In Texas, balance billing is prohibited for emergency care, for ground and air ambulance trips, and for out-of-network providers who treat you at an in-network hospital or facility. Those protections come from Senate Bill 1264, which took effect January 1, 2020, and from the federal No Surprises Act, which took effect January 1, 2022. Together they limit what you owe to your plan’s standard in-network copay, deductible, and coinsurance whenever you had no meaningful chance to pick an in-network provider.1Texas Department of Insurance. How Consumers Are Protected From Surprise Medical Bills The gaps matter too: self-funded employer plans that haven’t opted in, care you deliberately sought out-of-network, and certain federal consent waivers all sit outside the shield.
When You Cannot Be Balance Billed
Emergency Care
If you receive emergency treatment, no provider or facility can bill you beyond your in-network cost-sharing amount, whether or not the provider or hospital is in your network. You owe only your plan’s standard copayment, coinsurance, and deductible.1Texas Department of Insurance. How Consumers Are Protected From Surprise Medical Bills Emergencies are the clearest example of care you can’t shop for.
Out-of-Network Providers at In-Network Facilities
Most surprise bills come from this scenario. You choose an in-network surgeon and an in-network hospital, but the anesthesiologist, radiologist, or pathologist involved turns out to be out-of-network. Under SB 1264, those providers cannot balance bill you when you had no practical way to choose them.1Texas Department of Insurance. How Consumers Are Protected From Surprise Medical Bills Your insurer treats the charges as in-network for your copay, deductible, and out-of-pocket maximum, and the rest gets sorted out between the provider and the insurer.
Ground Ambulance
Since January 1, 2024, Texas has extended balance billing protection to emergency medical services and ground ambulance trips. Health plans must pay an amount set by state law, and your responsibility is capped at normal in-network cost-sharing.2Texas Department of Insurance. Balance Billing Biennial Report The provision originally carried a September 1, 2025 sunset date because lawmakers expected federal legislation that never arrived. SB 916, signed in June 2025, extends the protection through September 1, 2027.3Texas Legislature Online. Bill Analysis – SB 916 The federal No Surprises Act deliberately excluded ground ambulances, so this remains a state-by-state issue.
Air Ambulance
The federal No Surprises Act prohibits out-of-network air ambulance providers from balance billing you. Your plan must apply in-network cost-sharing, and any charges count toward your in-network deductible and out-of-pocket maximum.4CMS (Centers for Medicare & Medicaid Services). The No Surprises Act’s Prohibitions on Balance Billing Air ambulance bills routinely run into tens of thousands of dollars, and you rarely get a say in which company responds.5U.S. Department of Health and Human Services. Air Ambulance Use and Surprise Billing
When You Can Still Be Balance Billed
The exceptions are where people get hurt. Missing one of these is what turns a surprise bill into a real financial problem.
Self-Funded Employer Plans That Haven’t Opted In
If your employer self-funds its health plan, federal ERISA rules govern it rather than Texas insurance law. The federal No Surprises Act still provides a baseline of protection, but the Texas dispute resolution process and payment rules under SB 1264 apply only if your plan sponsor has elected to opt in under Insurance Code Chapter 1275.6Texas Department of Insurance. Balance Billing: Independent Dispute Resolution Most large employers self-fund, and many haven’t opted in. Your federal protections still block balance billing in emergencies and for ancillary services at in-network facilities, but the payment methodology and dispute process differ from what state-regulated plan members see.
Elective Out-of-Network Care
When you knowingly choose an out-of-network provider for non-emergency care at an out-of-network facility, no balance billing protection applies. If you travel across town to see a specialist who isn’t in your plan’s network, and that specialist practices at an out-of-network clinic, the provider can bill you for the full difference between their charges and whatever your insurer pays. The protections exist because you didn’t have a meaningful chance to choose; when you did have that chance and passed it up, they fall away.
