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Individual & Family Marketplace Plans

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Individual Health Plans For You and Your Family

Also known as Affordable Care Act (ACA) plans or health insurance exchange plans, Baylor Scott & White Health Plan offers you a range of Gold, Silver and Bronze Marketplace plans with different coverage levels, deductibles and benefits tailored to individuals and families.

All of our plans offer coverage for preventive care, telehealth, maternity and wellness programs. Pharmacy benefits are also included. And you'll have access to more than 25,000 in-network doctors and the renowned Baylor Scott & White Health system.

*If you don't live in one of the counties shown on the map or if you'd prefer to see additional options, click here.

Enroll

We're happy to help you find a plan that fits your health needs as well as your budget. We can also check to see if you're eligible for assistance with the Advance Premium Tax Credit or Cost Share Reduction program.

Visit our Direct Enrollment Portal to enroll, get a quote or compare plans.

Plan Details

Gold

Are you are looking for a health plan with no or low deductibles and/or copays? Then our Marketplace Gold Plans are for you.

For benefit comparisons, formulary information and plan documents, call us at 866.522.2515 or click below to view.

Silver

With our Marketplace Silver Plans, you will pay lower premiums than our Gold Plans. Your deductible may be as low as $0 and your copayments for doctor visits or medications may be as low as $5.

The costs and benefit levels of our Marketplace Silver Plans all depend on your income and how that compares to the Federal Poverty Level (FPL). If you qualify for one of our lower cost-sharing Silver Plans, you will have lower copays, lower deductibles and further assistance through tax credits. To see if you qualify for a subsidy, try this subsidy calculator.

For benefit comparison, formulary information and plan documents, call us at 866.522.2515 or click below to view.

Bronze

These are our most affordable Marketplace plans. With a Bronze Plan, you will pay lower premiums with slightly higher out-of-pocket costs.

Do you just want to be protected if the unexpected happens without paying large monthly premiums? Our Marketplace Bronze plans provide preventive care and limited options before you reach your deductible, but provide coverage when you need it. We also allow you to pair a Health Savings Account (HSA) with your Bronze Plan. See the HMO Bronze HSA Eligible Plan option for details.

For benefit comparisons, formulary information and plan documents, call us at 866.522.2515 or click below to view.

Important Plan Information

We know that health insurance can be confusing, and we want to make the process a little easier for you and your family. That's why we've gathered information on the topics listed below to help explain our payment policies and other important aspects of your Marketplace plan coverage.

Your plan provides no benefits for services you receive from out-of-network physicians or providers, with specific exceptions as described in your Evidence of Coverage and below:

  • You may have to use an out-of-network provider for emergency or out-of-area urgent care services.
  • If Baylor Scott & White Health Plan determines medically necessary care cannot be provided by any healthcare provider participating in the Baylor Scott & White Health Plan network, your PCP may refer you to an out-of-network provider.

If Baylor Scott & White Health Plan approves a referral for out-of-network services because no network physician or provider is available, or if you have received out-of-network emergency care, Baylor Scott & White Health Plan will, in most cases, resolve the out-of-network physician's or provider's bill so that you only have to pay any applicable in-network copayment, coinsurance and deductible amounts.

What is balance billing?

Good question! Here's what you need to know: a facility-based physician or other healthcare practitioner may not be included in your health benefit plan's provider network. The non-network facility-based physician or other healthcare practitioner may balance bill you for amounts not paid by the health benefit plan; and if you receive a balance bill, you should contact Baylor Scott & White Health Plan.

How can I protect myself from a bill?

  • For planned procedures, find out in advance whether your providers are contracted with Baylor Scott & White Health Plan. This is especially important in the case of facility-based providers, such as radiologists, anesthesiologists, pathologists and neonatologists.
    • NOTE: Even if a hospital is in our network, there may be doctors and laboratories providing services at that hospital who might not be.
  • Review your plan documents and/or call Baylor Scott & White Health Plan to make sure the services you will get are covered under your policy. If the services are not covered, you will have to pay the charges.
  • Shop around. TDI's rates.texashealthcarecosts.org lists average costs for common medical procedures in different regions of Texas. Websites such as NewChoicehealth.com and FairHealthConsumer.org can also help you estimate the prices of various procedures.

