Changing Insurances? What are considerations for specialty care? Does Texas have rules for HMO Access? Parents..Know the language and laws of Texas!

"You chose a managed care organization (MCO) because your primary doctor is in the plan's network, but later you learn that you don't have access to your longstanding specialists, who may be more important to your health care - Before selecting a plan, look at the MCO's network of providers. 

Consider whether the MCO offers you access to your specialists (such as psychiatrists or rehabilitation specialists) as well as your PCP. 

For people with disabilities, access to a specialist can be more important than access to their regular doctor. If you ask for a list of specialists, the MCO is required to give it to you."

It appears that we are going through a cycle where families may experience difficulty with specialty access.  Please learn the language health care insurance and review your rights. 

Your primary care, employer (or even the health plan) may not be aware of the difficulties that you face with access. Let them know. They can help. 

Cook Childrens' in Fort Worth compiled an excellent review.  Read More Here

Texas law provides protections by requiring
 that HMOs....

• have adequate personnel and facilities
• make covered health care services available within a certain distance of your home or workplace
• allow referrals to out-of-network doctors and hospitals when medically necessary services aren't available within the network
• allow members to change a PCP up to four times a year
• allow members with chronic, disabling, or life-threatening illnesses to use specialists as their PCPs under certain circumstances
• allow members with terminal illness, disability, life-threatening condition, or pregnancy to temporarily continue seeing doctors no longer with the network if the doctor agrees to continue treatment at the HMO's contracted rate
• pay for emergency care if not getting immediate medical care could place your health - or the health of your unborn child if you're pregnant - in serious jeopardy. If you get emergency treatment at a hospital outside the HMO's network, you may be transferred to a network doctor or hospital after your condition is stabilized.

Referrals for Specialty Care - Its your primary care providers' responsibility for managing your care.

In most HMO plans the enrollee's primary care physician (PCP) is responsible for managing the enrollee's primary, preventative, acute and chronic health care needs and for initiating any required specialist referrals.

HMO-contracted specialists are also responsible for providing covered health care services and for coordinating the enrollee's health care, which may include the reporting of the enrollee's medical status to the referring healthcare provider and/or the HMO.

From Texas Department of Insurance......

Network Availability

Q. How does an HMO deliver care?
A. An HMO delivers care by providing or arranging for health care services directly or indirectly through contracts and subcontracts with physicians, providers, and/or other HMOs.

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Q. What determines whether an HMO has an adequate health care delivery system?
A. All covered health care services that are offered by the HMO shall be sufficient in number and location to be readily available and accessible within the geographical service area to all enrollees. The HMO must have a sufficient number of primary care physicians and specialists with hospital admitting privileges at participating facilities who are available and accessible 24 hours per day, seven days per week, within the HMO's geographical service area. Additionally, an HMO shall make emergency care available and accessible 24 hours per day, seven days per week, without restrictions as to where the services are rendered.

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Q. What are the accessibility and availability requirements for an HMO?
A. An HMO is required to provide an adequate network which would consist of contracted physicians and providers for its entire geographical service area.* All covered health care services must be accessible and available to enrollees within certain travel distances. The distance from any point in the HMOs service area to a point of service can be no greater than:

• 30 miles for primary care and general hospital care; and
• 75 miles for specialty care, specialty hospitals, and single healthcare service plan physicians or providers.

An HMO must arrange and make available urgent care within:

• 24 hours for medical and dental conditions; and
• 24 hours for behavioral health conditions.

An HMO must arrange and make available routine care within:

• 3 weeks for medical conditions;
• 8 weeks for non-emergent dental conditions; and
• 2 weeks for behavioral health conditions

An HMO must arrange and make available preventive care within:

• 2 months for a child;
• 3 months for an adult; and
• 4 months for dental services.

*Geographic Service Area is defined as a geographic area within which direct service benefits are available and accessible to HMO enrollees who live, reside, or work within that geographic area.

http://www.tdi.texas.gov/hmo/mcqa/hmofaq.html#17