With a number of new and fluctuating state and federal laws and regulations, Texas Department of Insurance (TDI) Commissioner Cassie Brown has her plate full when it comes to health plan regulation.
At the same time, the agency’s newest commissioner – appointed in September 2021 during the COVID-19 pandemic – understands the complexity of these laws can mean confusion for physicians and patients.
“With that in mind, one of my priorities is to improve customer service and education,” Commissioner Brown told Texas Medicine.
For physicians, that includes helping them navigate the complaints system, independent dispute resolution (IDR) process, and prompt-pay requirements, among others, she says. For patients, that means promoting the use of plain language to help them understand the insurance policies they’re buying.
“It is my hope that providers and plans continue to work together in the interest of consumers,” she said. “I believe in open lines of communication. If you see opportunity for improvement at our end, please let us know. I prefer to hear about challenges sooner rather than later. I can’t fix a problem if I don’t know it’s a problem.”
Here are excerpts from Texas Medicine’s interview.
What is TDI doing to monitor, measure and enforce network adequacy?
Texas has some of the strongest network adequacy standards in the nation. and TDI has developed a framework for ensuring health plans maintain networks that provide consumers with reliable access to the care they need. Health plans must:
• Pass qualifying exams before they can enter the market;
• File comprehensive annual reports detailing network adequacy compliance;
• Provide justification for any circumstance where an access plan is needed; and
• Participate in triennial quality of care exams.
What can TMA/physicians do to help with TDI’s network adequacy efforts?
One method TDI uses to ensure a carrier is attempting to contract with providers is to reach out to the providers [that health plans] designated … as refusing to contract, to be sure an opportunity to contract was offered by the health plan, and if so, on what date was the last contact made. This outreach to providers has not been very successful. So, TDI has met with TMA regarding ways to get better responses from providers [and let physicians know] that it was OK to respond to the emails or letters from TDI, that it was not a scam to avoid.
How can physicians successfully communicate with TDI when they have complaints?
TDI has a complaint portal that is available to consumers and providers to submit complaints. The complaint resolution time frames have continued to decrease in the past 18 months with TDI resolving most complaints in about 22 days.
Some federal guidance is still pending, but with regard to surprise billing, what are the main things physicians need to know about TDI’s role, existing state law, and the new federal No Surprises Act (NSA)?
Existing state law will continue to apply to fully insured, TDI-regulated plans along with Texas’ Employees Retirement System and Teacher Retirement System. The federal law will apply to everything not covered by Texas law. The Texas Medical Board and the Texas Board of Nursing will enforce the NSA provisions for providers they regulate. Enforcement for facilities and other providers will be handled by the Centers for Medicare & Medicaid Services (CMS).
CMS surveyed TDI and provider regulatory agencies on enforcement. We speak regularly to those other agencies on the existing law and continue to meet with them on the NSA implementation, enforcement, and opportunities for coordinated messaging to ensure plans and providers can find accurate information regarding state and federal balance billing legislation.
We updated our website to help consumers and providers know if a plan is regulated by Texas or the federal government and where to get help with a surprise bill. This included updating our overview of Texas and federal balance billing protections webpage.
Texas’ mediation/arbitration system for surprise bills has been refined over the years, and TMA has weighed in on that process. How would you rate the current arbitration system’s success?
Senate Bill 1264 was a landmark piece of legislation to take consumers out of billing disputes in certain cases. TDI worked to implement rules and infrastructure in a very short time. We’ve consistently received positive feedback from parties on both sides of the independent dispute resolution system, and staff are ready to assist plans or providers with questions on the IDR portal or process. There have been some complaints and growing pains as both plans and providers continue to familiarize themselves with the process, but consumer complaints have dropped significantly. Consistent with the time frames in the legislation, the IDR process ensures that disputes are resolved timely.
Have you seen SB 1264 impact network adequacy, which many physicians point to as a root cause of surprise bills?
TDI expects plans to continue to follow laws on network adequacy, prompt payment of clean claims, and contractual obligations. With SB 1264, TDI reminded health plans of their obligations on emergency care, prompt payment, and accurate consumer information. The hope is that arbitration will incentivize plans and providers to find an agreed price, enter into contracts, and avoid the arbitration process. TDI will continue to collect data on network participation for TDI-regulated plans in our biennial report on the Texas IDR system scheduled to be released in December 2022.
What can you tell physicians about how to prepare for implementation of the gold-card law, House Bill 3459? The law is the first of its kind and, in TMA’s experience, has garnered national attention. Are you experiencing that as well?
Plans will have the primary responsibility for applying gold-carding provisions to eligible providers. Providers will not have to take proactive steps to benefit from the provisions. Providers should keep in mind that House Bill 3459 applies only to TDI-regulated plans, which constitute about 15% of the health care market. Providers should read and familiarize themselves with their rights and responsibilities once the rule is published. We hope the proposed rules will be clear and easy to follow, but we encourage providers to submit comments on the proposal to help us clarify where needed. And once the rule is adopted, we encourage providers to submit complaints for TDI-regulated plans that fail to follow the requirements.
At its recent annual meeting, the National Council of Insurance Legislators included a session on the Texas law, which TMA participated in. I’m sure there will be interest from other regulators once the law is fully implemented and as similar legislation is proposed in other states.
Turning to the public health emergency, do you have any insight into whether health plans might, on their own, continue the telemedicine flexibilities instituted during the pandemic? What can physicians expect in terms of transitioning back to other pre-pandemic insurance-related policies?
Gov. Greg Abbott rescinded suspensions of insurance-related statutes and rules issued in response to the COVID-19 pandemic [including telemedicine], effective Sept. 20, 2021. TDI posted a bulletin in July 2021 outlining actions we are taking to return to the ordinary course of business.
Telemedicine played a vital role in health access during the pandemic. [In addition to adopting emergency tele-medicine rules], TDI also encouraged health plans to act on their own to be as flexible as possible to ensure consumers could get care. [Although the governor rescinded the telemedicine flexibilities] we understand that federal regulators have continued, during the COVID-19 public health emergency, a policy of enforcement discretion with respect to federal privacy and security standards for communications platforms used for telemedicine. A large segment of the market is not under TDI regulation, but TDI will continue to enforce coverage requirements for state-regulated plans and encourage health plans to embrace telehealth for the benefit of their enrollees.
I would like to add that we are grateful for you. We know these last few years dealing with COVID have strained physicians and other health care workers. Thank you for your care and dedication in serving Texans.
Tex Med. 2022;118(2):30-31
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