Policy changes
Over the last year, we’ve made some important changes to our medical policies to help address rising health care costs. These changes have been implemented in compliance with our provider contracts and are helping us regulate costs on behalf of our members.
Our changes include:
- •Improving how we review claims before they’re paid to make sure they accurately align with the services provided
- •Adjusting payment policies for mid-level providers
- •Lowering lab and drug costs in the BlueCare program
How these changes work
Pre-payment claims reviews
Simply put, inaccurate coding from providers drives up costs for our members. Following national best practices, our improved process will allow us to catch more coding inaccuracies before paying claims, reduce overpayments, ensure fair pricing and improve efficiency. Our reviews always include oversight from expert members of our medical and claims teams.
Mid-level provider reimbursement
BlueCare specialty drug markups
We reimburse providers for administering specialty drugs, and they add markups to the prices of the drugs themselves to cover their services. But it’s no longer feasible to pay a 20% markup on these medications. So, we’re reducing that markup to 6%, which aligns with how we pay for these drugs on behalf of members under other health plans.
BlueCare laboratory reimbursement
We’ve updated our processes so that BlueCare can seek lab services and reimbursements from providers at affordable rates. Doing so ensures our Medicaid members receive top lab services at a reasonable cost.
The Situation
We hope not. We are currently negotiating with Baptist Memorial Hospital-Memphis (BMH) in order to reach an agreement on a new contract for our BlueCare and TennCareSelect networks. We value the care that BMH clinicians provide and are committed to working toward a resolution that supports affordability and access for the Tennessee communities we serve.
Our current contract with BMH extends through October 31, 2025. If we aren’t able to come to an agreement before October 31, BMH providers and facilities will be considered out of network for our BlueCare and TennCareSelect members beginning November 1, 2025.
All other BlueCross plans will be unaffected and remain in-network with BMH, through October 31 and beyond.
The role of BlueCross BlueShield of Tennessee is to provide access to quality care at the best possible prices. Our members are asking us for help in managing rapidly rising healthcare costs, and we’re responding by making changes that will provide them with much-needed savings. These changes include improving the way we review claims before they’re paid, to make sure they accurately align with the services provided, adjusting payment policies for mid-level providers, and lowering lab and drug costs in the BlueCare Tennessee program.
It’s important to note that these changes to lab fees, physician-administered medication payments and mid-level provider payments are in line with what hospitals and providers across the state already accept from our competitors – and our provider partners signed contracts with us that allow us to make these changes. We have notified facilities and affiliated physicians of these changes and are negotiating with Baptist Memorial Hospital-Memphis (BMH) to reach a new agreement before our current contract expires on October 31, 2025.
BMH is an important part of the Tennessee provider community. We respect the care their clinicians deliver and hope to reach an agreement that will allow them to remain in our networks. BlueCare and TennCareSelect members will continue to have in-network access at BMH facilities and affiliated physicians through October 31 – and beyond, if they agree to reasonable rates. If BMH ultimately leaves any of our networks, we’ll work proactively with BlueCare and TennCareSelect members to make sure they get the care they need.
We’re working to negotiate an agreement that will keep its clinicians and facilities in our BlueCare and TennCareSelect networks. We want to assure all members of these networks that they will continue to have in-network access at BMH facilities and with their physicians through October 31, 2025 – and beyond, if they agree to reasonable rates. We’re sharing this information now because we believe you deserve transparency.
If we cannot reach an agreement, BMH will leave our BlueCare and TennCareSelect plans after October 31, 2025. If you are covered by one of our impacted plans, any care you receive at BMH facilities or from its affiliated providers on or after November 1, 2025, will be considered out of network.
All other BlueCross plans will be unaffected and remain in-network with BMH, through October 31 and beyond.
Your Care
If an agreement is not reached by October 31, 2025, all members of our BlueCare and TennCareSelect plans will need to seek care from other facilities beginning November 1, 2025.
If you’re covered by one of those plans, any care you receive at BMH facilities or from affiliated providers on or after November 1, 2025, will be considered out of network, and you will likely be required to pay more for the care you receive there.
Our 2025 BlueCare and TennCareSelect plans include several generous out-of-network benefits to help mitigate costs. This means that you could continue using your preferred BMH-affiliated providers with nominal cost differences, even if we are unable to reach an agreement and they go out of network on November 1, 2025.
To see the out-of-network benefits included in your plan, consult your Evidence of Coverage here. These are based on your BlueCare plan, which you can find on the bottom left corner of your Member ID card.
We’re committed to coordinating care for our members and helping them get the services they need. We maintain an excellent network of hospitals and surgery centers where you and your family can receive care. Your BlueCare and TennCareSelect plans give you the freedom to visit the in-network healthcare facility of your choice. Members can call the telephone number on the back of their Member ID card or visit bcbst.com for help finding alternative care options.
However, if we’re unable to reach an agreement, you’re a BlueCare or TennCareSelect member, and you use a BMH facility or clinician on or after November 1, 2025, you’ll be getting care from an out-of-network facility. This means you’ll pay more for the same care that you could receive from an in-network facility, and in some instances be responsible for the full cost of that care. View our list of alternative in-network facilities where you can seek care if BMH does go out of network.
Yes, you should always go to the closest emergency room. Emergency room benefits for true emergencies will not be affected if BMH leaves our network. Covered emergency room benefits for true emergencies are covered as in-network. Please note that, if admitted and once stabilized, you will need to be transferred to a participating facility. See below for the definition of a true emergency.
