BCBS – TX

Blue Cross Blue Shield of Texas (BCBSTX) is the largest small group insurer in the state by far with more than 600,000 members and 83% market share. The majority of new fully-insured small groups are written with BCBSTX. They have the largest PPO and HMO networks in the state and the lowest-priced HMO plans in nearly every market. The Baylor Scott & White PPO plan rates do beat BCBSTX in most markets, but their network is significantly smaller than BCBSTX. BCBSTX normally requires employee apps, which can be a pain, but it appears there is a census enrollment option (more info in the enrollment paperwork section). They are a little more lenient with their eligibility requirements than other carriers – for instance, they are the only carrier in the state that will allow a “one person group,” and a group with part-time owners is also ok. Their underwriting is normally pretty quick; often you will hear back within 24 hours of submitting a case.

BCBSTX is owned by Health Care Service Corporation (HCSC), one of the largest health insurers in the nation. HCSC owns BCBS plans in Illinois (their headquarters), Montana, New Mexico, Oklahoma, and Texas. The websites and many of the processes will be similar for these five carriers.

Service Area

BCBSTX offers coverage in every county in Texas (all 254 counties and 27 rating areas). They have a state-wide HMO, so there are no restrictions for members who live in Texas. Employees who live outside of Texas will need to select a PPO plan. The PPO plan is nationwide as members have access to the BCBS networks across the country.

Plan Options

• Available Plans: There are 35 PPO plans and 36 HMO plans that have the same in-network benefits (the benefits are mirrored across the two networks). There is one additional HMO plan with no deductible and with copays rather than coinsurance for all services. So, in total, there are 71 plans.
• Plan Offerings: Employers can offer up to 6 plan options to employees, including “ghost” plans with no current enrollment. This allows for a mixture of PPO and HMO plans, copay and HSA plans, and plans with different deductibles and out-of-pocket limits.
• Drug Formulary: All small group ACA plans have the same prescription drug forumlary. Copay plans have a six-tier benefit. Four of those tiers have lower copayments if the member goes to one of six preferred in-network pharmacies.
• Plan Designs: View the 2024 small group plan grid.

Provider Network

BCBSTX has two provider networks: Blue Choice PPO and Blue Advantage HMO. Here’s a member flier about the two networks.

• PPO Network: The Blue Choice PPO network is the largest in the state and includes most major hospital systems. PPO plans end with the letters CHC (for Choice).
• HMO Network: The Blue Advantage HMO network is a statewide HMO and the largest in the state (larger than most carriers’ PPO networks). Members who select the HMO will have to choose a primary care physician and get referrals to see a specialist. Here’s a member flier about the PCP requirement and referral process. HMO plans end with the letters ADT (for Advantage Texas), but when doing an online provider search, it’s abbreviated BAV (for Blue Advantage).
• Compare the PPO and HMO Networks: Statewide, the HMO has about 90% of the hospitals, 79% of the PCPs, and 84% of the specialists compared to the PPO network. There are 660 In-Network Hospitals, 12,006 In-Network PCPs, and 54,357 In-Network Specialists in the HMO network. Different market areas have network comparison fliers: Austin  DFW  East Texas  Houston  San Antonio  South Texas/Valley  West Texas
• Provider Search: To search for BCBSTX providers, including PCPs, existing members can log in here. Non-members can Search for Doctors as a Guest. After clicking the link, enter the zip code and select a network. For the PPO plans, select Blue Choice PPO [BCA], which is about the 8th option in the drop-down. For the HMO plans, select Blue Advantage HMO [BAV], which is the fifth option. When searching for a PCP on the HMO plans, the employee can select the Primary Care drop-down below the search bar, but unfortunately there’s no way to see all of the PCP options at once – you have to choose Family Practice, General Practice, Internal Medicine, etc. Also not all doctors on the list are available as PCPs;  you have to search for one that has a PCP ID number, which will need to be included on the employee enrollment form. PCP numbers look like this: H08565NK01.

