TMA Seeks TDI Review of Blue Cross HMO Emergency Policy
By David Doolittle

HMO_Update

“Under Texas law, are health maintenance organizations (HMOs) allowed to punish patients who seek care for what they legitimately believe is a medical emergency?”

That is the question the Texas Medical Association and 18 other Texas medical societies posed to the Texas Department of Insurance (TDI) in response to a new Blue Cross Blue Shield of Texas (BCBSTX) policy that could require some HMO members to pay 100 percent of their out-of-network emergency medical bills.

As Texas Medicine Today reported last month, in a memo, BCBSTX said that beginning June 4, its fully insured group and retail HMO members may be required to pay their entire medical bill if they go to an out-of-network emergency room for certain non-life-threatening conditions.  

In response, TMA, the Texas College of Emergency Physicians, the Texas Society of Anesthesiologists, and others have asked TDI to evaluate the policy.

Under Texas law setting forth HMO coverage requirements, “emergency care” is defined with a “prudent layperson standard”, which shields patients from having to self-diagnose emergencies See Texas law below.

“With this policy, BCBSTX is asking that patients act as highly trained diagnosticians, skills our members spent many years of their lives acquiring,” the letter said. “BCBSTX is asking them to diagnose their symptoms at a critical and emotional moment, when time could be of the essence. As a result, it is very likely that extremely ill patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die.”

The organizations instead recommend BCBSTX educate enrollees on in-network options, including medical homes, urgent-care centers, and emergency facilities.

Texas Medicine Today will continue to monitor the situation and will provide updates as they come up.

 

Texas law (i.e., Texas Insurance Code §§843.002(7) and 1271.155) uses the “prudent layperson” standard for emergency care coverage by HMOs:

(7)  “Emergency care” means health care services provided in a hospital emergency facility, freestanding emergency medical care facility, or comparable emergency facility to evaluate and stabilize medical conditions of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the individual’s condition, sickness, or injury is of such a nature that failure to get immediate medical care could:

(A)  place the individual’s health in serious jeopardy;

(B)  result in serious impairment to bodily functions;

(C)  result in serious dysfunction of a bodily organ or part;

(D)  result in serious disfigurement; or

(E)  for a pregnant woman, result in serious jeopardy to the health of the fetus.

 

Last Updated On

May 10, 2018

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David Doolittle

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Dave Doolittle is editor of Texas Medicine and Texas Medicine Today. Dave grew up in Austin, where he attended culinary school as well as the University of Texas. He spent years covering Central Texas for the Austin American-Statesman newspaper. He is the father of two girls, a proud Longhorn, and an avid motorsports fan.

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