Plan Year 2020 · BCBSTX App With the BCBSTX App, your benefits are at your fingertips, wherever...

2019 Summer Enrollment Brochure 1

Road to Your Medical Benef itsSummer Enrollmen�

Plan Year

2020

2019

2019 SUMMER ENROLLMENT GUIDEThe 2020 health plan year begins on September 1, 2019 and runs through August 31, 2020.

www.healthselectoftexas.com

ROAD TO YOUR MEDICAL BENEFITS

2 2019 Summer Enrollment Brochure

WELCOME TO PLAN YEAR 2020Your health is important, and we are here with you every step along your journey. In this brochure, you will learn about changes to your medical benefits, how to avoid unexpected costs and the best places to go for different types of care. You will also learn about important resources to help you make the most of your medical benefits.

The Employees Retirement System of Texas® (ERS) manages the Texas Employees Group Benefits Program (GBP). HealthSelect of Texas® and Consumer Directed HealthSelectSM are part of the GBP and are administered by Blue Cross and Blue Shield of Texas (BCBSTX). ERS sets plan benefits and pays claims. BCBSTX manages the provider network, processes claims and provides customer service.

Stay up to date on the latest Summer Enrollment updates.www.healthselectoftexas.com

TABLE OF CONTENTS

Welcome to Plan Year 2020 ..................................................................................... 2

Benefit Changes ........................................................................................................ 3

Benefit Highlights ...................................................................................................... 3

Cost-Saving Tips ....................................................................................................... 4

Resources ................................................................................................................... 5

Plan Options ............................................................................................................... 6

Plan Decision Tool ......................................................................................................7

Plan Information .........................................................................................................7

Options For Care ........................................................................................................ 8

Take Advantage Of Preventive Services ...............................................................10

Health Plans Comparison Chart ............................................................................. 12

Health Plans Comparison Chart .............................................................................13

Non-Discrimination Policy ......................................................................................14

Language Assistance ..............................................................................................15

Contact Information ................................................................................................16

Plan Year

2020


BENEFIT CHANGESOut-of-Pocket MaximumBeginning January 1, 2020, the total in-network out-of-pocket maximums will increase in alignment with the Internal Revenue Service (IRS) out-of-pocket maximum for group benefit plans.

∙ $6,750 per individual (up from $6,650 in calendar year 2019) ∙ $13,500 per family (up from $13,300 for calendar year 2019)

Out-of-pocket maximums reset each calendar year. For details about what your plan covers, visit your plan’s Master Benefit Plan Document on the HealthSelect website.

BENEFIT HIGHLIGHTSBenefit questions If you have questions about your medical benefits or claims, or need help finding an in-network provider, call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, Monday–Friday 7 a.m. - 7 p.m. and Saturday 7 a.m. - 3 p.m. CT.

Care managementBCBSTX care management clinicians can review your treatment plan , provide educational content and help coordinate care among your providers. If you have questions about asthma, cancer, COPD, diabetes, cardiac conditions or any other health issue that you or your covered family members are dealing with, call BCBSTX toll-free at (800) 252-8039, Monday-Friday, 8 a.m. - 6:30 p.m. CT and ask to speak with a clinician. Visit the ”Care Management” page on the HealthSelect website to see an informative video about the program.

Health and wellnessHealthSelect benefits include access to several programs and incentives to help you on your journey to wellness.For health and wellness programs and resources, visit www.healthselectoftexas.com and click on “Health and Wellness/Incentives”.

Medical virtual visitsIf you are enrolled in HealthSelect of Texas, HealthSelectSM Out-of-State, or HealthSelectSM Secondary, medical virtual visits are available at no cost to you. With medical virtual visits, you and your eligible dependents can consult a licensed board-certified doctor online for your urgent health care needs 24 hours and day, 7 days a week, including weekends and holidays. Consumer Directed HealthSelect participants will be required to meet their annual deductible before visits are covered, subject to coinsurance after the deductible is met.

