Mayo Clinic Coverage When in Texas

[Echard]

Our family is receiving on-going treatment at Mayo Clinic in Minnesota for some health issues. We live in Texas.

We currently rely on a corporate PPO plan so coverage isn’t an issue. However we will transition off next year and still have 5 years to age 65/Medicare.

The Texas ACA only has HMO’s, EPO’s, and POS’s, no PPO’s. It doesn’t seem that any of the plans cover service outside the local area. It’s difficult to tell. I’m not even sure if other cities like Dallas are covered.

Has anyone figured out how to get care outside your local area, and specifically another state/facility like Mayo?

 

[Aerides]

It really depends on your provider/insurer. In FL, with BCBS, I do have some out-of-network flexibility on the ACA, but that's a PPO.

 

[Rianne]

I also have an ongoing health relationship with Mayo in Rochester. You are already in the system and have had treatment. I would be on the phone with them exploring options in your situation. It seems it's difficult to get into Mayo, for the first visit. I don't know how they handle patients who have already been treated and have an ongoing relationship. I was told by my Dr there, concerned about a continuing treatment over time. She said you're in. Don't worry.

 

[Echard]

I learned something today from talking with a health insurance broker. Apparently ton of ppo plans have been removed from the marketplace because of a new ruling by the Biden administration. They are forcing these PPO plans to the ACA marketplace.

Now that would potentially solve the problem of PPO availability, but unfortunately Trump will blow it up.

 

[MichaelB]

I learned something today from talking with a health insurance broker. Apparently ton of ppo plans have been removed from the marketplace because of a new ruling by the Biden administration. They are forcing these PPO plans to the ACA marketplace.

Now that would potentially solve the problem of PPO availability, but unfortunately Trump will blow it up.

Texas residents have been complaining for years about the lack of PPO options. It’s not anything new or recent.

Insurance is not federally regulated, it is regulated by each state. The lack of ACA PPO plans in Texas is a local / state issue and the federal gov’t has no say in the matter.

It would also be helpful to leave the partisan implications out of the discussion.

 

[respond2u]

Our family is receiving on-going treatment at Mayo Clinic in Minnesota for some health issues. We live in Texas.

We currently rely on a corporate PPO plan so coverage isn’t an issue. However we will transition off next year and still have 5 years to age 65/Medicare.

The Texas ACA only has HMO’s, EPO’s, and POS’s, no PPO’s. It doesn’t seem that any of the plans cover service outside the local area. It’s difficult to tell. I’m not even sure if other cities like Dallas are covered.

Has anyone figured out how to get care outside your local area, and specifically another state/facility like Mayo?

Like Rianne above (Mayo Clinic Coverage When in Texas), when I went to the Mayo Clinic with (at the time) Texas BCBS, they said "don't worry, it's covered". I also suggest you call and ask.

[Historically, I recall that prior to medical insurance they used to guess what a patient could pay and charge that and not track you down if you couldn't pay. ]

 

[justtryharder]

I learned something today from talking with a health insurance broker. Apparently ton of ppo plans have been removed from the marketplace because of a new ruling by the Biden administration. They are forcing these PPO plans to the ACA marketplace.

Now that would potentially solve the problem of PPO availability, but unfortunately Trump will blow it up.

Please stop. The Biden administration isn’t “forcing these PPO plans” on anyone.

Texas plans aren’t great for out of network needs like Mayo. Other states are better in that regard.

 

[Pluperfect]

when I went to the Mayo Clinic with (at the time) Texas BCBS, they said "don't worry, it's covered".

When was this? And what type of plan was it? Employer sponsored? Bought on the ACA marketplace?

 

[big-papa]

Our family is receiving on-going treatment at Mayo Clinic in Minnesota for some health issues. We live in Texas.

We currently rely on a corporate PPO plan so coverage isn’t an issue. However we will transition off next year and still have 5 years to age 65/Medicare.

The Texas ACA only has HMO’s, EPO’s, and POS’s, no PPO’s. It doesn’t seem that any of the plans cover service outside the local area. It’s difficult to tell. I’m not even sure if other cities like Dallas are covered.

