2015 Health Insurance Consumer Legislative Update

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In 2015, the Texas Legislature passed a number of bills that will directly affect your health insurance benefits.

 

SB 481.  This bill is the most significant change and it affects your rights when you receive a bill from certain hospital providers.  SB 481 permits you to request mediation if you receive a bill over $500 from an out-of-network facility-based physician.  In practical terms, this means that if you receive a bill for over $500 from an out-of-network physician for an emergency room visit, you can contact the Texas Department of Insurance to mediate the claim.

 

There are a few important caveats that you should be aware of before you request mediation. 

 

 

1)  The bill must be over $500 after you have met your cost-sharing responsibilities (deductible, copay, and/or coinsurance).

 

2)  The mediation program does not extend to self-funded ERISA plans or indemnity plans since those are governed by federal, not state, law.

 

In addition to SB 481, you should also be aware of the new laws below and how they affect your benefits:

 

HB 1621 requires your health benefit plan to continue to cover contested services during a concurrent utilization review.  The utilization review agent must notify you of an adverse determination regarding your benefits at least 30 days before your plan stops paying for your services.

 

HB 1624 requires health benefit plans to display formulary information conspicuously on their website.  Formulary information includes the type of prescriptions drugs covered under the pland the price for each drug.  Ready access to formulary information can help you better estimate out-of-pocket costs for your prescription drugs. The law also requires insurers to keep their physician directories up to date.  This will help you when you are looking for a new doctor in your existing plan and let you know what doctors are available when you are shopping for a new plan.

 

HB 2813 requires health benefit plans to cover CA 125 tests for the early detection of ovarian cancer. Your doctor can tell you if this test is appropriate for you.

 

SB 425 requires freestanding emergency medical care facilities to notify you that the facility is a freestanding emergency medical care facility and that it charges rates comparable to a hospital emergency room.  It also must notify you that the facility or the provider who sees you may not be an in-network provider.  Freestanding emergency medical centers (also known as freestanding ERs) can be much more convenient than a hospital ER in an emergency.  However, to avoid the high cost of emergency room care in a non-emergency care situation, plan in advance by locating the nearest in-network urgent care centers.

 

 

 

 

I joined OPIC as a staff attorney in 2011.  I specialize in life, health, and disability insurance law.  I know that consumers can find themselves frustrated with these insurance issues at very difficult times in their lives—during sickness, after an injury, and after the loss of a loved one.  I am grateful that I can utilize my expertise to educate and empower insurance consumers as they navigate these challenges.