Eligibility, Participation, and Contribution

• Small Group Market: In Texas, a small group is one with 2-50 total employees (including owners, full-time employees, and part-time employees, whether eligible for benefits or not. This is known as ATNE (Average Total Number of Employees).
• Full-Time Status: An employee averaging 30 or more hours per week is considered full-time and eligible for benefits in Texas. BCBSTX follows this standard. Part-time employees are not eligible for coverage.
• Effective Dates: Coverage can start on the 1st or 15th of any month.
• Eligibility: Like every carrier in Texas, any group with 2 eligible people qualifies for small group coverage. BCBSTX will accept owner-only groups with no W-2 employees as long as the group is set up as a partnership or an LLC filing as a partnership. This includes husband-and-wife groups.
• Owner Eligibility: With BCBSTX, there is no requirement that the owners work full-time in the business. This is more lenient than state law, which says that owners do not have to work full-time hours to be eligible for coverage as long as the group can stand on its own without the part-time owner (in other words, as long as there is a combination of two full-time owners and/or employees).
• One-Person Groups: BCBSTX will also accept “one-person groups” as long as there are at least two eligible people (owners and/or full-time W-2 employees).
• Participation: BCBSTX requires 75% participation among eligible owners/employees after removing those with valid waivers (those with other group, individual, or government coverage).
• Contribution: The employer must contribute at least 50% of the employee-only premium for the lowest-priced plan offered, whether the group is age or composite rated.
• NPNC Groups: Per ACA rules, the participation and contribution requirements are waived for groups that enroll during the small group open enrollment period. In Texas, this runs from November 1 to December 15 for a January 1 effective date. These groups are often referred to as No Participation No Contribution (NPNC) Groups.

Enrollment Paperwork

Each group applying with BCBSTX must complete the following forms:

Benefit Program Application (BPA): This is the employer application. It’s long, but a lot of the pages are just informational and there’s nothing to complete. There is an optional proxy form because BCBSTX is a mutual legal reserve company. The last two pages are for groups offering an HMO; if no HMO is offered, then the last page does not need to be completed/signed. One section that often confuses people is near the front and asks about the ERISA plan year. In most cases, the plan ERISA plan sponsor is just the employer, so enter the name just as it appears on page 1. The plan year should start with the effective date and end one year later. So, for a March 1 group, the ERISA year would be 3/1/2024 – 2/28/2025, for example.

Employer Group Information (EGI) Form: This page asks about group size this year and last year to determine if the group is subject to certain laws, like COBRA or Medicare Secondary Payer. On the front page, be sure to enter the current year as the Effective Year – the question is on the right side of the page and easy to miss.

Texas Supplemental Employment Verification (TSEV) Form: This form needs to be completed if there are any owners or new employees who are not listed on the group’s Texas Workforce Commission (TWC) report, also known as the wage & tax report. Employees who are on the TWC report do not need to be listed on the TSEV, and this form does not need to be completed at all if all eligible employees/owners are listed on the TWC.

Employee Apps and Waivers: An app or waiver must be completed and signed for each eligible employee and owner. Electronic signatures are permissible, but BCBSTX does not accept spreadsheet enrollments. If a husband and wife both work for the same company, they could enroll together as a family, with one as the primary member and the other as the dependent spouse. In that case, the dependent spouse would complete a waiver form and indicate that he/she has other group coverage through BCBSTX. Here is the employee app in Spanish.

Payment: Not required when the group is applying for coverage. Once the group is approved and billing is set up, BCBSTX will bill the group or the group can log in to Blue Access for Employers to make a one-time payment or set up auto-draft.

Enrollment Checklist: View the one-page enrollment checklist.

Ernollment Kit: Want evertyhing in 0ne PDF? Download the enrollment kit to get the enrollment checklist and and required forms in a single document.

Enrollment Spreadsheet: It appears BCBSTX will allow a spreadsheet enrollment. Download the reference guide.

Documentation Requirements

In addition to the BCBSTX group paperwork, the employer will need to provide documentation tying every eligible owner and full-time (30+ hours/week) employee to the business.

