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Katrina Daniel Doug Danzeiser Dianne Longley Texas Department of Insurance Life, Health & Licensing Program

Texas Department of Insurance. Texas Association of Health Plans 2008 Managed Care Conference & Trade Show. Katrina Daniel Doug Danzeiser Dianne Longley Texas Department of Insurance Life, Health & Licensing Program. Texas Department of Insurance. Doug Danzeiser.

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Katrina Daniel Doug Danzeiser Dianne Longley Texas Department of Insurance Life, Health & Licensing Program

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  1. Texas Department of Insurance Texas Association of Health Plans2008 Managed Care Conference & Trade Show Katrina Daniel Doug Danzeiser Dianne Longley Texas Department of Insurance Life, Health & Licensing Program

  2. Texas Department of Insurance Doug Danzeiser Deputy Commissioner for Regulatory Matters Life, Health & Licensing Program

  3. Texas Department of Insurance CHAPTER 21SUBCHAPTER BINSURANCE 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

  4. Texas Department of Insurance 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

  5. Texas Department of Insurance CHAPTER 21SUBCHAPTER WAcquired Brain Injury • HB 1919 • §§21.3101 - 21.3107 • www.tdi.state.tx.us/rules/2008/documents/21.3101-21.3107.pdf

  6. Texas Department of Insurance 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

  7. Texas Department of Insurance CHAPTER 21SUBCHAPTER JJAutism 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 disorder

  8. Texas Department of Insurance CHAPTER 21SUBCHAPTER MMWellness ProgramsHB 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

  9. Texas Department of Insurance CHAPTER 21SUBCHAPTER NNNoninsurance 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

  10. Texas Department of Insurance 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 termination

  11. Texas Department of Insurance 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

  12. Texas Department of Insurance CHAPTER 3 SUBCHAPTER YLong 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

  13. Texas Department of Insurance HB 522Standards for ID Cards andEligibility 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?

  14. Texas Department of Insurance HB 472 • Regulation of TPAs, including workers’ compensation administrators • Prohibits compensation based upon savings from adverse claim decisions

  15. Texas Department of Insurance Genetic Testing • Genetic Information Nondiscrimination Act of 2008 • Medicare Supplement Rules

  16. Texas Department of Insurance For more information or questions, contact Doug.Danzeiser@tdi.state.tx.us 512-475-1964

  17. Texas Department of Insurance Dianne Longley Director of Research and Analysis Life, Health & Licensing Program

  18. Texas Department of Insurance Senate Bill 1731 Consumer Access to Health Care Information • “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

  19. Texas Department of Insurance 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

  20. Texas Department of Insurance 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)

  21. Texas Department of Insurance 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

  22. Texas Department of Insurance 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

  23. Texas Department of Insurance 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

  24. Texas Department of Insurance 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

  25. Texas Department of Insurance 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

  26. Texas Department of Insurance 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

  27. Texas Department of Insurance 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

  28. Texas Department of Insurance 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

  29. Texas Department of Insurance 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

  30. Texas Department of Insurance 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 November

  31. Texas Department of Insurance 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

  32. Texas Department of Insurance For more information or questions, contact Dianne.Longley@tdi.state.tx.us 512-305-7298

  33. Texas Department of Insurance Katrina Daniel Associate Commissioner Life, Health & Licensing Program

  34. Sunset Purpose and History • Agency reviews every 12 years…mostly • Last Sunset review by the 73rd Legislature in 1993 • Abolished the Board of Insurance

  35. Review 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

  36. Who Is Sunset? 12-Member Commission 5 Senators 5 Representatives 4-year terms & & 1 Public Member 1 Public Member 2-year terms Appointed by the Lieutenant Governor Appointed by the Speaker of the House Chair and Vice Chair rotate between the Senate and House each biennium. Texas Sunset Advisory Commission

  37. Sunset Advisory Commission Members Chair, Representative Carl Isett, Lubbock Vice-Chair, Senator Glenn Hegar, Jr., Katy

  38. TDI Approach to Sunset • Attitude of openness • Opportunity for self examination • Opportunity for a fresh perspective

  39. SER 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

  40. Sunset 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

  41. Opportunities for Public Input • Stakeholder letter from Sunset (2007) • Sunset Staff Report Hearing – June 24th and 25th • Response to Staff Report • Legislative Session

  42. Sunset 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)

  43. Healthy 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

  44. Texas Department of Insurance Hurricane Ike • TDI assistance in approximately 20 Disaster Recovery Centers • Bulletins

  45. Texas Department of Insurance Helpful Resources • TDI Website: • www.tdi.state.tx.us • LHL Main Line: • 512-305-7342 • Life/Health Division: • LifeHealth@tdi.state.tx.us • Health & Workers’ Compensation Network Certification and Quality Assurance Division • HWCN@tdi.state.tx.us • 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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