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PPO and POS plans

PPO and POS plans at a glance

KelseyCare POS plan is similar to a PPO. It gives you a network, but you can go out of that network at a higher cost at the time of service. Both have lower time-of-service payments when you stay in network. Pages 14-16 display comparison information to help you make your decision. These are key features of the PPO and POS plans.

Aetna PPO NEW!
Your favorite doctor not in your network? Aetna PPO gives you the flexibility to choose whether you want to use one of the fine doctors in the large network or go outside it.		 BCBSTX PPO
Reliable coverage and a huge service area – more than 10,000 primary-care physicians and 36,000 specialists. In-network and out-of-network services are covered at different rates.		 KelseyCare Advantage Plus Choice POS
The KelseyCare POS gives you access to the Kelsey-Seybold network and lets you go to specialists outside the network.
PPO and POS service areas
Spans 24 counties. United States plus Puerto Rico. Every Kelsey-Seybold clinic.
Plan features and costs comparison

You don’t have to select a primary-care physician, but it is recommended that you have one. No referrals are needed for specialists.
$15 copayment for most services in network.
You can use an out-of-network doctor, but you’ll pay 15 percent of the Medicare-approved fee.

 You can choose any doctor, hospital or specialist. You don’t have to select a primary-care physician, and referrals are not required for specialist visits.
PCP visits are $35, and specialists visits $55 – an increase of $5 each.
Services are subject to deductibles, copayments and coinsurance. You may have to file a claim for reimbursement.		 You don’t have to select a primary-care physician, but you do need to stay in the Kelsey-Seybold network for routine care and most services.
Zero copayment for PCP visits. Your PCP must be in-network.
You can visit an out-of-network specialist who accepts Medicare assignment. You’ll pay 20 percent of the Medicare-approved fee. If the doctor only accepts Medicare, you may pay up to 35 percent of the Medicare-approved fee.
PPO and POS in-network hospitals chart
Access to 59 in-network and unlimited out-of-network hospitals. Access to more than 13,000
in-network hospitals in Texas.		 Access to 20 in-network and unlimited out-of-network hospitals.
Prescription coverage
Medicare Part B drugs are covered with a 15 percent coinsurance. Medicare Part B drugs are covered for a $35 or $50 copayment. Medicare Part B drugs are covered with a 15 percent coinsurance, to $1,500. After that, KelseyCare will pay for Part B drugs at 100 percent.
Extra benefits
Free healthy lifestyle coaching, and vision, hearing, and dental discounts. Free health education and case management. Vsion and eyewear discounts through Davis Vision. You also have access to BlueExtras Discount Program. Free health education, wellness programs and nutrition therapy. Discounts for eyewear, hearing aids and dental services. Up to 10 free round trips to in-network doctors or hospitals per year.

 

POS Service Area

PPO and POS Service areas

If Aetna or KelseyCare Advantage Plus Choice POS expand into other counties, we will notify you about enrollment opportunities.

Aetna PPO counties are:

Bexar, Brazoria, Chambers, Collin, Comal, Dallas, Denton, El Paso, Fort Bend, Galveston, Grayson, Harris, Jefferson, Johnson, Kaufman, Kendall, Liberty, Montgomery, Nueces, Orange, Rock Wall, Tarrant, Travis, Williamson

KelseyCare Advantage Plus Choice POS 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

 

 

 

 

 

 

The BCBSTX PPO service area is nationwide, plus Puerto Rico.
POS 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 PPO/POS comparison chart to see all the features. The BCBSTX PPO copayments in bold red are changes that will be effective May 1.

PPO and POS plan features and costs comparison
Plan feature What you pay
  Aetna PPO KelseyCare Advantage Plus Choice POS BCBSTX PPO
In-network
  In-network Out-of-network In-network Out-of-network In-network Out-of-network
Deductible (Individual/Family)
 N/A N/A N/A
 N/A
$200/$600
 $400/$1,200
PCP office visit copayment
 $15 15% $0 N/A $35 40% after deductible
Specialist office visit copayment
 $15 15% $15 20% of Medicare-approved fees $55 40% after deductible
Routine physical copayment
 $0 15% $0 N/A $0 40% after deductible
Well woman/man exam
 $0 15% $0 N/A $0 40% after deductible
Inpatient copayment/coinsurance $0 15% $300 $1000 (days 1-60)
$250/day (days 61-90)
$500/day (days 91-150)		 $500 + 20% $1,000 + 40%
Emergency room
 $50 $50 $50 $50 $150 + 20% $150 + 40%
Ambulance
 $15 15% $100 $100 20% 40% after deductible
Outpatient surgery $0 15% $150/$175 20% of Medicare-approved fees 20% 40% after deductible
Prescriptions
participating pharmacy
31-day supply 90-day supply 31-day supply 90-day supply 30-day supply 90-day supply
Generic $10 $20
$10 $20 $10
$20
Preferred brand $30 $60 $30 $60 $35 $70
Non-preferred brand $45 $90 $45 $90 $50 $100
Specialty drugs $45 $90 $45 N/A $35/$50* N/A

* Specialty-prescription drugs must be obtained through the Triessent Specialty Drug Program.

BCBSTX PPO
  From To
PCP visit $30 $35
Specialist visit $50 $55
Generic prescription $10 $10
Preferred Brand prescription $30 $35
Non-preferred brand prescription $45 $50

Mail order = 90 day supply for 2x copayments

 

PPO and POS in-network hospitals

Listed below are in-network hospitals for the PPO and POS Medicare plans. Out-of-network hospitals require higher copayments. For a complete list, check the Web sites or call one of the numbers in the contact box on page 1. In an emergency, you may seek treatment at any hospital.

In-network hospitals for the PPO and POS plans
Hospital KelseyCare Advantage Plus Choice POS Aetna PPO BCBSTX PPO
Angleton Danbury Medical Center
   X X
Bayshore Medical Center   X X
Brazosport Regional Health System   X X
CHRISTUS St. John X X X
CHRISTUS St. Catherine X X X
Clear Lake Regional Medical Center   X X
East Houston Medical Center   X  
Houston Northwest Medical Center   X X
Kingwood Medical Center   X X
Mainland Medical Center   X X
M.D. Anderson Cancer Center X*   X
Memorial Hermann Hospital Syst.     X
Methodist Hospital     X
Park Plaza   X X
St. Joseph Medical Center   X X
St. Luke’s Episcopal Hospital X X X
St. Luke’s - Sugarland X X X
St. Luke’s - Woodlands X X X
Spring Branch Medical Center   X X
Tomball Regional Hospital X   X
West Houston Medical Center   X X
Woman’s Hospital of TX X   X

* By referral only.

 

 

 

  
 
 
 
 
 

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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.