Health plan and prescription checklist

Health plan and prescription checklist

January 10, 2018

Changes as of January 1, 2018

Some of the following changes occur every year. Some are one-time changes to specific health insurance plan benefits. Annual deductibles, coinsurance maximums, and out-of-pocket maximums reset on January 1 of each year, unless otherwise noted below.

Deductibles
If you are enrolled in: When does my deductible restart?
HealthSelectSM of Texas (living or working in Texas) and you are not enrolled in Medicare In-network: You do not have a deductible if you see in-network providers.

Out-of-network: Your out-of-network deductible resets on January 1.

Prescription drug deductible starts over on January 1.
HealthSelect Out-of-State (your eligibility county on file with ERS is outside Texas) In-network: You do not have a deductible if you see in-network providers.

Out-of-network: Your out-of-network deductible resets on January 1.

Prescription drug deductible starts over on January 1.
Consumer Directed HealthSelectSM In-network: Your in-network deductible resets on January 1.

Out-of-network: Your out-of-network deductible resets on January 1.

Prescription drug deductible starts over on January 1.
HMO Plans

Community First Health Plans

KelseyCare powered by Community Health Choice

Scott & White Health Plan
You do not have a deductible.

Prescription drug deductible starts over on September 1.
HealthSelect Secondary (i.e., you are Medicare eligible and retired, or a return to work retiree with retiree level benefits) You do not have a deductible.

Prescription drug deductible starts over on January 1.
HealthSelect Medicare Advantage (through Humana) or KelseyCare Advantage There is no medical deductible.

Prescription drug deductible starts over on January 1.

Out-of-network freestanding emergency rooms

What is changing?
As of January 1, 2018, HealthSelect participants who get medical care from a freestanding emergency room (ER) that is not in the HealthSelect network will probably pay much more of the cost. Participants will now be responsible for any billed charges that exceed the amount HealthSelect pays, regardless of whether the services were the result of a true emergency or non-emergency.

What is a freestanding emergency room?
Freestanding ERs may seem like an appealing alternative to hospital emergency rooms. Usually found in residential shopping centers or other convenient locations, freestanding ERs can easily be confused with urgent care centers or convenience clinics. They may also look like small hospital ERs. They provide emergency medical services, but are not affiliated and are not physically connected to a hospital (or a department of a hospital). Most freestanding ERs are not in the HealthSelect network.

Find out more about freestanding emergency rooms.

Mediation for out-of-network bills of $500 or more

As of January 1, 2018, if you visit an out-of-network emergency facility or freestanding emergency room, or you receive services from an out-of-network hospital-based health care provider at an in-network facility and you are billed for $500 or more for those services (not including your copayment, coinsurance and deductible), you have the right to dispute the billed amount and ask for a mediation.

You can get more information on how you may be able to reduce some of your out-of-pocket cost through mediation by contacting the Texas Department of Insurance at www.tdi.texas.gov/consumer/cpmmediation.html or (800) 252-3439.

If you get a bill from an out-of-network provider for under $500, you can request a claim review by calling a BCBSTX Personal Health Assistant at (800) 252-8039 Monday–Friday, 7 a.m. - 7 p.m. and Saturday 7 a.m. - 3 p.m. CT.