Mental healthIf you have questions about mental health benefits or claims, or need help finding an in-network provider, call BCBSTX toll-free at (800) 252-8039, Monday–Friday 7 a.m. - 7 p.m. and Saturday 7 a.m. - 3 p.m. CT. You can also call a counselor 24/7 toll-free at (800) 442-4093 anytime.

Mental health virtual visitsGet access to a broader network of licensed mental health professionals. With mental health virtual visits, you can consult with a licensed mental health professional any day of the week online for the same cost as an in-network mental health office visit. You must make appointments in advance, but appointments are typically available within 5-7 days on average, but could take up to two weeks.

Network of doctors, hospitals and providersThe HealthSelect network includes more than 50,000 providers. To receive the highest level of benefits and keep your health care costs down, make sure that your providers are in your plan’s network before you receive care.

To find a network provider, visit www.healthselectoftexas.com and click “Find a Doctor/Hospital” or call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, Monday-Friday 7 a.m. - 7 p.m. and Saturday 7 a.m. - 3 p.m. CT.

Find an in-network provider on the go with the BCBSTX App. Text BCBSTXAPP to 33633 to get a download link.*

*Message and data rates may apply. Read terms, conditions and privacy policy at bcbstx.com/mobile/text-messaging.


COST-SAVING TIPS

1 Message and data rates may apply. Read terms, conditions and privacy policy at bcbstx.com/mobile/text-messaging.

Stay in the networkYou’ll pay less if you see an in-network provider. Go to the “Find a Doctor/Hospital” page on www.healthselectoftexas.com or call (800) 252-8039 to find a provider or check network status, or you can download the BCBSTX App by texting BCBSTXAPP to 33633 to get a download link.1

Talk to your doctor or primary care provider Before you see a specialist, talk to your primary care provider (PCP) and if needed, get a referral and/or prior authorization for certain services. If you don’t have a PCP selected, you can call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039 for help finding a PCP, or you can log in to your Blue Access for Members account and go to the

“Doctors and Hospitals” tab and click “Select Primary Care Physician”.

ReferralsReferrals are required under the HealthSelect of Texas (In-Area) plan. A referral is an order from your PCP that must be obtained and authorized through BCBSTX for you to see a specialist. For most services, you need to get a referral before you can get medical care from anyone except your PCP. If you don’t get a referral before you receive services, your services will be considered out-of-network and you will pay more, even if the provider is in your plan’s network.

Prior authorizationsYou are required to get prior authorization from BCBSTX for certain services, like inpatient hospital stays, surgery, durable medical equipment, etc. In general, in-network providers are responsible for getting prior authorization before they provide services. To see the full list of services that require prior authorization, visit your plan’s Master Benefit Plan Document on the HealthSelect website.

Know before you goYour benefits include several options for care. Virtual visits, retail health clinics, urgent care and other provider options can save you money when you or your covered family members need treatment for an urgent situation that is not an emergency. Visit the

“Options for Care” page on www.healthselectoftexas.com to learn more.

Some services do not require a referral. Learn more at www.healthselectoftexas.com.

Find more details about referrals and prior authorizations at www.healthselectoftexas.com. Go to the “Medical Benefits” tab, then “Referrals and Prior Authorizations.”

You can see the status of your referrals and prior authorizations by logging in to your Blue Access for Members account.

Go to www.healthselectoftexas.com and click “Log In” in the upper right-hand corner. If you do not have an account, click

“Register Now” and use your medical ID card to create an account.


RESOURCESBlue Access for MembersSM Blue Access for Members is your secure online participant portal where you can: ∙ view your claims and

explanation of benefits (EOB) , ∙ find in-network doctors, hospitals and

other providers, ∙ select and change your PCP,

∙ check the costs of services covered under your plan,

∙ download a temporary ID card and ∙ confirm your prior authorizations and

referrals on file.

To access Blue Access for Members, visit www.healthselectoftexas.com and click on “Log In” in the upper right corner.

