Introduction
In 2001, the 77th Legislature passed HB 1610 to amend Insurance Code Chapter 38 to add Subchapter F. The subchapter directs TDI to collect and report cost and utilization data for mandated benefits and mandated offers. TDI adopted the rule to implement the statute in 2002 and the rule amendments in 2017. The 2017 data call was the first data call to reflect the rule amendments.
28 Texas Administrative Code Sections 21.3401 – 21.3409 specifies that certain health benefit plan issuers and health maintenance organizations (HMOs) are required to submit data to TDI annually about mandated health benefits and mandated offers of coverage. TDI provides the following instructions, as well as other resources located on the Mandated benefits data call index page, to help issuers collect the data and submit the reports.
Applicability
The data call applies to health benefit plan issuers subject to Insurance Code Section 38.251 and who report to the National Association of Insurance Commissioners (NAIC)[1] a total of $10 million or more in direct premiums earned in Texas in a particular year for the following:
- individual comprehensive health coverage;
- small group comprehensive health coverage; or
- large group comprehensive health coverage.
Only issuers who meet these requirements are required to submit data relating to mandated health benefits and mandated offers of coverage.
Issuers who do not meet these requirements are not required to submit exempt reports.
Issuers will need to report data for any enrollees and their dependents covered by plans subject to the mandated benefits and offers regardless of where they reside. This includes situations where enrollees and their dependents live in different states.
Report submission
Per the 2017 rule amendments, the reporting year is the previous calendar year. The report is due each year on June 1.
The following are the guidelines regarding report submission:
- Issuers must submit data via the online reporting forms prescribed in the Mandated benefits data call index page.
- Different issuers cannot consolidate information into one report. One report should be submitted for each NAIC number.
Reporting form
Issuers required to file a report must complete the data call using an online reporting form (LAH345) located on the Mandated benefits data call index page of TDI’s website.
The reporting form has the following sections:
- Cover sheet;
- Part A: Aggregate data;
- Part B: Mandated benefits – individual data;
- Part C: Mandated benefits – small group data;
- Part D: Mandated benefits – large group data;
- Part E: Mandated offers – individual data;
- Part F: Mandated offers – small group data;
- Part G: Mandated offers – large group data;
- Part H: Mandated benefits and offers claims identification;
- Part I: Additional information; and
- Part J: Data certification.
Cover sheet
Issuers must provide all requested information. If the answer to all three applicability questions is “No,” skip to Part J – Data certification.
- Issuer name: Enter the issuer’s name.
- NAIC number: Enter the issuer’s NAIC number.
- Issuer type: Select either “insurance” or “HMO” using the drop-down menu.
- Reporting year: Field is pre-filled with the current reporting year.
- Submission date: Select the report submission date using the date picker tool.
- Issuer mailing address: Enter the mailing address for the issuer, including the city, state (drop-down menu), and ZIP code.
- Are you a third-party administrator reporting on behalf of the named issuer? Select either “Yes” or “No” using the drop-down menu.
- Contact name: Enter the first and last name of the person designated by the issuer to discuss the report with TDI staff.
- Title: Enter the title of the contact person.
- Phone number: Enter the contact person’s direct telephone number. Include an extension, if applicable.
- Email address: Enter the contact person’s email address.
- Contact mailing address: Enter the mailing address for the contact person, including the city, state (drop-down menu), and ZIP code.
- May TDI release this email address? Select either “Yes” or “No” using the drop-down menu.
- Data call applicability – individual: Select either “Yes” or “No” using the drop-down menu. If the answer is “Yes,” the report must be completed and submitted. If the answer is “No,” leave Parts B and E of the report blank.
- Data call applicability – small group: Select either “Yes” or “No” using the drop-down menu. If the answer is “Yes,” the report must be completed and submitted. If the answer is “No,” leave Parts C and F of the report blank.
- Data call applicability – large group: Select either “Yes” or “No” using the drop-down menu. If the answer is “Yes,” the report must be completed and submitted. If the answer is “No,” leave Parts D and G of the report blank.
