12/15/2023
New Medicare-eligible retirees have joined our Blue Cross Group Medicare Advantage Open Access (PPO)SM plans for retirees of employer groups and Blue Cross Medicare Advantage Flex (PPO)SM plan for individuals. These are open access, national PPO plans without network restrictions.
If you’re a Medicare provider, you may treat these members regardless of your contract or network status with Blue Cross and Blue Shield of Texas. That means you don’t need to participate in BCBSTX Medicare Advantage networks or in any other BCBSTX networks to see these members.
The only requirements are that you agree to see the member as a patient, accept Medicare assignment and submit claims to the Plan.
Check for New Member ID Cards
As with all our members, it’s important to ask to see the member’s ID card before all appointments, and to check eligibility and benefits. All Medicare Advantage members receive new ID cards Jan. 1. Newly enrolled members also have new ID numbers.
Please update your records with new ID numbers. Use the entire member ID number, including the alpha prefix, to verify benefits and successfully process claims.
You can identify these members by the plan type listed on their ID card: Blue Cross Group Medicare Advantage Open Access (PPO) or Blue Cross Medicare Advantage Flex (PPO).
If you have questions, call the customer service number on the member’s ID card.
Open Access PPO Retiree Groups
On Jan. 1, 2024, approximately 11,000 retirees from The Texas A&M University System joined our Blue Cross Group Medicare Advantage Open Access (PPO) plan called 65 Plus Medicare Advantage Plan (PPO).
Medicare providers may see these members and retirees of other employer groups that joined or soon will join the Blue Cross Group Medicare Advantage Open Access (PPO) plan:
- Baptist General Convention of Texas
- Buckner International Group
- City of Austin
- City of Hurst
- City of Irving
- Ector County
- Nautilus Hyosung America Inc.
- Oncor Electric Delivery Company LLC
- Plumbers Local Union Number 68
- Sempra Texas Holdings Corp.
- Southwestern Baptist Theological Seminary
- Southwestern Health Benefit Fund
- Tarrant County Appraisal District
- University of Texas System (UT CARE™ Medicare PPO)
- Vistra Energy
- The Weir Group
- Zachry Holding
Flex and Open Access Advantages
These plans cover the same benefits as Medicare Advantage Parts A and B plus additional benefits per plan. Members’ coverage levels are the same inside and outside their plan service area nationwide for covered benefits.
- Blue Cross Group Medicare Advantage Open Access (PPO) is available to retirees of employer groups. It includes medical coverage and may include prescription drug coverage. Plan members may have to pay deductibles, copays and coinsurance, depending on their benefit plan.
- Blue Cross Medicare Advantage Flex (PPO) is available to individuals. It includes medical coverage and prescription drug coverage. It doesn’t require member cost share.
Referrals aren’t required for office visits. Prior authorization may be required for certain services from Medicare Advantage-contracted providers with BCBSTX.
For Reimbursement
Follow the billing instructions on the member’s ID card. When you see these members, you’ll submit the claims to the Plan and not Medicare.
- If you’re a Medicare Advantage-contracted provider with any Blue Cross and Blue Shield Plan, you’ll be paid your contracted rate. You’re required to follow utilization management review requirements and guidelines.
- If you’re a Medicare provider who isn’t contracted for Medicare Advantage with any BCBS Plan, you’ll be paid the Medicare-allowed amount for covered services. You may not balance bill the member for any difference in your charge and the allowed amount.* You aren’t required to follow utilization management guidelines. However, you may request a review to confirm medical necessity.
* Blue Cross Group Medicare Advantage Open Access (PPO) members may be responsible for cost share for supplemental dental services from non-contracted Medicare providers.
Providers not contracting with BCBSTX are under no obligation to treat Blue Cross Medicare Advantage Flex (PPO) or Blue Cross Group Medicare Advantage Open Access (PPO) members, except in emergency situations.
Checking eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, any claims received during the interim period and the terms of the member’s certificate of coverage applicable on the date services were rendered.