HealthSelectSM of Texas is a point-of-service plan. Consumer Directed HealthSelectSM and HealthSelect Out-of-State are preferred provider organization (PPO) plans. In both types of plans what you pay for care depends on the provider.
You will pay less if you go to a provider in the network, but if you want to go to a provider who isn’t in the network, you can. You’ll still get coverage, you’ll just pay more.
Here are three ways you’ll pay more if you go out of the HealthSelect network for care:
- You’ll have to pay an out-of-network deductible before the plan pays anything. (With Consumer Directed HealthSelect, the out-of-network deductible is twice as much as the in-network deductible.)
- After you meet the deductible, you’ll have to pay out-of-network coinsurance.
- You won’t get the lower price the plan negotiates with an in-network provider (referred to as the allowable amount or negotiated rate) and you may be responsible for the difference between the amount billed by the provider and the allowable amount. This is known as balance billing, and the cost could be significant (see box below).
HealthSelect participants in Texas have access to more than 50,000 network doctors, providers and hospitals across the state. (If you live or work outside Texas, you also have a large provider network.)
To make the most of your health care benefits:
- Choose a primary care physician (PCP) from the many providers who are in the HealthSelect network.
- Get a referral from your PCP for any specialist care. If you see a specialist without a referral, you’ll pay out-of-network costs, even if the specialist is in the HealthSelect network. Also, keep in mind that only your PCP can give you a specialist referral. If the specialist you see refers you to a second specialist, you must get a referral for the second specialist from your PCP. (HealthSelect Out-of-State, Consumer Directed Health Select, and HealthSelect Secondary participants do not have to get referrals to specialists.)
- Before seeing a specialist—even if referred to him or her by your PCP—double-check his or her status. That’s true for specialists at in-network hospitals and other facilities. Just because the hospital is in the network doesn’t mean everyone practicing there is. Also, keep in mind that some specialists may be in network only when they are working at a specific location. If the specialist you’re seeing works out of more than one office or facility, make sure you’re seeing him or her at a location that’s in the network.
- If you need any tests done, check to see if these tests are done in an in-network facility or lab. For example, if you need to get blood drawn, ask your provider to send you to an in-network lab. Ask your PCP to send in-office tests—such as cultures obtained to check for pneumonia or strep throat—to an in-network facility or lab.
People who go out-of-network are often surprised by how much they have to pay. One of the reasons they may have larger than expected bills is because of balance billing. Balance billing happens when the provider bills the patient for the difference between the amount the provider charges and the plan’s allowable amount—which is the balance left on the bill. Until someone gets a balance bill, they don’t realize how much going out-of-network can cost. Depending on the service, balance bills can be hundreds or even thousands of dollars in additional cost to you as a member.
An allowable amount is the maximum amount a health plan will pay a health care provider, such as a doctor or laboratory, for a service that’s covered under the plan. When you see an in-network provider, the allowable amount is the amount the provider has agreed to charge for a service. Health plans do not negotiate the allowable amount for a service with an out-of-network provider, so what the plan pays may be less than what the provider charges. If your out-of-network provider charges more than the plan’s allowable amount, you may have to pay the difference (see Balance Billing).
You can avoid these extra costs by choosing an in-network provider.
If you have questions about your benefits or how to use them, call a Personal Health Assistant toll-free at (800) 252-8039 (TTY 711), Monday–Friday, 7 a.m. – 7 p.m. CT and Saturday, 7 a.m .- 3 p.m. CT.
Of course, in any emergency, call 911 or go to the nearest emergency room. Most health plans require that you notify them or your PCP within 24 to 48 hours of your emergency room visit if it resulted in admittance to the hospital. And remember: non-network freestanding emergency room benefits are subject to a higher copay and you could be balance billed. For that reason, we recommend using an in-network emergency room, when possible.
If you are enrolled in a health maintenance organization (HMO), the only time out-of-network services are covered is in the event of an emergency.
To find out what is and isn’t covered by your plan, check out your health plan’s Summary of Benefits.
Source: ERS (October 2018)