Dec. 22, 2023
Texas House Bill 2002: PPO Out-of-pocket Expense Credit
Specifically applies to:
- Individual & Family Markets PPO plans
- Student Health PPO plans
- Fully insured group PPO plans, including small, mid-market and large, PPO, Municipality/County School plans
- Blue Balance FundedSM PPO plans
Does not apply to:
- Employees Retirement System/Teacher Retirement System plans
What you need to know: Texas House Bill 2002 gives members a way to get cost-sharing credit for cash payments they made to providers who do not file insurance claims in certain situations, such as when:
- A member paid an out-of-network provider for a service that’s covered by their health plan.
- The provider did not submit a claim to Blue Cross and Blue Shield of Texas for the same service.
- The amount the member paid the out-of-network provider is less than the average discounted rate that BCBSTX normally pays a provider who is in their plan’s network for the service.
We’ve modified our existing Texas medical claim form so that members can use it to submit a traditional claim or use it to claim the PPO out-of-pocket expense credit. We’ve added two checkboxes, one of which the member must select:
- “To Pay Insured/Subscriber” — Traditional claim form/process to get reimbursed for a payment made to a provider).
- “To get in-network credit for your cash payment to an out-of-network provider” — New PPO out-of-pocket expense credit process.
- Note: There is a Learn More
link under this second checkbox that includes instructions to help members understand if this option applies to their claim.
What members need to do to claim the PPO out-of-pocket expense credit:
- Step 1: Visit an out-of-network provider and agree on a cost with them for the care.
- Step 2: Submit a completed claim form with an itemized receipt and proof of payment. Members need to check the box that says, “To Claim PPO Out-of-pocket Expense Credit.”
- Step 3: BCBSTX reviews the claim and checks the amount the member paid to make sure it’s less than the average discounted rate we would pay a provider who is in their plan’s network for the same service.
- Step 4: We credit the member’s in-network deductible and out-of-pocket maximum, if needed.
When does this go into effect? Sept. 1, 2023, for plans delivered, issued for delivery, or renewed on or after Jan. 1, 2024.
