1. (a) The governing body as described in the Insurance Code Article 20A.07, shall be responsible for the development, approval, implementation and enforcement of administrative, operational, personnel and patient care policies, procedures and related documents for the operation of the HMO.
2. (b) The HMO shall provide a full time chief executive officer or operations officer and at least one full time medical director, and if a limited service health care plan or single service health care plan, a full-time director, who is available within a service area.

3. (c) The HMO may establish one or more service areas within Texas. Each defined service area must meet the following:

   1. (1) demonstrate to the department the ability to provide continuity, accessibility, availability and quality of services;
   2. (2) specify the counties and zip codes, or any portions thereof, included in the service area;
   3. (3) provide a complete physician and provider listing for all enrollees residing, living or working in the service area;
   4. (4) maintain separate cost center accounting for each service area to facilitate the reporting of divisional operations as required for HMO financial reporting.

4. (d) The HMO shall ensure the service area maintains the following:

   1. (1) if a basic health care service plan, a medical director, and if a limited health care service plan or a single health care service plan, a director who:

      1. (A) shall be currently licensed in Texas or otherwise authorized to practice in this state in the field of services offered by the HMO;
      2. (B) shall reside in the service area; and
      3. (C) may serve in a part-time capacity and shall be available at all times to each service area. However, the medical director or a physician designee or single service director or designee meeting the criteria described in subparagraphs (A) and (B) of this paragraph, shall be available at all times to address complaints, clinical issues, utilization review and any quality of care inquiries on behalf of the HMO.
   2. (2) compliance with all requirements for quality improvement and utilization review functions as described in Subchapter T of this chapter (relating to Quality of Care).

Source Note:The provisions of this §11.1606 adopted to be effective December 8, 1997, 22 TexReg 11684; amended to be effective November 2, 1998, 23 TexReg 11347.