TEXAS AHEAD OF THE GAME “There’s a big difference between excessive billing and balance billing because doctors can’t get into networks,” Dr. Valenti emphasized. Texas already has a long history of consumer protections, Dr. Callas adds, and
if existing laws don’t work, it’s because they don’t demand enough transparency and accountability from health plans, not doctors. In 2015, TMA negotiated a compromise under Senate Bill 481 by Sen. Kelly
Hancock (R-North Richland Hills). The bill lowers the threshold for patients to initiate mediation over balance bills from $1,000 to $500. TMA also strongly supported House Bill 1624 by Rep. John Smithee (R-Amarillo). The legislation strengthens requirements for health plans to publicly post accurate network directories on their websites, but officials say plans are slowly responding. TMA’s Task Force on Balance Billing and Council on Legislation also contin-
ue to analyze a host of legislative and regulatory proposals in Texas and beyond, with a careful eye on legislation aiming to restrict out-of-network physicians’ ability to balance bill for services they legitimately provide. Other proposals around the country range from requiring certain price disclosures by physicians, hospitals, and others to tying out-of-network payment amounts to a state-certi- fied database of geographic-specific charges, such as
FAIRHealth.org. At the federal level, however, CMS at the last minute reversed course on net-
work adequacy standards for ACA plans that — much like Texas law — originally contained specific, minimum criteria. They also included cost-sharing provisions that allow patients to get credit for balance bills toward in- network deductibles if insur- ers don’t notify them ahead of time of their out-of-pocket re- sponsibility. Read the full rule at tma.tips/CMSNetworkAd equacyRule2017. CMS suggested it was
holding off “to provide states time to adopt the NAIC Net- work Adequacy Model Act,” which suggests — but does not mandate — states incor- porate quantitative time and distance criteria, for example. It also requires that any bill- ing statement out-of-network professionals send to insured patients must inform them they are “responsible for paying their applicable in- network cost-sharing amount, but [have] no legal obligation to pay the remaining balance.” Whether or how much insur- ers would pay is left up to state law. Read the model act at tma.tips/NAICModelAct. CMS reiterates nothing in
2016 TEXAS ACA MARKETPLACE HEALTH PLANS*
• Aetna • Ambetter from Superior Health Plan (filed under Celtic Insurance Com- pany)
• Allegian Insurance Company† • Blue Cross and Blue Shield of Texas • CHRISTUS Health Plan • Cigna Health and Life Insurance Company • Community First • Community Health Choice • FirstCare Health Plans • Humana Insurance Company • IdealCare (filed under Sendero Health Plans, Inc.) • Molina Health Plan • Oscar Insurance of Texas • Prominence HealthFirst of Texas, Inc. • Scott & White Health Plan† • UnitedHealthcare (filed under All Savers Insurance Company)
*Not all plans and product types may be available in every Texas county. For more details, visit TMA’s Affordable Care Act Resource Center,
www.texmed.org/aca.
†Offer preferred provider organization plans. May 2016 TEXAS MEDICINE 35
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