1

August 27, 2010

Mr. Jim Mayhew

Office of Consumer Information and Insurance Oversight

Department of Health and Human Services

Attention: OCIIO-994-IFC

P.O. Box 8016

Baltimore, MD 21244-1850

RIN 0991-AB69 

Re: Patient Protection and Affordable Care Act: Preexisting Condition Exclusions, Lifetime and 

Annual Limits, Rescissions, and Patient Protections; Final Rule and Proposed Rule; as published in 

the Federal Register on June 28, 2010.

Dear Mr. Mayhew:

The Texas Medical Association (TMA) appreciates this opportunity to comment on proposed 

regulations relating to restrictions on rescissions and health plan coverage of out-of-network

emergency services, which are statutorily authorized under Sections 2712 and 2719A of the Public 

Health Services Act, respectively, as amended by the Patient Protection and Affordable Care Act

(PPACA). 

TMA is a private voluntary, nonprofit association of Texas physicians and medical students. TMA 

was founded in 1853 to serve the people of Texas in matters of medical care, prevention and cure of 

disease, and improvement of public health. Today, its mission is to “Improve the health of all 

Texans.” Its almost 46,000 members practice in all fields of medical specialization. It is located in 

Austin and has 119 component county medical societies around the state. 

TMA has a keen interest in advocating for consumer and patient protection laws promoting fairness

and transparency in the health insurance industry. Establishing protections against unjustified (i.e., 

non-fraud induced) rescissions at the state level has been a legislative priority for TMA in the past 

as part of its proposed Health Insurance Code of Conduct reforms. Accordingly, TMA strongly 

contends that establishing meaningful protections against unwarranted rescissions (at both the 

federal and state level) is vital to ensuring that consumers/patients: (1) have health insurance 

coverage upon which they may rely, (2) are not unfairly penalized for unintentional errors or 

omissions contained within their insurance applications, and (3) are not unfairly penalized for a 

historical diagnosis unrelated to the current condition upon which the rescission was initiated. 

Additionally, TMA has long-recognized the need for patient access to and health plan coverage of 

emergency services. Thus, TMA generally supports patient protections directed at broadening 

patient coverage for emergency services; however, TMA urges the Department of Health and 
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Human Services’ (DHHS), Department of Labor, and Department of the Treasury: (1) to be 

circumspect in formulating and implementing the cost-sharing protections stemming from Section 

2719A of the Public Health Services Act and (2) to continue to acknowledge the vitally important 

need for retention of the physician’s right to balance bill for his services (as discussed in more 

detail below).

TMA appreciates the Departments’ efforts in drafting its request for comments and in appropriately 

seeking and considering stakeholder responses regarding restrictions on rescissions and patient 

protections pertaining to out-of-network coverage for emergency services. TMA, therefore,

respectfully offers the following comments on the proposed and final rules on rescissions and outof-network emergency services coverage, as published in the Federal Register on June 28, 2010.

I. Prohibition on Rescissions (26 CFR 54.9815-2712T, 29 CFR 2590.715-2712, 45 

CFR 147.128)1

First, TMA strongly agrees with the Departments’ statements and findings regarding the need for 

protections against non-fraud related rescissions of health insurance coverage, as set forth in the 

preamble to the rules. Robust protections from unwarranted rescissions are necessary to protect

individuals who might otherwise be subjected to rescissions each year (i.e., approximately 10,700 

people) from the financial devastation that often accompanies the sudden and unexpected loss of 

health insurance coverage.

2

 As the preamble to the proposed rule states “these ... regulations 

implement the statutory provision enacted by Congress to protect the most vulnerable Americans, 

those that incur substantial medical expenses due to a serious medical condition ... by ensuring that 

such individuals do not unjustly lose health coverage by a rescission.”3

Notably, the statutory provisions and the rules provide two main protections to consumers: (1) a 

requirement that the plan provide notice to the covered person prior to rescinding coverage and (2) 

a requirement that rescissions be limited to instances of fraud and intentional misrepresentation. 

Section 2712 of the Public Health Services Act does not specify a particular timeframe for the 

notice requirement. TMA, however, supports the Departments’ promulgation of a minimum notice 

period of 30 calendar days, as contained within 45 CFR 147.128(a). TMA strongly contends that

the inclusion of a reasonable notice period in the rules is important to effectuating the consumer 

protection-driven intent of the law. Without a sufficient notice period, consumers may be faced 

with an immediate interruption in health insurance coverage without adequate, if any, warning. 

