28 TAC §§ 21.3401 21.3409
The Commissioner of Insurance adopts new Subchapter Z, §§21.3401 - 21.3409 concerning the collection and reporting of data related to mandated benefits and offers of coverage. Sections 21.3401 - 21.3409 are adopted with changes to the proposed text as published in the August 2, 2002 issue of the Texas Register (27 TexReg 6799).
The new sections are necessary to implement the provisions of Subchapter F, Chapter 38 of the Insurance Code, as added by Acts 2001, 77th Texas Legislature, in House Bill 1610, concerning data collecting and reporting related to mandated health benefits. The primary purpose of the bill is to compile accurate data on the cost and utilization of specific mandates so that the state may better study their impact on health benefit coverage.
Section 21.3401 sets forth the purpose and scope of the subchapter and clarifies that licensed third party administrators (TPAs) who provide administrative services to carriers described in §§21.3401(b)(1), (2), or (3) must collect and report the data. Because these TPAs collect data on behalf of the health benefit plan issuers they are included as entities to whom the rule applies. Section 21.3401(a) has been changed to provide clarity as to the purpose of the subchapter. Section 21.3402 defines the terms used in the subchapter. The term "reasonable estimate" was added to the definition for administrative costs and average annual premium to clarify the information expected to be provided pursuant to the rule’s requirements. A definition for "family coverage" has been added to the definitions at §21.3402(4) to clarify the reporting requirements referenced in §21.3407. Section 21.3403 requires health benefit plan issuers to collect data and prepare a report pursuant to the requirements of §§21.3406 and 21.3407. Section 21.3404 establishes the deadline for the submission of the report and content of the report. Section 21.3404 has been changed to establish March 1, 2004 as the first reporting deadline. Section 21.3405(a) outlines the exceptions to the reporting of certain data. Section 21.3405(b) describes limited instances when an HMO would not be required to collect and report data where an HMO does not directly process data because services are prepaid under a capitated payment arrangement, and where the HMO does not receive complete and accurate encounter data. Section 21.3406 added colorectal cancer screening to the provides a list of mandates for which data is to be collected and reported. The benefit for Coverage of Certain Tests For Detection of Colorectal Cancer was added to the list of mandates at §21.3406(a)(20) and (b)(9). The title of the mandated benefit at §21.3406(a)(15) and (b)(4) has been changed to "Diabetes, Care, Supplies, and Services" to mor e accurately reflect the nature of the benefit. Section 21.3407 prescribes the format for the data and report to be submitted. Section 21.3407(a) has been changed to clarify the reporting procedure using the department’s website. Changes have been made to §§21.3407(b)(9), (b)(10), (c)(1), (c)(2), (d)(1) and (d)(2) to collect consistent information based on accrual method of accounting. Section 21.3408 provides that the failure to comply with this subchapter will subject an issuer to sanctions and penalties. Section 21.3409 provides for severability of any section held invalid.
SUMMARY OF COMMENTS AND AGENCY’S RESPONSE TO COMMENTS.
General.
Comment: Several commenters noted that they support the concept of the rule and want to report accurate and useful data.
Response: The department appreciates the comments and believes the rule will provide valuable data.
Comment: A commenter suggested that an estimate of the cost for carriers to comply with the rule may be necessary.
Response: The department disagrees as any costs attributed to compliance are a direct result of the statute and not the rule.
Comment: A commenter stated that more data can be gained from the medical community than from insurers, as the costs associated with the individual medical protocols and treatments are more readily available from the health community.
Response: The department understands the concern. However, as payors, health benefit plan carriers are also in a position to collect and report this data. The scope of this rule is limited to those entities over which the department has jurisdiction consistent with the statutory framework.
A commenter had difficulty finding information on the referenced website.
The department appreciates these comments, as they are helpful in the development of efficient electronic communication. The department has corrected the problems with the website and apologizes for any inconvenience.
A commenter recommends staged phase-in of reporting requirements, beginning with claims data, and creation of an advisory committee to facilitate implementation of a complete and accurate reporting process, as well as to ascertain ways of gathering data with minimal administrative expense.
