Medical bills can be stressful, especially when unexpected charges appear after a hospital visit or emergency care. Many patients are unaware that they may be charged extra fees when treated by out-of-network providers, even at in-network facilities. This practice, known as “balance billing” or “surprise billing,” can lead to costly medical expenses that catch patients off guard. Fortunately, laws are in place to protect you from these unfair charges, ensuring that you only pay your plan’s in-network costs in certain situations. In this guide, we’ll break down your rights, explain how balance billing works, and show you how to safeguard yourself from surprise medical bills.
Table of Contents
- Understanding Balance Billing and Surprise Billing
- Your Protections Against Balance Billing
- Services at In-Network Hospitals and Surgical Centers
- Additional Protections You Have
Understanding Balance Billing and Surprise Billing
When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. This means you shouldn’t be charged more than your plan’s copayments, coinsurance, and/or deductible.
What Is Balance Billing?
When you see a doctor or other healthcare provider, you may be responsible for certain out-of-pocket costs, such as copayments, coinsurance, or a deductible. However, if you visit an out-of-network provider or healthcare facility, you may have to pay additional costs or even the full bill. Since out-of-network providers have not signed a contract with your health plan, they can charge you the difference between what your plan pays and the full price of the service—this is called balance billing. These charges are often significantly higher than in-network costs and may not count toward your deductible or annual out-of-pocket limit.
What Is Surprise Billing?
Surprise billing happens when you unexpectedly receive a balance bill. This typically occurs when you cannot choose who provides your care, such as in emergencies or when an in-network hospital unexpectedly uses out-of-network providers. These surprise bills can be costly, sometimes reaching thousands of dollars, depending on the procedure or service of the emergency room you visited.
Your Protections Against Balance Billing
Emergency Services
If you have an emergency medical condition and receive treatment from an out-of-network provider or facility, the maximum they can charge you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You cannot be balance billed for emergency services. This protection applies even after you are stabilized, unless you provide written consent to waive your rights.
Services at In-Network Hospitals and Surgical Centers
If you receive care at an in-network hospital or ambulatory surgical center, certain providers may still be out-of-network. However, the most these providers can bill you is your in-network cost-sharing amount. This applies to specialties such as:
- Emergency medicine
- Anesthesia
- Pathology
- Radiology
- Laboratory services
- Neonatology
- Assistant surgeons
- Hospitalists
- Intensivists
These providers cannot balance bill you or ask you to waive your protections. If you receive other types of services at an in-network facility, out-of-network providers can balance bill you—but only if you provide written consent. However, you are never required to waive your protections, and you can always choose an in-network provider or facility.
Additional Protections You Have
When balance billing is not allowed, you are also protected in the following ways:
- You are only responsible for your in-network cost-sharing amount (copayments, coinsurance, and deductibles). Your health plan covers additional costs owed to out-of-network providers and facilities.
- Your health plan must:
- Cover emergency services without requiring prior authorization.
- Cover emergency services provided by out-of-network providers.
- Base your cost-sharing on in-network rates and reflect this amount in your explanation of benefits.
- Apply any payments for emergency or out-of-network services to your in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, contact the federal No Surprises Help Desk at (800)985-3059 or the Texas Department of Insurance at (800) 252-3439,
Visit http://www.cms.gov/nosuprises/consumers for more information about your rights under federal law. Visit https://www.tdi.texas.gov/medical-billing/surprises-balance-billing.html for more information about your rights under Texas Law.
