KelseyCare CHC transition FAQs

KelseyCare powered by Community Health Choice Transition Frequently Asked Questions

KelseyCare powered by Community Health Choice (KelseyCare powered by Community), a health maintenance organization (HMO) serving the Houston area, has voluntarily chosen to withdraw from the Texas Employees Group Benefits Program (GBP). Starting September 1, 2019, the plan will no longer be available to employees and retirees of State of Texas agencies and institutions.

Please see the following information and frequently asked questions for more details about this change. In addition, ERS and its program administrators will send information directly to members who are currently enrolled in KelseyCare powered by Community.

Participants not enrolled in Medicare-primary – Current KelseyCare powered by Community participants who are not enrolled in Medicare-primary coverage will be automatically enrolled in HealthSelect of Texas, a statewide point-of-service plan administered by Blue Cross and Blue Shield of Texas (BCBSTX), unless they make the one of the following choices during Summer Enrollment:

  • Consumer Directed HealthSelect, a statewide high-deductible preferred provider organization (PPO) plan administered by BCBSTX, with a health savings account; or
  • waiving GBP health coverage.

Medicare-primary participants – Current KelseyCare powered by Community participants who are enrolled in Medicare-primary coverage will be automatically enrolled in HealthSelect Secondary, a nationwide plan administered by Blue Cross and Blue Shield of Texas (BCBSTX), unless they make one of the following choices before September 1, 2019:

  • the HealthSelect Medicare Advantage Plan preferred provider organization (MA PPO), a nationwide plan insured by Humana;
  • the KelseyCare Advantage Medicare health maintenance organization (MA HMO) serving the Houston area; or
  • waiving GBP health coverage.
Your new plan will be effective starting September 1, 2019. You should get your new ID cards for medical and prescription coverage by late August.

We encourage you to learn about your new coverage by reading the plan’s guide or its Summary of Benefits and Coverage (SBC). The HealthSelect Medicare Advantage Plan preferred provider organization (MA PPO) and KelseyCare Advantage Medicare health maintenance organization (MA HMO) don’t have SBCs.
 
KelseyCare powered by Community Health Choice has voluntarily withdrawn from the GBP because it determined the plan can no longer meet the financial requirements. To participate in the GBP, HMOs must produce a certain level of plan savings compared to the HealthSelect of Texas plan. In the current health care marketplace, KelseyCare powered by Community was unable to commit to meet this requirement.

ERS appreciates the participation of KelseyCare powered by Community over the last few years and is pleased that Kelsey-Seybold providers will still be available to GBP participants through HealthSelect of Texas, Consumer Directed HealthSelect and, for Medicare-primary participants, the KelseyCare Advantage Medicare HMO.
If you want to enroll in HealthSelect of Texas, you don’t have to do anything during Summer Enrollment. You and any eligible dependents currently enrolled in KelseyCare powered by Community Health Choice will be automatically enrolled in HealthSelect of Texas.

If you want to enroll in Consumer Directed HealthSelect, add or drop a dependent’s health coverage, waive or opt out of health coverage, you must take one of the following actions to make the change during your Summer Enrollment phase:
  • Log in to your ERS OnLine account at any time of the day or night.
  • If you’re still employed at an agency or institution, you can contact your human resources department during business hours.
  • If you’re a retiree, you can contact ERS directly during business hours at (866) 399-6908, toll-free.
We encourage you to learn about your new coverage by reading the plan’s guide or Summary of Benefits and Coverage (SBC).
 
Please contact ERS as soon as possible at (877) 275-4377, toll-free. When prompted by the menu, say “Medicare Number.” Then provide your Medicare information to the representative. With your information, ERS will help you enroll in the HealthSelect Medicare Advantage Plan PPO or the KelseyCare Advantage Medicare HMO, as well as HealthSelect Medicare Rx Part D prescription drug coverage.

If you don’t contact ERS before September 1, 2019, you will be automatically enrolled in HealthSelect Secondary, which has higher dependent, tiered and part-time premiums, and higher out-of-pocket costs. As a retiree enrolled in Medicare, you can change your health plan at any time of the year, by contacting ERS.

