Page 18 - 2021 Summer Enrollment

Service
HealthSelect of Texas® and HealthSelectSM Out-of-State
In-Network
HealthSelect of Texas and HealthSelect Out-of-State
Out-of-Network
Consumer Directed HealthSelectSM High-deductible Health Plan
In-Network
Consumer Directed HealthSelect High-deductible Health Plan
Out-of-Network
Hearing aids (for covered participants over age 18)
High-tech radiology
(CT scan, MRI and nuclear medicine)2
Hospice care2
Plan pays up to $1,000 per ear every three years. In-network and out-of-network hearing aids are covered at the same benefit level.
Plan pays up to $1,000 per ear every three years after deductible is met.
Hearing aids
(for participants age 18 and under)
Plan pays 100%, limit of one hearing aid per ear every three years. In-network and out-of-network hearing aids are covered at the same benefit level.
20% coinsurance after annual in-network deductible is met. In- network and out-of-network hearing aids are covered at the same benefit level.
$100 copay plus 20% coinsurance
20% coinsurance
$100 copay plus 40% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
20% coinsurance deductible is met
20% coinsurance deductible is met
after annual
after annual
40% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
Home health care2
20% coinsurance
40% coinsurance after annual deductible is met
20% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
Inpatient hospital facility
(semi-private room and day’s board, and intensive care unit)2
• $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% coinsurance after annual deductible is met.
• $750 copay max, up to 5 days per hospital stay
• $2,250 copay max per calendar year per person
20% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
Maternity care doctor charges only; inpatient hospital copays will apply
$25 or $40 for first pre-natal visit; no charge for routine post natal appointments
40% coinsurance after annual deductible is met
No charge for routine prenatal appointments and 20% coinsurance for first post-natal visit after annual deductible
is met
40% coinsurance after annual deductible is met
Medications
and injections administered by
a provider (see below for outpatient medications and injections)2
• Physician's office: Covered at 100% after copay (or 100%
if no charge is assessed for office visit)
• Any other outpatient location: 20% coinsurance.
• Preventive vaccines covered at 100%
40% coinsurance after annual deductible is met
20% coinsurance after annual deductible is met
Preventive vaccines covered at 100%
40% coinsurance after annual deductible is met
Office surgery and diagnostic procedures
Private duty nursing2
Routine eye exam, one per year per participant
Surgery (outpatient) other than in physician’s office2
20% coinsurance 20% coinsurance
$40 copay
$100 copay plus 20% coinsurance
40% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
$100 copay plus 40% coinsurance after annual deductible is met
20% coinsurance deductible is met
20% coinsurance deductible is met
20% coinsurance deductible is met
20% coinsurance deductible is met
after annual after annual
after annual
after annual
40% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
PCP office visit
$25 copay
40% coinsurance after annual deductible is met
20% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
Retail health/ convenience care clinic
$25 copay
40% coinsurance after annual deductible is met
20% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
Routine preventive care
No cost to participant(s)
40% coinsurance after annual deductible is met
No cost to participant(s)
40% coinsurance after annual deductible is met
Skilled nursing facility/inpatient rehabilitation facility services2
20% coinsurance
40% coinsurance after annual deductible is met
20% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
Specialist physician office visit
$40 copay with valid PCP referral on file
40% coinsurance after annual deductible is met
20% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
2Preauthorization may be required.
Compare Health Plans 18