| If your annual base salary is: $75,000 or less |
If your annual base salary is: more than $75,000 |
|||
|---|---|---|---|---|
| Employee-Only Coverage | Other Coverage Levels | Employee-Only Coverage | Other Coverage Levels | |
| BMC Flat Seed | $200 in January and July for a total of $400 | $0 | $0 | |
| BMC matches your contributions1 | Up to $350 | Up to $1,100 | Up to $500 | Up to $1,000 |
| BMC will match your HSA contributions each pay period in 2022. | ||||
| Your contribution limit | Up to $3,400 | Up to $6,800 | Up to $3,650 | Up to $7,300 |
| Total 2024 Contribution2 allowed by the IRS (yours and BMC's) |
$4,150 | $8,300 | $4,150 | $8,300 |
IN-NETWORK |
OUT-OF-NETWORK |
|
|---|---|---|
| Annual Deductible | $1,850 single/$3,700 all other coverage levels | $3,700 single/$7,400 all other coverage levels |
| Annual Out-of-Pocket Maximum (includes deductible and copays) | $3,700 single / $7,400 all other coverage levels | $7,400 single / $14,800 all other coverage levels (excludes amounts above usual and customary) |
| Lifetime Maximum Benefit | Unlimited | Unlimited |
| General Medical Expenses | ||
| Primary & Specialist Doctor Office Visit (includes maternity care) | 85% covered after deductible | 65% covered after deductible |
| MDLIVE Physician3 | $44 | Not applicable |
| Inpatient Hospital Care (requires preauthorization) | ||
| Hospitalization4 | 85% covered after deductible | 65% covered after deductible |
| Inpatient Physician and Surgeon Services4 | 85% covered after deductible | 65% covered after deductible |
| Inpatient Lab and X-ray5 | 85% covered after deductible | 65% covered after deductible |
| Maternity and Delivery Services & Newborn Nursery Services6 | 85% covered after deductible | 65% covered after deductible |
| Outpatient Care | ||
| Outpatient Surgery | 85% covered after deductible | 65% covered after deductible |
| Outpatient Laboratory Services & X-ray Services5 | 85% covered after deductible | 65% covered after deductible |
| Preventive Care | ||
| Annual Physical Exam & Immunizations | 100% covered per exam (no deductible applies) | 65% covered after deductible |
| Well-Baby & Well-Child Exams and Immunizations | 100% covered per exam (no deductible applies) | 65% covered after deductible |
| Well-Woman Exam | 100% covered per exam (no deductible applies) | 65% covered after deductible |
| Other Preventive Care & Cancer Screenings7 | 100% covered per exam (no deductible applies) | 65% covered after deductible |
| Emergency Services | ||
| Hospital Emergency Facility | 85% covered after deductible | 85% covered after deductible |
| Non-Emergency Care in a Hospital Emergency Room | Not covered | Not covered |
| Urgent Medical Care (at a non-hospital free standing facility) | 85% covered after deductible | 85% covered after deductible |
| Chiropractic Services | ||
| Spinal Manipulation | 85% covered after deductible Maximum of 25 visits each calendar year (in-and out-of-network services combined) |
65% covered after deductible Maximum of 25 visits each calendar year (in-and out-of-network services combined) |
| Short-Term Rehabilitation Therapy 8 | ||
| Outpatient Physical, Speech, Occupational Therapy | 85% covered after deductible; 60-visit combined maximum per year |
65% covered after deductible; 60-visit combined maximum per year |
| Mental Health, Substance Abuse Care | ||
| Mental Health: Inpatient & Outpatient Coverage | 85% covered after deductible | 65% covered after deductible |
| Rehab and Detox: Inpatient & Outpatient Coverage | 85% covered after deductible | 65% covered after deductible |
| Residential Treatment Facility (stays in a residential treatment facility for treatment of mental disorders, alcoholism or drug abuse) | 85% covered after deductible | 65% covered after deductible |
| MDLIVE® Behavioral Therapy | $80 to $175 per consultation before deducible depending on provider selected; 85% covered after deductible | Not applicable |
| Other Benefits | ||
| Condition Management | BCBSTX Condition Management programs offer support for people diagnosed with chronic conditions such as asthma, diabetes, heart problems and others. | |
| Prescription Drugs | Prescription Drugs are covered through Prime Therapeutics, an affiliate of BCBSTX. | |
| Health Savings Account | You will have a Health Savings Account opened for you through Fidelity. BMC deposits employer contributions, and you may choose to deposit your own contributions into this account. | |