Health plan renewal

Texas Housebill 2015 (Reporting of Claims Information)

A Texas Housebill has been signed into law that will impact employers who sponsor group healthcare plans and are in the process of negotiating terms for the next calendar  plan year. This bill has received little notice from those that would benefit the most from it - the plan sponsor and brokerage/consulting community.     House bill 2015, sponsored by State Representative. John Smithee (R-Amarillo) allows greater access to healthcare claims information from health plans to negotiate at renewal. This information has been limited in the past, as carriers have been less than forthcoming with information that might weaken their negotiating position or overextend protections afforded to them under the federal HIPAA laws. Within 30 days from the date of a written request from the sponsoring employer, plan, or plan administrator, the health carrier must provide a report on claims information. The contents of this report would include:

- aggregate paid claims experience by month, including claims experience for medical, dental, and pharmacy benefits, as applicable; - total premium paid by month; - total number of covered employees on a monthly basis by coverage tier; - the total dollar amount of claims pending as of the date of the report; - a separate description and individual claims report for any individual whose total paid claims exceeded $15,000 during the 12- month period preceding the date of the report, including the following information – a unique identifying number or code for the individual, the amounts paid, dates of service, and applicable procedure codes; and - for claims that were not part of the report, a statement of precertification requests for hospital stays of five days or longer made during the 30 days preceding the date of the report.

The report, which must be provided in writing or through a secure electronic file or web portal, must contain all information that the issuer has that, is requested by the employer, plan, or plan administrator for a 36 month period. "Having a better understanding of a company's risks is an important of negotiating from a position of strength, explains Steve Harris, CEBS, a Vice President with Lockton Dunning Benefits in Dallas. "Since the top 30% of claimants can often account for 80% of the claim costs, understanding these conditions can play a key factor in the final negotiated rates." For most employers, the impact of this bill will be felt in the latter half of this year, as negotiations begin for plan years beginning on or after January 1, 2009.

You might find that carrier representatives or brokers may be uninformed about the new law or might claim that disclosure is in violation of HIPAA privacy rules. The bill does prohibit the disclosure of information the issuer is otherwise prohibited from disclosing under a state or federal law that is more stringent in its privacy.