2018 MEDICAL BENEFITS GUIDE - Blue Cross Blue … can also sign up using the mobile app from BCBSTX....

2017 FALL ENROLLMENT BROCHURERETIREES AND OTHERS ELIGIBLE FOR MEDICAREJanuary 1 , 2018 – December 31 , 2018

www.ers.texas.gov | (800) 252-8039 | www.healthselectoftexas.com

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WELCOME!

CONTENTSWhat You Need to Know ............................................................................................................ 3

We Are Here to Help .................................................................................................................. 4

Don’t Forget Your ID Card! ........................................................................................................ 6

Additional Support .................................................................................................................... 7

Preventive Services ................................................................................................................... 8

Online Access ............................................................................................................................ 9

Programs and Services ........................................................................................................... 10

Take Steps to Well-Being ......................................................................................................... 12

Other Resources ...................................................................................................................... 13

Get Fit ...................................................................................................................................... 14

Sample Explanation of Benefits ..........................................................................................15-17

Plan Specifics

HealthSelectSM of Texas ................................................................................................18-19

HealthSelectSM Out-of-State ........................................................................................ 20-21

Consumer Directed HealthSelectSM ............................................................................. 22-23

HealthSelectSM Secondary ............................................................................................24-25

WELCOME www.healthselectoftexas.com

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We’re proud to be serving you.

Blue Cross and Blue Shield of Texas (BCBSTX) is the new administrator for HealthSelect of Texas and Consumer Directed HealthSelect medical plans starting September 1, 2017. The Employees Retirement System of Texas (ERS) sets the benefits and pays the claims, while BCBSTX manages the provider network, processes claims and provides customer service.

HealthSelect provides you with comprehensive benefits and access to programs and tools that can help you and your family members improve your health and well-being. To learn more about your benefits and coverage under HealthSelect you can call a Personal Health Assistant from BCBSTX toll-free at (800) 252-8039, Monday – Friday from 7 a.m. to 7 p.m. central time (CT), and Saturday from 7 a.m. to 3 p.m. CT. Starting September 1, 2017, you can also go to www.healthselectoftexas.com for more information.

Whether you have a health problem and need care, or you’re healthy and want to stay well, your HealthSelect medical plan can help by offering:

• BCBSTX’s Personal Health Assistants can help guide you at each step along the way – from helping you find a primary care physician (PCP), to connecting you with clinicians, to telling you about wellness programs*

• A large provider network of more than 50,000 doctors, hospitals and other providers

• Support to help with continuing care or answering your questions about the HealthSelect transition to BCBSTX

• Clinicians to help you with chronic health problems

• If you’re not sure where to go for care, or you just have questions, calling the 24/7 Nurseline toll-free at (800) 581-0368 may help you. With the 24/7 Nurseline, you and your covered family members have access to caring registered nurses at any time, any day of the year**

• Virtual visits are available at no cost to you if you are enrolled in HealthSelect of Texas, HealthSelect Out-of-State or HealthSelect Secondary.

• Discounts on health and wellness products and services from top retailers

• A Fitness Program that gives you access to discounted memberships at over 9,000 health clubs and gyms nationwide***

www.healthselectoftexas.com WHAT YOU NEED TO KNOW

WHAT YOU NEED TO KNOW

* Member communications and information from Personal Health Assistants are not meant to replace the advice of health care professionals. Participants are encouraged to seek the advice of their doctors to discuss their health care needs. Decisions regarding course and place of treatment remain with the member and his or her health care providers.

** For medical emergencies, call 911. 24/7 Nurseline is not a substitute for your doctor’s care and advice. Talk to your doctor about any health questions or concerns.

*** The one-time enrollment fee and monthly membership fee for the Fitness Program are both subject to applicable taxes. The Fitness Program is provided by Tivity Health, an independent contractor that administers the Prime Network of fitness centers. The Prime Network is made up of independently owned and operated fitness centers. The HealthSelect Fitness Program is provided as a value-added benefit to HealthSelect participants in addition to your health plan. It is NOT insurance. Use of the HealthSelect Fitness Program does not change monthly payments, nor do costs of the services or products count toward any HealthSelect plan maximums and/or plan deductibles. Fitness center access is provided only by vendors that take part in this program.

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Help is just a phone call or click awayBCBSTX’s Personal Health Assistants are trained to help you and your covered family members plan for better health care and save money by:

• Helping you better understand your plan’s benefits and coverage

• Giving you cost estimates for health care services or procedures before you go to the doctor or hospital*

• Helping you with referrals and prior authorizations

• Scheduling appointments

• Connecting you with a clinician to help you learn more about a diagnosis or health issue

• Sharing information about useful web tools, and helping you use them

Click to Chat — Starting September 1, 2017, go to www.healthselectoftexas.com. Online chat is available Monday - Friday 8 a.m. - 5 p.m. CT.

WE ARE HERE TO HELP

WE ARE HERE TO HELP www.healthselectoftexas.com

How can I talk to a Personal Health Assistant?It’s easy! Just call toll-free at (800) 252-8039 Monday - Friday 7 a.m. - 7 p.m. CT and Saturday 7 a.m. - 3 p.m. CT.

Personal Health Assistants are also available via chat through the HealthSelect website by using Click to Chat. They are standing by and ready to help you with your benefits questions.

24/7 NurselineIf you’re not sure where to go for care, or you just have questions, calling the 24/7 Nurseline may help you. With the 24/7 Nurseline, you and your covered family members have access to caring registered nurses at any time, any day of the year. Call toll-free at (800) 581-0368.

* Personal Health Assistants offer cost estimates for various in-network providers, facilities and procedures. Lower pricing and cost savings are dependent on the provider or facility of your choosing. Cost estimates are just an estimate. In addition to your applicable deductibles, copayments and/or coinsurance, the actual cost of the services may vary based on a number of factors including the date of service, the actual procedure performed and what services were billed by the provider and your benefit plan. Coverage is subject to the limitations, exclusions and terms of your plan.

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Make sure your provider is in the network!The HealthSelect provider networks include tens of thousands of doctors and other health care providers. You can see a provider who is not in the network, but you will probably pay more.

Even if a hospital is in the HealthSelect network, the doctors, anesthesiologists, radiologists, and other providers who practice at that hospital may not be. Starting September 1, 2017, go to www.healthselectoftexas.com to search for in-network providers.

If you do not find your current provider in the directory, you can call a Personal Health Assistant toll-free at (800) 252-8039 to find out if you can keep seeing that provider for a limited time.

