CHAPTER 1215. REPORTING OF CLAIMS INFORMATION
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE A. HEALTH COVERAGE IN GENERAL
CHAPTER 1215. REPORTING OF CLAIMS INFORMATION
Sec. 1215.001. DEFINITIONS. (a) Except as provided by
Subsection (b), in this chapter:
(1) "Employer" has the meaning assigned by 29 U.S.C. Section
1002(5).
(2) "Governmental entity" means a state agency or political
subdivision of this state.
(3) "Group health plan" has the meaning assigned by 45 C.F.R.
Section 160.103, except that the term does not include disability
income or long-term care insurance.
(4) "Health insurance issuer" has the meaning assigned by 45
C.F.R. Section 160.103.
(5) "Plan" means an employee welfare benefit plan as defined by
29 U.S.C. Section 1002(1).
(6) "Plan administrator" means an administrator as defined by 29
U.S.C. Section 1002(16)(A).
(7) "Plan sponsor" has the meaning assigned by 29 U.S.C. Section
1002(16)(B).
(8) "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.
(9) "Protected health information" has the meaning assigned by
45 C.F.R. Section 160.103.
(b) A reference to a federal statute or regulation under
Subsection (a) means that statute or regulation as it existed on
September 1, 2007, except that the commissioner, by rule, may
adopt a definition based on a later amended, enacted, or adopted
federal statute or regulation if the commissioner determines that
use of the later amended, enacted, or adopted statute or
regulation is consistent with the purposes of this chapter and
promotes regulatory consistency.
Added by Acts 2007, 80th Leg., R.S., Ch.
700, Sec. 1, eff. September 1, 2007.
Sec. 1215.002. APPLICABILITY OF CHAPTER TO GOVERNMENTAL ENTITY;
APPLICABILITY OF OTHER LAW WITH REFERENCE TO GOVERNMENTAL ENTITY.
(a) This chapter applies to a governmental entity that enters
into a contract with a health insurance issuer that results in
the health insurance issuer delivering, issuing for delivery, or
renewing a group health plan.
(b) For purposes of this chapter, a health insurance issuer
shall treat a governmental entity described by Subsection (a) as
a plan sponsor or plan administrator.
(c) A report of claim information provided under this section to
a governmental entity is confidential and exempt from public
disclosure under Chapter 552, Government Code.
Added by Acts 2007, 80th Leg., R.S., Ch.
700, Sec. 1, eff. September 1, 2007.
Sec. 1215.003. RECEIPT OF AND RESPONSE TO REQUEST FOR CLAIM
INFORMATION. (a) Not later than the 30th day after the date a
health insurance issuer receives a written request for a written
report of claim information from a plan, plan sponsor, or plan
administrator, the health insurance issuer shall provide the
requesting party the report, subject to Subsections (d), (e), and
(f). The health insurance issuer is not obligated to provide a
report under this subsection regarding a particular employer or
group health plan more than twice in any 12-month period.
(b) A health insurance issuer shall provide the report of claim
information under Subsection (a):
(1) in a written report;
(2) through an electronic file transmitted by secure electronic
mail or a file transfer protocol site; or
(3) by making the required information available through a
secure website or web portal accessible by the requesting plan,
plan sponsor, or plan administrator.
(c) A report of claim information provided under Subsection (a)
must contain all information available to the health insurance
issuer that is responsive to the request made under Subsection
(a), including, subject to Subsections (d), (e), and (f),
protected health information, for the 36-month period preceding
the date of the report or the period specified by Subdivisions
(4), (5), and (6), if applicable, or for the entire period of
coverage, whichever period is shorter. Subject to Subsections
(d), (e), and (f), a report provided under Subsection (a) 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 number of covered employees on a monthly basis by
coverage tier, including whether coverage was for:
(A) an employee only;
(B) an employee with dependents only;
(C) an employee with a spouse only; or
(D) an employee with a spouse and dependents;
(4) the total dollar amount of claims pending as of the date of
the report;
(5) a separate description and individual claims report for any
individual whose total paid claims exceed $15,000 during the
12-month period preceding the date of the report, including the
following information related to the claims for that individual:
(A) a unique identifying number, characteristic, or code for the
individual;
(B) the amounts paid;
(C) dates of service; and
(D) applicable procedure codes and diagnosis codes; and
(6) for claims that are not part of the report described by
Subdivisions (1)-(5), a statement describing precertification
requests for hospital stays of five days or longer that were made
during the 30-day period preceding the date of the report.
