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Texas Department of Insurance
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Subchapter T. Submission of Clean Claims


The Texas Department of Insurance (the department) proposes new §21.2826, concerning waiver of statutory provisions as to Medicaid and Children´s Health Insurance Program (CHIP) plans. The new section is the result of Senate Bill (SB) 418, 78 th Regular Legislative Session, which contained numerous provisions regarding the prompt payment of claims by"). Among other things, SB 418 added new Art. 21.30 concerning waiver of requirements for certain programs administered by the Health and Human Services Commission. The purpose of this proposal is to implement this provision, as described more fully herein.

As allowed by SB 418, the department adopted §21.2826 on an emergency basis effective August 16, 2003, which was the date that certain provisions of SB 418 went into effect. The emergency section is still in effect but will be withdrawn at the time this proposal, after notice and comment, is adopted.

Article 21.30 allows the commissioner of insurance, in consultation with the Commissioner of the Health and Human Services Commission, to determine whether certain provisions of Art. 3.70-3C and the HMO Act, Chapter 843, will cause a negative fiscal impact to the state with respect to providing benefits or services under the Medicaid and CHIP plans and, if so, to waive application of those provisions. Based upon a request from the Commissioner of the Health and Human Services Commission, proposed §21.2826 states that certain stated provisions of the statute and rules do not apply to Medicaid and CHIP plans provided by a carrier to persons enrolled in those programs.

Kimberly Stokes, Senior Associate Commissioner for Life, Health and Licensing, has determined that for each year of the first five years the proposed section will be in effect there will be no fiscal impact to state and local governments as a result of the enforcement and 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 section is in effect, the public benefits anticipated as a result of proposed §21.2826 will be lower costs of coverage and administration to the Medicaid and CHIP plans which, absent the waiver, could result in higher costs of providing program services, as well as higher administrative costs for the state, according to the Texas Health and Human Services Commission. Any potential cost to persons required to comply with this section for each of the first five years the proposed amendments will be in effect is the result of the enactment of SB 418 and not the result of the adoption, enforcement, or administration of the section. Ms. Stokes has also determined that there is no adverse economic impact on entities affected by the rule that qualify as a small business or micro-business under Government Code §2006.001 as a result of the proposed section. In addition, it is neither legal nor feasible to waive the provisions of the proposed section for small or micro businesses since Article 21.30 applies to all Medicaid and CHIP plans regardless of the size of the carrier providing the plan.

To be considered, written comments on the proposal must be submitted no later than 5:00 p.m. on December 1, 2003, to Gene C. Jarmon, 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 Kimberly Stokes, Senior Associate Commissioner, Life, Health and Licensing Program, Mail Code 107-2A, Texas Department of Insurance, P.O. Box 149104 , Austin , Texas 78714-9104 . A request for a public hearing should be submitted separately to the Office of the Chief Clerk.

The amendments are proposed under the Insurance Code Article 21.30, and §36.001. Article 21.30 allows the commissioner of insurance, under the circumstances stated therein, to waive application of certain provisions of SB 418 as to the Medicaid or CHIP plans. Section 36.001 of the Insurance Code provides that the commissioner of insurance may adopt any rules necessary and appropriate to implement the powers and duties of the Texas Department of Insurance under the Insurance Code and other laws of this state.

The following article is affected by this proposal: Insurance Code Art. 21.30

§21.2826. Waiver. The provisions of Texas Insurance Code Articles 3.70-3C, Sections 3A, 3C-3J, 10-12; and 21.52Z; Chapter 843, Subchapter J and Sections 843.209 and 843.319; as well as this subchapter and §§3.3703(20), 11.901(10), 19.1723, and 19.1724 of this title (relating to Contracting Requirements, Required Provisions, Preauthorization and Verification, respectively) are not applicable to Medicaid and Children's Health Insurance Program (CHIP) plans provided by an HMO or preferred provider carrier to persons enrolled in the medical assistance program established under Chapter 32, Human Resources Code, or the child health plan established under Chapter 62, Health and Safety Code.

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