| When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldnt be charged more than your plans copayments, coinsurance and/or deductible. |
What is balance billing (sometimes called surprise billing)?
When you see a doctor or other health care provider, you may owe certain , like a , , or . You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isnt in your health plans network.
Out-of-network means providers and facilities that havent signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plans deductible or annual out-of-pocket limit.
Surprise billing is an unexpected balance bill. This can happen when you 釵硃紳t control who is involved in your carelike 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
Youre 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 they can bill you is your plans in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You 釵硃紳t be balance billed for these emergency services. This includes services you may get after youre 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 can bill you is your plans in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers 釵硃紳t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other types of services at these in-network facilities, out-of-network providers 釵硃紳t balance bill you unless you give written consent and give up your protections.
Youre never required to give up your protections from balance billing. You also arent required to get out-of-network care. You can choose a provider or facility in your plans network.
When balance billing isnt allowed, you also have these protections:
- Youre only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
- Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (also known as 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 in-network deductible and out-of-pocket limit.
Need an Estimate?
You have the right to receive a Good Faith Estimate explaining how much your medical care will cost. For more information, please email your request to patientbillestimates@uthscsa.edu.
Need Assistance?
If you think youve been wrongly billed:
You may contact our Customer Service Office at 210-450-6330 or 1-888-410-2777 or send an email to CustomerService@uthscsa.edu.
If you have a State of Texas regulated insurance plan or have coverage through the Texas employee or Teacher Retirement System, then you may have additional protections regarding surprise medical bills. For more information, please visit .
For information or assistance with balance billing questions from the State of Texas Department of Insurance, visit .
Visit for more information about your rights under federal law. The federal phone number for information and complaints is: 1-800-985-3059.