Presentation on theme: "Health Coverage for You and Your Family"— Presentation transcript:
1 Health Coverage for You and Your Family Welcome to our enrollment presentation for TRS-ActiveCare’s plan year.
2 ActiveCare 1-HD, 2 and 3 Plans 2013-2014 Plan Year PPO Plan OverviewLet’s take a look at the PPO medical plan options administered by Blue Cross and Blue Shield of Texas.ActiveCare 1-HD, 2 and 3 Plans Plan Year
3 New Deductible and Out-of-Pocket Maximum for ActiveCare 1-HD ActiveCare 1-HD meets IRS definition of a high deductible health plan for all coverage tiersMay 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 basisIndividuals can establish an HSA with banks and credit unionsPlan YearPlan YearAC1AC1-HDDeductible (employee only/family)$1,200/$3,000$2,400/$2,400$2,400/$4,800Out-of-Pocket Maximum (employee only/family; does not include deductibles)$2,000/$6,000$3,000/$5,000$3,850/$4,200The deductibles and out-of-pocket maximum will increase for ActiveCare 1-HD.ActiveCare 1-HD meets the IRS definition of a high deductible health plan (HDHP) for all tiers of coverage (employee only, employee and spouse, employee and child(ren), and employee and family), and offers plan participants the opportunity to contribute pretax dollars into a health savings account (HSA). An HSA allows individuals to 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. Employers may set up plans for employees as well, in which case the employer will generally be arranging the HSA for the employee.TRS does not offer health savings accounts, but some entities participating in TRS-ActiveCare do provide this option to their employees. Individuals can also establish an HSA by working directly with financial institutions offering this product. Many banks and credit unions offer custodial account services for individuals wishing to establish an HSA. TRS does not have a list of these institutions and does not endorse any particular HSA product. Please contact financial institutions serving your area to obtain further information.
4 New Deductible and Out-of-Pocket Maximum for ActiveCare 2 Plan YearPlan YearActiveCare 2Deductible (individual/family)$750/$2,250$1,000/$3,000Out-of-Pocket Maximum (individual/family; does not include deductibles)$2,000/$6,000$4,000/$8,000The deductibles and out-of-pocket maximums also increased for ActiveCare 2.
5 Family Deductible Illustration Amy covers spouse and three dependents TedBobSueChrisActiveCare 1-HD with $4,800 family deductibleThe family deductible may be met by one or more peoplePlan pays benefits once entire $4,800 is met ̶ there is no individual deductible to meet$4,800ActiveCare 2 with a $1,000 individual deductible and a $3,000 family deductiblePlan pays benefits for an individual as his/her deductible is metEveryone helps to meet the family deductible, but no one person pays more than the individual amountFamily Deductibles and the Differences between PlansA deductible is the amount of out-of-pocket expense that must be paid for health care services by the plan participant before becoming payable by the health plan. For ActiveCare 1-HD, before the plan pays for any of your family’s covered medical expenses, the entire amount of the deductible must be met first. It can be met by one family member or a combination of family members; however, there are no benefits until covered expenses equaling the deductible amount ($4,800) have been incurred.For ActiveCare 2 (and ActiveCare 3), the deductible applies to each covered person individually, up to the maximum per family. For example, under ActiveCare 2, which has a $1,000 individual and $3,000 family deductible, if Amy incurs $1,000 in medical bills, her deductible is met and the plan will pay any subsequent medical bills for her for the year even though the family deductible of $3,000 has not been met yet. Plan pays benefits once the entire $3,000 is met.TedBobAmySueChris$1,000$800$600$400$200
6 Out-of-Pocket (OOP) Maximum Illustration Amy covers spouse and three dependents TedBobSueChrisActiveCare 1-HD with $4,200 family OOP maximumThe family out-of-pocket maximum may be met by one or more peoplePlan pays benefits once entire $4,200 is met ̶ there is no individual amount to meet$4,200ActiveCare 2 with a $4,000 individual and $8,000 family OOP maximumPlan pays benefits for an individual as his/her OOP maximum is metEveryone helps to meet the family OOP maximum, but no one person pays more than the individual amountOut-of-Pocket Maximum: Once you reach your plan’s out-of-pocket maximum, the plan pays 100% of any eligible expenses for the remainder of the plan year.Under ActiveCare 1-HD, the family out-of-pocket maximum may be met by one or more people. The plan pays 100% of eligible member expenses once entire $4,200 is met.Under ActiveCare 2, which has a $4,000 individual and $8,000 family OOP max, the plan pays benefits as each individual out-of-pocket maximum is met. Everyone helps to meet the family OOP max, but no one person pays more than the individual amount.TedBobAmySueChris$4,000$2,000$1,000$600$400
7 PPO Network for ActiveCare 1-HD, 2 and 3 Statewide (all 254 counties)No need to:Select a Primary Care PhysicianObtain referrals for specialist careReceive highest level of benefits:Pay less for careNo balance billingNo claim formsProvider files claim for youAlways verify provider network statusNon-Network:You pay more of the cost of out-of-network benefitsHigher deductibles, coinsuranceYou may need to file your own claimYou could be balance billed for amounts over allowed amountBefore we talk about the plan options, let’s review the provider network of doctors and hospitals for the ActiveCare 1-HD, 2 and 3 plans. Administered by Blue Cross and Blue Shield of Texas, the PPO network for TRS-ActiveCare is the largest network of its kind in the state of Texas. It offers access to over 59,000 physicians and more than 590 hospitals in Texas and is available in all 254 counties. Employees have the freedom to choose their own doctor at the point of service. No Primary Care Physician (PCP) or referrals required. Each time an employee or eligible dependent needs health care, he or she needs to decide whether to see an in-network provider or an out-of-network provider.With in-network providers:Receive highest level of benefitsNo claims to file in most cases (network provider will usually file the claims)No balance billing; network providers cannot bill for costs exceeding the allowable amount.With non-network providers:Receive non-network level of benefits (reduced level from network)May have to file own claimsMay be billed for charges exceeding the BCBSTX allowable amount.