Transition of Care BenefitsIf you are currently receiving treatment from a doctor who will not be in BCBSTX’s HealthSelect network after September 1, 2017, you may be able to continue treatment with that doctor temporarily. This is called transition of care. To continue with your care, certain eligibility guidelines need to be met. A transition of care form is available for you to submit to BCBSTX by mail or fax.

To determine whether you qualify for transition of care, it may be necessary for BCBSTX to request medical information from your current physician(s).

Medical conditions that may be eligible for transition of care benefits include:

• Pregnancy in the second and third trimester

• Long-term treatment of cancer, heart disease or transplants

• Terminal illness if life expectancy is less than six months

Starting September 1, 2017, you can fill out the form online or download it by going to www.healthselectoftexas.com. To speak to a Personal Health Assistant call toll-free at (800) 252-8039, Monday - Friday 7 a.m. - 7 p.m. CT or Saturday 7 a.m. - 3 p.m. CT.

www.healthselectoftexas.com WE ARE HERE TO HELP

WE ARE HERE TO HELPWE ARE HERE TO HELP

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HealthSelect Medical ID Card Samples

DON’T FORGET YOUR ID CARD! www.healthselectoftexas.com

Don’t forget your ID card!Make sure you let your doctors, hospitals, and other providers know that your insurance plan has changed as of September 1, 2017. You can expect to get new medical ID cards from BCBSTX in late August. Make sure your current and future providers have the information from your new medical ID card from BCBSTX.

You will receive a separate ID card for pharmacy benefits from your prescription drug benefits plan administrator. You need to use this ID card when you pay for prescriptions at the pharmacy. Go to www.healthselectoftexas.com to access information about your prescription drug benefits.

DON’T FORGET YOUR ID CARD!

Subscriber Name:JOHN SMITHIdentification Number:JEA123456789Group Number: 123456Coverage Date: 09/01/17

PCP: Dr. DAVID JONES

Dependent Name:JANE SMITH

HME $25/$40PCP/Specialist$150Emergency Room$50Urgent Care$0Virtual Visit

Subscriber Name:JOHN WILLIAMSIdentification Number:JNA123456789Group Number: 123456Coverage Date: 09/01/17

HME

Dependent Name:JANE WILLIAMS

Note: On most medical ID cards you will see HME, which indicates that you are in the HealthSelect network. It does not mean you are in an HMO.

7www.healthselectoftexas.com ADDITIONAL SUPPORT

Need additional support?Whether it’s learning how to take care of yourself through healthy eating and exercise, getting help for an emotional problem or dealing with a more difficult health challenge, we’re here to help. Because everyone is unique and requires a customized solution for success, we take a holistic approach to your well-being. Our team of clinicians and Personal Health Assistants are on your side and ready to work with you.

Here are some examples of what we can help you with:

• Are you trying to lose weight?

• Do you need counseling for an ongoing situation?

• Are you dealing with a chronic or serious illness such as heart disease or diabetes?

• Do you have back pain?

• Are you trying to control asthma or do you live with chronic obstructive pulmonary disease (COPD)?

• Do you want to quit smoking?

Call toll-free at (800) 252-8039, Monday-Friday 7 a.m. - 7 p.m. CT, or Saturday 7 a.m. - 3 p.m. CT to speak with a Personal Health Assistant.

ADDITIONAL SUPPORT

8 PREVENTIVE SERVICES www.healthselectoftexas.com

Preventive Services Covered at 100%*Preventive check-ups and screenings can detect illnesses and medical problems early and improve overall health for you and your family members. When you use an in-network provider, your HealthSelect plan covers preventive screenings and services at no cost to you.

You have many preventive care benefits, including:

• Routine checkups

• Screenings

• Preventive vaccinations

• Prenatal care

• Well-woman visits

• Domestic violence screenings

• Contraception approved by the Food and Drug Administration (FDA)

Learn more on immunization recommendations and schedules by visiting the Centers for Disease Control and Prevention website at www.cdc.gov/vaccines.

PREVENTIVE SERVICES

* Under the Affordable Care Act, certain preventive and women’s health services are paid at 100% (at no cost to the participant) dependent upon physician billing and diagnosis. In some cases, such as when screenings and tests are diagnostic rather than preventive, the participant will be responsible for payment.

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Online AccessBeginning September 1, 2017, you can get information about your HealthSelect benefits and network, anytime, anywhere. Our custom website, Blue Access for MembersSM, is a great place to start. You can register online after September 1, 2017, through the HealthSelect website at www.healthselectoftexas.com, using the information on your medical ID card.

Keep your benefits at your fingertips! With the Blue Access for Members website you can:

• Stay informed on the go and better manage your health, wellness and benefits

• Find a network doctor, hospital or urgent care facility

• Check the cost and quality of doctors and services covered under your plan

• Check the status or history of a claim

• View Explanation of Benefits (EOB) statements

• Ask for a new ID card or save a digital copy to your phone

• Confirm prior authorization and referral requirements for certain services

• Connect with a Personal Health Assistant by phone or chat

• Tell us how you prefer to communicate and set up requests for text alerts*

www.healthselectoftexas.com ONLINE ACCESS

ONLINE ACCESS

* Message and data rates may apply. Read terms, conditions and privacy policy at bcbstx.com/mobile/text-messaging.

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Take advantage of these programs and servicesVirtual VisitsAs part of your HealthSelect benefits, you and your covered family members can get the care you need for minor illnesses and injuries without having to leave your home or go to the doctor’s office!

Virtual visits offers convenient, high quality care if your primary care physician is not available, if you become ill while traveling, or as an alternative to visiting a hospital emergency room or urgent care facility for non-emergency health conditions.

Good news! Virtual visits are available at no cost to you if you are enrolled in HealthSelect of Texas, HealthSelect Out-of-State or HealthSelect Secondary.

Consumer Directed HealthSelect participants will be required to meet their annual deductible before virtual visits are covered, subject to coinsurance after the deductible is met.

Here’s how virtual visits work:

• Consult with a board-certified doctor online from a computer or mobile device using secure live audio and video technology. You can either speak to a doctor right away or make an appointment to see a doctor later at a time that works best for you

• Doctors diagnose and treat a wide range of non-emergency medical conditions, such as cold, flu, sinus problems, sore throat, pink eye and bronchitis

• Most visits take about 10-15 minutes and doctors can write a prescription, if needed, for you to pick up at a local pharmacy

• The service is available 24-hours a day, including nights, weekends and holidays

• You can choose between the contracted virtual visit providers Doctor on Demand or MDLIVE®*

Please note: virtual visits are not recommended for conditions requiring an exam or test, complex or chronic conditions, and sprains, broken bones or injuries requiring bandaging.

