Who do you want to cover?

 
District contribution
Rates per pay period
Based on 24 pay periods
Plan limits
Annual deductible - individual/family
Annual out-of-pocket maximum
Your cost for covered servicesCoinsurance applies after you have paid your deductible
Preventive care exams *
Primary care (PCP)
Specialists
Inpatient - hospital
Outpatient - hospital
Outpatient - freestanding and surgical center
Emergency care
Non-emergency care in an emergency room
Urgent care facility
Lab, X-ray, diagnostic mammogram, diagnostic scans (MRI, MRA, CAT, PET) - outpatient hospital
Lab, X-ray, diagnostic mammogram, diagnostic scans (MRI, MRA, CAT, PET) - freestanding facility, independent lab
Maternity - delivery
Mental health & substance abuse - inpatient **
Mental health & substance abuse - outpatient **
Prescription
Annual pharmacy deductible
Annual out-of-pocket maximum
Prescription drugs - 30-day retail
Prescription drugs - 90-day mail or retail
1.21
2.10
1.21
2.10
2.17
3.54
2.17
3.54
1.57
2.64
1.57
2.64
3.07
4.89
3.07
4.89
1.73
2.88
1.73
2.88
3.47
5.49
3.47
5.49
2.53
4.08
2.53
4.08
5.47
8.49
5.47
8.49
3.41
5.40
3.41
5.40
7.67
11.79
7.67
11.79
4.93
7.68
4.93
7.68
11.47
17.49
11.47
17.49
5.41
8.40
5.41
8.40
12.67
19.29
12.67
19.29
10.21
15.60
10.21
15.60
24.67
37.29
24.67
37.29
20.01
30.30
20.01
30.30
49.17
74.04
49.17
74.04
District contribution
Rates per pay period
Based on 24 pay periods
Memorial Hermann ACO $93.26
Open Access Select $48.00
KelseyCare HMO $152.67
Plan limits
Annual deductible - individual/family
Memorial Hermann ACO

$2,500/$5,000

Open Access Select

$4,500/$9,000

KelseyCare HMO

$2,000/$5,500

Annual out-of-pocket maximum
Memorial Hermann ACO

$6,500/$13,000

Open Access Select

$7,100/$14,200

KelseyCare HMO

$6,400/$12,800

Your cost for covered services
Preventive care exams *
Memorial Hermann ACO

Free

Open Access Select

Free

KelseyCare HMO

Free

Primary care (PCP
Memorial Hermann ACO

$50

Open Access Select

0% for the first $225, then 30%​

KelseyCare HMO

$30

Specialists
Memorial Hermann ACO

$100

Open Access Select

0% for the first $225, then 30%

KelseyCare HMO

$60

Inpatient - hospital
Memorial Hermann ACO

20% 

Open Access Select

30% 

KelseyCare HMO

20% after $150 copay per day for first 5 days 

Outpatient - hospital
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20%

Outpatient - freestanding and surgical center
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20% after $150 copay

Emergency care
Memorial Hermann ACO

20% + $250 copay (waived if admitted)

Open Access Select

30% 

KelseyCare HMO

20% after $200 copay

Non-emergency care in an emergency room
Memorial Hermann ACO

40%

Open Access Select

50%

KelseyCare HMO

20% after $200 

Urgent care facility
Memorial Hermann ACO

$75

Open Access Select

30%

KelseyCare HMO

$50 

Lab, X-ray, diagnostic mammogram, diagnostic scans (MRI, MRA, CAT, PET) - outpatient hospital
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20%

Lab, X-ray, diagnostic mammogram, diagnostic scans (MRI, MRA, CAT, PET) - freestanding facility, independent lab
Memorial Hermann ACO

20%

Open Access Select

See office visit or 30% if in a facility

KelseyCare HMO

20%

Maternity - delivery
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20% after $150 copays per day for first 5 days 

Mental health & substance abuse - inpatient**
Memorial Hermann ACO

20% 

Open Access Select

30% 

KelseyCare HMO

20% after $150 copay per day for first 5 days 

Mental health & substance abuse - outpatient**
Memorial Hermann ACO

$50

Open Access Select

30% 

KelseyCare HMO

$30

District contribution
Rates per pay period
Based on 24 pay periods
Memorial Hermann ACO $429.82
Open Access Select $312.07
KelseyCare HMO $566.86
Plan limits
Annual deductible - individual/family
Memorial Hermann ACO

