December 1, 2006 Mandated Benefits Data Call: Data Collection Instructions

(October 1, 2005 - September 30, 2006 Reporting Period)

The following instructions are provided to assist companies in the filing of data relating to mandated health benefits and mandated offers of coverage as required under 28 TAC §§21.3401–21.3409 (Subchapter Z). The information must be filed in the format described in Texas Administrative Code §21.34, Subchapter Z, "Data Collecting and Reporting Relating To Mandated Health Benefits and Mandated Offers of Coverage." Companies should refer to the rule to determine the circumstances under which a company is required to file a report. Each licensed company required to file such report is required to submit a separate reporting form. It is not acceptable to submit more than one form for a single company or consolidate information from different companies on one form.

These instructions are to be used by all companies submitting the required mandated health benefits and mandated offers of coverage reporting form. Included are references to standard medical reporting codes including codes from the most recent edition of Physicians' Current Procedural Terminology (CPT), and International Classification of Diseases - Clinical Modification (ICD-9-CM). The codes listed in these instructions are provided to assist companies in identifying claims data relevant to the various mandated benefits and offers. Please note, however, that these codes may not be inclusive of all relevant codes since companies' reporting requirements and claims filing procedures vary. As such, companies are instructed to use these codes as a reference tool but may add additional codes as you determine is appropriate. Companies are required to maintain a current list of all codes used to report data on each specific mandated benefit and mandated offer and will provide such list to the Texas Department of Insurance upon request.

In reporting the required data, please note that in some cases the mandated benefits apply only to specific groups of people. For example, the mammography screening mandated benefit applies only to women age 35 and older. As such, mammography claims data should not be reported for women under age 35 or for any men. A basic description of each mandated benefit is included in the chart that lists suggested ICD and CPT codes. Carefully review these descriptions to be certain your reports include only the claims for those individuals subject to the mandated benefit requirement. Companies are responsible for assuring that the data reported is consistent with what is required under law.

Insurers must provide all company identifying information, including the company's NAIC Number, NAIC Group Number, Company Name, Group Name, and complete Mailing Address. The company's contact individual for questions regarding the information filed in the form must also be provided including the person's name, title, direct phone number, mailing address and e-mail address. Finally, companies should be sure to select "2006" in the drop-down box labeled "Reporting Year".

Companies must also provide the following information:

• Total premium for applicable individual accident and health policies and contracts - this amount includes the total premium written in Texas on applicable individual policies and contracts that are subject to the Mandated Benefits and Offers as described in §21.3406(b) for the reporting period. Only written premiums on applicable policies and contracts (i.e., those subject to the mandated benefit requirements) should be included. Responses should be rounded to the nearest dollar.
• Total premium for applicable group accident and health policies and contracts - this amount includes the total premium written in Texas on applicable group policies and contracts that are subject to the Mandated Benefits and Offers as described in §21.3406(a) for the reporting period. Only written premiums on applicable policies and contracts (i.e., those subject to the mandated benefit requirements) should be included. Responses should be rounded to the nearest dollar.
• Total claims paid for applicable individual accident and health policies and contracts - this amount includes the total dollar amount of all claims paid under the applicable individual policies that are subject to the Mandated Benefits and Offers as described in §21.3406(b) for the reporting period. This total amount includes claims paid for all covered services, including both mandated benefits and claims for all other covered services. Responses should be rounded to the nearest dollar.
• Total claims paid for applicable group accident and health policies and contracts - this amount includes the total dollar amount of all claims paid under the applicable group policies that are subject to the Mandated Benefits and Offers as described in §21.3406(a) for the reporting period. This total amount includes claims paid for all covered services, including both mandated benefits and claims for all other covered services. Responses should be rounded to the nearest dollar.

This section requires information on specific claim data for each mandated benefit and mandated offer for group and individual business. Separate forms are provided for group claims and individual claims. Companies should refer to the attached list of suggested ICD and CPT codes for reporting this data.