Such an interruption could be devastating to an individual’s finances, since the insurer would no 

longer be responsible for the consumer’s medical claims (including those claims that had previously 

been accepted and/or paid). Additionally, the interruption in coverage could detrimentally affect 

the individual’s health if he or she foregoes necessary treatment during that period.

4

 Thus, it is 

 

1 Note that that all references in this letter referring to 45 CFR 147.128 apply to the corresponding language contained 

within 26 CFR 54.9815-2712T and 29 CFR 2590.715-2712.

2 Note that this number is cited in the preamble to the rules. See 75 Fed. Reg. 37208 in which it states that “the NAIC 

Regulatory Framework Task Force collected data on 52 companies covering the period 2004-2008, and found that 

rescissions averaged 1.46 per thousand policies in force. This estimate implies that there are approximately 10,700 

rescissions per year.”

3

75 Fed. Reg. 37198.

4

See 75 Fed. Reg. 37208-37209, stating “Gaps in health insurance, even if brief, can have significant health and 

financial consequences. A survey from the Commonwealth Fund found that about three of five adults with any time 

uninsured said they had not received needed health care in the past year because of costs—more than two times the rate 
3

imperative that individuals be afforded sufficient time to contest a rescission or to explore other 

options for coverage while the plan is considering rescinding coverage. The 30-calendar-day notice 

requirement of 45 CFR 147.128(a) provides the individual with much-needed time to prepare for 

any rescission-related fallout. Any period of time less than 30 days would be insufficient for the 

individual to seek alternate coverage and would, therefore, be unreasonable.

Next, TMA supports the Department’s conclusion concerning rescissions as expressed in Example 

1 in 45 CFR 147.128(a)(3). In Example 1, the Department establishes a scenario under which a 

plan rescinds coverage after an individual is diagnosed with breast cancer. The insurer’s decision 

to rescind is based upon the individual’s failure to disclose (in a medical history questionnaire that 

asked “is there anything else relevant to your health that we should know”) visits with a 

psychologist that occurred six years prior to the individual’s breast cancer diagnosis. The rule states 

that rescinding coverage under this set of facts would be improper, because the individual’s failure 

to disclose the psychologist visits was inadvertent. Further, the rule concludes: “Therefore, it was 

not fraudulent or an intentional misrepresentation of material fact.” TMA supports this 

interpretation and application of the rule’s fraud and “intentional misrepresentation” language. The 

conclusion to Example 1 provides valuable guidance to insurers regarding the Departments’ 

position on the scope of the rescission restrictions and ensures that consumers are not subject to 

rescissions based upon innocent errors or omissions (i.e., representations made without the intent to 

deceive the insurer). 

Additionally, TMA supports the language in the preamble acknowledging a history of “some 

questionable practices ... [in the area of rescissions] including insurance companies rescinding 

coverage even when discrepancies are unintentional or caused by others, for conditions that are 

unknown to policyholders, and for discrepancies unrelated to medical conditions for which patients 

sought medical care.”5 (emphasis added). Importantly, the proposed rules address each of the 

listed “questionable practices,” with the exception of the last practice (i.e, rescissions based upon 

discrepancies unrelated to the medical condition for which the patient sought care). In order to 

address this concern, TMA recommends that the Departments clarify that an insurer is prohibited 

from rescinding coverage unless the intentional misrepresentation of material fact occurring in the 

application is directly related to the individual’s medical claim(s). To illustrate this point, in 

Example 1, the plan could only rescind coverage if the patient’s omission was related to a past 

history with breast cancer.6

 

of adults who were insured all year. Further 44 percent of respondents who had experienced any coverage break 

during the prior year said they had failed to go to a doctor or a clinic when they had a medical problem because of 

costs, compared with 15 percent of adults who did not experience such breaks.”

