CHAPTER 38. DATA COLLECTION AND REPORTS - Texas Statutes

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.