Employees Retirement System of Texas
HealthSelect
SM
of Texas (Out-of-State) Plan
Effective: September 1, 2021
Group Number: 238000
Master Benefit Plan Document
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
I TABLE OF CONTENTS
TABLE OF CONTENTS
SECTION 1 - WELCOME ................................................................................................................ 1
Nondiscrimination and Accessibility Requirements ............................................................... 2
Getting Help in Other Languages or Formats ........................................................................ 3
SECTION 2 - INTRODUCTION ....................................................................................................... 6
Eligibility for the Texas Employees Group Benefits Program ................................................ 6
Cost of Coverage ................................................................................................................... 8
How to Select Coverage ........................................................................................................ 8
When Coverage Begins ......................................................................................................... 9
Changing Your Coverage .................................................................................................... 11
SECTION 3 - HOW THE PLAN WORKS ...................................................................................... 13
Accessing Benefits............................................................................................................... 13
BlueCard
®
Program and Beyond: Accessing Your Healthcare Benefits While Traveling ... 15
Allowable Amounts .............................................................................................................. 18
Deductibles .......................................................................................................................... 19
Copay ................................................................................................................................... 20
Coinsurance ......................................................................................................................... 20
Inpatient Copay Maximum ................................................................................................... 20
Out-of-Pocket Coinsurance Maximum ................................................................................. 20
Total Network Out-of-Pocket Maximum ............................................................................... 21
SECTION 4 - PRIOR AUTHORIZATION ...................................................................................... 25
Prior Authorization ............................................................................................................... 25
Reduction in Benefits If Prior Authorization Is Not Obtained ............................................... 27
SECTION 5 - SCHEDULE OF BENEFITS AND COVERAGE ..................................................... 29
SECTION 6 - DETAILS FOR COVERED HEALTH SERVICES .................................................. 56
Acquired Brain Injury ........................................................................................................... 56
Allergy Treatment................................................................................................................. 56
Ambulance Services ............................................................................................................ 57
Bariatric Surgery .................................................................................................................. 57
Chiropractic Treatment ........................................................................................................ 59
Christian Science Practitioner Services ............................................................................... 59
Clinical Trials ........................................................................................................................ 59
Congenital Heart Disease (CHD) Services .......................................................................... 61
COVID-19 Services During the Declaration of National Emergency ................................... 61
Dental Services .................................................................................................................... 62
Diabetes Services ................................................................................................................ 64
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
II TABLE OF CONTENTS
Durable Medical Equipment (DME) ..................................................................................... 66
Emergency Room Services - Outpatient ............................................................................. 67
Family Planning and Infertility Services ............................................................................... 68
Habilitation and Rehabilitation Services - Outpatient Therapy ............................................ 68
Hearing Aids ........................................................................................................................ 69
High-Tech Radiology - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient .... 70
Home Health Care ............................................................................................................... 70
Hospice Care ....................................................................................................................... 71
Hospital - Inpatient Stay ....................................................................................................... 72
Lab, X-Ray and Diagnostics ................................................................................................ 73
Maternity Care ..................................................................................................................... 73
Medical Supplies .................................................................................................................. 74
Medications and Injections - Outpatient............................................................................... 74
Mental Health Services ........................................................................................................ 75
Neurobiological Disorders - Autism Spectrum Disorder Services ....................................... 76
Nutritional Counseling .......................................................................................................... 77
Ostomy Supplies .................................................................................................................. 78
Physician Fees for Surgical and Medical Services .............................................................. 78
Physician's Office Services - Sickness and Injury ............................................................... 78
Preventive Care Services .................................................................................................... 79
Private Duty Nursing - Outpatient ........................................................................................ 80
Prosthetic Devices ............................................................................................................... 81
Reconstructive Procedures .................................................................................................. 82
Retail Health Clinic............................................................................................................... 83
Scopic Procedures - Outpatient Diagnostic and Therapeutic .............................................. 83
Serious Mental Illness Services ........................................................................................... 83
Skilled Nursing Facility/Inpatient Rehabilitation Facility Services ........................................ 84
Substance Use Disorder Services ....................................................................................... 85
Surgery - Outpatient............................................................................................................. 86
Telemedicine ........................................................................................................................ 87
Temporomandibular Joint (TMJ) Services and Orthognathic Surgery ................................ 87
Therapeutic Treatments - Outpatient ................................................................................... 88
Therapies for Children with Developmental Delays ............................................................. 88
Transplant Services ............................................................................................................. 89
Urgent Care Center Services ............................................................................................... 90
Virtual Visits ......................................................................................................................... 90
Vision Examinations............................................................................................................. 90
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
III TABLE OF CONTENTS
SECTION 7 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER ....................... 91
Alternative Treatments ......................................................................................................... 91
Dental ................................................................................................................................... 92
Devices, Appliances and Prosthetics................................................................................... 92
Drugs ................................................................................................................................... 93
Educational Services ........................................................................................................... 93
Experimental or Investigational or Unproven Services ........................................................ 94
Foot Care ............................................................................................................................. 94
Medical Supplies and Equipment ........................................................................................ 94
Nutrition ................................................................................................................................ 95
Personal Care, Comfort or Convenience ............................................................................. 96
Physical Appearance ........................................................................................................... 97
Procedures and Treatments ................................................................................................ 97
Providers .............................................................................................................................. 99
Reproduction/Infertility ......................................................................................................... 99
Services Provided Under Another Plan ............................................................................. 100
Transplants ........................................................................................................................ 100
Travel ................................................................................................................................. 100
Types of Care .................................................................................................................... 100
Vision and Hearing............................................................................................................. 101
All Other Exclusions ........................................................................................................... 101
SECTION 8 - CLAIMS PROCEDURES ...................................................................................... 104
Claims Processing for Network and Non-Network Benefits .............................................. 104
If Your Provider Does Not File Your Claim ........................................................................ 104
Claim Payment and Assignment ........................................................................................ 105
Explanation of Benefits (EOB) ........................................................................................... 106
Timely Filing Claim Limitations .......................................................................................... 106
Claim Denials and Appeals ................................................................................................ 107
External Review Program .................................................................................................. 112
Authorized Representative ................................................................................................ 116
SECTION 9 - COORDINATION OF BENEFITS (COB) .............................................................. 118
Determining Which Plan Is Primary ................................................................................... 118
When This Plan Is Secondary ........................................................................................... 120
When a Participant Qualifies for Medicare ........................................................................ 121
Medicare Crossover Program ............................................................................................ 123
Overpayment and Underpayment of Benefits ................................................................... 123
SECTION 10 - SUBROGATION AND REIMBURSEMENT........................................................ 125
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
IV TABLE OF CONTENTS
Right of Recovery .............................................................................................................. 125
Right to Subrogation .......................................................................................................... 125
Right to Reimbursement .................................................................................................... 126
Third Parties ....................................................................................................................... 126
Subrogation and Reimbursement Provisions .................................................................... 126
SECTION 11 - WHEN COVERAGE ENDS ................................................................................. 129
Extended Coverage ........................................................................................................... 129
COBRA .............................................................................................................................. 130
SECTION 12 - OTHER IMPORTANT INFORMATION ............................................................... 135
Qualified Medical Child Support Orders (QMCSOs) ......................................................... 135
Your Relationship with Blue Cross and Blue Shield of Texas and the Employees
Retirement System of Texas ............................................................................................. 135
Relationships between Network Providers, Blue Cross and Blue Shield of Texas and
HealthSelect ....................................................................................................................... 135
Your Relationship with Providers ....................................................................................... 136
Interpretation of the Plan ................................................................................................... 136
Records .............................................................................................................................. 136
How to Access the Master Benefit Plan Document ........................................................... 137
SECTION 13 - GLOSSARY ........................................................................................................ 138
SECTION 14 - IMPORTANT ADMINISTRATIVE INFORMATION ............................................. 157
ATTACHMENT I - THE EMPLOYEES RETIREMENT SYSTEM OF TEXAS SUMMARY NOTICE
OF PRIVACY PRACTICES ......................................................................................................... 158
STATEMENT OF RIGHTS UNDER THE NEWBORNS' AND MOTHERS' HEALTH
PROTECTION ACT .................................................................................................................... 160
ADDENDUM - LIST OF COVERED PREVENTIVE CARE SERVICES ..................................... 164
ADDENDUM - RESOURCES TO HELP YOU STAY HEALTHY ............................................... 167
Holistic Health Management Program ............................................................................... 167
24/7 Nurseline Support and Services: The Right Care at the Right Time ......................... 167
Web and Mobile Wellness Programs and Blue Points ...................................................... 167
Fitness Program ................................................................................................................. 168
HealthSelectShoppERS
SM
................................................................................................. 168
Programs for Weight Loss and Weight Management and Tobacco Cessation: Wondr
(formerly Naturally Slim), Real Appeal, Weight Management Coaching and Tobacco
Cessation Coaching ........................................................................................................... 170
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
1 SECTION 1 – WELCOME
SECTION 1 - WELCOME
Important Information Box
■ For more information about COVID-19 Covered Health Services, see Section 6, Details for
Covered Health Services under the heading COVID-19 Services during the Declaration of
National Emergency.
■ Medical and mental health member services, claim inquiries, Prior Authorization, Personal
Health Support: (800) 252-8039 (TTY: 711);
■ Claims submittal address: Blue Cross and Blue Shield of Texas - Claims, P.O. Box 660044;
Dallas, Texas 75266-0044; and
■ Online assistance: www.healthselectoftexas.com.
HealthSelect of Texas
®
(HealthSelect) is a self-funded benefit plan offered through the Texas
Employees Group Benefits Program (GBP or Program) by the Employees Retirement System of
Texas (ERS).
HealthSelect is pleased to provide you with this Master Benefit Plan Document (MBPD), which
describes the health Benefits available to you and your eligible covered family members. It
includes information regarding:
• who is eligible;
• services that are covered, called Covered Health Services;
• services that are not covered, called Exclusions;
• how Benefits are paid; and
• your rights and responsibilities under the Plan.
This MBPD is designed to meet your information needs. It supersedes any previous printed or
electronic MBPD for this Plan.
Important
Health care services, supplies or Medications and Injections are only Covered Health Services if
Medically Necessary (See definitions of Medically Necessary and Covered Health Service in
Section 13, Glossary). The fact that a Physician or Other Provider has performed or prescribed a
procedure or treatment, or the fact that it may be the only available treatment for a Sickness,
Injury, Mental Illness, substance-related and addictive disorder, disease or its symptoms, does
not make the procedure or treatment a Covered Health Service under the Plan.
ERS intends to continue this Plan, but reserves the right, in its sole discretion, to modify, change,
revise, amend or terminate the Plan at any time, for any reason, and without prior notice, or as
directed by the state of Texas. This MBPD is not to be construed as creating an employment
contract or any rights or benefits, except as expressly provided herein as authorized and limited
by Chapter 1551 of the Texas Insurance Code.
BCBSTX is a health care Claims Administrator and the third-party administrator for HealthSelect.
One of BCBSTX’ goals is to give you the tools you need to make wise health care decisions.
BCBSTX also administers HealthSelect claims. Although BCBSTX will assist you in many ways, it
does not guarantee any Benefits. The GBP, as administered by ERS, is ultimately responsible for
paying Benefits described in this MBPD.
Please read this MBPD thoroughly to learn how the HealthSelect Out-of-State Plan works. If you
have questions, contact your Benefits Coordinator or a BCBSTX Personal Health Assistant at
(800) 252–8039 (TTY: 711).
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
2 SECTION 1 – WELCOME
How To Use This MBPD
■ Read the entire MBPD and share it with your family. Then keep it for future reference.
■ Many of the sections of this MBPD are related to other sections. You may not have all the
information you need by reading just one section.
■ You can find copies of your MBPD and any future Amendments at
www.healthselectoftexas.com or you may request printed copies by contacting BCBSTX at
(800) 252-8039 (TTY: 711).
■ Capitalized words in the MBPD have special meanings and are defined in Section 13,
Glossary.
■ If eligible for coverage, the words "you" and "your" refer to Participants as defined in Section
13, Glossary.
■ The Employees Retirement System of Texas is also referred to as the Plan Administrator.
■ If there is a conflict between this MBPD, MBPD Amendments and any benefit summaries
provided to you, this MBPD and its Amendments will control.
Important
Your Provider does not have a copy of your MBPD and is not responsible for knowing or
communicating your Benefits.
Nondiscrimination and Accessibility Requirements
BCBSTX, on behalf of itself and its affiliated companies, and ERS comply with applicable federal
civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability,
or sex. Neither BCBSTX nor ERS excludes people or treats them differently because of race,
color, national origin, age, disability, or sex.
BCBSTX and ERS provide free aids and services to people with disabilities to communicate with
them effectively, such as:
• qualified sign language interpreters;
• written information in other formats (large print, audio, accessible electronic formats, other
formats);
• free language services to people whose primary language is not English, such as: qualified
interpreters; and
• information written in other languages.
If you need these services, please call BCBSTX at (800) 252-8039 (TTY: 711), or you may call
ERS.
If you believe that BCBSTX has failed to provide these services or discriminated in another way
on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in
writing by mail or email with the Civil Rights Coordinator identified below.
A grievance must be
sent within 60 calendar days of the date that you become aware of the discriminatory action and
contain the name and address of the person filing it along with the problem and the requested
remedy.
A written decision will be sent to you within 30 calendar days. If you disagree with the decision,
you may file an appeal within 15 calendar days of receiving the decision.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
3 SECTION 1 – WELCOME
Blue Cross and Blue Shield of Texas Civil Rights Coordinator
Blue Cross and Blue Shield of Texas Civil Rights Coordinator
Blue Cross and Blue Shield of Texas Civil Rights Grievance
300 E. Randolph St, - 35
th
Floor
Chicago, Illinois 60601
(855) 664-7270, (TTY: 711)
CivilRightsCoordinator@hcsc.net
If you need help filing a grievance, the Civil Rights Coordinator identified above is available to
help you.
You can also file a complaint directly with the U.S. Dept. of Health and Human services online, by
phone or mail:
Online https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Phone: (800) 368-1019, (800) 537-7697 (TDD)
Mail:
U.S. Dept. of Health and Human Services
200 Independence Avenue, SW Room 509F, HHH Building
Washington, D.C. 20201
Getting Help in Other Languages or Formats
You have the right to get help and information in your language at no cost. To request an
interpreter, call BCBSTX at (855) 710-6984, press 0. (TTY: 711).
This notice is also available in other formats such as large print. To request the document in
another format, please call BCBSTX at (800) 252-8039, (TTY: 711), Monday through Friday, 8
a.m. to 8 p.m.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
4 SECTION 1 – WELCOME
Language
Translated Taglines
1. Spanish
Si usted o alguien a quien usted está ayudando tiene preguntas, tiene
derecho a obtener ayuda e información en su idioma sin costo alguno. Para
hablar con un intérprete comuníquese con el número del Servicio al Cliente
que figura en el reverso de su tarjeta de miembro. Si usted no es miembro
o no posee una tarjeta, llame al 855-710-6984.
TTY 711
2. Vietnamese
Nếu quý vị hoặc người mà quý vị giúp đỡ có bất kỳ câu hỏi nào, quý vị có quyền
được hỗ trợ và nhận thông tin bằng ngôn ngữ của mình miễn phí. Để nói
chuyện với thông dịch viên, gọi số dịch vụ khách hàng nằm ở phía sau thẻ hội
viên của quý vị. Nếu quý vị không phải là hội viên hoặc không có thẻ, gọi số 855-
710-6984. TTY 711
3. Chinese
如果您, 或您正在協助的對象, 對此有疑問, 您有權利免費以您的母語獲得幫助
和訊息。洽詢一位翻譯員, 請致電印在您的會
員卡背面的客戶服務電話號碼。
如果您不是會員, 或沒有會員卡, 請致電 855-710-6984。聽力語言殘障服務
專線 711
4. Korean
만약 귀하 또는 귀하가 돕는 사람이 질문이 있다면 귀하는 무료로 그러한
도움과 정보를 귀하의 언어로 받을 수 있는 권리가 있습니다. 회원 카드
뒷면에 있는 고객 서비스 번호로 전화하십시오. 회원이 아니시거나 카드가
없으시면 855-710-6984 으로 전화주십시오.. TTY 711
5. Arabic
تﺎﻣﻮﻠﻌﻤﻟاو ةﺪﻋﺎﺴﻤﻟا ﻰﻠﻋ لﻮﺼﺤﻟا ﻲﻓ ﻖﺤﻟا ﻚﯾﺪﻠﻓ ،ﺔﻠﺌﺳأ هﺪﻋﺎﺴﺗ ﺺ ﺨ ﺷ ىﺪﻟ وأ ﻚﯾﺪﻟ نﺎﻛ نإ
ءﻼﻤﻌﻟا ﺔﻣﺪﺧ ﻢﻗر ﻰﻠﻋ ﻞﺼﺗا ،يرﻮﻓ ﻢﺟﺮﺘﻣ ﻰﻟإ ث ﺪ ﺤ ﺘ ﻠ ﻟ . ﺔﻔﻠﻜﺗ ﺔﯾا نود ﻦﻣ ﻚﺘﻐﻠﺑ
ﺔﯾروﺮﻀﻟا
ﻰﻠﻋ ﻞﺼﺗﺎﻓ ،ﺔﻗﺎﻄﺑ ﻚﻠﻤﺗ ﻻ ﺖ ﻨ ﻛ وأ ،ا
ً
ﻮﻀﻋ ﻦﻜﺗ ﻢﻟ نﺈﻓ. ﻚﺘﯾﻮﻀﻋ ﺔﻗﺎﻄﺑ ﺮﮭظ ﻰﻠﻋ
رﻮﻛﺬﻤﻟا
6984-710-
8551. TTY 711
6. Urdu
رﮔا پآ ،وﮐ ﺎﯾ ﯽﺳﮐ ﮯﺳﯾا درﻓ وﮐ سﺟ ﯽ ﮐ پ آ ددﻣ ﮯﮨررﮐ ،ںﯾﮨ ﯽﺋوﮐ لاوﺳ شﯾﭘرد ﮯﮨ ،وﺗ پ آ وﮐ
ﯽﻧﭘا نﺎﺑز ںﯾﻣ تﻔﻣ ددﻣ روا تﺎﻣوﻠﻌﻣ ل ﺻ ﺎ ﺣ ﮯﻧرﮐ ﺎﮐ ﻖ ﺣ ﮯﮨ۔ م ﺟ ر ﺗ ﻣ ﮯﺳ تﺎﺑ ﮯﻧرﮐ ﮯﮐ ﮯﯾﻟ
،
رﻣﮢﺳﮐ
سورﺳ رﺑﻣﻧ رﭘ لﺎﮐ ںﯾرﮐ وﺟ پ آ ﮯﮐ ڈرﺎﮐ ﯽﮐ ت ﺷ ﭘ رﭘ ج ر د ﮯﮨ۔ رﮔا پآ رﺑﻣﻣ ںﯾﮩﻧ ،ںﯾﮨ ﺎﯾ
پآ ﮯ ﮐ سﺎﭘ ڈرﺎﮐ ںﯾﮩﻧ ﮯﮨ ،وﺗ 6984-710-855 ر ﭘ لﺎﮐ ںﯾرﮐ۔
TTY 711
7. Tagalog
Kung ikaw, o ang isang taong iyong tinutulungan ay may mga tanong,
may karapatan kang makakuha ng tulong at impormasyon sa iyong
wika nang walang bayad. Upang makipag-usap sa isang tagasalin-
wika, tumawag sa numero ng serbisyo para sa kustomer sa likod ng
iyong kard ng miyembro. Kung ikaw ay hindi isang miyembro, o kaya
ay walang kard, tumawag sa 855-710-6984.TTY 711
8. French
Si vous, ou quelqu'un que vous êtes en train d’aider, avez des
questions, vous avez le droit d'obtenir de l'aide et l'information dans
votre langue à aucun coût. Pour parler à un interprète, composez le
numéro du service client indiqué au verso de votre carte de membre.
Si vous n’êtes pas membre ou si vous n’avez pas de carte, veuillez
composer le 855-710-6984.ATS 711
9. Hindi


,








,


,



  
         

     ,         
        ,      ,  855-
710-6984    TTY 711
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
5 SECTION 1 – WELCOME
Language
Translated Taglines (Cont’d)
10. Persian-Farsi
ار نﯾا ﻖﺣ ،دﯾﺷﺎﺑ ﮫﺗﺷاد ﯽﻟاؤﺳ ،دﯾﻧﮐ ﻲﻣ ﮏﻣﮐ وا ﮫﺑ ﺎﻣﺷ ﮫﮐ ﯽﺳﮐ ﺎﯾ ،ﺎﻣﺷ رﮔا
تﮭﺟ. دﯾﯾﺎﻣﻧ تﻓﺎﯾرد تﺎﻋﻼطا و ﮏﻣﮐ نﺎﮕﯾار روط ﮫﺑ ،دوﺧ ن ﺎ ﺑ ز ﮫﺑ ﮫﮐ دﯾراد
ترﺎﮐ تﺷﭘ رد ﮫﮐ یا هرﺎﻣﺷ ﮫﺑ یرﺗﺷﻣ تﺎﻣدﺧ ﺎﺑ ،ﯽھﺎﻔﺷ مﺟرﺗﻣ ﮏﯾ ﺎﺑ وﮕﺗﻔﮔ
تﯾوﺿﻋ ترﺎﮐ ﺎﯾ ،دﯾﺗﺳﯾﻧ وﺿﻋ رﮔا. دﯾرﯾﮕﺑ سﺎﻣﺗ تﺳا هدﺷ جرد ﺎﻣﺷ تﯾوﺿﻋ
دﯾﯾﺎﻣﻧ لﺻﺎﺣ سﺎﻣﺗ 855-710-6984 هرﺎﻣﺷ ﺎﺑ ،دﯾرادﻧ. TTY 711
11. German
Falls Sie oder jemand, dem Sie helfen, Fragen haben, haben Sie das
Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu
erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die
Kundenservicenummer auf der Rückseite Ihrer Mitgliedskarte an.
Falls Sie kein Mitglied sind oder keine Mitgliedskarte besitzen, rufen
Sie bitte 855-710-6984 an. TTY 711
12. Gujarati
           
...
    ,   
       .     
,       855-710-6984    .
TTY 711
13. Russian
Если у вас или человека, которому вы помогаете, возникли
вопросы, у вас есть право на бесплатную помощь и информацию,
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участника. Если вы не являетесь участником или у вас нет
карточки, позвоните по телефону 855-710-6984. Линия TTY 711
14. Japanese
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ない場合は 855-710-6984 までお電話ください。TTY 専用番号は
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15. Laotian
ຖ
້
າທ
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ານ
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ໍ
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ບນາຍແປພາສາ, ໃຫ
້
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່
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855-710-
6984.TTY 771
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
6 SECTION 2 – INTRODUCTION
SECTION 2 - INTRODUCTION
What this section includes
■ Who's eligible for coverage under the Plan;
■ The factors that impact your cost for coverage;
■ Instructions and timeframes for selecting coverage for yourself and your eligible Dependents;
■ When coverage begins; and
■ When you can make coverage changes under the Plan.
Eligibility for the Texas Employees Group Benefits Program
You are eligible to enroll in health coverage offered by the Texas Employees Group Benefits
Program (GBP or Program) if you are a regular full-time or part-time State Agency Employee as
defined in Section 13, Glossary, an Institution of Higher Education Employee as defined in
Section 13, Glossary, or a Retiree as defined in Section 13, Glossary, with at least 10 years of
service credit at the time of retirement, or required or permitted to enroll by Chapter 1551 of the
Texas Insurance Code.
Eligibility for the Out-of-State Plan
As an Employee, you are eligible for coverage in the Out-of-State Plan if neither the county of
your personal residence nor your place of employment is in the Plan Service Area.
• You must notify your Benefits Coordinator directly, or go to ERS OnLine at
www.ers.texas.gov
to notify your Benefits Coordinator, that you base your eligibility for
coverage on either the county of your personal residence or your place of employment. If
both the location of your residence and place of employment are outside the Plan Service
Area, your coverage will be the Out-of-State Plan. If the location of your residence changes
from outside the Plan Service Area to inside the Plan Service Area your coverage may
change from the Out-of-State Plan to the In-Area Plan. Changes will become effective the
first day of the month following your change of personal residence.
• If you base your eligibility for the In-Area Plan on the county of your place of employment,
then a change in location of residence will not cause a change in plan.
• If you are age 65 or older and Actively Working, you are eligible for coverage in the In-Area
Plan, with Medicare as your Secondary Plan.
As a Retiree, you may be eligible for coverage in the Out-of-State Plan depending on which Plan
you had before retirement, the county of your personal residence and your age.
If you retire while under age 65 and you are not Medicare eligible:
• If your personal residence or county of eligibility is located outside the Plan Service Area, you
are eligible for coverage in the Out-of-State Plan.
• If, prior to retirement, you lived outside of the Plan Service Area but elected coverage in the
In-Area Plan based on the county of your place of employment, you may elect to be covered
in the In-Area Plan upon retirement. You may continue coverage in the In-Area Plan until you
either reach age 65 or change to the HealthSelect Out-of-State Plan based on a change in
residence outside of the Plan Service Area. Once you change to the HealthSelect Out-of-
State Plan, you may not change back to the In-Area Plan unless you, while under age 65,
move your residence inside the Plan Service Area.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
7 SECTION 2 – INTRODUCTION
If you retire while under age 65 and you are Medicare eligible:
• If your personal residence is located in the Plan Service Area, you are eligible under the In-
Area Plan. However, Medicare is your Primary Plan and HealthSelect coverage is your
Secondary Plan. See Section 9, Coordination of Benefits, for more information.
If you retire at age 65 or later, you are not eligible for the In-Area Plan but may be eligible for the
HealthSelect Secondary Plan.
Important Reminder
If you retired after September 1, 1992, or if you are a Dependent of a Subscriber who retired
after September 1, 1992, and you are eligible for Medicare, you will need to enroll in Medicare.
If you do not enroll in Medicare, Benefits payable under the Plan will be reduced, and that cost
could be significant. For more information on how and when to enroll, contact Medicare at
(800) 633-4227, or visit Medicare.gov.
If you are eligible for Medicare due to End Stage Renal Disease, you should enroll in Medicare.
If you choose not to enroll, Benefits payable under the Plan will be reduced, and that amount
could be significant.
For more information on how Benefits will be calculated if you are eligible for Medicare and
choose not to enroll, see Section 9, Determining the Allowable Amount When This Plan Is
Secondary to Medicare.
Your eligible Dependents may also participate in the Program and the Out-of-State Plan. An
eligible Dependent is considered to be:
• Subscriber’s spouse – an individual to whom the Subscriber is legally married. This includes
a ceremonially married spouse whose marriage is documented by a valid marriage license or
an informally married spouse whose marriage is documented by a valid Declaration of
Informal Marriage filed with the appropriate governmental authority;
• Subscriber’s child who is under age 26, including a natural child, a stepchild, a foster child, a
legally adopted child, and a child placed for adoption or ward, as defined in Section
1002.030, Texas Estates Code;
• a child who is not a Subscriber’s child referenced in the immediately preceding bullet point
and who is related to the Subscriber by blood or marriage and was claimed as the
Subscriber’s dependent on his/her federal income tax return for the year prior to enrolling the
child and for each subsequent year in which the child is enrolled (unless the child is born in
the year first enrolled or the Subscriber has shown good cause for not claiming the child); or
• a child age 26 or over who (i) is certified by an approved practitioner to be mentally or
physically incapacitated from gainful employment and (ii) either earns less than the monthly
wage standard for enrolling in Children’s Health Insurance Program in Texas for a family of
one at the time of application or reevaluation or earns more than this wage standard for a
period of six months or longer in any calendar year and demonstrates that he/she is
dependent on the Subscriber for care or support and either lives with the Subscriber or has
care provided by the Subscriber on a regular basis.
A child who is at least 26 years of age and who is unmarried on the date of and following the
expiration of the child’s continuation coverage under COBRA ceases to be a Dependent and may
continue coverage as a Subscriber who is a Former COBRA Unmarried Child.
A Former COBRA Unmarried Child may enroll a newly acquired dependent child within 31 days
of the child’s date of birth or placement for adoption, but the Former COBRA Unmarried Child
may not enroll any other Dependents.
An eligible Dependent who lives outside of the Plan Service Area may elect to participate in the
Out-of-State Plan even if the Subscriber, under whose coverage the Dependent is covered,
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
8 SECTION 2 – INTRODUCTION
participates in the In-Area Benefits Plan. If the Dependent returns to live in the Plan Service Area,
he or she may elect to change participation to the In-Area Plan.
The Subscriber's Dependents may not enroll in a GBP health plan unless the Subscriber is also
enrolled in a GBP health plan. The Subscriber and Dependents must be enrolled in the same
health plan unless (i) the Subscriber and/or Dependents have different Medicare eligibility, or (ii)
either the Subscriber or the Dependent enrolls in the HealthSelect Out-of-State plan because
their county of residence or work on file with ERS is outside of the Plan Service Area. If the
Subscriber and his/her Dependent are both eligible to enroll in a GBP health plan as the
Subscriber, he/she may each be enrolled as the Subscriber or be covered as a Dependent of the
other person's plan, but not both. In addition, if you and your spouse are both Subscribers under
a GBP health plan, only one parent may enroll your child as a Dependent on this Plan.
Cost of Coverage
The Subscriber and his/her Employer may share in the cost of the Plan. The Subscriber
contribution amount may depend on GBP eligibility and length of enrollment and whether the
Subscriber chooses to enroll any Dependents.
The Subscriber’s contributions are deducted from his/her paychecks or annuity checks depending
on the elections chosen. If the Subscriber is receiving retiree benefits, contributions are deducted
from his/her annuity post-tax. If the Subscriber is receiving full-time employee benefits, then
contributions are deducted from his/her paycheck on a pre-tax basis. This means contributions
are deducted before tax dollars come out of the Subscriber’s check, before federal income and
Social Security taxes are withheld, and (in most states) before state and local taxes are withheld.
This gives the Subscriber’s contributions a special tax advantage and lowers the Subscriber’s
actual out-of-pocket costs. The amount of contributions is subject to review, and the Employees
Retirement System of Texas Board of Trustees reserves the right to change the contribution
amount from time to time.
You can obtain current contribution rates by calling your Benefits Coordinator or logging on to
www.ers.texas.gov
.
How to Select Coverage
On your eligibility date, you are automatically enrolled in either the In-Area or Out-of-State Plan,
depending on your eligibility county. If you do not want HealthSelect coverage, you must either
select another coverage, if available, or waive coverage with your Benefits Coordinator, or online,
on or before your eligibility date.
If your Employer is an Institution of Higher Education that participates in the GBP, as defined in
Section 13, Glossary, and your Employer pays the contribution for your health coverage for the
first 60 days of employment, you are automatically enrolled in either the In-Area or Out-of-State
Plan, depending on your eligibility county, on the first day of Active Work. If you do not want
HealthSelect coverage, you must either select another coverage, if available, or waive coverage
with your Benefits Coordinator or online, on or before the 30th day of Active Work. The change in
coverage is effective on the first day of the following month.
In order to enroll a Dependent, you must provide the Dependent information to your Benefits
Coordinator on a Benefits Election Form and a Dependent Child Certification form online.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
9 SECTION 2 – INTRODUCTION
Important
If you wish to change your benefit elections following your marriage or the birth or adoption of a
child, placement for adoption of a child or other family status change, you must contact your
Benefits Coordinator, or make the change through ERS OnLine, within 31 days of the event. If
the change in benefit elections is based on a change in Medicare or Medicaid status, or
Children's Health Insurance Program (CHIP) status, you have 60 days. Otherwise, you will need
to wait until the next Annual Enrollment to change your elections. Retirees may drop their health
plan coverage or change to a different GBP health plan coverage for which they are eligible at
any time, with the coverage change effective the first of the month following the coverage
change date.
When Coverage Begins
Once your Benefits Coordinator receives your properly completed enrollment information,
coverage for Subscribers will begin as follows:
• if you are new to the Program or you have a break in Active Service, on the first day of the
month following the completion of a 60-day waiting period, unless the 60th day falls on the
first day of a month; in which case coverage begins that day;
• if you have previous Program health coverage with no break in Active Service, on the first
day of Active Work or retirement; or
• if you are employed by an Institution of Higher Education on the first day of Active Work if
your Employer pays for coverage during the waiting period; otherwise on the first day of the
month following the completion of a 60-day waiting period, unless the 60th day falls on the
first day of a month; in which case coverage begins that day.
Coverage for the Subscriber’s eligible Dependents will begin as follows:
• if the Subscriber is eligible for coverage without a waiting period and the Subscriber’s
Dependent information is received on or before the Subscriber’s first day of eligibility,
coverage will be effective on the first day of eligibility. If the Subscriber’s Dependent
information is received within 31 days after the Subscriber’s eligibility date, the coverage will
become effective on the first day of the month following receipt of the Dependent information;
• if the Subscriber is subject to a waiting period and the Subscriber’s Dependent information is
received before the first day of the month after the 60-day waiting period, Dependent
coverage will be effective on the first day of the month after the waiting period; or
• if the Subscriber’s Dependent information is not received before these deadlines, then the
Subscriber will need to wait until the next Annual Enrollment to add coverage for his or her
eligible Dependents.
For eligible Dependents acquired after a Subscriber’s eligibility date, or as addressed in the
Changing Your Coverage subsection below, coverage will begin as follows:
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
10 SECTION 2 – INTRODUCTION
NEWLY ACQUIRED
DEPENDENT
DATE COVERAGE IS
EFFECTIVE
ENROLLMENT
NOTIFICATION
REQUIREMENT
(the Subscriber must notify
his/her Benefits Coordinator
to enroll, the newly acquired
Dependent or enroll through
ERS in the time frame
indicated below)
Spouse or Dependent
stepchild that the Subscriber
acquires via marriage
The first of the month
following the date of the
marriage
Enroll within 31 days of the
date of the marriage
Newborn natural child At birth for 31 days without
enrollment
Enroll within 31 days after the
date of birth to continue the
child’s coverage
An eligible newborn who is
not the Subscriber’s natural
child and meets the
definition of Dependent of
the Subscriber
The first of the month
following the date of the birth
Enroll within 31 days of the
date of the birth
An eligible child related by
blood or marriage who is not
the Subscriber’s natural child
and meets the definition of
Dependent of the Subscriber
The first of the month
following the date the child
related by blood or marriage
becomes a Dependent of the
Subscriber
Enroll within 31 days of the
date the child becomes a
Dependent of the Subscriber
A child placed with the
Subscriber for adoption
On the date of placement with
the Subscriber for adoption
Enroll within 31 days of the
placement for adoption
A foster child placed with the
Subscriber
On the first day of the month
following the date on which
the foster child becomes a
Dependent of the Subscriber
Enroll within 31 days of the
date the foster child becomes
a Dependent of the Subscriber
A child in possession of a
Subscriber designated as
managing conservator
On the first day of the month
following the date on which
the Subscriber is designated
the child’s managing
conservator
Enroll within 31 days of the
date the Subscriber is
designated the child’s
managing conservator
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
11 SECTION 2 – INTRODUCTION
NEWLY ACQUIRED
DEPENDENT
DATE COVERAGE IS
EFFECTIVE
ENROLLMENT
NOTIFICATION
REQUIREMENT
(the Subscriber must notify
his/her Benefits
Coordinator to enroll the
newly acquired Dependent
or enroll through ERS in the
time frame indicated below)
An eligible Dependent who is
the subject of a National
Medical Support Notice
On the date a valid National
Medical Support Notice is
received by the Plan
Enroll within 31 days of the
date of a valid National
Medical Support Notice
An eligible child who is not
the Subscriber’s natural child,
stepchild, child related by
blood or marriage, adopted
child, or foster child, and
meets the definition of
Dependent of the Subscriber
Effective the first of the month
following the date the child
becomes a Dependent of the
Subscriber
Enroll within 31 days of the
date the child becomes a
Dependent of the Subscriber
An eligible Dependent who
has lost eligibility for
Medicaid or CHIP, or who
has become eligible for
premium assistance through
Medicaid or the Health
Insurance Premium Payment
(HIPP) Program (HIPP)
On the first day of the month
following the date on which
the Dependent loses eligibility
for Medicaid or CHIP, or
becomes eligible for premium
assistance through Medicaid
or HIPP
Enroll within 60 days of the
date the Dependent loses
eligibility for Medicaid or
CHIP, or becomes eligible for
premium assistance through
Medicaid or HIPP
If You Are Hospitalized When Your Coverage Begins
If you are an Inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility on
the day your coverage begins, the Plan will pay Benefits for Covered Health Services related to
that Inpatient Stay beginning the first day of eligible coverage, as long as you receive Covered
Health Services in accordance with the terms of the Plan.
You should notify BCBSTX of the inpatient hospitalization within 48 hours of the day your
coverage begins, or as soon as is reasonably possible. Network Benefits are available only if you
receive Covered Health Services from Network Providers. Prior Authorization is required for the
Inpatient Stay.
Changing Your Coverage
You may make coverage changes during the Plan Year only if you experience a
Qualifying Life Event (QLE), or during Annual Enrollment. The change in coverage
must be consistent with the QLE (e.g., you cover your spouse following your
marriage or your child following an adoption). The following are considered QLEs for
purposes of the Plan:
• change in marital status;
• change in Dependent status;
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
12 SECTION 2 – INTRODUCTION
• change in employment status;
• significant cost of Benefits or coverage change imposed by a third party;
• loss of coverage due to the exhaustion of another employer's COBRA benefits, provided you
were paying for premiums on a timely basis;
• change of address that results in loss of coverage eligibility;
• change in Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) status; or
• an applicable National Medical Support Notice.
If you wish to change your elections, you must contact your Benefits Coordinator, or make the
change through ERS OnLine, within 31 days of the QLE, If the change in benefits election is
based on a change in Medicare, Medicaid or CHIP status, you have 60 days. Otherwise, you may
not make a change until the next Annual Enrollment. Retirees may drop their health plan
coverage or change to a different GBP health plan coverage for which they are eligible at any
time, with the coverage change effective the first of the month following the coverage change
date.
Notes:
• Any child who is placed with the Subscriber for adoption will be eligible for coverage on the
date the child is placed with the Subscriber, even if the legal adoption is not yet final.
• Any changes based on a QLE are effective on the first day of the month following the date of
the QLE (except when a child is newborn, adopted or subject to a National Medical Support
Order, as previously stated in this section).
Change in Coverage due to Qualifying Life Event – Example
Jane is married and has two children who are eligible Dependents. At Annual Enrollment, she
elects not to participate in the GBP’s health coverage because her husband, Tom, has family
coverage under his employer's medical plan. In October, Tom loses his job as part of a
downsizing. As a result, Tom loses his eligibility for medical coverage. Due to Tom’s change in
employment status, Jane can elect family medical coverage under the GBP’s health coverage
outside of Annual Enrollment.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
13 SECTION 3 – HOW THE PLAN WORKS
SECTION 3 - HOW THE PLAN WORKS
What this section includes
■ Accessing Benefits;
■ BlueCard
®
Program and Beyond: Accessing Your Healthcare Benefits While Traveling;
■ Allowable Amounts;
■ Deductibles;
■ Copay;
■ Coinsurance;
■ Inpatient Copay Maximum;
■ Out-of-Pocket Coinsurance Maximum; and
■ Total Network Out-of-Pocket Maximum.
Accessing Benefits
You can choose to receive Network Benefits or Non-Network Benefits. Generally, when you
receive Covered Health Services from a Network Provider, you pay less than you would if you
receive the same care from a Non-Network Provider. Therefore, in most instances, your out-of-
pocket expenses will be less if you use a Network Provider.
In most cases, if you receive care from Non-Network Providers, the Plan generally pays Benefits
at a lower level and reimburses the Non-Network Provider at an amount less than a Network
Provider. You may also be required to pay the amount that exceeds the Non-Network Allowable
Amount (sometimes referred to as Balance Billing). Balance Billing can result in significant
increased cost to you and this amount does not apply to any out-of-pocket maximum. It is very
important that you ask the Non-Network Provider about his/her billed charges before you receive
care. Emergency Health Services received at a Non-Network Hospital are covered at the Network
level until your Physician determines that it is medically appropriate to transfer you to a Network
Hospital.
You should not be Balance Billed for any amounts above your Participant responsibility for
Deductibles, Copayments and Coinsurance in the following instances:
• Emergency services or supplies you receive from a Non-Network Provider;
• services from a Non-Network Provider that you receive in a Network Facility, unless you
agreed in writing in advance to receive the Non-Network services; or
• lab or diagnostic imaging services you receive from a Non-Network lab or diagnostic imaging
service that were ordered by a Network Provider, unless you agreed in writing in advance to
receive the Non-Network services.
If you receive a bill for amounts above your responsibility in the scenarios listed above without
providing your written consent in advance, please contact a BCBSTX Personal Health
Assistant at (800) 252-8039 (TTY: 711).
Network Benefits apply to Covered Health Services that are provided by a Network Provider or
coordinated through BCBSTX. Referrals to Specialists are not required under the HealthSelect
Out-of-State Plan. Additionally, you do not need to designate a primary care provider (PCP)
under the HealthSelect Out-of-State Plan.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
14 SECTION 3 – HOW THE PLAN WORKS
Reminder: Stay in Network!
You should always confirm your Provider is contracting before you receive services. It’s always
a good idea to ask your Provider for the name(s) of the laboratories and Other Providers they
use so that you can choose a Network Provider. This can significantly reduce your out-of-pocket
expenses.
Emergency Health Services are always paid at the Network Benefit level regardless of whether
services are received at a Network or Non-Network Hospital until your Physician determines that
it is medically appropriate to transfer you to a Network Hospital. For more information on
Emergency Health Services Benefits, including the difference in Benefits for Emergency Health
Services received in a Hospital, a Freestanding Emergency Department or a Freestanding
Emergency Room, go to Section 5, Schedule of Benefits and Coverages under the heading
Emergency Services, and Section 6, Details for Covered Health Services. For more information
about potential Balance Billing related to Emergency Health Services, see the discussion of
Allowable Amounts below in this Section 3, How the Plan Works.
Network Benefits apply when Covered Health Services are provided by a Network Provider or
Network Facility. Additionally, you are responsible for confirming that your Provider is a Network
Provider before you receive services. If you have questions or need assistance locating a
Network Provider, contact a BCBSTX Personal Health Assistant at (800) 252-8039 (TTY: 711) or
by logging into your Blue Access for Members account at www.healthselectoftexas.com.
Non-Network Benefits apply to Covered Health Services that are provided by a Non-Network
Provider or Non-Network Facility. Certain Non-Network services may also require Prior
Authorization. For more information on obtaining Prior Authorization, or when a Prior
Authorization is required, see Section 4, Prior Authorization.
Additionally, you are responsible for confirming that your Provider is a Network Provider before
you receive services. If you have questions or need assistance locating a Network Provider,
contact a BCBSTX Personal Health Assistant at (800) 252-8039 (TTY: 711).
Non-Network Benefits apply to Covered Health Services that are provided by a Non-
Network Provider or Non-Network Facility. Certain Non-Network services may also require
Prior Authorization. For more information on obtaining Prior Authorization, or when a Prior
Authorization is required, see Section 4, Prior Authorization.
Note for Participants with Medicare Primary
Prior Authorization is not required when Medicare is your Primary Plan. If you have questions
about your Benefits or would like to confirm when a Prior Authorization is required under this
Plan, contact a BCBSTX Personal Health Assistant at (800) 252-8039 (TTY: 711), Monday–
Friday from 7 a.m. - 7 p.m. central time (CT) or Saturday from 7 a.m. - 3 p.m. CT.
When Covered Health Services from Non-Network Providers Will Be Paid
as Network
When Covered Health Services are not available from a Network Provider in your area, you may
be eligible to receive Network Benefits from a Non-Network Provider. In such rare instances, your
Provider will notify BCBSTX, and they will work with you and your Provider to authorize and
coordinate care.
The Plan allows such Referrals only when there is no Network Provider to provide the necessary
medical care within a 75-mile radius of the Participant’s address on file. In some instances, if a
PCP is unavailable to provide medical care to a Participant within a 30-mile radius of the
Participant’s address on file, an exception must be authorized by BCBSTX in advance to consider
a Non-Network PCP at the Network Benefits level.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
15 SECTION 3 – HOW THE PLAN WORKS
When you receive Covered Health Services on this basis, the Plan will pay Network Benefits for
those Covered Health Services, even if one or more of those Covered Health Services is received
from a Non-Network Provider.
Network Benefits also apply to Covered Health Services that are provided on a non-emergent
basis at a Network Facility by a Non-Network Emergency Care Physician, assistant surgeon,
surgical assistant, laboratory technician, radiologist, anesthesiologist, pathologist, or consulting
Physician, as long as all other Plan requirements are met, such as Prior Authorization (when
required).
Claims that are provided on a non-emergent basis at a Network Facility by a Non-Network
Emergency Care Physician, assistant surgeon, surgical assistant, laboratory technician,
radiologist, anesthesiologist, pathologist, or consulting Physician will be reimbursed as set
forth under Allowable Amounts as described in Section 13, Glossary.
• You may not be billed for the amount that exceeds your Participant responsibility for
Deductibles, Copayments, and Coinsurance as part of the Allowable Amount, unless the
Non-Network Provider has obtained your written consent in advance.
Looking for a Network Provider?
