(a), the Department only has the statutory authority to presume a health benefit plan issuer to be in compliance with state statutory and regulatory requirements if the health benefit issuer has received nonconditional accreditation by a national accreditation organization and the national accreditation organization's accreditation requirements are the same, substantially similar to, or more stringent than the Department's statutory and regulatory requirements. Therefore, in §21.4104(b) delegations by health benefit plan issuers without nonconditional accreditation must be to delegated entities, delegated third parties, and utilization review agents that have received nonconditional accreditation or certification by a national accreditation if those delegated functions are to be presumed in compliance with state statutory and regulatory requirements. The revised language will help clarify which subsection of §21.4104 applies: Subsection (a) of §21.4104 applies to delegations by health benefit plan issuers with nonconditional accreditation and subsection (b) applies to delegations by health benefit plan issuers without nonconditional accreditation.

The various national accreditation organizations that accredit health benefit plan issuers have distinct terminology and descriptions for determining and awarding a particular accreditation status or level of accreditation. Consequently, levels of accreditation issued by national accreditation organizations differ. As a result, it is necessary for the Department to review individual health benefit plan issuers' accreditation status on a case-by-case basis to determine if a particular health benefit plan issuer has achieved a level of accreditation that meets the Department's definition of nonconditional accreditation in §21.4102(6). This definition defines nonconditional accreditation to mean: "[f]inal accreditation survey results that a national accreditation organization issues stating an outcome that meets or exceeds the requirements of the national accreditation organization in a particular category and that is not conditional or contingent upon the health benefit plan issuer correcting any deficiencies." A health benefit plan issuer who has achieved provisional accreditation from a national accreditation organization may meet some, but not all of the requirements for being nonconditionally accredited. Therefore, the Department would not consider such a level of provisional accreditation of a national accreditation organization to meet the definition of nonconditional accreditation in §21.4102(6). If a national accreditation organization offers various levels of accreditation, then the Department will consider the various levels of accreditation awarded by the national accreditation organization in its evaluation of national accreditation organization standards with the Department standards and in its evaluation of health benefit plan issuers for presumed compliance with state statutory and regulatory requirements as required by the Insurance Code Chapter 847.

5. NAMES OF THOSE COMMENTING FOR AND AGAINST THE PROPOSAL.

For: the National Committee for Quality Assurance (NCQA).

Against: None.

6. STATUTORY AUTHORITY. The sections are adopted pursuant to the Insurance Code §§847.005(a), (d), and (e); 847.006(a) and (b); 847.007(a), (b), and (c); 1272.001(a)(1) and (a)(3); 4201.002(14); and 36.001. Section 847.005(a) states that a health benefit plan issuer is presumed to be in compliance with state and statutory regulatory requirements if the health benefit plan issuer has received nonconditional accreditation by a national accreditation organization and the national accreditation organization's accreditation requirements are the same, substantially similar to, or more stringent than the Department's statutory or regulatory requirements. Section 847.005(d) provides that the Commissioner may take appropriate action, including the imposition of sanctions under Chapter 82, against a health benefit plan issuer who is presumed under subsections (a), (b), or (c) of §847.005 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 health benefit plan issuer under subsections (a), (b), or (c). Section 847.005(e) provides that the Department shall monitor and analyze periodically as prescribed by rule by the Commissioner updates and amendments made to national accreditation organization 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. Section 847.006(a) provides that the Commissioner may require a health benefit plan issuer to submit to the Commissioner the accreditation report issued by the national accreditation organization. Section 847.006(b) states that an accreditation report submitted under subsection (a) is proprietary and confidential information under Chapter 552, Government Code, and is not subject to subpoena. Section 847.007(a) states that in conducting an examination of a health benefit plan issuer, the Commissioner shall accept the accreditation report submitted by the health benefit plan issuer as a prima facie demonstration of the health benefit plan issuer's compliance with the processes and standards for which the issuer has received nonconditional accreditation and may adopt relevant findings in a health benefit plan issuer's accreditation report in the Department 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. Section 847.007(b) provides that subsection (a) does not apply to any process or standard of a health benefit plan issuer that is not covered as part of the health benefit plan issuer's accreditation and that this section does not set minimum quality standards but only operates as a replacement of duplicate requirements. Section 847.007(c) provides that the Commissioner may by rule determine the application of compliance with national accreditation organization 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 utilization review agent. Section 1272.001(a)(1) defines delegated entity. Section 1272.001(a)(3) defines delegated third party. Section 4201.002(14) defines utilization review agent. Section 36.001 provides that the Commissioner may adopt any rules necessary and appropriate to implement the powers and duties of the Department under the Insurance Code and other laws of this state.

