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Health Coverage for You and Your Family. PPO Plan Overview ActiveCare 1-HD, 2 and 3 Plans 2013-2014 Plan Year.

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Presentation on theme: "Health Coverage for You and Your Family. PPO Plan Overview ActiveCare 1-HD, 2 and 3 Plans 2013-2014 Plan Year."— Presentation transcript:

1 Health Coverage for You and Your Family

2 PPO Plan Overview ActiveCare 1-HD, 2 and 3 Plans 2013-2014 Plan Year

3 New Deductible and Out-of-Pocket Maximum for ActiveCare 1-HD 3 ActiveCare 1-HD meets IRS definition of a high deductible health plan for all coverage tiers May contribute pretax dollars into a health savings account (HSA) to help pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis Individuals can establish an HSA with banks and credit unions 2012-2013 Plan Year2013-2014 Plan Year AC1AC1-HD Deductible (employee only/family) $1,200/$3,000$2,400/$2,400$2,400/$4,800 Out-of-Pocket Maximum (employee only/family; does not include deductibles) $2,000/$6,000$3,000/$5,000$3,850/$4,200

4 New Deductible and Out-of-Pocket Maximum for ActiveCare 2 4 2012-2013 Plan Year2013-2014 Plan Year ActiveCare 2 Deductible (individual/family) $750/$2,250$1,000/$3,000 Out-of-Pocket Maximum (individual/family; does not include deductibles) $2,000/$6,000$4,000/$8,000

5 Family Deductible Illustration Amy covers spouse and three dependents 5 $4,800 $1,000$800 $400 AmySue Chris TedBob Sue ActiveCare 1-HD with $4,800 family deductible The family deductible may be met by one or more people Plan pays benefits once entire $4,800 is met ̶ there is no individual deductible to meet ActiveCare 2 with a $1,000 individual deductible and a $3,000 family deductible Plan pays benefits for an individual as his/her deductible is met Everyone helps to meet the family deductible, but no one person pays more than the individual amount Bob $600 Amy Ted $200 Chris

6 Out-of-Pocket (OOP) Maximum Illustration Amy covers spouse and three dependents 6 $4,200 $4,000$2,000 $600 AmySue Chris TedBob Sue ActiveCare 1-HD with $4,200 family OOP maximum The family out-of-pocket maximum may be met by one or more people Plan pays benefits once entire $4,200 is met ̶ there is no individual amount to meet ActiveCare 2 with a $4,000 individual and $8,000 family OOP maximum Plan pays benefits for an individual as his/her OOP maximum is met Everyone helps to meet the family OOP maximum, but no one person pays more than the individual amount Bob $1,000 Amy Ted $400 Chris

7 PPO Network for ActiveCare 1-HD, 2 and 3 7 Non-Network: You pay more of the cost of out-of-network benefits –Higher deductibles, coinsurance You may need to file your own claim You could be balance billed for amounts over allowed amount Always verify provider network status Network Statewide (all 254 counties) No need to : –Select a Primary Care Physician –Obtain referrals for specialist care Receive highest level of benefits: –Pay less for care –No balance billing No claim forms –Provider files claim for you

8 PPO Plan Overview (Network Level of Benefits) 8 ActiveCare 1-HDActiveCare 2ActiveCare 3 Deductible $2,400 employee only $4,800 family $1,000 individual $3,000 family $300 individual $900 family Out-of-Pocket Maximum (does not include copays or deductibles) $3,850 employee only $4,200 family $4,000 individual $8,000 family $1,000 per individual Coinsurance (Plan pays/ participant pays) 80% / 20% Office Visit Copay20% after deductible $30 for primary $50 for specialist $20 for primary $30 for specialist Primary means care provided by family practitioners, internists, OB/GYNs and pediatricians. All other physicians are specialists.

