TDI Proposes HMO Rule Rewrite

Whenever a state agency undertakes a wholesale overhaul of a set of regulations important to physicians and patients, TMA examines the proposal extremely carefully. That's why a TMA staff team spent weeks studying the Texas Department of Insurance's (TDI's) Oct. 7 proposed repeal and rewrite of the entire regulatory chapter on HMOs. 

In a 101-page comment letter, TMA focused on payment for emergency out-of-network care and network adequacy standards. TMA urged TDI to continue to require HMOs to "fully reimburse" non-network physicians at the usual and customary rate or at an agreed rate for out-of-network services provided when a network physician is not available and the patient is referred out of network. TMA was pleased TDI did not weaken, as an early draft indicated, the mileage standards for determining HMO network adequacy, and TMA encouraged it to strengthen those standards and other consumer protections the association helped win in TDI's rules on PPOs. 

TMA strongly supported TDI's proposed inclusion of requirements for HMOs to:

  • File annual network adequacy reports to aid the department in monitoring HMO compliance with network adequacy standards;
  • Notify enrollees of a substantial decrease of network facility-based physicians in network facilities;
  • Provide enrollees with certain network demographic information; and
  • Designate their networks as an "approved hospital care network" or a "limited hospital care network," depending upon their compliance or failure to comply with the network adequacy requirements for hospitals. 

Action, Dec. 1, 2016

Last Updated On

December 01, 2016

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