Blue Cross Blue Shield and Methodist Hospitals cannot agree on terms

December 9, 2010

The impasse between Methodist Hospitals & Blue Cross Blue Shield (BCBS) Insurance could impact Northside ISD's 14,000 employees and families if it is not resolved by January 1, 2014.  NISD communicated this information to all employees as the District transitions from Humana Insurance to BCBS on Jan. 1.  

Please review the NISD- prepared Frequently Asked Questions often as they will be updated as necessary.

FREQUENTLY ASKED QUESTIONS 
CONCERNING
BLUE CROSS BLUE SHIELD OF TEXAS AND METHODIST HEALTHCARE HOSPITALS

1.     Is the Methodist Hospital System still an in network provider for Blue Cross Blue Shield of Texas (BCBSTX)?

As of this writing, Hospital Corporation of America (HCA), the owners of the Methodist Healthcare System, and BCBSTX continue to negotiate.  The Contract between them is set to expire December 31, 2013.  Should the parties not reach agreement, Methodist Healthcare System hospitals would not be in the BCBSTX network of providers effective 1/1/2014.

2.    What Methodist Hospitals will this affect?

A failure to reach a settlement agreement will affect all Methodist Healthcare System facilities throughout the State of Texas.  The affected San Antonio area hospitals are: Methodist Hospital, Methodist Texan Hospital, Methodist Specialty & Transplant Hospital, Metropolitan Methodist Hospital, Northeast Methodist Hospital, Methodist Ambulatory Surgery Hospital – Northwest, and Methodist Stone Oak Hospital.

3.    Will employees have to change doctors?

The contract negotiations involve only the HCA group of hospital facilities which includes the Methodist Healthcare System.  Most all physicians have their own agreement with BCBSTX and are not affected by this process.  For this reason, employees will be able to use any of the current BCBSTX in-network physicians.

4.    Northside has such a large employee population how could either BCBSTX or HCA not come to a compromise?

While Northside does have a large employee population, these negotiations potentially affect 350,000 lives across the greater San Antonio area and a much greater number for all the remaining areas in the State of Texas.  In that same vein HCA owns or has substantial interest in almost 40 hospitals across Texas.  Both BCBSTX and HCA are negotiating in the interest of their individual needs and concerns.

5.    Did Northside know about the potential loss of Methodist Healthcare when BCBSTX was chosen?

No, in the selection process Northside addressed this issue with the following question, and received the following response:

Question: Are you anticipating any material changes in this network size (for either hospitals or providers) in the next 12 months? Please list below any major hospitals or physician practice groups that will require network contract negotiations and/or renewal during the first 12 months of the proposed coverage period.

Response: There are currently no significant changes in our network to report at this time for our PPO network.

6.    When will BCBSTX finalize this issue with Methodist?

While we hope this situation is resolved in the near future and prior to January 1, 2014, the negotiations are not controlled by Northside and we do not know when the issue will be resolved. An updated announcement will be sent as soon as the final agreement between HCA and BCBSTX has been established.

7.    What is the effect on NISD employees if the negotiations between BCBSTX and HCA are unsuccessful?

The short answer is Methodist Healthcare facilities and its affiliates will not be in the BCBSTX network.

8.    What will be the effect of a NISD employee choosing to be treated at a Methodist facility as an out of network provider?

When you seek care from a network doctor or hospital, your BCBSTX plan pays a larger portion of your health care costs than it pays for services by a non-network provider. When you receive care outside the network, you still have coverage, but you may pay more of the cost, including any charges exceeding the BCBSTX allowed amount.

If the doctor, hospital or health care facility you visit is part of the BCBSTX network, you'll get your health care at lower prices. But if you go out of your network for health care, it can become a lot more expensive.

Here's an example.

Say you go to a doctor that's in network and the total charge is $250. A discount is applied to that amount for the BCBSTX negotiated rate with the doctor. The discount is $75. BCBSTX pays $140. You'll have to pay the remainder, which is $35.  The advantage of going to an in-network provider is that the provider cannot balance bill you for the amount over the allowable.

Now let's say you go to a doctor that's out of network. No discount is applied to the total charge. BCBSTX will still pay $140, as long as your out of network (OON) deductible has been met, plus you'll be responsible for the $110 amount that exceeded the allowable.  Total member responsibility will either be $250 when the OON deductible has not been met or $110 when the OON deductible has been met.