While the department encourages a dialogue between the department and carriers to develop consistent standards for compliance with this rule, the department disagrees that a staged phase-in is appropriate. Insurance carriers have been reporting similar data to the department as part of the annual group accident and health data call. This rule incorporates the experience obtained under the department’s previous data collection efforts. In addition, the rules closely follow data collection requirements that have been in effect for 10 years under Virginia law and should thus be familiar to many of the carriers affected by this rule. As such, the department believes a phased-in reporting period is not necessary and would unnecessarily delay the availability of information needed to appropriately evaluate the cost of mandated health insurance benefits.
Comment: A commenter advised that in Virginia the rule started as a basic requirement but as mandates were added the rule became more comprehensive. The added mandates resulted in significant impact to the companies in Virginia due to reprogramming costs.
Response: The department appreciates the commenter’s cost concern. The department has attempted to make this rule comprehensive to avoid such reprogramming costs. The department anticipates future rule amendments; however, the department will give any future cost implication due consideration during the proposed rule and adoption process.
§21.3401.A commenter requests clarification that health plans are not required to report data for CHIP or Medicaid programs or Medicare Supplement policies.
Response: The department agrees and clarifies that the rule is not intended to require reporting with regard to any coverages to which mandates are not applicable, such as Medicaid, CHIP, or Medicare supplement. However, carriers should be aware that the statute empowers the commissioner to request from the Texas Health and Human Services Commission data related to mandates that apply to individuals covered by the Medicaid program.
Comment: A commenter requests clarification of the responsibilities of third party administrators (TPAs) for reporting data.
Response: While the rule does not require TPAs to report data directly to the department, TPAs must collect data to enable carriers to comply with the reporting requirements of the rule. If a carrier contracts with a TPA to process claims, the carrier must be able to obtain the required information from the TPA.
§21.3402. A commenter notes that there were no definitions of references in the rule to "policies, contracts, and certificates."
Response: The department points out that "policies, contracts, and certificates" are terms widely used and understood in the business of insurance, and thus declines to define these terms in the rule. Previous data calls by the department have used this reference and carriers are reporting the information without difficulty.
§§21.3402(1), 21.3407(c)(4) and (d)(4). A commenter believes the rule does not make clear how administrative costs are to be calculated, thus making it difficult to report them. Another commenter believes that the method used to allocate administrative costs should be specified or reported. Another commenter requests that the department clarify that estimates or extrapolations of percentages of administrative expenses are acceptable methods of reporting.
Response: The rule provides considerable flexibility for carriers to ascertain the administrative costs associated with their coverage of a mandated benefit. The department has added language to allow for a reasonable estimate of costs associated with each mandate. Carriers may develop their own methodology for calculating administrative costs. Carriers must maintain the methodology and documentation supporting the allocation of administrative costs. As the department begins to collect reports under the rule, it may promulgate more standard procedures by which to report these costs.
§21.3404. A commenter noted that the rule does not specify an effective date and a commenter presumes that first reports are due in 2003. A commenter believes this is problematic because health plans did not have notice until August 2002 of the year they are supposed to report. Another commenter believes that required programming changes may make it impossible to provide a year’s worth of data next March.
Response: The department agrees with the commenters’ concerns regarding implementation. Therefore, the rule has been changed to reflect that the first report must be submitted by March 1, 2004 and will contain data for the 2003 calendar year.
§21.3405. A commenter suggests that rather than requiring a certification that the health plan’s disclosure would violate privacy laws, the department should change the rule to make sure it is requesting information consistent with HB 1610. There are concerns with confidentiality or collecting and submitting individually identifiable data.
Response: The department recognizes the commenter’s concern and appreciates the interest in maintaining consumer privacy. The rule requires carriers to submit information online at the department's website. There is no mechanism in the online reporting form for individually identifying confidential information, and the department does not expect that reporting of any of the required information would violate privacy laws. Should a carrier believe its report would violate privacy laws, however, the rule allows it to withhold the information and certify its finding. The department believes this is a reasonable alternative which follows the legislature’s direction and preserves the rule’s effect.
Comment: A commenter notes that since health plans cannot verify or validate data from delegated entities or TPAs, they should not be required to report this data not processed by the health plan. The commenter also questions whether, in regard to behavioral health claims, a health plan is required to report data for an entity that may not be acting as a TPA. Another commenter noted that for heavily capitated agreements like lab services or radiology, some companies do not receive actual encounter data from providers and will be able to submit only hard estimates.
