PPO and POS plans

PPO and POS plans at a glance

There are two Medicare PPO/POS plans to choose from. This page displays PPO/POS comparison information to help you make your decision. KelseyCare Point-of-Service plan is similar to a PPO. It gives you a network, but you can go out of that network at a higher cost at the time of service. Both have lower time-of-service payments when you stay in network. These are key features of the MA PPO and POS plans you can choose from:

Aetna PPO KelseyCare Advantage Plus Choice POS

Your favorite doctor not in your network? Aetna PPO gives you the flexibility to choose whether you want to use one of the fine doctors in the large network or go outside it.

Like Kelsey-Seybold and its low monthly premiums but want a little more flexibility? The KelseyCare Advantage Plus Choice POS gives you access to the Kelsey-Seybold network and lets you go to specialists outside the network for just a little more cost.

PPO and POS service areas - see page 14

A network that spans 24 counties.

Every Kelsey-Seybold clinic is in the network.

Plan features and costs comparison - see page 8

You don’t have to select a primary-care physician, but it is recommended that you have one. No referrals are needed for specialists.

$15 copayment for most services in network.

You can use an out-of-network doctor, but you’ll pay 15 percent of the Medicare-approved fee.

You don’t have to select a primary-care physician, but you do need to stay in the Kelsey-Seybold network for routine care. Most services, such as PCP, urgent-care centers, therapy, nursing, home health and well-woman and well-man exams must be in network.

Zero copayment for PCP visits. Your PCP must be in network.

You can visit an out-of-network specialist if the doctor accepts Medicare assignment. If you do, you’ll pay 20 percent of the Medicare-approved fee for services. If the doctor only accepts Medicare, but not Medicare assignment, you may pay up to 35 percent of the Medicare-approved fee.

PPO and POS in-network hospitals chart - see page 12

Access to 59 in-network and unlimited out-of-network hospitals.

Access to 20 in-network hospitals and unlimited out-of-network hospitals.

Prescription coverage - see pages 22-23

Medicare Part B drugs are covered with a 20 percent coinsurance.

Medicare Part B drugs are covered with a 15 percent coinsurance, to $1,500. After you have paid $1,500, KelseyCare will pay for Part B drugs at 100 percent.

Extra benefits - see the fold-out PPO and POS plan comparison chart

Extra benefits include free case management, healthy lifestyle coaching, and vision, hearing, and dental discounts.

Extra benefits include free case management, health education, wellness programs, and nutrition therapy, and discounts for eyewear and hearing aids in network. Up to 20 free rides (10 round trips) to in-network doctors or hospitals per year.

PPO and POS service areas

If Aetna or KelseyCare Advantage Plus Choice POS expand into other counties, we will notify you about enrollment opportunities. See a map of the PPO and POS service areas.

Aetna PPO counties are:
Bexar, Brazoria, Chambers, Collin, Comal, Dallas, Denton, El Paso, Fort Bend, Galveston, Grayson, Harris, Jefferson, Johnson, Kaufman, Kendall, Liberty, Montgomery, Nueces, Orange, Rock Wall, Tarrant, Travis, Williamson

KelseyCare Advantage Plus Choice POS counties are:
Ft. Bend, Harris, Montgomery and Galveston zip codes: 77510, 77511, 77517, 77518, 77539, 77546, 77549, 77563, 77565, 77568, 77573, 77574, 77590, 77591, 77592.

What it costs per month

Use the chart below to find the contribution for the coverage you elect. Use the worksheet provided in your packet to calculate your monthly rates.