We encourage you to learn about your new coverage by reading the plan’s guide.
 
If you’re not enrolled in Medicare and join HealthSelect of Texas or Consumer Directed HealthSelect, you can still see Kelsey-Seybold providers with in-network benefits. If you’re in HealthSelect of Texas and want access to Kelsey-Seybold providers, you must choose a Kelsey-Seybold provider as your primary care provider (PCP) and notify Blue Cross and Blue Shield of Texas of your choice.  If you’re in Consumer Directed HealthSelect, you don’t have to choose a PCP. 

If you’re enrolled in Medicare, you must join the KelseyCare Advantage Medicare HMO to have access to Kelsey-Seybold providers. If you join the HealthSelect Medicare Advantage PPO or HealthSelect Secondary plan, you cannot see Kelsey-Seybold providers, but can go to any other provider who accepts Medicare. 
ERS will have more information in the coming weeks about annual deductibles and other costs that reset on a yearly basis.
If you haven’t retired yet, and you or your eligible dependents aren’t enrolled in Medicare, you and your dependents must be enrolled in the same GBP plan. The only time you and your dependents may be enrolled in different GBP health plans is if you are retired and enrolled in Medicare and your dependents are not enrolled in Medicare, or vice versa.
There are several major differences between the plans:
  • Dependent, part-time and tiered premiums are higher in HealthSelect of Texas. In addition, out-of-pocket costs for some services will be higher.
  • In HealthSelect of Texas, you must choose a primary care provider (PCP) who is in the HealthSelect network, and you must get referrals from your PCP to see most specialists. If you don’t choose a PCP on file with BCBSTX or don’t get referrals from your PCP, you will pay more for care – sometimes a lot more.
  • Like in KelseyCare, you’ll pay more for care if you go outside the network. But in HealthSelect of Texas, the plan will pay 60% of approved charges for out-of-network care. You would be responsible for the remaining 40%, plus any amount over HealthSelect’s approved amount (known as balance billing).
  • HealthSelect of Texas has a large, statewide provider network – much larger than KelseyCare’s regional network.
  • If you choose a PCP from Kelsey-Seybold who is on file with BCBSTX, that PCP will coordinate all your care within Kelsey-Seybold’s specific network group. If you seek care from a provider outside Kelsey-Seybold’s group, you’ll pay the out-of-network cost, even if the provider is in the HealthSelect network. You can change your PCP at any time by contacting BCBSTX or using their member web portal, Blue Access for Members.
  • Prescription drug benefits are administered by OptumRx, and you’ll get a separate ID card for your prescription plan. Coverage and benefits for certain prescription drugs may be different between Navitus (KelseyCare’s prescription benefits manager) and OptumRx.
  • In HealthSelect of Texas, you have access to popular programs and value-added benefits, such as virtual visits for medical and mental health, Naturally Slim and Real Appeal weight management programs, the Blue Points incentive program, Well onTarget self-directed courses and health coaches, and the BCBSTX Fitness Program, among others.
    • Please note that HealthSelect of Texas members who choose a Kelsey-Seybold PCP on file with BCBSTX will have access to Kelsey-Seybold’s Virtual Health program for virtual medical visits, but not to Doctor on Demand or MDLIVE virtual medical visits. Participants with a Kelsey-Seybold PCP can use Doctor on Demand and MDLIVE for scheduled mental health virtual visits only.
  • Visit the HealthSelect of Texas website to learn more
There are several major differences between the plans:
  • Dependent, part-time and tiered premiums are higher in Consumer Directed HealthSelect.
  • Consumer Directed HealthSelect has an annual in-network deductible of $2,100 for individual coverage and $4,200 for family coverage. That means the plan doesn’t pay for anything except in-network preventive care until you meet the annual deductible for covered medical services and prescriptions. After you meet the deductible, you pay 20% coinsurance for eligible in-network medical care and prescriptions. (The annual deductible and post-deductible coinsurance are higher if you go out of network.)
  • If you enroll in Consumer Directed HealthSelect, you can contribute to a tax-free health savings account (HSA) to help you save for health costs and pay less in federal income taxes. If you’re eligible, the state will contribute to your HSA: $45 a month for individual coverage or $90 a month for family coverage.
    • HSAs don’t have use-it-or-lose-it restrictions, and you can keep all the money when you change health plans or even leave state employment.
  • Consumer Directed HealthSelect has a large, statewide provider network – much larger than KelseyCare’s regional network. And you’ll have access to in-network providers across the U.S., if you need care while traveling outside Texas. You don’t have to stay in the network, but you’ll save money if you do.
  • The Consumer Directed HealthSelect plan does not require participants to choose a PCP or get referrals to see specialists.
  • Prescription drug benefits are administered by OptumRx, and you’ll get a separate ID card for your prescription plan.
  • In Consumer Directed HealthSelect, you have access to popular programs and value-added benefits, such as virtual visits for medical and mental health, Naturally Slim and Real Appeal weight management programs, the Blue Points incentive program, Well onTarget self-directed courses and health coaches, and the BCBSTX Fitness Program, among others.
    • Please note that Consumer Directed HealthSelect members can use Kelsey-Seybold’s Virtual Health program, Doctor on Demand or MDLIVE, and out-of-pocket costs may apply.
  • Consumer Directed HealthSelect is not available to people enrolled in Medicare. 
  • Visit the Consumer Directed HealthSelect website to learn more