Wage and Tax Statement: For most small employers, the wage & tax statement is the best evidence of an employer-employee ralationship. That’s why every carrier in every state will ask for the wage & tax report, when available, when a company is applying for group health insurance benefits. In Texas, the wage & tax statement is called the Texas Workforce Commission Report, or TWC Report. This report will need to be “reconciled” by indicating next to each employee’s name whether they are Full-Time (FT), Part-Time (PT), or Termed (along with the date of termination). Other documentation can be provided for owners and employees who do not appear on the wage & tax report.

New Employees: If a new employee W-2 employee is not on the latest TWC report, then the carrier will want a copy of the employee’s W-4. BCBSTX also asks for a copy of at least one pay stub showing Federal Income Tax as well As FICA (Social Security and Medicare) taxes being withheld. From experience, it seems that even though BCBSTX asks for the copy of a pay stub, they will often approve a group with just the W-4 and no pay stub, so it’s worth submitting without the pay stub if it’s unavailable and seeing if they ask for it.

Owners: For businesses that are not set up as C-Corps (and most small businesses are not C-Corps), the business owner usually is not on the wage & tax report. For that reason, other documentation will be required tying them to the business. For estabilished businesses, the carrier will want the most recent tax return for the business or business owner (the schedule C for a proprietorship or single-member LLC, the 1065 and K-1’s for a partnership or LLC filing as a partnership, and the 1120S and K-1s for an S-Corp or an LLC filing as an S-Corp).

New Businesses: New businesses that have not yet filed a tax return will need to provide other documentation tying the owner to the business.

• Certificate of Formation: The vast majority of small businesses are set up as Limited Liability Companies, or LLCs. To set up an LLC, the company must file a Certificate of Formation with the Texas Secretary of State. The Certificate of Formation lists the initial members (or owners) of the company.
• Certificate of Filing: After the Certificate of Formation is filed with the Secretary of State’s office, the SOS provides the new business with a Certificate of Filing. It confirms that the Certificate of Formation was received and has been filed with the state.
• EIN Letter: Most businesses also apply for a taxpayer ID number, also called an Employer Identification Number (EIN). When approved (instantly), the company can download their EIN letter. This letter, obviously, shows the company’s EIN. But it serves a more important role: it shows whether the LLC has chosen to be treated as a single-member LLC, partnership, or S-Corp by stating which tax form the business will be required to file. For an LLC filing as a partnership, it will state that the company needs to file form 1065; for an S-Corp, it will state that the company needs to file form 1120S. NOTE that an LLC filing as a partnership does not need any W-2 employees; the two (or more) partners can sign up for coverage if they work full-time in the business, and the requirements are even more relaxed with BCBSTX, which does not require the owners to work full-time and will accept a “one-person group” as long as there are two owners or an owner and full-time employee.
• Partnership Agreement Addendum/Exhibit: Becasue a business owner must own at least 2% of the business in order to be eligible for coverage, and because the percentage ownership is not shown on the Certificate of Formation, it might be necessary to submit the partnership agreement or at least the addendum or exhibit from the partnership agreement showing the percentage ownership for each partner/owner. Click here for an example.

Ancillary Benefits

BCBSTX offers a full range of ancillary benefits, but all ancillary benefits other than dental are administered by Dearborn. The group is billed separately from health for these products, and there’s a different employer portal login. For all ancillary other than dental, at least two enrollees are required. Learn more about ancillary products and services.

Dental: Blue Cross Blue Shield has one of the largest dental networks in the country. BCBSTX offers both employer-paid and voluntary dental plans. As with medical, a one-person group is allowed as long as two people are eligible (one can enroll, one can waive). There is no waiting period for major services. The plans will show “high” and “low” options. On the high options, periodontics and endodontics are covered as a basic benefit (paid at 80% on most plans). On the low option, perio and endo are covered as a major benefit (paid at 50% on most plans). Dental Contributory Plans plan grid  |  Dental Voluntary Plans plan grid  |  Dental Plan Summaries for each plan  |  Dental Member Flier

