BCBSTX Canceling PPO Plans for 2016

[LOL!]

OK - that last paragraph is still blowing my mind.

That last paragraph does not say that the HMO plan(s) price(s) will not be going up. I think one can be assured that even the HMO plans will have higher prices. I interpret the last paragraph as saying the HMO plans will not have to go up as much as they would if we had a PPO plan.

 

[BarbWire]

Not good news. I have been on BCBSTX now for 2.5 years. After year 1 they cancelled my PPO and I got on another PPO for year 2 which was pricier and less coverage. Sounds like next year I will need to switch to an HMO.

Yep. They cancelled the PPO that I had in 2013 and 2014, so this year I selected a HSA eligible, high deductible PPO plan. Much more expensive with a higher deductible than the old plan I liked....

I see an ophthalmologist four times a year -- referred by my optometrist. No primary care physician involved. I assume that with an HMO I will need to find a primary care physician, and s/he will be gatekeeper for everything.

My PPO also covers me when traveling, both in the US and, on a limited basis, overseas. Another plus for PPOs

It sounds like BCBS PPOs in New Mexico will also get the ax.

2016 may be the time to move to a state with PPO coverage, no state income tax, and no inheritance/estate tax.

 

[BarbWire]

Here's a thought: the Dallas Morning News story says that BCBSTX will stop offering the Blue Choice PPO.

I wonder if they will also stop offering the Blue Edge HSA PPO? It's probably a goner as well, but I suppose there is a slight chance that these are profitable for BCBS.

 

[Ian S]

Here in Arizona, BCBS is not for profit and I haven't heard of them dropping their PPO's for next year. However, they are asking for hefty premium increases and since regulators here can't stop the increases, we're bound to get them. Interestingly, what they call an HMO is really just a limited PPO network - you don't need a referral to see a specialist.

Looking forward to joining Medicare next year as I turn 65.

 

[MichaelB]

Here's a thought: the Dallas Morning News story says that BCBSTX will stop offering the Blue Choice PPO.

I wonder if they will also stop offering the Blue Edge HSA PPO? It's probably a goner as well, but I suppose there is a slight chance that these are profitable for BCBS.

I don't think so. From Audrey1's link and post above

We won't be offering PPO insurance plans in the individual, retail market. However, we intend to continue to offer HMO plans. This change does not affect our employer group customers or the grandfathered PPO individual plan members.

 

[Disappointed]

Wow, this is bad news. I have Blueshield of California Gold 80 PPO, the premium went up about 13% in 2015. Even with this PPO plan, the in network providers are limited. Some providers will accept BS plans that are employers provided but will not accept BS plans through ACA. I will need to check and see if PPO will still be offered in 2016.


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Mp

 

[MBSC]

Hopefully over the next week more information will be made available on this and we will have a better idea what is happening, if other states are seeing the same trends, and what options will be available.

Here is a new article with information on other areas.

Highmark Health said it would reduce its range of offerings on the Affordable Care Act marketplaces, becoming the latest insurer to retrench amid steep financial losses.

The big Pittsburgh-based nonprofit company said it would continue to sell plans related to the federal health overhaul in all of the areas it currently serves, which span Pennsylvania, Delaware and West Virginia. But “we will have less products in the market overall,” said David L. Holmberg, the company’s chief executive, who said Highmark had lost $318 million on its individual health-law plans in the first six months of 2015, after rolling out a very broad array of options that had attracted many consumers with chronic conditions who required costly care.

He said the company was still working on the details of its offerings, but it expects a “mix shift” toward plans that offer more limited choices of health-care providers. Such plans typically have lower premiums than versions with broader networks.

In North Carolina, where Blue Cross and Blue Shield of North Carolina said the operating loss on its health-law business in its first year was $123 million, the insurer has said it would no longer offer its broadest-network plans in three of the state’s most populous cities, Charlotte, Raleigh and Durham.

