Definitions; Exclusive Provider Benefit Plans, Emergency Care
See the bold text below:
Section 1301.001. Definitions
(1) “Exclusive provider benefit plan” means a benefit plan in which an insurer excludes benefits to an insured for some or all services, other than emergency care services required under Section 1301.155, provided by a physician or health care provider who is not a preferred provider.
(1-a) “Health care provider” means a practitioner, institutional provider, or other person or organization that furnishes health care services and that is licensed or otherwise authorized to practice in this state. The term includes a pharmacist and a pharmacy. The term does not include a physician.
(2) “Health insurance policy” means a group or individual insurance policy, certificate, or contract providing benefits for medical or surgical expenses incurred as a result of an accident or sickness.
(3) “Hospital” means a licensed public or private institution as defined by Chapter 241, Health and Safety Code, or Subtitle C, Title 7, Health and Safety Code.
(4) “Institutional provider” means a hospital, nursing home, or other medical or health-related service facility that provides care for the sick or injured or other care that may be covered in a health insurance policy.
(5) “Insurer” means a life, health, and accident insurance company, health and accident insurance company, health insurance company, or other company operating under Chapter 841, 842, 884, 885, 982, or 1501, that is authorized to issue, deliver, or issue for delivery in this state health insurance policies.
(5-a) “Out-of-network provider” means a physician or health care provider who is not a preferred provider.
(6) “Physician” means a person licensed to practice medicine in this state.
(6-a) “Post-emergency stabilization care” means health care services that are furnished by an out-of-network provider, including an out-of-network hospital, freestanding emergency medical care facility, or comparable emergency facility, regardless of the department of the facility in which the services are furnished, after an insured is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the emergency care, as defined by
Section 1301.155, is furnished.
(7) “Practitioner” means a person who practices a healing art and is a practitioner described by Section 1451.001 or 1451.101.
(7-a) “Preauthorization” means a determination by an insurer that medical care or health care services proposed to be provided to a patient are medically necessary and appropriate.
(8) “Preferred provider” means a physician or health care provider, or an organization of physicians or health care providers, who contracts with an insurer to provide medical care or health care to insureds covered by a health insurance policy.
(9) “Preferred provider benefit plan” means a benefit plan in which an insurer provides, through its health insurance policy, for the payment of a level of coverage that is different from the basic level of coverage provided by the health insurance policy if the insured person uses a preferred provider.
(10) “Service area” means a geographic area or areas specified in a health insurance policy or preferred provider contract in which a network of preferred providers is offered and available.
(11) “Verification” means a reliable representation by an insurer to a physician or health care provider that the insurer will pay the physician or provider for proposed medical care or health care services if the physician or provider renders those services to the patient for whom the services are proposed. The term includes precertification, certification, recertification, and any other term that would be a reliable representation by an insurer to a physician or provider.
(12) “Freestanding emergency medical care facility” means a facility licensed under Chapter 254, Health and Safety Code.
See generally https://law.justia.com/codes/texas/2022/insurance-code/title-8/subtitle-d/chapter-1301/subchapter-a/section-1301-001/. This statute was amended in 2023 by HB 3359. See https://capitol.texas.gov/BillLookup/History.aspx?LegSess=88R&Bill=HB3359
Section 1301.0053. Exclusive Provider Benefit Plans, Emergency Care
Prompt Payment Deadlines
(a) If an out-of-network provider provides emergency care as defined by Section 1301.155 or post-emergency stabilization care to an enrollee in an exclusive provider benefit plan, the issuer of the plan shall reimburse the out-of-network provider at the usual and customary rate or at a rate agreed to by the issuer and the out-of-network provider for the provision of the services and any supply related to those services. The insurer shall make a payment required by this subsection directly to the provider not later than, as applicable:
(1) the 30th day after the date the insurer receives an electronic clean claim as defined by Section 1301.101 for those services that includes all information necessary for the insurer to pay the claim; or
(2) the 45th day after the date the insurer receives a nonelectronic clean claim as defined by Section 1301.101 for those services that includes all information necessary for the insurer to pay the claim.
(b) For emergency care or post-emergency stabilization care subject to this section or a supply related to that care, an out-of-network provider or a person asserting a claim as an agent or assignee of the provider may not bill an insured in, and the insured does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the insured’s exclusive provider benefit plan that:
(1) is based on:
(A) the amount initially determined payable by the insurer; or
(B) if applicable, a modified amount as determined under the insurer’s internal appeal process; and
(2) is not based on any additional amount determined to be owed to the provider under Chapter 1467.
(c) This section may not be construed to require the imposition of a penalty under Section 1301.137.
(d) Post-emergency stabilization care that is subject to this section and a supply related to that care are subject to Chapter 1467 in the same manner as if the care and supply are emergency care, as defined by Section 1301.155.
(e) This section does not apply to claims for post-emergency stabilization care if all of the conditions described by 42 U.S.C. Section 300gg-111(a)(3)(C)(ii)(II) are met.
See https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1301.htm.
This statute was amended in 2023 by HB 3359. See https://capitol.texas.gov/BillLookup/History.aspx?LegSess=88R&Bill=HB3359