New Year HealthSelect Checklist - These changes are effective 1/1
1. Out-of-Network Freestanding Emergency Room (FSER)
What is changing?
Beginning January 1, 2018, if you receive services from an out-of-network freestanding emergency room (FSER), you will pay much more of the cost. HealthSelect will no longer pay the amount billed by the out-of-network FSER as it did in the past – even if the care is due to a true emergency. You will pay more of the cost if you receive services from an out-of-network FSER because now the plan’s payment to the FSER is less than the amount paid to a hospital ER or an in-network FSER. This means that you will be responsible for the amount billed by the out-of-network FSER that exceeds the amount paid by the plan, regardless of whether the services were the result of a true emergency or non-emergency.
What is a Freestanding Emergency Room?
A freestanding emergency room (FSER) is a medical care facility that provides emergency services, is not affiliated with a hospital and is not physically connected to a hospital (or a department of a hospital). In some parts of Texas, FSERs seem to be showing up everywhere. A freestanding ER can easily be confused with an urgent care center or convenience clinic and may also look like a small hospital ER. They are frequently located near a shopping center or other convenient location. While a FSER may seem like an appealing and convenient alternative when you need emergency care, you need to pay close attention before you seek care at a FSER. You will probably pay more—sometimes thousands of dollars more— for emergency care at an out-of-network FSER.
How do I know if I am at an out-of-network FSER?
Usually in-network emergency rooms are physically connected to a hospital. If the FSER is not physically connected to a hospital, chances are you may be at an out-of-network FSER and you will pay more of the cost for any services you receive at the out-of-network FSER. Show your medical ID card and ask if they are in-network for your plan. Before you find yourself in an emergency, we recommend using the Provider Finder tool to locate 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 seek emergency services from an out-of-network FSER.
How does my cost differ if I seek emergency care at the hospital emergency room?
For a hospital emergency room (or hospital emergency department, or a hospital-affiliated FSER), your copay and coinsurance are the same whether in or out-of-network.
- $150 ER copay
- No deductible
- The plan pays 80% of charges
For an out-of-network FSER, you will pay more starting January 1, 2018.
- $300 copay (effective September 1, 2017)
- No deductible if true emergency but out-of-network deductible applies if not a true emergency
- The plan pays 80% of the out-of-network allowable amount if true emergency and 60% of the out-of-network allowable amount if not a true emergency. The out-of-network allowable amount is often much less than the amount billed by the facility, which means you are then responsible for more of the cost.
- You may be responsible for any difference between the amount billed by the facility and the out-of-network allowable amount, which could be significant. This is sometimes referred to as balance billing.
Before you seek emergency care, remember, you have options for in-network care. The hospital emergency room (ER) is for life-threatening or very serious conditions that require immediate care. There are other lower-cost alternatives if you do not have a life-threatening or critical condition.
- Virtual Visits — lets you see a doctor via your smartphone, tablet or computer for non-emergency medical conditions. HealthSelect of Texas In-Area 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 In-Area 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 In-Area 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 — 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 and call 911 if the situation is life threatening. HealthSelect of Texas In-Area and HealthSelect Out-of-State participants pay a $150 copay plus 20% coinsurance (copay applies to hospital copay if admitted).
If you need help locating an in-network provider, call a Personal Health Assistant from Blue Cross and Blue Shield of Texas (BCBSTX) at (800) 252-8039. The 24/7 Nurseline can also help you if you need help deciding where to go for care. You can reach the 24/7 Nurseline at (800) 581-0368.
2. You have the right to dispute out-of-network bills of $500 or more.
Effective January 1, 2018, if you visit an out-of-network emergency facility or FSER, or you receive services from an out-of-network hospital-based physician (doctors and other health care providers) and you get a bill for $500 or more connected to those services (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 reduce some of your out-of-pocket cost through mediation by contacting the Texas Department of Insurance at www.tdi.texas.gov/consumer/cpmmediation.html or (800) 252-3439.
If you get a bill from an out-of-network provider for under $500, you can request a claim review by calling a Personal Health Assistant from BCBSTX at (800) 252-8039 Monday–Friday, 7 a.m. - 7 p.m. and Saturday 7 a.m. - 3 p.m. central time.
3. Annual deductibles, coinsurance maximums, and out-of-pocket maximums reset for HealthSelect plans on January 1, 2018.
For HealthSelect plans, annual deductibles, coinsurance maximums, and out-of-pocket maximums reset on January 1 of each year, unless otherwise noted in the deductible table shown below.
Coinsurance is your share of the cost for a healthcare service such as a lab test, x-ray, physical therapy or other medical services. A coinsurance maximum is the total amount of coinsurance you are required to pay each year before your health plan begins to pay 100% of your cost for covered medical expenses.
The total out-of-pocket maximum is the maximum amount you will have to pay in covered medical and prescription drug costs, including deductibles, copays, and coinsurance before the plan begins to pay all covered services at 100%.
A deductible is the amount you must pay out-of-pocket each year before your plan starts to pay its share of the cost. You may have a single deductible or a family deductible. The chart below will help you determine when a deductible applies.
|If you are enrolled in:||When does my deductible restart?|
|HealthSelect of Texas In-Area (living or working in Texas) and you are not enrolled in Medicare||In-network: You do not have a deductible if you see in-network providers. Out-of-network: Your out-of-network deductible resets on January 1.|
|HealthSelect Out-of-State (your eligibility county on file with ERS is outside Texas)||In-network: You do not have a deductible if you see in-network providers. Out-of-network: Your out-of-network deductible resets on January 1.|
|Consumer Directed HealthSelect||In-network: Your in-network deductible resets on January 1. Out-of-network: Your out-of-network deductible resets on January 1.|
|HealthSelect Secondary (i.e., you are Medicare eligible and retired, or a return to work retiree with retiree level benefits)||You have an overall deductible of $200 per individual, or $600 per family. Your deductible for this plan will reset on January 1.|
We are here to help
If you have any questions about your HealthSelect medical benefits, call a Personal Health Assistant from BCBSTX at (800) 252-8039 Monday–Friday, 7 a.m. - 7 p.m. and Saturday 7 a.m. - 3 p.m. central time. If you are enrolled in a plan other than HealthSelect, refer to the number on the back of your medical ID card.