INSURANCE CODE
TITLE 2. TEXAS DEPARTMENT OF INSURANCE
SUBTITLE A. ADMINISTRATION OF THE TEXAS DEPARTMENT OF INSURANCE
CHAPTER 38. DATA COLLECTION AND REPORTS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 38.001. INQUIRIES. (a) In this section, "authorization"
means a permit, certificate of registration, or other
authorization issued or existing under this code.
(b) The department may address a reasonable inquiry to any
insurance company, including a Lloyd's plan or reciprocal or
interinsurance exchange, or an agent or other holder of an
authorization relating to:
(1) the person's business condition; or
(2) any matter connected with the person's transactions that the
department considers necessary for the public good or for the
proper discharge of the department's duties.
(c) A person receiving an inquiry under Subsection (b) shall
respond to the inquiry in writing not later than the 10th day
after the date the inquiry is received.
(d) A response made under this section that is otherwise
privileged or confidential by law remains privileged or
confidential until introduced into evidence at an administrative
hearing or in a court.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Amended by:
Acts 2005, 79th Leg., Ch.
1295, Sec. 1, eff. September 1, 2005.
Sec. 38.002. UNDERWRITING GUIDELINES FOR PERSONAL AUTOMOBILE AND
RESIDENTIAL PROPERTY INSURANCE; FILING; CONFIDENTIALITY. (a) In
this section:
(1) "Insurer" means an insurance company, reciprocal or
interinsurance exchange, mutual insurance company, capital stock
company, county mutual insurance company, Lloyd's plan, or other
legal entity engaged in the business of personal automobile
insurance or residential property insurance in this state. The
term includes:
(A) an affiliate as described by Section 823.003(a) if that
affiliate is authorized to write and is writing personal
automobile insurance or residential property insurance in this
state;
(B) the Texas Windstorm Insurance Association created and
operated under Chapter 2210;
(C) the FAIR Plan Association under Chapter 2211; and
(D) the Texas Automobile Insurance Plan Association under
Chapter 2151.
(2) "Personal automobile insurance" means motor vehicle
insurance coverage for the ownership, maintenance, or use of a
private passenger, utility, or miscellaneous type motor vehicle,
including a motor home, mobile home, trailer, or recreational
vehicle, that is:
(A) owned or leased by an individual or individuals; and
(B) not primarily used for the delivery of goods, materials, or
services, other than for use in farm or ranch operations.
(3) "Residential property insurance" means insurance coverage
against loss to residential real property at a fixed location or
tangible personal property provided in a homeowners policy, which
includes a tenant policy, a condominium owners policy, or a
residential fire and allied lines policy.
(4) "Underwriting guideline" means a rule, standard, guideline,
or practice, whether written, oral, or electronic, that is used
by an insurer or its agent to decide whether to accept or reject
an application for coverage under a personal automobile insurance
policy or residential property insurance policy or to determine
how to classify those risks that are accepted for the purpose of
determining a rate.
(b) Each insurer shall file with the department a copy of the
insurer's underwriting guidelines. The insurer shall update its
filing each time the underwriting guidelines are changed. If a
group of insurers files one set of underwriting guidelines for
the group, they shall identify which underwriting guidelines
apply to each company in the group.
(c) The office of public insurance counsel may obtain a copy of
each insurer's underwriting guidelines.
(d) The department or the office of public insurance counsel may
disclose to the public a summary of an insurer's underwriting
guidelines in a manner that does not directly or indirectly
identify the insurer.
(e) Underwriting guidelines must be sound, actuarially
justified, or otherwise substantially commensurate with the
contemplated risk. Underwriting guidelines may not be unfairly
discriminatory.
(f) The underwriting guidelines are subject to Chapter 552,
Government Code.
Added by Acts 2003, 78th Leg., ch. 206, Sec. 8.01, eff. June 11,
2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 2B.004, eff. April 1, 2009.
Sec. 38.003. UNDERWRITING GUIDELINES FOR OTHER LINES;
CONFIDENTIALITY. (a) This section applies to all underwriting
guidelines that are not subject to Section 38.002.
