HMO Departure FAQs for active employees and non-Medicare retirees

Starting September 1, 2021, Scott and White Care Plan (SWCP) and Community First Health Plans (CFHP) will no longer be offered in the Texas Employees Group Benefits Program (GBP) as an enrollment option.

Updated: August 2021

At their May 20, 2020 meeting, the ERS Board of Trustees approved ERS staff’s recommendation not to proceed with the HMO bidding process when the current contracts expire on September 1, 2021. The Board agreed with ERS staff that it is in the best interest of the GBP and its contributing employers and members to discontinue HMO participation in the GBP. You will stay enrolled in SWCP and CFHP through August 31, 2021.

ERS understands that changes like this can be hard for some members. We put a great deal of thought into the decision, and will work to make the transition as easy as possible for our members. For more information about why this change is happening, please see the “Why is this change happening?” section in the HMO decommissioning webpage on ERS website.

Central Texas and San Antonio-area HMO participants and their eligible dependents who are not enrolled in Medicare primary will be automatically enrolled in HealthSelect of Texas® administered by Blue Cross and Blue Shield of Texas (BCBSTX), starting September 1, 2021. HealthSelect of Texas is a self-funded, point-of- service health plan that requires PCP selection and referrals to see specialists. It has a large statewide network of providers. There is no annual medical deductible if you stay in the HealthSelect network. You do not have to do anything to be enrolled in HealthSelect of Texas plan.

During Summer Enrollment, you can choose to enroll in Consumer Directed HealthSelectSM (also administered by BCBSTX) or waive GBP coverage. Consumer Directed HealthSelect is a high-deductible plan paired with a health savings account (HSA). A member who waives GBP coverage and has other group health insurance that is comparable to GBP health insurance may be eligible for the Health Insurance Opt-Out Credit. You can make your choice during your Summer Enrollment phase and your change will be effective on September 1.

HealthSelect of Texas and Consumer Directed HealthSelect plans both have the HealthSelect Prescription Drug Program, administered by OptumRx for prescription drug coverage. You will receive more information from OptumRx this summer.

HMO participants should see little difference in medical and prescription drug benefits between the HMO and HealthSelect of Texas, and in most instances, the HealthSelect of Texas benefits are better. Some of the important features of HealthSelect plans are:

  • Select a PCP: HealthSelect of Texas participants must designate a primary care provider (PCP.) The PCP will serve as your first point of contact when you need non-emergency care. Your PCP is also responsible for coordinating your care, submitting referrals for some in-network specialists and writing orders for lab and imaging services. HealthSelect of Texas participants are encouraged to choose a PCP during Summer Enrollment to ensure your PCP is listed on your medical ID card you will receive in August. HealthSelect of Texas participants who do not name an in-network PCP will have out-of-network benefits—even if they see in-network providers—after their first 60 days in the plan, until they name a PCP.

If you enroll in Consumer Directed HealthSelect, you do not need to choose a PCP, but will benefit from having an in-network PCP to manage your overall health and wellness. (See "Choose a Primary Care Provider" to learn more.)

  • Providers: About 95% of providers in SWCP and CFHP networks already participate in the HealthSelect network. After you change to one of ERS’ HealthSelect plans, you may still be able to see your current providers.  You can verify your provider’s network status by calling a BCBSTX Personal Health Assistant toll-free at (800) 252-8039 (TTY: 711).

    The HealthSelect network is much larger than a regional HMO network and regularly adds new providers. If your provider is not in the HealthSelect network, you will have a much larger network of available providers to choose from.

    If your provider is not in the HealthSelect network, you can nominate him or her by filling out a form on HealthSelect website so BCBSTX can contact your provider and invite them to join the network. Please remember that a recommendation does not guarantee that the provider will want to be in-or accepted into-the network.

    It’s important to know that new providers may join, and some current providers may choose to leave the network before September 2021.
  • Medical benefits: In-network benefits in HealthSelect of Texas are largely the same and, in some cases, better than in your HMO. In addition, the HealthSelect plans cover out-of-network services, although participants usually pay more for out-of-network care.

    In Consumer Directed HealthSelect, your out-of-pocket costs could be much higher than in your HMO, but your HSA could help offset those costs. See the plan comparison chart to compare current benefits in the different plans.

  • Referrals: The HealthSelect of Texas plan requires you to have an authorized referral on file with BCBSTX to see most specialists. If you do not have a referral on file before seeing most specialists, your medical services will be considered out-of-network, even if the specialist you see is in the HealthSelect network. This means you will pay more – sometimes a lot more. Referrals are not required in Consumer Directed HealthSelect.