Starting September 1, 2017, go to www.healthselectoftexas.com to learn more about virtual visits. There are links to websites for Doctor on Demand or MDLIVE. When you go to the respective websites/mobile apps you will then be able to register an account and to conduct a virtual visit.

PROGRAMS AND SERVICES www.healthselectoftexas.com

PROGRAMS AND SERVICES

* In the event of an emergency, this service should not take the place of an emergency room or urgent care center. MDLIVE and Doctor on Demand doctors do not take the place of your primary care doctor. MDLIVE and Doctor On Demand are independent companies that provide virtual visit services for Blue Cross and Blue Shield of Texas. MDLIVE and Doctor On Demand operate and administer the virtual visit program and are solely responsible for their operations and that of their contracted providers. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. The telemedicine services made available through Doctor On Demand are provided by licensed physicians practicing within a group of independently owned professional practices collectively known as “Doctor On Demand Professionals”. These professional practices provide services via the Doctor On Demand telehealth platform. Doctor On Demand, Inc. does not itself provide any physician, mental health or other healthcare provider services. MDLIVE is not an insurance product nor a prescription fulfillment warehouse. MDLIVE operates subject to state regulations and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE and Doctor on Demand do not prescribe DEA-controlled substances, non-therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. Internet/Wi-Fi connection is needed for computer access. Data charges may apply when using your tablet or smartphone. Check your phone carrier’s plan for details. Service is limited to interactive-audio/video (video only), along with the ability to prescribe, when clinically appropriate, in Idaho, Montana, New Mexico and Oklahoma. Virtual visits are currently not available in Arkansas. Service availability depends on member’s location.

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Need Help Knowing Where to Go for Care?Sometimes it’s easy to know when you should go to an emergency room (ER). At other times, it’s less clear. Where do you go when you have an ear infection, or are generally not feeling well? The emergency room is an option, but it is an expensive one. You have choices for receiving care that will work with your benefits and give you access to the care you need. Know when to use each for non-emergency treatment.

First, stay in the HealthSelect network. It’s important that when seeking care you and your family stay within your network to help control costs.

Knowing how your plan works may help you save money.Your benefits are based on your health plan’s fee schedule. Doctors, hospitals, clinics and urgent care facilities (these are all called “providers”) who contract independently with the network have agreed to accept our negotiated rates as payment in full. When you receive care from an in-network provider, you will usually pay less out of pocket than at an out-of-network provider.

If you receive care from a provider that is outside your network, you may have to pay more for your care or even the full cost. Providers outside the network may “balance bill” you, which means they will charge you the amount that is above your health plan’s fee schedule.

Before you go for medical care, make sure the doctor or hospital is part of your network.

There are several ways to find a network provider:

You can check online to see if your doctors are in BCBSTX’s network. Go to www.healthselectoftexas.com starting September 1, 2017.

If you need help finding a provider, you can call a Personal Health Assistant toll-free at (800) 252-8039, Monday - Friday 7 a.m. - 7 p.m. CT or Saturday 7 a.m. - 3 p.m. CT.

www.healthselectoftexas.com PROGRAMS AND SERVICES

PROGRAMS AND SERVICES

* Medical Practice Pulse Report 2009, Press Ganey Associates ** Urgent Care Benchmarking Study Results. Journal of Urgent Care Medicine, January 2012. *** Emergency Department Pulse Report 2010 Patient Perspectives on American Health Care. Press Ganey Associates.

Care Center Type Details

Virtual Visits

• You can speak to a board-certified doctor using live audio and video technology for treatment of urgent care situations. If necessary, a doctor can prescribe medication for you and send it to your preferred pharmacy.

• Access to care for non-emergency medical issues whether you’re at home or traveling.

• Average wait time is less than 10 minutes.

• Available 24 hours a day, seven days a week.

Doctor’s Office

• Your doctor knows you and your medical history best and can treat you or refer you to a specialist if necessary.

• Generally, the doctor’s office is the best place to go for non-emergency care.

• Average wait time is 24 minutes.*• Office hours vary.

Urgent Care Provider

• Often used when your doctor’s office is closed, and there is no true emergency. • Many have online and/or telephone check-in.

• Average wait time is 11- 20 minutes.** • Generally open evenings, weekends

and holidays.

Hospital Emergency Room (ER)

• Best option for a life or limb-threatening condition, such as chest pain lasting more than two minutes, shortness of breath, stroke symptoms, uncontrolled bleeding, or fainting and seizures.

• You may receive multiple bills for services such as the hospital facility and each doctor you see, such as emergency room doctors, radiologists, pathologists, anesthesiologists, etc.

• Average wait time is 4 hours, seven minutes.***

• Open 24 hours a day, seven days a week.

12 TAKE STEPS TO WELL-BEING www.healthselectoftexas.com

Weight Management Programs with Long-Lasting Results On September 1, 2017, HealthSelect plan participants will have access to two weight management programs at no additional cost if you meet certain eligibility requirements.

Naturally Slim® and Real Appeal® help you develop healthy habits that can lead to long-lasting results. Whether you want to drop a few pounds or make a more significant change, these weight management programs may help you shed pounds and lead a healthier life!

Naturally Slim and Real Appeal are available at no cost to eligible employees, spouses and dependents 18 and older (excludes Medicare primary participants) enrolled in HealthSelect of Texas or Consumer Directed HealthSelect plans, and with a BMI of 23 or higher.

To learn more about these programs, speak to a Personal Health Assistant toll-free at (800) 252-8039 Monday-Friday 7 a.m. − 7 p.m. CT, and Saturday 7 a.m. − 3 p.m. CT. After September 1, 2017, you can go to www.healthselectoftexas.com to learn more about these two programs. Go to www.naturallyslim.com/healthselect to enroll in Naturally Slim or go to www.healthselect.realappeal.com to enroll in Real Appeal.

Please note: Your plan will only pay for you to participate in one program at a time. If you register for both programs at the same time, you will be responsible for paying the full cost of the second program.

Naturally Slim and Real Appeal are independent companies that contract directly with ERS to provide wellness services for the HealthSelect of Texas and Consumer Directed HealthSelect plans. They are solely responsible for the products and services that they provide.

TAKE STEPS TO WELL-BEING

13www.healthselectoftexas.com OTHER RESOURCES

Looking for a New Way to Experience Wellness? BCBSTX’s Well onTarget® online portal offers personalized tools and resources to help you — no matter where you may be on the path to health and wellness. The site is designed to give you the support you need to make healthy choices, all while rewarding you for your hard work. This site can be accessed starting September 1, 2017, after logging into Blue Access for Members, which can be found at www.healthselectoftexas.com.

