Section 1301.005 - 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. Tex. Ins. Code § 1301.005
Amended by Acts 2023, Texas Acts of the 88th Leg.- Regular Session, ch. 740,Sec. 3, eff. 9/1/2023, app. only to an insurance policy that is delivered, issued for delivery, or renewed on or after September 1, 2024.Amended by Acts 2023, Texas Acts of the 88th Leg.- Regular Session, ch. 740,Sec. 2, eff. 9/1/2023, app. only to an insurance policy that is delivered, issued for delivery, or renewed on or after September 1, 2024.Amended By Acts 2011, 82nd Leg., R.S., Ch. 288, Sec. 8, eff. 9/1/2011.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. 4/1/2005.