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Broker News | June 2016 | Vol. 11 No. 6
Broker News | June 2016 | Vol. 11 No. 6

In/Out of Network Differential for Excellus BlueCross Blue Shield Large Group PPO Products

As part of Excellus BlueCross BlueShield’s ongoing effort to improve the quality and affordability of the health care our members receive, we are instituting a few changes to our PPO portfolio for plans with an effective date of January 1, 2017 and after.

Preferred Provider Organizations (PPOs) represent a form of managed care in which providers agree to accept discounted fees in exchange for the expectation that their patient volume will increase or at least be maintained.

In order to maintain our position with these PPO provider discounts, we are required to encourage members to utilize in network PPO providers through benefit design and have identified an opportunity to highlight our network strength in our product designs.

This multi-year strategy will:

  • Adjust our preferred portfolio
  • Focus on HDHPs first (2017)
  • Transition the rest of our Copay and Hybrid PPO plans (2018)

Non-PPO/Non-Par providers are providers that have no contractual relationship with Blue Cross Blue Shield and, therefore, offer less protection for you and your employees, as far as costs and quality efforts.                      

Which segments are impacted by this benefit design change?

> Small Group portfolio                                                                                                                                                                
>Large Group and Self-funded portfolio, including Custom plan types

Please note: Grandfathered groups, both fully-insured and self-funded, are also required with this benefit design change but are allowed to keep their grandfathering status. 

What percent of members will truly be impacted by this change? 

The vast majority of providers participate in Excellus BCBS PPO networks, leaving less than 1% of claims incurred with Non-PPO providers.

Overall strategy:

All PPO High Deductible Health Plans (HDHP) will now have a separate in and out network deductible and a separate in and out of network out of pocket maximum.

In addition, both the deductible and out of pocket maximums for out of network will always be double that of the in-network.            

Current State  2016 1/1/2017 Effective date and beyond
  In-network Out-of-network In-network Out-of-network
Deductible Combined in- and out-of-network Deductible Separate in-network deductible Separate out-of-network deductible ($ will be 2X the in-network deductible)
OOPM Combined in- and out-of-network Out Of Pocket Maximum Separate in-network Out Of Pocket Maximum Separate out-of- network deductible  ($ will be 2X the in-network Out Of Pocket Maximum)
Coinsurance Coinsurance  IN Coinsurance OUT Coinsurance in

If Coinsurance In= Coinsurance Out

Coinsurance  +10%


This type of benefit design model has been shown to provide the best foundation to encourage members to use our PPO network so we can continue to keep the strong discount provided through the BlueCard network.

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