TX| Texas Department of Insurance (TDI) adopted amendments to 28 TAC §11.202, 11.301, 11.302, 11.501-11.504, 11.506, 11.701, 11.901,11.902, 11.1402, 11.1604, and 11.2503, through Commissioner’s Order No. 2026-10140, issued September 21, 2026. The attached Texas Department of Insurance adoption order substantially updates HMO post-certification filing, form, service-area, rate, provider-contract, and enrollee-disclosure requirements. Texas HMOs must use a controlled pre-implementation review process: obtain Commissioner approval before implementing specified material operational or document changes, submit other designated changes shortly after they take effect, ensure evidence-of-coverage and rate materials are filed before use, and build prescribed consumer protections and notices into contracts and operational processes. The amendments are directed to HMOs rather than all insurers generally, so applicability should be confirmed by product and entity type.
Five key compliance obligations
- File—and obtain approval before use—of material HMO changes. Before implementing specified changes, an HMO must submit a written filing and receive the Commissioner’s approval for items such as evidence-of-coverage forms; service-area descriptions and maps; certain member handbooks and health-plan terms; material emergency-procedure or network-configuration changes; certain provider, affiliate, management, loan, reinsurance/stop-loss, and compensation arrangements; organizational-document amendments; and use of a name or assumed name on applicable forms.
- File designated post-effective changes within 30 days. Within 30 days after the effective date, an HMO must file for TDI review or information changes including its schedule-of-charges methodology, prescription-drug coverage modifications, CHIP member-handbook changes, specified provider and insurer contract forms or substantive revisions, delegated-entity agreements, quality-assurance program changes, fidelity-bond changes, officer/director and biographical-information changes, and certificate-of-authority changes. These submissions are not deemed approved merely because they are filed.
- Submit complete filings promptly and respond to TDI requests within 10 business days. TDI will not accept an incomplete filing for review. For approval-required changes, TDI may treat the filing as approved if it does not disapprove it within 30 days after determining the filing complete, although it may extend its review once for up to an additional 30 days. If TDI seeks corrections or additional information and the HMO does not respond within 10 business days, TDI may consider the filing withdrawn.
- Obtain approval before changing service areas or issuing/revising evidence of coverage. An HMO must secure TDI approval before expanding, reducing, or adding a service area, with a complete application that includes current and proposed maps, network-configuration information, financial projections, and related amended materials. Likewise, HMO evidence-of-coverage forms—including agreements, certificates, applications, riders, schedules of benefits, and related forms—must have unique form numbers and Commissioner approval before they are issued, delivered, or used in Texas. An applicant must file clean final and redlined evidence-of-coverage versions no later than the 10th calendar day after certificate-of-authority approval or issuance.
- Maintain required enrollee protections, disclosures, and contract provisions on an ongoing basis. HMO contracts and evidence-of-coverage materials must contain prescribed provisions, including complaint/appeal information, emergency-services information, cancellation/nonrenewal and grace-period terms, eligibility and newborn-coverage rules, claims procedures, out-of-network referral protections, service-area details, and rate-change disclosures. Key timing requirements include at least 30 days’ written notice for many cancellations, 15 days for fraud-based cancellations, 90 days for discontinuance of a type of individual coverage, 180 days’ notice to TDI and enrollees for discontinuance of all individual basic coverage in a service area, and 60 days’ written notice of a rate increase where required. Physician and provider agreements must include hold-harmless protections, and changes to the specified hold-harmless language cannot take effect earlier than 15 days after TDI receives written notice.