 
There are few major differences in the plans:
  • The KelseyCare Advantage Medicare health maintenance organization (MA HMO) is available only to people enrolled in Medicare-primary coverage who live in the eight-county service area. It has the same Houston-area provider network as KelseyCare powered by Community Health Choice, but dependent, part-time and tiered premiums are lower in the KelseyCare Advantage MA HMO.
  • The KelseyCare Advantage MA HMO is a Medicare Advantage plan, which replaces both original Medicare and other Texas Employees Group Benefits Program (GBP) coverage as your primary and secondary coverage. When you become eligible for Medicare and enroll in Medicare Parts A and B, contact ERS with the information on your Medicare card to enroll in the KelseyCare Advantage MA HMO.
  • You’ll also pay less in out-of-pocket costs in the KelseyCare Advantage MA HMO.
  • Enrollment in the KelseyCare Advantage MA HMO includes a comprehensive Part D prescription drug program called HealthSelect Medicare Rx, administered by UnitedHealthcare. You’ll get a separate ID card for HealthSelect Medicare Rx.
  • KelseyCare Advantage MA HMO participants have access to SilverSneakers, a fitness program that allows free visits to popular gyms.
  • Visit the KelseyCare Advantage website to learn more
There are few major differences in the plans:
  • The HealthSelect Medicare Advantage Plan preferred provider organization (MA PPO) is available only to people enrolled in Medicare Parts A and B.
  • Dependent, part-time and tiered premiums are lower in the HealthSelect MA PPO.
  • The HealthSelect MA PPO is a Medicare Advantage plan, which, during the period in which you are enrolled, replaces both original Medicare and other Texas Employees Group Benefits Program (GBP) coverage as your primary and secondary coverage. When you become eligible for Medicare and enroll in Medicare Parts A and B, contact ERS with the information on your Medicare card to enroll in the HealthSelect MA PPO.
  • You’ll also pay less in out-of-pocket costs in the HealthSelect MA PPO.
  • The medical plan is insured by Humana, with Part D prescription drug coverage administered by UnitedHealthcare. You’ll get separate cards for the health plan and prescription plan.
  • You will not be able to see Kelsey-Seybold providers under this plan, but can see any other provider who accepts Medicare. If you see providers in the Humana network, Humana will file your claims for you.
  • HealthSelect MA PPO participants have access to the SilverSneakers fitness program, as well as other popular value-added programs to help you maintain or improve your health.
  • Visit the HealthSelect Medicare Advantage Plan website to learn more
HealthSelect Secondary is HealthSelect of Texas for people enrolled in Medicare-primary coverage. There are few major differences in the plans:
  • Dependent, part-time and tiered premiums are higher in HealthSelect Secondary.
  • This plan coordinates benefits with your Medicare-primary coverage, meaning this plan will pay for benefits only after your Medicare-primary plan has paid.
  • You’ll also pay more in out-of-pocket costs in HealthSelect Secondary, including an annual deductible of $200 for individual coverage or $600 for family coverage for medical care (in addition to the $50 per person per year prescription drug deductible).
  • Once you meet the annual medical deductible, you will be responsible for paying 30% coinsurance for most medical services.
  • The plan is administered by Blue Cross and Blue Shield of Texas, with Part D prescription drug coverage administered by UnitedHealthcare. You’ll get separate ID cards for the health plan and prescription plan.
