City of Houston Open Enrollment 2010

New Plays / Overview	Prescription highlights
Comparison of plans	Contribution
HMO	Dental
PPO and POS	Resources
Network-free

HMO Plans

HMO plans at a glance

There are three Medicare HMO plans and the BCBSTX plan to choose from. The following are key features of each plan:

BCBSTX HMO The reliable coverage you’re familiar with, with a huge service area and access to more then 8,000 primary-care physicians and 22,000 specialists. This plan allows you to live in many areas of Texas and still get the money savings of an HMO.	Texas HealthSpring HMO Great coverage at a low price. Texas HealthSpring is a great savings opportunity for those who live in Houston, southeast and east Texas, and parts of the Valley.	TexanPlus HMO The plus is the low-cost of this quality plan. TexanPlus is a great savings opportunity for retirees who live in Houston and southeast Texas.	KelseyCare Advantage HMO KelseyCare is the lowest-cost health-insurance option available from the city. But, you have to stay in the Kelsey-Seybold network for services, and Kelsey-Seybold clinics are only in eight counties. You can travel from anywhere in Texas to a Kelsey-Seybold clinic for services.
Service areas
Established physician networks covering 220 Texas counties.	Established physician networks in 25 Texas counties.	Established physician networks in 12 Texas counties.	A network of quality, accessible Kelsey-Seybold physicians in eight counties.
Plan features and costs comparison
You must select a primary-care physician, and your PCP must refer you to network specialists. Copayments for PCP visits are $25 and specialist visits cost $50 – an increase of $5 per doctor visit. Out-of-network coverage for emergencies only.	You must have a primary-care physician, and your PCP must refer you to network specialists. PCP visits cost $10. Worldwide emergency care is available.	You must have a primary-care physician, and your PCP must refer you to network specialists. PCP visits cost $10. Nationwide emergency care is available.	You don’t need a primary-care physician, and you don’t need a referral to see a network specialist. Zero copayment for PCP visits. Worldwide emergency care is available.
Hospitals
Access to 11,460 hospitals in Texas.	Access to 50 hospitals.	Access to nearly 50 hospitals.	Access to 20 hospitals.
Prescription coverage
Medicare Part B drugs are covered for a $35 or $50 copayment.	Medicare Part B drugs are covered with a 15 percent coinsurance, to $1,000. After you have paid $1,000, Texas HealthSpring will pay for Part B drugs at 100 percent.	Medicare Part B drugs are covered with a 10 percent coinsurance, to $1,500. After you have paid $1,500, TexanPlus will pay for Part B drugs at 100 percent.	Medicare Part B drugs covered with a 15 percent coinsurance, to $1,500. After you have paid $1,500, KelseyCare will pay for Part B drugs at 100 percent.
Extra benefits
Extra benefits include free case management, health education, and vision and eyewear are covered at in-network facilities. You also have access to the BlueExtras Discount Program.	Extra benefits include free health-club membership for Silver Sneakers and discounts for hearing aids and dental services. Up to 30 free rides (15 round trips) to the doctor, pharmacy or hospital per year.	Extra benefits include the “Nifty after 50” program, and discounts on fitness memberships, hearing exams, dental services, eye exams and lenses. There is a one-time $500 reimbursement on a hearing aid.	Extra benefits include free case management, health education, wellness programs and nutrition therapy, and discounts for eyewear and hearing aids. Up to 20 free rides (10 round trips) to the doctor or hospital per year.

HMO Service areas

If TexanPlus, Texas HealthSpring or KelseyCare expand into other counties, we will notify you about enrollment opportunities.

TexanPlus HMO counties are:

Austin, Brazoria, Chambers, Fort Bend, Galveston zip codes: 77510, 77511, 77517, 77518, 77539, 77546, 77549, 77563, 77565, 77568, 77573, 77574, 77590, 77591, 77592, Harris, Hardin, Jefferson, Liberty, Montgomery, Orange, and Waller

Texas HealthSpring HMO counties are:

Angelina, Brazoria, Cameron, Chambers, Fort Bend, Galveston zip codes: 77510, 77511, 77517, 77518, 77539, 77546, 77549, 77563, 77565, 77568, 77573, 77574, 77590, 77591, 77592, Harris, Hardin, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, Sabine, San Augustine, San Jacinto, Shelby, Tyler, Walker, Waller and Willacy

KelseyCare Advantage HMO counties are:

Brazoria, Chambers, Ft. Bend, Harris, Liberty, Montgomery, Galveston zip codes: 77510, 77511, 77517, 77518, 77539, 77546, 77549, 77563, 77565, 77568, 77573, 77574, 77590, 77591, 77592 and Waller

Areas in red are counties in the service area for BCBSTX HMO. The 34 counties in blue are not in the BCBSTX service area.

