TMA Backs Network Adequacy Bill and Other Insurance Reforms
By Emma Freer

With just a week until the bill-filing deadline, the Texas Medical Association is backing state legislation that furthers patients’ access to care by requiring adequate networks and bolstering prior authorization reforms, among other protections. 

State Rep. Greg Bonnen, MD (R-Friendswood), a neurosurgeon, recently filed House Bill 3359, which would promote adherence to the state’s network adequacy rules – regulations TMA was instrumental in developing – by putting them into statute and by strengthening enforcement by the Texas Department of Insurance (TDI). Sen. Charles Schwertner, MD (R-Georgetown), an orthopedic surgeon, is expected to file a companion bill in his chamber.  

Both lawmakers serve on various committees that are likely to hear insurance-related bills. Representative Bonnen chairs the House Appropriations Committee and serves on the Select Committee on Health Care Reform. Senator Schwertner chairs the Senate Business and Commerce Committee and serves on the Senate Finance and State Affairs committees.  

Despite Texas’ network adequacy regulations being among the strongest in the country, TMA continues to receive reports of health plans taking advantage of waiver processes and offering plans that don’t provide patients with a sufficient panel of in-network physicians. 

More than 90% of the commercial health plan networks filed with TDI in 2022 didn’t meet state network adequacy standards and instead operated under a waiver, or “access plan,” detailing how the plan would cover such gaps, according to the state agency. 

HB 3359 would help improve the waiver process by codifying requirements that health plans monitor network adequacy compliance on an ongoing basis and by erecting guardrails, including new transparency measures and renewal limits.  

TMA was instrumental in developing the TDI rules defining network adequacy back in 2011. They include limits on how far patients must travel for in-network care. 

HB 3359 would help preserve and strengthen those protections by: 

• Prohibiting health plans from unilaterally amending certain terms in contracts with physicians and other health care professionals; and 
• Mandating that post-emergency stabilization care claims are routed under state surprise billing laws for exclusive provider organizations rather than the federal No Surprises Act, among other provisions.  

In addition to network adequacy, TMA hopes to build on the success of the 2021 “gold card” law, which exempts physicians who earn approvals on at least 90% of prior authorization requests for a given service or medication from onerous preapproval requirements for that service or medication. 

TMA spearheaded the law, which appears to be working for many physicians, but there’s still work to be done to ensure eligible health plans are held accountable under the new law. So, TMA Chief Lobbyist Clayton Stewart says the association hopes to revisit the issue this session. 

TMA’s other legislative priorities include prohibiting the health plan practice of “white-bagging” certain drugs and bolstering the “prudent layperson” standard in emergency care, both of which have been the subject of bills in recent sessions. 

House Bill 1647 by Rep. Cody Harris (R-Palestine) would prohibit the practice of white-bagging – insurers requiring physicians or facilities to purchase drugs through a specialty pharmacy – which health plans say saves money but causes potential dosage discrepancies for physicians and their patients. 

Senate Bill 1139 by Senator Schwertner and House Bill 1236 by Rep. Tom Oliverson, MD (R-Cypress), would update the definition of emergency care under certain health plans to protect patients – or prudent laypeople – who use their reasonable judgment in making a trip to an emergency department, including in cases where their condition is later determined not to be emergent.