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Resource Center

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2017 Individual Applications

2017 Individual HMO Application | Spanish
2017 Individual PPO Application | Spanish

2017 Individual Brochures

2017 Individual Plans Overview

2017 Individual and Family HMO Plans

Bronze 6550 H.S.A. HMO | Spanish
Bronze 6850 HMO | Spanish

Silver 4500 HMO | Spanish

Gold 001 HMO | Spanish
Gold 1000 HMO | Spanish
Gold 2500 HMO | Spanish

2017 Individual and Family PPO Plans

Silver 2850 H.S.A. PPO | Spanish
Silver 4500 PPO | Spanish

2017 Small and Large Group Brochures

Large Group HMO Plan Overview
Large Group PPO Plan Overview

Small Group HMO Plan Overview
Small Group PPO Plan Overview

2017 Small Group Applications

Small Group HMO Employee Application | Spanish
Small Group HMO Employer Application

Small Group PPO Employee Application | Spanish
Small Group PPO Employer Application

2017 Large Group Applications

Large Group HMO Employee Application | Spanish
Large Group HMO Employer Application

Large Group PPO Employee Application | Spanish
Large Group PPO Employer Application

2017 Small Group HMO Plans

2017 HMO Select Bronze 6550 HSA | Spanish
2017 HMO Select Bronze 6850 | Spanish
2017 HMO Select Silver 002 | Spanish
2017 HMO Select Silver 3000 | Spanish
2017 HMO Select Silver 4000 HSA | Spanish
2017 HMO Select Gold 001 | Spanish
2017 HMO Select Gold 1500 | Spanish
2017 HMO Select Gold 2000 | Spanish

2017 Small Group PPO Plans

2017 PPO Select Bronze 5000 HSA | Spanish
2017 PPO Select Bronze 6550 HSA | Spanish
2017 PPO Select Bronze 6850 | Spanish
2017 PPO Select Silver 3000 | Spanish
2017 PPO Select Silver 4000 HSA | Spanish
2017 PPO Select Silver 4500 | Spanish
2017 PPO Select Silver 5000 | Spanish
2017 PPO Select Gold 1000 | Spanish
2017 PPO Select Gold 1500 | Spanish
2017 PPO Select Gold 2000 | Spanish
2017 PPO Select Gold 2000-3500 | Spanish
2017 PPO Select Gold Copay | Spanish
2017 PPO Select Platinum 500 | Spanish

2017 Large Group HMO Plans

2017 HMO Select 001 | Spanish
2017 HMO Select 002 | Spanish
2017 HMO Select 2000-100 | Spanish
2017 HMO Select 3000-100 HSA | Spanish
2017 HMO Select 3000-80 | Spanish
2017 HMO Select 5000-100 | Spanish
2017 HMO Select 6550-100 HSA | Spanish
2017 HMO Select 6600-100 Standard | Spanish

2017 Large Group PPO Plans

2017 PPO Select 002 | Spanish
2017 PPO Select 500-80 | Spanish
2017 PPO Select 1000-80 | Spanish
2017 PPO Select 1500-80 | Spanish
2017 PPO Select 2000-100 | Spanish
2017 PPO Select 2000-80 | Spanish
2017 PPO Select 2500-70 | Spanish
2017 PPO Select 2500-80 | Spanish
2017 PPO Select 3000-100 | Spanish
2017 PPO Select 3000-100 HSA | Spanish
2017 PPO Select 3000-80 | Spanish
2017 PPO Select 3000-80 HSA | Spanish
2017 PPO Select 5000-100 | Spanish
2017 PPO Select 5000-100 HSA | Spanish
2017 PPO Select 5000-70 | Spanish
2017 PPO Select 5000-80 HSA | Spanish
2017 PPO Select 6550-100 HSA | Spanish
2017 PPO Select 6600-100 Standard | Spanish
2017 PPO Select Standard Copay | Spanish

Additional Submission Forms

Late Submission Form
Deductible Credit Form

Employee Verification Form
Cobra and Medicare Survey
Group Data Submission Agreement

