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SUBCHAPTER Z. Data Collecting and Reporting Relating to Mandated Health Benefits and Mandated Offers of Coverage 28 TAC §§ 21.3401 ­ 21.3409

The Texas Department of Insurance proposes new §§21.3401 ­ 21.3409 concerning the collection and reporting of data related to mandated benefits and offers of coverage. The 77 th Texas Legislature enacted House Bill 1610 which added new Subchapter F, Data Collection and Reporting Relating to Health Benefits and Mandated Offers of Coverage, Chapter 38, §§38.251 - 38.254, to the Texas Insurance Code requiring the commissioner to adopt rules concerning reporting of data related to the provision of mandated benefits and offers of coverage. The department proposes new Subchapter Z to implement the requirements of §§38.251 - 38.254.

Proposed §21.3401 sets forth the purpose and scope of the subchapter and clarifies that licensed third party administrators (TPAs) who provide administrative services to carriers described in (b)(1), (2), or (3) must collect and report the data. Because these TPAs collect data on behalf of the health benefit plan issuers they are thus included in who must provide the data. Proposed §21.3402 defines the terms used in the subchapter. Proposed §21.3403 requires health benefit plan issuers to collect data and prepare a report pursuant to the requirements of proposed §§21.3406 and 21.3407. Proposed §21.3404 establishes the deadline for the submission of the report and the content of the report. Section 21.3405(a) outlines the exceptions to the reporting of certain data. Proposed §21.3405(b) describes limited instances when an HMO would not be required to collect and report data. However, licensed TPAs described in §21.3401 (b)(4) must collect and report the data to the issuer for whom they provide administrative services. Proposed §21.3406 lists the mandates for which data is to be collected and reported. Proposed §21.3407 prescribes the format for the data and report to be submitted. Proposed §21.3408 provides that the failure to comply with this subchapter will subject an issuer to sanctions and penalties. Proposed §21.3409 provides for severability of any section held invalid.

Kim Stokes, Senior Associate Commissioner, Life, Health and Licensing Division, has determined that for each year of the first five years the proposed sections will be in effect, there will be no fiscal impact to state and local governments as a result of the enforcement or administration of the rule. There will be no measurable effect on local employment or the local economy as a result of the proposal.

Ms. Stokes has determined that for each year of the first five years the sections are in effect, the public benefits anticipated as a result of the proposed sections will be increased awareness of the costs and utilization of mandated benefits and offers of coverage. The costs to comply with the proposed sections are the result of the legislative enactment of HB 1610, which created Sections 38.251- 38.254 of the Insurance Code. Licensed TPAs are subject to the subchapter if they perform administrative services for a health benefit plan issuer that meets the rule´s minimum financial requirements set forth in §21.3401 (b)(1), (2), and (3). It is the department´s position that any potential cost to the TPAs who perform these services is minimal as the TPAs are already capturing and in all likelihood transmitting this data to the issuer. Furthermore, it is neither legal nor feasible to waive or modify the requirements of this rule for small or micro businesses because, pursuant to the statute, the data must be retrieved whether it is collected by the health plan issuer or the TPA that performs the administrative services for the carrier.

To be considered, written comments on the proposal must be submitted no later than 5:00 p.m. on September 3, 2002, to Lynda H. Nesenholtz, General Counsel and Chief Clerk, Mail Code 113-2A, Texas Department of Insurance, P. O. Box 149104, Austin, Texas 78714-9104. An additional copy of the comment must be simultaneously submitted to Kim Stokes, Senior Associate Commissioner, Life, Health and Licensing Division, Mail Code 107-2A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. Any requests for a public hearing should be submitted separately to the Office of the Chief Clerk.

The subchapters are proposed under the Texas Insurance Code Sections 38.252 and 36.001. Section 38.252 directs the Commissioner to adopt rules requiring the reporting of specific data by health benefit plan issuers. Section 36.001 provides that the Commissioner of Insurance may adopt rules to execute the duties and functions of the Texas Department of Insurance only as authorized by statute.

The following sections are affected by this proposal: Texas Insurance Code §§38.251-38.254

§21.3401. Purpose and Scope.

(a) Purpose. The purpose of this subchapter is to identify and set forth the requirements for mandates about which issuers of health benefit plans that are subject to this subchapter must collect and report data to the Commissioner.

