Balance BillingFrequently Asked Questions
What is the Texas “Surprise Billing” law?
Texans with state-regulated health insurance have new protections against some surprise medical bills, also called “balance bills,” under the Texas “Surprise Billing” Law.
What are surprise medical bills?
Surprise bills, sometimes called balance bills, happen when a provider charges more for treatment than your health benefit plan pays – and you get the bill for the difference. You may get a balance bill when you get care from a doctor, hospital, or other health care provider outside your health plan’s network. Sometimes, you may choose to seek care out of your plan’s network knowing that you will receive a bill. But often, a balance bill can be a surprise. This often happens in three situations:
- While getting treatment at an in-network hospital or facility, you also get care from another provider who does not have a network contract with a Community First Commercial HMO Plan.
- You are visiting an in-network doctor, but that doctor sends your lab work or imaging to an out-of-network provider for testing or review.
- Surprise When getting emergency treatment at an out-of-network hospital or emergency facility.
The billing law bans providers from sending balance bills to you in those cases. Instead, providers can work directly with your health plans to agree on payment for those bills.
I was treated in an emergency room. Why am I getting this surprise bill?
If you visited an out-of-network hospital or emergency facility because you were experiencing an emergency and needed immediate care, and then you received a surprise bill, please call us at the Member Services phone number listed on your Community First Health Plans Member ID card.
How does the Surprise Billing law protect me?
The law protects you from being surprise billed for more than your deductible, copays, or coinsurance if:
- You are treated by an out-of-network provider in a network facility.
- You get emergency services and supplies.
- Your in-network doctor uses an out-of-network diagnostic imaging provider or lab.
For example, if your in-network doctor takes a blood sample in his office and sends it to an out-of-network lab, you are protected from balance billing unless you signed a balance billing waiver in advance. However, you are not protected if your in-network doctor orders an X-ray of your foot and you choose to go to an out-of-network imaging center. The difference is that, in this case, you had an opportunity to choose an in-network imaging center.
What is a Balance Billing Waiver?
If you see an out-of-network provider at a network facility or if you visit an out-of-network lab or imaging center, those providers may ask you to sign a Balance Billing Waiver Form.
If you sign this form, you are giving up your protections against balance billing and the provider can bill you over the amount of your deductible, copays, and coinsurance.
Please Note: The waiver cannot be used in an emergency or when an out-of-network doctor was assigned to a case, such as when an anesthesiologist is assigned to a surgery.
If I signed a Balance Billing Waiver and I changed my mind, what can I do?
You must sign the Balance Billing Waiver at least 10 business days before getting services for it to be effective. If you signed a waiver 10 business days or more before getting the service and then change your mind, you can:
- Cancel a waiver within five business days of signing.
- Tell the provider that you are canceling the services. The provider can’t charge you a cancellation fee or any other type of fee for canceling the service.
If you have questions, contact your health plan.
What if I signed a Balance Billing Waiver but I’m being billed more than I expected?
Community First Health Plans can’t prevent an out-of-network provider from billing you when you signed a Balance Billing Waiver. However, we can explain to you what your health plan covers, and what amounts apply to your deductibles, copays, and coinsurance. Call the Member Services phone number listed on your Community First Health Plans Member ID card for this information.
If you feel that the out-of-network provider is billing you more than you agreed at the time you signed the Balance Billing Waiver, contact the Texas Department of Insurance at 1-800-252-3439.
How do I know if I am protected by the Surprise Billing law?
This law does not apply to all Texans. The law applies to you if you meet one of the following:
- You are a Member of a Community First Commercial HMO Plan.
- You are covered by the Employee Retirement System (ERS).
- You are covered by the Teacher’s Retirement System (TRS).
This law does not apply to:
- Other self-funded, employer-sponsored health plans
- The Federal Employee Plan
- Plans issued by health plans outside Texas
If you are not sure what type of plan you have, please contact the Member Services phone number listed on your Member ID card.
I’ve heard that I have to go to mediation or arbitration to avoid paying my balance bill. How does the mediation or arbitration process work?
Your health plan and provider may use the mediation or arbitration processes to help resolve disagreements about payment. You will not be involved in this process.
Does this law change my appeal rights?
No. You still have all of your rights to appeal and complain to your health plan about how your claim was handled. Please consult your Member Handbook or Evidence of Insurance or contact Member Services at the number listed on your Community First Health Plans Member ID card for information on how you can appeal.
What should I do if I receive a balance bill I didn’t expect?
Call the Member Services phone number listed on your Community First Health Plans Member ID card. We can help you determine if you should have been billed. If you should not have been billed, we can contact your provider to remind them of the surprise billing law and educate them on their options.
Where can you find information on how to select an in-network provider?
Register for or log in to our secure Member Portal. Then, click on “Find a Provider ” to find doctors, specialists, labs, imaging centers and hospitals in your network. You can also visit Commercial.CommunityFirstHealthPlans.com to view the Provider Directory or call the Member Services phone number listed on your Community First Health Plans Member ID card to ask for help finding an in-network provider.
Your Surprise Billing Rights Under Federal Law
Starting January 1, 2022, you are protected from surprise bills in many situations where you don’t have a choice in where to get care. Instead, the responsibility for agreeing on the price for services is on the health care provider and the insurance company. The provider and insurer use an independent reviewer, called an arbitrator or mediator, to help them decide how much can be charged for the services provided.
The law outlaws surprise medical bills from various Texas health care providers, including:
- Out-of-network providers at in-network hospitals, birthing centers, ambulatory surgical centers, and free-standing emergency medical care facilities.
- Out-of-network providers and facilities, including hospitals and free-standing emergency medical care facilities, that provide emergency services and supplies.
- Certain out-of-network diagnostic imaging services and laboratories.
If you visit a health care provider outside of your plan’s network, they may ask you to sign a form that would allow them to balance bill you before they provide any care. It is very important that you read any paperwork that a doctor asks you to sign. They cannot ask you to sign this form if you received emergency services.
If you believe you’ve been wrongly billed, you may contact:
Texas Department of Insurance
Austin, TX 78701