(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.
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