Higher HealthSelect costs for out-of-network freestanding ERs

Know your options – and the costs – for urgent and emergency care

If you are enrolled in a HealthSelectSM plan, you will probably pay more—sometimes thousands of dollars more—if you get medical care at a freestanding emergency room (ER) that is not in the HealthSelect network. 

You have the right to dispute certain out-of-network bills of $500 or more

As of January 1, 2018, if you visit an out-of-network emergency facility or freestanding ER, or you get services from an out-of-network hospital-based health care provider at an in-network facility and you get a bill for $500 or more (not including your copayment, coinsurance and deductible), you have the right to dispute the billed amount and ask for a mediation. You can get more information on how you may be able to pay less out-of-pocket through mediation by contacting the Texas Department of Insurance at www.tdi.texas.gov/consumer/cpmmediation.html or (800) 252-3439.

Freestanding ERs may seem like an appealing alternative to hospital ERs. They are usually found in residential shopping centers or other convenient locations, and can easily be confused with urgent care centers or convenience clinics. Freestanding ERs may also look like small hospital ERs. They provide emergency medical services, but are not affiliated with and are not physically connected to a hospital (or a department of a hospital). Most freestanding ERs are currently not in the HealthSelect network.

Before you’re in an emergency, we suggest using the HealthSelect Provider Finder to find in-network emergency care options near you. In case of a true emergency, you should go to the nearest emergency room. But remember, even if it is a true emergency, you will pay more of the cost if you get emergency services from an out-of-network freestanding ER. 

What has changed?

You will now be responsible for any billed charges above the amount HealthSelect pays, whether the services were the result of a true emergency or non-emergency. 

How does my cost differ if I get emergency care at the hospital emergency room?

The following chart shows the difference in costs between freestanding ERs and hospital-affiliated emergency facilities. If you go to an out-of-network facility, you may be responsible for any difference between the amount billed by the facility and the out-of-network allowable amount (sometimes called “balance billing”), which could be significant. The “balance bill” would be in addition to the higher copays and coinsurance.

 
HealthSelectSM of Texas and HealthSelect Out-of-State
Out-of-Pocket Costs for Freestanding Emergency Facilities*
Freestanding Emergency Room
(freestanding ER not affiliated with a hospital)
In-Network Out-of-Network
As of January 1, 2018, you may be balance billed by provider.
 
True Emergency $150 copay
+
20% coinsurance
$300 copay
+
20% coinsurance

Annual out-of-network deductible does not apply. 
Non-Emergency $150 copay
+
20% coinsurance
$300 copay
+
40% coinsurance

After meeting the annual out-of-network deductible ($500/individual, $1,500/family)
Freestanding Emergency Department
(hospital-affiliated freestanding emergency facility)
In-Network Out-of-Network
As of January 1, 2018, you may be balance billed by provider.
True Emergency $150 copay
+
20% coinsurance
$150 copay
+
20% coinsurance

Annual out-of-network deductible does not apply.
Non-Emergency $150 copay
+
20% coinsurance
$150 copay
+
40% coinsurance

After meeting the annual out-of-network deductible ($500/individual, $1,500/family)

Where should I go for different kinds of care?

Hospital emergency rooms are for life-threatening or very serious conditions that need immediate care.

There are lower-cost options if you do not have a life-threatening or critical condition.

  • Virtual visit — See a doctor via your smartphone, tablet or computer for non-emergency medical conditions. HealthSelect of Texas and HealthSelect Out-of-State participants pay no copay for this visit.
  • Doctor’s office — Your primary care physician (PCP) knows you and your health history and can provide routine and preventive care and treatment for a current health issue, or refer you to a specialist. HealthSelect of Texas and HealthSelect Out-of-State participants pay a $25 copay for in-network PCP visits.
  • Urgent care center — Urgent care centers offer treatment for non-life-threatening injuries or illnesses, including sprains, minor infections and minor burns. HealthSelect of Texas and HealthSelect Out-of-State participants pay a $50 copay plus 20% of the contracted allowable amount for in-network urgent care centers.
  • Emergency room — This is typically the highest-cost option. If you need immediate treatment of a life-threatening or critical condition, go to the nearest emergency room. Do not ignore an emergency. Call 911 if the situation is life threatening. HealthSelect of Texas and HealthSelect Out-of-State participants pay a $150 copay plus 20% coinsurance. (Copay applies to the hospital copay, if you’re admitted.)
Learn more about Options for Care.