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[UPDATE 4-4-2019]

It pays to stand up for your rights. The Patient Choice Coalition of Texas has reported that is has achieved a major victory for the first major test for House Bill 574 codified in the Texas Insurance Code in chapters 1301 and 843. According to PCCOT, Aetna has already sent out letters rescinding their action (again) to many providers who protested the delisting through the coalition. It is not yet clear what will happen to providers of plan members of certain self-funded Aetna plans who failed to exercise their rights under Texas law and their in-network agreement.

Delisting of Texas Providers

The Patient Choice Coalition of Texas (PCCOT) has reported that in late fall of 2018, over 3,000 healthcare providers across the state of Texas began to receive threatening letters informing them that effective January 1, 2019, the targeted providers would no longer participate in certain network plans. The reason? These letters stated "because you frequently refer to providers who do not participate in [the network]".

The Patient Choice Coalition of Texas (PCCOT) has reported that in late fall of 2018, over 3,000 healthcare providers across the state of Texas began to receive threatening letters informing them that effective January 1, 2019, the targeted providers would no longer participate in certain network plans. The reason? These letters stated "because you frequently refer to providers who do not participate in [the network]".

"…because you frequently refer to providers who do not participate in [the network]"

Aetna delisting letter.

If you are an Aetna plan member with out-of-network benefits in the State of Texas, you should be worried that your access to providers is being squeezed at all angles, this time, at point of referral.

Patient Rights Under Texas Law

In September of 2015, the Texas state legislature passed landmark protections of patients in accessing the healthcare providers they trust under their paid health plans. House Bill 574 codified in the Texas Insurance Code in chapters 1301 and 843 provided simple, yet effective safeguards to prohibit insurance companies to engage in retaliatory actions against healthcare providers when patients choose to use their out-of-network benefits.

Section 1301.0058 of the Texas Insurance Code is applicable here:

PROTECTED COMMUNICATIONS BY PREFERRED PROVIDERS.

(a) An insurer may not in any manner prohibit, attempt to prohibit, penalize, terminate, or otherwise restrict a preferred provider from communicating with an insured about the availability of out-of-network
providers for the provision of the insured's medical or health care services.

(b) An insurer may not terminate the contract of or otherwise penalize a preferred provider solely because the provider's patients use out-of-network providers for medical or health care services.

Aetna Backpedals

Since the letters went out in fall of 2018, some providers have reported receiving letters that rescinded the delisting altogether, but others received a follow-up letter stating that the delisting would only apply to self-funded plans. This position obviously being presented as a means to circumvent the legislative intent by suggesting that the Texas Insurance Code's protection of Texas citizens are preempted by Federal law. It is well established that ERISA and other Federal law does in fact preempt certain state law, but it is hard to believe that a court would allow these aggressive tactics by some insurance payers to go unchecked.

As of the publishing of this post, PCCOT has also reported some providers have been given a "reprieve" until April 1, 2019. The reason for the delay seems unclear, but patient advocates in this great state of Texas and around the country are hoping that these acts of intimidation and punishment of patients for accessing benefits that they already paid for is stifled.

Nasir Pasha, Esq.

By

Nasir N. Pasha is the managing attorney of Pasha Law, providing essential legal services and support to businesses and corporations in California, Illinois, New York, and Texas. He oversees all of the firm’s operations and is a pivotal force in maintaining client relationships and ensuring that each transaction is brought to its best possible conclusion.

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