An ambulance company billed me after my emergency room trip, and my plan says the company is out of network. Do I owe that bill?

Texas has a rule for the ground ambulance bill. Start with what it covers. It uses the term emergency medical services provider, as that term is defined in the Health and Safety Code [1]. But it does not include an air ambulance [1]. So if you were flown, this is not your rule, and these sources do not say which one is.

Next, what your plan must pay. Did the city, county or other political subdivision submit its rate to the department? Then the insurer pays that rate, for the place the service or the transport began [2]. If no rate was submitted, the insurer pays the lesser of two amounts [2]. One is the provider's billed charge [2]. The other is 325 percent of the current Medicare rate, with any extenders and modifiers that apply [2]. The insurer must pay the provider directly [3]. The deadline is the 30th day after a clean electronic claim, or the 45th day after a clean claim on paper [3].

Now your side of it. An out-of-network emergency medical services provider may not bill you more than your copayment, coinsurance and deductible [4]. The law adds that you do not have financial responsibility above that amount [4]. The bar also covers anyone claiming as an agent or assignee of the provider [4]. Your share is based on the amount the insurer first determined payable, or on the modified amount from its internal appeal [4]. So a bill for the leftover balance is the one to dispute in writing.

Two limits to know before you lean on this. The section says in plain words that it expires September 1, 2027 [5]. Care given after that date may run on a different rule, so check the date of your transport. And these are the rules for a preferred provider benefit plan. An HMO, or a plan that pays its own claims at work, runs on other rules, so ask your plan which rule it is applying to your claim.

Find the date and the type of transport on the bill [1]. Then find the amount your plan says you owe on the Explanation of Benefits, and compare it with the amount the company is asking for [4]. Then ask your plan whether it paid a rate submitted by the city or county, or the lesser of the billed charge and 325 percent of Medicare [2]. What rule covers an air ambulance bill: "Don't know yet" here.