Vision: BCBSTX offers ten different stand-alone vision plans. The plans feature fixed composite rates (even if the group has age rates for medical/dental) and a spreadsheet enrollment. Even though the rates are fixed, the sold quote must be submitted with the paperwork. It’s a little confusing because there is a box to check for vision on the Benefit Program Application (the employer app used for medical), but there is no box on the employee enrollment form about dental. Vision is processed separately from medical, and a separate approval email will be sent. It often takes nearly a month for a new vision group to be approved. Billing is separate from the medical and easy for a client to overlook if tey’re expecting a single bill, so be sure to let them know. Vision plan grid

Life and Disability: Life and Disability (STD, LTD) insurance is offered through Dearborn. While employers/employees can sign up using the same forms as the medical, billing is separate and there is a separate employer employer for life. Life and Disability producer flier  | Quote sheet for groups of 10+

Supplemental: BCBSTX also offers accident and critical illness plans, administered through Dearborn and billed separately from the medical.

Useful Links

Website: BCBSTX.com

Forms: Current small group forms can be found on this page.

SBCs: The SBC for each plan for each month can be found by typing in the plan number at www.plansummary.com.

Plan Booklets: For customers that want more info than can be found on the SBCs, you can send them the plan booklet.

Small Group Microsite: The microsite has lots of forms and marketing material for new and renewing groups.

Ancillary Info: Find information, forms, and employer/producer login links on the ancillary page.

Contact Information

Frequently Asked Questions

Below is a list of small group FAQs from the BCBSTX website.

How many employees do I need to qualify for small business health insurance?

To qualify for group coverage as a small business, your company needs between two and 50 full-time employees (including the owner). All full-time, permanent employees of an employer are eligible for insurance under a group policy. And 70% of eligible employees must select health plan coverage.

A full-time employee for group insurance purposes is one who works at least 30 hours in the employer’s normal work week and for whom the employer withholds Income Tax (UW approval required for less than 30 hours; no approval is needed for employees who work more than 30 hours per week).

For guidance on other qualifiers, call 833-923-1785.

What documents do I need to enroll in health insurance?

Employers must provide their most recent Texas Workforce Commission quarterly wage and tax statement (TWC Report) for all employees and indicate full time, part time, seasonal, temporary, or terminated status for each employee on the document.

If your company is a new business, you may not have this document. This will require a state filed proof of business, and W-4’s for all W-2 employees.

Partnerships with no other employees require UI 3/40 and state filed proof of business. If they do not claim wages, K-1 documents for all partners of the group are required. If they are listed as stockholders, they do not qualify for coverage.

Can I include 1099 contractors in my group plan?

Yes, however 1099 contractors cannot exceed 10% of the eligible employees. Therefore, 1099 contractors are not eligible on group sizes between 2 and 9 employees.

Are Partners and Proprietors of my firm eligible for health insurance?

Partners, proprietors, and members of the firm must meet all requirements applicable to full-time or part-time employees to be eligible.

Are retirees eligible for small group insurance plans?

Only individuals who are insured under a group policy prior to retirement may be insured after retirement. When a Blue Cross and Blue Shield of Texas group policy replaces that of another carrier, under which retired persons were insured, proof that the employees have satisfied the minimum years of service and achieved the limiting age must be submitted for review.

How do deductibles, coinsurance, premiums, and copays work?

Deductibles, coinsurance, and copays are all mechanisms that allow health insurance companies and individuals to share costs. Deductible is a fixed amount an employee is required to pay before reimbursement by the health plan (coinsurance) begins. Coinsurance is the percentage of the cost of a covered health care service the employee is responsible for paying after they’ve met their deductible. Premium is the monthly amount that must be paid for a health insurance plan. Copay is the fixed dollar amount a member is required to pay for covered services or prescriptions at the time you receive them. Learn more about how insurance works.

How do out-of-pocket maximums work?

This is the most employees have to pay out of their own pocket for expenses under the insurance plan during the year. Learn more about how insurance works.

What’s the difference between in-network and out-of-network benefits?

Doctors, hospitals, or other providers who accept your employees’ health insurance plans are “in-network,” also known as participating providers. Doctors who do not take these plans are “out-of-network.” In-network provider services are paid at a higher benefit level. Learn more about how insurance works.

