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Frequently Asked Questions

What is your service area?

Our HMO service area is comprised of the following three (3) counties: Harris, Fort Bend and Montgomery.

Our PPO service area is comprised of the following seven (7) counties: Harris, Fort Bend, Montgomery, Brazoria, Galveston, Walker and Wharton.

What is a deductible?

A deductible is a fixed amount of money you have to pay before most, if not all, of the policy’s benefits can be enjoyed. However, in many health insurance policies, you can use some services, like a visit to the emergency room or a routine doctor’s visit, without meeting the deductible first. These services will vary with each type of plan.

What is coinsurance?

After you pay any plan deductibles, you may still be responsible for a percentage of the billed charges for services you receive. This is called coinsurance. For instance, if your health plan pays 80% of billed charges, your coinsurance is the remaining 20%.

What is a copay?

A copay is the amount due by the insured and payable to the provider at the time of service. Copays do not apply to the annual deductible, but do accumulate toward the out of pocket maximum.

What is my out-of-pocket maximum and how does it work?

The out-of-pocket maximum includes the deductible and coinsurance, and is the annual limit on the cost of your healthcare. After you have met the out-of-pocket maximum, your plan pays 100% for covered services received from In Network providers and facilities for the remainder of the year.

How are emergency services covered?

All Memorial Hermann HMO and PPO plans include worldwide coverage for emergencies. In the event you need to seek emergency care, benefits are covered as in network, regardless of where services are rendered. Please refer to your certificate of coverage for specific information about how emergency services are covered when rendered by a foreign provider.

How do I know who is in the Memorial Hermann network?

Plan benefits include access to all Memorial Hermann hospitals, Memorial Hermann Convenient Care Centers, Urgent Care Clinics and walk-in facilities, which include CVS Minute Clinics, HEB RediClinics and Walgreens Take Care Clinics.

To search for In Network providers or facilities, please us our Provider Search.

How do I know which labs are in the Memorial Hermann network?

In network labs include Memorial Hermann Diagnostic Laboratories, LabCorp and Quest Diagnostics, Inc. NOTE: It’s important to ask your healthcare provider where your specimen will be sent for analysis. Use of an in network lab will ensure maximum savings.

Can I use providers or facilities outside the Memorial Hermann network?

If you are enrolled in one of our HMO plans, out of network benefits are only available in emergency situations.

If you are enrolled in one of our PPO plans, there are limited out of network benefits available. Out of network benefits give you the option to use any provider or facility; however, in most cases, your out of pocket costs will be significantly higher.

I have an out of area dependent. What network will they use?

Out of area dependents who are members of our PPO Plan have access to the PHCS Healthy Directions and MultiPlan Complimentary networks. Dependents of a primary HMO Plan subscriber who reside outside of our service area cannot be enrolled in our HMO Plan.

What are Essential Health Benefits?

The Affordable Care Act ensures health plans available in the individual market offer a comprehensive package of items and services, known as Essential Health Benefits. Essential Health Benefits must include benefits within the following ten (10) categories: Ambulatory Patient Services; Emergency Services; Hospitalization; Maternity and Newborn Care; Mental Health and Substance Use Disorder Services, including Behavioral Health Treatment; Prescription Drugs; Rehabilitative and Habilitative Services and Devices; Laboratory Services; Preventive and Wellness Services; Chronic Disease Management; Pediatric Services, including Dental and Vision care.

What is the Individual Mandate?

The Affordable Care Act requires you be enrolled in a health insurance plan that meets basic minimum standards (see Essential Health Benefits). If you can afford health insurance, but choose not to enroll, you may have to pay a tax penalty. For 2016, the penalty is the greater of $695 or 2.5% of your modified, adjusted gross income.