prove they have sufficient networks be- fore offering plans in the exchanges. Although the federal minimum stan-
dards did not change, if states have a more stringent standard, that higher standard prevails. “In states with suffi- cient network adequacy reviews, CMS will use a state’s reviews as part of its evaluation,” says federal guidance. Ms. Daniel says the bar in Texas is
“fairly high, so I think the federal gov- ernment will accept that as a standard for plans.” As for rate review, TDI says it plans to continue to assess premium rate in- creases as it has in the past to determine whether a proposed increase is just, fair, reasonable, and adequate under state insurance laws. But the federal gov- ernment has the discretion to decide whether a state’s rate review process is “effective.” “If they don’t think your state process meets federal standard, they will assume
that regulatory responsibility,” Ms. Dan- iel said.
Who’s in? Insurers, too, are dealing with challeng- es, from sifting through last-minute fed- eral guidance and building networks to balancing a potentially high-risk popula- tion of enrollees with affordable pricing. Most of the federal rules were not final until March of this year. “Clearly, this is a very complex piece of legislation, and any time a new pro- gram of this magnitude affects this many consumers, we can anticipate there are going to be some struggles. But the [federal government] has rolled out other programs that are equally com- plex before,” said Dan McCoy, MD, chief medical officer for Blue Cross and Blue Shield of Texas, which applied to partici- pate in the exchange. “We are making the assumption the exchanges will open on time — and we have no indication
that’s not true — and we are working diligently internally to make sure we are ready to meet the requirements and to participate.” That started with a letter campaign
in August 2012 that continues to solicit participation from physicians across the state in what he described as a low-cost, high-quality network. But Dr. McCoy, also a member of the TMA Board of Trustees, emphasized that physician participation in exchange plans is optional, and “accepting or de- clining that invitation in no way impacts participation in other [Blues] networks.” Nor would physicians who do decide to join have to go through additional cre- dentialing if they already participate in other Blues PPO or HMO networks. The carrier plans to offer a similar selection of HMO and PPO products both in and outside of the exchange, he says, in addition to participating in the so called “metallic” cost-sharing plans federal rules created to give patients af- fordable options.
Texas Medical Boardard appearance?
Pending
When Unhappy Patients, Ad Problems or Competitor Accusations lead to a Texas Medical Board investigation, ISC hearing or SOAH trial, your choice of attorney could make the difference in your future.
e difference in your future.
• In a “bronze” plan, insurers pay for 60 percent of benefits; patients, 40 percent.
• In a “silver” plan, insurers pay for 70 percent of benefits; patients, 30 per- cent.
• In a “gold” plan, insurers pay for 80 percent of benefits; patients, 20 per- cent.
• In a “platinum” plan, insurers pay for 90 percent of benefits; patients, 10 percent.
Federal approval of the Texas Blues’
experience and tenacity backed by his firm’s depth-of-staff and range of talent can put justice on your side.
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Medical Litigation
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52 TEXAS MEDICINE August 2013
Gaines West Lead Counsel
260 Addie Roy Rd., Suite 110 • Austin, TX 78746
1515 Emerald Plaza • College Station, TX 77845 Austin – 512.501.3617
Principal Office – 979.694.7000
exchange network is pending. But with participation from physicians across Texas’ 254 counties, Dr. McCoy said his company “feels comfortable” the ex- change network is adequate. Once approved, the company will de- cide the services needed in a particular area and then move on to pricing premi- ums and developing fee schedules, likely in late summer. Like with any insurance products, the company says it will base premium prices on underlying medical costs and services, and physicians will be paid based on their specialty and the type of policy.
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