Blue Cross to Put Off HMO Emergency Coverage Policy Until August
By Steve Levine


Blue Cross and Blue Shield of Texas (BCBSTX) will delay for 60 days a new HMO emergency care policy it had originally planned to begin on Monday, June 4.

Under the new policy, the health plan’s fully insured group and retail HMO members could be required to pay 100 percent of their medical bills if they go to an out-of-network emergency room for certain non-life-threatening conditions. In a statement, BCBSTX said it will use the additional 60 days to answer questions posed by state insurance regulators “while continuing to educate our members on the importance of appropriately using emergency services.”

In a letter to BCBSTX obtained by the Texas Medical Association, Texas Department of Insurance (TDI) Associate Commissioner Melissa Hield asked for answers to six questions about the new policy, why it was proposed, how it will work, and patients’, physicians’, and providers’ appeal rights. 

“TDI may have further questions or require additional documentation to ensure the process complies with requirements and protects Texans,” she wrote.

“We are pleased with the delay and the concern shown by the commissioner of insurance,” said TMA President Douglas Curran, MD. “We expect to see changes that explicitly acknowledge Texas’ legal protections for patients seeking emergency care. 

“As we said in our letter to the commissioner, ‘We do not believe patients should be expected to self-diagnose to determine whether their symptoms are serious enough to warrant an emergency department visit.’”

In mid-May, TMA and 18 state medical societies sent a letter asking Insurance Commissioner Kent Sullivan whether the BCBSTX policy runs afoul of the state’s “prudent layperson standard,” which shields patients from having to self-diagnose emergencies.

“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 says. “BCBSTX is asking them to diagnose their symptoms at a critical and emotional moment, when time could be of the essence.”

In a news story, the Dallas Morning News quoted a TDI official who expressed similar concerns. “When you’re facing an unknown situation at 2 o’clock in the morning, you need to be able to act quickly,” said TDI spokeswoman Stephanie Goodman.

BCBSTX's statement said it still plans to implement what it calls “this thoughtful, multi-step review process” on Aug. 6 “to provide protection for our members from inappropriate billing, egregious charges, and fraud, waste and abuse by out-of-network emergency departments.”

Last Updated On

June 27, 2018

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Steve Levine

VP, Communication

(512) 370-1380
Steve Levine

A former statehouse reporter, political press secretary, and state agency spokesman, Steve Levine has directed the Communication Division at TMA since 1997. He oversees Texas Medicine, Texas Medicine Today, TMA's media and public relations activities, and the TMA Knowledge Center, website, and social media activities.

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