Insurance Information Careers

TEXAS HEALTH CARE STATUTES

The Texas Department of Insurance Code, Section 1301.155 on Emergency Care requires that insurance companies pay emergency facilities “at the insured’s in-network benefit level” for all services.

Additionally, the Patient Protection and Affordable Care Act added numerous patient protections that require health plans covering emergency services to provide such coverage without need for prior authorization, regardless of the participating status of the provider, at the in-network level.

The “prudent layperson” standard is a generally accepted principle in the healthcare industry that applies to emergency medical care. This standard was created to protect consumers from high medical costs that arise from emergency situations, allowing them to be charged at in-network rates. However, insurance companies have been reluctant to apply this standard for care issued at freestanding emergency centers (FECs).

By not providing usual and customary reimbursement rates, insurance providers violate the intent of the medical community and legislators who turned the prudent layperson standard into law. Furthermore, health plans are required to pay for emergency visits for medical situations in which a person believes his or her health is threatened.

The final medical diagnosis should not influence whether the insurer pays for the emergency room visit, and insurers cannot legally apply the claim towards the out-of-network benefits.

Chargemaster

ATTENTION: ALL PATIENTS

The following notice has been posted in accordance with Texas House Bill 2041 and is hereby effective September 1, 2019
  • This facility is a licensed Freestanding Emergency Medical Care Facility.
  • This facility charges rates comparable to a hospital emergency room and may charge a facility fee.
  • The facility or physician providing medical care at the facility may be an out-of-network provider for the patient’s health benefit plan provider network.
  • The physician providing medical care at this facility may bill separately from the facility for the medical care provided to a patient.
  • This facility is an out-of-network provider for all health benefit plans.
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