5

75 Fed. Reg. 37208.

6 Note that allegations of rescissions based upon omissions completely unrelated to the current diagnosis have occurred 

in Texas, as well as other states. For example, as noted in a January 23, 2009 TMA press release: “The Fort Worth 

Star-Telegram reported last summer about a Waxahachie woman who was diagnosed with breast cancer and was 

scheduled for a double mastectomy. But days before the surgery her insurance company, Blue Cross and Blue Shield of 

Texas, canceled her insurance. Its reason? She did not disclose a prior medical condition — acne — on her insurance 

application. She asked her congressman for help. Months later, at the congressman’s urging, Blue Cross reinstated the 

patient’s insurance, and she rescheduled her surgery. A spokeswoman for Blue Cross said health privacy laws limit her 

ability to discuss the patient’s situation. But she told the Star-Telegram that patients have a right to appeal policy 

cancellations. Meanwhile, the Waxahachie patient believes her delay in care caused by her health insurer’s red tape 

may eventually cost her life.” See http://www.texmed.org/Template.aspx?id=7411
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Finally, TMA notes that Section 2712 of the Public Health Services Act and the proposed rules seek 

to provide a basic level of protection from unjust rescissions (i.e., those rescissions that are not 

grounded upon fraud or intentional misrepresentations made in the completion of insurance 

applications). Given the fundamental nature of the protections afforded under Section 2712 of the 

Public Health Services Act and the attendant rules, it is quite possible that state laws may impose 

rescission-related consumer protection measures that exceed the new federal requirements. To 

ensure that insurers properly conduct their underwriting prior to issuance of coverage, rather than 

engaging in the type of “post-claims underwriting”7that sometimes occurs with rescissions, it is 

imperative that any more stringent state laws (including common law) continue be given full effect

(even after the effective date of the federal rules). To that end, TMA strongly supports the 

Departments’ inclusion of an express provision in the rules (i.e., 45 CFR 147.128(b)) sanctioning

the applicability of other more stringent state law, as well as other federal law. 45 CFR 147.128(b) 

is important, because it clarifies the Department’s intent to create a federal floor, rather than a 

ceiling with regard to its restrictions on rescissions. 

II. Patient Protections (26 CFR 54.9815-2719AT, 29 CFR 2590.715-2719A, and 45 

CFR 147.138)8

A. General Rules Regarding Prior Authorizations/Out-of-Network Payments (45 CFR 

147.138(b)(2))

Next, Section 45 CFR 147.138(b)(2) of the rules requires non-grandfathered group health plans 

(and/or health insurance issuers offering group or individual health insurance) that provide

emergency services benefits to provide coverage for emergency services: (1) without the need for a 

prior authorization (even for out-of-network services) and (2) without regard to whether the health 

care provider is a participating network provider. TMA supports these basic emergency service 

coverage requirements. These provisions of the rule largely track the underlying law (i.e., Section 

2719A) and are important steps towards ensuring that many patients have basic insurance coverage 

for emergency services without being penalized for a plan’s inadequate networks and/or utilizing a 

non-plan participating provider. 

Additionally, the rule ensures that the patient’s access to benefits for emergency services is not 

mired with undue or cumbersome administrative burdens (such as prior authorization requirements

imposed either in or out-of-network). As stated in the preamble, “these provisions will ensure that 

patients get [access to benefits for] emergency care when they need it, especially in situations 

where prior authorization cannot be obtained due to exigent circumstances or an in-network 

provider is not available to provide the services.”

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In emergencies, time is often of the essence. Patients do not always have sufficient time to adhere 

to a plan’s requirements for prior authorizations, confirm the provider’s in-network status, or locate

(or delay treatment for) an available in-network provider. Section 2719A of the Public Health 

Services Act and the proposed rules properly acknowledge and attempt to address the financial 

 

7

See 75 Fed. Reg. 37208. 

8 Note that all references in this letter referring to 45 CFR 147.138 apply to the corresponding language in 26 CFR 

54.9815-2719AT and 29 CFR 2590.715-2719A.

9

See 75 Fed. Reg. 37198. 
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implications associated with this timing issue; thereby recognizing the primacy of patient access to 

benefits for emergency medical care over the plan’s administrative requirements.

Further, TMA House of Delegates’ policy10 supports the notion of requiring health plans to provide 

fair payment for services rendered under the Emergency Medical Treatment and Labor Act 

mandate (without limiting or restricted balance billing for out-of-network services).

11

 Removing 

prior authorization barriers and extending coverage to care provided by out-of-network providers 

are important steps towards this end (by at least ensuring some payment from the health plan). 

Section (b)(3) of the proposed rules, however, touches upon the fairness of that payment and the 

continued need for and right to balance bill (as discussed more fully below).

