TEXAS HEALTH INSURANCE RISK POOL
POLICY DEDUCTIBLES & BENEFITS
(PART 2)
By Patricia Barrett, CFP CDFA Mediator
POLICY DEDUCTIBLES & BENEFITS:
After you have paid the maximum out-of-pocket (coinsurance maximum), the policy will pay 100% of covered expenses for the rest of the year. There is a lifetime maximum of $2 million. The Calendar Year Deductible, the emergency care deductible, physician office visit copayments and charges for outpatient prescription drugs do not count toward the Coinsurance Maximum (maximum out-of-pocket).
|
WHAT YOU PAY |
Plan I
|
Plan II
|
Plan III
|
Plan IV
|
|
Calendar Year Deductible
|
$1000
|
$2500
|
$5000
|
$7500
|
|
Coinsurance for Preferred Providers
|
20%
|
20%
|
20%
|
20%
|
|
Coinsurance for Non-Preferred Providers
|
40%
|
40%
|
40%
|
40%
|
|
Coinsurance Max for Preferred Providers per Year
|
$3000
|
$3000
|
$3000
|
$3000
|
|
Coinsurance Max Non-Preferred Providers per Year
|
$10,000
|
$10,000
|
$10,000
|
$10,000
|
Benefits
|
Hospital |
Average semi-private room rate. No more than one visit per physician per day. |
|
Intensive Care Or Cardiac Care Unit |
No more than 3 times the aberage semi-private room rate. |
|
Hospital or other facility for Emergency Care |
Subject to $75 deductible. Note that emergency care provided by non-preferred provider is paid as if received form a preferred provider |
|
Physician Office Visit (Preferred Providers) for injury or illness |
$30 copayment per visit, 5 visits per year. Visits after the first 5, subject to Calendar Year Deductible & Coinsurance. |
|
Outpatient Therapy, including Physical, Occupational & Speech Language Therapy |
Combined Maximum benefit $2000 per year. (Does not apply to brain injury or serious mental illness) |
|
Skilled Nursing Facility |
45 days per year |
|
Home Health Care |
Calendar year maximum benefit of lesser of 60 visits or $5000 |
|
Hospice Care |
Lifetime maximum benefit of lesser of 180 days or $10,000 |
|
Transplants |
$300,000 combined lifetime maximum benefit |
|
Serious Mental Illness |
Calendar year maximum benefit of 30 inpatient days and 50 outpatient visits. |
|
Preauthorization Provision |
If preauthorization is not obtained, benefits are reduced by 50%. |
Preauthorization is required for the following services:
1. Hospital admission
2. Skilled nursing facility admission
3. Home health care visits
4. Hospice care
5. Durable medical equipment over $2,000.
6. “Certain” benefits administered by the Pharmacy Manager.
Pharmacy Benefits
This benefit does not apply to insured persons eligible for Medicare. The pool offers a statewide network of pharmacies, a mail order program and a special medications program through Medco Health Solutions, the Pharmacy Manager. Certain drugs require prior authorization by the Pharmacy Manager before you can obtain a covered prescription. Some of the drugs, including human growth hormones, require prior authorization and can be obtained on the pool website, www.txhealthpool.org.
Benefits for outpatient prescription drugs are subject to a calendar year deductible of $200 for Plans, I, II and II and of $500 for Plan IV. For prescriptions filled at a network pharmacy, you will pay $10 for generic or $25 for name brand drugs.
The mail order program is set up through the Pharmacy Manager, allowing you to obtain a 90-day supply, rather than 30-day. You pay $25 for generic and $60 for name brands.
If you fill a prescription at a non-participating pharmacy, you pay the charges and submit a claim to the Pharmacy Manager. After the Prescription Drug Deductible and the copayment, the plan pays the amount that would have been paid by the policy for the same prescription if dispensed by a network pharmacy.
For more information, see Exclusions and Premiums and Summary of Coverage.
