banner-about-us-health-insurance

Frequently asked questions about health insurance at ETMC

The East Texas Medical Center Regional Healthcare System accepts most major insurance plans. See below for many of the frequently asked questions we hear from patients about health insurance. If you don’t see your question answered here, call your health insurance provider for more information.

What specific plans does ETMC accept?

ETMC will file claims to any health insurance company you authorize, but coverage depends on whether your plan includes ETMC in its network. If a facility or provider is not in your network, you may be responsible for all or most of the cost. Before receiving services from ETMC, contact your health insurance company to verify that the facility and provider are included in your plan’s network.

Health insurance plans in which ETMC currently participates:

CommercialProductAccepted at ETMC TylerAccepted at ETMC Regional Hospitals and First Physicians
AccessDirect PlatinumPPOXX
AetnaPPOXX
Aetna - TRSPPOXX
Blue Cross Blue ShieldHMOXX
Blue Cross Blue ShieldPPOXX
Beech StreetPPOXX
CignaPendingX
Coventry/First HealthX
HealthSmartX
MultiPlanPPOXX
National ChoiceCareXX
PHCSPPOXX
United HealthcarePPOXX
United ERS Health SelectXX
USA MCOXX
Health Insurance MarketplaceAccepted at ETMC TylerAccepted at ETMC Regional Hospitals and First Physicians
Blue Advantage HMOXX
Managed MedicaidProductAccepted at ETMC TylerAccepted at ETMC Regional Hospitals and First Physicians
AmerigroupSTARXX
Cenpatico - Behavioral Health Center and PittsburgSTAR, STAR+PLUS, CHIPX
Cigna-HealthSpringSTAR+PLUSXX
MolinaCHIP, CHIP PerinatalXX
MultiplanSTAR, STAR+PLUS, CHIP, CHIP PerinatalXX
Superior HealthPlanSTAR, STAR+PLUS, CHIP, CHIP Perinatal, Foster CareXX
Texas Childrens Health PlanSTAR, STAR Kids, CHIPXX
UnitedHealthcareSTAR, STAR+PLUS, CHIPXX
Medicare AdvantageAccepted at ETMC TylerAccepted at ETMC Regional Hospitals and First Physicians
AetnaXX
Care Improvement Plus/XL HealthXX
Cigna-HealthSpringXX
HumanaXX
Medicare, Medicaid and other Government ProgramsProductAccepted at ETMC TylerAccepted at ETMC Regional Hospitals and First Physicians
Blue Cross Blue ShieldXX
Champ VAX
Health Choice - Oklahoma state employeesPPOXX
Humana TRICARE - Active Duty/RetiredXX
MedicaidXX
MedicareXX
Palmetto GBAXX
TML MultiStateXX
Tri Care 4 LifeXX
Student InsuranceAccepted at ETMC TylerAccepted at ETMC Regional Hospitals and First Physicians
Brokerage Store Student AccidentXX
Lonestar Athletic Injury NetworkXX
UnitedHealthcare Student ResourcesXX
Workers' CompensationProductAccepted at ETMC TylerAccepted at ETMC Regional Hospitals and First Physicians
Coastal CompXX
CorVelXX
FocusXX
IMOHMOXX
RockportXX

Other common questions

Does ETMC accept health insurance plans from the healthcare.gov Health Insurance Marketplace?

ETMC accepts all Blue Cross Blue Shield plans currently sold through the Health Insurance Marketplace. Refer to the list of health insurance plans ETMC participates in for a complete list of all plans accepted.

What insurance documents do I need to bring with me to ETMC?

Please bring your current health insurance card(s), along with a photo ID.

How do I choose ETMC as my healthcare provider?

First check with your health insurance plan to make sure it is included as an in-network provider. To find a physician, visit etmc.org or call
903-531-8890.

How can I see a specialist at ETMC with my health insurance?

Depending on your health plan, you may need a referral from your primary care physician (PCP) to see a specialist. Specialists also need to be in your network. If a referral is needed, your physician must send the referral order to your insurance company for approval. Confirm this approval before making an appointment with a specialist.
If your plan does not require a referral, you may contact any of our specialists to verify that they are in your network and schedule an appointment. Call 903-596-ETMC for more information.

What should I know about my health insurance plan?

