Summary of Benefits for
2021 BSW SeniorCare Advantage Premium (HMO)

BSW SeniorCare Advantage Premium (HMO) H8142-006 is a 2021 Medicare Advantage Plan or Medicare Part-C plan by Scott and White Health Plan available to residents in Texas. This plan does not provide additional Medicare prescription drug (Part-D) coverage. The BSW SeniorCare Advantage Premium (HMO) has a monthly premium of $199.00 and has an in-network Maximum Out-of-Pocket limit of $4,500 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,500 out of pocket. This can be a extremely nice safety net.

BSW SeniorCare Advantage Premium (HMO) is a Local HMO *. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered by the plan.

Scott and White Health Plan works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for BSW SeniorCare Advantage Premium (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Scott and White Health Plan and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Scott and White Health Plan except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.

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1-855-778-4180
Mon-Fri 8am-9pm EST
Sat 9am-9pm EST

2021 Scott and White Health Plan Medicare Advantage Plan Costs

2021 BSW SeniorCare Advantage Premium (HMO) Summary of Benefits

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	$0 copay
Endodontics	Not covered
Extractions	50% coinsurance
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	50% coinsurance
Restorative services	50% coinsurance

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$0 copay
Diagnostic tests and procedures	$0 copay
Lab services	$0 copay
Outpatient x-rays	$0 copay

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Doctor Visits

Primary	$0 copay
Specialist	$0 copay

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$40 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$0 copay
Routine foot care	Not covered

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Ground Ambulance

$40 copay

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Hearing

Fitting/evaluation	$0 copay
Hearing aids	$0 copay
Hearing exam	$0 copay

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Inpatient Hospital Coverage

$0 copay

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	$0 copay
Prosthetics (e.g., braces, artificial limbs)	$0 copay

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$0 copay
Outpatient group therapy visit	$0 copay
Outpatient group therapy visit with a psychiatrist	$0 copay
Outpatient individual therapy visit	$0 copay
Outpatient individual therapy visit with a psychiatrist	$0 copay

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MOOP

$4,500 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$0 copay

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Preventive Care

$0 copay

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Preventive Dental

Cleaning	$0 copay
Dental x-ray(s)	$0 copay
Fluoride treatment	Not covered
Oral exam	$0 copay

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Rehabilitation Services

Occupational therapy visit	$0 copay
Physical therapy and speech and language therapy visit	$0 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $15 per day for days 21 through 100

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Transportation

$0 copay

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Vision

Contact lenses	$0 copay
Eyeglass frames	$0 copay
Eyeglass lenses	$0 copay
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	$0 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Reviews for BSW SeniorCare Advantage Premium (HMO) H8142

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in BSW SeniorCare Advantage Premium (HMO) Plans Performance

Health Plan Customer Service Rating for BSW SeniorCare Advantage Premium (HMO)

BSW SeniorCare Advantage Premium (HMO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Sat 8am-11pm EST
Sun 9am-6pm EST

Coverage Area for BSW SeniorCare Advantage Premium (HMO)

(Click county to compare all available Advantage plans)

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Source: CMS.
Data as of September 9, 2020.
Notes: Data are subject to change as contracts are finalized. For 2021, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit. Includes 2021 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.