Below is the HillCo client report from the September 2 HHSC public hearing for proposed amendments to rules concerning a prohibition on Children's Health Insurance Program balance billing
The Texas Health and Human Services Commission (HHSC) proposes to amend §370.4, concerning Definitions, and §370.453, concerning Balance Billing, to clarify that balance billing is prohibited in the Children's Health Insurance Program (CHIP) by any network or non-network provider who provides covered medical or dental services to a CHIP member.
Public Testimony
Dr. Dick Bryant, Texas Society of Anesthesiologists
- Not testifying on these rules specifically
- Got clarification from CMS that they never said that a patient cannot be balanced billed by the provider – instead they said the beneficiary was prohibited from cost sharing that exceeds the limit in the federal law
- Texas would have to hold the patient harmless
- Either prevents balanced billing by the provider or the MCO would need to pay a reasonable and customary amount for out of network service
- Concern that the Texas got it wrong with its rulemaking – consequences if rule goes forward:
- The provider will be unduly burdened – MCO receives the premium from the state and is obligated to maintain an adequate network
- If the provider cannot balance bill, it in effect releases the insurance company from creating an adequate network
- Forces patients out of in-network providers and decreases access to care
- Asking that the rule be modified to clarify that the MCO is held liable for the difference between the rate the state allows and the amount the provider is charged – will incentivize appropriate rates
Dr. Shareef Safron, Texas Society of Anesthesiologists
- Opposition to the rule
- Federal law doesn’t prohibit a provider for billing for a service rendered, but they DO prohibit a beneficiary from having liability for the payment of the bill, and lay the responsibility square on the MCO
- MCOs are contracted by the state to provide health care to CHIP enrollees in order to receive premium payments – then the MCOs pay providers under a capitated model
- This law is saying that it will not keeping MCOs accountable to their contractual obligation to maintain adequate networks and deliver efficient health care
- The state will artificially set the rates for in and out-of-network providers
- Robs MCOS of any kind of incentives
- Texas Children’s Hospital in Houston is very large provider to CHIP patients and the Greater Houston Anesthesiology provides a significant amount of care to their patients
- When they were negotiating their CHIP product, they were told it was a set rate and that they would just have to accept it
- Very low, based on a percentage of Medicaid rates which is significantly below market value
- Texas Children’s believe that balanced billing is not an option, and they did not offer any contractually obligated option to make the patient whole by holding them harmless
- The Anesthesiologist was not going to bill the patient the difference so there was no negotiation
- Sets a very poor precedent
James Cullington, Texas Society of Plastic Surgeons
- Poor patients should be held harmless
- The difference in rates between managed care and regular Medicaid makes no sense
- Need standardization based off usual and customary rates
- This will incentivize a network to develop with usual and customary rate reimbursements
- Happy to work with HHSC to find a better process