Humana Off-Exchange PPO for most of Texas

[Fermion]

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?

 

[MichaelB]

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.

 

[TheKrell]

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.

 

[ziggy29]

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.

 

[audreyh1]

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.

 

[MBSC]

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/in...ion;Texas;Cigna Health Flex 6400 - Houston TX

Available in:

Houston: Austin, Brazoria*, Brazos, Chambers*, Fort Bend, Galveston, Grimes, Harris, Liberty, Montgomery, San Jacinto*, Walker*, Waller, Washington counties.
*Partial counties

 

[rodi]

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.

 

[Katsmeow]

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/in...ion;Texas;Cigna Health Flex 6400 - Houston TX

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).

 

[MBSC]

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.

 

[audreyh1]

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.

 

[Katsmeow]

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.

 

[GTFan]

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 ..

 

[audreyh1]

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.

 

[audreyh1]

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.

 

[Sue J]

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.

 

[Katsmeow]

That is interesting. I will probably have to change where I get my mammogram done next year. For 20 years I've gotten my mammograms at Memorial Hermann hospitals. Memorial Hermann will still be in network with the plan I think I will have next year.

But, they get their mammograms read by MD Anderson. And, that is out of network.

For my 2014 mammogram, I got this bill from MD Anderson for a doctor. It said pending insurance and nothing was do but I wondered why I was getting a bill from MD Anderson. I called and found out why. I also told them there was no pending insurance claim from them. They submitted it and it was denied as being too late. I am still getting monthly pending insurance statements on that. I'll be irritated if they try to bill me for it since it is their fault they didn't submit it timely.

Anyway, for 2016, I wouldn't be able to go to Memorial Hermann for my mammograms even though it is in network because MD Anderson is not in network. I'll have to try to find an in network place that reads its own mammograms.

 

[HtownRose]

^ yeah went through the same thing this year. The rollout of switching the reading of the mammograms to MD Anderson was very poorly done. Once my exam was scheduled, Memorial Hermann sent me an email explaining MD Anderson's involvement & gave a phone # to call if I had questions. It was the wrong phone # - went to the collections department. About that time they bought a lot of radio ads touting the connection. Then after my exam I got bills for months from MD Anderson (luckily none of which I had to pay). Should've left well enough alone IMO.

 

[meierlde]

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.

Essentially the Humana PPO is offered outside of the Houston and Austin Tx metro and between them.

Just like if you live in a more remote town you need to check that your single choice local hospital is in network. (Or for even smaller towns find out where they send folks and check that as well). Since unless you need the services of a level 1 trauma center and helicopter transport you will go to the local hospital.

 

[ziggy29]

Essentially the Humana PPO is offered outside of the Houston and Austin Tx metro and between them.

Just like if you live in a more remote town you need to check that your single choice local hospital is in network. (Or for even smaller towns find out where they send folks and check that as well). Since unless you need the services of a level 1 trauma center and helicopter transport you will go to the local hospital.

True, we rural folks are used to dealing with that. We basically have a three-tiered system here (and some other small towns in the boonies: The local hospital(s) for urgent care and relatively minor emergencies, or at least those that aren't obviously life-threatening; a regional hospital for more significant things (with a level 3 trauma center), and for more serious and/or specialized emergency needs, a trip to San Antonio, Austin or Houston is generally in order (including the level 1 trauma centers). Pretty much all of the hospitals are in our PPO network options (and *most* are in the BCBSTX HMOs offered on the Marketplace), though some have ER doctors, anesthesiologists or radiologists out of the network (though paid at in-network rates for emergencies apart from balance billing potential).

When we lived in the Hill Country we had a small, local hospital with an ER that wasn't really all that highly regarded; we lived about six blocks away from it. Very often we'd hear helicopters in town. Almost always, that was another patient going to the local ER, being stabilized as best as possible and then transported to (usually) Austin or San Antonio for further treatment.

