Southwestern Benefit Designers - Blogs #Accident InsuranceSouthwestern Benefit Designers - Blogs #Accident Insurancehttps://www.swbdmg.com/blogs/tag/accident-insuranceWed, 15 Oct 2025 14:34:09 -0700http://zoho.com/sites/<![CDATA[BCBS TX — MyBlue Health HMO: Using PCPs vs Select PCPs]]>https://www.swbdmg.com/blogs/post/bcbs-tx-—-myblue-health-hmo-using-pcps-vs-select-pcps

MyBlue Health HMO: Overview

  • In January 2020, Standard Products launched the Texas high performance network in the Dallas and Harris Markets to establish a competitive product aimed to deliver value and offer a competitiaaaave offering for subsidized market providing access to high quality care at an affordable price.

  • While the MyBlue Health network is mirrored after the Blue Advantage HMO product, Blue Advantage HMO and Blue Advantage Plus are different products that do not have relation/combination with MyBlue Health.

  • A consumer not located in the zip codes where MyBlue Health is available, will not have the ability to enroll in the product.
  • A key feature of the MyBlue Health HMO is the Sanitas Medical Group collaboration model.

MyBlue Health HMO: Sanitas Benefits

  • All BCBSTX members (all lines of business) can utilize Sanitas Medical Group professionals and Sanitas Medical Centers but only MyBlue Health HMO members who selected a Sanitas PCP have a $0 PCP cost share when at a scheduled PCP visit with their Sanitas PCP

  • MyBlue Health HMO members don't have to use Sanitas PCPs; if they don't, they're encouraged to stay in network on their MyBlue Health HMO plan and would pay applicable cost shares

    • The Sanitas $0 PCP benefit is only for members who:

    1. live in Dallas or Harris county

    2. select a MyBlue Health HMO policy in the Retail ACA QHP market (on & off exchange)

    3. choose a PCP from the Sanitas Medical Group

  • General plan benefits apply to services excluded from or not listed as included at $0
  • General plan benefits apply to all services provided outside of Sanitas Medical Group, even if referred from a Santas PCP

Select PCP Practice Groups

Bexar County:

CentroMed


Dallas County:

Sanitas Medical Centers


Harris County:

Sanitas Medical Centers


Travis County:

CommUnityCare

Lone Star Circle of Care


Williamson County:

CommUnityCare

Lone Star Circle of Care

Select PCP Practice Groups for Expansion Counties

Cameron County:

Su Clinica Familiar

Harlingen Physician Network

BHS Physicians Network (dba Baptist Medical Network)


Collin/Denton/Tarrant County:

VMO Primary Providers N TX PLLC


El Paso County:

Centro De Salud Familiar La Fe Inc

Project Vida Health Center


Hidalgo County:

South Texas Health System Clinics


*other independent community physicians may be eligible to serve as a Select PCP

]]>Mon, 24 Oct 2022 13:18:40 +0000<![CDATA[ Case Study: M Company]]>https://www.swbdmg.com/blogs/post/allstate-initial-quote-pre-underwriting-vs-final-pricing-after-u-w-produced-a-7.8-lower-final-price

Allstate initial quote (pre-underwriting) vs final pricing after u/w produced a 7.8% lower final price

By David Rubey, Sr. Advisor -- Group & Individual Health, Life, and Disability

After u/w we typically see pricing lower than the initial quote. Therefore, to accurately show premium differences/savings it is best to get employees to complete the medical questions up-front.   However, we know that is not always realistic, so Allstate will provide an illustrative quote on census data. 


NOTE; this group has a recent newborn with ongoing potential medical bills, along with some other employees with claims, i.e. it is not some perfect / no-claims, best possible case scenario, and they still received lower premium rates after underwriting. 


Comparison of premium of the Fully Insured Guarantee Issue renewal plan. This is also lowest premium of all major FI / GI carrier quotes.


                                                                HMO plan with $3,500 deductible                          Allstate PPO w/ National PPO                   Renewal % higher than Allstate

Employee Only:                                                         $503.09                                                          $347.07                                                           45%

Employee + Spouse:                                               $1,006.18                                                      $832.93                                                            21%   

Employee + Child(ren):                                           $1,006.18                                                      $659.42                                                            53%

Employee + Family:                                                 $1,509.27                                                      $1,110.58                                                        36%


 


Comparing to PPO rates so as to be closer to Apples to Apples price comparison

Current carrier PPO Plan Option:

EE Only:                                                                       $564.75                                                                         63%

EE + S:                                                                          $1,129.50                                                                      37%

EE + C:                                                                          $1,129.50                                                                      71%

EE + F:                                                                          $1,694.75                                                                       53%

* Both renewal and Allstate plans have a $3,500 deductible.   Renewal max out-of-pocket is $7,900 while Allstate's is $8,550. 

 

Most employee of this group have Family coverage.  Based on current enrollment this group will save over 35% with a well recognized national PPO network vs renewal with an HMO network.  If comparing to PPO network pricing, the cost saving would exceed 50%.  Since this group now has employees in other states, a national PPO network is important to them.


The Allstate plan is also on a level premium funded participating contract.  This simply means that approx. 6 months after the plan year end, Allstate will compare claim dollars spent vs claim fund dollars.  If there is a positive balance, 50% of the balance will be paid back to “M” company.  If there is a negative balance, “M” company will not pay any more than the initial premium already paid. 


Seeing a nearly 8% pricing difference in the quote after medical questionnaires were completed shows the importance of getting these done up front when possible.  After the full underwriting is done, there is still  ZERO obligation to use Allstate.  However, with most of our clients, the potential to save 25%, 30%, even 50%+ is motivation enough for employees to complete the questionnaires. This is especially true when the employees are sharing in the cost of the insurance. In looking at the EE + Family cost, presuming the company pays 50% of employee only price and $0 towards spouse/child premium costs, the employees are looking at saving, approximately $485/mo or roughly $5,800 per year out of their pocket (or added to their bring home pay).  That is effectively a SIGNIFICANT pay increase for the employee, while on this group of 10 employees, it is also SAVING the company over $18,500 per year in their costs, with potential to save even more in good claim years. 

With this type of saving, employers can offer more benefits to better compete with larger employers, like group life, AND employees will have more money to have for other ancillary lines of coverage like voluntary life, dental, vision, Accident Medical/GAP coverage, etc.  similar to what many larger employers are offering in an effort to attract and retain top level employees. 
]]>Tue, 11 Oct 2022 13:02:00 +0000