(b) Scope. This subchapter applies to:

(1) a health benefit plan issuer that reports in its most recently filed annual statement a total of $10 million or more in direct premiums earned in the state of Texas for group accident and health insurance policies;

(2) a health benefit plan issuer that reports in its most recently filed annual statement a total of $2 million or more in direct premiums earned in the state of Texas for individual accident and health insurance policies;

(3) a health benefit plan issuer that is a basic service health maintenance organization and reports in its most recently filed annual statement a total of $10 million or more in direct commercial premiums earned in the state of Texas;

(4) a licensed third party administrator that performs claims payment services for any health benefit plan issuer that meets the requirements of paragraph (1) - (3) of this subsection.

§21.3402. Definitions. The following words and terms, when used in this subchapter, shall have the following meaning unless the context clearly indicates otherwise:

(1) Administrative costs - All costs directly associated with each mandate other than the claim amounts. Administrative costs should not include any start-up costs unless those costs were incurred during the reporting year.

(2) Average annual premium attributable to each mandate - An estimate of the average annual premium cost per individual policy or group certificate for each mandate based on the health benefit plan issuer´s actual experience for the reporting year. If average costs across policies or certificates cannot be determined, the average annual premium must be based on an estimate of the health benefit plan issuer´s most commonly issued standard individual or group policy.

(3) Direct premium - Premium received by a health benefit plan issuer in return for coverage, but not including premium received for providing reinsurance.

(4) Health benefit plan issuer - An insurer or health maintenance organization that issues a plan that provides benefits for medical and surgical expenses incurred as the result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document.

(5) Mandates - Benefits or coverages listed in §21.3406 of this subchapter (relating to Mandates for Which Data Must Be Reported) that are required to be included in an individual or group health benefit plan or required to be offered and made available to the holder of an individual or group contract or the purchaser of an individual or group health benefit plan.

(6) Number of claims paid - The total number of separate, individual claims paid by the health benefit plan issuer.

(7) Total number of lives covered ­ The total number of lives covered under a policy, contract or certificate, including the certificate, contract or policyholder and all dependents covered by the policy, contract or certificate for a reporting year.

§21.3403. Collection of Data Necessary to Provide Report. Each health benefit plan issuer to which this subchapter applies shall collect the data required by this subchapter for each mandate set forth in §21.3406 of this subchapter (relating to Mandates for Which Data Must Be Reported) and shall prepare and file a report as required by §21.3407 of this subchapter (relating to Reporting of Required Information).

§21.3404. Deadline for Submission of Reports. Health benefit plan issuers shall annually submit the report required by this subchapter no later than March 1, and shall include all data for benefits and coverages for which payment was made during the previous calendar reporting year.

§21.3405. Exceptions to Required Reporting and Justification for Exceptions.

(a) A health benefit plan issuer subject to this subchapter shall not be required to report data that:

(1) could reasonably be used to identify a specific enrollee in a health benefit plan; or

(2) violates confidentiality requirements of state or federal law or regulation applicable to an enrollee in a health benefit plan.

(b) A health benefit plan issuer that is an HMO shall not be required to report data for a particular benefit or coverage if:

(1) the HMO does not directly process the claim because the services are prepaid under a capitated payment arrangement; or

(2) the HMO does not receive complete and accurate encounter data.

(c) A health benefit plan issuer that does not report data for a reason set forth in subsection (a) of this section must submit, in addition to the report required by this subchapter, an addendum containing:

(1) a general description of the type of data that has been omitted;

(2) the specific provision of each state or federal law or regulation that is the basis for omitting the data; and

(3) a certification that the data could not be identified in such a way that would enable it to be included in the report without violating subsection (a) of this section.

(d) A health benefit plan issuer that omits data for a reason set forth in subsection (b) of this section must submit, in addition to the report required by this subchapter, an addendum containing a description of the arrangements or circumstances that except the health benefit plan issuer from reporting the data as required.

§21.3406. Mandates for Which Data Must Be Reported.

