Texas Department of Insurance (TDI) <br/>Complaint Stakeholders Meeting
To protect insurance consumers by:
- regulating the industry fairly and diligently
- promoting a stable and competitive market
- providing information that makes a difference.
I. Welcome and antitrust statement -- Audrey Selden, Senior Associate Commissioner, Consumer Protection
- Complaint reviews
II. High-level Complaint Processing Framework - overview -- Valerie Brown, Director, Complaints Resolution, Consumer Protection
III. Legislative implementation
- Discount health plan complaints -- Valerie Brown
- HB 2256 Out-of-network provider health claim mediation program and rules -- Doug Danzeiser, Deputy Commissioner, Life, Health & Licensing
- HB 1919 Autism spectrum disorder coverage and applied behavior analysis -- Charles Reyna, Program Specialist, Health and Workers' Compensation Networks, Life, Health & Licensing
- Sunset schedule and 2010 stakeholder meetings -- Pat Brewer, Special Projects Director, Health and Workers' Compensation Networks, Life, Health & Licensing
• Technical Advisory Committee on Claims Processing (TACCP)
• Chiropractors and pharmacists
• Healthy Texas
• 2010 Compliance Conference
• Texas State Disaster Coalition (TSDC)
IV. Disaster preparedness and pandemic response -- Jack Evins, Director, Advertising, Consumer Protection
V. Requirement to maintain a complaint record/log -- Jack Evins
VI. Meet in small groups to discuss complaint issues -- Attendees and TDI staff
1. Dial 877-226-9790
2. Enter passcode 9241684
I. Welcome and antitrust statement
Audrey Selden welcomed the attendees and reviewed the agenda and antitrust statement. TDI staff is happy to meet individually with carriers to review their complaints; to schedule a meeting, please send an e-mail to firstname.lastname@example.org.
II. High-level Complaint Processing Framework
Valerie Brown, Director, Complaints Resolution, Consumer Protection, reviewed TDI's high-level complaint processing framework. For companies, a "best practice" is to provide a detailed and timely response to TDI about the complaint. If a company has a question about why a complaint has been coded "justified," please send the question in writing, including the complaint ID number, to Valerie at email@example.com or via fax to 512-305-7463. Valerie's direct number is 512-463-6503.
Complaints about discount health care programs: During the 2009 legislative session, the responsibility for regulating discount health care programs was transferred from the Texas Department of Licensing and Regulation to TDI, effective April 1, 2010. TDI began handling complaints about discount health care programs on September 1, 2009. For more information visit the Discount Health Care Programs Resource Page.
TDI offers a free eNews service. To learn more about eNews and register to receive free e-mail newsletters, visit the website.
III. Legislative implementation
HB 2256: Doug Danzeiser, Deputy Commissioner, Life, Health & Licensing, explained that HB 2256, passed during the recent legislative session, addresses the "balance billing" issue involving out-of-network hospital-based providers, including anesthesiologists, radiologists, pathologists, and neonatologists under insured PPO plans. The statute requires that the provider and carrier participate in an informal conference call to settle the claim before the mediation process. In addition, these providers are required to include a reference to the availability of the new mediation program on their bills. TDI explains the new procedure and provides a mediation request form on the Mediation for Out-of-Network Hospital-based Health Care Provider Claims page. The State Office of Administrative Hearings (SOAH) will schedule the mediations and provide mediators. TDI, SOAH, and the Texas Medical Board are working on rules related to the new mediation program. Also there are other provisions of HB 2256 about PPO networks that will be addressed in the TDI rules.
TDI rules process: Doug noted that TDI's rule process involves first posting an informal draft and having a stakeholder meeting to gather input about the draft rule. Based on this input, TDI may revise the draft rule, then post it for a formal hearing. Following receipt of comments, additional revisions may be made. Then the final rule is published and adopted by the Commissioner. TDI welcomes carriers' input as rules are developed and encourages their participation especially regarding the development of cost notes. TDI seeks to meet legislative intent while keeping costs as low as possible for carriers and to do this, carriers input is essential. The best way to stay informed about TDI rulemaking is to subscribe to eNews. Also view informal draft, proposed and adopted rules on TDI's website. Doug's direct phone number is 512-475-1964.
HB 1919 Autism spectrum disorder coverage and applied behavior analysis: Charles Reyna, Program Specialist, Health & Workers' Compensation Networks (HWCN) - Life, Health & Licensing, provided an update on the requirements for mandatory coverage of autism spectrum disorder. HB 1919 mandated this coverage in 2007. In the 2009 legislative session, HB 451 expanded the requirements. At this time, both apply and require that certain group benefit plans must cover generally recognized services provided by health care practitioners according to a treatment plan prescribed by the enrollee's primary care physician or developed by the insured's physician. TDI has received complaints indicating that carriers are not understanding some of these requirements. Carriers must cover the services in the patient's treatment plan, and treatment plans may vary by patient based on medical necessity. TDI wishes to partner with carriers to assure implementation of these statutes. If carriers have questions, please contact the HWCN staff via e-mail to HWCN@tdi.texas.gov or call 512-322-4266.
