Summary of 1997 Managed Care and Consumer Protection Legislation

GENERAL HMO AND PPO SAFEGUARDS: SB 385/SB 383  

Allows the commissioner of insurance to establish standards relating to HMO enrollees' access to health care services, minimum physician/patient ratios, mileage requirements for primary and specialty care, maximum travel time, and maximum waiting time for obtaining an appointment.

X  

Directs the Office of Public Insurance Counsel to develop an annual HMO report card providing physicians, providers, and consumers of health care objective information to compare health plans in Texas.

X  

Allows patients and physicians to file a complaint with the Texas Department of Insurance if attempts to resolve a problem through the HMO's internal complaint process have failed or if they are dissatisfied with the HMO's response. TDI must investigate complaints within 60 days of receiving all necessary documentation.

X  

Requires physicians to post a notice in their offices informing patients about how to resolve a complaint with their HMO or file a complaint with TDI. (Note: Standard notice is in development by TMA)  

X  

PATIENT SAFEGUARDS  

Requires plans to allow non-network referrals if medically necessary services are not available within the network and are requested by a network physician. Plans must reimburse non-network physicians at the usual and customary or an agreed upon rate. A plan may not deny an out-of-network request unless it is reviewed by a specialist of the same or similar specialty as the requesting physician.

X  

Allows patients with special circumstances, such as a disability or life-threatening illness, to continue treatment with a terminated physician for up to 90 days, or nine-months if the condition is terminal. During this time, the plan must reimburse the treating physician at the contracted rate.

X  

X  

Allows patients with chronic, life-threatening, or disabling illnesses to apply to the plan's medical director to have a specialist as their primary care physician (PCP). The specialist must agree to coordinate all aspects of the patient's care as well as satisfy the plan's requirements for PCP participation.

X  

Prohibits the denial, limitation, or termination of covered, medically necessary rehabilitation services and therapies if they meet or exceed treatment goals for an enrollee. For a physically disabled person, treatment goals may include maintenance of functioning or prevention of or slowing of further deterioration.

X  

Defines "emergency care" using a prudent layperson standard.

X  

X  

Forbids health plans from using financial incentives that act as an inducement to limit medically necessary services. This provision does not prohibit the use of capitation as a method of payment.

X  

X  

Requires contracts between plans and physicians to contain language allowing patients currently undergoing treatment to receive "reasonable advance notice" of their physician's impending termination; however, the plan may not notify other patients until the effective date of the termination.

X  

Establishes standards and physician due process protections for informing plan enrollees of their physician's termination. If the physician is terminated by the network, the insurer is prohibited from notifying enrollees until the effective date of the termination or at such time as a review panel makes a formal recommendation regarding termination, whichever is later, unless there is imminent harm to the patient.

X  

X  

If a physician voluntarily terminates the relationship with an insurer, he/she is required to provide reasonable notice to the enrollees under their care, though the insurer must provide assistance to the physician in ensuring that notice requirements are met.

X  

PHYSICIAN SAFEGUARDS  

Mandates that health plans reimburse physicians for covered services within 45 days of receiving a claim containing the necessary documentation for processing or within the calendar days specified by contract.

X  

X  

Requires plans to initiate capitated payments to a physician within 60 days of a patient's selection of or assignment to his or her practice.

X  

Prohibits MCO retaliation against physicians who file a complaint on behalf of a patient or communicate with the patient regarding their medical condition, treatment options, or health plan benefits as they relate to their medical condition(s).

X  

X  

Establishes due process standards for physicians terminated or excluded from health plans.

X  

X  

Allows profiled physicians to obtain, upon request, a plan's economic profiling criteria, including the standards by which physicians are measured and any characteristics that may account for individual physician's "variations from expected costs."

X  

X  

Specifies that contracts between HMOs and physicians may not indemnify the HMO for tort liability resulting from acts or omissions of the HMO. A PPO contract may not require a physician or physician group to execute hold-harmless clauses in order to shift liability from the insurer to the provider.

X  

X  

Establishes standardized patient and physician complaint mechanisms, including provisions for filing written and oral complaints and time frames for responding to the complaint.

X  

Requires that notification of an HMO's adverse determination include a statement regarding the clinical or contractual basis for the decision. The notice must also include the Texas Department of Insurance's toll-free telephone number and address.

X  

Mandates that PPOs have a mechanism for resolving complaints initiated by the insured or health professional. The complaint mechanism must provide for reasonable due process, including a peer review panel for health professionals.

X  

UTILIZATION REVIEW PROTECTIONS: SB 384  

Specifies that UR personnel who gather information relating to patients' medical condition, diagnosis, or treatment options must be physicians, nurses, physician assistants, or health care providers qualified to provide the service requested by the provider.

X  

Requires that UR decisions be made in accordance with currently accepted medical or health care practices and that screening criteria be objective, valid, compatible with established medical practices, and flexible enough to allow deviations from the norm when justified on an individual basis.

X  

Requires that denials of service be reviewed by an appropriate physician or other health care provider to determine medical necessity.

X  

Requires notification of adverse determinations to specify the clinical basis for the denial and to provide a description of the complaint and appeal process.

X  

Establishes time frames and procedures for UR agents' notification of adverse determinations and patient appeals.

X  

Specifies that Medicaid managed care plans must abide by the provisions of the UR Act.

X  

HMO LIABILITY: SB386  

Allows HMO enrollees to sue their HMO if the HMO's decision to deny or delay medically necessary care results in patient harm. Liability created under this bill does not apply to employers or workers' compensation carriers.

X  

Establishes independent review organizations (IRO) and mechanisms for patients to appeal an adverse determination through the IRO.

X