Updates to the Blue Cross Medicare Advantage (PPO) and Blue Cross Medicare Advantage (HMO) Preauthorization Lists (2024)


Recap of Options Offered During the 2016 Open Enrollment Period


January 31 marked the end of the third annual enrollment period through the Health Insurance Marketplace. Blue Cross and Blue Shield of Texas (BCBSTX) remained committed to providing all Texans with sustainable health plan options that meet the varying needs of the state's population and contribute to the state's overall health. BCBSTX offers health insurance in all 254 counties in Texas and is the only health insurance provider offering individuals access to health insurance through the Federal Health Insurance marketplace in 58 of those counties.

2016 Individual Network Options
Individual members are those who buy their own insurance that is not provided by an employer or through a government program (Medicare, Medicaid, or CHIP). The following options were offered to individual members:

  • BCBSTX offered its Blue Advantage (BAV) HMOSM again to individual members both on and off the Health Insurance Marketplace.
  • BCBSTX offered the new Blue Advantage PlusSM HMO plan with added Point of Service (POS) benefits to individual members both on and off the Health Insurance Marketplace. This new HMO utilizes the Blue Advantage HMO network of doctors and hospitals while still having out-of-network benefits.
  • BCBSTX also offered Blue Cross Blue Shield Premier 101SM, a multi-state plan that utilizes the Blue Advantage HMO network; and has the same preauthorization requirements as Blue Advantage HMO. Blue Cross Blue Shield Premier 101 is only available to Individual members on the Health Insurance Marketplace.
    Please Note: Multi-State Plans are designed to increase consumer options on the exchanges. They are only available in the Individual market segment, through the Public Exchange. Multi-State Plans are bound by the same ACA regulations as other Qualified Health Plans, i.e., Essential Health Benefits, Out of Pocket Maximum regulations, etc.

Small Business Health Options Program (SHOP) Options
BCBSTX will continue to offer the Blue Choice PPO to small group members on the Small Business Health Options Program (SHOP). Small Group members will also still have access to our Blue Advantage HMO product. As a reminder, the terms of your BCBSTX agreements apply to plans offered on and off the SHOP. The terms of the agreement also require providers to offer their services to a BCBSTX member, regardless of where they purchased their coverage.

Identifying Your Patients' BCBSTX Insurance Plan
To identify your patient's BCBSTX plan, please view our sample ID cards. Plan specific alpha prefixes are assigned to every Blue Cross Blue Shield (BCBS) plan and start with X, Y, Z or Q. The first two positions indicate the BCBS Plan to which the member/subscriber belongs, while the third position identifies the product in which the member/subscriber is enrolled. Note: ZG identifies the Texas Plan.

  • To identify a patient who has the BAV HMO plan look for the alpha prefix or Texas alpha prefix which will start with “ZG*”" on the member ID card. The first two positions indicate the Plan to which the member/subscriber belongs while the third position identifies the product in which the member/subscriber is enrolled.
  • To identify a patient who has the BAV Plus, look for alpha prefix "ZGN" on the member ID card.
  • To identify a patient who has the 'Blue Cross Blue Shield Premier 101' multi-state plan (not specific to Texas), look for alpha prefix "VAL" on the member ID card.

Resources to Provide to your Patient's with Questions
If you have patients that are seeking assistance with their transition of care, we encourage you and your patients to contact BCBSTX with your questions through the phone numbers below. Our member advocates will work closely with your patients to ensure they have someone to speak with directly regarding their transition of care plan.

Member Customer Service: 888-697-0683
Pre-Authorization: 855-462-1785
Behavioral Health: 800-729-2422

BCBSTX provides a wide range of services and online tools to help renewing members make informed health decisions.

  • Provider Finder®: Members can select the best network provider for their needs based on location, as well as view industry-respected third party quality indicators, costs and patient-submitted reviews on an easy-to-navigate website.
  • Blue Access for MembersSM: Members can access information on their policy, including status of claims, alerts, temporary ID cards and more. This also includes Blue Access MobileSM, which allows members to find a doctor, hospital or urgent care facility in addition to benefit information.
  • 24/7 Nurseline: Members can speak with registered nurses about health concerns, common health information and tips and advice on where to go to receive necessary care.

You can also contact your local network management representative with any questions you may have.

BCBSTX Provider Relations Office LocationsTelephone NumberFax Number
Corpus Christi361-878-1623361-852-0624
Dallas, East Texas972-766-8900 / 800-749-0966972-766-2231
El Paso915-496-6600, press 2915-496-6611 915-469-6614
Houston, Beaumont713-663-1149713-663-1227
Lubbock, Amarillo806-783-4610806-783-4666
Midland, Abilene, San Angelo432-620-1406432-620-1428
San Antonio361-878-1623361-852-0624
Updates to the Blue Cross Medicare Advantage (PPO) and Blue Cross Medicare Advantage (HMO) Preauthorization Lists (2024)


Why are people leaving Medicare Advantage plans? ›

Most individuals that dislike a Medicare Advantage plan usually have had a bad experience with in-network providers, plan authorizations for medical care, or having to wait a long time to have an appointment scheduled. Some of these concerns can be attributed to the healthcare provider.