BCBSTX App With the BCBSTX App, your benefits are at your fingertips, wherever you are. Text BCBSTX to 33633 to download. You can: ∙ find an in-network doctor, hospital or

urgent care facility near you, ∙ chat with a BCBSTX Personal

Health Assistant1,

∙ view prior authorizations and referrals, ∙ check the status or history of a claim and ∙ request a temporary ID card or save a

digital copy to your phone.

BCBSTX Personal Health Assistants Call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, Monday – Friday 7 a.m. – 7 p.m. and Saturday 7 a.m. – 3 p.m. CT. BCBSTX Personal Health Assistants are here to help you understand and use your health plan benefits. They can: ∙ answer questions about benefits, ∙ assist with prior authorizations

and referrals, ∙ provide information about programs and

benefits available to you, ∙ help you locate an in-network provider,

∙ explain health care costs and options for care,

∙ provide you with cost estimates for services,

∙ schedule or cancel doctor’s appointments, ∙ help you use self-service tools and ∙ connect you to other resources.

24/7 Nurseline If you’re not sure where to go for care, call the 24/7 Nurseline and speak with a registered nurse toll-free at (800) 581-0368. Call any time, any day of the year.1

1 For medical emergencies, call 911. BCBSTX Personal Health Assistants and the 24/7 Nurseline are not substitutes for a doctor ’s care. Talk to your doctor about any health questions or concerns.


HealthSelect of Texas®

� Active employees � Non-Medicare-eligible retirees � Live or work in Texas

HealthSelect of Texas is a point-of-service health plan available to active employees, non-Medicare-eligible retirees and their eligible dependents who live or work in the State of Texas.

Plan Highlights

∙ Copay for in-network office visits

∙ Your Primary Care Provider (PCP) coordinates your care and manages any referrals you may need to see specialists.

∙ You need to designate a PCP for you or your eligible dependents within 60 days of the first day you have HealthSelect coverage, or you will have to pay out-of-network charges, even if you see a provider who is in the HealthSelect network.

∙ No deductible for in-network services

∙ When seeking care, be sure to use an in-network provider. Visit www.healthselectoftexas.com, click on “Find a Doctor/Hospital,” look for HealthSelect of Texas and click “Search.”

Consumer Directed HealthSelect

� Active employees � Non-Medicare-eligible retirees � Live or work in Texas

Consumer Directed HealthSelect is a high-deductible health plan available to active employees, non-Medicare-eligible retirees and their eligible dependents.

Plan Highlights

∙ You pay the full cost for your health care and prescriptions (except preventive care) until you meet the annual deductible.

∙ You are not required to select a PCP; however, having a PCP is important to managing your overall health.

∙ This plan has a high-deductible health plan paired with a health savings account (HSA).

∙ You have access to the same provider network as HealthSelect of Texas (In-Area) participants.

∙ You do not need a referral to see a specialist.

∙ You can use funds in your HSA to pay for qualified medical expenses, including your deductible and coinsurance.

∙ If you are enrolled in Medicare, you are not eligible for this plan.

∙ The monthly premium for dependent coverage is lower than HealthSelect of Texas.

HealthSelect Out-of-State

� Active employees � Non-Medicare-eligible retirees � Live or work outside of Texas

HealthSelect Out-of-State is available only to active employees, non-Medicare-eligible retirees and their eligible dependents living or working outside the State of Texas.

Plan Highlights

∙ Benefits are the same as HealthSelect of Texas.

∙ You are not required to select a PCP; however, having a PCP is important to managing your overall health.

∙ You do not need a referral to see a specialist.

∙ You don’t have to meet a deductible for in-network services. You will have a copay for certain services like PCP and specialist office visits.

∙ When seeking care, be sure to use a network provider. To find an out-of-state network provider, visit www.healthselectoftexas.com, click on “Find a Doctor/Hospital,” look for HealthSelect Out-of-State and click “Search.”

PLAN OPTIONS


PLAN DECISION TOOLNeed help deciding which plan is right for you? Use the Plan Decision Tool. Go to www.healthselectoftexas.com and click

“HealthSelect Plans,” then “Plan Decision Tool.”