(a) The following is a list of mandates about which data relating to group health benefit plan must be filed under §21.3403 of this subchapter (relating to Collection of Data Necessary to Provide Report):

(1) In Vitro Fertilization Procedures, Insurance Code Article 3.51-6, Section 3A and §11.510(1) of this title (relating to Mandatory Offers);

(2) HIV or AIDS Related Illnesses, Insurance Code Articles 3.51-6, Section 3C; 3.51-6D; 3.50-2, Section 5(j)(1); 3.50-3, Section 4C(1); and 3.51-5A(a)(1) and §3.3057(d) of this title (relating to Standards for Exceptions, Exclusions, and Reductions Provision);

(3) Chemical Dependency, Insurance Code Article 3.51-9, and Subchapter HH, §§3.8001-3.8030 of this title (relating to Standards for Reasonable Cost Control and Utilization Review for Chemical Dependency Treatment Centers);

(4) Serious Mental Illnesses, Insurance Code Articles 3.51-14, 3.50-2 and §11.509(5) of this title (relating to Additional Mandatory Benefit Standards: Group Agreement Only);

(5) Serious Mental Illnesses, Insurance Code Articles 3.50-3 and 3.51-5A(a)(2) and (b);

(6) Treatment in Psychiatric Day Treatment Facility, Insurance Code Article 3.70-2(F) and §§11.509(5) and 11.510(3) of this title;

(7) Loss or Impairment of Speech or Hearing, Insurance Code Article 3.70-2(G) and §11.510(2) of this title;

(8) Low Dose Mammography, Insurance Code Article 3.70-2(H);

(9) Phenylketonuria (PKU), Insurance Code Article 3.79;

(10) Prescription Contraceptive Drugs and Devices and Related Services, Insurance Code Article 21.52L;

(11) Temporomandibular Joint Procedures, Insurance Code Article 21.53A and §11.509(6) of this title;

(12) Osteoporosis, Detection and Prevention, Insurance Code Article 21.53C;

(13) Immunizations, Insurance Code Articles 21.53F,and 20A.09F and §§11.506(2) and 11.508(a)(9)(G) of this title (relating to Mandatory Contractual Provisions: Group, Individual, and Conversion Agreement and Group Certificate, and Mandatory Benefit Standards: Group, Individual and Conversion Agreements);

(14) Prostate Cancer Testing, Insurance Code Articles 21.53F and 3.50-4, Sec. 18D and §11.508(a)(9)(E) of this title;

(15) Diabetes Self-Management Training, Insurance Code Articles 21.53D and 21.53G and §§21.2601 ­ 21.2607 of this title (relating to Diabetes);

(16) Hearing Screening for Children, Insurance Code Article 21.53F;

(17) Telemedicine/Telehealth, Insurance Code Article 21.53F and §11.1607(i), (j) and (k) of this title (relating to Accessibility and Availability Requirements);

(18) Reconstructive Surgery Incident to a Mastectomy, Insurance Code Article 21.53I and §11.508(a)(5)(A) of this title;

(19) Certain Benefits Related to Acquired Brain Injury, Insurance Code Article 21.53Q;

(20) Reconstructive Surgery for Craniofacial Abnormalities in A Child, Insurance Code Article 21.53W; and

(21) Oral Contraceptives, §21.404(3) of this title (relating to Underwriting) and Prescription Contraceptive Drugs and Devices and Related Services, Insurance Code Article 21.52L

(b) The following is a list of mandates about which data relating to individual health benefit plan must be filed under §21.3403 of this subchapter:

(1) HIV or AIDS Related Illnesses, Insurance Code Articles 3.51-6, Section 3C; 3.51-6D; 3.50-2, Section 5(j)(1); 3.50-3, Section 4C(1); and 3.51-5A(a)(1), and §3.3057(d) of this title;

(2) Immunizations, Insurance Code Articles 21.53F and 20A.09F, and §§11.506(2) and 11.508(a)(9)(G) of this title;

(3) Prostate Cancer Testing, Insurance Code Articles 21.53F and 3.50-4, Sec. 18D and §11.508(a)(9)(E) of this title;

(4) Diabetes Self-Management Training, Insurance Code Articles 21.53D and 21.53G, and §§21.2601 ­ 21.2607 of this title;

(5) Hearing Screening for Children, Insurance Code Article 21.53F;

(6) Telemedicine/Telehealth, Insurance Code Article 21.53F and §11.1607(i), (j) and (k) of this title;

(7) Reconstructive Surgery Incident to a Mastectomy, Insurance Code Article 21.53I and §11.508(a)(5)(A) of this title;

(8) Certain Benefits Related to Acquired Brain Injury, Insurance Code Article 21.53Q;

(9) Reconstructive Surgery for Craniofacial Abnormalities in A Child, Insurance Code Article 21.53W;

(10) Oral Contraceptives, §21.404 of this title (relating to Underwriting) and Prescription Contraceptive Drugs and Devices and Related Services, Insurance Code Article 21.52L; and

(11) Low Dose Mammography, Insurance Code Article 3.70-2(H).

