Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 353 - MEDICAID MANAGED CARE
Subchapter A - GENERAL PROVISIONS
Section 353.4 - Managed Care Organization Requirements Concerning Out-of-Network Providers
Universal Citation: 1 TX Admin Code ยง 353.4
Current through Reg. 49, No. 38; September 20, 2024
(a) Network adequacy. HHSC is the state agency responsible for overseeing and monitoring the Medicaid managed care program. Each managed care organization (MCO) participating in the Medicaid managed care program must offer a network of providers that is sufficient to meet the needs of the Medicaid population who are MCO members. HHSC monitors MCO members' access to an adequate provider network through reports from the MCOs and complaints received from providers and members. Certain reporting requirements are discussed in subsection (g) of this section.
(b) MCO requirements concerning coverage for treatment of members by out-of-network providers for non-emergency services.
(1) Nursing facility
services. A health care MCO must reimburse an out-of-network nursing facility
for medically necessary services authorized by HHSC, using the reasonable
reimbursement methodology in subsection (f) of this section. Nursing facility
add-on services are considered "other authorized services" under paragraph (2)
of this subsection, and are authorized by STAR+PLUS MCOs.
(2) Other authorized services. The MCO must
allow referral of its member(s) to an out-of-network provider, must timely
issue the proper authorization for such referral, and must timely reimburse the
out-of-network provider for authorized services provided if the criteria in
this paragraph are met. If all of the following criteria are not met, an
out-of-network provider is not entitled to Medicaid reimbursement for
non-emergency services:
(A) Medicaid covered
services are medically necessary and these services are not available through
an in-network provider;
(B) a
participating provider currently providing authorized services to the member
requests authorization for such services to be provided to the member by an
out-of-network provider; and
(C)
the authorized services are provided within the time period specified in the
MCO's authorization. If the services are not provided within the required time
period, a new request for referral from the requesting provider must be
submitted to the MCO prior to the provision of services.
(3) School-based telemedicine medical
services. If a telemedicine medical service provided by an out-of-network
physician to a member in a primary or secondary school-based setting meets the
conditions for reimbursement in §
354.1432 of this title (relating to
Telemedicine and Telehealth Benefits and Limitations), a health care MCO must
reimburse the out-of-network physician without prior authorization, even if the
physician is not the member's primary care provider. The MCO must use the
reasonable reimbursement methodology described in subsection (f)(2) of this
section to reimburse an out-of-network physician.
(c) MCO requirements concerning coverage for treatment of members by out-of-network providers for emergency services.
(1) An MCO may not refuse to reimburse an
out-of-network provider for medically necessary emergency services.
(2) Health care MCO requirements concerning
emergency services.
(A) A health care MCO may
not refuse to reimburse an out-of-network provider for post-stabilization care
services provided as a result of the MCO's failure to authorize a timely
transfer of a member.
(B) A health
care MCO must allow its members to be treated by any emergency services
provider for emergency services, and services to determine if an emergency
condition exists. The health care MCO must pay for such services.
(C) A health care MCO must reimburse for
transport provided by an ambulance provider for a Medicaid recipient whose
condition meets the definition of an emergency medical condition.
Facility-to-facility transports are considered emergencies if the required
treatment for the emergency medical condition, as defined in §
353.2 of this subchapter (relating
to Definitions), is not available at the first facility and the MCO has not
included payment for such transports in the hospital reimbursement.
(D) A health care MCO is prohibited from
requiring an authorization for emergency services or for services to determine
if an emergency condition exists.
(3) Dental MCO requirements concerning
emergency services.
(A) A dental MCO must
allow its members to be treated for covered emergency services that are
provided outside of a hospital or ambulatory surgical center setting, and for
covered services provided outside of such settings to determine if an emergency
condition exists. The dental MCO must pay for such services.
(B) A dental MCO is prohibited from requiring
an authorization for the services described in subparagraph (A) of this
paragraph.
(C) A dental MCO is not
responsible for payment of non-capitated emergency services and
post-stabilization care provided in a hospital or ambulatory surgical center
setting, or devices for craniofacial anomalies. A dental MCO is not responsible
for hospital and physician services, anesthesia, drugs related to treatment,
and post-stabilization care for:
(i) a
dislocated jaw, traumatic damage to a tooth, and removal of a cyst;
(ii) an oral abscess of tooth or gum origin;
and
(iii) craniofacial
anomalies.
(D) The
services and benefits described in subparagraph (C) of this paragraph are
reimbursed:
(i) by a health care MCO, if the
member is enrolled in a managed care program; or
(ii) by HHSC's claims administrator, if the
member is not enrolled in a managed care program.
(d) Health care MCO requirements concerning coverage for services provided to certain members by an out-of-network "specialty provider" as that term is defined in § 353.7(c) of this subchapter (relating to Continuity of Care with Out-Of-Network Specialty Providers).
(1) A health care MCO may not
refuse to reimburse an out-of-network "specialty provider" enrolled as a
provider in the Texas Medicaid program for services provided to a member under
the circumstances set forth in §
353.7 of this subchapter.
(2) In reimbursing a provider for the
services described in paragraph (1) of this subsection, a health care MCO must
use the reasonable reimbursement methodology in subsection (f)(2) of this
section.
(e) An MCO may be required by contract with HHSC to allow members to obtain services from out-of-network providers in circumstances other than those described in subsections (b) - (d) of this section.
(f) Reasonable reimbursement methodology.
(1) Out-of-network nursing facilities.
(A) Out-of-network nursing facilities must be
reimbursed at or above 95 percent of the nursing facility unit rate established
by HHSC for the dates of service for services provided inside of the MCO's
service area.
(B) Out-of-network
nursing facilities must be reimbursed at or above 100 percent of the nursing
facility unit rate for the dates of services for services provided outside of
the MCO's service area.
(2) Emergency and authorized services
performed by out-of-network providers.
(A)
Except as provided in §
353.913 of this chapter (relating
to Managed Care Organization Requirements Concerning Out-of-Network Outpatient
Pharmacy Services) or subsection (j)(2) of this section, the MCO must reimburse
an out-of-network, in-area service provider the Medicaid FFS rate in effect on
the date of service less five percent, unless the parties agree to a different
reimbursement amount.
(B) Except as
provided in §
353.913 of this chapter, an MCO
must reimburse an out-of-network, out-of-area service provider at 100 percent
of the Medicaid FFS rate in effect on the date of service, unless the parties
agree to a different reimbursement amount, until the MCO arranges for the
timely transfer of the member, as determined by the member's attending
physician, to a provider in the MCO's network.
(3) For purposes of this subsection, the
Medicaid FFS rates are defined as those rates for providers of services in the
Texas Medicaid program for which reimbursement methodologies are specified in
Chapter 355 of this title (relating to Reimbursement Rates), exclusive of the
rates and payment structures in Medicaid managed care.
(g) Reporting requirements.
(1) Each MCO that contracts with HHSC to
provide health care services or dental services to members in a service area
must submit quarterly information in its Out-of-Network quarterly report to
HHSC.
(2) Each report submitted by
an MCO must contain information about members enrolled in each HHSC Medicaid
managed care program provided by the MCO. The report must include the following
information:
(A) the types of services
provided by out-of-network providers for the MCO's members;
(B) the scope of services provided by
out-of-network providers to the MCO's members;
(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).
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