2016 Individual Brochures

2016 Individual Elect HMO Plan Overview
2016 Individual Elect PPO Plan Overview

2016 Individual and Family HMO Plans

Bronze 5000 H.S.A. HMO
Bronze 5500 H.S.A. HMO
Bronze 6850 HMO

Silver 2250 HMO
Silver 2500 HMO

Gold 001 HMO
Gold 2500 HMO

2016 Individual and Family PPO Plans

Bronze 5000 H.S.A. PPO
Bronze 5250 H.S.A. PPO
Bronze 6850 PPO

Silver 2600 H.S.A. PPO
Silver 3000 PPO
Silver 4000 PPO

Gold 1250 PPO
Gold 2000 PPO

Platinum 500 PPO

2016 Group Brochures

Large Group HMO Plan Overview
Large Group PPO Plan Overview

Small Group HMO Plan Overview
Small Group PPO Plan Overview

2016 Small Group Applications

Small Group HMO Employee Application

Small Group PPO Employee Application

2016 Large Group Applications

Large Group HMO Employee Application

Large Group PPO Employee Application

2016 Small Group HMO Plans

Select Bronze 6850 HMO
Select Silver 2500-100 HMO
Select Gold 001 HMO

2016 Small Group PPO Plans

Select Bronze 4000 HSA PPO
Select Bronze 5000 PPO
Select Bronze 5500 HSA PPO
Select Bronze 6850 PPO
Select Silver 2000 PPO
Select Silver 2500-5500 PPO
Select Silver 2600 HSA PPO
Select Silver 3000 HSA PPO
Select Silver 3000 PPO
Select Silver 3500 HSA PPO
Select Silver 4500 PPO
Select Silver 4500-100 PPO
Select Silver Copay PPO
Select Gold 1000 PPO
Select Gold 1500 PPO
Select Gold 2000-2500 PPO
Select Gold 2000-3500 PPO
Select Gold Copay PPO
Select Platinum 500 PPO

2016 Large Group HMO Plans

Select 001 HMO
Select 002 HMO
Select 2000-100 HMO
Select 3000-80 HMO
Select 3000-80 HSA HMO
Select 3000-100 HSA HMO
Select 5000-50 HMO
Select 5000-80 HSA HMO
Select 5000-100 HMO
Select 6550-100 HSA HMO
Select 6600-100 HMO

2016 Large Group PPO Plans

Select 250-80 PPO
Select 500-80 PPO

2015 Small Group HMO Plans

Select Bronze 5500 HSA HMO
Select Bronze 6450 HSA HMO
Select Gold 001 HMO
Select Gold 2000-100 HMO
Select Silver 2500-100 HMO

2015 Small Group PPO Plans

Select Bronze 3000 HSA PPO
Select Bronze 5000 PPO
Select Bronze 5250 PPO
Select Bronze 5500 HSA PPO
Select Bronze 6600 PPO
Select Gold 1000 PPO
Select Gold 1500 PPO
Select Gold 2000-2500 PPO
Select Gold 2000-3500 PPO
Select Gold Copay PPO
Select Platinum 500 PPO
Select Silver 2000 HSA PPO
Select Silver 2000 PPO
Select Silver 2500 HSA PPO
Select Silver 3000 HSA PPO
Select Silver 3000 PPO
Select Silver 4000 PPO
Select Silver Copay PPO

2015 Large Group HMO Plans

Select 001 HMO
Select 2000-100 HMO
Select 3000-80 HMO
Select 3000-80 HSA HMO
Select 3000-100 HSA HMO
Select 5000-80 HMO
Select 5000-80 HSA HMO
Select 5000-100 HMO
Select 6450-100 HSA HMO
Select 6600-100 Premier HMO
Select 6600-100 Standard HMO
Select Premier Copay HMO
Select Standard Copay HMO

2015 Large Group PPO Plans

Select 250-80 PPO
Select 500-80 PPO
Select 500-85 PPO
Select 1000-80 PPO
Select 1500-80 PPO
Select 1500-100 HSA PPO
Select 1500-100 PPO
Select 2000-80 PPO
Select 2000-100 HSA PPO
Select 2000-100 PPO
Select 2500-70 PPO
Select 2500-80 PPO
Select 3000-50 HSA PPO
Select 3000-80 HSA PPO
Select 3000-80 PPO
Select 3000-100 HSA PPO
Select 3000-100 PPO
Select 5000-50 HSA PPO
Select 5000-70 PPO
Select 5000-80 HSA PPO
Select 5000-80 PPO
Select 5000-100 HSA PPO
Select 5000-100 PPO
Select 6450-100 HSA PPO
Select 6600-100 Premier PPO
Select 6600-100 Standard PPO
Select Premier Copay PPO
Select Standard Copay PPO

Successful Returns©

Successful Returns Fact Sheet
Outcomes
Directions to the Facility

WorkLink©

WorkLink Fact Sheet
Quick Reference Guide
Providers Process Guide
Work Status Form
Pre-Authorization Form

Nonsubscribers

Texas Department of Insurance; Division of Workers' Compensation
Texas Association of Responsible Nonsubscribers (TXANS)
Overview of Nonsubscriber Programs
Nonsubscriber FAQ

Longshore

Department of Labor (DOL)
DOL Longshore First Report of Injury
DOL Division of Longshore & Harbor Workers' Compensation (DLHWC)
Longshore FAQ

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