145.032.Improving Network Adequacy in Health Insurance Plans.

145.032

Improving Network Adequacy in Health Insurance Plans: Following is Texas Medical Association policy on improving network adequacy in health insurance plans: Allow Consumers to Purchase the Product They Demand. TMA supports legislation that will require all state-regulated insurers offering preferred provider benefit plans to offer, for purchase, additional coverage to settle claims for labor and delivery, emergency care, and any subsequent admission to the hospital at the preferred level of coverage. This should apply to individual, small group, and large group coverage. Protect and Keep Old and New Consumer Protections. TMA should advocate to ensure Texas consumers continue to receive the advantage of Texas Department of Insurance HMO emergency care/inadequate network protections and the new PPO/PPBP rules that credit all payments for out-of-network care in emergencies (or where the network is inadequate) to a consumer’s in-network deductible and out-of-pocket maximum. Also, the PPO/PPBP regulations, which provide guidance to insurers that usual and customary charges must be used to settle claims where the network is inadequate, should also remain unchanged. Authorize the Office of Public Insurance Counsel to Monitor Networks. TMA should support legislation that seeks to augment the Office of Public Insurance Counsel’s (OPIC’s) authority to monitor network adequacy in the HMO and PPO/PPBP lines of insurance business. OPIC should be granted statutory authority to file complaints with the Texas Department of Insurance (TDI) TDI upon OPIC’s discovery of an inadequate network or other violation of network adequacy laws or regulations. OPIC currently issues HMO report cards for use by consumers. These report cards should be required to contain an evaluation of HMO network adequacy, and OPIC should be charged with the duty to develop and issue report cards for PPO/PPBP plans that include an evaluation of those networks. Authorize the Office of Public Insurance Counsel to Intervene in Access Plan Filings and Network Adequacy Waiver Filings. TMA should support legislation that will require HMOs and insurers to provide a copy of any such filings to the Office of Public Insurance Counsel (OPIC) and permit OPIC to oppose Texas Department of Insurance approval of any filed access plan requests if OPIC finds the access plans or waiver applications unacceptable. Stabilize Networks. The network directories that consumers depend on are notoriously inaccurate. TMA should support legislation that will stabilize the networks the insurers market by restricting without cause terminations of physicians and providers. The legislation should prohibit insurers from exercising without cause termination clauses within the first six calendar months and last three calendar months of each year. TMA should support legislation that will authorize the Office of Public Insurance Counsel to file complaints with the Texas Department of Insurance on inaccurate HMO and PPO/PPBP directories (CSE Rep. 2-A-15; reaffirmed BOT Rep. 12-A-16).

Last Updated On

October 07, 2016