With the contract dispute between BlueCross BlueShield of Texas (BCBSTX) and Texas Health Resources (THR) still unresolved, it is important that anyone using THR health care providers be prepared for the possibility that an agreement may not be reached by the December 31, 2010, deadline.
If the BCBSTX-THR contract is not renewed, effective January 1, 2011, THR hospitals, ancillary facilities (e.g., out-patient surgical centers, imaging centers and behavioral health facilities), and doctors affiliated only with THR hospitals, will no longer participate in the BCBSTX BlueChoice® PPO network available to SMU faculty and staff. In this case, you have two choices:
1.  Choose a new primary care physician or specialist who participates in the BCBSTX network. Many doctors are affiliated with multiple hospitals so there is a good chance your doctor(s) is/are affiliated with other in-network hospitals. See Additional Information below.
2.  Continue using THR physicians and hospitals, with the understanding that you (and SMU) will pay a much larger portion of the cost of care. Below are two examples of out-of-pocket expenses for services provided on an in-network vs. out-of-network basis for an individual enrolled in the BCBSTX $2,000 Deductible option.
Office Visit / In Network / Out of Network
Billed Charge / $190.00 / $266.00
Allowed Amount / $91.20 / $156.94
Plan Provisions / $25 Office Visit Copay / $4,000 deductible + 40% of remaining charges
($8,000 Annual Out-of-Pocket Max)
Employee's Portion / $25.00 / $156.94
SMU's Portion / $66.20 / $0.00
Surgery / In Network / Out of Network
Billed Charge / $41,666.67 / $62,500.00
Allowed Amount / $20,000.00 / $41,875.00
Plan Provisions / $2,000 deductible + 20% of remaining charges
($5,500 Annual OOP Max) / $4,000 deductible + 40% of remaining charges
($8,000 Annual OOP Max)
Employee's Portion / $5,475.00 / $7,843.06
SMU's Portion / $14,525.00 / $34,031.94
If the BCBSTX-THR contract is not renewed, and you continue to receive care from THR providers on or after January 1, 2011, it is important that you fully understand the impact this will have on your out-of-pocket expenses, as well as SMU expenses.
Transitional Care Benefits
Coverage will be allowed at the in-network level of reimbursement for special circumstances or certain medical conditions, when specific criteria is met and approved. Special circumstances or medical conditions that may qualify for Transitional Care Benefits include, but are not limited to:
·  Existing pregnancy in the third trimester, or a high-risk pregnancy
·  Certain pre-scheduled surgeries
·  Patients currently under the care of an oncologist and receiving chemotherapy
·  Ongoing acute care
o  required due to recent trauma, surgery, disability or a life threatening condition or lengthy illness
·  Ongoing psychiatric/substance abuse care
·  Ongoing physical /occupational therapy
o  required due to recent acute-care stay, trauma, surgery or lengthy illness
It is important that you understand that approval of Transitional Care Benefits is determined on a case-by-case basis.
·  If you feel that you or an enrolled family member may qualify for Transitional Care Benefits, call BCBSTX Customer Service at 877-768-2005.
Additional Information
Click on www.membersforafairdeal.com → Options for Care for:
·  A list of hospitals and ancillary facilities and a list of physicians that will be impacted if the BCBSTX-THR contract is not renewed.
·  A list of alternative BCBSTX in-network facilities.
Click on www.bcbstx.com to search for in-network doctors affiliated with non-THR facilities.
·  Click on Find a Doctor
·  Under Step 1 (Select a Health Plan/Network), choose BlueChoice® PPO Plan.
·  Select a Provider Type (Primary Care Physician or Specialist).
·  When you select a specific doctor, you will see their affiliated hospitals.
The Department of Human Resources will provide updates as soon as possible. We remain hopeful that BCBSTX and THR will reach an agreement and have a contract in place for 2011.