Tex. Ins. Code Section 1305.154
Network-carrier Contracts


(a)

Except for emergencies and out-of-network referrals, a network may provide health care services to employees only through a written contract with an insurance carrier. A network-carrier contract under this section is confidential and is not subject to disclosure as public information under Chapter 552 (Public Information), Government Code.

(b)

A carrier and a network may negotiate the functions to be provided by the network, except that the network shall contract with providers for the provision of health care, and shall perform functions related to the operation of a quality improvement program and credentialing in accordance with the requirements of this chapter.

(c)

A network’s contract with a carrier must include:

(1)

a description of the functions that the carrier delegates to the network, consistent with the requirements of Subsection (b), and the reporting requirements for each function;

(2)

a statement that the network and any management contractor or third party to which the network delegates a function will perform all delegated functions in full compliance with all requirements of this chapter, the Texas Workers’ Compensation Act, and rules of the commissioner or the commissioner of workers’ compensation;

(3)

a provision that the contract:

(A)

may not be terminated without cause by either party without 90 days’ prior written notice; and

(B)

must be terminated immediately if cause exists;

(4)

a hold-harmless provision stating that the network, a management contractor, a third party to which the network delegates a function, and the network’s contracted providers are prohibited from billing or attempting to collect any amounts from employees for health care services under any circumstances, including the insolvency of the carrier or the network, except as provided by Section 1305.451 (Employee Information; Responsibilities of Employee)(b)(6);

(5)

a statement that the carrier retains ultimate responsibility for ensuring that all delegated functions and all management contractor functions are performed in accordance with applicable statutes and rules and that the contract may not be construed to limit in any way the carrier’s responsibility, including financial responsibility, to comply with all statutory and regulatory requirements;

(6)

a statement that the network’s role is to provide the services described under Subsection (b) as well as any other services or functions delegated by the carrier, including functions delegated to a management contractor, subject to the carrier’s oversight and monitoring of the network’s performance;

(7)

a requirement that the network provide the carrier, at least monthly and in a form usable for audit purposes, the data necessary for the carrier to comply with reporting requirements of the department and the division of workers’ compensation with respect to any services provided under the contract, as determined by commissioner rules;

(8)

a requirement that the carrier, the network, any management contractor, and any third party to which the network delegates a function comply with the data reporting requirements of the Texas Workers’ Compensation Act and rules of the commissioner of workers’ compensation;

(9)

a contingency plan under which the carrier would, in the event of termination of the contract or a failure to perform, reassume one or more functions of the network under the contract, including functions related to:

(A)

payments to providers and notification to employees;

(B)

quality of care;

(C)

utilization review; and

(D)

continuity of care, including a plan for identifying and transitioning employees to new providers;

(10)

a provision that requires that any agreement by which the network delegates any function to a management contractor or any third party be in writing, and that such an agreement require the delegated third party or management contractor to be subject to all the requirements of this subchapter;

(11)

a provision that requires the network to provide to the department the license number of a management contractor or any delegated third party who performs a function that requires a license as a utilization review agent under Chapter 4201 (Utilization Review Agents) or any other license under this code or another insurance law of this state;

(12)

an acknowledgment that:

(A)

any management contractor or third party to whom the network delegates a function must perform in compliance with this chapter and other applicable statutes and rules, and that the management contractor or third party is subject to the carrier’s and the network’s oversight and monitoring of its performance; and

(B)

if the management contractor or the third party fails to meet monitoring standards established to ensure that functions delegated to the management contractor or the third party under the delegation contract are in full compliance with all statutory and regulatory requirements, the carrier or the network may cancel the delegation of one or more delegated functions;

(13)

a requirement that the network and any management contractor or third party to which the network delegates a function provide all necessary information to allow the carrier to provide information to employees as required by Section 1305.451 (Employee Information; Responsibilities of Employee); and

(14)

a provision that requires the network, in contracting with a third party directly or through another third party, to require the third party to permit the commissioner to examine at any time any information the commissioner believes is relevant to the third party’s financial condition or the ability of the network to meet the network’s responsibilities in connection with any function the third party performs or has been delegated.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 134 (H.B. 1006), Sec. 5, eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.009, eff. April 1, 2009.
Acts 2009, 81st Leg., R.S., Ch. 1330 (H.B. 4290), Sec. 3, eff. September 1, 2009.

Source: Section 1305.154 — Network-carrier Contracts, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1305.­htm#1305.­154 (accessed Jun. 5, 2024).

1305.001
Short Title
1305.002
Purpose
1305.003
Limitations on Applicability
1305.004
Definitions
1305.005
Participation in Network
1305.006
Insurance Carrier Liability for Out-of-network Health Care
1305.007
Rules
1305.008
Administrator Certificate of Authority Required
1305.051
Certification Required
1305.052
Certificate Application
1305.053
Contents of Application
1305.054
Action on Application
1305.055
Use of Certain Insurance Terms by Network Prohibited
1305.056
Restraint of Trade
1305.101
Providing or Arranging for Health Care
1305.102
Management Contracts
1305.103
Treating Doctor
1305.104
Selection of Treating Doctor
1305.106
Payment of Health Care Provider
1305.107
Telephone Access
1305.151
Transfer of Risk
1305.152
Network Contracts with Providers
1305.153
Provider Reimbursement
1305.154
Network-carrier Contracts
1305.155
Compliance Requirements
1305.201
Network Financial Requirements
1305.251
Examination of Network
1305.252
Examination of Provider or Third Party
1305.301
Network Organization
1305.302
Accessibility and Availability Requirements
1305.303
Quality of Care Requirements
1305.304
Guidelines and Protocols
1305.351
Utilization Review in Network
1305.353
Notice of Certain Utilization Review Determinations
1305.354
Reconsideration of Adverse Determination
1305.355
Independent Review of Adverse Determination
1305.356
Contested Case Hearing on and Judicial Review of Independent Review
1305.401
Complaint System Required
1305.402
Complaint Initiation and Initial Response
1305.403
Record of Complaints
1305.404
Retaliatory Action Prohibited
1305.405
Posting of Information on Complaint Process Required
1305.451
Employee Information
1305.502
Consumer Report Cards
1305.503
Confidentiality Requirements
1305.551
Determination of Violation
1305.552
Disciplinary Actions
1305.1545
Restrictions on Payment and Reimbursement

Accessed:
Jun. 5, 2024

§ 1305.154’s source at texas​.gov