Time of service costs

Use the chart below to compare plan features and time of service costs. This is a brief comparison of covered features. Be sure to use the fold-out HMO comparison chart to see all the features. The BCBSTX HMO copayments in bold red are changes that are effective May 1.

HMO plan features and costs comparison
Plan feature	What you pay
	KelseyCare Advantage HMO		TexanPlus		Texas HealthSpring		BCBSTX HMO
Deductible (Individual/Family)	N/A		N/A		N/A		N/A
PCP office visit copayment	$0		$10		$10		$25
Specialist office visit copayment	$15		$25		$25		$50
Routine physical copayment	$0		$0		$0		$0
Well woman/man exam	$0		$0		$0		$0
Inpatient copayment/coinsurance	$300		$300		$275		$500
Emergency room	$50		$50		$50		$150
Ambulance	$100		$50		$100		$100
Outpatient surgery	$150/$175		$125 / $175		$200		$200
Prescriptions participating pharmacy	31-day supply	90-day supply	30-day supply	90-day supply	30-day supply	90-day supply	30-day supply	90-day supply
Generic	$10	$20	$10	$20*	$10	$20	$10	$20
Preferred brand	$30	$60	$30	$60*	$30	$60	$35	$70
Non-preferred brand	$45	$90	$45	$90*	N/A	N/A	$50	$100
Specialty drugs	$45	N/A	$45	$90*	$45**	$90**	$35/$50 ***	N/A

* TexanPlus has no mail-order option; however, you can fill a 90-day prescription for two-months copayment at your local network pharmacy.
** Prior authorization required
*** Specialty-prescription drugs must be obtained through the Triessent Specialty Drug Program.

New copayments on May 1, 2010
BCBSTX HMO
	From	To
PCP visit	$20	$25
Specialist visit	$45	$50
Generic prescription	$10	$10
Preferred Brand prescription	$30	$35
Non-preferred brand prescription	$45	$50

Mail order = 90 day supply for 2x copayments

HMO networks chart

The chart below shows the networks available in each of the HMO plans you can select. TexanPlus, Texas HealthSpring and BCBSTX HMO require you to select a PCP to direct your care. To see if your preferred physicians are in one of the networks, use the contact information.

Physician Group	KelseyCare Advantage HMO	TexanPlus HMO	Texas HealthSpring	BCBSTX HMO
Brazosport Regional Health System			X
Clear Creek Clinic			X
CyFair IPA		X
Family Practice Associates
Heritage		X
North Central LPO		X
Independent Physicians			X	X
Integranet		X
Katy IPA		X
Kelsey-Seybold (20 clinics)	X	X	X	X
Memorial Clinical Associates		X	X
Northwest Diagnostic Clinic		X		X
Pasadena LPO		X
Physicians of East Texas			X
Renaissance			X	X
Sr. SelectCare Clinic		X
Sadler Clinic			X	X
Southeast Regional LPO		X
Village Family Practice		X	X

HMO hospitals chart

The chart below shows the hospitals in the Houston area available in each of the HMO plans. For a complete list, check the Web sites or call one of the numbers on the contact page. In an emergency, you may seek treatment at any hospital, but you may be transferred to a network facility as soon as your condition is stabilized.

Physician Group	KelseyCare Advantage HMO	TexanPlus HMO	Texas HealthSpring	BCBSTX HMO
Angleton Danbury Medical Center		X		X
Bayshore Medical Center		X	X	X
Brazosport Regional Health System		X
CHRISTUS St. John	X	X	X	X
CHRISTUS St. Catherine	X			X
Clear Lake Regional Medical Center		X	X	X
East Houston Medical Center		X	X
Houston Northwest Medical Center		X	X	X
Kingwood Medical Center		X	X	X
Mainland Medical Center		X	X	X
M.D. Anderson Cancer Center	X*			X*
Memorial Hermann Hospital Syst.	X (12 facilities)	X (12 facilities)	X (12 facilities)	X
Methodist Hospital		X	X	X
Park Plaza		X	X	X
St. Joseph Medical Center		X	X	X
St. Luke’s Episcopal Hospital	X	X (Kelsey only)	X (Kelsey only)	X
St. Luke’s - Sugarland	X	X	X	X
St. Luke’s - Woodlands	X	X (Kelsey only)	X (Kelsey only)	X
Spring Branch Medical Center		X	X	X
Tomball Regional Hospital	X	X	X	X
West Houston Medical Center		X	X	X
Woman’s Hospital of TX	X	X (Kelsey only)	X	X

* By referral only.

If there exists a conflict between this Enrollment Guide Website and the official plan documents for each plan, the official plan documents will prevail. The city of Houston reserves the right to change, modify, increase or terminate any benefits.