Surprise Medical Bills

Starting this year, there’s a new law to protect you from surprise medical bills. Learn more about who and what the new law covers.

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[MUSIC PLAYING] SPEAKER 1: Have you ever received a bill that you didn't expect? And wouldn't it be nice if that wasn't allowed? Like, I'm sorry, you are not allowed to charge me that. Well, guess what? Texas passed a law that prevents some of those surprise medical bills, but the law doesn't apply to everyone in every situation. So listen up, and we'll tell you how to protect yourself.

First, let's get everyone on the same page. Do you know what it means to be in-network or out-of-network? I'm not talking about your friends on social media. I'm talking about your health insurer's network of doctors, hospitals, and other health care providers. When you visit a doctor or other provider who isn't a part of your insurer's network, you're seeing an out-of-network provider, and out-of-network providers may send you a bill for amounts on top of what your insurer already paid for the care you received.

It's called balance billing, or surprise billing, and it can get really expensive. Some people have gone bankrupt trying to pay a surprise bill. Bankrupt. So how do you know who's in-network? Well, look for your insurer's provider network search tool. Blue Cross and Blue Shield of Texas members can find a provider on our app or our website. Tools like these can help you locate doctors, and specialists, hospitals, and pharmacies that are in-network.

You can also call the number on the back of your ID card to ask for assistance locating an in-network provider. Easy enough, right? Well, usually it is. Unfortunately, sometimes even if the facility you visit is in-network, the doctor who treats you could be out-of-network. For example, your surgeon and your hospital could both be in-network, but what about the anesthesiologist who treated you during your procedure?

They could be out-of-network. Similarly, you may have had a blood draw that your in-network doctor's office did, but then your physician could send your lab work to an out-of-network lab. Both of these situations can lead you to receiving a surprise medical bill through no fault of your own. It seems unfair, right? Well, Texas lawmakers thought so too.

Fortunately, a new law protects some Texans from surprise bills, especially in situations where you don't have a choice in where to get care. This law takes the patient out of the middle. It places the negotiating responsibility where it belongs, on the health care provider and the insurance company. With this new law in place, providers should not send you a surprise bill for amounts above your deductible, copay, or coinsurance, and this applies to three types of situations.

You should not get a surprise bill for emergency services and supplies. You shouldn't receive a surprise bill from an out-of-network provider who treats you at an in-network facility, like the anesthesiologist that I mentioned. And lastly, you shouldn't get a surprise bill when you're in-network doctor uses an out-of-network provider for diagnostic imaging or lab work.

In these last two situations that don't involve emergency care, there's another exception, and we're going to talk about it in a minute. The law is already in effect, and the rules apply to any care you received on or after January 1, 2020. However, there are some exceptions to the rule. It's important to know that this law does not apply to all health plans. It only applies to fully insured state regulated plans issued to groups and individuals through HMOs, and PPOs, and EPOs.

And you might be thinking, OK, how am I supposed to know if that includes me? Well, you can tell by looking at your ID card. The law applies to anyone with a Blue Cross and Blue Shield of Texas ID card that has TDI printed on it, and it might apply if you have DOI on your card. It does not apply to Medicare. It also doesn't apply to many employer sponsored plans, with the exception of ERS and TRS. They actually are impacted.

So just play it safe. Call your insurer to find out if this law applies to you. There's another important exception we should talk about. If you visit a health care provider outside your network, they may ask you to sign a form before they provide care. This form gives them the right to balance bill you, because you're choosing to receive out-of-network care.

OK, this form, it looks like this. And the provider must give it to at least 10 business days before the service is performed. By signing the form, you agree to pay more for out-of-network care and give up important legal protections. If it were me, I'd think long and hard before I'd agree to waive my rights for consumer protection. So what happens if you sign now and then you regret it later?

Well, you have five business days to change your mind and revoke your agreement after you sign the form. And members who sign the form still have the right to appeal their claim following the standard claims appeal process described in your health benefit plan. You should also know that there are some situations in which the doctor can't ask you to sign a form allowing them to balance bill you.