In addition to other helpful information, www.healthselectoftexas.com, HealthSelect’s
dedicated website, contains a directory of Network health care professionals and Facilities.
While Network status may change from time to time, www.healthselectoftexas.com has the
most current source of Network information. Use www.healthselectoftexas.com to search for
Physicians available in your Plan.
Network Providers
BCBSTX or its affiliates arrange for health care Providers to participate in the Network. At your
request, BCBSTX will send you a directory of Network Providers free of charge. Keep in mind, a
Provider's Network status may change so the most up-to-date source of Network Providers is the
HealthSelect dedicated website located online at www.healthselectoftexas.com
. You may also
contact a BCBSTX Personal Health Assistant, to verify a Provider's status or request a Provider
directory, at (800) 252-8039 (TTY: 711).
Network Providers are independent practitioners and are not employees of HealthSelect,
BCBSTX or ERS.
BlueCard
®
Program and Beyond: Accessing Your Healthcare Benefits
While Traveling
Wherever you travel, you have access to healthcare benefits.
If you are traveling outside of your state of residence but within the United States, the BlueCard
Program provides access to contracted Providers in other states. If you are traveling outside of
the country, Blue Cross Blue Shield Global
®
Core provides access to providers abroad.
Traveling Prepared
If you know you will be traveling, there are some things you can do to travel prepared.
• Call a BCBSTX Personal Health Assistant at (800) 252-8039 (TTY: 711), Monday–Friday
from 7 a.m. - 7 p.m. central time (CT) or Saturday from 7 a.m. - 3 p.m. CT with any questions.
• Bring your medical ID card.
• If you receive care while traveling, keep all the associated receipts and paperwork.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
16 SECTION 3 – HOW THE PLAN WORKS
How to Find a Provider
Finding a provider while traveling is just like finding a provider at home. You have a few options:
• Call a BCBSTX Personal Health Assistant at (800) 252-8039 (TTY: 711), Monday–Friday
from 7 a.m. - 7 p.m. central time (CT) or Saturday from 7 a.m. - 3 p.m. CT.
• Go online to use the Provider Finder
®
tool.
o For travel within the United States, Provider Finder is accessible via
www.healthselectoftexas.com and by logging in to the secure Participant portal, Blue
Access for Members
SM
.
o For travel outside of the United States, the international Provider Finder is accessible via
www.bcbsglobalcore.com
.
• Download the BCBSTX Mobile App and use the Provider Finder tool. Text “BCBSTXAPP” to
33633 to get the app on your mobile device.
Emergency Care
In the event of an Emergency, while you are traveling, visit the nearest Emergency Facility.
The Plan pays Network Benefits for Covered Health Services, billed as Emergency services,
regardless of where you receive care. However, in some cases you may have to pay up front
and file a claim to be reimbursed. Keep all your paperwork and follow the instructions for filing
a claim below. For more information on Emergency Health Services Benefits, including the
difference in Benefits cost for Emergency Health Services received in a Hospital, a
Freestanding Emergency Department or a Freestanding Emergency Room, go to Section 5,
Schedule of Benefits and Coverages under the heading Emergency Services, and Section 6,
Details for Covered Health Services. For more information about potential Balance Billing
related to Emergency Health Services, see the discussion of Allowable Amounts below in this
Section 3, How the Plan Works.
Non-Emergency Care
To visit a provider for non-Emergency care while traveling, find a Contracted Provider using the
Provider Finder or by calling a BCBSTX Personal Health Assistant at (800) 252-8039 (TTY: 711).
You must contact a BCBSTX Personal Health Assistant at (800) 252-8039 (TTY: 711) to obtain
Prior Authorization for non-Emergency Inpatient Services.
Traveling Within the United States
If you see a BlueCard contracted provider (verify via Provider Finder or calling a Personal Health
Assistant) while traveling within the United States, the Commonwealth of Puerto Rico, or the U.S.
Virgin Islands, the Plan pays Network Benefits for Covered Health Services.
If you see a Non-Contracted Provider for non-Emergency services, the Plan pays for Covered
Health Services at the Non-Network Benefit level and subject to the Non-Network Annual
Deductible. Generally, when you receive Covered Health Services from a Network Provider, you
pay less than you would if you receive the same care from a Non-Network Provider.
Virtual Visits
If you are traveling within the United States, Virtual Visits are a convenient option for non-
Emergency care. Virtual Visits are services provided by a Virtual Network Provider for the
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
17 SECTION 3 – HOW THE PLAN WORKS
diagnosis and treatment of low acuity, non-Emergency medical and mental health conditions
through the use of interactive audio and video telecommunication and transmissions, and audio-
visual communication technology. A Virtual Visit is different from a Telemedicine visit, which is a
provider-platform visit. With a Virtual Visit from a Virtual Network Provider, you can speak to a
board-certified doctor using live audio and video technology for treatment. If necessary, a doctor
can prescribe medication and electronically send the prescription to your selected pharmacy. The
service is available 24-hours a day, including nights, weekends and holidays. Virtual Visits are not
available while traveling outside of the United States.
Traveling Outside the United States– Blue Cross Blue Shield Global
®
Core
If you see a Contracted Provider (verify via www.bcbsglobalcore.com
or by calling a Personal
Health Assistant) while traveling outside of the United States, the Plan pays for Covered Health
Services at the Non-Network Benefit level and subject to the Non-Network Annual Deductible
and Non-Network Plan provisions. If you see a Non-Network Provider, the Plan still pays for
Covered Health Services at the Non-Network Benefit level and subject to the Non-Network
Annual Deductible, but you could be Balance Billed.
How to Submit a Claim
If you visited a Non-Network Provider within the United States or any provider outside of the
United States, you’ll likely need to submit a claim for reimbursement.
For care received within the United States, submit claims to Blue Cross and Blue Shield of
Texas.
Submit the domestic claim form, found online at www.healthselectoftexas.com
, with an
itemized bill of services rendered. Please put your group and ID number on all pages of your
submission.
Claims can be submitted by mail to:
Blue Cross Blue Shield of Texas
P.O. Box 660044
Dallas, TX 75266-0044
For assistance with the claims submission process, call a BCBSTX Personal Health Assistant at
(800) 252-8039 (TTY: 711), Monday–Friday from 7 a.m. - 7 p.m. CT or Saturday from 7 a.m. - 3
p.m. CT.
For care received abroad, submit claims to Service Center.
Send a completed Blue Cross Blue Shield Global Core claim form, found online at
www.bcbsglobalcore.com
, with an itemized bill of services rendered to the Global Core Service
Center to begin the claims process.
Claims can be submitted by mail to:
Blue Cross Blue Shield Global Core Service Center
P.O. Box 2048
Southeastern, PA 19399
Claims also can be emailed to claims@bcbsglobalcore.com
.
Following the instructions on the claim form will help ensure timely processing of your claim. If
you need assistance with your claim submission, you should call the Blue Cross Blue Shield
Global Core Service Center at (800) 810-BLUE (2583) 24 hours a day, 7 days a week.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
18 SECTION 3 – HOW THE PLAN WORKS
Blue Cross, Blue Shield, the Blue Cross and Blue Shield symbols, BlueCard, and Blue Cross
Blue Shield Global
®
Core are trademarks of the Blue Cross Blue Shield Association, an
association of independent Blue Cross and Blue Shield companies.
Note: Whether you receive care within the United States or Outside of the United States,
Participants have 18 months to submit a claim from the date of service. Providers have 365 days
from the date of service to submit a claim. Claims received outside of this time frame will be
denied.
Don't Forget Your HealthSelect Medical ID Card
Remember to show your HealthSelect medical ID card every time you receive Covered Health
Services from a Provider. If you do not show your ID card, a Provider does not know that you are
enrolled in the Plan and cannot determine your benefits. If you forgot to pack your Medical ID
Card, you can access a temporary card by logging into your Blue Access for Members account
online or the BCBSTX App.
Allowable Amounts
Allowable Amounts are the maximum amounts, determined by BCBSTX, that the Plan could
pay for Benefits for Covered Health Services while the Plan is in effect. The Plan payment
reduces the Allowable Amount for any applicable Deductibles, Copayments, and/or
Coinsurance amounts the Participant could be responsible for as indicated in Table 1 in Section
3, How The Plan Works and Tables 2 & 3 in Section 5, Schedule of Benefits and Coverage.
Allowable Amount determinations are subject to BCBSTX’ reimbursement policy guidelines, as
described in Addendum – Calculating Allowable Amounts.
BCBSTX enters into agreements with Providers who agree to accept the Allowable Amount.
When you use Contracted Providers, you are not responsible for the difference in the
Allowable Amounts and the amount the Provider bills. When you use Providers that are not in
your Network, and you receive Non-Network Covered Health Services, the Plan will not pay
Benefits until you have met your Annual Non-Network Deductible, and you may be
responsible for paying, directly to the Non-Network Provider, any difference between the
amount the Provider bills you and the Allowable Amount. This is also referred to as Balance
Billing. For more information on how your share of the cost for Covered Health Services is
impacted by using a Network or Non-Network Provider, see Accessing Benefits in this Section
3, How The Plan Works.
To find an estimate of your share of the cost for health care services or procedures before you
go to the doctor or hospital, log in to your Blue Access for Members account online at
www.healthselectoftexas.com and search for specific procedures within the HealthSelect
Provider Finder. You can also call a BCBSTX Personal Health Assistant toll-free at (800) 252–
8039 (TTY: 711) for help.
Reminder
An Explanation of Benefits (EOB) will be provided to you for claims processed by BCBSTX and
will show you the Allowable Amount, any amounts paid by the Plan, and the amount you are
responsible for. If your claim is denied in whole or in part, the EOB will include the reason for
the denial or partial payment. Please note that your EOB will not reflect amounts you may have
already paid to the Provider.
ERS has delegated to BCBSTX the discretion to determine whether a treatment or supply is a
Covered Health Service and how the Allowable Amounts will be determined and otherwise
covered under the Plan, per guidelines established by the Plan and BCBSTX. ERS has the
discretion to interpret all terms and conditions under the Plan, as described under
Interpretation of the Plan in Section 12, Other Important Information.
For information regarding how the Allowable Amount is determined see the Addendum -
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
19 SECTION 3 – HOW THE PLAN WORKS
Calculating Allowable Amounts.
Important
In general, a Non-Network Allowable Amount is less than a Network Allowable Amount. This
means the Plan will usually pay less towards Non-Network Covered Health Services than
Network Covered Health Services. When you receive Covered Health services from a Non-
Network Provider, your cost is generally higher because you may be responsible for the amount
exceeding the Plan’s Allowable Amount. (This is referred to as Balance Billing). For example,
this may apply if you receive Covered Health Services at a Non-Network Facility or from a Non-
Network Provider. See Section 3, How the Plan Works, under the heading Accessing Benefits
for more information on Balance Billing and when it may apply.
Deductibles
Annual Non-Network Deductible
The Annual Non-Network Deductible is the portion of the Allowable Amounts you must pay each
Calendar Year for Covered Health Services before you are eligible to begin receiving Non-
Network Benefits.
Covered Health Services that are subject to the Annual Non-Network Deductible and also subject
to a visit or day limit will be included in reaching both the Annual Non-Network Deductible and the
maximum day or visit Benefit limit.
The Annual Non-Network Deductible for each Participant is $500, with a family maximum of
$1,500 per Calendar Year. However, if two or more Participants who are covered by the same
Subscriber are injured in the same accident, the family maximum will not apply. Instead, only one
Participant’s Non-Network Deductible is required for the Calendar Year in which the accident
occurred.
Bariatric Deductible
The separate Bariatric Deductible is the amount an Employee must pay for Bariatric Surgery
before becoming eligible to begin receiving Network Benefits for such surgery. There is no
coverage for Bariatric Surgery provided by a Non-Network Provider. Additionally, the Bariatric
Surgery Benefit is not available to Retirees or Dependents.
The separate Bariatric Deductible is $5,000.
Allowable Amounts that apply to the separate Bariatric Deductible do not apply to the Out-of-
Pocket Coinsurance Maximum or Total Out-of-Pocket Maximum.
Note: For a complete description of guidelines and coverage for Bariatric Surgery, including the
lifetime maximum benefit amount, refer to Section 5, Schedule of Benefits and Coverage, and
Section 6, Details for Covered Health Services, under the heading Bariatric Surgery.
Additional Deductible
Before you are admitted to a Non-Network Hospital or other Facility for Inpatient care, whether for
medical, mental health, Serious Mental Illness or substance-related and addictive disorder
treatment, you must obtain Prior Authorization from BCBSTX as described in Section 4, Prior
Authorization.
If you do not obtain Prior Authorization, an Additional Deductible will apply before you are eligible
to begin receiving Non-Network Benefits.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
20 SECTION 3 – HOW THE PLAN WORKS
The Additional Deductible is $200 and applies each time you fail to obtain Prior Authorization for
a Non-Network Inpatient admission as required, as detailed under Reduction in Benefits if Prior
Authorization is Not Obtained in Section 4, Prior Authorization.
Copay
A Copay is the amount you pay each time you receive certain Covered Health Services. The
Copay is a flat dollar amount and is paid at the time of service or when billed by the Provider. If
the Allowable Amount is less than the Copay, you are only responsible for paying the Allowable
Amount and not the Copay.
Copays do not count toward the Out-of-Pocket Coinsurance Maximum nor toward the Annual
Non-Network Deductible. However, Copays count toward the Total Out-of-Pocket Maximum.
Coinsurance
Coinsurance is a fixed percentage of Allowable Amounts that you are responsible for paying for
certain Covered Health Services. The amount you pay for Coinsurance for Network Covered
Health Services received is determined after you pay any applicable Copays. For Non-Network
Covered Health Services, the amount you pay for Coinsurance is determined after you meet the
Annual Non-Network Deductible and pay any applicable Copays.
The payments you make as Coinsurance apply to your Out-of-Pocket Coinsurance Maximum.
Examples
Coinsurance: Let's assume that you receive Plan Benefits for Durable Medical Equipment from a
Network Provider. Since the Plan pays 80% of Allowable Amounts, you are responsible for
paying the other 20%. This 20% is your Coinsurance.
Copay: Let's assume that you receive Plan Benefits for Physician’s Office Services from a
Network Specialist. Your Specialist Copay is $40 and the Plan pays 100% of Allowable Amounts
after you pay the Copay.
Inpatient Copay Maximum
The annual Inpatient Copay Maximum is the most you pay each Calendar Year in Copays for
Inpatient Stays in a Hospital or for Inpatient care for Mental Health Services, Serious Mental
Illness Services or Substance Use Disorder Services. There is a combined Network and Non-
Network Inpatient Copay Maximum for this Plan. Once you reach the applicable Inpatient Copay
Maximum, you are not required to pay any more Inpatient Copays for the remainder of the
Calendar Year.
When you pay any Inpatient Copay for a Network or Non-Network Inpatient Stay, it applies
toward the Inpatient Copay Maximum.
The Inpatient Copay Maximum is separate from the Plan Out-of-Pocket Coinsurance Maximum.
However, Copays for Inpatient Stays that apply to the Inpatient Copay Maximum also apply to the
Total Out-of-Pocket Maximum.
Out-of-Pocket Coinsurance Maximum
The annual Out-of-Pocket Coinsurance Maximum is the most you pay for Coinsurance each
Calendar Year for Covered Health Services. There are separate Network and Non-Network Out-
of-Pocket Coinsurance Maximums for this Plan. Once you reach the applicable Out-of-Pocket
Coinsurance Maximum, you will not be required to pay any more Coinsurance for the remainder
of the Calendar Year, except as noted below.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
21 SECTION 3 – HOW THE PLAN WORKS
If your eligible out-of-pocket Coinsurance expenses, except as noted below, in a Calendar Year
exceed the Out-of-Pocket Coinsurance Maximum, the Plan pays 100% of Allowable Amounts, not
including Copays, for Covered Health Services through the end of the Calendar Year.
Exceptions: Benefits for Bariatric Surgery are not paid at 100% even after the Out-of-Pocket
Coinsurance Maximum is reached. The Plan will continue to pay Bariatric Surgery at 80% for
Network Benefits (Non-Network Benefits are not covered).
Table 1 below identifies what does and does not apply toward your Out-of-Pocket Coinsurance
Maximum.
Total Network Out-of-Pocket Maximum
The Total Network Out-of-Pocket Maximum is the Plan’s overall limit on the amount you will pay
out of pocket for your Network cost sharing for Covered Health Services and Covered Drugs each
Calendar Year. The Total Network Out-of-Pocket Maximum includes Copays, Coinsurance and
applicable Deductibles, as described below. Once you reach the Total Network Out-of-Pocket
Maximum, you will not be required to pay any more out-of-pocket expenses for Network Benefits
for the remainder of the Calendar Year, except as noted below. Note: See Table 1 below and
Table 2 in Section 5, Schedule of Benefits and Coverage, for details on what applies to the Total
Network Out-of-Pocket Maximum.
If your eligible out-of-pocket expenses in a Calendar Year exceed the Total Network Out-of-
Pocket Maximum, except as noted below, the Plan pays 100% of Allowable Amounts for Covered
Health Services and Covered Drugs for that level of Benefits through the end of the Calendar
Year.
Exceptions: Benefits for Bariatric Surgery are not paid at 100% even after the Total Network
Out-of-Pocket Maximum is reached. The Plan will continue to pay Bariatric Surgery at 80% for
Network Benefits (Non-Network Benefits are not covered).
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
22 SECTION 3 – HOW THE PLAN WORKS
Table 1 below identifies what does and does not apply toward your Total Network Out-of-Pocket
Maximum.
TABLE 1
Plan Features
Applies to the
Network
Out-of-Pocket
Coinsurance
Maximum?
Applies to the
Total Network
Out-of-Pocket
Maximum?
Applies to the
Non-Network
Out-of-Pocket
Coinsurance
Maximum?
Copays, including those that apply to
the Inpatient Copay Maximum
No Yes No
Payments toward the Annual Non-
Network Deductible
Not Applicable Not Applicable No
Payments toward the Network
separate Bariatric Deductible
No No Not Applicable
Additional Deductible amounts you
are required to pay if you do not
obtain Prior Authorization from
BCBSTX for an Inpatient Stay at a
Non-Network Hospital or other
Facility*
Not Applicable Not Applicable No
Coinsurance payments for Bariatric
Surgery
No No Not Applicable
Coinsurance payments for all other
Covered Health Services
Yes Yes Yes
Services or supplies that are for non-
Covered Health Services excluded
under the Plan
No No No
Expenses not covered because a
maximum Benefit has been reached
No No No
Amounts you must pay out-of-pocket
when no Benefits are paid by the Plan
if you do not obtain Prior Authorization
from BCBSTX*
Not Applicable Not Applicable No
Charges that exceed Allowable
Amounts as determined by BCBSTX
No No No
*See Reduction in Benefits if Prior Authorization is Not Obtained in Section 4, Prior Authorization, for a list of services this
applies to.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
23 SECTION 3 – HOW THE PLAN WORKS
How the Plan Works – Example
The following example illustrates how Annual Non-Network Deductibles, Copays and Out-of-
Pocket Coinsurance Maximums, Total Network Out-of-Pocket Maximum and Coinsurance work in
practice: Let's say Gary has individual coverage under the Plan. He has met his Annual Non-
Network Deductible and needs to see a Physician. The flow chart below shows what happens
when he visits a Network Physician versus a Non-Network Physician.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
24 SECTION 3 – HOW THE PLAN WORKS
Network Benefits
Non-Network Benefits
1. Gary goes to see his
Network Primary Care
Provider and presents his
HealthSelect medical ID
card.
1. Gary goes to see a Non-Network Physician and
presents his HealthSelect medical ID card.
2. He receives treatment from
his Primary Care Provider.
The Plan's Allowable
Amount for the Network
office visit equals $125.
2. He receives treatment from the Physician. The
Allowable Amount for his visit to his Non-Network
Physician is $85 however, the Physician's fee is
$225.
3. On his way out, Gary pays
a $25 Primary Care
Provider Copay. Since
Network Primary Care
Provider office visits are
covered at 100% after the
Copay, Gary does not pay
any Coinsurance and he
has met his financial
obligations for this office
visit.
3. The Physician's office requests no payment,
informing Gary that it will bill
BCBSTX directly. *
4. The Plan pays $100 ($125
Allowable Amount minus
the $25 Copay).
4. Since Gary has met his Non-Network Annual
Deductible, he is responsible for paying
Coinsurance for this visit. After
BCBSTX processes
the claim from the Provider, it is determined that
Gary is responsible for paying Coinsurance directly
to the Physician. Gary is responsible for $34 (40%
of $85).
5. BCBSTX applies the $25
toward Gary's Total Network
Out-of-Pocket Maximum.
5. Gary receives a bill from the Physician for the $34,
and pays the Physician directly.
BCBSTX pays $51 to
the Physician (60% of $85).
6. The Physician's office, at its discretion, might bill
Gary for the remaining $140 (sometimes referred
to as Balance Billing):
$225
-
$85
=
$140
(Physician's
fee)
(Allowable
Amount)
Gary's $140 payment does not apply to his Non-
Network Out-of-Pocket Coinsurance Maximum.
*Although Non-Network Providers have the right to request payment in full at the time of service, they bill BCBSTX directly
in most cases.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
25 SECTION 4 – PRIOR AUTHORIZATION
SECTION 4 - PRIOR AUTHORIZATION
What this section includes
■ How to obtain Prior Authorization for certain Covered Health Services; and
■ What services require Prior Authorization.
Prior Authorization
It is recommended that you confirm with BCBSTX that all Covered Health Services listed below
have been prior authorized as required.
The Plan requires Prior Authorization for certain Covered Health Services. In general, when
Covered Health Services are provided by a BCBSTX Network Provider, the Network Provider is
responsible for obtaining Prior Authorization. There are some Covered Health Services,
however, for which you are responsible for obtaining Prior Authorization. Covered Health
Services for which Prior Authorization is required are identified below and in Section 6, Details
for Covered Health Services, within each Covered Health Service category.
Before receiving these services from a Provider, you may want to contact BCBSTX to determine
whether the Hospital, Physician and Other Providers are current Network Providers and if so, that
they have obtained the required Prior Authorization. Network Facilities and Network Providers
cannot bill you for services they fail to prior authorize as required. To verify that a Provider is in
Network or to check the status of a Prior Authorization, you may contact BCBSTX at (800) 252-
8039 (TTY: 711). You can also go online to www.healthselectoftexas.com
and log in to Blue
Access for Members to view your current Prior Authorizations.
When you choose to receive certain Covered Health Services from Non-Network Providers, you
are responsible for obtaining Prior Authorization before you receive these services. Your
obligation to obtain a Prior Authorization also applies when a Non-Network Provider intends to
admit you to a Network Facility or refers you to other Network Providers.
To obtain Prior Authorization, call BCBSTX at (800) 252-8039 (TTY: 711). This call starts the
utilization review process. The utilization review process is a set of formal techniques designed to
monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of,
health care services, procedures or settings. Once you have obtained the Prior Authorization,
please review the documentation carefully so that you understand the authorized services and
which Providers are authorized to deliver the authorized services.
Covered Health Services That Require Prior Authorization
Network Covered Health Services
Network Providers are responsible for obtaining Prior Authorization from BCBSTX before they
provide most services to you. These services include:
• Bariatric Surgery (only covered when performed by Network Providers at a Network Blue
Distinction Center);
• Durable Medical Equipment and supplies that are greater than $1,000;
• genetic/molecular testing;
• high-tech radiology exams (such as CT scan, Nuclear Stress Test, MRI, PET scan);
• home health services;
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
26 SECTION 4 – PRIOR AUTHORIZATION
• home infusion therapy (only covered for Network Providers);
• inpatient admissions;
• inpatient Hospice and rehabilitation;
• long term acute care;
• maternity inpatient care (for deliveries with complications);
• Mental Health Services for inpatient, Residential Treatment Facility, and Partial
Hospitalization;
• neurobiological disorders for inpatient, Residential Treatment Facility, and Partial
Hospitalization;
• non-emergent air and ground ambulance;
• orthognathic surgery;
• outpatient behavioral health services;
o services for outpatient behavioral health services (including intensive outpatient program
(IOP) for Mental Health Services and Substance Use Disorder; repetitive transcranial
magnetic stimulation (rTMS); electro-convulsive therapy (ECT); and Applied Behavioral
Analysis (ABA), for Autism Spectrum Disorders only);
• outpatient surgery, including injections (unless performed in the physician office setting);
• physical therapy, occupational therapy, and speech therapy;
• Private Duty Nursing;
• radiation therapy for cancer;
• Reconstructive Procedures;
• Skilled Nursing Facility;
• sleep studies, including positive airway pressure devices (CPAP/APAP) and initial supplies;
• specialty drugs (contact a BCBSTX Personal Health Assistant for additional information);
• Substance Use Disorders for inpatient, Residential Treatment Facility, and Partial
Hospitalization; and
• transplant services.
Non-Network Covered Health Services
When you choose to receive certain Covered Health Services from Non-Network Providers, you
are responsible for obtaining Prior Authorization from BCBSTX before you receive these services.
In many cases, your Non-Network Benefits will be reduced if BCBSTX did not provide Prior
Authorization, as described below under Reduction in Benefits If Prior Authorization Is Not
Obtained.
The Non-Network services that require you to request BCBSTX Prior Authorization are:
• Durable Medical Equipment and supplies that are greater than $1,000;
• genetic/molecular testing;
• high-tech radiology exams (such as CT scan, Nuclear Stress Test, MRI, PET scan);
• home health services;
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
27 SECTION 4 – PRIOR AUTHORIZATION
• inpatient admission;
• inpatient hospice and rehabilitation;
• long-term acute care;
• maternity inpatient care (for deliveries with complications);
• Mental Health Services for inpatient, Residential Treatment Facility, and Partial
Hospitalization;
• neurobiological disorders for inpatient, Residential Treatment Facility, and Partial
Hospitalization;
• non-emergent air and ground ambulance;
• orthognathic surgery;
• outpatient behavioral health services;
o services for outpatient behavioral health services (including intensive outpatient program
(IOP) for Mental Health Services and Substance Use Disorder; repetitive transcranial
magnetic stimulation (rTMS); electroconvulsive therapy (ECT); and applied behavioral
analysis (ABA), for Autism Spectrum Disorders only);
• outpatient surgery, including injections (unless performed in the physician office setting);
• physical therapy, occupational therapy, and speech therapy;
• Private Duty Nursing;
• radiation therapy for cancer;
• Reconstructive Procedures;
• Skilled Nursing Facility;
• sleep studies, including positive airway pressure devices (CPAP/APAP) and initial supplies;
• specialty drugs (contact a BCBSTX Personal Health Assistant for additional information);
• Substance Use Disorders for inpatient, Residential Treatment Facility, and Partial
Hospitalization; and
• transplant services.
Reductions in Benefits will apply if you do not obtain Prior Authorization from BCBSTX. Refer to
the Reduction in Benefits if Prior Authorization is Not Obtained section shown below, and to
Section 6, Details for Covered Health Services.
Note: If you are admitted to a Non-Network Hospital, Skilled Nursing Facility or Inpatient
Rehabilitation Facility as a result of an Emergency, you or your representative must notify
BCBSTX within 48 hours after the admission.
Contacting BCBSTX is easy.
Simply call (800) 252-8039 (TTY: 711).
Reduction in Benefits If Prior Authorization Is Not Obtained
If you do not obtain Prior Authorization from BCBSTX for these Non-Network services, Benefits
are subject to an Additional Deductible of $200:
• high-tech radiology;
• inpatient admissions;
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
28 SECTION 4 – PRIOR AUTHORIZATION
• long-term acute care;
• maternity inpatient care (for deliveries with complications);
• Mental Health Services for inpatient, Residential Treatment Facility, and Partial
Hospitalization;
• neurobiological disorders for inpatient, Residential Treatment Facility, and Partial
Hospitalization;
• orthognathic surgery;
• outpatient behavioral health services;
• outpatient behavioral health services (including intensive outpatient program (IOP) for Mental
Health Services and Substance Use Disorder; repetitive transcranial magnetic stimulation
(rTMS); electroconvulsive therapy (ECT); and applied behavioral analysis (ABA), for Autism
Spectrum Disorders only);
• physical therapy, occupational therapy, and speech therapy;
• Reconstructive Procedures (including but not limited to breast reduction surgery);
• Substance Use Disorders for inpatient, Residential Treatment Facility, and Partial
Hospitalization; and
• transplant services.
If you do not obtain Prior Authorization from BCBSTX for the below Non-Network services, you
are responsible for paying all charges and no Benefits will be paid:
• Durable Medical Equipment and supplies that are greater than $1,000;
• genetic/molecular testing;
• home health services;
• inpatient Hospice and rehabilitation;
• non-emergent air and ground ambulance;
• outpatient surgery, including injections (unless performed in the physician office setting);
• Private Duty Nursing;
• radiation therapy for cancer;
• Skilled Nursing Facility;
• sleep studies, including positive airway pressure devices (CPAP/APAP) and initial supplies;
and
• specialty drugs (contact a BCBSTX Personal Health Assistant for additional information).
Special Note Regarding Medicare
If you are enrolled in Medicare as your Primary Plan, you are not required to obtain Prior
Authorization from BCBSTX before receiving Covered Health Services, regardless of whether
Medicare covers the services. Since Medicare is primary and pays benefits first, this Plan will pay
medical Benefits second as described in Section 9, Coordination of Benefits (COB).
If you have questions about your Benefits or would like to confirm when a Prior Authorization is
required under this Plan, contact a BCBSTX Personal Health Assistant at (800) 252-8039 (TTY:
711), Monday–Friday from 7 a.m. - 7 p.m. central time (CT) or Saturday from 7 a.m. - 3 p.m. CT.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
29 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
SECTION 5 - SCHEDULE OF BENEFITS AND COVERAGE
Note
If you have Medicare coverage, see Section 9, Coordination of Benefits, for details on when and
how HealthSelect will coordinate with Medicare.
Table 2 below contains the Plan’s Copays, Annual Non-Network Deductible, other deductibles,
and maximums applicable for Covered Health Services.
TABLE 2
Plan Features Network Non-Network
Copays
1
(Copay is per visit unless otherwise
stated)
• Emergency Room Services
$150 $150
• Freestanding Emergency Room (FSER
not affiliated with Hospital)
$150 $300
• Freestanding Emergency Department -
(FSER Department that is Hospital-
affiliated)
$150 $150
• High-Tech Radiology - CT, PET, MRI,
MRA and Nuclear Medicine - Outpatient
$100 $100
• Hospital - Inpatient Stay (Copay is per
day, up to a maximum of $750 per
admission and a maximum of $2,250 per
Calendar Year*)
$150 $150
• Mental Health Services - Inpatient Stay
(Copay is per day, up to a maximum of
$750 per admission and a maximum of
$2,250 per Calendar Year*)
$150 $150
*If you are discharged and then readmitted to any Hospital within 24 hours for the same condition,
the Copays you paid for the initial admission are combined with the Copay(s) for the readmission to reach
the per-admission maximum.
• Physician's Office Services - PCP
$25 Not Applicable
2
• Physician's Office Services - Specialist
$40 Not Applicable
2
• Mental Health or Substance Disorder
Office Services
$25 Not Applicable
2
• Retail Health Clinic
$25 Not Applicable
2
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
30 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 2 (Cont’d)
Plan Features
Network Non-Network
Copays
1
(Cont’d)
(Copay is per visit unless
otherwise stated)
• Surgery - Outpatient (Copay is per day or
visit)
$100 $100
• Urgent Care Center Services
$50 Not Applicable
2
• Virtual Visits for Medical Services
$0 Not Covered
• Virtual Visits for scheduled Mental Health
Services
$0 Not Covered
Annual Non-Network Deductible
3, 4
• Participant, per Calendar Year
Not Applicable $500
• Family, per Calendar Year (not to exceed
the applicable Individual amount per
Participant for Non-Network Benefits)
Not Applicable $1,500
Additional Deductible (applies each time
you do not obtain Prior Authorization as
required in Section 4, Prior Authorization
under Reduction in Benefits if Prior
Authorization is Not Obtained)
Not Applicable $200
Separate Bariatric Deductible
5
$5,000 Not Covered
Out-of-Pocket Coinsurance Maximum
6
per
Calendar Year, per Participant
$2,000 $7,000
Inpatient Copay Maximum
7
per Calendar
Year, per Participant
$2,250
Total Network Out-of-Pocket Maximum
8
• Participant, per Calendar Year
Effective 1/1/20-
12/31/21:
$6,750
Effective 1/1/22:
$7,000
Not Applicable
9
• Family, per Calendar Year (not to exceed
the applicable Individual amount per
Participant for Network Benefits)
Effective 1/1/20-
12/31/21:
$13,500
Effective 1/1/22:
$14,000
Not Applicable
9
Lifetime Maximum Benefit
Unlimited
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
31 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
1
Copays do not apply toward the Deductible or Out-of-Pocket Coinsurance Maximum. However, Copays apply toward the
Total Network Out-of-Pocket Maximum.
2
Coinsurance applies to this Benefit. See Table 3 below for details.
3
The Annual Non-Network Deductible does not apply toward the Out-of-Pocket Coinsurance Maximum for any Covered
Health Services.
4
If two or more Participants who are covered by the same Subscriber are injured in the same accident, the family Annual
Deductible will not apply. Instead, only one Participant’s Non-Network Deductible is required for the Calendar Year in
which the accident occurred.
5
The Separate Bariatric Deductible does not apply to the Network Out-of-Pocket Coinsurance Maximum or to the Total
Network Out-of-Pocket Maximum.
6
The Network Out-of-Pocket Coinsurance Maximum accumulates separately from the Non-Network Out-of-Pocket
Coinsurance Maximum.
7
The Inpatient Copay Maximum is separate from the Out-of-Pocket Coinsurance Maximum. Copays for Inpatient Stays
that apply to the Inpatient Copay Maximum also apply to the Total Network Out-of-Pocket Maximum.
8
The Total Network Out-of-Pocket Maximum includes the Network Out-of-Pocket Coinsurance Maximum of $2,000, the
Inpatient Copay Maximum of $2,250 and any other Copays.
9
There is no Total Out-of-Pocket Maximum for Non-Network Benefits.
This Table 3 contains the percentages of the Allowable Amount paid by the Plan pays for the
Covered Health Services listed. You are responsible for the Coinsurance, which is the percentage
of Allowable Amounts not paid by the Plan. For detailed descriptions of Covered Health Services
and Benefits, refer to Section 6, Details for Covered Health Services.
Important
In general, a Non-Network Allowable Amount is less than a Network Allowable Amount. This
means the Plan will generally pay less toward Non-Network Covered Health Services than
Network Covered Health Services. If you receive Covered Health Services from a Non-Network
Provider, your cost is generally higher because you may be responsible for the amount exceeding
the Plan’s Allowable Amount, which can be significantly more than when you receive Covered
Health Services from a Network Provider. (This is referred to as Balance Billing.) This may also
apply if you receive Covered Health Services at a Network Facility from a Non-Network Provider
on a non-emergent basis. See Section 3, How the Plan Works, under the heading Accessing
Benefits for more information on Balance Billing and when it may apply.
Important Notice on COVID-19 Benefits
For more information about COVID-19 Covered Health Services, see Section 6, Details for
Covered Health Services under the heading COVID-19 Services During the Declaration of
National Emergency.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
32 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Acquired Brain Injury
• Physician's Office Services
(Copay is $25 per visit for a
PCP or $40 per visit for a
Specialist)
PCP
100% after you pay
the Copay
Specialist
100% after you pay
the Copay
All Physicians
60% after you meet
the Annual
Non-Network
Deductible
• Hospital - Inpatient Stay
(Copay is $150 per day, up
to a maximum of $750 per
admission and a maximum
of $2,250 per Calendar
Year)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
• Rehabilitation Services -
Outpatient Therapy
80%
60% after you meet
the Annual
Non-Network
Deductible
Allergy Treatment
Administered in
a Physician’s office 100%
Administered in
any other
outpatient location
80%
60% after you meet
the Annual
Non-Network
Deductible
Ambulance Services
(Emergency and
Non-Emergency)
80%
80% of billed
charges
Annual
Non-Network
Deductible
does not apply
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
33 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Bariatric Surgery (for Active
Employees only, not
Dependents)
You must pay a $5,000
separate Bariatric Deductible
specific to Bariatric Surgery
before the Plan pays Benefits.
One surgery and maximum
benefits of $13,000 per lifetime.
Note: Bariatric Surgery is
only covered at a Blue
Distinction Center
• Physician's Office Services
(Copay is $25 per visit for a
PCP or $40 per visit for a
Specialist)
PCP
100% after you pay
the Copay
Specialist
100% after you pay
the Copay
Not Covered
• Physician Fees for Surgical
and Medical Services
80%* Not Covered
• Hospital - Inpatient Stay
(Copay is $150 per day, up
to a maximum of $750 per
admission and a maximum
of $2,250 per Calendar
Year)
80%* after you pay
the Copay
Not Covered
• Lab and X-Ray
80%* Not Covered
*Coinsurance for Bariatric Surgery
does not apply to the Out-of-Pocket
Coinsurance Maximum or Total
Network Out-of-Pocket Maximum.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
34 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Chiropractic Treatment
Maximum Benefits of $75 per
visit and maximum of 30 visits
per Calendar Year. Copay is
$40 per visit for chiropractic
office visit.
(Copay for Airrosti Providers is
$25 per visit and maximum of
30 visits per Calendar year.
Maximum benefit of $75 per
visit does not apply to Airrosti
Providers.)
For office visits:
100% after you pay the Copay
For all other services in the office in
an outpatient setting: 80%
60% after you meet
the Annual
Non-Network
Deductible
Christian Science
Practitioner Services
80%
60% after you meet
the Annual
Non-Network
Deductible
Clinical Trials
• Physician's Office Services
(Copay is $25 per visit for a
PCP or $40 per visit for a
Specialist)
PCP
100% after you pay
the Copay
Specialist
100% after you pay
the Copay
All Physicians
60% after you meet
the Annual Non-
Network Deductible
• Hospital - Inpatient Stay
(Copay is $150 per day, up
to a maximum of $750 per
admission and a maximum
of $2,250 per Calendar
Year)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual Non-
Network Deductible
• Physician Fees for Surgical
and Medical Services
80%
60% after you meet
the Annual Non-
Network Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
35 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Congenital Heart Disease
(CHD) Services
• Hospital - Inpatient Stay
(Copay is $150 per day,
up to a maximum of $750
per admission and a
maximum of $2,250 per
Calendar Year)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
• Physician's Office
Services (Copay is $25
per visit for a PCP or $40
per visit for a Specialist)
PCP
100% after you pay
the Copay
Specialist
100% after you pay
the Copay
All Physicians
60% after you meet
the Annual
Non-Network
Deductible
• Physician Fees for
Surgical and Medical
Services
80%
60% after you meet
the Annual
Non-Network
Deductible
• Scopic Procedures -
Outpatient Diagnostic and
Therapeutic
80%
60% after you meet
the Annual
Non-Network
Deductible
• Surgery - Outpatient
(Copay is $100 per surgery)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
36 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Dental Services
• Accident-Related
80%
80% Annual
Non-Network
Deductible does
not apply
• Medical Condition-Related
80%
60% after you
meet the Annual
Non-Network
Deductible
• Dental Anesthesia
o Hospital - Inpatient Stay
(Copay is $150 per day,
up to a maximum of
$750 per admission and
a maximum of $2,250
per Calendar Year)
80% after you pay
the Copay
60% after you
pay the Copay
and after you
meet the Annual
Non-Network
Deductible
o Surgery - Outpatient
(Copay is $100 per
surgery)
80% after you pay
the Copay
60% after you
pay the Copay
and after you
meet the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
37 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Diabetes Services
See Durable Medical Equipment
in Section 6, Details for Covered
Health Services, for limits.
• Diabetes Self-Management
and Training/Diabetic Eye
Examinations/Foot Care
o Physician's Office
Services (Copay is $25
per visit for a PCP or $40
per visit for a Specialist)
PCP
100% after you pay
the Copay
Specialist
100% after you pay
the Copay
All Physicians
60% after you meet
the Annual
Non-Network
Deductible
• Diagnostic A1c Testing for
Participants diagnosed with
diabetes
80%
60% after you meet
the Annual Non-
Network Deductible
• Diabetes Self-Management
Items
o Diabetes equipment
80%
60% after you meet
the Annual
Non-Network
Deductible
o Diabetes supplies
C
ertain diabetic supplies are
covered at no cost under the
HealthSelect of Texas
Prescription Drug Program. See
Section 6
- Details for Covered
Health Services under the
heading
Diabetic Supplies.
80%
80%
Annual
Non-Network
Deductible does not
apply
Durable Medical Equipment
(DME)
80%
60% after you meet
the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
38 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Emergency Services
• Hospital Emergency Room
- Outpatient
o True Emergency
(Copay is $150 per
visit)
Note: The Emergency Room
copay is waived if you are
admitted as an Inpatient directly
from the Emergency Room.
Your Covered Health Services
will be considered under the
Hospital - Inpatient Stay
instead.
80% after you pay the $150 Copay
80% after you pay
$150 Copay
Annual Non-
Network Deductible
does not apply
o Non-Emergency
80% after you pay the
$150 Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
• Freestanding Emergency
Room (FSER not affiliated
with Hospital)
o True Emergency
Note: The Emergency Room
copay is waived if you are
admitted as an Inpatient directly
from the Emergency Room.
Your Covered Health Services
will be considered under the
Hospital - Inpatient Stay
instead.
80% after you pay the $150 Copay
80% after $300 the
Copay
Annual Non-
Network Deductible
does not apply
o Non-Emergency
80% after you pay
the $150 Copay
60% after you pay
the $300 Copay
and meet the
Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
39 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Emergency Services (Cont’d)
• Freestanding Emergency
Department – (FSER
Department that is Hospital-
affiliated)
o True Emergency
80% after you pay the $150 Copay
80% after $150
Copay
Annual Non-
Network Deductible
does not apply
o Non-Emergency
80% after you pay
the $150 Copay
60% after you pay
the $150 Copay
and meet the
Annual
Non-Network
Deductible
• Facility-Based Providers
(includes Radiologists,
Anesthesiologists,
Pathologists and Labs, and
Emergency Room
Physicians, and could
include other Facility-based
Providers)
o True Emergency
80%
80%
Annual Non-
Network Deductible
does not apply
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
40 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Emergency Services (Cont’d)
o Non-Emergency*
*For Non-Network Facility-
Based Providers that practice
in a Network Facility, Network
Benefits apply to the
Participant; but Plan
reimbursement to the Non-
Network Hospital-Based
Provider is at the Non-Network
level.
For Non-Network Facility-
Based Providers that practice
in a Non-Network Facility, Non-
Network Benefits apply,
See Section 3, How the Plan
Works, under the heading
Accessing Benefits for more
information on Balance Billing
and when it may apply to Non-
Network Facility-Based
Providers.
80%
60% after you meet
the Annual Non-
Network Deductible
Family Planning and
Infertility Services
•
FDA-approved women’s
contraception methods,
voluntary sterilization and
contraceptive counseling
100%
60% after you meet
the Annual
Non-Network
Deductible
• All other family planning
services and supplies
80%
60% after you meet
the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
41 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Habilitation and
Rehabilitation Services -
Outpatient Therapy (including
physical therapy, occupational
therapy, and speech therapy)
80%
60% after you meet
the Annual
Non-Network
Deductible
Hearing Aids Requiring a
Prescription
Maximum Benefits of $1,000
per ear for any consecutive 36-
month period and $1 per
battery. The $1,000 maximum
does not apply to hearing aids
for Participants 18 years of age
and younger)
100%
100%
Annual
Non-Network
Deductible
does not apply
High-Tech Radiology - CT,
PET, MRI, MRA and Nuclear
Medicine – Outpatient
(Copay is $100 per visit)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
Home Health Care
• Home infusion therapy
80% Not Covered
• All other home health care
services
80%
60% after you meet
the Annual
Non-Network
Deductible
Maximum of 100
visits per Calendar
Year for Non-Network
Benefits. Both
Network and
Non-Network visits
apply to this
maximum.
Hospice Care
80%
60% after you meet
the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
42 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Hospital - Inpatient Stay
(Copay is $150 per day, up to a
maximum
of $750 per admission and a
maximum of $2,250 per
Calendar Year)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
Lab, X-Ray and Diagnostics –
Outpatient
See Section 3, How the Plan
Works, under the heading
Accessing Benefits for more
information on Balance Billing
and when it may apply to Non-
Network lab and diagnostic
imaging services.
80%
60% after you meet
the Annual
Non-Network
Deductible
Mammogram - Diagnostic
100%
60% after you meet
the Annual Non-
Network Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
43 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Maternity Care
• Physician's Services
No Copay or Coinsurance
applies
to Network prenatal visits and
to Network obstetrician delivery
services. Complications of
Pregnancy are treated as
Physician’s Office Services -
Sickness and Injury.
100%
All Physicians
60% after you meet
the Annual
Non-Network
Deductible
• Hospital - Inpatient Stay
(Copay is $150 per day, up
to a maximum of $750 per
admission and a maximum
of $2,250 per Calendar
Year)
A separate Copay, Coinsurance
and Deductible will not apply for
a newborn child unless the
child’s length of stay in the
Hospital exceeds the mother’s
or unless the mother is not a
HealthSelect Plan Participant.