9 PPO Plan Overview (Network Level of Benefits) 9 Preventive Care Clarification ServicesActiveCare 1-HDActiveCare 2ActiveCare 3 Preventive Care Plan pays 100% (deductible waived) Plan pays 100% (no copay required) Routine eye exam (one per plan year) Hearing exam 20% after deductible $30 for primary $50 for specialist $20 for primary $30 for specialist 100% coverage for certain age- and gender-specific preventive care services when network providers are used Must be billed by provider as “preventive care”

10 PPO Plan Overview (Network Level of Benefits) 10 Benefits (continued) ServicesActiveCare 1-HDActiveCare 2ActiveCare 3 High-tech Radiology (CT scan, MRI, nuclear medicine) 20% after deductible $100 copay per service, plus 20% after deductible Inpatient Hospital20% after deductible $150 copay per day, plus 20% after deductible ($750 max copay per admission; $2,250 max/year) $150 copay per day, plus 20% after deductible ($750 max copay per admission; $2,250 max/year) Emergency Room20% after deductible $150 copay, plus 20% after deductible (copay waived if admitted) $150 copay, plus 20% after deductible (copay waived if admitted) Outpatient Surgery20% after deductible $150 copay per visit, plus 20% after deductible

11 11 New!! Effective Sept. 1, 2013 MRIs CAT or CT Scans Endoscopy procedures Colonoscopy procedures Back or spinal surgery Knee surgery Shoulder surgery Hip or joint replacement surgery Bariatric surgery Benefits Value Advisor Real-time access to current cost and quality transparency Appointment scheduling Clinical decision support tools Understanding benefits and how to best use them Referrals to condition management programs Preauthorization coordination Help get benefits information and find network providers for: One-Call Solution: 1-866-355-5999 Customer Service

12 Prescription Drugs ActiveCare 1-HD, 2 & 3 2013-2014 Plan Year

13 Your Prescription Drug Plan 13 Express Scripts administers your prescription drug plans on behalf of TRS –ActiveCare 1-HD, 2, and 3 plans Benefit includes both a retail and mail component Express Scripts has its own mail-order pharmacy where specialist pharmacists focus on compliance and lower cost options for the patient, and the automated filling system ensures the prescription is filled accurately.* Express Scripts buys medication from the most reputable suppliers *Express Scripts’ mail-order pharmacies fill about 2 million prescriptions per week through a highly automated process that is 99.9997% accurate and is 23 times more accurate than a retail pharmacy “Dispensing Error Rate in a Highly Automated Mail-Service Pharmacy Practice”; Nov. 2007, Pharmacology, a peer-reviewed journal of the American College of Clinical Pharmacy

14 Prescription Drug Benefits – Network Level 14 * If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug. Chart illustrates benefits when network pharmacies are used. Non-network benefits are also available; see Enrollment Guide for more information. FeaturesActiveCare 1-HDActiveCare 2ActiveCare 3 Drug Deductible (per person, per plan year) Subject to plan year deductible $0 generic; $200 brand $75 Retail Short-Term (up to 31-day supply) Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) 20% coinsurance after deductible $20 $40* $65* $15 $35* $60* Retail Maintenance (after first fill, up to 31-day supply) Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) $25 $50* $80* $20 $45* $75* Mail Order and Retail-Plus (up to 90-day supply) Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) $45 $105* $180* $45 $105* $180* Specialty Medications (retail or mail) 20% coinsurance after deductible $200 per fill

15 New ID Cards for ActiveCare Plans 1, 1-HD and 2 Participants All current ActiveCare 1 participants will receive replacement cards for the new plan option in which they are enrolled. ActiveCare 1-HD and ActiveCare 2, participants will be mailed replacement prescription ID cards reflecting the upcoming changes to benefit design. The effective dates printed on the cards will be the more recent of either the participant’s effective date with the plan or 9/1/10. Participants should expect to receive new cards around mid- to late-August. Participants making changes after the replacements have been mailed will result in a second set of cards being sent. 15

16 Specialized Care is the Key to Quality Outcomes Specialization and participant engagement are critical components to controlling health care costs and driving quality clinical outcomes: Specialist pharmacist Online Tools Closing gaps in care My Rx Choices ® Mobile App Other available resources 16

17 Extremely Satisfied/Very Satisfied with overall counseling experience Specialist Pharmacists are specially trained to counsel patients about their conditions and connect with physicians and healthcare coaches Average patient call lasts 12 minutes Calls are monitored and recorded for training Pharmacists spend their time focused on a single condition Advanced tools let pharmacists see the “whole patient” along with their drug regimen across prescribers and pharmacies 97% of patients Specialist Pharmacists are an integral part of the healthcare continuum 17 “We strive to have our pharmacists deliver the level of patient care that any of us would want for our families.” Glen Stettin, M.D., Express Scripts’ Chief Medical Officer