Response: Whether the rule requires a carrier to report data from a particular function it has contracted with a third party to perform will depend on the nature of the arrangement between the carrier and the third party. The TPA statute, art. 21.07-6(14), requires TPAs to collect data regarding transactions on behalf of carriers. Therefore, carriers should experience no difficulty in obtaining information required by the rule. Entities providing services to HMO enrollees on a prepaid, predetermined basis, however, fit the statutory exemption in which a HMO does not directly process the claim or receive complete and accurate encounter data. The rule requires HMO’s making use of this exception to submit an addendum to the report describing the circumstances which qualify the HMO for the exception.
§21.3406. A commenter notes that colorectal cancer testing is not included in the rule for data collection, but that it would be tied to a specific code and should be included.
Response: The department appreciates the commenter’s concern and has included colorectal cancer screening under Article 21.53S, TIC Coverage of Certain Tests for Detection of Colorectal Cancer to the list of mandated benefits for which data is required. Because carriers can readily identify colorectal cancer screening services with specific CPT codes, reporting of these services should not impose any undue hardship on carriers and will provide information valuable in evaluating the cost of specific mandated health insurance benefits.
§21.3406(a)(4) and (5).A commenter notes that under the mandate relating to serious mental illness, there is no reference to the required two-for-one coverage under crisis stabilization.
Response: The lack of standardized CPT codes for this particular benefit prevents collecting and reporting the information in the manner required by the rule. Accordingly, the department did not propose a data requirement for this coverage. §21.3406(a)(15) and (b)(4). A commenter notes that the title "self-management training" may not accurately reflect the nature of the paragraph.
Response: The department agrees and has changed the title to "Diabetes Care, Supplies, and Services."
§21.3406(c). A commenter is unsure when the department will provide suggested procedure and diagnosis codes that may be used in capturing required data. The commenter suggests that the department establish a workgroup to develop health reporting measures.
Response: The department has already developed the procedure and diagnosis codes referenced in the rule and they are available on the department’s website. The codes are not mandatory and are meant as a suggestion and to provide guidance. This provides flexibility for carriers in determining the codes to use for collecting and reporting information. The department is aware that these codes are frequently updated. A non-mandatory set of codes will avoid the necessity for frequent updates to the rule.
§21.3407(c) and (d).A commenter suggests that reporting serious mental illness data separately by the level of coverage required under various statutes will be extremely difficult and costly. The commenter suggests merging reporting under all relevant laws that require coverage of serious mental illness.
Response: It is the department’s understanding that administration of these benefits is generally done on a capitated basis, and thus the rule would not require reporting with regard to those benefits. Where a carrier directly processes such data, or where it delegates that duty to a third party on a basis other than a prepaid capitation arrangement, however, the rule requires carriers to report this data separately.
Comment: A commenter believes the rule should include all large and small groups, since small employers are subject to some mandates.
Response: The department agrees. The rule includes small group policies or certificates in "the number of contracts or certificates" subject to reporting requirements.
Comment: A commenter expresses concern that the rule will require reporting of proprietary information such as pricing data and seeks assurance that this data will remain confidential.
Response: The department anticipates that the reports to be generated from the reported data will be summary in nature and will not include company-specific data. However, data provided to the department is subject to the Public Information Act. A request for company-specific data will be handled in accordance with the Public Information Act and carriers will have the opportunity to claim protection for their data as provided by the Act. Carriers should utilize the mechanism in the on-line reporting form to designate whether their submitted data contains proprietary elements.
§21.3407(c)(3).A commenter suggests that the rule require insurance companies to report the number of contracts or certificates that would be issued without the coverage if the mandated benefit were voluntary. This change would give the data a context for comparison and better allow the legislature to determine the impact.
Response: While the department understands and appreciates the utility of this information, it appears to be outside the scope of the information immediately contemplated by the statute. The department also believes there are too many questions regarding the practical implementation of this requirement to adopt it at this time. .
§21.3407(e) and (h). A commenter believes that certain data collection requirements allow for too much subjectivity in deriving the costs and premiums attributable to each mandate. The commenter suggests that companies be required to provide a detailed methodology used to determine the estimate.