Do you need to file a medical claim directly to Baylor Scott & White Health Plan?

Did you pay for covered health services over the required copayment/coinsurance?

When seeking care from a provider in the Baylor Scott & White Health Plan network, we don't expect you to pay any more for covered health services beyond the required copayments/coinsurance. If you pay for covered health services in addition to the required copayment(s), you are entitled to reimbursement for such payment if:

  • You submit written proof of and claim for payment to Baylor Scott & White Health Plan
  • The written proof and claim for payment are acceptable to Baylor Scott & White Health Plan
  • Baylor Scott & White Health Plan receives the written proof and claim for payment within sixty (60) days of the date the benefits were received by you.
  • You have complied with the terms of the Evidence of Coverage

If you fail to submit written proof of and claim of payment within sixty (60) days, you may still be entitled to reimbursement provided you can document as soon as reasonably possible after the 60-day period good cause why the claim could not be filed within this time period.

Note: Reimbursement will not be allowed if a claim is made beyond one year from the date of service the covered health services were first acquired.

You can obtain forms for the submission of written proof of payment by contacting our Customer Service Department at 844.633.5325 for more information or open a copy of the claim form.

Once you fill out the claim form, mail it to:
Baylor Scott & White Health Plan
ATTN: Pay Me
1206 W. Campus Dr.
Temple, TX 76502

Do you need to file for reimbursement on a prescription pharmacy claim?

  • Complete this Member Reimbursement Form and mail in for consideration of coverage.
  • Enclose a copy of the pharmacy receipt with your claim submission.

Do you disagree with our resolution on your claim?

If you disagree with our resolution, you may appeal our decision. A provider who was not involved in the initial decision will review the appeal.

You may appeal our decision that a service is not medically necessary. A provider who was not involved in the initial decision will review the appeal.

If you are unable to make your monthly premium payment on time, you do have a grace period before losing coverage.

Members with tax credit:

If you are receiving a premium tax credit under the Affordable Care Act, you have a three-month grace period for paying premiums. If full payment of the premium is not made within the three-month grace period, then coverage will retroactively terminate on the last day of the first month of the three-month grace period.

Medical Claim Overview during Grace Period
  • Baylor Scott & White Health Plan coverage will remain in force and will continue to pay claims incurred during the second and third month of the grace period; however, any providers who file claims or who seek preauthorization for benefits to you or your covered dependents will be notified that you have lapsed in payment of premiums.
  • If you fail to pay your premium, Baylor Scott & White Health Plan will cancel your coverage retroactive to the last day of the first month of the grace period. Claims incurred during the first month of the grace period will be paid.
  • Baylor Scott & White Health Plan shall have no obligation to pay for any benefits provided to you or your dependents on or after the date of termination and you shall be liable to the provider for the cost of those benefits. Baylor Scott & White Health Plam will seek reimbursement from providers for claims incurred during the second and third month of the grace period.
Pharmacy Claim Overview during Grace Period
  • If you are in the first month grace period, Baylor Scott & White Health Plan will continue to pay your pharmacy claims.
  • If you are in your second or third month grace period Baylor Scott & White Health Plan will not pay pharmacy claims. You will be responsible for 100% of pharmacy costs during the second and third month of the grace period.
  • Once you pay back overdue premiums, at your request, Baylor Scott & White Health Plan will reimburse you for the covered expense according to the enrolled plan benefits.

Members without tax credit:

If you are not receiving a premium tax credit, you have a 31-day grace period for paying premiums. If full payment of the premium is not made within the 31-day grace period, then coverage will automatically terminate on the last day of the coverage period for which premiums have been paid.

A previously paid claim can be reversed by Baylor Scott & White Health Plan — this is a retroactive denial.

When Baylor Scott & White Health Plan retroactively denies a claim, you will be responsible for payment on the claim to the provider. To prevent retroactive denials, you can:

  1. Make sure you receive prior authorization on any service requiring it before getting care. Find out more by talking to your physician.
  2. Provide Baylor Scott & White Health Plan with updated information on any other health insurance you may have so we can coordinate payment with the other insurance company.
  3. Pay your premiums on time. Your monthly invoice lists the date payment is due. You can also set up automatic monthly premium payments.

