Blue Cross and Blue Shield could drop Ascension

Most people who have Blue Cross and Blue Shield of Texas insurance plans would have to pay out-of-network prices if they chose to go to an Ascension hospital. In-network versus out of network affects how high the deductible is before insurance begins to pay and it affects your out-of-pocket maximum expenses — the amount which, once you reach it, the insurance company begins to pay 100% of the costs.

Ascension Texas hospitals might no longer be in-network for people who have Blue Cross and Blue Shield of Texas insurance plans starting Feb. 1.

Patients receiving care at Ascension hospitals who are insured by Blue Cross and Blue Shield of Texas received a letter this week from Ascension outlining the potential impact.

Who is affected?

Blue Cross and Blue Shield of Texas estimates 66,000 of its members accessed care at a Central Texas Ascension hospital last year. These members include city of Austin employees, University of Texas employees, state employees and people who receive insurance through the Texas Teacher Retirement System. Blue Cross and Blue Shield of Texas is the largest health insurance provider in the state with more than 6 million members.

This potential change would affect people who have Blue Choice PPO, Blue Essentials, Blue Advantage HMO and Medicare Advantage (PPO) plans. It does not affect Blue Cross and Blue Shield of Texas' Medicare Advantage (HMO) and Medicaid networks.

What does not being in-network mean?

Most people who have Blue Cross and Blue Shield of Texas insurance plans would have to pay out-of-network prices if they chose to go to an Ascension hospital. In-network versus out of network affects how high the deductible is before insurance begins to pay and it affects your out-of-pocket maximum expenses — the amount which, once you reach it, the insurance company begins to pay 100% of the costs. These differ by plan, but in many cases, the difference in deductibles and out-of-pocket maximums are double, potentially costing families thousands of dollars.

Which hospitals are included?

It affects care at these Central Texas hospitals and their clinics: Dell Seton Medical Center, Ascension Seton, Dell Children's Medical Center, Ascension Seton Southwest, Ascension Seton Northwest., Ascension Seton Hays, Ascension Seton Williamson, Ascension Seton Bastrop, Ascension Seton Smithville, Ascension Seton Highland Lakes in Burnet, Ascension Seton Edgar B. Davis in Luling, and Ascension Providence in Waco.

It does not affect most of the 2,400 doctors who are at Ascension Seton hospitals because they have separate contracts with the insurance company, which are not up until May or June, depending on the plan. It does not affect Ascension Seton Shoal Creek mental health hospital because of a different contract, but it does affect all clinics attached to the Ascension Seton hospitals.

Why is this happening?

Hospital systems and insurance companies regularly review contracts prior to renewing them. Ascension Seton and Blue Cross and Blue Shield of Texas have been in negotiations since the fall. The contract, which was a multiyear contract, runs through Jan. 31.

"It's not like we're at an impasse," said Shara McClure, division vice president for health care delivery at Blue Cross and Blue Shield of Texas, "We're continuing to talk, continuing to come back with proposals."

Ascension Texas, which includes the Ascension Seton hospitals in Central Texas and Ascension Providence in Waco, declined to answer questions about the negotiations and the impact on its patients.

It did provide a written statement: "We are seeking to renew our Blue Cross Blue Shield of Texas (BCBSTX) agreement with reasonable and updated contract terms to help ensure its members in Central Texas can continue to access our unique combination of high-quality, advanced and affordable care. Ascension Texas is continuing to work with Blue Cross Blue Shield of Texas on contract terms that will ensure BCBSTX policyholders maintain in-network access to Ascension Texas hospitals, physicians and hospital-based clinics including Dell Children's Medical Center, and select joint venture facilities, including Ambulatory Surgery Centers. Without a commitment to reasonable terms, our current agreement with BCBSTX will end on January 31, 2023, for BCBSTX's Commercial and Medicare Advantage members."

Ascension Texas' 11 hospitals had a 2021 operating profit of $399.6 million, according to the National Academy for State Health Policy's Hospital Cost Toll and Resources. Health Care Service Corporation Group, which owns Blue Cross and Blue Shield of Texas, had a net income in 2020 of $3.889 billion, according to Best's Credit Report.

McClure of Blue Cross and Blue Shield of Texas said the differences between it and Ascension Texas involve reimbursement rates for services, which are "a lot of money," McClure said, "multi-, multimillions."

Blue Cross and Blue Shield of Texas has offered a cost coverage increase, but "so far their demands have been higher than we're willing to pay," McClure said. She said that compared with the other two hospital systems in the area — St. David's HealthCare and Baylor Scott & White Health — Ascension Seton is "already the highest cost system in the market," and the "children's facility (Dell Children's) is one of the highest in the state."

The hospital system and insurance company are also fighting over some language in the contract that McClure said would prevent the insurance company from doing claim reviews to make sure bills have appropriate changes.

Blue Cross and Blue Shield of Texas said it also wouldn't be able to offer plans that exclude Ascension hospitals, which it might want to do.

"We want to be able to maintain sovereignty," McClure said.

Caught in all of this are the patients. "We hope that we come to a deal," McClure said. "That would help with anyone's anxiety."

Are there exceptions to being out-of-network?

There are situations that could still be covered at in-network rates by Blue Cross and Blue Shield of Texas, McClure said.

If someone has an emergency or a trauma and is at a facility that is out-of-network, it is treated as in-network, she said.

If someone is in the middle of treatment for a chronic condition, a life-threatening situation or acute situation, or just had surgery and is doing follow-up, or if they are pregnant and have an established relationship with a hospital and doctor in that hospital, those cases can be considered "continuity of care" and can apply to receive in-network coverage.

If there are services that can only be done at an out-of-network hospital in Central Texas, those can be given in-network coverage, after approval.

If an agreement is not reached by Feb. 1, but is reached soon after, it is possible that Blue Cross and Blue Shield would give people who were caught in the gap in-network rates. That has happened in the past, McClure said.

What can Blue Cross and Blue Shield members do?

Blue Cross and Blue Shield of Texas and Ascension recommend that people call the insurance number on the back of their card to verify coverage and out-of-pocket expenses before a scheduled procedure or health test at an affected hospital or before going to a clinic that might be affected.

Ascension also provided a website, healthcare.ascension.org/BCBSTX. and phone number, 833-620-0183, for additional information.

Most people who have Blue Cross and Blue Shield of Texas insurance plans would have to pay out-of-network prices if they chose to go to an Ascension hospital. In-network versus out of network affects how high the deductible is before insurance begins to pay and it affects your out-of-pocket maximum expenses — the amount which, once you reach it, the insurance company begins to pay 100% of the costs.