Making sure your medical care is covered

Making sure your medical care is covered

March 6, 2019

“They laugh alike, they walk alike, sometimes they even talk alike… you can lose your mind...”
 
The lyrics from the theme song for The Patty Duke Show seem appropriate for a discussion about freestanding emergency rooms (ERs). Since the facilities got approval to operate, their numbers have grown in Texas. They seem to be everywhere and look a lot like other health care providers, such as urgent care clinics. But there are important differences, including cost.
 
Most freestanding ERs and the professionals who work at them are not affiliated with a hospital and are not in the HealthSelect or HMO networks. This means you may pay much more out of pocket .
 
Clearly, if you have a true emergency, get treatment as soon as possible at a nearby emergency facility. Still, you can plan ahead. Find out which ERs and hospitals are in your health plan’s network. Go to your plan’s website and use the provider search tool to find ERs that are in your plan’s network. Have the information handy—in your wallet, on your refrigerator and/or the glovebox of your car—so you’ll know where to go if you need emergency care.

What can I do if I think I’ve been unfairly billed for emergency care?

Emergency health care providers in Texas are required to mediate out-of-network bills to patients when the bill is $500 or more after applicable out-of-pocket costs, such as copays, coinsurance and deductibles.

To learn more, contact the Texas Department of Insurance.

Options for when your condition isn’t life-threatening
 
Urgent care clinics are good for problems that can't wait for a doctor's appointment but aren't life-threatening, such as ear infections, coughs, sprains and cuts.
 
If you are in HealthSelectSM of Texas or HealthSelectSM Out-of-State, in-network urgent care clinics have a $50 copay, plus 20% coinsurance (Consumer Directed HealthSelectSM and HealthSelectSM Secondary participants have to meet their deductible before the plan begins to pay anything for visits to urgent care clinics.)
 
If you are in the any of the HMO plans offered through ERS, you will have a $50 copay, plus 20% coinsurance for in-network urgent care clinics.
 
HealthSelect participants can also consult with a doctor online or over the phone with a medical virtual visit. These virtual visits might be a good option for some non-emergency ailments, such as a sore throat, cold or flu, cough or rash—and the price is right. Medical virtual visits from Doctor on Demand or MDLIVE are covered at no cost to participants enrolled in the HealthSelect of Texas and HealthSelect Out-of-State plan. For participants enrolled in Consumer Directed HealthSelect and HealthSelect Secondary, you must first meet your annual deductible, and then coinsurance will apply.

And finally, all GBP plans offer 24-hour assistance. Call if you are uncertain about what care you need and where you get it:

 

  • HealthSelect participants can call the 24/7 Nurseline, toll free, at (800) 581-0368.
  • Those enrolled in Community First Health Plans can call Member Services at (210) 358-6262 or toll-free at (877) 698-7032.
  • The KelseyCare powered by Community Health Choice Nurse Line is (713) 442-0000.
  • The Scott & White Health Plan nurse advice line is toll-free at (877) 505-7947.
Knowing your options and deciding where to go can make a big difference in how much you pay.
 
HealthSelect participants can review this chart for a quick overview of low–cost to high-cost options.
 
Participants in any plan can check out the Summary of Benefits and Coverage for more information.