If you were rushed to an Emergency Room with a serious illness or injury, you may later receive bills from the ER, attending doctors, imaging technicians or other providers who treated you. When you experienced your emergency, you may have been able to direct whomever was transporting you to a facility that you knew was in your health insurance network. Or you may have not been capable at that moment to do that. And you may have been moved from the ER to Intensive Care in a Hospital. In any of these cases, it is quite likely that you will receive surprise out-of-network (OON) charges in the mail.
The liability that you have to pay these bills depends on the type of health insurance plan that you possess. If your insurance is through your employer, it may be a federally regulated, ‘self-funded’ plan. If this is the case, you cannot use any of the remedies described below. This gaping hole in consumer protection may be closed soon as a bipartisan bill to address this issue is currently being prepared by members of the U.S. Senate. Check with your company’s HR department to find out if your plan is ‘self- funded’. If your plan is self-funded, there are still some actions you can take that may reduce or eliminate what you are required to pay. See Item 3 in the attached link: https://forabettertexas.org/images/HW_2018_SurpriseMedicalBill_WhatToDo.pdf
For HMOs and EPOs:
If your policy is a Health Maintenance Organization (HMO), Exclusive Provider Organization (EPO) or a Point of Service (POS) plan, Texas law protects you from paying more than the in-network deductibles and copayments included in your policy. If you have a Qualified Health Plan as defined in the Affordable Care Act (ACA), your total cost is limited by the maximum yearly out-of-pocket specified in the plan. The maximum for 2019 is in the range $575 to $7900. All ACA (Obamacare) plans in Central Texas counties are either HMOs or EPOs.
Unfortunately, the law doesn’t prevent the providers from billing you. In a recent case that came to my attention, the OON bills exceeded $50,000. You need to be aware of the actions that you must take to avoid having to pay the OON charges. Here are the steps to take for each OON bill you receive.
- If you have an HMO or EPO, call your insurer (the insurer doesn’t know what was billed directly to the policyholder). Say “I received an out-of-network, balance bill. I expect you to hold me harmless from this bill by finding an acceptable payment rate with the provider, as required in state law.”
- If you have an EPO, the insurer’s representative may reply that you have to apply for medication with the Texas Department of Insurance. In this case, do apply, using the form included in this link: https://www.tdi.texas.gov/consumer/cpmmediation2.html
- If the insurer does not resolve the issue, you will need to file a complaint, as outlined in this link: https://www.tdi.texas.gov/consumer/complfrm.html
Do not give up and make payment for the OON charges. The law is on your side.
For PPOs and some Texas state employee and teacher health plans:
If your plan is a Preferred Provider Organization (PPO) or you have coverage in ERS HealthSelect, TRS-ActiveCare, or TRS-Care, state law dictates that you may request mediation if your surprise bill is more than $500 on top of amounts owed for your deductible or copayments/coinsurance, and the bill was for one of the following types of care:
- Emergency care provided by a doctor, hospital, free-standing ER, or clinic. Ambulance bills are NOT included.
- Non-emergency care from an out-of-network doctor or other provider while you were at an in-network facility, including in-network hospitals, free-standing ERs, surgery centers, and birthing centers. Use this link to apply for mediation: https://www.tdi.texas.gov/consumer/cpmmediation2.html
The material presented here has been taken from information given in a paper on this
subject from the Center for Public Policy Priorities (CPPP) in Austin. For much more detail on this topic, including suggestions as to the wording to use when filing a complaint, refer to: https://forabettertexas.org/images/HW_2018_SurpriseMedicalBill_WhatToDo.pdf
The above-referenced paper also covers handling of surprise bills for those insured through Medicaid, Texas CHIP or Medicare. I want to credit Stacey Pogue, Senior Policy Analyst, CPPP, for providing the advice and information included here.
The CPPP is an independent public policy organization that uses data and analysis to advocate for solutions that enable Texans of all backgrounds to reach their full potential.