Part A: Aggregate data
Issuers must provide total premiums earned, total claims incurred, and total member months for all health benefit plans subject to the mandated benefit and mandated offer requirements in Texas during the reporting year.
- Total direct premiums earned during the year: Enter the dollar amount of the total premiums earned for all plans subject to mandated benefits and mandated offers during the reporting year. Issuers will round responses to the nearest dollar and not use dollar signs, decimals, or commas.
- Total claims incurred during the year: Enter the dollar amount of the total claims incurred for all plans subject to mandated benefits and mandated offers during the reporting year. Issuers will round responses to the nearest dollar and not use dollar signs, decimals, or commas.
- Total member months for the year: Enter the total number of member months for enrollees of all plans subject to mandated benefits and mandated offers for the reporting year. Issuers will enter whole numbers and not use decimals or commas.
Parts B, C, and D: Mandated benefits – individual data, small group data, and large group data
Issuers must provide the following information as applicable:
- Claims incurred during the year: Enter the total dollar amount of the claims incurred for each mandated benefit during the reporting year. Issuers will round responses to the nearest dollar and not use dollar signs, decimals, or commas.
- Number of claims incurred during the year: Enter the total number of separate claims incurred for each mandated benefit during the reporting year. Issuers will enter whole numbers and not use decimals or commas.
- Total member months for the year: Enter the total number of member months for all enrollees covered for each mandated benefit during the reporting year regardless of whether the enrollees incurred claims for the mandated benefit. Issuers will enter whole numbers and not use decimals or commas.
Notes: All mandates listed may not apply to all plan types. If a mandate does not apply, leave the fields blank. If a mandate does apply but has no claims, enter "0" in the claims fields.
Please include any data reported or omitted in this section that needs explanation in Part I – Additional information.
Parts E, F, and G: Mandated offers – individual data, small group data, and large group data
Issuers must provide the following information as applicable:
- Claims incurred during the year: Enter the total dollar amount of the claims incurred for each mandated offer during the reporting year. Issuers will round responses to the nearest dollar and not use dollar signs, decimals, or commas.
- Number of claims incurred during the year: Enter the total number of separate claims incurred for each mandated offer during the reporting year. Issuers will enter whole numbers and not use decimals or commas.
- Total member months for the year: Enter the total number of member months for all enrollees covered for each mandated offer during the reporting year regardless of whether the enrollees incurred claims for the mandated offer. Issuers will enter whole numbers and not use decimals or commas.
Notes: All the offers listed may not apply to all plan types. If an offer does not apply, leave the fields blank. If an offer does apply but has no claims, enter "0" in the claims fields.
Please include any data reported or omitted in this section that needs explanation in Part I – Additional information.
Part H: Mandated benefits and offers claims identification
Issuers must provide the following information:
- Medical billing codes: List the medical billing codes and filters used to identify applicable claims for each mandated benefit and mandated offer of coverage.
Issuers must list the medical billing codes and filters in this section of the report. Do not simply state, “See mandated benefits code list” or submit the codes as a separate email attachment. TDI uses this information to better understand the data and identify potential causes of data inconsistencies between responding issuers.
For additional information, please see the methodologies document and code workbook located in the additional resources section on the Mandated benefits data call index page.
Please include any data reported or omitted in this section that needs explanation in Part I – Additional information.
Part I: Additional information
Issuers can use the additional information field to provide important information about their data. This field should contain data clarifications as necessary.
Part J: Data certification
After entering the reporting data, issuers must complete the data certification fields. The form cannot be submitted if these fields are incomplete.
- Attestation: Click on the box next to the attestation statement and a checkmark will appear.
- Contact information: Provide the name, title, and direct telephone number of a person with authority to certify the data. This individual should be a corporate officer, actuary, attorney, or accountant.
If an authorized agent is completing the data call on behalf of this individual, include both parties in the name field. For example, enter Bob Jones, on behalf of Pam Smith. However, the title field should only specify the title of the person with the authority to certify the data. A separate affidavit is not required.
Data collection codes, methodologies, and frequently asked questions
TDI provides the additional resources shown below on the Mandated benefits data call index page to help issuers collect and report the data.