B. Cost-sharing Requirements (45 CFR 147.138 (b)(3)) 

TMA supports Section 2719A(b)(1)(C)(ii)(II) of the Public Health Services Act, as amended by 

PPACA, which requires health plans to apply the same cost-sharing requirements (i.e., coinsurance 

and copayments) for emergency services provided out-of-network as the cost-sharing that would be

applied if the services were provided in-network. Additionally, TMA supports the basic goal of 

Section 2719A and of the rule’s cost-sharing requirements, which is to alleviate some of the 

financial burden that patients incur when plans impose differing cost-sharing requirements for innetwork and out-of-network emergency services. 

As the preamble to the rule acknowledges:

Implementing reduced cost sharing for the use of in-network providers provides 

financial incentive for enrollees to use these providers, with whom plans often have 

lower-cost contractual arrangements. In emergency situations, however, the choice 

of an in-network provider may not be available—for example, when a patient is 

some distance from his or her local provider networks or when an ambulance 

transports a patient to the nearest hospital which may not have contractual 

arrangements with the person’s insurer. In these situations, the differing copayment 

or coninsurance arrangements could place a substantial financial burden on the 

patient. These ... regulations eliminate this disparity in out-of-pocket burden for 

enrollees, leading to potentially substantial financial benefit.12 

Certainly, the goal of creating cost-sharing requirements that do not penalize patients for utilizing 

out-of-network emergency services is laudable. However, TMA strongly encourages the 

Department to carefully consider the best and most appropriate means of achieving this goal, as set 

forth in its proposed regulations.

 

10 TMA House of Delegates Policy. 130.019 Emergency Medical Treatment and Active Labor Act: The Texas Medical 

Association supports requirements for health care payment plans to provide fair payment for services rendered under 

the Emergency Medical Treatment and Active Labor Act mandate and opposes efforts to limit or restrict balance billing 

of patients for out-of-network physician services (Amended Res. 402-A-09).

11 Note that, as acknowledged in the preamble to the rule, “In applying the rules relating to emergency services, the 

statute and these interim final regulations define the terms emergency medical condition, emergency services and 

stabilize. These terms are defined generally in accordance with their meaning under Emergency Medical Treatment

and Labor Act (EMTALA), section 1867 of the Social Security Act. There are, however, some variances from the 

EMTALA definitions.” See 75 Fed. Reg. 37212.

12 75 Fed. Reg. 37214.
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1. Balance Billing (45 CFR 147.138 (b)(3)(i))

First, TMA applauds the Department for appropriately recognizing that the provider’s right to 

balance bill is unaffected by the cost-sharing limitations imposed on plans under Section 2719A of 

the Public Health Services Act. Further, TMA supports the inclusion of express language

safeguarding the provider’s right to balance bill, as included in the rule. Specifically, the rule 

states:

Any cost-sharing requirement expressed as a copayment amount or co-insurance rate 

imposed with respect to a participant, beneficiary, or enrollee for out-of-network 

emergency services cannot exceed the cost-sharing requirement imposed with 

respect to a participant, beneficiary, or enrollee if the services were provided innetwork. However, a participant, beneficiary, or enrollee may be required to pay, in 

addition to the in-network cost sharing, the excess of the amount the out-of-network 

provider charges over the amount the plan or issuer is required to pay under this 

paragraph (b)(3)(i). (emphasis added).

The aforementioned italicized language, contained within the rule, properly acknowledges the 

legislative intent that balance billing not be considered part of the participant’s cost-sharing that is 

restricted under the law. Section 2719A of the Public Health Services Act specifically identifies

coinsurance and copayments when referring to cost-sharing. Additionally, as properly 

acknowledged in the preamble to the rule, “Section 1302(c)(3)(B) of the Affordable Care Act 

excludes such balance billing amounts from the definition of cost sharing...” Thus, the plain 

language of the underlying law evinces a clear intent to protect the provider’s ability to bill for the 

difference between his charges and the amounts collected from the participant in the form of 

coinsurance/copayments and the plan in the form of at least the minimum out-of-network payment

mandated by the rule.

