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Old 11-06-2015, 07:13 PM   #21
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Originally Posted by TheKrell View Post
The comments in the post above (audreyh1) are essentially correct. Apparently, Blue Cross "wanted" to continue with individual PPOs in Texas.

But under Obamacare law, if they raised the rates on their individual Texas PPOs they would have been FORCED to raise rates on other plans as well to comply with the law.

They are allowed to continue with employer-sponsored PPOs and some older individual PPO plans that are grandfathered only because these have exemptions in Obamacare law.
Well - that's their story anyway.
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Old 11-06-2015, 07:31 PM   #22
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The major insurers have introduced separate policy offerings that are marketed directly to the consumer or through brokers. The only way to see them is directly on their website. The policies are ACA compliant, but are not eligible for premium assistance. Hopefully you can find one among them.
Our situation is a little different. The kids and I have been insured through retiree insurance from the Megacorp DH retired from (he is on medicare).

They have contracted with a private exchange to offer us plans and they Megacorp gives us a set amount of money that we can apply to any insurance. As far as I can tell, with one exception, the plans offered are all the ACA compliant plans for the individual market. The have a listing of marketplace (exchange) plans and then a list of non-marketplace plans. Those are basically the plans you can buy directly from insurers. We can go direct to any insurer if we want and would still get the subsidy from Megacorp.

The big issue that is causing lots of consternation, of course, is the disappearance of individual PPOs in Texas. Megacorp was taken by surprise on this.

So, we were told previously that we would be able to get similar coverage through the exchance to the group PPO we had before but it would be cheaper.

The problems in Texas are not just the disappearance of the PPOs, it is the very narrow networks on the plans on the individual markets -- whether on or off exchange. We live near Houston and there are entire plans that don't any of the really good hospitals in the area. The plans are full of hospitals I've never heard of.

The best non-PPO option is the Cigna LocalPlus Network EPO. It was a really good network of hospitals with all of the major hospitals with one big, glaring exception. The exception is M.D. Anderson. A lot of people are really upset that you can't get any plan with M.D. Anderson in it. My husband is on traditional Medicare and he could go to M.D. Anderson if he got cancer. I would not be able to these non-PPO plans as it is not in network on any and there is literally no out of network coverage at all. This is a real problem for people who are getting treatment from M.D. Anderson that literally can't be gotten anywhere else. Here is an article that discusses the problem:

Loss of insurance plans could devastate cancer patients - Houston Chronicle

In our case, at this private exchange, we do have one PPO option which is based on the LocalPlus network. It doesn't show up on Cigna's web page so I guess it is some sort of group PPO that has been offered to us so we have at least one PPO.

But it is really limited in its out of network option. The deductible for a family is $25,000 and the out of pocket maximum is $50,000! But, it would theoretically allow you to go to M.D. Anderson out of network if it was a situation where they had the best treatment for something (of course, you would still be exposed to balance billing).

I don't like the idea of HMOs or EPOs because of the lack of out of network coverage. And, this one PPO is not so great. And, even the LocalPlus Network is much narrower than our current network. But, it is the best of the ones on offer.
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Old 11-07-2015, 04:27 AM   #23
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The best non-PPO option is the Cigna LocalPlus Network EPO. It was a really good network of hospitals with all of the major hospitals with one big, glaring exception. The exception is M.D. Anderson. A lot of people are really upset that you can't get any plan with M.D. Anderson in it. My husband is on traditional Medicare and he could go to M.D. Anderson if he got cancer.
+1
For anyone interested, the website below lists the Plan/Network combinations M.D. Anderson Cancer Center does accept. However, a lot of them, like the 'Humana National POS Open Access', are group/employer networks not available on individual plans.

Insurance Plans & Billing Information | MD Anderson Cancer Center
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Old 11-07-2015, 09:46 AM   #24
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For anyone interested, the website below lists the Plan/Network combinations M.D. Anderson Cancer Center does accept. However, a lot of them, like the 'Humana National POS Open Access', are group/employer networks not available on individual plans.

Insurance Plans & Billing Information | MD Anderson Cancer Center
The cruel irony is that the Humana PPO is accepted by MD Anderson, but you can't even get it in the Houston area where the hospital is located.

