Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise 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.
You are protected from balance billing for:
Emergency servicesIf 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.
If you are insured by a state-regulated HMO or PPO insurance plan (including the state employee and teacher retirement systems), Texas law also protects you from surprise medical bills for emergency services.
Certain services at an in-network hospital or ambulatory surgical centerWhen 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 are insured by a state-regulated insurance plan (including the state employee and teacher retirement systems), Texas law also protects you from surprise medical bills for services received from an out-of-network facility-based provider at an in-network facility unless you receive a written disclosure from the provider and give written consent in advance. Texas law also protects you from surprise medical bills from out-of-network laboratory services or diagnostic imaging.
When balance billing isn’t allowed, you also have the following protections:
If you believe you’ve been wrongly billed, you may contact The Texas Department of Insurance Consumer Help Line at 1-800-252-3439.
Visit https://www.cms.gov/nosurprises/consumers or call 1-800-985-3059 for more information about your rights under federal law. Visit https://www.tdi.texas.gov/tips/texas-protects-consumers-from-surprise-medical-bills.html for more information about your rights under Texas law.