7. TEXT.

§21.4101. Purpose and Scope.

(a) General purpose. This subchapter implements provisions of the Health Care Quality Assurance Act (Act), codified as the Insurance Code Chapter 847. The general purpose of the Act and this subchapter is to provide standards for the appropriate recognition of accreditation of health benefit plan issuers by nationally recognized accreditation organizations. These standards will facilitate increased affordability of health benefit plan coverage for consumers and eliminate the duplication of effort by both health benefit plan issuers and state agencies.

(b) Applicability. This subchapter applies to an entity that:

(1) issues a health benefit plan as defined in the Insurance Code §847.003(2);

(2) holds a license or certificate of authority issued by the commissioner; and

(3) provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including those entities listed in the Insurance Code §847.004.

§21.4102. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise.

(1) Accreditation report--The final report a national accreditation organization issues that contains a detailed analysis of the accreditation survey results including the scores of the health benefit plan issuer and the extent to which the health benefit plan issuer meets or exceeds, or fails to meet, the required accreditation standards.

(2) Delegated entity--Has the meaning assigned by the Insurance Code §1272.001(a)(1).

(3) Delegated third party--Has the meaning assigned by the Insurance Code §1272.001(a)(3).

(4) Health benefit plan--Has the meaning assigned by the Insurance Code §847.003(2).

(5) National accreditation organization--Has the meaning assigned by the Insurance Code §847.003(3).

(6) Nonconditional accreditation--Final accreditation survey results that a national accreditation organization issues stating an outcome that meets or exceeds the requirements of the national accreditation organization in a particular category and that is not conditional or contingent upon the health benefit plan issuer correcting any deficiencies.

(7) Summary results--A synopsis of the final accreditation survey results, excluding numeric scores and percentages that a national accreditation organization issues that provides the accreditation outcome results of the health benefit plan issuer, such as in report card format, but that is not a complete and detailed report of the accreditation survey results.

(8) Utilization review agent--Has the meaning assigned by the Insurance Code §4201.002(14).

§21.4103. Presumed Compliance.

(a) Health benefit plan issuer presumed compliance. Pursuant to the Insurance Code §847.005(a), a health benefit plan issuer shall be presumed to be in compliance with state statutory and regulatory requirements if:

(1) a national accreditation organization has issued the health benefit plan issuer nonconditional accreditation applicable to its operations within the state of Texas; and

(2) the national accreditation organization's accreditation requirements are the same, substantially similar to, or more stringent than the department's statutory and regulatory requirements.

(b) Examination. Pursuant to the Insurance Code §847.007(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 evidence of the health benefit plan issuer's compliance with the processes and standards for which the issuer has received nonconditional accreditation; and

(2) may adopt relevant findings from 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.

(c) Exceptions. Pursuant to the Insurance Code §847.007(b), this section does not:

(1) apply to any process or standard of a health benefit plan issuer that is not covered as part of the health benefit plan issuer's accreditation; or

(2) set minimum quality standards.

(d) Submission of report. Pursuant to the Insurance Code §847.006(a), at the department's request, the health benefit plan issuer seeking presumed compliance pursuant to subsection (b) of this section must provide to the department a complete copy of the accreditation report issued by the national accreditation organization.

(e) Loss of nonconditional accreditation. If a health benefit plan issuer loses nonconditional accreditation, the health benefit plan issuer shall report this change in accreditation status to the department not later than the 30th day following the date the national accreditation organization notifies the health benefit plan issuer of the loss of nonconditional accreditation status. A health benefit plan issuer will be subject to immediate examination by the department if it loses its nonconditional accreditation status.

§21.4104. Health Benefit Plan Issuers Contracting with Delegated Entities, Delegated Third Parties, and Utilization Review Agents.

