1. (a) The governing body as described in Insurance Code §843.004, shall have ultimate responsibility for the development, approval, implementation and enforcement of administrative, operational, personnel and patient care policies and procedures related to the operation of the HMO.

2. (b) The HMO shall have a chief executive officer or operations officer who shall be accountable for the administration of the health plan, including:

   1. (1) developing corporate strategy;
   2. (2) overseeing marketing programs;
   3. (3) overseeing medical management functions; and
   4. (4) ensuring compliance with all applicable statutes and rules pertaining to the operations of the HMO.

3. (c) The HMO shall have a clinical director who:

   1. (1) shall be currently licensed in Texas or otherwise authorized to practice in this state in the field of services offered by the HMO. For example:

      1. (A) a basic HMO shall have a physician;
      2. (B) a dental HMO shall have a dentist or physician;
      3. (C) a vision HMO shall have an optometrist or physician; and
      4. (D) a limited services HMO shall have a physician.
   2. (2) shall reside in the state of Texas;
   3. (3) shall be available at all times to address complaints, clinical issues, utilization review and any quality of care issues on behalf of the HMO;
   4. (4) shall demonstrate active involvement in all quality management activities; and
   5. (5) shall be subject to the HMO's credentialing requirements, as appropriate.

4. (d) The HMO may establish one or more service areas within Texas. Each defined service area must:

   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; and
   4. (4) maintain separate cost center accounting for each service area to facilitate the reporting of divisional operations as required for HMO financial reporting.

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; amended to be effective February 24, 2005, 30 TexReg 854.