Filings Made Easy for Life, Health and Licensing

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Filings Made Easy for Life, Health and Licensing
LHL Legislative Implementation
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Legislation From Last Session
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HB 2015

• Requires an insurer to provide (within 30 days)
• i) paid claims by month
• ii) monthly premiums
• iii) employee census data
• iv) dollar amount of pended claims
• v) individual claims report for employees with
  claims over 15,000 (including amounts paid,
  dates of service, and procedure and diagnosis
  codes) and
• pre-certification requests for hospital stays
  over four days.

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HB 2015 Request for Additional Information

• Within 10 days
• In writing
• Carrier must provide information on
• Prognosis or recovery
• Most recent case management
• Expected future costs and treatment plan
• Within 15 days

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HB 2015 -IMPLEMENTATION ISSUES

• Identifying Information / Small Groups
• Effective Date
• Providing incorrect data

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HB 472

• Regulation of TPAs, including workers
  compensation administrators.

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New Requirements Under HB 472
 4151.1042 - Requires written contract between
carriers and administrators which assigns
responsibilities for such things as

• determining benefits
• premium rates
• reimbursement procedures
• claims payment procedures
• reinsurance

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Requirements under HB 472
Continued

• If more than 100 enrollees - insurer must conduct
  on-site audit of administrator every two years.

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Requirements under HB 472
Continued

• TPA may not be compensated based on savings due
  to adverse determinations regarding claims for
  benefits, reductions of or limitations on
  benefits.

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Transfer of Administrator Licensing Regulation
at TDI

• April 1, 2008 - function of licensing /
  regulating administrators transferred to TDIs
  Financial Program.
• TPA Section and staff have physically moved.

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New Contact Information

• TPA/Premium Finance Section, MC 305-TPA/PF
• 333 Guadalupe
• P.O. Box 149104
• Austin, Texas 78714-9104
• [phone] phone
• [phone] fax
• Staff
• Elaine Cabrera [phone]
• Elaine.cabrera_at_tdi.state.tx.us
• Robert Keumpel [phone]
• Robert.keumpel_at_tdi.state.tx.us

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HB 472 Rulemaking

• Stakeholder meeting - October 2007.
• 3 sets of informal rules published - Nov. 2007.
• Chapters 1, 5 anticipate publication in June.
• Chapter 1 - criminal history and fingerprinting
• Chapter 5 - self insurance groups and
  subcontractors

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HB 472 Rulemaking
Continued

• Chapter 7 (administrators) Anticipate
  publication in mid to late summer.
• Working with stakeholders on issues
• bill review and prohibited compensation
• audit and oversight
• defining "adjusting" and "settling" claims.

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HB 472 Rulemaking
Continued

• Questions about TPA rules may be directed to
• Kevin Brady
• Deputy Commissioner for Financial Program
• [phone]
• kevin.brady_at_tdi.state.tx.us

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SB 1731

• Publication of health plan provider average
  reimbursement rates by region
• Insurer Report Cards
• Creates advisory committee to study
  facility-based provider network adequacy

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SB 1731
Continued

• Requires health plans to provide enrollee
  warnings about balance billing
• Identify contracted facilities with uncontracted
  providers
• Upon Request must provide an estimate of payments
  it will make

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SB 10 Medicaid Reform and Health Care Benefit
Programs

• Note Though authorized by the Texas Legislature,
  some provisions are dependent on approval from
  CMS
• Expands coverage of the uninsured through a
  non-Medicaid program could include purchase of
  an insured benefit plan
• Creates Texas Health Opportunity Pool (HOP) trust
  fund to provide coverage/premium assistance to
  uninsured and funding for uncompensated care
  providers includes requirement that TDI and HHSC
  develop premium assistance program for low-income
  persons
• Requires TDI and HHSC to study and recommend
  options for creation of a small employer premium
  assistance program requires report to
  Legislature by 11-1-08

