Baylor Scott and White Plan Guide for Texas 2024

All You Need to Know About Baylor Scott & White Plans for 2024

When searching for health insurance, most insurance shoppers begin with the big names: Blue Cross Blue Shield, Aetna, and UnitedHealthcare. These companies are at the top of the list for health insurance in Texas. But did you know there are other health insurers out there? You have options that can possibly save money and provide you with the same health coverage as the big three above. This is because of the health mandate—All insurance providers must offer the same insurance for all. At CoverMile, we assist shoppers with understanding what Baylor Scott & White plans offer and will guide you through what their coverage chart means to you.

Health Insurance Terms to Understand

Before we begin, let’s go over the definitions of the terms you will see frequently but may not understand completely. These terms will be the same, whatever health insurance company you select. Knowing the basics will help you determine the best health insurance coverage for your family situation.

Deductible – A deductible is the amount you will pay out-of-pocket before the coinsurance kicks in. Baylor Scott & White has deductibles between $0 and $9450, depending on the plan you select. Deductibles are based on the calendar year and refresh each year. They also determine your premium. The higher your deductible, the lower your premium will be; the lower your deductible, the higher your premium. Deductibles are broken down into two parts:

            Individual: This is the per-person deductible.

            Family:This is the deductible for the entire family.

These numbers will be listed on your Summary of Benefits, often in fraction form. For instance, $750 Single/$1500Family; or abbreviated, $750/$1500. Each family member has their own $750 out-of-pocket expense to reach. You can read more about deductibles here.

Coinsurance – Coinsurance is the cost-sharing benefit between you and the insurance company. It is expressed as a percentage. For example, on the Silver metal tier, you pay 40% of medical expenses after your deductible is met. Your Summary of Benefits always shows the coinsurance portion you will pay. This, too, refreshes each year.

Out-of-Pocket Max – Insurance plans have an out-of-pocket max. This is a failsafe to help those with larger families, who visit the doctor regularly, or those with chronic medical conditions. When you meet your deductible, pay through your coinsurance, and reach your out-of-pocket max, Baylor Scott & White will pay 100 percent of medical expenses for that person on the policy. This continues for the remainder of the calendar year.

Primary Care Physician – Your Primary Care Physician (PCP) is the main doctor you see for your medical care. Baylor Scott & White is an HMO and, in some locations, an EPO; you are required to coordinate all treatment through them. All BSW health insurance plans offer Pediatric Primary Care Physician visits with a zero-dollar copay.

Copay –Copays are fees doctors and facilities charge for an office visit. It is important to understand that this fee is for the visit alone and not for the treatment you may receive. It can be a flat dollar amount or a co-insurance-like percentage and can vary by plan. Some treatments, like a well checkup or immunizations, can be included in your visit. See your medical plan for details.

Now that you know the basics of health insurance, let’s go over the plans Baylor Scott & White has to offer.

Baylor Scott & White and the Affordable Care Act

Baylor Scott & White, sometimes referred to simply as Scott and White, offers health insurance plans in Texas as part of the Affordable Care Act. Their Bronze, Silver, and Gold plans are available on the Marketplace as well as on their website. You can view a full selection of their plans on their website.

Below, we have listed a variety of plans that BS&W offers. We’ve arranged them based on price, deductible, and coinsurance. To simplify our table, we have listed deductibles and out-of-pocket maximums as a fraction. The first number is the individual person, and the second is for the family. Also, keep in mind that these numbers reflect in-network doctors and facilities.

Baylor Scott & White Bronze

Baylor Scott & White Bronze metal level tier offers three plans on the Marketplace. Each has nearly the same deductible. One is a High Deductible Health Plan (HDHP) paired with a Health Saving Account (HSA). HDHPs offer a low premium, which allows you to contribute those savings to a spending account for your medical expenses as they arise. The downfall is you do not see your coinsurance until you meet your deductible, so everything up till then is out of pocket. However, the more you contribute to your HSA, the more you have to use toward your medical expenses, and you can elect to have those funds deducted from your paycheck pretax.

