1 katrina daniel doug danzeiser dianne longley texas department of insurance life, health &...
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Katrina DanielKatrina Daniel
Doug DanzeiserDoug Danzeiser
Dianne LongleyDianne Longley
Texas Department of InsuranceTexas Department of Insurance
Life, Health & Licensing ProgramLife, Health & Licensing Program
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Texas Association of Health PlansTexas Association of Health Plans2008 Managed Care Conference & Trade Show2008 Managed Care Conference & Trade Show
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Doug DanzeiserDoug Danzeiser
Deputy Commissioner for Regulatory MattersDeputy Commissioner for Regulatory Matters
Life, Health & Licensing ProgramLife, Health & Licensing Program
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CHAPTER 21SUBCHAPTER B
INSURANCE ADVERTISING, CERTAIN TRADE PRACTICES,
AND SOLICITATION
• HB 2251 and HB 2252 • 28 TAC §§ 21.102 - 21.104• 21.106 - 21.109• 21.113 - 21.116• 21.119 - 21.122
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SUBCHAPTER B, cont.HB 2251 and HB 2252
• Regulations on web advertising• Insurer must include all appropriate disclosures
and information on its website only if a web page is not classified as an institutional advertisement
• Permits advertising to include the availability of health-related services or information. Must disclose any separate charge
• www.tdi.state.tx.us/rules/2007/documents/21.102-21.122.pdf
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CHAPTER 21SUBCHAPTER W
Acquired Brain Injury
• HB 1919• §§21.3101 - 21.3107• www.tdi.state.tx.us/rules/2008/documents/
21.3101-21.3107.pdfTexas
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SUBCHAPTER W, cont.
• Address expanded coverage of acquired brain injury provisions to include coverage of post-acute care and cognitive rehabilitation
• Specify content and procedures for distribution of a notification of coverage that issuers are required to provide annually
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CHAPTER 21SUBCHAPTER JJ
Autism Spectrum Disorder
• HB 1919• §21.4401 - 21.4404• Must provide coverage under medical and
surgical provisions of plan for all generally recognized services prescribed in relation to autism spectrum disorderT
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CHAPTER 21SUBCHAPTER MMWellness Programs
HB 2252
• 28 TAC §§21.4701 - 21.4707• May establish premium discounts, rebates,
or a reduction in copayments, coinsurance, or deductibles in return for participation in programs promoting disease prevention, wellness and health
• www.tdi.state.tx.us/rules/2008/0919-059.html
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CHAPTER 21SUBCHAPTER NN
Noninsurance Benefits and FeaturesHB 1847
• 28 TAC §§21.4801 - 21.4807
• Standards applicable to noninsurance benefits intended to be offered in connection with a policy
• Must be reasonably related to the type of insurance policy or certificate being issued
• www.tdi.state.tx.us/rules/2008/noninsurance_be.html Texas
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SUBCHAPTER NN, cont.
• Policy Form Must provide: – explanation of how the noninsurance benefit may
be obtained;– a statement disclosing:
• (i) whether benefit is optional and• (ii) identifiable charge, if any
– information about the benefit– conditions for termination and notice of
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CHAPTER 26 SUBCHAPTER D
Health Group CooperativesSB 1255
• 28 TAC §§26.402 and 26.404
• A cooperative composed of both small and large employers may be treated as a large employer for purposes of the Insurance Code Chapter 1501
• www.tdi.state.tx.us/rules/2007/0215B-059.html
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CHAPTER 3 SUBCHAPTER Y
Long Term CareSB 22
• Standards for:– long-term care non-partnership insurance coverage – long-term care partnership insurance coverage under individual
and group policies, annuity contracts, and life insurance policies that provide long-term care benefits within the policy or by rider
• Allow individuals to protect assets equal to insurance benefits received from a partnership policy so such assets will not be taken into account in determining eligibility for Medicaid
• www.tdi.state.tx.us/rules/2008/documents/longterm.pdf
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HB 522Standards for ID Cards and
Eligibility Verification
• Interim Update - www.tdi.state.tx.us/committee/documents/HB522interimrpt.pdf
• Committee Report Due 12/1/08
• ID Cards – WEDI Standards?
• Eligibility – CAQH/CORE – Phase I, II?
