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Senate
SB 155 was passed by the Senate. This
bill is supported by BCBSTX (Blue Cross Blue Shield of Texas). Health
benefit plans are subject to continuing review of their processes and
standards to maintain accreditation. Many of these processes and standards
are also reviewed by state agencies, resulting in increased agency costs and
increased health benefit plan administrative costs. This bill streamlines
the accreditation process and fosters coordination among state agencies in
order to make health benefit plan coverage more affordable for consumers and
to eliminate duplication of effort by both health benefit plans and state
agencies. My opinion>>
Good in cutting costs as long as it does not impair quality care delivered
or privacy of patients. I have noticed in other states such as Utah
that insurance carriers that own the system will abuse it to snoop for
medical based information beyond what they are entitled to.
House
HB 112 by Martha Wong (R-Houston) was
heard by the House Ways and Means Committee on Wednesday. The bill
provides a tax credit for certain corporations for certain purchases
that promote healthy living for employees. The bill was left pending.
My opinion>> Good idea as long as it
does not impede "Health Savings Accounts". Ambitious bill because she
really needs to get approval / permission from federal government and
IRS?? Right??.
HB 794 by Dianne White Delisi
(R-Temple) would require the Commissioner of Health and Human Services
to establish an advisory committee on health care information technology
to develop a long-range plan for health care information technology,
including the use of electronic medical records, computerized clinical
support systems, computerized physician order entry, regional data
sharing interchanges for health care information, and other methods of
incorporating information technology in pursuit of greater cost
effectiveness and better patient outcomes in health care was passed by
the House.
My opinion>> I still have a
problem with this bill if it is connected to cyberspace.......
Workers' Compensation
My overall opinion>> Overall rates will be and are projected to be on the rise when you "SUBSCRIBE" to workers compensation. That is why I am not an advocate of this and have several of you (clients) on "NON-SUBSCRIBED" alternative policies to provide MORE CONTROL and live on your own merits and be REWARDED in CHEAPER PREMIUMS because of this. Cindy, Andy, Dole and Jay.....you can see what I am talking about here?? These particular clients listed (FIRST NAME ONLY TO PROTECT THEIR PRIVACY) either employ high risk employees because industry or employ over 500 employees. IT IS SIMPLY too expensive to be pooled in with everyone. You need to be rewarded on your own merits and efforts to control accidents vs. premiums vs. coverage amounts after a deductible. It is quite difficult to manage a general pool of risk with the objective in mind is to keep costs low. This is one of the primary reasons that Texas allows employers to "OPT OUT" OR "UN-SUBSCRIBE". Can you imagine running a company in other states where Workers' Compensation is MANDATORY and you don't have a choice and you must enroll and pay the premiums or be shut down??? BELIEVE ME we have clients in that situation now outside of TEXAS.
HB 7 by Burt Solomons
(R-Carrollton) the House version of workers’ compensation reform and the
sunset bill for Texas Workers’ Compensation Commission was returned to
the House Business and Industry Committee for some technical corrections
and then voted out again. Yesterday it passed the House on the third
reading.
It would:
* Abolish the Texas Workers’
Compensation Commission and transfer most agency functions to Texas
Department of Insurance
* Create the Office of Injured
Employee Counsel to provide services for injured workers and take over
functions of the ombudsman program
* Authorize the establishment of
workers’ compensation health care networks
* Repeal the requirement for the
agency to regulate and maintain an Approved Doctor List of eligible
providers. My opinion>> Ohh
boy....no way to control what doctor a employee can see to prove
continual injury or disability?? This part = increase in workers comp.
premiums.
* Reduce from 28 days to 14 days the
waiting period for injured workers to receive their first week of
benefit payments My opinion>>
This part = increase in workers comp. premiums.
* Require workers’ compensation
insurance carriers to develop a Texas Department of Insurance-certified
informal dispute resolution process and require injured workers,
employers, and carriers involved in an income benefit dispute to utilize
the process before filing a dispute with Texas Department of Insurance.
My opinion>> ??? cutting out
litigation attorneys to save costs? Who will burden "proof"??
* Require a pre-hearing conference to
identify contested issues for the formal contested case hearing and
eliminate the current Benefit Review Conference
* Authorize parties to a dispute to
appeal the hearing decision directly to district court;
* Require medical disputes to go
through an initial informal dispute resolution process with the
insurance carrier and provide for an Independent Review Organization to
decide unresolved disputes; and My
opinion>> This is laughable here. What they are really
saying is a independent carrier can deny a claim...they pick the
independent review organization to resolve disputes??? I have seen this
in other states and it spells to me >>> Long time to RESOLVE. What
rights do the employer have??? Can't find information on this.
* Require the Workers’ Compensation
Research Group at Texas Department of Insurance to develop and issue an
annual informational report card on workers’ compensation networks and
conduct other studies. My opinion>>
Well.....is it because they are going to field test ideas on trial and
error basis to see how it can be approved??? I wouldn't want to be in
that experiment myself.
HMO REFORM
My opinion>> Reading
through much of it just verifies in my mind the ever ongoing struggle
between physicians wanting to be paid more and insurance carriers
wanting to pay them less. The patient / policy holder is caught
in-between. There has been allot of thought put into this.
GENERALLY I JUST DON'T RECOMMEND HMO COVERAGE FOR OUR CLIENTELE.
HB 3188/Smith, Todd
Relating to provisions of health care
services by health maintenance organizations.
