Tex.
Ins. Code Section 1662.104
Network Rate Disclosures
(a)
If a health benefit plan issuer or administrator does not use negotiated rates for health care provider reimbursement, the issuer or administrator shall disclose for purposes of Section 1662.103 (Required Information)(a)(1)(C) derived amounts to the extent those amounts are already calculated in the normal course of business.(b)
If a health benefit plan issuer or administrator uses underlying fee schedule rates for calculating cost sharing, the issuer or administrator shall disclose for purposes of Section 1662.103 (Required Information)(a)(1)(C) the underlying fee schedule rates in addition to the negotiated rate or derived amount.(c)
The applicable rates, including for both individual health care services and supplies and services and supplies in a bundled payment arrangement, that a health benefit plan issuer or administrator must provide under Section 1662.103 (Required Information)(a)(1)(C) must be:(1)
except as provided by Subdivision (2), reflected as dollar amounts with respect to each covered health care service or supply that is provided by a network provider;(2)
the base negotiated rate applicable to the service or supply before an adjustment for enrollee characteristics if the rate is a negotiated rate subject to change based on enrollee characteristics;(3)
associated with the national provider identifier, tax identification number, and place of service code for each network provider;(4)
associated with the last date of the contract term or expiration date for each health care provider-specific applicable rate that applies to each covered service or supply; and(5)
indicated with a notation where a reimbursement arrangement other than a standard fee-for-service model, including capitation or a bundled payment arrangement, applies.
Source:
Section 1662.104 — Network Rate Disclosures, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1662.htm#1662.104 (accessed Jun. 5, 2024).
