Why do we have to report this data?
The 85th Legislature passed House Bill 10 directing the Texas Department of Insurance and the Health and Human Services Commission to conduct studies and prepare reports on benefits for medical or surgical expenses and for mental health conditions and substance use disorders. The agencies must submit their reports to the legislature by September 1, 2018. The report data will be aggregated and will not reveal any proprietary information of the respondents.
How do you determine which issuers are subject to the data call?
This data call applies to issuers that report to the National Association of Insurance Commissioners (NAIC) 25,000 or more covered lives as of the last day of the reporting period. This threshold applies separately to individual, small group, and large group health benefit coverage rather than to the total of the three categories. Issuers that do not meet the threshold for any particular category are not required to submit reports for that particular category. For example, if an issuer had 30,000 covered lives in the individual category, of which only 400 were enrolled in PPO plans and the remainder in EPO plans, it would be required to complete both the individual PPO and individual EPO data reports since it meets the individual category threshold. Likewise, if the issuer had 10,000 covered lives in the small group category across all product types, it is exempt from reporting for the small group category.
In addition, all Medicaid managed care organizations (MCOs) are required to submit data.
When are the reporting periods and the report due date?
The reporting period is January 1, 2017, to December 31, 2017, for commercial plans and September 1, 2016, to August 31, 2017, for Medicaid MCOs. The deadline for submitting reports is the close of business on Tuesday, May 1, 2018.
How do we submit the report?
Issuers and MCOs will submit the information for the data call using two excel workbooks located on the HB 10 Data Collection Index Page of TDI’s website. Respondents will submit the completed workbooks to TDI by email to HealthSurveys@tdi.texas.gov with “HB 10 Data Call” entered as the subject of the message.
Are we required to report Medicare information in this data call?
No. The bill only refers to collecting Medicaid information for the study in addition to data from commercial plans.
We have a Medicaid product issued by our HMO. Is Medicaid to be included in the same workbook as Commercial HMO or do you want two separate workbooks?
Report only Medicaid information on the Medicaid spreadsheet and only commercial information in the HMO spreadsheet. The information cannot be “co-mingled” since the Medicaid and CHIP information will be sent to HHSC for analysis and the commercial information will be retained by TDI for analysis.
In the instructions, Page 8 refers to peer-to-peer reviews and this appears to be a different than the peer-to-peer request related to the pre-authorization request on Page 7. What is being asked for in lines 27- 30 of the workbook or the corresponding regulation?
Lines 27-30 refer to physician-to-physician reviews of adverse determinations that pertain to services that have already occurred.
Will TDI provide a drug list for MH/SUD for reporting?
TDI does not have a list of MH/SUD drugs available – refer to the drug classifications based on AHFS codes as shown in the pharmacy sheets in the plan-specific workbook.
What services fall into the category of inpatient residential treatment?
TDI considers residential to refer to any live-in health care facility providing treatment for medical and/or MH/SUD conditions.
What if the limit on number of days varies within the category?
Please enter a range (minimum and maximum) of the number of days covered within the category.
Please provide clarification regarding the last question on the pharmacy tabs of the plan specific workbook.
As of April 19, 2018, the fourth question shown is being changed as follows: “Are any drugs in this category subject to any other method designed to reduce costs other than prior authorization or step therapy (e.g., cost sharing that varies by drug tier)?” Issuers will enter “Y” or “N” to answer the question instead of providing a number as prompted by the previous version of the question. The reporting form itself will not be revised in an effort to not cause problems for any issuers who have already begun completing the form for submission. Any answers submitted as numbers will be counted as follows: a “0” response will equal “N” and any number greater than 0 will equal a “Y.”
What if we have other questions about the data call?
You can send any questions you have by email to HealthSurveys@tdi.texas.gov.