(b) For purposes of this section, "insurer" means a reciprocal
or interinsurance exchange, mutual insurance company, capital
stock company, county mutual insurance company, Lloyd's plan,
life, accident, or health or casualty insurance company, health
maintenance organization, mutual life insurance company, mutual
insurance company other than life, mutual, or natural premium
life insurance company, general casualty company, fraternal
benefit society, group hospital service company, or other legal
entity engaged in the business of insurance in this state. The
term includes an affiliate as described by Section 823.003(a) if
that affiliate is authorized to write and is writing insurance in
this state.
(c) The department or the office of public insurance counsel may
obtain a copy of an insurer's underwriting guidelines.
(d) Underwriting guidelines are confidential, and the department
or the office of public insurance counsel may not make the
guidelines available to the public.
(e) The department or the office of public insurance counsel may
disclose to the public a summary of an insurer's underwriting
guidelines in a manner that does not directly or indirectly
identify the insurer.
(f) When underwriting guidelines are furnished to the department
or the office of public insurance counsel, only a person within
the department or the office of public insurance counsel with a
need to know may have access to the guidelines. The department
and the office of public insurance counsel shall establish
internal control systems to limit access to the guidelines and
shall keep records of the access provided.
(g) This section does not preclude the use of underwriting
guidelines as evidence in prosecuting a violation of this code.
Each copy of an insurer's underwriting guidelines that is used in
prosecuting a violation is presumed to be confidential and is
subject to a protective order until all appeals of the case have
been exhausted. If an insurer is found, after the exhaustion of
all appeals, to have violated this code, a copy of the
underwriting guidelines used as evidence of the violation is no
longer presumed to be confidential.
(h) A violation of this section is a violation of Chapter 552,
Government Code.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999. Renumbered from Insurance Code Sec. 38.002 and amended by
Acts 2003, 78th Leg., ch. 206, Sec. 8.01, eff. June 11, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 2B.005, eff. April 1, 2009.
SUBCHAPTER B. HEALTH BENEFIT PLAN PROVIDER REPORTING
Sec. 38.051. DEFINITION. In this subchapter, "health benefit
plan provider" means an insurance company, group hospital service
corporation, or health maintenance organization that issues:
(1) an individual, group, blanket, or franchise insurance
policy, an insurance agreement, a group hospital service
contract, or an evidence of coverage, that provides benefits for
medical or surgical expenses incurred as a result of an accident
or sickness; or
(2) a long-term care benefit plan, as defined by Section
1651.003.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 2B.006, eff. April 1, 2009.
Sec. 38.052. REQUIRED INFORMATION; RULES. (a) A health benefit
plan provider shall submit information required by the department
relating to the health benefit plan provider's:
(1) loss experience;
(2) overhead; and
(3) operating expenses.
(b) The department may also request information about
characteristics of persons covered by a health benefit plan
provider, including information relating to:
(1) age;
(2) gender;
(3) health status;
(4) job classification; and
(5) geographic distribution.
(c) A health benefit plan provider may not be required to submit
information under this section more frequently than annually.
(d) The commissioner shall adopt rules governing the submission
of information under this subchapter.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
SUBCHAPTER C. DATA COLLECTION AND REPORTING RELATING TO HIV AND
AIDS
Sec. 38.101. DEFINITIONS. In this subchapter:
(1) "HIV" and "AIDS" have the meanings assigned by Section
81.101, Health and Safety Code.
(2) "Health benefit plan coverage" means a group policy,
contract, or certificate of health insurance or benefits
delivered, issued for delivery, or renewed in this state by:
(A) an insurance company subject to a law described by Section
841.002;
(B) a group hospital service corporation under Chapter 842;
(C) a health maintenance organization under Section 1367.053,
Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapters
222, 251, and 258, as applicable to a health maintenance
organization, and Chapters 843, 1271, and 1272; or
(D) a self-insurance trust or mechanism providing health care
benefits.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 2B.007, eff. April 1, 2009.
Sec. 38.102. PURPOSE. The purpose of this subchapter is to:
(1) ensure that adequate health insurance and benefits coverage
is available to the citizens of this state;
(2) ensure that adequate health care is available to protect the
public health and safety; and
(3) ascertain the continuing effect of HIV and AIDS on health
insurance coverage and health benefits coverage availability and
adequacy in this state for purposes of meeting the public's
health coverage needs.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.103. DATA COLLECTION PROGRAM. (a) The department shall
maintain a program to gather data and information relating to the
effect of HIV and AIDS on the availability, adequacy, and
affordability of health benefit plan coverage in this state.
