What are the key rules under Texas Senate Bill 1264 regarding balance billing?
Texas Senate Bill 1264 prohibits out-of-network healthcare providers from balance billing patients with state-regulated health insurance (TDI-regulated HMOs, EPOs, and preferred provider plans) for emergency services, out-of-network care at in-network facilities (when the patient had no choice of provider), and out-of-network diagnostic/imaging/laboratory services ordered by an in-network physician. Instead, the patient pays only their in-network cost-sharing, and the provider must seek reimbursement directly from the insurer or trigger the TDI Independent Dispute Resolution (IDR) arbitration process.
1. The Scope of Texas Senate Bill 1264
Enacted to shield consumers from catastrophic surprise medical bills, SB 1264 amended Texas Insurance Code Chapter 1467.
It specifically covers emergency care, facility-based providers (anesthesiologists, radiologists, pathologists, emergency physicians, and assistant surgeons) operating in an in-network hospital or ambulatory surgical center, and diagnostic testing ordered by network physicians.
2. The TDI Independent Dispute Resolution (IDR) Process
How out-of-network providers get paid fair market value
If the insurer's initial payment is unacceptable, the provider can initiate informal dispute resolution within 30 days:
1. File notice of informal settlement with the health plan.
2. Engage in a mandatory 30-day teleconference or written negotiation period.
3. If unresolved, request binding baseball-style arbitration via the TDI online portal. The loser pays arbitration fees, incentivizing fair pre-arbitration settlements.