New Texas Insurance Laws: Why “Out-of-Network” Doesn’t Mean “Out-of-Pocket”
If you’ve been delaying your knee or hip surgery because ATX Orthopedics is “out-of-network” for your plan, there is good news. Recent updates to Texas insurance laws (including HB 3359) have drastically changed how your insurance company handles your payments.
The “In-Network Credit” for Out-of-Network Care
For many Texans, the biggest hurdle to seeing a specialist of their choice was the “Separate Deductible” trap. Previously, if you saw an out-of-network surgeon, your payments went into a separate, much higher bucket that never seemed to get filled.
That has changed. Under current Texas law, if your state-regulated health plan has an inadequate network or you receive care at an in-network facility, your insurance company may be required to:
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Apply your out-of-network surgery payments directly to your in-network deductible.
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Count those payments toward your annual out-of-pocket maximum.
How to Tell if You Are Protected
These protections apply to “state-regulated” plans. You can identify these easily by looking at your insurance card:
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Look for “TDI” or “DOI”: If you see these letters printed on your card, you are protected by Texas state law.
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PPO and EPO Plans: These protections are strongest for Preferred Provider and Exclusive Provider plans.
Why This Matters for Your Surgery
At ATX Orthopedics, we believe you should choose your surgeon based on their expertise—like Dr. Gallagher’s muscle-sparing knee techniques or Dr. Amis’s specialized hand surgery—not just a list of names in an insurance directory.
Because your surgery payments now “cross over” to your main deductible, you can reach your yearly maximum faster, often resulting in your insurance covering 100% of your other healthcare costs for the remainder of the year.