• 2017 Guide thumbnail

    2017 Comparing thumbnailOPIC'S 2017 HMO Reports Available

    The Office of Public Insurance Counsel released its annual HMO reports Comparing Texas HMOs 2017 and Guide to Texas HMO Quality 2017. The reports review plan members' satisfaction with aspects of their HMO and basic services covered by the HMO.

Health Highlights

What the Fifth Circuit’s Decision in Ariana M. v. Humana Means for Texas Consumers

  • Texans who receive health insurance coverage through ERISA plans, which includes employees of most large and mid-sized companies, will likely have more of their claims covered as the result of a recent decision by the U.S. Court of Appeals for the Fifth Circuit (Fifth Circuit).

  • When an ERISA plan administrator denies a claim, the consumer has a right to appeal that decision for further review by the insurer and eventually a Texas district court.

  • The Fifth Circuit overturned a previous decision that required Texas district courts to defer to the ERISA plan’s factual determinations when there is an appeal of a claim denial. Factual determinations in these kinds of cases often involve disagreements over whether a person needs medical care and/or how long a person needs medical care, and whether the ERISA plan should pay for that medical care.

  • Texas district courts will no longer defer to ERISA plan administrators on these decisions about medical treatment and other factual issues. Instead, the Texas district courts will now perform their own independent review (a de novo review) of these cases. This change will improve the patient’s chance of success in getting claims paid when their doctor disagrees with an ERISA plan’s decision to deny a claim for medical treatment.

  • The Office of Public Insurance Counsel (OPIC) and Texas Department of Insurance (TDI) submitted amicus briefs in support of Texas consumers’ right to have the medical opinions of their doctors fully reviewed by an objective third party.

Read the decision here.
Read OPIC’s amicus brief here.
Read an article about the decision here.

Mediation Process for "Balance Billing" Expanded in Texas

Senate Bill 507 by Senator Kelly Hancock expanded the availability of mediation for the settlement of certain out-of-network claims involving balance billing. For claims for health care or medical services or supplies provided after January 1, 2018, the bill:
  • Allows mediation for emergency care balance bills over $500 at any healthcare facility, regardless of network status.
  • Expands the scope of mediation to all types of out-of-network providers treating patients at in-network hospitals and other facilities, including freestanding emergency departments.
  • Extends the mediation option to individuals who receive coverage through the Teachers Retirement System of Texas. Previously, only enrollees in the Employees Retirement System of Texas or individuals enrolled in health plans regulated by the Texas Department of Insurance were eligible for mediation.
  • Requires health care providers and other facilities to include a statement on eligible balance bills informing consumers of the mediation process and that they may be able to reduce out-of-pocket costs for an out-of-network claim by contacting the Texas Department of Insurance (TDI).

Health plans regulated by TDI will include either "DOI" or "TDI" on their health insurance cards.
The complete text of Senate Bill 507 is available here.
A copy of the form to request mediation is available here.