– HHS - ASC X12N Version 4010, 5010? Texas
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HB 472
• Regulation of TPAs, including workers’ compensation administrators
• Prohibits compensation based upon savings from adverse claim decisions
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Genetic Testing
• Genetic Information Nondiscrimination Act of 2008
• Medicare Supplement Rules
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Dianne LongleyDianne Longley
Director of Research and AnalysisDirector of Research and Analysis
Life, Health & Licensing ProgramLife, Health & Licensing Program
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Senate Bill 1731
• “Transparency” legislation designed to provide consumers with information they need to make informed health care decisions
• Creates new reporting/data requirements for – Facilities– Physicians– Health plans
• Requires TDI and DSHS to provide information, oversight of implementation
Consumer Access to Health Care Information
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DSHS Consumer Guide
• Adds Health and Safety Code Chapter 324, requiring DSHS to publish “Consumer Guide to Health Care”, including info on:– Pricing practices and variations among
providers– Information on correlation between billed/avg
charges and actual charges based on patient’s unique circumstances
– Consumer liability for costs– Advice to consumers for obtaining cost
information in advance
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Health Plan Requirements
• Insured notices/estimates of payment• Annual reporting of reimbursement rates to TDI
(requires rules)• Annual reporting of consumer-comparison
information for HMOs and PPOs (requires rules)• Reporting of In-network/Out-of-network data for
study of network adequacy (requires rules)
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Insurer Disclosures re. Out-of-Network Providers
• HMOs/PPOs must provide notice to enrollees – A facility-based provider may not be in the plan
network, even though the facility is; and
– An out-of-network facility-based physician may balance bill the enrollee
• Disclosure must be provided in writing– At issuance or renewal of policy
– With any explanation of benefits
– And included on plan’s website
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Insurer Information on Facility-Based Providers
• Health plans must identify any in-network facilities that use FBPs who are out-of-network
• Facilities with non-participating providers must be identified in a separate and conspicuous manner in provider directory or on the insurer’s website
• TDI working with health plans to provide a standard template for displaying this information in a simple, understandable manner
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Insurer Notices and Information re. Charges/Billing
• On request, insurer must provide an enrollee:– a prospective estimate of what the insurer will pay
for proposed health care services or supplies– an estimate of what the insured’s personal
responsibility will be for proposed services or supplies
– information on whether a physician/provider is in-network
• Any Explanation of Benefits that indicates a payment to a non-network physician has been paid at usual and customary amounts must also include TDI’s consumer protection toll-free number for complaints
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Insurer Reimbursement Rate Reporting Rules
• Multiple stakeholder meetings held to discuss data options
• Agreed to collect rate data for services commonly used or for which consumers may plan in advance
• Data will be reported for selected CPT and DRG codes, and for multiple geographic areas
• TDI negotiating with AMA re. use of CPT codes; rules on hold pending agreement with AMA
• TDI will aggregate data and report information on website
• Data will also appear on DSHS website
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Consumer Information Annual Report
• TDI is required to collect and publish the following HMO/PPO information: – Financial data– Enrollment information– An evaluation of enrollee satisfaction– An evaluation of quality of care– Coverage areas– Accreditation status– Premium costs– Plan costs – Premium increases– Range of benefits provided– Co-payments and deductibles– The accuracy and speed of claims payment– Credentials of contracted physicians– Number of providers
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Annual Reporting Rule Status
• TDI held multiple stakeholder meetings to discuss reporting options
• Rules currently in draft stage for PPBP reporting
• Informal rule expected within next 6 weeks• TDI designing new web pages for displaying
information; will be posing HMO data already collected ASAP
• Draft rules for additional HMO data expected early 2009
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TDI Study of Network Adequacy
• Requires appointment of advisory committee, appointed by Commissioner of Insurance
• Committee required to study facility-based provider network adequacy of health benefit plans
• For this study, Facility-Based Provider includes radiologist, anesthesiologist, pathologist, emergency department physician, neonatologist
• Health plans will be required to provide data based on TDI rules; data will be evaluated by TDI and advisory committee
• Report due to Legislature in December, 2008
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TDI Study of Network Adequacy