18 18 Omission Not Using Controller Medication for Asthma Omission Express Scripts’ online tools and mobile apps help connect patients and their caregivers Online prescription management:  Refills, renewals and order status  Worry-free Fills ®  Transfer to mail  Claims, balances and history  Locate a pharmacy  Preferences Benefit education and management:  Benefit highlights  Forms and cards  Pricing and coverage details  New! Accessibility features Gap In Care Alerts Help participants identify and address potential safety issues with their prescriptions

19 Pharmacy Care Online Alerts 19 Adherence Omission On track

20 Close-up: Sample Alert Message 20 Ability for patients to self-close gaps as appropriate Information about the alert and why it’s important Printable information to take to the doctor Access to email Express Scripts pharmacists Links to additional resources Video clips relevant to each alert

21 My Rx Choices ® Your online savings tool Lower your cost for prescriptions with My Rx Choices ® –Features include: Personal assessment of cost-saving opportunities based on your prescription plan and the medications you use Print a kit to help your doctor better understand the economic impact of different medication alternatives Alternative medications are based upon greatest cost savings to you presented in order, starting with the highest value Brand-to-generic and retail-to-mail comparisons are shown Simply visit You’ll need to take a moment to register before using this service. You can also call 1-866-355-5999 You have to shop your benefit. Prices can vary at different retail pharmacies 21

22 Managing prescription with ease: Transfer to mail online conversion program 22

23 23 New! Accessibility Features

24 Innovation that can help participants make better decisions for healthier outcomes 24 Save money Enable informed decisions Auto populate with personalized information Update in real-time Improve care Boost compliance and adherence Manage Refills and Renewals Unique functionality not available anywhere in healthcare today

25 Information Resources TRS Website – –Pharmacy Benefit Highlights –List of maintenance medications –FAQs –Download forms Express Scripts Participant Website – –Prior authorization list –Formulary information –Locate a participating pharmacy –Generics Rx Advantage –My Rx Choices® / Price a Medication –Health and wellness information –Mobile App –Check prescription status –Order mail order refills –Download forms –Express Scripts widget Customer Service – 1-866-355-5999 Benefits Booklet 25

26 FirstCare Health Plans HMO Plan Option

27 Company Overview We have been part of the TRS-ActiveCare program since 2003 and currently cover more than 13,000 school employees and their dependents We are a hospital-based health plan, founded in 1985 and are owned by Covenant Health System in Lubbock and Hendrick Medical Center in Abilene We focus exclusively on the Texas market and have offices in Abilene, Amarillo, Lubbock, and Waco FirstCare’s mission is to provide members with comprehensive health care coverage at an affordable price 27

28 Rate Overview The national average increase for health insurance premiums is 9 to 11 percent per year For plan year 2013, the overall rate increase is less than 2.5 percent 28 Coverage Category2013 - 2014 Employee Only$391.50 Employee and Spouse$985.06 Employee and Child(ren)$622.62 Family$994.84

29 Benefit Highlights No referrals to network specialists No routine claim forms No pre-existing limitations College-age dependents living outside our service area have full coverage (address must be on file) NOTE: Care must be accessed through our affiliate provider networks Secure online access to membership and claim information at 29

30 Medical Benefits for 2013-2014 No Plan Changes! 30 2013 - 2014 Deductible $600 per individual $1,500 per family Out-of-Pocket Maximum $4,000 per individual $8,000 per family Office Visit Primary Care – $25 Specialist – $60 Inpatient / Outpatient 25% after deductible (member share)

31 Rx Benefit Comparison for 2013-2014 31 2013 - 2014 Deductible $100 per Individual $300 per Family Rx Yearly Maximum Unlimited Copayment Tier 1 (Generic) – $10 Tier 2 (Preferred Brand Name) – $30 Tier 3 (Non-Preferred Brand Name) – $60 Tier 4 (Specialty)* – 20% *After $4,000 member out-of-pocket expense, cost is covered 100% by FirstCare

32 Service Area – 93 Counties Across Texas 32 TRS-ActiveCare Service Area To be eligible to enroll in FirstCare, you must live, reside or work in one of the shaded counties.

