When you receive emergency care or receive treatment by an out-of-network (OON) 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 be responsible for 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 do not have 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 deductible and 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:
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.
https://www.tdi.texas.gov/medical-billing/surprise-balance-billing.html or by calling the Consumer Help Line at 800-252-3439.
Certain services at an in-network hospital or ambulatory surgical center
When you receive services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. I n these cases, the most a provider may bill you is your plan’s in-network cost-sharing amount. 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 onIy responsible for paying your share of the cost (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 or would like more information regarding your rights under federal law, you may contact the Department of Health and Humana Services at 1.800.985.3059 or visit www.cms.gov/nosurprises. Visit https://www.tdi.texas.gov/medical-billing/surpise-balance-billing.html for more information about your rights under Texas law for state regulated plans.