Has anyone figured out how to get care outside your local area, and specifically another state/facility like Mayo?

I don't know about Mayo Clinic coverage out of state for ACA plans, but yes there are ACA plans here in TX that cover multiple regions in the state and several from BCBSTX that cover the entire state. It really depends on the plan.

Cheers.

 

[Echard]

Texas residents have been complaining for years about the lack of PPO options. It’s not anything new or recent.

Insurance is not federally regulated, it is regulated by each state. The lack of ACA PPO plans in Texas is a local / state issue and the federal gov’t has no say in the matter.

It would also be helpful to leave the partisan implications out of the discussion.

I was not intending in any way whatsoever to make a partisan comment on the situation. I was simply pointing out the facts from what has factually happened with the Biden administration action, and the stated Trump policy of eliminating the ACA.

Regarding state/local control of ACA PPO plans, Texas follows the national/federal ACA offerings. The state does not have it's own exchange. So what is offered in Texas is what is offered by the federal exchange.

 

[big-papa]

I was not intending in any way whatsoever to make a partisan comment on the situation. I was simply pointing out the facts from what has factually happened with the Biden administration action, and the stated Trump policy of eliminating the ACA.

Regarding state/local control of ACA PPO plans, Texas follows the national/federal ACA offerings. The state does not have it's own exchange. So what is offered in Texas is what is offered by the federal exchange.

I live in TX. I don't understand what you mean by "national/federal ACA offerings". That Texas doesn't have its own exchange has nothing to do with it. It just means that the Federal exchange does the administration work instead of the state of TX. Plans still have to register with the state and meet state requirements.

Affordable Care Act Resources for Health Carriers

PPACA Resources for Health Carriers

www.tdi.texas.gov

The plan I'm on is only sold in the county I live in and several adjacent counties and nowhere else in TX and nowhere else in the country.

Cheers.

 

[Aerides]

I was not intending in any way whatsoever to make a partisan comment on the situation. I was simply pointing out the facts from what has factually happened with the Biden administration action, and the stated Trump policy of eliminating the ACA.

Regarding state/local control of ACA PPO plans, Texas follows the national/federal ACA offerings. The state does not have it's own exchange. So what is offered in Texas is what is offered by the federal exchange.

The situation in TX has been that way long before Trump or Biden. And there are tons of other states that offer PPO/EPO and other plans, just look at Florida, for example. Providers in Texas only offer HMOs.

But everywhere is different, some locations are better than others. Insurance providers offer plans per county, and the coverage expansion differs with provider. Almost none of them (or actually none?) offer plans that have in-network coverage out of state.

 

[big-papa]

The situation in TX has been that way long before Trump or Biden. And there are tons of other states that offer PPO/EPO and other plans, just look at Florida, for example. Providers in Texas only offer HMOs.

But everywhere is different, some locations are better than others. Insurance providers offer plans per county, and the coverage expansion differs with provider. Almost none of them (or actually none?) offer plans that have in-network coverage out of state.

This isn't correct. In TX, there are primarily HMOs, but there are also some EPOs as well. But definitely no PPO's these days.

Of course by law they all have to cover emergencies at any hospital, even out of state. But none with full coverage out of state. However, there are some plans that have the ability to go to a CVS Minute Clinic out of state as in-network.

Most of the plans here in TX cover only regions. There are a couple of higher-end plans from BCBSTX that cover the entire state.

Cheers.

 

[MichaelB]

I was not intending in any way whatsoever to make a partisan comment on the situation. I was simply pointing out the facts from what has factually happened with the Biden administration action, and the stated Trump policy of eliminating the ACA.

Fact or opinion, describing and contrasting policy approaches from the 2 political parties does indeed bring partisan politics into the discussion.

I am not aware of any actions taken in recent years to change the ACA. Legislative action was taken to increase access to subsidies and some of the original rules were reinstated, but there has been no change to the core ACA. Perhaps your insurance agent would provide some examples of recent policy measures and show us how they affected insurance policy availability in Texas.