1. Number of Claims Paid - enter the total number of separate claims/medical encounters paid for each mandated benefit.
   
   
2. Total Mandated Benefit Claims/Medical Expenses Paid ($) - enter the total dollar amount of claims/medical expenses paid for each mandated benefit. Responses should be rounded to the nearest dollar.
   
   
3. Number of Group Certificates or Individual Contracts
   -Group business: companies should report the number of group certificates (not the number of group contracts) issued or renewed in Texas during the reporting period and which contain the mandated benefits for which you are reporting claims data.
   -Individual business: companies should report the number of individual contracts issued or renewed in Texas during the reporting period which contain the mandated benefits for which you are reporting claims data.
   
   
4. Annual Administrative Cost ($) - companies should report the total annual administrative costs directly associated with each mandated benefit/offer. Start-up costs (i.e., the cost of revising policy forms during the first year when a new mandate is implemented) should not be included unless those costs were incurred during the reporting period. Responses should be rounded to the nearest dollar.

This section requires information on the portion of premium that is attributed to each mandated benefits. Data is requested for group and individual benefit plans. In addition, data must be reported separately for individual policies that cover a single person and individual policies that provide family coverage. Premiums for group policies must also be reported separately based on whether the premium is for a single employee/member or for family coverage. Family coverage includes coverage of the employee, spouse and all dependents.

1. Average Annual Premium Cost Per Person Attributable to each Mandate - This section requires companies to provide an estimate of average annual premium costs per person for each mandated benefit. While we realize that actual costs may vary somewhat from group to group, or policy to policy, statewide average premiums must be reported for each mandated benefit. We also understand that companies do not usually calculate separate rates for each mandated benefit. However, to comply with the requirements of Article 38.251, Texas Insurance Code, companies must estimate a premium cost for each benefit based on the company's actual claims experience such as disclosed in Part A of this report. If "average" costs across policies cannot be determined, base your estimate on the company's most popular standard individual policy and/ or group certificate to complete the information requested in this section.
   
   For each mandated benefit, provide the actual dollar amount of the annual premium for each individual policy or group certificate issued that is attributable to each mandated benefit. Annual cost-per-individual policy or group certificate must be provided separately for single coverage and family coverage. For example, if the average annual cost of providing benefits for mammography screening is estimated at $4.00 for individual policies covering a single person and $5.25 for individual policies that provide family coverage, you will enter 4.00 or 4 under the column heading "Single Individual Policies" and 5.25 under the column heading "Family Individual Policies". While it is not necessary to enter decimal points and zeroes for even dollar amounts (i.e., $2.00, $3.00, $4.00), decimals must be included for any value that includes cent amounts (i.e., $2.25, $3.25, $4.25). Without the decimal, the value will be read, in total dollars so that $2.25 become $225.
   
   
2. Number of Group Certificates or Individual Contracts - On the first line, provide the total number of applicable individual contracts and/or group certificates issued and/or renewed by the company during the reporting period in the appropriate fields under each heading. Separate numbers must be provided for contracts/certificates covering an individual (single) person and contracts/certificates providing family coverage. On the second line, provide the total number of individual contracts and/or group certificates in force on the last day of the reporting period in the appropriate fields under each heading.
   
   
3. Number of Lives Covered - On the first line, provide the total number of lives covered under individual policies and/or group certificates issued or renewed by the company in Texas during the reporting period in the appropriate fields under each heading. Separate data must be provided for policies/certificates covering an individual (single) person and policies/certificates providing family coverage. All family members covered (employee or enrollee, spouse and all dependents) must be included in the calculations for family coverage. On the second line, provide the total number of lives covered under individual policies and/or group certificates in force on the last day of the reporting period in the appropriate fields under each heading.

Return to the Mandated Benefits Survey Index Page.

For more information contact: MBSurvey@tdi.state.tx.us