PLAN INFORMATIONFor more plan information visit www.healthselectoftexas.com and click on Summer Enrollment.

HealthSelectof Texas

ConsumerDirected

HealthSelect

HealthSelect Out-of-State

Copay for primary care provider office visit Yes No Yes

Required to select a primary care provider to receive in-network benefits Yes No No

Annual deductible (when you stay in the network) No Yes No

Requires referrals to see specialists Yes No No

Preventive care services covered at no cost* Yes Yes Yes

Includes a health savings account No Yes No

*Preventive care is covered at 100% when appropriately coded as preventive care per the Affordable Care Act guidelines and when you visit a provider in your plan’s network.

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OPTIONS FOR CARE

1 For in-network medical vir tual visit providers, HealthSelect of Texas®, HealthSelectSM Out-of-State and HealthSelectSM Secondary participants have a $0 copay. Consumer Directed HealthSelectSM participants will have to meet the plan’s annualdeductible and then the applicable coinsurance for vir tual visits.

GET CARE WHEN YOU NEED ITIt’s important to know where to go when you need medical care. Knowing your options and deciding where to go can make a big difference in how much you pay. You will pay less for your health care if you see providers who are in the HealthSelect network. The costs noted below are average out-of-pocket costs. To find out more, go to www.healthselectoftexas.com.

Virtual Visits for Medical Care1 — $0

Get non-emergencwy medical care when you need it. Connect by phone call or video conference to a board-certified doctor anytime, wherever you are. Virtual visits are available at no cost to you if you are enrolled in HealthSelect of Texas®.1

Doctor’s Office — $

Generally the best place to go for non-emergency care such as health exams, routine shots, colds and flu. Your doctor knows you and your medical history and can treat you, and refer you to a specialist if needed.

Retail Health Clinic — $$

Often located in stores and pharmacies to provide convenient, low-cost treatment for certain preventive and minor medical problems. Walk-in clinics can be a lower out-of-pocket cost than urgent care.

Urgent Care Provider — $$$

Often used when your doctor’s office is closed and you need immediate, but non-emergency care such as X-rays and stitches.

Hospital Emergency Room — $$$$

A life-threatening serious medical condition that typically arises suddenly is a true emergency. You should go to the nearest hospital ER or call 911. You may receive multiple bills for services such as hospital facility, laboratory fees and for each provider you see such as the emergency room doctor, radiologist, pathologist or anesthesiologist.

Freestanding Emergency Rooms — $$$$$$

Most freestanding emergency room facilities and providers are out-of-network, so your share of the bill can be significantly higher. These facilities are sometimes confused with urgent care centers or with small hospital ERs. You will recognize a freestanding ER because it will have an Emergency or ER sign and is not attached to a hospital.

For an out-of-network FSER, you will pay more. ∙ You must pay a $300 copay. ∙ There is not a deductible if true emergency but out-of-network

deductible applies if not a true emergency. ∙ The plan pays 80% of the out-of-network allowable amount if true

emergency and 60% of the out-of-network allowable amount if not a true emergency.

∙ You may be responsible for any difference between the amount billed by the facility and the out-of-network allowable amount, which could be significant.


