February > Be a Wise Healthcare Consumer
Be a Wise Healthcare Consumer
Seek Treatment from a BCBSTX Network Provider
Your UT SELECT PPO medical plan (administered by Blue Cross Blue Shield of Texas – BCBSTX) allows you the freedom of choice each time you need medical care to seek treatment from a BCBSTX network or non-network provider. There are significant out-of-pocket cost and administrative service differences between network and non-network providers.
- pass on the highest level of benefits to members,
- provide you the convenience of filing claims with BCBSTX on your behalf,
- do not balance bill you for costs exceeding the BCBSTX allowable charges,
- will preauthorize necessary services, as needed.
Conversely, treatment from a non-network provider will result in:
- the lowest level of benefits (non-network) for treatment,
- you will need to file/submit your own insurance claim,
- you may be billed for charges exceeding the BCBSTX allowable amount for covered services,
- you must preauthorize any necessary services, as needed.
Aside from the basic differences listed above, you’ll pay a copay for an office visit with an in-network provider ($30 for a family care physician, $35 to see a specialist). For the same type of appointment with a non-network provider, you pay an amount to be applied toward the annual deductible rather than a certain office visit copay, and once you have met the annual deductible, additional payments will be applied to the coinsurance.
Deductible and Coinsurance
A deductible is the amount of out-of-pocket expense that must be paid for health care services by the covered individual before becoming payable by UT SELECT. Coinsurance is a participant's share of covered services and supplies, not counting the deductible or copays. It is usually a percentage of the allowable amount.
If you seek treatment requiring the application of the deductible and coinsurance, benefits are processed as follows:
- Annual Deductible (per plan year): $350 per individual; $1,050 per family,
- Coinsurance: 20% of BCBSTX allowable charges,
- Out-of-pocket maximum (per plan year): $2,500 per individual; $7,500 per family
- Annual Deductible (per plan year): $750 per individual; $2,250 per family,
- Coinsurance: 40% of BCBSTX allowable charges,
- 100% of any charges over the allowable amount,
- Out-of-pocket maximum (per plan year): $5,000 per individual; $15,000 per family
Your UT SELECT plan will pay 100% of the cost (no copayment) for these Wellness services, if received from a participating BCBSTX in-network provider:
- Routine mammogram (one per plan year)
- Osteoporosis screening
- Immunizations up to age 6
- Diagnostic Lab and Radiology
If the Wellness services above are received from a non-network provider, the member is responsible for the applicable deductible, coinsurance, and 100% of any charges over the allowable amount.
Additional detailed benefits information is available in the 2010 – 2011 UT SELECT Health Benefits Guide at www.utsystem.edu/benefits/pubs/medical_guide.pdf.
Dental procedures such as teeth cleaning, sealants, fluoride treatments, X-rays, fillings, extractions, dentures and other dental ailments are all eligible expenses that can be paid for with your PayFlex Card™. However, there are a few things to remember when using your card to pay for dental expenses.
- Your Flexible Spending Account dollars (i.e., PayFlex Card) cannot be used to pay for cosmetic dental procedures such as dental veneers, bonding and teeth whitening.
- You can only swipe your card for the amount you are responsible for.
- Let’s say you visit the dentist to repair a cracked composite filling.
- You receive a bill for $300 and your dentist is estimating your out-of-pocket expense is $72.
- In this case, since your portion is merely an estimate, you should wait to receive the Explanation
of Benefits (EOB) from your insurance provider before using the PayFlex Card to pay for the
filling. If insurance pays 80% of the cost, you are only responsible for paying $60.
- To pay the $60, you may provide your dentist with the number on your PayFlex Card or you can
pay with another form of payment and submit a claim for reimbursement.
- Let’s say you swipe your card to pay for a dental service and the expense is approved at the point-of-sale.
- A month later, you receive a Request for Documentation letter from PayFlex requesting
documentation for the transaction.
- Based on the merchant description, it is unclear what you paid for with your
Sample: ABC Family Dentistry
Date: 02/18/2011 Amount: $45.60 Account: (2010) Healthcare
- In this case, an EOB or itemized statement is required to confirm the transaction was an eligible
expense and to confirm the date of purchase or service.
- To confirm your expense, login to www.utflex.com and upload your EOB or fax or mail your documentation and letter to PayFlex.