(a) Network adequacy. Each MCO participating in CHIP
must offer a network of providers that is sufficient to meet the needs
of CHIP members enrolled in the MCO. HHSC uses reports from the MCOs
and complaints received from providers and members to monitor MCO
members' access to an adequate provider network. Subsection (c) of
this section describes the reporting requirements with which an MCO
must comply.
(b) MCO requirements concerning treatment of members
by out-of-network providers.
(1) An MCO must allow a provider to submit a referral
of its member(s) to an out-of-network provider, must timely issue
the proper authorization for such referral consistent with managed
care contract requirements for authorization of medically necessary
services, and must reimburse the out-of-network provider for authorized
services provided in accordance with statutory and contractual timeframes
when:
(A) CHIP covered services are medically necessary,
as described in section 370.4(49) of this chapter (relating to Definitions),
and these services are not available through an in-network provider;
(B) a provider currently providing authorized services
to the member requests authorization for such services to be provided
to the member by an out-of-network provider; and
(C) the authorized services are provided within the
time period specified in the MCO's authorization. If the services
are not provided within the required time period, the requesting provider
must submit a new referral request to the MCO prior to the provision
of services.
(2) An MCO may not refuse to reimburse an out-of-network
provider for emergency services.
(3) Health care MCO requirements concerning emergency
services.
(A) A health care MCO must allow its members to be
treated by any emergency services provider for emergency services,
and for services to determine if an emergency condition exists. The
health care MCO must pay for such services.
(B) A health care MCO may not require an authorization
for emergency services or for services to determine if an emergency
condition exists.
(C) A health care MCO may not refuse to reimburse an
out-of-network provider for post-stabilization care services provided
as a result of the MCO's failure to arrange for and authorize a timely
transfer of a member.
(4) Dental MCO requirements concerning emergency services.
(A) A dental MCO must allow its members to be treated
for covered emergency services provided outside of a hospital or ambulatory
surgical center setting and for covered services provided outside
of such settings to determine if an emergency condition exists. The
dental MCO must pay for such services unless subparagraph (C) of this
paragraph specifies otherwise.
(B) A dental MCO may not require an authorization for
the services described in subparagraph (A) of this paragraph.
(C) A dental MCO is not responsible for payment of
non-capitated emergency services and post-stabilization care provided
in a hospital or ambulatory surgical center setting or for devices
for craniofacial anomalies. A dental MCO is not responsible for hospital
and physician services, anesthesia, drugs related to treatment, and
post-stabilization care for:
(i) a dislocated jaw, traumatic damage to a tooth,
or removal of a cyst;
(ii) an oral abscess of tooth or gum origin; or
(iii) craniofacial anomalies.
(D) The services and benefits described in subparagraph
(C) of this paragraph are reimbursed through the health care MCO.
(5) An MCO may be required by contract with HHSC to
allow members to obtain services from out-of-network providers in
circumstances other than those described in paragraphs (1) - (4) of
this subsection.
(c) Reporting requirements.
(1) Each MCO that contracts with HHSC to provide health
care services or dental services to members in a service area must
submit an Out-of-Network quarterly report to HHSC.
(2) Each Out-of-Network quarterly report must contain
information about members enrolled in CHIP. The report must include
the following information:
(A) For a health care MCO, the total number of hospital
admissions, as well as the number of admissions that occur at each
out-of-network hospital. Each out-of-network hospital must be identified.
(B) For a health care MCO, the total number of emergency
room visits, as well as the total number of emergency room visits
that occur at each out-of-network hospital. Each out-of-network hospital
must be identified.
(C) Total dollars billed for services other than those
described in subparagraphs (C) and (D) of this paragraph, as well
as total dollars billed by out-of-network providers for other services.
(D) Any additional information that HHSC requires.
(3) HHSC will determine the specific form of the report
described in this subsection and will include the report form as part
of the CHIP managed care contract between HHSC and the MCOs.
(d) Utilization.
(1) Upon review of the reports described in subsection
(c) of this section, HHSC may determine that an MCO exceeded the maximum
out-of-network usage standards HHSC set for out-of-network access
to health care services and dental services during the reporting period.
(2) Out-of-network usage standards.
(A) Inpatient admissions: No more than 15 percent of
a health care MCO's total hospital admissions, by service area, may
occur in out-of-network facilities.
(B) Emergency room visits: No more than 20 percent
of a health care MCO's total emergency room visits, by service area,
may occur in out-of-network facilities.
(C) Other services: For services that are not included
in subparagraph (A) or (B) of this paragraph, no more than 20 percent
of total dollars billed to an MCO may be billed by out-of-network
providers.
(3) Special considerations in calculating a health
care MCO's out-of-network usage of inpatient admissions and emergency
room visits.
(A) In the event that a health care MCO exceeds the
maximum out-of-network usage standard set by HHSC for inpatient admissions
or emergency room visits, HHSC may modify the calculation of that
health care MCO's out-of-network usage for that standard if:
(i) the admissions or visits to a single out-of-network
facility account for 25 percent or more of the health care MCO's admissions
or visits in a reporting period; and
(ii) HHSC determines that the health care MCO has made
all reasonable efforts to contract with that out-of-network facility
as a network provider without success.
(B) In determining whether a health care MCO has made
all reasonable efforts to contract with the single out-of-network
facility described in subparagraph (A) of this paragraph, HHSC will
consider at least the following information:
(i) How long the health care MCO has been trying to
negotiate a contract with the out-of-network facility;
(ii) The in-network payment rates the health care MCO
has offered to the out-of-network facility;
(iii) The other, non-financial contractual terms the
health care MCO has offered to the out-of-network facility, particularly
those relating to prior authorization and other utilization management
policies and procedures;
(iv) The health care MCO's history with respect to
claims payment timeliness, overturned claims denials, and provider
complaints;
(v) The health care MCO's solvency status; and
(vi) The out-of-network facility's reasons for not
contracting with the health care MCO.
(C) If the conditions described in subparagraph (A)
of this paragraph are met, HHSC may modify the calculation of the
health care MCO's out-of-network usage for the relevant reporting
period and standard by excluding from the calculation the inpatient
admissions or emergency room visits to that single out-of-network
facility.
(e) Reimbursement rates.
(1) HHSC does not set reimbursement rate standards
for out-of-network CHIP providers. MCOs are required to reimburse
providers for emergency services and assessments in accordance with
Texas Insurance Code §1271.155.
(2) A health care or dental MCO providing CHIP out-of-network
services must comply with the reimbursement standards set forth by
the Texas Department of Insurance for out-of-network providers.
(f) Provider complaints.
(1) HHSC accepts and investigates provider complaints
regarding overuse of out-of-network providers.
Cont'd... |