| (a) Network adequacy. HHSC is the state agency responsible
for overseeing and monitoring the Medicaid managed care program. Each
managed care organization (MCO) participating in the Medicaid managed
care program must offer a network of providers that is sufficient
to meet the needs of the Medicaid population who are MCO members.
HHSC monitors MCO members' access to an adequate provider network
through reports from the MCOs and complaints received from providers
and members. Certain reporting requirements are discussed in subsection
(g) of this section.
(b) MCO requirements concerning coverage for treatment
of members by out-of-network providers for non-emergency services.
(1) Nursing facility services. A health care MCO must
reimburse an out-of-network nursing facility for medically necessary
services authorized by HHSC, using the reasonable reimbursement methodology
in subsection (f) of this section. Nursing facility add-on services
are considered "other authorized services" under paragraph (2) of
this subsection, and are authorized by STAR+PLUS MCOs.
(2) Other authorized services. The MCO must allow referral
of its member(s) to an out-of-network provider, must timely issue
the proper authorization for such referral, and must timely reimburse
the out-of-network provider for authorized services provided if the
criteria in this paragraph are met. If all of the following criteria
are not met, an out-of-network provider is not entitled to Medicaid
reimbursement for non-emergency services:
(A) Medicaid covered services are medically necessary
and these services are not available through an in-network provider;
(B) a participating 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, a new request for
referral from the requesting provider must be submitted to the MCO
prior to the provision of services.
(3) School-based telemedicine medical services. If
a telemedicine medical service provided by an out-of-network physician
to a member in a primary or secondary school-based setting meets the
conditions for reimbursement in §354.1432 of this title (relating
to Telemedicine and Telehealth Benefits and Limitations), a health
care MCO must reimburse the out-of-network physician without prior
authorization, even if the physician is not the member's primary care
provider. The MCO must use the reasonable reimbursement methodology
described in subsection (f)(2) of this section to reimburse an out-of-network
physician.
(c) MCO requirements concerning coverage for treatment
of members by out-of-network providers for emergency services.
(1) An MCO may not refuse to reimburse an out-of-network
provider for medically necessary emergency services.
(2) Health care MCO requirements concerning emergency
services.
(A) 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 authorize a timely transfer of
a member.
(B) A health care MCO must allow its members to be
treated by any emergency services provider for emergency services,
and services to determine if an emergency condition exists. The health
care MCO must pay for such services.
(C) A health care MCO must reimburse for transport
provided by an ambulance provider for a Medicaid recipient whose condition
meets the definition of an emergency medical condition. Facility-to-facility
transports are considered emergencies if the required treatment for
the emergency medical condition, as defined in §353.2 of this
subchapter (relating to Definitions), is not available at the first
facility and the MCO has not included payment for such transports
in the hospital reimbursement.
(D) A health care MCO is prohibited from requiring
an authorization for emergency services or for services to determine
if an emergency condition exists.
(3) Dental MCO requirements concerning emergency services.
(A) A dental MCO must allow its members to be treated
for covered emergency services that are 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.
(B) A dental MCO is prohibited from requiring 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 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,
and removal of a cyst;
(ii) an oral abscess of tooth or gum origin; and
(iii) craniofacial anomalies.
(D) The services and benefits described in subparagraph
(C) of this paragraph are reimbursed:
(i) by a health care MCO, if the member is enrolled
in a managed care program; or
(ii) by HHSC's claims administrator, if the member
is not enrolled in a managed care program.
(d) Health care MCO requirements concerning coverage
for services provided to certain members by an out-of-network "specialty
provider" as that term is defined in §353.7(c) of this subchapter
(relating to Continuity of Care with Out-Of-Network Specialty Providers).
(1) A health care MCO may not refuse to reimburse an
out-of-network "specialty provider" enrolled as a provider in the
Texas Medicaid program for services provided to a member under the
circumstances set forth in §353.7 of this subchapter.
(2) In reimbursing a provider for the services described
in paragraph (1) of this subsection, a health care MCO must use the
reasonable reimbursement methodology in subsection (f)(2) of this
section.
(e) 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 subsections (b) - (d)
of this section.
(f) Reasonable reimbursement methodology.
(1) Out-of-network nursing facilities.
(A) Out-of-network nursing facilities must be reimbursed
at or above 95 percent of the nursing facility unit rate established
by HHSC for the dates of service for services provided inside of the
MCO's service area.
(B) Out-of-network nursing facilities must be reimbursed
at or above 100 percent of the nursing facility unit rate for the
dates of services for services provided outside of the MCO's service
area.
(2) Emergency and authorized services performed by
out-of-network providers.
(A) Except as provided in §353.913 of this chapter
(relating to Managed Care Organization Requirements Concerning Out-of-Network
Outpatient Pharmacy Services) or subsection (j)(2) of this section,
the MCO must reimburse an out-of-network, in-area service provider
the Medicaid FFS rate in effect on the date of service less five percent,
unless the parties agree to a different reimbursement amount.
(B) Except as provided in §353.913 of this chapter,
an MCO must reimburse an out-of-network, out-of-area service provider
at 100 percent of the Medicaid FFS rate in effect on the date of service,
unless the parties agree to a different reimbursement amount, until
the MCO arranges for the timely transfer of the member, as determined
by the member's attending physician, to a provider in the MCO's network.
(3) For purposes of this subsection, the Medicaid FFS
rates are defined as those rates for providers of services in the
Texas Medicaid program for which reimbursement methodologies are specified
in Chapter 355 of this title (relating to Reimbursement Rates), exclusive
of the rates and payment structures in Medicaid managed care.
(g) 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 quarterly information in its Out-of-Network quarterly report
to HHSC.
(2) Each report submitted by an MCO must contain information
about members enrolled in each HHSC Medicaid managed care program
provided by the MCO. The report must include the following information:
(A) the types of services provided by out-of-network
providers for the MCO's members;
(B) the scope of services provided by out-of-network
providers to the MCO's members;
Cont'd... |
