Medical Plans
BMC provides you with three medical plan options, so you can select the one that’s right for you and your family.
BMC Medical Plan Options
Blue Cross Blue Shield of Texas (BCBSTX) Health Savings Account (HSA)
A high-deductible medical plan with a tax-free Health Savings Account (HSA). This medical plan offers you a choice of medical care providers similar to a traditional PPO plan and provides in- and out-of-network benefits. BMC matches employee HSA contributions up to $1,100. The match you receive depends on your annual base salary and who you cover. For employees with an annual base salary of $75,000 or less, BMC seeds (contributes money to) their HSAs with $400, $200 in January and $200 in July. Unused money in your HSA rolls over from year to year for you to use for future health expenses. Prescription drug coverage is provided through Prime Therapeutics.
Blue Cross Blue Shield of Texas (BCBSTX) Preferred Provider Organization (PPO)
A medical plan that lets you decide where to receive care each time you need it. If you use a provider in the PPO network, you pay less for health services. If you receive care from a non-network provider, you pay a larger portion of the cost, and the cost itself is higher. Prescription drug coverage is provided through Prime Therapeutics.
Kaiser Health Maintenance Organization (HMO)
Available only in California, the Kaiser HMO is a managed care medical plan that provides medical and prescription drug benefits only when you receive care within the HMO network and when the care is coordinated by your primary care physician.
Finding a Network Provider
It’s easy to locate network providers for the BCBSTX HSA, the BCBSTX PPO and the Kaiser HMO. You can find a list of participating providers on the BCBSTX website, Evive, and on the Kaiser website or you can contact BCBSTX and Kaiser directly by phone to request a provider directory.
If you are enrolled in one of the BCBSTX coverage options and you choose not to use a network provider for your medical services, your out-of-pocket costs will be higher (for a comparison of in- and out-of-network coverage, see Plan Details). You may also have to file a claim form to receive reimbursement for services within 12 months of the date of the service. Prescription drug claims through Prime Therapeutics must be processed by Prime in-network pharmacy or through the Express Scripts mail-order program. If you choose not to use a Prime network pharmacy, your benefit will be reduced to 50% of the drug cost and you will need to submit a claim form for reimbursement.
If you are enrolled in the Kaiser HMO coverage option, no benefits are payable for services or prescription drugs provided by facilities, providers or pharmacies outside of the Kaiser network except in certain emergency situations. This includes coverage for dependents living outside the coverage area and certain emergency situations for all covered members. Please check with Kaiser directly about this coverage.
Deductible and Out-of-Pocket Maximum
Under the BCBSTX medical plans, you have a deductible to meet each plan year (the Kaiser HMO has no annual deductible). The deductible is fully paid by you. Once the plan deductible is met, the plan begins paying at the appropriate level. The BCBSTX PPO and HSA Plans have separate deductibles for in-network and out-of-network coverage. See the Plan Details for the deductibles and coinsurance or copay levels for the PPO and HSA plans.
IRS guidelines specify that if you enroll in a qualified High Deductible Health Plan (HDHP) like the BCBSTX HSA and elect coverage for one or more family members, individual deductibles do not apply. You must meet the entire family deductible before the plan begins paying for any covered individual (except preventive care and certain preventive prescription drugs).
If you reach the annual deductible, BMC pays 85% of eligible in-network expenses, and you pay the rest through coinsurance. Once you reach the out-of-pocket maximum, BMC pays 100% of most eligible in-network expenses for the rest of the year. If you are enrolled in the BCBSTX HSA Plan and have family coverage (employee plus spouse, employee plus child(ren) or employee plus family) the single out-of-pocket maximum does not apply. You will need to satisfy the $7,400 (in-network) or $14,800 (out-of-network) out-of-pocket maximum before BMC pays 100% of the cost.
Medicare and Your BMC Medical Benefits
If you are an active employee or covered dependent and you become eligible for Medicare, you can choose to:
- Continue primary coverage under the BMC plans. You can also enroll in Medicare, but Medicare will be the secondary payer. You can enroll in both Medicare Part A and Part B, or enroll in Part A only and delay enrollment in Part B.
- Drop coverage under the BMC plans and have Medicare as your primary source of coverage.
If you delay enrollment in Medicare beyond age 65 because you are covered by the BMC plans, you will be able to enroll in Medicare later (after you are no longer covered by BMC) without the usual enrollment penalty. Typically, you will have a "special enrollment period" of eight months from the time you no longer have employer-based coverage to enroll in Medicare. If you wait longer than eight months to enroll, you will lose your special enrollment rights and will have to wait until the annual enrollment period, and you will have to pay higher Medicare premiums.
