You are protected from surprise billing or balance billing when you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center.
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 copayments, coinsurance, and/or a deductible. You may have other costs or must pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities without a contract with your health plan. Out-of-network providers may bill you for the difference between your plan’s agreement 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 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:
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.
Texas law protects patients with state-regulated health insurance (about 16 percent of Texans) from surprise medical bills in emergencies or when they don’t have a choice of doctors. The law bans doctors and providers from sending surprise medical bills to patients in those cases.
Certain services at an in-network hospital or ambulatory surgical center
Certain providers may be out-of-network when you get services from an in-network hospital or ambulatory surgical center. 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.
Texas law also prohibits balance billing for any health care, medical service, or supply provided at an in-network facility by an out-of-network physician or other provider and for services by diagnostic imaging providers and laboratory service providers provided in connection with a health care service performed by a network physician or provider.
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.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles you would pay if the provider or facility were in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact 1-800-985-3059.
Visit https://www.cms.gov/nosurprises (opens in new tab) for more information about your rights under federal law.