Data collection methodologies will ensure report data is consistent and falls within the scope of each mandate. The methodologies include the requirements and limitations for each mandate, as applicable. Age and gender parameters are also provided, as well as information to avoid reporting duplicate data.
Code workbook includes medical billing codes to help issuers identify claims data about the various mandated benefits and mandated offers. The workbook may not include all relevant codes because of the variation in reporting requirements and claims filing procedures for each issuer. Issuers should use these codes as a reference too and may use additional codes as appropriate.
Frequently asked questions provide answers to commonly asked questions about the data call.
Definitions
- Claims incurred – Paid claims plus amounts held in reserve for claims that have been incurred but have not yet been paid.
- Direct premium – The amount of health premiums earned for comprehensive health coverage as reported on an issuer's submission to the NAIC for the year for which it is reporting data.
- Health benefit plan – A benefit plan regulated under Insurance Code Title 8 (Health Insurance and Other Health Coverages), Subtitles A (Health Coverage in General), B (Group Health Coverage), C (Managed Care), D (Provider Plans), and G (Health Coverage Availability).
- Mandated benefit – A health benefit listed in the table in the appendix that must be included in a health benefit plan.
- Mandated offer – An offer of coverage listed in the table in the appendix that must be offered and made available to the holder or sponsor of an individual or group health benefit plan.
- Medical billing codes – Standard code sets used to bill for specific medical services, including the Healthcare Common Procedure Coding System (HCPCS) and diagnosis-related group (DRG) system established by the Centers for Medicare and Medicaid Services (CMS), the Current Procedural Terminology (CPT) code set maintained by the American Medical Association, and the International Classification of Diseases (ICD) code sets developed by the World Health Organization.
- Member months – The cumulative number of months that all enrollees were covered during the reporting year.
- Reporting entity – A health benefit plan issuer or third-party administrator that performs claims payment services for a health benefit plan issuer subject to this data call.
- Reporting year – A one-year period, beginning each January 1 and ending the following December 31, when health benefit plan issuers must collect the data required by this data call.
- Third-party administrator – An administrator holding a certificate of authority under Insurance Code Chapter 4151 (Third-Party Administrators).
Interactive form instructions
Issuers will need to complete the online reporting form (LAH345) on-screen using their web browser. Additional information on how to complete and submit the reporting form is below:
- Round currency fields to the nearest dollar—do not use dollar signs, decimals, or commas. For example, enter $500,000 as Dollar signs and commas will appear after moving to the next field.
- Enter numerical (non-currency) fields with whole numbers—do not use decimals or commas. For example, enter 2,500 as 2500. Commas will appear after moving to the next field.
- The form will not accept text responses in numerical or currency fields. If the requested data for a mandate or offer is not applicable, leave the fields blank. Please provide any necessary explanations in Part I – Additional information.
Questions?
Send questions about the mandated benefits data call to MBSurvey@tdi.texas.gov.
Mandated Benefits Data Call
Benefits
- Acquired Brain Injury
- Autism Spectrum Disorder
- Serious Mental Illness - 45/60
- Low-Dose Mammography Cancer Screening
- Reconstructive Surgery Following Mastectomy
- Diabetes Equipment, Supplies, and Self-Management Training
- Formulas for PKU or Other Heritable Diseases
- Temporomandibular Joint (TMJ) Diagnosis and Treatment
- Osteoporosis Detection and Prevention
- Prostate Cancer Screening
- Colorectal Cancer Screening
- Childhood Immunizations
- Hearing Screening for Children
- Chemical Dependency – Inpatient Only
- Chemical Dependency – Outpatient Only
- Prescription Contraceptive Drugs, Devices, and Related Services
- HPV and Cervical Cancer Screening
- Ovarian Cancer Screening
- Cardiovascular Disease - Early Detection
- Amino Acid-Based Elemental Formulas
Offers
- Loss or Impairment of Speech or Hearing
- In Vitro Fertilization
- Developmental Delays in Children
[1] NAIC Supplemental Health Care Exhibit – Part 1