28 Tex. Admin. Code § 21.5071 - Payments to Emergency Medical Services Providers
(a) This section applies to a health benefit
plan issuer or administrator that is subject to one of the following statutes:
(1) Insurance Code §
1271.159, concerning
Non-Network Emergency Medical Services Provider;
(2) Insurance Code §
1275.054, concerning
Out-of-Network Emergency Medical Services Provider Payments;
(3) Insurance Code §
1301.166, concerning
Out-of-Network Emergency Medical Services Provider;
(4) Insurance Code §
1551.231, concerning
Out-of-Network Emergency Medical Services Provider Payments;
(5) Insurance Code §
1575.174, concerning
Out-of-Network Emergency Medical Services Provider Payments; or
(6) Insurance Code §
1579.112, concerning
Out-of-Network Emergency Medical Services Provider Payments.
(b) For a covered health care or
medical service, supply, or transport that is provided to an enrollee by an
out-of-network emergency medical services (EMS) provider, a health benefit plan
issuer or administrator must pay:
(1) for a
service or transport that originated in a political subdivision that sets,
controls, or regulates the rate, the lesser of the billed charge or the
applicable rate for that political subdivision that is published in the EMS
provider rate database established by the department and adjusted as required
in subsection (d) of this section; or
(2) if there is not a rate published in the
EMS provider rate database for the political subdivision in which the service
or transport originated, the lesser of:
(A)
the provider's billed charge; or
(B) 325% of the current Medicare rate,
including any applicable extenders or modifiers.
(c) For claims incurred during a plan year
that starts before September 1, 2024, for a claim for emergency medical
services that is provided on or after January 1, 2024, and before September 1,
2025, a health benefit plan issuer or administrator that must make a payment
consistent with subsection (b)(1) of this section must use the rate data
published in the department's EMS provider rate database for calendar year
2024.
(d) For claims incurred
during a plan year that starts on or after September 1, 2024, a health benefit
plan issuer or administrator that must make a payment consistent with
subsection (b)(1) of this section must pay the lesser of:
(1) the billed charge;
(2) the rate published in the department's
EMS provider rate database for calendar year 2024 increased by 10%;
or
(3) the rate published in the
department's EMS provider rate database for calendar year 2024 increased by the
Medicare Economic Index rate that applies to the first day of the new plan
year.
(e) Figure: 28 TAC
§
21.5071(e)
provides examples illustrating how a health benefit plan should apply published
rates to a plan year under subsection (d) of this section.
Notes
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