Your Rights and Protections Against Surprise Medical Bills

As of January 1, 2022, the Centers for Medicare and Medicaid (“CMS”) have started enforcing new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Through new rules aimed to protect consumers, excessive out-of-pocket costs are restricted, and emergency services must continue to be covered without any prior authorization, and regardless of whether or not a provider or facility is in-network.

Similarly, Texas law bans balance bills for emergency care and care provided at in-network facilities when the patient didn’t have a choice of doctors for services received on or after January 1, 2020. Texas law authorizes arbitration (for doctors) and mediation (for facilities) to resolve payment disputes in those cases.

The law carves out a narrow exception when a consumer chooses an out-of-network doctor or provider at an in-network facility.

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.

Overview

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 cannot 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

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services.

These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You are not required to receive care out-of-network. You may choose a provider or facility that is in your plan’s network.

Waiver of Balance Billing

State law does authorize a balance billing waiver if certain requirements are met, and you consent in writing. If you sign the waiver form, you lose the protection of the law. The waiver can never be signed in the case of emergency if you did not have a choice of providers. The Harbor Health Medical Group provider will give you an estimated payment that will include the date of service, the service or supply with code and name of the service or supply, the amount to be billed, and how much you will be responsible for. To learn more, see 28 Texas Administrative Code Sections 21.4901 to 21.4904.

IMPORTANT: You do not have to sign a waiver form. But if you do not sign the waiver form, the provider or facility might not treat you. You can choose to get care from a provider or facility in your health plan’s network.

When balance billing is not allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, 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 following federal and state agencies.

CMS can provide some assistance for questions about a complaint with your insurance company, medical provider or healthcare facility including investigating any insurance companies, medical providers or facilities over which CMS has jurisdiction. CMS will provide answers to your questions or provide you with the group or individuals who can assist you. You may contact CMS at the No Surprises Help Desk at 1-800-985-3059 or submit an online complaint here, https://nsa-idr.cms.gov/consumercomplaints/s/?language=en_US.

For state-regulated health plans including the Texas Employee Retirement System, the Teacher Retirement System, and the Texas Employees Group Benefit Plan you may contact the Texas Department of Insurance at https://www.tdi.texas.gov/medical-billing/surprise-balance-billing.html.

If you wish to file a complaint about a doctor, physician assistants, acupuncturists, surgical assistants, respiratory care practitioners, medical radiologic technologists, medical physicist, and perfusionists, you may contact the Texas Medical Board at https://www.tmb.state.tx.us/page/place-a-complaint.

If you want to file a complaint about your health plan or insurance company you may contact Texas Health and Human Services at https://www.hhs.texas.gov/about/contact-us.

Formulario de protección de facturas sorpresa

Con mi firma, reconozco que:

Estoy obteniendo servicios de Harbor Health. Estoy renunciando a algunas protecciones de facturación al consumidor bajo la ley federal. Es posible que tenga que pagar los cargos completos por estos artículos y servicios. Se me dio un aviso por escrito (en papel o electrónicamente) al menos tres días hábiles antes de mi visita programada con Harbor Health que explicaba que Harbor Health no está en la red de mi plan de salud, describía el costo estimado de cada servicio y revelaba lo que puedo deber si acepto ser tratado por Harbor Health. Comprendo plena y completamente que algunas o todas las cantidades que pague podrían no contar para el deducible o el límite de gastos de mi bolsillo de mi plan de salud (si lo hay).

Puedo informar por escrito a Harbor Health para terminar este acuerdo antes de recibir los servicios.

• ¿Tiene preguntas sobre este aviso y presupuesto? Póngase en contacto con Harbor Health llamando al 1-855-481-8374.
• ¿Tiene preguntas sobre sus derechos? Póngase en contacto con el Texas Department of Insurance llamando al 1-800-252-3439 o con el servicio de asistencia de CMS No Surprises llamando al 1-800-985-3059.

IMPORTANTE: No tiene que firmar este formulario y puede elegir recibir atención de un proveedor que esté en la red de su plan de salud.

Es posible que el contenido de este formulario no se aplique a usted.