Tex.
Ins. Code Section 843.461
Enforcement Actions
(a)
After notice and opportunity for a hearing, the commissioner may:(1)
suspend or revoke a certificate of authority issued to a health maintenance organization under this chapter;(2)
impose sanctions under Chapter 82 (Sanctions);(3)
issue a cease and desist order under Chapter 83 (Emergency Cease and Desist Orders); or(4)
impose administrative penalties under Chapter 84 (Administrative Penalties).(b)
The commissioner may take an enforcement action listed in Subsection (a) against a health maintenance organization if the commissioner finds that the health maintenance organization:(1)
is operating in a manner that is:(A)
significantly contrary to its basic organizational documents or health care plan; or(B)
contrary to the manner described in and reasonably inferred from other information submitted under Section 843.078 (Contents of Application), 843.079 (Contents of Application: Limited Health Care Service Plan), or 843.080 (Modification or Amendment of Application Information);(2)
issues an evidence of coverage or uses a schedule of charges for health care services that does not comply with the requirements of Sections 843.346 (Payment of Claims), 1271.001-1271.005, 1271.007 (Religious Convictions), 1271.151 (Provision of Basic Health Care Services), 1271.152 (Standards for Basic Health Care Services), and 1271.156 (Benefits for Rehabilitation Services and Therapies), and Subchapters B, C, E, F, and G, Chapter 1271 (Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges);(3)
does not meet the requirements of Section 843.082 (Requirements for Approval of Application)(1);(4)
provides a health care plan that does not provide or arrange for basic health care services, provides a limited health care service plan that does not provide or arrange for the plan’s limited health care services, or provides a single health care service plan that does not provide or arrange for a single health care service;(5)
cannot fulfill its obligation to provide:(A)
health care services as required under its health care plan;(B)
limited health care services as required under its limited health care service plan; or(C)
a single health care service as required under its single health care service plan;(6)
is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;(7)
has not implemented the complaint system required by Section 843.251 (Complaint System Required; Commissioner Rules and Examination) in a manner to resolve reasonably valid complaints;(8)
has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner or a person on behalf of the health maintenance organization has advertised or merchandised the health maintenance organization’s services in an untrue, misrepresentative, misleading, deceptive, or unfair manner;(9)
would be hazardous to its enrollees if it continued in operation;(10)
has not complied substantially with:(A)
this chapter or a rule adopted under this chapter; or(B)
Section 1367.053 (Coverage Required), Subchapter A (Applicability of Certain Definitions), Chapter 1452 (Physician and Provider Credentials), Subchapter B, Chapter 1507 (Consumer Choice of Benefits Plans), Chapter 222 (Life, Health, and Accident Insurance Premium Tax), 251 (General Provisions), or 258 (Health Maintenance Organizations), as applicable to a health maintenance organization, or Chapter 1271 (Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges) or 1272 (Delegation of Certain Functions by Health Maintenance Organization) or a rule adopted under one of those provisions; or(11)
has not taken corrective action the commissioner considers necessary to correct a failure to comply with this chapter, any applicable provision of this code, or any applicable rule or order of the commissioner not later than the 30th day after the date of notice of the failure or within any longer period specified in the notice and determined by the commissioner to be reasonable.(c)
The commissioner may suspend or revoke a certificate of authority only after complying with this section.
Source:
Section 843.461 — Enforcement Actions, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.843.htm#843.461 (accessed Jun. 5, 2024).
