TEXAS: New HMO Regulations Scaled Back
The Texas Department of Insurance has decided not to force HMOs to pay for several services that regulators were considering as they prepare to implement "15 new laws passed during the 1997 legislative session." Spokesperson Dana Palmer said of the decision, "It's something we were collecting information on because of all the complaints we've received in those areas. It was not contemplated that it would be part of the final proposed rule, but we do have the information and the comments if any future benefit requirements are needed in this area." The Dallas Morning News reports that the department decided against mandating coverage for prescription drugs, blood plasma therapy for hemophiliacs, breast reduction surgery and treatment for severe obesity. Regulators also "[e]limated a proposal that would have prohibited HMOs from removing medications from their prescription offerings in the middle of a contract year," and killed a "provision that would have required HMOs to acknowledge claim forms submitted by" providers.
Still Have Some Teeth
The proposed rules continue to include several coverage mandates, including requirements that HMOs "pay for in-vitro fertilization, unlimited home health care and diabetes equipment." The draft rules also would increase the duration of time a patient can be asked to wait for a preventive-care visit from two to three months (one to two months for children). The department also "[i]ncreased the number of HMO enrollees who can be seen by each primary-care physician, from 1,500 enrollees to 2,000," and removed mandatory coverage for mammographies and emergency dental care.
The Compromising Spirit
Differences of opinion on the matter aside, "both insurers and consumer groups said they were impressed that the insurance department tried to gather as much feedback as possible on the proposed regulations." Geoff Wurzel, executive director of the Texas Association of Health Plans, said, "The department's efforts though the process have been very open -- more open than it has ever been in the past." The industry lauded the state for its hands-off approach, leaving decisions on coverage up to HMOs and employers. HMO industry representatives also "praised the state for considering the cost impact of the proposed services." Wurzel said, "You start adding everything together, and it becomes more and more expensive -- and it's another mandate." Consumer groups, however, argued that all plans should include some prescription drug services. Lisa McGiffert, a senior policy analyst with Consumers Union, said, "It's absurd to think that any health insurance policy would be considered adequate if it didn't cover prescription drugs" (Ornstein, 6/30).
Before taking effect, the proposed HMO rules will be the subject of a public hearing in Austin on Aug. 3. The regulations can be viewed online at www.tdi.state.tx.us.