If you have any questions, please contact Baylor Scott & White Health Plan Customer Service at 844.633.5325.

Do you think that you may have overpaid on your monthly premium invoice? If so, please let us know. Simply call Baylor Scott & White Health Plan Customer Service at 844.633.5325 and we'll assist you.

If we find that you are due a refund and you pay your monthly bill by check, we will mail you a refund check. You should receive it within 7-10 business days from the date the refund is approved.

If you are due a full refund, and pay your monthly bill by auto draft or electronic funds transfer (EFT) using a bank account or credit card, we will credit your account. If you are owed a partial refund payment, Baylor Scott & White Health Plan will mail you a refund check instead. In either case, you should receive a refund within 7-10 business days from the date the refund is approved.

Medically necessary care is healthcare resulting from an illness or injury, and, for some services, requires prior authorization by Baylor Scott & White Health Plan.

We require that certain medical services, care, or treatments be preauthorized before we will pay for all related covered health services. Prior authorization means that we review in advance and confirm that proposed services, care, or treatments are medically necessary. If you fail to get proper authorization on the services, care or treatment that require preauthorization, they will not be covered. You are responsible for ensuring that your doctor obtains prior authorization for any proposed services at least three (3) calendar days before you receive them.

A decision on a request for prior authorization for medical services will typically be made within 72 hours of us receiving the request for urgent cases or 15 days for non-urgent cases.

For a listing of services requiring prior authorization, please contact Customer Service at 844.633.5325. A paper copy is available upon request.

Note: This listing is subject to change.

Information about pharmacy benefit drug prior authorizations.

Inpatient or outpatient? This hospital or that one? Part of getting the right care is making sure you're in the right place, and that's what our Concurrent Review process is about.

When you are in the hospital, our Utilization Management (UM) staff of licensed nurses and medical doctors reviews information about your care that is provided by the hospital. We use this information to determine whether the inpatient setting is right for your condition and to make sure that you are in the hospital for the right length of time to treat your condition. If you are outside of the Baylor Scott & White Health Plan network, we also need to make sure that either your care is an emergency or that you could not have gotten your care within the network.

The drugs you need may not be listed on our formulary. If that is the case, you or your provider can submit a formulary exception request to get a coverage determination.

Requests can be submitted online, or by phone, fax or mail. For more info, visit us on our pharmacy information page.

The medication you seek an exception for will initially be reviewed by our pharmacy benefit manager, OptumRx.

Initial requests for formulary exception are reviewed within 24 hours for expedited requests and 72 hours for standard requests. To request an expedited review for emergency circumstances, indicate that you need an expedited or urgent review on the request form or verbally if initiating the request via phone. If the drug is denied, you have the right to an external review.

If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case to an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). We must follow the IRO's decision.

An IRO review may be requested by a member, member's representative, or prescribing provider by mailing, calling or faxing the request:

Note: The member or the member's legal guardian must sign the consent to release medical information to the IRO (included as part of IRO form).

The URA will comply with the Independent Review Organization's determination with respect to the medical necessity or appropriateness of healthcare items and services, and the experimental or investigational nature of healthcare items and services for an enrollee.

To request an expedited external review for exigent circumstance, indicate the request is for urgent care on the Request Form or verbally if initiating the request by phone.

For standard exception review of medical requests where request was denied, the timeframe for review is 72 hours from when we receive the request.

For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request.

An Explanation of Benefits (EOB) is a form that we will send you after you or a covered family member gets healthcare services. After receiving covered health services, an EOB will show you what was billed and what Baylor Scott & White Health Plan paid.

The EOB is one way Baylor Scott & White Health Plan helps keep you in the driver's seat.

Carefully read and review any EOB you receive. It provides a list of services that your medical provider or supplier claims to have provided to you. Simple errors can often be corrected by contacting the provider and/or health insurer's customer service department. However, if the EOB contains inaccuracies or discrepancies that cause you to question whether an honest claim for payment has been submitted, you should contact our Special Investigations Unit (SIU) to report this information

Note: This is not an actual EOB and may be different from the one you receive from us.