Further public policy supports the continued ability for physicians to balance bill. Without 

safeguarding the physician’s ability to balance bill, the physician would be forced to accept the 

minimums established by the regulations. The regulations would, therefore, effectively act in the 

capacity of a de facto involuntary contract for out-of-network services and severely restrict the 

physician’s ability to set a value for his own services. It is imperative that the Departments 

recognize that physicians must act as any other rational business decisionmaker and evaluate 

whether to sign a health plan’s contract based upon the terms and rates offered by each plan. The 

physician’s acceptance of a given contract will depend upon many factors, including the 

reasonableness of the plan’s offer and the revenue needed by the physician to pay overhead 

expenses. Without the ability to make such an assessment and to set his own rates (i.e., to balance 

bill), a physician may simply be unable to sustain his practice. As the diagram below illustrates, 

Medicare rates have not kept pace with physician practice operating costs.
7

Trends in Practice Expense – From 1992

Sources: Percent change from 1992 calculated from average multispecialty practice cost reported in annual MGMA 

Cost Reports, from the Consumer Price Index – All Urban Consumers published by the U. S Dept of Labor and from 

the conversion factors applied in the Medicare physician fee schedule by the U.S. Dept.of Health and Human 

Services, Center for Medicare and Medicaid Services.

Consequently, mandating that health plans pay a minimum for out-of-network emergency services 

(e.g., the greatest of discounted in-network rates, Medicare rates, or the plan’s usual, customary and 

reasonable rate) and simultaneously restricting the physician’s ability to balance bill would likely

negatively impact the overall supply of available physicians. Further, the plans would have little, if 

any, incentive to create a network or offer reasonable contracts to physicians. Certainly, decreasing 

the supply of physicians is not the result intended by this consumer protection law (nor is any

restriction on balance billing specifically contemplated by the law, as previously noted). Thus, 

TMA strongly supports the Departments’ inclusion of the language expressly recognizing the 

physician’s continued and unrestricted ability to balance bill the patient for his charges that are in 

excess of the plan’s minimum out-of-network payment and the participant’s copayments and 

coinsurance. Further, TMA urges the Department to retain the language of 45 CFR 

147.138(b)(3)(i) as it relates to balance billing.

2. Minimum Out-of-Network Payments (45 CFR 147.138(b)(3)(A)-(C))

Next, the preamble to the rule states that because “it would defeat the purpose of the protections in 

the statute if a plan or issuer paid an unreasonably low amount to a provider, even while limiting 

the coinsurance or copayment associated with that amount to in-network amounts,” the rule 

establishes a minimum “reasonable amount to be paid for services by some objective standard.”13

The “objective standards” established by the rule include the greatest of three possible amounts, 

namely: (1) the amount (or median of the amount) negotiated with in-network providers for the 

emergency services furnished; (2) the amount for the emergency service calculated using the same 

method the plan generally uses to determine payments for out-of-network services (such as usual, 

customary and reasonable charges), but substituting the in-network cost-sharing provisions for the 

 

13 75 Fed. Reg. 37194.
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out-of-network cost-sharing provisions; and (3) the amount that would be paid under Medicare for 

the emergency services.14

While, as previously stated, TMA supports “requirements for health care payment plans to provide 

fair payment for services rendered under the Emergency Medical Treatment and Active Labor Act” 

and TMA appreciates the Departments’ efforts to establish a minimum “reasonable amount” to be 

paid by plans and insurers, we have concerns with the three amounts delineated in the rule (even 

if—as the rule correctly specifies—the amounts are used as a floor (not a ceiling) for plan payments

and the physician is still permitted to balance bill without limitation).

First, it should be noted that two of the three rates contained within 45 CFR 147.138(b)(3)(A)-(C) 

are largely within the plan’s control and are, therefore, subject to plan data manipulation. Clearly, 

the plan makes the ultimate decision on what rates to accept in-network under the first methodology 

(i.e., Section 147.138(b)(3)(A)). Additionally, the second methodology (i.e., use of the usual, 

customary, and reasonable (UCR) amount) is determined solely by the plan based upon internal 

and/or external data sources available to the carriers. Recent events related to the use of one

external data source, Ingenix, a wholly-owned subsidiary of UnitedHealth Group, illustrate the 

inherent conflicts that may characterize and problems that may plague insurer-determined out-ofnetwork payment amounts. In 2008, Ingenix was the subject of an investigation by the New York 

Attorney General Andrew Cuomo (and a later lawsuit initiated by the American Medical

Association). Upon completing his investigation, the Attorney General determined that rates 

established under Ingenix had been unfairly set, and many insurers subsequently agreed to 

discontinue use of the Ingenix database upon the establishment of a new independent database.

