“They tried to split the baby about 20 times, and we ended up with a 400-page rule based on three lines in a bill that I think are going to be incredibly difficult to implement and are largely at odds with the reality of how health care is delivered.”
• Ensure availability of contracted phy- sicians and providers by ensuring that network physicians are avail- able where the patient actually lives, works, and seeks treatment in the designated service area;
• Allow waivers in narrow circum- stances, such as when plans cannot contract with an adequate number of physicians in certain specialties;
• Give consumers important informa- tion to enhance their decision making, such as requiring physicians to dis- close to the patient at the time of the referral to another physician whether that physician is in or out of network and requiring insurers to disclose on their websites information about their networks, as well as give patients a way to obtain a real time estimate of how much the insurer will pay for a particular out-of-network service;
• Give information to TDI to enhance its ability to regulate, such as requir- ing insurers to provide data about the number and type of physicians with whom they have contracted, and to demonstrate what specialties may not be available at in-network facilities.
their facility-based physicians to con- tract with the health plans.
• Require annual network adequacy re- ports and access plans if networks do not meet adequacy standards.
• Set payment standards for out-of-net- work claims, including standardizing how “usual and customary” charges and claims data may be used in set- ting payments, giving patients credit for balance-billed amount paid when there was no choice to stay in net- work, and giving patients comparison information based on the insurer’s ne- gotiated rates to allow them to bet- ter negotiate balance bills. The rules require an insurer to base its usual and customary rates on generally ac- cepted industry standards that fairly and accurately reflect market rates and geographic differences in cost, not use data more than three years old, and pay all covered services at least at the plan’s basic benefit level of coverage.
32 TEXAS MEDICINE November 2011
The complete rules are online at www
.tdi.texas.gov/rules/2011/documents/3- 3701-3-3713fi.pdf. The actual adopted rules start on page 330 of the 400-plus page document.
Setting the standards
TDI adopted the new rules earlier this year under provisions of House Bill 2256, authored in 2009 by state Rep. Kelly Hancock (R-North Richland Hills) and sponsored in the Senate by Sen. Robert Duncan (R-Lubbock). The rules take ef- fect May 19, 2012, a delay that TDI and TMA officials say is necessitated by the amount of work health plans, hospitals, and others will have to put in to comply with the rules.
But the debate on network adequacy goes back at least as far as 2007, when Senator Duncan passed Senate Bill 1731 which, in part, required TDI to create a workgroup to study adequacy issues. According to a TDI summary, the rules enhance PPO regulation to:
Getting it right Both Mr. Geeslin and Dr. Hinchey say the rulemaking process took a long time because of the complexity of the issues. “When you look at how much care is
provided through these networks, this wasn’t just about making a few modifica- tions to an existing rule,” Commissioner Geeslin said. “This was about a major change in public policy.” Dr. Hinchey credits Mr. Geeslin with
remaining intimately involved through- out the process, including being present to hear all stakeholder comments on the proposed rules. Mr. Geeslin says adoption of the rule was one of the bigger challenges during his tenure as insurance commissioner. “This process had started with some
research that we had done on network adequacy and also a great deal of stake- holder outreach. So this wasn’t some- thing that was started and finished in a three-month period. It was one of those long, long processes, and it was very deliberate,” he said. “When you have
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