| (a) For an out-of-network claim for which the insured
is protected from balance billing under Insurance Code Chapter 1301,
concerning Preferred Provider Benefit Plans, or when no preferred
provider is reasonably available, an insurer must pay the claim at
the preferred level of coverage, including with respect to any applicable
copay, coinsurance, deductible, or maximum out-of-pocket amount. The
insurer must pay the claim according to the following payment standards:
(1) for emergency care and post-emergency stabilization
care, the applicable payment standards are under §1301.0053,
concerning Exclusive Provider Benefit Plans: Emergency Care; and §1301.155,
concerning Emergency Care;
(2) for certain care provided in a health care facility,
the applicable payment standards are under §1301.164, concerning
Out-of-Network Facility-Based Providers;
(3) for certain diagnostic imaging or laboratory services
performed in connection with care provided by a preferred provider,
the applicable payment standards are under §1301.165, concerning
Out-of-Network Diagnostic Imaging Provider or Laboratory Service Provider;
(4) until August 31, 2025, for certain services and
transports provided by an emergency medical services provider, other
than air ambulance, the applicable payment standards are under §1301.166,
concerning Out-of-Network Emergency Medical Services Provider; and
(5) for services provided by a nonpreferred provider
when a preferred provider is not available within the network adequacy
standards established in §3.3704(f) of this title (relating to
Freedom of Choice; Availability of Preferred Providers), the applicable
payment standards are under Insurance Code §1301.005, concerning
Availability of Preferred Providers; Service Area Limitations, and
Insurance Code §1301.0052, concerning Exclusive Provider Benefit
Plans: Referrals for Medically Necessary Services.
(b) If medically necessary covered services are not
available through a preferred provider within the network adequacy
standards under §3.3704(f) of this title (relating to Network
Requirements) and the services are not subject to subsection (a)(1)
- (4) of this section, the insurer must:
(1) for a preferred or exclusive provider benefit plan:
(A) facilitate the insured's access to care consistent
with the access plan and documented plan procedures specified in §3.3707(j)
of this title (relating to Waiver Due to Failure to Contract in Local
Markets); and
(B) inform the insured that:
(i) the out-of-network care the insured receives for
the identified services will be covered under the preferred level
of coverage with respect to any applicable cost-sharing and will not
be subject to any service area limitation;
(ii) the insured can choose to use a physician or provider
recommended by the insurer without being responsible for an amount
in excess of the cost sharing under the plan, or an alternative nonpreferred
provider chosen by the insured, with the understanding that the insured
will be responsible for any balance bill amount the alternative nonpreferred
provider may charge in excess of the insurer's reimbursement rate;
and
(iii) the amount the insurer will reimburse for the
anticipated services.
(2) for an exclusive provider plan:
(A) process a referral to a nonpreferred 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; and
(B) provide for a review by a physician or provider
with expertise in the same specialty as or a specialty similar to
the type of physician or provider to whom a referral is requested
under subparagraph (A) of this paragraph before the insurer may deny
the referral.
(c) Reimbursements of all nonpreferred providers for
services that are covered under the health insurance policy are required
to be calculated pursuant to an appropriate methodology that:
(1) if based on claims data, is based upon sufficient
data to constitute a representative and statistically valid sample;
(2) is updated no less than once per year;
(3) does not use data that is more than three years
old; and
(4) is consistent with nationally recognized and generally
accepted bundling edits and logic.
(d) Except for an exclusive provider benefit plan,
an insurer is required to pay all covered out-of-network benefits
for services obtained from health care providers or physicians at
least at the plan's out-of-network benefit level of coverage, regardless
of whether the service is provided within the designated service area
for the plan. Provision of services by health care providers or physicians
outside the designated service area for the plan must not be a basis
for denial of a claim.
(e) Consistent with Insurance Code §1301.140,
concerning Out-of-Pocket Expense Credit, an insurer must establish
a procedure by which an insured may:
(1) identify the average discounted rate paid by the
insurer to a given type of preferred provider for a covered service
or supply;
(2) obtain a covered service or supply; and
(3) claim a credit, under the preferred level of coverage,
toward the insured's deductible and annual maximum out-of-pocket amount,
for the amount paid by the insured, if:
(A) the amount the insured paid is less than the insurer's
average discounted rate;
(B) the insurer has not paid a claim for the service
or supply; and
(C) the insured submits the documentation identified
by the insurer, according to the process set forth on the insurer's
website and in the insured's certificate of insurance.
(f) An insurer must cover a clinician-administered
drug under the preferred level of coverage if it meets the criteria
under Insurance Code Chapter 1369, Subchapter Q, concerning Clinician-Administered
Drugs.
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| Source Note: The provisions of this §3.3708 adopted to be effective December 6, 2011, 36 TexReg 3411; amended to be effective February 21, 2013, 38 TexReg 827; amended to be effective November 3, 2016, 41 TexReg 8605; amended to be effective April 25, 2024, 49 TexReg 2497 |
