LEGISLATIVE AFFAIRS
What’s “adequate”? New rules seek better physician access under PPO networks
BY KEN ORTOLON It was a four-year odyssey that took two pieces of legislation and years of study by state insurance officials and rep- resentatives of physicians, hospitals, health plans, and others, but the Texas Department of Insurance (TDI) has finalized rules defining adequate physi- cian networks for preferred provider health plans. While insurers say the rules will be burdensome and difficult to implement, physicians believe they fi- nally will put the onus on health plans to actively pursue adequate physician networks and lessen the likelihood that patients will have to go out of network for care, paying more out of their own pocket. Physicians, particularly facility-based physicians, also retained protections against health plans forcing them into contracts.
cian networks and will give patients more trans- parency about their in-net- work and out-of-network options.
The rules include net- work adequacy standards that limit how far patients must travel for either pri- mary or specialty care. Insurers cannot require patients in urban areas to travel more than 30 miles for primary care or gener- al hospital care, while the limit for rural patients is 60 miles. Plus, they cannot force urban or rural pa- tients to travel more than 75 miles to see a specialist or get care at a specialty hospital.
TMA officials say those
Former Texas Medical Association President William Hinchey, MD, of San Antonio, says insurance regulators “got a lot of right answers” in the new network adequacy rules for PPOs.
“It took a long time, but we got a good product in the end,” said former Texas Medical Association President William Hinchey, MD, of San Antonio. “Finally, we have some defini- tion about an adequate network beyond the health mainte- nance organizations.” Former Texas Insurance Commissioner Mike Geeslin, who took a personal interest in developing the new rules, says they give patients “greater clarity” on their health plans’ provisions, including who is an in-network provider and who is out of network.
Despite health plan skepticism, he is confident the rules will succeed in getting insurers to develop more adequate physi-
standards are similar to standards already in place for HMOs.
In addition, the rules
retain a prohibition against forcing facility-based phy- sicians to sign contracts
with the same health plans as their facilities to keep their medical staff privileges, but they permit insurers to require physicians to tell patients that they are referring them to out- of-network physicians. Other provisions:
• Require health plans to provide accurate listings of physi- cians and other providers in their networks and to pay a larger share of the actual costs when patients go to out-of- network physicians because of inaccurate directories.
• Establish an “approved hospital care network” for plans whose hospitals succeed in getting a high percentage of
November 2011 TEXAS MEDICINE 31
JIM LINCOLN
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