(c) The Department will provide, on the Department´s Web site, www.tdi.state.tx.us , suggested procedure and diagnosis codes that may be used in capturing the required data for the report. Regardless of whether a health benefit plan issuer uses the suggested codes or some other method of capturing the required information, each health benefit plan issuer shall maintain information and documentation supporting the accuracy and completeness of the data and the report, including, but not limited to, a list of all procedural and diagnosis codes used in collecting data for the report for five years following the submission of the report upon which the information was based. Upon receiving a request from the department, a health benefit plan issuer shall make available the supporting information described in this subsection.

§21.3407. Reporting of Required Information.

(a) A health benefit plan issuer shall submit the data required by this section electronically by accessing a link provided on the Department´s Web site, www.tdi.state.tx.us

(b) Each health benefit plan issuer shall provide the following information for the reporting year:

(1) the year for which the data is being reported;

(2) the health benefit plan issuer´s NAIC Number;

(3) the health benefit plan issuer´s company name;

(4) the health benefit plan issuer´s mailing address;

(5) if applicable, any group NAIC number and group name;

(6) the name, title, direct telephone number, mailing address and email address of an individual who is responsible for the report;

(7) the total direct premiums earned in the state of Texas for group accident and health insurance policies or contracts which are subject to one or more of the mandates set forth in §21.3406(a) ;

(8) the total direct premiums earned in the state of Texas for individual accident and health insurance policies or contracts which are subject to one or more of the mandates set forth in §21.3406(b);

(9) the total dollar amount of claims paid for the reporting year on all group policies or contracts for which premium is being reported; and

(10) the total dollar amount of claims paid for the reporting year on all-individual policies or contracts for which premium is being reported.

(c) Each health benefit plan issuer shall provide for each of the mandates set forth in §21.3406(a) of this subchapter (relating to Mandates for Which Data Must be Reported) the following information for the reporting year:

(1) The number of claims paid;

(2) The total dollar amount of the claims paid;

(3) The number of policies, contracts or certificates about which information is being reported; and

(4) The total dollar amount of administrative costs incurred during the reporting year.

(d) Each health benefit plan issuer shall provide, for each of the mandates set forth in §21.3406(b) of this subchapter, the following information for the reporting year:

(1) The number of claims paid;

(2) The total dollar amount of the claims paid;

(3) The number of policies, contracts or certificates about which the information is being reported; and

(4) The total dollar amount of administrative costs incurred during the reporting year.

(e) Each health benefit plan issuer shall provide, for each of the mandates set forth in §21.3406(a) of this subchapter, the average annual premium per policy, contract or certificate attributable to each mandate for each group certificate about which data is being reported, and must report separate data for certificates providing individual coverage and certificates providing family coverage during the reporting year.

(f) Each health benefit plan issuer shall provide the total number of group certificates issued or renewed and the total number of certificates in force, during the reporting year, and must report separate data for the total number of certificates providing individual coverage and the total number of certificates providing family coverage during the reporting year.

(g) Each health benefit plan issuer shall provide the total number of lives covered under group certificates issued, renewed, or in force during the reporting year, and must report separate data for the total number of certificates providing individual coverage and the total number of certificates providing family coverage during the reporting year.

(h) Each health benefit plan issuer shall provide, for each of the mandates set forth in §21.3406(b) of this subchapter, the average annual premium attributable to each mandate for individual policies about which data is being reported, and must report separate data for policies providing individual coverage and policies providing family coverage during the reporting year.

(i) Each health benefit plan issuer shall provide the total number of individual policies issued or renewed and the total number of policies in force during the reporting year, and must report separate data for total number of policies providing individual coverage and the total number of policies providing family coverage during the reporting year.

(j) Each health benefit plan issuer shall provide the total number of lives covered under individual policies issued, renewed or in force during the reporting year and must report separate data for the total number of policies providing individual coverage and the total number of policies providing family coverage during the reporting year.

§21.3408. Compliance. Failure to comply with this subchapter shall subject any entity included in the scope of this subchapter to the sanctions and penalties provided in the Insurance Code Chapters 28A, 82, 83, and 84.

§21.3409. Severability. If any section or portion of a section of this subchapter or its applicability to any person or circumstance is held invalid by a court, the remainder of the subchapter or the applicability of the provision to other persons or circumstances shall not be affected.



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