(b) The commissioner may adopt rules necessary to implement this
subchapter, including rules relating to:
(1) reporting schedules;
(2) report forms;
(3) lists of data and information required to be reported; and
(4) reporting procedures, guidelines, and criteria.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.104. COMPILATION OF DATA AND INFORMATION; REPORT. (a)
The department shall compile the data and information included in
reports required by this subchapter into composite form and shall
prepare at least annually a written report of:
(1) the composite data and information; and
(2) the department's analysis of the availability, adequacy, and
affordability of health benefit plan coverage in this state.
(b) Subject to Section 38.106, the department shall make the
report available to the public and may charge a reasonable fee
for the report to cover the cost of making the report available.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.105. RECOMMENDATIONS AND REPORTS TO LEGISLATURE. (a)
The commissioner may submit to the legislature written
recommendations for legislation the commissioner considers
necessary to resolve problems related to the effect of HIV and
AIDS on the availability, adequacy, and affordability of health
benefit plan coverage in this state.
(b) The department, on request of the lieutenant governor, the
speaker of the house of representatives, or the presiding officer
of a legislative committee, shall provide to the legislature
additional composite data and information and analyses based on
the reports required by this subchapter. Reports prepared under
this subsection shall be available to the public as required by
Section 38.104.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.106. INFORMATION CONFIDENTIAL. (a) If the commissioner
determines that information or reports submitted under this
subchapter would reveal or might reveal the identity of an
individual or associate an individual with a company, the
commissioner shall declare the information or reports
confidential, and the information or reports may not be made
available to the public.
(b) Information made confidential under this section may be
examined only by the commissioner and department employees.
(c) Data and information reported by an insurer under this
subchapter are not subject to public disclosure to the extent
that the information is protected under Chapter 552, Government
Code. The data and information may be compiled into composite
form and made public if information that could be used to
identify the reporting insurer is removed.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
SUBCHAPTER D. LIABILITY INSURANCE CLOSED CLAIM REPORTS
Sec. 38.151. DEFINITIONS. In this subchapter:
(1) "Insurer" means:
(A) an insurance company or other entity that is admitted to do
business and authorized to write liability insurance in this
state, including:
(i) a county mutual insurance company;
(ii) a Lloyd's plan insurer; and
(iii) a reciprocal or interinsurance exchange; and
(B) a pool, joint underwriting association, or self-insurance
mechanism or trust authorized by law to insure its participants,
subscribers, or members against liability.
(2) "Liability insurance" means:
(A) general liability insurance;
(B) medical professional liability insurance;
(C) professional liability insurance other than medical
professional liability insurance;
(D) commercial automobile liability insurance;
(E) the liability portion of commercial multiperil insurance
coverage; and
(F) any other type or line of liability insurance designated by
the commissioner under Section 38.163.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.152. EXEMPTION. This subchapter does not apply to a
farm mutual insurance company or to a county mutual fire
insurance company writing exclusively industrial fire insurance
as described by Section 912.310.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 2B.008, eff. April 1, 2009.
Sec. 38.153. CLOSED CLAIM REPORT. (a) Not later than the 10th
day after the last day of the calendar quarter in which a claim
for recovery under a liability insurance policy is closed, the
insurer shall file with the department a closed claim report if
the indemnity payment for bodily injury under the coverage is
$75,000 or more.
(b) A closed claim report must be filed in a form prescribed by
the commissioner.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
267, Sec. 1, eff. September 1, 2009.
