IMPORTANT NOTICE: The Y2014 Pool calendar year medical deductibles (except the HSAQ plan) will be prorated.
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Health Pool Plan Benefits as of 03/01/2013
[see Outline and Policy for specifics related to each benefit]
| Medical Deductibles/ Coinsurance |
Plan I (Insured Pays) |
Plan II (Insured Pays) |
Plan III |
Plan IV (Insured Pays) |
Plan V HDHP/ HSA Qualified (Insured Pays) |
|
| Deductible (Calendar Year) |
$1000 | $2500 | $5000 | $7,500 | $3,000 | |
| Coinsurance for PPO Providers |
20% | 20% | 20% | 20% | 0% | |
| Coinsurance for Non-PPO Providers |
40% | 40% | 40% | 40% | 40% | |
| Coinsurance Maximum for PPO Providers (Calendar Year) |
$3000 | $3000 | $3000 | $5,000 | $0 | |
|
|
Plan I (Deductible + Coinsurance) |
Plan II (Deductible + Coinsurance) |
Plan III (Deductible + Coinsurance) |
Plan IV (Deductible + Coinsurance) |
Plan V |
|
| $1000 + $3000 = $4000 Annually |
$2500 + $3000 = $5500 Annually |
$5000+$3000 =$8000 Annually |
$7,500+$5,000 =$12,500 Annually |
$3,000 Annually |
||
|
Annual Pharmacy Deductible/Copays |
$200 (No Copay limit) |
$200 (No Copay limit) |
$200 (No Copay limit) |
$500 (No Copay limit) |
$1,450 Deductible/ $1,500 Copay Maximum |
|
NOTES:
- The Coinsurance Maximum for Non-PPO Providers for all plans is $10,000 in a Calendar Year.
- The Lifetime Maximum benefit for all plans is $4,000,000.
- Plans III, IV and V are not available to individuals eligible for Medicare. Plans I & II are available to supplement Medicare Disability. Plans I and II do not provide outpatient prescription drug benefits to Medicare-eligibles due to the availability of Medicare Part D.
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The Calendar Year Deductible, the Emergency Care Deductible, Physician Office Visit Copayments, and Charges for Outpatient Prescription Drugs DO NOT COUNT toward the Coinsurance Maximums.
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After the insured pays the medical deductible for the policy, the policy pays the amount of Covered Expenses in excess of the Coinsurance Amount subject to policy limits. For Covered Expenses from a Preferred Provider, once you have paid your Coinsurance Maximum, the policy pays 100% of Covered Expenses from Preferred Providers for the rest of the Calendar Year. In no event will the policy pay more than the Lifetime Maximum for each Insured Person.
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The deductible amount selected may not be changed to a lower amount after the Policy is issued. You may request to change to a higher deductible, if offered, but only one such change will be allowed in a calendar year. The change will be effective on the first of the month following the date your written request is received, or a later date if requested.
Summary-Health Pool Plan Benefits
[see Outline and Policy for specifics related to each benefit]
| Hospital | Average semi-private room rate. No more than one visit per physician per day |
| Intensive Care or Cardiac Care Unit | No more than 3 times the average semi-private room rate |
| Assistant Surgeon or Surgical First Assistant | One assistant, no more than 25% of the primary surgeon’s fee |
| Hospital or other facility for Emergency Care | Subject to additional $100 deductible per visit (not credited toward coinsurance maximum). Does not apply to Plan V |
| Physician Office Visits-for covered illness or injury | PPO Plan: $30 copayment per visit, for first 6 visits per calendar year. Thereafter, visits are subject to Calendar Year Deductible & Coinsurance. Non-PPO Plan: Subject to Calendar Year Deductible and/or Coinsurance |
| Home Health Care | Lesser of 60 visits or $5,000 per calendar year |
| Skilled Nursing Facility | 45 days per calendar year |
| Hospice Care | Lesser of 180 days or $10,000 lifetime maximum |
| Named Transplants | Subject to a lifetime combined maximum benefit for all transplants of $300,000. Transplants covered include: kidney, pancreas, heart, liver, lung and bone marrow. Includes preparation and transportation. |
| Physical, Speech, Occupational Therapy | $5,000 per calendar year |
| Serious Mental Illness | Calendar year maximum benefit of 30 inpatient days and 50 outpatient visits. |
| Preauthorization Provisions | If a preauthorization requirement is not met, benefits for covered services and supplies will be reduced 50%. Preauthorization required for: inpatient admissions, skilled nursing facility admissions; home health care services, home infusion therapy, hospice care, transplants, and durable medical equipment over $2,000. |
| Outpatient Prescription Drugs |
See Pharmacy Program page of website. |
Summary – Other Health Pool Medical Plan Benefits
[See Outline and Policy for specifics related to each benefit]
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How do I get insurance with no money?
