exas passed one of the country’s stronger surprise-billing laws in 2019, and then most Texans didn’t get it. SB 1264 reaches only state-regulated health plans — about 16% of Texans, by the Texas Department of Insurance’s own description. Everyone else is covered by a federal law instead, or by nothing. Sorting out which bucket you’re in is the first move, because the two systems have different processes, different agencies, and different phone numbers. What follows is what Texas law actually gives you, including two rights that apply no matter whose plan you have — or whether you have one at all.
The balance-billing ban, and who it actually covers
SB 1264 (86th Legislature, 2019) bars out-of-network facility-based providers, emergency providers, and certain related lab and imaging providers from balance billing patients. The Act took effect September 1, 2019, and its protections apply to services provided on or after January 1, 2020. When it applies, it applies automatically — you are not supposed to have to do anything.
The catch is scope. State insurance law reaches state-regulated plans. TDI’s own page on the law describes those plans as covering “about 16% of Texans.” TDI does not define, on that page, whether that share is measured against all Texans, all insured Texans, or all privately insured Texans — so we are reporting the figure as TDI states it rather than converting it into something more precise than the source supports.
How to tell which system you're in
TDI’s consumer guidance says to look at your insurance ID card for a “TDI” or “DOI” mark, which indicates a state-regulated plan. TDI separately lists plans that follow the state law: the Employees Retirement System, TRS-ActiveCare, TRS-Care Standard for non-Medicare retirees, Texas Farm Bureau plans, and self-funded plans that have voluntarily agreed to follow it.
Texas mediation and arbitration is not a patient process
This one is widely misreported, including in advice written for patients. Under the current SB 1264 independent dispute resolution system, for dates of service on or after January 1, 2020, mediation and arbitration are disputes between the out-of-network provider and the health plan. The patient is not a party, and there is no dollar threshold a patient has to clear. That is the design: you are removed from the fight, the provider and the plan argue over the balance, and you owe your in-network cost share.
There is an older, consumer-initiated mediation program that required the disputed amount to exceed $500, and you will still find it described online as if it were current. It only covers care delivered before January 1, 2020. Treat any advice telling you to file for mediation yourself as a sign the source is out of date.
The itemized bill right — and the statute that moved
This one applies whether you are insured or paying cash, and it is more powerful than most people realize. Texas Health and Safety Code Chapter 185, created by SB 490 in 2023 and effective September 1, 2023, requires that a provider requesting payment from a patient “shall submit with the request a written, itemized bill of the alleged amount due for each service and supply provided,” no later than the 30th day after the provider receives final payment from a third party.
The bill has to contain a plain-language description of each service or supply, any billing code submitted to a third party along with the amounts billed to and paid by that third party, and the amount the provider says you owe for each item. Under § 185.002(d), you are entitled to obtain an itemized bill on request at any time after the first one is issued.
The Texas estimate right, which stacks on the federal one
Separately from the federal good faith estimate, Texas Health and Safety Code § 324.101 entitles a consumer to an estimate of a facility’s billed charges for an elective inpatient admission or a nonemergency outpatient surgical procedure, requested before scheduling. HB 1314 (89th Legislature) tightened the deadline effective September 1, 2025: the facility must provide the estimate by e-mail not later than five business days after the request, down from the previous tenth-business-day rule. Two things to know before you use it. The facility is required to tell you that requesting an estimate may delay scheduling — and beware of stale sources, because several statute aggregators still display the repealed ten-day text. If you are shopping a planned procedure in Texas and you are self-pay, you can ask under both this and the federal estimate right. They are different rights with different deadlines, and there is no reason to pick one.
