2016 Open Enrollment - Where did my PPO go?

Blue Cross and other Texas insurers are dropping their PPO plans

We're right on the cusp of the 2016 Open Enrollment Period that begins November 1st and we've received hundreds of calls from clients that found shocking news from Blue Cross, Humana, and even United Health stating that their plans are being terminated and they are being moved to an HMO plan!  While many of us are in disbelief, the truth is that all carriers in the Houston market and many other Texas markets won't have an available PPO plan offered by the major carriers.  In the vacuum left by these terminating PPO plans we'll need to examine the HMO network plan design.  While this process can be hard to understand, don't worry, we're here to assist you through this search.

What is an HMO?
An HMO or Health Management Organization is a network of providers, hospitals, and facilities used by insurance companies to help provide medical services to policy owners.  Unlike PPO networks, an HMO network is "managed" by gatekeepers that are primary care physicians or PCPs for short.  The PCP is your go-to point of contact and you must see that doctor to get a referral to see a specialist.  If you knew that you had a foot problem that needed the help of a Podiatrist, you'll need to see your PCP first to get a referral to that doctor.  Health insurance companies use PCPs as a way to limit access to more expensive specialists.  HMOs can be great as they often are more affordable than the PPO plan you are accustomed to.  The biggest concern many insurance policy holders have is that HMO networks tend to be much smaller than your normal PPO network.

Are You Sure PPOs are Dead?
We do have one or two new options in the Texas market that might provide PPO choice.  Right now we know that Memorial Hermann Health Plans will offer a PPO, but this is really the only viable option for clients that live near the Memorial Hermann hopitals and facilities in Houston or in the surrounding areas.  Most clients out of Houston can't consider these plans.  In fact, because you are pretty much limited to Memorial Hermann options, I'd call this network more of an EPO.  An EPO is more complicated than I'll describe here, but the policy owner effectively sees this plan as an HMO that doesn't require a referral.  The Aetna PD network, Cigna Local Plus, and UHC networks in rural Texas are all these types of smaller networks that don't require a referral.  Despite this, if you live close to a Memorial Hermann facility, it may be a good option.

Business Owners - Take Action To Obtain A PPO
Perhaps you have had an individual policy with Blue Cross and don't like the idea of losing your PPO.  Many of our clients are business owners that have simply opted to buy a health plan on the individual market.  In the beginning of 2016, some carriers will actually allow us to write 1 or 2 person groups, (yes, that is correct a 1 person group!), and thus we should be able to help you maintain your PPO coverage.  To be clear, you must have verifiable business documents like a TIN (Taxpayer ID, not a social security number), Articles of Incorporation filed with the State and even Quarterly Wage and Tax Statements.  If you have all of these formal documents we should be able to help you, however we'll need to take action quickly.  This great opportunity is only available for a short time. 

UPDATE - 11.6.15
Over the last week several carriers have offered clarifiying criteria to obtain the "1 man group" and purchase a group plan with access to PPO networks.  In the paragraph above we outlined that the business needs to be able to produce a Quarterly Wage and Tax Statement, thus, this means that a person within the organization must be paid or classified as a w-2 employee.  Right now that means that even if you have a part-time employee on w-2 wages you should qualify for obtaining this plan.  Conversely, if you are a 1099 income earner because you receive consulting fees or contract wages, you won't qualify under this set up unless you get busy creating a formal entity and paying an employee w-2 wages.  It seems like nailing Blue Cross down in this situation has been difficult and it has been a moving target, but we'll press on working with them to get these plans in place.

If you are a current Texas Health Design client please know that we are concerned about your health plan and will help you navigate the challenges created by the loss of your plan.  New plans and final pricing will be "dropped" on Sunday, November 1st for all of us to see!  It is mind-boggling to us to believe that we won't see final options till November 1st, but that is the case.  Once they are available, we'll begin emailing you the universe of plans we believe are affordable, well designed, and offer the best and largest networks.  We will email quotes to all of our clients within the first two weeks of Open Enrollment.  As soon as you get those quotes, please open them, print, and call us at 713-422-2935.  We'll help you wade through the new options and make sense of all of the choices.  If we haven't heard from you we'll contact you via phone call and email every week or two through January 31st.  If you want to receive your quotes right away, simply call us and we'll move you to our priority list. 

If you are not a current Texas Health Design client, please contact us and we'll help you sort through all of the complicated terms and assist in the selection process.  We want to educate you and inform you rather than sell you a plan.  It is important you know what you are getting and you understand these really complex offerings.  If you need a subsidy, we can help.  We'll help you determine how much finanical assistance you can receive to help pay your health premiums.  Call us today at 713-422-2935 or simply click ContactUs!

Want to get started now and need a subsidy?  Check out this link to determine how much you'll receive to pay for health insurance in 2016.  You'll be able to select a plan and save your progress along the way. - TexasHealthDesignMarketPlaceInfo

Jason Bohmann
Owner - Texas Health Design