| November 30, 2015 News Alert Managing Your Patients' Questions on Their Individual Plans In light of the open enrollment season, Blue Cross and Blue Shield of Texas (BCBSTX) providers are getting questions from patients about changes to our individual health plans. The content in this special alert is designed to guide you through these specific changes. Table of contents: - Learn more about our individual network changes
- Transition your patient's care
- Get answers to your patients’ frequently asked questions
- Join our new networks
Please Note: Most of our members will not be impacted by the changes, including: - Grandfathered members (Grandfathered plans are plans that existed on March 23, 2010, when the Affordable Care Act became law.)
- Patients covered by large and small employer groups
- Patients covered by Medicare and Medicaid
Learn More About Our Individual Network Changes
In previous issues of Blue Review, we announced changes to the health plan options we will be offering to individual members in 2016. Texas residents are now looking at all their coverage options during open enrollment, which began on Nov. 1, 2015, and goes through Jan. 31, 2016.
We will again offer our Blue Advantage (BAV) HMOSM to individual members, both on and off the Health Insurance Marketplace. Individual members are anyone who buys their own insurance that is not provided by an employer or through a government program (Medicare, Medicaid, or CHIP). In addition, we will offer the new Blue Advantage PlusSM HMO plan with added Point of Service (POS) benefits. These added POS benefits give members more flexibility when they need care. This new HMO utilizes the Blue Advantage HMO network of doctors and hospitals while still having limited out-of-network benefits. The BAV and BAV Plus plans will be offered in all 254 counties across the state. BCBSTX will no longer offer the Blue Choice PPOSM plan that we offered in 2014 and 2015 to individual members, unless members are covered by grandfathered plans, large and small group employers or Medicare and Medicaid. We will automatically transition individual members who had Blue Choice PPO in 2015 to the BAV Plus plan if they do not select a different plan during open enrollment. Again, members who will not be impacted by this change include: - Patients covered by large and small employer groups
- Patients with individual coverage who have grandfathered plans (Grandfathered plans are plans that existed on March 23, 2010, when the Affordable Care Act became law.)
- Patients covered by Medicare and Medicaid
With our individual members moving to HMO plans, we have created educational materials to help them understand how HMOs work, how POS works and the importance of care coordinated through a primary care physician. You can share these materials with your patient. We've also included a list of FAQs in this newsletter to assist you further in answering questions from patients.
Transition Your Patients' Care
We understand that some of your patients who are transitioning to Blue Advantage or Blue Advantage Plus from Blue Choice PPO plan may be undergoing a complex course of treatment under your care (e.g., cardiology, cancer, pediatrics, pregnancy, etc). We realize this type of care is critical, and we want to work with you and your patients to minimize the impact of this change to their ongoing care. Our registered nurse case managers will work with current providers, Blue Advantage primary care physicians and our members to make the transition as smooth as possible.
Please note that many of our members will not require transition of care, because they are not impacted by these changes: - Patients covered by large and small employer groups
- Patients with individual coverage who have grandfathered plans (Grandfathered plans are plans that existed on March 23, 2010, when the Affordable Care Act became law.)
- Patients covered by Medicare and Medicaid.
We’ve identified about 4,300 members across Texas that may need additional assistance because of current courses of treatment. We have been reaching out to them directly, via phone calls and letters, to ensure they are taken care of during this transition. We have been contacting the specialist caring for these members, as well to make sure we provide the information you need to continue the planned care of your patients. In addition, understand that every day, scores of our members who battle cancer receive treatment at more than 70 hospitals across Texas with dedicated cancer services, as well as stand-alone cancer specialty centers. We have thousands of specialists in leading medical groups across the state, including oncologists, hematologists, radiologists, surgeons and other specialties. If you have patients who are being treated for serious health conditions or are in the last trimester of pregnancy, we encourage you reach out to us to discuss the coordination of patient care through their transition to their new plan. Your patients can also inquire about our care management program by calling 855-462-1781 between 8 a.m. and 5 p.m. CT, Monday through Friday. This program is offered to our members at no additional cost. Other important numbers to know: - Member Customer Service: 888-697-0683
- Pre-Authorization: 855-462-1785
- Behavioral Health: 800-729-2422
You can also visit our website for more information at bcbstx.com.
Get Answers to Your Patients’ Frequently Asked Questions
The following frequently asked questions can help you as you discuss these changes with your impacted patients. You can also refer them directly to our website to see a list of our member FAQs and educational fliers.
When is Open Enrollment?
Open Enrollment for individuals runs from Nov. 1, 2015, through Jan. 31, 2016.
During this time, your patients can also: - Look at other plan choices
- Compare plans and prices
- See if they can get financial help
What Will Be Different for Individual Plans in 2016?
There are some changes to the plans that BCBSTX is offering in the individual market in 2016. We are no longer offering PPO insurance plans in the individual, retail market. However, BCBSTX will continue to offer HMO plans, like our Blue Advantage HMO. We’ll also have a new plan, the Blue Advantage Plus plan, that will give your patients the advantages of an HMO with the added option of using providers other than Blue Advantage network providers, and still have some of the costs covered. See below for a comparison of BAV and BAV Plus: | Blue Advantage HMO | Blue Advantage Plus | Out-of- pocket Costs | Coinsurance & copays are lower than other plans. For non-emergency care, members will be responsible for the full cost of their care if they go outside their network or get care without a PCP referral. | Higher coinsurance & copays than HMO plans. Members get maximum benefits when using HMO network providers, but can get a portion of costs covered when using a provider not in the network.