Going further, Blue Cross and Blue Shield of New Mexico, also a unit of Health Care Service Corp., recently said it wouldn’t offer health plans through the state’s health-law exchange next year, after a New Mexico regulator rejected its request for a rate increase that averaged 51.6%. The company said in a statement on its website that it had lost $19.2 million last year on the 35,000 people enrolled in its individual plans. It will continue to sell certain plans to individuals in the state, though off the exchange.

Lisa Reid, an official at the New Mexico regulator, said the company hadn’t shown evidence that justified its requested increase. New Mexico’s exchange will still have four insurers, with “a lot of good choices for people,” she said.

Source: Highmark Is Latest to Trim Offerings Under Health Law - WSJ

 

[audreyh1]

In the past two weeks we've had a chance to do a lot more analysis of what BCBS is offering in lieu of the discontinued PPO - the Advantage HMO + which requires referral from your PCP for specialist access, but which does have some provision for out-of-network care.

Seeing Doctors and Specialists

At first things didn't look too bad. All but one of our doctors would be in network. And I would be able to see my gynecologist without referral - important as he is treating several issues. And this offering was also HSA compatible, a plus for us. I'm wasn't too worried about referrals to do follow-up visits with a couple of specialists next year, although my current arrangement for low-cost ultrasounds may have required me jumping through some extra hoops.

Considering Other Medical Costs

But in general the BCBS Advantage network is much smaller than the PPO network and for us this offering started to break down when we looked at coverage for things like lab services and hospital coverages.

Labs can be quite expensive - much more than doctor's visits. I have one twice yearly set of panels that BCBS routinely discounts to about 10% of what the lab bills. We're talking about ~$1800 in charges knocked down to about $150 of what I end up paying when the lab sends me the bill.

Here are links to some of the coverage differences:

In looking at laboratories, only one of several that our doctor's have used in the past couple of years was in network for the Blue Advantage network. Take a peek at the attached PDF for the big differences. [Sorry, it will download the PDF, I didn't know how to make it just display.]

For hospital-based physicians: an important thing to look at to get an idea of how likely your services are to be out-of-network for local hospitals. You can see from checking your area here, that the Advantage HMO network is much smaller than the BlueChoice PPO network. This link lets you compare between the networks for hospitals your area: Provider Finder - Important Message

Out of Network Coverage

What got DH - is that although the plan offers 50% coinsurance of allowed out-of-network charges after the $15K out-of-network deductible is met, there is no max OOP for the out-of-network case. With a much smaller preferred network, you are much more likely to encounter out-of-network billing.

Conclusions

The doctor's visits themselves won't break the bank, even if we had to pay the initial billing price which tends to run 2 to 3x what BCBS allows. It's all the other stuff that is so expensive, with the increased potential of out-of-network charges and balanced billing. It wouldn't take much to make an otherwise cheap monthly insurance rate jack up total medical expenses per year.

 

[Katsmeow]

We were on a group PPO this year for retiree coverage (DH is on medicare so I am buying for 2 of our kids and me). This year Megacorp is having us buying policies on the individual market and they are subsidizing most of the cost.

So, when I found out there were no PPOs (Megacorp said they didn't expect that either) I started looking for plans with the broadest coverage. I did look at this one because it did have some out of network coverage. The real deal breaker for me was the lack of an out of pocket max for out of network coverage, particularly with the deductible so high to even get to it.

I also don't like having to have a referral and in our area (Houston) the really narrow hospital network. For example, St. Luke's is on there, but the Memorial Hermann and Methodist hospitals aren't. I wanted a network that would have all 3 of these.

I might have been able to live with the narrower network if there had been true out of network coverage with even a high OOP max. (The PPO that Cigna was apparently originally going to offer and then decided not to recently had a $25k individual and $50k family OOP max for out of network).

But, with no OOP max on the out of network stuff, the really narrow hospital network was a dealbreaker for me. I'm pretty sure we are going to pick a Cigna EPO using the LocalPlus network. Referral to a specialist is not required and the hospital network is broader (having St. Luke's, Memorial Hermann and Methodist hospitals on it).

