HMO Plan - OON Doctor - what is Covered?

[kgmom219]

I've learned a lot from this thread! Thanks to all contributors.

There are some companies that don't have Out-of-Network coverage. For example United HealthCare says that with their 2015 Exchange plans, you are either in the HMO network, or you are "not covered".

It sounds like in many regions, it's best for the client to bite the bullet and pay an additional $100+ dollars to stay in a PPO, because the extra headaches and costs of going out-of-network will negate those premium savings anyway.. if they need to use the plan within the first year or two.
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On the UHC plans, its important to learn if you are selling the Choice or Navigate networks OFF Exchange vs. Choice/Navigate PLUS.

This is critical. If the word "plus" is not included, there is not an OON benefit (excluding emergencies).

 

[AllenChicago]

August 5, 2015

I'm resurrecting this thread because of the serious situation coming to Texas for 2016. As many of you know, BCBS-Tx is canceling all PPO IFPlans and converting them to HMO, unless the insured jumps to another company.

Tonight I went to the BCBS-Tx provider finder (https://public.hcsc.net/providerfinder/search.do?corpEntCd=TX1&nextPage=) and did a comparison of the number of PPO primary care physicians in Texas against the number of HMO primary care physicians. The result.. 17,385 PPO / 6,740 HMO. For hospitals, it's 426 PPO / 258 HMO.

Since BCBS-TX is the largest carrier in the state, will many of their PPO physicians begin subscribing to their HMO network, to keep from losing so many patients? Or, do the physicians really not care because most of their patients probably have group health insurance, which isn't affected?

 

[taterpeeler]

August 5, 2015

I'm resurrecting this thread because of the serious situation coming to Texas for 2016. As many of you know, BCBS-Tx is canceling all PPO IFPlans and converting them to HMO, unless the insured jumps to another company.

Tonight I went to the BCBS-Tx provider finder (https://public.hcsc.net/providerfinder/search.do?corpEntCd=TX1&nextPage=) and did a comparison of the number of PPO primary care physicians in Texas against the number of HMO primary care physicians. The result.. 17,385 PPO / 6,740 HMO. For hospitals, it's 426 PPO / 258 HMO.

Since BCBS-TX is the largest carrier in the state, will many of their PPO physicians begin subscribing to their HMO network, to keep from losing so many patients? Or, do the physicians really not care because most of their patients probably have group health insurance, which isn't affected?

this is going on nationwide allen... not a big deal... this was expected

 

[kgmom219]

this is going on nationwide allen... not a big deal... this was expected

I agree its not a big deal, mainly because its always been this way here. My pediatrician doesnt take HMO. My internist doesn't. The largest hospital system doesnt want Blue Advantage or Exchange biz.

 

[AllenChicago]

this is going on nationwide allen... not a big deal... this was expected

Wrong. Not happening nationwide. Name another state where the largest carrier canceled all PPO IFPlans and told hundreds of thousands of customers to accept the puny HMO network, or shop elsewhere?

It's happening to some extent in Illinois, with BCBS reducing the PPO network size by 30% for 2016. But it's still a PPO, and a 30% reduction is nowhere near as severe as the 64% reduction coming to BCBS-Tx IFPlan PPO customers.

IMO, what's about to happen in the IFPlan market in Texas is unique. Once the letters start arriving in mailboxes, I think we'll see that this was not "expected". It will shock...especially when they visit the BCBS-Tx "Provider Finder" tool... and later learn that there is no Out-of-Network coverage. (There's "emergency" OON coverage, but who/how determines that your out-of-network E.R. visit was a "covered" emergency?)

 

[kgmom219]

Wrong. Not happening nationwide. Name another state where the largest carrier canceled all PPO IFPlans and told hundreds of thousands of customers to accept the puny HMO network, or shop elsewhere?

It's happening to some extent in Illinois, with BCBS reducing the PPO network size by 30% for 2016. But it's still a PPO, and a 30% reduction is nowhere near as severe as the 64% reduction coming to BCBS-Tx IFPlan PPO customers.

IMO, what's about to happen in the IFPlan market in Texas is unique. Once the letters start arriving in mailboxes, I think we'll see that this was not "expected". It will shock...especially when they visit the BCBS-Tx "Provider Finder" tool... and later learn that there is no Out-of-Network coverage. (There's "emergency" OON coverage, but who/how determines that your out-of-network E.R. visit was a "covered" emergency?)

Its an HMO. By definition, there's no OON coverage except in emergency. In TX, "emergency" is defined by the patient, under state law. So if you go in for "chest pains" and it turns out to be heart burn, its covered.

 

[Ann H]

Wrong. Not happening nationwide. Name another state where the largest carrier canceled all PPO IFPlans and told hundreds of thousands of customers to accept the puny HMO network, or shop elsewhere?

It's happening to some extent in Illinois, with BCBS reducing the PPO network size by 30% for 2016. But it's still a PPO, and a 30% reduction is nowhere near as severe as the 64% reduction coming to BCBS-Tx IFPlan PPO customers.

IMO, what's about to happen in the IFPlan market in Texas is unique. Once the letters start arriving in mailboxes, I think we'll see that this was not "expected". It will shock...especially when they visit the BCBS-Tx "Provider Finder" tool... and later learn that there is no Out-of-Network coverage. (There's "emergency" OON coverage, but who/how determines that your out-of-network E.R. visit was a "covered" emergency?)

Texas is a leader in some ways. Pre-ACA, I read a study that made me think, "Hmmmm, should I get a TX non-resident license?" That's because the study showed that TX had one of the largest uninsured populations paired with one of the largest subsidy eligible populations, and the study predicted a low rate-shock compared to the rest of the nation. That was a goldmine. For a short time. Now over-utilization has hit.

AZ is about the opposite. AZ has the lowest SLCSP premium, meaning few get subsidies. Those that do get subsidies are in rural areas, really poor, or at least "poor on paper". Most of AZ doesn't get subsidies. That wasn't good for ON-exchange sales, but good for group & OFF-exchange sales. It's interesting to see that AZ has more carriers, and more PPO options that survived. BCBSAZ canned PPO only for ACA-compliant IFP, not Group, Grandmothered or Grandfathered. It's a big hit, but not as big as the hit in other states like TX. And certainly not as big as states that have already gone down this path.

 

[taterpeeler]

Allen, sorry your just wrong..... Oklahoma terming the PPO according to a mga friend form yesterday(not confirmed) next, I thought someone told me Arizona did this..... its going to happen and will be happening faster than a california wild fire.

Obamacare was built to be local care.... was said over and over in the passage. Local care is code word for HMO

 

[somarco]

I have not written BCBSGA IFP in years but when the calendar turned over to 1/1/14 all the BX offerings were HMO. I doubt they have introduced a PPO plan for 2015 but haven't checked.

BX is so overpriced here, commissions so low and network so skinny that eHealth doesn't even show them as an option.

 

[sman]

I agree its not a big deal, mainly because its always been this way here. My pediatrician doesnt take HMO. My internist doesn't. The largest hospital system doesnt want Blue Advantage or Exchange biz.

You see a pediatrician? How old are you?

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I have not written BCBSGA IFP in years but when the calendar turned over to 1/1/14 all the BX offerings were HMO. I doubt they have introduced a PPO plan for 2015 but haven't checked. BX is so overpriced here, commissions so low and network so skinny that eHealth doesn't even show them as an option.

No, they haven't introduced a PPO. Unfortunately, in some areas of the state, they are the only on-exchange option. In some counties there's only one PCP available. It's pretty pathetic.