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
• Physician Fees for Surgical
and Medical Services (Non-
obstetric services)
80%
60% after you meet
the Annual
Non-Network
Deductible
• Lab, X-Ray and
Diagnostics – Outpatient
See Section 3, How the
Plan Works, under the
heading Accessing
Benefits for more
information on Balance
Billing and when it may
apply to Non-Network lab
and diagnostic imaging
services.
80%*
*If the services are billed by the
Provider as preventive, coverage will
be at 100%.
60% after you meet
the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
44 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Medical Supplies
80%
60% after you meet
the Annual
Non-Network
Deductible
Medications and Injections
(Copay is $25 per visit for PCP
or $40 per visit for Specialist if
administered during Physician’s
office visit)
Note: Medications and
Injections that are preventive in
nature are covered as shown
under Preventive Care Services
in this section.
Outpatient prescription
medications may be covered
under the HealthSelect
Prescription Drug Program
administered by OptumRx.
Refer to the HealthSelect
Prescription Drug Program
for self-administered
medication information.
Administered in a Physician’s office
100% after you pay
the Copay*
Administered in any other outpatient
location
80%
*Covered at 100% if no office visit
charge is assessed.
Administered in a
Participant's home
Not Covered
Administered in any
other outpatient
location
60% after you meet
the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
45 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Mental Health Services
See Neurobiological Disorders - Autism Spectrum Disorder Services and
Serious Mental Illness Services in this section for these Benefits.
• Hospital - Inpatient Stay
(Copay is $150 per day, up
to a maximum of $750 per
admission and a maximum
of $2,250 per Calendar
Year)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
• Outpatient Facility Care
(Partial Hospitalization/Day
Treatment and Intensive
Outpatient Treatment)
80%
60% after you meet
the Annual
Non-Network
Deductible
• Outpatient Physician or
Mental Health Provider
Services (Copay is $25 per
visit)
100% after you pay
the Copay
60% after you meet
the Annual
Non-Network
Deductible
• Virtual Visits for Scheduled
Mental Health Visits using a
Virtual Network Provider
Benefits are available only
when services are delivered
through a Network Virtual
Provider.
You can find a Network Virtual
Provider at
www.healthselectoftexas.co
m or by calling BCBSTX at
(800) 252-8039 (TTY: 711).
Effective 07/01/2021
100%
Not Covered
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
46 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Neurobiological Disorders -
Autism Spectrum Disorder
Services
•
Hospital - Inpatient Stay
(Copay is $150 per day, up
to a maximum of $750 per
admission and a maximum
of $2,250 per Calendar
Year)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
• Outpatient Facility Care
(Partial Hospitalization/Day
Treatment and Intensive
Outpatient Treatment)
80%
60% after you meet
the Annual
Non-Network
Deductible
•
Outpatient Physician or
Mental Health Provider
Services (Copay is $25 per
visit)
100% after you pay
the Copay
60% after you meet
the Annual
Non-Network
Deductible
• Applied Behavioral
Analysis (ABA)
treatment
See Neurological Disorders-
Autism Spectrum Disorder
Services in Section 6, Details
for Covered Health Services,
for more details.
Administered in a Mental Health
Provider’s office
100% after you pay the $25
Copay
Administered in any other
outpatient location, including the
home
80%
60% after you
meet the
Annual
Non-Network
Deductible
Nutritional Counseling
(Copay is $25 per visit for a
PCP or $40 per visit for a
Specialist)
PCP
100% after you pay
the Copay
Specialist
100% after you pay
the Copay
All Physicians
60% after you meet
the Annual
Non-Network
Deductible
Ostomy Supplies
80%
60% after you meet
the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
47 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Physician Fees for Surgical
and Medical Services
(includes services for Second
Opinion)
80%
60% after you meet
the Annual
Non-Network
Deductible
Physician's Office Services -
Sickness and Injury
(Diagnostic) (includes
services for Second Opinion)
• PCP (Copay is $25 per
visit)
100% after you pay
the Copay*
60% after you meet
the Annual
Non-Network
Deductible
• Specialist (Copay is $40
per visit)
• Network obstetrician or
gynecologist, (Copay is $40
per visit)
100% after you pay
the Copay*
60% after you meet
the Annual
Non-Network
Deductible
*No Copay applies when a
Physician's charge is not
assessed
• Outpatient Clinic Facility
Services
80%
60% after you meet
the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
48 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Physician's Office Services -
Sickness and Injury
(Diagnostic) (includes
services for Second Opinion)
(Cont’d)
• In addition to the Copay
stated in this section, the
Copays or Coinsurance
and any Deductible for the
following services apply
when the Covered Health
Service is performed in a
Physician's office:
• high-tech radiology and
nuclear medicine described
under High-Tech Radiology
- CT, PET, MRI, MRA and
Nuclear Medicine –
Outpatient;
• diagnostic and therapeutic
scopic procedures
described under Scopic
Procedures - Outpatient
Diagnostic and
Therapeutic; and
• Outpatient surgery
procedures described
under Surgery – Outpatient.
• Lab, X-Ray and
Diagnostics – Outpatient
80%*
*If these services are billed by the
Provider as preventive, coverage will
be at 100%.
60% after you meet
the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
49 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Preventive Care Services
(See chart in Addendum – List
of Covered Preventive Care
Services.)
• Note: Under the Affordable
Care Act, certain
Preventive Care Services
are paid at 100%
(i.e., at no cost to the
Participant) conditioned
upon Physician billing and
diagnosis. In some cases,
you may be responsible for
payment on certain related
services, such as
diagnostic services and/or
services provided by a Non-
Network Provider) that are
not guaranteed payment at
100% by the Affordable
Care Act.
100%
60% after you meet
the Annual
Non-Network
Deductible
Private Duty Nursing -
Outpatient
80%
60% after you meet
the Annual
Non-Network
Deductible
Maximum of 96 hours
per Calendar Year for
Non-Network Benefits
Prosthetic Devices
80%
60% after you meet
the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
50 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Reconstructive Procedures
• Physician's Office Services
(Copay is $25 per visit for a
PCP or $40 per visit for a
Specialist)
PCP
100% after you pay
the Copay
Specialist
100% after you pay
the Copay
All Physicians
60% after you meet
the Annual
Non-Network
Deductible
• Hospital - Inpatient Stay
(Copay is $150 per day, up
to a maximum of $750 per
admission and a maximum
of $2,250 per Calendar
Year)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
• Physician Fees for Surgical
and Medical Services
80% 60% after you meet
the Annual Non-
Network Deductible
• Prosthetic Devices
80% 60% after you meet
the Annual Non-
Network Deductible
• Surgery – Outpatient
(Copay is $100 per
surgery)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
Retail Health Clinic
Copay is $25 per visit
100% after you pay the Copay
60% after you meet
the Annual Non-
Network Deductible
Scopic Procedures -
Outpatient Diagnostic and
Therapeutic
80%
60% after you meet
the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
51 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Serious Mental Illness
Services
• Hospital - Inpatient Stay
(Copay is $150 per day, up
to a maximum of $750 per
admission and a maximum
of $2,250 per Calendar
Year)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
• Outpatient Facility Care
(Partial Hospitalization/Day
Treatment and Intensive
Outpatient Treatment)
80%
60% after you meet
the Annual
Non-Network
Deductible
• Outpatient Physician or
Mental Health Provider
Services (Copay is $25 per
visit)
100% after you pay
the Copay
60% after you meet
the Annual
Non-Network
Deductible
Skilled Nursing
Facility/Inpatient
Rehabilitation Facility
Services
80%
60% after you meet
the Annual
Non-Network
Deductible
Substance Use Disorder
Services
•
Hospital - Inpatient Stay
(Copay is $150 per day, up
to a maximum of $750 per
admission and a maximum
of $2,250 per Calendar
Year)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
• Outpatient Facility Care
(Partial Hospitalization/Day
Treatment and Intensive
Outpatient Treatment)
80%
60% after you meet
the Annual
Non-Network
Deductible
•
Outpatient Physician or
Mental Health Provider
Services (Copay is $25 per
visit)
100% after you pay
the Copay
60% after you meet
the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
52 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Surgery - Outpatient
(Copay is $100 per surgery)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
Telemedicine Visits -
Sickness and Injury
• PCP Telemedicine visit
(Copay is $25 per visit)
• Mental Health Provider
Telemedicine visit
(Copay is $25 per visit)
100% after you pay
the Copay*
60% after you meet
the Annual
Non-Network
Deductible
• Specialist Telemedicine
visit (Copay is $40 per visit)
• Network obstetrician or
gynecologist Telemedicine
visit, (Copay is $40 per
visit)
100% after you pay
the Copay*
60% after you meet
the Annual
Non-Network
Deductible
*No Copay applies when a
Physician's charge is not
assessed
Telemedicine visits for Covered
Health Services are covered at
the same Benefits as in-person
visits for the services listed
throughout this Schedule of
Benefits. (So, for example,
Telemedicine visit Benefits for
Preventive Care Services can
be located under the heading
Preventive Care Services in this
chart.)
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
53 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Temporomandibular Joint
(TMJ) Services and
Orthognathic Surgery
• Physician's Office Services
(Copay is $25 per visit for a
PCP or $40 per visit for a
Specialist)
PCP
100% after you pay
the Copay
Specialist
100% after you pay
the Copay
All Physicians
60% after you meet
the Annual
Non-Network
Deductible
• Hospital - Inpatient Stay
(Copay is $150 per day, up
to a maximum of $750 per
admission and a maximum
of $2,250 per Calendar
Year)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
• Physician Fees for Surgical
and Medical Services
80%
60% after you meet
the Annual
Non-Network
Deductible
• Surgery - Outpatient
(Copay is $100 per
surgery)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
Therapeutic Treatments -
Outpatient
80%
60% after you meet
the Annual
Non-Network
Deductible
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
54 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Transplant Services
• Physician's Office Services
(Copay is $25 per visit for a
PCP or $40 per visit for a
Specialist)
PCP
100% after you pay
the Copay
Specialist
100% after you pay
the Copay
All Physicians
60% after you meet
the Annual
Non-Network
Deductible
• Hospital - Inpatient Stay
(Copay is $150 per day, up
to a maximum of $750 per
admission and a maximum
of $2,250 per Calendar
Year)
80% after you pay
the Copay
60% after you pay
the Copay and after
you meet the
Annual
Non-Network
Deductible
• Physician Fees for Surgical
and Medical Services
80%
60% after you meet
the Annual
Non-Network
Deductible
Urgent Care Center Services
(Copay is $50 per visit)
80% after you pay
the Copay
60% after you meet
the Annual
Non-Network
Deductible
Virtual Visits for Medical
Services using a Network
Virtual Provider
Benefits are available only when
services are delivered through a
Network Virtual Provider.
You can find a Network Virtual
Provider at
www.healthselectoftexas.co
m or by calling BCBSTX at
(800) 252-8039 (TTY: 711).
100% Not Covered
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
55 SECTION 5 – SCHEDULE OF BENEFITS AND COVERAGE
TABLE 3 (Cont’d)
Covered Health Services
1
Percentage of Allowable Amounts Payable by the Plan:
Network Non-Network*
Vision Examinations
• Routine Eye Exam (Copay
is $40 per visit)
Maximum of one routine exam
per Participant per Calendar
Year.
100% after you pay
the Copay
60% after you meet
the Annual
Non-Network
Deductible
• Non-routine or follow-up
visits (Copay is $40 per
visit)
100% after you pay
the Copay
60% after you meet
the Annual
Non-Network
Deductible
1
You must obtain Prior Authorization from (BCBSTX), as described in Section 4, Prior Authorization, to receive full
Benefits before receiving certain Covered Health Services from a Non-Network Provider. In general, if you visit a
Network Provider, that Provider is responsible for obtaining Prior Authorization from BCBSTX before you receive certain
Covered Health Services. See Section 6, Details for Covered Health Services, for further information.
*In general, a Non-Network Allowable Amount is less than a Network Allowable Amount. This means the Plan will usually
pay less towards Non-Network Covered Health Services than Network Covered Health Services. As a result, when you
receive Covered Health Services from a Non-Network Provider, your cost is generally higher. You may be responsible
for the amount exceeding the Plan’s Allowable Amount, which can be significantly more than when you receive Covered
Health Services from a Network Provider. This is referred to as Balance Billing. For example, this may apply if you
receive Covered Health Services at a Network Facility from a Non-Network Provider. You may not be responsible for an
amount that exceeds your Participant responsibility for Deductibles, Copayments, and Coinsurance as part of the Plan’s
Allowable Amount for services provided by a Non-Network Facility-based Provider if performed at a Network Facility or
Non-Network laboratory or diagnostic imaging services in connection with care delivered by a Network Provider unless
the Non-Network provider obtained your written acceptance of financial liability in advance. See, Section 3, How the Plan
Works, under the heading Accessing Benefits for further information.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
56 SECTION 6 – DETAILS FOR COVERED HEALTH
SERVICES
SECTION 6 - DETAILS FOR COVERED HEALTH SERVICES
What this section includes
■ Covered Health Services for which the Plan pays Benefits; and
■ Covered Health Services that require you obtain Prior Authorization from BCBSTX before
you receive services, and any reduction in Benefits that may apply if you do not obtain Prior
Authorization from BCBSTX.
This section supplements Table 3 in Section 5, Schedule of Benefits and Coverage.
Table 3 provides you with the percentage of Allowable Amount payable by the Plan, along with
Benefit limitations, Copay and Annual Non-Network Deductible information for each Covered
Health Service. This section provides more details about Covered Health Services and the
Benefits for those services. These details provide any additional limitations that may apply and,
identify the Covered Health Services for which you must obtain Prior Authorization from BCBSTX.
The Covered Health Services in this section appear in the same order as they do in Table 3 for
easy reference. Health care services that are not covered are described in Section 7, Exclusions:
What the Medical Plan Will Not Cover.
Reminders
All Covered Health Services must be determined by the Plan to be Medically Necessary.
Capitalized terms are defined in Section 13, Glossary, and may help you to understand the
Benefits in this section.
Acquired Brain Injury
The Plan pays Benefits for the treatment of conditions that are the result of, and related to,
acquired brain injury. Covered Health Services include, but are not limited to:
• cognitive rehabilitation therapy;
• cognitive communication therapy;
• community reintegration services;
• neurocognitive therapy and rehabilitation;
• neurobehavioral, neurophysiological, neuropsychological, and psychophysiological testing or
treatment;
• neurofeedback therapy;
• post-acute transition services; and
• remediation.
Allergy Treatment
The Plan pays for Benefits for allergy treatment, including injections, testing and antigens/serum,
received in a Physician's office or other Outpatient Facility when no other health service is
received
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
57 SECTION 6 – DETAILS FOR COVERED HEALTH
SERVICES
Ambulance Services
The Plan covers Emergency ambulance services and transportation provided by a licensed
ambulance service to the nearest Hospital that offers Emergency Health Services. See Section
13, Glossary, for the definition of Emergency and Emergency Health Services.
Ambulance service by air is covered in an Emergency if ground transportation is impossible, or
would seriously jeopardize your life or health. If special circumstances exist, the Plan may pay
Network Benefits for Emergency air transportation to a Hospital that is not the closest Facility to
provide Emergency Health Services.
The Plan also covers transportation provided by a licensed professional ambulance (either
ground or air ambulance, as the Plan determines appropriate) between Facilities when the
transport is requested by a Physician and is:
• from a Non-Network Hospital to a Network Hospital;
• to a Hospital that provides a higher level of Medically Necessary care that was not available
at the original Hospital;
• when the nearest appropriate Hospital is not accepting patients, has no available beds,
has no accepting physicians or when the air ambulance cannot land;
• to a more Cost-Effective acute care Facility; or
• from an acute Facility to a sub-acute setting.
In most cases, BCBSTX will initiate and direct non-Emergency ambulance transportation. If you
are requesting non-Emergency air and/or ground ambulance services, please remember that
you must obtain Prior Authorization from BCBSTX as soon as possible prior to the transport. For
Non-Network Providers, if Prior Authorization is not obtained from BCBSTX, you will be
responsible for paying all charges and no Benefits will be paid, regardless of whether the
ambulance service is provided by a Network Provider or Non-Network Provider.
Bariatric Surgery
Bariatric Surgery is the surgical treatment of obesity provided by or under the direction of a
Physician. The Plan covers Bariatric Surgery provided that all of the following are true:
• you are an active Employee with five continuous years of GBP employment with no breaks in
GBP coverage (Benefits for Bariatric Surgery are not available to Dependents or Retirees,
including a Subscriber who is covered as a Dependent instead of a Subscriber under the
Plan.);
• you have medical records documenting that you have a minimum of a five-year history of a
Body Mass Index (BMI) of 40 or greater; and
• you have one or more conditions considered to be a co-morbidity, uncontrolled even at
maximum medical management, and which is generally expected to be reversed or improved
by bariatric treatment. Co-morbidities include, but are not limited to:
o type 2 diabetes;
o cardiovascular disease (e.g., stroke, myocardial infarction, stable or unstable angina
pectoris, hypertension or coronary artery bypass); and
o life-threatening cardiopulmonary problems (e.g., severe sleep apnea, Pickwickian
syndrome, obesity-related cardiomyopathy).
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
58 SECTION 6 – DETAILS FOR COVERED HEALTH
SERVICES
In addition to meeting the above criteria, the following must also be true:
• you have documented active participation in a comprehensive, non-surgical weight reduction
program for at least 12 consecutive months during the 24-month period before the date of
your request for Prior Authorization for Bariatric Surgery;
• you have been evaluated by a licensed professional counselor, psychologist, or psychiatrist
at least once within the 12 months before the date of your request for Prior Authorization for
Bariatric Surgery; and
• the surgery will be performed at a Blue Distinction Center by a Network surgeon even if there
are no Blue Distinction Centers near you.
Following the Bariatric Surgery, you must provide documentation that you have participated in a
medically supervised lifestyle management program for maintaining weight loss and healthy
lifestyle goals for 12 consecutive months after the date of surgery.
Benefits are available for Bariatric Surgery services that meet the definition of a Covered Health
Service, as defined in Section 13, Glossary, and that are not considered Experimental or
Investigational or Unproven Services.
Benefits are limited to $13,000 and one Bariatric Surgery per lifetime unless there are
complications directly resulting from Bariatric Surgery that was covered by and paid for by the
Plan. A separate Bariatric Deductible applies to this Benefit. See Section 3, How the Plan Works,
for details about this deductible.
Note: Allowable Amounts for Bariatric Surgery do not apply to the Out-of-Pocket Coinsurance
Maximum or to the Total Out-of-Pocket Maximum. Even if these Out-of-Pocket Maximums are
met, Allowable Amounts for Bariatric Surgery will not be paid at 100%. The Copays and
Coinsurance shown in Table 3 in Section 5, Schedule of Benefits and Coverage, will continue to
apply.
Note: The Bariatric Surgery period is one month before and 12 months following the date of the
surgery. Covered Health Services provided by a Physician or other covered health care Provider
are allowed under this Benefit for up to 12 months after the date of surgery.
You will have access to certain Blue Distinction Centers, as defined in Section 13, Glossary, for
Bariatric Surgery services.
For Bariatric Surgery services to be considered Covered Health Services, you must contact
BCBSTX and speak with a nurse consultant and receive Prior Authorization prior to receiving
services. You may contact BCBSTX by calling at (800) 252-8039 (TTY: 711).
There is no coverage for Bariatric Surgery that fails to meet all Plan requirements as described in
this Bariatric Surgery section or that is not performed by a Network Provider at a Blue Distinction
Center.
Please remember that you must obtain Prior Authorization before you have a pre-surgical
evaluation. If Prior Authorization from BCBSTX is not obtained, you will be responsible for
paying all charges and no Benefits will be paid by the Plan.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
59 SECTION 6 – DETAILS FOR COVERED HEALTH
SERVICES
Chiropractic Treatment
The Plan provides Benefits for Chiropractic Treatment when provided by a licensed Doctor of
Chiropractic.
For chiropractic services, other than maintenance or preventive Chiropractic Treatment, your
chiropractor will be required to submit a treatment plan that outlines goal-directed rehabilitation
services. Benefits can be denied or limited for Participants who are not progressing in goal-
directed Chiropractic Treatment or if treatment goals have previously been met. Benefits under
this section are not available for maintenance or preventive Chiropractic Treatment.
Benefits for Chiropractic Treatment are limited to $75 per visit, regardless of whether the Provider
is Network or Non-Network. Any combination of Network Benefits and Non-Network Benefits for
Chiropractic Treatment is limited to 30 visits per Calendar Year.
If you receive Chiropractic Treatment from Airrosti Rehab Centers, you will have a $25 Copay per
visit. The maximum Benefit of $75 per visit will not apply to Airrosti Rehab Center Providers.
However, the 30 visit Benefit maximum will still apply.
Note
Airrosti providers are not able to treat Participants with Medicare coverage (regardless of if
Medicare is your Primary or Secondary Plan). If you have Medicare and are seeking additional
treatment options, talk to your PCP about other potential treatment, or call a BCBSTX Personal
Health Assistant at (800) 252-8039 (TTY: 711) for help locating other Network Providers.
Christian Science Practitioner Services
Benefits are provided for recognized services of a Christian Science Practitioner when in lieu of
Physician or Other Provider services.
Clinical Trials
Benefits for routine patient care costs incurred during participation in a qualifying Phase I, II, III or
IV Clinical Trial for the prevention, detection or treatment of a life-threatening disease or
condition. Benefits are provided for the reasonable and necessary items and services used to
prevent, detect and treat complications arising from participation in a qualifying Clinical Trial.
Benefits are available only when the Participant is clinically eligible for participation in the Clinical
Trial as defined by the researcher.
Benefits for routine patient care costs for Clinical Trials include, but are not limited to:
• Covered Health Services for which Benefits are typically provided absent a Clinical Trial;
• Covered Health Services required solely for the provision of the investigational item or
service, the clinically appropriate monitoring of the effects of the item or service, or the
prevention of complications; and
• Covered Health Services needed for reasonable and necessary care arising from the
provision of an investigational item or service.
The following are not considered routine patient care costs for Clinical Trials and no Benefits are
payable:
• the Experimental or Investigational Service or item;
• items and services provided solely to satisfy data collection and analysis needs and that are
not used in the direct clinical management of the patient;
• items and services associated with managing the Clinical Trial;
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
60 SECTION 6 – DETAILS FOR COVERED HEALTH
SERVICES
• items and services that are inconsistent with widely accepted and established standards of
care for the particular diagnosis;
• any item or service that is not a Covered Health Service or is specifically excluded under the
Plan, regardless of whether the item or service is required in connection with participation in a
Clinical Trial; and
• items and services provided by the research sponsors free of charge for any person enrolled
in the trial.
A qualifying Clinical Trial is a Phase I, Phase II, Phase III, or Phase IV Clinical Trial that is
conducted in relation to the prevention, detection or treatment of cancer or other life-threatening
disease or condition and is described in any of the following bullet points:
• Federally funded trials. The study or investigation is approved or funded (which may include
funding through in-kind contributions) by one or more of the following:
o National Institutes of Health (NIH), including the National Cancer Institute (NCI) (including
a cancer center that has been designated by the NCI as a Clinical Cancer Center or
Comprehensive Cancer Center);
o Centers for Disease Control and Prevention (CDC);
o Agency for Healthcare Research and Quality (AHRQ);
o Centers for Medicare and Medicaid Services (CMS);
o a cooperative group or center of any of the entities described above, the Department of
Defense (DOD) or the Department of Veterans Affairs (VA);
o a qualified non-governmental research entity identified in the guidelines issued by the
National Institutes of Health for center support grants;
o the Department of Veterans Affairs, the Department of Defense or the Department of
Energy as long as the study or investigation has been reviewed and approved through a
system of peer review that is determined by the Secretary of Health and Human Services
to both:
- be comparable to the system of peer review of studies and investigations used by the
National Institutes of Health; and
- assure unbiased review of the highest scientific standards by qualified individuals
who have no interest in the outcome of the review; or
o an institutional review board of an institution in Texas that has an agreement with the
Office for Human Research Protections of the U.S. Department of Health and Human
Services;
• the study or investigation is conducted under an investigational new drug application
reviewed by the U.S. Food and Drug Administration;
• the study or investigation is a drug trial that is exempt from having such an investigational
new drug application;
• the Clinical Trial must have a written protocol that describes a scientifically sound study and
have been approved by all relevant institutional review boards (IRBs) before Participants are
enrolled in the trial. The Plan may, at any time, request documentation about the trial; or
• the subject or purpose of the trial must be the evaluation of an item or service that meets the
definition of a Covered Health Service and is not otherwise excluded under the Plan.
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Congenital Heart Disease (CHD) Services
The Plan pays Benefits for Congenital Heart Disease (CHD) services ordered by a Physician.
Benefits include, but are not limited to, the Facility charge and the charge for supplies and
equipment. Benefits are available for the following CHD services:
• evaluation;
• fetal echocardiograms;
• interventional cardiac catheterizations;
• in-utero surgery to correct CHD or heart defects;
• Outpatient diagnostic testing; and
• surgical interventions.
CHD services other than those listed above are excluded from coverage, unless determined by
BCBSTX to be proven procedures for the involved diagnoses. Contact BCBSTX at (800) 252-
8039 (TTY: 711) for information about CHD services.
If you receive Congenital Heart Disease services, the Plan pays Benefits as described under:
• Hospital – Inpatient Stay;
• Physician's Office Services - Sickness and Injury;
• Physician Fees for Surgical and Medical Services;
• Scopic Procedures - Outpatient Diagnostic and Therapeutic;
• Surgery – Outpatient; and
• Therapeutic Treatments – Outpatient.
Please remember that you must obtain Prior Authorization from BCBSTX for an Inpatient
Hospital Stay. For Non-Network Benefits when Prior Authorization from BCBSTX is not obtained,
Benefits for Covered Health Services for the Inpatient Stay will be subject to an Additional
Deductible of $200.
COVID-19 Services During the Declaration of National Emergency
On March 13, 2020, President Donald J. Trump signed the Proclamation Declaring a National
Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak (Public Health
Emergency) beginning March 1, 2020.
The Family First Coronavirus Response Act (FFCRA) was signed into law March 18, 2020.
Section 6001 of the FFCRA, as amended by the Coronavirus Aid, Relief, and Economic Security
Act (the CARES Act), generally requires coverage for certain items and services related to
diagnostic testing for the detection of SARS-CoV-2, the virus that causes COVID-19, or the
diagnosis of COVID-19 during the Public Health Emergency.
Under the FFCRA and the CARES Act, this Plan will provide medically appropriate required
coverages as outlined below without imposing cost-sharing requirements (including Deductibles,
Copays, and Coinsurance), Prior Authorization, or other medical management requirements
through the end of the Public Health Emergency period. Services are subject to change based on
updates to the Public Health Emergency requirements.
• Network Telemedicine and Virtual Visit Covered Health Benefits related to COVID-19;
• Medically appropriate diagnostic testing for the detection of diagnosis of COVID-19 when
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ordered by any healthcare professional authorized to do so under state law.
• Administration of COVID-19 vaccine when administered by Providers and Pharmacies,
including Network and Non-Network Pharmacies and Providers.
Prior Authorization requirements are waived for COVID-19 related services during the Public
Health Emergency.
If you have questions regarding Benefits related to COVID-19, contact a BCBSTX Personal
Health Assistant at (800) 252-8039 (TTY: 711).
Dental Services
Accident-Related
Dental services are covered by the Plan when all of the following are true:
• treatment is necessary because of accidental damage caused by physical trauma, including
but not limited to, such Injury resulting from domestic violence or a medical condition, to
sound and natural teeth (i.e., teeth with no major restorations and no periodontal
involvement) and/or dental work that was in place at the time of the Injury, including, but not
limited to, crowns, veneers, bridges and implants;
• the dental damage did not occur as a result of normal activities of daily living or extraordinary
use of the teeth;
• dental services are performed by a Doctor of Dental Surgery or a Doctor of Medical Dentistry;
and
• the dental damage is severe enough that initial contact with a Physician or dentist occurred
within 72 hours of the accident. (You may request an extension of this time period provided
that you do so within 60 days of the dental damage and if extenuating circumstances exist
due to the severity of the accident that caused the dental damage).
Dental services for final treatment to repair the accidental dental damage must be completed
within 24 months of the accident.
The Plan provides Benefits for only the following treatment of accidental dental damage:
• Emergency examination;
• endodontic (root canal) treatment;
• extractions;
• necessary diagnostic X-rays;
• post-traumatic crowns if such are the only clinically acceptable treatment;
• prefabricated post and core;
• replacement of lost teeth due to the Injury;
• restoration or replacement of dental work that was in place at the time of the Injury, including,
but not limited to, crowns, veneers, bridges and implants;
• simple minimal restorative procedures (fillings);
• temporary repairs immediately following the Injury that will allow any of the above permanent
repairs to be performed; and
• temporary splinting of teeth.
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Alternate Benefit for Accident-Related Dental Services
If you require new dental work, such as crowns or implants, or repair/replacement of dental work
that was in place at the time of the Injury, as described above, the Plan will pay benefits for the
most Cost-Effective procedure(s) recommended by the treating Provider. However, if you choose
to have a more costly procedure(s), the Plan may reimburse you for a portion of your costs, up to
a maximum of the amount of the more Cost-Effective procedure. When you submit your claim,
you must include an estimate from the Provider for the more Cost-Effective procedure(s) in
addition to receipts for the alternate procedure(s) actually performed. You will receive a maximum
reimbursement of the amount estimated for the more Cost-Effective procedure(s).
Medical Condition-Related
The Plan also covers dental care (oral examination, X-rays, extractions and non-surgical
elimination of oral infection) required for the direct treatment of a medical condition limited to:
• medical transplant procedures;
• initiation of immunosuppressives (medication used to reduce inflammation and suppress the
immune system);
• treatment or correction of a Congenital Anomaly when provided to an eligible Dependent
child; and
• direct treatment of cancer or cleft palate.
The Plan also provides Benefits for Covered Health Services for oral surgery for the following:
• excision of neoplasms, including benign, malignant and premalignant lesions, tumors and
non-odontogenic cysts;
• incision and drainage of cellulitis;
• surgical procedures involving sinuses, salivary glands and ducts;
• removal of teeth if integral to a medical procedure prior to radiation therapy of the head and
neck, but not the dental reconstruction for the replacement of the extracted teeth;
• replacement of natural teeth lost as a result of radiation therapy performed while you are a
Participant in the Plan;
• reconstruction after tumor removal (including bone grafting and dental implants if necessary
to stabilize a maxillofacial prosthesis such as an obturator); and
• removal of broken teeth if necessary to reduce jaw fracture.
Dental Anesthesia
The Plan provides Benefits for dental anesthesia for a Participant whose dentist provides
documentation that states he or she cannot undergo local anesthesia because of a documented
physical, mental or medical reason.
Charges for the dental procedure itself, including, but not limited to, the professional fees of the
dentist, are not covered.
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Diabetes Services
The Plan pays Benefits for the Covered Health Services identified below.
Covered Diabetes Services
Diabetic Eye
Examinations/Foot Care
Benefits under this section include, but are not limited to, medical
eye examinations (dilated retinal examinations) and preventive
foot care for Participants with diabetes.
Diabetes Self-
Management Training
Programs
Benefits are provided for Outpatient self-management training,
including, but not limited to:
• training after the initial diagnosis of diabetes regarding the
care and management of diabetes, nutritional counseling
and proper use of diabetes equipment and supplies;
• training after a significant diagnosed change in symptoms or
condition requiring change in self-management regime; and
• periodic training warranted by the development of new
techniques and treatment for diabetes.
These services must be ordered by a Physician and provided by
appropriately licensed or registered health care professionals.
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Covered Diabetes Services
Diabetic Self-
Management Items
Insulin pumps and supplies for the management and treatment of
diabetes, based upon the medical needs of the Participant.
Covered diabetes equipment is specifically defined as:
• blood glucose monitors, including monitors designed to be
used by blind individuals;
• insulin infusion devices;
• insulin pumps and associated appurtenances; and
• podiatric appliances (shoes, shoe inserts and foot orthotics)
for the prevention of complications associated with diabetes.
Insulin pumps are subject to all the conditions of coverage stated
under Durable Medical Equipment in this section.
Covered diabetes supplies are specifically defined as:
• alcohol wipes;
• glucagon emergency kits;
• injection aids;
• lancets and lancet devices;
• syringes;
• test strips for blood glucose monitors; and
• visual reading and urine tests strips.
Note: Certain diabetic supplies including, but not limited to:
glucometers, test strips, lancets and lancing devices, alcohol
swabs and wipes, are covered with a copay under the HealthSelect
of Texas Prescription Drug Program administered by OptumRx.
The Free Glucose Meter Program, administered by LifeScan,
allows Participants to receive a free glucometer annually. Test
strips for use with the Free Glucose Meter Program are also
available at no cost when filled at a Network pharmacy. Diabetic
supplies obtained through the HealthSelect of Texas
Prescription Drug Program cannot also be obtained from the
HealthSelect of Texas medical Plan. Note: The brands of blood
glucose meters and test strips covered under this benefit are
subject to change. You can find a list of covered glucometers and
test strips at www.HealthSelectRx.com
or by calling the
HealthSelect of Texas Prescription Drug Program toll-free at (855)
828-9834 (TTY: 711).
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Please remember, to receive Non-Network Benefits you must obtain Prior Authorization from
BCBSTX before obtaining any Durable Medical Equipment (DME) for the management and
treatment of diabetes if the retail purchase cost or cumulative retail rental cost of a single item
will exceed $1,000. If Prior Authorization from BCBSTX is not obtained for diabetic supplies or
diabetic DME exceeding $1,000, you are responsible for paying all charges and Benefits will
not be paid.
To receive Network Benefits for Diabetic DME, you must purchase or rent the DME from a
Network Provider. Your Provider must prescribe the Medically Necessary equipment or supply.
Diabetic supplies can be purchased from either a Network Provider or Non-Network Provider
(or retail location), at the Network Benefit level. If you purchase your supplies from a Non-
Network Provider or retail location, you may have to file a claim for reimbursement. You have
the option of obtaining certain diabetic supplies under this plan or the HealthSelect Prescription
Drug Program administered by OptumRx, but not both. For details about diabetic supply
coverage of diabetic supplies under the HealthSelect Prescription Drug Program, go to
www.healthselectrx.com.
Durable Medical Equipment (DME)
The Plan pays for Durable Medical Equipment (DME) that is:
• ordered or provided by a Physician for Outpatient use;
• not consumable or disposable;
• used for medical purposes with respect to treatment of a Sickness, Injury or disability or their
symptoms;
• durable enough to withstand repeated use;
• not implantable within the body (except as noted below); and
• appropriate for use, and primarily used, within the home.
If more than one piece of DME can meet your functional needs, you will receive Benefits only for
the most Cost-Effective piece of equipment. Benefits are provided for a single unit of DME
(example: one insulin pump) and for repairs of that unit.
Examples of DME include, but are not limited to:
• continuous positive airway pressure device (CPAP or BIPAP);
• equipment to administer oxygen (e.g., respirator);
• equipment to assist mobility, such as a standard wheelchair;
• Hospital beds;
• delivery pumps for tube feedings;
• negative pressure wound therapy pumps (e.g., wound vacuums);
• burn garments;
• insulin pumps and all related insulin pump supplies as described under Diabetes Services in
this section;
• external cochlear devices and systems. (Note: Cochlear implants are also covered by the
Plan under Hospital - Inpatient Stay, Rehabilitation Services - Outpatient Therapy or Surgery
- Outpatient in this section);
• cranial remolding orthotics (e.g., cranial helmets);
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• braces that stabilize an injured body part, including, but not limited to, necessary adjustments
to shoes to accommodate braces. Braces that stabilize an injured body part and braces to
treat curvature of the spine are considered Durable Medical Equipment and are a Covered
Health Service. Braces that straighten or change the shape of a body part are excluded from
coverage. Dental braces are also excluded from coverage; and
• equipment for the treatment of chronic or acute respiratory failure or conditions.
The Plan also covers batteries, tubings, nasal cannulas, connectors, headgear, and masks used
in connection with DME.
Benefits also include speech aid devices and tracheo-esophageal voice devices required for
treatment of severe speech impediment or lack of speech directly attributed to Sickness or Injury.
Note: DME is different from prosthetic devices – see Prosthetic Devices in this section.
Benefits are provided for the repair/replacement of a type of Durable Medical Equipment once
every three Calendar Years.
At the Plan's discretion, replacements may be covered when the DME is damaged beyond repair
due to normal wear and tear, when repair costs exceed new purchase price or when a
replacement piece of DME is required due to the Participant’s growth or other physical change or
a change in the Participant’s abilities or medical condition occurs sooner than the three-year
timeframe. Repairs, including, but not limited to, the replacement of essential accessories, such
as hoses, tubes, mouth pieces, etc., for necessary DME are only covered when required to make
the item/device serviceable and the estimated repair expense does not exceed the cost of
purchasing or renting another item/device. Requests for repairs may be made at any time and are
not subject to the three-year timeline for replacement.
Please remember, to receive Non-Network Benefits you must obtain Prior Authorization from
BCBSTX before obtaining any DME or supplies if the retail purchase cost or cumulative retail
rental cost of a single item will exceed $1,000. If Prior Authorization from BCBSTX is not
obtained for supplies or DME exceeding $1,000, you are responsible for paying all charges and
Benefits will not be paid.
To receive Network Benefits you must purchase or rent DME from a Network Provider. Your
Provider must prescribe the Medically Necessary equipment or supply.
Note: Positive airway pressure devices (CPAP/APAP) and initial supplies require Prior
Authorization regardless of rental or purchase cost. If Prior Authorization from BCBSTX is not
obtained for positive airway pressure devices (CPAP/APAP) and initial supplies, you will be
responsible for paying all charges and no Benefits will be paid.
Emergency Room Services - Outpatient
The Plan's Emergency room services Benefit pays for Outpatient treatment at a Hospital or
Alternate Facility when required to stabilize a patient or initiate treatment.
If you continue a stay in a Non-Network Hospital after the date your Physician determines that it
is medically appropriate to transfer you to a Network Hospital, you may be responsible for paying
the amount exceeding Allowable Amounts.
If you are admitted as an Inpatient to a Hospital directly from the Emergency room, you will not
have to pay the Copay for Emergency room services. The Benefits for an Inpatient Stay in a
Network Hospital will apply instead.
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Network Benefits will be paid for an Emergency admission for a Non-Network Hospital stay as
long as BCBSTX is notified within 48 hours, or the next business day, after you are admitted to a
Non-Network Hospital. If you continue your stay in a Non-Network Hospital after the date your
Physician determines that it is medically appropriate to transfer you to a Network Hospital, Non-
Network Benefits will apply.
Emergency room Benefits may be available when you seek such services to treat a condition
you reasonably believe is an Emergency; however, you may receive Non-Network Benefits if
you receive services at a Non-Network Hospital or Other Facility that are not billed by the
Provider or Facility as a true Emergency.
A Freestanding Emergency Room and Freestanding Emergency Department are medical care
Facilities that are structurally separate and distinct from a Hospital that provides Emergency
Health Services.
Please note that Benefits may be different for Freestanding Emergency Rooms and Freestanding
Emergency Departments as described in Section 5- Schedule of Benefits and Coverage under
the heading Emergency Services.
Please remember that you or your representative must call BCBSTX within 48 hours, or the
next business day, after you are admitted to a Non-Network Hospital as a result of an
Emergency. If BCBSTX is not notified, Benefits for the Inpatient Hospital Stay will be subject to
the $200 Additional Deductible and Benefits will be paid at the Non-Network level.
Family Planning and Infertility Services
The Plan pays Benefits for voluntary family planning services and supplies. Coverage is provided
for contraceptive counseling, elective sterilization procedures (tubal ligation or vasectomy),
contraceptives drugs administered by a Provider (e.g., Depo-Provera, Norplant) and
contraceptive devices (e.g., diaphragm, intrauterine device (IUD)), including fitting and removal.
Note: Oral contraceptives are covered under the HealthSelect Prescription Drug Program
administered by OptumRx.
Infertility Benefits are only for diagnostic laboratory and X-ray procedures, therapeutic injections
and surgical treatment necessary for the diagnosis and treatment of involuntary infertility (i.e.,
infertility that is not a result of voluntary sterilization).
For services specifically excluded, refer to Section 7, Exclusions: What the Medical Plan Will Not
Cover, under the heading Reproduction/Infertility.
Habilitation and Rehabilitation Services - Outpatient Therapy
The Plan provides short-term Outpatient Habilitation and rehabilitation services for the following
types of therapy:
• cardiac rehabilitation;
• cognitive rehabilitation therapy following a traumatic brain Injury or cerebral vascular
accident;
• occupational therapy;
• physical therapy;
• post-cochlear implant aural therapy;
• pulmonary rehabilitation; and
• speech therapy.
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Benefits provided under this section include “Habilitation” services, which are health care services
that help a person keep, learn or improve skills and functioning for daily living prescribed by a
Participant’s treating Physician pursuant to a treatment plan to develop a function not previously
developed as a result of a disabling condition, or a disorder resulting from Sickness, Injury,
trauma or other event or condition suffered by the Participant prior to the development by that
Participant of one or more functional life skills such as walking or talking. Benefits for Habilitation
services do not apply to Educational services. Custodial Care, respite care, day care, therapeutic
recreation, vocational training and residential treatment are not Habilitation services.
To be Covered Health Services, all Habilitation services or rehabilitation services must be
performed by a licensed therapy Provider under the direction of a Physician (when required by
state law) and must be provided in a Physician's office or on an Outpatient basis at a Hospital or
Alternate Facility. Your Provider will be required to submit a treatment plan that outlines goal-
directed Habilitation services or rehabilitation services. Benefits can be denied or shortened for
Participants who are not progressing in goal-directed rehabilitation services or if rehabilitation
goals have previously been met.
Benefits for Durable Medical Equipment and prosthetic devices, when used as a component of
Habilitation services, are described under Durable Medical Equipment and Prosthetic Devices in
this section.
Massage therapy is a Covered Health Service when Medically Necessary and provided by a
licensed therapy Provider, subject to all the conditions of this section.
Except as described below under Therapies for Children with Developmental Delay Services, the
Plan will pay Benefits for speech therapy for the treatment of disorders of speech, language,
voice, communication and auditory processing only when:
• the speech impediment or dysfunction results from a Congenital Anomaly or Injury or
Sickness, including, but not limited to, stroke, cancer or Autism Spectrum Disorder;
• needed following the placement of a cochlear implant; or
• used to treat stuttering, stammering, or other articulation disorders not related to an
underlying medical condition.
Hearing Aids
The Plan pays Benefits for hearing aids requiring a Prescription that are for the correction of a
hearing impairment (a reduction in the ability to perceive sound which may range from slight to
complete deafness). Hearing aids are electronic amplifying devices designed to bring sound more
effectively into the ear. A hearing aid consists of a microphone, amplifier and receiver.
Benefits are available for a hearing aid that is purchased as a result of a written recommendation
by a Physician. Benefits are provided for the hearing aid and for charges for associated fitting and
testing.
Any combination of Network Benefits and Non-Network Benefits for hearing aids, including fitting,
testing and molds, are limited to $1,000 per hearing impaired ear for any consecutive 36-month
period. Eligible Participants 18 years of age and younger are not subject to the $1,000 Benefit
limit for hearing aids. Eligible Participants 18 years of age and younger may also receive
coverage for one cochlear implant per ear with internal replacement as Medically Necessary.
Hearing aid batteries are not included in the hearing aid Benefit limit. Hearing aid batteries are
covered at 100% up to maximum of $1 per battery. You must submit a receipt with a completed
claim form located under the Publications and Forms section at www.healthselectoftexas.com
.
Benefits do not include dispensing fees, except for those Participants 18 years of age and
younger, or repairs to a hearing aid, even if the hearing aid purchase was a Covered Health
Service under the Plan.
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Note: Limited coverage of bone anchored hearing aids is provided as described under Prosthetic
Devices in this section.
High-Tech Radiology - CT, PET Scans, MRI, MRA and Nuclear Medicine -
Outpatient
The Plan pays Benefits for CT scans, PET scans, MRI, MRA, nuclear medicine, and major
diagnostic services received on an Outpatient basis at a Hospital or Alternate Facility or in a
Physician's office.
Benefits under this section include, but are not limited to:
• the Facility charge and the charge for supplies and equipment; and
• Physician services for radiologists, anesthesiologists and pathologists.
Benefits for other Physician services are described in this section under Physician Fees for
Surgical and Medical Services.
When you use a Network Provider, the Network Provider is responsible for obtaining Prior
Authorization for high-tech radiology services. If you use a Non-Network Provider, you are
responsible for ensuring Prior Authorization is obtained from BCBSTX. If Prior Authorization is
not obtained, you will be responsible for an Additional Deductible of $200 in addition to your
Non-Network Deductible, Copay, and Coinsurance.
Home Health Care
Covered Health Services are services that a Home Health Agency provides if you need care in
your home due to the nature of your condition. Services must be:
• ordered by a Physician;
• provided by or supervised by a registered nurse (R.N.) or licensed vocational nurse (L.V.N.),
or provided by either a home health aide or licensed practical nurse (L.P.N.) and supervised
by a registered nurse, in your home;
• not considered Custodial Care, as defined in Section 13, Glossary; and
• provided on a part-time or Intermittent Skilled Nursing Care schedule when Skilled Care is
required. Refer to Section 13, Glossary, for the definition of Skilled Care.
BCBSTX will decide if Skilled Care is needed by reviewing both the skilled nature of the service
and the need for Physician-directed medical management. A service will not be determined to be
Skilled Care simply because there is not an available caregiver.