I don't think we will go broke from out of network physicians at an in network hospital. What I would like would be to have out of network coverage if I was to get cancer and wanted to go to MD Anderson out of network. But, with no max OOP on out of network coverage the BCBS product isn't appealing at all.

 

[W2R]

[...]I also don't like having to have a referral and in our area (Houston) the really narrow hospital network. For example, St. Luke's is on there, but the Memorial Hermann and Methodist hospitals aren't. I wanted a network that would have all 3 of these.

[...]What I would like would be to have out of network coverage if I was to get cancer and wanted to go to MD Anderson out of network.

I'm just shocked that you Texans, even Houstonians, won't have MD Anderson in your networks. If you can't go there, then who can? What will happen to MD Anderson? And Memorial Hermann is pretty well known too, and probably Methodist also. I mean, I don't know much about medical care or insurance but honestly this sounds disastrous.

 

[Katsmeow]

I'm just shocked that you Texans, even Houstonians, won't have MD Anderson in your networks. If you can't go there, then who can? What will happen to MD Anderson? And Memorial Hermann is pretty well known too, and probably Methodist also. This sounds disastrous.

MD Anderson is accepting group plans (like the one most people get from employers) and traditional Medicare and Medicaid. It is basically just plans from the individual market that they aren't on this year. So, for next year, if my husband got cancer he could go to MD Anderson (he is on traditional Medicare) but if it was me I couldn't.

As for non-MD Anderson hospitals the big 3 groups in this area are St. Luke's, Methodist and Memorial Hermann. Some plans have none of them in their network. Several have just one. The only one I found that had all 3 was the Cigna LocalPlus network.
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[W2R]

MD Anderson is accepting group plans (like the one most people get from employers) and traditional Medicare and Medicaid. It is basically just plans from the individual market that they aren't on this year. So, for next year, if my husband got cancer he could go to MD Anderson (he is on traditional Medicare) but if it was me I couldn't.

As for non-MD Anderson hospitals the big 3 groups in this area are St. Luke's, Methodist and Memorial Hermann. Some plans have none of them in their network. Several have just one. The only one I found that had all 3 was the Cigna LocalPlus network.

Wow. Well, at least MD Anderson won't have to just close up shop, thank goodness. That's a relief to know.

Still, this seems like an awful turn of events, and probably foreshadows a worse situation in the future.

 

[Katsmeow]

Wow. Well, at least MD Anderson won't have to just close up shop, thank goodness. That's a relief to know.

Still, this seems like an awful turn of events, and probably foreshadows a worse situation in the future.

I think it is a difficult situation for MD Anderson. Let's say an insurer had chosen to have MD Anderson be on one individual market plan. Everyone on those plans who currently have cancer and are treated by MD Anderson would have chosen that plan. So, the plan would lose a lot of money. Basically, it only makes sense for them to be on a lot of individual market plans or none of them.

And for people in most Texas counties (but not the Houston area) there is one PPO out there so they can at least get MD Anderson as out of network. It is one of life's ironies that that plan isn't offered in Houston so we can't get it. That is the real problem here...there is no PPO in the Houston area.

 

[W2R]

I think it is a difficult situation for MD Anderson. Let's say an insurer had chosen to have MD Anderson be on one individual market plan. Everyone on those plans who currently have cancer and are treated by MD Anderson would have chosen that plan. So, the plan would lose a lot of money. Basically, it only makes sense for them to be on a lot of individual market plans or none of them.

And for people in most Texas counties (but not the Houston area) there is one PPO out there so they can at least get MD Anderson as out of network. It is one of life's ironies that that plan isn't offered in Houston so we can't get it. That is the real problem here...there is no PPO in the Houston area.

It's ironic/outrageous that those Houstonians who are indigent and on Medicaid, could get their cancer treated at MD Anderson and Medicaid would pay for it as an in-network hospital. But those Houstonians who have scrimped and saved and therefore are not qualified for Medicaid, can't get the same benefits because there is no PPO in Houston.