  • You will not be able to see Kelsey-Seybold providers under this plan, but can see any other provider who accepts Medicare. 
  • In HealthSelect Secondary, you have access to popular programs and value-added benefits, such as virtual visits for medical and mental health, Naturally Slim and Real Appeal weight management programs, the Blue Points incentive program, Well onTarget self-directed courses and health coaches, and the BCBSTX Fitness Program, among others.
  • See the HealthSelect Secondary information on the HealthSelect of Texas website to learn more
If you’re not enrolled in Medicare, you can waive or opt out of Texas Employees Group Benefits Program (GBP) health coverage during Summer Enrollment and enroll yourself and/or your dependents in other coverage through the ACA Marketplace or the private insurance market. If you’re enrolled in Medicare, you can waive GBP health coverage and enroll yourself and/or your dependents in other coverage in the Medicare Marketplace. If you have a spouse or co-parent who has employer-sponsored coverage, you can see if that coverage is more affordable for you and/or your children. Please keep in mind:
  • Your KelseyCare powered by Community Health Choice coverage will continue through August 31, 2019. (If you’re a retiree enrolled in Medicare, you might be able to change it sooner.)
  • You probably will have only a limited time to sign up for other coverage. Please consult ACA or Medicare rules, or your spouse’s/co-parent’s human resources department.
  • The other coverage might not be as good as your coverage through the GBP.
  • If you waive or opt out of GBP health coverage, you will lose your GBP prescription drug coverage and Basic Term Life Insurance ($5,000 life and AD&D policy for employees, $2,500 life policy for retirees).
  • If you can prove to ERS that other coverage for yourself (not your dependents) is as good as or better than GBP coverage, you might be eligible for the Opt-Out Credit, which can be applied toward GBP dental, vision and/or Voluntary AD&D insurance premiums. (Retirees are not eligible for Voluntary AD&D Insurance.)
  • Even if you drop your GBP health coverage, you can keep or enroll in/apply for other insurance plans offered through the GBP: dental, vision, voluntary AD&D, optional and dependent life, and disability. Active employees can also enroll in TexFlex, even if they don’t have health coverage through the GBP. (Please note: AD&D insurance, disability insurance and TexFlex are not available to retirees. New optional life, dependent life and disability insurance requires evidence of insurability (EOI), and coverage is not guaranteed.)
  • Eligible Medicare-enrolled participants with limited income may qualify for a government program that helps pay for Medicare Part D prescription drug costs. If you qualify for the low-income subsidy (LIS), you may get assistance in paying for some of your prescription drug costs. To apply for the Medicare LIS, fill out the Social Security Administration’s “Application for Extra Help with Medicare Prescription Drug Plan Costs” (SSA-1020) form.
All Texas Employees Group Benefits Program (GBP) health plans offer high-quality coverage at a reasonable cost. However, if you don’t like your new GBP coverage, you can change it under certain conditions:
  • Members not enrolled in Medicare can change or drop plans during the next Summer Enrollment or within 31 days of a qualifying life event.
  • Retirees enrolled in Medicare can change or drop their health plan any time of the year.
If you enroll in a non-GBP health plan, you should check the rules and requirements of that plan to understand when you can change or drop coverage.