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You are here: Home . bulletins . 2015 . b-0011-15

COMMISSIONER'S BULLETIN # B-0011-15

June 05, 2015


To: ISSUERS OF PREFERRED PROVIDER BENEFIT PLANS, HEALTH MAINTENANCE ORGANIZATION PLANS, AND SPECIFIED GOVERNMENTAL EMPLOYEE PLANS IN THE STATE OF TEXAS


Re: HEALTH CARE REIMBURSEMENT RATE INFORMATION DATA CALL AND ALTERNATIVE TEST OF METHODOLOGY PROPOSED IN THE INFORMAL DRAFT OF THE RULE

LETTER OF INTENT DUE:  July 1, 2015

DATA SUBMISSION DUE:  September 1, 2015, for reporting period January 1, 2015, to June 30, 2015

This bulletin announces the annual data call for health care reimbursement rate information under Insurance Code Chapter 38, subchapter H.  This subchapter requires TDI to collect health benefit plan reimbursement rate information in a uniform format, and to disseminate the combined rates derived from this data by geographical regions in the state.  This data call applies to issuers of preferred provider benefit plans, health maintenance organization plans, and specified governmental employee plans under Insurance Code Chapters 1551, 1575, 1579, and 1601.  The rules that implement this statute are in 28 Texas Administrative Code Chapter 21, subchapter KK.  Issuers typically submit this data by completing form LHL616.  For the 2015 reporting period, issuers may comply by submitting either LHL616 or the alternative methodology, described below.

To improve the quality of the data collected under the rules, TDI recently posted an informal draft of revisions to subchapter KK and anticipates formally proposing changes to the rule in the near future.  In light of the substantive nature of the proposed changes, issuers have the option to submit a more limited set of test data using the methodology proposed in the informal draft of the rule, instead of the full reporting of the 2015 reimbursement rate information under LHL616 and the current rule.  The alternative data collection will give issuers a head start in implementing the proposed methodology and enable issuers to communicate to TDI any problems or concerns with the methodology in the informal draft of the rule before the changes are formally proposed.  TDI anticipates that most issuers will elect to submit the alternative test data, accompanied by any feedback on the methodology.  This feedback will assist TDI’s efforts to adopt a revised rule that yields more accurate and relevant reimbursement rate data.

Failure to comply with the requirements of the data call using either methodology by September 1, 2015, is a violation of the Insurance Code and may subject the issuer to penalty.

Companies that choose to submit test data and feedback do not need to submit form LHL616.

Test of Informal Draft Rule Methodology:

A letter of intent, reflecting the company’s intention to submit the alternative test data instead of LHL616 is due July 1, 2015.  Please email ReimbursementRates@tdi.texas.gov to indicate which option the company has elected.  The instructions for submitting test data using the methodology proposed in the informal draft rule are at www.tdi.texas.gov/health/reimbursement.html.  As previously noted, companies that choose to submit the alternative test data do not need to submit form LHL616.

Companies that are exempt by rule from the data collection should not submit alternative test data, but should follow the instructions below for submitting an exemption statement.  

Full Data Collection (LHL616):

A letter of intent, reflecting the company’s intention to submit the LHL616 report, rather than test the proposed methodology is due July 1, 2015.  Please email ReimbursementRates@tdi.texas.gov to indicate which option the company has elected.  The instructions below apply only to companies choosing not to submit alternative test data.  

Issuers choosing to respond to the data call with reimbursement rate data must use the Microsoft Excel form LHL616, which is located online at www.tdi.texas.gov/health/reimbursement.html.  Form LHL616 must be submitted electronically to ReimbursementRates@tdi.texas.gov.  

TDI requests that responding issuers voluntarily comply with reporting data for updated ZIP codes.  Newly added ZIP codes that are not in 28 Texas Administrative Code Chapter 21, subchapter KK are 73960 (Panhandle), 75033 and 76190 (Metroplex), 77407, 77498, 77523, and 78542 (Gulf Coast).  Data for these ZIP codes should be included in data reported for the corresponding regions.

Certain group health benefit plan issuers may submit to TDI an exemption statement, and the data required in Section B of form LHL616, to support an exemption in place of the full report.  As required by 28 TAC §21.4506(e), a group health benefit plan issuer asserting an exemption must certify that the group health benefit plan issuer is exempt from the reporting requirement applicable to its health benefit plans for one of the following reasons:

(1)   The total number of all covered lives in private market preferred provider benefit plans operating under Insurance Code Chapter 1301 and offered by the health benefit plan issuer in Texas does not exceed 10,000 persons as of December 31 of the year preceding the report; or

(2)   The total number of all covered lives in the private market health maintenance organization plans operating under Insurance Code Chapter 843 and offered by the health benefit plan issuer does not exceed 10,000 persons as of December 31 of the year preceding the report.

If you are unable to download the form, or have any questions concerning this data call, you may contact TDI by email at ReimbursementRates@tdi.texas.gov.

 
David C. Mattax
Commissioner of Insurance



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Last updated: 06/05/2015

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