 

[Katsmeow]

It's ironic/outrageous that those Houstonians who are indigent and on Medicaid, could get their cancer treated at MD Anderson and Medicaid would pay for it as an in-network hospital. But those Houstonians who have scrimped and saved and therefore are not qualified for Medicaid, can't get the same benefits because there is no PPO in Houston.

I don't begrudge MD Anderson treating people with traditional Medicaid and Medicare. I think it should do so as a hospital created by the Texas Legislature and part of the UT system. However, I think it should be in network for all Texas plans that are willing to pay it at least the amount it would be reimbursed under Medicaid or Medicare. It should be serving the people of Texas.

It is ironic that if someone in Texas who can't go to MD Anderson due to it being out of network were to move to another state, then that person (now a non-Texas) could change plans and perhaps could get a PPO that would provide out of network coverage to enable that person to go to MD Anderson.

 

[Gotadimple]

I've been pondering this exchange about MD Anderson and HMO v PPO. The reality is that MD Anderson et al are specialty care centers. That's one point.

The second point is that government agencies (Medicare and Medicaid) include MD Anderson because they discount the cost of care significantly. And, coincidentally, pass the losses on that care on to the private side insurers in their negotiations.

That MD Anderson's care is so great, it becomes a magnet for adverse selection, as Katsmeow pointed out. If it were an in-network provider, the plans would lose their shirts providing coverage to very sick populations. By keeping it as a specialty center, they can negotiate treatment on a case-by-case basis.

That brings me to the third point. With MD Anderson as part of a PPO, one can select to have their care with them without referral. But with an HMO, one must be referred to them. Just because they are not in-network for an HMO, does not mean that the plan wouldn't refer you out to them, if your case warranted their special services.

The same was true last year in Washington state, but, the hospital was Seattle Children's Hospital. They weren't in a majority of the Obamacare offerings. Plans couldn't afford to provide coverage if patients could self-select for care. But, if necessary and if they were the only place for the specialized care, plans would refer to Childrens.

Regarding the dearth of hospitals and labs in the Houston area: contact your state insurance commissioner, and your state legislators. I'm not familiar with Texas insurance regulation, but these plans must submit their network to the insurance commissioner, and one of the things they check for in addition to rates, is the breadth of the network. Specifically are there enough hospitals to serve the population in the region where the plan operates.

Just a thought.

Rita

 

[Alan]

It is ironic that if someone in Texas who can't go to MD Anderson due to it being out of network were to move to another state, then that person (now a non-Texas) could change plans and perhaps could get a PPO that would provide out of network coverage to enable that person to go to MD Anderson.

As it happens my retiree insurance is a PPO with BCBS of Louisiana and since our costs increased so much for 2016 I had a look at plans I could buy and was also shocked to see how very narrow the networks were, and that we would have to switch doctors, hospitals etc. I hadn't noticed that MD Anderson was missing from the networks, only because cancer is not yet an issue for us.

 

[samclem]

That MD Anderson's care is so great, it becomes a magnet for adverse selection, as Katsmeow pointed out. If it were an in-network provider, the plans would lose their shirts providing coverage to very sick populations. By keeping it as a specialty center, they can negotiate treatment on a case-by-case basis.

That brings me to the third point. With MD Anderson as part of a PPO, one can select to have their care with them without referral. But with an HMO, one must be referred to them. Just because they are not in-network for an HMO, does not mean that the plan wouldn't refer you out to them, if your case warranted their special services.

Can you provide some insight into how that works on a practical basis? If I've got cancer and my HMO's in-network provider is treating me with the standard chemo protocol for it (which hasn't changed in 20 years, with poor QOL and poor outcomes) and MD Anderson has more options, and they are more attractive? Or MD Anderson has several research trials going on that offer some promise, etc. Who ultimately decides if I'm getting appropriate care?