• Committee appointed last year; equal number of members representing health plans, providers and hospitals See http://www.tdi.state.tx.us/committee/sb1731main.html
• Health plans have voluntarily provided data for committee’s consideration throughout the process; appreciate cooperation and TAHP’s assistance in coordinating requests
• Data collection requirements for TDI rules have been the subject of much discussion and debate; multiple drafts reviewed by committee
• Proposed rule published September 30th; hearing on October 14th
• Report due to Legislature December, 2008
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TDI REQUEST FOR ASSISTANCE
• When informal rules are published, please review and comment
• Equally important, PLEASE PROVIDE COST ESTIMATES WHEN REQUESTED
• The lack of response from health plans re. costs has delayed several rules in recent months. This is YOUR opportunity to participate in the process
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TDI/HHSC Joint Study of Premium Assistance Program
• SB 10 (Medicaid Reform) requires TDI and HHSC to study and recommend a small employer premium assistance program
• Report nearing completion; will be finalized and delivered to Legislature in NovemberT
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HB 1977 Risk Pool Study• Requires TDI to study scope of problem
associated with the restriction that prohibits individuals with access to very limited group benefit plans from enrolling in the Texas Health Insurance Risk Pool
• Also required to propose recommendations for addressing the problem
• TDI surveyed health plans; working with Risk Pool and staff to develop options
• Findings will be included in TDI’s biennial report to the Legislature
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Katrina DanielKatrina Daniel
Associate CommissionerAssociate Commissioner
Life, Health & Licensing ProgramLife, Health & Licensing Program
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Sunset Purpose and HistorySunset Purpose and History
• Agency reviews every 12 years…mostly
• Last Sunset review by the 73rd Legislature in 1993
• Abolished the Board of Insurance
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Review ObjectivesReview Objectives
Determining the need for agency functions Evaluating the agency on criteria outlined in
the Texas Sunset Act (Chapter 325, Government Code)
12 Sunset criteria are based on standards of effectiveness, efficiency, fairness, and accountability
Texas Sunset Advisory Commission
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Who Is Sunset?Who Is Sunset?
5 Senators
1 Public Member
5 Representatives
1 Public Member
Appointed by the Lieutenant Governor
Appointed by the Speaker of the House
4-year terms
2-year terms
Chair and Vice Chair rotate between the Senate and House each biennium.
12-Member Commission
& &
Texas Sunset Advisory Commission
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Sunset Advisory Commission Sunset Advisory Commission MembersMembers
Chair, Representative Carl Isett, Lubbock
Vice-Chair, Senator Glenn Hegar, Jr., Katy
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TDI Approach to SunsetTDI Approach to Sunset
• Attitude of openness
• Opportunity for self examination
• Opportunity for a fresh perspective
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SER Policy IssuesSER Policy Issues
• Four broad agency-wide issues:• Better assist customers and maintain a
stable market
• Expand TDI’s role to better ensure that Texans have adequate coverage
• Provide additional flexibility to firmly and fairly regulate the market
• Modify the organizational structure
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Sunset Review ScheduleSunset Review Schedule
• TDI began preparing for Sunset review early 2007
• Submitted the Self-Evaluation Report (SER) August 2007
• Review work with Sunset staff began fall 2007
• Decision Hearing September 24, 2008
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Opportunities for Opportunities for Public InputPublic Input
• Stakeholder letter from Sunset (2007)• Sunset Staff Report Hearing – June
24th and 25th
• Response to Staff Report• Legislative Session
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Sunset Review ResourcesSunset Review Resources
Self-Evaluation Report(www.tdi.state.tx.us/reports/sunset/documents/tdiser.pdf)
Sunset Resource Page(http://www.tdi.state.tx.us/general/sunset.html)
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Healthy TexasHealthy Texas
Part of SB 10
Directs the Department to: Analyze the underserved segments of the small group market
Propose a program that would offer health coverage to eligible people
Report to the legislature November 1, 2008
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Hurricane Ike
• TDI assistance in approximately 20 Disaster Recovery Centers
• Bulletins
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Helpful ResourcesHelpful Resources• TDI Website:
www.tdi.state.tx.us • LHL Main Line:
512-305-7342• Life/Health Division:
[email protected]• Health & Workers’ Compensation Network
Certification and Quality Assurance Division [email protected]
• The Texas Health Options Website: www.TexasHealthOptions.com
• TDI Proposed/Adopted Rules: www.tdi.state.tx.us/commish/parules.html
• Texas Legislature Website: www.capitol.state.tx.us
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