TDI Overhaul of HMO Licensing and Regulation Rules – Rule Review and Drafting Update

The agency held a stakeholder meeting to discuss the review of 28 TAC, Ch. 11, regarding Health Maintenance Organizations.  The agency asked for stakeholder comments before a draft rule is published.
 

• TDI is reviewing the entire chapter; it has been some time since the last complete revision
• Some ideas include:
  • Deleting subchapter M, Acquisition of, Control of, or Merger of a Domestic HMO
  • Deleting subchapter N, HMO Solvency Surveillance Committee Plan of Operation
  • Multiple small clean up items
  • Changes in HMO filings; proposing to update filing rules and outline what the agency is looking for in rate filings
  • Incorporating newly mandated benefits into filings
  • Looking into e-filing for rate documents
  • Possibly making PBMs a single service HMO
     

Melissa, Texas Association of Health Plans

• Likes the list
• Submitted written comments
• Would like to remove the public notice newspaper requirement

 
Trey Berndt, AARP

• Submitted written comments on network adequacy and balanced billing
• Would like the agency to keep in mind that many new folks are being enrolled into HMO markets and will be insured for the first time; people need to be able to understand their rights and the system in general; informing requirements need to be as consumer friendly as possible

 
Clayton Travis, Texans Care for Children

• Would like elaboration in regard to HHSC rules versus TDI rules for Medicaid HMOs
  • Agency staff responded: TDI is mostly involved with network adequacy, and takes an oversight role, as well as initial approval through the department of insurance
     

Barbara Holmes

• Because Medicaid HMOs don’t set their own premiums additional solvency requirements through TDI seem incongruent with what HHSC is trying to do
• The excess growth charge model penalizes Medicaid HMOs; additional solvency standards should be cut and brought back to HHSC standards

• A stakeholder asked what changes will be made in regard to network adequacy
  • Agency staff responded: have not finalized what the agency will change in network adequacy; considering urban versus rural and micro versus macro counties regarding network adequacy standards; out of network billing may need to be the same for PPO and EPO plans
  • Wanted to hear from stakeholders before any big changes are made

• A lot of alignment needs to be done in regard to other state’s requirements, which will make it easier on health plans but also want to consider that the needs of Texans are different than the needs of other state’s citizens
• PBMs need to be third party administrators but there have been questions lately regarding whether they should be single service HMOs; it may be a legislative request if the agency does not have this authority
• Would like stakeholders to think about whether TDI should have special processes and provisions for employer group waiver plans
  • A stakeholder noted that it doesn’t seem that PBMs have the same risk that a single service HMO has

• Next steps regarding this rule review:
  • Will be drafting an informal set of rules; will take around two months
  • After drafting, the rules will be sent through the approval process and will be submitted for a formal posting for further comment and questions
  • Would like the rule to be adopted by the first part of January
  • If something won’t fit into the rule it will be added as a legislative request for legislative action to be taken

• Dave Bryant asked what part of the chapter is up for review
• The entire 28 TAC, Ch. 11 for HMOs; network adequacy, policy alignment, essential benefits, rate filings, etc.