Texas § IN.1301.005 - AVAILABILITY OF PREFERRED PROVIDERS

§ IN.1301.005. AVAILABILITY OF PREFERRED PROVIDERS

AVAILABILITY OF PREFERRED PROVIDERS; SERVICE AREA LIMITATIONS. (a) An insurer offering a preferred provider benefit plan shall ensure that both preferred provider benefits and basic level benefits, including benefits for emergency care, as defined by Section 1301.155 , and post-emergency stabilization care, are reasonably available to all insureds within a designated service area. This subsection does not apply to an exclusive provider benefit plan. (b) If services are not available through a preferred provider within a designated service area under a preferred provider benefit plan or an exclusive provider benefit plan, an insurer shall reimburse a physician or health care provider who is not a preferred provider at the same percentage level of reimbursement as a preferred provider would have been reimbursed had the insured been treated by a preferred provider. (c) Subsection (b) does not require reimbursement at a preferred level of coverage solely because an insured resides out of the service area and chooses to receive services from a provider other than a preferred provider for the insured's own convenience. (d) A service area, other than a statewide service area, may include noncontiguous geographic areas but may not divide a county. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005. Amended by: Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772 ), Sec. 8, eff. September 1, 2011. Acts 2023, 88th Leg., R.S., Ch. 740 (H.B. 3359 ), Sec. 2, eff. September 1, 2023. Acts 2023, 88th Leg., R.S., Ch. 740 (H.B. 3359 ), Sec. 3, eff. September 1, 2023.