Sec. 38.154. CONTENT OF CLOSED CLAIM REPORT FORM. (a) The
closed claim report form adopted by the commissioner for a report
under Section 38.153 must require information relating to:
(1) the identity of the insurer;
(2) the liability insurance policy, including:
(A) the type or types of insurance;
(B) the policy limits;
(C) whether the policy was an occurrence or claims-made policy;
(D) the classification of the insured; and
(E) reserves for the claim;
(3) details of:
(A) any injury, damage, or other loss that was the subject of
the claim, including:
(i) the type of injury, damage, or other loss;
(ii) where and how the injury, damage, or other loss occurred;
(iii) the age of any injured party; and
(iv) whether an injury was work-related;
(B) the claims process, including:
(i) whether a lawsuit was filed;
(ii) where a lawsuit, if any, was filed;
(iii) whether attorneys were involved;
(iv) the stage at which the claim was closed;
(v) any court verdict;
(vi) any appeal;
(vii) the number of defendants; and
(viii) whether the claim was settled outside of court and, if
so, at what stage; and
(C) the amount paid on the claim, including:
(i) the total amount of a court award;
(ii) the amount paid by the insurer;
(iii) any amount paid by another insurer;
(iv) any amount paid by another defendant;
(v) any collateral source of payment;
(vi) any structured settlement;
(vii) the amount of noneconomic compensatory damages;
(viii) the amount of prejudgment interest;
(ix) the amount paid for defense costs;
(x) the amount paid for punitive damages; and
(xi) the amount of allocated loss adjustment expenses; and
(4) any other information that the commissioner determines to be
significant in allowing the department and the legislature to
monitor the liability insurance industry to ensure its solvency
and to ensure that liability insurance is available, is
affordable, and provides adequate protection in this state.
(b) The department may require an insurer to include in a closed
claim report information relating to payment made for property
damage and other damage on the claim under the coverage.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.155. SUMMARY CLOSED CLAIM REPORT. (a) An insurer shall
file with the department a summary closed claim report for a
claim for recovery under a liability insurance policy if the
indemnity payment for bodily injury under the coverage is less
than $75,000 but more than $25,000.
(b) A summary closed claim report must be filed, in a form
prescribed by the commissioner, not later than the 10th day after
the last day of the calendar quarter in which the claim is
closed.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
267, Sec. 2, eff. September 1, 2009.
Sec. 38.156. CONTENT OF SUMMARY CLOSED CLAIM REPORT FORM. The
summary closed claim report form adopted by the commissioner for
a report under Section 38.155 must require information relating
to:
(1) the identity of the insurer;
(2) the liability insurance policy, including:
(A) the type or types of insurance;
(B) the classification of the insured; and
(C) reserves for the claim;
(3) details of:
(A) the claims process, including:
(i) whether a lawsuit was filed;
(ii) whether attorneys were involved;
(iii) the stage at which the claim was closed;
(iv) any court verdict;
(v) any appeal; and
(vi) whether the claim was settled outside of court and, if so,
at what stage; and
(B) the amount paid on the claim, including:
(i) the total amount of a court award;
(ii) the amount paid to the claimant by the insurer;
(iii) the amount paid for defense costs;
(iv) the amount paid for punitive damages; and
(v) the amount of loss adjustment expenses; and
(4) any other matter that the commissioner determines to be
significant in allowing the department and the legislature to
monitor the liability insurance industry to ensure its solvency
and to ensure that liability insurance is available, is
affordable, and provides adequate protection in this state.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.157. AGGREGATE REPORT. (a) An insurer shall file with
the department one report containing the information required
under this section for all claims closed within the calendar year
for which the indemnity payments for bodily injury under the
coverage are $25,000 or less, including claims for which an
indemnity payment is not made on closing.
(b) The report must include, in summary form, at least the
following information:
(1) the aggregate number of claims; and
(2) the aggregate dollar amount paid out.
(c) The report must be filed in a form and in a manner
prescribed by the commissioner.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
267, Sec. 3, eff. September 1, 2009.
Sec. 38.158. ALTERNATIVE REPORTING. (a) After notice and public
hearing, the commissioner may provide for alternative reporting
in the form of sampling of the required closed claim data instead
of requiring insurers to file the closed claim data required by
this subchapter.
(b) The department may use a statistical reporting agency to
reconcile the data.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
267, Sec. 4, eff. September 1, 2009.
Sec. 38.159. COMPILATION OF DATA; REPORT. The department shall
compile the data included in individual closed claim reports and
summary closed claim reports into a composite form and shall
prepare annually a written report of the composite data. The
department shall make the report available to the public.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.160. ELECTRONIC DATABASE. The commissioner may:
(1) establish an electronic database composed of reports filed
with the department under this subchapter;
(2) provide the public with access to that data;
(3) establish a system to provide access to that data by
electronic data transmittal processes; and
(4) set and charge a fee for electronic access to the database
in an amount reasonable and necessary to cover the costs of
access.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.161. REPORT TO LEGISLATURE. (a) The department shall
submit copies of the report required by Section 38.159 to the
presiding officers of each house of the legislature.