Please Note: There is no cap on out-of-pocket expenses for out-of-network services. | Choice of Doctors | Members must select a primary care physician (PCP) to coordinate their care within the network. | Members must select a primary care physician (PCP) to coordinate their care, but they can go outside their network and receive a lessor benefit. However, they may be responsible for amounts in excess of the Allowable Amount. | Referrals | Required in order to see Specialists | To receive in-network benefits, referrals are required in order to see a specialist | Out-of-network Physicians | Not Covered | Limited Coverage | Ideal for … | People looking to keep costs low and predictable. | People who want the cost controls of an HMO, with the added choice of using providers outside the HMO network. | Why is the Individual Blue Choice PPO Going Away?
BCBSTX was the only insurer to offer an individual PPO insurance plan across the state to individuals in 2014 and 2015. Since the Affordable Care Act began, the market has changed. We found that the individual PPO plan was no longer sustainable at the cost it was being offered. Because we want to make sure that our plans are affordable, we decided to not offer individual PPO plans in 2016. However, please note that these changes will not impact: - Grandfathered members (Grandfathered plans are plans that existed on March 23, 2010, when the Affordable Care Act became law.)
- Patients covered by large and small employer groups
- Patients covered by Medicare and Medicaid
The Blue Choice PPO will still be available for the members listed above in 2016. Why Couldn’t BCBSTX Just Keep Offering the Individual PPO Plans and Raise the Rates?
The Affordable Care Act requires that we set our individual plan rates based on all of our individual members' claims history. This means that if the costs of one plan are high, it will raise the rates of all other plans, not just the high-cost plan. If we kept the Blue Choice PPO, this would have raised the rates so much for all our other plans that most people wouldn't be able to afford them. By dropping the PPO, we can still offer our other plans at reasonable rates. My Patient Has a PPO Plan, What Will this Mean for Them?
If your patient has an employer group PPO plan, this will not affect them. If your patient enrolled in the individual Blue Choice PPO plan last year, they won't be able to keep their PPO plan in 2016. My Patient's Blue Choice PPO Is "Grandfathered." What Will this Mean for Them?
If your patient has a grandfathered individual PPO plan, it will still be available in 2016. Grandfathered individual plans are plans that existed on March 23, 2010, when the Affordable Care Act became law. If your patient isn't sure if their plan is grandfathered, please have them check their plan details or call the customer service number on the back of their BCBSTX member ID card. Will My Patients Be Able to Keep Me as a Doctor and Go to the Same Hospital if They Switch Plans?
Currently, BCBSTX has two provider networks for our individual plans: Blue Choice PPO and Blue Advantage HMO. With the Blue Choice PPO individual plans going away, providers that decided not to join the BAV HMO network in 2016 will no longer be an in-network option for most of our individual members. If your members have a grandfathered plan, they will still have access to the Blue Choice network. If you are not in the Blue Advantage network, we will work with your patients to lessen the impact on the transition of care. Additionally, providers who would like to participate in our networks may initiate the contracting process through the BCBSTX provider portal on bcbstx.com/provider. What if My Patient Has Questions About Medication Refills or Changes?
For information about 2016 prescription drug plan benefits, your patient can visit Prescription Drug Benefit Changes for 2016 Individual or Employer Offered Metallic Plans or contact the Pharmacy Program number on the back of their ID card. Who Can My Patients Talk to if They Have Questions?
Please encourage your patients to talk with their insurance agent or call the customer service number on the back of their BCBSTX member ID card. What Should My Patients Do if They Have a Medical Condition and Need Help with the Transition of Their Care?
Your patients should take important steps to make sure their care continues smoothly: - Find out if their potential new doctor is a primary care physician (PCP) in the Blue Advantage HMO network by visiting findadoctortx.com or calling us at 888-697-0683.
- Learn about benefits and coverage by visiting staybluetx.com or calling us at 888-697-0683.
- Select a PCP and speak with him or her about their care plan and next steps.
- They should check with their PCP to see if a new authorization or referral is required for their 2016 course of care.
BCBSTX is here to help your patients manage their health care benefits during the change to their new HMO plan. BCBSTX offers case management programs to help with the transition of care. The care management program helps with coordination of care, counseling on how to manage chronic conditions, and education on resources to help your patients make more informed health care decisions for themselves and their covered family members. If your patient is being treated for a serious health condition, or are in the last trimester of pregnancy, please invite them to sign up for our care management program by calling 855-462-1781 from 8 a.m. to 5 p.m. CT, Monday through Friday. The program is offered to BCBSTX members at no additional cost. My Patient Needs Help Paying for Medical Insurance. What Information Can I Provide Them?
Many Texans may be eligible for financial assistance from the Health Insurance Marketplace to help offset their insurance costs. Currently, 93 percent of Texas residents and their families receive payment assistance from the federal government in the form of a premium tax credit. Your patients can calculate the estimated amount they may qualify for by visiting BCBSTX’s Premium Tax Credit Estimator.
Join our new networks
Our 2016 offerings reflect our commitment to expanding coverage to millions of uninsured Texans. Providers who do not currently participate in our Blue Advantage network but would like to consider participating may initiate the contracting process through the BCBSTX provider portal on bcbstx.com/provider or by contacting your local network management representative.
BCBSTX Provider Relations
Office Locations | Telephone Number | Fax Number | Austin | 512-349-4847 | 512-349-4853 | Corpus Christi | 361-878-1623 | 361-852-0624 | Dallas, East Texas | 972-766-8900 /
800-749-0966 | 972-766-2231 | El Paso | 915-496-6600, press 2 | 915-496-6611
915-469-6614 | Houston, Beaumont | 713-663-1149 | 713-663-1227 | Lubbock, Amarillo | 806-783-4610 | 806-783-4666 | Midland, Abilene, San Angelo | 432-620-1406 | 432-620-1428 | San Antonio | 361-878-1623 | 361-852-0624 |
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