The federal No Surprises Act became effective Jan. 1, 2022. It established a federal law prohibiting balance billing for out-of-network, self-pay, and uninsured patients from certain surprise medical bills. The law also created patient price transparency rules by requiring certain physicians to provide their patients with good faith estimates.

 

Texas Senate Bill 490 became effective September 1, 2023, and defined the No Surprise Act for Texas. It applies to state regulated PPO, EPO, and HMO plans, as well as Employee Retirement System/Teacher Retirement System plans.  It also applies to health plans offered by certain non-profit agricultural organizations. Services covered by this law include:

• Out-of-network emergency care and related supplies.

• Services and related supplies from an out-of-network, facility-based provider at an in-network facility.

• Services and related supplies provided by out-of-network diagnostic imaging or laboratory services provider, if performed in connection with a health care service performed in-network.

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What is balance billing?

Balance billing occurs when a health care provider bills a patient after the patient’s health insurance company has paid its portion. The balance bill is for the difference between the amount the provider charges and the price the insurance company sets, after the patient pays any co-pay, co-insurance, or deductible.

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Balance billing can occur when a consumer receives health care services from an out-of-network provider or an out-of-network facility.

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In-network providers agree with an insurance company to accept the insurance payment in full. In-network providers agree not to balance bill. Out-of-network providers do not have this agreement with the insurance company. Therefore, in the past they sometimes billed the patient for the amount not covered by insurance.

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Some health plans, such as Preferred Provider Organization (PPO) or Point of Service (POS) plans, offer some coverage for out-of-network care, but the provider can still balance bill the patient. Other plans offer no coverage for out-of-network providers and leave the financial responsibility entirely on the consumer.

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Balance billing is prohibited in both Medicare and Medicaid.

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What is surprise billing?

Surprise billing occurs when a patient receives a balance bill after unknowingly receiving care from an out-of-network provider or an out-of-network facility, such as a hospital. This can occur in emergency and non-emergency situations.

Some states have enacted protections for consumers against surprise billing. However, state laws do not apply to self-insured health plans, which account for the majority of people who get coverage through an employer. Now, federal law adds additional protections.

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What protections are in place?

A new federal law, the No Surprises Act, protects you from: emergency out-of-network medical bills including air ambulances, and non-emergency services at an in-network facility.

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A facility (such as a hospital or freestanding emergency room (ER)) or a provider (such as a doctor or licenced therapist) may not bill you more than your in-network cost sharing amount for emergency services. This is true even if the emergency services you received were at an out-of-network facility or performed by an out-of-network provider.

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Under your health plan, you are still responsible for cost sharing amounts that may include copays, coinsurance, and deductibles. You are also protected when you receive non-emergency services from out-of-network providers at in-network facilities. An out-of-network provider may not bill you more than your in-network co-pay, co-insurance, or deductible for services performed at an in-network facility.

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You can still consent in advance to receive care from an out-of-network provider in some situations and agree to pay the provider amounts above your in-network co-pay, co-insurance, or deductible.

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What else should I know?

You must receive notice of your rights under the new law from your health plan and from the facilities and providers that serve you. If you think the protections have not been applied correctly, you can file an appeal with your insurance company or request external review of the company’s decision.

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You also can file a complaint with the federal Department of Health and Human Services.

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IF YOU BELIEVE YOU’VE BEEN WRONGLY BILLED, YOU MAY CONTACT:

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The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or  visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

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The Texas Department of Insurance Consumer Help Line at 1-800-252-3439 or visit https://www.tdi.texas.gov/tips/texas-protects-consumers-from-surprise-medical-bills.html or https://www.tdi.texas.gov/medical-billing/surprise-balance-billing.html for more information about your rights under Texas law.

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Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

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You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees.

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Make sure your healthcare provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

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If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate.

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GET MORE INFORMATION

For questions or more information about your right to a Good Faith Estimate, visit https://www.cms.gov/nosurprises or call 1-800-MEDICARE (1-800-633-4227).