(d) A health insurance issuer may not disclose protected health
information in a report of claim information provided under this
section if the health insurance issuer is prohibited from
disclosing that information under another state or federal law
that imposes more stringent privacy restrictions than those
imposed under federal law under the Health Insurance Portability
and Accountability Act of 1996 (Pub. L. No. 104-191). To
withhold information in accordance with this subsection, the
health insurance issuer must:
(1) notify the plan, plan sponsor, or plan administrator
requesting the report that information is being withheld; and
(2) provide to the plan, plan sponsor, or plan administrator a
list of categories of claim information that the health insurance
issuer has determined are subject to the more stringent privacy
restrictions under another state or federal law.
(e) A plan sponsor is entitled to receive protected health
information under Subsections (c)(5) and (6) and Section 1215.004
only after an appropriately authorized representative of the plan
sponsor makes to the health insurance issuer a certification
substantially similar to the following certification:
"I hereby certify that the plan documents comply with the
requirements of 45 C.F.R. Section 164.504(f)(2) and that the plan
sponsor will safeguard and limit the use and disclosure of
protected health information that the plan sponsor may receive
from the group health plan to perform the plan administration
functions."
(f) A plan sponsor that does not provide the certification
required by Subsection (e) is not entitled to receive the
protected health information described by Subsections (c)(5) and
(6) and Section 1215.004, but is entitled to receive a report of
claim information that includes the information described by
Subsections (c)(1)-(4).
(g) In the case of a request made under Subsection (a) after the
date of termination of coverage, the report must contain all
information available to the health insurance issuer as of the
date of the report that is responsive to the request, including
protected health information, and including the information
described by Subsections (c)(1)-(6), for the period described by
Subsection (c) preceding the date of termination of coverage or
for the entire policy period, whichever period is shorter.
Notwithstanding this subsection, the report may not include the
protected health information described by Subsections (c)(5) and
(6) unless a certification has been provided in accordance with
Subsection (e).
(h) A plan, plan sponsor, or plan administrator must request a
report under Subsection (a) before or on the second anniversary
of the date of termination of coverage under a group health plan
issued by the health benefit plan issuer.
Added by Acts 2007, 80th Leg., R.S., Ch.
700, Sec. 1, eff. September 1, 2007.
Sec. 1215.004. REQUEST FOR ADDITIONAL INFORMATION. (a) On
receipt of the report required by Section 1215.003(a), the plan,
plan sponsor, or plan administrator may review the report and,
not later than the 10th day after the date the report is
received, may make a written request to the health insurance
issuer for additional information in accordance with this section
for specified individuals.
(b) With respect to a request for additional information
concerning specified individuals for whom claims information has
been provided under Section 1215.003(c)(5), the health insurance
issuer shall provide additional information on the prognosis or
recovery if available and, for individuals in active case
management, the most recent case management information,
including any future expected costs and treatment plan, that
relate to the claims for that individual.
(c) The health insurance issuer must respond to the request for
additional information under this section not later than the 15th
day after the date of the request under this section unless the
requesting plan, plan sponsor, or plan administrator agrees to a
request for additional time.
(d) The health insurance issuer is not required to produce the
report described by this section unless a certification has been
provided in accordance with Section 1215.003(e).
Added by Acts 2007, 80th Leg., R.S., Ch.
700, Sec. 1, eff. September 1, 2007.
Sec. 1215.005. COMPLIANCE WITH CHAPTER DOES NOT CREATE
LIABILITY. A health insurance issuer that releases information,
including protected health information, in accordance with this
chapter has not violated a standard of care and is not liable for
civil damages resulting from, and is not subject to criminal
prosecution for, releasing that information.
Added by Acts 2007, 80th Leg., R.S., Ch.
700, Sec. 1, eff. September 1, 2007.
Sec. 1215.006. ADMINISTRATIVE PENALTIES. A health insurance
issuer that does not comply with this chapter is subject to
administrative penalties under Chapter 84.
Added by Acts 2007, 80th Leg., R.S., Ch.
700, Sec. 1, eff. September 1, 2007.