CHAPTER 1660. ELECTRONIC DATA EXCHANGE
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE J. HEALTH INFORMATION TECHNOLOGY
CHAPTER 1660. ELECTRONIC DATA EXCHANGE
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1660.001. FINDINGS AND PURPOSE. (a) The legislature finds
that patients deserve accurate, instantaneous information about
coverage and financial responsibility to make well-informed
decisions about their treatment and spending.
(b) The legislature finds that the ability of health benefit
plan issuers and administrators to exchange eligibility and
benefit information with physicians, health care providers,
hospitals, and patients will ensure a more efficient and
effective health care delivery system.
(c) The legislature finds that electronic access to eligibility
information will reduce the amount of time and resources spent on
administrative functions, prevent abuse and fraud, streamline and
simplify processing of insurance claims, and increase
transparency in premium cost and health care cost.
(d) The legislature finds that patients often request
information about their health care coverage from their health
care providers and that health care providers therefore need
access to real-time information about their patients' eligibility
to receive health care under the health benefit plan, coverage of
health care under the health benefit plan, and the benefits
associated with the health benefit plan.
(e) The legislature finds that adoption of technology by
insurers, health maintenance organizations, and health care
providers to facilitate use of electronic data exchange standards
currently available will make coverage and health care electronic
transactions more predictable, reliable, and consistent.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.
Sec. 1660.002. DEFINITIONS. In this chapter:
(1) "Administrator" has the meaning assigned by Section
4151.001.
(2) "Advisory committee" means the technical advisory committee
on electronic data exchange.
(3) "Enrollee" means an individual who is insured by or enrolled
in a health benefit plan.
(4) "Health benefit plan" means an individual, group, blanket,
or franchise insurance policy or insurance agreement, a group
hospital service contract, or an evidence of coverage that
provides health insurance or health care benefits.
(5) "Transaction standards" means the Health Insurance
Portability and Accountability Act of 1996 (Pub. L. No. 104-191)
transaction standards of the Centers for Medicare and Medicaid
Services under 45 C.F.R. Part 162.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.
Sec. 1660.003. APPLICABILITY. (a) This chapter applies only to
a health benefit plan that provides benefits for medical or
surgical expenses incurred as a result of a health condition,
accident, or sickness, including an individual, group, blanket,
or franchise insurance policy or insurance agreement, a group
hospital service contract, or an individual or group evidence of
coverage or similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating under Chapter
842;
(3) a fraternal benefit society operating under Chapter 885;
(4) a stipulated premium insurance company operating under
Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a health maintenance organization operating under Chapter
843;
(7) a multiple employer welfare arrangement that holds a
certificate of authority under Chapter 846; or
(8) an approved nonprofit health corporation that holds a
certificate of authority under Chapter 844.
(b) This chapter does not apply to:
(1) a Medicaid managed care program operated under Chapter 533,
Government Code;
(2) a Medicaid program operated under Chapter 32, Human
Resources Code;
(3) the state child health plan or any similar plan operated
under Chapter 62 or 63, Health and Safety Code; or
(4) a health benefit plan offered by an insurer or health
maintenance organization that provides coverage only for dental
services.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.
Sec. 1660.004. GENERAL RULEMAKING. The commissioner may adopt
rules as necessary to implement this chapter, including rules
requiring the implementation and provision of the technology
recommended by the advisory committee.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.
SUBCHAPTER B. ADVISORY COMMITTEE
Sec. 1660.051. ADVISORY COMMITTEE; COMPOSITION. (a) The
commissioner shall appoint a technical advisory committee on
electronic data exchange.
(b) The advisory committee is composed of:
(1) at least one representative from each of the following
groups or entities:
(A) health benefit coverage consumers;
(B) physicians;
(C) hospital trade associations;
(D) representatives of medical units of institutions of higher
education;
(E) representatives of health benefit plan issuers;
(F) health care providers; and
(G) administrators; and
(2) representatives from:
(A) the office of public insurance counsel;
(B) the Texas Health Insurance Risk Pool; and
(C) the Department of Information Resources.
(c) Members of the advisory committee serve without
compensation.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.
Sec. 1660.052. APPLICABILITY OF CERTAIN LAWS. The following
laws do not apply to the advisory committee:
(1) Section 39.003(a); and
(2) Chapter 2110, Government Code.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.
Sec. 1660.053. ADVISORY COMMITTEE POWERS AND DUTIES. The
advisory committee shall advise the commissioner on technical
aspects of using the transaction standards and the rules of the
Council for Affordable Quality Healthcare Committee on Operating
Rules for Information Exchange to require health benefit plan
issuers and administrators to provide access to information
technology that will enable physicians and other health care
providers, at the point of service, to generate a request for
eligibility information that is compliant with the transaction
standards.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.