Covered Health Services for home health care include, but are not limited to:
• physical, occupational (when consisting of traditional physical therapy modalities), speech
and respiratory therapy services provided by a licensed therapist; and
• supplies and equipment routinely provided by a Home Health Agency.
For services specifically excluded, refer to Section 7, Exclusions: What the Medical Plan Will Not
Cover, under the heading Types of Care.
Benefits under this section are provided for home infusion therapy, which is the administration of
fluids, nutrition or medication (including, but not limited to, all additives, and chemotherapy) by
intravenous or gastrointestinal (enteral) infusion or by intravenous injection in the home setting.
There is no coverage for home infusion therapy unless it is performed by a Network Provider.
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Home infusion therapy includes, but is not limited to:
• drug and intravenous solutions;
• pharmacy compounding and dispensing services;
• all equipment and ancillary supplies necessitated by the defined therapy;
• delivery services;
• patient and family education; and
• nursing services.
Non-Network Benefits for home health care are limited to 100 visits per Calendar Year. One visit
equals four hours of Skilled Care services. Home health care visits from both Network and Non-
Network Providers apply to this limit.
Please remember for receive Non-Network Benefits, you must obtain Prior Authorization from
BCBSTX before receiving services. If Prior Authorization from BCBSTX is not obtained, you are
responsible for paying all charges and Benefits will not be paid.
Hospice Care
Hospice care is an integrated program recommended by a Physician which provides comfort and
support services for the terminally ill Participant. Hospice care can be provided on an Inpatient or
Outpatient basis and includes physical, psychological, social, spiritual and respite care for the
terminally ill Participant and short-term grief (bereavement) counseling for immediate family
members while the Participant is receiving Hospice care. Benefits are available only when
Hospice care is received from a licensed Hospice, which can include a Hospital.
Benefits for Outpatient Hospice care include, but are not limited to:
• part-time or intermittent nursing care by a registered nurse (R.N.) or licensed vocational
nurse (L.V.N.); and
• part-time or intermittent home health aide services that consist primarily of caring for the
Participant.
Benefits for Inpatient Hospice care include, but are not limited to:
• all usual nursing care by a registered nurse (R.N.) or licensed vocational nurse (L.V.N.); and
• room and board and all routine services, supplies and equipment provided by the Hospice
Facility.
Benefits for Inpatient or Outpatient Hospice care include, but are not limited to:
• physical, occupational (when consisting of traditional physical therapy modalities), speech,
and respiratory therapy services provided by a licensed therapist; and
• counseling services by licensed social workers and pastoral counselors routinely provided by
the Hospice agency, including bereavement counseling.
For services specifically excluded, refer to Section 7, Exclusions: What the Medical Plan Will Not
Cover, under the heading Types of Care.
Please remember, to receive Non-Network Benefits, you must obtain Prior Authorization from
BCBSTX before receiving services. If Prior Authorization from BCBSTX is not obtained, you are
responsible for paying all charges and Benefits will not be paid.
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Hospital - Inpatient Stay
Hospital - Inpatient Stay Benefits are available for:
• non-Physician services and supplies received during an Inpatient Stay;
• room and board in a Semi-private Room; and
• Physician services for radiologists, anesthesiologists, pathologists, assistant surgeons,
surgical assistants, consulting Physicians and Emergency room Physicians.
Note: The Plan will pay the difference in cost between a Semi-private Room and a private room
only when a Semi-private Room is not available or if a private room is Medically Necessary
according to generally accepted medical practice.
Benefits for a Hospital - Inpatient Stay are available only when the Inpatient Stay is necessary to
prevent, diagnose or treat a Sickness or Injury. Benefits for other Facility-based Physician
services provided in a Hospital are described in this section under Physician Fees for Surgical
and Medical Services.
If you are discharged and then readmitted to the Hospital within 24 hours for the same condition,
the Copays you paid for the initial admission are combined with the Copay(s) for the readmission
to reach the per-admission maximum.
Example
You are admitted to the Hospital and have an Inpatient Stay of three days, paying a Copay of
$450 ($150 per day for three days). You are discharged at 5 p.m. on the third day and then
readmitted at 8:30 a.m. the following morning for the same condition and have an Inpatient
Stay of four days. You will pay an additional Copay of $300 ($150 per day for two days),
because that amount is combined with the $450 Copay to reach the per-admission maximum
of $750.
Benefits for Emergency admissions and admissions of less than 24 hours are described under
Emergency Room Services and Surgery - Outpatient, Scopic Procedures - Diagnostic and
Therapeutic, and Therapeutic Treatments - Outpatient, respectively, in this section.
For scheduled admissions, please remember for Non-Network Benefits, you must obtain Prior
Authorization from BCBSTX before you are admitted. If Prior Authorization from BCBSTX is not
obtained, Benefits will be subject to the $200 Additional Deductible.
For Emergency admissions (also termed non-scheduled admissions) please remember that you
or your representative must notify BCBSTX within 48 hours after you are admitted to a Non-
Network Hospital as a result of an Emergency. If BCBSTX is not notified, Benefits for the
Inpatient Hospital Stay will be subject to an Additional Deductible of $200 and Benefits will be
paid at the Non-Network level.
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Lab, X-Ray and Diagnostics
Covered Health Services for Sickness and Injury-related diagnostic purposes, received on an
Outpatient basis at a Hospital or Alternate Facility include, but are not limited to:
• lab and radiology/X-ray;
• mammography, including digital breast tomosynthesis/3D mammography; and
• bone density screening.
Benefits under this section include, but are not limited to:
• the Facility charge and the charge for supplies and equipment; and
• Physician services for radiologists, anesthesiologists and pathologists.
When these services are performed in a Physician's office, Benefits are described under
Physician's Office Services - Sickness and Injury in this section.
Benefits for other Physician services are described in this section under Physician Fees for
Surgical and Medical Services. Lab, X-ray and diagnostic services for Preventive Care are
described under Preventive Care Services in this section. CT scans, PET scans, MRI, MRA,
nuclear medicine and major diagnostic services are described under High-Tech Radiology - CT,
PET Scans, MRI, MRA and Nuclear Medicine - Outpatient in this section.
Diagnostic mammograms are covered at 100% of the Allowable Amount when the service is
provided by a Network Provider. You could pay more of the cost when using a Non-Network
Provider.
Please remember, to receive Non-Network Benefits for sleep studies, you must obtain Prior
Authorization from BCBSTX before scheduled services are received. If Prior Authorization from
BCBSTX is not obtained, you are responsible for paying all charges and Benefits will not be
paid.
Maternity Care
The Plan provides Benefits for Covered Health Services related to Pregnancy and maternity care.
Covered Health Services include, but are not limited to, all maternity-related medical services for
prenatal care, postnatal care, delivery services provided by the delivering Physician or midwife (a
midwife must be a Certified Nurse Midwife licensed as an Advanced Practice Nurse), laboratory
tests, sonograms, stress tests, amniocentesis and expenses for the Hospital- Inpatient Stay,
including assistant surgeon or anesthesiologist fees if required. Benefits to treat any related
Complications of Pregnancy will be paid at the same level as Benefits for any other medical
condition, Sickness, or Injury.
A Copay will be required for the initial Network Provider office visit for maternity care but will not
be required for subsequent maternity care visits. Dependent children will be eligible for maternity
care benefits.
The Plan will pay Benefits for an Inpatient Stay of at least:
• 48 hours for the mother and newborn following an uncomplicated vaginal delivery; or
• 96 hours for the mother and newborn following an uncomplicated delivery by caesarean
section.
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These are federally mandated requirements under the Newborns’ and Mothers’ Health Protection
Act of 1996 which apply to this Plan. The Hospital or Other Provider is not required to get Prior
Authorization for the time periods stated above. Prior Authorizations are required for longer
lengths of stay. If the mother agrees, the attending Physician may discharge the mother and/or
the newborn child earlier than these minimum timeframes.
If the mother or newborn is discharged before the minimum hours of coverage, the Plan provides
coverage for Post-Delivery Care for the mother and newborn. The Post-Delivery Care may be
provided at the mother’s home, a health care Provider’s office, or a health care Facility.
Both before and during a pregnancy, Benefits include the services of a genetic counselor when
provided or referred by a Physician. These Benefits are available to all Participants in the
immediate family. Covered Health Services include related tests and treatment.
Charges for well-baby nursery care, including the initial examination, of a newborn child during
the mother’s Hospital admission for the delivery will be considered Hospital – Inpatient Stay
expenses of the child and will be subject to the benefit provisions and benefit maximums as
described under Hospital – Inpatient Stay in this section. Please remember for Non-Network
Benefits, you must obtain Prior Authorization from BCBSTX as soon as reasonably possible if
the Inpatient Stay for the mother and/or the newborn will be longer than the timeframes
indicated above. If Prior Authorization from BCBSTX is not obtained, Benefits for the extended
stay are subject to an Additional Deductible of $200.
Note: If the newborn remains hospitalized after the mother is released, in order to ensure that
an Additional Deductible is not applied, you should obtain a separate Prior Authorization for the
child and arrange to have the child admitted to the Hospital in his or her own name for
treatment by a Physician or Other Provider for the non-routine services.
Medical Supplies
The Plan pays Benefits for medical or disposable supplies when the supplies are prescribed by a
Physician. Covered Health Services include, but are not limited to:
• urinary catheters;
• wound care or dressing supplies given by a Provider during treatment for Covered Health
Services; and
• medical-grade compression stockings when considered Medically Necessary. The stockings
must be prescribed by a Physician, individually measured and fitted to the patient.
Coverage also includes disposable supplies necessary for the effective use of Durable Medical
Equipment and diabetic supplies for which Benefits are provided as described under Durable
Medical Equipment and Diabetes Services in this section.
Medications and Injections - Outpatient
The Plan pays for Medications and Injections that are administered on an Outpatient basis in a
Hospital, Alternate Facility or Physician's office. The Plan also pays for Medications and
Injections that are administered in a Participant's home but only by a Network Provider. Examples
of what would be included under this category are antibiotic injections in the Physician's office,
inhaled medication in an Urgent Care Center for treatment of an asthma attack or Medically
Necessary growth hormone therapy.
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Benefits under this section are provided only for Medications and Injections that, due to their
characteristics (as determined by BCBSTX), must typically be administered or directly supervised
by a qualified Provider or licensed/certified health professional, unless approved for self-
administration by the United States Food and Drug Administration (FDA).
Benefits under this section do not include medications that are typically available by prescription order
or refill at a pharmacy under the HealthSelect Prescription Drug Program administered by OptumRx.
Additional information is located at www.HealthSelectRx.com
.
Mental Health Services
The Plan pays Benefits for Mental Health Services for the treatment of Mental Illness received on
an Inpatient or Outpatient basis in a Hospital, an Alternate Facility or in a Provider's office.
Services must be received from a Mental Health Provider as defined in Section 13, Glossary.
Note: Benefits for Serious Mental Illness, as defined in Section 13, Glossary, will be paid at the
same level as Benefits for any other condition, Sickness or Injury. See Serious Mental Illness
Services in this section and in Section 5, Schedule of Benefits and Coverage.
Covered Health Services include, but are not limited to, the following services:
• crisis intervention;
• diagnostic evaluations and assessment;
• electroconvulsive treatment;
• individual, family, therapeutic group and Provider-based case management services;
• individual or group psychotherapy;
• Intensive Outpatient Treatment;
• medication management;
• mental health counseling;
• Partial Hospitalization/Day Treatment;
• psychodynamic therapy;
• psychological testing and assessment;
• psychotropic drugs, including their administration;
• referral services;
• services at a Residential Treatment Center;
• treatment planning; and
• treatment and/or procedures.
BCBSTX, who will authorize the services, will determine the appropriate setting for the treatment.
If an Inpatient Stay is required, it is covered on a Semi-private Room basis.
Note: The Plan will pay the difference in cost between a Semi-private Room and a private room
only when a Semi-private Room is not available or if a private room is Medically Necessary
according to generally accepted medical practice.
You are encouraged to contact BCBSTX for coordination of care. Contact a BCBSTX Personal
Health Assistant (800) 252-8039 (TTY: 711) for assistance. Inpatient Mental Health Services
must be authorized and overseen by BCBSTX.
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For Non-Network Benefits, you must obtain Prior Authorization from BCBSTX to receive
Inpatient Benefits. Even with inpatient Benefits applied, you could pay more of the cost when
using a Non-Network Provider at a Network inpatient Facility. In addition, without Prior
Authorization, Covered Health Services for the Inpatient Stay are subject to an Additional
Deductible of $200. When you obtain Prior Authorization, BCBSTX will work with you to
determine the appropriate setting for your treatment. Please refer to Section 4, Prior
Authorization, for the specific services that require Prior Authorization. Please call BCBSTX at
(800) 252-8039 (TTY: 711) for assistance.
For Emergency admissions (also termed non-scheduled admissions) please remember that you
or your representative must notify BCBSTX within 48 hours after you are admitted to a Non-
Network Facility. If BCBSTX is not notified, Benefits for the Inpatient Hospital Stay are subject
to an Additional Deductible of $200 and Benefits are paid at the Non-Network level of Benefits.
Neurobiological Disorders - Autism Spectrum Disorder Services
The Plan pays Benefits for Autism Spectrum Disorders including Intensive Behavioral Therapies
such as Applied Behavior Analysis (ABA) that are all of the following:
• focused on the treatment of core deficits of Autism Spectrum Disorder;
• provided by a Mental Health Provider who is a master’s level clinician licensed, certified, or
registered by an appropriate agency in the state where services are being provided for
services treating Autism Spectrum Disorder symptoms, or by a master’s level clinician with an
appropriate state license who is a Board-Certified Behavior Analyst (BCBA), or by an
appropriately trained and qualified paraprofessional directly supervised by the BCBA;
•
• focused on treating maladaptive/stereotypic behaviors that are posing danger to self, others
and property and impair daily functioning; and
• backed by credible peer-reviewed research demonstrating that the services have a
measurable and beneficial effect on health outcomes.
These Covered Health Services include only the behavioral component of treatment for Autism
Spectrum Disorders. Medical treatment of Autism Spectrum Disorders is a Covered Health
Service for which Benefits are available under the applicable medical Covered Health Services
categories as described in this section and subject to the terms and limitations of the Plan.
Covered Health Services include, but are not limited to, the following services provided on either
an Outpatient or Inpatient basis:
• crisis intervention;
• diagnostic evaluations and assessment;
• individual, family, therapeutic group and Provider-based case management services;
• Intensive Outpatient Treatment;
• medication management;
• Partial Hospitalization/Day Treatment;
• referral services;
• services at a Residential Treatment Facility;
• treatment planning; and
• treatment and/or procedures.
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BCBSTX, who will authorize the services, will determine the appropriate setting for the treatment.
If an Inpatient Stay is required, it is covered on a Semi-private Room basis.
Note: The Plan will pay the difference in cost between a Semi-private Room and a private room
only when a Semi-private Room is not available or if a private room is Medically Necessary
according to generally accepted medical practice.
You are encouraged to contact BCBSTX for coordination of care. Inpatient Mental Health
Services for Autism Spectrum Disorders must be authorized and overseen by BCBSTX. In
addition, BCSTX will authorize and oversee Benefits for Intensive Behavioral Therapy.
Clinical Management: Following Prior Authorization of Intensive Behavioral Therapy, BCBSTX will
perform clinical management of these Benefits. Clinical management includes Provider eligibility
verification. In addition, an Autism specialist will review detailed treatment plans from the treating
Provider for both initial and ongoing treatment. At a minimum, treatment plans are reviewed every
six months by the Autism specialist for progress and appropriateness of care.
For Non-Network services, you must obtain Prior Authorization from BCBSTX to receive
Inpatient Benefits. Even with inpatient Benefits applied, you could pay more of the cost when
using a Non-Network Provider at a Network inpatient Facility. In addition, without Prior
Authorization, Covered Health Services for the Inpatient Stay are subject to an Additional
Deductible of $200. When you obtain Prior Authorization, BCBSTX will work with you to
determine the appropriate setting for your treatment. Please refer to Section 4, Prior
Authorization, for the specific services that require Prior Authorization. Please call (800) 252-
8039 (TTY: 711).
For Emergency admissions (also termed non-scheduled admissions) please remember that you
or your representative must notify BCBSTX within 48 hours after you are admitted to a Non-
Network Facility. If BCBSTX is not notified, Benefits for the Inpatient Hospital Stay are subject
to an Additional Deductible of $200 and Benefits are paid at the Non-Network level.
For Non-Network Benefits, you must obtain Prior Authorization from BCBSTX for Intensive
Behavioral Therapy, including Applied Behavior Analysis (ABA). Without Prior Authorization
Covered Health Services are subject to an Additional Deductible of $200 Additional Deductible
and Benefits are paid at the Non-Network level.
Nutritional Counseling
The Plan pays Benefits for medical education services provided in a Physician's office or
Inpatient setting by an appropriately licensed or health care professional when:
• medical education services are required for a disease in which patient self-management is an
important component of treatment; and
• there exists a knowledge deficit regarding the disease which requires the intervention of a
trained health professional.
Some examples of such medical conditions include, but are not limited to:
• congestive heart failure;
• coronary artery disease;
• diabetes;
• gout (a form of arthritis);
• hyperlipidemia (excess of fatty substances in the blood);
• phenylketonuria (a genetic disorder diagnosed at infancy);
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• renal failure; and
• severe obstructive airway disease.
Nutritional counseling services include, but are not limited to, the education, counseling, or
training of a Participant regarding diet, regulation or management of diet or the assessment or
management of nutrition.
In addition, the Plan provides Benefits for dietary or nutritional evaluations for Participants with
Developmental Delay that are determined to be necessary to, and provided in accordance with,
an Individualized Family Service Plan issued by the Interagency Council on Early Childhood
Intervention.
Ostomy Supplies
Benefits for ostomy supplies include, but are not limited to:
• pouches, face plates and belts;
• irrigation sleeves, bags and ostomy irrigation catheters;
• skin barriers; and
• deodorants, filters, lubricants, tape, appliance cleaners, adhesive and adhesive remover.
Physician Fees for Surgical and Medical Services
The Plan pays Benefits for Physician fees for surgical procedures and other medical care
received from a Physician in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility,
Alternate Facility, or for Physician house calls.
Benefits under this section include Second Opinions from Physicians related to Medical
Necessary Covered Health Services and surgical procedures or other medical care as described
above.
Physician's Office Services - Sickness and Injury
The Plan pays Benefits for Covered Health Services received in a Physician's office for the
evaluation, diagnosis and treatment of a Sickness or Injury. Benefits are provided under this
section regardless of whether the Physician's office is free-standing, located in a clinic or located
in a Hospital or is an Outpatient Clinic Facility. Benefits under this section include, but are not
limited to, allergy injections and hearing exams in case of Injury or Sickness.
Benefits under this section include Second Opinions from Physicians related to Medically
Necessary Covered Health Services and procedures provided in a Physician’s office.
Covered Health Services include genetic counseling. Benefits are available for Genetic Testing
determined to be Medically Necessary following genetic counseling when ordered by the
Physician and authorized in advance by BCBSTX.
Covered Health Services also include Telemedicine services, such as the use of electronic media
for diagnosis, consultation, treatment, transfer of medical data and medical education.
Benefits under this section include lab, radiology/X-ray or other diagnostic services performed in
the Physician's office. Benefits for high-tech radiology such as CT scans, PET scans, MRI, MRA,
nuclear medicine and major diagnostic services performed in the Physician's office are described
under High-Tech Radiology - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient in
this section.
Benefits for preventive services are described under Preventive Care Services in this section.
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To receive Non-Network Benefits for Genetic Testing such as BRCA (breast cancer gene), you
must obtain Prior Authorization from BCBSTX. If Prior Authorization from BCBSTX is not
obtained, you are responsible for paying all charges and Benefits are not paid.
Please Note
Your Physician does not have a copy of your MBPD, and is not responsible for knowing or
communicating your Benefits.
Preventive Care Services
The Plan pays Benefits for Preventive Care services provided on an Outpatient basis at a
Physician's office, an Alternate Facility or a Hospital. To be considered Preventive Care, Covered
Health Services, services must be received from a Network Provider and/or Facility. Preventive
Care services encompass medical services that have been demonstrated by clinical evidence to
be safe and effective in either the early detection of disease or in the prevention of disease, have
been proven to have a beneficial effect on health outcomes and include the following as required
under applicable law:
• evidence-based items or services that have a rating of "A" or "B" in the current
recommendations of the United States Preventive Services Task Force (USPSTF);
• immunizations that have a recommendation from the Advisory Committee on Immunization
Practices of the Centers for Disease Control and Prevention (CDC);
• with respect to infants, children and adolescents, evidence-informed Preventive Care and
screenings provided for in the comprehensive guidelines supported by the federal Health
Resources and Services Administration (HRSA); and
• with respect to women, such additional Preventive Care and screenings as provided for in
comprehensive guidelines supported by the federal HRSA. Preventive Care Services
described in this section are those that are relevant for implementing the Affordable Care Act
to the extent required by applicable law, and as it may be amended, and subject to
determination and interpretation by the Plan.
Diagnostic mammography is covered at 100% of the Allowable Amount when received by a
Network Provider. You could pay more of the cost when using a Non-Network Provider.
Preventive Services that are currently rated as A or B according to the United States Preventive
Services Task Force (USPSTF), or as recommended by the CDC or HRSA, are listed in
Addendum - List of Covered Preventive Care Services. This list is subject to change according to
the guidelines and recommendation provided by USPSTF, CDC, or HRSA, as determined by the
Plan. Coverage is subject to guidelines based on age, dosage, and frequency.
Please Note
If the Preventive Care guidelines include an annual limit, the limit will apply on a Calendar Year
basis.
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Breastfeeding Support, Services and Supplies
The Plan provides Benefits for lactation support and counseling sessions to female Participants in
conjunction with childbirth. To be considered Preventive Care, Covered Health Services, services
must be received from a Network Provider and/or Facility.
Benefits are provided for breastfeeding counseling and support services when rendered by a
Provider, during pregnancy and/or in the post-partum period. Benefits include the rental or the
purchase of manual or electric breast pumps, accessories and supplies. Benefits for breast
pumps are limited to one per pregnancy, or one per newly eligible newborn Dependent who is not
a Participant’s natural child. Limited benefits are also included for the rental of Hospital grade
breast pumps. You may be required to pay the full amount and submit a claim form to BCBSTX
with a written prescription and the itemized receipt for the manual electric or Hospital grade
breast pump, accessories and supplies. Visit www.healthselectoftexas.com
to obtain a claim
form.
Preventive Care Benefits defined under the federal HRSA requirement provide for the cost of
purchasing one breast pump per pregnancy or one per newly eligible newborn Dependent
who is not a Participant’s natural child. You may purchase a breast pump from a Network
DME Provider or Physician. You may also purchase a breast pump at a retail location and
submit a claim as described in Section 8, Claims Procedures. Benefits for breast pumps with a
valid Prescription Order rented or purchased from an In-Network Provider or a retail location
are provided at 100% of Allowable Amounts. For breast pumps purchased from a retail
location, you must submit a claim form to BCBSTX for reimbursement.
If you use a Non-Network Provider, the Benefits may be subject to the Annual Non-Network
Deductible, Coinsurance, Copay and/or benefit maximum.
For more information, contact a BCBSTX Personal Health Assistant at (800) 252-8039 (TTY:
711).
The Plan pays Benefits only for a breast pump purchased 30 days or less before the newborn
delivery date or newborn placement for adoption date. You or your Provider should provide the
delivery date on the claim. Breast pumps are covered under the Plan as long as they are
purchased within the duration of breastfeeding.
Note: Any shipping costs related to purchase of a breast pump are not Covered Health
Services under this Benefit.
Private Duty Nursing - Outpatient
The Plan covers Private Duty Nursing care when ordered and provided under the direction of a
Physician and given on an Outpatient basis by a licensed nurse such as a Registered Nurse
(R.N.), Licensed Vocational Nurse (L.V.N.) or Licensed Practical Nurse (L.P.N.).
Benefits are available when Skilled Care is needed, and nursing intervention is required at least
every two to three hours and when one or more of the following is true:
• the Participant’s condition makes him or her homebound; or
• the Participant’s condition plus the geographic distance make it unreasonable for him or her
to obtain the needed services in an Outpatient Facility or Physician’s office; or
• the Participant’s condition makes him or her technology dependent;
• services are needed on a continuous basis (e.g., suctioning or hemodynamic monitoring) to
assure immediate intervention if required; or
• the services are more Cost-Effective in the home than an alternative setting.
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The Participant’s treatment plan should be reviewed periodically (no less than every 60 days, or
as determined by the Plan) and updated by the Physician.
Benefits are provided for the time devoted to providing the Participant with Medically Necessary
services.
Non-Network Benefits are limited to 96 hours per Calendar Year.
Note: The Plan does not pay Benefits for Custodial Care or Domiciliary Care, even if ordered by
a Physician, as defined in Section 13, Glossary.
To receive Non-Network Benefits you must obtain Prior Authorization from BCBSTX before
receiving services. If Prior Authorization from BCBSTX is not obtained, you are responsible for
paying all charges and Benefits are not paid.
Prosthetic Devices
The Plan pays Benefits for prosthetic devices and appliances that replace a limb or body part, or
help an impaired limb or body part work. Examples include, but are not limited to:
• artificial arms, legs, feet and hands;
• artificial face, eyes, ears and nose; and
• breast prosthesis following mastectomy as required by the Women's Health and Cancer
Rights Act of 1998, including mastectomy bras and lymphedema stockings for the arm.
Benefits under this section are also provided for bone anchored hearing aids only for Participants
who have either of the following:
• craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable
hearing aid; or
• hearing loss of sufficient severity that it would not be adequately remedied by a wearable
hearing aid.
Note: Procedures related to covered bone anchored hearing aids are also covered by the Plan
under Hospital - Inpatient Stay or Surgery - Outpatient in this section.
Benefits under this section are provided only for external prosthetic devices and do not include
any device that is fully implanted into the body.
If more than one prosthetic device can meet your functional needs, Benefits are available only for
the most Cost-Effective prosthetic device. The device must be ordered or provided either by a
Physician or under a Physician's direction. If you purchase a prosthetic device that exceeds these
minimum specifications, the Plan may pay only the amount that it would have paid for the
prosthetic that meets the minimum specifications, and you may be responsible for paying any
difference in cost.
At the Plan's discretion, replacements may be covered when the prosthetic device is damaged
beyond repair due to normal wear and tear, when repair costs are more than the cost of
replacement or when a replacement prosthetic device is required due to the Participant’s growth
or other physical change or a change in the Participant's abilities or medical condition.
Replacement of artificial limbs or any part of such devices may be covered when the condition of
the device or part requires repairs that cost more than the cost of a replacement device or part.
Note: Prosthetic devices are different from DME - see Durable Medical Equipment (DME) in this
section.
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To receive Non-Network Benefits, you must obtain Prior Authorization from BCBSTX before
obtaining any prosthetic device that exceeds $1,000 in cost per device. If Prior Authorization
from BCBSTX is not obtained, you are responsible for paying all charges and Benefits will not
be paid.
Reconstructive Procedures
Reconstructive Procedures are services performed when the primary purpose of the procedure is
either to treat a medical condition or to improve or restore physiologic function for an organ or
body part and not primarily change or improve the physical appearance of a healthy organ or
body part. Reconstructive Procedures include surgery or other procedures that are associated
with an Injury, Sickness or Congenital Anomaly.
Improving or restoring physiologic function means that the organ or body part is made to work
better. An example of a Reconstructive Procedure is surgery on the inside of the nose so that a
person's breathing can be improved or restored.
Benefits for Reconstructive Procedures include breast reconstruction following a mastectomy and
reconstruction of the non-affected breast to achieve symmetry. Replacement of an existing breast
implant is covered by the Plan if the initial breast implant followed mastectomy. Other services
required by the Women's Health and Cancer Rights Act of 1998, including, but not limited to,
breast prostheses and treatment of complications, are provided in the same manner and at the
same level as those for any other Covered Health Service. You can contact BCBSTX at (800)
252-8039 (TTY: 711) for more information about Benefits for mastectomy-related services.
When the purpose of a procedure is to improve the appearance of a healthy body part, it is a
Cosmetic Procedure and it is excluded from coverage under the Plan. For Participants age 19
and over, procedures that correct an anatomical Congenital Anomaly without improving or
restoring physiologic function are considered Cosmetic Procedures. An example is upper eyelid
surgery. At times, this procedure will be done to improve vision, which is considered a
Reconstructive Procedure. In other cases, improvement in appearance is the primary intended
purpose, which is considered a Cosmetic Procedure. This Plan does not provide Benefits for
Cosmetic Procedures, as defined in Section 13, Glossary.
A Participant may suffer negative psychological consequences or socially avoidant behavior as
a result of an Injury, Sickness or Congenital Anomaly, but that does not qualify the surgery to
address the condition (or other procedures done to relieve such consequences or behavior) as
a covered Reconstructive Procedure.
For Participants under the age of 19, Reconstructive Procedures that improve the function of, or
attempt to create a normal appearance of, an abnormal structure caused by a Congenital
Anomaly, development deformity, trauma, tumor, infection or disease are not considered
Cosmetic Procedures and are Covered Health Services under the Plan.
For scheduled Non-Network Reconstructive Procedure admissions, you must obtain Prior
Authorization from BCBSTX before you are admitted. If Prior Authorization from BCBSTX is not
obtained, Benefits are subject to an Additional Deductible of $200.
For a non-scheduled Reconstructive Procedure, you or your representative must notify
BCBSTX within 48 hours after you are admitted to a Non-Network Hospital. If BCBSTX is not
notified, Benefits for the Inpatient Hospital Stay are subject to an Additional Deductible of $200
and Benefits are paid at the
Non-Network level.
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Retail Health Clinic
The Plan pays Benefits for Covered Health Services provided in a Retail Health Clinic. Benefits
for Retail Health Clinics will be determined as shown in Section 5, Schedule of Benefits and
Coverage. Retail Health Clinics provide diagnosis and treatment of uncomplicated minor
conditions in situations that can be handled without a traditional Provider office visit or Emergency
Care visit. Retail Health Clinics are often located in a retail setting such as a supermarket or
pharmacy and may be staffed by Advanced Practice Nurses and Physician Assistants.
Scopic Procedures - Outpatient Diagnostic and Therapeutic
The Plan pays Benefits for diagnostic and therapeutic scopic procedures and related services
received on an Outpatient basis at a Hospital or Alternate Facility or in a Physician's office.
Diagnostic scopic procedures are minimally invasive medical examinations that enable
visualization, performance of biopsies and polyp removal. Examples of diagnostic scopic
procedures include, but are not limited to, colonoscopy, sigmoidoscopy, and endoscopy.
Therapeutic scopic procedures are usually surgical in nature. Examples of therapeutic scopic
procedures include, but are not limited to, bronchoscopy and esophagoscopy.
Benefits under this section include, but are not limited to:
• the Facility charge and the charge for supplies and equipment; and
• Physician services for anesthesiologists, pathologists and radiologists.
Benefits for other Physician services are described in this section under Physician Fees for
Surgical and Medical Services.
Please note that Benefits under this section do not include surgical scopic procedures, which are
for the purpose of performing surgery. Benefits for surgical scopic procedures are described
under Surgery - Outpatient. Examples of surgical scopic procedures include, but are not limited
to, arthroscopy, laparoscopy, bronchoscopy, hysteroscopy.
Serious Mental Illness Services
Benefits for the Medically Necessary treatment of Serious Mental Illness, as defined in Section
13, Glossary, are paid at the same level as Benefits for any other condition, Sickness or Injury.
The Plan pays Benefits for Covered Health Services received on an Inpatient or Outpatient basis
in a Hospital, an Alternate Facility or in a Provider's office. Services must be received from a
Physician or a Mental Health Provider as defined in Section 13, Glossary.
Covered Health Services include, but are not limited to, the following services:
• crisis intervention;
• diagnostic evaluations and assessment;
• electroconvulsive treatment;
• individual, family, therapeutic group and Provider-based case management services;
• individual or group psychotherapy;
• Intensive Outpatient Treatment;
• medication management;
• mental health counseling;
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• Partial Hospitalization/Day Treatment;
• psychodynamic therapy;
• psychological testing and assessment;
• psychotropic drugs, including their administration;
• referral services;
• services at a Residential Treatment Facility;
• treatment and/or procedures; and
• treatment planning.
Covered Health Services also include transcranial magnetic stimulation (TMS) provided on an
Outpatient basis for an adult patient with a major depressive disorder that is a Serious Mental
Illness that has not been responsive to other Medically Necessary treatments.
BCBSTX, who will authorize the services, will determine the appropriate setting for the treatment.
If an Inpatient Stay is required, it is covered on a Semi-private Room basis.
Note: The Plan will pay the difference in cost between a Semi-private Room and a private room
only when a Semi-private Room is not available or if a private room is Medically Necessary
according to generally accepted medical practice.
You are encouraged to contact BCBSTX for coordination of care at (800) 252-8039 (TTY: 711).
Inpatient Mental Health Services must be authorized and overseen by BCBSTX.
For Non-Network services, you must obtain Prior Authorization from BCBSTX to receive
Inpatient Benefits. Even with inpatient Benefits applied, you could pay more of the cost when
using a Non-Network Provider at a Network inpatient Facility. Without Prior Authorization,
Covered Health Services for the Inpatient Stay are subject to an Additional Deductible of $200.
When you obtain Prior Authorization, BCBSTX will work with you to determine the appropriate
setting for your treatment. Please refer to Section 4, Prior Authorization, for the specific
services that require Prior Authorization. Call BCBSTX at (800) 252-8039 (TTY: 711) for
assistance.
For Emergency admissions (also termed non-scheduled admissions) you or your representative
must notify BCBSTX within 48 hours after you are admitted to a Non-Network Facility as a
result of an Emergency. If BCBSTX is not notified, Benefits for the Inpatient Hospital Stay are
subject to an Additional Deductible of $200 and Benefits are paid at the Non-Network level.
Skilled Nursing Facility/Inpatient Rehabilitation Facility Services
The Plan pays Facility services Benefits for an Inpatient Stay in a Skilled Nursing Facility or
Inpatient Rehabilitation Facility. Benefits include, but are not limited to:
• non-Physician services and supplies received during the Inpatient Stay;
• room and board in a Semi-private Room; and
• Physician services for radiologists, anesthesiologists and pathologists.
Note: The Plan will pay the difference in cost between a Semi-private Room and a private room
only when a Semi-private Room is not available or if a private room is Medically Necessary
according to generally accepted medical practice.
Benefits are available when skilled nursing and/or Inpatient Rehabilitation Facility services are
needed on a daily basis. Benefits are also available in a Skilled Nursing Facility or Inpatient
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Rehabilitation Facility for treatment of a Sickness or Injury that would have otherwise required an
Inpatient Stay in a Hospital.
Benefits for other Physician services are described in this section under Physician Fees for
Surgical and Medical Services.
The Plan will determine if Benefits are available by reviewing both the skilled nature of the service
and the need for Physician-directed medical management. A service will not be determined to be
"skilled" simply because there is not an available caregiver.
Benefits are available only if:
• the initial confinement in a Skilled Nursing Facility or Inpatient Rehabilitation Facility was or
will be a Cost-Effective alternative to an Inpatient Stay in a Hospital; and
• the Skilled Care services to be provided are not primarily Custodial Care.
You are expected to improve to a predictable level of recovery. Your Provider will be required to
submit a treatment plan that outlines goal-directed rehabilitation services. Benefits can be denied
or shortened for Participants who are not progressing in goal-directed rehabilitation services or if
discharge rehabilitation goals have previously been met.
Note: The Plan does not pay Benefits for Custodial Care or Domiciliary Care, even if ordered by
a Physician, as defined in Section 13, Glossary.
For scheduled admissions, you must obtain Prior Authorization from BCBSTX before you are
admitted. If Prior Authorization BCBSTX is not obtained, you are responsible for paying all
charges and Benefits are not paid.
For Emergency admissions (also termed non-scheduled admissions) you or your representative
must notify BCBSTX within 48 hours after you are admitted to a Non-Network Facility as a
result of an Emergency. If BCBSTX is not notified, you are responsible for paying all charges
and Benefits will not be paid.
Substance Use Disorder Services
The Plan pays Benefits for Substance Use Disorder Services (also known as substance-related
and addictive disorders services) received on an Inpatient or Outpatient basis in a Hospital, an
Alternate Facility or in a Provider's office.
Covered Health Services include, but are not limited to, the following services:
• crisis intervention;
• detoxification (sub-acute/non-medical);
• diagnostic evaluations and assessment;
• individual, family, therapeutic group and Provider-based case management services;
• Intensive Outpatient Treatment;
• medication management;
• Partial Hospitalization/Day Treatment;
• referral services;
• services at a Residential Treatment Facility;
• treatment and/or procedures; and
• treatment planning.
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BCBSTX, who will authorize the services, will determine the appropriate setting for the treatment.
If an Inpatient Stay is required, it is covered on a Semi-private Room basis.
Note: The Plan will pay the difference in cost between a Semi-private Room and a private room
only when a Semi-private Room is not available or if a private room is Medically Necessary
according to generally accepted medical practice.
You are encouraged to contact BCBSTX for coordination of care at (800) 252-8039 (TTY: 711).
Inpatient Substance Use Disorder Services must be authorized and overseen by BCBSTX.
For Non-Network services, you must obtain Prior Authorization from BCBSTX to receive
Inpatient Benefits. Even with Inpatient Benefits applied, you could pay more of the cost when
using a Non-Network Provider at a Network inpatient Facility. Without Prior Authorization,
Covered Health Services for the Inpatient Stay are subject to an Additional Deductible of $200.
When you obtain Prior Authorization, BCBSTX will work with you to determine the appropriate
setting for your treatment. Please refer to Section 4, Prior Authorization, for the specific
services that require Prior Authorization. Call BCBSTX at (800) 252-8039 (TTY: 711) for
assistance.
For Emergency admissions (also termed non-scheduled admissions) please remember that you
or your representative must notify BCBSTX within 48 hours after you are admitted to a Non-
Network Facility as a result of an Emergency. If BCBSTX is not notified, Benefits for the
Inpatient Hospital Stay are subject to an Additional Deductible of $200 and Benefits are paid at
the Non-Network level.
Surgery - Outpatient
The Plan provides Benefits for surgery and related services received on an Outpatient basis at a
Hospital or Alternate Facility or in a Physician's office.
Covered Health Services under this section include, but are not limited to:
• surgery and related services;
• the Facility charge and the charge for supplies and equipment;
• certain surgical scopic procedures (examples of surgical scopic procedures include
arthroscopy, laparoscopy, bronchoscopy and hysteroscopy); and
• Physician services for radiologists, anesthesiologists and pathologists.
Examples of surgical procedures performed in a Physician's office include, but are not limited to,
mole removal and ear wax removal.
To receive Non-Network Benefits for sleep apnea surgeries you must obtain Prior Authorization
from BCBSTX before scheduled services are received or, for non-scheduled services, within 48
hours or as soon as is reasonably possible. If Prior Authorization from BCBSTX is not obtained,
you are responsible for paying all charges and Benefits are not paid.
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Telemedicine
The Plan covers Telemedicine visits with your Primary Care Provider, Mental Health Provider
and other Specialists for Covered Health Services.
Telemedicine is when certain medical and mental health services are provided by your Primary
Care Provider, Mental Health Provider, and other Specialists through use of a provider-
platform that may include interactive audio, video, other electronic media or advanced
telecommunications technology
Your Primary Care Provider, Mental Health Provider, and other Specialists may be able to
provide many of the services you would normally have in a face to face visit via a Telemedicine
visit. Contact your Provider(s) to find out if they are offering this convenient option for care, if a
Telemedicine visit is appropriate for your care, and how to schedule a Telemedicine visit.
Telemedicine visits are covered the same as in-person Primary Care Provider, Mental Health
Provider, and other Specialist services, visits, or consultations as listed in Section 5, Schedule
of Benefits and Coverage.
Prior-Authorizations may be required for Telemedicine visits, depending on the type of service.
See Section 3, How the Plan Works and Section 4, Prior Authorizations for additional details on
the Covered Health Services that require a Prior Authorization.
Telemedicine services are different than Virtual Visits. See Virtual Visits in this section for more
information on what a Virtual Visits is and when a Virtual Visit may be appropriate.
If you have questions or need assistance locating a Network Provider, contact a BCBSTX
Personal Health Assistant at (800) 252-8039 (TTY: 711).
Temporomandibular Joint (TMJ) Services and Orthognathic Surgery
The plan pays for the initial diagnosis and surgical treatment of temporomandibular joint
dysfunction (TMJ) when provided by or under the direction of a Physician.
Coverage includes, but is not limited to, necessary treatment required as a result of accident,
trauma, a Congenital Anomaly, developmental defect, or pathology.
Covered diagnostic treatment includes, but is not limited to, examination, radiographs and
applicable imaging studies and consultation.
Benefits are provided for TMJ surgical treatment if:
• there is clearly demonstrated radiographic evidence of significant joint abnormality;
• non-surgical treatment has failed to adequately resolve the symptoms; and
• pain or dysfunction is moderate or severe.
Benefits for surgical services include, but are not limited to, arthroscopy, arthroplasty, arthrotomy
and open or closed reduction of dislocations. Benefits also include oral surgery to reduce a
dislocation of, excisions of and injection of the temporomandibular joint.
The Plan also provides Benefits for orthognathic surgery.
Benefits for an Inpatient Stay in a Hospital and Hospital-based Physician services are described
in this section under Hospital – Inpatient Stay and Physician Fees for Surgical and Medical
Services, respectively.
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For Non-Network Benefits, you must obtain Prior Authorization BCBSTX before orthognathic
surgery is performed on an Inpatient basis. If Prior Authorization from BCBSTX is not obtained,
Benefits for the Inpatient Stay are subject to an Additional Deductible of $200.
Therapeutic Treatments - Outpatient
The Plan pays Benefits for therapeutic treatments received on an Outpatient basis at a Hospital
or Alternate Facility, including, but not limited to, dialysis (both hemodialysis and peritoneal
dialysis), intravenous chemotherapy or other intravenous infusion therapy and radiation oncology.
Covered Health Services include medical education services that are provided on an Outpatient
basis at a Hospital or Alternate Facility by appropriately licensed or registered health care
professionals when:
• education is required for a disease in which patient self-management is an important
component of therapeutic treatment; and
• there exists a knowledge deficit regarding the disease which requires the intervention of a
trained health professional.
Covered Health Services under this section include, but are not limited to:
• the Facility charge and the charge for related supplies and equipment; and
• Physician services for anesthesiologists, pathologists and radiologists. Benefits for other
Physician services are described in this section under Physician Fees for Surgical and
Medical Services.
Benefits are paid as described under Physician's Office Services when these services are
performed in a Physician's office.
To receive Non-Network Benefits, you must obtain Prior Authorization from BCBSTX for all
outpatient therapeutic treatments before scheduled services are received or, for non-scheduled
services, within 48 hours or as soon as is reasonably possible.
If Prior Authorization from BCBSTX is not obtained, you are responsible for paying all charges
and Benefits are not paid.
Therapies for Children with Developmental Delays
The Plan provides Benefits for rehabilitation and habilitation services Benefits for Dependent
children with Developmental Delay that are determined to be necessary to, and provided in
accordance with, an Individualized Family Service Plan issued by the Interagency Council on
Early Childhood Intervention. Covered Health Services include:
• occupational therapy evaluations and services;
• physical therapy evaluations and services;
• speech therapy evaluations and services; and
• dietary or nutritional evaluations.
The Individualized Family Service Plan must be submitted to BCBSTX prior to beginning services
and if there are changes to the Individualized Family Service Plan.
Once the child reaches the age of three, when services under the Individualized Family Service
Plan are completed, Benefits are available as otherwise covered under this Plan. All provisions of
this Plan will apply, including but not limited to, defined terms, limitations and exclusions, and
benefit maximums.
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It is recommended that you confirm with BCBSTX that all Covered Health Services have been
prior authorized as required. Contact a BCBSTX Personal Health Assistant at (800) 252-8039
(TTY: 711) for additional information.
Transplant Services
The Plan pays Benefits for transplant services Benefits only if Inpatient Facility services
(including, but not limited to, evaluation for transplant, organ procurement and donor searches)
for transplant procedures are ordered by a Physician. Benefits are available to the donor and the
recipient when the recipient is covered under this Plan. If the recipient is not a Participant in this
Plan but the donor is a Participant in this Plan, then the recipient’s plan is the Primary Plan and
this Plan is the Secondary Plan for the donor’s expenses in all cases, regardless of coordination
of benefits rules to the contrary. The transplant must meet the definition of a Covered Health
Service and cannot be Experimental or Investigational, or Unproven. Examples of transplants for
which Benefits are available include, but are not limited to:
• bone marrow (either from you or from a compatible donor) and peripheral stem cell
transplants, with or without high dose chemotherapy. Not all bone marrow transplants meet
the definition of a Covered Health Service;
• cornea;
• heart;
• heart/lung;
• intestinal;
• kidney;
• kidney/pancreas;
• liver;
• liver/kidney;
• liver/intestinal;
• lung; and
• pancreas.
Donor costs directly related to organ removal are Covered Health Services for which Benefits are
payable through the organ recipient's coverage under the Plan or through the donor’s coverage
under this Plan with the recipient’s plan being the Primary Plan with this Plan being the
Secondary Plan.
