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Texas Health Insurance Pool
1-888-398-3927
TDD 1-800-735-2989

www.txhealthpool.org
texashealthpool@bcbstx.com

Policy Sample
 
(Standard Plans I-IV)
Effective
06/01/201
3

Policy Sample
(High Deductible Health Plan
/
HSA-Qualified Plan V)
Effective
06/01/2013

  BCBSTX Medical
Policy  Guidelines

 

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    Contacts

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        About the Pool

 

www.txhealthpool.org
texashealthpool@bcbstx.com

 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 

Health Pool Benefits


IMPORTANT NOTICE:  The Y2014 Pool calendar year medical deductibles (except the HSAQ plan) will be prorated. 
[Click Here] for more information.


Health Pool Plan Benefits as of 03/01/2013

[see Outline and Policy for specifics related to each benefit]

Medical
Deductibles/
Coinsurance
Plan I
(Insured Pays)
Plan II
(Insured Pays)

 Plan III
(Insured Pays)

Plan IV
(Insured Pays)
Plan V
HDHP/
HSA Qualified
(Insured Pays)
Deductible
(Calendar Year)
$1000$2500$5000$7,500$3,000
Coinsurance for 
PPO Providers
20%20%20%20%0%
Coinsurance for 
Non-PPO
Providers
40%40%40%40%40%
Coinsurance 
Maximum 
for PPO Providers
(Calendar Year) 
$3000$3000$3000$5,000$0



Annual PPO Medical Maximum Out-of-Pocket
Amounts


Plan I
(Deductible 
+
Coinsurance)

Plan II

(Deductible 
+
Coinsurance)

Plan III
(Deductible
+
Coinsurance)

Plan IV
(Deductible
+
Coinsurance)

 


Plan V
HDHP/
HSA-Qualified

  

$1000 + $3000 
= $4000 Annually

 

 

$2500 + $3000 
= $5500 Annually

 

$5000+$3000
=$8000  Annually

 

$7,500+$5,000
=$12,500 Annually

 

$3,000
Annually

Annual Pharmacy Deductible/Copays



$200
(No Copay limit)


$200
(No Copay limit)

 



$200
(No Copay limit)

 



$500
(No Copay limit)

 



$1,450 Deductible/
$1,500 Copay Maximum

 

NOTES:

  • The Coinsurance Maximum for Non-PPO Providers for all plans is $10,000 in a Calendar Year.
     
  • The Lifetime Maximum benefit for all plans is $4,000,000.
     
  • Plans III,  IV and V are not available to individuals eligible for Medicare. Plans I & II are available to supplement Medicare Disability.  Plans I and II do not provide outpatient prescription drug benefits to Medicare-eligibles due to the availability of Medicare Part D.
     
  • The Calendar Year Deductible, the Emergency Care Deductible, Physician Office Visit Copayments, and Charges for Outpatient Prescription Drugs DO NOT COUNT toward the Coinsurance Maximums.

  • After the insured pays the medical deductible for the policy, the policy pays the amount of Covered Expenses in excess of the Coinsurance Amount subject to policy limits.  For Covered Expenses from a Preferred Provider, once you have paid your Coinsurance Maximum, the policy pays 100% of Covered Expenses from Preferred Providers for the rest of the Calendar Year.  In no event will the policy pay more than the Lifetime Maximum for each Insured Person.

  • The deductible amount selected may not be changed to a lower amount after the Policy is issued. You may request to change to a higher deductible, if offered, but only one such change will be allowed in a calendar year.  The change will be effective on the first of the month following the date your written request is received, or a later date if requested.

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Summary-Health Pool Plan Benefits


[see Outline and Policy for specifics related to each benefit]

HospitalAverage semi-private room rate.  No more than one visit per physician per day
Intensive Care or Cardiac Care UnitNo more than 3 times the average semi-private room rate
Assistant Surgeon or Surgical First AssistantOne assistant, no more than 25% of the primary surgeon's fee
Hospital or other facility for Emergency CareSubject to additional $100 deductible per visit (not credited toward coinsurance maximum). Does not apply to Plan V
Physician Office Visits-for covered illness or injuryPPO Plan: $30 copayment per visit, for first 6 visits per calendar year.  Thereafter, visits are subject to Calendar Year Deductible & Coinsurance.  Non-PPO Plan:  Subject to Calendar Year Deductible and/or Coinsurance
Home Health CareLesser of 60 visits or $5,000 per calendar year
Skilled Nursing Facility45 days per calendar year
Hospice CareLesser of 180 days or $10,000 lifetime maximum
Named TransplantsSubject to a lifetime combined maximum benefit for all transplants of $300,000. Transplants covered include:  kidney, pancreas, heart, liver, lung and bone marrow. Includes preparation and transportation.
Physical, Speech, Occupational Therapy$5,000 per calendar year
Serious Mental IllnessCalendar year maximum benefit of 30 inpatient days and 50 outpatient visits.
Preauthorization ProvisionsIf a preauthorization requirement is not met, benefits for covered services and supplies will be reduced 50%. Preauthorization required for: inpatient admissions, skilled nursing facility admissions; home health care services, home infusion therapy, hospice care, transplants, and durable medical equipment over $2,000.
Outpatient Prescription Drugs
 
See Pharmacy Program page of website. 
      

