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Policy Specimen Effective 01/01/2008

  Outline of Coverage Effective 01/01/2008

  BCBSTX Medical Policy  Guidelines

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Davis Vision Discount Program

 

Texas Health Insurance
Risk Pool
1-888-398-3927
TDD 1-800-735-2989
 
www.txhealthpool.org
texasriskpool@bcbstx.com
 
 
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Health Pool Benefits


[This is only a summary of information. This summary is NOT a legal document. Refer to the Health Pool's Outline, Contract (Policy) and Application for complete information.]



 Health Pool Plan Benefits as of 01/01/2008
[see Outline and Policy for specifics related to each benefit]
Deductibles/
Coinsurance		 Plan I
(Insured Pays)		 Plan II
(Insured Pays)

 Plan III
(Insured Pays)

 Plan IV
(Insured Pays)
Deductible
(Calendar Year)		 $1000 $2500 $5000 $7,500
Coinsurance for 
PPO Providers		 20% 20% 20% 20%
Coinsurance for 
Non-PPO Providers		 40% 40% 40% 40%
Coinsurance 
Maximum 
for PPO Providers
(Calendar Year) 		 $3000 $3000 $3000 $5,000
Coinsurance 
Maximum 
for Non-PPO 
Providers
(Calendar Year) 		 None None None None
 
Maximum
Out-of-Pocket
Amounts 		Plan I
(Deductible 
+
Coinsurance)		 Plan II
(Deductible 
+
Coinsurance)		 Plan III
(Deductible
+
Coinsurance)		 Plan IV
(Deductible
+
Coinsurance)
Using PPO 
Providers		 $1000 + $3000 
= $4000 Annually		 $2500 + $3000 
= $5500 Annually

$5000+$3000
=$8000  Annually

 $7,500+$5,000
=$12,500 Annually
Using 
Non-PPO 
Providers		 No Maximum No Maximum No Maximum No Maximum

Lifetime 
Maximum Benefit Amount

$1,500,000

$1,500,000

 $1,500,000 $1,500,000

NOTES:

  • Plan IV is not available to individuals eligible for Medicare.

  • 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.  There is no Coinsurance Maximum for Covered Expenses from a Non-Preferred Provider.  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]

Hospital Average semi-private room rate
No more than one visit per physician per day
Intensive Care or Cardiac Care Unit No more than 3 times the average semi-private room rate
Assistant Surgeon or Surgical First Assistant One assistant, no more than 25% of the primary surgeon's fee
Hospital or other facility for Emergency Care Subject to additional $75 deductible per visit (not credited toward coinsurance maximum)
Physician Office Visits-for covered illness or injury PPO: $30 copayment per visit, for first 4 visits per calendar year.  Thereafter, visits are subject to Calendar Year Deductible & Coinsurance.  Non-PPO:  Subject to Calendar Year Deductible and Coinsurance
Home Health Care Lesser of 60 visits or $5,000 per calendar year
Skilled Nursing Facility 45  days per calendar year
Hospice Care Lesser of 180 days or $10,000 lifetime maximum
Named Transplants Subject 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 $2,000 per calendar year
Serious Mental Illness Calendar year maximum benefit of 30 inpatient days and 50 outpatient visits.
Preauthorization Provisions If 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, during the 12 months before the Pool policy effective date.  

Insureds who qualify under the COBRA exception are subject to a minimum 6-month preexisting condition
waiting period.

Policy Exclusions

See Outline of Coverage for a complete list of benefit exclusions:

Outline of Coverage (as of 01/01/2008)

 

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Updated on:  07/02/2008