When doctors, hospitals or other health care providers join an insurance plan network, they agree to charge certain prices for certain services, known as the allowable amount. When a health care provider isn’t part of the health plan’s network, there is no set agreement on the allowable amount. A “surprise” bill happens when participants are expected to pay not just the out-of-network deductible and/or coinsurance or copay amount, but also the difference between the plan’s allowable amount and what the out-of-network provider charges. Sometimes, the difference can be hundreds or even thousands of dollars.
What is being done to protect patients from surprise billing?
As a participant in a HealthSelectSM plan administered by Blue Cross and Blue Shield of Texas (BCBSTX), you may have received a surprise bill if you got care from an out-of-network provider. If you got medical care on or after January 1, 2020, a new Texas law protects you from surprise bills in certain situations, such as when you don’t have a choice in the provider. You would still need to pay your plan’s out-of-network deductible and/or coinsurance.
The law, which applies to participants in Texas Employees Group Benefits Program (GBP) health plans, prohibits surprise medical bills from various Texas health care providers for services received on or after January 1, 2020, including:
- Out-of-network providers who are practicing at in-network facilities such as hospitals, birthing centers, ambulatory surgical centers and freestanding emergency rooms
- Out-of-network physicians and facilities, including hospitals and freestanding emergency rooms, that provide care in emergency situations
- Out-of-network diagnostic imaging and laboratory services that are provided in connection with a service from an in-network provider.
Important: Some providers in situations like those described above may ask participants to sign a form, known as a waiver, before they provide any care. This waiver would allow them to balance bill the patient. It is very important you read all paperwork a doctor or facility asks you to sign. A provider may not use this waiver in emergency situations.
This legislation only applies when services are performed in the State of Texas. Providers outside the state are not required to follow Texas law. Additionally, this legislation would not apply to services ordered by a provider within Texas if performed outside of Texas. This legislation also does not apply to any out-of-network services participants may have received prior to January 1, 2020.
Five steps for HealthSelect participants to take charge of their health care costs
There are easy steps you can take to make sure you’re getting the highest level of benefits from your HealthSelect plan:
- Choose in-network providers. If you visit a health care provider outside of the HealthSelect network, they will likely pay more for care. To find providers in the network, log in to Blue Access for Members and use Provider Finder, or call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039.
- Choose a primary care provider (PCP). HealthSelect of Texas® participants are required to choose a PCP to get the highest level of benefits and keep their health care costs down. The PCP serves as the first point of contact when non-emergency medical care is needed. You can select or change your PCP by calling a BCBSTX Personal Health Assistant or by logging in to Blue Access for Members.
- Get prior authorizations and referrals when necessary. In HealthSelect of Texas, a PCP is responsible for making referrals for participants to see specialists. In all HealthSelect plans, they write orders for lab and imaging services. PCPs and other in-network providers must also obtain prior authorization for certain services they’d like you to get. Your PCP will need to submit a referral or prior authorization request to BCBSTX before your visit. You should always check to see if a referral or prior authorization is on file with BCBSTX before you receive services that require them. If you do not have a referral or prior authorization on file, you may pay more because your visit will be considered out-of-network. Learn more about referrals and prior authorizations.
- Get a cost estimate. If you have an upcoming procedure, you can use Provider Finder to search for estimated costs. You can log in to your Blue Access for Members account to compare the cost of a procedure or service from different providers in your area.
- Know options for care. It’s important to know where to go when you need medical care. From virtual visits to doctor’s offices, to urgent care centers and emergency rooms, knowing your options and deciding where to go can make a big difference in how much you pay. You should be prepared before you go and, if possible, make sure ahead of time that the place you go to for care is in the network. Of course, in case of a true emergency, your costs will be covered as though you are in network, even if the hospital is not.
If you have any questions regarding surprise medical bills, your HealthSelect medical benefits, or if you need help choosing a PCP or finding a provider, contact a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, Monday-Friday, 7 a.m. – 7 p.m. and Saturday, 7 a.m. – 3 p.m. CT.
Source: ERS Update Express (May 2020)