(b) The department, on request of the lieutenant governor, the
speaker of the house of representatives, or the presiding officer
of a legislative committee, shall provide to the legislature
additional composite data based on closed claim reports and
summary closed claim reports. Reports prepared under this
subsection shall be available to the public.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.162. INFORMATION CONFIDENTIAL. (a) Information
included in an individual closed claim report or an individual
summary closed claim report submitted by an insurer under this
subchapter is confidential and may not be made available by the
department to the public.
(b) Information included in an individual closed claim report or
an individual summary closed claim report may be examined only by
the commissioner and department employees.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.163. RULES AND FORMS. The commissioner may adopt
necessary rules to:
(1) implement this subchapter;
(2) define terminology, criteria, content, and other matters
relating to the reports required under this subchapter; and
(3) designate other types or lines of liability insurance
required to provide information under this subchapter.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
SUBCHAPTER E. STATISTICAL DATA COLLECTION
Sec. 38.201. DEFINITION. In this subchapter, "designated
statistical agent" means an organization designated or contracted
with by the commissioner under Section 38.202.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.202. STATISTICAL AGENT. The commissioner may, for a
line or subline of insurance, designate or contract with a
qualified organization to serve as the statistical agent for the
commissioner to gather data relevant for regulatory purposes or
as otherwise provided by this code.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.203. QUALIFICATIONS OF STATISTICAL AGENT. To qualify as
a statistical agent, an organization must demonstrate at least
five years of experience in data collection, data maintenance,
data quality control, accounting, and related areas.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.204. POWERS AND DUTIES OF STATISTICAL AGENT. (a) A
designated statistical agent shall collect data from reporting
insurers under a statistical plan adopted by the commissioner.
(b) The statistical agent may provide aggregate historical
premium and loss data to its subscribers.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.205. DUTY OF INSURER. An insurer shall provide all
premium and loss cost data to the commissioner or the designated
statistical agent as the commissioner or agent requires.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.206. FEES. (a) A designated statistical agent may
collect from a reporting insurer any fees necessary for the agent
to recover the necessary and reasonable costs of collecting data
from that reporting insurer.
(b) A reporting insurer shall pay the fee to the statistical
agent for the data collection services provided by the
statistical agent.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
Sec. 38.207. RULES. The commissioner may adopt rules necessary
to accomplish the purposes of this subchapter.
Added by Acts 1999, 76th Leg., ch. 101, Sec. 1, eff. Sept. 1,
1999.
SUBCHAPTER F. DATA COLLECTING AND REPORTING RELATING TO MANDATED
HEALTH BENEFITS AND MANDATED OFFERS OF COVERAGE
Sec. 38.251. APPLICABILITY. This subchapter applies to any
issuer of a health benefit plan that is subject to this code 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.
Added by Acts 2001, 77th Leg., ch. 852, Sec. 1, eff. Sept. 1,
2001.
Sec. 38.252. COLLECTION OF INFORMATION; REPORT. (a) The
commissioner shall require a health benefit plan issuer to
collect and report cost and utilization data for each mandated
health benefit and mandated offer designated by the commissioner.
(b) The commissioner shall designate by rule:
(1) the issuers of health benefit plans that must collect and
report data based on the annual dollar amounts of Texas premium
collected by the health benefit plan issuer;
(2) the specific mandated health benefits and mandated offers of
coverage for which data must be collected;
(3) a description of the data that must be collected;
(4) the beginning and ending dates of the reporting periods,
which shall be no less than every two years;
(5) the date following the end of the reporting period by which
the report shall be submitted to the commissioner;
(6) the detail and form in which the report shall be submitted;
and
(7) any other reasonable requirements that the commissioner
determines are necessary to determine the impact of mandated
benefits and mandated offers of coverage for which data
collection and reporting is required.
(c) The commissioner shall not require reporting of data:
(1) that could reasonably be used to identify a specific
enrollee in a health benefit plan;
(2) in any way that violates confidentiality requirements of
state or federal law applicable to an enrollee in a health
benefit plan; or
(3) in which the health maintenance organization operating under
Section 1367.053, Subchapter A, Chapter 1452, Subchapter B,
Chapter 1507, Chapter 222, 251, or 258, as applicable to a health
maintenance organization, Chapter 843, Chapter 1271, and Chapter
1272 does not directly process the claim or does not receive
complete and accurate encounter data.