Response: The department disagrees. The rule requires that carriers have an identifiable methodology to attribute these costs to specific mandates. Carriers must maintain the methodology, along with supporting documentation, and provide it to the department upon request.
Comment: A commenter believes estimates to be meaningless and stated that in order to get credible, reliable data, the department should meet with carrier representatives to establish an industry-wide accounting method for expressing the requirements.
Response: The department disagrees that there must be an industry-wide method of reporting all data elements required under this rule. The legislature requires carriers to provide data which shows the utilization and cost of particular mandates. Neither the statute nor this rule requires a particular methodology. To the extent possible, specific data collection and reporting requirements are provided for certain data elements. For those data elements that do not require a standardized reporting methodology, carriers must maintain their methodology for calculating these figures and be able to provide supporting documentation upon request. The department will certainly consider input from carriers and other interested parties regarding standardizing the collection and reporting methodology for future amendments.
Comment: A commenter notes that it may be difficult or impossible to track or apportion premium by each mandated benefit and by family/individual coverage, and requests a workgroup to resolve these issues. Another commenter stated that carriers will have difficulty reporting individual and family coverage because those terms are not clearly defined. The commenter requests clarification of the meaning of the term "family."
Response: Article 38.252(a), Texas Insurance Code, requires the commissioner to collect utilization and cost data for each mandated benefit. The department interprets this language to require collection of premium information in order to ascertain the effects mandated benefits have on costs to policyholders. While some carriers may not routinely develop the data requested, carriers have provided similar information in previous reports to the department and to the Joint Interim Committee on Mandated Health Benefits. Carriers have also been reporting comparable data for more than a decade under the aforementioned Virginia requirements. Though reporting of this data may require some carriers to develop reports specifically for this purpose, carriers should be able to meet this requirement. Further, the data is necessary to meet the requirements the Texas Legislature has specified in Article 38.252(a). The department has added a definition of "family coverage" to clarify the data required by the rule.
§21.3407(e) - (j). A commenter notes it will be very costly to program its operations to differentiate reporting between group and individual health benefit plans. Another commenter expresses concern regarding the difficulty in reporting information on an individual or family basis due to variability in family status and the possible addition of dependents during a reporting year.
Response: The department clarifies that the rule does not require health plans to report claims costs separately for individual and family certificates under group plans. The rule requires health plans to report estimated premium costs for specific mandates for certificates issued under a group plan to a single individual (i.e., employee only) and for certificates issued to an employee and family (i.e., employee, spouse and dependents). Carriers routinely develop separate premium rates for individual/employee-only coverage and for family coverage that includes the employee, spouse and dependents. Because the premiums charged under these two different circumstances vary considerably, it is logical that the premium expense attributed to mandated benefits will also vary considerably. As such, the department believes it is important that the cost differences be reflected in the data reported to clearly present an accurate premium cost report. Insurers should have the actuarial expertise to develop this information. Further, insurers have routinely reported this information under the existing Virginia mandated benefit reporting requirements, and discussions with the Virginia Bureau of Insurance indicate that there has been no difficulty in obtaining this data. As such, the department declines to adjust the reporting requirements of premium data as it relates to individual and family coverage. However, the department has clarified what is meant by the term "family coverage" in order to accurately describe the data required by the rule.
§21.3408. A commenter notes that this section indicates that companies could be liable for penalties under Chapter 28A and suggests removal of this reference.
Response: The department declines to change the rule. The rule does not require individually identifiable information and calls for reporting of only summary data, thus it is unlikely that a carrier’s report would violate Chapter 28A. HB 1610, however, indicates a strong legislative emphasis on individual privacy, and thus the department believes the reference is an appropriate reminder. Moreover, all carriers to which this rule applies are covered entities under Chapter 28A, and thus any such violation would be actionable under that Chapter whether or not the department deleted the reference in this rule.
NAMES OF THOSE COMMENTING FOR AND AGAINST THE SECTIONS.
For with changes: Office of Public Insurance Counsel, Old Surety Life, Texas Association of Health Plans, Aetna, Scott and White Health Plans and Magellan Behavioral Health.
The subchapter is adopted under the Texas 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 rules to execute the duties and functions of the Texas Department of Insurance only as authorized by statute.