 

[audreyh1]

I guess we're going to go ahead and sign up for this Humana PPO, in spite of the stiff price tag. I'm really loathe to switch insurance companies, but I feel as if I have no choice.

Who knows what will be offered next year - we'll be taking it one year at a time!

 

[REWahoo]

Who knows what will be offered next year - we'll be taking it one year at a time!

Your new sig line: "Health Insurance After FIRE - we have to redesign it every dang year!"

 

[audreyh1]

Your new sig line: "Health Insurance After FIRE - we have to redesign it every dang year!"

You got that right, buddy! Until Medicare!

 

[MBSC]

The Humana PPO is now available in the Houston and Austin areas through brokers/agents. It is scheduled to appear on the Humana website December 18th.

Hello agents,

Big news! If you have clients that want a true, broad network, national PPO plan, we’ve got one back in Austin and Houston now!

The Humana ChoiceCare PPO Bronze 6450 HSA style plan that has been available in most counties in Texas is now going to be available in the 26 counties where the NPOS network was recently discontinued. This includes AUSTIN and HOUSTON!

Starting immediately, we will have the ability to quote plans in Texas for 26 counties (Austin, Bastrop, Bosque, Brazoria, Burnet, Caldwell, Chambers, Colorado, Falls, Fayette, Ft. Bend, Galveston, Grimes, Hays, Hamilton, Harris, Lee, Liberty, Limestone, Milam, Montgomery, Travis, Waller, Washington, Wharton, Williamson) that were previously unavailable for 2016. Since that time, a new Humana plan, TX Bronze 6450 ChoiceCare PPO, has been added for 2016 coverage and is now available to clients.

Thank you!
Kristen Rohde
Humana Accounts

Humana is now selling a PPO in Harris County and any other county in which they previously had not been. It appears to be a very comprehensive plan with MDA IN NETWORK. The network is Choice Care. The plan will also be sold in every county in Texas. Starting immediately, they will have the ability to quote plans in Texas for 26 counties that were previously unavailable for 2016.

This plan will be available on their quoting and enrollment tools on December 18th. If you need to obtain a quote prior to the 18th, please contact them at 1-800-833-2572 to obtain a quote for a January 1st effective date. If you are looking to obtain coverage for a January 1st effective date, you will need to enroll once the plans are active in the quoting and enrollment tools, and contact Humana to request their January effective date.

Reference: Breaking News Houston - We Have a Humana PPO - J-Vibe

This week, Humana announced they will offer their PPO plan to the missing counties for 2016. Only the Bronze plan will be available as a PPO to go along with Humana’s HMO offerings. If you purchase this plan you’re paying a premium for the network, but sometimes the flexibility is worth it and this will be the only plan that has MD Anderson and others in network.

This plan won’t show on the Humana site until December 18th. Humana will not be able to confirm your plan until after December 18th, which is after the December 15th deadline for most other plans. However, if you live in one of the counties where this plan was not being offered, you will still be able to get a January 1st 2016 effective date if you enroll through (an agent or Humana 800 number), it just may not be confirmed until after the 18th.

If you sign up before Dec 15th, we can get you a Jan 1st start date and you can cancel your other plan before you even use it. If you miss the Dec 15th deadline, open enrollment goes through Jan 31st. Jan 15th is the deadline for Feb 1st start dates and Jan 31st is the deadline for Mar 1st start dates. You could use your current plan for a month or two, and then use the Humana PPO effective February or March 1st 2016.

Reference: Take Command Health - Humana PPO now available in Houston Metro-Area!

 

[audreyh1]

Wow! That's an amazing change!

 

[BarbWire]

Wow.

So this is off-exchange only, right?

To see plan details -- since it isn't available in Austin yet -- is the best bet to put in the zipcode of another county? Would the plan details be the same?

And I suppose the only way to get a rate quoted is through a broker or the Humana 800 number.

I was going to pull the trigger on the limited Scott and White PPO tomorrow, but now I will have to rethink.

Wow.