SURPRISE MEDICAL BILL?
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In a medical emergency, you are rushed to the nearest emergency room. You can’t “shop around” to find doctors and ERs in your insurer’s network.
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The insurance company and out‐of‐network doctor or other health care provider fight over the bill. Doctors charge high prices and insurers pay low rates. Instead of resolving their disagreements, they pass the bill straight to you!
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You unknowingly get health care that is outside of your insurer’s network of providers
While recovering at home, you get a surprise bill—big out‐of‐network charges on top of the expected deductible and copays. What to do if this happens to you? If you have an HMO or EPO, it must make sure you are not stuck with surprise bills from emergency care. If you have a PPO, there is a “mediation” system. You are not on your own! There is free in‐person assistance in your community!
If you have received a surprise medical bill and would like advice on what you may be able to do, call MHP Salud at 956‐246‐4125. A Navigator will be able to assess your situation and provide you with orientation.
This information was developed by:
The project described was supported by Funding Opportunity Number CA‐NAV‐15‐001 from the Centers for Medicare and Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of the HHS or any of its agencies.
How Would I Know if I Qualify for Mediation?
What if I Have an
You may qualify for mediation if:
HMO or EPO?
you have a PPO insurance plan, or you are a state employee with HealthSelect coverage. your insurance ID card has the letters “TDI” or “DOI” on it. you got care at a hospital that is in your insurer’s network, but receive a bill from a doctor that was not in your insurer’s network and is: o over $500 o from one of these types of doctors: a radiologist, an anesthesiologist, a pathologist, an emergency department physician, a neonatologist, or an assistant surgeon
How do I Request Mediation? If you think you will qualify or you aren’t sure, you can request mediation. You will use the form found at the following link, or ask an assister for one. Fill out the form and send it in by mail, fax, or email. The directions are found on the form. English mediation request form: http://www.tdi.texas.gov/forms/consumer/mediationform.pdf Spanish mediation request form: http://www.tdi.texas.gov/forms/consumer/mediationformsp.pdf
How does Mediation Work and How Much does it Cost? There is no cost for mediation. If you are eligible, your insurance company and doctor will talk over the phone to see if they can resolve the billing issue. You can join the call, too, but do not have to. Most disputes are settled through the first phone call.
HMOs and EPOs generally do not cover health care you get out‐of‐ network. But, they both must protect you from surprise bills if you got out‐of‐network care in a medical emergency or there were not any in‐ network doctors who were available to treat you. You will still have to pay your deductible, copayment or coinsurance. However, if you are billed for more than that amount by an out‐of‐network doctor, hospital, or other medical provider, call your HMO or EPO to report the bill. If the HMO/EPO does not resolve the bill for you, file a complaint with the Texas Department of Insurance by calling 1‐800‐252‐3439, or a navigator can help you.
What if I Have Medicaid or Medicare? Medicaid and Medicare have even stronger consumer protections against surprise medical bills, so in general, you should not get surprise bills. If you receive a surprise out‐of‐ network medical bill, call the customer support number on your insurance ID card to report the problem or ask a navigator for help.
The project described was supported by Funding Opportunity Number CA‐NAV‐15‐001 from the Centers for Medicare and Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of the HHS or any of its agencies.
para servicios médicos?
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En una emergencia, te llevan a la sala de urgencias más cercana. No puedes “detenerte a buscar” doctores y salas de urgencia dentro de la red de tu aseguradora.
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La aseguradora, el(la) doctor(a) u otro proveedor de servicios médicos se ponen a pelear para ver a quién le toca la factura Los doctores cobran precios altos y las aseguradoras pagan precios bajos. En vez de resolverla entre ellos, ¡te pasan la factura directa a ti!
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Sin saberlo, recibes cuidado de salud fuera de la red de proveedores de tu aseguradora.
¿Qué puedes hacer si esto te pasa a ti? Si tienes un plan tipo HMO o EPO, el plan debe asegurar que no seas responsable de facturas indebidas de cuidados de urgencia. Si tienes un plan tipo PPO, hay un sistema de mediación. ¡No estás solo(a)! ¡Hay asistencia gratuita y en persona en tu comunidad!
Mientras te recuperas en casa, te sorprenden con una factura con altos cobros de servicios recibidos fuera de la red, además de los deducibles y copagos que ya esperabas.
Si has recibido una factura inesperada para servicios médicos recibidos y necesitas consejos sobre las opciones que podrías tener, llama a MHP Salud al 956‐246‐4125. Un(a) navegador(a) te podrá ayudar a evaluar tu situación y darte orientación sobre tus próximos pasos a tomar.
Este recurso de información fue desarrollado por:
The project described was supported by Funding Opportunity Number CA‐NAV‐15‐001 from the Centers for Medicare and Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of the HHS or any of its agencies.
¿Cómo me entero si califico para la mediación?
¿Qué pasa si tengo
Podrías calificar para la mediación si:
un HMO o EPO?
tienes un plan tipo PPO, o si eres un empleado del estado de Texas con cobertura HealthSelect. tu tarjeta de seguro médico contiene las letras “TDI” o “DOI”. recibiste cuidado de un hospital que está dentro de la red de tu aseguradora, pero te llega una factura de un(a) doctor(a) que está fuera de la red de tu aseguradora y: o la cantidad supera $500 dólares. o viene de un(a) radiólogo(a), anestesiólogo(a), patólogo(a), médico del departamento de urgencias, especialista en neonatología o asistente de cirujano(a).
¿Cómo pido el servicio de la mediación? Si crees que calificas o no estás seguro(a), puedes pedir el servicio de la mediación. Usarás el formulario que encontrarás al visitar los vínculos a continuación, o bien, puedes pedir uno al visitar un(a) asesor(a) o navegador(a). Llena el formulario y mándalo por correo postal, por fax o por correo electrónico. Las instrucciones están incluidas en el formulario. Formulario en inglés: http://www.tdi.texas.gov/forms/consumer/mediationform.pdf
Por lo general, los planes HMO y EPO no cubren el cuidado médico que recibes fuera de la red. Sin embargo, deberían protegerte de facturas indebidas si obtuviste cuidados médicos urgentes fuera de red, o no había doctores dentro de la red para tratarte. Serás responsable por tu deducible, copagos o el coseguro, sin embargo, si te llega una factura adicional a esa cantidad de un(a) doctor(a), hospital u otro proveedor de servicios fuera de la red, llama a tu plan HMO o EPO para reportar la factura. Si el plan HMO/EPO no te resuelve la factura, denúncialo con el departamento de seguros de Texas (TDI) al 1‐800‐252‐3439, o un(a) navegador(a) te puede orientar.
¿Qué pasa si tengo Medicaid o
Formulario en español: http://www.tdi.texas.gov/forms/consumer/mediationformsp.pdf
Medicare?
¿Cómo funciona la mediación
Los programas de Medicaid y Medicare protegen aún más al consumidor de facturas inesperadas, así que no las deberías recibir. Si te llega una factura de servicios médicos fuera de red, habla al teléfono del servicio al consumidor localizado en tu tarjeta de seguro médico para reportarlo o pide ayuda en persona de un(a) navegador(a).
y cuánto cuesta? La mediación no tiene costo. Si calificas, tu aseguradora y el(la) doctor(a) hablarán por teléfono para ver si pueden resolver la factura. Puedes participar en la llamada también, si quieres, pero no es necesario. La mayoría de los casos se resuelven con la primera llamada.
The project described was supported by Funding Opportunity Number CA‐NAV‐15‐001 from the Centers for Medicare and Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of the HHS or any of its agencies.
