Medical Plans

Compare Your Health Benefit Options

Harris County provides three medical plan options: Base PPO, Plus PPO and the KelseyCare ACO Plan. Base and Plus PPO plans each provide you with the same Aetna network, including out-of-network benefits.

An ACO, or Accountable Care Organization, is a group of doctor, facilities and other healthcare professionals who work together to ensure your care is coordinated. With the KelseyCare ACO plan, your care team provides the personalized care you need, plus a more streamlined healthcare experience.

Choose The Option That’s Right For You

BASE PLAN

The Base Plan is designed to keep your monthly costs low through higher deductibles and out-of-pocket maximums. You’ll pay more for services that you use, but you’ll pay the lowest premiums.

PLUS PLAN

With the Plus Plan, you’ll pay a higher monthly premium, but your deductibles, out-of-pocket maximums and costs for services will be lower.

KELSEYCARE ACO PLAN

The KelseyCare ACO plan offers the same out-of-pocket experience as our Plus Plan  no deductible, lower copays — at Base Plan premiums. You are limited to in-network providers only. However, you still have access to Aetna’s broad network for Urgent and Emergency Care needs.

Cost and service comparisons follow.

Machine-Readable Files

This link leads to the machine-readable files that are made available in response to the federal Transparency in Coverage Rule and include negotiated service rates and out-of-network allowed amounts between health plans and health care providers. The machine-readable files are formatted to allow researchers, regulators and application developers to more easily access and analyze data.

Click Here

Helpful Terms to Know

BENEFICIARY — A person named to receive the income or inheritance from a will, insurance policy, trust, etc.

COINSURANCE — The amount you pay, as a percentage of the cost of your allowed services, after you reach the deductible until you reach the plan’s out-of-pocket maximum.

COPAYMENT — The fixed dollar amount you will pay for a healthcare service.

DEDUCTIBLE — When applicable, the initial amount you pay before your insurance begins covering certain services.

DEPENDENT — A person who is eligible for coverage under a policyholder’s health insurance coverage.

OUT-OF-POCKET MAXIMUM — The most you will pay per calendar year for covered, in-network healthcare expenses including prescription drugs. Once this limit is met, the plan pays 100% on eligible expenses for the remainder of the calendar year.

PREMIUM — The amount you pay for insurance. In most cases, Harris County pays all or a portion of the premium.

Understanding In-Network vs. Out-of-Network

Whether you choose the Base, Plus or KelseyCare ACO medical plan, the coverage is through the Aetna Choice POS II (Open Access) network. It’s a large network of providers and facilities covering almost every medical service you may need.

Yet a great benefit of your healthcare plan is that you aren’t limited to in-network providers. You always have the choice to decide when, where and how to receive medical care. So if you prefer to select a primary care physician (PCP) or other provider who isn’t part of the network, you always have that freedom. Just be aware that if you use an out-of network provider or facility, you will be responsible for paying the difference between the covered amount and the amount charged by the provider/facility.

You are limited to in-network providers with the selection of the KelseyCare ACO plan.

YOUR BEST VALUE

We want you and your dependents to have the care you need, so considerable effort has been made to ensure that the OAP network offers a wide range of qualified choices. When you select an in-network provider or facility, you’ll get the lowest costs. The County will save money, too.

To see if a provider or facility is part of the network, go to aetna.com or use the Aetna Health App.

In-Network Only!

Bariatric Surgery • Dialysis
For these services, you will be responsible for the entire cost if you use an out-of-network provider/facility.

Plan Services Overview

Use this overview of services/costs for a deeper comparison between all plans — Base PPO, Plus PPO and KelseyCare ACO.

In all cases, staying in-network provides the best value. In the overview, “You Pay” refers to the amount you are responsible for of eligible expenses. Note that this is not a comprehensive list of services, limitations or exclusions. Please log in at aetna.com for more covered services and to estimate your out-of-pocket cost and additional provisions.

Medicare Primary: If you or your dependent have Medicare as your primary insurance, your Harris County health plan (Aetna) will cover the remaining 20% for in-network covered services once the Medicare Part B deductible is met.

