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Health Plan Highlights
For the past decade, the city of Houston has offered high-quality health coverage with a rock-bottom price tag for employees. And despite soaring health-care costs, employees will continue to enjoy a stellar plan that remains affordable.
Thanks to the determination in our negotiations with HMO Blue Texas, we were able to reduce a possible 24% cost increase down to 13% for May 2005. With the one-year cost for the city’s health plans for FY06 reaching $225 million, a few changes are necessary to keep the plans affordable for employees, retirees and the city.
City employees and retirees have long enjoyed one of the finest health plans in the United States, with quality, accessible, affordable health care. The city has worked hard to keep the payments affordable and the plans responsive to your needs. But with medical inflation continuing in double digits, this is becoming more and more difficult. Health benefits costs continue to skyrocket across the country and all businesses are feeling the pinch, but the city continues to work hard to provide employees and retirees with quality, accessible, and affordable health care.
Thanks to the determination in our negotiations with HMO Blue Texas, we were able to reduce a possible 24% cost increase down to 13% for May 2005. With the one-year cost for the city’s health plans for FY06 reaching $225 million, a few changes are necessary to keep the plans affordable for employees, retirees and the city.
To keep the plans affordable, we have targeted two areas for modification. Details of those changes are explained in this Enrollment Guide. Our philosophy has always been to try to keep changes to your contributions as low as possible, and look to certain plan features for modification - instead of passing along large contribution increases every year. If you don’t use the plan much, the plan changes won’t affect you much. People who use the plans more will carry a larger portion of plan costs.
The HMO Blue Texas HMO and PPO are still the plans of choice. The HMO requires that all of your medical care be directed by your primary care physician (PCP) and you can only use network providers (except for emergency care.) The PPO allows for more flexibility, with no gatekeeper and an out-of-network option, but you will pay greater contributions, copayments, and coinsurance than in the HMO.
The PPO plan was introduced in May 2004, and received about the same enrollment as the previous Point of Service plan - 4% of employees and retirees. It provides a larger network of physicians in Houston and the US, but requires greater cost-sharing from participants.
Plan Feature Changes
There are benefits changes in both the HMO and PPO plans that will become effective on May 1, 2005. They are:
Annual well woman and well man exams will now have a $0 copament in both the HMO and PPO plans. This does not apply to routine physicals. Specialist copayments will go from $20 to $45 in the HMO and from $30 to $50 in the PPO.Office visits for family planning/infertility, preventive care, rehab services, and visits from home health care professionals will not be considered a visit to the specialist. You will pay the PCP level copayment for these services. Step therapy has been introduced in the prescription drug plan. Click here for more details.
Certain drugs are no longer covered. Click here for more details.
The following plan features are effective May 1, 2005. Refer to the plan document for covered benefits and exclusions. Click here to download a comprehensive comparison.
HMO |
PPO In-network |
PPO Out-of-network |
||
| Deductible | N/A |
$200/$600 |
$400/$1,200 |
|
| Office visit | $20 |
$30 |
40% |
|
| Specialist | $45 |
$50 |
40% |
|
| Routine physical | $20 |
$30 |
40% |
|
| Well-woman/man exam | $0 |
$0 |
40% |
|
| Inpatient admission | $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**) non-mail order | ||||
| Generic | $10 |
$10 |
$10 |
|
| Preferred brand | $30 |
$30 |
$30 |
|
| Non-preferred brand | $45 |
$45 |
$45 |
|
| Prescriptions (90-day supply) mail order | ||||
| Generic | $20 |
$20 |
$20 |
|
| Preferred brand | $60 |
$60 |
$60 |
|
| Non-preferred brand | $90 |
$90 |
$90 |
|
| Maximum copay / coinsurance (Individual / Family) |
$1,500/$3,000 |
$3,000/$6,000 |
$5,000/$10,000 |
|
| Out-of-Area plan benefits are not displayed in this chart. Click here to download a comparison chart. | ||||
Two New Medicare Advantage Plans
What's new ... Medicare Advantage plans.
Something you’ll really like. We’re introducing two new Medicare Advantage plans for our Medicare-covered retirees and their Medicare-covered dependents that will save you some major money.
Your two new choices: TexanPlus and Texas HealthSpring.
Both are managed locally and are similar to the HMO-type benefits and prescription drug plan provided by the city – but with mighty attractive financial incentives. Such as:
 |
Lower monthly contributions: 85 to 92-percent savings on “retiree only” contributions. |
|
Lower copayments: 50 to 75-percent savings on standard PCP visits. |
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Familiar plan design: similar to the HMO BlueTexas HMO plan. |
|
Prescription drug plan closely resembling the city’s HMO and PPO drug plan. |
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Possibility for split-family elections. |
|
Opportunity to switch from the Medicare Advantage plans to the HMO or PPO on the first day of any month in 2005. Then on Jan. 1 or May 1 starting in 2006. |
What are my Medicare Advantage plan options?
They’re very similar to the HMO. In some areas the city’s plan offers a more generous benefit but in other areas, especially in out-of-pocket savings, the new plans are more generous. The plans recall the NYLCare65 plan offered until 2000. Click here to see a description of benefits. Or download the comparison chart for more plan features.Both Medicare Advantage plans are based in Houston and offer quality health care, maintaining many of the doctor-patient relationships you already enjoy.