Bronze	BSW Vital Bronze HMO 009	BSW Vital Bronze HMO 007	BSW Savers  HMO – HSA – 006
Deducible	$8000/$16,000	$7500/$15,000	$7500/$15,000
Coinsurance	30%	50%	0% after deductible
Out-of-Pocket Max	$9450/$18,900	$9400/$18,800	$7500/$15,000
Primary Care Visit	$0 for first/$40 Adult copay/ $0 Pediatric	$50 copay adult/ $0 pediatric copay	0% after deductible
Telehealth Visit	$0	$0	0%
Specialist Visit	$100 copay	$100 copay	0% after deductible
Emergency Room	30%	50%	0% after deductible
Urgent Care	$100 copay	$75 copay	0% after deductible
Inpatient Hospital	30%	50%	0% after deductible
Outpatient Hospital	30%	50%	0% after deductible
Prescription (Pharmacy)	$25/$55/$150/ $500*	$25/$50/$100/ $500*	0% after deductible

*Prescriptions are Generic, Preferred, Non-Preferred Brand. and Specialty

Baylor Scott & White Silver

Baylor Scott & White has three basic Silver metal plans. All are offered through the Affordable Care Act Marketplace. One can receive the benefit of premium tax credits if one meets certain income requirements.

Silver	BSW Prime Silver HMO – 003	BSW Prime Silver HMO – 008	BSW Prime Silver HMO – 005
Deducible	$5900/$11,800	$5900/$11,800	$1200/$2400
Coinsurance	40%	40%	0%
Out-of-Pocket Max	$9100/$18,200	$9450/$18,900	$9450/$18,900
Primary Care Visit	$40 Adult copay/ $0 Pediatric	$0 for first 2 visits/ $25 Adult copay/ $0 Pediatric	$0 for first visit/ $45 Adult copay/ $0 Pediatric
Specialist Visit	$80 copay	$35 copay	$85 copay
Emergency Room	40%	50%	$750
Urgent Care	$60 copay	$35 copay	$85 copay
Telehealth Visit	$0	$0	$0
Inpatient Hospital	40%	50%	$2000
Outpatient Hospital	40%	50%	$1000
Prescription (Pharmacy)	$20/$40/$80/ $350	$15/$90/$140/ $500*	$20/$100/$140/ $500*

*Prescriptions are Generic, Preferred, Non-Preferred Brand. and Specialty

One can also qualify for cost-sharing reductions (CSR) if they live between 100% and 250% of the Federal Poverty Level (FPL). Below are the CSR plans available to those who qualify through the Marketplace. These plans will have lower copays and out-of-pocket maximums. We are only showing three of the nine plans offered.

Silver	BSW Prime Silver HMO 03 – CSR 73 AV	BSW Prime Silver HMO 08 – CSR 87 AV	BSW Prime Silver HMO 05 – CSR 94 AV
FPL bracket	201% – 250%	151% – 200%	100% -105
Deducible	$5700/$11,400	$1000/$2000	$0/$0
Coinsurance	40%	35%	25%
Out-of-Pocket Max	$7,200/14,400	$3150/$6300	$1200/$2400
Primary Care Visit	$40 copay/ $0 Pediatric	$0 for first 2 visits/ $5 Adult copay/ $0 Pediatric	$0 copay/ $0 Pediatric
Specialist Visit	$80 copay	$20 copay	$10 copay
Emergency Room	40%	35%	$200 copay
Urgent Care	$45 copay	$20 copay	$10 copay
Telehealth Visit	$0	$0	$0
Inpatient Hospital	40%	35%	$50 copay
Outpatient Hospital	40%	35%	$100 copay
Prescription (Pharmacy)	$0/$20/$40/$80/ $350	$0/$45/$140/ $500*	$0/$15/$55/ $500*

Baylor Scott & White Gold

Baylor Scott & White Gold has four plans, three of which are offered on the Marketplace. The other is offered through their website. Gold is the highest level of coverage. It generally provides the lowest deductibles, copays, and overall cost of insurance. However, with the level of insurance comes the price tag. Gold plans are best suited for those who visit the doctor frequently, have chronic medical conditions, or expect to require advanced medical care in the near future.

Another thing to note, when shopping for Gold metal plans, read the Summary of Benefits carefully. Many benefits do not kick in until after you’ve met your deductible. If you need assistance selecting a policy, contact CoverMile. We would be glad to assist you with selecting the policy best suited for your family’s needs.

Gold	BSW Elite Gold HMO – 001	BSW Elite Gold HMO – 004	BSW Elite Gold HMO – 012
Deducible	$1500/$3000	$1100/$2200	$1500/$3000
Coinsurance	25%	25%	20%
Out-of-Pocket Max	$8700/$17,400	$9450/$18,900	$9300/$18,600
Primary Care Visit	$30 copay/ $0 Pediatric	$0 for first 2 visits/ $40 Adult copay/ $0 Pediatric	$0 copay
Specialist Visit	$60 copay	$65 copay	$60 copay
Emergency Room	25%	$750 copay	$750 copay
Urgent Care	$45 copay	$60 copay	$60 copay
Telehealth Visit	$0	$0	$0
Inpatient Hospital	25%	$1500 copay	20%
Outpatient Hospital	25%	$300 copay	$500 copay
Prescription (Pharmacy)	$15/$50/$60/ $250*	$15/$55/$150/ $500*	$15/$55/$150/ $500*

