Negotiations Between Excellus BlueCross BlueShield (BCBS) and Area Providers

Contract discussions between third party administrators and health care providers are a routine aspect of the renewal process, and in nearly every case, end successfully. As health care costs continue to outpace the general rate of inflation, it’s never been more important to manage costs through favorable and appropriate provider contract agreements.

Across the nation and locally, it has become a common strategy for health care providers to notify their patients and the media about concerns they are having with their contract discussions with health insurers.

In the past, contract discussions were rarely made public. Today, more providers are using public pressure as a negotiation tactic. This is why you may hear about these discussions more often.

Certain providers including, Family Care Medical Group (FCMG) and St. Joseph’s Health are stating they will leave the Excellus BCBS network, as they have done with other major insurance carrier networks in the past, if they don’t come to a mutually agreeable solution. St. Joseph’s Health, a member of the Trinity Health System is currently in similar discussions with Aetna and Humana and has stated they will leave their networks effective Jan. 1, 2025 if agreements are not reached.

It is important to recognize that the University is not privy to the contract terms and negotiations between Excellus BCBS and providers, nor can it control a provider’s decision to participate in any network. However, the University has been closely monitoring the situation, discussing options with other large, local employers and is in regular communication with Excellus BCBS regarding this area of concern. We have urged them to reach a resolution quickly and in a manner that is favorable to our faculty and staff.

The University’s response was further detailed in a recent email to all benefits-eligible faculty and staff from Andy Gordon, senior vice president and chief human resource officer.

If providers, such as FCMG and St. Joseph’s, are no longer in Excellus BCBS’s network, they will be considered an out-of-network provider, so it is important to consider the following:

• The SUBlue and SUPro health plans cover eligible services provided by these providers but the claims will be processed as out-of-network. This means you will generally be responsible for higher out-of-pocket costs.
• The SUOrange health plan does not provide coverage for services from an out-of-network provider. If you are enrolled in SUOrange and are seen by an out-of-network provider, the cost of the visit will not be covered, and you will be responsible for paying the entire amount.
• If your provider is currently in-network and decides to no longer participate with Excellus BCBS in 2025, it is recommended that you consider enrolling in SUBlue or SUPro to have access to out-of-network coverage.

After evaluating your options, you may decide that it is in your best interest to start seeking services from an in-network provider. If you would like to learn more about in-network providers, call the University’s dedicated customer care team at Excellus BCBS by calling 800.493.0318 (TTY: 800.662.1220). You can also visit the Excellus BCBS website to locate care options.

Excellus BCBS and WellNow Urgent Care announced they have executed a new provider contract agreement. Members will have in-network access to Wellnow’s urgent care facilities effective Nov. 15, 2024. Members with questions about their benefits or coverage at WellNow may contact the Excellus BCBS Dedicated Customer Care Team at 800.493.0318 (TTY: 800.662.1220) Monday through Thursday from 8 a.m.-8 p.m. EST or Friday from 9 a.m.-8 p.m. EST.

Currently, the University is in a multi-year contract with Excellus BCBS and would not be able to simply switch to another insurer at this time. The process of switching third party administrators would take approximately one-and-a-half years to implement successfully. The fact that Excellus and certain medical providers engaged in this protracted contract negotiation will be considered when evaluating the University’s next contract.

The University self-insures its plan for the benefit of its faculty and staff. With a self-insured plan, costs are generally lower than a fully insured plan, as the plan sponsor or employer pays only for the health care claims costs of its own participants. Additionally, the plan has more flexibility to customize benefit plan design, as it is not regulated by most state requirements.

Partnering with a third-party administrator, such as Excellus BCBS, provides support to process claims, review for medical necessity, provide superior customer service support, contract with providers to participate in their network and administer other medical management programs.

• Under self-insured health plans, employers assume all financial risk for providing benefits to employees, allowing for more flexibility in plan design and potential cost savings, but also carrying more financial risk and administrative burden.

• Fully insured health plans involve employers paying a fixed premium to a health insurance carrier for their employees’ medical expenses, offering financial predictability but at higher premium to cover the cost of medical claims, their associated risk, and the insured costs, fees and taxes.

If you would like to learn more about in-network providers, call the University’s dedicated customer care team at Excellus BCBS by calling 800.493.0318 (TTY: 800.662.1220). You can also visit the Excellus BCBS website to locate care options.

The three separate major hospitals in the Syracuse area include Upstate University Hospital, Crouse Hospital and St. Joseph’s Health, which all currently participate with Excellus BCBS. If any of the three hospitals makes the decision to exit the Excellus BCBS network, they will be considered an out-of-network provider and the others would remain in-network, pending additional contract negotiations.

If you are enrolled in the SUBlue or SUPro health plans, eligible services provided by an out-of-network provider will still be covered but processed as an out-of-network claim, which means you will be responsible for higher out-of-pocket costs. SUOrange does not provide coverage for services with an out-of-network provider. If are enrolled in SUOrange and are seen by an out-of-network provider, the cost of the services will not be covered, and you will be responsible for paying the entire amount.

Excellus BCBS and WellNow Urgent Care announced they have executed a new provider contract agreement. Members will have in-network access to Wellnow’s urgent care facilities effective Nov. 15, 2024. Members with questions about their benefits or coverage at WellNow may contact the Excellus BCBS Dedicated Customer Care Team at 800.493.0318 (TTY: 800.662.1220) Monday through Thursday from 8 a.m.-8 p.m. EST or Friday from 9 a.m.-8 p.m. EST.

