TEXAS HEALTH AETNA SELECT PLAN 1000
Your Cost for Covered Medical Services
| Plan Features |
TEXAS HEALTH AETNA SELECT PLAN 1000 |
|
Texas Health Aetna Open Access EPO Plus Preferred Network |
|
| Deductible |
$1,000 individual / $3,000 family |
| Medical and Rx Out-of-Pocket Maximum1 |
$6,850 individual / $13,700 family |
| Office Visits |
$30 copay for PCP; $50 copay for specialist |
| Maternity Office Visits |
$30 copay for initial office visit; no cost for additional visits |
| Inpatient Hospital Care6 |
10% after deductible |
| Virtual Visits |
$0 |
| Emergency Room3 |
$100 copay, then 10% after deductible |
| Urgent Care Center |
$50 copay |
| Outpatient Surgery8 |
Office visit copay applies; |
| Routine Physicals4 |
$0 |
| Well-Woman/Man Exams (Including Pap Test or PSA Test)4 |
$0 |
| Well-Child Care (Including Immunizations)4 |
$0 for first visit of the year, $30 copay for additional visits during the year |
| Colonoscopy4 |
$0 |
| Mammography5 |
$0 |
| Outpatient Diagnostic Lab & X-ray (Excluding MRI, CT, PET Scans)2,8 |
No additional charge if processed in doctor’s office; 10% after deductible if not in doctor’s office |
| MRI, CT & PET Scans2,8 |
10% after deductible |
| Outpatient Therapy7 |
$30 per visit |
1 The annual out-of-pocket maximum includes the annual deductible, medical coinsurance, medical copays, prescription coinsurance and prescription copays. It does not include non-compliance penalties, your premiums, or expenses that are not covered by the plan.
2 Whenever you have an X-ray or lab service, you may incur two separate charges. One is for the service itself, and the other is for the radiologist or pathologist who interprets the results. The radiologist or pathologist must be in-network for charges to be covered under Texas Health Aetna Select 1000, UHC Choice 500 and UHC Choice 1000.
3 Non-emergency use of the emergency room is not covered
4 Wellness exams are covered in full if the claims administrator determines the physical is for preventive care. Additional screenings or services will be considered diagnostic services and will be covered after you pay the applicable copay or deductible and coinsurance. At the time of your preventive care visit, if other services are performed that are not preventive services, as determined by the claims administrator, they will not be paid at 100% even if they are submitted as part of a claim for preventive care. Some items require you to pay the appropriate copay or coinsurance, including electrocardiograms (EKGs), focused office visits, thyroid scans, breast MRI, vitamin D assays, and transvaginal ultrasounds.
5 One per year is covered in full; additional screenings are covered, however you pay the coinsurance after your deductible.
6 Includes network providers for all of the following: inpatient doctor’s visits and consultations, surgeon, anesthesiologist, pathologist, and radiologist.
7 Up to a combined total of 60 visits per year are covered for outpatient physical, occupational, and speech therapy. Pulmonary rehabilitation services are each covered up to 20 visits. Up to 36 cardiac rehabilitation visits are covered. Up to a combined total of 20 visits per year are covered for Chiropractic, Acupuncture, and Spinal Manipulation.
8 When your doctor requests tests or services such as lab work, X-rays, MRIs, CT scans, physical therapy or rehabilitation at a free-standing facility that isn’t affiliated with a hospital, you should check the coinsurance level of that facility on your plan. Services performed at Preferred Hospitals or at a free-standing facility unaffiliated with a hospital are covered at 90% after deductible by the Texas Health Aetna Select Plan 1000 and the UHC Choice 500 and Choice 1000 plans, while care at non-Preferred hospitals is only covered at 30% after the deductible. Check with your plan administrator to verify whether a facility and/or doctor is covered under your plan and to learn how much your coinsurance would be.