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Old 07-25-2015, 09:25 AM   #21
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I think in most states, insurance regulation is more for show than anything else. Insurance companies pretty much get their way unless there's outright fraud involved.
Not where I live... the regulators only granted part of the increase the insurer had applied for last year. But that might be why we only have two choices.
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Old 07-25-2015, 12:07 PM   #22
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A couple of thoughts:

* You never want to be the ONLY company offering a product in a competitive marketplace. The only company offering a PPO plan gets adverse selection.
* Competitive marketplace: insurers try to make contracts with many providers, all who have multiple contracts with many insurers. Negotiations are not often "equal."
* Adverse selection: those who are sicker and know a drug or access to a specialist will be limited will choose a PPO plan over an HMO.
* BCBSTX ability to negotiate with providers contributes to the cost of a plan. If the majority of their members are on HMO's they can negotiate better reimbursement rates for all of their members (thereby keeping rates lower).
* Ultimately, an HMO can become more expensive than a PPO if the plan design is too "rich," that is, offers wider benefits. SO - play the market, look for the best deal you can get for the money, and where your favorite provider feels comfortable.

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Old 07-25-2015, 01:12 PM   #23
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My suspicion is that the recent announcements of the various health insurer mergers contributed in part to this.
You may be right. Neither of the two announced mergers will be approved in time to affect the 2016 offerings or insurance year, so there must be other drivers.

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HMOs? Perhaps better able to directly control their costs and lower their risk.
This is the strange part. The announcement linked by Audrey1 reported a $400M loss. If all the current PPO users took the BCBS HMO option, the premiums would decline but health care need would presumably stay the same. The potential loss would be greater unless BCBS managed a significant reduction in actual healthcare services provided.

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.
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Old 07-25-2015, 01:16 PM   #24
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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. Biggest issue with that is switching doctors again.
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Old 07-25-2015, 02:48 PM   #25
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Neither of the two announced mergers will be approved in time to affect the 2016 offerings or insurance year, so there must be other drivers.
+1 But there have been three: Anthem/Cigna, Aetna/Humana, and Centene/HealthNet.

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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.
BCBS South Carolina does not currently offer a PPO product on the ACA exchange.
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Old 07-25-2015, 03:39 PM   #26
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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.
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Old 07-26-2015, 10:32 AM   #27
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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.
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Old 07-26-2015, 12:53 PM   #28
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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.
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Old 07-26-2015, 03:40 PM   #29
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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.
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Old 07-26-2015, 04:02 PM   #30
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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
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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.
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Old 07-26-2015, 04:30 PM   #31
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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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Old 09-04-2015, 06:30 AM   #32
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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.
Quote:
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
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Old 11-16-2015, 10:45 AM   #33
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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.
Attached Files
File Type: pdf RGV Lab Techs - Blue Cross Blue Shield of Texas.pdf (65.6 KB, 4 views)
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Old 11-16-2015, 11:44 AM   #34
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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.
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Old 11-16-2015, 12:17 PM   #35
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[...]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.
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Old 11-16-2015, 12:25 PM   #36
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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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Old 11-16-2015, 12:29 PM   #37
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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.
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Old 11-16-2015, 12:33 PM   #38
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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.
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Old 11-16-2015, 12:40 PM   #39
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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.
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Old 11-16-2015, 12:59 PM   #40
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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.
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