The SUOrange health plan does not provide coverage for services with an out-of-network provider. If you are enrolled in SUOrange and seen by an out-of-network provider, the cost of the visit and related services will not be covered, and you will be responsible for paying the entire amount.

If your provider is currently in-network and decides to no longer participate with Excellus BCBS in 2025, it is recommended that you consider enrolling in SUBlue or SUPro during this year’s Open Enrollment period, Oct. 28-Nov. 8 through MySlice, to have access to out-of-network coverage.

Should you decide to remain in SUOrange and would like to learn more about in-network providers, call the University’s dedicated customer care team at Excellus BCBS by calling 800.493.0318 (TTY: 800.662.1220). You can also visit the Excellus BCBS website to locate care options.

• Review your health plan options to ensure you are enrolled in the health plan that meets your needs:
  • Learn more about the University’s three health plan options, SUBlue, SUOrange and SUPro on the Health Plan benefit webpage.
  • In general, the same services are covered under all three plans, but with different contributions and out-of-pocket cost sharing structure. A comparison of the three plans, including their associated costs, are highlighted in the At a Glance: A Comparison of Health Care Plans [PDF].
  • It is important to keep in mind that SUOrange does not provide coverage for services with an out-of-network provider. If you are seen by an out-of-network provider, the cost of the visit will not be covered, and you will be responsible for paying the entire amount. If your provider is currently in-network and decides to no longer participate with Excellus BCBS in 2025, it is recommended that you consider enrolling in SUBlue or SUPro during this year’s Open Enrollment, Oct. 28-Nov. 8, to have access to out-of-network coverage.
• Consider enrolling in a health care flexible spending account (FSA) to help afford eligible out-of-pocket costs:
  • Contributions to a health care FSA are deducted pre-tax, reducing your taxable income. The money is deposited into an FSA administered by HealthEquity and can only be used for eligible expenses incurred during the calendar year, such as copays, coinsurance, deductibles and out-of-pocket costs from your health plans (even if you are not on the University’s health plan), dental and vision expenses, prescriptions and eligible health care products.
  • Visit the health care FSA webpage for more information and helpful links to assist in planning your FSA contribution.

You can find a comparison of the three plans including their associated costs are highlighted in the At a Glance: A Comparison of CY 2024 Health Care Plans.

Detailed information about out-of-pocket cost-sharing levels for specific services under the three plans can be found in the Schedule of Benefits as follows: SUBlue, SUOrange and SUPro.

Patients undergoing treatment when their provider leaves the network have rights to continue their treatment at in-network costs for a period of time. Please contact the Excellus BCBS customer care team at 800.493.0318 (TTY: 800.662.1220) if you need additional assistance regarding your treatment. Excellus BCBS’s hours of operation are Monday through Thursday from 8 a.m. to 8 p.m. and Friday from 9 a.m. to 8 p.m.

Once a provider rejoins the Excellus network, any eligible services you incur will be covered as in-network.

• HR Shared Services is available 8:30 a.m. to 5 p.m., Monday through Friday, at 315.443.4042 to answer your personal questions. Appointments are available upon request. Walk-ins are welcome.

• Call the University’s dedicated Excellus BCBS customer service center at 800.493.0318 (TTY: 800.662.1220) if you need additional assistance regarding your personal medical or dental plan questions. Excellus BCBS’s hours of operation are Monday through Thursday from 8 a.m. to 8 p.m. and Friday from 9 a.m. to 8 p.m. For prescription drug questions, contact Optum Rx member services at 866.854.2945 (TTY: 711). They are available to assist you 24/7.

• Members can access the Excellus BCBS 24/7 Nurse Line at 800.493.0318 (TTY: 800.662.1220). Specially trained registered nurses from Excellus BCBS can provide support and education for members with chronic or complex health conditions, or provide answers to more general health questions, 24 hours a day, 7 days a week.

• During Open Enrollment, representatives from Excellus BCBS and Human Resources will be available in person, on campus to discuss your personal medical, dental or other benefit related questions. Dates and locations will be announced during Open Enrollment.

MDLIVE is available 24 hours a day, 7 days a week, even on holidays, to provide in-network care for non-emergency medical or behavioral health conditions. Board-certified doctors and licensed therapists treat a wide range of conditions and generally can prescribe medications. For more information, please visit the MDLIVE webpage.

Call the University’s dedicated Excellus BCBS customer care team at 800.493.0318 (TTY: 800.662.1220) if you need additional assistance regarding your personal medical or dental plan questions. Excellus BCBS’s hours of operation are Monday through Thursday from 8 a.m. to 8 p.m. and Friday from 9 a.m. to 8 p.m.

• Benefits-eligible employees have the choice of three health plan options, SUBlue, SUOrange and SUPro, through the University’s employee benefits program.
• Other options for health insurance outside the University’s plans are available and include:
  • Coverage through your spouse or partner. If this is a feasible option, you should compare the coverage and cost of the plans during the upcoming Open Enrollment period, Oct. 28-Nov. 8.
  • A variety of health insurance options are available through the Health Plan Marketplace of private insurers with subsidies available. More information about the Marketplace is available by phone at 800.318.2596 (federal) and 855.355.5777 (New York State).