Few things are more frustrating than receiving a bill from a doctor you never chose, like an out-of-network anesthesiologist at an in-network hospital. Texas and the federal government both have laws designed to protect patients from many of these surprise bills. Which one applies to you depends largely on the type of health plan you have.
Texas and Federal Protections at a Glance
| Texas Law | Federal No Surprises Act | |
|---|---|---|
| Which plans it covers | Generally state-regulated plans, such as many fully insured plans and state employee and teacher retirement plans | Most private health plans, including many self-funded employer plans |
| When it took effect | January 1, 2020 | January 1, 2022 |
| Typical protections | Emergency care and certain out-of-network services connected to in-network care | Emergency care, certain services at in-network facilities, and air ambulance services |
| What you usually pay | Your plan’s in-network cost sharing for protected services | Your plan’s in-network cost sharing for protected services |
Texas has also added protections for ground ambulance services under many state-regulated plans. Details can change, so check current guidance from the Texas Department of Insurance.
How to Tell Which Law Applies
Look at your insurance card. Many Texas state-regulated plans show “TDI” or “DOI” on the card. If yours doesn’t, your plan may be self-funded and fall under federal rules instead.
If You Get a Surprise Bill
- Don’t pay right away. Compare the bill with your plan’s explanation of benefits.
- Contact your health plan and ask whether the service is protected from balance billing.
- If it isn’t resolved, file a complaint with the Texas Department of Insurance or the federal No Surprises Help Desk, depending on your plan.
What These Laws Don’t Cover
Many protections don’t apply when you knowingly choose an out-of-network provider for planned care after receiving the required notice and giving consent.
Optima Financial Group in Plano, TX can help you understand how your health insurance plan is regulated and what protections apply. Policy terms vary. Families across Plano, TX and Collin County can reach out to Optima Financial Group anytime.