(a) Delegations by health benefit plan issuers with nonconditional accreditation. If a health benefit plan issuer with nonconditional accreditation has delegated one or more functions to a delegated entity, delegated third party, or utilization review agent, those delegated functions shall be presumed in compliance with state statutory and regulatory requirements if:

(1) the delegation was in place at the time of the national accreditation organization's review of the health benefit plan issuer; or

(2) the delegated entity, delegated third party, or utilization review agent has received nonconditional accreditation or certification by a national accreditation organization.

(b) Delegations by health benefit plan issuers without nonconditional accreditation. If a health benefit plan issuer without nonconditional accreditation has delegated one or more functions to a delegated entity, delegated third party, or utilization review agent, those delegated functions shall be presumed in compliance with state statutory and regulatory requirements if the delegated entity, delegated third party, or utilization review agent has received nonconditional accreditation or certification by a national accreditation organization that the department recognizes, as set forth in §21.4103 of this subchapter (relating to Presumed Compliance).

§21.4105. Department Monitoring and Analysis of National Accreditation Organization Standards.

(a) Analysis of standards. The department will compare statutory and regulatory requirements of the department for health benefit plan issuers with the standards of national accreditation organizations. The standards of national accreditation organizations that are the same, substantially similar to, or more stringent than the department statutory and regulatory requirements will be identified and used to determine the presumption of compliance of health benefit plan issuers.

(b) Monitoring schedule. The department shall, at least annually, monitor and analyze updates and amendments made to accreditation standards by national accreditation organizations to ensure that those standards remain the same, substantially similar to, or more stringent than the statutory and regulatory requirements of the department.

(c) Posting of standards. The department will post a table on its internet website that contains a summary of its comparison of national accreditation organization standards with the statutory and regulatory requirements of the department and indicates which portions of the examination process the department will presume compliance for accredited entities. The presumed compliance table listing the summary of the comparison of national accreditation standards and department statutory and regulatory requirements may be obtained from:

(1) the Department's internet website at: www.tdi.state.tx.us; or

4201.002(14) defines utilization review agent. Section 36.001 provides that the Commissioner may adopt any rules necessary and appropriate to implement the powers and duties of the Department under the Insurance Code and other laws of this state.

7. TEXT.

§21.4101. Purpose and Scope.

(a) General purpose. This subchapter implements provisions of the Health Care Quality Assurance Act (Act), codified as the Insurance Code Chapter 847. The general purpose of the Act and this subchapter is to provide standards for the appropriate recognition of accreditation of health benefit plan issuers by nationally recognized accreditation organizations. These standards will facilitate increased affordability of health benefit plan coverage for consumers and eliminate the duplication of effort by both health benefit plan issuers and state agencies.

(b) Applicability. This subchapter applies to an entity that:

(1) issues a health benefit plan as defined in the Insurance Code §847.003(2);

(2) holds a license or certificate of authority issued by the commissioner; and

(3) provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including those entities listed in the Insurance Code §847.004.

§21.4102. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise.

(1) Accreditation report--The final report a national accreditation organization issues that contains a detailed analysis of the accreditation survey results including the scores of the health benefit plan issuer and the extent to which the health benefit plan issuer meets or exceeds, or fails to meet, the required accreditation standards.

(2) Delegated entity--Has the meaning assigned by the Insurance Code §1272.001(a)(1).

(3) Delegated third party--Has the meaning assigned by the Insurance Code §1272.001(a)(3).

(4) Health benefit plan--Has the meaning assigned by the Insurance Code §847.003(2).

(5) National accreditation organization--Has the meaning assigned by the Insurance Code §847.003(3).

(6) Nonconditional accreditation--Final accreditation survey results that a national accreditation organization issues stating an outcome that meets or exceeds the requirements of the national accreditation organization in a particular category and that is not conditional or contingent upon the health benefit plan issuer correcting any deficiencies.

(7) Summary results--A synopsis of the final accreditation survey results, excluding numeric scores and percentages that a national accreditation organization issues that provides the accreditation outcome results of the health benefit plan issuer, such as in report card format, but that is not a complete and detailed report of the accreditation survey results.

(8) Utilization review agent--Has the meaning assigned by the Insurance Code §4201.002(14).

§21.4103. Presumed Compliance.

