TMA: CHIP Managed Care Plans Responsible for Out-of-Network Payments

Because federal law prohibits patients covered by the Children's Health Insurance Program (CHIP) from paying anything other than a copay, the state of Texas should require managed care organizations in CHIP to cover the costs for out-of-network physicians. That's the position TMA takes in a formal letter to the Texas Health and Human Services Commission. 

"The [health plans] are responsible, and should be held accountable, for setting rates at an appropriate level to attract an adequate number of physicians and other providers to join their networks and paying out-of-network providers at a rate sufficient to ensure balance billing does not occur," TMA General Counsel Rocky Wilcox wrote in TMA's comment letter. "Precluding medical providers from billing shifts the responsibility for the outstanding medical expense from the [plans] that voluntarily accepted network adequacy responsibilities and payment obligations under CHIP to physicians and other providers who never agreed to participate in CHIP or enter into a contract with the CHIP [plans]."

Action, Oct. 1, 2014

Last Updated On

April 27, 2018

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