Ins. Code Section 1301.166
Out-of-network Emergency Medical Services Provider
(a)In this section, “emergency medical services provider” has the meaning assigned by Section 773.003 (Definitions), 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 Section 38.006 (Emergency Medical Services Provider Balance Billing Rate Database), 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.
(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 Section 1301.101 (Definition) 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 Section 1301.101 (Definition) 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 Section 1301.137 (Violation of Claims Payment Requirements; Penalty).
(g)This section expires September 1, 2025.
Section 1301.166 — Out-of-network Emergency Medical Services Provider,
https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1301.htm#1301.166 (accessed Nov. 25, 2023).