• Hurricane Harvey – Preauthorized Health Care, Referrals, Notification of Hospital Admissions, and Medical Necessity Reviews
  • October 10, 2017
  • Governor Greg Abbott issued a proclamation declaring a disaster due to the effects of Hurricane Harvey. The proclamation directs that all necessary measures, both public and private, as authorized under §418.017 of the Texas Government Code, be implemented to meet that threat.

    President Donald Trump issued a major disaster declaration and ordered federal aid to supplement state and local recovery efforts in the area affected by Hurricane Harvey.

    Because of the potential storm damage to local, regional, and state-wide utilities and infrastructure, many insureds, enrollees, or certificate holders could be forced to evacuate their residence locations and health care service areas. Restrictions on insureds, enrollees, or certificate holders will result in many storm victims being without necessary health care or dental services. Insureds, enrollees, or certificate holders should not be left without their necessary health care or dental services during a disaster or threat of imminent disaster. Under these circumstances, it is the opinion of the Texas Department of Insurance that all health insurance companies and health maintenance organizations should waive penalties and restrictions on insureds, certificate holders, or enrollees when these insureds, enrollees, or certificate holders obtain necessary emergency and nonemergency health and dental services out-of-network as a result of the disaster through the duration of the governor's proclamations. Additionally, health insurance companies and health maintenance organizations should not deny payment for necessary emergency and nonemergency health and dental services that are obtained out-of-network as a result of the threat of imminent disaster through the duration of the governor's proclamations.

    The storm damage will also impact physicians and providers, both in the areas that are subject to evacuation requirements and in the areas to which evacuees are relocated, thus affecting the provision of health care services and the submission of claims for those services. Insureds, enrollees, or certificate holders should have access to necessary health care and dental services during a disaster, and physicians and providers should be able to provide such care and services without concern for applicable claim filing deadlines. Under these circumstances, it is the opinion of the Texas Department of Insurance that all health insurance companies and health maintenance organizations should extend, as necessary, through the duration of the governor's proclamations, any claim-filing deadlines for providers, insureds, certificate holders, or enrollees, including those set forth in Insurance Code §§1301.102 and 843.337(a), and 28 Texas Administrative Code §21.2806(a) and §21.2819.

    The Texas Department of Insurance also reminds insurance companies and health maintenance organizations subject to the prompt payment of claims provisions of the Texas Insurance Code and the Texas Administrative Code relating to catastrophic events. These provisions allow payors that experience a catastrophic event to toll applicable prompt payment deadlines upon communicating to the Texas Department of Insurance the occurrence and circumstances of a catastrophic event. The payor's initial notice should be in writing and addressed to Managed Care Quality Assurance Mail Code 103-6A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78701-9104.

    In addition, the damage to infrastructure and the increased need for health care services may frustrate the ability of insureds, enrollees, or certificate holders to comply with health plan contractual provisions, which could result in many hurricane victims being without necessary health care or dental services. Insureds, enrollees, or certificate holders should not be left without their necessary health care or dental services during a catastrophic event. Under these circumstances, the Texas Department of Insurance is of the opinion that all insurance companies and health maintenance organizations should waive contractual restrictions that require insureds, certificate holders, or enrollees to obtain preauthorization, referrals, notification of hospital admissions, or medical necessity reviews for specified health care or dental services through the duration of the governor's proclamations.