    You do not need a referral for:

    • chiropractic visits,
    • covered vision care, including routine and diagnostic eye exams,
    • mental health counseling,
    • OB/GYN visits,
    • occupational therapy, physical therapy or speech therapy and
    • Virtual Visits, urgent care centers or convenience care clinics.

However, to help with your transition into the HealthSelect of Texas plan, you will have a 90-day referral grace period and will receive in-network benefits if you see an in-network specialist without a referral. This means, if you see a HealthSelect in-network specialist from September 1 through November 30, 2021 and do not have a referral on file with BCBSTX, your specialist visit will be covered at the in-network benefit level. If you see a specialist who is not in the HealthSelect network, even during this 90-day referral grace period, you will receive out-of-network benefits.

After November 30, if you see a specialist without a referral on file, you will pay for your specialist visit at the out-of-network benefit level, even if your specialist is in-network.

  • Care from specialists: Your specialist(s) may sometimes require you to have additional testing or medical services. Any facility your specialist(s) sends you to must also be in-network for you to receive in-network benefits. Some services may also require prior authorization. You can check if services require prior authorization or a facility’s network status by calling a BCBSTX Personal Health Assistant. 
  • Prior authorization: Both HealthSelect plans, including Consumer Directed HealthSelect of Texas, requires prior authorization for certain covered health services. Usually, your in-network PCP and other network providers will get prior authorization before they provide these services to you.

However, in some cases you will need to get prior authorization yourself.  For example, when you choose to receive certain covered health services from out-of-network providers, you are responsible for getting prior authorization before you receive these services. You are also required to get prior authorization when a out-of-network provider intends to admit you to an in-network facility or refers you to other in-network providers. For these scenarios, call a BCBSTX Personal Health Assistant at (800) 252-8039 (TTY: 711) to submit a request for a prior authorization.

  • Prescription drug coverage: Prescription benefits for the HealthSelect plans is through the HealthSelect Prescription Drug Program administered by OptumRx. You do not need to enroll in these benefits. They are included with your automatic enrollment in the HealthSelect plans. You can purchase your prescriptions using in-network or out-of-network pharmacies, but you will pay more if you use an out-of-network pharmacy. You may also purchase your long-term medications at participating retail locations. You will continue to have a $50 annual prescription deductible. Your deductible starts and resets on January 1. Your deductible will not start over in September.

In Consumer Directed HealthSelect, your out-of-pocket prescription drug costs could be much higher than in your HMO, but your HSA could help offset those costs. See question 4 below for annual deductible amounts.

The HealthSelect drug formulary (that is, which prescription drugs are covered under the plan and at what member cost share) may be different than your HMO's formulary, which often happens with any plan changes.

For more information on the HealthSelect prescription drug benefits visit www.healthselectrx.com.

  • ID cards: You will get a medical ID card for health benefits from BCBSTX, and another ID card for prescription benefits from OptumRx. Show your new ID cards to your health care providers and at your pharmacy. If you do not show your new ID cards, your claims could be sent to the wrong plan and will be denied. You will get your new ID cards in August. If you are enrolled in HealthSelect of Texas and your BCBSTX medical ID card does not list a PCP, contact a BCBSTX Personal Health Assistant to select one as soon as possible. If you do not have a PCP listed on your card, after your first 60 days in the plan, all of your health care benefits will be paid as out-of-network regardless of whether the provider is in the network.

  • Premium contributions: If you pay a health care premium for yourself or for your dependent(s), your monthly premium cost will be higher in HealthSelect of Texas and possibly in Consumer Directed HealthSelect.

If the state currently pays all or part of your monthly health care premium, the state will continue to pay all or part of your premium.

See Plan Year 2022 premium rates.

  • Value-added benefits: You will have access to many popular value-added benefits at no additional cost, including weight-management programs, an online wellness portal with self-management programs, trackers and other tools and wellness resources, HealthSelectShoppERS, the Fitness Program and Blue Points, among others. (Note: Health plan administrators or carriers may discontinue or change their value-added programs at any time without notice.)

During your Summer Enrollment phase, you have the option to enroll in Consumer Directed HealthSelectSM, a high-deductible health plan.

This plan works much differently than an HMO. You must meet a deductible of $2,100 as an individual and $4,200 as a family before the plan will begin to pay for medical or prescription drug benefits, except for preventive care. The deductible resets on January 1.

