HEALTHSELECT OUT-OF-STATE BENEFITS AT A GLANCE...BENEFITS AT A GLANCE An overview of your medical...
Transcript of HEALTHSELECT OUT-OF-STATE BENEFITS AT A GLANCE...BENEFITS AT A GLANCE An overview of your medical...
HEALTHSELECT OUT-OF-STATE BENEFITS AT A GLANCEAn overview of your medical benefits.www.healthselectoftexas.com
Toll-free (800) 252-8039 Monday–Friday 7 a.m. - 7 p.m. central time (CT) and Saturday 7 a.m. - 3 p.m. CT
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HEALTHSELECT OUT-OF-STATE
Living or working outside of Texas?
HealthSelect Out-of-State is available only to active employees, participants not enrolled in Medicare, and their
eligible dependents living or working outside the state of Texas.
Some important things to know about the HealthSelect Out-of-State plan:
• You do not need to select a primary care
physician (PCP)
• You do not need a referral to see a specialist
• HealthSelect Out-of-State benefits are the same as
HealthSelect of Texas (In-Area)
• You no longer need to meet a deductible before
the plan begins to pay for covered health
services in-network
• You will have a copay for certain services like PCP
and specialist office visits
If you move outside Texas, please contact the Employees’ Retirement System of Texas to update your address
so that you can move to HealthSelect Out-of-State: go to www.ers.texas.gov or call toll-free (877) 275-4377.
If you live in Texas but have an eligible dependent living in another state, call a Personal Health Assistant
from Blue Cross and Blue Shield of Texas (BCBSTX) toll-free at (800) 252-8039 to move your dependent to
HealthSelect Out-of-State.
Why you may still want to have a PCP
Even though you are not required to have a PCP if you are enrolled in HealthSelect Out-of-State, having a PCP
can be a boost to your health.
Your PCP:
• Will get to know you – your health history, your
medications and your lifestyle
• Can treat many non-urgent health issues like
ear infections, rashes, allergies, fevers, colds,
flu and much more
• Will address routine medical care, such as
physicals and yearly exams
• Is your health coach who can show you better ways
to stay healthier
• Can decide if you need any tests or if you should
see a specialist
• Can help you with specialized care for a chronic
health issue, such as asthma, diabetes or
a heart problem
If you see a provider who is not in the network, you will need to meet a deductible of $500 per person/$1,500 per family.
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BENEFITS CHARTH
ealthSelect Out-of-State
Benefits1HealthSelectSM of Texas Out-of-State2
In-Network Out-of-Network
Calendar year deductible None$500 per person
$1,500 per family
Out-of-pocket coinsurance maximum3
$2,000 per person per calendar year
$7,000 per person per calendar year
Total out-of-pocket maximum4 (including deductibles, coinsurance and copays)5
$6,550 per person
$13,100 per familyNone
Primary care physician required No No
Primary care physicians’ office visits $25 40%*
Physicals† No charge 40%*
Specialty physicians’ office visits $40 40%*
Routine eye exam, one per year per participant6 $40 40%*
Routine preventive care† No charge 40%*
Diagnostic x-rays, lab tests, and mammography 20% coinsurance 40%*
Office surgery and diagnostic procedures 20% coinsurance 40%*
High-tech radiology (CT scan, MRI, and nuclear medicine)7,8,9
$100 copay plus 20% coinsurance
$100 copay plus 40%*
Urgent care clinic$50 copay plus 20% coinsurance
40%*
Maternity Care doctor charges only†; inpatient hospital copays will apply
No charge for routine prenatal appointments
$25 or $40 for first prenatal visit10
40%*
Chiropractic Care
a. Coinsurance$40 copay with office visit plus 20% coinsurance
40%*
b. Maximum benefit per visit $75 $75
c. Maximum visits Each participant Per calendar year
30 30
Inpatient hospital(semi-private room and day’s board, and intensive care unit)9
$150/day copay plus 20% coinsurance ($750 copay max-up to 5 days per hospital stay, $2,250 copay max per calendar year per person)
$150/day copay plus 40%* ($750 copay max-up to 5 days per hospital stay, $2,250 copay max per calendar year per person)
Benefits1HealthSelectSM of Texas Out-of-State2
In-Network Out-of-Network
Emergency care11
$150 plus 20% coinsurance (if admitted copay will apply to hospital copay)
$150 plus 20% coinsurance (if admitted copay will apply to hospital copay)
Outpatient surgery other than in physician’s office
$100 copay plus 20% coinsurance
$100 copay plus 40%*
Bariatric surgery12
a. Deductible $5,000 b. Coinsurance 20% c. Lifetime max $13,000
Not covered
Hearing aidsPlan pays up to $1,000 per ear every three years (no deductible).