ENROLLMENT

KelseyCare ACO BASE PPO PLUS PPO
IN-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
Annual Deductible
Individual
Family		 None $600
$1,800		 $1,000
$3,000		 None $1,000
$3,000
Maximum Out-of-Pocket
Individual
Family		 $6,350
$12,700		 $7,350
$14,700		 $10,000
$30,000		 $6,350
$12,700		 $30,000
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited
OFFICE SERVICES YOU PAY
Preventive Services* $0 $0 50% coinsurance after deductible is met $0 50% coinsurance after deductible is met
Employee Clinic $0 $0 Not applicable $0 Not applicable
Walk-in Clinic
CVS Minute Clinic
Other Walk-in Clinic		 $25
N/A		 $0
$30		 50% coinsurance after deductible is met $0
$25		 50% coinsurance after deductible is met
Primary Care Visit
(Telehealth and Office Visit)		 $15 $20 50% coinsurance after deductible is met $15 50% coinsurance after deductible is met
Specialist Office Visit
(Telehealth and Office Visit)		 $30 $40 50% coinsurance after deductible is met $30 50% coinsurance after deductible is met
Urgent Care $50 $50 50% coinsurance after deductible is met $50 50% coinsurance after deductible is met
EMERGENCY CARE YOU PAY
Ambulance Service $0 $300 $300 $0 $0
Emergency Room
If admitted, copay is waived. You are still responsible for inpatient services.		 $300 $300 $300 $300 $300
INPATIENT CARE YOU PAY
Hospital Services
Precertification and continued stay review required for all inpatient admissions.		 $600 20% coinsurance after deductible is met 50% coinsurance after deductible is met $600 50% coinsurance after deductible is met
Physician Services $0 20% coinsurance after deductible is met 50% coinsurance after deductible is met $0 50% coinsurance after deductible is met
Skilled Nursing Facility
Up to 100 days per calendar year. Requires precertification.		 $0 10% coinsurance after deductible is met 50% coinsurance after deductible is met $0 50% coinsurance after deductible is met
OUTPATIENT CARE YOU PAY
Facility Services $400 20% coinsurance after deductible is met 50% coinsurance after deductible is met $400 50% coinsurance after deductible is met
Outpatient Surgery $400 20% coinsurance after deductible is met 50% coinsurance after deductible is met $400 50% coinsurance after deductible is met
Diagnostic X-ray & Laboratory $0 $0 50% coinsurance after deductible is met $0 50% coinsurance after deductible is met
Diagnostic Mammogram
Includes 3D		 $0 $0 50% coinsurance after deductible is met $0 50% coinsurance after deductible is met
Outpatient Dialysis Treatment $0 $0 Not covered $0 Not covered
Complex Imaging
MRI, CAT scan, PET scan, etc. Requires precertification.		 $0 10% coinsurance after deductible is met
$0 (Maximum Savings Provider)		 50% coinsurance after deductible is met $100
$0 (Maximum Savings Provider)		 50% coinsurance after deductible is met
Rehabilitation/Therapy
Physical, speech and occupational. Limited to 60 visits per calendar year.		 $20 per visit $25 per visit 50% coinsurance after deductible is met $20 per visit 50% coinsurance after deductible is met
Basic Infertility Services
Diagnosis and Treatment Only		 Payable as any other expense; 50% coinsurance for insemination; fertility drugs excluded Payable as any other expense; 50% coinsurance after deductible is met for insemination; fertility drugs excluded 50% coinsurance after deductible is met; fertility drugs excluded Payable as any other expense; 50% coinsurance for insemination; fertility drugs excluded 50% coinsurance after deductible is met; fertility drugs excluded
MATERNITY YOU PAY
Initial Office Visit
(Specialist copay)		 $30 $40 50% coinsurance after deductible is met $30 50% coinsurance after deductible is met
Subsequent Visits $0 $0 50% coinsurance after deductible is met $0 50% coinsurance after deductible is met
Hospital Delivery
Separate cost share/copay for Mom & Baby.		 $600 20% coinsurance after deductible is met 50% coinsurance after deductible is met $600 50% coinsurance after deductible is met
Breast Pump & Supplies $0 $0 50% coinsurance after deductible is met $0 50% coinsurance after deductible is met
OTHER MEDICAL YOU PAY
Acupuncture $0 for up to 10 visits per calendar year $0 for up to 10 visits per calendar year $0 for up to 10 visits per calendar year $0 for up to 10 visits per calendar year $0 for up to 10 visits per calendar year
Allergy Treatment
Includes serum, injections and injectable drugs.		 $0 for up to 150 doses per calendar year $0 for up to 150 doses per calendar year 50% coinsurance after deductible is met $0 for up to 150 doses per calendar year 50% coinsurance after deductible is met
Chiropractic Care $0 for up to 10 visits per calendar year $0 for up to 10 visits per calendar year 50% coinsurance after deductible is met $0 for up to 10 visits per calendar year 50% coinsurance after deductible is met
Durable Medical Equipment $0 10% coinsurance after deductible is met 50% coinsurance after deductible is met $0 50% coinsurance after deductible is met
Hearing Aids
1 pair every 36 months		 20% coinsurance; no deductible 20% coinsurance; no deductible 20% coinsurance after deductible is met 20% coinsurance; no deductible 20% coinsurance after deductible is met
Home Healthcare
100 visits per calendar year		 $0 10% coinsurance after deductible is met 50% coinsurance after deductible is met $0 50% coinsurance after deductible is met
Hospice Care $250 10% coinsurance after deductible is met 50% coinsurance after deductible is met $250 + 10% coinsurance 50% coinsurance after deductible is met
Residential Treatment Facility $600 20% coinsurance after deductible is met 50% coinsurance after deductible is met $600 50% coinsurance after deductible is met

*Preventive Services — In accordance with the Affordable Care Act (ACA), includes age-appropriate care, screenings and standard immunizations. See the summary plan description for more detailed information on covered preventive services.