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SB 10
Continued

• Encourages Medicaid HMOs to provide
  non-traditional value- added services designed to
  improve health of enrollees
• Requires Medicaid HMO contracts to include
  performance incentives
• Expands assistance to enable Medicaid recipients
  to enroll in private group health plans
• Authorizes counties to create regional health
  plans to provide affordable health insurance
  coverage

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SB 10
Continued

• Creates the health and long term care insurance
  incentive committee to study health insurance/
  LTC markets and recommend options for expanding
  coverage
• TDI serves on Committee
• Must look at premiums, administrative costs,
  development of reinsurance system for claims
  exceeding 50,000, premium subsidies, inclusion
  of dependents regardless of age, use of health
  care technology to save money.

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HB 1 Three Share Grant Program

• Rider in Appropriation bill requires TDI to
  establish a three-share grant program
• Funds up to 300,000 in grants in FY 2008 and
  450,000 in FY 2009 to award grants to local
  government entities for research, planning and
  development of 3-share premium assistance programs

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HB 522

• Requires TDI to adopt standards for health plan
  ID cards and electronic exchange of insurance
  information

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HB 1594

• Provides for expedited credentialing and
  in-network payment of physicians joining
  established, contracted medical groups

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HB 1847

• Permits non-insurance benefits and related
  services for accident, health, life, and
  long-term care insurance

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HB 2251

• Regulates webpage advertising and amends other
  advertising provisions

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SB 1255

• Cooperatives

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HB 2467

• Modification of certain small and large employer
  health benefit plans

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SB 22

• Long-term care insurance

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HB 1919

• Coverage for Acquired Brain Injury
• Treatment of Children with Autism Spectrum
  Disorder

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SB 1884

• Effective September 1, 2007
• Lowers underpayment penalties.

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SB 1884

• 21.2815.  Failure to meet Statutory Claims
  Payment Period.
•            (d)  . . . the underpaid amount is
  calculated on the ratio of the balance owed by
  the carrier to the total contracted rate,
  including any patient financial responsibility,
  as applied to an amount equal to the billed
  charges minus the contracted rate. 

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SB 1253

• 10.200.  Fee for Examination of a Certified
  Workers Compensation Health Care Network.
•             (a)  As provided in Insurance Code
  1305.251, a network shall pay to the department
  an examination fee set by the Commissioner for
  expenses directly attributable to an examination
  of the network conducted pursuant to Insurance
  Code 1305.251 or 1305.252. 
•             (b)  The examination fee shall
  include the actual salary and expenses of the
  examiners directly attributable to the
  examination.
•          

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Other Clean Claim Rules

• 28 TAC 21.2802 and 21.2803
• CMS-1500 (08/05) and UB-04 CMS-1450
• NPI (Contingency Plans)

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Medicare Supplement Advertising Rules

• 3.3313.  Filing Requirements for Advertising.  A
  Medicare supplement policy shall not be deemed to
  meet the standards and requirements set forth in
  this subchapter unless the filing company has
  complied with the requirements of the following
  paragraphs.

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Medicare Supplement Advertising Rules continued
(1)  Every issuer providing Medicare supplement
insurance or benefits in this state shall provide
to the department for review a copy of any
Medicare supplement advertisement, as defined in
21.102 of this title (relating to Scope), other
than an institutional advertisement, as defined
in 21.102(6) that only references Medicare
supplement as a line of coverage offered, but
which does not otherwise describe Medicare
supplement insurance or benefits used to promote
a policy which is approved under the provisions
of this subchapter.  The copy of the
advertisement shall be submitted to the
department no later than 60 days prior to its
first use.  At the expiration of the 60-day
period provided by this paragraph, any
advertisement filed with the department shall be
deemed acceptable, unless before the end of that
60-day period the department has notified the
entity of its non-acceptance.
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• My phone
• 512-475-1964
• My e-mail
• doug.danzeiser_at_tdi.state.tx.us