 

[Katsmeow]

Can you provide some insight into how that works on a practical basis? If I've got cancer and my HMO's in-network provider is treating me with the standard chemo protocol for it (which hasn't changed in 20 years, with poor QOL and poor outcomes) and MD Anderson has more options, and they are more attractive? Or MD Anderson has several research trials going on that offer some promise, etc. Who ultimately decides if I'm getting appropriate care?

That is what worries me. For many cancers, I'm sure that the treatment you would get from MD Anderson would be a treatment that you could get from X network provider. In that case, I think the insurer could reasonably say there was no reason to go anywhere else.

But, in many cases, MD Anderson may have trials going on that no one else really has. I'm personally doubtful that you could really get approval to go there. Maybe it is easier than it seems...but I wonder.

Regarding the dearth of hospitals and labs in the Houston area: contact your state insurance commissioner, and your state legislators. I'm not familiar with Texas insurance regulation, but these plans must submit their network to the insurance commissioner, and one of the things they check for in addition to rates, is the breadth of the network. Specifically are there enough hospitals to serve the population in the region where the plan operates.

Leaving aside the MD Anderson issue, what I see on a lot of the individual market plans (both on and off exchange) is that they have a lot of hospitals on them in terms of numbers, but mostly they are not the "name" hospitals that are well known for quality care. They aren't the hospitals that I think most people in the area would ever think of when asked about hospitals. So, technically there are "enough" hospitals. It is just that they aren't really the hospitals that people want to go to.

Another issue is the lack of out of network coverage. I know that if I am out and about and have an accident and am taken to an ER (without my being able to say which one) that one of these HMOs/EPOs will cover the claim and pay what they would have paid in network. But, I'm still exposed to balanced billing and if I wake up 3 days later maybe the insurer will say I should have been transferred to an in network hospital after the first day and I'll have to fight for it to be covered.

If the hospital network is really broad (Cigna LocalPlus has a fair broad hospital network) then I don't have to worry about that as much as the odds go up that I am more likely to be sent to an in network hospital. The narrowed the network the more likely that I'll be sent to a hospital that is out of network.

 

[W2R]

That is what worries me. For many cancers, I'm sure that the treatment you would get from MD Anderson would be a treatment that you could get from X network provider. In that case, I think the insurer could reasonably say there was no reason to go anywhere else.

But, in many cases, MD Anderson may have trials going on that no one else really has. I'm personally doubtful that you could really get approval to go there.

Maybe I am naive, but I don't think I have ever heard of insurance paying for an experimental treatment.

When I was working, a co-worker found out she had an unusual type of cancer. She spent several days at MD Anderson in Houston getting tests and a thorough work-up and diagnosis by a fine medical team there. Her main doctor at MD Anderson then devised a treatment schedule. She came back to New Orleans, and got her treatments here. Her doctor communicated regularly with the doctor at MD Anderson via videoconferencing so that both could see how she was responding to treatment and discuss how well it was or wasn't working out. Then she flew back occasionally for some in person checkups.

Even though her treatments could be done here, she still benefited from access to MD Anderson, and needed to be able to pay MD Anderson and the doctor and labs there.

 

[audreyh1]

One thing that surprised DH and me in the offerings for 2014 was how aggressively priced the BCBS PPO pricing seemed.

DH was on a BCBS PPO individual insurance plan already. It had a higher deductible and higher OOP than was being offered with the new plans. It was not HSA compatible. His monthly cost would have been $478, but it was $351 with the new offering for the same network, lower deductibles and HSA compatibility. It was a no brainer for him, but of course he lost his grandfathered status.

At the time the Humana PPO quotes were $115 to $130 more per month - and would have been very close to what BCBS told him his new grandfathered PPO rate was.

Now I really wonder - well, we've wondered all along. Was part of their strategy to entice people to switch from grandfathered PPOs to the new plans, knowing they would drop the PPO option for the individual market at some point in the future?

Or were they just aggressive with pricing to get more folks to sign up with them, and then blindsided by the medical costs incurred?