*Prescriptions are Generic, Preferred, Non-Preferred Brand. and Specialty

Baylor Scott & White HMO/EPO for Central Texas

Baylor Scott & White has been primarily a North and Central Texas insurance provider. They have steadily extended their reach south, now including such counties as Bexar, which houses San Antonio; El Paso and Dallas County and their namesakes; and Travis County, where the state’s capital, Austin, resides. Within these counties, BSW has separate HMO and EPO plans. The plans are identical except for the network. The HMO is available in these 61 counties. The EPO is available in all but Bexar, El Paso, Bastrop, Comal, Hays, and Walker Counties.

Bronze	BSW Vital Bronze – HMO / EPO 001
Deducible	$8000/$16,000
Coinsurance	30%
Out-of-Pocket Max	$9450/$18,900
Primary Care Visit	$0 for first visit/ $40 Adult copay/ $0 Pediatric
Specialist Visit	$100 copay
Emergency Room	30%
Urgent Care	$100 copay
Inpatient Hospital	30%
Outpatient Hospital	30%
Prescription (Pharmacy)	$25/$55/$150/ $500*

Additional Coverages through Baylor Scott & White

Medicare Advantage

BS&W also offers Medicare Advantage plans. BS&W SeniorCare Advantage HMO. These plans are available to Central and North Texas residents. You can find out more through the links below:

Central: BS&W SeniorCare Advantage HMO Central

North: BS&W SeniorCare Advantage HMO North

STAR Medicaid

BS&Ws parent company is Scott and White Health. They offer STAR Medicaid and the CHIP program for low-income families, children, and pregnant women for those in Central Texas. You can contact them directly for more information.

Finding a Doctor or Facility in Your Network

Baylor Scott & White is an HMO and an EPO. You are required to remain within the provider network they are contracted with. Only in a medical emergency are you able to visit a medical facility outside the network. However, with an HMO, you may seek treatment with an out-of-network provider if medically necessary and with BS&W approval.

You can see a doctor virtually through the member portal or mobile app. There are three ways to contact a medical provider. Through an online questionnaire with a response, an appointment-based video visit, or MDLive where you can connect with a board-certified doctor via video or phone.

Baylor Scott & White allows you to search for doctors and facilities near you on their website. You can also determine the cost of treatment.

Baylor Scott & White Comparison Charts:

For a complete comprehensive list of Baylor Scott & White Affordable Care Act plans, follow the links below.

Comparison Chart	Plan	Plan
BSW Gold Plan	English	Spanish
BSW Silver Plan	English	Spanish
BSW Bronze Plan	English	Spanish

Benefit Notices:

Keep in mind that the above is a summary of highlights only.

–The benefits above represent what a member would pay. When a non-participating provider is used, benefits are reduced.

–If BS&W determines medically necessary care can’t be provided by an in-network provider, your PCP may refer an out-of-network provider.

–You are required to pay costs up to your deductible before the plan pays its portion for covered services. What is shown is the per-person deductible and out-of-pocket maximum. Please see your plan for details.

 –All percentages shown are of the allowable amount for covered services.

 –Prescription drug payment level tiers: Generic, Preferred, Non-Preferred Brand. and Specialty

–All services require prior authorization, or you may have a claim denied and have to pay out-of-pocket

Prescription Coverage with Baylor Scott & White

With all Baylor Scott & White health plans, subscribers receive prescription coverage. You can search your prescription drug by plan. Then, by name, class, and tier. Benefits plans have:

• Specialty Pharmacy Program – When you require specialty medication, to receive your maximum benefits, you must obtain your prescription from a Preferred Specialty Pharmacy provider. The two primaries are BS&W Specialty Care Team Pharmacy and Optum Specialty Pharmacy.
• Mail Order Pharmacy – BSW offers two options for mail order pharmacy—their own mail service and OptumRx. Baylor Scott & White offers medications as low as $5.
• Drug Pricing Tool – By selecting the plan you are on, you can select your medication and find the general cost of your prescription.
• 90-day Supply – Depending on your drug benefit, you may be able to receive a 90-day supply of your prescription to save on your medication cost.

Baylor Scott & White can help you find a pharmacy in your area through its website.

At CoverMile, we help you find the health insurance in Texas that best fits you and your family’s needs. We take the time to talk you through each plan, help you understand each Baylor Scott & White plan, and guide you through signing up for Affordable Care Act insurance. Contact us today.