Additional rules apply concerning COBRA coverage and Medicare.
If you are already Medicare-eligible or soon expect to be, please visit the Social Security website.
How Medicare Affects Your Health Savings Account
If you are age 65 or older, you can contribute to a Health Savings Account (HSA) and receive BMC contributions to your HSA until the month you enroll in Medicare. You are responsible for confirming that you have not enrolled in any Medicare plan by contacting the Social Security Administration at 1-800-772-1213. Contributing to an HSA while enrolled in Medicare will result in tax liabilities. For more information, read page 3 of the IRS publication, Health Savings Accounts and Other Tax-Favored Health Plans.
If you are planning to enroll in Medicare, call the Benefits Center at 1-877-262-4849 to have your HSA contributions stopped on the first day of the month that your Medicare coverage becomes effective. Remember that when you sign up for Social Security retirement benefits and are at least six months beyond your full retirement age (currently 66), Social Security will give you six months of retirement “back pay” and backdate your Medicare Part A enrollment six months. Under IRS rules you are liable to pay tax penalties on any contributions to your HSA account during the six months you had Medicare Part A. To avoid the penalties, you must stop all contributions to your HSA account up to six months before you sign up for your Social Security retirement benefits.
You can continue coverage under the HSA Plan (medical insurance only) and use your remaining HSA funds to pay for qualified medical expenses, including Medicare premiums.
Traveling Abroad
Your medical benefits travel with you when you venture outside the U.S. Before you leave home, contact your medical plan to learn what you would have to pay out of your own pocket if you need medical care while away. Remember, always carry your medical ID card with you, and in an emergency, go directly to the nearest hospital.
View this flier for more information about benefits that cover you when you travel.
Medical Coverage Support
BMC medical plans include coverage support for:
- HIV Drugs
- Gender Reassignment Surgery & Transitioning Services
- Hearing Services
- Developmental Therapy - ABA
- Physical and Occupational Therapy
- Breastfeeding Counseling and Support Services
- Behavioral Health Services
Compare the Medical Plans
BCBSTX HSA | BCBSTX PPO | Kaiser HMO | |
|---|---|---|---|
You Receive Care From | Any provider you choose In-network services cost you less | Any provider you choose In-network services cost you less | Providers in the network |
Out-of-Network Access | You are responsible for filing claim forms and paperwork for out-of-network services | You are responsible for filing claim forms and paperwork for out-of-network services | |
Claim Forms and Paperwork Are Filed By | In-Network Your doctor Out-of-Network You | In-Network Your doctor Out-of-Network You | In-Network Your provider |
Managing Your Health | You coordinate your care | You coordinate your care | Primary care physician coordinates care with you |
Out-of-Area Participant Coverage | Emergencies only—check with plan | ||
Monthly Premiums | |||
Your Cost Share | You pay for all medical services (except preventive) and prescription drug costs (except 15% of certain preventive prescription drugs) until you reach the deductible. After you reach the deductible, the cost is shared between BMC and you. | You only pay a copay for doctor’s visits and prescription drugs. Certain services are subject to a deductible, and then the cost is shared between BMC and you. | You only pay a copay for most services. |
Health Savings Account (HSA) | Learn more about the HSA. | ||
Health Care Flexible Spending Account (FSA) | You may make before-tax contributions for all eligible health expenses allowed by the IRS Publication 502. | You may make before-tax contributions for all eligible health expenses allowed by the IRS Publication 502. | |
Limited Use Flexible Spending Account (FSA) | You may make before-tax contributions for dental and vision care. After you have reached your deductible, you may also receive reimbursement for medical claims incurred after that date. |
BMC National Medical Plans
The amounts in the chart below are for in-network services only. If you go out of network, your amounts will be different.