Earn rewards Blue PointsSM can help motivate you to maintain a healthy lifestyle. With Blue Points you can earn points for taking part in various wellness activities such as completing a health assessment, synching and using a fitness device or app, Fitness Program visits and completing online courses. After you’ve earned enough points, you can redeem them in the online shopping mall. With the Blue Points program, HealthSelect participants can redeem up to 17,325 points ($99 value) each calendar year.* Any points that are unredeemed in a calendar year will roll over to the next year.

Take Advantage of Discounts With Blue365®, you may save money on health and wellness products and services from top retailers that are not covered by insurance. There are no claims to file and no referrals or prior authorizations required. Once you sign up for Blue365 at blue365deals.com/BCBSTX, weekly “Featured Deals” will be emailed to you. These deals offer special savings for a short period of time.**

OTHER RESOURCES

* Blue Points Program Rules are subject to change without prior notice. See the Program Rules on the Well onTarget Member Wellness Portal at wellontarget.com for further information. Redemption of points for items is limited to $99 per participant per calendar year.

** Blue365 is a discount program only for BCBSTX members. This is NOT insurance. Some of the services offered through this program may be covered under your health plan. Check your Master Benefit Plan Document or call BCBSTX toll-free at (800) 252-8039. for specific benefit facts. Use of Blue365 does not change your monthly payment, nor do costs of the services or products count toward any maximums and/ or plan deductibles. Discounts are only given through vendors who take part in this program. BCBSTX does not guarantee or make any claims or recommendations about the program’s services or products. You may want to talk to your doctor before using these services and products. BCBSTX reserves the right to stop or change this program at any time without notice.

24/7 NurselineIf you’re not sure where to go for care, or you just have questions, calling the 24/7 Nurseline may help you. With the 24/7 Nurseline, you and your covered family members have access to caring registered nurses at any time, any day of the year. Call toll-free at (800) 581-0368.

14 GET FIT www.healthselectoftexas.com

Ready to Get Fit?The Fitness Program offered by BCBSTX helps you make your fitness goals a reality. With access to more than 9,000 fitness centers nationwide, you can choose a gym that’s right for you. Covered members and eligible dependents (age 18 and older) are eligible to enroll.

Other program perks: No yearly program or gym contract: Participation is month to month. Fees are $25 per month per person to use any gym in the fitness program. There is a one-time sign-up fee of $25 per person.

Alternative medicine discounts: Save money with health and well-being providers, such as massage therapists, trainers and nutrition coaches.*

Starting September 1, 2017, go online to the HealthSelect website at www.healthselectoftexas.com to learn more about the program. You will have to log in to Blue Access for Members to find gyms and track your visits.

Easy to pay: After you sign up, it’s easy to set up an automatic credit card or bank account withdrawal to pay your monthly fee.

Sign up for the Fitness Program starting September 1, 2017! Call toll-free at (888) 762-BLUE (2583), Monday through Friday 8 a.m. – 9 p.m. in any continental U.S. time zone. You can also sign up online after you log in to Blue Access for Members.

GET FIT

* You must be a Fitness Program member to take advantage of these discounts.

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SAMPLE EXPLANATION OF BENEFITS

www.healthselectoftexas.com SAMPLE EXPLANATION OF BENEFITS

An Explanation of Benefits (EOB) is a notification provided to members when a health care benefits claim is processed by BCBSTX. The EOB shows how the claim was processed. The EOB is not a bill. Your provider may bill you separately.The EOB has THREE MAJOR sections:• Subscriber Information and Total of Claim(s) includes

the participant’s name, address, member ID number and group name and number. The Total of Claims table shows you the amount billed by your provider, any discounts applied by the HealthSelect plan, and the amount you may owe the provider.

• Service Detail for each claim includes:

- Patient and provider information

- Claim number and when it was processed

- Service dates and descriptions

- The amount billed

- The discounts or other reductions subtracted from amount billed

- Total amount covered

- The amount you may owe (your responsibility)

• Summary shows you what the plan covers for each claim and your responsibility including:

Plan Provisions

- The amount covered

- Less any amounts you may owe, like deductible, copay and coinsurance

Your Responsibility

- Deductible and copay amount

- Your share of coinsurance

- Amount not covered, if any

- Amount you may owe the provider. You may have paid some of this amount, like your copay, at the time you received the service.

16 SAMPLE EXPLANATION OF BENEFITS www.healthselectoftexas.com

The EOB may include additional information:

• Amounts Not Covered will show what benefit limitations or exclusions apply.

• Out-of-Pocket Expenses will show an amount when a claim applies toward your deductible or counts toward your out-of-pocket maximum.

• Fraud Hotline is a toll-free number to call if you think you are being charged for services you did not receive or if you suspect any fraudulent activity.

• An explanation of your right to appeal if your health plan doesn’t cover a health care claim.


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www.healthselectoftexas.com SAMPLE EXPLANATION OF BENEFITS

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

EXPLANATION OF BENEFITSAn EOB is a statement showing how claims were processed.This is not a bill. Your provider(s) may bill you directly for anyamount you may owe. KEEP FOR YOUR RECORDS.

SUBSCRIBER INFORMATIONHEALTHSELECT OF TEXAS

Member ID#: JEA123456789 Group #: 000238000

TOTAL OF CLAIM

Amount Billed $3,400.00

Discounts, reductions and payments - $2,800.00

You may have to pay your provider $600.00

SERVICE DETAIL - CLAIM (1 )

PATIENT: SUSAN SMITH PROVIDER: JOHN JONES CLAIM #: 123456T14950X

SERVICE DATE: 10/01/2017 Processed: 10/18/2017

PLAN PROVISIONS YOUR RESPONSIBILITY

Service Description Amount billedDiscounts and

reductionsAmount covered

(allowed)*Deductible andcopay amount

CoinsuranceAmount not

covered

Emerg Accident Care 3,000.00 3,000.00 600.00

Emerg Accident X-Ray 200.00 (1) 200.00

Emerg Accident Lab 200.00 (1) 200.00

CLAIM TOTALS $3,400.00 $400.00 $3,000.00 $0.00 $600.00 $0.00

*Amount covered (allowed) reflects the savings we’ve negotiated with your provider for this service. Your deductible, coinsurance and copay are based on the allowed amount. Your share of coinsurance is apercentage of the allowed amount after the deductible is met.

