Notice: Senate Bill 1264 Waiver Rules

Date: 06/10/20

The Texas Department of Insurance (TDI) has adopted a rule outlining the narrow exception to the state’s new surprise billing protections, which apply to Ambetter from Superior HealthPlan (Marketplace) healthcare services provided on or after January 1, 2020.

Senate Bill (SB) 1264 protects consumers with state-regulated health plans from surprise bills in emergencies and in cases where the consumer had no choice of providers. The legislation carves out a narrow exception when a consumer chooses an out-of-network doctor or provider at an in-network facility.

The new TDI rule:

• Clarifies that consumers can waive SB 1264 balance billing protections only in cases where they have a choice between an in-network provider and an out-of-network provider. The waiver cannot be used in an emergency or when an out-of-network doctor was assigned to a case, such as when an anesthesiologist is assigned to a surgery.
• Includes the Wavier form and instructions (PDF) (fillable version) (PDF) patients must sign at least 10 business days before receiving out-of-network care if the provider wants to balance bill the consumer instead of requesting arbitration or mediation.
• Applies only to state-regulated insurance plans, including Ambetter, and patients with coverage through the state employee or teacher retirement systems. Insurance cards for state-regulated plans have either Department of Insurance (DOI) or Texas Department of Insurance (TDI) printed on them (see examples.) It does not apply to self-funded employer-sponsored health plans or Medicare.

To review all rules, please review the TDI Disclosures by Out-Of-Network Providers (Waiver Rule) (PDF)

For additional details, please visit TDI’s website.

For questions, please contact your local Account Manager.