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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2023 – 12/31/2023
City of Austin: HRA Plan Coverage for: Individual + Family | Plan Type: HRA
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-888-907-7880 or at
www.bcbstx.com/coa. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call 1-855-756-4448 to request a copy.
Important Questions
Answers
Why This Matters:
What is the overall
deductible?
Tier 1 & Tier 2 In-Network:
$1,500 Individual / $3,000 Family
Out-of-Network: $3,000 Individual / $6,000 Family
Generally, you must pay all of the costs from providers up to the deductible
amount before this plan begins to pay. If you have other family members on the
plan, each family member must meet their own individual deductible until the
total amount of deductible expenses paid by all family members meets the
overall family deductible.
Are there services covered
before you meet your
deductible?
Yes. In-Network preventive care is covered before
you meet your deductible.
This plan covers some items and services even if you haven’t yet met the
deductible amount. But a copayment or coinsurance may apply. For example,
this plan covers certain preventive services without cost sharing and before you
meet your deductible. See a list of covered preventive services at
www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles
for specific services?
No.
You don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
Tier 1 & Tier 2 In-Network:
$5,000 Individual / $6,850 Family
Out-of-Network: $10,000 Individual / $20,000 Family
The out-of-pocket limit is the most you could pay in a year for covered services.
If you have other family members in this plan, they have to meet their own out-
of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the
out-of-pocket limit?
Premiums, preauthorization penalties,
balance-billing charges, and health care this plan
doesn’t cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket
limit.
Will you pay less if you use
a network provider?
Yes. See www.bcbstx.com/coa or call
1-888-907-7880 for a list of network providers.
You pay the least if you use a provider in Tier 1. You pay more if you use a Tier
2 provider. You will pay the most if you use an out-of-network provider, and you
might receive a bill from a provider for the difference between the provider’s
charge and what your plan pays (balance billing). Be aware, your network
provider might use an out-of-network provider for some services (such as lab
work). Check with your provider before you get services.
Do you need a referral to
see a specialist?
No.
You can see the specialist you choose without a referral.
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* For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/coa.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Tier 1 In-Network
Provider
(you will pay the least)
Tier 2 In-Network
Provider
Out-of-Network
Provider
(you will pay the
most)
Primary care visit to treat an injury
or illness
20% coinsurance
30% coinsurance
40% coinsurance
Virtual visits are available, please
refer to your plan policy for more
details.
Specialist visit
20% coinsurance
30% coinsurance
40% coinsurance
None
Preventive care/screening/
immunization
No Charge;
deductible does not
apply
No Charge;
deductible does not
apply
40% coinsurance
You may have to pay for services that
aren’t preventive. Ask your provider if
the services needed are preventive.
Then check what your plan will pay for.
No Charge for child immunizations
Out-of-Network through the 6th
birthday.
Diagnostic test (x-ray, blood work)
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance for Tiers 1 & 2
applies to independent lab and x-ray
facilities. All other places of treatment
are 20% coinsurance for Tier 1 and
30% coinsurance for Tier 2.
Imaging (CT/PET scans, MRIs)
20% coinsurance
30% coinsurance
40% coinsurance
Preauthorization is required.
Generic drugs (Tier 1)
20% coinsurance
20% coinsurance
Not Covered
Retail covers a 31-day supply. Mail
order covers a 90-day supply.
ACA $0 Preventive Drug List
medications are covered at no cost &
HSA Preventive Drug List – deductible
does not apply.
Preferred brand drugs (Tier 2)
20% coinsurance
20% coinsurance
Not Covered
Non-preferred brand drugs (Tier 3)
20% coinsurance
20% coinsurance
Not Covered
Specialty drugs
20% coinsurance
20% coinsurance
Not Covered
Specialty drugs must be obtained from
In-Network specialty pharmacy
provider. Specialty retail limited to a
30-day supply. Mail order is not
covered.
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* For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/coa.
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Tier 1 In-Network
Provider
(you will pay the least)
Tier 2 In-Network
Provider
Out-of-Network
Provider
(you will pay the
most)
Facility fee (e.g., ambulatory
surgery center)
20% coinsurance
30% coinsurance
40% coinsurance
None
Physician/surgeon fees
20% coinsurance
30% coinsurance
40% coinsurance
None
Emergency room care
20% coinsurance
20% coinsurance
20% coinsurance
None
Emergency medical transportation
20% coinsurance
20% coinsurance
20% coinsurance
Ground and air transportation covered.
Urgent care
20% coinsurance
20% coinsurance
40% coinsurance
None
Facility fee (e.g., hospital room)
20% coinsurance
30% coinsurance
40% coinsurance
Preauthorization is required;
50% penalty if not preauthorized
Out-of-Network.
Physician/surgeon fees
20% coinsurance
30% coinsurance
40% coinsurance
None
Outpatient services
20% coinsurance
20% coinsurance
40% coinsurance
Certain services must be
preauthorized; refer to your benefit
booklet* for details.
