| 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 shouldnāt be charged more than your planās copayments, coinsurance and/or deductible. |
What is ābalance billingā (sometimes called āsurprise billingā)?
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 isnāt in your health planās network.
āOut-of-networkā means providers and facilities that havenāt 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 ābalance billing.ā This amount is likely more than in-network costs for the same service and might not count toward your planās deductible or annual out-of-pocket limit.
āSurprise billingā is an unexpected balance bill. This can happen when you ³¦²¹²Ōāt control who is involved in your careālike 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.
Youāre 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 planās in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You ³¦²¹²Ōāt be balance billed for these emergency services. This includes services you may get after youāre 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 planās in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers ³¦²¹²Ōāt 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 ³¦²¹²Ōāt balance bill you unless you give written consent and give up your protections.
Youāre never required to give up your protections from balance billing. You also arenāt required to get out-of-network care. You can choose a provider or facility in your planās network.
When balance billing isnāt allowed, you also have these protections:
- Youāre 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 āprior authorizationā).
- 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 āGood Faith Estimateā explaining how much your medical care will cost. For more information, please email your request to patientbillestimates@uthscsa.edu.
Need Assistance?
If you think youāve 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.