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

Current through Reg. 49, No. 28; July 12, 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.