The primary benefit of Consumer Directed HealthSelect is that you can open a health savings account (HSA) to save money, tax-free, for eligible health expenses. Each month the state will contribute to your HSA: $45 per month for individual coverage or $90 for family coverage. You can also make tax-deductible contributions to your HSA, up to a certain amount determined each year by the IRS. The unused balance can be carried over from year to year, and goes with you if you change health plans or even leave state employment. The HSA is administered by Optum Bank, and you must open an Optum Bank HSA to get the state’s monthly contribution.

You don’t need to have a PCP on file with BCBSTX, but will benefit from seeing an in-network PCP.

It’s important to know that you could have higher out-of-pocket costs with this plan. After you meet your deductible, you will pay a percentage of the providers’ charges, which is called coinsurance. You will not have set copays for services.

Waive health plan coverage and selecting the Opt-out Credit:

You may waive your GBP health coverage. If you are an active state employee and waive your Texas Employees Group Benefits Program (GBP) health insurance because you have other group health insurance that is as good as or better than the state plan, you may select the Opt-Out credit. If you select the Opt-Out Credit, you will get a $60 credit ($30 credit for part-time employees and retirees) each month to help you pay for dental, vision and/or Voluntary Accidental Death & Dismemberment (AD&D) insurance. (Note: Retirees are not eligible for AD&D insurance.) . This is not a cash payment; any unused amount will not carryover from month to month. What you do not use on dental, vision and/or AD&D premiums, you forfeit.

Consider these before you waive your ERS health insurance:

  • You will lose your health plan, prescription drug coverage and the $5,000 ($2500 for retirees) Basic Term Life Insurance that comes as part of your ERS health insurance enrollment.
  • If the State of Texas currently pays all or part of your monthly premium, you will no longer get that premium contribution.
  • You cannot enroll your eligible dependents in a GBP health plan if you are not enrolled yourself.
  • You also cannot re-enroll yourself or your eligible dependents in ERS health coverage until Summer Enrollment 2022, with coverage starting in September 2022. If you have a qualifying life event, such as a marriage or birth you may be able to re-enroll in health coverage within 31 days of that event.
    • You can still continue or begin enrollment in other ERS plans: dental, vision,  Optional Term Life, and/or Dependent Term Life insurance; and for active employees, TexFlex flexible spending accounts, Voluntary AD&D Insurance, and/or Texas Income Protection Plan (TIPP) disability insurance. (Note: TexFlex, AD&D insurance and TIPP disability insurance are not available to retirees. If you are not already enrolled in Optional or Dependent Term Life Insurance or TIPP disability insurance, you will have to apply with evidence of insurability (EOI) and coverage is not guaranteed.)

Electing to “waive” coverage is not the same as choosing the Opt-Out Credit. You must make that election during Summer Enrollment to get the monthly credit.

If you are currently enrolled in an HMO and are receiving ongoing treatment from a provider who is not in the HealthSelect network, you may able to continue treatment with that provider temporarily. This is called transition of care. To continue with your care, certain eligibility guidelines need to be met.

Medical conditions that may be eligible for transition of care benefits are:

  • pregnancy in the second or third trimester,
  • long-term treatment of cancer,
  • heart disease,
  • organ transplants and
  • terminal illness if life expectancy is less than six months.

If your provider determines switching doctors may be harmful to your health, you may be eligible to continue treatment with your out-of-network provider for a certain amount of time based on your specific situation.

If one of these situations applies to you, you should download and complete the Participant request for Transition of Care Benefits and Release form. It provides information about your situation and authorizes BCBSTX to discuss your situation with your physician. Sign it and mail or fax the form to the address at the bottom of the form. Once BCBSTX receives the completed form, the BCBSTX medical team will contact your provider to review your case. Then, BCBSTX will let you know if the treatment is approved to be covered at an in-network benefit level until it is safe to transfer you to an in-network provider. If you prefer, you may call a BCBSTX Personal Health Assistant at (800) 252-8039 (TTY: 711) to request a copy of the form be emailed, faxed or mailed directly to you or your provider.

HealthSelect plans offer access to a dedicated holistic health clinician through the Care Management Program. Clinicians can help answer your questions, make sure you have the appropriate authorizations and help you navigate the healthcare system, coordinate care, schedule appointments and ensure you receive the appropriate levels of care.

Your HMO is responsible for all services received through August 31. Effective September 1, your HealthSelect plan is responsible for any covered health services you receive.

This means if you are admitted to the hospital before September 1, your current HMO plan will be responsible for any claims through August 31. Your HealthSelect plan will be responsible for payment of covered health services beginning September 1, including the remainder of your in-patient stay.

You will get an Explanation of Benefits (EOB) from your HMO plan for claims through August 31 and a separate EOB from BCBSTX for any claims beginning September 1.

