Health Plan Highlights

Health plan preview

Here’s your health plan scouting report — you have two options for your comprehensive medical plans, HMO and PPO. Both deliver championship care with predictable, budget-friendly costs.

The HMO plan requires that all your care be directed by your primary care physician. You must use network providers, except in case of emergency or referral by your network doctor.

The PPO plan offers more flexibility, more doctors, no PCP requirement and the option to go out-of-network. But you pay more for the added flexibility, in your contribution and at the time of service.

Type of services

Copayments for primary-care services and specialist services are determined by the type of service.

• If the service is performed by the PCP in the office, the lower copayment will apply, $25 in the HMO and $35 in the PPO in-network.
• If the service is performed in a specialist’s office, or in another location, the higher specialist copayment will apply, $50 in the HMO and $55 in the PPO in-network.
• Most services such as home visits, family planning, infertility treatment, physical therapy, and similar services are “specialist services,” and you will pay the higher copayment. Note: artificial insemination requires a 50 percent copayment of usual and customary for each procedure.

To see a comparison of plan features and your out-of-pocket costs, click here.

What’s new

Because of the rising cost of health care, we’ve had to adjust the copayment structure for doctors’ visits and prescription drugs. And for the first time, you can opt out of your city health plan at retirement and come back at a later date.

1. Copayments are changing

In an attempt to lessen the amount of your biweekly contribution increase, we’re increasing your copayments slightly. As of May 1, HMO members will pay $25 when you visit your primary-care physician, and $50 when you visit a specialist. PPO members will pay $35 when visiting your primary-care physician, and $55 when you visit a specialist.

Copayments for preferred brand-name drugs and non-preferred brand-name drugs are increasing $5 for a 30-day supply and $10 for a 90-day mail-order supply. Generics will remain $10, or less for many drugs at many stores.

2. Retirees can opt out of their city insurance plan and return to the city insurance plan in the future

Retirees will be able to disenroll from their city plan and re-enroll later. This Opt-out Opt-in feature could save you money during the opt-out period while providing you the security of knowing you can re-enroll in a city plan again in the future.

 

New Opt-out Opt-in feature for retiring employees and retirees

As a retiree, you have come to expect city medical and dental benefits. In the past, if you waived these benefits, you couldn’t come back to your city plan. Your only option was to keep the city’s plan, even if you could get less-costly coverage somewhere else.

Now, you can opt out of your city benefits and re-enroll later. So when you and your spouse are no longer eligible for medical benefits from another source you can still get great city benefits coverage. Even if you have a city Medicare plan, you can opt out and return later.

For retirees, there are rules that Medicare plans must follow. So before you opt out, check with your plan administrator about how Medicare’s rules will affect you. If you opt out of your city Medicare plan, you’ll automatically be enrolled in Original Medicare, and you’ll have to enroll in a prescription-drug plan if you want prescription-drug coverage. If you do not have a creditable Medicare Part D prescription-drug plan during your opt-out period, you may be limited to when you can enroll in a Part D plan and you may have to pay late-enrollment penalties.

Your opt-out applies to your dependents, including dependents covered under a Medicare plan. So if you drop your city coverage, your dependents’ city coverage will be dropped as well.

You can opt back into a city plan during any open enrollment, after a family status change that causes you to lose coverage, or after a 90-day waiting period.

To opt out, you must submit a Retiree Medical/Dental Opt-Out form to HR benefits. Your opt-out election is effective the first of the month after HR benefits receives your form. For more information, call 713-837-9400.

To re-enroll, you’ll need to submit a Retiree Medical/Dental Opt-In form to HR benefits and provide relationship documents for dependents you want to cover. If your opt-in election is caused by loss of coverage, you’ll need to submit a Certificate of Coverage from the insurance company or the company that provided the medical plan. You must opt in within 31 days after the family status change, or you’ll have to wait through the 90-day eligibility period.

*Generics are mandatory if available.

* Pediatricians/specialty care providers participating in the HMO network.
** Physicians may be available through independent contracts instead of through the IPA.
***Available through referral only.
****Kelsey-Seybold no longer provides services to Medicare-covered PPO members. See page 10 for more information.

Service Areas

The map below shows the broad coverage of the service area for HMO and PPO plans. The HMO includes more than 200 counties in Texas and the PPO includes every state, plus Puerto Rico. Your ID card is accepted by additional doctors and hospitals and a larger retail pharmacy network.

HMO

The HMO service area is as big as the state of Texas, except for these 34 counties — Archer, Bandera, Baylor, Clay, Coryell, DeWitt, Dimmit, Duval, Edwards, Falls, Foard, Frio, Gillespie, Goliad, Hamilton, Hardeman, Jim Hogg, Kerr, Kinney, Knox, LaSalle, Lampasas, Limestone, Live Oak, Llano, McMullen, Maverick, Real, Uvalde, Webb, Wichita, Wilbarger, Zapata, Zavala.

PPO

The BlueChoice PPO network is as big as America itself. That means employees and retirees under the plan can find contracted providers in every state, plus Puerto Rico.

To help you decide which plan is right for you, the chart below gives you a comparison of plan details.

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