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Changes to Individual PPO Policies - Information for Impacted Members

Nov. 01, 2015

BCBSTX will not be offering a PPO individual plan in 2016. This does not affect PPO plans that are offered by employers. It also does not affect PPO plans that were created before March 23, 2010, and have not been altered. Those are considered “grandfathered.” If you have a BCBSTX individual PPO plan that is affected, find out what this change means for you.

Changing to a new plan

If you are a Blue Choice PPO member, we will send you information in the mail about your coverage options for 2016 and federal tax credit information, if it applies to you.

We’ll be moving you to a new plan for 2016 automatically, so that you have no gap in coverage. This gives you time to decide on the best choice of coverage for you and your family.

When Open Enrollment begins on November 1, you can:

  • Keep the plan we pick for you. We will be moving our Blue Choice PPO members to our new Blue Advantage Plus plan, an HMO plan with added out-of-network benefits.
  • Pick another plan. You can pick from our Blue Advantage HMO or Blue Advantage Plus, both offered at different metallic levels for a price that fits your needs.

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What to do if you have a medical condition and need help with the transition of your care

When changing plans, you may find that not all your doctors are in your new plan’s network. If you are getting care for a medical condition, you should take these important steps to make sure your care continues smoothly:

  • Find out if your doctor is a primary care physician (PCP) in the Blue Advantage HMO network by visiting or calling us at 888-697-0683.
  • Learn about your benefits and coverage by visiting or calling us at 888-697-0683.
  • Select your PCP and speak with him or her about your care plan and next steps.
  • Houston-area residents: If you are in the middle of cancer treatment, search our Houston Cancer Care directory  to find cancer care specialists and hospitals in the Blue Advantage Network.

We’re here to help you manage your health care benefits during the change to your new HMO plan. BCBSTX offers case management programs to help with the transition of your care. The care management program helps with coordination of care, counseling on how to manage chronic conditions, and education on resources to help you make more informed health care decisions for you and your covered family members.

If you are being treated for a serious health condition, or are in the last trimester of pregnancy, we invite you to sign up for the care management program by calling 855-462-1781 from 8 a.m. - 5 p.m. Central time, Monday through Friday.

The program is offered to BCBSTX members and is at no additional cost to you.

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Frequently Asked Questions

When is Open Enrollment?

Open Enrollment for individuals runs from November 1, 2015 through January 31, 2016. If you are looking to buy your own health insurance plan for 2016, you can do so during this time.

If you already have health insurance, this is also the time you can:

  • Look at other plan choices
  • Compare plans and prices
  • See if you can get financial help

You'll be able to see what plans will be available starting in October, when the "window shopping" period begins. This will give you time to weigh your options, ask questions and decide what will work best for you – before it's time to sign up.

What will be different for individual plans in 2016?

There are some changes in the plans we intend to offer in the individual market in 2016. We won't be offering PPO insurance plans in the individual, retail market. However, we intend to continue to offer HMO plans. We’ll continue to offer our Blue Advantage HMOSM. We’ll also have a new plan, the Blue Advantage PlusSM plan, that gives you 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.

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.

Why couldn't you just keep offering the individual PPO plans and raise the rate for them?

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.

I have a PPO plan. What will this mean for me?

If you have an employer group PPO plan, this will not affect you. If you enrolled in the individual Blue Choice PPO plan last year, you won't be able to keep your PPO plan in 2016.

My Blue Choice PPO plan is "grandfathered." What will this mean for me?

If you have 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 you don't know if your plan is grandfathered, check your plan details or call the customer service number on the back of your BCBSTX member ID card.

Will I be able to keep my doctor and/or hospital if I switch plans?

Currently, we have two provider networks for our individual plans: Blue Choice PPO and Blue Advantage HMO. Some providers are only in the Blue Choice network, and some of them have decided not to join the Blue Advantage HMO network in 2016. So, with the Blue Choice PPO individual plans going away, these providers will no longer be an in-network option for most of our individual members. If you have a grandfathered plan, you will still have access to the Blue Choice network.

If your doctor is not in the Blue Advantage network, we will work with you and your doctor to lessen the impact of this change to your ongoing care.

What if I have questions about medication refills or changes?

For information about your 2016 prescription drug plan benefits, visit Prescription Drug Benefit Changes for 2016 Individual or Employer Offered Metallic Plans or contact the Pharmacy Program number on the back of your ID card.

Who can I talk to if I have questions?

We encourage you to talk with your insurance agent or call the customer service number on the back of your BCBSTX member ID card.

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Your BCBSTX health plan choices for 2016

This year, we are again offering our popular Blue Advantage HMOSM to individuals and small group members, both on and off the Health Insurance Marketplace. In addition, we will offer a new HMO that utilizes the Blue Advantage HMO network of doctors and hospitals while still having out-of-network benefits — the new Blue Advantage PlusSM plan.

Blue Advantage HMO

The Blue Advantage HMO plan has a select group of doctors, hospitals, clinics, pharmacies, labs, imaging centers and medical equipment vendors you can use when you need care — the Blue Advantage network. With Blue Advantage HMO, you will work with a primary care physician (PCP), who will be your personal doctor that manages all your care, makes sure you get the care you need, and coordinates your care with other network providers. This helps you get the right care, at the right time and the right place.

Learn more about HMO plans

Blue Advantage Plus

The Blue Advantage Plus plan is a point-of-service (POS) plan that allows members to have the pricing benefit of the Blue Advantage HMO while still having some out-of-network benefits.

Learn more about HMO POS plans

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Shopping for Coverage

Shop for 2016 health care coverage during Open Enrollment from November 1, 2015 to January 31, 2016. If your plan has been discontinued, you qualify for a Special Enrollment Period, which means you have until February 29, 2016, to enroll in a new plan.

You can:

  • Enroll directly with Blue Cross and Blue Shield of Texas, online or by calling our Sales Center at 855-896-2227
  • Work with a licensed agent/broker
  • Pick a plan on the Health Insurance Marketplace

Learn more about how to enroll.

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Need Help Paying for Insurance?

Many Texans may be eligible for financial assistance from the Health Insurance Marketplace to help offset their insurance costs. Currently, 93% of Texas residents and their families receive payment assistance from the federal government in the form of a premium tax credit. Calculate the estimated amount you may qualify for by visiting BCBSTX’s Premium Tax Credit Estimator.

For more information about the financial assistance available through the Marketplace, download our fact sheet: Are You Eligible for Help? pdf

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