Texas Surprise Billing Law

Overview

Texas SB 1264 established surprise billing protections effective January 1, 2020, predating the federal No Surprises Act. The law prohibits surprise billing in emergency and non-emergency settings where out-of-network providers deliver care at in-network facilities. Patients pay in-network cost-sharing amounts only.

Key Requirements

1. Emergency services are protected from surprise billing regardless of network status.
2. OON providers at in-network facilities cannot charge beyond in-network cost-sharing.
3. Plans must inform patients of surprise billing protections at point of care when possible.
4. Disputed amounts can be appealed to Texas Department of Insurance within 180 days of claim date.
5. OON provider disclosure required before non-emergency services when feasible.

Penalties and Enforcement

Texas Department of Insurance enforces SB 1264 surprise billing violations with fines up to $5,000 per claim. Plans and providers that engage in systematic surprise billing face license sanctions and network exclusion. Enforcement actions routinely result in restitution orders to affected patients.

Appeals and Exceptions

Any surprise billing charge can be appealed to Texas Department of Insurance for mediation. No exceptions exist for emergency services. Planned non-emergency services require documented patient consent before OON provider can enforce higher rates.

Interaction with Federal Law

Texas SB 1264 predates and aligns with the federal No Surprises Act. Both provide protections in emergency and OON facility scenarios. Texas enforcement often exceeds federal standards. Patients benefit from both state and federal protections where applicable.

Common Questions