This Versus That: Health Care Edition

The Pulse, May 2023 Edition

When it comes to your TRS-ActiveCare plan, you have many options. It starts with choosing either a high deductible plan or physician-directed plan during annual enrollment.

Once you enroll in your plan and need to go to the doctor, is the hospital or provider in-network? And how do you know if the care you need is diagnostic or preventive? And finally, knowing where to go for care when you need it is very important.

We're here to help you with these questions!

High Deductible Plan Versus Physician-Directed Plan

With TRS-ActiveCare, you can choose between one high deductible plan and two physician-directed plans.

To figure out which health plan is best for you and your family, we've highlighted plan features to show you what you can expect.

Physician-Directed Plans: TRS-ActiveCare Primary and TRS-ActiveCare Primary+

These physician-directed plans have a broad statewide network with no regional boundaries. You choose a Primary Care Provider (PCP) to coordinate your care. Other plan features include:

copays for doctor visits and generic drugs before you meet your deductible
no charge for diagnostic labs at your doctor's office or an independent lab
$0 preventive care
$0 option for TRS virtual health visits
specialist visits require a referral from your PCP

High Deductible (HD) Plan: TRS-ActiveCare HD

The high deductible plan has a nationwide network with lower premiums. It works with a health savings account (HSA) and has out-of-network coverage. Other plan features include:

no PCP required, but recommended
no referrals for specialist visits
$0 preventive care
you must meet your deductible before the plan starts to pay

In-Network Facility Versus Out-of-Network Provider

When you get services from an in-network facility, some providers in the facility may still be out-of-network. In these cases, the providers can bill only your plan's in-network cost-sharing amount. This applies to:

emergency medicine
anesthesia
pathology
radiology
laboratory
neonatology
assistant surgeon
hospitalist
intensivist services

So, if you get treated by an out-of-network provider at an in-network facility, your plan protects you from surprise billing or balance billing.

What is balance billing or surprise billing?

Balance billing is when out-of-network providers bill you for the difference between what your plan agreed to pay, and the full amount the out-of-network provider charges for a service.

This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

Surprise billing is an unexpected balance bill. This can happen when you can't control who gives you care.

For example, you have an emergency or schedule a visit at an in-network facility but get unexpected treatment from an out-of-network provider.

Learn more about balance (surprise) billing.

Diagnostic Care Versus Preventive Care

Knowing the difference between preventive care and diagnostic care can help you get the right care at the right time — and save you money.

Preventive care includes recommended annual vaccinations, wellness exams, and routine screenings and tests. It focuses on keeping you healthy and preventing illness and disease.

Your TRS-ActiveCare plan covers preventive care visits at 100%.

Diagnostic care focuses on diagnosing and treating chronic conditions or other health concerns.

It includes things like monitoring symptoms and ongoing pain management. Talking with your doctor about symptoms of a new or existing condition can also be diagnostic care.

Examples of Preventive and Diagnostic Care

Preventive Care	Diagnostic Care
Mammogram according to breast cancer screening recommendations	Follow-up mammogram after finding a lump
Colonoscopy according to current recommendations	Colon cancer screening after symptoms develop
Diabetes screening during annual exam	Follow-up screenings and care after a diabetes diagnosis

Learn more about covered preventive services.

Go Here, Not There

Knowing where to go for the right kind of care can save you time and money. Remember, if you have a life-threatening emergency, go to the nearest hospital or call 911.

Non-Emergency Care

Virtual Health —get 24/7 non-emergency care on the phone from a board-certified doctor for:

allergies
cold, fever
stomach problems

Primary Care Provider (PCP) — schedule an appointment with your PCP for:

minor injury or illness
no-cost annual wellness exams
no-cost routine screening

Retail walk-in clinic — found in stores and pharmacies, these clinics offer low-cost quality care without an appointment for:

cold, flu, fever
infections
sore or strep throat

Urgent carecenter – when you need immediate attention that isn't an emergency, go here for:

cuts that need stitches
minor burns
sprains

Life-Threatening Conditions

Emergency Room (ER) – If you think your life is in danger, immediately go to the nearest ER or call 911. ERs are for:

chest pain
heart attack
heavy bleeding
stroke
sudden or severe pain
trouble breathing
any condition you feel puts your life at risk

Avoid Freestanding ERs

Freestanding ERs look like urgent care centers. But they can cost you hundreds or even thousands more. They may also need to transfer you to a real ER, increasing your costs and delaying your care. Beware! Freestanding ERs:

look like urgent care centers but include “EMERGENCY" or “ER" in the name
are usually open 24/7 (urgent care centers typically close at night)
are not connected to a hospital (and therefore cannot admit you to a hospital if needed)

Your care will always cost less if you stay in network. You can find in-network facilities via Provider Finder®.

Learn more about where to go for care.

If you have questions, connect with a Personal Health Guide 24 hours a day, seven days a week. Call 1-866-355-5999 or chat through the BCBSTX App.

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