BSW SeniorCare Advantage Premium (HMO)

H8142 - 006 - 0
5 out of 5 stars (5 / 5)

BSW SeniorCare Advantage Premium (HMO) is a Medicare Advantage (Part C) Plan by Baylor Scott & White Health Plan.

This page features plan details for 2023 BSW SeniorCare Advantage Premium (HMO) H8142 – 006 – 0 available in Central Texas.

IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:

Locations

BSW SeniorCare Advantage Premium (HMO) is offered in the following locations.

Plan Overview

BSW SeniorCare Advantage Premium (HMO) offers the following coverage and cost-sharing.

Insurer:Baylor Scott & White Health Plan
Health Plan Deductible:$0.00
MOOP:$4,500 In-network
Drugs Covered:No

Ready to sign up for BSW SeniorCare Advantage Premium (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans. 

BSW SeniorCare Advantage Premium (HMO) qualifies for a monthly Medicare Give Back Benefit of $50.00.

Premium Reduction:$50.00

Premium Breakdown

BSW SeniorCare Advantage Premium (HMO) has a monthly premium of $199.00. This amount includes your Part C premium but does not include your Part B premium.
Part B Part C Part B Give Back Total
$164.90 $199.00 $50.00 $313.90
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.

Additional Benefits

BSW SeniorCare Advantage Premium (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-Network: No

Dental (comprehensive)

Diagnostic services: $0 copay (limits may apply) (authorization not required) (referral not required)
Endodontics: 50% coinsurance (limits may apply) (authorization not required) (referral not required)
Extractions: 50% coinsurance (limits may apply) (authorization not required) (referral not required)
Non-routine services: Not covered (no limits)
Periodontics: 50% coinsurance (limits may apply) (authorization not required) (referral not required)
Prosthodontics, other oral/maxillofacial surgery, other services: 50% coinsurance (limits may apply) (authorization not required) (referral not required)
Restorative services: 50% coinsurance (limits may apply) (authorization not required) (referral not required)

Dental (preventive)

Cleaning: $0 copay (limits may apply) (authorization not required) (referral not required)
Dental x-ray(s): $0 copay (limits may apply) (authorization not required) (referral not required)
Fluoride treatment: Not covered (no limits)
Oral exam: $0 copay (limits may apply) (authorization not required) (referral not required)

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI): $0 copay (authorization required) (referral not required)
Diagnostic tests and procedures: $0 copay (authorization required) (referral not required)
Lab services: $0 copay (authorization required) (referral not required)
Outpatient x-rays: $0 copay (authorization required) (referral not required)

Doctor visits

Primary: $0 copay
Specialist: $0 copay (authorization not required) (referral not required)

Emergency care/Urgent care

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

Foot care (podiatry services)

Foot exams and treatment: $0 copay (authorization not required) (referral not required)
Routine foot care: Not covered

Ground ambulance

$40 copay

Health plan deductible

$0.00

Health plan deductibles (other)

In-Network: No

Hearing

Fitting/evaluation: $0 copay (no limits) (authorization not required) (referral not required)
Hearing aids: $0 copay (limits may apply) (authorization not required) (referral not required)
Hearing exam: $0 copay (authorization not required) (referral not required)

Hospital coverage (inpatient)

$100 per stay (authorization required) (referral not required)

Hospital coverage (outpatient)

$0 copay (authorization required) (referral not required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$4,500 In-network

Medical equipment/supplies

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

Medicare Part B drugs

Chemotherapy: 20% coinsurance (authorization required)
Other Part B drugs: 20% coinsurance (authorization required)

Mental health services

Inpatient hospital – psychiatric: $100 per stay (authorization required) (referral not required)
Outpatient group therapy visit: $0 copay (authorization not required) (referral not required)
Outpatient group therapy visit with a psychiatrist: $0 copay (authorization not required) (referral not required)
Outpatient individual therapy visit: $0 copay (authorization not required) (referral not required)
Outpatient individual therapy visit with a psychiatrist: $0 copay (authorization not required) (referral not required)

Optional supplemental benefits

No

Preventive care

$0 copay (authorization not required) (referral not required)

Rehabilitation services

Occupational therapy visit: $10 copay (authorization not required) (referral not required)
Physical therapy and speech and language therapy visit: $10 copay (authorization required) (referral not required)

Skilled Nursing Facility

$0 per day for days 1 through 20
$15 per day for days 21 through 100 (authorization required) (referral not required)

Transportation

$0 copay (limits may apply) (authorization not required) (referral not required)

Vision

Contact lenses: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass frames: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass lenses: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglasses (frames and lenses): $0 copay (limits may apply) (authorization not required) (referral not required)
Other: Not covered (no limits)
Routine eye exam: $0 copay (limits may apply) (authorization not required) (referral not required)
Upgrades: Not covered

Wellness programs (e.g., fitness, nursing hotline)

Covered (authorization not required) (referral not required)

Ready to sign up for BSW SeniorCare Advantage Premium (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

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