Your Rights and Protections Against Surprise Medical Bills
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 shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. If you see a provider or visit a health care facility that isn’t in your health plan’s network, you may have additional costs or have to pay the entire bill.
“Out-of-network” means providers and facilities that haven’t 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 “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.
“Surprise billing” can happen when you can’t control who is involved in your care—like 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.
At UTHealth Houston and UT Physicians, you’re protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most we will bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You will not be balance billed for these emergency services. This includes services you may get after you’re 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, it is possible some providers may be out-of-network. In these cases, the most these out-of-network providers will bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t 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 can’t balance bill you, unless you give written consent and give up your protections.
We’ll never require you to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have these protections:
You’re 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 “prior authorization”).
- 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 “Good Faith Estimate” explaining how much your medical care will cost. For more information please email your request to our Customer Service Office at firstname.lastname@example.org.
Request an estimate for clinical services
UTHealth Houston and UT Physicians are happy to provide estimates for services. In order to enhance accuracy, when you request an estimate, please provide the procedure code (CPT) and the diagnosis code (ICD-10) for the services that are of interest.
This information can be provided to you by your physician or clinic, and is important to ensuring you are being provided an estimate for the appropriate treatment or procedure.
Please email your request to email@example.com.*
Once the information is provided, you will receive a response in 2-3 business days.
* Please keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed.
Getting a formal good-faith estimate for your care
If you would like a formal good-faith estimate regarding your upcoming scheduled services at UTHealth Houston and UT Physicians, please email firstname.lastname@example.org and include Estimate Request in the subject line. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.
If you think you’ve been wrongly billed:
You may contact our UTHealth Houston and UT Physicians Customer Service Office at 1-855-877-2808, or send an email to our team at email@example.com.
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 https://www.tdi.texas.gov/medical-billing/index.html.
For information or assistance with balance billing questions from the State of Texas Department of Insurance, visit https://www.tdi.texas.gov/medical-billing/surprise-balance-billing.html.
Visit http://www.cms.gov/nosurprises for more information about your rights under federal law. The federal phone number for information and complaints is: 1-800-985-3059.