TMA Recommendations
• Require health insurers to regularly report their medical loss ratios in a standardized format to the Texas Department of Insurance (TDI) as well as to purchasers and enrollees upon request.
• Require insurers to notify patients that rescission of their policy is under consideration, and why, before the actual cancellation.
• Prohibit health insurers from providing incentives to employees or contractors based on the number of rescissions they recommend.
• Allow Texas’ small businesses to challenge health insurance premium quotes, and require insurers to provide information to justify a premium increase.
• Enact tax breaks or other incentives for employers who offer appropriately structured, consumer-directed health plans to their workers.
• Direct the Employees Retirement System of Texas to offer appropriately structured, consumer-directed health plans to state workers.
• Require health insurers, at the time health care services are delivered, to pay patients’ and physicians’ claims immediately and calculate patients’ out-of-pocket responsibility.
• Prohibit third-party and discount brokers from trading physicians’ contracted payment rates without physicians’ knowledge and consent.
• Require health plans and third-party administrators that sell, lease, or share physician contract rates to report this activity to TDI.
• Establish tax incentives for businesses to provide health insurance for their employees.
• Require employers that directly receive Texas Enterprise Funds to offer insurance to their employees.
• Require TDI to collect data concerning health care charges and payments and disseminate aggregate, regional information in a uniform format.
• Require health plans to develop appropriate provider networks with appropriate in-network or out-of-network benefits based on the product the employer or enrollee is purchasing.
• Protect and support TDI Division of Workers’ Compensation (DWC) policies that reduce administrative hassles in preauthorization requests and peer review scheduling.
• Guarantee payment for an injured worker’s initial examination, which is used to determine compensability.
• Protect TDI-DWC due process procedures and make certain that physicians subjected to peer review are reviewed by professionals with the same training, education, and licensure as the physician being reviewed. A determination of maximum medical improvement or a disability rating should mirror such peer review principles.
62 TEXAS MEDICINE February 2013
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