Tex. Codes » Insurance Code · TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES · SUBTITLE C. MANAGED CARE · CHAPTER 1271. BENEFITS PROVIDED BY HEALTH MAINTENANCE ORGANIZATIONS; EVIDENCE OF COVERAGE; CHARGES
Texas Codes

Tex. Ins. Code § 1271.155 (2026)

Emergency Care

✓ current as of May 2026
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Sec. 1271.155. EMERGENCY CARE. (a) 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.

(b) 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 covered enrollees, including the treatment and stabilization of an emergency medical condition;

(3) services originated in a hospital emergency facility, freestanding emergency medical care facility, or comparable emergency facility following treatment or stabilization of an emergency medical condition shall be provided to covered enrollees as approved by the health maintenance organization, subject to Subsections (c) and (d); and

(4) supplies related to a service described by this subsection shall be provided to covered enrollees.

(c) 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.

(d) A health maintenance organization shall respond to inquiries from a treating physician or provider in compliance with this provision in the health care plan of the health maintenance organization.

(e) 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.

(f) 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 information necessary for the health maintenance organization to pay the claim; or

(2) the 45th day after the date the health maintenance organization receives a nonelectronic clean claim as defined by Section 843.336 for those services that includes all information necessary for the health maintenance organization to pay the claim.

(g) 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 on:

(A) the amount initially determined payable by the health maintenance organization; or

(B) if applicable, a modified amount as determined under the health maintenance organization's internal appeal process; and

(2) is not based on any additional amount determined to be owed to the physician or provider under Chapter 1467.

(h) This section may not be construed to require the imposition of a penalty under Section 843.342.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Amended by:

Acts 2009, 81st Leg., R.S., Ch. 1273 (H.B. 1357), Sec. 3, eff. March 1, 2010.

Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.03, eff. September 1, 2019.