33 Why Choose FirstCare? We have experience with TRS-ActiveCare benefits. In fact, we cover more than 13,000 school employees and their dependents. We are a hospital-based health plan that supports our local communities. Medical decisions are made locally by physicians who understand how health care is delivered in your area. A local FirstCare representative is available in your area to answer questions. Dedicated email address for TRS-ActiveCare members and Benefit Administrators – 33

34 Contact Us 34 You may submit your questions or comments via email to You can also write or call customer service at: FirstCare Health Plans 1901 West Loop 289 Suite #9 Lubbock, TX 79407 800-884-4901

35 How to Enroll 2013-2014 Plan Year How to Enroll

36 Who is Eligible to Enroll? To be eligible for TRS-ActiveCare coverage, you must: Be employed by a participating district/entity and –Be an active, contributing TRS member or –Be employed 10 or more regularly scheduled hours each week 36 Health care coverage for public school employees and their families

37 Employees NOT Eligible to Enroll State of Texas employees or retirees Higher education employees or retirees TRS retirees, receiving or who declined coverage under TRS-Care 37 These individuals are not eligible to enroll for TRS-ActiveCare coverage as employees, but they can be covered as a dependent of an eligible employee.

38 Dependent Eligibility 38 Spouse, including common law spouse A child under age 26: a natural child, an adopted child (or a child who is lawfully placed for legal adoption), foster child, or child under legal guardianship of the employee “Any other child” under the age of 26 (unmarried) in a regular parent-child relationship with the employee – Must meet residency and support criteria A grandchild under age 26 Unmarried disabled dependent (age 26+) – Must live with employee A dependent does not include a brother or sister of an employee unless the sibling is an unmarried individual under 26 years of age who is either: (1) under the legal guardianship of the employee, or (2) in a regular parent- child relationship with the employee and meets the “any other child” criteria Parents and grandparents of the covered employee do not meet the definition of an eligible dependent

39 Special Eligibility Situations If employee and spouse both work for a participating district/entity: –A spouse may be covered as an employee or as a dependent of an employee –Only one parent can cover dependent children A child (under age 26) employed by a district/entity and a contributing TRS member cannot be covered as a dependent –The child must be covered as an employee –If the child is not a contributing TRS member, the child may be covered as a dependent 39

40 Three Steps to Enroll 40 2 Complete an Enrollment Application and Change Form Available from your Benefits Administrator 1 Choose your health plan 3 Sign, date and submit form to your Benefits Administrator

41 Enrollment Enrollment Periods for 2013-2014 Plan Year: –April 22 – May 24 (Spring Enrollment) –August 1 – August 31 (Summer Enrollment) No pre-existing condition exclusion applies except for those who previously declined coverage (may be reduced by prior creditable coverage) Passive enrollment – If no plan or coverage changes, then no form required Premium adjusted to reflect any rate change, effective September 1 41 Exception: If an employee is enrolled in ActiveCare 1, he or she will be automatically enrolled in ActiveCare 1-HD effective September 1, 2013, unless he or she submits an Enrollment Application and Change Form to select a different TRS-ActiveCare plan option or terminate coverage

42 Enrollment Application and Change Form 42 Who needs to submit a form? New hires –Enrolling or declining TRS-ActiveCare coverage –Enrolling for TRS-ActiveCare coverage with a different participating district/entity ALL current employees: –In an effort to get everything correct from the start, everyone must complete a new enrollment form; even if you decline coverage.