§21.3401. Purpose and Scope.
(a) Purpose. The purpose of this subchapter is to require certain health benefit plan issuers to collect and report data regarding certain mandated health benefits to the commissioner.
(b) Scope. This subchapter applies to:
(1) a health benefit plan issuer that reports in its most recently filed annual statement a total of $10 million or more in direct premiums earned in the state of Texas for group accident and health insurance policies;
(2) a health benefit plan issuer that reports in its most recently filed annual statement a total of $2 million or more in direct premiums earned in the state of Texas for individual accident and health insurance policies;
(3) a health benefit plan issuer that is a basic service health maintenance organization and reports in its most recently filed annual statement a total of $10 million or more in direct commercial premiums earned in the state of Texas;
(4) a licensed third party administrator that performs claims payment services for any health benefit plan issuer that meets the requirements of paragraphs (1) - (3) of this subsection.
§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.
§21.3403. Collection of Data Necessary to Provide Report. Each health benefit plan issuer to which this subchapter applies shall collect the data required by this subchapter for each mandate set forth in §21.3406 of this subchapter (relating to Mandates for Which Data Must Be Reported) and shall prepare and file a report as required by §21.3407 of this subchapter (relating to Reporting of Required Information).
§21.3404. Deadline for Submission of Reports. Health benefit plan issuers shall annually submit the report required by this subchapter no later than March 1, and shall include all data for benefits and coverages for which payment was made during the previous calendar reporting year. The first reporting date for the rule will be March 1, 2004, for data from 2003.
§21.3405. Exceptions to Required Reporting and Justification for Exceptions.
(a) A health benefit plan issuer subject to this subchapter shall not be required to report data that:
(1) could reasonably be used to identify a specific enrollee in a health benefit plan; or
(2) violates confidentiality requirements of state or federal law or regulation applicable to an enrollee in a health benefit plan.
(b) A health benefit plan issuer that is an HMO shall not be required to report data for a particular benefit or coverage if:
(1) the HMO does not directly process the claim because the services are prepaid under a capitated payment arrangement; or
(2) the HMO does not receive complete and accurate encounter data.
(c) A health benefit plan issuer that does not report data for a reason set forth in subsection (a) of this section must submit, in addition to the report required by this subchapter, an addendum containing:
(1) a general description of the type of data that has been omitted;
(2) the specific provision of each state or federal law or regulation that is the basis for omitting the data; and
(3) a certification that the data could not be identified in such a way that would enable it to be included in the report without violating subsection (a) of this section.
(d) A health benefit plan issuer that omits data for a reason set forth in subsection (b) of this section must submit, in addition to the report required by this subchapter, an addendum containing a description of the arrangements or circumstances that except the health benefit plan issuer from reporting the data as required.
§21.3406. Mandates for Which Data Must Be Reported.
(a) The following is a list of mandates about which data relating to a group health benefit plan must be filed under §21.3403 of this subchapter (relating to Collection of Data Necessary to Provide Report):
(1) In Vitro Fertilization Procedures, Insurance Code Article 3.51-6, Section 3A and §11.510(1) of this title (relating to Mandatory Offers);
(2) HIV or AIDS Related Illnesses, Insurance Code Articles 3.51-6, Section 3C; 3.51-6D; 3.50-2, Section 5(j)(1); 3.50-3, Section 4C(1); and 3.51-5A(a)(1) and §3.3057(d) of this title (relating to Standards for Exceptions, Exclusions, and Reductions Provision);
(3) Chemical Dependency, Insurance Code Article 3.51-9, and Subchapter HH, §§3.8001-3.8030 of this title (relating to Standards for Reasonable Cost Control and Utilization Review for Chemical Dependency Treatment Centers);