Consent Waivers
Under the federal No Surprises Act, an out-of-network provider at an in-network facility can sometimes ask you to waive your balance billing protections before non-emergency treatment. The waiver is only valid under narrow conditions. The provider must give you written notice at least 72 hours before the service, the notice must include a good-faith estimate of what you’ll owe, and you must sign a written consent form.7CMS. When the Notice and Consent Exception Applies and When It Doesn’t: Guidelines for Use
The law also bars the waiver outright for several categories of care:
- Emergency services, before you’re stabilized.
- Ancillary services, including anesthesiology, radiology, pathology, neonatology, diagnostic services, hospitalists, intensivists, and assistant surgeons.
- Unforeseen urgent needs that come up during a visit.
- Situations where no in-network provider can perform the service at that facility.
A waiver handed to you for any of those categories is void. A waiver signed without the required notice and timing is also void.8eCFR. Part 149 Surprise Billing and Transparency Requirements Legitimate waivers are limited to scheduled, non-ancillary services where an in-network option was available and you chose to go out-of-network anyway. If you were pressured into signing something at check-in for an anesthesiologist or radiologist, that signature carries no legal weight.
How to Tell Whether Your Plan Is Covered
Before anything else, figure out what type of plan you have. State-regulated plans get the full range of Texas protections. Self-funded plans get the federal floor, plus Texas protections only if the employer opted in.
You usually can’t tell from your insurance card. A self-funded plan often uses the same insurer name and logo as a fully-insured plan. Three ways to check:
- Read your Summary Plan Description, which typically states whether the plan is self-funded or fully insured.
- Ask your employer’s HR or benefits department directly.
- Call the number on the back of your insurance card and ask whether the plan is self-insured.
If you’re on an individual or marketplace plan, it’s state-regulated, and the full Texas protections apply.
If You Are Uninsured or Paying Cash
If you don’t have insurance or choose to pay out of pocket, the federal No Surprises Act still applies. Healthcare providers must give you a good-faith estimate of expected charges before scheduled services. If you schedule at least three days out, the estimate must arrive within one business day. If you schedule at least ten days out, it must arrive within three business days.9eCFR. Requirements for the Patient-Provider Dispute Resolution Process
When the final bill exceeds the estimate by $400 or more, you can start a federal patient-provider dispute resolution process. You have 120 calendar days from receiving the bill to file. While the dispute is pending, the provider cannot send your bill to collections or charge late fees.9eCFR. Requirements for the Patient-Provider Dispute Resolution Process The collections freeze alone makes the process worth knowing about, since many uninsured patients pay inflated bills out of fear that delay will damage their credit.
What to Do if You Get a Surprise Bill
When a protection applies, you don’t owe more than your in-network cost-sharing. The provider and insurer resolve the rest without you, through state mediation or arbitration for Texas-regulated plans and through the federal independent dispute resolution process for federally regulated ones.10Texas Department of Insurance. FAQ: Mediation and Arbitration Requirements and Processes Your job is to get the complaint into the right hands.
For a state-regulated plan, contact the Texas Department of Insurance. You can submit a mediation request form by emailing ConsumerProtection@tdi.texas.gov or mailing it to TDI’s Consumer Protection division in Austin.11Texas Department of Insurance. Get Help With a Surprise Bill You Got From a Health Care Provider TDI’s website also walks you through questions to identify which process applies.12Texas Department of Insurance. How to Get Help With a Surprise Medical Bill
For a federally regulated plan, use the federal No Surprises Help Desk or the online Consumer Complaint Form. There is currently no deadline to file a federal complaint, though acting quickly while documentation is fresh helps.13CMS. No Surprises Act: How to Get Help and File a Complaint Gather your insurance card, the medical bill, and any explanation of benefits statements. If you signed a consent waiver, keep it, since an improperly executed one may be void. If you file federally and the plan turns out to be state-regulated, the federal agencies will refer the complaint to TDI, so filing in the wrong place won’t cost you the claim.