Emergency Care
As an Employee or Retiree under 65, when you or a covered dependent have an emergency, appropriate medical treatment should be obtained immediately. For information on how to access care, and for the definition of a medical emergency, visit the Benefits Book.
For medically necessary emergency care during the first 48 hours, services will be paid at the network level. You will pay a $100 emergency room copayment, plus 20% of the allowable amount. For more information about out-of-pocket expenses, review
Out-of-pocket Examples for Emergency Care for:
If you have met your out-of-pocket coinsurance maximum, you will not be required to pay the 20%, but you will still be responsible for the emergency room copayment amount. (Copayments paid for office visits, inpatient care, outpatient surgery, prescription drugs or emergency rooms do not apply toward your out-of-pocket coinsurance maximum.)
If treatment is received after the first 48 hours of an emergency, you will be required to obtain a referral from your Primary Care Physician (PCP) to receive network benefits. Read more about follow-up care.
Follow-up care after emergency treatment
As an Employee or Retiree under 65, HealthSelect provides network benefits for the first 48 hours of an emergency. For follow-up care after the first 48 hours (to include office visits, outpatient services, inpatient care), you will need to obtain a referral from your PCP in order to receive network benefits.
If you do not obtain a referral, you will receive non-network benefits paid on the BCBSTX allowable amount.
If you are receiving care from a non-contracting (non-network, non-ParPlan) provider, you can be billed for charges above the BCBSTX allowable amount. This means that in addition to paying a non-network deductible and non-network coinsurance of 40%, you also pay the difference between the provider's billed charge and the BCBSTX allowable amount.
If you obtain a referral from your PCP for treatment after the first 48 hours of your emergency, you will receive network benefits.
You can also review your Benefits Book for more information about network and non-network benefits.
Ambulance Services
HealthSelect pays benefits for Ambulance Services received at the time of an emergency and when determined to be medically necessary by BCBSTX.
Benefits are paid based on the allowable amount, and you are responsible for any balance billed by the provider. Review Out-of-Pocket Examples for Ambulance Services.
There are no benefits available for Ambulance Services UNLESS a patient is transported to the nearest hospital equipped and staffed to treat the condition.
Emergency care received outside of Texas and the United States
For emergency care received outside of Texas or the United States, you will receive network benefits for the first 48 hours.
For care received after the first 48 hours of the emergency, an out-of-plan referral may be requested to continue to receive network benefits. Your PCP may request this referral.
For non-emergency care, benefits are paid at the non-network benefit level on the allowable amount.
By using BCBS contracting providers, you will not be required to file claims and cannot be held responsible for charges above the allowable amount. Locate contracting providers outside Texas or outside the United States.