Regarding state/local control of ACA PPO plans, Texas follows the national/federal ACA offerings. The state does not have it's own exchange. So what is offered in Texas is what is offered by the federal exchange.

The exchange is simply a platform for consumers to view and access policies. It does not determine or affect the policies themselves. Thst is determined by the insurer and the state insurance regulator.

 

[Echard]

I live in TX. I don't understand what you mean by "national/federal ACA offerings". That Texas doesn't have its own exchange has nothing to do with it. It just means that the Federal exchange does the administration work instead of the state of TX. Plans still have to register with the state and meet state requirements.

Affordable Care Act Resources for Health Carriers

PPACA Resources for Health Carriers

www.tdi.texas.gov

The plan I'm on is only sold in the county I live in and several adjacent counties and nowhere else in TX and nowhere else in the country.

Cheers.

The difference has to do with the involvement by the state. Some states have their own marketplaces. Texas has chosen to not have one, nor ensure PPO's are available. Here is an AI summary of a few of the differences between state and federal marketplaces, and the AI is mostly accurate:

AI Answer

The Affordable Care Act (ACA) offers health insurance plans through state-based marketplaces and federally-facilitated marketplaces. The main difference between the two is the level of state involvement.

State-based marketplaces

• States establish and maintain online marketplaces
• States work directly with health insurance companies
• States manage enrollment and eligibility for tax credits
• States can design their own exchanges

Federally-facilitated marketplaces

• The federal government runs the marketplace
• Consumers apply for and enroll in coverage through Healthcare.gov

State-federal partnerships

• States manage their own exchanges but use the federal marketplace for enrollment

Factors that vary by state

• Monthly premiums: Monthly premiums for ACA Marketplace plans vary by state
  
  
• Tax credits: Tax credits and cost-sharing subsidies are available for eligible individuals
  
  
• Health plans: States can select a “benchmark” health plan as a standard

The situation in TX has been that way long before Trump or Biden. And there are tons of other states that offer PPO/EPO and other plans, just look at Florida, for example. Providers in Texas only offer HMOs.

But everywhere is different, some locations are better than others. Insurance providers offer plans per county, and the coverage expansion differs with provider. Almost none of them (or actually none?) offer plans that have in-network coverage out of state.

This was exactly my point. Other states have PPO's. Texas only offers HMO's/EPO's.

But with the federal government's move to eliminate the availability of off-exchange PPO plans in certain circumstances, it should have pushed states without PPO's to ensure PPO's are offered, including Texas. However, with the ACA future in question, now small businesses in Texas may have difficulty finding PPO's (as individuals rather than as a small business) because they aren't available on the ACA, and you can't get a small business plan off the exchange, in a lot of situations.

Again, none of this is political or partisan. It's a fact. And it is a fact that just happened. I called up insurance agents to buy a plan and it is not possible for me to do that because of what just happened.

 

[Echard]

Fact or opinion, describing and contrasting policy approaches from the 2 political parties does indeed bring partisan politics into the discussion.

I am not aware of any actions taken in recent years to change the ACA. Legislative action was taken to increase access to subsidies and some of the original rules were reinstated, but there has been no change to the core ACA. Perhaps your insurance agent would provide some examples of recent policy measures and show us how they affected insurance policy availability in Texas.

The exchange is simply a platform for consumers to view and access policies. It does not determine or affect the policies themselves. Thst is determined by the insurer and the state insurance regulator.

see my points above.

 

[MichaelB]

see my points above.

I did and think you are confusing the role of the marketplace with the role of the Texas Insurance Comissioner.

The marketplace does not determine which policies are offered to consumers or what the premiums are. That is the role of the Texas Insurance Commissioner.

Once they have reached an agreement, the marketplace is used as a common interface for consumers to review, select and enroll in policies.

In addition, consumers can and do enroll directly with the insurers. These non-marketplace policies must also meet ACA standards and are not eligible for subsidies, but they do exist.

If there are no PPOs available in Texas it is entirely the responsibility of the Texas State Insurance Commission.