(1) This service is considered part of another procedure performed on this date and should not be billed as a separate charge. No payment can be made. Based on our agreement with this provider, you arenot responsible for this charge.

Total covered benefits approved for this claim: $2,400.00 to FERNANDO G TORRES PA on 10-18-17.

SUMMARY (1)

PLAN PROVISIONS

Amount covered (allowed)* $3,000.00

Deductible and copay amount $0.00

Coinsurance - $600.00

Total $2,400.00

YOUR RESPONSIBILITY

Deductible and copay amount $0.00

Coinsurance + $600.00

Amount not covered $0.00

You may have to pay your provider $600.00

Fraud Hotline at 800-543-0867Health care fraud affects health care costsfor all of us. If you suspect any person orcompany of defrauding or attempting todefraud Blue Cross and Blue Shield ofTexas, please call our toll-free hotline. Allcalls are confidential and may be madeanonymously. For more information abouthealth care fraud, please go to bcbstx.com.

Patient: SUSAN SMITHBenefit Period: 09-01-17 Through 12-31-17 To date this patient has met $2,735.49 of her/his $6,550.00 out-of-pocket expense.

To date this patient has met $2,735.49 of her/his $6,550.00 in-network out-of-pocket maximum. To date $3,095.49 of the family $13,100.00 in-network out-of-pocket maximum has been met.

Jon Smith1234 Cedar RoadAPT #2Any Town, TX 76065

Log in at www.healthselectoftexas.com to see plan and claim details or to contact us through our secure Message Center.

Have questions about this EOB? Personal Health Assistants are here to help! 1-800-252-8039

1. Participant’s name and mailing address

2. Participant’s member ID and group number

3. Summary box for all claims including total billed by the provider, and discounts, reductions or payments made, and the amount you may owe

4. Detailed claim information for each claim

5. Patient name and service date

6. Provider information

7. Claim number and date the claim was processed

8. Service description

9. Amount billed for each service

10. The amount covered (allowed) for each service and the discounts or reductions subtracted from the amount your provider billed

11. Your share of the costs

12. Claim summary with amount covered less your responsibility

13. Deductible and/or out-of-pocket expense information

14. Health Care Fraud Hotline

P.O. Box 660044Dallas, TX 75266-0044

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18 HEALTHSELECT OF TEXAS www.healthselectoftexas.com

HEALTHSELECT OF TEXAS

HealthSelect of TexasHealthSelect Out-of-State

Consumer Directed HealthSelect

HealthSelect Secondary

HealthSelect of Texas is a point-of-service health plan available to active employees, retirees under 65, and their eligible dependents who live or work in the state of Texas. If you are enrolled in HealthSelect of Texas, you need to choose an in-network PCP. Your PCP coordinates your care and manages any referrals you may need to see specialists. If you see an in-network provider, you will not have to meet a deductible before the plan begins to pay for your health care services. There is a $500 per person/$1,500 per family deductible if you see a provider who is not in the HealthSelect network.

PCP SelectionStarting September 1, 2017, go to www.healthselectoftexas.com to see if your doctors are in the BCBSTX network.

If you do not find your current provider(s) in the directory, you can call a Personal Health Assistant toll-free at (800) 252-8039 to find out if you can keep seeing that provider for a limited time.

Referrals You must obtain referrals from your PCP before seeing specialists for care. To receive in-network benefits, your PCP will need to work with BCBSTX to submit the referral before your specialist visit. If you do not have a referral on file before you see a specialist, you will pay more, because your visit will be considered out-of-network. After September 1, 2017, all new referrals and prior authorizations will need to be issued by BCBSTX.

You do not need a referral for the following services:• Chiropractic visits*

• Eye exams (both routine and diagnostic)

• Mental health counseling

• OB/GYN visits

• Occupational therapy and physical therapy*

• Virtual visits, urgent care centers facilities and convenience care clinics

Prior AuthorizationYou need prior authorization for certain covered health services. Usually, your network PCP and other network providers will obtain prior authorization before they provide these services to you. However, in some cases you will need to obtain prior authorizations yourself.

Health services that require a prior authorization include, but are not limited to:• Durable medical equipment

• High-tech radiology (CT, PET, MRI, Nuclear Stress Test, etc.)

• Home health services

• Inpatient hospital stays, including inpatient mental health treatment

• Outpatient surgical procedures

• Skilled nursing services

Personal Health Assistants can help you if you have questions about your HealthSelect benefits, including what services require referrals and prior authorizations. Personal Health Assistants can also work with your doctor’s office to help coordinate referrals and prior authorizations.

* Chiropractic visits and occupational therapy and physical therapy require prior authorizations.

19www.healthselectoftexas.com HEALTHSELECT OF TEXAS

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Benefits1HealthSelect of Texas

In-Network Out-of-Network

Calendar year deductible None$500 per person

$1,500 per family

Out-of-pocket coinsurance maximum2

$2,000 per person per calendar year


Total out-of-pocket maximum3 (including deductibles, coinsurance and copays)4

$6,550 per person

$13,100 per familyNone

Primary care physician required Yes No

Primary care physicians’ office visits $25 40%*

Physicals† No charge 40%*

Specialty physicians’ office visits $40 40%*

Routine eye exam, one per year per participant5 $40 40%*

Routine preventive care† No charge 40%*

Diagnostic x-rays, lab tests, and mammography 20% coinsurance 40%*

Office surgery and diagnostic procedures 20% coinsurance 40%*

High-tech radiology (CT scan, MRI, and nuclear medicine)6,7,8

$100 copay plus 20% coinsurance

$100 copay plus 40%*

Urgent care clinic$50 copay plus 20% coinsurance

40%*

Maternity Care doctor charges only†; inpatient hospital copays will apply

No charge for routine prenatal appointments

$25 or $40 for first post-natal visit9

40%*

Chiropractic Care

a. Coinsurance20%; $40 copay plus 20% with office visit

40%*

b. Maximum benefit per visit $75 $75

c. Maximum visits each participant per calendar year

30 30

Inpatient hospital(semi-private room and day’s board, and intensive care unit)8

$150/day copay plus 20% coinsurance ($750 copay max-up to 5 days per hospital stay, $2,250 copay max per calendar year per person)

$150/day copay plus 40%* ($750 copay max-up to 5 days per hospital stay, $2,250 copay max per calendar year per person)

Benefits1HealthSelect of Texas


Emergency care10

$150 plus 20% coinsurance (if admitted copay will apply to hospital copay)


Outpatient surgery other than in physician’s office



Bariatric surgery11

a. Deductible $5,000 b. Coinsurance 20% c. Lifetime max $13,000

Not covered

Hearing aidsPlan pays up to $1,000 per ear every three years (no deductible).

