Page 17 - 2020 Summer Enrollment

HEALTH PLANS COMPARISON CHART
Effective September 1, 2020
Benefits
HealthSelectof Texas®
HealthSelectSM Out-of-State
Consumer Directed HealthSelectSM
Network
Non-Network
Network
Non-Network
Network
Non-Network
Maternity 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 office visit
40%*
20%; $40 copay plus 20% with office visit
40%*
20%**
40%*
b. Maximum benefit 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 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%*
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 office9
$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 covered
a. 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 deductible
1 Applies to calendar year, January 1 - December 31, 2020. 2 Does not include copays. 3 Out-of-pocket maximums are not increasing for Plan Year 2021. 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 Benefits 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 Benefit 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. Effective September 1, 2020, diagnostic mammograms are covered at no cost to the participant. Consumer Directed HealthSelect participants must meet their deductible and then pay 20% of the approved charges for diagnostic mammograms.
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 17