RIDING THE WAVES OF NETWORK ADEQUACY, con't
meetings, TDI Commissioner Geeslin essentially admonished all the stake holders in the room stating that some of the plans had no business providing a product in the State as their networks were appalling.
House Bill 2256 in 2009
In 2009, as a result of the TDI Study, HB 2256 was created, considered and passed by the 80th Legislature. The bill was designed to deal with Network Adequacy and OON Balance Bills through mediation. What resulted from this bill were a few lines of instruction to TDI and specific amendments to Subchapter A, Chapter 1301 by adding Section 1301.0055 to direct the TDI Commissioner to “…ensure availability of, and accessibility to, a full range of contracted physicians and health care providers to provide health care services to insureds…” This instruction was not prescriptive.
TDI WORKS TO IMPLEMENT HB 2256
TDI Commissioner Geeslan Transparency Approach: The Creation of May 19th, 2011 Version of Proposed Rules
Through 2010 and 2011, the work to write these rules made rapid progress via several iterative drafts in TDI. Under Commissioner Geeslin’s direction, there were several public hearings and opportunities to affect these rules by all stakeholders. Toward the end of 2011 we had a version of those rules that listed the following requirements for communicating with consumers about the adequacy of their networks so that they could make informed decisions. Commissioner Geeslin’s rules required a plan to make transparent many attributes by geographic area of network adequacy. They would have to publish the number of preferred providers by specialty and the ratio to insured; the percentage of preferred providers taking new patients and percentage that were board certified.
TSA and TMA felt at that time that we had a set of rules that were workable. We felt comfortable with the market pressure that transparency would bring. A consumer could now compare insurance products and determine who had a complete network and who did not. Further, there was a method of redress for patients who felt they were billed inordinately OON through a process of mediation for balance bills larger than $1000 where the provider did not inform the patient of estimated charges. This set of rules seemed poised to deliver transparency to the consumer and decrease unexpected OON balance bills by facility based physicians. Years of legislative, regulatory and stakeholder work went into to creating a completed product.
TDI Commissioner Kitzman Suspends May 19, 2011 Version
And then the tide changed. At the end of 2011, Commissioner Geeslin resigned to seek other opportunities. He was replaced by appointee, Commissioner Kitzman. At the end of 2011, Commissioner Kitzman put all draft rules for network adequacy on hold and instructed TDI to write a new
set. This time around, there were no stakeholder meetings prior to the writing. There was a draft released in February 2012. Essentially the language above was struck completely leaving no requirement for insurers to disclose the adequacy of their networks. Transparency to the consumer was scuttled to the deep. Further, the Commissioner was given great leeway to hand out exemptions to insurers for having inadequate networks.
On November 14, 2012, TSA and TMA attended the Public Stakeholder Hearing by TDI to view the newest set of Revised Kitzman Rules. Unfortunately, these continue to withhold any requirement for the insurers to disclose the adequacy of their networks.
TMA Review of Kitzman Version:
The TMA has written an extensive review of the TDI’s recent approach to creating adequate networks. TMA’s letter said Kitzman’s revised approach was an “…about-face” that the Department has done from the May 19, 2011 adopted PPBP rules without ever having allowed those adopted rules to be implemented.” It went on to say that TDI departed from standard operating procedure by not allowing the earlier version of rules to be implemented and then revised based on their effect from use. Instead, TDI’s modification of the rules with little justification was “…on its face, both wasteful of State resources and utterly devoid of any rational or legitimate justification.”
Commissioner Kitzman's Biennial Report to the Upcoming Legislature:
In the most recent entry to this story, Commissioner Kitzman has submitted her “Biennial Report to the 83rd Legislature” from December 2012. I paraphrase her:
The insurance company is often powerless to contract with providers and cannot offer a complete network.
TDI can only regulate one of the stakeholders – the insurer
The stakeholders cannot agree on a better solution.
What is TDI to do?
TDI cannot fulfill its duty to regulate the insurers to sell products that have complete networks.
TDI needs the 83rd Legislature to offer guidance, given it cannot fulfill its duty.
And so after hopeful swells in the direction of meaningful transparency to the consumer, subsequently thwarted by the undertow of unilateral decision‐making, the helm is returned back in the hands of the Texas Legislature this Session. It is our responsibility as TSA members to help navigate our state leaders back to the smooth waters of crystal clear comparable metrics for consumers to make informed decisions on which insurers are best for them.