Sec. 1660.054. DATA ELEMENTS. (a) The advisory committee shall
advise the commissioner on data elements required to be made
available by health benefit plan issuers and administrators. To
the extent possible, the committee shall use the framework
adopted by the Council for Affordable Quality Healthcare
Committee on Operating Rules for Information Exchange.
(b) The advisory committee shall consider inclusion in the
required information of the following data elements:
(1) the name, date of birth, member identification number, and
coverage status of the patient;
(2) identification of the payor, insurer, issuer, and
administrator, as applicable;
(3) the name and telephone number of the payor's contact
person;
(4) the payor's address;
(5) the name and address of the subscriber;
(6) the patient's relationship to the subscriber;
(7) the type of service;
(8) the type of health benefit plan or product;
(9) the effective date of the coverage;
(10) for professional services:
(A) copayment amounts;
(B) individual deductible amounts;
(C) family deductible amounts; and
(D) benefit limitations and maximums;
(11) for facility services:
(A) copayment and coinsurance amounts;
(B) individual deductible amounts;
(C) family deductible amounts; and
(D) benefit limitations and maximums;
(12) precertification or prior authorization requirements;
(13) policy maximum limits;
(14) patient liability for a proposed service; and
(15) the health benefit plan coverage amount for a proposed
service.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.
Sec. 1660.055. RECOMMENDATIONS REGARDING ADOPTION OF CERTAIN
TECHNOLOGIES; REPORT. (a) The advisory committee shall:
(1) make recommendations regarding the use by health benefit
plan issuers or administrators of Internet website technologies,
smart card technologies, magnetic strip technologies, biometric
technologies, or other information technologies to facilitate the
generation of a request for eligibility information that is
compliant with the transaction standards and the rules of the
Council for Affordable Quality Healthcare Committee on Operating
Rules for Information Exchange;
(2) ensure that a recommendation made under Subdivision (1) does
not endorse or otherwise confine health benefit plan issuers and
administrators to any single product or vendor; and
(3) recommend time frames for implementation of the
recommendations.
(b) The advisory committee shall:
(1) recommend specific provisions that could be included in a
department-issued request for information relating to electronic
data exchange, including identification card programs;
(2) provide those recommendations to the commissioner not later
than four months after the date on which the committee is
appointed; and
(3) issue a final report to the commissioner containing the
committee's recommendations for implementation by December 1,
2008.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.
SUBCHAPTER C. IDENTIFICATION CARD PILOT PROGRAM
Sec. 1660.101. PILOT PROGRAM. (a) The commissioner shall
designate a county or counties for initial participation in an
identification card pilot program to begin not later than May 1,
2008.
(b) The commissioner shall require the issuer of a health
benefit plan that is offered in the county or counties selected
for initial participation in the identification card pilot
program to issue identification cards that comply with
commissioner rules to each enrollee of the plan.
(c) The commissioner may implement the identification card pilot
program before, during, or simultaneously with the appointment
and formation of the advisory committee.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.
Sec. 1660.102. PILOT PROGRAM RULES. (a) The commissioner shall
adopt rules as necessary to implement the identification card
pilot program, including the coordination of a testing phase and
incorporation of changes identified in the testing phase.
(b) The commissioner may consider the recommendations of the
advisory committee or any information provided in response to a
department-issued request for information relating to electronic
data exchange, including identification card programs, before
adopting rules regarding:
(1) information to be included on the identification cards;
(2) technology to be used to implement the identification card
pilot program; and
(3) confidentiality and accuracy of the information required to
be included on the identification cards.
(c) The commissioner shall consider the requirements of any
federal program requiring health benefit plan issuers and
administrators to provide point-of-service access to physicians
and other health care providers regarding eligibility information
before adopting rules to implement this section.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.
Sec. 1660.103. REQUESTS FOR INFORMATION. The commissioner may
issue requests for information as needed to implement the
identification card pilot program under this subchapter.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.
Sec. 1660.104. HEALTH BENEFIT PLAN ISSUER COMPLIANCE. (a) Each
issuer of a health benefit plan that offers a health benefit plan
in a county or counties designated by the commissioner under
Section 1660.101 for initial participation in the identification
card pilot program shall comply with this subchapter and rules
adopted under this subchapter.
(b) To ensure timely compliance with the requirements of this
subchapter, the commissioner may require the issuer of a health
benefit plan to submit its procedures for implementation of the
requirements to the department in the form prescribed by the
commissioner.
Added by Acts 2007, 80th Leg., R.S., Ch.
209, Sec. 1, eff. May 25, 2007.