The Plan has specific guidelines regarding transplant services Benefits. Contact BCBSTX at
(800) 252-8039 (TTY: 711) for information about these guidelines.
You must obtain Prior Authorization from BCBSTX as soon as the possibility of a transplant
arises (and before the time a pre-transplantation evaluation is performed at a transplant
center). For Non-Network Benefits, if Prior Authorization BCBSTX is not obtained, Benefits for
an Inpatient Stay will be subject to an Additional Deductible of $200.
Support in the event of serious illness
If you or a covered family member has cancer or is in need of an organ or bone marrow
transplant, BCBSTX can put you in touch with quality treatment centers around the country.
Please call BCBSTX at (800) 252-8039 (TTY: 711) for more information.
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Urgent Care Center Services
The Plan provides Benefits for professional services received at an Urgent Care Center, as
defined in Section 13, Glossary. When Urgent Care services are provided in a Physician's office,
the Plan pays Benefits as described under Physician's Office Services - Sickness and Injury
earlier in this section.
Virtual Visits
The Plan covers Virtual Visits for certain Covered Health Services, including the diagnosis and
treatment of low acuity, non-Emergency medical conditions and certain Mental Health Services
for covered Participants, through the use of interactive audio and video telecommunication and
transmissions, and audio-visual communication technology. Virtual Visits allow for the
communication of medical information in real-time between the patient and a distant Physician,
behavioral health clinician or health care specialist, through use of interactive audio and video
communications equipment outside of a medical Facility (for example, from home or from work).
A Virtual Visit should not be used in place of regular visits to your Physician.
Benefits are available only when services are delivered through a Network Virtual Provider. This
Virtual Visits benefit does not include local Providers who offer Telemedicine services. For more
information, refer to Telemedicine above. You can find a Network Virtual Provider by going to
www.healthselectoftexas.com
and clicking on the medical benefits tab to access the Virtual
Visits link or by calling BCBSTX at (800) 252-8039 (TTY: 711).
Please Note: Not all medical or mental health conditions can be appropriately treated through a
Virtual Visit. The Network Virtual Provider will identify any condition for which treatment by in-
person Physician contact is necessary. Some Virtual Visit Provider groups may list other services
such as nutritional counseling or lactation services. These services are not covered by the Plan
when received from a Network Virtual Provider.
Covered Benefits under this section do not include charges for email, fax and standard telephone
calls, or for Telemedicine visits that occur within medical facilities, including facilities defined by
the Centers for Medicare & Medicaid Services (CMS) as originating facilities.
Vision Examinations
Covered Benefits include:
• vision screenings, which could be performed as part of an annual physical examination in a
Provider's office (vision screenings do not include refractive examinations to detect vision
impairment);
• one routine eye exam, including, but not limited to, refraction and glaucoma screening, to
detect vision impairment by a Provider in the Provider's office every Calendar Year. Routine
eye exams do not include contact lens exams; and
• non-routine or follow-up visits.
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SECTION 7 - EXCLUSIONS: WHAT THE MEDICAL PLAN
WILL NOT COVER
What this section includes
■ Services, supplies and treatments that are not Covered Health Services, except as may be
specifically provided for in Section 6, Details for Covered Health Services.
When Benefits are limited within any of the Covered Health Services categories described in
Section 6, Details for Covered Health Services, those limits are reflected in the corresponding
Covered Health Service category in Section 5, Schedule of Benefits and Coverage. Additional
limits may apply to some Covered Health Services that fall under more than one Covered Health
Service category. When this occurs, those limits are also stated in Section 5, Schedule of
Benefits and Coverage. Please review all limits carefully, as the Plan will not pay Benefits for any
of the services, treatments, items or supplies that exceed the Benefit limits.
Please note that in listing services or examples, when the MBPD says "this includes," or
"including, but not limited to," it is not the Plan's intent to limit the items to that specific
list. When the Plan does intend to limit a list of services or examples, the MBPD
specifically states that the list is limited to or covers only the specific items listed.
The Plan does not pay Benefits for the excluded services, treatments or supplies even if they are
recommended or prescribed by a Provider, are the only available treatment for your condition or
are determined by the Plan to be Medically Necessary. You are solely responsible for payment of
charges for all services and supplies excluded by the Plan and described in this section.
The following services, treatments and supplies are excluded from coverage under the
Plan:
Alternative Treatments
1. acupressure.
2. acupuncture.
3. aromatherapy.
4. hypnotism.
5. massage therapy except as described under Rehabilitation Services - Outpatient Therapy in
Section 6, Details for Covered Health Services.
6. medical marijuana treatment or therapy, including but not limited to cannabinoid treatments
and products such as oils, tinctures, and sprays.
7. rolfing (holistic tissue massage).
8. art therapy, music therapy, dance therapy, horseback therapy, wilderness experience therapy
and other forms of alternative treatment as defined by the National Center for
Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health. This
exclusion does not apply to Chiropractic Treatment and non-manipulative osteopathic care
for which Benefits are provided as described in Section 6, Details for Covered Health
Services.
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Dental
1. dental care, including, but not limited to, endodontics, periodontal surgery and restorative
treatment, except as identified under Dental Services in Section 6, Details for Covered Health
Services.
2. dental care that is required to treat the effects of a medical condition, but that is not
necessary to directly treat the medical condition, is excluded. An example of a non-covered
item is treatment of dental caries resulting from dry mouth due to radiation treatment or
medication.
3. diagnosis or treatment of or related to the teeth, jawbones or gums. Examples include, but
are not limited to:
• extractions (including, but not limited to, wisdom teeth);
• restoration and replacement of teeth;
• medical or surgical treatments of dental conditions; and
• services to improve dental clinical outcomes.
This exclusion does not apply to dental services for which Benefits are provided as described
under Dental Services in Section 6, Details for Covered Health Services.
4. dental implants, bone grafts, and other implant-related procedures.
This exclusion does not apply to dental services for which Benefits are provided as described
under Dental Services in Section 6, Details for Covered Health Services.
5. dental braces (orthodontics).
6. dental X-rays, supplies and appliances and all associated expenses, including, but not limited
to, hospitalizations and anesthesia.
This exclusion does not apply to:
• dental care (oral examination, X-rays, extractions and non-surgical elimination of oral
infection) required for the direct treatment of a medical condition; or
• hospitalization and anesthesia for certain Participants who cannot undergo local
anesthesia
This exclusion does not apply to dental services for which Benefits are available under the
Plan, as described in Section 6, Details for Covered Health Services.
7. treatment of malpositioned or supernumerary (extra) teeth, even if part of a Congenital
Anomaly.
Devices, Appliances and Prosthetics
1. devices used specifically as safety items or to affect performance in sports-related activities.
2. orthotic appliances and devices that straighten or re-shape a body part, except as described
under Durable Medical Equipment (DME) in Section 6, Details for Covered Health Services:
Examples of excluded orthotic appliances and devices include, but are not limited to, foot
orthotics or any orthotic braces available over-the-counter. This exclusion does not include
podiatric appliances for the prevention of complications associated with diabetes as
described under Diabetes Services in Section 6, Details for Covered Health Services.
3. the following items are excluded, even if prescribed by a Physician:
• blood pressure cuff/monitor;
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• enuresis alarm;
• non-wearable external defibrillator;
• trusses;
• ultrasonic nebulizers;
• fully implantable prosthetics; and
• prosthetics primarily designed to correct sexual dysfunction.
4. the repair and replacement of prosthetic devices when damaged due to misuse, malicious
breakage or gross neglect.
5. the replacement of lost or stolen prosthetic devices.
6. devices and computers to assist in communication and speech except for speech aid devices
and tracheo-esophageal voice devices for which Benefits are provided as described under
Durable Medical Equipment in Section 6, Details for Covered Health Services.
7. oral appliances to reduce snoring.
Drugs
1. Outpatient prescription drugs for Outpatient use that are filled by a prescription order or refill.
Note: Outpatient prescription medications are covered under the HealthSelect Prescription
Drug Program administered by OptumRx. Go to www.HealthSelectRx.com
for more
information about covered Outpatient use prescription medications.
2. self-injectable medications, except as described under Medications and Injections in Section
6, Details for Covered Health Services.
(This exclusion does not apply to medications which, due to their characteristics, as
determined by the Plan, must typically be administered or directly supervised by a qualified
Provider or licensed/certified health professional in an Outpatient setting). Note: Insulin and
certain self-injectable medications are Outpatient prescription medications covered under the
HealthSelect Prescription Drug Program administered by OptumRx.
3. growth hormone therapy that is not Medically Necessary.
4. non-injectable medications given in a Physician's office except as required in an Emergency
and consumed in the Physician's office.
5. over-the-counter drugs and treatments.
Educational Services
1. Services that are Educational in nature, as defined in Section 13, Glossary.
This exclusion does not apply to Diabetes Self-Management Training Programs for which
Benefits are provided as described under Diabetes Services in Section 6, Details for Covered
Health Services.
2. Tuition for or services that are school-based for children and adolescents under the
Individuals with Disabilities Education Act.
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Experimental or Investigational or Unproven Services
1. Experimental or Investigational Services or Unproven Services, as described in Section 13,
Glossary.
This exclusion applies even if Experimental or Investigational Services or Unproven Services,
treatments, devices or pharmacological regimens are the only available treatment options for
your condition.
This exclusion does not apply to Covered Health Services provided during a Clinical Trial for
which Benefits are provided as described under Clinical Trials in Section 6, Details for
Covered Health Services.
Foot Care
1. routine foot care services that include, but are not limited to:
• cutting or removal of corns and calluses;
• nail trimming or cutting; and
• debriding (removal of dead skin or underlying tissue).
This exclusion does not apply to foot care for severe systemic disease or preventive foot care
for Participants with diabetes for which Benefits are provided as described under Diabetes
Services in Section 6, Details for Covered Health Services.
2. hygienic and preventive maintenance foot care, except for Participants who are at risk of
neurological or vascular disease arising from diseases such as diabetes. Examples include,
but are not limited to:
• cleaning and soaking the feet;
• applying skin creams in order to maintain skin tone; and
• other services that are performed when there is not a localized Sickness, Injury or
symptom involving the foot.
3. treatment of flat feet.
4. treatment of subluxation of the foot.
5. arch supports.
6. shoe inserts, shoes (standard or custom), lifts and wedges and shoe orthotics.
This exclusion does not include podiatric appliances for the prevention of complications
associated with diabetes as described under Diabetes Services in Section 6, Details for
Covered Health Services.
Medical Supplies and Equipment
1. prescribed or non-prescribed medical and disposable supplies. Examples of excluded
supplies include, but are not limited to: compression stockings, ace bandages and wound
care or dressing supplies purchased over the counter.
This exclusion does not apply to:
• ostomy bags and related supplies for which Benefits are provided as described under
Ostomy Supplies in Section 6, Details for Covered Health Services;
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• disposable supplies necessary for the effective use of Durable Medical Equipment for
which Benefits are provided as described under Durable Medical Equipment in Section 6,
Details for Covered Health Services;
• urinary catheters;
• wound care or dressing supplies given by a Provider during treatment for Covered Health
Services;
• medical-grade compression stockings when considered Medically Necessary. The
stockings must be prescribed by a Physician, individually measured and fitted to the
patient; and
• diabetic supplies for which Benefits are provided as described under Diabetes Services in
Section 6, Details for Covered Health Services.
2. batteries, tubing, nasal cannulas, connectors and masks except when used with Durable
Medical Equipment.
3. the repair and replacement of Durable Medical Equipment when damaged due to misuse,
malicious breakage or gross neglect.
4. the replacement of lost or stolen Durable Medical Equipment.
Nutrition
1. services or supplies for Dietary and Nutritional Services, including home testing kits, vitamins,
dietary supplements and replacements, and special food items, except an Inpatient nutritional
assessment program provided in and by a Hospital and approved by BCBSTX.
2. nutritional counseling for either individuals or groups, except as identified under Diabetes
Services, under Therapies for Children with Developmental Delay Services and under
Nutritional Counseling in Section 6, Details for Covered Health Services.
3. enteral formulas and other nutritional and electrolyte formulas, including, but not limited to,
infant formula and donor breast milk (infant formula available over-the-counter is always
excluded) and home infusion therapy for over-the-counter fluids that do not require a
prescription, including, but not limited to, standard nutritional formulations used for enteral
nutrition therapy.
This exclusion does not apply to:
• enteral feedings or other nutritional formulas that are the only source or the majority of
nutrition or that are specifically created to treat inborn errors of metabolism or heritable
diseases such as phenylketonuria (PKU);
• Medically Necessary amino-acid based elemental formulas that are used for the
diagnosis and treatment of:
o immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food
proteins;
o severe food protein-induced enterocolitis syndrome;
o eosinophilic disorders, as evidenced by a biopsy; or
o impaired absorption of nutrients caused by disorders affecting the absorptive surface,
functional length, and motility of the gastrointestinal tract.
4. food of any kind. Examples include, but are not limited to:
• high-protein, low-protein or low-carbohydrate foods;
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• foods to control weight, treat obesity (including, but not limited to, liquid diets), lower
cholesterol or control diabetes;
• oral vitamins and minerals;
• meals you can order from a menu, for an additional charge, during an Inpatient Stay; and
• other dietary, nutritional and electrolyte supplements.
5. health education classes unless offered by BCBSTX or its affiliates, including, but not limited
to, asthma, smoking cessation, and weight control classes.
Personal Care, Comfort or Convenience
1. beauty/barber service.
2. guest service.
3. health club membership and programs.
4. personal or comfort items, including but not limited to televisions, telephones, guest beds,
admission kits, maternity kits and newborn kits provided by a Hospital or other Inpatient
Facility.
5. breast pumps except as Benefits are provided under the federal Health Resources and
Services Administration (HRSA) requirement as described under Preventive Care Services in
Section 6, Details for Covered Health Services.
6. concierge fees
7. supplies, equipment and similar incidentals for personal comfort. Examples include, but are
not limited to:
• air conditioners;
• air purifiers and filters;
• batteries and battery chargers, except as described under Hearing Aids and under
Durable Medical Equipment in Section 6, Details for Covered Health Services;
• car seats;
• chairs, bath chairs, feeding chairs, toddler chairs, chair lifts and recliners;
• dehumidifiers and humidifiers;
• ergonomically correct chairs;
• exercise equipment and treadmills;
• home modifications to accommodate a health need (including, but not limited to, ramps,
swimming pools, elevators, handrails, and stair glides);
• hot tubs, Jacuzzis, saunas and whirlpools;
• medical alert systems;
• music devices;
• non-Hospital beds, comfort beds, motorized beds and mattresses;
• personal computers;
• personal hygiene protection (for example, adult diapers);
• pillows;
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• power-operated vehicles;
• radios;
• strollers;
• safety equipment;
• vehicle modifications such as van lifts; and
• video players.
Physical Appearance
1. services or supplies for Cosmetic, Reconstructive or Plastic Surgery, even when Medically
Necessary, except as described in Reconstructive Procedures.
Examples include, but are not limited to:
• scar removal or revision procedures;
• breast enhancement procedures; and
• removal or replacement of an existing breast implant if the earlier breast implant was
performed as a Cosmetic Procedure.
2. physical conditioning programs such as athletic training, bodybuilding, exercise, fitness,
flexibility, spa treatments, and diversion or general motivational programs.
3. services or supplies for reduction of obesity or weight, including surgical procedures and
prescription drugs, even if the Participant has other health conditions which might be helped
by a reduction of obesity or weight, except for healthy diet counseling and obesity
screening/counseling as may be provided under Preventive Care Services.
This exclusion does not apply to:
• Covered HealthSelect weight loss programs, currently Wondr (formerly Naturally Slim)
and Real Appeal;
• Bariatric Surgery Benefits if program eligibility criteria are met as described in Section 6-
Details for Covered Health Services.
4. wigs regardless of the reason for the hair loss.
5. treatment of benign gynecomastia.
Procedures and Treatments
1. biofeedback.
2. tattoo removal or revision procedures (such as salabrasion, chemosurgery and other such
skin abrasion procedures).
3. hair removal or treatments for hair loss by any means.
4. procedures and treatments for skin wrinkles or any procedure or treatment to improve the
appearance of the skin, including, but not limited to, face lifts.
5. treatment for spider veins.
6. skin abrasion procedures performed as a treatment for acne.
7. medical and surgical treatment of snoring, except when provided as a part of treatment for
documented obstructive sleep apnea.
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8. rehabilitation services and Chiropractic Treatment to improve general physical condition that
are provided to reduce potential risk factors and where significant therapeutic improvement is
not expected, including, but not limited to, routine, long-term or maintenance/preventive
treatment.
9. speech therapy, except as described under Therapies for Children with Developmental Delay
Services or under Rehabilitation Services – Outpatient Therapy in Section 6, Details for
Covered Health Services.
10. a procedure or surgery to remove fatty tissue and/or hanging skin on any part of the body
including, but not limited to, panniculectomy, abdominoplasty, thighplasty, brachioplasty, or
mastopexy, even if hanging skin is due to weight loss or to Bariatric Surgery otherwise
covered under the Plan.
11. psychosurgery (lobotomy).
12. stand-alone multi-disciplinary smoking cessation programs. These programs usually include
services by health care Providers specializing in smoking cessation, such as a psychologist
or social worker, and also usually include intensive psychological support, behavior
modification techniques and medications to control cravings.
13. chelation therapy, except to treat heavy metal poisoning.
14. services provided by a chiropractor to treat a condition unrelated to an identifiable
neuromusculoskeletal condition, such as asthma or allergies, or services that do not meet the
definition of Chiropractic Treatment shown in Section 13, Glossary.
15. therapy treatments or procedures that result in similar or redundant therapeutic effects when
performed on the same body region during the same visit or office encounter.
16. gender reassignment surgery and services related to gender reassignment surgery.
17. non-surgical bariatric treatment, even if for morbid obesity.
18. Bariatric Surgery for Employees except as described under Bariatric Surgery in Section 6,
Details for Covered Health Services or Bariatric Surgery for Dependents or Retirees.
19. oral appliances and devices used to treat TMJ pain disorders or dysfunction of the joint, jaw,
jaw muscles and nerves.
20. the following services for the treatment of TMJ: any non-surgical treatment, including, but not
limited to, clinical examinations, arthrocentesis and trigger-point injections; surface
electromyography; Doppler analysis; vibration analysis; computerized mandibular scan or jaw
tracking; craniosacral therapy; orthodontics; occlusal adjustment and dental restorations.
21. health care services performed at a diagnostic Facility (Hospital or Alternate Facility) without
a written order from a Provider.
22. health care services which are self-directed to a free-standing or Hospital-based diagnostic
Facility.
23. health care services performed at a diagnostic Facility (Hospital or Alternate Facility), when
ordered by a Provider affiliated with the diagnostic Facility and when that Provider is not
actively involved in your medical care either prior to ordering the service or after the service is
received. This exclusion does not apply to mammography testing or bone density screening.
24. breast reduction surgery that is determined to be a Cosmetic Procedure. This exclusion does
not apply to breast reduction surgery that the Plan determines is for the treatment of a
physiologic functional impairment or is coverage required by the Women's Health and Cancer
Rights Act of 1998 for which Benefits are described under Reconstructive Procedures in
Section 6, Details for Covered Health Services.
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25. Mental Health Services as treatments for R-, T- and Z-code conditions as listed within the
current edition of the Diagnostic and Statistical Manual of the American Psychiatric
Association and/or Z codes listed within the current edition of the International Classification
of Diseases (ICD) of the World Health Organization.
Providers
1. health care services performed by a Provider who is your family member by birth or marriage,
including, but not limited to, your spouse, brother, sister, parent or child.
2. health care services that a Provider performs on himself or herself.
3. health care services performed by a Provider who has your same legal residence.
4. health care services performed by an unlicensed Provider or a Provider who is providing
health care services outside of the scope of his/her license.
5. any annual fee, retainer or similar fee paid to a Provider.
6. self-treatment by a Provider as a part of their training; treatment by an individual or Facility
outside the scope of licensed or otherwise authorized scope of practice.
Reproduction/Infertility
1. health services and associated expenses for infertility treatments, including, but not limited to,
artificial insemination, intra-fallopian transfer or other assisted reproductive technology,
regardless of the reason for the treatment. Also excluded are any services or supplies used in
any procedure in preparation for or performed as a direct result of and immediately after any
of the excluded procedures. This exclusion does not apply to services required to treat or
correct underlying causes of infertility.
Note: If a Pregnancy results from excluded infertility treatment, Pregnancy and newborn
services will be covered as described under Maternity Care in Section 5, Schedule of
Benefits and Coverage and Section 6, Details for Covered Health Services.
2. storage and retrieval of all reproductive materials (examples include, but are not limited to,
eggs, sperm, testicular tissue and ovarian tissue).
3. in vitro fertilization regardless of the reason for treatment. Also excluded are any services or
supplies used in any procedure in preparation for or performed as a direct result of and
immediately after in vitro fertilization.
4. surrogate parenting, donor eggs, donor sperm and host uterus.
5. the reversal of voluntary sterilization.
6. artificial reproductive treatments done for genetic or eugenic (selective breeding) purposes.
7. selective reduction surgery for multiple gestations. This exclusion does not apply if a
Physician states the Participant’s life would be endangered if the fetus was carried to term.
8. elective surgical, non-surgical or drug induced Pregnancy termination. This exclusion does
not apply if the Pregnancy termination is Medically Necessary.
9. services provided by a labor aide (doula).
10. parenting, pre-natal or birthing classes. This exclusion does not apply to breastfeeding
counseling as mandated by the Affordable Care Act.
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Services Provided Under Another Plan
Services for which coverage is available:
1. under another plan, except for Allowable Amounts payable as described in Section 9,
Coordination of Benefits (COB).
2. under workers' compensation, no-fault automobile coverage or similar plan if you could
purchase or elect it, or could have it purchased or elected for you.
3. while on active military duty.
4. for treatment of military service-related disabilities when you are legally entitled to other
coverage, and Facilities are reasonably accessible, as determined by the Plan.
Transplants
1. any and all transplants of organs, cells, and other tissues, except as described in Transplant
Services in Section 6, Details for Covered Health Services.
2. mechanical or animal organ transplants, except services related to the implant or removal of
a circulatory assist device (for example, a device that supports the heart while the patient
waits for a suitable donor heart to become available)
Travel
1. travel, lodging or transportation expenses, even if ordered by a Physician. This exclusion
does not apply to ambulance transportation for which Benefits are provided as described
under Ambulance Services in Section 6, Details for Covered Health Services.
Types of Care
1. Custodial Care as defined in Section 13, Glossary, or maintenance care.
2. Domiciliary Care, as defined in Section 13, Glossary.
3. multi-disciplinary pain management programs provided on an Inpatient basis for acute pain or
for exacerbation of chronic pain, unless determined by the Plan to be Medically Necessary.
4. Private Duty Nursing received on an Inpatient basis.
5. with respect to home health care, Hospice care, Outpatient Private Duty Nursing services or
care received in a Skilled Nursing Facility or Inpatient Rehabilitation Facility, the following:
• services provided for the convenience of the Participant or Participant’s family, such as
assistance with bathing, feeding, mobilizing, exercising or homemaking;
• services as a "sitter" or companion; and
• general supervision of exercises taught to the Participant including, but not limited to, the
actual carrying out of a maintenance program.
6. with respect to home health care, Hospice care or Outpatient Private Duty Nursing services,
the following:
• administration of oral medication;
• periodic turning and positioning in bed;
• food or home-delivered meals;
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• social casework or homemaker services; and
• transportation services.
7. respite care (Skilled Care or unskilled care to provide relief for a permanent caregiver),
unless provided as part of an integrated Hospice care program of services provided by a
licensed Hospice care agency for which Benefits are provided as described under Hospice
Care in Section 6, Details for Covered Health Services.
8. rest cures.
9. services of personal care attendants.
10. work hardening programs (individualized treatment programs designed to return a person to
work or to prepare a person for specific work).
Vision and Hearing
1. implantable lenses used only to correct a refractive error, including advanced lenses.
2. contact lens exams; purchase cost and associated fitting charges for eyeglasses or contact
lenses. This exclusion does not apply to glasses or contact lenses following cataract surgery
when Medically Necessary or contact lenses when prescribed to treat a Sickness or Injury of
the cornea.
3. dispensing fees for hearing aids.
4. repairs to a hearing aid, even if the hearing aid purchase was a Covered Health Service
under the Plan.
5. bone anchored hearing aids except when either of the following applies:
• for Participants with craniofacial anomalies whose abnormal or absent ear canals
preclude the use of a wearable hearing aid; or
• for Participants with hearing loss of sufficient severity that it would not be adequately
remedied by a wearable hearing aid, as documented by a Physician.
The Plan will not pay for more than one bone anchored hearing aid per Participant who
meets the above coverage criteria during the entire period of time the Participant is enrolled
in this Plan. In addition, repairs and/or replacement for a bone anchored hearing aid for
Participants who meet the above coverage are not covered, other than for malfunctions.
5. eye exercise or vision therapy, except any of the following therapies when ordered by a
Physician to treat the specific related condition:
• occlusion therapy for amblyopia;
• prism adaptation therapy for esotropia; or,
• orthoptic or vision therapy for convergence insufficiency.
6. surgery and other related treatment that is intended to correct nearsightedness,
farsightedness, presbyopia and astigmatism including, but not limited to, procedures such as
laser and other refractive eye surgery and radial keratotomy.
All Other Exclusions
1. autopsies and other coroner services and transportation services for a corpse.
2. charges for:
• missed appointments;
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102 SECTION 7 – EXCLUSIONS
• room or Facility reservations;
• completion of claim forms; and
• record processing.
3. charges prohibited by federal anti-kickback or self-referral statutes.
4. diagnostic tests that are:
• delivered in other than a Physician's office or health care Facility; or
• self-administered home diagnostic tests, including but not limited to, HIV and Pregnancy
tests, except for Cologuard screening as defined in Section 6, Details for Covered Health
Services.
5. expenses for health services and supplies:
• that would otherwise be considered Covered Health Services and are received as a
result of war or any act of war, whether declared or undeclared, while part of any armed
service force of any country. This exclusion does not apply to Participants who are
civilians injured or otherwise affected by war, any act of war or terrorism in a non-war
zone;
• that are received after the date your coverage under this Plan ends, including health
services for medical conditions that began before the date your coverage under the Plan
ends;
• for which you have no legal responsibility to pay, or for which a charge would not
ordinarily be made in the absence of coverage under this Plan;
• that exceed Allowable Amounts or any specified limitation in this MBPD; or
• for which a Non-Network Provider waives the Copay, Annual Non-Network Deductible or
Coinsurance amounts.
6. foreign language and sign language services.
7. long term (more than 30 days) storage of blood, umbilical cord or other biological material.
Examples include, but are not limited to, cryopreservation of tissue, blood and blood
products.
8. health services and supplies that do not meet the definition of a Covered Health Service as
shown in Section 13, Glossary.
9. health services related to a non-Covered Health Service: When a service is not a Covered
Health Service, all services related to that non-Covered Health Service are also excluded
even in an emergency. This exclusion does apply to services the Plan would otherwise
determine to be Covered Health Services if they are to treat complications that arise from the
non-Covered Health Service even if the treatment of the complication is considered to be
Medically Necessary, prescribed by a Physician or if the Participant has medical or
psychological conditions that could be helped by the surgery, services, supplies, treatments,
or procedures.
For the purpose of this exclusion, a "complication" is an unexpected or unanticipated
condition that is superimposed on an existing disease and that affects or modifies the
prognosis of the original disease or condition. Examples of a "complication" are bleeding or
infections, following a Cosmetic Procedure, that require hospitalization.
10. physical, psychiatric or psychological exams, testing, vaccinations, immunizations,
treatments, or vocational counseling when:
• required solely for purposes of education, sports or camp, travel, career or employment,
insurance, marriage or adoption; or as a result of incarceration;
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103 SECTION 7 – EXCLUSIONS
• conducted for purposes of medical research. This exclusion does not apply to Covered
Health Services provided during a Clinical Trial for which Benefits are provided as
described under Clinical Trials in Section 6, Details for Covered Health Services;
• related to judicial or administrative proceedings or orders; or
• required to obtain or maintain a license of any type.
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104 SECTION 8 – CLAIMS PROCEDURES
SECTION 8 - CLAIMS PROCEDURES
What this section includes
■ How Network and Non-Network medical and mental health claims work; and
■ What you may do if your medical or mental health claim is denied, in whole or in part.
Note: You may designate an Authorized Representative who has the authority to represent you in
all matters concerning your claim or appeal of a claim determination. If you have an Authorized
Representative, any references to “you” or “Participant” in this Section 8 will refer to the
Authorized Representative. See Authorized Representative below for details.
Claims Processing for Network and Non-Network Benefits
BCBSTX has a nationwide Network of participating Providers. Claims processing for Benefits
depends on whether you receive Covered Health Services from a Network or a Non-Network
Provider.
Network Benefits
In general, if you receive Covered Health Services from a Network Provider, BCBSTX will pay the
Physician or Facility directly. If a Network Provider bills you for any Covered Health Service other
than your Copay or Coinsurance, please contact the Provider or call BCBSTX at (800) 252-8039
(TTY: 711) for assistance.
Keep in mind, you are responsible for paying any Copay or Coinsurance owed to a Network
Provider at the time of service, or when you receive a bill from the Provider.
Non-Network Benefits
If you receive a bill for Covered Health Services from a Non-Network or Non-Contracted Provider,
you (or the Provider if they prefer) must send the bill to BCBSTX for processing. To make sure
the claim is processed promptly and accurately, a completed claim form must be attached and
mailed to BCBSTX at the following address:
Blue Cross and Blue Shield of Texas – Claims
P.O. Box 660044
Dallas, Texas 75266-0044
If Your Provider Does Not File Your Claim
You can obtain a claim form by visiting www.healthselectoftexas.com, calling BCBSTX at (800)
252-8039 (TTY: 711) or contacting your Benefits Coordinator. If you do not have a claim form,
simply attach a brief letter of explanation to the bill, and verify that the bill contains the information
listed below. If any of these items are missing from the bill, you can include them in your letter:
• your name and address;
• the Participant’s name, age and relationship to the Subscriber;
• the ID number as shown on your HealthSelect medical ID card;
• the name, address and tax identification number of the Provider of the service(s);
• a diagnosis from the Physician;
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105 SECTION 8 – CLAIMS PROCEDURES
• the date of service;
• an itemized bill from the Provider that includes:
o the Current Procedural Terminology (CPT) codes;
o a description of, and the charge for, each service;
o the date the Sickness or Injury began; and
o a statement indicating either that you are, or you are not, enrolled for coverage under any
other health insurance plan or program. If you are enrolled for other coverage you must
include the name and address of the other insurer(s).
Failure to provide all the information listed above may delay any reimbursement that may be due
you.
The above information should be filed with BCBSTX at the following address:
Blue Cross and Blue Shield of Texas – Claims
P.O. Box 660044
Dallas, Texas 75266-0044
Intentionally false statements of material fact may result in adverse action against you, including,
but not limited to, termination of your health coverage and expulsion from the GBP.
An act, practice, or omission that constitutes fraud, or an intentional misrepresentation of material
fact, as prohibited by the terms of the Plan or coverage, may result in rescission of coverage.
Prior to rescinding coverage, the Plan shall provide at least thirty (30) days advance written notice
to each Participant who would be affected.
Claim Payment and Assignment
After BCBSTX has processed your claim, you will receive payment for Benefits that the Plan
allows. If you have used a Non-Network Provider or Non-Contracted Provider, it is your
responsibility to pay the Non-Network Provider or Non-Contracted Provider the charges you
incurred. If you used a Non-Contracted Provider, it is your responsibility to pay the Non-
Contracted Provider any difference between what you were billed and what the Plan paid.
Providers may not bill you for amounts exceeding your Participant responsibility for
Deductibles, Copayments, and Coinsurance as part of the Plan Allowable Amount if you
receive services from a Non-Network Provider performed at a Network Facility, or Non-
Network laboratory or diagnostic imaging services in connection with care delivered by a
Network Provider, without your advance, written agreement. See Section 3, How the Plan
Works, under the heading Accessing Benefits for more information.
BCBSTX will pay Benefits to you unless:
• the Provider notifies BCBSTX that you have provided signed authorization to assign Benefits
directly to that Provider; or
• you make a written request for the Non-Network or Non-Contracted Provider to be paid
directly at the time you submit your claim.
BCBSTX will only pay Benefits to you or, with written authorization by you, to your Provider, and
not to a third party, even if your Provider has assigned Benefits to that party.
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106 SECTION 8 – CLAIMS PROCEDURES
Explanation of Benefits (EOB)
BCBSTX will send you a paper copy of an Explanation of Benefits (EOB) after processing each of
your medical claims submitted. The EOB will let you know the amount you are responsible for. If
any claim is denied in whole or in part, the EOB will include the reason for the denial or partial
payment. Please note that your EOB will not reflect amounts you may have already paid to the
Provider. If you would like to stop receiving paper copies of the EOBs and only receive EOBs
electronically, you may “go green” and turn off paper copies online at
www.healthselectoftexas.com
. See Section 13, Glossary, for the definition of Explanation of
Benefits. If you do not receive an EOB or would like a copy of your EOB, call a BCBSTX Personal
Health Assistant at (800) 252-8039 (TTY: 711).
Note: Upon receipt of a claim from your Provider, BCBSTX may need to request additional
information including medical records. BCBSTX will work directly with your Network Provider to
obtain the information needed.
Timely Filing Claim Limitations
Claims for services rendered must be filed within certain time limits to be eligible for Benefits and
payment under the Plan.
Network Provider Timely Filing Limitations
If you receive services from a Network Provider, your Provider is required to submit claims to
BCBSTX within 180 days from the date of service. If the claim is not submitted by your Provider
within 180 days from the date of service, the claim will be denied as untimely and no Benefits will
be paid to your Provider. You are not responsible for payment to a Network Provider for any
services or claims not submitted timely by the Network Provider to BCBSTX.
Non-Contracted Provider Timely Filing Limitations
If you received services from a Non-Contracted Provider, you may be required to pay up front and
file the claim to BCBSTX for the services rendered. For details on how to file a claim, see If Your
Provider Does Not File Your Claim, in this Section. Your claim submission for Non-Contracted
services must be received by BCBSTX within 18 months from the date of the service. If your
submitted Non-Contracted service claim is received by BCBSTX more than 18 months from the
date of service, the claim will be denied as untimely and Benefits will not be paid to you or your
Provider.
If you receive services from a Non-Contracted Provider in the state of Texas, the Provider has 95
days, from the date of service, to file the claim to BCBSTX. If the Non-Contracted Provider
submitted claim is received by BCBSTX more than 95 days from the date of service, the claim will
be denied as untimely and Benefits will not be paid to you or your Provider.
If you receive services from a Non-Contracted Provider outside the state of Texas, the Provider
has 12 months, from the date of service, to file the claim to BCBSTX. If the claim submitted by
your Provider is received BCBSTX more than 12 months from the date of service, the claim will
be denied as untimely and Benefits will not be paid to you or your Provider.
Non-Contracted Providers can bill you for services that are ineligible for Benefits under the Plan
because a claim was not submitted timely for payment to BCBSTX. To avoid additional cost, you
should discuss services you will receive with the Non-Contracted Provider prior to receiving care.
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107 SECTION 8 – CLAIMS PROCEDURES
Claim Denials and Appeals
If Your Claim Is Denied
If a claim for Benefits is denied in part or in whole, you may call BCSTX at (800) 252-8039 (TTY:
711) before requesting a formal appeal. If BCBSTX cannot resolve the issue to your satisfaction
over the phone, you have the right to file a formal appeal as described below.
BCBSTX may use one or more affiliated entities to provide utilization management services.
Those services may include review for Medical Necessity determination and one or more review
stages related to an appeal. The timing and process of each appeal remains generally the same
regardless of which entity is conducting the appeal. You may receive a letter from an entity
affiliated with BCBSTX with instructions for proper routing of your appeal during the first or
second appeal stage. These letters also include the Plan’s logo to indicate that they are
associated with HealthSelect. You may always call BCBSTX at (800) 252-8039 (TTY: 711) with
any questions.
How to Appeal a Denied Claim
If you wish to appeal a denied Pre-Service Request for Benefits, concurrent claim, or Post-
Service Claim, you or your Authorized Representative must submit your appeal within 180 days
of receiving the adverse benefit determination. Appeals can be submitted in writing via mail, fax,
or secure message within your Blue Access for Members account. You may also initiate an
appeal verbally by calling a BCBSTX Personal Health Assistant at (800) 252-8039 (TTY: 711).
The following information should be provided:
• the Participant’s name and ID number as shown on the HealthSelect medical ID card;
• the Provider's name;
• the date of medical service;
• the reason you disagree with the denial; and
• any documentation or other written information to support your appeal.
You or your Authorized Representative may send a written appeal to:
Blue Cross and Blue Shield of Texas - Appeals
P. O. Box 660044
Dallas, Texas 75266-0044
You do not need to submit appeals in writing for Urgent Requests for Benefits. For denied Urgent
Requests, you or your Provider can call BCBSTX at (800) 252-8039 (TTY: 711) to request an
appeal.
Types of claims
The timing of the claims appeal process is based on the type of claim you are appealing. If you
wish to appeal a claim, it helps to understand whether it is an:
■ Urgent Request for Benefits;
■ Pre-Service Request for Benefits;
■ concurrent care claim;
■ Post-Service Claim; or
■ rescission of coverage.
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108 SECTION 8 – CLAIMS PROCEDURES
First Internal Appeal
BCBSTX will conduct a full and fair review of your appeal. The appeal may be reviewed by:
• an appropriate individual(s) who did not make the initial benefit determination; and
• a health care professional with appropriate expertise who was not consulted during the initial
Benefit determination process.
Once the review is complete, if BCBSTX upholds the denial, you and your Provider will receive a
written explanation of the reasons and facts relating to the denial and a description of the
additional appeal procedures. If BCBSTX overturns the denial, you and your Provider will receive
notification of its decision and Benefits will be paid, as appropriate.
Notes:
• A denial of Benefits for medical services does not mean that you cannot receive the medical
services. A denial of the Benefits means the medical services are not covered by the Plan
and payments are not made by the Plan to you or any Providers by the Plan if you receive
the denied medical services, unless a subsequent appeal overturns the initial denial of
benefits.
• If your Urgent Request for Benefits was denied, you may request an expedited external
review at the same time you request an expedited internal appeal to BCBSTX. BCBSTX will
review the request to determine if the appeal should go directly to the expedited external
review instead of through the internal appeal process. If the request for appeal does not meet
the expedited external appeal criteria as determined by BCBSTX, the appeal will be handled
as an expedited internal appeal to BCBSTX.
Second Internal Appeal to Blue Cross and Blue Shield of Texas of an
Urgent Request for Benefits, a Pre-Service Request for Benefits, or a
Concurrent Claim
If you are not satisfied with the first internal appeal decision regarding an Urgent Request for
Benefits, a Pre-Service Request for Benefits, or a concurrent claim, you have the right to request
a second internal appeal from BCBSTX. You must file a written request for the second internal
appeal within 60 days from your receipt of the first internal appeal determination notification.
If you do not request a second internal appeal from BCBSTX within 60 days from your receipt of
the first internal appeal determination notification, the denial will be upheld due to untimely filing.
If your non-urgent Pre-Service Request for Benefits is denied, you may file a second internal
appeal to BCBSTX. If the denial is upheld at the second internal appeal level, BCBSTX will notify
you of the reason(s) for its decision and that your internal appeal options are exhausted. If the
appeal involves issues of medical judgment, you may request an external review. If BCBSTX
overturns its decision at the second internal appeal level, BCBSTX will notify you of its decision
and Benefits will be paid, as appropriate.
Note: Upon written request, Participants may examine documents relevant to their claims and/or
appeals at no cost and submit opinions and comments. BCBSTX will review all claims in
accordance with the rules established by the U.S. Department of Labor.
For more information on the appeals process, see the ERS’ Participant Guide to the Appeal
Process at https://www.ers.texas.gov/PDFs/GBP-Appeal-Process-Precedent-Manual
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109 SECTION 8 – CLAIMS PROCEDURES
Second Internal Appeal to ERS of a Post-Service Claim
If you are not satisfied with the first internal appeal decision regarding a Post-Service Claim,
you have the right to request a second internal appeal from ERS. You must file a written
request for the second internal appeal within 90 days from your receipt of the first level appeal
determination notification. If you do not request a second internal appeal from ERS within 90
days from your receipt of the first level appeal determination notification, the denial will be
upheld due to untimely filing.
If ERS upholds the denial at the second internal appeal level, ERS will notify you of the reasons
for its decision and that your internal appeal options are exhausted. If your appeal involves issues
of medical judgment, you may request an external review. If ERS overturns the denial, BCBSTX
will notify you and Benefits will be paid, as appropriate.
ERS does not review denials of Pre-Service Requests for Benefits, Urgent Requests for Benefits
or concurrent claims.
Appeal to ERS of a Rescission of Coverage
Rescission is the cancellation or discontinuance of coverage that has retroactive effect. Your
coverage may not be rescinded unless you or a person seeking coverage on your behalf
performs an act, practice or omission that constitutes fraud, or makes an intentional
misrepresentation of material fact. A cancellation or discontinuance of coverage that has only
prospective effect is not a rescission. A retroactive cancellation or discontinuance of coverage
based on a failure to timely pay required premiums or contributions toward the cost of coverage
(including COBRA premiums) is not a rescission. You will be given 30 days advance notice of
rescission. A rescission is considered an adverse benefit determination for which you may seek
internal review and external review.
If your coverage is rescinded by ERS, you have the right to request an internal appeal from ERS.
Your notification of rescission will contain instructions for filing an appeal. You must file a written
request for the internal appeal within 180 days from your receipt of the rescission notification. If
you do not request an appeal from ERS within 180 days from your receipt of the rescission
notification, the rescission will be upheld due to untimely filing.
If ERS upholds the rescission of coverage, ERS will notify you of the reason(s) for its decision
and that your internal appeal options are exhausted. You may request an external review of the
denial of your appeal related to a rescission of coverage.
Timely Review
BCBSTX and ERS will complete reviews within legally applicable time periods; however,
BCBSTX and ERS have the right to an extension under certain circumstances.
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110 SECTION 8 – CLAIMS PROCEDURES
Mediation/Arbitration Rights
There are mediation or arbitration rights under Chapter 1467 of the Texas Insurance Code. You
may refer to your EOB for specific information about any available mediation or arbitration
rights.
You should not be billed for any amounts above your responsibility for Deductibles, Copays
and Coinsurance in the following instances:
• Emergency Health Services or supplies you receive from a Non-Network Provider;
• Services from a Non-Network Provider that you receive in a Network Facility, unless you
agreed in writing in advance to receive the Non-Network services; or
• Lab or diagnostic imaging services you receive from a Non-Network lab or diagnostic imaging
service that were ordered by a Network provider, unless you agreed in writing in advance to
receive the Non-Network services.
If you receive a bill for amounts above your responsibility in the scenarios listed above without
providing your written consent in advance, please contact a BCBSTX Personal Health
Assistant at (800) 252-8039 (TTY: 711).
Tables 5 through 8 below describe the time frames which you and BCBSTX are required to
follow.
TABLE 5
Urgent Request for Benefits
1
Action to Be Taken Timing
2
If your Request for Benefits is complete, BCBSTX must notify you
within:
72 hours
If your Request for Benefits is incomplete, BCBSTX must notify
you that it is incomplete within:
24 hours
You must then provide the completed Request for Benefits to
BCBSTX within:
48 hours after receiving
notice of additional
information required
BCBSTX must notify you and your Provider of the benefit
determination within:
48 hours after receipt of
additional information
If BCBSTX denies your Request for Benefits, you must appeal an
adverse benefit determination no later than:
180 days after receiving
the adverse benefit
determination
BCBSTX must notify you of the first internal appeal decision within: 72 hours after receiving
the appeal
1
You do not need to submit Urgent appeals in writing. You should call BCBSTX as soon as possible to appeal an
Urgent Request for Benefits.
2
From when the request is made unless otherwise noted below.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
111 SECTION 8 – CLAIMS PROCEDURES
TABLE 6
Pre-Service Request for Benefits
Action to Be Taken Timing
1
If your Request for Benefits is filed improperly with BCBSTX, it
must notify you within:
5 days
If your Request for Benefits is incomplete BCBSTX must notify
you within:
15 days
You must then provide completed Request for Benefits information
to BCBSTX within:
45 days
BCBSTX must notify you of the Benefit determination:
if your Request for Benefits is complete, within:
15 days
after receiving the completed Request for Benefits (if your
Request for Benefits was incomplete as filed), within:
15 days
You must appeal an adverse benefit determination no later than: 180 days after receiving
the adverse benefit
determination
BCBSTX must notify you of the first internal appeal decision
within:
15 days after receiving
the first internal appeal
You must appeal the denial of your first internal appeal (by filing a
second internal appeal) no later than:
60 days after receiving
the first internal appeal
decision
BCBSTX must notify you of the second internal appeal decision
within:
15 days after receiving
the second internal
appeal
1
From when the request is made unless otherwise noted below.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
112 SECTION 8 – CLAIMS PROCEDURES
TABLE 7
Post-Service Claims
Action to Be Taken Timing
1
If your claim is incomplete, BCBSTX must notify you within: 30 days
You must then provide completed claim information to BCBSTX
within:
45 days
BCBSTX must notify you of the Benefit determination:
if the claim was complete as filed, within:
30 days
after receiving the completed claim (if the claim was incomplete as
filed), within:
30 days
You must appeal an adverse benefit determination no later than: 180 days after receiving
the adverse benefit
determination
BCBSTX must notify you of the first internal appeal decision no
later than:
30 days after receiving
the first internal appeal
You must appeal the denial of your first internal appeal (by filing
a second internal appeal with ERS) no later than:
90 days after receiving
the first internal appeal
decision
BCBSTX or ERS must notify you of the second internal appeal
decision within:
30 days after receiving
the second internal
appeal
1
From when the request is made unless otherwise noted below.
