Texas Balance Billing Law: Does the Card Say DOI or TDI?

Texas has a strong surprise billing law, and whether it reaches your bill is decided by three things in this order: the date of service, what your insurance card says, and which category of care you received. SB 1264 bans an out-of-network provider from billing you above your copay, coinsurance, and deductible for emergency care, for facility-based providers at a network facility, and for diagnostic imaging or laboratory work ordered by a network provider. It took effect 1 September 2019, and the changes in law it made apply only to a service or supply provided on or after 1 January 2020, codified at Texas Insurance Code chapters 1467 and 1456¹ (checked 30 July 2026).

I write the eligibility and billing pages here as a Certified Application Counselor, and this is the page I most often wish somebody had read first. Last autumn I sat with a man in Bexar County who had done everything right and lost seven weeks doing it. He had a five figure out-of-network bill from an anesthesiologist at a hospital that was in his network, which is exactly the situation the Texas law was written for. He wrote a careful complaint, attached the itemized bill, and filed it with the Texas Department of Insurance. TDI wrote back that it had no authority over his plan. His employer self-funds, and the plan had not opted in. Nothing in his complaint was wrong except the office it went to, and by the time he learned that, he had spent almost two months believing the matter was in hand.

So the card comes first, always. Nothing on this page is legal advice, this site is not TDI and has no authority over any plan, and no individual case can be decided here. Every figure below carries the date it was checked, and where TDI’s own words settle a question, they are quoted rather than paraphrased.

What does SB 1264 ban?

It bans out-of-network balance billing above your copay, coinsurance, and deductible in three defined situations, and it moves the price argument off your kitchen table and into a dispute process between the plan and the provider. The three situations are emergency care, care provided by facility-based providers at a network facility, and diagnostic imaging or laboratory services ordered by a network provider² (TDI page last updated 21 July 2026, checked 30 July 2026).

The second and third categories are where most real cases live, and both share the same shape: you chose an in-network facility or an in-network doctor, and somebody you never chose and never met sent a separate bill. The anesthesiologist, the radiologist reading the scan, the pathologist reporting the sample, the assistant surgeon, the outside laboratory that processed the blood draw your network physician ordered. You cannot shop for those people in the moment, which is precisely the market failure the statute addresses.

The law also builds the machinery for what happens next. Chapter 1467 sets up mediation for facilities and arbitration for providers, so the disagreement about the right price is resolved between the health plan and the provider rather than by pressing the patient¹ (checked 30 July 2026). That structural point is worth holding on to when a billing office implies you are the one who has to resolve it. Where the law applies, you are not a party to the price dispute.

Scale, so this reads as a system rather than an anecdote: people in the United States owe at least $220 billion in medical debt, with about 14 million adults (6%) owing more than $1,000 and about 3 million adults (1%) owing more than $10,000³ (KFF analysis of the 2021 Survey of Income and Program Participation, 2021 data, checked 30 July 2026). Surprise out-of-network bills are one of the reliable production lines feeding that total, which is why two governments legislated against them within two years of each other.

Before any of this, apply for financial assistance if the bill came from a hospital, because that runs on its own clock and is not affected by whose law reaches the plan: hospital charity care in Texas.

Which plans does Texas law reach?

The ones the Texas Department of Insurance regulates, and no others. TDI puts it in a single sentence: “Texas law applies to health plans regulated by TDI.” And the other half of the same sentence: “Federal law applies to health plans not regulated by TDI and air ambulance services.”² (TDI page last updated 21 July 2026, checked 30 July 2026).

That is the whole architecture. It is not that some Texans are protected and others are not; it is that different Texans are protected by different laws, with different processes and different complaint routes. Filing under the wrong one is the single most common expensive mistake in Texas medical billing, and it costs weeks rather than money, which somehow makes it worse.

The consumer test TDI gives is the insurance card itself. State protection applies where the card carries DOI, for department of insurance, or TDI, for Texas Department of Insurance. TDI also names specific plans: ERS plans including HealthSelect, TRS plans including TRS ActiveCare and TRS-Care Standard for non-Medicare retirees, and Texas Farm Bureau or an employer plan that has opted into the Texas balance billing laws, whose card “might have TXI on it”⁴ (TDI page last updated 23 July 2026, checked 30 July 2026).

