January 7, 2020
To the health plans of Texas:
As Texas begins the
implementation of Senate Bill 1264 to prohibit surprise billing, it is
critically important that health plans continue to take the steps necessary
to achieve the legislation’s key consumer protections.
As you know, the Texas
Department of Insurance has already put rules in place, developed an online portal for mediation and
arbitration requests, scheduled stakeholder meetings and webinars, and sent
out numerous emails with information about the new law.
TDI also will be monitoring how
health plans implement the legislation. In that regard, there are several
areas where we want to remind you of your responsibilities:
- State law requires health plans to cover medical
screenings necessary to rule out that an emergency condition exists.
- Claim denials based on a failure to meet the
prudent layperson standard for emergency care must be based on a
review of the patient’s presenting symptoms, not on the later
diagnosis code.
- Plans must meet statutory deadlines to promptly
adjudicate clean claims.
- Plans must be ready to provide accurate information
about the new law. This includes required notices about mediation and
arbitration on explanations of benefits (EOBs) and the ability to
quickly respond to questions from policyholders and contracted
providers.
We expect you to be proactive to
meet both the letter and spirit of SB 1264. Review your policies and
procedures and address potential issues quickly. We’ve created a SB 1264 page on
our website, and you can sign up on the page to get an email alert when new
events and information are posted. If you have questions or need to elevate
an issue, please email us at IDR@tdi.texas.gov.
As with any major,
transformative piece of legislation, this will require significant effort
on your part. We are prepared to work collaboratively to resolve any
issues. We appreciate your help and support as we work together to protect
consumers.
Very truly yours,
Kent C. Sullivan
Commissioner of Insurance
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