Texas Balance Billing Law

Overview

Texas SB 1264 (2019) prohibits balance billing in emergency and certain non-emergency situations. Emergency services are protected from balance billing regardless of network status. OON providers at in-network facilities cannot charge more than in-network cost-sharing. Disputes are resolved through Texas Department of Insurance mediation or arbitration.

Key Requirements

1. Emergency services cannot be subject to balance billing under any circumstance.
2. OON providers at in-network facilities must accept in-network cost-sharing as payment in full.
3. Plans must have a dispute resolution process for balance billing claims.
4. Patients can file complaints with Texas Department of Insurance within 180 days of claim.
5. Providers must disclose OON status before providing non-emergency services when feasible.

Penalties and Enforcement

Texas Department of Insurance enforces SB 1264 through complaint investigation and mediation. Violations result in fines up to $5,000 per claim. Plans and providers that systemat systematically violate balance billing rules face licensing sanctions and exclusion. Enforcement actions often require restitution to affected patients.

Appeals and Exceptions

Disputed balance billing charges can be appealed directly to the plan or escalated to Texas Department of Insurance for mediation. No exceptions exist for emergency services. OON facility scenarios require proof of in-network facility status.

Interaction with Federal Law

Texas SB 1264 aligns with federal No Surprises Act protections for emergency and facility-based services. Texas enforcement is independent and may be more aggressive than federal enforcement. SB 1264 provides additional protections in areas beyond federal scope.

Common Questions