YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS

(OMB Control Number: 0938-1401)

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care - like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. You are protected from balance billing for emergency services and certain services at an in-network hospital or ambulatory surgical center. You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

  • You are only responsible for paying your share of the cost (like co-payments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

  • Your health plan generally must:

    • Cover emergency services without requiring you to get approval for services in advance (prior authorization).

    • Cover emergency services by out-of-network providers.

    • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

    • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact: The Texas Department of Insurance Consumer Help Line at 1-800-252-3439 or visit www.tdi.texas.gov/tips/texas-protects-consumers-from-surprise-medical-bills or www.tdi.texas.gov/medical-billing/surprise-balance-billing for more information about your rights under Texas law.

GOOD FAITH ESTIMATE

You have the right to receive a ‘Good Faith Estimate’ explaining how much your medical care may cost.

Under the law, health care providers need to give patients who do not have insurance, or who are not using insurance, a cost estimate of the bill for medical items and services.

  • 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, drugs, equipment, and hospital fees.

  • Your health care provider must give you a ‘Good Faith Estimate’ in writing at least 1 business day before your medical service or item. You can also ask your health care provider for a ‘Good Faith Estimate’ before you schedule an item or service.

  • 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.

For questions or more information about your rights under Federal law visit www.cms.gov/nosurprises or call 979.968.6596