TABLE 8
Rescission of Coverage
Action to Be Taken
Timing
1
You must appeal a rescission of coverage, which is an adverse
benefit determination, to ERS no later than:
180 days after receiving
the adverse benefit
determination
ERS must notify you of the final internal appeal decision no
later than:
60 days after receiving
the first internal appeal
1
From when the request is made unless otherwise noted below.
External Review Program
If, after exhausting your internal appeals, you are not satisfied with the determination made by
BCBSTX or ERS, or if BCBSTX or ERS fails to respond to your appeal in accordance with
applicable regulations regarding timing, you may be entitled to request an immediate external
review of the determination made by BCBSTX or ERS. The process is available at no charge to
you.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
113 SECTION 8 – CLAIMS PROCEDURES
If one of the above conditions is met, you may request an external review of an adverse benefit
determination based upon any of the following:
• clinical reasons (the determination involves a question of medical judgment);
• rescission of coverage (coverage that was terminated retroactively); or
• as otherwise required by applicable law.
Note: You may also have the right to pursue external review in the event that BCBSTX or ERS
failed to comply with the internal claims and appeals process, except for those failures that are
based on de minimis violations that do not cause, and are not likely to cause, prejudice or harm to
you.
You or your Authorized Representative may request a standard external review by sending a
written request to the address set out in the determination letter. You or your Authorized
Representative may request an expedited external review, in urgent situations as detailed
below, by calling BCBSTX at (800) 252-8039 (TTY: 711) or by sending a written request to the
address set out in the determination letter. A request must be made within four months after
the date you receive BCBSTX’ or ERS’ determination.
An external review request should include all of the following:
• a specific request for an external review;
• the Participant’s name, address, and insurance ID number;
• your Authorized Representative's name and address, when applicable;
• the service that was denied, the date of service, the Provider’s name; and
• any new, relevant information that was not provided during the internal appeal.
An external review will be performed by an Independent Review Organization (IRO). BCBSTX
has entered into agreements with three or more IROs that have agreed to perform such reviews.
There are two types of external reviews available:
• a standard external review; and
• an expedited external review.
Standard External Review
A standard external review is comprised of all of the following:
• a preliminary review by BCBSTX of the request;
• a referral of the request by BCBSTX to the IRO;
• the review by the IRO; and
• a decision by the IRO.
Within the applicable time frame after receipt of the request, BCBSTX will complete a preliminary
review to determine whether the Participant for whom the request was submitted meets all of the
following:
• was covered under the Plan at the time the health care service or procedure that is at issue in
the request was provided;
• has exhausted the applicable internal appeals process; and
• has provided all the information and forms required so that BCBSTX may process the
request.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
114 SECTION 8 – CLAIMS PROCEDURES
After BCBSTX completes the preliminary review, BCBSTX will issue you a notification in writing
within five business days of receiving the request for the external review. If the request is eligible
for external review, BCBSTX will assign an IRO to conduct such review. BCBSTX will assign IRO
requests by either rotating claims assignments among the IROs or by using a random selection
process.
BCBSTX will provide the assigned IRO with the documents and information considered in making
BCBSTX’ or ERS’ determination. The documents include:
• all relevant medical records;
• all other documents relied upon by BCBSTX or ERS;
• all other information or evidence that you or your Provider submitted regarding the claim; and
• all other information or evidence that you or your Provider wish to submit regarding the claim,
including, as explained below, any information or evidence you or your Provider wish to
submit that was not previously provided.
The IRO will notify you in writing of the request’s eligibility and acceptance for external review.
You may submit in writing to the IRO within ten business days following the date you receive
notice from the IRO, any additional information that you want the IRO to consider when
conducting the external review. The IRO is not required to, but may, accept and consider
additional information submitted by you after ten business days. In reaching a decision, the IRO
will review the claim anew and will not be bound by any decisions or conclusions reached by
BCBSTX or ERS. The IRO will provide written notice of its determination (the “Final External
Review Decision”) within 45 days after it receives the request for the external review (unless the
IRO requests additional time and you agree). The IRO will deliver the notice of Final External
Review Decision to you and BCBSTX, and it will include the clinical basis for the determination.
Upon receipt of a Final External Review Decision reversing BCBSTX’ or ERS’ determination,
BCBSTX will notify you within 48 hours of receiving the IRO’s decision. The Plan will immediately
provide coverage or payment of the Benefits at issue in accordance with the terms and conditions
of the Plan. If the Final External Review Decision is that payment or referral will not be made, the
Plan will not be obligated to provide Benefits for the health care service or procedure and you will
have exhausted your appeal rights.
All Final External Review Decisions by an IRO are final and binding on all parties and not subject
to further appeal rights.
Expedited External Review
An expedited external review is similar to a standard external review. The most significant
difference between the two is that the time periods for completing certain portions of the review
process are much shorter, and in some instances you may file an expedited external review
before completing the internal appeals process.
You may make a written or verbal request for an expedited external review if you receive either of
the following:
• an adverse benefit determination of a claim or appeal if the adverse benefit determination
involves a medical condition for which the time frame for completion of a standard internal
appeal would seriously jeopardize the life or health of the Participant or would jeopardize the
Participant’s ability to regain maximum function and you have filed a request for an expedited
internal appeal; or
• a final appeal decision, if the determination involves a medical condition where the time frame
for completion of a standard external review would seriously jeopardize the life or health of
the Participant or would jeopardize the Participant’s ability to regain maximum function, or if
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
115 SECTION 8 – CLAIMS PROCEDURES
the final appeal decision concerns an admission, availability of care, continued stay, or health
care service, procedure or product for which the Participant received Emergency services,
but has not been discharged from a Facility.
Immediately upon receipt of the request, BCBSTX will determine whether the Participant meets
both of the following:
• was covered under the Plan at the time the health care service or procedure that is at issue in
the request was provided; and
• has provided all the information and forms required so that BCBSTX may process the
request.
After completing the review, BCBSTX will immediately send a notice in writing to you. Upon a
determination that a request is eligible for expedited external review, BCBSTX will assign an IRO
in the same manner BCBSTX utilizes to assign standard external reviews to IROs. BCBSTX will
provide all necessary documents and information considered in making the adverse benefit
determination or final adverse benefit determination to the assigned IRO electronically or by
telephone or facsimile or any other available expeditious method. The IRO, to the extent the
information or documents are available and the IRO considers them appropriate, must consider
the same type of information and documents considered in a standard external review.
In reaching a decision, the IRO will review the claim anew and not be bound by any decisions or
conclusions reached by BCBSTX. The IRO will provide notice of the Final External Review
Decision for an expedited external review as expeditiously as the Participant’s medical condition
or circumstances require, but in no event more than 72 hours after the IRO receives the request.
If the IRO’s notice of the Final External Review Decision is not in writing, within 48 hours of
providing such notice, the assigned IRO will provide written confirmation of the decision to you
and to BCBSTX.
All Final External Review Decisions by an IRO are final and binding on all parties and not subject
to further appeal rights.
You may contact BCBSTX at (800) 252-8039 (TTY: 711) for more information regarding external
review rights, or if making a verbal request for an expedited external review.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
116 SECTION 8 – CLAIMS PROCEDURES
Table 9 below describes the time frames which you, BCBSTX and the IRO are required to follow.
TABLE 9
External Review
Action to Be Taken Timing
1
You must submit a request for external review to BCBSTX within: Four months after the
date you receive the
second internal appeal
determination
For an expedited external review, the IRO will provide notice of its
determination within:
72 hours
For a standard external review, BCBSTX will complete a
preliminary review to ensure the request meets requirements for
an external review within:
5 business days
You may submit in writing to the IRO any additional information
that you want the IRO to consider within:
10 business days
For a standard external review, the IRO will provide written notice
of its determination within:
45 days
2
after receiving
the request for the
external review
1
From when the request is made unless otherwise noted below.
2
This time frame may be extended if the IRO requests additional time and you agree.
Concurrent Care Claims
If an on-going course of treatment was previously approved for a specific period of time or
number of treatments, and your request to extend the treatment is an Urgent Request for Benefits
as defined above, your request will be decided within 24 hours, provided your request is made at
least 24 hours prior to the end of the approved treatment.
BCBSTX will make a determination on your request for the extended treatment within 24 hours
from receipt of your request.
If your request for extended treatment is not made at least 24 hours prior to the end of the
approved treatment, the request will be treated as an Urgent Request for Benefits and decided
according to the time frames described above. If an on-going course of treatment was previously
approved for a specific period of time or number of treatments, and you request to extend
treatment in a non-urgent circumstance, your request will be considered a new request and
decided according to post-service or pre-service time frames, whichever applies.
Authorized Representative
A Participant may have one Authorized Representative, and only one Authorized Representative
at a time, to assist in submitting a claim or appealing a claim.
An Authorized Representative shall have the authority to represent the Participant in all matters
concerning the Participant’s claim or appeal of a claim determination. If the Participant has an
Authorized Representative, any references to “you” or “Participant” in this Section 8 will refer to
the Authorized Representative.
One of the following persons may act as a Participant’s Authorized Representative:
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
117 SECTION 8 – CLAIMS PROCEDURES
• an individual designated by the Participant in writing on a form approved by BCBSTX;
• a health care Provider designated by the Participant in writing on a form approved by
BCBSTX. For Urgent Care claims, a health care Provider may act as a Participant’s
Authorized Representative without the Participant’s written designation;
• a person holding the Participant’s durable power of attorney;
• if the Participant is legally incapacitated, a person appointed as guardian of the Participant by
a court of competent jurisdiction; or
• if the Participant is a minor, the Participant’s parent or legal guardian, unless BCBSTX is
notified that the Participant’s claim involves health care services where the consent of the
Participant’s parent or legal guardian is or was not required by law, in which case the
Participant may represent himself or herself with respect to the claim.
The authority of an Authorized Representative shall continue for the period specified in the
Participant’s appointment of the Authorized Representative or until the Participant is legally
competent to represent himself or herself and notifies BCBSTX in writing that the Authorized
Representative is no longer required.
Communication with Authorized Representative
1. If the Authorized Representative represents the Participant because the Authorized
Representative is the Participant’s parent or legal guardian or attorney in fact under a durable
power of attorney, BCBSTX shall send all correspondence, notices and benefit
determinations in connection with the Participant’s Claim to the Authorized Representative.
2. If the Authorized Representative represents the Participant in connection with the submission
of a Pre-Service Claim, including a claim involving Urgent Care, BCBSTX shall send all
correspondence, notices and benefit determinations in connection with the Participant’s claim
to the Authorized Representative.
3. If the Authorized Representative represents the Participant in connection with the submission
of a Post-Service Claim, BCBSTX will send all correspondence, notices and benefit
determinations in connection with the Participant’s Claim to the Participant and the
Authorized Representative.
4. It can take BCBSTX 30 days or more to notify all of its personnel about the termination of the
Participant’s Authorized Representative. It is possible that BCBSTX may communicate
information about the Participant to the Authorized Representative during this 30-day period.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
118 SECTION 9 – COORDINATION OF BENEFITS (COB)
SECTION 9 - COORDINATION OF BENEFITS (COB)
What this section includes
■ How your Benefits under this Plan coordinate with other medical plans;
■ How your coverage is affected if you become eligible for Medicare; and
■ Procedures in the event the Plan overpays Benefits.
Coordination of Benefits (COB) applies to you if you are covered by more than one health
benefits plan, including, but not limited to, any one of the following:
• another employer-sponsored health benefits plan;
• another group insurance plan;
• a medical component of a group long-term care plan, such as skilled nursing care;
• no-fault or traditional "fault" type medical payment benefits or personal Injury protection
benefits under an automobile insurance policy;
• medical payment benefits under any premises liability or other types of liability coverage; or
• Medicare or other governmental health benefit.
COB does not apply if your other health plan is a health insurance policy that is individually
underwritten or issued and prohibits COB. We recommend that you check with your other health
plan administrator if you are not sure if that plan prohibits COB.
Note: No-fault, fault, personal injury protection and liability coverage plans do not normally
contain order of benefit determinations provisions and would typically be primary. When payment
is made by this Plan as the Primary payor when another party should have paid as the primary
payor, this Plan will request reimbursement.
If coverage is provided under two or more plans, COB determines which plan is Primary and
which plan is Secondary. The plan considered Primary pays its benefits first, without regard to the
possibility that another plan may cover some expenses. Eligible allowable expense may be paid
under the other plan, which is considered Secondary. The Secondary Plan may determine its
benefits based on the benefits paid by the Primary Plan.
Don't forget to update your Dependents' Medical Coverage Information
Avoid delays on your Dependent claims by updating your Dependent's medical coverage
information. Visit www.healthselectoftexas.com or call BCBSTX at (800) 252-8039 (TTY:
711) to update your COB information. You will need the name of your Dependent's other
medical coverage, along with the policy number.
Determining Which Plan Is Primary
If you are covered by two or more plans, the benefit payment follows the rules below in this order:
• a plan that covers a Participant as an employee pays benefits before a plan that covers the
Participant as a dependent;
• the plan that covers an active employee pays before a plan covering a laid-off or retired
employee;
• your Dependent children will receive Primary coverage from the parent whose birth date
occurs first in a Calendar Year. If both parents have the same birth date, the plan that that
has been in effect the longest is the Primary Plan. This birthday rule applies only if:
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
119 SECTION 9 – COORDINATION OF BENEFITS (COB)
o the parents are married or living together whether or not they have ever been married
and not legally separated; or
o a court decree awards joint custody to the parents without specifying that one parent has
the responsibility to provide health care coverage.
• if two or more plans cover a Dependent child of divorced or separated parents and if there is
not a court decree stating that one parent is responsible for health care, the child will be
covered under the plan of:
o the parent with custody of the child; then
o the spouse of the parent with custody of the child; then
o the parent not having custody of the child; then
o the spouse of the parent not having custody of the child;
• if you are covered as an active employee by two plans, or you are covered as a retiree by two
plans, the plan that has covered the individual claimant for the longest period will pay first; the
expenses must be covered in part under at least one of the plans;
• if you have coverage under two or more medical plans and only one has COB provisions, the
plan without COB provisions will be the Primary Plan;
• if you are receiving COBRA continuation coverage under another employer plan, this Plan is
the Primary Plan; and
• finally, if none of the above rules determines which plan is Primary or Secondary, the
allowable expenses shall be shared equally between the plans meeting the definition of an
eligible plan for COB purposes.
Under any of the circumstances above, this Plan will not pay more than it would have paid had it
been the only plan in effect.
In general, if you are an Employee and covered under this Plan, this Plan will be the Primary
Plan and would apply to you and any of your covered Dependents even if they are enrolled in
Medicare coverage.
When you retire and are Medicare eligible, the order of your coverage in this Plan changes.
When you are an active Employee, you do not get to choose a Medicare primary plan.
For more information on how eligibility and enrollment for Medicare impact this Plan’s
Coordination of Benefits provisions, see the Section 2- Introduction and the header When a
Participant Qualifies for Medicare in this Section.
The following examples illustrate how the Plan determines which plan pays first and which plan
pays second.
Determining Primary and Secondary Plan – Examples
1) Let's say you and your spouse both have family medical coverage through your respective
employers. You are ill and visit your Physician. Since you're covered as a Subscriber under this
Plan, and as a Dependent under your spouse's plan, this Plan will pay Benefits for your
Physician’s office visit first.
2) Again, let's say you and your spouse both have family medical coverage through your
respective employers. You take your Dependent child to see a Physician. This Plan will look at
your birthday and your spouse's birthday to determine which plan pays first. If you were born on
June 11 and your spouse was born on May 30, your spouse's plan will pay first.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
120 SECTION 9 – COORDINATION OF BENEFITS (COB)
Table 10 summarizes common situations of dual coverage and whether HealthSelect would be
considered the Primary Plan or the Secondary Plan.
TABLE 10
Subscriber is…
…and is covered as a dependent
under another plan by:
…then HealthSelect is:
an Active Employee spouse's employer plan the Primary Plan
an Active Employee spouse's retiree plan the Primary Plan
a Retiree* spouse's employer plan the Primary Plan
a Retiree* spouse's retiree plan the Primary Plan
Subscriber is… …and has other coverage through: …then HealthSelect is:
an Active Employee
the Subscriber’s second active
employment
either Primary or Secondary
depending on which plan is
in force the longest
an Active Employee
the Subscriber’s retirement from
another employer
the Primary Plan
a Retiree*
the Subscriber’s second active
employment
the Secondary Plan
a Retiree*
the Subscriber’s retirement from
another employer
either Primary or Secondary
depending on which plan is
in force the longest
HealthSelect
enrolled Dependent
is…
…and is covered by a Subscriber
who is:
…then HealthSelect is:
an active employee of
a non-GBP Employer
an Active Employee the Secondary Plan
an active employee of
a non-GBP Employer
a Retiree the Secondary Plan
a retiree of a non-
GBP Employer
an Active Employee the Primary Plan
a retiree of a non-
GBP Employer
a Retiree
the Secondary Plan
*See Section 2- Introduction and this Section under the header When a Participant Qualifies for Medicare for more
information on how this Plan works when a Retiree is eligible for Medicare coverage.
When This Plan Is Secondary
When this Plan is the Secondary Plan, the Plan determines the amount it will pay for a Covered
Health Service according to the following:
• this Plan determines the amount it would have paid based on its Allowable Amount.
• this Plan pays the difference between the amount paid by the Primary Plan and this Plan’s
Allowable Amount.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
121 SECTION 9 – COORDINATION OF BENEFITS (COB)
• this Plan does not pay more than the Allowable Amount this Plan would have paid had it
been the only plan providing coverage.
• the maximum combined payments from all plans cannot exceed 100% of this Plan’s
Allowable Amount as determined by this Plan.
• this Plan’s Benefits may be reduced because of the Primary Plan’s benefits.
Determining the Allowable Amount When This Plan Is Secondary
If this Plan is Secondary and the health care services meet this Plan’s definition of a Covered
Health Service, this Plan will determine its Allowable Amount using the methodology described in
Section 3- How the Plan Works, under the heading Allowable Amounts.
The Allowable Amount is the maximum amount this Plan will pay for Covered Health Services
you receive. If you receive services from a Network Provider, you are not responsible for the
difference between the amount determined as your patient share by the Primary Plan and the
HealthSelect Allowable Amount. When the Primary Plan payment and the amount paid by this
Plan are equal to the HealthSelect Allowable Amount, you pay $0. If you receive Covered Health
Services from a Non-Network Provider, you may be responsible for additional amounts.
Example: Below is an example of how COB works when you have two health plans and this
Plan is the Secondary Plan.
Primary Plan
Amount
Billed by
Provider
Primary Plan’s
allowable expense
Primary Plan
Payment
Patient
Share
$1,000.00 $500.00 $100.00 $400.00
Secondary
Plan
(HealthSelect)
Amount
Billed by
Provider
Secondary Plan’s
Allowable Amount
Secondary Plan
Payment
Patient
Share
$1,000.00 $400.00
$300.00 (payment is
this Plan’s Allowable
Amount less the
Primary Plan Payment)
$0.00
You are not responsible for any amount exceeding your patient share as shown on the HealthSelect
Explanation of Benefits (EOB) document.
When a Participant Qualifies for Medicare
Determining Which Plan Is Primary
To the extent permitted by law, this Plan pays Benefits as the Secondary Plan to Medicare when
you become eligible for Medicare, even if you don’t enroll in Medicare. There are, however,
certain conditions when the Plan pays Benefits first and Medicare pays benefits second:
• persons who are Actively at Work with a State Agency or with an Institution of Higher
Education and their spouses; and
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
122 SECTION 9 – COORDINATION OF BENEFITS (COB)
• individuals with End-Stage Renal Disease (ESRD) for a limited period of time, as determined
by Medicare. Current federal legislation related to Medicare for individuals with End-Stage
Renal Disease states that group health plan coverage will be Primary for 30 months (during
your coordination period). After the coordination period, Medicare is the Primary Plan and this
plan is Secondary. If you do not enroll in Medicare Part B prior to Medicare becoming your
Primary Plan, Benefits payable under the Plan will be reduced, and that amount could be
significant. For more information regarding ESRD and Coordination of Benefits visit
Medicare.gov.
If you are Actively at Work and not Medicare-eligible but your spouse is Medicare-eligible (for
reasons other than End-Stage Renal Disease), this Plan will be Primary for your spouse if he or
she is your Dependent.
If you are a Retiree and are Medicare-eligible but are actively employed and covered under
another group health plan through that employer, then your active coverage will be Primary,
Medicare will be Secondary and this Plan will be Tertiary (i.e., will pay third).
Determining the Allowable Amount When This Plan Is Secondary to
Medicare
If this Plan is Secondary or Tertiary to Medicare, the Medicare-Approved Amount is the Allowable
Amount, as long as the Provider accepts Medicare Assignment. If the Provider does not accept
Medicare Assignment, the Medicare Limiting Charge (the most a Provider can charge you if they
don't accept Medicare Assignment) is the Allowable Amount. Medicare payments, combined with
Plan Benefits, will not exceed 100% of the total Allowable Amount.
If you retired and turned age 65 on or before September 1, 1992, Medicare is the Primary Plan
and this Plan is the Secondary Plan for Medicare Part A Benefits. However, if you do not have
Medicare Part B, this Plan is the Primary Plan for Part B Benefits, making Medicare the
Secondary Plan for Part B Benefits. This also applies to your covered spouse if he or she turned
age 65 on or before September 1, 1992.
If you retired after September 1, 1992 or if you are the Dependent of a Subscriber who retired
after September 1, 1992 and you are eligible for Medicare, this Plan is the Secondary or
Tertiary Plan to Medicare Part A and Part B Benefits for you and your covered spouse,
whether or not you are enrolled in Medicare.
If you are a Retiree and qualify for Medicare, and you do not enroll in Medicare Part B during
open enrollment, the Plan will pay for Covered Health Services at 20% of the Plan’s Allowable
Amount as described under How the Plan Works in Section 3, Allowable Amount .
If you are a Retiree and are not eligible for Medicare Part A because you or your spouse did not
contribute to Social Security, this Plan will be the Primary Plan for Medicare Part A Benefits if no
other medical coverage is available to you or your covered spouse. However, unless you retired
and turned age 65 on or before September 1, 1992, this Plan is the Secondary Plan to Medicare
Part B Benefits.
When This Plan Is Tertiary
When this Plan is the Tertiary Plan, the Plan determines the amount it will pay for a Covered
Health Service according to the following:
• the Plan determines the amount it would have paid based on its Allowable Amount.
• After both the Primary Plan and the Secondary Plan have paid, the Plan pays the difference
between the amount paid by the Primary and Secondary Plans and this Plan’s Allowable
Amount.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
123 SECTION 9 – COORDINATION OF BENEFITS (COB)
• this Plan does not pay more than the Allowable Amount this Plan would have paid had it
been the only plan providing coverage.
• the maximum combined payments from all plans cannot exceed 100% of this Plan’s total
Allowable Amount as determined by this Plan.
• this Plan’s Benefits may be reduced because of the Primary Plan and Secondary Plan’s
benefits.
Medicare Crossover Program
The Plan offers a Medicare Crossover program for Medicare Part A and Part B and Durable
Medical Equipment (DME) claims. Under this program, you do not have to file a separate claim
with the Plan to receive secondary Benefits for these expenses. Your Dependent will also have
this automated crossover, as long as he or she is eligible for Medicare and this Plan is your only
secondary medical coverage.
Once the Medicare Part A and Part B and DME carriers have reimbursed your health care
Provider, the Medicare carrier will electronically submit the necessary information to BCBSTX to
process the balance of your claim under the provisions of this Plan.
You can verify that the automated crossover took place when your copy of the Medicare
Summary Notice (MSN) states your claim has been forwarded to your secondary carrier.
This crossover process does not apply to expenses that Medicare does not cover. You must
continue to file claims for these expenses.
For information about enrollment or if you have questions about the program, call BCBSTX at
(800) 252-8039 (TTY: 711).
Overpayment and Underpayment of Benefits
If you are covered by more than one medical plan, it is possible the other plan will pay a benefit
that this Plan should have paid. If this occurs, the Plan may pay the other plan the amount it
should have paid.
If the Plan pays you more than it should under this COB section, you should promptly return the
overpayment amount. Otherwise, ERS may recover the overpayment by deducting from future
Benefits or by taking other legal action.
If the Plan overpays a health care Provider, the Plan may recover the excess amount from the
Provider pursuant to Refund of Overpayments, below.
Refund of Overpayments
If the Plan pays Benefits to or on behalf of a Participant, that Participant, or any other person or
organization that was paid, must make a refund to the Plan if:
• the Plan’s obligation to pay Benefits was contingent on the expenses incurred being legally
owed and paid by the Participant, but all or some of the expenses were not paid by the
Participant or were not legally required to be paid by the Participant;
• all or part of the Plan’s payment exceeded the allowed Benefits under the Plan; or
• all or part of the Plan’s payment was made in error.
The amount that must be refunded to the Plan equals the amount the Plan paid in excess of the
amount that the Plan should have paid under the Plan. If the refund is due from another person or
organization, the Participant agrees to assist the Plan in obtaining the refund if requested.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
124 SECTION 9 – COORDINATION OF BENEFITS (COB)
If the Participant, or any other paid person or organization, does not promptly refund the full
amount, ERS may reduce the amount of any future Benefits for the Participant that are payable
under the Plan. The reductions will equal the required refund amount.
Alternatively, ERS may impose one or more sanctions against the involved Participant(s) under
Section 1551.351, Texas Insurance Code.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
125 SECTION 10 – SUBROGATION AND REIMBURSEMENT
SECTION 10 - SUBROGATION AND REIMBURSEMENT
What this section includes
■ How your Benefits are impacted if you suffer a Sickness or Injury caused by a third party.
The Plan has a right to subrogation and reimbursement, as defined below.
Right of Recovery
The Plan has the right to recover Benefits it has paid on the Participant’s behalf that were:
• made in error;
• due to a mistake in fact;
• incorrectly paid by the Plan during the time period of meeting the Deductible for the Calendar
Year; or
• incorrectly paid by the Plan during the time period of meeting any Out-of-Pocket Maximum for
the Calendar Year.
Benefits paid because the Participant misrepresented facts are also subject to recovery.
If the Plan provides a Benefit for the Participant that exceeds the amount that should have been
paid, the Plan will:
• require that the overpayment be returned when requested; or
• reduce a future Benefit payment for you or your Dependent by the amount of the
overpayment.
If the Plan incorrectly pays Benefits to you or your Dependent during the time period of meeting
the Deductible and/or meeting any Out-of-Pocket Maximum for the Calendar Year, the Plan will
send you or your Dependent a monthly statement identifying the amount you owe with payment
instructions. The Plan has the right to recover Benefits by:
• submitting a reminder letter to you or a covered Dependent that details any outstanding
balance owed to the Plan; and
• conducting courtesy calls to you or a covered Dependent to discuss any outstanding balance
owed to the Plan.
Right to Subrogation
The right to subrogation means the Plan is substituted to and shall succeed to any and all legal
claims that the Participant may be entitled to pursue against any third party for Benefits that the
Plan has paid that are related to the Sickness or Injury for which a third party is or may be
considered responsible. Subrogation applies when the Plan has paid to or on behalf of the
Participant Benefits for a Sickness or Injury for which a third party is or may be considered
responsible, e.g., a third party’s insurance carrier if the Participant is involved in an auto accident
with a third party.
To the maximum extent allowed by Texas law, the Plan shall be subrogated to, and shall succeed
to, all rights of recovery from any or all third parties, under any legal theory of any type, for any
Benefits the Plan has paid to or on behalf of the Participant relating to any Sickness or Injury for
which any third party is or may be responsible.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
126 SECTION 10 – SUBROGATION AND REIMBURSEMENT
Right to Reimbursement
The right to reimbursement means that if a third party is or may be responsible to pay for the
Participant’s Sickness or Injury for which the Participant receives a settlement, judgment, or other
recovery from any third party, the Participant must use those proceeds to return to the Plan, to
the maximum extent allowed by Texas law, Benefits the Participant received for that Sickness or
Injury.
Third Parties
The following persons and entities are considered third parties:
• a person or entity alleged to have caused the Participant to suffer a Sickness, Injury or
medical damages, or who is legally responsible to pay for the Sickness, Injury or medical
damages;
• any insurer or other indemnifier of any person or entity alleged to have caused or who caused
the Sickness, Injury or medical damages; or
• any other persons or entities who are responsible for paying losses caused by the
Participant’s Sickness or Injury when such payments are subject to subrogation under Texas
law.
Subrogation and Reimbursement Provisions
As a Participant, you agree to the following:
• up to the maximum amount allowed by Texas law, the Plan has a first priority right to receive
payment on any claim against a third party before you receive payment from that third party.
Further, to the extent allowed by law, the Plan's first priority right to payment is superior to
any and all claims, debts or liens asserted by any medical Providers, including, but not limited
to, Hospitals or Emergency treatment facilities, that assert a right to payment from funds you
recover from an allegedly responsible third party.
• the Plan's subrogation and reimbursement rights apply to full and partial settlements,
judgments, or other recoveries paid or payable to you or your representative, no matter how
those proceeds are captioned or characterized and whether or not the third party disclaims
liability. Payments include, but are not limited to, economic, non-economic, and punitive
damages. The Plan is not required to help you to pursue your claim for damages or personal
injuries, and no amount of associated costs, including, but not limited to, attorneys' fees and
out-of-pocket expenses shall be deducted from the Plan’s recovery without the Plan’s
express written consent, except as required by Texas law. No so-called equitable or common
law, “Made-Whole Doctrine,” “Fund Doctrine,” or “Common Fund Doctrine” or “Attorney's
Fund Doctrine” shall defeat or limit this right.
• regardless of whether you have been fully compensated or made whole, the Plan may collect
from you the proceeds of any full or partial recovery that you or your legal representative
obtain, whether in the form of a settlement (either before or after any determination of liability)
arbitration, judgment or other monetary award, no matter how those proceeds are captioned
or characterized. Proceeds from which the Plan may collect include, but are not limited to,
economic, non-economic, and punitive damages. No "collateral source" rule shall limit the
Plan's subrogation and reimbursement rights that are allowed under Texas law.
• you will cooperate with the Plan and its agents in a timely manner to protect its legal and
equitable rights to subrogation and reimbursement, including, but not limited to:
o complying with the terms of this section;
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
127 SECTION 10 – SUBROGATION AND REIMBURSEMENT
o providing any relevant information requested;
o signing and/or delivering such documents as the Plan or its administering firm reasonably
request to secure the subrogation and reimbursement claim;
o notifying the Plan, in writing, of any potential legal claim(s) you may have against any and
all third parties for acts which caused Benefits to be paid or become payable;
o responding promptly to requests for information about any accident or injuries;
o appearing at medical examinations and legal proceedings, such as depositions or
hearings; and
o obtaining the Plan's consent or its administering firm’s consent before releasing any party
from liability or payment of medical expenses.
• if you receive payment as part of a settlement or judgment from any third party as a result of
a Sickness or Injury, and the Plan alleges some or all of those funds are due and owed to it
under Texas law, you agree to hold those settlement funds in trust, either in a separate bank
account in your name or in your attorney's trust account. You agree that you will serve as a
trustee over those funds to the extent of the Benefits the Plan has paid.
• if the Plan incurs attorneys' fees and costs in order to collect third party settlement funds held
by you or your representative, the Plan has the right to recover those fees and costs from you
to the maximum extent allowed by Texas law.
• you may not accept any settlement that does not fully reimburse the Plan to the maximum
extent allowed by Texas law, without its written approval.
• upon the Plan's request, you will assign to the Plan all rights of recovery against third parties
to the extent of Benefits the Plan has paid for a Sickness or Injury allegedly caused by a third
party or for which a third party is legally responsible to pay for your Sickness or Injury.
• the Plan's rights to recovery will not be reduced due to your own comparative negligence.
• the Plan may, at its option, take necessary and appropriate action to assert its rights under
this section, including, but not limited to, filing suit in your name, which does not obligate it in
any way to pay you part of any recovery the Plan might obtain.
• the provisions of this section also apply to the Participant’s spouse, parents, guardian, or
other representative of a Dependent child or Dependent spouse who incurs a Sickness or
Injury caused by a third party. If a parent or guardian may bring a claim for damages arising
out of a minor's Sickness or Injury, the terms of this subrogation and reimbursement clause
shall apply to that claim.
• the Participant’s spouse and the Dependent’s spouse are jointly and severally liable for the
Plan’s subrogation and reimbursement rights herein.
• in case of your wrongful death or survival claim, the provisions of this section apply to your
estate, the personal representative of your estate; your surviving spouse, parents, and
children; and your heirs or beneficiaries.
• your failure to cooperate with the Plan or its agents is considered a violation of the Plan. As
such, the Plan has the right to terminate your Benefits, deny future Benefits, take legal action
against you, and/or set off from any future Benefits the value of Benefits the Plan has paid
relating to any Sickness or Injury alleged to have been caused or caused by any third party to
the extent not recovered by the Plan due to you or your representative not cooperating with
the Plan.
• if a third party causes or is alleged to have caused you to suffer a Sickness or Injury while
you are covered under this Plan, the provisions of this section continue to apply, even after
you are no longer a Participant.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
128 SECTION 10 – SUBROGATION AND REIMBURSEMENT
• the Plan has the authority and discretion to resolve all disputes regarding the interpretation of
the language stated herein.
• subject to ERS’ oversight and control, the Plan and all administrators administering the terms
and conditions of the Plan’s subrogation and reimbursement rights have such powers and
duties as are necessary to discharge its duties and functions, including the exercise of its
discretionary authority to (1) construe and enforce the terms of the Plan’s subrogation and
reimbursement rights and (2) make determinations with respect to the subrogation amounts
and reimbursements owed to the Plan.
• no allocation of damages, settlement funds or any other recovery, by you, your estate, the
personal representative of your estate, your heirs, your beneficiaries or any other person or
party, shall be valid if it does not reimburse the Plan for 100 percent of its interest allowed
under Texas law unless the Plan provides written consent to the allocation.
• BCBSTX does not have the authority to accept any negotiable instrument or any payment
containing any terms or conditions that differ from or adds to the terms and conditions in this
MBPD or the terms and conditions previously accepted in a Mutual Release and Settlement
Agreement.
The retention, cashing, or depositing by BCBSTX of a negotiable instrument, such as a
check, with any additional or different terms or conditions or a restrictive endorsement shall
not be considered a discharge of the Participant's existing obligations nor an acceptance of
an offer by BCBSTX or ERS. Such action on the part of BCBSTX shall not create a new
contract between the parties nor constitute an accord and satisfaction of the
obligations. Moreover, such action shall not create an alteration or modification of the terms
and conditions of the Plan or the MBPD. BCBSTX and ERS retain the right to pursue the
totality of the amount due.
As a Participant in the Plan, you are obligated under the terms of the MBPD to cooperate with
the Plan to protect its subrogation rights and not prejudice the Plan’s right of recovery and
reimbursement.
As used in this Section 10, “Texas law” includes, but is not limited to, Texas Civil Practices and
Remedies Code, Chapter 140.
Note: The subrogation rights and obligations under the Plan shall be governed by Texas law
regardless of where the Participant resides or whether the Injury occurs in or outside the state of
Texas.
Example
Suppose you are injured in a car accident that is not your fault, and you receive Benefits under
the Plan to treat your injuries. If you subsequently bring suit against the insurer of the person
who caused the accident and receive a settlement, or receive payment from the insurer without
bringing suit, the Plan is entitled to direct payment from you for the Benefits it paid.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
129 SECTION 11 – WHEN COVERAGE ENDS
SECTION 11 - WHEN COVERAGE ENDS
What this section includes
■ Circumstances that cause coverage to end;
■ Extended coverage; and
■ How to continue coverage after it ends.
Your eligibility for Benefits automatically ends on the date that your coverage ends. When your
coverage ends, the Plan will still pay claims for Covered Health Services that you received before
your coverage ended. However, once your coverage ends, Benefits are not provided for health
services that you receive after your coverage ended, even if the underlying medical condition
occurred before your coverage ended, you are hospitalized, or are otherwise receiving medical
treatment.
Your coverage under the Plan will end on the earliest of:
• the last day of the month your employment with your Employer ends;
• the last day of the month your contributions were paid in full if you stop making the required
contributions;
• the last day of the month you are no longer eligible for coverage;
• the last day of the month that BCBSTX receives written notice from ERS to end your
coverage, or the date specified in the notice;
• the last day of the month you retire, unless you are eligible for other coverage as a Retiree; or
• the effective date you are expelled from the Plan as provided under Chapter 1551, Texas
Insurance Code.
Coverage for your eligible Dependents will end on the earliest of:
• the date your coverage ends;
• the last day of the month your contributions were paid in full if you stop making the required
contributions;
• the last day of the month that BCBSTX receives written notice from ERS to end your
coverage, or the date specified in the notice;
• the last day of the month your Dependents become ineligible as Dependents under this Plan;
or
• the effective date you are expelled from the Plan as provided under Chapter 1551, Texas
Insurance Code.
Extended Coverage
Coverage for a Disabled Child
While you are a Subscriber under this Plan, if an unmarried enrolled Dependent child with a
mental or physical disability reaches 26 years of age, the Plan will continue to cover the child, as
long as the child is mentally or physically incapacitated to such an extent that he or she is
dependent upon you for care or support.
You must apply with ERS to continue benefits before the first day of the month following the
child's 26th birthday. If an extension of coverage is temporarily approved, you must reapply with
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
130 SECTION 11 – WHEN COVERAGE ENDS
ERS for an additional extension of coverage for the child before the prior temporary extension
approval’s expiration date.
If you have a disabled Dependent who was not covered at the time they turned age 26, or if your
Dependent becomes disabled after they turned age 26, you may apply for coverage for them
during your next Annual Enrollment period or within the first 30 days from the date of your
Dependent child’s first medical treatment related to his or her disability.
As a new Employee, you may apply for coverage for a disabled Dependent age 26 and over
during your initial enrollment period as a new Employee.
Coverage for a Dependent child past age 26 is not guaranteed and is subject to approval by ERS.
COBRA
If you lose your Plan coverage, you may have the right to extend it under the Consolidated
Omnibus Budget Reconciliation Act of 1985 (COBRA), as defined in Section 13, Glossary.
Much of the language in this section comes from the federal law that governs continuation
coverage under COBRA. You should call ERS if you have questions about your right to continue
coverage under COBRA.
In order to be eligible for continuation coverage under COBRA, you must meet the definition of a
“Qualified Beneficiary.” A Qualified Beneficiary is any of the following persons who were covered
under the Plan on the day before a qualifying event:
• a Subscriber;
• a Subscriber's covered Dependent; or
• a Subscriber's covered spouse upon divorce.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
131 SECTION 11 – WHEN COVERAGE ENDS
Qualifying Events for Continuation Coverage under COBRA
Table 11 describes situations in which you may elect to continue coverage under COBRA for
yourself and your Dependents, and the maximum length of time you can receive continued
coverage. These situations are qualifying events, for purposes of continuation of coverage under
COBRA.
TABLE 11
If Coverage Ends Because of the
Following Qualifying Events:
You May Elect continuation coverage under
COBRA for up to the following maximum periods:
For Yourself For Your Spouse
For Your
Child(ren)
Your work hours are reduced
1
18 months 18 months 18 months
Your employment terminates for any
reason (other than gross misconduct)
18 months 18 months 18 months
You or your Dependent becomes
eligible for Social Security disability
benefits at any time within the first
60 days of losing coverage
2
Up to 29 months Up to 29 months
Up to 29
months
You die N/A 36 months 36 months
You divorce N/A 36 months 36 months
3
Your child is no longer an eligible
Dependent (e.g., reaches the
maximum age limit)
N/A N/A 36 months
You become entitled to Medicare
N/A See Table 12
See
Table 12
1
This can be a qualifying event under COBRA only for Employees of Institutions of Higher Education covered under the
Plan. The specific Institution of Higher Education determines the number of hours in a month an Employee must work to
be eligible for coverage under the Plan. When the number of hours is decreased so that the Employee is not eligible for
coverage under the Plan, then this a qualifying event under COBRA.
2
Subject to the following conditions: (i) the Qualified Beneficiary must give ERS notice of the disability not later than the
end of the first 18 months; (ii) the Qualified Beneficiary must agree to pay any increase in the required premium for the
additional 11 months over the original 18 months; and (iii) if the Qualified Beneficiary entitled to the 11 months of
coverage has non-disabled family members who are also Qualified Beneficiaries, then those non-disabled Qualified
Beneficiaries are also entitled to the additional 11 months of continuation coverage. Notice of any final determination that
the Qualified Beneficiary is no longer disabled must be provided to ERS within 30 days of such determination. Thereafter,
continuation coverage may be terminated on the first day of the month that begins more than 30 days after the date of that
determination.
3
This period applies to children who lose coverage due to the divorce. If the former spouse’s children were covered under
the Plan, they will lose coverage and may elect continuation coverage under COBRA. The COBRA election does not
apply to the Subscriber’s children who continue to be eligible for coverage as the Subscriber’s Dependents.
Note: While some Qualifying Life Events as described in Section 2, Introduction, are similar to
qualifying events under COBRA, you, or your eligible Dependent, do not need to elect COBRA
continuation coverage to take advantage of the special enrollment rights listed in that section.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
132 SECTION 11 – WHEN COVERAGE ENDS
How Your Medicare Eligibility Affects Dependent Continuation Coverage Under
COBRA
Table 12 below describes how your Dependents' continuation of coverage under COBRA is
impacted if you become eligible for Medicare.
TABLE 12
If Dependent Coverage Ends When:
Your Dependent May
Elect Continuation
Coverage Under
COBRA For Up To:
You become eligible for Medicare and don't experience any
additional qualifying events
36 months
You become eligible for Medicare, after which you experience a
second qualifying event
1
before the initial 18-month period expires
36 months
You experience a qualifying event
1
, after which you become
eligible for Medicare before the initial 18-month period expires;
and, if absent this initial qualifying event, your Medicare eligibility
would have resulted in loss of Dependent coverage under the
Plan
36 months
1
For example, your employment is terminated for reasons other than gross misconduct.
Getting Started
ERS will notify you by mail if you become eligible for continuation coverage under COBRA. The
notification will give you instructions for electing continuation coverage under COBRA, and advise
you of the monthly cost. Your monthly cost is the full cost, including both Subscriber and
Dependent costs, if applicable, plus a 2% administrative fee or other cost as permitted by law.
You will have up to 105 days from the date you receive notification or from the date your
coverage ends, whichever is later, to elect and pay the cost of your continuation coverage under
COBRA. The payment must include the monthly cost for all months retroactive to the date your
Plan coverage ended.
During the 105-day election period, the Plan will, only if you request, inform the Provider of your
right to elect continuation coverage under COBRA, retroactive to the date your COBRA eligibility
began.
While you are a Participant in the Plan under COBRA, you have the right to change your
coverage election:
• during Annual Enrollment; and
• following a Qualifying Life Event, as described under Changing Your Coverage in Section 2,
Introduction.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
133 SECTION 11 – WHEN COVERAGE ENDS
Notification Requirements
If your covered Dependents lose coverage due to divorce or loss of Dependent status, you or
your Dependents must notify the ERS or your Benefit Coordinator within 60 days of the latest of:
• the date of the divorce or an enrolled Dependent's loss of eligibility as an enrolled Dependent;
• the date your enrolled Dependent would lose coverage under the Plan; or
• the date on which you or your enrolled Dependent are informed of your obligation to provide
notice and the procedures for providing such notice.
You or your Dependents must also notify ERS when a secondary qualifying event occurs that will
extend continuation coverage under COBRA.
If you or your Dependents fail to notify ERS of these events within the 60-day period, the Plan is
not obligated to provide continued coverage to the affected Qualified Beneficiary. If you are
continuing coverage under COBRA, you must also notify ERS within 31 days of any Qualifying
Life Event.
Once you have notified ERS, you will then be notified by mail of your election rights under
COBRA.
Notification Requirements for Disability Determination
If you extend your COBRA continuation coverage beyond 18 months because you are eligible for
disability benefits from Social Security, you must provide ERS with notice of the Social Security
Administration's determination within 60 days after you receive that determination, and before the
end of your initial 18-month continuation period.
The notice requirements will be satisfied by providing written notice to ERS at the address stated
in Section 14, Important Administrative Information. The contents of the notice must be such that
ERS is able to determine the covered Employee and qualified beneficiary(ies), the qualifying
event or disability, and the date on which the qualifying event occurred.
Trade Act of 2002
The Trade Act of 2002 amended COBRA to provide for a special second 60-day COBRA
continuation coverage election period for certain Subscribers who have experienced a termination
or reduction of hours and who lose group health plan coverage as a result. The special second
COBRA continuation coverage election period is available only to a very limited group of
individuals: generally, those who are receiving trade adjustment assistance (TAA) or 'alternative
trade adjustment assistance' under a federal law called the Trade Act of 1974. These Subscribers
are entitled to a second opportunity to elect COBRA continuation coverage for themselves and
certain family members (if they did not already elect COBRA continuation coverage), but only
within a limited period of 60 days from the first day of the month when an individual begins
receiving TAA (or would be eligible to receive TAA but for the requirement that unemployment
benefits be exhausted) and only during the six months immediately after his/her group health plan
coverage ended.