(4) Serious Mental Illnesses, Insurance Code Articles 3.51-14, 3.50-2 and §11.509(5) of this title (relating to Additional Mandatory Benefit Standards: Group Agreement Only);
(5) Serious Mental Illnesses, Insurance Code Articles 3.50-3 and 3.51-5A(a)(2) and (b);
(6) Treatment in Psychiatric Day Treatment Facility, Insurance Code Article 3.70-2(F) and §§11.509(5) and 11.510(3) of this title;
(7) Loss or Impairment of Speech or Hearing, Insurance Code Article 3.70-2(G) and §11.510(2) of this title;
(8) Low Dose Mammography, Insurance Code Article 3.70-2(H);
(9) Phenylketonuria (PKU), Insurance Code Article 3.79;
(10) Prescription Contraceptive Drugs and Devices and Related Services, Insurance Code Article 21.52L;
(11) Temporomandibular Joint Procedures, Insurance Code Article 21.53A and §11.509(6) of this title;
(12) Osteoporosis, Detection and Prevention, Insurance Code Article 21.53C;
(13) Immunizations, Insurance Code Articles 21.53F,and 20A.09F and §§11.506(2) and 11.508(a)(9)(G) of this title (relating to Mandatory Contractual Provisions: Group, Individual, and Conversion Agreement and Group Certificate, and Mandatory Benefit Standards: Group, Individual and Conversion Agreements);
(14) Prostate Cancer Testing, Insurance Code Articles 21.53F and 3.50-4, Sec. 18D and §11.508(a)(9)(E) of this title;
(15) Diabetes Care, Supplies, and Services, Insurance Code Articles 21.53D and 21.53G and §§21.2601 21.2607 of this title (relating to Diabetes);
(16) Hearing Screening for Children, Insurance Code Article 21.53F;
(17) Telemedicine/Telehealth, Insurance Code Article 21.53F and §11.1607(i), (j) and (k) of this title (relating to Accessibility and Availability Requirements);
(18) Reconstructive Surgery Incident to a Mastectomy, Insurance Code Article 21.53I and §11.508(a)(5)(A) of this title;
(19) Certain Benefits Related to Acquired Brain Injury, Insurance Code Article 21.53Q;
(20) Certain Tests For Detection of Colorectal Cancer, Insurance Code Article 21.53S;
(21) Reconstructive Surgery for Craniofacial Abnormalities in A Child, Insurance Code Article 21.53W; and
(22) Oral Contraceptives, §21.404(3) of this title (relating to Underwriting) and Prescription Contraceptive Drugs and Devices and Related Services, Insurance Code Article 21.52L
(b) The following is a list of mandates about which data relating to individual health benefit plan must be filed under §21.3403 of this subchapter:
(1) HIV or AIDS Related Illnesses, Insurance Code Articles 3.51-6, Section 3C; 3.51-6D; 3.50-2, Section 5(j)(1); 3.50-3, Section 4C(1); and 3.51-5A(a)(1), and §3.3057(d) of this title;
(2) Immunizations, Insurance Code Articles 21.53F and 20A.09F, and §§11.506(2) and 11.508(a)(9)(G) of this title;
(3) Prostate Cancer Testing, Insurance Code Articles 21.53F and 3.50-4, Sec. 18D and §11.508(a)(9)(E) of this title;
(4) Diabetes Care, Supplies, and Services, Insurance Code Articles 21.53D and 21.53G, and §§21.2601 21.2607 of this title;
(5) Hearing Screening for Children, Insurance Code Article 21.53F;
(6) Telemedicine/Telehealth, Insurance Code Article 21.53F and §11.1607(i), (j) and (k) of this title;
(7) Reconstructive Surgery Incident to a Mastectomy, Insurance Code Article 21.53I and §11.508(a)(5)(A) of this title;
(8) Certain Benefits Related to Acquired Brain Injury, Insurance Code Article 21.53Q;
(9) Certain Tests For Detection of Colorectal Cancer, Insurance Code Article 21.53S;
(10) Reconstructive Surgery for Craniofacial Abnormalities in A Child, Insurance Code Article 21.53W;
(11) Oral Contraceptives, §21.404 of this title (relating to Underwriting) and Prescription Contraceptive Drugs and Devices and Related Services, Insurance Code Article 21.52L; and
(12) Low Dose Mammography, Insurance Code Article 3.70-2(H).
(c) The Department will provide, on the Department’s Web site, www.tdi.state.tx.us, suggested procedure and diagnosis codes that may be used in capturing the required data for the report. Regardless of whether a health benefit plan issuer uses the suggested codes or some other method of capturing the required information, each health benefit plan issuer shall maintain information and documentation supporting the accuracy and completeness of the data and the report, including, but not limited to, a list of all procedural and diagnosis codes used in collecting data for the report for five years following the submission of the report upon which the information was based. Upon receiving a request from the department, a health benefit plan issuer shall make available the supporting information described in this subsection.
