When you get emergency care or get treated by an out-of-network provider you are protected from surprise billing or balance billing.
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in- network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Senate Bill 1731 enacted by the 80th Texas Legislature, created new rights for Texas health plan consumers to help them avoid unexpected health care bills. Consumers can request a cost estimate from a health care facility provider, physician, or from their health insurance company or HMO before receiving care. Carriers and health care providers must provide these estimates within 10 business days. Additionally, Texas law requires health carriers to use information technology to provide certain information to consumers, such as information on the "estimated financial responsibility for the health care provided to the enrollee." Many carriers have developed shopping tools that allow their enrollees to obtain estimates for the cost of certain services across in-network providers.
All of these tools, combined with Texas' network adequacy protections, help to mitigate the risk of balance billing. Consumers are encouraged to obtain cost estimates in advance of planned procedures and to ensure all providers involved in treatment are in-network.
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
If you would like to file a federal complaint, please contact the Centers for Medicare & Medicaid Services (CMS) at 1.800.985.3059 or by visiting https://www.cms.gov/nosurprises/consumers.
If you would like to file a state complaint, please “File a Complaint” with the Texas Department of Insurance by visiting https://appscenter.tdi.texas.gov/medarb/p/login.