Jennifer Ahrens,

1
Texas Association of Health Plans Conference

• Jennifer Ahrens,
• Doug Danzeiser and
• Dianne Longley
• Texas Department of Insurance
• Life, Health Licensing Program

2
Jennifer Ahrens

• Senior Associate Commissioner
• Life, Health Licensing Program

3
80th Texas LegislatureTrends for Insurance

• Flexibility
• Transparency
• Accessibility

4
Provider Ombudsman

• Part of prompt pay efforts
• Transferred from Consumer Protection to Life,
  Health Licensing in November 2006

5
Provider Ombudsman (Cont.)

• Consumer Protection continues to handle
  individual provider complaints
• Provider Ombudsman monitors complaint trends
  among carriers and across issues
• Collects and analyzes quarterly prompt pay data
  from carriers
• Conducts quarterly and ad hoc TACCP meetings
• Facilitates report development and
  recommendations to the legislature from the TACCP

6
Prompt PayNew Underpayment CalculationSB 1884
Effective September 1, 2007

• Paid on or before the 45th day after the end of
  the applicable statutory claim period
• Billed charges 1,500
• Amount of contracted rate 1,000
• Patients cost share 0
• Amount paid timely 800
• Amount underpaid on contracted rate 200
• 200 / 1,000 ( 20) X 1,500
• 300 (the underpaid amount)
• Multiply by 50
• 150 penalty payment

7
Recent Enforcement Actions

• Silent PPOs
• Recent Order - 15,000 Fine
• Violation of TIC 1301.056 and 542

8
Recent Enforcement Actions (Cont.)

• Medicare Supplement Marketing
• Two Orders Against Company
• First 95,000 for failure to have required
  procedures regarding marketing
• Second 95,000 holding carrier responsible for
  acts of agents
• Four orders entered against carriers subagents

9
Recent Enforcement Actions (Cont.)

• Prompt Pay
• A number of cases
• Recent order
• 45,000 Fine - failure to timely and accurately
  process and pay particular type of claim

10
Recent Enforcement Actions (Cont.)

• Health Reinsurance System
• Recent Order
• 150,000 (carrier and TPA jointly)
• Improper submission of lives to the THRS
• Prompt pay violations

11
Recent Enforcement Actions (Cont.)

• Unauthorized Insurance
• Recent Proposal for Decision
• Agent - 1,000,000 proposed fine for unauthorized
  stop loss insurance
• Recent Criminal Sentencing
• Agent 27 year federal sentence for unauthorized
  health insurance

12
Sunset Review

• Review in 2007 to 2009
• Sunset will seek stakeholder input
• Self Evaluation Report
• (http//www.tdi.state.tx.us/reports/sunset/documen
  ts/tdiser.pdf)
• Sunset Resource Page
• (http//www.tdi.state.tx.us/general/sunset.html)

13
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

14
Dianne Longley

• Director of Special Projects
• Life, Health Licensing Program

15
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 Medicaid HMO contracts to include
  performance incentives

16
SB 10 (Cont.)

• Encourages Medicaid HMOs to provide
  non-traditional value- added services designed to
  improve health of enrollees
• Expands assistance to enable Medicaid recipients
  to enroll in private group health plans
• Authorizes small employers and counties to create
  regional health plans to provide affordable
  health insurance coverage
• 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

17
SB 10 (Cont.)

• 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.

18
SB 1731 Consumer Access to Health Care
Information

• HHSC must collect and provide information
  regarding facility pricing practices
• Establishes pricing requirements for physician
  and facility billing practices
• Disclosure
• Cost estimates
• Itemized statements
• Refunds
• Requires creation of Consumer Guide to Health
  Care, posting on HHSC and Texas Medical Board
  websites

19
SB 1731 Insurance Provisions

• Requires TDI to collect health benefit plan
  reimbursement rates info must be published on
  Dept. of State Health Services website and may
  also be published on TDI website
• TDI staff is working with stakeholders (including
  TAHP members) to develop reporting requirements
• Draft rule will be published for comment this
  fall adoption target date is December 31, 2007
• .

20
SB 1731 Insurance Provisions (Cont.)

• Requires TDI to collect and publish HMO and PPO
  data regarding enrollee satisfaction, quality of
  care, premium costs and increases, plan benefits,
  claims payment, and network adequacy
• TDI staff is working with stakeholders to
  determine what data to collect to meet statutory
  requirements
• Draft rule will be published for comment early
  next year adoption target date is early spring

21
SB 1731 Insurance Provisions (Cont.)

• Requires TDI to work with advisory committee to
  study network adequacy rules required to collect
  necessary data
• TDI has solicited nominations for advisory
  committee and expects to finalize appointments
  within the next week
• Upon request, requires health plans/HMOs to
  provide a prospective estimate of payments for
  medical services and information on whether
  proposed services are covered
• Requires health plans/HMOs and facility-based
  physicians providing out-of-network services to
  provide notice of balance billing to enrollees
  and patients

22
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
• TDI currently drafting grant requirements and
  hopes to post application by end of year

23
Doug Danzeiser

• Deputy Commissioner for Regulatory Matters
• Life, Health Licensing Program

24
HB 472
Regulation of TPAs, including workers
compensation administrators. Prohibits
compensation based upon savings from adverse
claim decisions
25
HB 522
Requires TDI to adopt standards for health plan
ID cards and electronic exchange of insurance
information
26
HB 1594
Provides for expedited credentialing and
in-network payment of physicians joining
established, contracted medical groups
27
HB 1847
Permits non-insurance benefits and related
services for accident, health, life, and
long-term care insurance
28
HB 2015
Reporting of claim information under certain
group health plans providing administrative
penalties
29
HB 2251
Regulates webpage advertising and amends other
advertising provisions
30
SB 1255
The powers and duties of certain small and large
employer health cooperatives
31
Helpful Resources

• TDI Website
• www.tdi.state.tx.us
• LHL Main Line
• 512-305-7342
• Life/Health Division
• LifeHealth_at_tdi.state.tx.us
• Health Workers Compensation Network
  Certification and Quality Assurance Division
• HWCN_at_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