§21.3407. Reporting of Required Information.
(a) A health benefit plan issuer shall submit the data required by this section electronically by accessing a link designated on the Department’s Web site, www.tdi.state.tx.us, for reporting of the required information.
(b) Each health benefit plan issuer shall provide the following information for the reporting year:
(1) the year for which the data is being reported;
(2) the health benefit plan issuer’s NAIC Number;
(3) the health benefit plan issuer’s company name;
(4) the health benefit plan issuer’s mailing address;
(5) if applicable, any group NAIC number and group name;
(6) the name, title, direct telephone number, mailing address and email address of an individual who is responsible for the report;
(7) the total direct premiums earned in the state of Texas for group accident and health insurance policies or contracts which are subject to one or more of the mandates set forth in §21.3406(a) of this subchapter (relating to Mandates for Which Data Must be Reported);
(8) the total direct premiums earned in the state of Texas for individual accident and health insurance policies or contracts which are subject to one or more of the mandates set forth in §21.3406(b) of this subchapter;
(9) the total dollar amount of claims incurred for the reporting year on all group policies or contracts for which premium is being reported; and
(10) the total dollar amount of claims incurred for the reporting year on all-individual policies or contracts for which premium is being reported.
(c) Each health benefit plan issuer shall provide for each of the mandates set forth in §21.3406(a) of this subchapter the following information for the reporting year:
(1) The number of claims incurred;
(2) The total dollar amount of the claims incurred;
(3) The number of policies, contracts or certificates about which information is being reported; and
(4) The total dollar amount of administrative costs incurred during the reporting year.
(d) Each health benefit plan issuer shall provide, for each of the mandates set forth in §21.3406(b) of this subchapter, the following information for the reporting year:
(1) The number of claims incurred;
(2) The total dollar amount of the claims incurred;
(3) The number of policies, contracts or certificates about which the information is being reported; and
(4) The total dollar amount of administrative costs incurred during the reporting year.
(e) Each health benefit plan issuer shall provide, for each of the mandates set forth in §21.3406(a) of this subchapter, the average annual premium per policy, contract or certificate attributable to each mandate for each group certificate about which data is being reported, and must report separate data for certificates providing individual coverage and certificates providing family coverage during the reporting year.
(f) Each health benefit plan issuer shall provide the total number of group certificates issued or renewed during the reporting year, and the total number of certificates in force on a date to be provided by the department in the reporting form, and must report separate data for the total number of certificates providing individual coverage and the total number of certificates providing family coverage during the reporting year.
(g) Each health benefit plan issuer shall provide the total number of lives covered under group certificates issued or renewed during the reporting year, and the total number of certificates in force on a date to be provided by the department in the reporting form, and must report separate data for the total number of certificates providing individual coverage and the total number of certificates providing family coverage during the reporting year.
(h) Each health benefit plan issuer shall provide, for each of the mandates set forth in §21.3406(b) of this subchapter, the average annual premium attributable to each mandate for individual policies about which data is being reported on a date to be provided by the department in the reporting form, and must report separate data for policies providing individual coverage and policies providing family coverage during the reporting year.
(i) Each health benefit plan issuer shall provide the total number of individual policies issued or renewed during the reporting year, and the total number of policies in force on a date to be provided by the department in the reporting form and must report separate data for total number of policies providing individual coverage and the total number of policies providing family coverage during the reporting year.
(j) Each health benefit plan issuer shall provide the total number of lives covered under individual policies issued, renewed or in force during the reporting year and must report separate data for the total number of policies providing individual coverage and the total number of policies providing family coverage during the reporting year.
§21.3408. Compliance. Failure to comply with this subchapter shall subject any entity included in the scope of this subchapter to the sanctions and penalties provided in the Insurance Code Chapters 28A & B, 82, 83, and 84.
§21.3409. Severability. If any section or portion of a section of this subchapter or its applicability to any person or circumstance is held invalid by a court, the remainder of the subchapter or the applicability of the provision to other persons or circumstances shall not be affected.