Tex. Ins. Code Section 1579.112
Out-of-network Emergency Medical Services Provider Payments


(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), the administrator of a managed care plan provided under this chapter shall pay for a covered health care or medical service performed for, or a covered supply or covered transport related to that service provided to, an enrollee 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)

The administrator 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 administrator 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 administrator receives an electronic claim for those services that includes all information necessary for the administrator to pay the claim; or

(2)

the 45th day after the date the administrator receives a nonelectronic claim for those services that includes all information necessary for the administrator 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 enrollee receiving a health care or medical service or supply or transport described by Subsection (b) in, and the enrollee does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee’s managed care plan that is based on:

(1)

the amount initially determined payable by the administrator; or

(2)

if applicable, a modified amount as determined under the administrator’s internal appeal process.

(f)

This section expires September 1, 2025.
Added by Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 14, eff. September 1, 2023.
Sec. 1579.151. REQUIRED PARTICIPATION OF SCHOOL DISTRICTS WITH 500 OR FEWER EMPLOYEES. (a) Each school district with 500 or fewer employees and each regional education service center is required to participate in the program.

(b)

Notwithstanding Subsection (a), a school district otherwise subject to Subsection (a) that, on January 1, 2001, was individually self-funded for the provision of health coverage to its employees may elect not to participate in the program.

(c)

An educational district described by Section 1579.002 (General Definitions)(5)(B) that, on January 1, 2001, had 500 or fewer employees may elect not to participate in the program.

(d)

Expired.
Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.

Source: Section 1579.112 — Out-of-network Emergency Medical Services Provider Payments, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1579.­htm#1579.­112 (accessed Jun. 5, 2024).

1579.001
Short Title
1579.002
General Definitions
1579.003
Definition of Employee
1579.004
Definition of Dependent
1579.005
Confidentiality
1579.006
Exemption from Process
1579.007
Exemption from State Taxes and Fees
1579.008
Coverage Exempt from Insurance Law
1579.009
Balance Billing Prohibition Notice
1579.010
Information Regarding Appeals
1579.051
Administration of Group Program
1579.052
Authority to Adopt Rules
1579.053
Personnel
1579.054
Competitive Bidding Requirements
1579.055
Contract Award
1579.057
Pharmacy Benefit Manager Contracts
1579.101
Plans of Group Coverages
1579.102
Catastrophic Care Coverage Plan
1579.104
Optional Coverages
1579.105
Preexisting Condition Limitation
1579.106
Prior Authorization for Certain Drugs
1579.107
Disease Management Services
1579.108
Limitations
1579.109
Emergency Care Payments
1579.110
Out-of-network Facility-based Provider Payments
1579.111
Out-of-network Diagnostic Imaging Provider or Laboratory Service Provider Payments
1579.112
Out-of-network Emergency Medical Services Provider Payments
1579.152
Participation of Other School Districts
1579.153
Participation by Certain Risk Pools
1579.154
Participation by Charter Schools
1579.155
Program Participation: Election
1579.201
Definition
1579.202
Eligible Employees
1579.203
Selection of Coverage
1579.204
Certain Part-time Employees
1579.205
Payment by Participating Entity
1579.251
State Assistance
1579.252
Contribution by Participating Entities
1579.253
Contribution by Employee
1579.254
Contributions Held in Trust for Fund
1579.255
Interest Assessed on Late Payment of Contributions by Participating Entities
1579.301
Fund
1579.302
Composition of Fund
1579.303
Payments from Fund
1579.304
Investment of Fund
1579.1045
Alternative Group Health Coverage Prohibited
1579.1061
Exemption from Preauthorization Requirements for Physicians and Health Care Providers Providing Certain Health Care Services

Accessed:
Jun. 5, 2024

§ 1579.112’s source at texas​.gov