Insurance Benefits & Coverage

How Insurance Coverage Works

Insurance companies often have a network of healthcare providers, including emergency facilities, that they have contracts with. If you seek treatment at an in-network emergency facility, your insurance will typically cover a larger portion of the costs. Out-of-network facilities might still be covered, but the insurance might pay a smaller percentage, leaving you responsible for a higher portion of the bill.

Your insurance plan may have a co-payment (a fixed amount you pay for a specific service), co-insurance (a percentage of costs you're responsible for after meeting your deductible), and a deductible (the amount you pay out-of-pocket before your insurance starts covering costs). These factors affect how much you'll pay for emergency services.

Remember, insurance plans often have specific criteria for what qualifies as an emergency medical condition. Services received for these conditions are typically covered differently than non-emergency services.

In some cases, insurance companies might require prior authorization for emergency services to ensure they're medically necessary. However, in emergencies where immediate care is needed, this step might be waived or handled retroactively.

In Texas, if a patient receives services from an out-of-network provider at an in-network facility (like anesthesiology or radiology services during a procedure), they are protected from excessive balance billing.

After receiving emergency services, you'll get an EOB from your insurance company detailing the services provided, what was covered, and what you're responsible for paying. Reviewing this document helps understand your financial obligations.

If your insurance denies coverage for emergency services, you have the right to appeal the decision. This involves providing additional information or contesting the decision.