‘usual and customary’ charges to physi- cians, if necessary, to protect policyhold- ers from balance-billing issues when a complete network solution is unavail- able,” the legislative report says. On the other hand, TDI now says dis- closing out-of-network claim amounts or decreases in network participation doesn’t necessarily give patients a timely or accurate view of the status of a health plan’s network. Contract negotiations may only temporarily affect a network, and the additional reporting require- ments could translate to higher plan costs for patients.
In their place, the new rules require
insurers to report whether they’ve ob- tained a waiver from the network ad- equacy standards for certain specialists, which “the department believes … will be of more practical use” to current or prospective policyholders.
Other provisions would still give pa-
tients recourse to challenge insurers if a listing is outdated and to get their out- of-network care paid.
Double standard?
But TMA officials say that puts the bur- den on patients to chase after insurers, when state laws intended for health plans to provide up-front protections to avoid balance billing in the first place. “If patients have more information,
they can make a more informed choice, and that’s going to lower their costs,” Dr. Hinchey said. Making sure health plans have robust networks is even more important before they introduce new products into the market, Mr. Spangler says. That includes EPOs, which have more stringent out-of- network restrictions than PPOs and only cover emergency services provided by
non-network physicians and hospitals. Instead of holding health plans to a higher standard for these networks, the new rules lower the bar for both, TMA officials say. They also further exempt EPOs from existing insurance regula- tions by, among other things, requiring less up-front proof to regulators of their networks’ completeness. In addition, TDI’s broad definition of closed EPO networks could allow health plans to indirectly contract with physi- cians for limited services, yet still count that to meet their network adequacy requirements. That could be unfair to patients trying to discern their coverage and to physicians who may not realize a contract they directly negotiated with one party has been “rented out” by that party for other purposes, TMA officials warn.
All of these changes also could have
Physician-reported contractual relationships
BCBS United Healthcare Aetna Cigna Humana Source: TMA 2012 Physician Survey 24 TEXAS MEDICINE March 2013 86% 84% 82% 81% 77%
broader implications for insurer conduct in federal health insurance exchanges established by PPACA, Mr. Spangler says. The federal reform law mandates that health plans participating in the ex- changes cover a set of minimum benefits, or “essential health benefits,” such as preventive and wellness care, emergency services, mental health services, pediat- ric care, and prescription drugs. States that require plans to cover services be- yond that must defray those extra costs. Some Texas health plans argued to TDI that crediting patients’ out-of-net- work expenses toward their deductibles as the adopted rules currently do could count as a state-mandated benefit that the state would then have to pay for. The federal Department of Health and Human Services (HHS) says that such cost-sharing would not count as a “benefit,” which refers to treatment. But TMA asked the federal govern- ment to put that in writing in its final regulations governing essential health benefits.
The association also asked HHS to set
more specific minimum network adequa- cy standards that, among other things, require insurers to prove they have suf- ficient networks before offering plans in the exchanges. If states have a more stringent standard, that higher standard would prevail.
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