1. (a) An HMO shall file an application for approval with the department before the HMO may expand an existing service area, reduce an existing service area, or add a new service area.

2. (b) If any of the following items are changed by a service area expansion or reduction application, the new item or any amendments to an existing item must be submitted for approval or filed for information, as specified in §11.301 of this title (relating to Filing Requirements):

   1. (1) a description and a map with key and scale, showing both the currently approved service area and the proposed new service area as required by §11.204(12) of this title (relating to Contents);
   2. (2) a form of any new contracts or amendment of any existing contracts in the new area, as described in §11.204(13) of this title;
   3. (3) network configuration information, as required by §11.204(18) of this title;
   4. (4) a brief narrative description of the administrative arrangements, organizational charts as described in §11.204(6) of this title, and other pertinent information;
   5. (5) biographical data sheets for any new management staff assigned to the new area;
   6. (6) any new or amended evidence of coverage to be used in the new area, in accordance with the requirements of Subchapter F of this chapter (relating to Evidence of Coverage);
   7. (7) the formula or method for calculating the schedule of charges for any new or amended evidence of coverage in accordance with Subchapter H of this chapter (relating to Schedule of Charges);
   8. (8) copies of leases, loans, agreements and contracts to be used in the proposed new area, including information described in §11.301(4)(C), (E), and (G) of this title;
   9. (9) separate and combined sources of financing and financial projections as described in §11.204(10) of this title;
   10. (10) any new or amended officers' and employees' fidelity bonds, in accordance with §11.204(7) and (13)(D) of this title;
   11. (11) any new or amended reinsurance agreements, insurance or other protection against insolvency, as specified in §11.204(15) of this title; and
   12. (12) a description of the method by which the complaint procedure, as specified in the Insurance Code §843.251, et seq. and related regulations, will be made reasonably available in the new service area or division, including a toll free call, and the information and complaint telephone number required by the Insurance Code §521.102, where applicable. For HMOs subject to the Insurance Code §521.102, the toll free call required by this rule and the toll free information and complaint number required by the Insurance Code §521.102 may be the same number.
3. (c) The department shall not accept an application for review until the application is complete. An application to modify the certificate of authority that requires the commissioner's approval in accordance with the Insurance Code §843.080 and Chapter 1271 Subchapter C is considered complete when all information required by §11.301 of this title, this section, and §§11.1901 - 11.1902 of this title (relating to Quality of Care) that is reasonably necessary for a final determination by the department, has been filed with the department.
4. (d) Before consideration of a service area expansion or reduction application, the HMO must be in compliance with the requirements of §§11.1901 - 11.1902 of this title in the existing service areas and in the proposed service areas.

Source Note:The provisions of this §11.302 adopted to be effective January 1, 1980, 4 TexReg 4618; amended to be effective December 6, 1984, 9 TexReg 6010; amended to be effective July 15, 1986, 11 TexReg 3074; amended to be effective December 7, 1987, 12 TexReg 4415; amended to be effective August 17, 1992, 17 TexReg 5354; amended to be effective November 2, 1998, 23 TexReg 11347; amended to be effective February 24, 2005, 30 TexReg 854; amended to be effective November 15, 2006, 31 TexReg 9298.