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 your plan’s network, there is no set agreement on the allowable amount. A “surprise” bill 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.
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 might have gotten a surprise bill if you got care from an out-of-network provider. If you get 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 State of Texas employees Texas Employees Group Benefits Program (GBP) health plans, prohibits surprise medical bills from various Texas health care providers for services you receive on or after January 1, 2020
- 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.
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.
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 of 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 you may have received prior to January 1, 2020.
Five steps to take charge of your health care costs
There are easy steps you can take to make sure you’re getting the highest level of benefits from your health plan:
- 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 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). 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.
- 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. Learn more about referrals and prior authorizations.
- Get a cost estimate. If you have an upcoming procedure, use Provider Finder to search for estimated costs. 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 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-network. Of course, if you have a true emergency, your costs will be covered as though you are in-network, even if the hospital is not.
If you have any additional 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.