Tennessee Balance Billing Law

Overview

Tennessee HB 748/SB 692, codified in TCA §56-7-1002, effective July 1, 2020, protects patients from balance billing for emergency services at hospitals. Patients are responsible only for in-network cost-sharing amounts when treated by out-of-network providers during emergency care. The federal No Surprises Act, effective January 1, 2022, expands protections to include scheduled non-emergency services provided by out-of-network providers at in-network facilities.

Key Requirements

1. Emergency Service Coverage: When a patient receives emergency care at a hospital, the patient's in-network cost-sharing applies regardless of whether the emergency provider is in-network or out-of-network.
2. Out-of-Network Provider Obligation: Out-of-network emergency providers must bill the insurance company at applicable rates. They cannot pursue the patient for amounts above the in-network cost-sharing obligations.
3. Insurer Enforcement: Tennessee insurers must adjust claims to reflect in-network rates for emergency services and educate members about their protections.
4. Federal NSA Expansion: As of January 1, 2022, scheduled non-emergency services at in-network facilities by out-of-network providers also cannot result in patient balance bills unless advance consent is obtained.
5. TDCI Oversight: The Tennessee Department of Commerce and Insurance enforces balance billing protections and accepts complaints from patients regarding violations.

Penalties and Enforcement

Health insurers that violate Tennessee balance billing law are subject to enforcement action by the Tennessee Department of Commerce and Insurance. Violations include continuing to process emergency claims at out-of-network rates or failing to adjust bills upon patient request. Insurers found in violation are required to refund the balance amount to patients and may face citations and fines.

Appeals and Exceptions

Patients have the right to appeal any claim adjustment or denial related to balance billing protection. Exceptions are limited; emergency services are covered by the in-network rate standard without exception. For non-emergency services at in-network facilities, exceptions exist only if the patient provides advance written consent (72 hours) to accept out-of-network charges.

Interaction with Federal Law

Tennessee's balance billing law complements the federal No Surprises Act. The federal law applies to all health plans, including ERISA self-funded plans that are otherwise exempt from state insurance regulation. For ERISA plans, CMS enforces the federal NSA; for state-regulated plans, TDCI enforces Tennessee law and the federal NSA.

Common Questions