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Health Plan Highlights
HMO and PPO Plan Highlights
There are no benefit changes for May 2007!
We are happy to announce that are no changes to the medical plans for the 2007 plan year. You are experiencing an increase to your contributions.
The HMO and PPO plans offer a choice of plan that delivers comprehensive care, predictable and budgetable health costs, and to offer a choice.
The HMO requires that all of your care be directed by your Primary Care Physician and you must use network providers, except in the case of emergency. There is more flexibility in the PPO, more doctors, no PCP requirement, and the option to go out-of-network. The trade-off is that you pay more for this flexibility, in your contribution and at the time of service.
You are familiar with the features of these plans, which are summarized in the chart on this page. These plan features have not changed since May 2006. For a detailed comparison click here.
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HMO and PPO plan features
Health plan features at-a-glance |
Plan feature |
What you pay |
| |
HMO |
PPO In-network |
PPO Out-of-network |
Deductible (Individual/Family) |
no deductible |
$200/$600 |
$400/$1,200 |
PCP office visit copayment |
$20 |
$30 |
40% |
Specialist office visit copayment |
$45 |
$50 |
40% |
Routine physical copayment |
$0 |
$0 |
40% |
Well woman/man exam |
$0 |
$0 |
40% |
Inpatient admission copayment/coinsurance |
$500 |
$500 + 20% |
$1000 + 20% |
Emergency room |
$150 |
$150 + 20% |
$150 + 20% |
Ambulance |
$100 |
20% |
20% |
Outpatient surgery |
$200 |
20% |
40% |
Prescriptions (30-day supply) participating pharmacy copayment |
Generic |
$10 |
$10 |
$10 |
Preferred brand |
$30 |
$30 |
$30 |
Nonpreferred brand |
$45 |
$45 |
$45 |
Prescriptions (90-day supply) mail-order copayment |
Generic |
$20 |
$20 |
$20 |
Preferred brand |
$60 |
$60 |
$60 |
Nonpreferred brand |
$90 |
$90 |
$90 |
Annual maximum copay/coinsurance (Individual/Family) |
$1,500/$3,000 |
$3,000/$6,000 |
$5,000/$10,000 |
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Type of Service
Copayments for primary care services and specialist services are determined by the type of service.
- If the service is performed by the primary care provider in the office, the lower copayment will apply, $20 in the HMO and $30 in the PPO.
- If the service is performed in a specialist’s office, or in another location, the higher specialist copayment will apply, $45 in the HMO and $50 in the PPO.
Services such as home health visits, family planning and infertility treatment, physical therapy and other similar services are considered “specialist services,” and you will pay the higher copayment.
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Which doctors can help you win?
This chart is a partial listing of doctor groups in the HMO and PPO. Many doctors contract independently with the PPO. For a complete list, go to www.bcbstx.com and search by doctor name or by zip code.
Doctors in the HMO and PPO |
Physician Group |
HMO |
PPO |
Baylor |
* |
X |
CardioVascular Care Providers, Inc. |
† † |
X |
Independent Physicians, if listed |
X |
|
Inpatient Consultants of Texas |
|
X |
Kelsey-Seybold Clinic |
X |
X |
The Limited Provider Network |
X |
** |
MD Anderson Cancer Center |
† † |
X |
Medical Clinic of Houston |
|
X |
Memorial Hermann Healthnet Network Providers |
† |
X |
Northwest Diagnostic Clinic |
X |
X |
OB/Gyn Associates |
|
X |
Renaissance |
X |
** |
Sadler Clinic |
X |
X |
UT Physicians |
|
X |
UTMB-Galveston |
|
X |
* Pediatricians/specialty care providers participating in the HMO
** Physicians in these groups may be in the PPO through independent contracts instead of through the IPA.
† Physicians may be in the HMO through independent contracts instead of through the IPA.
†† Available through referral only.
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Which plan is right for me?