Examples of Health IssuesVirtual Visits for Medical Care1 — $0

∙ Allergies ∙ Bladder/Urinary tract infection ∙ Bronchitis

∙ Cold and flu ∙ Headache ∙ Nausea

∙ Pink eye ∙ Sore throat ∙ Rash

Doctor’s Office — $

∙ Fever, colds and flu ∙ Sore throat ∙ Minor burns

∙ Stomach ache ∙ Ear or sinus pain ∙ Physicals

∙ Flu shots ∙ Shots ∙ Minor allergic reactions

Retail Health Clinic — $$

∙ Infections ∙ Cold and flu ∙ Allergies

∙ Minor injuries or pain ∙ Shots ∙ Flu shots

∙ Sore throat ∙ Skin problems

Urgent Care Provider — $$$

∙ Migraines or headaches ∙ Abdominal pain ∙ Cuts that need stitches

∙ Sprains or strains ∙ Bladder/Urinary tract infection ∙ Animal bites

∙ Back pain

Hospital Emergency Room — $$$$

∙ Chest pain ∙ Stroke ∙ Seizures

∙ Head or neck injuries ∙ Sudden or severe pain ∙ Fainting, dizziness, weakness

∙ Uncontrolled bleeding ∙ Problem breathing ∙ Broken bones

Freestanding Emergency Rooms — $$$$$$

A freestanding emergency room (FSER) is a medical care facility that provides emergency services, and typically is not affiliated with a hospital or physically connected to a hospital. FSERs are frequently located near a shopping center or other convenient neighborhood location. While a FSER may seem like a convenient option when you need emergency care, most are out-of-network and you will pay more—sometimes thousands of dollars more—for care and you still may need to be sent to a hospital for emergency care.


TAKE ADVANTAGE OF PREVENTIVE SERVICES

1 Under the Affordable Care Act, certain preventive health services are paid at 100% (at no cost to the participant) depending upon physician billing and diagnosis. In some cases, you may be responsible for payment on certain related services that are not guaranteed payment at 100% by the Affordable Care Act.

YOUR FAMILY’S RACE TO BETTER HEALTH BEGINS WITH A SINGLE STEPTaking advantage of preventive health care services

Preventive check-ups and screenings can help find illnesses and medical problems early and improve the health of you and everyone in your family.

Your health plan covers screenings and services with no out-of-pocket costs like copays or coinsurance as long as you visit a doctor in your plan’s provider network. This is true even if you haven’t met your deductible if your plan has one.

For more details on what preventive services are covered at no cost to you, refer to the back of this flier for a listing of services, call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, see Covered Preventive Services in the Master Benefit Plan Document at www.healthselectoftexas.com on the Publications and Forms page.

Learn more on immunization recommendations and schedules by visiting the Centers for Disease Control and Prevention website at www.cdc.gov/vaccines.

THESE PREVENTIVE SERVICES ARE COVERED AT NO COST TO YOU WHEN YOU VISIT AN IN-NETWORK DOCTOR.1

JUST FOR WOMEN

� Breast cancer screening, genetic testing and counseling (mammography including digital breast tomosynthesis/3-D mammography)

� Breastfeeding support, supplies and counseling � Certain contraceptive methods and counseling � Cervical cancer screening � Chlamydia, gonorrhea, syphilis, HIV and hepatitis B screenings

� Counseling for tobacco use during pregnancy � Osteoporosis screening � Screenings during pregnancy, including screenings

for anemia, gestational diabetes, bacteriuria, Rh(D) compatibility, preeclampsia1

CERTAIN VACCINES

Learn more on immunization recommendationsand schedules by visiting: www.cdc.gov/vaccines

� Diphtheria, Pertussis, Tetanus � Haemophilus Influenzae Type B (Hib) � Hepatitis A and B � Human Papillomavirus (HPV) � Inactivated Poliovirus (Polio) � Influenza (Flu) � Measles, Mumps, Rubella (MMR)

� Meningitis � Pneumococcal � Rotavirus � Varicella (Chicken Pox) � Zoster (Herpes, Shingles)


FOR ADULTS

Annual preventive medical history and physical exam

SCREENINGS FOR

� Abdominal aortic aneurysm � Cardiovascular disease (CVD) including

cholesterol screening and statin use for the prevention of CVD

� Colorectal and lung cancer � Depression

� Falls prevention � High blood pressure, obesity,

diabetes and depression � Sexually transmitted infections, HIV,

HPV and hepatitis � Tuberculosis

COUNSELING FOR

� Alcohol misuse � Domestic violence � Healthy diet and physical activity

counseling for adults who are overweight or obese and have additional cardiovascular disease risk factors

� Weight loss � Sexually transmitted infections � Skin cancer prevention � Tobacco use � Use of aspirin to prevent heart attacks