Cash discounts are lawful, and the statute says so sideways
Patients sometimes worry that asking for a cash price is asking a provider to do something improper. Texas Insurance Code Chapter 552 addresses the opposite conduct: § 552.003 makes it a Class B misdemeanor to knowingly charge a patient a higher price for the same product or service because an insurer will pay for part of it. And § 552.001(a) expressly exempts from the chapter a health care provider giving a lower price to an uninsured patient under its own discount policy, or to Medicaid, Medicare, indigent or charity-care patients. The illegal act is surcharging the insured, not discounting the uninsured.
Two more things worth knowing
- A suit on an unpaid debt in Texas is subject to a four-year limitations period under Civil Practice and Remedies Code § 16.004(a)(3). The limitations period governs suing on the debt; it does not by itself erase the underlying obligation.
- Texas has no state statute restricting medical-debt credit reporting. Roughly fifteen states have passed one; Texas is not among them, and the federal rule that would have removed medical debt from credit reports nationwide was vacated by a federal court in Texas in July 2025.
- SB 1784 in the 2025 session would have required providers to give patients 60 days' written notice before starting debt collection. It passed the Senate and stalled in the House. It is not law, and you should be careful with any advice that assumes it is.
Who to call
- Texas Department of Insurance consumer help line — 800-252-3439. For state-regulated plans, balance-billing questions, and insurance complaints. (TDI publishes the number on its contact page but not its current hours, so call during Central-time business hours.)
- Federal No Surprises Help Desk — 1-800-985-3059, seven days a week. For self-funded plans, and for uninsured or self-pay patients using the good faith estimate and dispute process.
“A bill that never came with a compliant itemization is a bill the provider is not supposed to be collecting on.”
Once you have the line items, check them against what other Austin providers charge for the same services.
Browse verified Austin prices →- Does the Texas surprise billing law protect me?
- Only if you are in a state-regulated health plan. SB 1264 (2019) bans balance billing by out-of-network facility-based and emergency providers for services on or after January 1, 2020, but the Texas Department of Insurance describes state-regulated plans as covering about 16% of Texans. Self-funded employer plans — which the Legislature's own analysis put at at least 40% of the Texas market — are federally regulated and covered by the federal No Surprises Act instead. Check your insurance card for a TDI or DOI mark.
- How do I request mediation for a surprise medical bill in Texas?
- For care on or after January 1, 2020, you don't — and that's the point of the law. Under SB 1264's independent dispute resolution system, mediation and arbitration are between the out-of-network provider and the health plan; the patient is not a party and there is no dollar threshold for the patient. The older consumer-initiated mediation program, which required a disputed amount over $500, applies only to care delivered before January 1, 2020.
- Am I entitled to an itemized medical bill in Texas?
- Yes. Texas Health and Safety Code § 185.002 requires a provider requesting payment to submit a written, itemized bill of the amount due for each service and supply, no later than the 30th day after the provider receives final payment from a third party, and entitles you to obtain one on request at any time after the first is issued. Section 185.002(e) bars a provider from pursuing debt collection unless it has complied. Note the statute excludes federally qualified health centers from its definition of health care provider.
- Can a Texas provider give me a cash discount for paying without insurance?
- Yes. Texas Insurance Code § 552.001(a) expressly exempts from the state's illegal-pricing chapter a provider that gives a lower price to an uninsured patient under its own discount policy, or to Medicaid, Medicare, indigent or charity-care patients. What the chapter prohibits is the reverse — § 552.003 makes it a Class B misdemeanor to knowingly charge a higher price for the same service because an insurer will pay part of it.
- Can I get a written price estimate from a Texas hospital before a procedure?
- Yes, and it is a separate right from the federal good faith estimate. Texas Health and Safety Code § 324.101 entitles a consumer to an estimate of a facility's billed charges for an elective inpatient admission or nonemergency outpatient surgical procedure, requested before scheduling. HB 1314, effective September 1, 2025, requires the facility to send it by e-mail no later than five business days after the request — shortened from the previous ten-business-day rule, which some statute websites still display. The facility must also warn you that asking may delay scheduling. If you are uninsured or self-pay, you can use both this and the federal estimate right.