Sunset review and stakeholder meetings schedule: Pat Brewer, Special Projects Director, HWCN - Life, Health & Licensing, explained that the Sunset Advisory Commission reviewed the Texas Department of Insurance in 2008 and made recommendations on the agency to the 81st Legislature. However, the legislation containing the Sunset recommendations and continuing the agency failed to pass. Instead, legislation passed in the 1st Called Session of the 81st Legislative Session continues the agency until 2011 and limits the Sunset Commission's review of the Texas Department of Insurance to the appropriateness of the recommendations made on the agency by the Sunset Commission to the 81st Legislature. The Sunset staff has begun its review of TDI and a hearing has been set for May 24 and 25. For more information about the Sunset process, visit the Sunset Advisory Commission's website.
TDI has established stakeholder groups on various topics and there is a link to each group's web resource page on the TDI Complaints Stakeholders page.
- Technical Advisory Committee on Claims Processing (TACCP) includes representatives appointed by the Commissioner. TACCP consults with the Commissioner before the adoption of any rules regarding, and advises the Commissioner on technical aspects of, coding of health care services and claims development, submission, processing, adjudication, and payment.
- Chiropractor and Pharmacy stakeholder groups meet quarterly to discuss recent legislation, issues, and complaints of interest to these providers. For more information and to view the meeting schedule, please visit the Chiropractors Resource Page and Pharmacists Resource Page.
- Healthy Texas is a new statewide program to increase the availability of insurance for small businesses. Stakeholder meetings regarding rules and other aspects of the new program were held last fall and more are coming. Meetings are posted on the TDI agency calendar.
- TDI will host a Compliance Conference for insurers in May. The P&C conference is set for May 11 and the life and health conference for May 12. Watch TDI's website for the agenda to be posted in February.
- Texas State Disaster Coalition (TSDC) members include P&C, life, health, and workers' compensation carriers, the Texas Division of Emergency Management, FEMA and other governmental agencies, the American Red Cross, consumer groups, and emergency management and industry trade associations. TSDC meets quarterly and the next meeting is set for April 15.
IV. Disaster preparedness and pandemic response
Jack Evins, Director, Advertising, Consumer Protection and TDI's liaison to the Texas Division of Emergency Management, noted that disaster preparation is a key issue for both the industry and TDI -- how prepared are we to continue to provide services to Texas policyholders in the event of a disaster? In Texas, there is no longer a "disaster season" as ice and hail storms, wildfire, and floods can occur throughout the year. TDI requests all licensed companies and surplus lines carriers to complete an annual disaster plan survey and is currently seeking input on the 2010 survey questions. To provide comments, please send an e-mail to firstname.lastname@example.org. TDI plans to issue the survey in March or April 2010. In addition, disaster planning should address the threat of pandemics. At the most recent TSDC meeting, the State Department of Health Services reported on the addition of a plan for mass casualties to the state's emergency management plan. For more information, please review the recent Texas State Disaster Coalition meeting notes.
V. Requirement to maintain a complaint record/log
Jack explained that TDI rules require licensed companies to maintain a complaint record and HMOs are required to maintain a complaint log. The complaint record/log must include a record of all complaints received by the carrier from its policyholders regarding its operations and meet certain minimum requirements specified in TDI rules. In the past, TDI has fined carriers for not having a complaint record or log or not meeting the minimum requirements contained in the Texas Insurance Code Chapter 21, Subchapter Q, for insurers, or §11.205 for HMOs. The complaint record/log should include all complaints received by the carrier, not only those referred to the carrier by TDI. More important, TDI encourages carriers to use their complaint record/log to identify opportunities for improving their business processes and customer service, and decreasing complaints to TDI. Conclusion
Audrey reminded the group that TDI's mission statement is to protect insurance consumers by: regulating the insurance industry fairly and diligently, promoting a stable and competitive market, and providing information that makes a difference. The complaints process helps us in each area, and provides useful data to assist consumers and to assess how companies are doing. Complaints can be an early indicator of a solvency issue with a particular company and lead to an enforcement action; or they can indicate the need for TDI to educate consumers about a particular coverage in a policy. TDI invites carriers to provide feedback on what is working and what can be improved about the complaints process, and to share strategies and suggestions for process improvements. Thank you for participating in the complaints stakeholders meeting.
For more information contact:
Last updated: 09/06/2014