(a) This section applies to a health benefit plan issuer or administrator that is subject to one of the following statutes:
  (1) Insurance Code §1271.159, concerning Non-Network Emergency Medical Services Provider;
  (2) Insurance Code §1275.054, concerning Out-of-Network Emergency Medical Services Provider Payments;
  (3) Insurance Code §1301.166, concerning Out-of-Network Emergency Medical Services Provider;
  (4) Insurance Code §1551.231, concerning Out-of-Network Emergency Medical Services Provider Payments;
  (5) Insurance Code §1575.174, concerning Out-of-Network Emergency Medical Services Provider Payments; or
  (6) Insurance Code §1579.112, concerning Out-of-Network Emergency Medical Services Provider Payments.
(b) For a covered health care or medical service, supply, or transport that is provided to an enrollee by an out-of-network emergency medical services (EMS) provider, a health benefit plan issuer or administrator must pay:
  (1) for a service or transport that originated in a political subdivision that sets, controls, or regulates the rate, the lesser of the billed charge or the applicable rate for that political subdivision that is published in the EMS provider rate database established by the department and adjusted as required in subsection (d) of this section; or
  (2) if there is not a rate published in the EMS provider rate database for the political subdivision in which the service or transport originated, the lesser of:
    (A) the provider's billed charge; or
    (B) 325% of the current Medicare rate, including any applicable extenders or modifiers.
(c) For claims incurred during a plan year that starts before September 1, 2024, for a claim for emergency medical services that is provided on or after January 1, 2024, and before September 1, 2025, a health benefit plan issuer or administrator that must make a payment consistent with subsection (b)(1) of this section must use the rate data published in the department's EMS provider rate database for calendar year 2024.
(d) For claims incurred during a plan year that starts on or after September 1, 2024, a health benefit plan issuer or administrator that must make a payment consistent with subsection (b)(1) of this section must pay the lesser of:
  (1) the billed charge;
  (2) the rate published in the department's EMS provider rate database for calendar year 2024 increased by 10%; or
  (3) the rate published in the department's EMS provider rate database for calendar year 2024 increased by the Medicare Economic Index rate that applies to the first day of the new plan year.
(e) Figure: 28 TAC §21.5071(e) provides examples illustrating how a health benefit plan should apply published rates to a plan year under subsection (d) of this section.
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Source Note: The provisions of this §21.5071 adopted to be effective January 3, 2023, 48 TexReg 8372