(a) Health benefit plan issuer presumed compliance. Pursuant to the Insurance Code §847.005(a), a health benefit plan issuer shall be presumed to be in compliance with state statutory and regulatory requirements if:

(1) a national accreditation organization has issued the health benefit plan issuer nonconditional accreditation applicable to its operations within the state of Texas; and

(2) the national accreditation organization's accreditation requirements are the same, substantially similar to, or more stringent than the department's statutory and regulatory requirements.

(b) Examination. Pursuant to the Insurance Code §847.007(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 evidence of the health benefit plan issuer's compliance with the processes and standards for which the issuer has received nonconditional accreditation; and

(2) may adopt relevant findings from 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.

(c) Exceptions. Pursuant to the Insurance Code §847.007(b), this section does not:

(1) apply to any process or standard of a health benefit plan issuer that is not covered as part of the health benefit plan issuer's accreditation; or

(2) set minimum quality standards.

(d) Submission of report. Pursuant to the Insurance Code §847.006(a), at the department's request, the health benefit plan issuer seeking presumed compliance pursuant to subsection (b) of this section must provide to the department a complete copy of the accreditation report issued by the national accreditation organization.

(e) Loss of nonconditional accreditation. If a health benefit plan issuer loses nonconditional accreditation, the health benefit plan issuer shall report this change in accreditation status to the department not later than the 30th day following the date the national accreditation organization notifies the health benefit plan issuer of the loss of nonconditional accreditation status. A health benefit plan issuer will be subject to immediate examination by the department if it loses its nonconditional accreditation status.

§21.4104. Health Benefit Plan Issuers Contracting with Delegated Entities, Delegated Third Parties, and Utilization Review Agents.

(a) Delegations by health benefit plan issuers with nonconditional accreditation. If a health benefit plan issuer with nonconditional accreditation has delegated one or more functions to a delegated entity, delegated third party, or utilization review agent, those delegated functions shall be presumed in compliance with state statutory and regulatory requirements if:

(1) the delegation was in place at the time of the national accreditation organization's review of the health benefit plan issuer; or

(2) the delegated entity, delegated third party, or utilization review agent has received nonconditional accreditation or certification by a national accreditation organization.

(b) Delegations by health benefit plan issuers without nonconditional accreditation. If a health benefit plan issuer without nonconditional accreditation has delegated one or more functions to a delegated entity, delegated third party, or utilization review agent, those delegated functions shall be presumed in compliance with state statutory and regulatory requirements if the delegated entity, delegated third party, or utilization review agent has received nonconditional accreditation or certification by a national accreditation organization that the department recognizes, as set forth in §21.4103 of this subchapter (relating to Presumed Compliance).

§21.4105. Department Monitoring and Analysis of National Accreditation Organization Standards.

(a) Analysis of standards. The department will compare statutory and regulatory requirements of the department for health benefit plan issuers with the standards of national accreditation organizations. The standards of national accreditation organizations that are the same, substantially similar to, or more stringent than the department statutory and regulatory requirements will be identified and used to determine the presumption of compliance of health benefit plan issuers.

(b) Monitoring schedule. The department shall, at least annually, monitor and analyze updates and amendments made to accreditation standards by national accreditation organizations to ensure that those standards remain the same, substantially similar to, or more stringent than the statutory and regulatory requirements of the department.

(c) Posting of standards. The department will post a table on its internet website that contains a summary of its comparison of national accreditation organization standards with the statutory and regulatory requirements of the department and indicates which portions of the examination process the department will presume compliance for accredited entities. The presumed compliance table listing the summary of the comparison of national accreditation standards and department statutory and regulatory requirements may be obtained from:

(1) the Department's internet website at: www.tdi.state.tx.us; or

(2) the Health and WC Network Certification and QA Division, Mail Code 103-6A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104.

(d) Updates to standards. The department will update the table of standards posted on its internet website on at least an annual basis, as necessary, to reflect changes made to national accreditation organization standards.

§21.4106. Confidentiality.

(a) Accreditation reports. Pursuant to the Insurance Code §847.006(b), accreditation reports submitted to the department are proprietary and confidential under the Government Code Chapter 552 and are not subject to subpoena.

(b) Summary results. Pursuant to the Insurance Code §847.006(c) the summary results of a national accreditation organization are not proprietary information and are subject to public disclosure under the Government Code Chapter 552.



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