Added by Acts 2001, 77th Leg., ch. 852, Sec. 1, eff. Sept. 1,
2001.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 2B.009, eff. April 1, 2009.
Sec. 38.253. MAINTENANCE OF INFORMATION. Each health benefit
plan issuer shall maintain at its principal place of business all
data collected pursuant to this subchapter, including information
and supporting documentation that demonstrates that the report
submitted to the commissioner is complete and accurate. Each
health benefit plan issuer shall make this information and any
supporting documentation available to the commissioner upon
request.
Added by Acts 2001, 77th Leg., ch. 852, Sec. 1, eff. Sept. 1,
2001.
Sec. 38.254. UTILIZATION AND COST DATA TO COMMISSIONER. (a)
Upon request from the commissioner, the Texas Health and Human
Services Commission shall provide to the commissioner data,
including utilization and cost data, which is related to the
mandate being assessed to the population covered by the Medicaid
program, including a program administered under Chapter 32, Human
Resources Code, and a program administered under Chapter 533,
Government Code, even if the program is not necessarily subject
to the mandate.
(b) The commissioner may utilize data as defined in Subsection
(a) to determine the impact of mandated benefits and mandated
offers of coverage for which data collection and reporting is
requested.
Added by Acts 2001, 77th Leg., ch. 852, Sec. 1, eff. Sept. 1,
2001. Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.002,
eff. Sept. 1, 2003.
SUBCHAPTER G. DATA REPORTING BY CERTAIN LIABILITY INSURERS
Sec. 38.301. INSURER DATA REPORTING. (a) Each insurer that
writes professional liability insurance policies for nursing
institutions licensed under Chapter 242, Health and Safety Code,
including an insurer whose rates are not regulated, shall, as a
condition of writing those policies in this state, comply with a
request for information from the commissioner under this section.
(b) The commissioner may require information in rate filings,
special data calls, or informational hearings or by any other
means consistent with this code applicable to the affected
insurer that the commissioner believes will allow the
commissioner to:
(1) determine whether insurers writing insurance coverage
described by Subsection (a) are passing to insured nursing
institutions on a prospective basis the savings that accrue as a
result of the reduction in risk to insurers writing that coverage
that will result from legislation enacted by the 77th
Legislature, Regular Session, including legislation that:
(A) amended Article 5.15-1 to limit the exposure of an insurer
to exemplary damages for certain claims against a nursing
institution; and
(B) amended Sections 32.021(i) and (k), Human Resources Code,
added Section 242.050, Health and Safety Code, and repealed
Section 32.021(j), Human Resources Code, to clarify the
admissibility of certain documents in a civil action against a
nursing institution; or
(2) prepare the report required of the commissioner under
Section 38.252 or any other report the commissioner is required
to submit to the legislature in connection with the legislation
described by Subdivision (1).
(c) Information provided under this section is privileged and
confidential to the same extent as the information is privileged
and confidential under this code or any other law governing an
insurer described by Subsection (a). The information remains
privileged and confidential unless and until introduced into
evidence at an administrative hearing or in a court of competent
jurisdiction.
Added by Acts 2001, 77th Leg., ch. 1284, Sec. 4.01, eff. June 15,
2001. Renumbered from Insurance Code Sec. 38.251 by Acts 2003,
78th Leg., ch. 1276, Sec. 10A.501, eff. Sept. 1, 2003.
Sec. 38.302. RECOMMENDATIONS TO LEGISLATURE. The commissioner
shall assemble information and take other appropriate measures to
assess and evaluate changes in the marketplace resulting from the
implementation of the legislation described by Section 38.251 and
shall report the commissioner's findings and recommendations to
the legislature.
Added by Acts 2001, 77th Leg., ch. 1284, Sec. 4.01, eff. June 15,
2001. Renumbered from Insurance Code Sec. 38.252 by Acts 2003,
78th Leg., ch. 1276, Sec. 10A.501, eff. Sept. 1, 2003.