Notes of Decisions
Cited in 12 cases (10 in the last 5 years), 2012–2026 · leading case: Emergency Health Centre at Willowbrook, L.L.C. v. Unitedhealthcare of Texas, Inc., 892 F. Supp. 2d 847 (S.D. Tex. 2012).
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Emergency Health Centre at Willowbrook, L.L.C. v. Unitedhealthcare of Texas, Inc., 892 F. Supp. 2d 847 (S.D. Tex. 2012). · cites it 3× “for the valid covered claims violates the Texas Insurance Code § 1271.155 Emergency Care and constitutes a false or misleading act or practice in the business of insurance.”
Tex. Med. Res., LLP v. Molina Healthcare of Tex., Inc., 356 F. Supp. 3d 612 (N.D. Tex. 2019). “See Tex. Ins. Code Ann. § 1271.155 "[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.”
Molina Healthcare of Texas, Inc. v. ACS Primary Care Physicians Sw., PA & Emergency Servs. of Texas, PA (Tex. App. 2024). · cites it 4× “” TEX. INS. CODE § 1271.155(a). The statute does not define “usual and customary rate.”
Molina Healthcare of Texas, Inc. v. ACS Primary Care Physicians Sw., PA & Emergency Servs. of Texas, PA (Tex. App. 2024). · cites it 4× “” TEX. INS. CODE § 1271.155(a). The statute does not define “usual and customary rate.”
Christus Santa Rosa Health Care Corp., Et Al. v. Unitedhealthcare Ins. Co. (E.D. Tex. 2026). · cites it 4× “TEX. INS. CODE §§ 1271.155, 1301.0053, 1301.”
Unitedhealthcare Ins. Co. Unitedhealthcare of Texas, Inc. v. Acs Primary Care Physicians Sw., P.A. Hill Cnty. Emergency Med. Assocs., P.A. Longhorn Emergency Med. Assocs., P.A. Cent. Texas Emergency Assocs., P.A. Emergency Assocs. of Cent. Texas, P.A. Emergency Servs. of Texas, P.A. (Tex. 2023). · cites it 3× “1 Recent amendments to 1 TEX. INS. CODE §§ 1271.155(a), 1301.0053(a), 1301.”
Texas Med. Resources, LLP Texas Physician Resources, LLP & Pediatric Emergency Med. Grp., LLP v. Molina Healthcare of Texas, Inc. (Tex. App. 2021). · cites it 2× “That regulation governed the certificate of authority to operate as an HMO and listed the items an HMO must include in an application for a certificate, and subsection (20) 6 Texas Insurance Code sections 1271.155 (HMO plans), 1301.”
Altus Cmty. Healthcare, LP v. UnitedHealthcare Ins. Co. DO NOT DOCKET. CASE REMANDED to the 152nd Jud. Dist. Court of Harris Cnty., Texas (S.D. Tex. 2025). · cites it 2× “” Tex. Ins. Code § 1271.155(a). Because Plaintiff found Defendant’s reimbursements to be below the usual and customary rate, Plaintiff appealed the reimbursements to Defendant and the Texas Department of Insurance, and the parties participated in an unsuccessful mediation.”
State of Texas v. Xerox Corp. Settlement Proceeds (Tex. App. 2025). · cites it 2× “13, 15 Tex. Ins. Code § 1271.155(a) ............”
Dallas Med. Ctr., LLC v. Molina Healthcare of Texas, Inc. (Tex. App. 2021). “” TEX. INS. CODE ANN. § 1271.155(a). The Texas Administrative Code obligates MCOs, such as Molina, to reimburse an out-of-network, in-area service provider for emergency and authorized services at “the Medicaid [Fee For Service] rate in effect on the date of the service less…”
Molina Healthcare of Texas, Inc. v. ACS Primary Care Physicians Sw., PA & Emergency Servs. of Texas, PA (Tex. App. 2024). “After submitting the case on the appellate record and the arguments properly raised by the parties, the Court holds that there was reversible error in the trial court’s judgment in the following respects: appellees ACS Primary Care Physicians Southwest, PA and Emergency Services…”
Lone Star 24 HR ER Facility, LLC v. Blue Cross Blue Shield of Texas (W.D. Tex. 2025). “” Tex. Ins. Code § 1271.155(a) (effective March 1, 2010 to present)(amended September 1, 2019, with no change to this section).”
— Tex. Ins. Code § 1271.155(a) — 9 cases
Molina Healthcare of Texas, Inc. v. ACS Primary Care Physicians Sw., PA & Emergency Servs. of Texas, PA (Tex. App. 2024). “” TEX. INS. CODE § 1271.155(a). The statute does not define “usual and customary rate.”
Molina Healthcare of Texas, Inc. v. ACS Primary Care Physicians Sw., PA & Emergency Servs. of Texas, PA (Tex. App. 2024). “” TEX. INS. CODE § 1271.155(a). The statute does not define “usual and customary rate.”
Unitedhealthcare Ins. Co. Unitedhealthcare of Texas, Inc. v. Acs Primary Care Physicians Sw., P.A. Hill Cnty. Emergency Med. Assocs., P.A. Longhorn Emergency Med. Assocs., P.A. Cent. Texas Emergency Assocs., P.A. Emergency Assocs. of Cent. Texas, P.A. Emergency Servs. of Texas, P.A. (Tex. 2023). “1 Recent amendments to 1 TEX. INS. CODE §§ 1271.155(a), 1301.0053(a), 1301.”
Altus Cmty. Healthcare, LP v. UnitedHealthcare Ins. Co. DO NOT DOCKET. CASE REMANDED to the 152nd Jud. Dist. Court of Harris Cnty., Texas (S.D. Tex. 2025). “” Tex. Ins. Code § 1271.155(a). Because Plaintiff found Defendant’s reimbursements to be below the usual and customary rate, Plaintiff appealed the reimbursements to Defendant and the Texas Department of Insurance, and the parties participated in an unsuccessful mediation.”
State of Texas v. Xerox Corp. Settlement Proceeds (Tex. App. 2025). “13, 15 Tex. Ins. Code § 1271.155(a) ............”
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