Going out of network could mean you'll have to pay a larger percentage of the cost or the total cost, depending on your particular plan. You may also pay a higher coinsurance percentage and have higher annual coinsurance and out-of-pocket maximums.

To get the most out of your health insurance plan, it’s best to make sure your doctor or hospital is in your network. 

9.    What other area hospitals are in the BCBSTX network?

Other local area hospitals which will remain within the BCBSTX network include:

Acuity Hospital South
Baptist Emergency Hospital – Westover Hills
Baptist Emergency Hospital – Hausman
Baptist Emergency Hospital – Overlook
Baptist Emergency Hospital
Baptist Health System
Baptist Health System Healthlink
Children’s Hospital of San Antonio
Christus Santa Rosa Health System
Christus Santa Rosa Hospital – City Center
Christus Santa Rosa Hospital – Westover
Christus Santa Rosa Hospital – Medical Center
Foundation Surgical Hospital
Global Rehabilitation Hospital SA LP
Healthsouth Risoa
Kindred Hospital
LifeCare Hopitals
Mission Trails Baptist
Nix Health Care System
North Central Baptist
Northeast Baptist Hospital
Select Specialty Hospital
South Texas Spine & Surgical Hospital
Southwest General Hospital
St Luke’s Baptist Hospital
University Health System
Warm Springs Rehabilitation Hospital
Warm Springs Specialty Hospital

10.  How do I know if a hospital is in-network?

You can find all in network providers at the BCBSTX website, www.BCBSTX.com.  Use the “Find a Doctor” option and search for hospitals.  You can also contact BCBSTX Customer Service at 1-877-213-6884 for assistance.

11.  Do I need an insurance card to determine in-network eligibility?

Most NISD employees should receive their BCBSTX ID card in the mail sometime between December 9, 2013, and December 16, 2013.  If you have not received a card by December 16, 2013, contact BCBSTX Customer Service at (877) 213-6884 and request a replacement card be sent to you.  (Verify your address at this time also.)  In the event you need to visit your doctor or a treating facility before receiving your card, you can use the following information to assist in verifying in-network eligibility.

Account Number: 115932
PPO Group Number: 115932
HDHP Group Number: 115940

12.  What if I have a procedure scheduled and the negotiations are unsuccessful?

We suggest you monitor the negotiations very closely and inquire with your doctor about alternative plans.  Many doctors have privileges at several local hospitals.

13.   What if I already plan on being hospitalized over the Winter Break and had planned to be in the hospital after January 1, 2014?

You should be eligible to apply for Transition of Care.  If you or a family member is on a health plan and currently receiving medical care from physician(s) or facilities (hospitals) that are not listed in BCBSTX provider directory, it will be necessary to complete a Transition of Care form if you wish to continue with this provider. In the same way, if you anticipate being in a Methodist Health Care hospital on January 1, 2014 you should request Transition of Care.

If approved for Transition of Care, benefits would be paid at the in-network level for a specified period of time, typically up to 90 days. The form must be submitted prior to the effective date of coverage, January 1, 2014

Examples of situations requiring Transition of Care consideration are:

Receiving cancer treatment/therapies
Being treated for a terminal illness
In third trimester of pregnancy
In cardiac rehabilitation 

Please understand that it may be necessary for BCBSTX to request medical information from your current physician(s). After 90 days, the BCBSTX Medical Director will review any requests for benefits, made in writing, according to the BCBSTX prior authorization review process.

The form may be found on the Human Resources Intranet website and is available in the Benefits and Risk Management Office, Human Resources Department, 5617 Grissom Road, (210) 397-8620.

14.  Will BCBSTX be available with support staff to help facilitate the transition?

BCBSTX Customer Service is aware of the HCA situation and will be able to assist NISD employees with any additional questions they may have.  The BCBSTX Customer Service number is 1-877-213-6884 is operational from 8:00 AM to 6:00 PM, CST, daily. 

15.  If an employee or family member has an emergency such as a heart attack, will BCBSTX make an exception (if all is not yet finalized with HCA)?

Emergency conditions are always covered at in-network charges.  However, if a new contract between HCA and BCBSTX has not been completed, the employee or  family member may have to move to an in-network hospital, once stabilized, to continue to receive in network benefits.

