28 Tex. Admin. Code § 11.1611 - Out-of-Network Claims; Non-Network Physicians and Providers
(a) For an out-of-network claim for which the
enrollee is protected from balance billing under Insurance Code Chapter 1271,
concerning Benefits Provided by Health Maintenance Organizations; Evidence of
Coverage; Charges, the HMO must pay the claim according to that chapter and
Insurance Code Chapter 1467, concerning Out-of-Network Dispute Resolution, as
applicable.
(b) For an
out-of-network claim that does not fall under subsection (a) of this section,
if the services are medically necessary, covered under the plan, and not
available through a network physician or provider within the applicable network
adequacy standards, the HMO must pay the claim as required under Insurance Code
§
1271.055, concerning
Out-of-Network Services, and:
(1) facilitate
the enrollee's access to care consistent with subsection (c) of this section
and the access plan and documented plan procedures specified in §
11.1607(j) of
this title (relating to Accessibility and Availability Requirements);
and
(2) inform the enrollee of
their rights under this section, including:
(A) the out-of-network care that the enrollee
receives for the identified services will be covered under the same benefit
level as though the services were received from a network physician or provider
and will not be subject to any service area limitation;
(B) the enrollee can ask the HMO to recommend
a physician or provider that the enrollee can use without being responsible for
an amount in excess of the cost-sharing under the plan and the enrollee should
contact the HMO if they receive a balance bill;
(C) if the enrollee chooses not to use the
physician or provider the HMO recommends, they may choose to use an alternative
non-network physician or provider with the understanding that the enrollee will
be responsible for any balance bill amount the alternative non-network
physician or provider may charge in excess of the HMO's usual and customary
rate; and
(D) the amount of the
HMO's usual and customary rate for the anticipated
services.
(c)
If medically necessary covered services, other than emergency care, are not
available through a network physician or provider within the applicable network
adequacy standards, on the request of a network physician or provider the HMO
must:
(1) consistent with Insurance Code §
1271.055, process a
referral to a physician or provider within the time appropriate to the
circumstances relating to the delivery of the services and the condition of the
patient, but in no event to exceed five business days after receipt of
reasonably requested documentation;
(2) concurrent with the referral, approve a
network gap exception and facilitate access to care to ensure the enrollee can
access a physician or provider that:
(A) has
expertise in the necessary specialty;
(B) is reasonably available considering the
medical condition and location of the enrollee; and
(C) the enrollee may use without being
responsible for an amount in excess of the enrollee's cost-sharing
responsibilities for care from a network physician or
provider;
(3) if the HMO
approves a referral to a physician or provider that meets the criteria in
subsection (c)(2) of this section, the HMO must also, upon request from an
enrollee or an individual acting on behalf of an enrollee and within the time
appropriate to the circumstances, recommend at least one additional physician
or provider that meets the criteria in subsection (c)(2) of this section;
and
(4) if the HMO approves a
referral to a physician or provider that does not meet the criteria in
subsection (c)(2) of this section,
(A) the HMO
must inform the enrollee of:
(i) why the
physician or provider does not meet the criteria in subsection (c)(2) of this
section; and
(ii) the enrollee's
right to request that the HMO recommend physicians or providers that meet the
criteria; and
(B) upon
request by the enrollee or an individual acting on behalf of the enrollee and
within the time appropriate to the circumstances, the HMO must recommend a
choice of at least two physicians or providers that meet the criteria in
subsection (c)(2) of this section.
(d) After determining that a claim from a
non-network physician or provider for services provided under this section is
payable, an HMO must issue payment to the non-network physician or provider at
the usual and customary rate or at a rate agreed to by the HMO and the
non-network physician or provider. If the rate was not agreed to by the
physician or provider, the HMO must provide an explanation of benefits to the
enrollee that includes a statement that the HMO's payment is at least equal to
the usual and customary rate for the service, that the enrollee should notify
the HMO if the non-network physician or provider bills the enrollee for amounts
beyond the amount paid by the HMO, of the procedures for contacting the HMO on
receipt of a bill from the non-network physician or provider for amount beyond
the amount paid by the HMO, and the number for the department's toll-free
consumer information help line for complaints regarding payment.
(e) Any methodology used by an HMO to
calculate reimbursements of non-network physicians or providers for covered
services not available from network physicians or providers must comply with
the following:
(1) if based on claims data,
then the methodology must be based on sufficient data to constitute a
representative and statistically valid sample;
(2) any claims data underlying the
calculation must be updated no less than once per year and not include data
that is more than 3 years old; and
(3) the methodology must be consistent with
nationally recognized and generally accepted bundling edits and
logic.
(f) An HMO must
cover a clinician-administered drug under the plan's in-network benefit if it
meets the criteria under Insurance Code Chapter 1369, Subchapter Q, concerning
Clinician-Administered Drugs.
Notes
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