It appears the individual PPO uses in the "Choice Care PPO" group which MD Anderson shows as accepting in this link.

I wonder if we may see people try to fake their home address and open a PO box where the PPO is sold.
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Old 11-09-2015, 09:13 AM   #25
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This Humana PPO option is available to us. But it represents a large monthly price increase - like 55%!. When I compared three company's PPO options for 2014, Humana was the most expensive.

Yet - the 2016 price is just very slightly higher than what I paid in 2013 for a PPO when I was in the Texas Health Risk Pool. We've had two years of much lower insurance premiums. Now it looks like we'll be going back to what we used to pay – if we go this route.

I have to look carefully at what coverage I can still get under the new BCBS plans. Most of the doctors are still available in network. I don't have a problem with referrals in general, as long as I have unrestricted access to my gyn. But I worry about not having any coverage out of network.

Burning question for us - do we pay up for a PPO knowing that we'll have some level of coverage and a wide network plus out of network coverage if necessary, or do we hope we can manage within the more limited network with no out-of-network coverage and hope not have any nasty surprises.

That's were the whole question of "insurance" comes in. You don't know what might happen. All the cases of cancer that I know of, for example, could not have waited to start treatment. If some options are not available to you right off the bat, what can you do? I am very loath to take those kinds of risks.
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Old 11-09-2015, 09:29 AM   #26
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That's were the whole question of "insurance" comes in. You don't know what might happen. All the cases of cancer that I know of, for example, could not have waited to start treatment. If some options are not available to you right off the bat, what can you do? I am very loath to take those kinds of risks.
Would you be in a position to somewhat *game* the system in the unfortunate extreme case where your current health plan did not cover certain cancer treatments but another one did? IE, a quick move to a different area triggering open enrollment?
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Old 11-09-2015, 09:34 AM   #27
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Burning question for us - do we pay up for a PPO knowing that we'll have some level of coverage and a wide network plus out of network coverage if necessary, or do we hope we can manage within the more limited network with no out-of-network coverage and hope not have any nasty surprises.

That's were the whole question of "insurance" comes in. You don't know what might happen. All the cases of cancer that I know of, for example, could not have waited to start treatment. If some options are not available to you right off the bat, what can you do? I am very loath to take those kinds of risks.
This is a tough call. Going out of network, even for minor needs, can be outrageously expensive. When I did that math 2 years ago I looked at the total cost for both of us for the entire period until we were eligible for Medicare and decided to pay it. We spend a lot of time on the road or away from home, and it would only take one out of network incident to offset the entire cost difference. Past experience also confirms that when there is a need for serious and immediate treatment, network and financial aspects of care become secondary.

That said, easier for me to write this now because we have a decent second option.
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Old 11-10-2015, 10:52 PM   #28
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We signed up for the Texas Humana PPO.

About 25 years ago, I had a medical issue where I saw about 6 different doctors over about 5 months, and had all the various, expensive tests done. None could figure out my problem. I got a recommendation for another doctor, (number 7). His looks and persona was right out of Hollywood's central casting. He talked to me, IN HIS OFFICE, and spent a good 10 minutes having me describe my problems.

We then went into the exam room, where he takes one finger and pokes around and asked me to cough. He said, "You have a hernia, let me operate, and I can make you feel like $1 million". No tests, no x-rays, no MRI, no sonogram, JUST that gray stuff between the doctor's ears."

Four days later (the government was not too involved in healthcare then), he did the surgery and I recovered. Problem completely solved!

So, after that experience, I always want to have my options open on what doctors I might see. The Texas Humana PPO has a large network that looks good, but I want my options. I wouldn't buy any HMO for $23.80.
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Old 11-11-2015, 06:54 AM   #29
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So, after that experience, I always want to have my options open on what doctors I might see. The Texas Humana PPO has a large network that looks good, but I want my options. I wouldn't buy any HMO for $23.80.
When I was in California I was a member of the Kaiser HMO. And I actually liked that for the most part, long wait times for routine appointments notwithstanding. I liked the simplicity of the model. You KNEW the network -- basically any Kaiser facility. You knew if a Kaiser doctor said something was medically necessary, it was covered. DW had a maxillofacial surgery in 2000 that many insurers wouldn't touch, and the Kaiser doctor said it was medically necessary, so it was covered for a copayment of $10.

