DUE: December 1, 2010 - Reporting Period October 1, 2009 to September 30, 2010
You are hereby notified of the Mandated Benefits Data Call for the reporting period of October 1, 2009 to September 30, 2010. As specified by 28 TAC §§21.3401-21.3409, certain accident and health carriers, HMOs, and TPAs are required to submit data to the Texas Department of Insurance (TDI) relating to mandated health benefits and mandated offers of coverage no later than December 1, 2010. This data call applies to companies that meet any of the earned premium threshold criteria outlined below:
(1) A health benefit plan issuer that reported $10 million or more in direct premiums earned for group accident and health insurance policies in the state of Texas on its 2009 annual statement;
(2) A health benefit plan issuer that reported $2 million or more in direct premiums earned for individual accident and health insurance policies in the state of Texas on its 2009 annual statement;
(3) A health benefit plan issuer that is a basic service health maintenance organization and reported $10 million or more in direct commercial premiums earned in the state of Texas on its 2009 annual statement; or
(4) A licensed third party administrator that performs claims payment services for any health benefit plan issuer that meets the requirements of (1) - (3) above.
As defined in 28 TAC §21.3402(5), a health benefit plan issuer is "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."
Companies are required to submit the Mandated Benefits Data Call through an online Web application which is located at http://www.tdi.state.tx.us/health/mbindex.html. Data entry may begin on November 7, 2010, and all data must be submitted to the Department no later than December 1, 2010.
To access the Web application, companies must first submit a password request from a business e-mail address to MBSurvey@tdi.state.tx.us . TDI reassigns company passwords each year to ensure data security, and companies are encouraged to submit a password request as soon as possible.
The data call consists of a mandatory cover sheet, claim and premium forms for individual mandated benefits, claim and premium forms for group mandated benefits, and a voluntary "additional information" form on which companies can explain certain data elements as needed.
Sample data collection forms, data call instructions, password request instructions, exemption request instructions, statutory citations, and ICD-9-CM and CPT code citations are also available at the above referenced link. Due to the volume and complexity of the data involved, insurers and HMOs may want to consider printing the sample survey forms that have been provided before accessing the live data entry forms.
Exemption Requirements
Companies that did not reach any of the earned premium threshold criteria outlined above as reported on the company's 2009 annual statement are automatically exempted from the Mandated Benefits Data Call and are not required to submit an exemption request to TDI.
Some companies that meet the earned premium threshold criteria may also be exempt based on the types of accident and health insurance policies they issued during the reporting period. Companies that believe they should be granted an exemption from the reporting requirements must submit a written exemption request as described below.
To determine which companies are required to submit the Mandated Benefits Data Call, TDI will identify companies that reported $10 million or more in total group accident and health premiums and/or $2 million or more in total individual accident and health premiums on their 2009 annual statement. This annual statement data does not enable TDI to identify which specific types of accident and health insurance products are included in the total premiums reported. Since not all accident and health insurance policies are subject to the mandated benefit requirements, the accident and health premiums reported on a company's annual statement may include policies that do not include mandated benefits and are not subject to these reporting requirements. Examples of some policies exempt from the reporting requirements include plans that provide benefits only for accidental death or dismemberment, only for credit insurance, only for dental or vision care, only for hospital expenses, only for long term care, or only for disability benefits. Other types of policies are also exempt from mandated benefit requirements.
Insurers that meet one or more of the earned premium threshold criteria for accident and health policies ($10 million for group policies or $2 million for individual policies) are eligible to submit an exemption request if:
(1) The accident and health policies issued and reported in your annual statement do not contain or provide mandated benefits subject to the call, or
(2) You received premiums totaling less than $10 million for group policies and less than $2 million for individual policies that provided mandated benefit coverage subject to the call.
Exemption requests must be submitted in writing to MBSurvey@tdi.state.tx.us, and exemptions will only be approved upon written confirmation by TDI. All exemption requests must specifically identify the types of policies for which accident and health premium was reported on the company's 2009 annual statement as well as the premium associated with each type of policy. The detailed information must enable TDI to confirm that direct premiums earned for accident and health benefit plans with mandated benefits totaled less than $10 million for group plans and $2 million for individual plans.
Basic-service HMOs are also eligible to submit an exemption request if they wrote less than $10 million in commercial risk premiums in Texas (excluding Medicare, Medicaid and CHIP premiums).
If you have questions concerning this bulletin please contact Glenn Daniel at the Texas Department of Insurance at 512-305-7892 or via e-mail at MBSurvey@tdi.state.tx.us.
Katrina Daniel
Senior Associate Commissioner
Life, Health & Licensing Program