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

1. Texas Department of Insurance 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 Pay:New 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 • Patient’s 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 carrier’s 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/documents/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@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