Why are there different network options?

Our network plan offerings are built to create health insurance coverage options that fit any budget across different metallic coverage tiers. For more detail on the networks available to you, visit our Plan Options page.

What are Smart networks?

A Smart network is a group of providers that encompass a specific geographical area, and is less broad than a standard PPO network. Plans with a smaller network typically have lower premiums. Learn more about how insurance works.

What are essential health benefits?

Essential health benefits are included in every health plan, no matter which plan you choose. The Affordable Care Act requires these benefits to be included in all individual, family, and employer-sponsored plans. Visit our Plan Options page to see all essential health benefits included in our plans.

What Plans do we cover?

BCBSTX plans provide comprehensive benefits with options to fit your employees’ needs and your organization’s budget. For more detail on the plans available to you, visit our Plan Options page.

How much should I contribute?

Employers offering group coverage are required to pay at least 50% of their employees’ premiums. You may pay a higher percentage if you choose; making insurance more affordable for your employees can increase participation. If you purchase group coverage between November 1 and December 15 for a January 1 or January 15 effective date, the minimum contribution requirement is waived. Learn more about the benefits of offering health insurance.

When can I apply for health coverage for my business?

You can apply for health coverage at any time throughout the year. If you purchase group coverage between November 1 and December 15 for a January 1 or January 15 effective date, the minimum amount you are required to contribute towards your employees’ premium, as well as the number of employees required to participate – are waived.

When I purchase health insurance for my employees, how long does the policy last?

Each policy has a 12-month contract term. We will reach out to you before the contract term expires to discuss your options for renewing your policy.

When can I purchase health insurance for my business and when does it become effective?

You can buy coverage any time during the year and indicate a desired coverage start date. Once your business is approved for coverage, you will receive a notice confirming the date on which your coverage will begin. It will be effective for all enrolled employees starting on that date.

As a small business, do I qualify for tax advantages for offering health insurance for my employees?

Yes, you may be eligible to take a deduction on the amount you contribute towards the premium cost on your employees behalf. Please contact your tax professional for more details on the tax advantages you may qualify for by offering your employees health insurance.

Do my employees enjoy tax benefits for enrolling in the coverage I sponsor?

It is possible. You can take a pre-tax deduction from employees’ paychecks to cover the portion of the total premium that they are required to pay. This deduction reduces their taxable income and the amount of income taxes owed.

Through the Affordable Care Act, individuals may be eligible for subsidies for purchasing coverage through the individual market place if they meet income requirements. If you have additional questions, please contact your tax professional for more information.

How would a group policy I offer my employees differ from an individual policy that they purchase through the market place?

Group insurance policies allow employers to offer their employees and their dependents a wider choice of options, with access to more robust plans and larger networks. Monthly premium costs are shared between the employer and the employee.

In the individual market place, there may be fewer options to choose from, plans typically have a higher deductible and smaller networks, and employees are responsible for 100% of the monthly premium.

Can I extend the offer of coverage to my employee’s spouses and/or children?

Yes, coverage can be extended to spouses and/or children of any employees who enroll in coverage. You can decide if you want to contribute to the cost of their coverage.

What if I have employees who reside out of state?

We offer plans that include out-of-state coverage. If you have employees that reside out of state, you should consider including one of these plans. To find out which plans offer out-of-state coverage, review our 2024 Small Group Plans.

How is dental insurance different from health insurance?

Health insurance includes coverage for a wide range of medical care. However, health care plans only include pediatric dental coverage. Dental insurance can help you and your employees access quality dental care.

Dental insurance includes coverage for oral care, such as regular check-ups, orthodontics, oral surgery, and other dental services. Like health insurance, dental insurance includes networks, coinsurance, deductibles, and annual out-of-pocket maximums.

Is any dental care covered by health care coverage?

All health care plans include pediatric dental coverage. However, coverage for adults is only available through a dental insurance plan.

What are the advantages of offering dental Insurance?

Combining health and dental coverage through BCBSTX streamlines the administration of both programs, helping you manage your overall benefit costs. Employees with both BCBSTX health and dental plans have access to BlueCare Dental Connection^SM, which includes educational information and outreach to help your employees make important decisions about their dental care.

