(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.
(c) MCO requirements concerning coverage for treatment of members by out-of-network providers for emergency services.
  (1) An MCO may not refuse to reimburse an out-of-network provider for medically necessary emergency services.
  (2) Health care MCO requirements concerning emergency services.
    (A) A health care MCO may not refuse to reimburse an out-of-network provider for post-stabilization care services provided as a result of the MCO's failure to authorize a timely transfer of a member.
    (B) A health care MCO must allow its members to be treated by any emergency services provider for emergency services, and services to determine if an emergency condition exists. The health care MCO must pay for such services.
    (C) A health care MCO must reimburse for transport provided by an ambulance provider for a Medicaid recipient whose condition meets the definition of an emergency medical condition. Facility-to-facility transports are considered emergencies if the required treatment for the emergency medical condition, as defined in §353.2 of this subchapter (relating to Definitions), is not available at the first facility and the MCO has not included payment for such transports in the hospital reimbursement.
    (D) A health care MCO is prohibited from requiring an authorization for emergency services or for services to determine if an emergency condition exists.
  (3) Dental MCO requirements concerning emergency services.
    (A) A dental MCO must allow its members to be treated for covered emergency services that are provided outside of a hospital or ambulatory surgical center setting, and for covered services provided outside of such settings to determine if an emergency condition exists. The dental MCO must pay for such services.
    (B) A dental MCO is prohibited from requiring an authorization for the services described in subparagraph (A) of this paragraph.
    (C) A dental MCO is not responsible for payment of non-capitated emergency services and post-stabilization care provided in a hospital or ambulatory surgical center setting, or devices for craniofacial anomalies. A dental MCO is not responsible for hospital and physician services, anesthesia, drugs related to treatment, and post-stabilization care for:
      (i) a dislocated jaw, traumatic damage to a tooth, and removal of a cyst;
      (ii) an oral abscess of tooth or gum origin; and
      (iii) craniofacial anomalies.
    (D) The services and benefits described in subparagraph (C) of this paragraph are reimbursed:
      (i) by a health care MCO, if the member is enrolled in a managed care program; or
      (ii) by HHSC's claims administrator, if the member is not enrolled in a managed care program.
(d) Health care MCO requirements concerning coverage for services provided to certain members by an out-of-network "specialty provider" as that term is defined in §353.7(c) of this subchapter (relating to Continuity of Care with Out-Of-Network Specialty Providers).
  (1) A health care MCO may not refuse to reimburse an out-of-network "specialty provider" enrolled as a provider in the Texas Medicaid program for services provided to a member under the circumstances set forth in §353.7 of this subchapter.
  (2) In reimbursing a provider for the services described in paragraph (1) of this subsection, a health care MCO must use the reasonable reimbursement methodology in subsection (f)(2) of this section.
(e) An MCO may be required by contract with HHSC to allow members to obtain services from out-of-network providers in circumstances other than those described in subsections (b) - (d) of this section.
(f) Reasonable reimbursement methodology.
  (1) Out-of-network nursing facilities.
    (A) Out-of-network nursing facilities must be reimbursed at or above 95 percent of the nursing facility unit rate established by HHSC for the dates of service for services provided inside of the MCO's service area.
    (B) Out-of-network nursing facilities must be reimbursed at or above 100 percent of the nursing facility unit rate for the dates of services for services provided outside of the MCO's service area.
  (2) Emergency and authorized services performed by out-of-network providers.
    (A) Except as provided in §353.913 of this chapter (relating to Managed Care Organization Requirements Concerning Out-of-Network Outpatient Pharmacy Services) or subsection (j)(2) of this section, the MCO must reimburse an out-of-network, in-area service provider the Medicaid FFS rate in effect on the date of service less five percent, unless the parties agree to a different reimbursement amount.
    (B) Except as provided in §353.913 of this chapter, an MCO must reimburse an out-of-network, out-of-area service provider at 100 percent of the Medicaid FFS rate in effect on the date of service, unless the parties agree to a different reimbursement amount, until the MCO arranges for the timely transfer of the member, as determined by the member's attending physician, to a provider in the MCO's network.
  (3) For purposes of this subsection, the Medicaid FFS rates are defined as those rates for providers of services in the Texas Medicaid program for which reimbursement methodologies are specified in Chapter 355 of this title (relating to Reimbursement Rates), exclusive of the rates and payment structures in Medicaid managed care.
(g) Reporting requirements.
  (1) Each MCO that contracts with HHSC to provide health care services or dental services to members in a service area must submit quarterly information in its Out-of-Network quarterly report to HHSC.
  (2) Each report submitted by an MCO must contain information about members enrolled in each HHSC Medicaid managed care program provided by the MCO. The report must include the following information:
    (A) the types of services provided by out-of-network providers for the MCO's members;
    (B) the scope of services provided by out-of-network providers to the MCO's members;
Cont'd...