SUBCHAPTER H. HEALTH CARE REIMBURSEMENT RATE INFORMATION
Sec. 38.351. PURPOSE OF SUBCHAPTER. The purpose of this
subchapter is to authorize the department to:
(1) collect data concerning health benefit plan reimbursement
rates in a uniform format; and
(2) disseminate, on an aggregate basis for geographical regions
in this state, information concerning health care reimbursement
rates derived from the data.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 8, eff. September 1, 2007.
Sec. 38.352. DEFINITION. In this subchapter, "group health
benefit plan" means a preferred provider benefit plan as defined
by Section 1301.001 or an evidence of coverage for a health care
plan that provides basic health care services as defined by
Section 843.002.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 8, eff. September 1, 2007.
Sec. 38.353. APPLICABILITY OF SUBCHAPTER. (a) This subchapter
applies to the issuer of a group health benefit plan, including:
(1) an insurance company;
(2) a group hospital service corporation;
(3) a fraternal benefit society;
(4) a stipulated premium company;
(5) a reciprocal or interinsurance exchange; or
(6) a health maintenance organization.
(b) Notwithstanding any provision in Chapter 1551, 1575, 1579,
or 1601 or any other law, and except as provided by Subsection
(e), this subchapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579; and
(4) basic coverage under Chapter 1601.
(c) Except as provided by Subsection (d), this subchapter
applies to a small employer health benefit plan provided under
Chapter 1501.
(d) This subchapter does not apply to:
(1) standard health benefit plans provided under Chapter 1507;
(2) children's health benefit plans provided under Chapter 1502;
(3) health care benefits provided under a workers' compensation
insurance policy;
(4) Medicaid managed care programs operated under Chapter 533,
Government Code;
(5) Medicaid programs operated under Chapter 32, Human Resources
Code; or
(6) the state child health plan operated under Chapter 62 or 63,
Health and Safety Code.
(e) The commissioner by rule may exclude a type of health
benefit plan from the requirements of this subchapter if the
commissioner finds that data collected in relation to the health
benefit plan would not be relevant to accomplishing the purposes
of this subchapter.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 8, eff. September 1, 2007.
Sec. 38.354. RULES. The commissioner may adopt rules as
provided by Subchapter A, Chapter 36, to implement this
subchapter.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 8, eff. September 1, 2007.
Sec. 38.355. DATA CALL; STANDARDIZED FORMAT. (a) Each health
benefit plan issuer shall submit to the department, at the time
and in the form and manner required by the department, aggregate
reimbursement rates by region paid by the health benefit plan
issuer for health care services identified by the department.
(b) The department shall require that data submitted under this
section be submitted in a standardized format, established by
rule, to permit comparison of health care reimbursement rates.
To the extent feasible, the department shall develop the data
submission requirements in a manner that allows collection of
reimbursement rates as a dollar amount and not by comparison to
other standard reimbursement rates, such as Medicare
reimbursement rates.
(c) The department shall specify the period for which
reimbursement rates must be filed under this section.
(d) The department may contract with a private third party to
obtain the data under this subchapter. If the department
contracts with a third party, the department may determine the
aggregate data to be collected and published under Section 38.357
if consistent with the purposes of this subchapter described in
Section 38.351. The department shall prohibit the third party
contractor from selling, leasing, or publishing the data obtained
by the contractor under this subchapter.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 8, eff. September 1, 2007.
Sec. 38.356. CONFIDENTIALITY OF DATA. Except as provided by
Section 38.357, data collected under this subchapter is
confidential and not subject to disclosure under Chapter 552,
Government Code.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 8, eff. September 1, 2007.
Sec. 38.357. PUBLICATION OF AGGREGATE HEALTH CARE REIMBURSEMENT
RATE INFORMATION. The department shall provide to the Department
of State Health Services for publication, for identified regions
of this state, aggregate health care reimbursement rate
information derived from the data collected under this
subchapter. The published information may not reveal the name of
any health care provider or health benefit plan issuer. The
department may make the aggregate health care reimbursement rate
information available through the department's Internet website.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 8, eff. September 1, 2007.
Sec. 38.358. PENALTIES. A health benefit plan issuer that fails
to submit data as required in accordance with this subchapter is
subject to an administrative penalty under Chapter 84. For
purposes of penalty assessment, each day the health benefit plan
issuer fails to submit the data as required is a separate
violation.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 8, eff. September 1, 2007.