OK, so I know that was a lot of information to hear all at once. That's why Blue Cross also made it available on bcbstx.com. You can come back to it later. Just click on Find a Doctor or Hospital, click on the tab, click Know Your Network on the left side, and then you'll find these tips in the stay in-network section.

Still have questions? Call the number on the back of your ID card and a customer advocate will walk you through the options. You can also call the Texas Department of Insurance at 1-800-252-3439, or go to tdi.texas.gov for more information.



Frequently Asked Questions

What is the new Texas “Surprise Billing” law?

Starting Jan. 1, Texans with state-regulated health insurance have new protections against some surprise medical bills, also called balance bills.

What are surprise medical bills?

Surprise bills, sometimes called balance bills, happen when a provider charges more for treatment than your health benefit plan pays – and you get the bill for the difference. You may get a balance bill when you get care from a doctor, hospital, or other health care provider outside your health plan’s network. Sometimes, you may choose to seek care out of your plan’s network and know you will receive a bill. But often, a balance bill can be a surprise. This often happens in three 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 (BCBSTX).
  • 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.

The new 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.

I was treated in an emergency room. Why am I getting this surprise bill?

If you visited an out-of-network hospital or emergency facility because you were experiencing an emergency and needed immediate care, and then you received a surprise bill, please call us at the customer service number on the back of your BCBSTX member ID card.

How does the Surprise Billing law protect me?

The law protects you from being surprise billed for more than your deductible, copay or coinsurance if:

  • You are treated by an out-of-network provider in a network facility.
  • You get emergency services and supplies.
  • 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, copayments 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 ten business days before getting services for it to be effective. If you signed a waiver ten 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, copayments and coinsurance. Call the customer service number on the back of 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 1-800-252-3439.

When does this new law go into effect?

The law covers services received on or after January 1, 2020. (See below for your protections for services before 1/1/20).

How do I know if I am protected by the new “Surprise Billing” law?

This law does not apply to all Texans. The law applies to you if your meet one of the following:

  • Your member ID card has a “TDI” printed on it.
  • You are covered by the Employee Retirement System (ERS).
  • You are covered by the Teacher’s Retirement System (TRS).
BCBSTX member ID card

This law does not apply to:

  • Other self-funded employer-sponsored health plans
  • Medicare
  • The Federal Employee Plan
  • Plans issued by health plans outside Texas

If you are not sure what type of plan you have, please contact the customer service number on the back of your member ID card.

If I saw an out-of-network provider before Jan. 1, 2020, am I responsible for the balance bill?

Maybe, but you may have legal rights that could protect you from having to pay that bill:

  • HMO Members: If you are being balance billed by a provider that you saw for emergency treatment before 2020, please call the customer service number on the back of your BCBSTX member ID. Tell us that you have been balance billed for an emergency service and you want us to handle the bill. You should also call us if you get a balance bill for a service you received from an out-of-network provider because there was not a network provider available.
  • PPO & ERS Members: You may be able to request that the provider and BCBSTX mediate (negotiate) the bill. Generally, this is an option for bills over $500 from out-of-network facility-based providers or emergency care services.

I’ve heard that I have to go to mediation or arbitration to avoid paying my balance bill. How does the mediation or arbitration process work?

For services you received on Jan. 1, 2020 or later, your health plan and provider may use the mediation or arbitration processes to help resolve disagreements about payment. You will not be involved in this process.

Does this new law change my appeal rights?

No. You still have all of your rights to appeal and complain to your health plan about how your claim was handled. Please consult your benefit booklet or contact the number on the back of your member ID card for information on how you can appeal.

What should I do if I receive a balance bill I didn’t expect?

Call the customer service number on the back of your BCBSTX member ID card. We can help you determine if you should have been billed. If you should not have been billed, we can contact your provider to remind them of the surprise billing law and educate them on their options.

Where can you find information on how to select an in-network provider?

Register for or log in to Blue Access for MembersSM, our secure member website. Then, use Provider Finder® to find doctors, specialists and hospitals in your network. You can also call the customer service number on the back of your BCBSTX member ID card to ask for help finding an in-network provider.