16.  For scheduled procedures, test, and labs, should employees ask their physician to refer them to an in network physician and facility?

Employees, who are anticipating an in-patient or out-patient procedure at a Methodist Healthcare facility after 1/1/2014, would be prudent to ask their doctor about alternative plans which could include using a facility other than a Methodist hospital or postponing the procedure in anticipation of a settlement in the negotiations.

17.  I am expecting to deliver my baby within the first 3 months of 2014 and have already registered with Methodist hospital for the delivery. Will I still be able to receive network benefits if I deliver at Methodist?

No, if negotiations are not successful any charges billed by Methodist will be processed at the out-of-network level of benefits. Your doctor and any other medically necessary network provider who treats you while in the hospital will be considered at the in-network level. If you are scheduled to deliver prior to April 1, 2014, please refer to question 12 for assistance on transition of care.

18.  If I experience complications during my pregnancy and my doctor sends me to the emergency room at Methodist for evaluation and treatment, will the bill be paid as in-network?

Emergency care is always covered at the in-network level of benefits. To continue to receive network benefits you may be required to transfer to a network hospital if further hospitalization is required once you are stabilized.

19.  My in-network OB/GYN doctor only has practice privileges at hospitals in the Methodist system. How will services ordered by my in-network doctor to be performed at a Methodist hospital be covered by BCBSTX?

Charges billed by the Methodist Hospital system will be processed as out-of-network expenses. You may wish to discuss with your doctor options for hospital-based services, including delivery, to be performed at other network facilities.

20.  If my baby is delivered at an in-network hospital (other than a Methodist Hospital) and has complications requiring transfer to the Neonatal Intensive Care Unit at Methodist Children’s Hospital, will the bill be paid as in-network?

Emergency services are always paid at the in-network level of benefits. Babies, who require a level of care that cannot be provided at the hospital where they are delivered, will receive in-network benefits when transferred to the nearest hospital suitably equipped to meet the emergent medical needs of the child. Once the baby is stabilized, transfer to a network hospital may be necessary to continue to receive network benefits.

21.   If BCBSTX and HCA do not reach an agreement by January 1, 2014, can employee drop the coverage so they can get on a spouse’s plan?

If an agreement to maintain the Methodist Healthcare System of hospitals in the BCBSTX network of providers has not been reached or is not imminent by 1/1/2014, the District, as an exception to policy, will allow employees to drop their BCBSTX health insurance for the purpose of enrolling in a spouse’s or other family member’s coverage.  Upon completion of an agreement between BCBSTX and HCA, no further changes will be permitted except as qualified life events. 

Employees who drop coverage to enroll on another plan will not be allowed to return to the BCBSTX plan at a later date except during Annual Enrollment or as a result of a qualifying life event.

22.   Can we continue our old Humana coverage through COBRA?

No.  COBRA coverage is the same coverage provided by the employer.  In our case, COBRA coverage becomes coverage through BCBSTX effective 1/1/2014.

23.   Can Northside employees purchase coverage through the Market Place established by the Affordable Care Act (ACA)? 

The contract negotiations between BCBSTX and HCA have no effect on an individual’s option to purchase health insurance through the Market Place.  However, since Northside does provide affordable health insurance which meets the ACA standard of minimum essential coverage, most employees will not qualify for a subsidy to assist with the purchase of the insurance.

24.   Can Northside join the TRS Active Care insurance?

The District does not consider TRS Active Care to be a health insurance alternative which would be in the best interest of the District and its employees.  Since participation in TRS Active Care is a permanent commitment, it is not considered a viable alternative to the current situation.

25.   Has Dr. Woods and Board been briefed on this problem?

Dr. Woods and the members of the Board of Trustees are well informed of the ongoing negotiations between BCBSTX and HCA.  They continue to monitor the situation and consider all alternatives to determine which would best benefit the District and its employees.  Employees will continue to be advised of the status of the negotiations and any changes in the District’s health plan.

26.  If BCBSTX and HCA do not reach an agreement, will employees receive a reduction in premiums?

BCBSTX will continue to pay claims for all service provided, in or out of network, at the appropriate reimbursement levels.  For this reason, there will be no reduction in premiums.