June 5, 2020
Updated 06/05/2020 Posted April 13, 2020
For more information on this bill, review the Out-of-Network Provider Surprise Billing Senate Bill (SB) 1264 page on the provider website. It includes answers to Frequently Asked Questions.
Overview: A new Texas law, Senate Bill (SB) 1264, protects health plan members who receive medical care on or after Jan. 1, 2020, from surprise bills in many situations where a member doesn’t have a choice in where to get care.
The law outlaws surprise medical bills from various Texas health care providers, including:
- Out-of-network physicians and facilities, including hospitals and free-standing emergency medical care facilities that provide emergency services and supplies
- Out-of-network providers who are practicing at in-network hospitals, birthing centers, ambulatory surgical centers and free-standing emergency medical care facilities
- Out-of-network diagnostic imaging and laboratory services that are provided in connection with a service from an in-network provider
Under this law, a member must not be billed above their cost-share for non-network emergency care, facility-based care or lab/diagnostic imaging.
What does this mean for in-network providers? You should refer Blue Cross and Blue Shield of Texas (BCBSTX) members to in-network doctors, specialists, hospitals, labs and imaging centers, when applicable.
Which members does it apply to? It applies to members who are covered by fully-insured plans, the Employee Retirement System (ERS) and the Teacher’s Retirement System (TRS).
NOTE: Members with fully-insured plans will have “TDI or DOI” printed on their member ID cards.
This law does not apply to members covered by self-funded (administrative services only) health plans, Blue Cross Medicare OptionsSM, the Federal Employee Plan (FEP) and plans issued by health plans outside of Texas.
Dispute Resolution: In the event, an out-of-network provider and insurer cannot agree on payment for services provided, an independent reviewer selected by the out-of-network provider and insurer is used to help resolve the payment dispute.
Waiver: Members covered by SB 1264 can opt to have services provided by out-of-network providers by signing the Balance Billing Waiver form. This form waives the protections against balance billing and allows the provider to bill members over deductible, copayments and coinsurance. The waiver cannot be used in an emergency or when an out-of-network provider was assigned to a case, such as an anesthesiologist during surgery.
Have questions? Contact our Provider Services line at 1-800-451-0287.
Please help your patients and our members by referring or recommending BCBSTX in-network providers. Refer to Find a Doctor or Hospital on the provider website.