Take the card out and look at it now, before you need to. The marking is usually small, often near the plan name or the customer service block on the reverse, and it is the difference between two entirely different bodies of law.

One deliberate omission on this page. TDI publishes no sentence itemizing which categories of plan are excluded from SB 1264, and several articles on this subject supply one anyway. This site does not, because an invented exclusion list attributed to a regulator is how a reader with a protected plan concludes they have nothing and stops. The verified framing is the one above: state law covers TDI-regulated plans, federal law covers the rest. If you cannot tell which yours is from the card, TDI’s help line will tell you, and that call is worth making before you write anything.

What about a self-funded employer plan?

A self-funded ERISA plan sits outside SB 1264 unless it has opted in, and Texas publishes the list of the ones that have. Texas HB 1592 allows ERISA plans to elect participation in independent dispute resolution, and TDI maintains an opt-in list of the plans that have made that election⁵ (checked 30 July 2026).

This is the category that catches people, and it catches them silently. A self-funded plan is usually administered by a familiar insurance company whose name and logo appear on the card, so the plan looks identical to a fully insured one from the outside. The employer, not the insurer, is carrying the risk, and that is what puts the plan under federal law rather than state law.

Two practical moves. Ask your employer’s benefits contact, in writing, one question: is the plan fully insured or self-funded, and if self-funded, has it opted in to the Texas balance billing laws. Then check the plan against TDI’s published opt-in list yourself rather than relying on the answer. Neither step takes long, and both are far cheaper before a complaint than after one.

If the answer is that state law does not reach your plan, you are not without protection. The federal No Surprises Act has covered most emergency services, non-emergency services from out-of-network providers at in-network facilities, and out-of-network air ambulance services since 2022⁶ (checked 30 July 2026). Read the No Surprises Act next, because for a self-funded plan that is your page rather than this one.

What do you owe when the law applies?

Your deductible, copay, and coinsurance, and nothing above that. TDI states the mechanism and the result together: health plans have to pay an amount set by Texas law for the care the statute covers, and “you don’t have to pay more than your deductible, copay, or coinsurance”² (checked 30 July 2026).

That turns a vague grievance into a checkable sum. Take the plan documents, find the cost sharing that applies to the service in question, add it up, and compare it against what the provider is billing you. If the billed figure is higher on a service the law reaches, that is not a negotiation and not a hardship request. It is a bill that should not have been sent in that amount.

Two things to do in the same week. First, ask the plan for the explanation of benefits for the claim and read what it says the provider was paid and what it says you owe, because the explanation of benefits and the provider’s statement disagreeing with each other is itself the evidence. Second, ask the provider’s billing office, in writing, to confirm whether it is treating the claim as subject to the Texas balance billing laws, and keep the reply. Both documents are what a complaint later turns on.

If the provider’s total looks wrong for reasons beyond the balance bill, work the detail as well: reading an itemized bill covers requesting the line by line statement, and negotiating a hospital bill covers what remains after the legal question is settled.

Emergency care, and why it is treated differently

Emergency care sits inside SB 1264 precisely because nobody shops for it, and the federal law makes the same judgment. The Texas ban covers emergency care regardless of whether the provider or facility was in your network² (checked 30 July 2026), and the federal No Surprises Act protects people in group and individual health plans from surprise bills for most emergency services⁶ (checked 30 July 2026).

The legal reason both laws single out emergencies is the same reason a separate federal statute governs the door. Under EMTALA, a Medicare-participating hospital that offers emergency services must provide a medical screening examination and stabilizing treatment for an emergency medical condition “regardless of an individual’s ability to pay”⁷ (CMS page last modified 10 March 2026, checked 30 July 2026). Both halves of that belong in the same breath: the hospital must screen and stabilize you, and a bill still follows, because EMTALA is a right to be seen rather than a payment. See EMTALA and the emergency room.

None of this is a reason to weigh a bill against an emergency. Chest pain, trouble breathing, a face or arm gone weak, bleeding that will not stop: go, and let the billing question be next week’s problem. Texas has the highest uninsured rate in the country, 16.7% in 2024 against 8.2% nationally⁸ (2024 data, checked 30 July 2026), and the cost of hesitating has been paid here more than anywhere else.