 

[big-papa]

I did and think you are confusing the role of the marketplace with the role of the Texas Insurance Comissioner.

The marketplace does not determine which policies are offered to consumers or what the premiums are. That is the role of the Texas Insurance Commissioner.

Once they have reached an agreement, the marketplace is used as a common interface for consumers to review, select and enroll in policies.

In addition, consumers can and do enroll directly with the insurers. These non-marketplace policies must also meet ACA standards and are not eligible for subsidies, but they do exist.

If there are no PPOs available in Texas it is entirely the responsibility of the Texas State Insurance Commission.

Exactly, but I doubt that this state would ever "require" PPOs be made available, being something of a "low regulation" state.

Cheers.

 

[Echard]

I did and think you are confusing the role of the marketplace with the role of the Texas Insurance Comissioner.

The marketplace does not determine which policies are offered to consumers or what the premiums are. That is the role of the Texas Insurance Commissioner.

Once they have reached an agreement, the marketplace is used as a common interface for consumers to review, select and enroll in policies.

In addition, consumers can and do enroll directly with the insurers. These non-marketplace policies must also meet ACA standards and are not eligible for subsidies, but they do exist.

If there are no PPOs available in Texas it is entirely the responsibility of the Texas State Insurance Commission.

I think you are confused. You keep pointing out what I’ve already said. The exact point I’ve already made is that the Texas plan does not have PPO’s because the state of Texas hasn’t done anything to ensure they are available. Other states have.

The hope by federal
officials was that eliminating the availability of certain PPO plans for small businesses would put pressure on states without PPO’s for individuals on their exchanges to make them available. However the change of administrations will reduce or eliminate that pressure.

Regarding either individual or small businesses enrolling with insurance PPO’s outside the ACA, that is why I’ve used the terms “certain” or “some”. Specifically, insurance that doesn’t require a health questionnaire for pre-existing conditions.

The bottom line is that up until a few months ago, people who were in early retirement could purchase a two person small business PPO that didn’t require health questionnaires. People who would need that live in states where the state has chosen to not ensure PPO’s are offered on their exchanges. This leaves people with serious limited choices going forward.

 

[Echard]

Exactly, but I doubt that this state would ever "require" PPOs be made available, being something of a "low regulation" state.

Cheers.

I don’t disagree that Texas might have not done anything anyway given its low regulation orientation.

 

[big-papa]

I don’t disagree that Texas might have not done anything anyway given its low regulation orientation.

In that context then, a valid reason as to why Texas doesn't have any PPO ACA plans is simply because the insurance companies haven't deemed the demand to be high enough to make them profitable enough.

 

[Pluperfect]

In that context then, a valid reason as to why Texas doesn't have any PPO ACA plans is simply because the insurance companies haven't deemed the demand to be high enough to make them profitable enough.

About ten years ago, Blue Cross suddenly stopped offering ACA PPO plans with access to a nationwide network. It was a big deal because there's a mail service in Texas that thousands of fulltime RVers use as their domicile. Granted, there were no doubt many more people on Medicare than on ACA plans, but I can tell you there was plenty of demand for a PPO plan with nationwide coverage in Livingston, Texas, anyway. Still would be if all the under-65s hadn't abandoned Texas and changed their domicile to Florida, where Florida Blue is hanging in there with plans that include access to a nationwide network.

 

[Rianne]

Our family is receiving on-going treatment at Mayo Clinic in Minnesota for some health issues. We live in Texas.

We currently rely on a corporate PPO plan so coverage isn’t an issue. However we will transition off next year and still have 5 years to age 65/Medicare.

Echard, you're missing the point. It's up to Mayo and since they've already treated you-your family is getting on-going treatment at Mayo Clinic, I am pretty sure they will work with you, whatever insurance you have. Mayo has huge coffers. Part of their mission is to help patients regardless. The hard part is getting that first appointment. The specialists, the best in the world, are paid salaries. They are not in it for individual gain. Many members of my family were/are treated there. Believe me, it is worth the 7 hour drive it takes us to get there.