MEDICAL ECONOMICS
Adequate to inadequate TDI undoes network adequacy rules
BY AMY LYNN SORREL Four legislative sessions span- ning nearly a decade. At least three pieces of leg- islation. Years of study by insurance officials and a state-appointed commit- tee made up of physicians, hospitals, health plans, and consumers.
All of that wasn’t enough for new leadership at the Texas Department of Insurance (TDI) to imple- ment already adopted rules that, at the legislature’s re- quest, finally defined an “adequate physician net- work” in PPO health plans, says Texas Medical Asso- ciation Past President Wil- liam W. Hinchey, MD. He served on the workgroup that studied the issue and whose work ultimately led to legislation and rules that set some standards to protect patients from unexpected bills for more expensive out-of-network care, so-called balance bills. Although her predeces-
sor, Mike Geeslin, approved them for adoption in July 2011 to take effect in May 2012, current TDI Commissioner Eleanor Kitzman rescinded those regulations in December 2011. In their place, TDI released newly drafted rules last Novem- ber that physicians say undermine the legislature’s mandate to hold health plans accountable for their networks and instead shift that burden to patients by removing important safeguards. On top of that, TMA officials worry the new rules lower the
TDI Commissioner Eleanor Kitzman says her new network adequacy rules align regulations for various health plan products. Physicians say they let insurers off the hook.
bar for even more limited “exclusive” provider orga- nization (EPO) networks that health plans can now sell, instead of making in- surers adhere to uniform network standards. In its biennial report to the legislature, the agency told lawmakers it planned to adopt the new rules in early 2013, although formal adoption was still pending at press time. The report is online at
www.tdi
.texas.gov/reports/docu ments/finalbie13.pdf. Insurance officials con- tend a lack of consensus on the adopted rules, cou- pled with more recent leg- islation passed in the midst of developing the PPO network adequacy rules, prompted the need for re- visions. Those factors also underlie TDI’s decision to delay final implementation of the new regulations un- til it gets further guidance from lawmakers. Dr. Hinchey says the years of work and state resources poured into the issue are guidance enough.
The original rules tracked standards already in place for HMOs, he says. “So we have a precedent. What this boils down to is if [health plans] are going to sell a product, they have to first make sure it’s a good one. And if they don’t, they can’t punish the patient.”
The San Antonio pathologist says the earlier rules struck a balance that impacted all stakeholders: Patients had more
March 2013 TEXAS MEDICINE 21
JIM LINCOLN
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