Ground ambulance: the one place the date changes the answer

Do not assume ground ambulance is a gap in Texas, because since 1 January 2024 it is not. Federal law names air ambulance and omits ground ambulance, which is where the belief comes from, and it is only half the picture. Texas law bans balance billing for emergency medical services and trips provided by a ground ambulance on or after 1 January 2024, on plans TDI regulates² (TDI page last updated 21 July 2026, checked 30 July 2026). Texas law does not reach air ambulance; federal law does. The two are complementary rather than overlapping.

So an ambulance bill runs through three questions in order: ground or air, what the card says, and when the trip happened. An insurer telling a Texan with a TDI-regulated plan that the surprise billing law does not cover a ground ambulance trip taken in 2024 or later is wrong, and that is a complaint rather than a conversation. This is the most frequently mis-stated bill in the state, so it has a page of its own: ambulance bills in Texas.

What to do if a balance bill arrives anyway

Work it in this order, and put every step in writing with the date.

1. Establish which law reaches the plan. Card first, then the employer’s answer on self-funded status, then TDI’s opt-in list if relevant⁵.
2. Check the date of service. SB 1264 reaches services provided on or after 1 January 2020, and ground ambulance trips on or after 1 January 2024² (checked 30 July 2026).
3. Confirm the category. Emergency care, a facility-based provider at a network facility, or imaging or laboratory work ordered by a network provider.
4. Get the explanation of benefits and the itemized bill, and compare what each says you owe.
5. Tell the provider in writing that you believe the service is covered by the Texas balance billing laws, name the date of service, and ask it to confirm its position in writing.
6. Then complain, to the right body. If TDI regulates the plan, the consumer help line is 800-252-3439 toll free, or 512-676-6000 in Austin, “8 a.m. to 5 p.m. Central time, Monday through Friday”⁹ (checked 30 July 2026). The filing detail is in complaining to the Texas Department of Insurance.

Two habits that cost nothing and change outcomes. Write down the name of every person you speak to and the date you spoke to them, because staff turnover in billing offices is high and an unattributed promise is worth very little in month three. And do not agree a payment plan on a bill you are disputing as unlawful, because agreeing terms is an acknowledgement that the amount is owed: payment plans and what to avoid.

Meanwhile, the parallel tracks stay open. A hospital’s financial assistance application runs on its own clock, and under section 501(r) a nonprofit hospital should refrain from extraordinary collection actions for at least 120 days from the first post-discharge billing statement, with an application period that ends on the later of several dates including the 240th day after that statement¹⁰ (checked 30 July 2026). An account already with a collection agency is therefore not a closed door: medical bill collections in Texas.

What this page cannot tell you

Whether your specific bill is unlawful, because that turns on your plan documents, your card, and the date and category of the service, and only the plan and the regulator can apply those to your case. This site publishes no plan by plan table of which Texas products are TDI-regulated, because a table like that is wrong the month an employer changes funding arrangements, and a reader who trusts a stale row either files in the wrong place or gives up a protection they hold.

What is stable is the structure. The date rule, the card test, the three categories, and the sentence about what you owe are read off TDI’s own pages and stamped 30 July 2026. TDI updated the independent dispute resolution page on 21 July 2026 and the consumer page on 23 July 2026, which is recent enough that the current wording is worth re-reading before you write, and this page will be re-checked against both.

For the broader order of operations on any Texas medical bill, start at medical bills in Texas. For what these products are and are not before you buy one, short term plans and health shares covers the arrangements TDI warns are outside its reach entirely, and Marketplace plans in Texas covers the regulated alternative. If you have no plan at all, the levers are different and they are set out in cash prices and self-pay discounts and getting care without insurance in Texas. Where coverage itself is the question, health coverage in Texas is the place to start.

This site is published independently. It is not part of the Texas Department of Insurance, the State of Texas, the Texas Health and Human Services Commission, or the Centers for Medicare and Medicaid Services, it regulates nothing and decides nothing, and it cannot tell you whether a particular bill breaks a particular law. TDI can, and the call is free.