Consumers with state regulated health plans are protected from getting surprise balance bills if they get emergency care out-of-network or have no choice of providers.
What is Balance Billing?
Balance billing can occur when consumers get care or medical supplies from out-of-network healthcare providers, such as doctors, hospitals, or labs. Out-of-network providers do not have a contract with your health plan. If your health plan doesn’t pay the full amount of what the out-of-network provider charges, then the provider sends you a bill to for the remaining amount. This remaining amount is known as a balance bill. Senate Bill 1264, passed by the 86th Legislature prevents balance billing when consumers don’t have the option to see a provider in their health plan’s network.
Who is Protected from Balance Billing?
You are protected from balance billing if you are enrolled in an HMO, PPO, or EPO that is regulated by the State of Texas or are enrolled in certain state group health plans (ERS group plan, TRS-Care, or TRS-ActiveCare). Health plan ID cards for state-regulated plans will display “TDI” (Texas Department of Insurance) or “DOI” (Department of Insurance) somewhere on the card.
*️⃣ This does not apply to Medicare or self-funded employer sponsored plans.
Can Doctors Still Send Me a Balance Bill?
Senate Bill 1264 allows you to waive your protections from balance billing if you choose to see an out-of-network provider at an in-network facility. This is only allowed in cases where you have a choice between seeing an in-network or out-of-network provider.
*️⃣ This waiver cannot be used in an emergency or when an out-of-network doctor is assigned to a case.
For an out-of-network provider to be able to send you a balance bill:
- You must have the choice between an in-network or out-of-network provider, and choose to the use the out-of-network provider.
- You must be given notice and a disclosure statement from the out-of-network provider that explains they are not in your health plan’s network, estimates your costs, and asks you to waive your protections from balance billing.
- The notice and disclosure must be given to you before scheduling the appointment, and must be signed by you at least 10 business days before getting the nonemergency out-of-network care.
- Out-of-network providers cannot charge you a nonrefundable fee, deposit, or cancellation fee before you decide to choose the out-of-network care and waive your rights from balance billing protections.
Terms to Know
Out-of-network – Health care services provided by a doctor or hospital that does not have an agreement with your health plan.