| (a) General requirements for explanation of benefits.
A health benefit plan issuer or administrator subject to Insurance
Code §1271.008, concerning Balance Billing Prohibition Notice; §1275.003,
concerning Balance Billing Prohibition Notice; §1301.010, concerning
Balance Billing Prohibition Notice; §1551.015, concerning Balance
Billing Prohibition Notice; §1575.009, concerning Balance Billing
Prohibition Notice; or §1579.009, concerning Balance Billing
Prohibition Notice must provide written notice in accordance with
this section in an explanation of benefits in connection with a health
care or medical service or supply or transport provided by a non-network
provider or an out-of-network provider:
(1) to the enrollee and physician or provider, which
must include:
(A) a statement of the billing prohibition, as applicable;
and
(B) the total amount the physician or provider may
bill the enrollee under the health benefit plan and an itemization
of in-network copayments, coinsurance, deductibles, and other amounts
included in that total; and
(2) to the physician or provider, for a claim that
is subject to mediation or arbitration under Insurance Code Chapter
1467, concerning Out-of-Network Claim Dispute Resolution, a conspicuous
statement in not less than 10-point boldface type that is substantially
similar to the following: "If you disagree with the payment amount,
you can request mediation or arbitration. To learn more and submit
a request, go to www.tdi.texas.gov. After you submit a complete request,
you must notify {HEALTH BENEFIT PLAN ISSUER OR ADMINISTRATOR NAME}
at {EMAIL}."
(b) Specific requirements for explanation of benefits
provided by health benefit plans subject to Insurance Code Chapter
1275. In addition to the requirements in subsection (a) of this section,
the following requirements apply.
(1) For a health benefit plan offered by a nonprofit
agricultural organization under Insurance Code Chapter 1682, concerning
Health Benefits Provided by Certain Nonprofit Agricultural Organizations,
the notice to a physician or provider for a claim must also include
the following instruction that is substantially similar to the following:
"The request for mediation or arbitration must identify the plan type
as 'Ag Plan.'"
(2) For a self-insured or self-funded plan under ERISA
where the plan sponsor has elected to apply Insurance Code Chapter
1275, concerning Balance Billing Prohibitions and Out-Of-Network Claim
Dispute Resolution for Certain Plans, to the plan for the relevant
plan year, the notice to a physician or provider for a claim must
also include a statement that is substantially similar to the following:
"The plan sponsor has opted in to the Texas Independent Dispute Resolution
Process under Insurance Code Chapter 1275 for this plan year. A dispute
related to this claim must proceed through the Texas process and may
not proceed through the Federal No Surprises Act Independent Dispute
Resolution Process. The request for mediation or arbitration must
identify the plan type as 'ERISA Opt-In.'"
(c) Requirements for ID cards issued to enrollees of
health benefit plans subject to Insurance Code Chapter 1275. For a
plan that is delivered, issued for delivery, or renewed on or after
90 days following the effective date of this section, a health benefit
plan issuer or administrator that is subject to Insurance Code §1275.003
must include the letters "TXI" on the front of the ID card issued
to enrollees.
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| Source Note: The provisions of this §21.5040 adopted to be effective December 23, 2019, 44 TexReg 7988; amended to be effective June 27, 2023, 48 TexReg 3409; amended to be effective January 3, 2024, 48 TexReg 8372 |