Durable medical equipment8 20% coinsurance 40%*

Ambulance services (non-emergency)8 20% coinsurance 40%*

Mental health care

a. Outpatient physician or mental health provider office visits

$25 copay 40%*

b. Hospital Mental health inpatient stay(copay is $150 per day, up to a maximum of $750 per admission and a maximum of $2,250 per calendar year)


$150/day copay plus 40% ($750 copay max-up to 5 days per hospital stay, $2,250 copay max per calendar year per person)

c. Outpatient facility care(partial hospitalization/ day treatment and extensive outpatient treatment)

20% coinsurance 40%*

* Note: 40% coinsurance after you meet the annual out-of-network deductible. 1 Benefits are paid on allowable amounts; using providers who contract with Blue Cross and Blue Shield of Texas

will protect you from liability for amounts over the allowable amount.2 Does not include copays.3 Out-of-pocket maximums are not mutually exclusive from other out-of-pocket limits. This means that a participant’s

total network out-of-pocket maximum could contain a combination of coinsurance and/or copayments. (For example, a participant could pay up to $6,550 in copayments alone if there was no coinsurance paid throughout the year. If a participant met the $2,000 coinsurance out-of-pocket maximum, he/she would pay $4,550 in copayments, totaling $6,550 in overall out-of-pocket expense.)

4 Includes medical and prescription drug copays, coinsurance and deductibles. Excludes non-network and bariatric services.

5 For treatment charges, one visit per plan year. 6 Outpatient testing only. Does not apply to inpatient services. 7 No copay if high-tech radiology is performed during ER visit or inpatient admission.8 Preauthorization required. 9 Copay depends on whether treatment is given by PCP or specialist10 Benefits shown do not apply to out-of-network freestanding ERs. For information about this coverage, see the

Master Benefit Plan Document.11 Active employees only; see health plan for additional requirements/limitations. The deductible and coinsurance

paid for bariatric surgery does not apply to the total out-of-pocket maximum.† Under the Affordable Care Act, certain preventive and women’s health services are paid at 100% (at no cost to the

participant) dependent upon physician billing and diagnosis. In some cases, the participant will still be responsible for payment on some services.

This comparison chart offers a general overview of benefits and their associated out-of-pocket expenses under HealthSelect plans. Contact a Personal Health Assistant for specific questions. Call toll-free at (800) 252-8039, Monday-Friday 7 a.m. - 7 p.m. CT, or Saturday 7 a.m. - 3 p.m. CT to speak with a Personal Health Assistant.

20 HEALTHSELECT OUT-OF-STATE www.healthselectoftexas.com

HEALTHSELECT OUT-OF-STATE

HealthSelect Out-of-StateConsum

er Directed HealthSelectHealthSelect Secondary

HealthSelect of Texas

Living or working outside of Texas?HealthSelect Out-of-State is available only to active employees, retirees not enrolled in Medicare, and their eligible dependents living or working outside the state of Texas.

If you move outside Texas, please contact ERS to update your address so that you can move to HealthSelect Out-of-State benefits. If you live in Texas but have an eligible dependent living in another state, contact a BCBSTX Personal Health Assistant to move your dependent to HealthSelect Out-of-State.

Here are some important things to know about the HealthSelect Out-of-State plan:• You do not need to select a PCP

• You do not need a referral to see a specialist

• HealthSelect Out-of-State benefits are now the same as HealthSelect of Texas

• You no longer need to meet a deductible

• You will have a copay for certain services like PCP and specialist office visits

Why you may still want to have a PCPEven though you are not required to have a PCP if you are enrolled in HealthSelect Out-of-State, having a PCP is important and can be a boost to your health.

Your PCP:• Will get to know you – your health history, your medications and

your lifestyle

• Can treat many non-urgent health issues like ear infections, rashes, allergies, fevers, colds, flu and much more

• Will address routine medical care, such as physicals and yearly exams

• Is your health coach who can show you better ways to stay healthier

• Can decide if you need any tests or if you should see a specialist

• Can help you with specialized care for a chronic health issue, such as asthma, diabetes or a heart problem

If you see a provider who is not in the network, you will need to meet a deductible of $500 per person/$1,500 per family.

21www.healthselectoftexas.com HEALTHSELECT OUT-OF-STATE

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Benefits1HealthSelectSM of Texas Out-of-State2


Calendar year deductible None$500 per person

$1,500 per family

Out-of-pocket coinsurance maximum3



Total out-of-pocket maximum4 (including deductibles, coinsurance and copays)5

$6,550 per person

$13,100 per familyNone

Primary care physician required No No

Primary care physicians’ office visits $25 40%*

Physicals† No charge 40%*

Specialty physicians’ office visits $40 40%*

Routine eye exam, one per year per participant6 $40 40%*

Routine preventive care† No charge 40%*

Diagnostic x-rays, lab tests, and mammography 20% coinsurance 40%*

Office surgery and diagnostic procedures 20% coinsurance 40%*

High-tech radiology (CT scan, MRI, and nuclear medicine)7,8,9



Urgent care clinic$50 copay plus 20% coinsurance

40%*



$25 or $40 for first post-natal visit10

40%*

Chiropractic Care

a. Coinsurance20%; $40 copay plus 20% with office visit

40%*


c. Maximum visits Each participant Per calendar year

30 30




Benefits1HealthSelectSM of Texas Out-of-State2


Emergency care11



Outpatient surgery other than in physician’s office



Bariatric surgery12

a. Deductible $5,000 b. Coinsurance 20% c. Lifetime max $13,000

Not covered

Hearing aidsPlan pays up to $1,000 per ear every three years (no deductible).

Durable medical equipment9 20% coinsurance 40%*

Ambulance services (non-emergency)9 20% coinsurance 40%*

Mental health care


$25 copay 40%*

b. Hospital Mental health inpatient stay(copay is $150 per day, up to a maximum of $750 per admission and a maximum of $2,250 per calendar year)




20% coinsurance 40%*

* Note: 40% coinsurance after you meet the annual out-of-network deductible. 1 Benefits are paid on allowable amounts; using providers who contract with Blue Cross and Blue Shield of Texas will

protect you from liability for amounts over the allowable amount.2 HealthSelect Out-of-State applies to employees and retirees under age 65 and their eligible dependents who live or

work outside of Texas. You cannot enroll in Out-of-State coverage unless your work or home address is outside of Texas.

