Health Benefits and Mandated Offers of Coverage
28 TAC §§21.3402 and 21.3404
The Commissioner of Insurance adopts amendments to §§21.3402 and 21.3404 concerning the collection and reporting of data related to mandated benefits and offers of coverage. The amendments are adopted without changes to the proposed text as published in the October 10, 2003 issue of the Texas Register (28 TexReg 8808) and will not be republished.
The amendments are necessary to provide the reported information to the Legislature in a more timely fashion, as well as to respond to a petition for adoption of rules. The change to the first reporting date is in response to a petition from the Texas Association of Life & Health Insurers (TALHI). As originally adopted, 28 TAC §21.3404 required the first report on mandated benefits to be submitted by March 1, 2004 . TALHI´s petition urged that compliance on this date would place a strain on companies, as it was the same date that they must file annual financial statements. The petition requested an amendment to change the date of the first report from March 1, 2004 to either April 1 or May 1, 2004 . The amendment changes the first reporting date from March 1, 2004 to April 1, 2004 , with subsequent reports due annually on December 1. The change in subsequent reporting deadlines will address TALHI´s concern as well as decrease the age of the most recent data available to the Legislature, from approximately thirteen months to four months, at the commencement of each regular session. The amendment will thus enhance the quality and timeliness of the report for the Legislature.
The amendment to §21.3402 adds a definition of "reporting year" to clarify that the reporting year begins on October 1 of each year and ends on September 30 of the following year. The amendment to §21.3404 effects changes to the annual reporting deadline. The amendment changes the deadline for the first report from March 1, 2004 , to April 1, 2004 . This report will include data collected from January 1, 2003 , through December 31, 2003 . Subsequently, the adoption would require entities subject to the rule to gather data during the reporting year (October 1 of each year through September 30 of the following year) and report the data by December 1 following the end of each reporting year. Thus, the second report will contain data gathered during the reporting year period of October 1, 2003 through September 30, 2004 , and be due on December 1, 2004 .
No comments were received.
The amendments are adopted under the Insurance Code §§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 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.
§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--A reasonable estimate of 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--A reasonable 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 earned by a health benefit plan issuer in return for coverage, but not including premium received for providing reinsurance.
(4) Family coverage--The rating or pricing classification of coverage offered to an employee/member, spouse and all other dependents to be covered by the plan.
(5) 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.
(6) 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.
(7) Number of claims paid--The total number of separate, individual claims paid by the health benefit plan issuer.
(8) 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.
(9) Reporting year A one year period, beginning each October 1 and ending the following September 30, during which health benefit plan issuers must collect the data required by §21.3407 of this Subchapter (relating to Reporting of Required Information).
§21.3404. Deadline for Submission of Reports.
(a) Health benefit plan issuers shall annually submit the report required by this subchapter no later than December 1, and shall include all data for benefits and coverages for which payment was made during the previous reporting year.
(b) Notwithstanding the requirements of subsection (a) of this section, the first reporting date for the rule will be April 1, 2004 , for data collected from January 1, 2003 through December 31, 2003 .