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I went to an emergency room that is not in my HMO network. The hospital and the ER doctor billed me. What does my HMO owe, and what do I owe?

Health insuranceWho paysTexasChecked Nov 6, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: Texas Insurance Code · Chapter 1271 · § 1271.155(a) «Emergency Care» View original ↗

In short

  1. Your HMO must pay for emergency care by non-network providers [1].
  2. You owe only your share under the plan, and no more [6].
  3. The plan has one hour to answer on care after you are stable [3].

What this means

Texas puts the duty on the HMO first. It must pay for emergency care by non-network physicians or providers [1]. It pays at the usual and customary rate, or at an agreed rate [1]. This duty does not turn on contracts. The plan must comply whether or not the provider has a contract with the HMO [4].

The law lists what the coverage must include. First, a medical screening examination. The law means the exam needed to find out whether an emergency medical condition exists [2]. Second, necessary emergency care. That includes the treatment and stabilization of the condition [2]. Third, services that start in an emergency facility after that care, as approved by the HMO [2]. Fourth, the supplies related to those services [2].

That word approved has its own clock, and it is short. The HMO must approve or deny coverage of poststabilization care when the treating doctor asks [3]. It must answer within the time right for the case and the patient [3]. And it may not take more than one hour from the request [3]. Was your care after stabilization called unapproved? Then ask when the request was made, and when the answer came.

Then the money. The HMO must pay that provider directly [5]. The deadline is the 30th day after a clean electronic claim. For a claim on paper it is the 45th day [5]. And your side is capped. That provider may not bill you more than your copayment, coinsurance and deductible [6]. The same bar covers anyone claiming as an agent or assignee [6]. The law adds that you owe nothing above that amount [6]. Your share is based on the amount the HMO first determined payable [6]. If its internal appeal changed that, the changed amount is used [6]. And it may not be based on any extra amount owed under Chapter 1467 [6]. Your explanation of benefits should show this. The notice must state the billing prohibition that applies [7]. It must also give the total the provider may bill you, itemized [7].

Your next step

Put the bill next to your explanation of benefits. Find the billing prohibition line and the total you may be billed [7]. Then write to the provider billing office and to the HMO on the same day. Say this was emergency care, and that your share is limited to your copayment, coinsurance and deductible [6]. Ask the office for a corrected bill. Was any care called unapproved after you were stable? Then ask the HMO in writing for the time of the request and the time of its answer [3]. Ask it to confirm the amount it determined payable, and the date it paid the provider [5]. The sources give no deadline for your own letter. The dates they do give are the plan's: one hour for a poststabilization answer, and the 30th or 45th day to pay [3] [5].

Check it yourself

Find on your explanation of benefits the total that provider may bill you. Compare it with the bill [7]. Then read your plan papers on emergency care, and on care after you are stable [2]. Then ask the hospital when it asked the HMO to approve care after you were stable [3]. Did your visit meet the legal test for an emergency medical condition? "Don't know yet" here. The plan applies that test, and the definition sits elsewhere in the law.

Where this comes from (7)

  1. [1] Texas Insurance Code · Chapter 1271 · § 1271.155(a) «Emergency Care» · checked 2026-11-06

    A health maintenance organization shall pay for emergency care performed by non-network physicians or providers at the usual and customary rate or at an agreed rate.

  2. [2] Texas Insurance Code · Chapter 1271 · § 1271.155(b) «Emergency Care» · checked 2026-11-06

    A health care plan of a health maintenance organization must provide the following coverage of emergency care: (1) a medical screening examination or other evaluation required by state or federal law necessary to determine whether an emergency medical condition exists shall be provided to covered enrollees in a hospital emergency facility or comparable facility; (2) necessary emergency care shall be provided to cover…

  3. [3] Texas Insurance Code · Chapter 1271 · § 1271.155(c) «Emergency Care» · checked 2026-11-06

    A health maintenance organization shall approve or deny coverage of poststabilization care as requested by a treating physician or provider within the time appropriate to the circumstances relating to the delivery of the services and the condition of the patient, but not to exceed one hour from the time of the request.

  4. [4] Texas Insurance Code · Chapter 1271 · § 1271.155(e) «Emergency Care» · checked 2026-11-06

    A health care plan of a health maintenance organization shall comply with this section regardless of whether the physician or provider furnishing the emergency care has a contractual or other arrangement with the health maintenance organization to provide items or services to covered enrollees.

  5. [5] Texas Insurance Code · Chapter 1271 · § 1271.155(f) «Emergency Care» · checked 2026-11-06

    For emergency care subject to this section or a supply related to that care, a health maintenance organization shall make a payment required by Subsection (a) directly to the non-network physician or provider not later than, as applicable: (1) the 30th day after the date the health maintenance organization receives an electronic clean claim as defined by Section 843.336 for those services that includes all informatio…

  6. [6] Texas Insurance Code · Chapter 1271 · § 1271.155(g) «Emergency Care» · checked 2026-11-06

    For emergency care subject to this section or a supply related to that care, a non-network physician or provider or a person asserting a claim as an agent or assignee of the physician or provider may not bill an enrollee in, and the enrollee does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee's health care plan that: (1) is based o…

  7. [7] Texas Insurance Code · Chapter 1271 · § 1271.008(a) «Balance Billing Prohibition Notice» · checked 2026-11-06

    A health maintenance organization shall provide written notice in accordance with this section in an explanation of benefits provided to the enrollee and the physician or provider in connection with a health care service or supply provided by a non-network physician or provider. The notice must include: (1) a statement of the billing prohibition under Section 1271.155 , 1271.157 , or 1271.158 , as applicable; (2) the…

How we found this

We matched your question to 7 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.

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Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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