BCBSTX HSA | BCBSTX PPO | |
|---|---|---|
Annual Deductible | $1,850 single $3,700 all other coverage levels | $875 single $1,750 all other coverage levels |
Annual Out-of-Pocket Maximum (includes deductible and copays) | $3,700 single $7,400 all other coverage levels | $3,700 single $7,400 all other coverage levels |
Lifetime Maximum Benefit | Unlimited | Unlimited |
General Medical Expenses | ||
Primary Doctor Office Visit (includes maternity care) | 85% covered after deductible | $25 copay |
MDLIVE Physician1 | $48 | $25 |
Specialist Doctor Office Visit | 85% covered after deductible | $40 copay |
Inpatient Hospital Care (requires preauthorization) | ||
Hospitalization2 | 85% covered after deductible | 85% covered after deductible |
Inpatient Physician and Surgeon Services2 | 85% covered after deductible | 85% covered after deductible |
Inpatient Lab and X-ray3 | 85% covered after deductible | 85% covered after deductible |
Maternity and Delivery Services & Newborn Nursery Services4 | 85% covered after deductible | |
Outpatient Care | ||
Outpatient Surgery | 85% covered after deductible | 85% covered after deductible; if performed as a part of an office visit and billed by a physician applicable copay applies |
Outpatient Laboratory Services & X-ray Services3 | 85% covered after deductible | 85% covered after deductible; if performed as a part of an office visit and billed by a physician applicable copay applies |
Preventative Care | ||
Annual Physical Exam & Immunizations | 100% covered per exam (no deductible applies) | 100% covered |
Well-Baby & Well-Child Exams and Immunizations | 100% covered per exam (no deductible applies) | 100% covered |
Well-Woman Exam | 100% covered per exam (no deductible applies) | 100% covered |
Other Preventive Care & Cancer Screenings5 | 100% covered per exam (no deductible applies) | 100% covered |
Maternity Care5 | ||
Office Visit: Prenatal/Postnatal | 85% covered after deductible | $25 copay, initial visit only |
In-Hospital Delivery & Newborn Nursery Services | 85% covered after deductible | 85% covered after deductible |
Emergency Services | ||
Hospital Emergency Facility | 85% covered after deductible | 85% covered after deductible and after $250 copay |
Non-Emergency Care in a Hospital Emergency Room | Not Covered | Not Covered |
Urgent Medical Care (at a non-hospital free standing facility) | 85% covered after deductible | 85% covered after deductible |
Non-Urgent Use of Urgent Care Provider (at a non-hospital free standing facility) | 85% covered after deductible | 85% covered after deductible |
Chiropractic Services | ||
Spinal Manipulation Maximum of 25 visits each calendar year (in-and out-of-network services combined) | 85% covered after deductible Maximum of 25 visits each calendar year (in-and out-of-network services combined) | 85% covered after deductible Maximum of 25 visits each calendar year (in-and out-of-network services combined) |
Short-Term Rehabilitation Therapy6 | ||
Outpatient Physical, Speech, Occupational Therapy 60-visit combined maximum per year | 85% covered after deductible; 60-visit combined maximum per year | 85% covered after deductible; 60-visit combined maximum per year |
Mental Health, Substance Abuse Care | ||
Mental Health: Inpatient & Outpatient Coverage | 85% covered after deductible | $25 copay |
Rehab and Detox: Inpatient & Outpatient Coverage | 85% covered after deductible | 85% covered after deductible |
Residential Treatment Facility (stays in a residential treatment facility for treatment of mental disorders, alcoholism or drug abuse) | 85% covered after deductible | 85% covered after deductible |
MDLIVE® Behavioral Therapy | $80 to $175 per consultation before deducible depending on provider selected 85% covered after deductible | $25 |
Other Benefits | ||
Condition Management | BCBSTX Condition Management programs offer support for people diagnosed with chronic conditions such as asthma, diabetes, heart problems and others. | |
Prescription Drugs | Prescription Drugs are covered through Prime Therapeutics, an affiliate of BCBSTX. Please see Prescription Drugs for more information. | |
Health Savings Account | You will have a Health Savings Account opened for you through Fidelity. BMC deposits employer contributions, and you may choose to deposit your own contributions into this account. Please see Health Savings Account for more information. | |
(1) Your payments to MDLIVE do not count toward the in-network deductible and out-of-pocket maximums for the HSA and PPO medical plans. (2) The plan covers bariatric surgery and some transplants if performed at a Blue Distinction Center. (3) Certain high-tech radiology tests (CT scans and MRIs) require prior authorization except during a medical emergency. Authorization is not required for low resolution diagnostic services, including mammograms, sonograms, and x-rays. (4) Your newborn is automatically covered under the plan for the first 31 days after the date of birth. If you wish to continue coverage for the newborn beyond that date, you must add the child to your medical coverage through the MyBMC Rewards website (select the Change Your Coverage tab) within 31 days after the newborn’s date of birth. (5) Other preventive exams and cancer screenings may have age and time limit restrictions. (6) Additional plan authorization review required after 30 days. Important: Other limitations may apply. If you have questions about the PPO or HSA medical plans or need more information, take a look at the plan documents on the MyBMC Rewards website (click on the Plan Information tile.) | ||