The plan administrator must pay covered services and related supplies or transport for certain out-of-network emergency medical services providers, and the provider generally may not bill the participant above copays, coinsurance, and deductibles.
For expiration of this section, see Subsection (f). Sec. 1551.231. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES PROVIDER PAYMENTS. (a) In this section, "emergency medical services provider" has the meaning assigned by Section 773.003, Health and Safety Code, except that the term does not include an air ambulance. (b) Except as provided by Subsection (c), the administrator of a managed care plan provided under the group benefits program shall pay for a covered health care or medical service performed for, or a covered supply or covered transport related to that service provided to, a participant by an out-of-network provider who is an emergency medical services provider at: (1) if the political subdivision has submitted the rate to the department under Section 38.006, the rate set, controlled, or regulated by the political subdivision in which: (A) the service originated; or (B) the transport originated if transport is provided; or (2) if the political subdivision has not submitted the rate to the department, the lesser of: (A) the provider's billed charge; or (B) 325 percent of the current Medicare rate, including any applicable extenders and modifiers. (c) A political subdivision may annually adjust a rate submitted under Section 38.006 by not more than the lesser of: (1) the Medicare Ambulance Inflation Factor; or (2) 10 percent of the provider's previous calendar year rates. (d) The administrator shall make a payment required by this section directly to the provider not later than, as applicable: (1) the 30th day after the date the administrator receives an electronic claim for those services that includes all information necessary for the administrator to pay the claim; or (2) the 45th day after the date the administrator receives a nonelectronic claim for those services that includes all information necessary for the administrator to pay the claim. (e) An out-of-network provider who is an emergency medical services provider or a person asserting a claim as an agent or assignee of the provider may not bill a participant receiving a health care or medical service or supply or transport described by Subsection (b) in, and the participant does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the participant's managed care plan that is based on: (1) the amount initially determined payable by the administrator; or (2) if applicable, the modified amount as determined under the administrator's internal appeal process. (f) This section expires September 1, 2027. Added by Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 10, eff. September 1, 2023. Amended by: Acts 2025, 89th Leg., R.S., Ch. 784 (S.B. 916), Sec. 6, eff. September 1, 2025. SUBCHAPTER F. GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE COVERAGE PLAN