Feb. 28, 2020

Texas Senate Bill 1264 Offers Surprise Medical Bill Protection

Balance or “surprise” billing happens when an out-of-network health care provider bills a patient for the difference between what they charge for a service and what the insurance company pays for that service.

During the 2019 Texas Legislature, Senate Bill 1264  was passed to protect health plan members from surprise billing. The law went into effect for services on or after Jan. 1, 2020, and applies to treatment situations where members don’t have a choice in where to get care, such as:
 

• Out-of-network providers who are practicing at in-network hospitals, birthing centers, ambulatory surgical centers and free-standing emergency medical care facilities
• Out-of-network physicians and facilities, including hospitals and free-standing emergency medical care facilities, that provide emergency services and supplies
• Out-of-network diagnostic imaging and laboratory services that are provided in connection with a service from an in-network provider

How it works: SB 1264 encourages providers and insurance companies to come to an agreement on the price for services and removes the member from the process. The bill also ensures that members are not responsible for amounts above their deductible, coinsurance and copayments in those situations listed above. If the provider and insurer aren’t able to agree on the price, an independent reviewer called an arbitrator or mediator will review the claim. The mediator will use set criteria, including benchmark pricing data, to choose between the provider’s or insurer’s price.

Important note: Out-of-network providers may ask members to sign a form called a balance bill waiver that allows the provider to balance bill. This form removes the protections of the law and must be signed by the provider and member 10 business days before services are provided. A member has five business days after signing the waiver to revoke the agreement. It is very important that members read any paperwork a provider asks them to sign.

SB 1264 applies to members of the following groups:

• Fully insured HMO
• Fully insured PPO
• ERS
• TRS

SB 1264 does NOT apply to:

• Other self-funded employer-sponsored health plans
• Medicare
• The Federal Employee Plan
• Plans issued by health plans outside Texas