To get insurance without having to pay any money upfront isn’t possible. You will have to cover at least the first month’s installment on your policy. If you are currently short of cash and need insurance urgently, you will probably need to find a safe and fast way to get cash.
Overnight payday loans are a great option to get money within 24 hours for anyone who can repay them quickly on time. You can get money very fast (sometimes even within a few hours) for any purpose – including for buying insurance. Whether you apply online or in person, the application form is easy, straightforward, and requires only basic personal and financial information. The loan process is convenient and there is no collateral involved. There are few requirements – be at least 18 years old, be a legal US citizen or resident, have a valid bank account in your name and a stable income. Payday loans are suitable for people with bad credit.
BlueChoice Network
The Pool has selected the BlueChoice Network as the Pool’s Preferred Provider Organization (PPO). Although you may choose any medical provider or hospital, you will save money by using providers from the BlueChoice Network.
If you choose a BlueChoice provider, the Policy will pay a greater coinsurance rate and the BlueChoice provider’s rate will be based on the contract rate of the network. If you choose a Non- Preferred Provider, the Policy will pay a lower coinsurance rate and there is no coinsurance maximum. Also, Covered Expenses for a Non-Preferred Provider will be based on the Allowable Amount, which may be less than the provider’s billed rate and which could result in a greater expense to you.
If you choose not to use a BlueChoice provider, it is still beneficial to use a “ParPlan” provider. While not a network preferred provider, a ParPlan provider will not bill you for the difference between covered expenses and the provider’s billed charges.
There are other advantages to using BlueChoice and ParPlan providers. They will handle the initial paperwork so you do not have to file claims. They may also precertify benefits for you, although it is ultimately your responsibility to ensure that your services have been authorized by the Pool.
If there are no BlueChoice providers available to you, you must contact the Administrator’s precertification referral department at its toll free number. Generally, a BlueChoice provider will be considered to be unavailable to you if you reside more than 30 miles from a BlueChoice provider. If there are no BlueChoice providers available to you and you contact the Administrator before obtaining services from a Non Preferred Provider, Covered Expenses for treatment or services by the Non Preferred Provider will be paid at the Preferred Provider coinsurance level.
If an Insured Person’s Preferred Provider’s arrangement with the Network, chosen by the Pool for this Policy, terminates and, at the time of such termination, the Insured Person has special circumstances, benefits for Covered Expenses received from that provider will be paid as if the Covered Expenses were received from a Preferred Provider until: in the case of an Insured Person who has been diagnosed with a terminal illness, the end of nine months after the effective date of termination; in the case of an Insured Person who, at the time of termination, is past the 24th week of pregnancy, delivery of the child, immediate post-partum care and the follow-up checkup within the first six weeks after the delivery; or in all other special circumstances, the end of 90 days after the date of termination.
BlueCard Program
The BlueCard Program provides access to Preferred Providers of other Blue Cross and/or Blue Shield Plans outside Texas. If You incur expenses outside Texas through the BlueCard Program, You must pay the Preferred Provider Coinsurance amounts after satisfaction of the Deductible. Covered Expenses for a BlueCard program provider will be calculated using the lesser of the billed charges of the BlueCard provider or the negotiated rate the Administrator pays the local Blue Cross and/or Blue Shield Plan.
Preexisting Condition Limitation
During the first 12 months following the effective date of coverage, the Policy will not pay benefits for any charges or expenses for a preexisting condition.
This waiting period will be reduced by the number of months the Insured was covered by creditable coverage in place during the 12 months before the
Pool policy effective date.
Insureds who enroll under the COBRA exception and did not exhaust continuation are subject to a minimum 6-month preexisting condition waiting period.