3 Does not include copays.4 Out-of-pocket maximums are not mutually exclusive from other out-of-pocket limits. This means that a participant’s


5 Includes medical and prescription drug copays, coinsurance and deductibles. Excludes non-network and bariatric services.

6 For treatment charges, one visit per plan year.7 Outpatient testing only. Does not apply to inpatient services.8 No copay if high-tech radiology is performed during ER visit or inpatient admission.9 Preauthorization required. 10 Copay depends on whether treatment is given by PCP or specialist11 Benefits shown do not apply to out-of-network freestanding ERs. For information about this coverage, see the

Master Benefit Plan Document.12 Active employees only; see health plan for additional requirements/limitations. The deductible and coinsurance

paid for bariatric surgery does not apply to the total out-of-pocket maximum. † Under the Affordable Care Act, certain preventive and women’s health services are paid at 100% (at no cost to the



22 CONSUMER DIRECTED HEALTHSELECT www.healthselectoftexas.com

CONSUMER DIRECTED HEALTHSELECT

HealthSelect Out-of-StateConsum

er Directed HealthSelectHealthSelect Secondary

HealthSelect of Texas

Consumer Directed HealthSelect Consumer Directed HealthSelect is a high-deductible health plan paired with a health savings account (HSA)*. Here are some things to keep in mind:

• No PCP required

• Referrals not needed to see specialists

• Deductible must be met before any services (other than preventive care) are paid for by the plan: $2,100 in-network deductible per person/$4,200 per family and includes in-network medical and prescription drug expenses

• Preventive services – like annual check-ups and preventive vaccinations – covered at 100% when you visit an in-network doctor, even if you haven’t met the deductible

• This plan is paired with a Health Savings Account (HSA) to help you pay for higher out-of-pocket costs

Be ready for out-of-pocket costs with a health savings account (HSA) You can use your HSA to pay for qualified medical expenses, including your deductible and coinsurance.

• The State of Texas will add pre-tax dollars to your HSA account each month: in FY18, the state will contribute $45 per month ($540 per year) for individual coverage and $90 per month ($1,080 per year) for family coverage to your HSA

• Make tax-free contributions to your HSA through payroll deductions or independently

• HSAs are portable: you can use your HSA on qualified medical expenses. If you change to a different health plan or change employers the money in your HSA stays with you

• Your unused HSA balance will carry over from one year to the next, so you won’t lose money in your account at the end of the year

• Your HSA is administered by a separate custodian — not BCBSTX: information about your account custodian can be found online at www.healthselectoftexas.com beginning September 1, 2017

* Participants who are enrolled in any part of Medicare (Part A, B, C and/or D), receive benefits under TRICARE or TRICARE for Life, or have a health care flexible spending account (like a TexFlex health care account) in the same plan year are not eligible for an HSA.

** Important Information about HSAs: HSA contributions and limits may change from year to year, or based on eligibility requirements and the participant’s age. Maximums are set by the IRS and include both pre-tax and post-tax contributions to an HSA. HSAs have tax and legal ramifications.

If you see a provider outside your plan’s network, there is a $4,200 per person/$8,400 per family deductible.

23www.healthselectoftexas.com CONSUMER DIRECTED HEALTHSELECT

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Benefits1Consumer Directed HealthSelect


Emergency care8 20%* 20%*

Outpatient surgery other than in physician’s office 20%* 40%**

Bariatric surgery Not covered Not covered

Hearing aidsPlan pays up to $1,000 per ear every three years (after deductible is met).

Durable medical equipment7 20%* 40%**

Ambulance services (non-emergency)7 20%* 40%**

Mental health care


20%* 40%**

b. Hospital Mental health inpatient stay 20%* 40%**


20%* 40%**

Benefits1Consumer Directed HealthSelect


Calendar year deductible$2,100 per person

$4,200 per family

$4,200 per person

$8,400 per family

Out-of-pocket coinsurance maximum2 None None

Total out-of-pocket maximum3

(including deductibles, coinsurance and copays)4

$6,550 per person

$13,100 per family

$13,100 per person

$26,200 per family

Primary care physician required No No

Primary care physicians’ office visits 20%* 40%**

Physicals† No charge 40%**

Specialty physicians’ office visits 20%* 40%**

Routine eye exam, one per year per participant5 20%* 40%**

Routine preventive care† No charge 40%**

Diagnostic x-rays, lab tests, and mammography 20%* 40%**

Office surgery and diagnostic procedures 20%* 40%**

High-tech radiology(CT scan, MRI, and nuclear medicine)6,7

20%* 40%**

Urgent care clinic 20%* 40%**



20% coinsurance for first post-natal visit

40%**

Chiropractic Care

a. Coinsurance 20%* 40%**


c. Maximum visits Each participant Per calendar year

30 30


20%* 40%**

* Note: 20% coinsurance after you meet the annual in-network deductible** Note: 40% coinsurance, after you meet the annual out-of-network deductible 1 Benefits are paid on allowable amounts; using providers who contract with Blue Cross and Blue Shield of Texas will

protect you from liability for amounts over the allowable amount.2 Does not include copays.3 Out-of-pocket maximums are not mutually exclusive from other out-of-pocket limits. This means that a participant’s


4 Includes medical and prescription drug coinsurance and deductibles. Excludes non-network and bariatric services.5 For treatment charges, one visit per plan year.6 Outpatient testing only. Does not apply to inpatient services.7 Preauthorization required.8 Benefits shown do not apply to out-of-network freestanding ERs. For information about this coverage, see the Master

Benefit Plan Document.† Under the Affordable Care Act, certain preventive and women’s health services are paid at 100% (at no cost to the



24 HEALTHSELECT SECONDARY www.healthselectoftexas.com

HEALTHSELECT SECONDARY

HealthSelect of TexasHealthSelect Out-of-State

Consumer Directed HealthSelect

HealthSelect Secondary

HealthSelect Secondary HealthSelect Secondary is available to retirees and their eligible dependents enrolled in Medicare. This plan has a different network than HealthSelect of Texas because it coordinates your medical plan coverage with Medicare. This means that HealthSelect Secondary pays for services only after Medicare has paid first. If you are required to pay a portion of the cost, you need to meet a deductible of $200 per person/$600 per family before HealthSelect Secondary begins to pay for services (other than preventive care). Medicare and HealthSelect Secondary deductibles run concurrently.