If a Subscriber qualifies or may qualify for assistance under the Trade Act of 1974, he or she
should contact ERS for additional information. The Subscriber must contact ERS promptly after
qualifying for assistance under the Trade Act of 1974 or the Subscriber will lose his or her special
COBRA rights. COBRA continuation coverage elected during the special second election period
is not retroactive to the date that Plan coverage was lost but begins on the first day of the special
second election period.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
134 SECTION 11 – WHEN COVERAGE ENDS
When Continuation Coverage Under COBRA Ends
COBRA continuation coverage will end, before the maximum continuation period, on the earliest
of the following dates:
• the date, after electing continuation coverage, that coverage is first obtained under any other
group health plan;
• the date, after electing continuation coverage, that you or your covered Dependent first
becomes entitled to Medicare;
• the date coverage ends for failure to make the required premium payment; or
• the date coverage would otherwise terminate under the Plan as described in the beginning of
this section.
Note: If you selected continuation coverage under a prior plan which was then replaced by
coverage under this Plan, continuation coverage will end as scheduled under the prior plan or in
accordance with the terminating events listed in this section, whichever is earlier.
Uniformed Services Employment and Reemployment Rights Act
A Subscriber who is absent from employment for more than 30 days by reason of service in the
Uniformed Services may elect to continue Plan coverage for the Subscriber and the Subscriber's
Dependents in accordance with the Uniformed Services Employment and Reemployment Rights
Act of 1994, as amended (USERRA).
The terms "Uniformed Services" or "Military Service" mean the Armed Forces, the Army National
Guard and the Air National Guard when engaged in active duty for training, inactive duty training,
or full-time National Guard duty, the commissioned corps of the Public Health Service, and any
other category of persons designated by the President in time of war or national emergency.
If qualified to continue coverage pursuant to the USERRA, Subscribers may elect to continue
coverage under the Plan by notifying their Employer in advance, and providing payment of any
required contribution for the health coverage. This may include the amount the Employer normally
pays on a Subscriber's behalf. If a Subscriber's Military Service is for a period of time less than 31
days, the Subscriber may not be required to pay more than the regular contribution amount, if
any, for continuation of health coverage.
A Subscriber may continue Plan coverage under USERRA for up to the lesser of:
• the 24-month period beginning on the date of the Subscriber's absence from work; or
• the day after the date on which the Subscriber fails to apply for, or return to, a position of
employment.
Regardless of whether a Subscriber continues health coverage, if the Subscriber returns to a
position of employment that is eligible for participation in the GBP, the Subscriber's health
coverage and that of the Subscriber's eligible Dependents will be reinstated under the Plan. No
exclusions or waiting period may be imposed on a Subscriber or the Subscriber's eligible
Dependents in connection with this reinstatement, unless a Sickness or Injury is determined by
the Secretary of Veterans Affairs to have been incurred in, or aggravated during, the performance
of military service.
You should call your Benefits Coordinator if you have questions about your rights to continue
health coverage under USERRA.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
135 SECTION 12 – OTHER IMPORTANT INFORMATION
SECTION 12 - OTHER IMPORTANT INFORMATION
What this section includes
■ Qualified Medical Child Support Orders;
■ Your relationship with BCBSTX and the Employees Retirement System of Texas;
■ Relationships between Providers, BCBSTX and HealthSelect;
■ Interpretation of the Plan;
■ Records; and
■ How to access the Master Benefit Plan Document.
Qualified Medical Child Support Orders (QMCSOs)
A qualified medical child support order (QMCSO) is a judgment, decree or order issued by a court
or appropriate state agency that requires a child to be covered for medical benefits. Generally, a
QMCSO is issued as part of a paternity, divorce, or other child support settlement.
If the Plan receives a National Medical Support Notice for your child that instructs the Plan to
cover the child, your Benefits Coordinator will review it to determine if it meets the requirements
for a QMCSO. If it is determined that it does, and your child meets the definition of an eligible
Dependent, your child will be enrolled in the Plan as your Dependent, and the Plan will be
required to pay Benefits as provided under the Plan.
Note: A National Medical Support Notice will be recognized as a QMCSO if it meets the
requirements of a QMCSO.
Your Relationship with Blue Cross and Blue Shield of Texas and the
Employees Retirement System of Texas
In order to make choices about your health care coverage and treatment, it is important you
understand how BCBSTX interacts with the Plan and how it may affect you. The ERS Board of
Trustees has contracted with BCBSTX as a third-party administrator of the Plan to assist in the
administration of the Plan. Neither ERS nor BCBSTX provides medical services or makes
treatment decisions.
BCBSTX processes claims for Benefits and communicates with you regarding decisions about
whether the Plan will cover the health care that you may receive. The Plan pays for Covered
Health Services, which are more fully described in this MBPD.
BCBSTX is not an employer or employee of ERS for any purpose with respect to the
administration or provision of Benefits under this Plan.
Relationships between Network Providers, Blue Cross and Blue Shield of
Texas and HealthSelect
The relationships between BCBSTX and Network Providers are solely contractual relationships
between independent contractors. Network Providers are not agents or employees of ERS,
HealthSelect or BCBSTX. ERS and its employees are not agents or employees of Network
Providers, nor are BCBSTX and its employees’ agents or employees of Network Providers.
BCBSTX arranges for health care Providers to participate in the HealthSelect Network and
administers the HealthSelect Plan, on behalf of ERS subject to ERS’ oversight. Network
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136 SECTION 12 – OTHER IMPORTANT INFORMATION
Providers are independent practitioners who run their own offices and Facilities. BCBSTX’
credentialing process confirms public information about the Providers' licenses and other
credentials, but does not assure the quality of the services provided. ERS and BCBSTX do not
have any other relationship with Network Providers. ERS and BCBSTX are not liable for any act
or omission of any Provider in caring for any Participant receiving health care services covered
under the Plan.
Your Relationship with Providers
The relationship between you and any Provider is that of Provider and patient. Your Provider is
solely responsible for the quality of the health care goods and services provided to you. You are
responsible for:
• choosing your own Provider;
• paying, directly to your Provider, any amount identified as a Participant’s responsibility,
including Copays, Coinsurance, any Annual Non-Network Deductible, other deductibles and
any amount a Non-Network Provider charges that exceeds Allowable Amounts;
• paying, directly to your Provider, the cost of any health care service not covered by the Plan;
• deciding if each Provider treating you is right for you (this includes Network and Non-Network
Providers you choose as well as Providers to whom you have been referred); and
• deciding with your Provider what care you should receive, even if it is not covered under the
Plan.
Interpretation of the Plan
ERS has discretion to interpret Plan provisions including this MBPD and any Amendment or
Addendum.
ERS has delegated to BCBSTX the discretion to determine whether a treatment or supply is a
Covered Health Service and how the Allowable Amounts will be determined and otherwise
covered under the Plan, according to guidelines established by the Plan and/or BCBSTX.
In certain circumstances, for purposes of overall cost savings or efficiency, ERS, in its discretion,
may approve Benefits for services that would otherwise not be Covered Health Services. The fact
that ERS does so in any particular case shall not in any way be deemed to require ERS to do so
in other similar cases.
Records
All Participant records that are in the custody of ERS or BCBSTX are confidential and not subject
to public disclosure under Chapter 552, Texas Government Code, Section 1551.063, Texas
Insurance Code, and the federal Health Insurance Portability and Accountability Act of 1996
(HIPAA).
For complete listings of your medical records or billing statements, BCBSTX recommends that
you contact your health care Provider. Providers may charge you reasonable fees to cover their
costs for providing records or completing requested forms. If you request medical forms or
records from BCBSTX, it also may charge you reasonable fees to cover costs for completing the
forms or providing the records.
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137 SECTION 12 – OTHER IMPORTANT INFORMATION
How to Access the Master Benefit Plan Document
A copy of this Master Benefit Plan Document and other Plan information may be downloaded
from www.healthselectoftexas.com
. You may also request a copy of this Master Benefit Plan
Document by making a written request to ERS. The copy will be provided for a reasonable charge
within 30 days of its receipt of the request.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
138 SECTION 13 – GLOSSARY
SECTION 13 - GLOSSARY
What this section includes
■ Definitions of terms used throughout this Master Benefit Plan Document (MBPD).
Many of the terms used throughout this MBPD may be unfamiliar to you or have a specific
meaning with regard to the way the Plan is administered and how Benefits are paid. This section
defines terms used throughout this MBPD, but it does not describe the Benefits provided by the
Plan.
Act – the Texas Employees Group Benefits Act (Texas Insurance Code, Chapter 1551).
Actively at Work, Actively Working, Active Work, Active Service or Active Duty – the active
expenditure of time and energy in the service of the Employer, including elected officials of the
State who are eligible for coverage under the Act. An Employee will be considered to be on
Active Duty on each day of a regular paid vacation or regular paid sick leave, or on a regular non-
working day, provided he was Actively at Work on the last preceding work-day.
Addendum – an attached written description of additional or revised provisions to the Plan. The
Benefits and exclusions of this Master Benefit Plan Document and any Amendments thereto shall
apply to the Addendum except that in the case of any conflict between the Addendum and Master
Benefit Plan Document and/or Amendments to the Master Benefit Plan Document, the Addendum
shall be controlling.
Additional Deductible – the amount you must pay if you do not obtain Prior Authorization before
you are admitted for an Inpatient Stay, whether for medical, mental health or substance-related
and addictive disorder treatment. The Additional Deductible is $200 and applies each time you fail
to obtain Prior Authorization for an Inpatient Stay as required.
Affordable Care Act (ACA) – federal law that includes the Patient Protection and Affordable
Care Act (Public Law 111-148; March 23, 2010; 124 Stat. 119) and the Health Care and
Education Reconciliation Act of 2010 (Public Law 111-152; March 30, 2010; 124 Stat. 1029),
as amended. This is also referred to as the federal health care reform statute.
Airrosti Rehab Center – a Facility that provides Chiropractic Treatment to Participants not
enrolled in Medicare by using applied integration for the rapid recovery of soft tissue.
Allowable Amounts – the maximum amounts, determined by BCBSTX, that the Plan could pay
for Benefits for Covered Health Services while the Plan is in effect.
Allowable Amounts determinations are subject to BCBSTX’ reimbursement policy guidelines.
BCBSTX develops the reimbursement policy guidelines, in BCBSTX’ discretion, following
evaluation and validation of all Provider billings in accordance with one or more of the following
methodologies:
• as indicated in the most recent edition of the Current Procedural Terminology (CPT), a
publication of the American Medical Association, and/or the Centers for Medicare and
Medicaid Services (CMS);
• as reported by generally recognized professionals or publications;
• as used for Medicare; or
• as determined by medical staff and outside medical consultants pursuant to other appropriate
source or determination that BCBSTX accepts.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
139 SECTION 13 – GLOSSARY
Alternate Facility – a health care Facility that is not a Hospital and that provides one or more of
the following services on an Outpatient basis, as permitted by law:
• surgical services;
• Emergency Health Services; or
• rehabilitative, laboratory, diagnostic or therapeutic services.
An Alternate Facility may also provide Mental Health or Substance Use Disorder Services on an
Outpatient basis or Inpatient basis (for example a Residential Treatment Facility).
Amendment – any attached written description of additional or alternative provisions to the Plan.
Amendments are effective only when distributed by the Plan Administrator. Amendments are
subject to all conditions, limitations and exclusions of the Plan, except for those that the
Amendment specifically changes.
Annual Enrollment – the period of time during which eligible Subscribers may enroll themselves
and their eligible Dependents in the Plan. ERS determines the period of time that is the Annual
Enrollment period.
Annual Non-Network Deductible (or Non-Network Deductible) – the amount you must pay for
Covered Health Services in a Calendar Year before the Plan will begin paying Non-Network
Benefits in that Calendar Year. The Non-Network Deductibles are shown in Table 2 in Section 5,
Schedule of Benefits and Coverage.
Applied Behavior Analysis – Intensive Behavioral Therapy, generally given or supervised by a
Board-Certified Behavior Analyst (BCBA), which consists of a series of behavioral
and/or habilitative interventions for the treatment of Autism Spectrum Disorders.
Authorized Representative – a person authorized to act on behalf of a Participant. This does
not include a Provider or other entity acting as an assignee of a Participant’s claim. See
Authorized Representative in Section 8, Claims Procedures, for information on how to properly
designate an Authorized Representative. An Authorized Representative must be properly
designated in order to protect against improper disclosure of information about a Participant
including protected health or other confidential information.
Autism Spectrum Disorders – a neurodevelopmental disorder marked by enduring problems
communicating and interacting with others, along with restricted and repetitive behavior, interests
or activities.
Balance Billing – the difference between the Non-Network Allowable Amount and the amount
billed by a Non-Network Provider. This difference can be billed by a Non-Contracted Provider.
Bariatric Deductible – the amount an Employee must pay for Bariatric Surgery before he or she
is eligible to begin receiving Network Benefits for such surgery. Benefits are not paid for Bariatric
Surgery provided by a Non-Network Provider. The separate Bariatric Deductible is shown in
Table 3 in Section 5, Schedule of Benefits and Coverage, under Bariatric Surgery.
Bariatric Surgery – is the surgical treatment of morbid obesity, and includes the gastric bypass
procedure as one of several classes of operations.
Behavioral Health Practitioner – means a Physician or Professional, appropriately licensed
Other Provider who renders services for the treatment of Mental Illness, Serious Mental Illness or
Substance Use Disorder, only as listed throughout MBPD.
Benefits – Plan payments for Covered Health Services, subject to the Act, the ACA, the Rules of
the ERS Board of Trustees, the terms and conditions of the Plan and any Addendums and/or
Amendments.
Benefits Coordinator – a person employed by your Employer to provide assistance for
Participants with various benefit programs, including the Plan. ERS is the Benefits Coordinator for
Retirees.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
140 SECTION 13 – GLOSSARY
BlueCard
®
Program – a Blue Cross Blue Shield Association program that allows Participants to
access care while traveling within the United States and its territories.
Blue Cross Blue Shield Global
®
Core – a Blue Cross Blue Shield Association program that
allows Participants to access limited care while traveling outside the United States and its
territories.
Blue Cross and Blue Shield of Texas – the Plan’s third-party administrator and the company
that, with its affiliates, provides certain services and claim administration services for the Plan on
behalf of the Plan Administrator.
Blue Distinction Center - a Facility that has entered into an agreement with BCBSTX to provide
Covered Health Services for the treatment of specific diseases or conditions.
Body Mass Index (BMI) – a calculation used in obesity risk assessment which uses a person's
weight and height to approximate body fat.
BMI – see Body Mass Index (BMI).
Calendar Year – the annual period of time from January 1 to December 31, inclusive, as
distinguished from Plan Year which is from September 1 through August 31, inclusive.
CHD – see Congenital Heart Disease (CHD).
Chiropractic Treatment – the therapeutic application of chiropractic treatment and/or
manipulative treatment with or without ancillary physical therapy and/or rehabilitative methods
rendered to restore or improve motion, reduce pain and improve function in the management of
an identifiable neuromusculoskeletal condition.
Claim Administrator – means BCBSTX, a division of Health Care Service Corporation and the
Plan’s third-party administrator, when providing claims administration.
Clinical Trial – a scientific study designed to identify new health services that improve health
outcomes. In a Clinical Trial, two or more treatments are compared to each other and the
Participant is not allowed to choose which treatment he or she will receive.
COBRA – see Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
Coinsurance – the percentage of Allowable Amounts you are required to pay for certain Covered
Health Services as described in Section 3, How the Plan Works. The percentage of Allowable
Amounts paid by the Plan for Covered Health Services is shown in Table 3 in Section 5,
Schedule of Benefits and Coverage.
Complications of Pregnancy – complications (when Pregnancy is not terminated) for which
diagnoses are distinct from Pregnancy but adversely affected or caused by Pregnancy, such as
nephritis, cardiac decompensation and miscarriage. It does not include false labor, occasional
spotting, Physician prescribed rest during Pregnancy, morning Sickness, hyperemesis
gravidarum, preeclampsia, eclampsia, and similar conditions associated with Pregnancy not
constituting a nosologically distinct complication of Pregnancy. Covered Health Services for
Complications of Pregnancy do not include services and supplies provided at termination of
Pregnancy.
Congenital Anomaly – a physical developmental defect that is present at birth and is identified
within the first twelve months after birth.
Congenital Heart Disease (CHD) – any structural heart condition or abnormality that has been
present since birth. Congenital heart disease may:
• be passed from a parent to a child (inherited);
• develop in the fetus of a woman who has an infection or is exposed to radiation or other toxic
substances during her Pregnancy; or
• have no known cause.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
141 SECTION 13 – GLOSSARY
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) – a federal law that
requires employers to offer continued health insurance coverage at the insured’s expense to
certain Employees and their Dependents whose group health insurance has been terminated.
Contracted Provider – a Hospital, Physician, Behavioral Health Practitioner, or Other Provider
who has entered into an agreement with BCBSTX (or other participating Blue Cross and/or Blue
Shield Plan) as a managed care Provider.
Copay – the set dollar amount you are required to pay for certain Covered Health Services as
described in Section 3, How the Plan Works.
Cosmetic Procedures – procedures or services that change or improve appearance without
significantly improving physiological function, as determined by the Plan. Reshaping a nose with
a prominent bump is a good example of a Cosmetic Procedure because appearance would be
improved, but there would be no improvement in a function, e.g., breathing.
Cost-Effective – the least expensive item or service that performs the necessary function. This
term applies to Durable Medical Equipment, prosthetic devices and certain other Covered Health
Services.
Covered Drug – Note: this term applies to Outpatient prescription medications covered under
the HealthSelect of Texas Prescription Drug Program administered by OptumRx. Any legend
drug (a drug that, by law, can be obtained only by prescription) or injectable insulin, including
disposable pens, syringes and needles needed for self-administration that meets the following
requirements:
• that is Medically Necessary and is ordered by a Prescriber naming a Participant as the
recipient;
• for which a written or verbal Prescription Order or Refill is prepared by a Prescriber;
• for which a separate charge is customarily made;
• that is used for the purpose for which U.S. Food and Drug Administration (FDA) approval has
been given, or used consistent with the applicable program criteria approved by the
Prescription Drug List (PDL) Management Committee;
• that is dispensed by a Pharmacy and is received by the Participant while covered under this
Program, except when received in a Physician’s or Other Provider’s office, or during
confinement while a patient in a Hospital or other acute care institution or Facility; and
• that is not identified in Section 7, Exclusions: What the Prescription Drug Program Will Not
Cover, as not covered.
Covered Health Services – those health services, supplies and Medications and Injections,
which the Plan determines to be:
• Medically Necessary;
• included in Sections 5 and 6, Schedule of Benefits and Coverage and Details for Covered
Health Services, described as a Covered Health Service;
• provided to a Participant who meets the Plan's eligibility requirements, as described under
Eligibility in Section 2, Introduction; and
• not identified in Section 7, Exclusions: What the Medical Plan Will Not Cover, as not covered.
COVID-19 - A respiratory disease caused by the SARS-CoV-2 virus.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
142 SECTION 13 – GLOSSARY
Custodial Care – services that do not require special skills or training and that:
• provide assistance in activities of daily living (including, but not limited to, feeding or cooking,
dressing, going to the toilet, preventive and pain-relieving skin care, bathing, ostomy care,
incontinence care, checking of routine vital signs and ambulating or exercising functions);
• are provided for the primary purpose of meeting the personal needs of the Participant or
maintaining a level of function (even if the specific services are considered to be skilled
services), as opposed to improving that function to an extent that might allow for a more
independent existence; or
• do not require continued administration by trained medical personnel in order to be delivered
safely and effectively.
Declaration of Informal Marriage – a document that memorializes that a man and a woman
desire to consider themselves married for all legal purposes. The completed document requires
the notarized signatures of both parties and must be filed with the District Clerk of the county of
the couple’s residence.
Deductible – see Annual Non-Network Deductible.
Dependent – an individual who, because of a statutorily defined relationship with a Subscriber,
meets the eligibility requirements specified in the Plan, as described under Eligibility in Section 2,
Introduction, and is enrolled as a Participant in the Plan. A Dependent does not include anyone
who is enrolled in the Plan as a Subscriber. No one can be enrolled as a Dependent of more than
one Subscriber.
Developmental Delay – a significant variation in normal development as measured by
appropriate diagnostic instruments and procedures, in one or more of the following areas:
• cognitive development;
• physical development;
• communication development;
• social or emotional development; or
• adaptive development.
DME – see Durable Medical Equipment (DME).
Domiciliary Care – a supervised living arrangement in a home-like environment, providing
assistance with activities of daily living, for Participants who are unable to live independently
because of age-related impairments or physical, mental or visual disabilities.
Durable Medical Equipment (DME) – any medical equipment appropriate for use in the home to
aid in a better quality of living for Participants with a Sickness, Injury or disability, and that meets
the requirements specified under Durable Medical Equipment (DME) in Section 6, Details for
Covered Health Services.
Educational – services, supplies, and related expenses provided to address a Participant’s
Developmental Delays, or otherwise provide training, skills, practice and exercises designed to
enhance academic performance, to teach positive behaviors and/or discourage inappropriate,
destructive or otherwise negative conduct. It includes, but is not limited to, special education or
conventional learning techniques, operant conditioning or other forms of training.
Emergency – a serious medical condition or symptom resulting from Injury, Sickness or
Mental Illness, or substance-related and addictive disorder which:
• arises suddenly; and
• in the judgment of a reasonable person, requires immediate care and treatment,
generally received within 24 hours of onset, to avoid jeopardy to life or health.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
143 SECTION 13 – GLOSSARY
The Plan determines if a medical condition is an Emergency based on factors that include,
but are not limited to, medical information supplied by the Participant’s Provider.
Emergency Health Services – health care services and supplies necessary for the treatment of
an Emergency.
Employee – an appointive or elective state officer (including a judicial officer) or employee in the
service of the state of Texas, including an employee of an Institution of Higher Education, as
defined in Section 1551.003 of the Act and in this Glossary, and any persons required or
permitted by the Act to enroll as Subscribers. Eligibility for participation in the Plan for Employees
is limited to the specific statutes that include them as Employees. This definition does not infer
any greater eligibility for or right of access to the Benefits provided by this Plan than the statutes
establishing each class of eligible persons.
Employer – the state of Texas and all its agencies, certain political subdivisions or Institutions of
Higher Education, as defined in this Glossary, that employ or employed a Subscriber.
End-Stage Renal Disease (ESRD) –a medical condition in which a person's kidneys cease
functioning on a permanent basis leading to the need for a regular course of long-term dialysis or
a kidney transplant to maintain life. Beneficiaries may become entitled to Medicare based on
ESRD.
EOB – see Explanation of Benefits (EOB).
ESRD – see End-Stage Renal Disease (ESRD)
Experimental or Investigational Services – medical, surgical, diagnostic, psychiatric mental
health, substance-related and addictive disorder or other health care services, technologies,
supplies, treatments, procedures, drug or other therapies, medications or devices that, at the time
the Plan makes a determination regarding coverage in a particular case, the Plan determines to
be any of the following:
• not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the
proposed use and not identified in the American Hospital Formulary Service or the United
States Pharmacopoeia Dispensing Information as appropriate for the proposed use;
• subject to review and approval by any institutional review board for the proposed use
(Devices which are FDA approved under the Humanitarian Use Device exemption are not
considered to be Experimental or Investigational); or
• the subject of an ongoing Clinical Trial that meets the definition of a Phase I, II or III Clinical
Trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA
oversight.
Exceptions:
• routine patient care costs for Clinical Trials for which Benefits are available as described
under Clinical Trials in Section 6, Details for Covered Health Services.
• If you are not a Participant in a qualifying Clinical Trial as described under Clinical Trials in
Section 6, Details for Covered Health Services, and have a significantly life-threatening
Sickness, Injury or other medical condition, ERS, or BCBSTX as its designee, may, at its
discretion, consider an otherwise Experimental or Investigational Service to be a Covered
Health Service for that Sickness, Injury or other medical condition. Prior to such a
consideration, the Plan must first establish, based on good faith medical judgment supported
by sufficient scientific evidence that although Experimental or Investigational, the service has
significant potential as an effective life-sustaining treatment for that Sickness, Injury or other
medical condition.
• In making its determination, ERS, or BCBSTX as its designee, will refer to a certification the
Participant’s Physician must provide stating that he or she, based on good-faith medical
judgment, believes:
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
144 SECTION 13 – GLOSSARY
o the Sickness, Injury or other medical condition is significantly life threatening and
imminently fatal if the treatment is limited to Covered Health Services; and
o although designated as Experimental or Investigational, the service has significant
potential as an effective life-sustaining treatment for the Sickness, Illness or condition.
• In addition to clinical studies regarding the Experimental or Investigational Service, the Plan
may consider scientifically grounded standards based on Physician specialty society
recommendations and professional standards of care. The Plan reserves the right to obtain
expert opinion(s) in determining whether an otherwise Experimental or Investigational Service
shall be considered as a Covered Health Service for a particular Sickness, Injury or other
medical condition. The decision to apply Physician specialty society recommendations, the
choice of expert and the determination of when to use any such expert opinion, shall be
within the Plan's sole discretion.
Appeals from a BCBSTX pre-service decision not to consider the Experimental or Investigational
Service to be a Covered Health Service will be handled as an appeal of an Urgent Request for
Benefits under Section 8, Claims Procedures of this MBPD.
Explanation of Benefits (EOB) – a statement provided by BCBSTX to you, your Physician, or
another health care professional regarding a specific claim for health services or supplies that
explains:
• the Benefits provided (if any);
• the allowable reimbursement amounts;
• Deductibles;
• Coinsurance and Copays;
• any other reductions;
• the net amount paid by the Plan;
• the amount that is your responsibility (the amount you may owe your Provider); and
• the reason(s) why the service or supply was not covered by the Plan.
Facility – a Hospital, Alternate Facility, Inpatient Rehabilitation Facility, Freestanding Emergency
Room, Freestanding Emergency Department, Skilled Nursing Facility, Residential Treatment
Facility or Urgent Care Center (all as defined in this Glossary) or other institution that is licensed
to provide services and supplies covered by the Plan and that is approved by BCBSTX. Other
Facilities include, but are not limited to:
• substance-related and addictive disorder treatment facilities;
• birthing centers;
• Hospices;
• imaging centers;
• independent laboratories;
• psychiatric day treatment facilities;
• radiation therapy centers; and
• renal dialysis centers.
In states where there is a licensure requirement, other Facilities must be licensed by the
appropriate state administrative agency.
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145 SECTION 13 – GLOSSARY
Facility-Based Provider/Physician – a Physician, Health Care Practitioner, or other health
care Provider who provides health care or medical services to patients of a Hospital Facility
This includes, but is not limited to, Emergency care Physicians, consulting Physicians,
assistant surgeons, Durable Medical Equipment Providers, surgical assistants, laboratory
technicians, radiologists, anesthesiologists and pathologists.
Former COBRA Unmarried Child – A child of an Employee or Retiree who is unmarried; whose
GBP coverage as a dependent has ceased; and who upon expiration of continuation coverage
under the Consolidated Omnibus Budget Reconciliation Act, Public Law 99-272 (COBRA)
reinstates GBP coverage.
Freestanding Emergency Department – medical care Facility that provides Emergency Health
Services that is affiliated with a Hospital but that is not physically connected to a Hospital (i.e.,
structurally separate and distinct).
Freestanding Emergency Room – medical care Facility that provides Emergency Health
Services that is not affiliated with a Hospital and is not physically connected to a Hospital (i.e.,
structurally separate and distinct).
Genetic Testing – examination of blood or other tissue for chromosomal and DNA abnormalities
and alterations, or other expressions of gene abnormalities that may indicate an increased risk for
developing a specific disease or disorder.
Group Benefits Program (GBP or the Program) – the Texas Employees Group Benefits
Program as established by the Act and administered by the Employees Retirement System of
Texas and its Board of Trustees pursuant to the Act.
Habilitation – a process aimed at helping people attain, keep or improve skills and functioning
for daily living, including, but not limited to physical, occupational, and speech-language
therapy.
HealthSelect
of Texas
®
Plan or HealthSelect – a self-funded health benefit plan offered by
ERS through the Texas Employees Group Benefits Program. It includes an In-Area Plan, a
HealthSelect
SM
Out-of-State Plan, a High Deductible Health Plan that is part of Consumer
Directed HealthSelect
SM
, a HealthSelect
SM
Secondary Plan, and a Prescription Drug Program.
HealthSelectShoppERS
SM
– a program available to active employees and their dependents who
are also Participants covered under the HealthSelect of Texas In-Area, HealthSelect Out-of-State
and Consumer Directed HealthSelect Plans, where eligible Participants can save money and
earn incentives when shopping for and choosing lower cost Facilities for certain medical services.
Refer to Addendum – Resources to Help You Stay Healthy, for details about the program.
Home Health Agency – a program or organization authorized by law to provide health care
services in the home and certified by Medicare as a supplier of home health care.
Hospice – a Facility or agency primarily engaged in providing Hospice care as described in
Section 6, Details for Covered Health Services, licensed under state law, and certified by
Medicare as a supplier of Hospice care.
Hospital – an institution, operated as required by law, that is:
• primarily engaged in providing health care services, on an Inpatient basis, for the acute care
and treatment of sick or injured individuals. Care is provided through medical, mental health,
substance-related and addictive disorder, diagnostic and surgical Facilities, by or under the
supervision of a staff of Physicians; and
• has 24-hour nursing services.
A Hospital is not primarily a place for rest, Custodial Care, Domiciliary Care or care of the aged
and it is not a Skilled Nursing Facility, convalescent home or similar institution.
Individualized Family Service Plan – an initial and ongoing treatment plan for Developmental
Delay of eligible children up to age 3.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
146 SECTION 13 – GLOSSARY
Injury – bodily damage other than Sickness or disability, including all related conditions and
recurrent symptoms.
Inpatient Copay Maximum – the most you are required to pay each Calendar Year in Copays
for Inpatient Stays in a Hospital or for Inpatient care for Mental Health Services, Serious Mental
Illness Services or Substance Use Disorder Services. There are separate Network and Non-
Network Inpatient Copay Maximums for this Plan. The Inpatient Copay Maximum amount is
shown in Table 2 in Section 5, Schedule of Benefits and Coverage. Refer to Section 3, How the
Plan Works, for a description of how the Inpatient Copay Maximum works.
Inpatient – a Participant who has been admitted to a Hospital, Nursing Facility or Inpatient
Rehabilitation Facility or an Inpatient Facility for Mental Health Services, Serious Mental Illness
Services or Substance Use Disorder Services.
Inpatient Rehabilitation Facility – a long term acute rehabilitation center, a Hospital (or a
special unit of a Hospital designated as an Inpatient Rehabilitation Facility) that provides
rehabilitation services (including physical therapy, occupational therapy and/or speech therapy)
on an Inpatient basis, as authorized by law.
Inpatient Stay – an uninterrupted confinement, following formal admission to a Hospital, Skilled
Nursing Facility or Inpatient Rehabilitation Facility or an Inpatient Care Facility for Mental Health
Services, Serious Mental Illness Services or Substance Use Disorder Services.
Institution of Higher Education – a public junior college, a senior college or university, or any
other agency of higher education within the meaning and jurisdiction of Chapter 61, Texas
Education Code. It does not include an entity in The University of Texas System, as described in
Section 65.02, Texas Education Code and an entity in The Texas A&M University System, as
described in Subtitle D, Title 3, Texas Education Code, including the Texas Veterinary Medical
Diagnostic Laboratory.
Intensive Behavioral Therapy – an umbrella term for a variety of outpatient behavioral
interventions that aim to reinforce adaptive behaviors, reduce maladaptive behaviors and improve
the mastery of functional age-appropriate skills in people with Autism Spectrum Disorder. The
most common Intensive Behavioral Therapy is Applied Behavior Analysis (ABA).
Intensive Outpatient Treatment – a structured Outpatient mental health or substance-related
and addictive disorder treatment program that may be free-standing or Hospital-based and
provides services for at least three hours per day, two or more days per week.
Intermittent Skilled Nursing Care – skilled nursing care that is provided either for:
• fewer than seven days each week; or
• fewer than eight hours each day for a period of 21 days or less.
The Plan may make exceptions for special circumstances when the need for additional skilled
nursing care is finite and predictable.
Marriage and Family Therapy/Counseling – the provision of professional therapy services to
individuals, families, or married couples, singly or in groups, involving the professional application
of family systems theories and techniques in the delivery of therapy services to those persons.
The term includes, but is not limited to, the evaluation and remediation of cognitive, affective,
behavioral, or relational dysfunction within the context of marriage or family systems.
Medicaid – a federal program administered and operated individually by participating state and
territorial governments and providing health care coverage to eligible low-income people.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
147 SECTION 13 – GLOSSARY
Medical Social Services – those social services relating to the treatment of a Participant’s
medical condition. Such services include, but are not limited to:
• assessment of the social and emotional factors related to the Participant’s medical condition,
need for care, response to treatment and adjustment to care; and
• assessment of the relationship of the Participant’s medical and nursing requirements to the
home situation, financial resources, and available community resources.
Medical Supplies - expendable items required for care related to a Sickness or Injury. Not all
Medical Supplies are Covered Health Services under the Plan. See Medical Supplies in Section
6, Details for Covered Health Services and Medical Supplies and Equipment in Section 7,
Exclusions, for a description.
Medically Necessary, Medical Necessity – health care services provided for the purpose of
preventing, evaluating, diagnosing or treating a Sickness, Injury, Mental Illness, substance-
related and addictive disorder, Serious Mental Illness, or disease (and symptoms), that are all of
the following as determined by the Plan. The health care services must be:
• performed in accordance with Generally Accepted Standards of Medical Practice;
• clinically appropriate, in terms of type, frequency, extent, site and duration, and considered
effective for your Sickness, Injury, Mental Illness, substance-related and addictive disorder,
Serious Mental Illness, or disease (and symptoms);
• not primarily performed for your comfort or convenience or that of your health care Provider;
and
• not more costly than an alternative drug, service(s) or supply that is at least as likely to
produce equivalent therapeutic or diagnostic results as alternatives with respect to the
diagnosis or treatment of your Sickness, Injury, Mental Illness, substance-related and
addictive disorder, Serious Mental Illness, or disease (and symptoms).
Generally Accepted Standards of Medical Practice are standards that are based on credible
scientific evidence published in peer-reviewed medical literature generally recognized by the
relevant medical community, relying primarily on controlled Clinical Trials, or, if not available,
observational studies from more than one institution that suggest a causal relationship between
the health care services and positive health outcomes.
If no credible scientific evidence is available, then standards based on Physician specialty society
recommendations or professional standards of care may be considered. The Plan reserves the
right to consult expert opinion in determining whether health care services are Medically
Necessary. The decision to apply Physician specialty society recommendations, the choice of
expert and the determination of when to use any such expert opinion, shall be within the Plan's
sole discretion.
BCBSTX develops and maintains clinical policies that describe the Generally Accepted Standards
of Medical Practice scientific evidence, prevailing medical standards and clinical guidelines
supporting its determinations regarding specific health services. These clinical policies (as
developed by BCBSTX and revised from time to time), are available to Participants at
www.bcbstx.com
or by calling BCBSTX at (800) 252-8039 (TTY: 711), and to Physicians and
other health care professionals at www.bcbstx.com.
The authority of the Plan to determine Medical Necessity is subject to the right of the Employees
Retirement System of Texas Board of Trustees to order payment of a claim even though
BCBSTX has not abused its discretion in denying the claim.
Medicare – Parts A, B, C and D of the insurance program for Americans 65 years of age and
over as well as younger Americans with certain disabilities, established by Title XVIII, United
States Social Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later
amended.
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Medicare-Approved Amount –the maximum amount Medicare pays a Provider that accepts
Medicare Assignment. It may be less than the actual amount a doctor or supplier bills.
Medicare Assignment – means that your Provider agrees (or is required by law) to accept the
Medicare-Approved Amount as full payment for services covered by Medicare.
Medicare Limiting Charge – if you are enrolled in Medicare, this is the maximum amount
Medicare allows Providers who do not accept Medicare Assignment to bill Participants. Not all
services are subject to the Medicare Limiting Charge, including supplies or equipment. For more
information on the Medicare Limiting Charge, go to Medicare.gov
.
Medicare Summary Notice (MSN) – a statement provided by Medicare to you, your Physician,
or another health care professional regarding a specific claim for health services processed by
Medicare and explains:
• the Benefits provided (if any);
• the Medicare-Approved Amounts;
• Deductibles;
• the net amount paid by Medicare;
• the amount you may owe your Provider; and
• the reason(s) why the service or supply was not covered by the Plan.
Medications and Injections – U.S. Food and Drug Administration (FDA)-approved prescription
medication and injections administered in connection with a Covered Health Service by a
Physician or other health care Provider within the scope of the Provider's license, and not
otherwise excluded under the Plan. Medications and Injections do not include medications that
are typically available by prescription order or refill at a pharmacy under the HealthSelect
Prescription Drug Program administered by OptumRx.
Mental Health Provider - a Provider who is licensed to provide services and/or supplies for
treatment of Mental Illness and acts within the scope of that license. Mental Health Providers
include, but are not limited to:
• Doctor of Psychology (Psy.D. or Ph.D.) (certified as a health service Provider);
• psychiatrist (M.D. or D.O.);
• addictionologist (M.D. or D.O.);
• nurse-practitioner;
• Licensed Clinical Social Worker (LCSW) or Licensed Masters Social Worker – Advanced
Practice (LMSW-AP);
• Licensed Marriage and Family Therapist (LMFT);
• licensed professional counselor;
• licensed dependency counselor; and
• licensed psychological associate.
Mental Health Providers must be licensed by the appropriate state administrative agency where
the services are provided.
Mental Health Provider also includes an Applied Behavior Analysis (ABA) Provider – a Mental
Health Provider who has advanced training in developmental disorders and ABA at the Masters
or higher level and is certified as a Board-Certified Behavior Analyst (BCBA) by the Behavior
Analyst Certification board, or an appropriately trained and qualified paraprofessional directly
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149 SECTION 13 – GLOSSARY
supervised by the above. If the state where services are provided licenses ABA professionals, the
state licensure is required in addition to the above.
Mental Health Services – Covered Health Services performed for the diagnosis and treatment of
Mental Illnesses, as described in Section 6, Details for Covered Health Services. The fact that a
condition is listed in the current Diagnostic and Statistical Manual of the American Psychiatric
Association does not mean that treatment for the condition is a Covered Health Service.
Mental Illness – mental health or psychiatric diagnostic categories listed in the current Diagnostic
and Statistical Manual of the American Psychiatric Association, or any other diagnostic coding
system as used by the Plan, whether or not the cause of the disease, disorder or condition is
physical, chemical, or mental, in nature or origin, unless the service or diagnostic category is
listed in Section 7, Exclusions: What the Medical Plan Will Not Cover.
Network – (sometimes referred to as HealthSelect Network) a nationwide system of Providers
developed by BCBSTX or its affiliate to provide Covered Health Services to Participants in the
Plan. Each Network Provider has a participation agreement in effect (either directly or indirectly)
with BCBSTX or with its affiliate to participate in the Network. BCBSTX’ affiliates are those
entities affiliated with BCBSTX through common ownership or control with BCBSTX or with
BCBSTX’ ultimate corporate parent, including direct and indirect subsidiaries.
A Provider may enter into an agreement to provide only certain Covered Health Services, but not
all Covered Health Services, or to be a Network Provider for only certain products. In this case,
the Provider will be a Network Provider for the Covered Health Services and products included in
the participation agreement, and a Non-Network Provider for other Covered Health Services and
products. The participation status of Providers may change from time to time.
You may find out the services for which a Provider is a Network Provider by calling BCBSTX at
(800) 252-8039 (TTY: 711).
Network Benefits - Benefits that the Plan pays for Covered Health Services provided by Network
Providers. Refer to Section 5, Schedule of Benefits and Coverage, for details about how Network
Benefits apply.
Non-Contracted Provider – means a Hospital, Physician, Behavioral Health Practitioner, or
Other Provider who has not entered into an agreement with BCBSTX (or other participating Blue
Cross and/or Blue Shield Plan) as a managed care Provider.
Non-Network – when used to describe a Provider of health care services, this means a Provider
outside of the Network as established and maintained by BCBSTX.
Non-Network Benefits - description of how Benefits are paid for Covered Health Services
provided by Non-Network Providers. Refer to Section 5, Schedule of Benefits and Coverage, for
details about how Non-Network Benefits apply.
Non-Network Deductible – see Annual Non-Network Deductible.
Other Provider - means a person or entity, other than a Hospital or Physician, that is
appropriately licensed where required to provide to a Participant a service or supply described
herein as Covered Health Services. Other Provider shall include:
1
. Facility Other Provider - an institution or entity, only as listed:
a. Chemical Dependency Treatment Center
b. Crisis Stabilization Unit or Facility
c. Durable Medical Equipment Provider
d. Home Health Agency
e. Home Infusion Therapy Provider
f. Hospice
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150 SECTION 13 – GLOSSARY
g. Imaging Center
h. Independent Laboratory
i. Prosthetics/Orthotics Provider
j. Psychiatric Day Treatment Facility
k. Renal Dialysis Center
l. Residential Treatment Facility for Children and Adolescents
m. Skilled Nursing Facility
n. Therapeutic Center
2. Professional Other Provider - a person or practitioner, when acting within the scope of his
license and who is appropriately certified, only as listed:
a. Advanced Practice Nurse
b. Certified Nurse Midwife licensed as Advance Nurse Practitioner
c. Doctor of Chiropractic
d. Doctor of Dentistry
e. Doctor of Optometry
f. Doctor of Podiatry
g. Doctor in Psychology
h. Licensed Acupuncturist
i. Licensed Audiologist
j. Licensed Chemical Dependency Counselor
k. Licensed Dietitian
l. Licensed Hearing Instrument Fitter and Dispenser
m. Licensed Marriage and Family Therapist
n. Licensed Clinical Social Worker
o. Licensed Occupational Therapist
p. Licensed Physical Therapist
q. Licensed Professional Counselor
r. Licensed Speech-Language Pathologist
s. Licensed Surgical Assistant
t. Nurse Anesthetist
u. Nurse First Assistant
v. Physician Assistant
w. Psychological Associates who work under the supervision of a Doctor in Psychology
In states where there is a licensure requirement, Other Providers must be licensed by the
appropriate state administrative agency.
Out-of-State – describes the part of the HealthSelect Plan that is available to Participants whose
eligibility county is outside of Texas.
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151 SECTION 13 – GLOSSARY
Out-of-Pocket Coinsurance Maximum – the most you are required to pay each Calendar Year
for Coinsurance. Refer to Section 5, Schedule of Benefits and Coverage, for the Out-of-Pocket
Coinsurance Maximum amount. Refer to Section 3, How the Plan Works, for a description of how
the Out-of-Pocket Coinsurance Maximum works.
Outpatient – a Participant who has been treated at a Hospital or Facility for other than Inpatient
treatment.
Outpatient Clinic Facility – a health care Facility that is not a Hospital or an Alternate Facility
and that provides Physician’s office services for Sickness or Injury on an Outpatient basis, as
permitted by law.
Partial Hospitalization/Day Treatment – a structured ambulatory program that may be free-
standing or Hospital-based and that provides services for at least 20 hours per week.
Participant – an Employee, Retiree, or a Dependent, as defined in the Act, and surviving
Dependents of deceased Employees and Retirees, or other persons eligible for coverage as
provided under the Act while eligible for coverage and enrolled under the Plan. References to
"you" and "your" throughout this Master Benefit Plan Document are references to a Participant.
Personal Health Assistant (PHA) – a BCBSTX Personal Health Assistant provides customer
service resources to help Participants navigate the health care system, including information on
cost and quality transparency, Prior Authorization coordination, connection with clinical
Educational resources and appointment scheduling.
Physician – any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and
qualified by law. Please Note: The fact that a Provider is described as a Physician does not
mean that Benefits for services from that Provider are available to you under the Plan.
Plan – the HealthSelect Out-of-State Plan.
Plan Administrator – the Employees Retirement System of Texas (ERS) or its designee.
Plan Service Area – the geographical area or areas designated by the Employees Retirement
System of Texas Board of Trustees as the area that determines eligibility for the plan. See
Section 2, Introduction, for more details.
Plan Year – The time period that begins on September 1 of each year and ends August 31 of
the following year.
Post-Delivery Care - postpartum health care services provided in accordance with accepted
maternal and neonatal physical assessments. The term includes:
• parent education;
• assistance and training in breast-feeding and bottle feeding; and
• the performance of any necessary and appropriate clinical tests.
Post-Service Claim - a claim for Benefits that is not a Pre-Service Request for Benefits or Urgent
Request for Benefits. Post-Service Claims include claims that involve only the payment or
reimbursement of Allowable Amounts for Covered Health Services that have already been
provided.
Preauthorization or Predetermination – See Prior Authorization.
Pregnancy – includes, but is not limited to, prenatal care, postnatal care and childbirth.
Complications of Pregnancy are considered separately as defined in this section.
