Surprise! Balance Billing Still a Focus at the Capitol
By Joey Berlin Texas Medicine April 2018

Committees in both chambers of the Texas Legislature are studying complex issues throughout this year to prepare for the legislative session in 2019. As the year progresses, we’ll periodically look at the health care-related issues lawmakers are tackling in the legislative interim and how TMA is advocating for medicine on those fronts.

Legislative_callasIf the goal is a health insurance landscape that serves and satisfies everyone, mark your calendar for about eight years past never.

Still, a year after the house of medicine scored big wins on some of the state’s biggest insurance issues, the Texas Legislature is trying to dive further into what is and what isn’t working. Health insurance looms large in lawmakers’ interim charges for 2018, and surprise medical bills – the issue where medicine notched perhaps its biggest victory of 2017 – are again at the forefront, serving as a study subject for multiple committees. The Texas Medical Association is doing its part to drive the discussion.

In January, Beaumont anesthesiologist Ray Callas, MD, (above) went to bat for TMA on surprise bills when he testified before the Senate Business and Commerce Committee. As part of its interim charges, the committee is examining “the settlement of out-of-network health benefit claims.” 

The charge came after last year’s passage of TMA-supported Senate Bill 507 by Sen. Kelly Hancock (R-North Richland Hills), which greatly expanded balance billing mediation for out-of-network care while maintaining the $500 threshold for mediating a bill. It took effect for certain claims for services beginning Jan. 1, 2018. (See “Closing the Gap,” December 2017 Texas Medicine, pages 22-28.)

Dr. Callas, a member of the TMA Board of Trustees, said accurate, up-to-date network directories are essential to help consumers make the best choices. Health plans are required to update their online directories monthly, “allowing bad information to linger even when plans have available information [to] update that directory on a more constant basis,” he said.

Late last year, Houston emergency physician Arlo Weltge, MD, also stressed the importance of accurate – as well as adequate — networks when he testified to the House Insurance Committee.

“Balance billing only occurs when services are received … out-of-network, either [from] facilities or [from] physicians,” Dr. Weltge said. He told the committee the Texas Department of Insurance (TDI) “generally has strong adequacy rules in place. However, TDI’s PPO network adequacy rules are reliant on self-reported data by the health plans, and many health plans are currently receiving waivers. The legislature could strengthen TDI’s oversight of network adequacies by giving them additional enforcement capacities.”

Dr. Weltge noted TMA supported House Bill 477 by Nicole Collier (D-Fort Worth) last session, which would have required agents who sell individual health plans to educate customers about a plan’s copayments, deductibles, and coinsurance, among other provisions. That bill passed the House but died in a Senate committee. 

At the Senate Business and Commerce hearing in January, Dr. Callas also testified for TMA on the prospect of interstate insurance sales — a popular talking point among politicians in recent years. If lawmakers decide out-of-state health insurance sales are a viable option, he said, they should consider: 

  • Interstate products with in-network/out-of-network distinctions should meet Texas network adequacy standards and adhere to Texas prompt-pay requirements;
  • Each company or HMO should meet Texas’ minimum financial solvency standards; and 
  • Jurisdiction for any legal challenge involving the insurance product shouldn’t undermine TDI. 

Decade-long funding for CHIP ends nervous uncertainty

Washington, D.C.’s patented government gridlock may show no sign of slowing down – or, in the case of gridlock, speeding up. 

But at least for the next decade, more than 400,000 vulnerable Texans won’t have to worry about the Children’s Health Insurance Program (CHIP) getting caught in the teeth of Washington infighting and inactivity.

In February — following passage of a short-term budget deal that provided six years of funding for CHIP – Congress passed another budget agreement that tacked on an additional four years of CHIP funding. That covers CHIP through 2027 and removes the vital program from the list of political footballs being slung, pitched, and fumbled all over the Capitol.

“It’s just a huge victory for kids and children’s health advocates to know that the funding is safe and secure for an entire decade,” said San Antonio pediatrician Ryan Van Ramshorst, MD, chair of TMA’s Select Committee on Medicaid, CHIP, and the Uninsured.

While long-term CHIP funding is itself a massive relief, the funding agreement comes with both positive and negative news for Texas’ efforts to cover its children.

One piece of good news is that the budget deal retained the “maintenance of effort” provision mandated in the Affordable Care Act (ACA). That provision prevents states from cutting CHIP eligibility levels if they cover 300 percent of the federal poverty level or less. Texas covers children in families with incomes up to 201 percent of federal poverty.

On the other hand, the enhanced federal matching funding the ACA provided to states will be scaled back beginning in 2020. In 2018 and 2019, Texas will maintain its current enhanced match rate, which each year falls around 92 or 93 percent. The following year, all states’ federal match will decrease by 11.5 percent. Then, in 2021, the matching CHIP rates for each state will return to pre-ACA levels. For Texas, that will be approximately 71 percent. Funding allotments for 2024-2027 haven’t been determined.

“I’m in favor of preserving the maintenance of effort provision,” Dr. Van Ramshorst said. “Anything that protects kids’ ability to access health care is a good thing. And in a state like Texas, which doesn’t have the brightest track record when it comes to coverage for kids, I think having that additional protection is really important.

“Ideally, the enhanced match would’ve been preserved. But I think to make the bill more acceptable in a bipartisan fashion, it had to be negotiated back down. That’s disappointing, but again, the fact that we got 10 years is just huge. I honestly didn’t think that was going to happen.”

Interestingly, according to a Congressional Budget Office (CBO) analysis released before passage of the funding extensions, re-upping CHIP through 2027 actually saves the government money – an estimated $6 billion in decreased deficit. “[T]he federal costs of the alternatives to providing coverage through CHIP (primarily Medicaid, subsidized coverage in the marketplaces, and employment-based insurance) are larger than the costs of providing coverage through CHIP during that period,” according to the CBO. 


Texas Chip by the Numbers

419,235: Texas children enrolled in traditional CHIP as of November 2017, per the Texas Health and Human Services Commission 

201%: Texas CHIP covers uninsured children in families with incomes up to 201% of the federal poverty level

92.82%: Enhanced federal matching funds rate for Texas CHIP, 2018

Tex Med. 2018;114(4):16-17
April 2018 Texas Medicine Contents
Texas Medicine Main Page

Last Updated On

April 27, 2018

Originally Published On

April 02, 2018