Understanding Your Insurance Deductible

The More You Know

When it comes to health care insurance and billing there’s a lot to know. Wouldn’t it be refreshing to have an advocate helping you navigate the confusing process? You found it.

It’s important to mention that due to federal regulations, free standing Emergency Rooms such as Emergis ER are not able to participate in Medicare, Medicaid or Tricare. In the event of any life-threatening situation, we will never refuse treatment regardless of the ability to pay.

You will be responsible for the percentage of your emergency room bill required by your insurance plan. The Emergis team will help you understand your insurance deductible and at the end of your visit, you will be asked to pay your emergency room copay.

Assessment / No Treatment: In the event that you are assessed but decide not to be treated at our facility, you will be assessed a minimal fee as mandated by the state of Texas.

In-Network vs. Out of Network: According to Texas guidelines, all insurance carriers are required to pay in-network benefits for any member seeking emergency medical treatment. Texas law requires that your insurance carrier pay for your emergency care, whether the emergency room is in-network or out of network.

The state of Texas empowers you to use a prudent layperson standard when considering what constitutes an emergency.

State law requires patients to be reimbursed for emergency room visits by their insurance carrier. If your insurance company refuses payment for your emergency room visit, you can file a grievance with the Texas Department of Insurance. To learn more about the Texas Department of Insurance, please visit http://www.tdi.state.tx.us.

Other common terms and what they mean:

  • Coinsurance: the specified percentage of the claim amount that is allowed but not paid by the carrier.
  • Copay: the amount required to be paid to a provider by or on behalf of a patient in connection with services rendered.
  • Covered services: services that are specified under the terms of the patient’s benefit coverage.
  • Deductible: the specified amount paid annually by the patient before they can receive insurance benefits.
  • In-network: covered services provided to patients by a provider who is contracted with a particular health plan.
  • Out-of-network: covered services provided to patients by a provider who is not contracted in a particular payer’s network.
  • Preauthorization: approval must be obtained from the insurance company prior to receiving a medical service or procedure.

For more medical billing terms, take a look at the Texas Department of Insurance’s Glossary of Common Insurance Terms:http://www.tdi.texas.gov/consumer/glossary.html