Durable medical equipment9 20% coinsurance 40%*
Ambulance services (non-emergency)9 20% coinsurance 40%*
Mental health care
a. Outpatient physician or mental health provider office visits
$25 copay 40%*
b. Hospital Mental health inpatient stay
$150/day copay plus 20% coinsurance ($750 copay max-up to 5 days per hospital stay, $2,250 copay max per calendar year per person)
$150/day copay plus 40%* ($750 copay max-up to 5 days per hospital stay, $2,250 copay max per calendar year per person)
c. Outpatient facility care(partial hospitalization/ day treatment and extensive outpatient treatment)
20% coinsurance 40%*
* Note: 40% coinsurance after you meet the annual out-of-network deductible. 1 Benefits are paid on allowable amounts; using providers who contract with Blue Cross
and Blue Shield of Texas will protect you from liability for amounts over the allowable amount.
2 HealthSelect Out-of-State applies to employees and retirees under age 65 and their eligible dependents who live or work outside of Texas. You cannot enroll in Out-of-State coverage unless your work or home address is outside of Texas.
3 Does not include copays.4 Out-of-pocket maximums are not mutually exclusive from other out-of-pocket limits.
This means that a participant’s total network out-of-pocket maximum could contain a combination of coinsurance and/or copayments.
5 Includes medical and prescription drug copays, coinsurance and deductibles. Excludes non-network and bariatric services.
6 For treatment charges, one visit per plan year.7 Outpatient testing only. Does not apply to inpatient services.8 No copay if high-tech radiology is performed during ER visit or inpatient admission.9 Preauthorization required. 10 Copay depends on whether treatment is given by PCP or specialist11 Benefits shown do not apply to out-of-network freestanding ERs. For information about
this coverage, see the Master Benefit Plan Document.12 Active employees only; see health plan for additional requirements/limitations. The
deductible and coinsurance paid for bariatric surgery does not apply to the total out-of-pocket maximum.
† Under the Affordable Care Act, certain preventive and women’s health services are paid at 100% (at no cost to the participant) dependent upon physician billing and diagnosis. In some cases, the participant will still be responsible for payment on some services.
This comparison chart offers a general overview of benefits and their associated out-of-pocket expenses under HealthSelect plans. Contact a Personal Health Assistant for specific questions. Call toll-free at (800) 252-8039, Monday-Friday 7 a.m. - 7 p.m. CT, or Saturday 7 a.m. - 3 p.m. CT to speak with a Personal Health Assistant.
Blue Cross and Blue Shield of Texas is the third-party administrator for the HealthSelectSM of Texas and Consumer Directed HealthSelectSM plans.
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 746164.0917
CONTACT INFORMATION
We’re Here to HelpCustomer Service: Personal Health Assistants
Blue Cross and Blue Shield of Texas’ Personal Health Assistants are trained to
help you and your covered family members plan for better health care.
Call toll-free (800) 252-8039
Monday–Friday 7 a.m. - 7 p.m. CT and Saturday 7 a.m. - 3 p.m. CT
24/7 Nurseline
If you’re not sure where to go for care or you just have questions, calling the
24/7 Nurseline may help you. With the 24/7 Nurseline, you and your covered
family members have access to caring registered nurses at any time, any day
of the year. Call toll-free (800) 581-0368.
Mental Health
Your medical plan offers mental health benefits to support your emotional
and psychological well-being. Call a Personal Health Assistant toll-free at
(800) 252-8039 if you have questions about your benefits or need help
finding an in-network mental health provider.
Prescription Drugs
For information regarding prescription drug benefits for active employees
and their dependents, call the HealthSelect Prescription Drug Program at
(855) 828-9834.
Send claims and correspondence, including claim appeals, to:
Blue Cross and Blue Shield of Texas
PO Box 660044
Dallas, TX 75266-0044
www.healthselectoftexas.com