My opinion>> good or bad? Is Mr. Smith a
physician? I have seen similar bills in other states. It usually passes
but is fought aggressively by insurance carriers because it causes a
problem with how the contract physicians at fee schedules. The carriers
simply say they are going to pass the increase in cost onto the policy
holders. I simply can't support any bill that could cause a rate
increase. More reading on this in a sample state thrown into arms? Go
here and see how serious it can get>>
http://benefitsmanager.net/senate_bill_34.htm
An HMO must make all reasonable
efforts to ensure that its network includes physicians and providers
under contract in sufficient numbers to provide services to enrollees
through those physicians.
An HMO must provide notice to its
enrollees of the HMO’s efforts to ensure the sufficient number of
physicians. Adds language to include an enrollee’s right to not be
balanced billed by out of network hospital based physicians, unless the
physicians, prior to treatment, disclose their non-network status to the
member. The bill creates the same requirements for PPOs.
HB 3405/Rose
Relating to health benefit plan
coverage for a hospital stay following mastectomy and certain related
procedures.
Coverage for a required hospital stay
following a mastectomy is required for a standard consumer choice health
benefit plan that provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness.
SB 1448/Averitt
Relating to the applicability of
certain laws relating to portability of certain health benefit coverage
provided to school district employees.
This requires school districts to
apply HIPAA Portability preexisting condition requirements to their
health benefit plans, eliminating the previously available opt-out.
SB 1516/Deuell
Relating to the adequacy of health
maintenance organization health care delivery networks and availability
of preferred provider benefits.
An HMO must make all covered services
be readily available and accessible to its enrollees. Urgent care
should be available within 24 hours for medical, dental and behavioral
health conditions. Routine care available within three weeks for
medical conditions; within eight weeks for dental conditions; and within
two weeks for behavioral health conditions. Preventative health
services will be available within two months for a child age 16 or
younger; within three months for an adult; and within four months for
dental services. Enrollees should be able to travel within 30 miles for
primary care and general hospital care and within 75 miles for specialty
care. The HMO is not required to expand services to cover enrollees who
live outside the service area, but work within the service area.
There will be a sufficient number of
primary care physicians and specialists with privileges in each
participating hospital within the HMO delivery network. The HMO
violates this if it does not have a contractual relationship with all
physicians or physician groups providing medical services
* pursuant to exclusive arrangements
between participating hospital and physicians or physician groups;
* who are compensated by the
participating hospital for emergency room call coverage; or
* exclusively providing specialty
medical services in a participating hospital by the virtue of being the
only such specialist or specialist group practicing within the general
geographic area around the participating hospital.
If an enrollee is limited to a limited
provider network, the HMO must ensure that the above criteria are met.
An HMO is subject to administrative penalties for failure to meet the
above. Each day the HMO fails to meet the requirements is a separate
violation.
If medically necessary covered
services are not available through the network, an HMO may allow
referral to a non-network physician and will fully reimburse the
non-network physician the amount as submitted on the claim. The request
must come to the HMO from the network physician and be within a
reasonable amount of time.
If a non-network physician provides
services within a hospital participating in an HMO’s delivery network,
the HMO will fully reimburse the non-network physician the amount as
submitted on the claim.
An HMO will pay for emergency care
performed by non-network physicians at the amount as submitted on the
claim; no longer as the usual and customary rate or at an agreed rate.
It sets up a mandatory mediation
process to promote voluntary agreement between parties regarding
participation in a health care delivery network. Mediation is handled
by a consensus panel consisting of three mediators. One is appointed by
the health plan, one by the physician or physician group and one
appointed by the previous mediators. If a mediation agreement is
reached, then the panel will provide information for the preparation of
a mediation agreement. If an agreement is not made, the panel will
report to the commissioner as such. A health plan or physician may
receive an administrative penalty from its regulatory agency for bad
faith negotiations during mediation.
Sets the same provisions for PPOs,
except requires payment of the unadjusted amount as submitted on the
claim to a non-preferred provider in the event of network inadequacy or
emergency.
SB 1738/Duncan (Companion is HB
2224/Isett)
Relating to consumer access to health
care information and consumer protection for services provided by or
through hospitals and ambulatory surgical centers.
This bill deals with the transparency
of healthcare costs. It will require a facility to provide notice to a
consumer before or on admission to the facility, a list of the
facility’s, physician’s or vendor’s charge list, procedure charge list
and estimate of charges. The Department of State Health Services will
identify a list of the 100 most common procedures in Texas and update
this list every two years. Each facility will be required to maintain a
charge list of these procedures.
This bill provides for a patient to
not be billed for more than a reasonable charge for a health care
service or supply.
The waiver of co-payments by a
facility to out-of-network patients is prohibited. Balance billing by a
health care provider who accepts the usual and customary rate as defined
by the health insurance policy or plan is restricted.
It is expected that the committee will
consider how this bill will be implemented.
TimeTable
May 9 Last day
for House committees to report HBs/HJRs
May 30 Last day of 79th Regular
Session
June 19 Last day Governor can
sign or veto bills passed during the previous legislative Session.
August 29 Most new laws take
effect, unless they were given specific effective dates. Some bills
become law when the Governor signs them.
PLEASE CALL YOUR CONGRESSMAN!!! PUT IN
YOUR OPINIONS AND OPPOSE ANYTHING THAT COULD CAUSE YOUR RATES TO
INCREASE!!!