What are my surprise medical bill rights in Texas?

Understanding Surprise Medical Bills

Imagine you go to a hospital that is 'in-network' with your insurance plan. This means your insurance has an agreement with them about prices. But then, you get a bill from a doctor you never met, like an anesthesiologist, who works at that hospital but is 'out-of-network.' This unexpected bill is often called a surprise medical bill.

A surprise bill usually happens when you get care from a provider or facility that isn't part of your insurance plan's network. This can be confusing because you might not have had a choice in who treated you, especially in an emergency. The provider then bills you for the difference between what your insurance paid and their full charge. This is known as 'balance billing.'

Balance billing can leave you with a much higher bill than you expected. It often happens when you receive services from an out-of-network provider at an in-network hospital or facility. You might not even know they were out-of-network until the bill arrives.

The Federal No Surprises Act

The No Surprises Act is a federal law that started in January 2022. It protects most people with health insurance from many surprise medical bills. This law applies if you have a group health plan or individual health insurance coverage.

Under this Act, you generally only have to pay your in-network cost-sharing (like your copay, deductible, or coinsurance) for certain services. This is true even if you get care from an out-of-network provider or facility. The law covers emergency services, and non-emergency services you get at an in-network hospital or surgery center.

For example, if you go to an in-network hospital for an emergency, and an out-of-network doctor treats you, the hospital or doctor cannot bill you for more than your in-network cost-sharing. They can't 'balance bill' you in these situations.

• Emergency services, even if the facility or provider is out-of-network.
• Non-emergency services from out-of-network providers at an in-network hospital or surgery center.
• Air ambulance services.

Texas Laws Against Surprise Billing

Texas had protections against surprise medical bills even before the federal No Surprises Act. These state laws cover people with certain types of health plans, specifically those regulated by the Texas Department of Insurance (TDI). This often includes HMOs and many PPO plans bought in Texas.

Texas law provides similar protections, generally preventing balance billing for emergency care and for certain out-of-network services you receive at an in-network facility. If you have a state-regulated plan, these Texas laws work alongside the federal protections.

If you receive a surprise bill that's covered by Texas law, there's a process to resolve it. Your insurance company and the provider can use a mediation or arbitration process through the Texas Department of Insurance to decide on a fair payment. You, as the patient, are not involved in this part of the payment dispute.

Who These Protections Cover

Most people with private health insurance are covered by either federal or state surprise billing laws. This includes people with employer-sponsored plans (fully insured plans) and those who buy insurance directly or through the marketplace.

You are generally protected when you receive emergency services, or when you receive non-emergency services at an in-network facility where you didn't choose an out-of-network provider. This means you should only owe your in-network cost-sharing.

However, there are some situations where you might not be fully protected. For example, ground ambulance services are typically not covered by the federal No Surprises Act or many state laws. Also, if you knowingly choose an out-of-network provider for non-emergency care and sign a special waiver agreeing to pay more, these protections might not apply.

• **Protected:** Most insured patients for emergency care.
• **Protected:** Most insured patients for non-emergency care at an in-network facility when an out-of-network provider is involved without your choice.
• **Not Protected:** Ground ambulance services often fall outside these laws.
• **Not Protected:** Some self-funded employer health plans may have different rules, though federal law still applies to many aspects.
• **Not Protected:** If you choose an out-of-network provider for non-emergency care and sign a specific form agreeing to pay the difference.

Steps to Take If You Get a Surprise Bill

Receiving a surprise medical bill can be upsetting, but don't panic. There are clear steps you can take to address it. Remember, you have rights, and you don't have to pay a bill you believe is unfair or illegal.

• **Do Not Pay Immediately:** First, hold off on paying the bill. Paying it might make it harder to dispute later.
• **Review Your Explanation of Benefits (EOB):** Your EOB from your insurance company will show what they paid and what they believe you owe. Compare this to the bill from the provider. Look for codes or notes that explain why something wasn't covered as expected.
• **Contact Your Insurance Company:** Call your health plan. Ask them why the bill was processed the way it was. Explain that you believe it's a surprise bill and ask about your protections under the No Surprises Act or Texas law. They should be able to help you understand your rights and the next steps.
• **Contact the Provider:** Speak with the billing department of the provider who sent the bill. Explain that you believe you've been balance billed illegally. Refer to the No Surprises Act or Texas law. Ask them to re-bill your insurance correctly or adjust the charge.
• **File a Complaint or Seek Assistance:** If your insurance or the provider isn't helpful, you can file a complaint. For federal protections, contact the No Surprises Help Desk. For state-regulated plans, contact the Texas Department of Insurance (TDI). They can investigate and help resolve the dispute.
• **Keep Records:** Save copies of all bills, EOBs, and notes from phone calls (who you spoke to, date, time, what was discussed). This documentation is very important if you need to dispute the bill further.