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  H.B. No. 2015
 
 
 
 
AN ACT
  relating to the reporting of claim information under certain group
  health plans; providing administrative penalties.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subtitle A, Title 8, Insurance Code, is amended
  by adding Chapter 1215 to read as follows:
  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.
         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.
         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.
         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).
         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.
         Sec. 1215.006.  ADMINISTRATIVE PENALTIES.  A health
  insurance issuer that does not comply with this chapter is subject
  to administrative penalties under Chapter 84.
         SECTION 2.  The following laws are repealed:
               (1)  Article 21.49-15, Insurance Code;
               (2)  Chapter 1209, Insurance Code; and
               (3)  Section 1501.614, Insurance Code.
         SECTION 3.  The change in law made by this Act applies only
  to a report of claim information that is requested on or after
  January 1, 2008.  A report of claim information that is requested
  before January 1, 2008, is governed by the law as it existed before
  the effective date of this Act, and that law is continued in effect
  for that purpose.
         SECTION 4.  This Act takes effect September 1, 2007.
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
 
         I certify that H.B. No. 2015 was passed by the House on May 4,
  2007, by the following vote:  Yeas 144, Nays 0, 2 present, not
  voting.
 
  ______________________________
  Chief Clerk of the House   
 
 
         I certify that H.B. No. 2015 was passed by the Senate on May
  22, 2007, by the following vote:  Yeas 31, Nays 0.
 
  ______________________________
  Secretary of the Senate    
  APPROVED:  _____________________
                     Date          
   
            _____________________
                   Governor