BCBS plans for individuals to change

July 26--WICHITA FALLS, Texas -- Hundreds of thousands of Texans will learn this fall that they might not be able to keep their doctor, a promise made by President Barack Obama and his administration.

According to a document sent to health insurance underwriters and agents in Texas recently, Blue Cross Blue Shield of Texas will get rid of Preferred Provider Organization, or PPO, plans for individuals in Texas and convert them to the limiting Health Maintenance Organization, or HMO, plans.

People with employer-provided PPO plans will not be affected by the change.

"The retail market has evolved significantly since the opening of the Health Insurance Marketplace in 2014," BCBS told agents. "These changes require BCBSTX to make adjustments that will allow us to continue offering sustainable health insurance options."

And by "sustainable", the company means its sustainability.

BCBSTX told agents that based on 2014 numbers, the company lost $400 million the first year of Obamacare based on the amount of money sent out in claims versus the amount received through premiums.

In all, the change will affect more than 360,000 Texans.

Kelly Fristoe, an underwriter in Wichita Falls with Financial Partners, said on Friday the change will cause problems, especially for those with individual plans who might be hospitalized late December and carries over into January. He said the PPO-to-HMO change will happen overnight from Dec. 31 to Jan. 1.

"Let's just say you happen to be in the hospital Dec. 27 and you fell taking your Christmas lights down and you have a busted something and you're waiting to have surgery. You're already admitted to the hospital and you have PPO coverage," he said. "As of Jan. 1, if we stay on the track that we're on and providers don't sign up for HMO coverage, then on Jan. 1, that facility is not in the network.

"You think about the dynamics associated with that, and it's going to throw a monkey wrench for a lot of this community."

Fristoe said more details on how BCBSTX will change their plans should come out in early October. He said the insurance provider has said the change might not be a transition to a traditional HMO, but it could be a middle-of-the-road option between an HMO and a PPO.

A PPO, he said, allows for coverage, to some degree, for in-network and non-network providers. An HMO only provides coverage for in-network providers. For example, under the HMO plans for this area, Kell West is part of BCBSTX's HMO coverage and only a few primary care physicians and specialists accept HMO insurance.

Fristoe said the change BCBSTX is going through is a result of the economics of the Affordable Care Act. He said his hope is BCBSTX will choose a hybrid of the PPO and HMO plans to lessen the blow on consumers.

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