FOR CHILDREN

Annual preventive medical history and physical exam

SCREENINGS FOR

� Autism � Cervical dysplasia � Depression � Developmental delays � Dyslipidemia � Hearing loss, hypothyroidism, sickle

cell disease and phenylketonuria (PKU) in newborns

� Hematocrit or hemoglobin � Lead poisoning � Obesity � Sexually transmitted infections and HIV � Tuberculosis � Vision screening

ASSESSMENTS AND COUNSELING

� Alcohol and drug use assessment for adolescents

� Obesity counseling � Oral health risk assessment, dental

caries prevention fluoride varnish and oral fluoride supplements

� Skin cancer prevention counseling


HEALTH PLANS COMPARISON CHARTEffective September 1, 2019

5/26/2017Chart_2017_Comparison

Employee and Non-Medicare-Eligible RetireeHEALTH PLANS COMPARISON CHART

Effective September 1, 2017

Benefi tsHealthSelect of Texas® HealthSelectSM Out-of-State Consumer Directed HealthSelectSM

Network Non-Network Network Non-Network Network Non-Network

Annual deductible None $500 per person1

$1,500 per family1 None $500 per person1

$1,500 per family1

$2,100 per person1

$4,200 per family1

$4,200 per person1 $8,400 per family1

Out-of-pocket coinsurance maximum2,3

$2,000 per personper calendar year1



$7,000 per personper calendar year1 None None

Total out-of-pocket maximum

Participant(per Calendar Year)

Family(per Calendar Year, not to exceed the applicable Individual amount per Participant for Network Benefi ts)

Effective 1/1/19 - 12/31/19

$6,650 per person$13,300 per family

Effective 1/1/20 - 12/31/20


None

Effective 1/1/19 - 12/31/19


Effective 1/1/20 - 12/31/20


None

Effective 1/1/19 - 12/31/19


Effective 1/1/20 - 12/31/20


None

Primary care physician required Yes No No No No No

Primary care physicians’ offi ce visit $25 copay 40%* $25 copay 40%* 20%** 40%*

Mental health care

a. Outpatient physician or mental health provider offi ce visits

$25 copay 40%* 20% 40%* 20%** 40%*

b. Hospital mental health inpatient stay9

$150/day copay plus 20% ($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)

$150/day copay plus 20% ($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)

20%** 40%*

c. Outpatient facility care (partial hospitalization/ day treatment and extensive outpatient treatment)7,9

20% 40%* 20% 40%* 20%** 40%*

Specialty physicians’ offi ce visits $40 40%* $40 40%* 20%** 40%*

Routine eye exam, one per year per participant

$40 40%* $40 40%* 20%** 40%*

Routine preventive care# No charge 40%* No charge 40%* No charge 40%*

Diagnostic x-rays, lab tests, and mammography

20% 40%* 20% 40%* 20%** 40%*

Offi ce surgery and diagnostic procedures 20% 40%* 20% 40%* 20%** 40%*

High-tech radiology (CT scan, MRI, and nuclear medicine)7,8,9

$100 copay plus 20%

$100 copay plus 40%*

$100 copay plus 20%

$100 copay plus 40%* 20%** 40%*

Urgent care clinic $50 copay plus 20% 40%* $50 copay

plus 20% 40%* 20%** 40%*


HEALTH PLANS COMPARISON CHARTEffective September 1, 2019

Benefi tsHealthSelect of Texas® HealthSelectSM Out-of-State Consumer Directed HealthSelectSM

Network Non-Network Network Non-Network Network Non-NetworkMaternity care doctor charges only#; inpatient hospital copays will apply

No charge for routine prenatal appointments$25 or $40 for initial visit6

40%*No charge for routine prenatal appointments$25 or $40 for initial visit6

40%*No charge for routine prenatal appointments 20%** for initial visit

40%*

Chiropractic care

a. Coinsurance 20%; $40 copay plus 20% with offi ce visit 40%* 20%; $40 copay plus