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Thus, insurer-controlled measures have been demonstrated to lack reliability or objectivity as 

indicators of what is a “reasonable” amount for a plan to pay providers for out-of-network 

emergency services (even if the plan must pay the greatest of the three computations). TMA, 

however, appreciates the Departments’ efforts to reduce gaming of these computations by (1) 

requiring use of the median of the in-network rates (rather than the average, which is more easily 

affected by outliers) and (2) prohibiting further reduction of the UCR by disallowing reductions for 

out-of-network cost sharing that generally apply under the plan or health insurance coverage with 

respect to out-of-network services.

16

 However, it is important to note, at the present time, due to 

the position taken by most carriers that their method of calculating payments (e.g., UCR) is 

proprietary data, the plans still have ultimate control over these methodologies and there is little or 

no transparency associated with these numbers. Thus, the payments cannot be properly reviewed 

by the consumer or the provider to ensure that the plan is, in fact, complying with the rule and 

paying (at a minimum) the greatest of the three computations in Section 147.138(b)(3).

Next, TMA supports the Departments’ desire to include a method for calculating the minimum outof-network payment that is independent of the plans, as intended with the inclusion of Section 

147.138(b)(3)(C). TMA agrees that it is critical that the rule contain a method for calculating outof-network payments that is easily quantifiable, publicly available, and independently formulated so 

that a true, transparent floor for out-of-network payments for emergency services may be

 

14 Id.

15See Emily Berry, “New database for out-of-network pay set to replace disputed Ingenix system,” American Medical News, 

Nov. 9, 2009, available at: http://www.ama-assn.org/amednews/2009/11/09/bil21109.htm

16 See Section 147.138(b)(3)(B).
9

established. Finding the appropriate methodology, however, is easier said than done. At the 

present time, Medicare appears to be the only method of computation that even attempts to meet the 

aforementioned description. However, it is important to note that Medicare is not a reflection of 

prevailing market rates for out-of-network emergency services. Medicare rates fluctuate based 

upon political factors and other factors entirely unrelated to the commercial insurance market. The 

ever-present, recurring threat of 21% cuts related to the Sustainable Growth Rate (SGR) is

illustrative of the clear and growing disconnect between and among Medicare, the commercial 

insurance market, and the costs that medical practices incur when treating patients.

Further, the Medicare rates referenced in the rule lack the specificity necessary to provide guidance 

to plans/issuers and providers as to the true basis for the Medicare-determined component of the 

floor established by the rules. The regulations include the basic citation for the Medicare payment 

provisions (i.e., part A or part B of title XVIII of the Social Security Act, 42 U.S.C. 1395 et seq.). 

Presumably, the Departments are referring to 100% of the participating provider’s Medicare fee 

schedule, as contained within Part A and B. However, it is important for the Departments to note 

that other fee schedules references are included within the general citation, such as the nonparticipating provider fee schedule (i.e., a limiting charge of 115% of 95% Medicare fee schedule 

contained within 42 U.S.C.1395w-4). Thus, TMA seeks clarification as to the Department’s 

intended application of the provider fee schedule.

Given all of the aforementioned difficulties associated with using Medicare as one of the amounts 

for establishing a floor for out-of-network emergency services payments, TMA stresses the 

importance of the Department revisiting this issue as more information regarding out-of-network 

rates becomes publicly available and other independent databases, such as the FAIR (Fair and 

Independent Research) Health Database (resulting from the settlement over Ingenix’s alleged 

abuses) become operational.

Finally, to ensure plan/issuer compliance with the emergency services’ coverage and payment 

provisions of the rule, TMA recommends that the DHHS regularly audit the determinations of outof-network payment minimums, mandate reporting of such minimums, and require such reporting 

to be updated on a quarterly basis. These actions would provide much-needed transparency to the 

process.

III. Conclusion

Once again, TMA thanks you for the opportunity to provide these comments. If you should have 

any questions or need any additional information, please do not hesitate to contact me or the 

following staff of the Texas Medical Association: Lee A. Spangler, JD, TMA Vice President, 

Division of Medical Economics; Patricia Kolodzey, TMA Associate Director, Legislative Affairs; 

or Kelly Walla, JD, LLM, TMA Associate General Counsel at TMA’s main number 512-370-1300.

Sincerely,

Susan Bailey, MD
10

President

Texas Medical Association