Monthly PPO and POS contribution rates for Jan. 2010

Retiree only

Retiree + 1

Retiree + family

No Medicare

With Medicare

No Medicare

1 with Medicare

2 with Medicare

No Medicare

1 with Medicare

2 with Medicare**

BCBS PPO*** under age 65

$580.58

$507.90

$1,492.56

$1090.70

$714.10

$2,086.74

$1435.48

$1298.40

BCBS PPO *** over age 65

$817.06

$507.90

$817.06

$1,90.70

$714.10

$2,156.80

$1,435.48

$1,298.40

Medicare plans, over age 65 with Medicare

Aetna PPO

N/A

$54.84

N/A

$54.84 each member

N/A

$54.84 each member

KelseyCare Advantage Plus Choice POS

N/A

$17.24

N/A

$17.24 each member

N/A

$17.24 each member

* Rates displayed for the BCBS PPO are discounted for participants who do not use tobacco products. If the participant or a family member uses tobacco products, the rate is $25 higher per month. This additional amount does not apply to Aetna PPO or KelseyCare Advantage Plus Choice POS.
** If you have more than two members with Medicare, please call the benefits division at 713-837-9400.
*** These rates will change on May 1, 2010.

Time of service costs

Use the chart below to compare plan features and time of service costs. This is a brief comparison of covered features. Be sure to use the fold-out PPO/POS comparison chart to see all the features.

PPO and POS plan features and costs comparison

Plan feature

What you pay

Aetna PPO

KelseyCare Advantage Plus Choice POS

BCBS PPO In-network

In-network

Out-of-network

In-network

Out-of-network

In-network

Out-of-network

Deductible (Individual/Family)

N/A

N/A

N/A

N/A

$200/$600

$400/$1,200

PCP office visit copayment

$15

15%

$0

N/A

$30

40% after deductible

Specialist office visit copayment

$15

15%

$15

20% of Medicare-approved fees

$50

40% after deductible

Routine physical copayment

$0

15%

$0

N/A

$0

40% after deductible

Well woman/man exam

$0

15%

$0

N/A

$0

40% after deductible

Inpatient copayment/coinsurance

$0

15%

$300

$1000 (days 1-60)

$250/day (days 61-90)

$500/day (days 91-150)

$500 + 20%

$1,000 + 40%

Emergency room

$50

$50

$50

$50

$150 + 20%

$150 + 40%

Ambulance

$15

15%

$100

$100

20%

40% after deductible

Outpatient surgery

$0

15%

$150/$175

20% of Medicare-approved fees

20%

40% after deductible

Prescriptions participating pharmacy

31-day supply

90-day supply

31-day supply

90-day supply

30-day supply

90-day supply

Generic

$10

$20

$10

$20

$10

$20

Preferred brand

$30

$60

$30

$60

$30

$60

Non-preferred brand

$45

$90

$45

$90

$45

$90

Specialty drugs

$45

$90

$45

N/A

$45*

N/A

* Specialty prescription drugs must be obtained through the Triessent Specialty Drug Program.

PPO and POS in-network hospitals

Listed below are in-network hospitals for the PPO and POS Medicare plans. Out-of-network hospitals require higher copayment. For a complete list, check the Web sites or call one of the numbers in the contact box on page 1. In an emergency, you make seek treatment at any hospital.

In-network hospitals for the PPO and POS plans

Hospital

KelseyCare Advantage Plus Choice POS

Aetna PPO

BCBS PPO

Angleton Danbury Medical Center

X

X

Bayshore Medical Center

X

Brazosport Regional Health System

X

CHRISTUS St. John

X

X

X

Clear Lake Regional Medical Center

X

X

East Houston Medical Center

X

Houston Northwest Medical Center

X

X

Kingwood Medical Center

X

X

Mainland Medical Center

X

M.D. Anderson Cancer Center

X*

X*

Memorial Hermann Hospital Syst.

X (12 facilities)

X

Methodist Hospital

X

Park Plaza

X

X

St. Joseph Medical Center

X

X

St. Luke’s - Woodlands

X

X

X

St. Luke’s Episcopal Hospital

X

X

X

Spring Branch Medical Center

X

X

West Houston Medical Center

X

X

Women’s Hospital of TX

X

* By referral only.

 

 

  
 
 
 
 
 

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