| (C) 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;
(D) 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;
(E) total dollars for paid claims by MCOs, 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; and
(F) any additional information required by HHSC.
(3) HHSC determines the specific form of the report
described in this subsection and includes the report form as part
of the Medicaid managed care contract between HHSC and the MCOs.
(h) Utilization.
(1) Upon review of the reports described in subsection
(g) of this section that are submitted to HHSC by the MCOs, HHSC may
determine that an MCO exceeded maximum out-of-network usage standards
set by HHSC 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 for paid claims by the MCO for services provided
may be provided 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 the 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 considers
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.
(i) Provider complaints.
(1) HHSC accepts provider complaints regarding reimbursement
for or overuse of out-of-network providers and conducts investigations
into any such complaints.
(2) When a provider files a complaint regarding out-of-network
payment, HHSC requires the relevant MCO to submit data to support
its position on the adequacy of the payment to the provider. The data
includes a copy of the claim for services rendered and an explanation
of the amount paid and of any amounts denied.
(3) Not later than the 60th day after HHSC receives
a provider complaint, HHSC notifies the provider who initiated the
complaint of the conclusions of HHSC's investigation regarding the
complaint. The notification to the complaining provider includes:
(A) a description of the corrective actions, if any,
required of the MCO in order to resolve the complaint; and
(B) if applicable, a conclusion regarding the amount
of reimbursement owed to an out-of-network provider.
(4) If HHSC determines through investigation that an
MCO did not reimburse an out-of-network provider based on a reasonable
reimbursement methodology as described in subsection (f) of this section,
HHSC initiates a corrective action plan. Refer to subsection (j) of
this section for information about the contents of the corrective
action plan.
(5) If, after an investigation, HHSC determines that
additional reimbursement is owed to an out-of-network provider, the
MCO must:
(A) pay the additional reimbursement owed to the out-of-network
provider within 90 days from the date the complaint was received by
HHSC or 30 days from the date the clean claim, or information required
that makes the claim clean, is received by the MCO, whichever comes
first; or
(B) submit a reimbursement payment plan to the out-of-network
provider within 90 days from the date the complaint was received by
HHSC. The reimbursement payment plan provided by the MCO must provide
for the entire amount of the additional reimbursement to be paid within
120 days from the date the complaint was received by HHSC.
(6) If the MCO does not pay the entire amount of the
additional reimbursement within 90 days from the date the complaint
was received by HHSC, HHSC may require the MCO to pay interest on
the unpaid amount. If required by HHSC, interest accrues at a rate
of 18 percent simple interest per year on the unpaid amount from the
90th day after the date the complaint was received by HHSC, until
the date the entire amount of the additional reimbursement is paid.
(7) HHSC pursues any appropriate remedy authorized
in the contract between the MCO and HHSC if the MCO fails to comply
with a corrective action plan under subsection (j) of this section.
(j) Corrective action plan.
(1) HHSC requires a corrective action plan in the following
situations:
(A) the MCO exceeds a maximum standard established
by HHSC for out-of-network access to health care services and dental
services described in subsection (h) of this section; or
(B) the MCO does not reimburse an out-of-network provider
based on a reasonable reimbursement methodology as described in subsection
(f) of this section.
(2) A corrective action plan imposed by HHSC requires
one of the following:
(A) reimbursements by the MCO to out-of-network providers
at rates that equal the allowable rates for the health care services
as determined under §32.028 and §32.0281, Texas Human Resources
Code, for all health care services provided during the period:
(i) the MCO is not in compliance with a utilization
standard established by HHSC; or
(ii) the MCO is not reimbursing out-of-network providers
based on a reasonable reimbursement methodology, as described in subsection
(f) of this section;
(B) initiation of an immediate freeze by HHSC on the
enrollment of additional recipients in the MCO's managed care plan
until HHSC determines that the provider network under the managed
care plan can adequately meet the needs of the additional recipients;
(C) education by the MCO of members enrolled in the
MCO regarding the proper use of the MCO's provider network; or
(D) any other actions HHSC determines are necessary
to ensure that Medicaid recipients enrolled in managed care plans
provided by the MCO have access to appropriate health care services
or dental services, and that providers are properly reimbursed by
the MCO for providing medically necessary health care services or
dental services to those recipients.
(k) Application to Pharmacy Providers. The requirements
of this section do not apply to providers of outpatient pharmacy benefits,
except as noted in §353.913 of this chapter (relating to Managed
Care Organization Requirements Concerning Out-of-Network Outpatient
Pharmacy Services).
|
| Source Note: The provisions of this §353.4 adopted to be effective January 22, 2006, 31 TexReg 281; amended to be effective February 17, 2010, 35 TexReg 1123; amended to be effective March 1, 2012, 37 TexReg 1283; amended to be effective September 1, 2014, 39 TexReg 5873; amended to be effective May 2, 2016, 41 TexReg 3095; amended to be effective September 1, 2021, 46 TexReg 5386; amended to be effective November 15, 2022, 47 TexReg 7533; amended to be effective April 2, 2024, 49 TexReg 2061 |
