Your Rights and Protections
When you get emergency care or are 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. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
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, like a copayment, coinsurance, or a deductible. You may have additional 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” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
Under Federal Law, you’re 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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 balance billed for these post-stabilization services.
Air Ambulance services
If your plan covers in-network air ambulance services and you get transportation from an out-of-network air ambulance service, the most they can bill you is your plan’s in-network cost-sharing amount (such as co-payments, coinsurance and deductibles). You can’t be balance billed for these air ambulance 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 there may be out-of-network. In these cases, the most those providers can 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 types of 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 out-of-network care. You can choose a provider or facility in your plan’s network.
Surprise Billing in Texas
Texans with state-regulated health insurance have protections against some surprise medical bills, also called balance bills. This often happens in these situations:
- While you are getting treatment at an in-network hospital or facility, you also get care from another provider who does not have a network contract with Blue Cross and Blue Shield of Texas.
- You visit an in-network doctor, but that doctor sends your lab work or imaging to an out-of-network provider for testing or review.
- You get emergency treatment at an out-of-network hospital or emergency facility.
- You get emergency treatment or transportation from an out-of-network ground ambulance service.
The Surprise Billing law bans providers from sending balance bills to you in those cases. Instead, providers can work directly with your health plans to agree on payment for those bills.
How does the Texas Surprise Billing law protect me?
The law protects you from being surprise billed for more than your deductible, copays or coinsurance if:
- You are treated by an out-of-network provider in a network facility.
- You get emergency services and supplies, including treatment or transportation from a ground ambulance service.
- Your in-network doctor uses an out-of-network diagnostic imaging provider or lab.
For example, if your in-network doctor takes a blood sample in his office and sends it to an out-of-network lab, you are protected from balance billing unless you signed a balance billing waiver in advance. However, you are not protected if your in-network doctor orders an X-ray of your foot and you choose to go to an out-of-network imaging center. The difference is that, in this case, you had an opportunity to choose an in-network imaging center.
What is a Balance Billing Waiver?
If you see an out-of-network provider at a network facility or if you visit an out-of-network lab or imaging center, those providers may ask you to sign a Balance Billing Waiver form.
If you sign this form, you are giving up your protections against balance billing and the provider can bill you over the amount of your deductible, copays and coinsurance.
Note: The waiver cannot be used in an emergency or when an out-of-network doctor was assigned to a case, such as when an anesthesiologist is assigned to a surgery.
If I signed a Balance Billing Waiver and I changed my mind, what can I do?
You must sign the Balance Billing Waiver at least 10 business days before getting services for it to be effective. If you signed a waiver 10 business days or more before getting the service and then change your mind, you can:
- Cancel a waiver within five business days of signing.
- Tell the provider that you are canceling the services. The provider can’t charge you a cancellation fee, or any other type of fee for canceling the service.
What if I signed a Balance Billing Waiver but I’m being billed more than I expected?
BCBSTX can’t prevent an out-of-network provider from billing you when you signed a Balance Billing Waiver. However, we can explain to you what your health plan covers, and what amounts apply to your deductibles, copays and coinsurance. Call the customer service number listed on your BCBSTX member ID card for this information.
If you feel that the out-of-network provider is billing you more than you agreed at the time you signed the Balance Billing Waiver, contact the Texas Department of Insurance at tel: 1-800-252-3439.
How do I know if I am protected by the Texas Surprise Billing law?
This law does not apply to all Texans. The law applies to you if you meet one of the following:
- Your member ID card has “TDI” printed on it.
- You are covered by the Employee Retirement System (ERS).
- You are covered by the Teacher’s Retirement System (TRS).
Exceptions to Texas Surprise Billing Protections
You could, however, still be required to pay an out-of-network bill in certain situations. Texas surprise billing protections only apply to insurance plans regulated by the state of Texas. If your insurance plan is not regulated by the state, you may still be protected by the Federal No Surprises Act. If neither the Texas or the Federal Acts apply, you may be billed for certain out-of-network charges.
When balance billing isn’t allowed, you also have these protections:
You’re 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.
Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (also known as “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 in-network deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact:
Texas Department of Insurance
1601 Congress Avenue
Austin, TX 78701
tel: 1-800-252-3439
The federal phone number for information and complaints is: tel: 1-800-985-3059.