$2,500/$5,000

Open Access Select

$4,500/$9,000

KelseyCare HMO

$2,000/$5,500

Annual out-of-pocket maximum
Memorial Hermann ACO

$6,500/$13,000

Open Access Select

$7,100/$14,200

KelseyCare HMO

$6,400/$12,800

Your cost for covered services
Preventive care exams *
Memorial Hermann ACO

Free

Open Access Select

Free

KelseyCare HMO

Free

Primary care (PCP
Memorial Hermann ACO

$50

Open Access Select

0% for the first $225, then 30%​

KelseyCare HMO

$30

Specialists
Memorial Hermann ACO

$100

Open Access Select

0% for the first $225, then 30%

KelseyCare HMO

$60

Inpatient - hospital
Memorial Hermann ACO

20% 

Open Access Select

30% 

KelseyCare HMO

20% after $150 copay per day for first 5 days 

Outpatient - hospital
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20%

Outpatient - freestanding and surgical center
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20% after $150 copay

Emergency care
Memorial Hermann ACO

20% + $250 copay (waived if admitted)

Open Access Select

30% 

KelseyCare HMO

20% after $200 copay

Non-emergency care in an emergency room
Memorial Hermann ACO

40%

Open Access Select

50%

KelseyCare HMO

20% after $200 

Urgent care facility
Memorial Hermann ACO

$75

Open Access Select

30%

KelseyCare HMO

$50 

Lab, X-ray, diagnostic mammogram, diagnostic scans (MRI, MRA, CAT, PET) - outpatient hospital
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20%

Lab, X-ray, diagnostic mammogram, diagnostic scans (MRI, MRA, CAT, PET) - freestanding facility, independent lab
Memorial Hermann ACO

20%

Open Access Select

See office visit or 30% if in a facility

KelseyCare HMO

20%

Maternity - delivery
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20% after $150 copays per day for first 5 days 

Mental health & substance abuse - inpatient**
Memorial Hermann ACO

20% 

Open Access Select

30% 

KelseyCare HMO

20% after $150 copay per day for first 5 days 

Mental health & substance abuse - outpatient**
Memorial Hermann ACO

$50

Open Access Select

30% 

KelseyCare HMO

$30

District contribution
Rates per pay period
Based on 24 pay periods
Memorial Hermann ACO $307.56
Open Access Select $205.08
KelseyCare HMO $416.43
Plan limits
Annual deductible - individual/family
Memorial Hermann ACO

$2,500/$5,000

Open Access Select

$4,500/$9,000

KelseyCare HMO

$2,000/$5,500

Annual out-of-pocket maximum
Memorial Hermann ACO

$6,500/$13,000

Open Access Select

$7,100/$14,200

KelseyCare HMO

$6,400/$12,800

Your cost for covered services
Preventive care exams *
Memorial Hermann ACO

Free

Open Access Select

Free

KelseyCare HMO

Free

Primary care (PCP
Memorial Hermann ACO

$50

Open Access Select

0% for the first $225, then 30%​

KelseyCare HMO

$30

Specialists
Memorial Hermann ACO

$100

Open Access Select

0% for the first $225, then 30%

KelseyCare HMO

$60

Inpatient - hospital
Memorial Hermann ACO

20% 

Open Access Select

30% 

KelseyCare HMO

20% after $150 copay per day for first 5 days 

Outpatient - hospital
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20%

Outpatient - freestanding and surgical center
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20% after $150 copay

Emergency care
Memorial Hermann ACO

20% + $250 copay (waived if admitted)

Open Access Select

30% 

KelseyCare HMO

20% after $200 copay

Non-emergency care in an emergency room
Memorial Hermann ACO

40%

Open Access Select

50%

KelseyCare HMO

20% after $200 

Urgent care facility
Memorial Hermann ACO

$75

Open Access Select

30%

KelseyCare HMO

$50 

Lab, X-ray, diagnostic mammogram, diagnostic scans (MRI, MRA, CAT, PET) - outpatient hospital
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20%

Lab, X-ray, diagnostic mammogram, diagnostic scans (MRI, MRA, CAT, PET) - freestanding facility, independent lab
Memorial Hermann ACO

20%

Open Access Select

See office visit or 30% if in a facility

KelseyCare HMO

20%

Maternity - delivery
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20% after $150 copays per day for first 5 days 

Mental health & substance abuse - inpatient**
Memorial Hermann ACO

20% 

Open Access Select

30% 

KelseyCare HMO

20% after $150 copay per day for first 5 days 

Mental health & substance abuse - outpatient**
Memorial Hermann ACO

$50

Open Access Select

30% 

KelseyCare HMO

$30

District contribution
Rates per pay period
Based on 24 pay periods
Memorial Hermann ACO $400.72
Open Access Select $266.24
KelseyCare HMO $531.06
Plan limits
Annual deductible - individual/family
Memorial Hermann ACO