Summary - Other Health Pool Medical Plan Benefits

[See Outline and Policy for specifics related to each benefit]

  • Acquired Brain Injury

  • Ambulance
  • Anesthesia
  • Blood

  • Breast Reconstruction in connection with mastectomy

  • Diabetes
  • Durable Medical Equipment

  • Genetic Testing and Counseling

  • Home infusion therapy

  • Hospital/Surgical

  • Miscellaneous Hospital Services and Supplies

  • Outpatient Care

  • Outpatient contraceptive services

  • Oxygen


  • Physical, Occupational, Speech, Language Therapy

  • Preadmission Testing

  • Complications of Pregnancy
  • Preventive Care
  • Prosthetic Devices


  • Radiation Therapy, Inhalation Therapy, Chemotherapy
  • Second Surgical Opinion
  • Surgeons
  • Surgical Services and Supplies from an Ambulatory Surgical Center and Hospital Outpatient Facility
  • X-rays and Laboratory Tests
 

BlueChoice Network

The Pool has selected the BlueChoice Network as the Pool's Preferred Provider Organization (PPO). Although you may choose any medical provider or hospital, you will save money by using providers from the BlueChoice Network.

If you choose a BlueChoice provider, the Policy will pay a greater coinsurance rate and the BlueChoice provider's rate will be based on the contract rate of the network. If you choose a Non- Preferred Provider, the Policy will pay a lower coinsurance rate and there is no coinsurance maximum. Also, Covered Expenses for a Non-Preferred Provider will be based on the Allowable Amount, which may be less than the provider's billed rate and which could result in a greater expense to you.

If you choose not to use a BlueChoice provider, it is still beneficial to use a "ParPlan" provider.  While not a network preferred provider, a ParPlan provider will not bill you for the difference between covered expenses and the provider's billed charges.  

There are other advantages to using BlueChoice and ParPlan providers. They will handle the initial paperwork so you do not have to file claims. They may also precertify benefits for you, although it is ultimately your responsibility to ensure that your services have been authorized by the Pool.

If there are no BlueChoice providers available to you, you must contact the Administrator's precertification referral department at its toll free number. Generally, a BlueChoice provider will be considered to be unavailable to you if you reside more than 30 miles  from a BlueChoice provider. If there are no BlueChoice providers available to you and you contact the Administrator before obtaining services from a Non Preferred Provider, Covered Expenses for treatment or services by the Non Preferred Provider will be paid at the Preferred Provider coinsurance level.

If an Insured Person's Preferred Provider's arrangement with the Network, chosen by the Pool for this Policy, terminates and, at the time of such termination, the Insured Person has special circumstances, benefits for Covered Expenses received from that provider will be paid as if the Covered Expenses were received from a Preferred Provider until: in the case of an Insured Person who has been diagnosed with a terminal illness, the end of nine months after the effective date of termination; in the case of an Insured Person who, at the time of termination, is past the 24th week of pregnancy, delivery of the child, immediate post-partum care and the follow-up checkup within the first six weeks after the delivery; or in all other special circumstances, the end of 90 days after the date of termination.

BlueCard Program

The BlueCard Program provides access to Preferred Providers of other Blue Cross and/or Blue Shield Plans outside Texas.  If You incur expenses outside Texas through the BlueCard Program, You must pay the Preferred Provider Coinsurance amounts after satisfaction of the Deductible.  Covered Expenses for a BlueCard program provider will be calculated using the lesser of the billed charges of the BlueCard provider or the negotiated rate the Administrator pays the local Blue Cross and/or Blue Shield Plan.

Preexisting Condition Limitation
During the first 12 months following the effective date of coverage, the Policy will not pay benefits for any charges or expenses for a preexisting condition.  
This waiting period will be reduced by the number of months the Insured was covered by creditable coverage in place during the 12 months before the 
Pool policy effective date.  

Insureds who enroll under the COBRA exception and did not exhaust continuation are subject to a minimum 6-month preexisting condition waiting period.

 

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