 

[Katsmeow]

Maybe I am naive, but I don't think I have ever heard of insurance paying for an experimental treatment.

I'm not really talking about something experimental, just something that you can't get everywhere. Here is an article talking about an example of this in connection with the whole MD Anderson thing:

Loss of insurance plans could devastate cancer patients - Houston Chronicle

Where the line is drawn as for what is not covered experimental treatment versus something that is covered but just not available everywhere is unclear to me. From the article:

The 59-year-old self-employed certified public accountant from The Woodlands area has a rare bone marrow disease that two years ago took a deadly turn, progressing to a form of leukemia so dire a doctor told her she should begin end-of-life care. But a Hail Mary plan put her in an experimental trial at Houston's medical crown jewel, the University of Texas M.D. Anderson Cancer Center. Against improbable odds, the treatment worked, dialing back her cancer from Grade 3 to Grade 1.



"Every day is a new miracle," she said, her honeyed drawl filled with awe.
Then came the Sept. 25 letter from her insurance carrier, Blue Cross Blue Shield of Texas, which said her Preferred Provider Organization (PPO) individual plan - one she picked specifically because, although expensive, it covered M.D. Anderson - was being dropped effective Dec. 31.


As many as 2,000 other patients at M.D. Anderson also may be cut off from coverage with the loss of such PPO plans either through the Affordable Care Act's federal exchange or, in the Gardeniers' case, bought privately in the individual market, said Dr. Lewis E. Foxhall, vice president of health policy at the cancer center.

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[Texas Proud]

Just curious how people are finding out what docs and hospitals are on a plan....

I have tried looking on BCBSTX and it takes a LOT of clicking etc. and I am not sure that I am getting the info I need...

 

[audreyh1]

Just curious how people are finding out what docs and hospitals are on a plan....

I have tried looking on BCBSTX and it takes a LOT of clicking etc. and I am not sure that I am getting the info I need...

Yes, it takes a bit of clicking and searching. One of the links I posted above gives hospital information statewide - links to specific regions for hospitals. The attached PDF shows the result of a different search.

But today I dropped by my main (specialist) doctor's office to ask a few questions and the office staff flat out said he is not in any HMO network. [-]So why is he showing up online as a provider in the Blue Advantage HMO network?!?! This makes me rather leery.[/-]

Doctor's office called me back today to tell me that they talked to the biller, and yes, the doctor is in the Blue Advantage network. I'm glad they double checked - and glad they let me know. They have been getting a lot of calls from patients that will no longer be in the BCBS PPO.

Also - one of the concerns I had was the high lab fees billed, which are then cut down to about 10% by the insurance company. Well, it turns out the doctor's office works with patients. They have their own in-house labs that costs a self-pay customer about the same as my insurance adjusted amount, but nothing is submitted to an insurance company in this case. If you have insurance they send it to one of the labs so that it gets billed to the insurance company by the lab. And they will send panels to a specific lab upon request, and have for many customers.

So two more immediate concerns are addressed. There is still the bigger picture of broader network available and better out-of-network coverage of a PPO versus the new BCBS Advantage + offering.

 

[audreyh1]

More indications that it's a good idea to call the provider:

I decided to check with my provider for mammograms, because I noticed that the hospital had billed my mammogram in 2015.

Well, that provider might still be in network, because the hospital itself is in network for at least a couple of things. Talking to "outpatient registration" they seemed to think that if the hospital is in network, their breast cancer center will be in network.

I'm not completely convinced with the BCBS Advantage Plan, as the hospital doesn't appear in the Advantage search and the radiologist appears on a different BCBS network, even though I got no radiologist fee this year for the PPO. But it is still possible.

It's hard to search as a prospective client. If I log in and search with my current insurance I get a very detailed list of area providers for a given service along with billing estimates! Not what the insurance company will cover, but it gives you an idea of the prices, and you can actually comparison shop.

This is a preventative procedure 100% covered under ACA, but the comparison shop is still useful information.