–Be familiar with your insurance benefits – it is your responsibility to know your insurance company’s requirements and processes in order to receive coverage.
–Verify that your doctor and ETMC are participating providers in your plan. The plans ETMC participates in may change without notice, so it is recommended that you check in regularly with your insurance company, especially before receiving services.
–If your insurance company requires an authorization prior to a service, ensure that the authorization has been received by your doctor and by the hospital.
–Most authorizations have limits on the number of visits or expiration dates – be aware of these and ensure the authorization is updated before services are delivered.
–You are responsible for your copay and other out-of-pocket expenses at the time of service. Be familiar with these costs, and ask your health insurance provider if you have any questions about these costs or need clarification.

What health insurance terms should I know?

–Premium: Your premium is the monthly cost of your health insurance plan. Usually, the more coverage a plan provides, the higher the premium you pay each month. When choosing health insurance, it is important to consider more than just the cost of the monthly premium – even though a premium may be cheaper on one plan, other costs associated with the plan (like the deductible, coinsurance or out-of-pocket max) may make it more expensive overall depending on your healthcare needs.
–Deductible: The deductible is the amount of money you pay before insurance starts to cover medical expenses. For example, if a procedure costs $5,000 and your deductible is $3,000, you will pay the first $3,000 and insurance will cover $2,000. Once you have met your deductible for the year, you start paying coinsurance (if your plan has coinsurance).
–Coinsurance: Some plans have coinsurance, which means you are responsible for a certain percentage of medical expenses after your deductible has been paid. For example, if your health insurance plan has 20 percent coinsurance, you pay for 20 percent of the full cost of medical expenses after you’ve met your deductible. Your insurance company will cover the remaining 80 percent. You will pay coinsurance until your out-of-pocket limit for the year has been reached.
–Copay: A copay is a fixed amount you pay for certain services that are specified in your health insurance plan. For example, a doctor’s visit may have a copay of $30, an emergency room visit may have a copay of $250 and generic prescriptions may have a copay of $10. This cost is usually due at the time of service, and the amount of money you spend on copays does not contribute to reaching your annual deductible. Once you have reached your annual deductible for the year, you are still responsible for copays on certain services. Copays are waived once your out-of-pocket maximum for the year has been reached.
–Out-of-pocket maximum: An out-of-pocket maximum is the most you’ll have to pay during a policy period (usually a year) for healthcare services. Your deductible, coinsurance and copays all go toward reaching your out-of-pocket max. Once you’ve reached your plan’s limit, insurance pays for 100 percent of the allowed amount for covered services.

What’s the difference between a PPO, HMO and EPO plan?

Your health insurance plan will be designated as PPO, HMO or EPO.
–PPO: Preferred provider organizations, or PPOs, cover care inside and outside of their provider network. However, members usually pay a higher percentage of the cost for out-of-network care, so it is important to check with your insurance provider and know who is and isn’t in your network. Members typically do not need a referral to see a specialist.
–HMO: Health maintenance organizations, or HMOs, only cover care provided by doctors and hospitals inside the HMO provider network. All healthcare is usually coordinated by a primary care physician (PCP) in the network, and HMOs often require members to get a referral from their PCP in order to see a specialist. As coverage does not extend outside of the provider network, be sure to check with your insurance provider for a list of in-network physicians.
–EPO: Exclusive provider organizations, or EPOs, are similar to HMOs in that they generally don’t cover care outside of the plan’s provider network. Unlike HMOs, however, members may not need a referral to see a specialist.

What is the healthcare.gov Health Insurance Marketplace?

The Health Insurance Marketplace is for people who don’t have health coverage through a job, Medicare, Medicaid, the Children’s Health
Insurance Program (CHIP) or another source that provides qualifying coverage. The open enrollment period for applying for coverage through the Health Insurance Marketplace was Nov. 1, 2015, through Jan. 31, 2016. If you didn’t enroll in a 2016 health insurance plan by Jan. 31, you are unable to enroll in a health insurance plan for 2016 through the exchange unless you qualify for a special enrollment period. For more information, visit healthcare.gov.

What is Medicare, and how can I apply for it?

Medicare is the federal health insurance program for people who are 65 or older, those who are younger with certain disabilities and people with end-stage renal disease. ETMC accepts Medicare, but you should know the details of your Medicare coverage and what costs you are responsible for. Qualified individuals can apply for Medicare at any time; see medicare.gov for more information.

What is Medicaid, and how can I apply for it?

Medicaid is a joint federal and state program that helps with medical costs for qualified people with limited income. Each state has different rules about eligibility, but you can apply for benefits in Texas at yourtexasbenefits.com. For more information about Medicaid, go to medicaid.gov.

Who should I contact if I have a question about a bill I received from ETMC?

You can review the ETMC Patient Billing Policy online. If you have a question about how much your health insurance covered, please contact your health insurance provider. For any ETMC billing questions, please contact the appropriate ETMC business office.