Your Rights & Protections: “Surprise Bills”

As of January 1, 2022, these Federal protections are in effect regarding balance billing (aka “surprise billing”).  Senate Bill 1264 from the Texas Legislature also protects consumers with state-regulated health insurance plans from unauthorized balance billing in emergencies or situations when the consumer did not select their provider.

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(OMB Control Number: 0938-1401)

You are protected from balance billing (aka “surprise billing”) when you receive emergency care or treatment from an out-of-network provider at an in-network hospital or ambulatory surgical center.

What is “balance billing” (aka “surprise billing”)?

When you see a health care provider, you may be required to pay certain out-of-pocket costs at the time of your appointment, such as a copayment, coinsurance, and/or a deductible.  You may need to cover additional costs or possibly pay for the full cost of treatment if you see a provider or visit a health care facility that isn’t in your health insurance plan’s network.

“Out-of-network” refers to providers and facilities that have not signed a contract with your health insurance 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, a practice known as “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 deductible.

“Surprise billing” is an unexpected balance bill. This can happen during treatments when you can’t control who is involved in your care.  For example, during a medical emergency when you are unable to elect a provider and determine their participation in your health care plan ahead of time, or if you receive care at an in-network facility but have one or more providers who are out-of-network.

You are protected from balance billing for:

Emergency services
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 cannot be balance billed for these emergency services.

Certain services at an in-network hospital or ambulatory surgical center 

When you get services from an in-network hospital or ambulatory surgical center, certain providers 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 cannot balance bill you and may not ask you to give up your protections to not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers cannot balance bill you unless you give written consent and give up your protections.

You are never required to give up your protection from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing is not allowed, you also have the following protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

Your health plan generally must:

+ Cover emergency services without requiring you to get 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 services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact:

Office of the Attorney General
Consumer Protection Division
PO Box 12548
Austin, TX 78711-2548

The Texas Department of Insurance also provides some helpful information balance billing protections, and about the mediation and arbitration process for negotiating these bills.  You can learn more here.

Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.