Here are some things to know about the HealthSelect Secondary plan:• You do not need to choose a PCP

• You do not need a referral

• Preventive services – like annual check-ups and preventive vaccinations – are covered at 100% when you visit an in-network doctor, even if you haven’t met the deductible

It’s important to know how HealthSelect Secondary coverage works with Medicare.If you are retired from the State of Texas and are eligible for Medicare (due either to your age or a disabling condition) you should enroll in Medicare Part A and Medicare Part B.* If you do not have this coverage, you will have to pay the remaining charges.

It is possible for you and family members with HealthSelect to have different coverage, dependent upon age and Medicare eligibility. For example, if both you and your spouse are enrolled in HealthSelect and you become eligible for Medicare, but your spouse is not eligible for Medicare, Medicare will be the primary benefit plan for you, and HealthSelect will continue to be the primary plan for your spouse. This is true until your spouse turns 65 and/or becomes eligible for Medicare.

Why you may still want to have a PCPYou are not required to have a PCP for HealthSelect Secondary. Also, referrals for a specialist are not required. But, having a PCP is important and can be a boost to your health.

Your PCP:• Will get to know you – your health history, your medications and

your lifestyle

• Can treat many non-urgent health issues like ear infections, rashes, allergies, fevers, colds, flu and much more

• Will address routine medical care, such as physicals and yearly exams

• Can show you better ways to stay healthier

• Will decide if you need any tests or if you should see a specialist

• Can help you with specialized care for a chronic health issue, such as asthma, diabetes or a heart problem

* If you do not qualify for free part A, provide a copy of the SSA documentation that you do not qualify for free Part A to Blue Cross and Blue Shield of Texas. If you turned 65 and retired prior to September 1, 1992 you are not required to purchase Part B.

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Benefits1 HealthSelect Secondary

Calendar year deductible$200 per individual

$600 per family

Coinsurance Maximum $3,000 per person

Office visits in conjunction with an illness or injury $0 copay / 30%2, 3 coinsurance

Specialty physician office visit $0 copay / 30%2, 3coinsurance

Diagnostic tests andx-rays, including allergy testing $0 copay / 30%2, 3 coinsurance

Diagnostic mammography $0 copay / 30%2, 3 coinsurance

Diagnostic lab services $0 copay / 30%2, 3 coinsurance

Preventive services†

(such as screening mammogram, physical, well woman exam, prostate cancer screening, etc.)

$0

Office surgery and diagnostic procedures $0 copay / 30%2, 3 coinsurance

Immunizations† $0

High-tech radiology(CT scan, MRI, and nuclear medicine)

$0 copay / 30%2, 3 coinsurance

Allergy injections and serum $0 copay / 30%2, 3 coinsurance

Routine eye exam 30%2,4

Routine hearing test 30%2

Diagnostic speech and hearing testing $0 copay / 30%2, 3 coinsurance

Speech and hearing therapy $0 copay / 30%2, 3 coinsurance

Hearing aids $1,000 benefit allowance per ear every 3 years

Chiropractic care $0 copay / 30%2, 3 coinsurance

Urgent care clinic $0 copay / 30%2, 3 coinsurance

Emergency care5 $0 copay / 30%2, 3 coinsurance

Inpatient hospital(semi-private room and days board, and intensive care unit)

$06 If provider doesn’t accept Part A, then coverage is 30%2, 3

Outpatient surgery $0 plus 30%2, 3 coinsurance

Skilled nursing facility• No deductible

• Plan pays 100%

Home health care

$0 copay/30%2, 3 coinsurance for home infusion therapy

Plan pays 100% for all other home health care services with a maximum of 100 visits per calendar year

Hospice $0 copay / 30%2, 3 coinsurance

Ambulance

$0 copay/30% 2,3 coinsurance.

Emergency care only. Not applicable to non-emergent transportation services.

Private duty nursing30%2

• Unlimited hours

Benefits1 HealthSelect Secondary

Mental health

a. Outpatient physician or mental health provider office visits $0 copay / 30%2, 3 coinsurance

b. Hospital Mental health inpatient stay (semi-private room and days board, and intensive care unit)

$06 If provider doesn’t accept Part A, then coverage is 30%2, 3

c. Outpatient facility care(partial hospitalization/day treatment and extensive outpatient treatment)

$0 copay / 30%2, 3 coinsurance

1 Benefits are paid on allowable amounts; using providers who contract with Blue Cross and Blue Shield of Texas will protect you from liability for amounts over the allowable amount.

2 After payment of deductible. HealthSelect note: Medicare and HealthSelect deductibles run concurrently. Member may be responsible for some charges when the provider does not accept Medicare assignment.

3 Payment amount is dependent upon the coordination of benefits (COB) between HealthSelect and original Medicare. Sometimes this means your expense is $0, but charges will vary depending upon COB. Please reference your Summary of Benefits for more information.

4 One per calendar year.5 Benefits shown do not apply to out-of-network freestanding ERs. For information about this coverage, see the

Master Benefit Plan Document.6 In the event that the provider/facility does not accept Medicare assignment (so the charges are not covered by

Medicare and therefore not subject to COB), you may be responsible for copay(s) and/or a coinsurance. Please see your Summary of Benefits for more information.

† Under the Affordable Care Act, certain preventive health and women’s services are paid at 100% (at no cost to the member) conditioned upon physician billing and diagnosis. In some cases, you may still be responsible for payment on some services. Some age requirements may apply.


www.healthselectoftexas.com HEALTHSELECT SECONDARY

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bcbstx.com

Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance.

We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 Email: [email protected]

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

Do you need this guide in Spanish?Starting September 1, 2017, this guide will be available online at www.healthselectoftexas.com in Spanish. Go to the “En español” link to access Spanish content. You can print the guide from the online PDF.

¿Necesita esta guía en español?Esta guía estará disponible en línea en español a partir del 1º de septiembre de 2017 en www.healthselectoftexas.com. Visite el enlace “En español” para ver contenido en español. Puede imprimir la guía usando el archivo PDF digital.

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bcbstx.com

CONTACT INFORMATIONHealthSelect website: www.healthselectoftexas.com

Blue Cross and Blue Shield of Texas

Customer Service and access to a Personal Health Assistant toll-free at (800) 252-8039 Monday-Friday 7 a.m. - 7 p.m. CT and Saturday 7 a.m - 3 p.m. CT

24/7 Nurseline (800) 581-0368

733214.0917

Starting September 1, 2017, Blue Cross and Blue Shield of Texas is the third-party administrator for the HealthSelectSM of Texas and Consumer Directed HealthSelectSM plans. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationBlue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

2018 MEDICAL BENEFITS GUIDE - Blue Cross Blue … can also sign up using the mobile app from BCBSTX....

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