It had its limitations, of course, but I did love that aspect of it (especially since we didn't travel much and we had plenty of Kaiser facilities nearby). Today's HMOs (and PPOs for that matter) are a hassle in terms of making you sick with worry about whether or not you really are "in network" with a "covered procedure" lest you get a massive bill a couple months later.

I haven't had Kaiser since we moved out of CA in 2003, and I don't know how much of that has changed. But back then, limitations aside, it made things simple and the "in network/out of network" angst was all but absent.

The Humana PPO seems to have a pretty good network and if I were still using an ACA policy and didn't qualify for a significant subsidy I'd probably go that way as well. Still not sure why it isn't available in the Houston or Austin areas, though.
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Old 11-11-2015, 07:48 AM   #30
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Would you be in a position to somewhat *game* the system in the unfortunate extreme case where your current health plan did not cover certain cancer treatments but another one did? IE, a quick move to a different area triggering open enrollment?
Not really.
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Old 11-12-2015, 07:20 AM   #31
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The Humana PPO seems to have a pretty good network and if I were still using an ACA policy and didn't qualify for a significant subsidy I'd probably go that way as well. Still not sure why it isn't available in the Houston or Austin areas, though.
The Baylor, Scott & White off-exchange PPOs are available in Austin.

https://swhp.inshealth.com/?allid=Sco27958

The Cigna Health Flex 6400 PPO has just been released for Houston. It still uses the LocalPlus Network making MD Anderson out-of-network, but the plan offers 50% co-insurance after the OON deductible is met. It is not HSA compatible.

www.cigna.com/individuals-families/2016-plans/sob/texas-houston/health-flex-6400

http://www.cigna.com/assets/docs/ind...20Houston%20TX

Available in:
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Houston: Austin, Brazoria*, Brazos, Chambers*, Fort Bend, Galveston, Grimes, Harris, Liberty, Montgomery, San Jacinto*, Walker*, Waller, Washington counties.
*Partial counties
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Old 11-12-2015, 08:01 AM   #32
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When I was in California I was a member of the Kaiser HMO. And I actually liked that for the most part, long wait times for routine appointments notwithstanding. I liked the simplicity of the model. You KNEW the network -- basically any Kaiser facility. You knew if a Kaiser doctor said something was medically necessary, it was covered. DW had a maxillofacial surgery in 2000 that many insurers wouldn't touch, and the Kaiser doctor said it was medically necessary, so it was covered for a copayment of $10.

It had its limitations, of course, but I did love that aspect of it (especially since we didn't travel much and we had plenty of Kaiser facilities nearby). Today's HMOs (and PPOs for that matter) are a hassle in terms of making you sick with worry about whether or not you really are "in network" with a "covered procedure" lest you get a massive bill a couple months later.

I haven't had Kaiser since we moved out of CA in 2003, and I don't know how much of that has changed. But back then, limitations aside, it made things simple and the "in network/out of network" angst was all but absent.

The Humana PPO seems to have a pretty good network and if I were still using an ACA policy and didn't qualify for a significant subsidy I'd probably go that way as well. Still not sure why it isn't available in the Houston or Austin areas, though.
This is one of the things I like about Kaiser - with it's closed network - there is NO chance of getting referred to a doctor that's not covered in the plan.

They even contract with specialists that aren't Kaiser employees. My husband saw a cardiologist for a while at Scripps (a competing hospital system) but it was paid by Kaiser. If a Kaiser doc refers you, it's covered. Period.
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Old 11-13-2015, 12:45 AM   #33
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The Cigna Health Flex 6400 PPO has just been released for Houston. It still uses the LocalPlus Network making MD Anderson out-of-network, but the plan offers 50% co-insurance after the OON deductible is met. It is not HSA compatible.

www.cigna.com/individuals-families/2016-plans/sob/texas-houston/health-flex-6400

http://www.cigna.com/assets/docs/ind...20Houston%20TX
Do you see anywhere on the Cigna web page where it talks about that PPO actually being available? I now you have links to the documents, but I was told on Wednesday that Cigna is not offering the PPO.

