Point of Service Medical Plan - Two Plan Options

The Harris County medical plans are offered through Aetna and afford you the opportunity to choose any doctor or other health care provider.  Whether you utilize in-network or out-of-network benefits depends on where and with whom you receive your care.  Neither plan requires a PCP selection or referrals for specialist visits.

Employees are given the opportunity each January to choose between the Base Plan OR Base Plus Plan.  These plans consist of a point-of-enrollment option for employees with a “Base” level of benefits at no cost for employee only coverage.  In addition, the County will pay 50% of the incremental cost of dependent coverage.  The “Base” plan offers a high level of affordable access to basic health and preventative services as well as protection to pay for high cost hospital and surgical expenses while containing premium cost increases for both the County and employees.  While many routine services on the “Base” plan only require a copayment; some inpatient and outpatient services are subject to an annual deductible and coinsurance when utilizing a provider in-network and/or out-of-network. 

The second option provided to employees is a “Plus” plan that allows employees to pay a higher contribution to receive a higher level of benefits.  The County will pay 50% of the incremental cost of dependent coverage.  The “Plus” plan has no deductibles or coinsurance when utilizing in-network providers, though out-of-network providers will be subject to deductibles on both the “Base” and “Plus” plans.

Both plans contain the same prescription drug benefit, which will encourage cost effective utilization of these benefits and provides potential savings to both employees and the County.

The Resource Guides describing these benefits are available electronically at http://www.hctx.net/hrrm under the 2012 Active or Retire Resource Guide tabs.

 

	BASE PLAN In-Network	BASE PLAN Out-of-Network
Annual Deductible (per calendar year)	$   500 Individual $1,500 Family	$1,000 Individual $3,000 Family
Coinsurance Limit	$2,500 Individual (plus deductible) $7,500 Family (plus deductible)	$8,000 Individual (plus deductible) $24,000 Family (plus deductible)
Lifetime Maximum Benefit	Unlimited except where otherwise indicated	$1,000,000
Physician's Office Copay Primary Care Specialist (Aexcel provider) Specialist (non-Aexcel prov)	100% after $25 copay 100% after $40 copay 100% after $50 copay	50% after deductible
Preventive Care	100% coverage	50% after deductible
Allergy Services (includes testing, serum and injections)	100% after $40  copay	50% after deductible
Maternity Care   Physician's Office    (prenatal & post natal)    In the Hospital    (for mother & newborn)	$40 for first visit only 80% after deductible	50% after deductible 50% after deductible
Diagnostic Laboratory & Radiology Services	100% coverage	50% after deductible
Complex Imaging/High Tech Radiology	90% after deductible (requires precertification)	50% after deductiible
Rehabilitation, Speech, Occupational and Physical Therapy	100% after a $25 copay, up to 60 visits per calendar year*	50% after deductible, up to 60 visits per calendar year*
Walk-In Clinic	100% after a $25 copay	50% after deductible
Urgent Care Facility	100% after a $50 copay	50% after deductible
Emergency Room	$300 copay; waived if confined, 80% after deductible if admitted	$300 copay; waived if confined, 50% after deductible if admitted
Outpatient Surgery	80% after deductible	50% after deductible
Inpatient Services	80% after deductible	50% after deductible
Home Health Care	90% after deductible, up to 100 visits per calendar year*	50% after deductible, up 100 visits per calendar year*