Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 353 - MEDICAID MANAGED CARE
Subchapter A - GENERAL PROVISIONS
Section 353.7 - Continuity of Care with Out-of-Network Specialty Providers

(a) A health care MCO must allow a member age 20 or younger, who has complex medical needs, to remain under the care of a Medicaid enrolled specialty provider from whom the member is receiving care at the time of the member's enrollment into the health care MCO, even if the specialty provider is an out-of-network provider.

(b) For the purpose of this section "complex medical needs" means a member receiving:

(c) For the purpose of this section "specialty provider" means one of the following provider types:

(d) A health care MCO must comply with the reasonable reimbursement methodology for authorized services performed by out-of-network providers as described in § 353.4(f)(2) of this chapter (relating to Managed Care Organization Requirements Concerning Out-of-Network Providers) until:

(e) If a member wants to remain under the care of a Medicaid enrolled specialty provider that is not in the health care MCO's provider network, the MCO must make a good-faith effort to negotiate a single-case agreement with the out-of-network specialty provider using a simple, timely, and efficient process developed by the MCO.

(f) A single-case agreement entered into under subsection (d)(1) of this section is not considered accessing an out-of-network provider for the purposes of Medicaid managed care organization network adequacy requirements.