We are getting our insurance through a private exchange since DH's former employer is subsidizing the premiums (DH is a retiree).

Last week the Cigna PPO was on the private exchange's web site and I was very interested in it. Then, it vanished from the web site.

I spoke to a benefits adviser on Wednesday and he said that they had pulled the data from Cigna but that the PPO is not actually available. He said that originally Cigna intended to offer it and has decided not to do so.

When I go to the Cigna web page and search for plans in Texas and in my county (one of the ones where is supposedly available) the PPO does not come in the listings.

Do you have a link to a page that says that it is actually available? (I recognize that you have a link to the PDFs about the plan, but that doesn't mean that the plan is actually available to purchase).
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Old 11-13-2015, 07:12 AM   #34
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If Cigna made a last minute decision to pull the PPO, then my source would not yet have the revised info. I will monitor to see if it vanishes from their database also. Sorry.
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Old 11-16-2015, 08:46 PM   #35
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We've been combing through the details in switching to the Humana PPO from the BCBS PPO. The coverage is not as complete as the BCBS PPO, but generally better than the BCBS Advantage + HMO that BCBS will switch us to:
  • All my doctors are still in network except my dermatologist whom I rarely see.
  • The center where I get my annual mammogram is no longer in network, but there are tons of imaging centers here that are in network.
  • The labs are all still in network.
  • The hospitals - coverage is somewhat narrower than before (BCBS PPO). The closest hospital - the anesthesiology group is no longer in network. Only 5% of the emergency physicians billed out of network in 2014, and other hospital-affiliated physicians are in network. There are other hospitals with more in-network coverage, including a good emergency hospital not far. But most area hospitals have no anesthesiologists in network, including the “flagship” doctor-owned hospital which is still in network, but not the anesthesiologist group.
Monthly cost per person will go up ~$200 - ouch!

Deductible is $6450, max OOP of $6450.

Out-of-network coverage has 25% coinsurance after you meet a $12,900 deductible, with max OOP of $25,800. This, of course, is just for the amount Humana is considers reasonable to pay, and you would still be exposed to balance billing.
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Old 11-16-2015, 10:24 PM   #36
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That seems not bad. Well, not bad compared to the alternative that I have. At least there is an out of network OOP max. On the Cigna PPO that it was apparently going to offer in Houston (but didn't) the out of network OOP was $50k with the out of network deductible $25k.
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Old 11-17-2015, 10:38 AM   #37
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This is the real problem with exchange plans - ever shrinking networks and elimination of PPOs coupled with excessively high out of network costs.

And I've seen plenty of articles saying regular folks can't afford the in-network deductibles on top of the premiums now.

Does not bode well for future of ACA ..
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Old 11-17-2015, 10:58 AM   #38
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Well - it turns out that my annual mammogram provider is probably still in network with Humana PPO since the hospital bills for the mammogram and their radiologist is also in network. Less clear with BCBS Advantage since the hospital does not show up in their general hospital grid, but is still listed for urgent/acute care and rehabilitation.

It pays to call the provider to find out what insurance they accept. Or find the provider's insurer list online - something I did for several labs, and someone else posted for MD Anderson.

The search functions aren't that complete. Because if you search on, for example, imaging - you get all the stand alone centers. It doesn't include the hospitals or other facilities where imaging is in network.
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Old 11-17-2015, 11:27 AM   #39
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Humana doesn't spell it out in the docs specific to the Humana Bronze 6450 Choicecare PPO, but as far as I can tell it is a nationwide network with providers across the country.

I don't know if I would need to see a provider when out of state except for emergency, which is covered. Even if we travel a lot. Our trips are usually less than a month.

They do specify that "Non-emergency care when traveling outside the U.S." is not covered.
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Old 11-17-2015, 11:56 AM   #40
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Here's my experience with mammograms this year. All my previous mammograms were done at a center that is out of network for my current plan. When I called my in network center to schedule for this year they asked me to get my films from my previous mammogram center. I called the previous one and they put my past films and reports on a CD and I picked it up and took it with me to my new mammogram center. It seems they get a lot of requests for this. It was very easy and no cost to me.
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