20% with offi ce visit 40%* 20%** 40%*

b. Maximum benefi t per visit $75 $75 $75 $75 $75 $75

c. Maximum visits Each participant Per calendar year

30 30 30 30 30 30

Inpatient hospital(semi-private room and day’s board, and intensive care unit)9

$150/day copay plus 20% ($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 maxper calendar year per person)

$150/day copay plus 20% ($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)

20%** 40%*

Emergency care$150 plus 20% (if admitted copay will apply to hospital copay)

$150 plus 20% (if admitted copay will apply to hospital copay)12

$150 plus 20% (if admitted copay will apply to hospital copay)

$150 plus 20% (if admitted copay will apply to hospital copay)12

20%** 20%**12

Outpatient surgery other than in physician’s offi ce9

$100 copay plus 20%

$100 copay plus 40%*

$100 copay plus 20%

$100 copay plus 40%* 20%** 40%*

Bariatric surgery9,10,11,13

a. Deductible $5,000 b. Coinsurance 20% c. Lifetime max $13,000

Not covereda. Deductible $5,000 b. Coinsurance 20% c. Lifetime max $13,000

Not covered Not covered Not covered

Hearing aids(Effective 09/01/18, the $1,000 maximum will no longer apply to hearing aids for minors 18 years and younger)

Plan pays up to $1,000 per ear every three years (no deductible).

Plan pays up to $1,000 per ear every three years (after deductible is met).

Durable medical equipment9 20% 40%* 20% 40%* 20%** 40%*

Ambulance services (non-emergency)9 20% 20% 20% 20% 20%** 20%**

*Note: 40% coinsurance after you meet the annual out-of-network deductible **Note: 20% coinsurance after you meet the annual in-network deductible1 Applies to calendar year, January 1 - December 31, 2019. 2 Does not include copays. 3 Effective January 1, 2020 the out-of-pocket maximum is increasing from $6,650 Ind/$13,300 Family to $6,750 Ind/$13,500 Family. 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 Copay depends on whether treatment is given by PCP or specialist. 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 Active employees only; see health plan for additional requirements/limitations. 11 The deductible and coinsurance paid for bariatric surgery does not apply to the total out-of-pocket maximum. 12 Benefi ts shown do not apply to out-of-network freestanding ERs. 13Covered bariatric services must be provided at Centers of Excellence to be eligible for reimbursement under the plan. For information about this coverage, see the Master Benefi t Plan Document. # 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.


NON-DISCRIMINATION POLICY

Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance.

We do not discriminate on the basis of race, color, national origin, sex, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 Email: [email protected]

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

bcbstx.com


LANGUAGE ASSISTANCE

bcbstx.com

www.healthselectoftexas.comMagellan Healthcare, Inc. , an independent company, manages mental health benefits for HealthSelect of Texas® and Consumer Directed HealthSelectSM.

BCBSTX contracts with Magellan Healthcare, an independent company, to manage mental healthbenefits. Magellan processes mental health claims, manages the mental health provider network and operates a customer service center for HealthSelect of Texas® and Consumer Directed HealthSelectSM.

BCBSTX manages mental health benefits and claims processing for HealthSelectSM Out-of-State and HealthSelectSM Secondary participants.

Blue Cross and Blue Shield of Texas is the third-party administrator for HealthSelect of Texas® and Consumer Directed HealthSelectSM.

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

749580.0219

CONTACT INFORMATION

We’re Here to HelpCall toll-free (800) 252-8039 (TTY: 711)

Monday—Friday 7 a.m. - 7 p.m.

and Saturday 7 a.m. - 3 p.m. CT

Live chat is available when you log in to your Blue Access for Members account or when you use the BCBSTX App.

Download the BCBSTX App

Text BCBSTX to 33633 to get a link.*

*Standard messaging rates apply.

Plan Year 2020 · BCBSTX App With the BCBSTX App, your benefits are at your fingertips, wherever...

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Transcript of Plan Year 2020 · BCBSTX App With the BCBSTX App, your benefits are at your fingertips, wherever...