Quick answer: Texas is a bifurcated state. State-regulated (fully-insured) health plans use Texas's own mediation/arbitration IDR system through the Texas Department of Insurance. Self-funded ERISA plans default to the federal No Surprises Act IDR process, unless they've voluntarily opted into the Texas process.
Texas and federal law both prohibit balance billing for emergency care, air ambulance services, and certain non-emergency care at in-network facilities where the patient had no choice of provider. For state-regulated plans, payment disputes go through the Texas IDR portal, where physicians use mediation and facilities and other providers use binding arbitration. For self-funded employer plans — which fall under ERISA and are federally regulated — disputes instead go through the federal IDR portal.
Texas has been the single largest user of IDR in the country. Texas accounted for more than 500,000 IDR cases in the most recent reporting year, far more than any other state, largely because Texas's fully-insured market is large and heavily contested by revenue-cycle firms. About two-thirds of those disputes settled during the 30-day open negotiation period and never reached formal arbitration.
State law protections have applied since January 1, 2020 for most non-emergency and emergency care. Ground ambulance protections were added January 1, 2024. Federal No Surprises Act protections took effect January 1, 2022.
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