TEXAS HEALTH AETNA SELECT PLAN 3000 and 1000
Your Cost for Covered Medical Services
| Plan Features |
TEXAS HEALTH |
TEXAS HEALTH |
|
Texas Health Aetna Open Access EPO Plus Preferred Network Doctors, Hospitals, and Free-standing Facilities |
||
| Deductible |
$3,000 individual / $6,000 family |
$1,000 individual / $3,000 family |
| Medical and Rx Out-of-Pocket Maximum2 |
$6,750 individual / $13,500 family |
$6,850 individual / $13,700 family |
| Office Visits |
10% after deductible |
$30 copay for PCP; $50 copay for specialist |
| Maternity Office Visits |
10% after deductible for initial office visit, no cost for additional visits |
$30 copay for initial office visit; no cost for additional visits |
| Inpatient Hospital Care |
10% after deductible |
10% after deductible |
| Telehealth |
$0 |
$0 |
| Emergency Room |
10% after deductible |
$100 copay, then 10% after deductible |
| Urgent Care Center |
10% after deductible |
$50 copay |
| Outpatient Surgery1 |
10% after deductible |
Office visit copay applies; |
| Routine Physicals3 |
$0 |
$0 |
| Well-Woman/Man Exams (Including Pap Test or PSA Test)3 |
$0 |
$0 |
| Well-Child Care (Including Immunizations)3 |
$0 |
$0 for first visit of the year, $30 copay for additional visits during the year |
| Colonoscopy3 |
$0 |
$0 |
| Mammography4 |
$0 |
$0 |
| Outpatient Diagnostic Lab & X-ray (Excluding MRI, CT, PET Scans)1 |
10% after deductible |
No additional charge if processed in doctor’s office; 10% after deductible if not in doctor’s office |
| MRI, CT & PET Scans1 |
10% after deductible |
10% after deductible |
| Outpatient Therapy5 |
10% after deductible |
$30 per visit |
1 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 to make sure they are in-network, and if you are in a UHC medical plan option 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, Texas Health Aetna Select Plan 3000, and the UHC Choice 500 and Choice 1000 plans, while care at non-Preferred hospitals, if you are in the UHC Choice 500 or Choice 1000 plans, is only covered at 30% after the deductible. Check with your insurance carrier to verify whether a facility and/or doctor is covered under your plan and to learn how much your co-insurance would be.
2 Maximum includes deductible, co-insurance, and copays for medical care and prescriptions.
3 Well 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.
4 One per year is covered. You pay the coinsurance for additional mammograms.
5 Up to a combined total of 60 visits per year are covered for outpatient physical, occupational, and speech therapy. Pulmonary and rehabilitation services are covered up to 20 visits. Up to 36 cardiac rehabilitation visits are covered.
6 Whenever you use an out-of-network provider, you pay for services when you receive them and file a claim for reimbursement of eligible expenses.
7 $1,000 penalty for failure to provide notification.