Why do doctors not like Medicare Advantage plans? ›

In some cases, your doctor may not agree with your insurance provider's decision to approve a less expensive treatment before paying for a more expensive one that your doctor may recommend. Providers in Medicare Advantage networks may also have to take time away from patients to spend it on pre-authorization paperwork.

What is the most highly rated Medicare Advantage plan? ›

Best Medicare Advantage Plans
  • Best Overall: AARP/UnitedHealthcare.
  • Lowest Cost: Cigna.
  • Great for Nationwide Coverage: Humana.
  • Best for Additional Drug Coverage in the Gap: Aetna.
  • Best for Patient Quality and Customer Satisfaction: Kaiser Permanente.

Why are medicare advantage plans bad? ›

Healthcare Gamble. Advantage plans have lower premiums and higher out-of-pocket costs than traditional Medicare plus Medigap. One-time medical events may sharply increase out-of-pocket spending under Advantage.

Why are hospitals refusing Medicare Advantage plans? ›

Why are hospitals dropping Medicare Advantage? Among other things, Medicare Advantage plans require patients to get prior authorization for more services than Original Medicare. Prior authorizations require time on the part of a medical provider, and the requests aren't always successful.

Why are insurance companies pushing Medicare Advantage? ›

Brokers have a financial incentive to encourage enrollment in Medicare Advantage plans because commissions are higher for Medicare Advantage than for Medigap and Part D plans that are purchased to complement traditional Medicare.

What is the scandal about Medicare Advantage? ›

The Indictment

In particular, the government alleges that in 2015, Boza and other coders began falsely diagnosing Medicare Advantage plan members with various chronic risk-adjusting conditions that were not diagnosed by the doctors who saw the members.

Are most people happy with their Medicare Advantage plans? ›

According to a new survey released today from the Commonwealth Fund, 96% of Medicare Advantage (MA) members and 93% of enrollees in traditional Medicare said that their Medicare coverage met their expectations, including 65% of each group who said their coverage fully met their expectations.

Can I drop my Medicare Advantage plan and go back to original Medicare? ›

You can drop your Medicare Advantage Plan and return to Original Medicare. You'll also be able to join a separate Medicare drug plan. During the Medicare Advantage Open Enrollment Period, if you have Original Medicare you can't: Switch to a Medicare Advantage Plan.

Which is better, a supplement or advantage plan? ›

Is a Medicare Supplement plan better than an Advantage plan? Medigap and Medicare Advantage plans offer different benefits, and which will better serve you depends on your specific health needs. Medigap plans offer additional coverage for people enrolled in Original Medicare, but they exclude prescription drugs.

Who is the largest provider of Medicare Advantage plans? ›

Standout feature: UnitedHealthcare offers the largest Medicare Advantage network of all companies, with more than 1 million network care providers. UnitedHealthcare.

What are the 6 things Medicare doesn't cover? ›

Some of the items and services Medicare doesn't cover include:
  • Long-term care (also called. custodial care. Custodial care. ...
  • Most dental care.
  • Eye exams (for prescription glasses)
  • Dentures.
  • Cosmetic surgery.
  • Massage therapy.
  • Routine physical exams.
  • Hearing aids and exams for fitting them.

Why do some people not like Medicare Advantage? ›

Restrictive networks

On Original Medicare, you can see any doctor who accepts Medicare (which is about 90% of doctors across the US). Medicare Advantage plans, however, have provider networks. In some cases, you'll have a higher share of costs when you see an out-of-network doctor.

What is better, original Medicare or Advantage plans? ›

In a nutshell, most Medicare Advantage plans provide similar coverage to Original Medicare with a Part D prescription drug plan and a Medicare supplement plan. Premiums and overall costs tend to be lower with Medicare Advantage, especially if you expect to have high costs for care.

What is the best supplemental insurance for Medicare? ›

Here's an overview of our top picks:
  • Best for Medigap plan options: AARP/UnitedHealthcare Medicare Supplement Insurance.
  • Best for member satisfaction: State Farm Medicare Supplement Insurance.
  • Best for premium discounts: Mutual of Omaha Medicare Supplement Insurance.
May 21, 2024

What is the future of Medicare Advantage plans? ›

Medicare Advantage (MA) is projected to be the line of business that drives the most profit for payers in 2026, 10. even while headwinds are emerging in the Medicare program. The Centers for Medicare & Medicaid Services (CMS) is projecting the Medicare trust fund will run out of money in 2031, 11.

Why do agents push Medicare Advantage plans? ›

A given carrier may pay slightly more commission to the agent (although there's a cap set by Medicare) and they may "sweeten" the plans to make them sound too good to be true. This is usually in the form of smaller benefits and add-ons at the expense of the important aspect of Advantage plans....the out-of-pocket max!

Are seniors happy with Medicare Advantage plans? ›

Despite most respondents in the survey reporting that their coverage met expectations, that finding does not suggest that enrollees are fully satisfied with every aspect of their Medicare coverage. Notably, though, there were few differences based on coverage type.


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