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Texas Department of Insurance
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March 6, 2020

BCBSTX to repay consumers for emergency claims, marketing errors

Blue Cross Blue Shield of Texas (BCBSTX) has agreed to repay consumers after a Texas Department of Insurance (TDI) review found delays in handling out-of-network emergency claims and incorrect information in consumer notices and marketing materials.

BCBSTX also will pay a $10 million fine.

“Consumers who had higher out-of-pocket costs due to the errors will get refunds,” said Texas Insurance Commissioner Kent Sullivan. “Ensuring the fair treatment of consumers and clear, timely consumer information are priorities for TDI.”

Based on a review of BCBSTX communications and how it processed out-of-network emergency claims, TDI found:

  • Incorrect information about how to resolve balance bills on explanations of benefits for many HMO members who received out-of-network emergency care.
  • Delays in processing out-of-network claims that went through an Emergency Benefit Management review process the company began using in August 2018.
  • Errors in marketing materials about plans offered in 2018 and 2019.

BCBSTX agreed to begin sending the consumer notices by May 1. Consumers with questions should call the number on their BCBSTX ID cards for member information.

BCBSTX enforcement order

Who may be eligible for refunds?

Emergency claims: Current or former BCBSTX members in fully insured HMO plans, including Affordable Care Act plans, who:

  • Received out-of-network emergency care between August 1, 2017, and December 31, 2019.
  • And paid or have an unresolved balance bill for that care.

Marketing materials: Current or former fully insured BCBSTX members enrolled in certain 2018 or 2019 plans who had higher out-of-pocket costs than expected based on information in plan documents provided by BCBSTX.

More about refunds

For more information, contact:

Last updated: 3/6/2020