DUE: March 10, 2011 - Reporting Period January 1, 2010 to June 30, 2010
The attached mandatory Health Care Claims Reimbursement Rate Report is being issued pursuant to §§38.351-38.358 of the Texas Insurance Code (TIC). This statute requires the Texas Department of Insurance (TDI) to collect data concerning health benefit plan reimbursement rates in a uniform format, and to disseminate information derived from this data on an aggregate basis by geographical region in Texas. TDI adopted the rules contained in Title 28, Subchapter KK of the Texas Administrative Code (TAC) to implement this statute, and these rules have an effective date of January 9, 2011.
The Health Care Claims Reimbursement Rate Report applies to issuers of preferred provider benefit plans, health maintenance organization plans, and specified governmental employee plans under Chapters 1551, 1575, 1579, and 1601 of the TIC. As stated in 28 TAC §21.4506(b), the first reporting date for the submission of data is March 10, 2011 (60 days from the effective date of the rule). This report will capture data regarding claims payments from January 1, 2010, to June 30, 2010.
The Health Care Claims Reimbursement Rate Report must be filed electronically via email to ReimbursementRates@tdi.state.tx.us using the prescribed Microsoft Excel form "LHL616". Companies may access form LHL616 using the link at the bottom of this bulletin, or on the TDI website at http://www.tdi.state.tx.us/forms/form10accident.html. To access the report form, the user must indicate acceptance of the End User Agreement concerning use of Current Procedural Terminology. Acceptance is indicated by clicking the button labeled "Accept." The content of the End User Agreement is provided in 28 TAC §21.4506(f).
A group health benefit plan issuer as specified in 28 TAC §21.4502(a) may submit to the department an exemption statement and the data required in Section B of form LHL616 to support an exemption in place of the full report. The group health benefit plan issuer asserting an exemption shall 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 the 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 the 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, please contact Glenn Daniel at 512-305-7892 or ReimbursementRates@tdi.state.tx.us.
Failure to comply with the requirements of this data call within the time limits specified may constitute a violation or violations of the TIC and may subject the insurer to the penalties provided by law.
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Katrina Daniel
Senior Associate Commissioner
Life, Health & Licensing Program