Prescriber – any health care professional who is properly licensed and qualified by law to
prescribe Prescription Drugs to humans. The fact that a Prescriber has prescribed a medication
or product, or the fact that it may be the only available treatment for a Sickness, Injury, Mental
Illness, substance-related and addictive disorder, disease or its symptoms does not make the
product a Covered Drug under the Program.
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152 SECTION 13 – GLOSSARY
Pre-Service Request for Benefits – a claim for Benefits where the Plan conditions receipt of the
Benefit, in whole or in part, on approval of the Benefit in advance of obtaining medical care. This
includes Covered Health Services which the Plan must approve or for which you must obtain
Prior Authorization from BCBSTX before non-Urgent Care is provided.
Preventive Care – care that consists of measures taken for disease prevention, as opposed to
diagnostic services or disease treatment.
Primary or Primary Plan - when you are covered by more than one health benefits plan, the
Primary Plan is the plan that pays benefits first under coordination of benefits (COB)
guidelines. Remaining Allowable Amounts may be paid under the other plan, which is called
the Secondary Plan. Refer to Section 9, Coordination of Benefits (COB), for details on COB
guidelines.
Prior Authorization – (sometimes known as preauthorization or predetermination) the utilization
review process that the Plan uses to determine whether certain services are Covered Health
Services under the Plan. See Section 4, Prior Authorization, for the list of services requiring Prior
Authorization and for details on the Prior Authorization process.
Private Duty Nursing – shift or continuous nursing care that encompasses nursing services for
Participants who require more individual and continuous care than is available from a visiting
nurse through a Home Health Agency. Private Duty Nursing services are provided where longer
durations of Skilled Care are required and may include shift care or continuous care 24 hours a
day, 7 days a week in certain settings. Private Duty Nursing care is not care provided primarily for
the comfort or convenience of the Participant.
Program – See Group Benefits Program (GBP).
Provider – a Facility, Hospital, Physician or Mental Health Provider that is licensed to provide
health care services and supplies and acts within the scope of that license and that is approved
by BCBSTX.
Qualifying Life Event (QLE) – a life experience whose occurrence that allows a Participant to
change health care coverage during a Plan Year, provided that the change in coverage is
consistent with the life event. See Changing Your Coverage in Section 2, Introduction, for a list of
Qualifying Life Events and how to change your coverage.
Reconstructive Procedure – a procedure performed to address a physical impairment where
the expected outcome is restored or improved function. The primary purpose of a Reconstructive
Procedure is either to treat a medical condition or to improve or restore physiologic function.
Reconstructive Procedures include, but are not limited to, surgery or other procedures which are
associated with an Injury, Sickness or Congenital Anomaly. The primary intended result of the
procedure is not changed or improved physical appearance. The fact that a person may suffer
psychologically as a result of the condition does not classify surgery or any other procedure done
to relieve the condition as a Reconstructive Procedure.
Residential Treatment Facility – a Facility that provides a program of effective Mental Health
Services or Substance Use Disorder Services treatment and meets all of the following
requirements:
• it is established and operated in accordance with applicable state law for residential treatment
programs;
• it provides a program of treatment under the active participation and direction of a Physician
and approved by BCBSTX;
• it has or maintains a written, specific and detailed treatment program requiring full-time
residence and full-time participation by the patient; and
• it provides at least the following basic services in a 24-hour per day, structured group setting:
o room and board;
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153 SECTION 13 – GLOSSARY
o evaluation and diagnosis;
o counseling; and
o referral and orientation to specialized community resources.
A Residential Treatment Facility that qualifies as a Hospital is considered a Hospital.
Retail Health Clinic - health care clinic often located in a retail setting such as a supermarket or
pharmacy, that provides treatment of common illnesses and routine Preventive Care services that
can be rendered by appropriately licensed Providers located in the clinic.
Retiree – (also known as annuitant) an Employee who has retired as defined in the Act and, for
purposes of Benefits under this Plan, is under the age of 65.
Routine Patient Care Costs - the costs of any Medically Necessary health care service for which
Benefits are provided under the Plan, without regard to whether the Participant is participating in
a clinical trial.
Routine patient care costs do not include:
• the investigational item, device, or service, itself;
• items and services that are provided solely to satisfy data collection and analysis needs that
are not used in the direct clinical management of the patient; or
• a service that is clearly inconsistent with widely accepted and established standards of care
for a particular diagnosis.
Second Opinion – an opinion from a second Provider or Other Provider as covered under this
Plan. Applicable Benefits for all Covered Health Services will apply. For coverage details, see
Section 5- Schedule of Benefits and Coverage and Section 6- Details for Covered Health
Services.
Secondary or Secondary Plan - when you are covered by more than one health benefits plan,
the Secondary Plan is the plan that pays benefits second, following the Primary Plan, under
coordination of benefits (COB) guidelines. The Secondary Plan may or may not pay all remaining
Allowable Amounts after the Primary Plan has paid, depending on how COB is determined. Refer
to Section 9, Coordination of Benefits (COB), for details on COB guidelines.
Semi-private Room - a room with two or more beds.
Serious Mental Illness - the following psychiatric illnesses as defined in the current Diagnostic
and Statistical Manual of the American Psychiatric Association:
• bipolar disorders (hypomanic, manic, depressive, and mixed);
• depression in childhood and adolescence;
• major depressive disorders (single episode or recurrent);
• obsessive-compulsive disorders;
• paranoid and other psychotic disorders;
• pervasive developmental disorders;
• schizo-affective disorders (bipolar or depressive); and
• schizophrenia.
Sickness – physical illness, disease or Pregnancy. The term Sickness as used in this MBPD
includes Mental Illness and substance-related and addictive disorder, regardless of the cause or
origin of the Mental Illness or substance-related and addictive disorder.
Skilled Care – skilled nursing, skilled teaching, and skilled rehabilitation services when:
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154 SECTION 13 – GLOSSARY
• they are delivered or supervised by licensed technical or professional medical personnel in
order to obtain the specified medical outcome and provide for the safety of the Participant;
• a Physician orders them;
• they are not delivered for the purpose of assisting with activities of daily living, including, but
not limited to, dressing, feeding, bathing or transferring from a bed to a chair;
• they require clinical training in order to be delivered safely and effectively; and
• they are not Custodial Care, as defined in this section.
Skilled Nursing Facility – a nursing Facility that is licensed and operated as required by law. A
Skilled Nursing Facility that is part of a Hospital is considered a Skilled Nursing Facility for
purposes of the Plan.
Specialist - (sometimes known as Specialist Physician) a Physician who has a majority of his
or her practice in areas other than general pediatrics, internal medicine, family practice or
general medicine.
Specialty Drug – Prescription Drugs that are used in the treatment of rare or complex conditions
and:
• may be administered by injection or infusion;
• may be high cost;
• have special delivery and storage requirements; and/or
• require close monitoring or care coordination by a pharmacist or Prescriber.
To find out whether a medication you take is considered a Specialty Drug, call the HealthSelect
Prescription Drug Program at (855) 828-9834. If you have questions about the Benefits that apply
to Specialty Drugs under this medical Plan, call a BCBSTX Personal Health Assistant at (800)
252-8039 (TTY: 711).
State Agency – a commission, board, department, division, Institution of Higher Education, or
other agency of the state of Texas created by the constitution or statutes of this state. This term
also includes the Texas Municipal Retirement System, the Texas County and District Retirement
System, the Teachers Retirement System and ERS.
Subscriber – the Participant who is the Employee, Retiree, or other person enrolled in the Plan
as provided for under the Act, and who is not a Dependent.
Substance Use Disorder Services – (also referred to as chemical dependency services)
Covered Health Services for the diagnosis and treatment of alcoholism and substance-related
and addictive disorder that are listed in the current Diagnostic and Statistical Manual of the
American Psychiatric Association, unless those services are specifically excluded by the Plan.
The fact that a disorder is listed in the Diagnostic and Statistical Manual of the American
Psychiatric Association does not mean that treatment of the disorder is a Covered Health Service.
Telemedicine -
Certain services through use of a provider-platform to provide health services
through the use of interactive audio, video, other electronic media or advanced
telecommunications technology. The term includes the use of electronic media for diagnosis,
consultation, treatment, transfer of medical data, and medical education. Telemedicine also
includes 1) compressed digital interactive video, audio, or data transmission; 2) clinical data
transmission using computer imaging by way of still image capture and store and forward; and 3)
other technology that facilitates access to health care services or medical specialty expertise.
Sometimes referred to as Telehealth.
Tertiary or Tertiary Plan - when you are covered by more than one health benefits plan, the
Tertiary Plan is the plan that pays benefits third, following both the Primary and Secondary Plans,
under coordination of benefits (COB) guidelines. The Tertiary Plan may or may not pay all
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
155 SECTION 13 – GLOSSARY
remaining Allowable Amounts after the Primary and Secondary Plans have paid, depending on
how COB is determined. Refer to Section 9, Coordination of Benefits (COB), for details on COB
guidelines.
Total Network Out-of-Pocket Maximum – the most you are required to pay each Calendar Year
for Network Coinsurance and Copays, as detailed in Section 5, Schedule of Benefits and
Coverage. Refer to Section 3, How the Plan Works, for a description of how the Total Network
Out-of-Pocket Maximum works.
Transitional Care – Mental Health Services/Substance Use Disorder Services that are provided
through transitional living Facilities, group homes and supervised apartments that provide 24-hour
supervision that are either:
• sober living arrangements such as drug-free housing and alcohol/drug halfway houses.
These are transitional, supervised living arrangements that provide stable and safe housing,
an alcohol/drug-free environment and support for recovery. A sober living arrangement may
be utilized as an adjunct to ambulatory treatment when treatment doesn't offer the intensity
and structure needed to assist the Participant with recovery; or
• supervised living arrangements that are residences such as transitional living Facilities, group
homes and supervised apartments that provide Participants with stable and safe housing and
the opportunity to learn how to manage their activities of daily living. Supervised living
arrangements may be utilized as an adjunct to treatment when treatment does not offer the
intensity and structure needed to assist the Participant with recovery.
Unproven Services – health services, including medications, that have not been determined to
be effective for treatment of the Sickness, Injury or other medical condition and/or not to have a
beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from
well-conducted randomized controlled trials or cohort studies in the prevailing published peer-
reviewed medical literature:
• Well-conducted randomized controlled trials are two or more treatments compared to each
other, with the patient not being allowed to choose which treatment is received.
• Well-conducted cohort studies from more than one institution are studies in which patients
who receive study treatment are compared to a group of patients who receive standard
therapy. The comparison group must be nearly identical to the study treatment group.
BCBSTX has a process by which it compiles and reviews clinical evidence with respect to certain
health services. From time to time, BCBSTX issues medical and drug policies that describe the
clinical evidence available with respect to specific health care services. These medical and drug
policies are subject to change without prior notice. You can view these policies at
www.bcbstx.com
.
Please Note: If you have a significantly life-threatening Sickness, Injury or other medical
condition, ERS, or BCBSTX as its designee may, at its discretion, consider an otherwise
Unproven Service to be a Covered Health Service for that Sickness, Injury or other medical
condition. Prior to such a consideration, the Plan must first establish, based on good faith medical
judgment supported by sufficient scientific evidence, that albeit unproven, the service has
significant potential as an effective life-sustaining treatment for that Sickness, Injury or other
medical condition.
In making its determination, ERS, or BCBSTX as its designee, will refer to a certification the
Participant’s Physician must provide stating that he or she, based on good-faith medical
judgment, believes:
• the Sickness, Injury or other medical condition is significantly life threatening and imminently
fatal if the treatment is limited to Covered Health Services; and
• although designated as Experimental or Investigational, the service has significant potential
as an effective life-sustaining treatment for the Sickness, Illness or condition.
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156 SECTION 13 – GLOSSARY
In addition to clinical studies regarding the Unproven Service, the Plan may consider scientifically
grounded standards based on Physician specialty society recommendations and professional
standards of care. The Plan reserves the right to obtain expert opinion(s) in determining whether
an otherwise Unproven Service shall be considered as a Covered Health Service for a particular
Sickness, Injury or other medical condition. The decision to apply Physician specialty society
recommendations, the choice of expert and the determination of when to use any such expert
opinion, shall be within the Plan's sole discretion.
Appeals from an ERS or BCBSTX decision not to consider the Experimental or Investigational
Service to be a Covered Health Service will be handled as an appeal of an Urgent Request for
Benefits under Section 8, Claims Procedures of this Master Benefit Plan Document.
Urgent Care – treatment of an unexpected Sickness or Injury that is not life-threatening but
requires Outpatient medical care that cannot be postponed. An urgent situation requires prompt
medical attention to avoid complications and unnecessary suffering, such as high fever, a skin
rash, or an ear infection.
Urgent Care Center – a Facility that provides Urgent Care services, as previously defined in this
section. In general, Urgent Care Centers:
• do not require an appointment;
• are open outside of normal business hours, so you can get medical attention for a minor
Sickness or Injury that occurs at night or on weekends; and
• provide an alternative to an Emergency room if you need immediate medical attention, but
your Physician cannot see you right away.
Urgent Request for Benefits – a claim for medical care or treatment with respect to which
application of the time periods for making non-urgent determinations (a) could seriously
jeopardize the life or health of the Participant or the ability of the Participant to regain maximum
function, or (b) in the opinion of the Participant’s Physician, would subject the Participant to
severe pain that could not be adequately managed without the care or treatment that is the
subject of the claim.
Virtual Network Provider –
an appropriately licensed Provider that has entered into a
contractual agreement with
BCBSTX to provide diagnosis and treatment of injuries and illnesses
through a Virtual Visit.
Virtual Visits - services provided by a Virtual Network Provider for the diagnosis and treatment of
low acuity, non-Emergency medical and mental health conditions through the use of interactive
audio and video telecommunication and transmissions, and audio-visual communication
technology.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
157 SECTION 14 – ADMINISTRATIVE INFORMATION
SECTION 14 - IMPORTANT ADMINISTRATIVE
INFORMATION
What this section includes
■ Plan administrative information.
This section includes information on the administration of the Plan. While you may not need this
information for your day-to-day participation, it is information you may find important.
Plan Administrator: The Plan Administrator is the Employees Retirement System of Texas
(ERS). ERS may, from time to time in its sole discretion, contract with outside parties to arrange
for the provision of administrative services including arrangement of access to a Network
Provider; claims processing and payment services, including coordination of Benefits and
subrogation; utilization management and complaint resolution assistance. This contracted
administrator for the Plan is BCBSTX. For Benefits as described in this MBPD, ERS also has
selected a Provider Network established by BCBSTX.
The Employees Retirement System of Texas
200 East 18th Street
Austin, TX 78701
(877) 275-4377
ERS retains all fiduciary responsibilities with respect to the Plan except to the extent ERS has
allocated to other persons or entities one or more fiduciary responsibility(s), as it has to BCBSTX,
with respect to the Plan.
Blue Cross and Blue Shield of Texas: The company that provides certain administrative
services for the Plan described in this MBPD.
Blue Cross and Blue Shield of Texas
P.O. Box 660044
Dallas, Texas 75266-0044
(800) 252-8039 (TTY: 711)
BCBSTX shall not be deemed or construed as an Employer for any purpose with respect to the
administration or provision of Benefits under the Plan. BCBSTX shall not be responsible for
fulfilling any duties or obligations of an Employer with respect to the Plan.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
158 ATTACHMENT I - SUMMARY NOTICE OF PRIVACY PRACTICES
ATTACHMENT I - THE EMPLOYEES RETIREMENT SYSTEM
OF TEXAS SUMMARY NOTICE OF PRIVACY PRACTICES
The Employees Retirement System of Texas (“ERS”) administers the Texas Employees
Group Benefits Program, including your health plan, pursuant to Texas law. THIS NOTICE
DESCRIBES HOW ERS MAY USE OR DISCLOSE MEDICAL INFORMATION ABOUT YOU
AND HOW YOU CAN GET ACCESS TO YOUR OWN INFORMATION PURSUANT TO THE
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (“HIPAA”)
PRIVACY RULE. PLEASE REVIEW THIS NOTICE CAREFULLY.
Uses and Disclosures of Health Information:
ERS and/or a third-party administrator under contract with ERS may use health information about
you on behalf of your health plan to authorize treatment, to pay for treatment, and for other
allowable health care purposes. Health care providers submit claims for payment for treatment
that may be covered by the group health plan. Part of payment includes ascertaining the medical
necessity of the treatment and the details of the treatment or service to determine if the group
health plan is obligated to pay. Information may be shared by paper mail, electronic mail, fax, or
other methods.
By law, ERS may use or disclose identifiable health information about you without your
authorization for several reasons, including, subject to certain requirements, for public health
purposes, for auditing purposes, for research studies, and for emergencies. ERS provides
information when otherwise required by law, such as for law enforcement in specific circumstances.
In any other situation, ERS will ask for your written authorization before using or disclosing any
identifiable health information about you. If you choose to sign an authorization to disclose
information, you can later revoke that authorization to stop any future uses and disclosures. ERS
cannot use or disclose your genetic information for underwriting purposes. ERS may change its
policies at any time. When ERS makes a significant change in its policies, ERS will change its
notice and post the new notice on the ERS website at www.ers.texas.gov
. Our full notice is
available at https://ers.texas.gov/PDFs/Forms/HIPAA-Notice-of-Privacy-Practices-(Long-
Form)
For more information about our privacy practices, contact the ERS Privacy Officer. ERS originally
adopted its Notice of Privacy Practices and HIPAA Privacy Policies and Procedures Document
April 14, 2003, and subsequently revised them effective February 17, 2010, and September 23,
2013.
Individual Rights:
In most cases, you have the right to look at or get a paper or electronic copy of health information
about you that ERS uses to make decisions about you. If you request copies, we will charge you
the normal copy fees that reflect the actual costs of producing the copies including such items as
labor and materials. For all authorized or by law requests made by others, the requestor will be
charged for production of medical records per ERS’ schedule of charges. You also have the right
to receive a list of instances when we have disclosed health information about you for reasons
other than treatment, payment, healthcare operations, related administrative purposes, and when
you explicitly authorized it. If you believe that information in your record is incorrect or if important
information is missing, you have the right to request that ERS correct the existing information or
add the missing information. You have the right to request that ERS restrict the use and
disclosure of your health information above what is required by law. If ERS accepts your request
for restricted use and disclosure then ERS must abide by the request and may only reverse its
position after you have been appropriately notified. You have the right to request an alternative
means of communications with ERS. You are not required to explain why you want the alternative
means of communication.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
159 ATTACHMENT I - SUMMARY NOTICE OF PRIVACY PRACTICES
Complaints:
If you are concerned that ERS has violated your privacy rights, or you disagree with a decision
ERS has made about access to your records, you may contact the ERS Privacy Officer. You also
may send a written complaint to the U.S. Department of Health and Human Services. The ERS
Privacy Officer can provide you with the appropriate address upon request.
Our Legal Duty:
ERS is required by law to protect the privacy of your information, provide this notice about our
information practices, follow the information practices that are described in this Notice, and obtain
your acknowledgement of receipt of this Notice.
Detailed Notice of Privacy Practices:
For further details about your rights and the federal Privacy Rule, refer to the detailed statement
of this Notice. You can ask for a written copy of the detailed Notice by contacting the Office of the
Privacy Officer or by visiting ERS’ web site at www.ers.texas.gov
. If you have any questions or
complaints, please contact the ERS Privacy Officer by calling (512) 867-7711 or (877) 275-4377
or by writing to ERS Privacy Officer, The Employees Retirement System of Texas, P.O. Box
13207, Austin, TX 78711-3207.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
160 STATEMENT OF RIGHTS UNDER THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT
STATEMENT OF RIGHTS UNDER THE NEWBORNS' AND
MOTHERS' HEALTH PROTECTION ACT
Under federal law, group health plans and health insurance issuers offering group health
insurance coverage generally may not restrict benefits for any hospital length of stay in
connection with childbirth for the mother or newborn child to less than 48 hours following a
vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the
plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse
midwife, or physician assistant), after consultation with the mother, discharges the mother or
newborn earlier.
Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs
so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to
the mother or newborn than any earlier portion of the stay.
In addition, a plan or issuer may not, under federal law, require that a physician or other health
care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours).
However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be
required to obtain precertification. For information on precertification, contact your plan
administrator.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
161 ADDENDUM –CALCULATING ALLOWABLE AMOUNTS
ADDENDUM – CALCULATING ALLOWABLE AMOUNTS
Allowable Amounts are determined by BCBSTX in accordance with its reimbursement policy
guidelines. Reimbursement policy guidelines include, but are not limited to, multiple surgery,
packaged services, and medically unlikely edits. BCBSTX develops its reimbursement policy
guidelines, in BCBSTX’ discretion, following evaluation and validation of all Provider billings in
accordance with one or more of the following methodologies:
• as indicated in the most recent edition of the Current Procedural Terminology (CPT), a
publication of the American Medical Association;
• as reported by generally recognized professionals or publications;
• as used for Medicare; or
• as determined by medical staff and outside medical consultants pursuant to other appropriate
source or determination that BCBSTX accepts.
Allowable Amounts are determined using payment methodologies that may include a diagnosis-
related group (DRG), fee schedule, package pricing, global pricing, per diem, case-rate,
capitation, discount, or other payment methodology.
Allowable Amounts for Contracted Providers
The Allowable Amount for Contracted Providers is determined by the Contracted Provider’s
agreement with BCBSTX and the BCBSTX reimbursement policy guidelines.
Allowable Amounts for Non-Contracted Providers
• All Non-Contracted Provider Allowable Amounts are subject to the following:
o Where Allowable Amounts for Covered Health Services are based on the BCBSTX
average contracted rate for PPO network Hospitals and Providers:
they are specific to the BCBSTX-defined PPO network geographic regions;
they reflect the average PPO network contracted rate for the applicable
region or statewide as indicated below; and
they are subject to BCBSTX-defined PPO network reimbursement policy
guidelines.
o Where Allowable Amounts for Covered Health Services are based on Medicare rates;
The “Medicare rate” means the rate for the geographic market, defined by zip
code, allowed by the Centers for Medicare and Medicaid Services (“CMS”)
for Medicare. The Medicare rate is derived from CMS information and
Medicare regulation, CMS reimbursement policy guidelines, and/or edits
(collectively “Medicare Policies”) and updated by BCBSTX on a quarterly
basis within ninety (90) days following the effective date of CMS
implementation of the change.
Allowable Amounts determined by BCBSTX using the Medicare rate will not
include any additional payments that may be permitted under the Medicare
laws or regulations which are not directly attributable to a specific claim
including, but not limited to, bonus payments, disproportionate share, and
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
162 ADDENDUM –CALCULATING ALLOWABLE AMOUNTS
graduate medical education payment.
if a claim includes a Covered Health Service that (a) does not have a rate
allowed by Medicare and (b) the service is not otherwise excluded from a
payment by Medicare in accordance with Medicare Policies, Allowable
Amounts are calculated when received:
• By a Facility other than a laboratory or diagnostic imaging center: at
50% of billed charges.
• By Facility-based Providers/Physicians, Professional Providers
providing services in a place of treatment other than a Facility,
Mental Health Providers, laboratories, and diagnostic imaging
centers: at 75% of the regional BCBSTX’ average contracted rate for
PPO Network Hospitals and Providers.
Important note: When Non-Contracting Providers may not Balance Bill Participants
Participants may not be billed by Non-Contracted Providers for Covered Health Services for
amounts beyond the Plan’s Deductible, Copayments and Coinsurance, for (a) Emergency Care,
(b) Facility-Based Provider/Physician services in a Network Facility, (c) diagnostic imaging
provider services in connection with a service performed by a Network Provider/Physician, or (d)
laboratory services in connection with a service performed by a Network Provider/Physician
unless specifically provided for below:
• A Participant may be balance billed by a Non-Contracting Facility-based Provider/Physician in
a Network Facility for amounts above the Participant’s Deductibles, Copayments, and
Coinsurance if the Participant signed a written waiver of Balance Billing protection at least 10
days prior to the delivery of the service; and
• A Participant may be balance billed by a Non-Contracting diagnostic imaging Provider or
laboratory in connection with a service performed by a Network Provider/Physician if the
Participant signed a written waiver of Balance Billing protection at least 10 days prior to the
delivery of the service.
• Allowable Amounts for Emergency Covered Health Services are based on the following
rate, for the same or similar service, when received:
o By a Facility that is not a Freestanding Emergency Room: at 100% of BCBSTX’
average statewide contracted rate for PPO network Hospitals and Providers.
o By Facility-based Providers/Physicians in a Facility (regardless of the Facility’s
contracted status): at 110% of the Medicare rate.
o By a Freestanding Emergency Room: at 75% of the average statewide contracted
rate for PPO Network Hospitals, Freestanding Emergency Departments and
Freestanding Emergency Rooms.
• Allowable Amounts for non-emergency Covered Health Services are based on the
following rate, for the same or similar service, when received:
o By Facilities not listed in another category below: at 85% of the Medicare rate.
o By Facility-based Providers/Physicians not listed in another category below, in a
Facility (regardless of the Facility’s contracted status): at 110% of the Medicare
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
163 ADDENDUM –CALCULATING ALLOWABLE AMOUNTS
rate.
o By a Freestanding Emergency Room: at 75% of the average statewide contracted
rate for PPO network Hospitals, Freestanding Emergency Departments and
Freestanding Emergency Rooms.
o By Professional Providers not listed in another category below, in a place of
treatment other than a Facility: at 85% of the Medicare rate.
o By professional Mental Health Providers not listed in another category below: at
85% of the Medicare rate.
o By a freestanding dialysis center, home health Provider or Skilled Nursing Facility:
at 75% of BCBSTX’ average statewide PPO network Provider contracted rates.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
164 ADDENDUM – LIST OF COVERED HEALTH SERVICES
ADDENDUM - LIST OF COVERED PREVENTIVE CARE
SERVICES
Preventive services listed below may change as USPSTF, CDC, and HRSA guidelines are modified
and implemented by the Plan as required by applicable law or regulation. Coverage is based on
age, risk factors, dosage, and frequency.
Under the Affordable Care Act, certain Outpatient preventive health services are paid at 100%
(i.e., at no cost to the Participant), when services are provided by a Network Provider, conditioned
upon Physician billing and diagnosis. In some cases, you may be responsible for payment on
certain related services that are not guaranteed payment at 100% by the Affordable Care Act.
For details on covered preventive services, visit the BCBSTX Preventive Care website at
www.healthselectoftexas.com
.
List of Covered Preventive Care Services
Adults
Health Screenings
Health Screenings- Adults
• Anxiety screening
• Blood pressure screening
• Cholesterol screening
• Type 2 diabetes screening
• HIV, HPV and STI screenings
• Hepatitis B screening
• Hepatitis C screening
• Obesity screening and
counseling
• Tuberculosis screening
• Syphilis screening
• Depression screening
• Baseline and monitoring
services tied to utilization of
HIV Preexposure Prophylaxis
(PrEP) medication.1x
• Alcohol and drug use
assessment
• Falls prevention
Women
• Osteoporosis
screening
• Chlamydia infection
screening
• Gonorrhea and
syphilis screening
• BRCA Genetic
Testing and
counseling
• Breast cancer
preventive
medications
• Contraceptive
methods and
counseling
• Well-woman visits
• Urinary
incontinence
screening
Pregnant Women
• Anemia screening for
iron deficiency
• Tobacco cessation
counseling
• Syphilis screening
• Hepatitis B screening
• Rh incompatibility blood
type testing
• Bacteriuria urinary tract
infection screening
• Breastfeeding support,
supplies, and
counseling
• Gestational diabetes
screening
• HIV screening
• Depression screening
• Preeclampsia screening
• Healthy weight gain
counseling
Men
• Abdominal aortic
aneurysm one-time
screening
1
HIV Preexposure Prophylaxis (PrEP) is covered at no cost under the HealthSelect of Texas Prescription Drug Program
administered by OptumRx. Go to www.HealthSelectRx.com
for more information.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
165 ADDENDUM – LIST OF COVERED HEALTH SERVICES
List of Covered Preventive Care Services (Cont’d)
Adults
Health Screening Cont.
Health Counseling
Immunizations
Cancer Screenings- Adults
• Breast cancer
mammography
(including digital breast
tomosynthesis /3-D
mammography)
• Breast cancer
chemoprevention
counseling
• Cervical cancer pap
test for women*
• Colorectal cancer
screenings including
Cologuard (at home
screening test), fecal
occult blood testing,
sigmoidoscopy, or
colonoscopy, including
specialist consultation
prior to visit, if required*
• Prostate cancer (PSA)
screening for men
• Lung cancer screening
Health Counseling- Adults
Doctors are encouraged to
counsel patients about
these health issues and
refer them to appropriate
resources
as needed:
• Healthy diet
• Weight loss
• Tobacco use
• Alcohol misuse
• Prevention of STIs
• Use of aspirin to
prevent cardiovascular
disease
• Intimate partner
violence screening
• Skin cancer behavioral
health counseling for
young adults,
adolescents, children
and parents of young
children.
Immunizations- Adults
• Haemophilus influenza
type B
• Hepatitis A and B
• Herpes Zoster (Shingles)
• Human Papillomavirus
(HPV)
• Influenza (Flu)
• Measles, Mumps,
Rubella
• Meningococcal
• Pneumococcal
(pneumonia)
• Tetanus, Diphtheria,
Pertussis
• Varicella (chicken pox)
• COVID-19 (covered at
100% when provided by
a Network or Non-
Network Provider)
*The HealthSelect Plan does not impose the age limitations outlined in the current USPSTF guidelines
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
166 ADDENDUM – LIST OF COVERED HEALTH SERVICES
List of Covered Preventive Care Services (Cont’d)
Children
Health Screenings Health Screening/Counseling Immunizations
Health Screenings-
Newborns
• Screening for
hearing loss,
hypothyroidism,
sickle cell disease,
and
phenylketonuria
(PKU)
• Gonorrhea preventive
medication for eyes
• Bilirubin concentrated
screening
• Blood screening
• Critical congenital heart
defect screening
• Vision screening
Health Screenings- Children
• Medical history for all
children throughout
development
• Height, weight, and
Body Mass Index (BMI)
measurements
• Developmental screening
• Autism screening*
• Behavioral assessment
• Visual acuity screening
• Oral health risk assessment
• Dental caries prevention
• Hematocrit or
hemoglobin
screening
• Lead screening
• Dyslipidemia screening
• Tuberculin testing
• Depression screening
• Alcohol and drug use
assessment
• Cervical dysplasia
screening
• HIV screening
• Blood Pressure screening
• Hepatitis B screening for
adolescents at high risk,
• .Anemia Screening
Health Counseling- Children
• Counseling and
screening to prevent
sexually transmitted
infections (STIs)
• Tobacco use interventions
• Obesity screening and
weight management
counseling
Skin cancer counseling
Immunizations- Children
• Diptheria,Tetanus,
Pertussis
• Haemophilus
influenza
type B
• Hepatitis A and B
• Human
Papillomavirus
(HPV)
• Influenza (Flu)
• Measles, Mumps,
Rubella
• Meningococcal
• Pneumococcal
(pneumonia)
• Inactivated
Poliovirus
• Rotavirus
• Varicella (chicken
pox)
• COVID-19 (covered
at 100% when
provided by a
Network or Non-
Network Provider)
*The HealthSelect Plan does not impose the age limitations outlined in the current USPSTF guidelines.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
167 ADDENDUM –RESOURCES TO HELP YOU STAY HEALTHY
ADDENDUM - RESOURCES TO HELP YOU STAY HEALTHY
Holistic Health Management Program
BCBSTX offers a holistic model to health that goes beyond a core set of specific diagnoses. The
approach addresses all of the conditions you may struggle with, including diabetes, coronary
artery disease (CAD), cardiovascular cluster (angina, peripheral artery disease and
atherosclerosis), congestive heart failure (CHF), asthma, chronic obstructive pulmonary disease
(COPD), cancer, chronic kidney disease, musculoskeletal conditions such as low back pain, and
complex, catastrophic conditions.
Social determinants of health have a significant impact on health outcomes, which is why we
have incorporated them into every step of our approach. Your health status is affected by your
access to services, the availability of community resources and healthy food choices, caregiver
support, and your financial status.
The BCBSTX holistic health management program provides you access to a clinician who:
• facilitates your holistic health needs, regardless of your chronic condition. You will be able to
work with a single, dedicated nurse for the duration of your enrollment in the program or your
benefit coverage.
• focuses his or her efforts on prevention and education.
• coordinates your health needs through multiple levels of care until you achieve your optimal
health.
• identifies clinical interventions and helps coordinate your care with community resources to
help eliminate duplicative services and reduce avoidable inpatient hospital stays,
readmissions and Emergency room visits.
• helps you find high quality, cost-efficient Providers to reduce your out-of-pocket expenses.
• works with your doctors to coordinate your appointments, if appropriate.
Whether you have an upcoming surgery and have questions, recently had a surgery and need
follow up support, or if you are managing a condition or are recently diagnosed, a BCBSTX
clinician can support you.
If you have questions about this program or wish to enroll, contact BCBSTX at (800) 252-8039
(TTY: 711) and ask to speak with a clinician.
24/7 Nurseline Support and Services: The Right Care at the Right Time
The 24/7 Nurseline is available in English and Spanish to all HealthSelect Participants. The
Nurseline can help you decide if you should see your primary care physician, go to an Urgent
Care Center or an Emergency room, or find other care as necessary.
You can speak with a nurse 24 hours a day, 7 days a week at (800) 581-0368.
Web and Mobile Wellness Programs and Blue Points
The Well onTarget web portal provides a wealth of resources to support your quest for learning
and promote your success and health through a range of interactive, educational features.
Key features of the Well onTarget web portal include:
• Self-directed wellness programs designed to support and motivate you to take charge of your
health;
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
168 ADDENDUM –RESOURCES TO HELP YOU STAY HEALTHY
• A health assessment and customized report;
• Online courses on various health and wellness topics; each course includes 6 lessons that
you can compete at your own pace;
• Health tools and activity trackers; you can also sync your fitness device;
• Reminders you can set to help you take action or complete an activity;
• Integration with wellness coaching;
• As part of Well onTarget, you have access to Blue Points – rewards for health living. You
earn points by completing activities in Well onTarget. You can redeem your points in the
online shopping mall available through Blue Access for Members.
To access the Well onTarget portal, log in to your Blue Access for Members account at
www.healthselectoftexas.com
.
You can take your wellness resources on the go with Always On – the Well onTarget mobile app,
which is available from both the Apple Store and Google Play.
Fitness Program
The BCBSTX Fitness Program is a flexible membership program that gives you unlimited access
to a nationwide network of more than 10,000 fitness centers.
Other program perks include:
• No long-term contract required: membership is month-to-month. After you pay a one-time
enrollment fee per Participant. Monthly fee vary dependent on which Fitness Program level
you enroll in.
• Convenient payment: once you sign up, your monthly fees are paid via automatic credit card
or bank account withdrawal.
• Health and wellness discounts: save money using the nationwide complementary and
alternative medicine network of 40,000 health and well-being Providers such as massage
therapists, personal trainers and nutrition counselors.
• Web resources: locate participating gyms and track your visits online.
It’s easy to join the Fitness Program. To join or get more information, call (888) 762-BLUE (2583)
Monday-Friday from 7 a.m.-7 p.m. CT or visit the HealthSelect website at
www.healthselectoftexas.com
.
The Plan reserves the right to discontinue or change this program at any time without notice.
HealthSelectShoppERS
SM
HealthSelectShoppERS is a program where eligible HealthSelect Participants can save money
and earn incentives when shopping for and choosing lower cost network Facilities for certain
medical services.
HealthSelectShoppERS is available to all benefits-eligible, active employees enrolled in
HealthSelect of Texas, HealthSelect Out-of-State or Consumer Directed HealthSelect. Medicare
primary Participants, COBRA Members, HealthSelect Secondary Participants and Retirees are not
eligible for the HealthSelectShoppERS rewards program. Return-to-Work Retirees who have
elected active coverage and who are enrolled in HealthSelect of Texas are eligible to participate. If
a Return-to-Work Retiree chooses retiree benefits, he/she is not eligible for
HealthSelectShoppERS.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
169 ADDENDUM –RESOURCES TO HELP YOU STAY HEALTHY
To earn a reward, Participants in the HealthSelectShoppERS program must have active coverage
in HealthSelect of Texas, HealthSelect Out-of-State, or Consumer Directed HealthSelect on the
date they shop for a rewards-eligible service, as well as the date the medical claim for the service is
processed by BCBSTX. Additionally, Participants must be eligible for a TexFlex
SM
health care
Flexible Spending Account (FSA) or Limited Purpose Flexible Spending Account (LPFSA) on the
date the incentive is received and processed by ERS in order to earn the incentive. To receive the
reward, the rewards-eligible service must be completed within thirteen months of shopping.
The program seamlessly integrates with BCBSTX’ Provider Finder tool found within Blue Access for
Members (BAM). Eligible HealthSelect Participants can shop through the Provider Finder for certain
elective, non-emergency medical services ordered by the Provider that are eligible for an incentive.
Shopping can also be conducted by calling a BCBSTX Personal Health Assistant.
When Participants shop for services, results are sorted and show the locations with the highest
eligible incentive and lowest cost. Generally, the first, second, and third lowest cost options have
corresponding incentives that can be earned.
The incentive amount is driven by the price variance between Facilities and not individual Providers
performing the procedure. Services eligible for an incentive include, but are not limited to: MRIs, CT
Scans, mammograms, and knee, shoulder, and hip surgery. The full list of eligible services is
available in Provider Finder. Log into Blue Access for Members at www.healthselectoftexas.com
,
click the “Doctors and Hospitals” tab, and then on “Find a Doctor or Hospital.” All eligible services
will be listed under the search bar. Incentive amounts and eligible services are subject to change.
There may be times where your Provider refers you to a Facility or location to complete your
medical service or procedure that is not eligible for a reward. This decision on where to get care
is always between you and your doctor. However, you must use a Facility who is eligible for the
program to receive a reward. If your Provider performing the medical service or procedure
refers you to a Facility that is not eligible for a reward under the program, a BCBSTX Personal
Health Assistant may be able to help coordinate the service with your Provider at a different
Facility or location (depending on your Provider’s privileges). In some instances, your Provider
may be unable to change your procedure or service to a rewards’ eligible location. For
assistance, call a BCBSTX Personal Health Assistant at (800)252-8039 (TTY: 711).
Remember, you can keep your out-of-pocket costs lower by choosing in-network Providers.
Note: A Prior Authorization may be required for your procedure or service. If you have questions
about Prior Authorizations, call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039
(TTY: 711), Monday–Friday 7 a.m. - 7 p.m. and Saturday 7 a.m. - 3 p.m. CT.
After shopping for a cost-effective service using the Provider Finder or by calling a Personal Health
Assistant, a Participant then completes their service with the Provider that is associated with their
shopping history on file with BCBSTX.
To view your shopping history, log into Blue Access for Members at
www.healthselectoftexas.com
and click the “Doctors and Hospitals” tab and then on “Find a
Doctor or Hospital” and then on your name on the top right of the screen. Select “Your Profile” from
the dropdown menu to see your shopping history.
BCBSTX will process the medical claim once received from the Facility and will tie the medical
claim to the incentive earned.
The incentive will be deposited into an eligible Subscriber’s TexFlex health FSA usually within 30-
45 days of the date the medical claim is processed by BCBSTX. If you are not already enrolled in
an FSA or LPFSA, ERS will set up an account for you. Rewards earned in December will be
processed in January of the following year. If it has been more than 45 days since you completed a
rewards-eligible service that you shopped for and your reward is not available in your TexFlex FSA
or LPFSA, please call a BCBSTX Personal Health Assistant for assistance.
HEALTHSELECT OF TEXAS (OUT-OF-STATE BENEFITS) PLAN
170 ADDENDUM –RESOURCES TO HELP YOU STAY HEALTHY
Incentives are made as employer contributions into the Participant’s FSA or LPFSA. A maximum
reward of $500 per member (including dependents) can be earned each Plan Year and is subject to
current FSA and LPFSA carry-over and forfeiture rules.
Employer contributions are made in addition to employee’s annual contribution amount. A
Participant can elect the maximum contribution amount and still be eligible to receive up to $500 in
incentives during the Plan Year.
The employer contribution is not taxable income, but will be reflected on the employees Form W-2
following the conclusion of the calendar year.
Each family (meaning a Subscriber and their covered Dependents) can earn up to $500 in
HealthSelectShoppERS incentives each Plan Year. The incentives earned can be used in paying
for a qualified FSA or LSFA expense as defined by the Internal Revenue Service. For more
information on the TexFlex program, visit www.texflexers.com
or contact TexFlex customer care
toll-free at (866) 353-9839 (TTY: 711). Representatives are available from 7 a.m. to 7 p.m. CT,
Monday-Friday, and 9a.m. to 2 p.m. CT, Saturday.
If you have questions about this program, contact a BCBSTX Personal Health Assistant at (800)
252-8039 (TTY: 711).
Remember, all decisions on where to receive care are between you and your provider. The Plan
reserves the right to discontinue or change this program at any time without notice.
Important notice for Participants in the Houston area with a Kelsey-Seybold PCP
Participants who select a Primary Care Provider (PCP) within the Kelsey-Seybold Clinic should
receive all services within the Kelsey Clinic. Your Kelsey PCP will not refer you to other
Providers for services available within the Kelsey clinic. If you see any Provider who is not
associated with Kelsey-Seybold, without your PCP’s direction, you will receive Non-Network
Benefits even if the Provider is in the BCBSTX HealthSelect Network.
If you have questions related to your HealthSelect benefits, the HealthSelectShoppERS
program or how your benefits work when you have a Kelsey PCP, call a BCBSTX Personal
Health Assistant at (800) 252-8039 (TTY: 711), Monday – Friday 7 a.m. – 7 p.m. and Saturday
7 a.m. – 3 p.m. CT.
Programs for Weight Loss and Weight Management and Tobacco
Cessation: Wondr (formerly Naturally Slim), Real Appeal, Weight
Management Coaching and Tobacco Cessation Coaching
The following programs are available to eligible Participants at no additional cost:
Wondr
The Wondr program, formerly Naturally Slim, can provide lasting weight loss, and it doesn’t
include starving, counting calories or eating diet food.
It’s 10-week online program that helps you eat right to reduce your risk of getting a serious
disease, like diabetes or heart disease, and improves your chances of living a happier and
healthier life. The easy-to-follow program is led by subject matter experts who will provide
ongoing support at the end of the program to help you maintain your weight loss success.
The program features informative videos and learning tools to teach you how to lose weight and
improve your overall health. You can connect on your computer or mobile device – apps for
iPhone and Android devices are available – and access videos, programs and recipes. A starter
kit is mailed directly to your home.
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Wondr is available to eligible employees, spouses and Dependents 18 and older (excluding
Medicare primary Participants) enrolled in HealthSelect of Texas or Consumer Directed
HealthSelect who have a BMI of 23 or higher.
To enroll, go to www.wondrhealth.com/healthselect
from your smartphone, tablet or computer.
Real Appeal
Real Appeal is an online weight loss program that provides a fresh approach to help you lose
weight. The program helps 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, Real Appeal may
help you shed pounds and lead a healthier life.
Real Appeal provides you with online coaching support sessions for 52 weeks to teach you
healthy habits. You’ll also receive a Success Kit and access to online resources to help you apply
what you’ve learned.
Real Appeal is available to eligible employees, spouses and Dependents 18 and older (excluding
Medicare primary Participants) enrolled in HealthSelect of Texas or Consumer Directed
HealthSelect who have a BMI of 23 or higher.
To enroll, go to https://realappeal.com/healthselect
from your smartphone, tablet or computer.
Please Note: Real Appeal is not available outside the United States, except for Puerto Rico.
Important note about dual enrollment in Wondr and Real Appeal
HealthSelect Participants are not able to receive services and benefits from Wondr and Real
Appeal at the same time.
If you receive services from both Wondr and Real Appeal within a 7-calendar day period, those
services will be denied because the Benefit maximum will have been reached.
Weight Management Coaching
Losing weight can help you feel better, have more energy and cut your risk for many conditions
like diabetes, heart disease and stroke.
By participating in the Weight Management program, you get:
• Personal coaching over the phone: A weight management specialist who is a health care
professional is assigned to you. You and your specialist create a personalized plan to reach
your weight loss goals. He or she can show you how different choices affect your health and
offer you the support you need. You’ll have regular phone calls with your weight management
specialist until you reach your goals.
• Access to online, self-directed courses: You can also take online courses at your own pace to
learn more about weight management, nutrition, fitness and stress.
To enroll in weight management coaching, contact a BCBSTX Personal Health Assistant at (800)
252-8039 (TTY: 711).
Tobacco Cessation Coaching
Quitting tobacco can be one of the most difficult things you will ever do, but we are here to help.
Using tobacco use can raise your chance of getting cancer, heart disease, lung diseases and
diabetes.
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When you are ready to quit using tobacco and improve your health and the way you feel,
BCBSTX Tobacco Cessation Program can help inspire and support you each step of the way.
When you join the Tobacco Cessation Program, you are assigned a tobacco specialist who can
help you work toward becoming tobacco-free. Through telephone coaching sessions, you and
your tobacco specialist will build a customized plan to quit your way. You’ll cover the basics of
tobacco cessation, set goals, get rid of barriers, find healthy choices and learn how to notice and
manage triggers.
To enroll with a tobacco cessation coach, contact a BCBSTX Personal Health Assistant at (800)
252-8039 (TTY: 711).