Texas Children's Health Plan

Individual Child Only Health Insurance

(936) 321-6286

Summary of Benefits	Copayment
Preventive Care Includes routine physical exams; well-child care; immunizations; and vision and hearing screenings	NO Copayment
Physician services (PCP and specialist) Outpatient (Office Visits) Inpatient (Hospital)	$25 per visit No Copayment
Routine Diagnostic Services Laboratory tests and x-rays	NO Copayment
Prescription Drugs Retail pharmacy, 30-day supply Mail order, 90-day supply	$10 generic; $25 brand per Rx $20 generic; $50 brand per RX
Hospital - inpatient All services (Physicians and hospital)	$250 per day; ($1,000 maximum per admission)
Hospital - outpatient Ultrasound, non-routine laborabory tests, therapeutic radiation treatment, inhalation therapy Surgery MRI and CT Diagnostic Services	$25 per visit $100 per visit $100 per visit
Emergency Room	$125 per visit
Urgent care center or facility	$75 per visit
Behavioral Health - inpatient* Includes residential service or other 24-hour therapeutically structured service. Covers up to 45 inpatient days, and 60 days of day treatment. A conversion is possible based on financial equivalence. * $20,000 lifetime maximum for behavioral health inpatient and outpatient combined	$250 per day; ($1,000 maximum per admission)
Behavioral Health - outpatient* Limited to 20 outpatient visits per contract year *$20,000 lifetime maximum for behavioral health inpatient and outpatient combined	$25 per visit
Rehabilitation Including occupational, physical, and speech therapy	$25 per visit
Kidney Dialysis Includes outpatient hospital kidney dialysis center and home dialysis services	$25 per visit
Ambulance Services	$250 per transport; waived if patient is admitted
Home health care includes skilled nursing; physical, occupational, speech or respiratory therapy; home health aide under the supervision of a RN; and medical equipment and supplies	$25 per visit
Diabetic services Blood glucose monitors, insulin pumps, insulin infusion device, podiatric appliances, test strips, visual reading and urine test strips, lancets and lancet devices, insulin and insulin analog, syringes, infections aides, oral agents for controlling blood sugar, glucagon emergency kits, and educational programs	NO Copayment
Durable medical equipment Rental or purchase of durable equipment, and internal and external prosthetic applliances	NO Copayment ($500 maximum per contract year)
Organ Transplant Services	Same as inpatient or outpatient services

Maximum Copayment for covered benefits shall not exceed $1,500/individual/yr.

Premium Rates

$129 Per month (2 years to 18 years of age)
$199 Per month (12 months to 23 months of age)
$247 Per month (32 days to 11 months of age)

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