Texas Insurance Code 1301.166 – Out-of-Network Emergency Medical Services Provider
(a) In this section, “emergency medical services provider” has the meaning assigned by § 773.003, Health and Safety Code, except that the term does not include an air ambulance.
(b) Except as provided by Subsection (c), an insurer shall pay for a covered medical care or health care service performed for, or a covered supply or covered transport related to that service provided to, an insured by an out-of-network provider who is an emergency medical services provider at:
(1) if the political subdivision has submitted the rate to the department under § 38.006, the rate set, controlled, or regulated by the political subdivision in which:
(A) the service originated; or
(B) the transport originated if transport is provided; or
(2) if the political subdivision has not submitted the rate to the department, the lesser of:
(A) the provider’s billed charge; or
(B) 325 percent of the current Medicare rate, including any applicable extenders and modifiers.
Terms Used In Texas Insurance Code 1301.166
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Person: includes corporation, organization, government or governmental subdivision or agency, business trust, estate, trust, partnership, association, and any other legal entity. See Texas Government Code 311.005
- Year: means 12 consecutive months. See Texas Government Code 311.005
(c) An insurer shall adjust a payment required by Subsection (b)(1) each plan year by increasing the payment by the lesser of the Medicare Inflation Index or 10 percent of the provider’s previous calendar year rates.
(d) The insurer shall make a payment required by this section directly to the provider not later than, as applicable:
(1) the 30th day after the date the insurer receives an electronic clean claim as defined by § 1301.101 for those services that includes all information necessary for the insurer to pay the claim; or
(2) the 45th day after the date the insurer receives a nonelectronic clean claim as defined by § 1301.101 for those services that includes all information necessary for the insurer to pay the claim.
(e) An out-of-network provider who is an emergency medical services provider or a person asserting a claim as an agent or assignee of the provider may not bill an insured receiving a medical care or health care service or supply or transport described by Subsection (b) in, and the insured does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the insured’s preferred provider benefit plan that is based on:
(1) the amount initially determined payable by the insurer; or
(2) if applicable, the modified amount as determined under the insurer’s internal appeal process.
(f) This section may not be construed to require the imposition of a penalty under § 1301.137.
(g) This section expires September 1, 2025.
For expiration of this section, see Subsection (g).
<