Virtual visits are available, please
refer to your plan policy for more
details.
Inpatient services
20% coinsurance
20% coinsurance
40% coinsurance
Preauthorization is required;
50% penalty if not preauthorized
Out-of-Network.
Office visits
20% coinsurance
30% coinsurance
40% coinsurance
Cost sharing does not apply for
preventive services. Depending on the
type of services, a coinsurance or
deductible may apply. Maternity care
may include tests and services
described elsewhere in the SBC (i.e.
ultrasound).
Childbirth/delivery professional
services
20% coinsurance
30% coinsurance
40% coinsurance
Childbirth/delivery facility services
20% coinsurance
30% coinsurance
40% coinsurance
Preauthorization is required;
50% penalty if not preauthorized Out-
of-Network.
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* For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/coa.
Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Tier 1 In-Network
Provider
(you will pay the least)
Tier 2 In-Network
Provider
Out-of-Network
Provider
(you will pay the most)
If you need help
recovering or
have other
special health
needs
Home health care
20% coinsurance
20% coinsurance
40% coinsurance
Limited to 120 visits per calendar
year.
Preauthorization is required.
Rehabilitation services
20% coinsurance
20% coinsurance
40% coinsurance
None
Habilitation services
20% coinsurance
20% coinsurance
40% coinsurance
Skilled nursing care
20% coinsurance
20% coinsurance
40% coinsurance
Preauthorization is required.
Inpatient: Unlimited
Outpatient: Limited to 60 days per
calendar year
Durable medical equipment
20% coinsurance
20% coinsurance
40% coinsurance
None
Hospice services
20% coinsurance
20% coinsurance
40% coinsurance
Preauthorization is required.
If your child
needs dental or
eye care
Children’s eye exam
20% coinsurance
30% coinsurance
40% coinsurance
None
Children’s glasses
Not Covered
Not Covered
Not Covered
None
Children’s dental check-up
Not Covered
Not Covered
Not Covered
None
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Cosmetic surgery
• Dental care (Adult and children)
• Hearing aids
• Infertility treatment
• Long-term care
• Non-emergency care when traveling outside the U.S.
• Private-duty nursing
• Routine foot care (except with diagnosis of
diabetes)
• Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Acupuncture (12 visits per year)
• Bariatric surgery (only at a Blue Distinction
Plus facility; limited to 1 per lifetime)
• Chiropractic care (20 visits per year)
• Routine eye care (Adult)
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Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-888-907-7880, or visit www.bcbstx.com. For group health coverage
subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at
1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured,
individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. Other coverage options may be
available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit
www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,
contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-888-907-7880 or visit www.bcbstx.com, the U.S. Department of
Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer
Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and
Blue Shield of Texas at 1-888-907-7880 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or
www.tdi.texas.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health
Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-888-907-7880.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-907-7880.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-888-907-7880.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-907-7880.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
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The plan would be responsible for the other costs of these EXAMPLE covered services.
Peg is Having a Baby
(9 months of in-network pre-natal care and a
hospital delivery)
Mia’s Simple Fracture
(in-network emergency room visit and follow
up care)
Managing Joe’s type 2 Diabetes
(a year of routine in-network care of a well-
controlled condition)
◼ The plan’s overall deductible $1,500
◼ Specialist coinsurance 20%
◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20%
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
Total Example Cost
$12,700
In this example, Peg would pay:
Cost sharing
Deductibles
$1,500
Copayments
$0
Coinsurance
$2,200
What isn’t covered
Limits or exclusions
$60
The total Peg would pay is
$3,760
◼ The plan’s overall deductible $1,500
◼ Specialist coinsurance 20%
◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20%
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
Total Example Cost
$5,600
In this example, Joe would pay:
Cost sharing
Deductibles
$1,500
Copayments
$0
Coinsurance
$800
What isn’t covered
Limits or exclusions
$20
The total Joe would pay is
$2,320
◼ The plan’s overall deductible $1,500
◼ Specialist coinsurance 20%
◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20%
This EXAMPLE event includes services like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost
$2,800
In this example, Mia would pay:
Cost sharing
Deductibles
$1,500
Copayments
$0
Coinsurance
$300
What isn’t covered
Limits or exclusions
$0
The total Mia would pay is
$1,800
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
bcbstx.com
Health care coverage is important for everyone.
We provide free communication aids and services for anyone with a disability or who needs language
assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age,
sexual orientation, health status or disability.
To receive language or communication assistance free of charge, please call us at 855-710-6984.
If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.
Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail)
300 E. Randolph St. TTY/TDD: 855-661-6965
35th Floor Fax: 855-661-6960
Chicago, Illinois 60601
You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:
U.S. Dept. of Health & Human Services Phone: 800-368-1019
200 Independence Avenue SW TTY/TDD: 800-537-7697
Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html
bcbstx.com
If you, or someone you are helping, have questions, you have the right to get help and information in your
language at no cost. To talk to an interpreter, call 855-710-6984.