Senate Bill 1264 is in effect as of January 1st, 2020 and aims to protect Texans against "Suprise Billing." Note that this only applies to fully insured plans regulated by the State of Texas, so self- insured and plans based in another state may not fall under these new protections. You also may not be protected if you are under a Temporary Short term plan or a Christian Share style plan.
This Bill does not do away with networks, and they will continue to be a big part of any insurance plan you purchase. You must still do your due diligence to see in network providers, clinics and hospitals. This bill is to help those who follow their network rules but were still stuck with a Suprise Bill.
Protection under SB1264 can be broken down into several categories:
1 - Emergency Services. In an emergency situation, you can utilize any emergency provider (whether they are in network or out of network) and you are not supposed to be balance billed. All claims associated with the emergency visit are supposed to processed an in network. Once the patient is stabilized, the insurance carrier can request that the patient be moved to an in network facility.
An important component of this is the definition of an "emergency". This has been a "gray area" for a long time, but an emergency visit is basically defined as a situation in which a reasonable adult would seek emergency care. SB1264 does not apply to visits to the emergency room for non emergency treatment, such as simple sore throats, etc.
This does not apply to Air Ambulances, which are known for Balance Billing over the insurance companies' reimbursement rates. There was a similar bill that was passed to address this directly, but the Texas Governor struck the bill down saying that the wording of that bill was inept to do what it intended and was going to be struck down later in the court system. We expect that this will be addressed again next legislation.
2 - In Network Facilities. If an insured visits an in network facility, such as a hospital, physician's office, etc., then all services associated with that visit are supposed to be processed as in network and there should be no balance billing. Example 1 - an insured visits their in network physician, who in turn sends the insured's lab work to an out of network laboratory. That lab claim is supposed to be processed as in network and no balance billing by the lab should occur. Example 2 - an insured is admitted to an in network hospital and is seen by an out of network physician. That physician's claim is supposed to be processed as in network and no balance billing by the physician should occur.
Protection under SB1264 does not apply if an in network physician refers an insured to an out of network facility or physician. It remains the insured's responsibility to make sure they are utilizing an in network provider in these situations. Example 1 - if an in network primary care physician refers an insured to an out of network orthopedic surgeon, the claims for that orthopedic surgeon would be processed as out of network and the insured could be balance billed. Example 2 - if an in network physician refers an insured to a free standing lab, imaging facility, etc., it remains the insured's responsibility to make sure that the facility they then visit is an in network provider. If they don't, the claim will be processed as out of network and balance billing can occur.
3 - Balance Bill Waiver. Protection under SB1264 does not apply if an insured signs a Balance Bill Waiver, wherein the insured acknowledges that the provider is out of network. Those charges will then be processed as out of network and balance billing can occur.
If there is a disagreement on the reimbursement rate from the insurance company to the provider, which has traditionally ended up billed to the insured as a "Balance Bill," the provider and insurance company are meant to leave the insured out of the middle and settle with "Baseball Style" arbitration. The State assigned arbitrator will look at the claim and the proposed reimbursement rates from both sides and decide which is more fair and that will be the final reimbursement, with no middle option. This will encourage both insurance companies and providers to do all that they can to find a reasonable arrangement before going this far.
One question we often get not specifically addressed above is this. If there are in network specialists in my network, but I am not comfortable with them, can I utilize an out of network physician and still have it covered as in network? The answer remains the same as it has been, which is "no", unless the insured gets prior approval from the insurance carrier.
