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. HealthSelect network providers agree to provide discounts that are often not available to other plans or the general public, which means the allowable amount is a very valuable benefit.
When a health care provider isn’t part of your plan’s network, there is no set agreement on the allowable amount.Balance billing happens when you 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. Balance billing becomes surprise billing when the patient didn’t have the opportunity to choose an in-network provider.
What is being done to protect patients from surprise billing?
As a participant in a HealthSelect plan administered by Blue Cross and Blue Shield of Texas (BCBSTX), you might have gotten a balance bill if you got care from an out-of-network provider. For medical care you get or have gotten on or after January 1, 2020, Texas law protects you from balance bills in certain situations, such as when you don’t have a choice in the provider. You will still need to pay your plan’s deductibles, copayments and coinsurance—but you shouldn’t have to pay the balance bill in those situations.
The law, which applies to all Texas Employees Group Benefits Program (GBP) health plans, prohibits surprise medical bills from various Texas health care providers for services you have 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; and
- out-of-network diagnostic imaging and laboratory services that are provided in connection with a service from an in-network provider.
It’s important to know that some providers in situations like those described above may ask you to sign a form, known as a waiver, before they provide any care. This waiver would allow them to balance bill you. It is very important that you read all paperwork that a doctor or facility asks you to sign. In Texas, providers are not allowed to use this waiver in emergency situations.
This legislation only applies when services are performed in Texas. Providers outside of the state are not required to follow Texas law. Additionally, this legislation does 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 you may have received before January 1, 2020.
Five ways to take charge of your health care costs
There are steps you can take to make sure you’re getting the highest level of benefits from your health plan. (Please note that these don’t apply to the HealthSelectSM Medicare Advantage Plan preferred provider organization.)
- Choose in-network providers. If you visit a health care provider outside of the HealthSelect network, you will likely pay more for care. To find providers in your HealthSelect plan’s network, log in to your Blue Access for MembersSM account and use Provider Finder to compare the cost of a procedure or service from different providers in your area. If you prefer to speak with BCBSTX directly, call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039.
- Choose a primary care provider (PCP). If you are enrolled in HealthSelect of Texas®, you are required to choose a primary care provider (PCP) to get the highest level of benefits and keep your health care costs down. Your PCP serves as your first point of contact when you need non-emergency medical care. You can select or change your PCP by calling a BCBSTX Personal Health Assistant or by logging in to Blue Access for Members. PCPs aren’t required for Consumer Directed HealthSelect, but they’re a good idea for managing your overall health.
- Get prior authorizations and referrals when necessary. In HealthSelect of Texas, your PCP is responsible for making referrals for you to see specialists. In all HealthSelect plans, they write orders for lab and imaging services. Your PCP 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. Consumer Directed HealthSelectSM doesn’t require referrals to specialists, but does require prior authorizations for certain services.
- Earn rewards with HealthSelectShoppERSSM. If you are enrolled in a HealthSelect of Texas medical plan, including Consumer Directed HealthSelect, you have access to the HealthSelectShoppERS program to compare costs for certain services and procedures at in-network facilities. If you use HealthSelectShoppERS and choose a high-quality but lower-cost option for your care, you can earn TexFlexSM health care or limited-purpose flexible spending account (FSA) incentives. Medicare-primary participants aren’t eligible for the program.
- Know your 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. Be prepared before you go and, if possible, make sure ahead of time that the place you go to for care is in the HealthSelect network. Of course, if you have a true emergency, your HealthSelect plan will cover costs at the in-network level, even if the hospital is not in the network.
Learn more about avoiding unexpected health costs.
If you have any additional questions regarding surprise medical bills or 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.