Commercial Plans – January 1, 2017, to December 31, 2017
Medicaid MCOs – September 1, 2016, to August 31, 2017
This data call is made under Sections 3 and 4 of HB 10, 85th Legislature, Regular Session (2017). HB 10 directs TDI and the Texas Health and Human Services Commission to conduct studies and prepare reports on benefits for medical or surgical expenses and mental health conditions and substance use disorders. TDI and the Texas Health and Human Services Commission are working in conjunction to collect the required data, and the request for data is being made in a single data call, to avoid requiring duplicate submissions by respondents that have information required by both agencies.
Section 3(b) specifies that TDI must collect and compare data from health benefit plan issuers subject to Insurance Code Chapter 1355, Subchapter F, and Section 4(b) specifies that the Texas Health and Human Services Commission must collect and compare data from MCOs. The agencies must collect data on medical or surgical benefits and mental health condition or substance use disorder benefits that are:
- subject to prior authorization or utilization review;
- denied as not medically necessary or experimental or investigational;
- internally appealed, including data that indicates whether the appeal was denied; or subject to an independent external review, including data that indicates whether the denial was upheld.
This data call applies to health benefit plan issuers subject to Insurance Code Chapter 1355, Subchapter F that report to the National Association of Insurance Commissioners covered lives of 25,000 or more as of the last day of the reporting period listed above. This 25,000-lives threshold applies separately to individual, small group, and large group comprehensive health coverage, rather than to the total of the three categories.
Issuers that do not meet the threshold for any particular category are exempt from the reporting requirements 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 preferred provider benefit plans and the remainder in exclusive provider benefit plans, it would be required to complete both the individual preferred provider benefit plan and individual exclusive provider benefit plan 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 MCOs are required to submit data.
Respondents must complete the data call using the reporting templates and instructions located on the HB 10 Data Collection Index Page on TDI's website. Submissions are due to TDI by the close of business on Tuesday, May 1, 2018.For more information contact: HealthSurveys@tdi.texas.gov.