Members who have health and dental insurance have experienced:
• 24% reduction in medical costs
• 41% fewer hospital admissions
• 34% fewer ER visits

How much do I have to contribute to my employees’ dental insurance premiums?

You can choose to offer a contributory or voluntary dental plan to your employees. If you choose a contributory dental plan, you must contribute at least 50% towards your employees’ dental insurance premiums. For voluntary plans, you are not required to contribute towards your employees’ premiums, but you have the option to contribute up to 49%.

What is life insurance?

Life insurance is a way to provide for loved ones in the event of death. It can be one of the wisest decisions a person can make to financially protect those who depend on them.

We provide both employer-paid and voluntary plans. Employees can also obtain coverage for their spouses and dependent children.

Major reasons given for owning life insurance include:
• Replace lost income
• Cover burial or other final expenses
• Pay off mortgage

What are the requirements for life insurance?

Most group life policies offer a certain amount of guaranteed coverage. Under certain circumstances employees and family members might have to go through the Evidence of Insurability (EOI) process to be considered for coverage. EOI may be required if:

• an employee applies for an amount of coverage higher than the guarantee issue amount
• an employee is currently enrolled and wants to increase his or her insurance amount
• an employee declines coverage during his or her initial eligibility period and then wants coverage at a later date

What is EOI?

EOI is an application process where employees provide information on the condition of their health or their dependent’s health to be considered for certain types of insurance coverage.

We offer online EOI submissions.

Online EOI submission eliminates or reduces the processing of paper applications for coverage requests, increases accuracy and confidentiality, and speeds up the overall application process.

Step-by-step instructions lead the employee through the application process, which usually takes about 15 to 30 minutes and can be submitted 24 hours a day, 7 days a week. Our system will provide confirmation to the employee that the application has been received. Once all the required information is received, a decision will be made, and a letter will be sent to you and the employee. Premium should not be deducted until you receive notification of our approval.

What information is required to process the EOI application?

Most EOI applications are processed using only the information provided. However, in some cases, we may require medical records from the applicant’s physician or a physical examination which is at our expense.

For additional information please contact your Group Administrator or call 1-800-721-7987.

What is short-term disability insurance?

An accident or illness can endanger an individual’s most important asset: the ability to earn a living. Our short-term disability (STD) plans pay benefits when sickness or injury prevents an employee from working full time. We offer STD programs tailored to meet the needs and cost expectations of both employers and employees.

We offer employer-sponsored and voluntary group STD plans that feature:

• Affordable premiums
• Evidence of Insurability not required on most plans
• Coverage for pregnancy, as well as disabilities caused by accidents or illnesses
• Benefits paid for total or partial disability
• Seamless claim transition from STD to LTD

When short-term disabilities become long-term disabilities: One Team, One Purpose

Many voluntary short-term disability (VSTD) claims end with the employees being able to go back to work. Some, however, will turn into long-term disability claims. Employers who also have voluntary long-term disability (VLTD) coverage benefit from having the same team manage both VSTD and VLTD claims. This means that no time is lost in the move from a VSTD to a VLTD claim, and the team’s purpose is to bring the claimant back to gainful employment, whenever possible.

What else is included in employer-sponsored group LTD plans & voluntary group LTD plans?

• Benefits for total or partial disability
• Return-to-work incentives for employees who can work on a partial or part-time basis
• Rehabilitation incentive income—unique in the industry—for those claimants who cannot return to their job but have skills that can transfer to a new occupation
• Social Security assistance services for employees who are totally disabled and eligible for Social Security benefits

Life and disability insurance products issued by Dearborn Life Insurance Company, 701 E 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of (State) is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

For additional information please contact your Group Administrator or call 1-800-721-7987.

How can I get a quote?

To get a quote for your health insurance, simply give us a call at 833-923-1785 or you can get a quote online.

Is there someone I can call if I have additional questions?

Our insurance specialists can answer any additional questions you may have as you consider your group health insurance options. Call us at 833-923-1785.