Texas Medical Neighborhood Plan Explained

Texas Medical Neighborhood Plan Explained from HISD Benefits on Vimeo.

There are two Texas Medical Neighborhood plan options

The Basic plan offers lower premiums than the Plus option but has higher deductible and coinsurance amounts. This means you will pay more when you need health care. If you do not visit the doctor often and use the plan mostly for preventive care, the Basic option may be right for you.

The Plus plan has higher premiums than the Basic plan, and the deductible and coinsurance amounts are lower. This means more of your expenses will be covered when you need care. If you think you will visit the doctor often and need more care, the Plus option may be right for you. When you enroll in the plan, you are required to select a Primary Care Physician from the Texas Medical Neighborhood Network. If you do not select a Primary Care Physician, one will be assigned to you based on your zip code. Your primary care doctor will provide routine and preventive care, and help you find the right network specialists when you need one. However, specialist referrals are not necessary if you want to see a specialist.

Important: The Texas Medical Neighborhood Network plan pays benefits ONLY when you receive care from network providers. If you seek care outside the network, you will pay the full cost of care out of your own pocket.

Both plans include prescription drug benefits administered by Express Scripts. You must meet a separate prescription drug deductible each year and then pay the appropriate copay for your prescriptions.

The Texas Medical Neighborhood Network

The Texas Medical Neighborhood Network is a broad network that includes most Aetna contracted providers in Houston and the surrounding areas. There are 20 specialist categories that are tiered. Those that are listed as “Maximum Savings” are considered Tier 1 providers, which means the plan will pay a higher coinsurance amount for these providers once the deductible is met. Those that are listed as “Standard Savings” are considered Tier 2 providers, which means the plan will pay a lower coinsurance amount for those providers once the deductible is met.

2023 Coverage Cost Comparison

For additional information, view The 2023 Benefits Guide.

1. Kelsey ACO PCP and specialist copays do not count toward the annual deductible but do apply toward the annual out-of-pocket maximum.
2. Free if you are enrolled in an HISD medical plan
3. Pre-certification may be required
4. OBGYN specialists are tiered.
5. Copay applies after the pharmacy deductible.
6. Preventive services are not subject to the deductible
7. The copays in the Kelsey plans are not subject to deductible

* If a footnote is not shown on this chart, it does not apply to this plan option.

How to Find a Provider

How to Find an In-Network Provider in the Texas Medical Neighborhood Plan from HISD Benefits on Vimeo.

To find a Texas Medical Neighborhood provider, click here >  

• This network has cost-effective and high-quality providers through care coordinated by a primary care physician (PCP).
• PCP Election Required – if you don’t select one, a PCP will be assigned to you and any covered dependents based on your zip code.
• No specialist referrals are needed but your PCP can help you coordinate your care, including any specialist visits.

Texas Medical Neighborhood Resource Guide
Benefits has created a Texas Medical Neighborhood Plan resource guide with important information about your plan.
Click here to view the guide.

There are currently 20 specialties subject to tiering in the Texas Medical Neighborhood Network plan. You will receive the maximum savings when you select a Tier 1 specialist. You will receive the standard savings (higher coinsurance) when you select a Tier 2 specialist.

Tiered specialties are:

• Allergy/Immunology
• Cardiology
• Cardiothoracic Surgery
• Dermatology
• Endocrinology
• Gastroenterology
• Infectious Disease
• Nephrology
• Neurology
• Neurosurgery
• Obstetrics/Gynecology
• Ophthalmology
• Orthopedics
• Otolaryngology
• Plastic Surgery
• Pulmonary/Critical Care
• Rheumatology
• Surgery
• Urology
• Vascular Surgery