TexanPlus Texas (866) 556-4607
HealthSpring (800) 846-2098
Medicare Advantage Plan Highlights
Here are some familiar benefits.
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Familiar physician networks: Kelsey-Seybold’s 250 Houston-area physicians in TexanPlus; Renaissance physicians in Texas HealthSpring. |
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Some new physicians who are not in the HMO Blue Texas network. |
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Plan design is similar to the HMO Blue Texas HMO. |
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The prescription benefits are similar to the HMO and PPO drug copayment structure, although there are differences in drug formularies and annual limits. |
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Access to familiar retail pharmacies like CVS, Walgreens, HEB, Kroger, Randalls and others. |
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Access to state-of-the-art medical facilities like St. Luke’s and Methodist hospitals. |
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Urgent-care center locations so convenient they could almost be considered a house call. |
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Both plans offer dramatic savings in monthly contributions and doctor-visit copayments. |
Medicare Advantage Plan Comparison
The following plan features are effective May 1, 2005. Refer to the plan document for covered benefits and exclusions. Click here to download a comprehensive comparison.
HMO |
PPO* In-network |
Texan Plus |
Texas HealthSpring |
||
| Deductible | N/A |
$200/$600 |
N/A |
N/A |
|
| Office visit | $20 |
$30 |
$5 |
$10 |
|
| Specialist | $45 |
$50 |
$25 |
$25 |
|
| Routine physical | $20 |
$30 |
$0 |
$10 |
|
| Well-woman/man exam | $0 |
$0 |
$0 |
$0 |
|
| Inpatient admission | $500 |
$500 + 20% |
$300 |
$275 |
|
| Emergency room | $150 |
$150 + 20% |
$50 |
$50 |
|
| Ambulance | $100 |
20% |
$50 |
$100 |
|
| Outpatient surgery | $200 |
20% |
$125 |
$200 |
|
| Prescriptions (30-day supply**) non-mail order | |||||
| Generic | $10 |
$10 |
$10 |
$10 |
|
| Preferred brand | $30 |
$30 |
$30* |
$30* |
|
| Non-preferred brand | $45 |
$45 |
$45* |
$45* |
|
| Prescriptions (90-day supply) mail order | |||||
| Generic | $20 |
$20 |
$20 |
$20 |
|
| Preferred brand | $60 |
$60 |
$60* |
$60* |
|
| Non-preferred brand | $90 |
$90 |
$90* |
$90* |
|
| Maximum copay / coinsurance (Individual / Family) |
$1,500/$3,000 |
$3,000/$6,000 |
$1,500 |
$1,500 |
|
| * $4,000 annual limit on preferred and nonpreferred brand prescriotions. ** TexanPlus has a 31-day supply |
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The following documents provide detailed information to help you with your consideration of the PPO plan. This official PPO plan document supersedes all information printed here.
The PPO Program: This includes definitions, eligibility, COB, COBRA, Appeals, etc. Section 1: Schedule of Benefits: describes in/out network, in/out of area
Section 2: What is Covered: the chart of covered benefits. Section 3: What is Not Covered - exclusions
Which payments apply to the annual maximum that you pay each year?
Payment Type Payment applies to annual maximum Payment required after annual maximum is reached Annual
Deductible
Coinsurance
Copayments * (excluding Rx)
Hospital Inpatient Copayment *
Copayments for prescriptions *
*Copayments do not apply to the deductible. Once the annual maximum is reached, you keep paying all copayments.
This chart is a partial listing of PPO doctor groups. 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.
|
Physician Group |
HMO |
PPO |
|
Baylor |
|
X |
|
CardioVascular Care Providers, Inc. |
|
X |
|
Diagnostic Clinic |
|
X |
|
Inpatient Consultants of Texas |
|
X |
|
Kelsey-Seybold Clinic |
X |
X |
|
McGovern Allergy Clinic |
|
X |
|
MD Anderson Cancer Center |
|
X |
|
Medical Clinic of Houston |
|
X |
|
Memorial Hermann Healthnet Network Providers |
|
X |
|
OB/Gyn Associates |
|
X |
|
PeopleFirst |
X |
* |
|
Renaissance |
X |
* |
|
Sadler Clinic |
|
X |
|
University Care Plus |
|
X |
| UTMB-Galveston |
X |
*Physicians in these groups may be in the PPO through independent contracts instead of through the IPA.
The chart below presents several considerations in making your choice between the HMO and PPO plans.
|
Features |
HMO |
PPO |
|
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 larger 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 | 7,000 PCPs and specialists in the counties surrounding Houston | 11,000 doctors in Houston area, and 600,000 doctors across the United States |
| Service Area | 220 counties in Texas | 49 states, excluding Montana |
| 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 | A 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 in-network; $400 out-of-network |
| Office visit copayment | Most common copay is $20. | Most common is $30 in-network. |
| Specialist visit copayment | Most common copay is $45. | Most common 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 copayment. |
Preventive care such as well-woman and well-man exams are free in-network and annual physicals are covered with a copayment..Limitations on out-of-network services. |
See medical rates for employees.
See medical rates for retirees.
See Medicare Advantage Plan rates for retirees.
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