By: Seaman (Senate Sponsor - Lucio) H.B. No. 888
(In the Senate - Received from the House May 10, 2005;
May 12, 2005, read first time and referred to Committee on State
Affairs; May 20, 2005, reported favorably by the following vote:
Yeas 6, Nays 0; May 20, 2005, sent to printer.)
A BILL TO BE ENTITLED
AN ACT
relating to the reporting of cost claims information under certain
health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1209.001, Insurance Code, is amended to
read as follows:
Sec. 1209.001. APPLICABILITY OF CHAPTER. (a) Except as
provided by Subsection (b), this [This] chapter applies only to a
group health benefit plan, including a small employer health
benefit plan written under Chapter 1501, that:
(1) provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including a group, blanket, or franchise insurance policy or
insurance agreement, a group hospital service contract, or a group
evidence of coverage or similar group coverage document that is
offered by:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842;
(C) a fraternal benefit society operating under
Chapter 885;
(D) a stipulated premium company operating under
Chapter 884;
(E) a reciprocal exchange operating under
Chapter 942;
(F) a health maintenance organization operating
under Chapter 843;
(G) a multiple employer welfare arrangement that
holds a certificate of authority under Chapter 846; or
(H) an approved nonprofit health corporation
that holds a certificate of authority under Chapter 844; and
(2) provides health benefits to the employees of one
or more employers that sponsor the plan.
(b) This chapter applies to a governmental entity that:
(1) is subject to competitive bidding requirements;
and
(2) enters into a contract with an insurance company
or other entity described by Subsection (a) under which the insurer
or other entity delivers, issues for delivery, or renews a policy,
contract, or evidence of coverage that provides health benefits.
SECTION 2. Chapter 1209, Insurance Code, is amended by
adding Section 1209.0015 to read as follows:
Sec. 1209.0015. DEFINITIONS. In this chapter:
(1) "Governmental entity" means a state agency or
political subdivision of this state.
(2) "Political subdivision" means a county,
municipality, school district, special-purpose district, or other
subdivision of state government that has jurisdiction limited to a
geographic portion of the state.
SECTION 3. Section 1209.002, Insurance Code, is amended to
read as follows:
Sec. 1209.002. CLAIMS COST INFORMATION. (a) On the
request of an employer sponsoring a group health benefit plan, the
health benefit plan issuer shall provide to the employer the claims
cost information for all plan participants [employees] covered by
the plan during the periods specified by this section [preceding
calendar year].
(b) Not later than the 30th day after the date a health
benefit plan issuer that covers an employer's employees under a
health benefit plan receives a written request for a written report
of claim information from the employer, the health benefit plan
issuer shall provide the employer the information required by this
section.
(c) A report of claim information provided under this
section must contain all information available to the health
benefit plan issuer that is responsive to the request made under
this section for the 36-month period preceding the date of the
request, except as provided by Subsection (d), or for the entire
period of coverage, whichever period is shorter. To the extent
allowed by federal law or other laws of this state relating to
privacy of an individual's identifiable health information and
subject to Subsection (e), a report provided under this section
must include:
(1) aggregate paid claims experience by month,
including claims experience for medical, dental, and pharmacy
benefits, as applicable;
(2) total premium paid by month;
(3) total dollar amount of pending claims as of the
date of the report;
(4) the total number of covered employees on a monthly
basis by coverage tier, including whether coverage was for an
employee only, an employee with dependents only, an employee with a
spouse only, or an employee with family; and
(5) the total number of large or catastrophic claims
exceeding $10,000, including the aggregate amounts paid for those
claims, and in the case of a large employer that has 200 or more
employees covered by the health benefit plan, an aggregate list of
all diagnosis codes for claims exceeding $25,000.
(d) For purposes of Subsections (c)(3) and (5), a report of
claim information provided under this section must contain all
information available to the health benefit plan issuer that is
responsive to the request made under Subsection (b) for the
24-month period preceding the date of the request or for the entire
period of coverage, whichever period is shorter.
(e) A report of claim information may not include
information that can be used to identify a specific individual
enrolled in the health benefit plan or the diagnosis of that
individual.
(f) In the case of a request made under this section after
the date of termination of coverage, the report must contain all
information available to the health benefit plan issuer as of the
date of the request that is responsive to the request, including the
information described by Subsections (c)(1)-(5), for applicable
periods.
(g) After termination of a policy, an employer may request a
health benefit plan issuer to supplement a report provided under
this section for any months not included in the initial report. The
health benefit plan issuer shall provide a supplement under this
subsection not later than the 30th day after the date the health
benefit plan issuer receives the request for the supplement.
(h) An employer must request a report under this section on
or before the second anniversary of the date of termination of
coverage under the health benefit plan.
(i) A report of claim information provided under this
section to a governmental entity:
(1) may be used only for contract bidding purposes;
and
(2) is confidential and exempt from public disclosure
under Chapter 552, Government Code.
(j) A health benefit plan issuer that does not comply with
this section is subject to administrative penalties under Chapter
84. [Claims cost information provided under this section:
[(1) may be provided in the aggregate or on a detailed
basis;
[(2) must be provided separately for each month during
which the group health benefit plan was in effect; and
[(3) may not include information, including diagnosis
code information, that may be used to identify a specific
individual enrolled in the plan or a diagnosis of that individual.]
SECTION 4. Section 1501.614 and Article 21.49-15, Insurance
Code, are repealed.
SECTION 5. The change in law made by this Act applies only
to a report of claim information that is requested on or after the
effective date of this Act. A report of claim information that is
requested before the effective date of this Act is governed by the
law as it existed before the effective date of this Act, and that
law is continued in effect for that purpose.
SECTION 6. This Act takes effect September 1, 2005.
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