Benefits

Higher HealthSelect costs for out-of-network freestanding ERs

Starting September 1, 2017, HealthSelect of Texas and HealthSelect Out-of-State participants will pay a higher co-pay for care at freestanding emergency rooms (ERs) that are not in the HealthSelect network.

The higher copay is in addition to coinsurance, which will be the same as the current HealthSelect coinsurance rates at these facilities. The change in copay applies only to freestanding ER facilities — the benefits for emergency doctors and any other providers you see during an emergency room visit (such as radiologists or pathologists) will stay the same.

The change in copay does not apply at hospital-based or hospital-affiliated emergency departments. The benefit for HealthSelect Secondary and Consumer Directed HealthSelect is not changing – out-of-pocket costs for emergency care in these plans will include the current deductibles, copays and coinsurance. This change does not affect participants in the Medicare Advantage plans or health maintenance organizations (HMOs).

The out-of-pocket costs for freestanding ERs will apply in both non-emergency and emergency situations. In addition, for non-emergency care at out-of-network freestanding ERs, the participant will have to meet the out-of-network deductible before the plan begins to pay anything. (The out-of-network deductibles are: HealthSelect of Texas and HealthSelect Out-of-State– $500 per individual, $1,500 per family; Consumer Directed HealthSelect – $4,200 per individual, $8,400 per family.) The table below provides more information about out-of-pocket costs at freestanding emergency facilities in emergency and non-emergency situations.

At this time, most freestanding ERs are not in the HealthSelect network. If you get care at a freestanding ER on or after September 1, you probably will pay higher out-of-pocket costs.


*Note: The change in copay applies only to freestanding ER facilities — the benefits for emergency doctors and any other providers you see during an emergency room visit (such as radiologists or pathologists) will stay the same.

More information about freestanding ERs and your coverage

What is a freestanding ER and how will I know if one is out of network?
A freestanding ER is a 24-hour medical facility that is not located in or affiliated with a hospital, but is licensed to provide the same level of care as a hospital-based ER. Most freestanding ERs do not participate in the HealthSelect network (or in any health plans’ networks).

Starting September 1, 2017, every freestanding ER in Texas will be required by state law to post at its facility and on its website which health plans’ networks it participates in. Every freestanding ER also must provide a patient with written confirmation of whether it participates in the network for the patient’s health plan. (There is other information freestanding ERs will have to provide to patients starting September 1. To learn more, see House Bill 3276.)

Take some time now – before an emergency happens – to learn about the in-network emergency and urgent care providers near your home, your work and other places you spend a lot of time (such as a relative’s house). Check the HealthSelect provider finder to find out which providers are in the network.

What’s the difference between a freestanding ER, a freestanding emergency department and an urgent care center?
Many freestanding ERs look like other health care providers, such as freestanding emergency departments and urgent care clinics. But there are important differences, including cost.

  • Freestanding emergency departments are hospital-affiliated, 24-hour emergency facilities that are not located in hospitals. They provide the same level of care as hospital-based emergency rooms, and usually are owned or operated by a hospital. Some freestanding emergency departments are in the HealthSelect network. Costs for in-network and out-of-network freestanding emergency departments are included in the table above.
  • Urgent care clinics are good for problems that can’t wait for a doctor’s appointment but aren’t life-threatening emergencies, such as ear infections, coughs, sprains and cuts. Urgent care clinics have a $50 copay, plus 20% coinsurance for in-network clinics or 40% coinsurance for out-of-network clinics. (Consumer Directed HealthSelect and HealthSelect Secondary participants have to meet the deductible before the plan begins to pay anything at urgent care clinics.)
  • Virtual visits, in which a patient can consult with a doctor online or over the phone, might be a good option for some non-emergency ailments, such as a sore throat, cough or rash. Beginning September 1, 2017, HealthSelect of Texas and HealthSelect Out-of-State participants will pay $0 out of pocket for in-network virtual visits – there won’t be a copay or coinsurance.

Learn more about where to go for different types of care.

Why is ERS raising the out-of-pocket costs for freestanding ERs?
During this year’s legislative session, state lawmakers directed ERS to find ways to lower overall plan costs in HealthSelect. ERS looked at several options and found that raising out-of-pocket costs for out-of-network freestanding ERs would have the smallest impact on members while lowering overall plan costs.

Because of this decision and other cost management activities, dependent premiums will go up less than 1% in Plan Year 2018, and there are no other increases in members’ costs.

What can I do if I think I’ve been unfairly billed for emergency care?
State lawmakers recently passed Senate Bill 507, which requires emergency health care providers in Texas to offer mediation in disputes about balance bills from emergency providers that come to $500 or more after applicable out-of-pocket costs (copays, coinsurance and deductibles), for services provided on or after January 1, 2018. To learn more, see Senate Bill 507 or contact the Texas Department of Insurance.

Source: ERS

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