 If you have questions about the EOBs you receive as a result of a hospital stay during this time frame, please contact your HMO plan or BCBSTX:

  • HealthSelect of Texas and Consumer Directed HealthSelect plans: Call BCBSTX toll free- at (800) 252-8039 (TTY: 711), Monday – Friday, 7 a.m. – 7 p.m. CT; Saturday 7 a.m. – 3 p.m. CT
  • SWCP: Call toll-free (800) 321-7947.
  • CFHP: Call (210) 227-2347, TTY (210) 358-6080, Monday – Friday, 8 a.m. – 5 p.m. CT

No. Your out-of-pocket expenses that go towards your out-of-pocket maximum amounts while you are enrolled in the HMO plan will carry over to your HealthSelect plan. Your of-pocket maximum amounts start over on January 1, 2022.

Yes. Your prior authorization will be honored by BCBSTX. 

If your approved prior authorization is with a provider who is not in the HealthSelect network, you will receive in-network benefits for those services until either the authorization end date, or November 30, whichever comes first. After that date, if you see this provider, you will receive out-of-network benefits and your out-of-pocket costs could be a lot higher. To find an in-network provider, use the Provider Finder tool at www.healthselectoftexas.com or call a BCBSTX Personal Health Assistant. 

If you have questions about your current prior authorization or the services that require prior authorization under HealthSelect of Texas, including Consumer Directed HealthSelect, call a BCBSTX Personal Health Assistant. Personal Health Assistants can also help you estimate your out-of-pocket costs for the services you and your covered dependents get.

Both SWCP and CFHP will be available for several months after September 1 to answer any questions you may have and support your transition to HealthSelect plan. The plan websites, your account information and the ERS dedicated call center will be available as follows:

HMO Participant's online account
(To see claims for service before September 1, 2021)
Plan website Call center
SWCP Available indefinitely Available through August 31, 2022 Available indefinitely
(800) 321-7947
CFHP Available through February 28, 2022 Available through August 31, 2022

Through February 28, 2022: 
(210) 358-6262; 

Starting March 1, 2022: (210) 358-6070

There are several ways to get more information about this change ERS, your HMO and/or HealthSelect will send you information in the coming months. Be sure to read any information they send in the mail or email. 
Don’t forget to update your personal information by logging in to your ERS OnLine account to make sure you don’t miss any important information.
  • Visit the ERS website: ERS has developed this webpage with information about HMO participants moving into HealthSelect plans. Check back from time to time for more updates. Also, see the health benefits page on the ERS website, to learn more about the HealthSelect plans.
  • Join a webinar or review a recording of the presentation: There are several informational webinars available throughout Summer Enrollment. There will be a presentation followed by question and answer session, which will be answered by ERS, BCBSTX, HMOs or OptumRX as required. You can see a schedule of the webinars on ERS Summer Enrollment page and also in your Summer Enrollment packet and attend one or more sessions.
  • Read through your Summer Enrollment packet: Look in the mail for the Summer Enrollment packet and review the flier with transition information and other details you need to know so you can make an informed choice during Summer Enrollment.
  • Call the health plan or ERS:
    • HealthSelect of Texas and Consumer Directed HealthSelect plans: Call BCBSTX toll free- at (800) 252-8039 (TTY: 711) Monday – Friday 7 a.m. – 7 p.m. CT; Saturday 7 a.m. – 3 p.m. CT 
      Website: healthselect.bcbstx.com/
    • HealthSelect Prescription Drug Plan: Call OptumRx toll-free (855) 828-9834 (TTY: 711) 24 hours a day, 7 days a week.
      Website: www.HealthSelectRx.com
    • SWCP: For claims and coverage information through August 31, call toll-free (800) 321-7947.
      Website: ers.swhp.org/
    • CFHP: For claims and coverage information through August 31, call (210) 227-2347, TTY (210) 358-6080 Monday – Friday 8 a.m. – 5 p.m. CT
      Website: members.cfhp.com
    • ERS: Call toll-free (877) 275-4377 (TTY: 711) Monday – Friday 8 a.m. – 5 p.m. CT
      Website: www.ers.texas.gov

No. State premium contributions apply only to GBP health plans.

All GBP health plans offer high-quality coverage at a reasonable cost. However, if you don’t like your new GBP coverage, you can change or drop plans during your Summer Enrollment phase or within 31 days of a qualifying life event, such as a marriage or adoption. Your prescription drug benefits are part of your health benefit. If you opt-out of your health plan, you are also giving up your prescription drug coverage and Basic Term Life Insurance coverage.

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.