Access your EOB online

  • Go to the member portal
  • On the left-hand menu bar, select "Insurance and Billing"
  • Next select the Health Plan ("Baylor Scott & White Health Plan")
  • Next select "Claims"
  • On the 'Claims' page, insure that the date range includes the start date of the service of the EOB you're looking for
  • Click the Claim number of the EOB you're looking for
  • The EOB displays on a separate browser tab
  • The EOB can be printed or downloaded

Whether you have coverage through a parent or spouse, or you are on Medicare, we know we may not be your only health insurer. The coordination of benefits process is the way to determine the primary payor for an insurance claim when coverage by two or more health insurance plans are in effect at the time a medical claim is filed.

We'll send you a letter from time to time asking if you have any additional coverage, and it is important that you respond so that we can keep our information up to date. If we don't receive your response within 45 days and we believe you have secondary coverage, we may start rejecting your claims.

Have you recently added a second insurance plan? Fill out the other insurance survey form and mail it to:

Baylor Scott & White Health Plan
1206 W. Campus Drive
Temple, TX 76502

You can also call our Marketplace Customer Service number at 844.633.5325.

Pharmacy and Drugs

Drug lists

Preventive care medications

Under the Affordable Care Act, also known as the healthcare reform law, Baylor Scott & White Health Plan covers some preventive care medications at 100% without charging a copay, coinsurance or deductible. The following list of drugs and products require a prescription (including over-the-counter medications) and must be filled at a network pharmacy to be covered at no cost share.

Specialty Pharmacy Drug Program

The Specialty Pharmacy Drug Program offers the choice of two specialty care pharmacies to help manage and access specialty drugs.

Upcoming formulary changes

Pharmacy information

Pharmacy locations

Network locations

Find network pharmacies by using the Provider Directory and Pharmacy Locator.

Need more detailed pharmacy information?

Learn more about your prescription drug costs with the Prescription Drug Cost Calculator.

Additional Individual and Family Plan Options

Additional plan options, which you may currently have or have chosen in the past, are available in the following counties for 2023:

HMO and EPO Plans: Austin, Bastrop*, Bell, Bexar*, Blanco, Bosque, Brazos, Burleson, Burnet, Caldwell, Coke, Coleman, Collin, Comal*, Concho, Coryell, Crockett, Dallas, Denton, El Paso*, Ellis, Erath, Falls, Fayette, Freestone, Grimes, Hamilton, Hays*, Hill, Hood, Irion, Johnson, Kimble, Lampasas, Lee, Leon, Limestone, Llano, Mason, McCulloch, McLennan, Madison, Menard, Milam, Mills, Reagan, Robertson, Rockwall, Runnels, San Saba, Schleicher, Somervell, Sterling, Sutton, Tarrant, Tom Green, Travis, Walker*, Waller, Washington, and Williamson.

* EPO Plans not available in these counties.

HMO Plan Information, Monthly Premiums and Application

An HMO — Health Maintenance Organization — gives you a range of benefits for a prepaid monthly fee. The plan focuses on wellness, prevention and treatment within a network of providers. Out-of-network providers are usually not covered, unless in an emergency. Designated primary care physicians and referrals are not required for in-network care.

The HMO plan offers access to more than 14,000 in-network doctors and the renowned Baylor Scott & White Health system. Other physicians and providers are also available in our networks.

2023 Documents
2022 Documents

EPO Plan Information, Monthly Premiums and Application

The EPO — Exclusive Provider Organization — has a separate provider network. As a member of the EPO, you can use doctors and hospitals within the EPO network, but cannot go outside the network for care. There are no out-of-network benefits, except emergency and urgent care. Designated primary care physicians and referrals are not required for in-network care.

The EPO plan offers access to more than 14,000 in-network doctors and the renowned Baylor Scott & White Health system. Other physicians and providers are also available in our networks.

2023 Documents
2022 Documents

Questions?

Call us at 866.522.2515.

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