An emergency is defined as a sudden and unexpected medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect to result in:
- serious impairment of bodily functions
- serious dysfunction of any bodily organ or part
- placing a person’s health in serious jeopardy
Examples of emergency conditions include: (1) severe chest pain, (2) uncontrollable bleeding and (3) unconsciousness.
Doctors and Health Facilities
If you have a BlueCare or TennCareSelect health plan, then any care you receive from BMH-affiliated providers will be considered out of network after October 31, 2025. This means you will likely be required to pay more for the care you receive on or after November 1, 2025.
We’re working hard to reach agreement because we know that BMH facilities and providers are the top choice for many BlueCare and TennCareSelect members in the Memphis area. We urge you to use our provider directory to see if your caregiver is in network.
Yes, it includes all facilities owned/operated by West Tennessee Healthcare. If we are not able to come to an agreement before Feb. 12, 2021, the West Tennessee Healthcare clinics listed below will be considered out-of-network.
- [Cardiology Outreach Clinic, Camden]
- [Cardiology Outreach Clinic, Lexington]
- [Cardiology Outreach Clinic, Paris]
- [Dizziness and Balance Clinic, Jackson]
- [Heart Rhythm Clinic, Jackson]
- [Lexington Medical Clinic]
- [Lift Health Clinic, Jackson]
Yes, this will impact imaging centers that are owned/operated by West Tennessee Healthcare, and its facilities that offer imaging services. Again, this change will not take place until Feb. 13, 2021. We hope to reach an agreement to keep these facilities in-network.
If you have an authorized test scheduled at a WTH facility or with a WTH-affiliated provider between now and Feb. 12, 2021, you will be considered in-network. Any authorized tests as of Feb. 13, 2021, will be considered out-of-network and you will likely be required to pay more for the care you receive. In addition to the hospital, the facilities offering imaging services listed below are part of West Tennessee Healthcare.
- [West Tennessee Imaging Center, Jackson]
- [West Tennessee Neuroscience & Spine, Jackson]
- Prime Care Medical Center, Selmer
Yes, this will impact rehabilitation and physical therapy services that are owned/operated by West Tennessee Healthcare. Again, this change will not take place until Feb. 13, 2021. We hope to reach an agreement to keep these facilities in-network.
If you have an appointment scheduled at a WTH facility or with a WTH-affiliated provider between now and Feb. 12, 2021 you will be considered in-network. Any appointments on or after Feb. 13, 2021, will be considered out-of-network and you will likely be required to pay more for the care you receive. The facilities listed below are part of West Tennessee Healthcare.
- Lift Center, Jackson
- [Sports Plus AquaTherapy, Jackson]
- [Sports Plus RehabCenters
- Alamo
- Brownsville
- Dyersburg
- Henderson
- Humboldt
- Lexington
- Medina
- Milan
- North, Jackson
- South, Jackson
- Trenton]
- [Work Plus Rehab Center, Jackson]
Yes, this will impact behavioral health services that are owned/operated by West Tennessee Healthcare. Again, this change will not take place until Feb. 13, 2021. We hope to reach an agreement to keep these facilities in-network.
If you have an appointment scheduled at one of the Pathways Behavioral Health facilities between now and Feb. 12, 2021, you will be considered in-network. Any appointments as of Feb. 13, 2021, will be considered out-of-network and you will likely be required to pay more for the care you receive.
The behavioral health facilities listed below are part of West Tennessee Healthcare.
- [Pathways, Dyer County
- Pathways, Haywood County
- Pathways, Henderson County
- Pathways, Jackson
- Pathways, Obion County
- Pathways Employee Assistance Program, Jackson
- Pathways, Lake County
- Pathways Peer Support Center – Comfort Center, Lexington
- Pathways Peer Support Center – Hope House, Dyersburg
- Pathways Peer Support Center – Rainbow Center, Jackson]
Your BlueCare and TennCareSelect plan gives you the freedom to visit the hospital of your choice. However, if we’re unable to reach an agreement and you use a BMH facility on or after November 1, 2025, you’ll be getting care out of network. That means you’ll pay more for the same care that you could receive from an in-network facility, and in some cases will have to pay the full amount for that care.
Scheduled Procedures/Ongoing Treatment
BMH remains in our all of our networks until October 31, 2025. Any authorized and scheduled surgeries between now and then will be covered as in network. We hope we can reach an agreement to keep their facilities and affiliated providers in our BlueCare and TennCareSelect networks beyond that time.
All other BlueCross plans will be unaffected and remain in-network with BMH, through October 31 and beyond.
In the event we don’t reach an agreement by October 31, 2025, you’ll have a few options when it comes to your care.
If you have ongoing services scheduled at a BMH facility, a nurse from BlueCross will work with you to help make sure you continue to receive appropriate care from an in-network healthcare provider. We want to be sure you don’t have any disruptions in care.
Under our Continuity of Care policy, some BMH patients may be granted in-network status. Patients who may qualify for this status include:
- Patients whose practitioner/facility are terminated from the network during treatment, i.e., chemotherapy or radiation patients
- Patients with complex medical and/or behavioral health conditions
If you think you qualify for in-network status, please call the Member Service telephone number on the back of your Member ID card or complete this form and return it to: BlueCross BlueShield of Tennessee, 1 Cameron Hill Circle, Ste. 0002, Chattanooga, TN 37402-0002.