No, in many common situations, balance billing is not legal in Texas. Texas law and federal law provide significant protections for patients, particularly for emergency services or when an out-of-network provider is used at an in-network facility. That said, balance billing is not banned in all circumstances—some employer-self-funded plans or certain out-of-state coverages may still allow it. So while many Texans are protected, you should check your insurance plan and circumstances closely.
What Is Balance Billing?
Balance billing (also called “surprise billing”) happens when you receive healthcare from a provider or facility that is out-of-network, and they bill you for the difference between what your insurer pays and what the provider charged. For example: you go to an in-network hospital for emergency care, but an out-of-network anesthesiologist treats you—then you get a large bill you didn’t expect.
Legal Protections in Texas
Emergency or Out-of-Network Care at In-Network Facilities
Texas law (via the No Surprises Act at the federal level and state implementation by the Texas Department of Insurance (TDI)) protects consumers from balance billing in specific situations:
- If you receive emergency services from an out-of-network provider, you can’t be billed more than your in-network cost-share.
- If you receive non-emergency services at an in-network hospital or ambulatory surgical center, and an out-of-network provider treats you (e.g., radiology, pathology), you have protections unless you give informed consent.
- Texas regulation §370.453 (1 Tex. Admin Code) prohibits providers in the CHIP program from balance billing covered services even if out-of-network.
Texas Implementation
TDI’s “Balance billing: Independent Dispute Resolution” page states:
“Texas and federal laws prohibit out-of-network providers, facilities, and ambulances from balance billing for certain health care services.”
If You Have State-Regulated Fully Insured Plan
TDI guidance: Starting Jan. 1 2020 for fully insured state-regulated plans, the ban on surprise medical bills applies.
When Balance Billing Might Still Be Legal
There are important exceptions where balance billing could still occur:
- If your employer’s health plan is self-funded (ERISA-governed), state protections may not apply.
- If you “opt in” and sign a waiver allowing balance billing. Some non-emergency care may allow this if informed consent is documented.
- If the provider gives less than required notice, or the facility is wholly out-of-network and you choose to go there rather than an in-network alternative.
- If services are performed by an out-of-network provider at an out-of-network facility with no protections triggered.
So the rule is: you’re safe in the common protected scenarios, but not entirely immune in every case.
What To Do as a Patient in Texas
Here are proactive steps:
- Check your insurance plan type – fully-insured vs. self-funded.
- Use in-network facilities when possible – this reduces surprise risk.
- Ask early – if you see an out-of-network provider at an in-network facility, ask if they balance bill.
- Do not sign a waiver unless you understand it – signing may remove your protections.
- If you get a large bill, contact TDI or file a dispute. Texas has an Independent Dispute Resolution process.
Final Note
Balance billing is generally not legal in Texas for consumers in many common situations, like emergency care or out-of-network providers at in-network facilities. Protections are robust, but they do not cover every service or every insurance plan type.
