In less than a week, about 500,000 Texans will be subject to a Blue Cross and Blue Shield of Texas change that could leave consumers on the hook for 100 percent of their emergency room bills.

The change to how the health insurer will evaluate emergency claims for people holding HMO plans officially takes effect June 4.

But as of Friday, May 25, the Texas Department of Insurance, which is charged with regulating the state’s insurance industry, could not confirm whether the new process has safeguards to protect consumers or if it is in compliance with state codes, as it remains in “ongoing discussions” with the health insurer.

“Our objective remains making sure consumers fully understand any changes and can get emergency care,” the agency said in a statement Friday.

Starting next month, when people with Blue Cross of Texas HMO policies go to an out-of-network emergency room, they could end up paying the entire bill if the health insurer's subsequent evaluation of the claim determines that the medical problem wasn't life-threatening or serious enough to warrant an ER visit. The process change was first reported a month ago.

Blue Cross joins a few other health insurers in adopting procedures aimed at thwarting the overuse of high-cost emergency facilities for conditions that can be treated in primary or urgent care centers for less.

But advocacy groups, professional medical associations and others raised concerns to Blue Cross. Separately, the state insurance commissioner sent a letter to Blue Cross on May 11 requesting more information.

“I am concerned that ambiguous standards can potentially produce undesirable results in the best of circumstances, but they can be particularly problematic when applied retroactively and aggressively,” said Kent Sullivan, Texas' Commissioner of Insurance, in a letter addressed to Dr. Dan McCoy, president of Blue Cross of Texas.

“None of us want patients to avoid seeking necessary medical care simply because they are uncertain of their insurance coverage," he said.

A separate letter also was sent by the state insurance department to Nancy Pruitt of the insurer’s parent company, the Health Care Service Corporation, seeking detailed answers to nine questions.

The department asked for examples of letters sent to consumers providing notice of the change, details about how the emergency room claims will now be handled, about how the process complies with state insurance code and if the changes could impact people who don’t have an HMO.

McCoy responded to Sullivan on May 17, offering assurance that the initiative “has been thoughtfully reviewed with the best interests of our members as a priority,” and noting that the company, for several years, has been on a campaign to educate Blue Cross members about what constitutes an emergency.

Blue Cross says it will continue to answer the insurance commissioner’s outstanding questions, as well as communicate with customers and health insurance brokers. However, its detailed responses to the state were marked confidential and proprietary, and are not available for the public to view.

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