$2,500/$5,000

Open Access Select

$4,500/$9,000

KelseyCare HMO

$2,000/$5,500

Annual out-of-pocket maximum
Memorial Hermann ACO

$6,500/$13,000

Open Access Select

$7,100/$14,200

KelseyCare HMO

$6,400/$12,800

Your cost for covered services
Preventive care exams *
Memorial Hermann ACO

Free

Open Access Select

Free

KelseyCare HMO

Free

Primary care (PCP
Memorial Hermann ACO

$50

Open Access Select

0% for the first $225, then 30%​

KelseyCare HMO

$30

Specialists
Memorial Hermann ACO

$100

Open Access Select

0% for the first $225, then 30%

KelseyCare HMO

$60

Inpatient - hospital
Memorial Hermann ACO

20% 

Open Access Select

30% 

KelseyCare HMO

20% after $150 copay per day for first 5 days 

Outpatient - hospital
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20%

Outpatient - freestanding and surgical center
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20% after $150 copay

Emergency care
Memorial Hermann ACO

20% + $250 copay (waived if admitted)

Open Access Select

30% 

KelseyCare HMO

20% after $200 copay

Non-emergency care in an emergency room
Memorial Hermann ACO

40%

Open Access Select

50%

KelseyCare HMO

20% after $200 

Urgent care facility
Memorial Hermann ACO

$75

Open Access Select

30%

KelseyCare HMO

$50 

Lab, X-ray, diagnostic mammogram, diagnostic scans (MRI, MRA, CAT, PET) - outpatient hospital
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20%

Lab, X-ray, diagnostic mammogram, diagnostic scans (MRI, MRA, CAT, PET) - freestanding facility, independent lab
Memorial Hermann ACO

20%

Open Access Select

See office visit or 30% if in a facility

KelseyCare HMO

20%

Maternity - delivery
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20% after $150 copays per day for first 5 days 

Mental health & substance abuse - inpatient**
Memorial Hermann ACO

20% 

Open Access Select

30% 

KelseyCare HMO

20% after $150 copay per day for first 5 days 

Mental health & substance abuse - outpatient**
Memorial Hermann ACO

$50

Open Access Select

30% 

KelseyCare HMO

$30

District contribution
Rates per pay period
Based on 24 pay periods
Memorial Hermann ACO $760.21
Open Access Select $484.30
KelseyCare HMO $973.37
Plan limits
Annual deductible - individual/family
Memorial Hermann ACO

$2,500/$5,000

Open Access Select

$4,500/$9,000

KelseyCare HMO

$2,000/$5,500

Annual out-of-pocket maximum
Memorial Hermann ACO

$6,500/$13,000

Open Access Select

$7,100/$14,200

KelseyCare HMO

$6,400/$12,800

Your cost for covered services
Preventive care exams *
Memorial Hermann ACO

Free

Open Access Select

Free

KelseyCare HMO

Free

Primary care (PCP
Memorial Hermann ACO

$50

Open Access Select

0% for the first $225, then 30%​

KelseyCare HMO

$30

Specialists
Memorial Hermann ACO

$100

Open Access Select

0% for the first $225, then 30%

KelseyCare HMO

$60

Inpatient - hospital
Memorial Hermann ACO

20% 

Open Access Select

30% 

KelseyCare HMO

20% after $150 copay per day for first 5 days 

Outpatient - hospital
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20%

Outpatient - freestanding and surgical center
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20% after $150 copay

Emergency care
Memorial Hermann ACO

20% + $250 copay (waived if admitted)

Open Access Select

30% 

KelseyCare HMO

20% after $200 copay

Non-emergency care in an emergency room
Memorial Hermann ACO

40%

Open Access Select

50%

KelseyCare HMO

20% after $200 

Urgent care facility
Memorial Hermann ACO

$75

Open Access Select

30%

KelseyCare HMO

$50 

Lab, X-ray, diagnostic mammogram, diagnostic scans (MRI, MRA, CAT, PET) - outpatient hospital
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20%

Lab, X-ray, diagnostic mammogram, diagnostic scans (MRI, MRA, CAT, PET) - freestanding facility, independent lab
Memorial Hermann ACO

20%

Open Access Select

See office visit or 30% if in a facility

KelseyCare HMO

20%

Maternity - delivery
Memorial Hermann ACO

20%

Open Access Select

30%

KelseyCare HMO

20% after $150 copays per day for first 5 days 

Mental health & substance abuse - inpatient**
Memorial Hermann ACO

20% 

Open Access Select

30% 

KelseyCare HMO

20% after $150 copay per day for first 5 days 

Mental health & substance abuse - outpatient**
Memorial Hermann ACO

$50

Open Access Select

30% 

KelseyCare HMO

$30

For any benefits question or concern, including 24/7 Nurse Line access, one call does it all.
Call us at 866-284-AISD (2473)