Texas Senate Bill SB486

Texas 2021 - 87th Regular

Caption

Relating to provider reimbursements and enrollee cost-sharing payments for services provided under a managed care plan by certain out-of-network providers.

Impact

This bill is expected to enhance the financial security of Medicaid enrollees by reducing unexpected medical costs associated with out-of-network providers. It will particularly benefit those who may not be aware of changes to their provider's network status upon seeking care. By mandating that Medicaid managed care organizations comply with these reimbursement rates, SB486 aims to prevent situations where patients are inadvertently penalized for needing services from previously included providers due to administrative changes.

Summary

SB486 is a legislative proposal that seeks to regulate provider reimbursements and enrollee cost-sharing payments for services rendered by certain out-of-network providers under managed care plans in Texas. The bill specifically addresses situations where Medicaid services are provided by a healthcare provider who, at the time of the patient's enrollment, was listed in the provider network but later fell out of it. Under this bill, such providers are entitled to be reimbursed at the in-network rate provided the service is delivered during the enrollee's coverage period, thereby ensuring that enrollees do not face higher out-of-pocket costs that they might encounter when seeking care from an out-of-network provider.

Contention

However, there could be concerns regarding the potential financial implications for managed care organizations who are mandated to reimburse out-of-network providers at the in-network rate. Some stakeholders may argue that this could increase operational costs for these organizations, potentially leading to higher premiums or changing the dynamics of provider networks. Additionally, there may be broader implications for out-of-network services, including the potential underproduction of such services as providers adjust to network changes to avoid reimbursement complications.