43 Enrollment Application and Change Form (Cont’d) Enrolling for the first time: Forms due to the Benefits Administrator before: –The end of the plan enrollment period, or –31 calendar days after the employee’s actively-at-work date, or –31 calendar days after a special enrollment event New hires may choose their effective date of coverage –Actively-at-work date, or –First of the month following their actively-at-work date 43 Full premium for the month will be due if choosing actively-at-work date; premiums are not pro-rated

44 Pre-existing Condition Exclusions 44 Pre-existing condition exclusions will not apply: –To any individual under the age of 19 –To employees that initially enroll when the district/entity begins participating in TRS-ActiveCare –To new hires who enroll within 31 days after their actively-at-work date –To HMO enrollees A 12-month pre-x waiting period may apply to employees or dependents enrolling in the ActiveCare PPO plans due to: –A special enrollment event –A transfer to another participating district/entity (or rehire by the same participating district/entity), if the employee or any covered dependent has any remaining pre-existing waiting period or a gap in coverage of 63 or more consecutive days. Exception: If a participant has been covered at any time since 2002, pre-x may apply if employee is hired by another participating district/entity (or rehired by same district/entity)

45 Making Changes/Special Enrollment Events 45 Enrollees may be able to enroll for coverage, change plan options, or change the dependents he or she covers during the plan year within 31 days after a special enrollment event occurs New dependent –Marriage, birth, adoption or placement for adoption –Special rules apply to newborns Loss of other coverage Changing districts/entities is not considered a special enrollment event

46 Newborns Covered first 31 days if employee has coverage –Does not apply to newborn grandchildren Must add newborn within 60 days after the date of birth or up to one year after the date of birth if: –Employee has “employee and family” or “employee and child(ren)” coverage at the time of birth and at the time of enrollment Plan changes must be made within 31 days after the newborn’s date of birth Not necessary to wait for newborn’s Social Security number –Submit application without SSN to enroll –Re-submit another form after SSN is issued 46

47 Cost for Health Coverage 2013-2014 Plan Year

48 Cost of Coverage 48 Funding to Help Offset the Cost of TRS-ActiveCare Coverage District/Entity (minimum)$198.33 State of Texas$75 Total Per Month$273.33 Funding applies to active, contributing TRS members Cost charts illustrate the monthly gross premiums

49 Monthly Cost for Coverage 49 See page 17 of Enrollment Guide $273.33 in district/entity and state funds to help pay for coverage

50 Application to Split Premium 50 Married couples working for different participating entities may “pool” funds Optional Requires an Application to Split Premium form to be completed by both employees and employers Form available online

51 ID Cards (mailed to your home) PPO plans (ActiveCare 1-HD, 2 and 3) –Separate cards for medical and prescription drugs Blue Cross and Blue Shield of Texas Express Scripts –BCBSTX will reissue ID cards to existing plan participants transitioning from AC1-HD to ActiveCare 1 (medical plan ID cards do not expire) –Prescription drug ID cards will be reissued by Express Scripts for ActiveCare 1-HD and ActiveCare 2 plan participants HMO plans –All HMO participants will receive new cards –Each individual covered under the plan will receive a card 51

52 Online Enrollment Support Available online – and Enrollment guide Summary of Benefits and Coverage (SBC) Downloadable forms (application and change form, application to split premium, claim form, etc.) Provider locator Enrollment presentation 52

53 53 Enrollment Info Blue Access for Members

54 Blue Access for Members SM 54 Online member management tool Research health conditions View claims history and print Explanation of Benefits (EOB) statements Locate a network doctor or hospital Order additional ID cards, or print a temporary ID Take a confidential health assessment Send secure email messages to BCBSTX Customer Advocates Monday thru Friday 7 a.m. to 10 p.m. (CT) EOBs are available online; you must log in and elect to receive paper copies

55 Blue Access Mobile SM 55 Public Site – No log-in required Health Care 101 Find a Doctor or Hospital Blue Access for Members Log-in Contact Information Provider Finder App For iPhone ® and Android ® phones Blue Access for Members SM Secure Site – Log-in Required ID Card My Coverage – Benefits / Eligibility Visits and Claims Health and Wellness – Diabetes, Obesity, Nutrition, Fitness, Metabolic Syndrome, Maternity Care, Member Care Profile User Profile Register for Blue Access for Members Text Messaging Static – One-Way SMS Messaging Diabetes Management, Claim Status Notification Alerts Dynamic – Two-Way Messaging member initiates text with keyword (ID Card Management)

56 What if I Have Questions? Call TRS-ActiveCare customer service for: –Claim questions/status –Network provider information –Membership and eligibility –Medical and Rx coverage questions –Inquiries (telephone and email) –ID card requests –Transition of care information –Help with online tools! 56 Customer Service 1-866-355-5999 Personalized Service

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