Which plan is right for me? |
Features |
HMO |
PPO |
|
You must select a PCP. Services are available from specific doctors for a specific copayment; no claims to file; no coverage out-of-network (except for emergencies.) |
Services are available from a large network of doctors; services are subject to deductible, copayment and coinsurance; you may have to file a claim; out-of-network coverage is available at a lower benefit level. |
Network |
8,463 PCPs and specialists in the counties surrounding Houston. |
12,955 doctors in the Houston area, and 600,000 doctors across the United States. |
Service Area |
220 counties in Texas. |
All 50 states, plus Puerto Rico. |
Network services |
Except for emergency care, only services provided in the network are covered. |
Services performed in-network and out-of-network are covered at different levels. |
Primary Care Physician |
Your PCP coordinates all medical care. |
Freedom to chose any doctor, hospital, or specialist. |
Referrals |
PCP must refer you to specialists and hospitals. |
Referrals are not required. |
Deductible |
No deductible or coinsurance. |
$200/$600 in-network.
$400/$1,200 out-of-network. |
PCP visit |
Most common copayment is $20. |
Most common copayment is $30 in-network. |
Specialist visit |
Most common copayment is $45. |
Most common copayment is $50 in-network. |
Coinsurance |
Most services covered at 100% after copayment. |
Services covered 80% (or 60% out-of-network) after annual deductible. |
Billing for services |
No balance billing.
No claims to file. |
No balance billing, unless you seek out-of-network services; you must file a claim to seek reimbursement. |
Preventive care |
Routine preventive care such as well-baby, well-woman, and well-man exams are free; annual physicals are covered with $0 copayment. |
Preventive care such as well-woman and well-man exams are free in-network and annual physicals are covered with $0 copayment. Limitations on out-of-network preventive services. |
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Are you or your dependents covered by Medicare ?
Get ahead of the game with a Medicare Advantage plan. You now have the choice of three MA plans; Aetna Private-Fee-for-Service, TexanPlus and Texas HealthSpring.
What’s the difference in these three city-sponsored MA plans?
TexanPlus offers HMO-type benefits to Medicare-covered retirees in the southeast Texas area. The network includes Kelsey Seybold and Heritage doctors from which to select a PCP.
Texas HealthSpring offers HMO-type benefits to Medicare-covered retirees in the southeast/east Texas areas and three counties in the Valley. The network includes Kelsey Seybold, Sadler Clinic and Renaissance doctors from which to select a PCP.
Aetna Private-Fee-for-Service offers copayment benefits for most services in all 50 United States. Any doctor or hospital that accepts Medicare assignment and Aetna’s terms and conditions can participate. There is no network, no directory, and no referral required to see a specialist.
Some of the exceptional benefits are:
- TexanPlus and Texas HealthSpring have plan designs similar to HMO Blue Texas HMO.
- Kelsey Seybold doctors participate in TexanPlus and Texas HealthSpring in the Houston area.
- Renaissance and Sadler doctors participate in Texas HealthSpring and Heritage doctors participate in TexanPlus.
- Aetna offers the possibility that 96% of the doctors in the U.S. that accept Medicare assignment will belong to their PFFS plan. PCP selection is recommended, but not required.
- All three plans have prescription benefits similar to the HMO and PPO drug copayment structure.
- Access to familiar retail pharmacies like CVS, Walgreens, HEB, Kroger, Randalls and others.
- Access to state-of-the-art medical facilities like St. Luke’s and Methodist Hospitals.
- Urgent-care center locations so convenient they could almost be considered a house call.
- The option for split-family elections – one stays in HMO or PPO, one elects a Medicare Advantage plan.
- Opportunity to switch back to the HMO or PPO within 90 days of enrollment in an MA plan, or on January 1, 2008 and again on May 1, 2008. If you are interested in one of the MA plans, call (713) 837-9400 or (888) 205-9266 for a copy of the Medicare Advantage guide, or click here for more information about Medicare Advantage plans.
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