8 PPO Plan Overview (Network Level of Benefits) ActiveCare 1-HDActiveCare 2ActiveCare 3Deductible$2,400 employee only$4,800 family$1,000 individual $3,000 family$300 individual$900 familyOut-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 individualCoinsurance (Plan pays/ participant pays)80% / 20%Office Visit Copay20% after deductible$30 for primary$50 for specialist$20 for primary$30 for specialistThere were no plan changes to ActiveCare 3.Plan overview. Let’s take a look at all three PPO plans. This chart illustrates benefits when network providers are used. As mentioned previously, non-network benefits are also available; see the Enrollment Guide for information.Deductibles: The set amount of out-of-pocket expense, if applicable, that must be paid for health care services by the covered person before the plan begins to share costs. For example, ActiveCare 1-HD has a $2,400 deductible, which must be met before the plan pays any benefits. The ActiveCare 2 deductible is $1,000 per individual and $3,000 per family, and ActiveCare 3 has a $300 individual deductible to meet when using network providers for health care services and $900 for family.Out-of-Pocket Maximum: If you reach your plan’s out-of-pocket maximum, the plan then pays 100% of any eligible expenses for the remainder of the plan year. Office visit copays continue after the out-of-pocket maximum is reached. As stated here, deductibles do not apply to the out-of-pocket maximums.Coinsurance: The percentage of medical expenses that you and the plan share. For example, the coinsurance amount when using network providers for all plans is "80/20." This means that the plan pays 80% and the plan participant pays 20% after any applicable deductible.Copayments: The set amount you pay for certain medical services and prescription drugs at the time of service. Note: For ActiveCare 2 and 3, the copay depends on whether the doctor is "primary" or a specialist. Primary means care provided by family practitioners, internists, OB/GYNs, and pediatricians. All other physicians are specialists.Primary means care provided by family practitioners, internists, OB/GYNs and pediatricians. All other physicians are specialists.Family Deductibles and the Differences between PlansA deductible is the amount of out-of-pocket expense that must be paid for health care services by the plan participant before becoming payable by the health plan. For ActiveCare 1-HD, before the plan pays for any of your family’s covered medical expenses, the entire amount of the deductible must be met first. It can be met by one family member or a combination of family members; however, there are no benefits until covered expenses equaling the deductible amount ($4,800) have been incurred.For ActiveCare 2 and ActiveCare 3, the deductible applies to each covered person individually, up to the maximum per family. For example, under ActiveCare 2, which has a $1,000 individual and $3,000 family deductible, if your daughter incurs $1,000 in medical bills, her deductible is met and the plan will pay any subsequent medical bills for your daughter for the year even though the family deductible of $3,000 has not been met yet.
9 PPO Plan Overview (Network Level of Benefits) Preventive Care ClarificationServicesActiveCare 1-HDActiveCare 2ActiveCare 3Preventive CarePlan pays 100% (deductible waived)Plan pays 100% (no copay required)Routine eye exam (one per plan year) Hearing exam20% after deductible$30 for primary$50 for specialist$20 for primary$30 for specialistThe TRS-ActiveCare PPO plans provide 100% coverage for certain preventive care services when network providers are used. However, not all preventive care benefits are covered at 100%, including routine eye and vision exams and hearing exams. For example: Although age-specific vision "screenings" are covered 100% in the network provider’s office, routine eye and vision "exams," such as those performed by an optometrist or an ophthalmologist, are subject to applicable copayment, deductible, and coinsurance.Sample preventive care services covered 100% when using network providers:Routine annual physicals (one per plan year)ImmunizationsWell-child careRoutine mammograms (one per plan year)Routine colonoscopiesBone density testScreening for prostate cancerSmoking cessation counseling servicesHealthy diet/obesity screening/counseling100% coverage for certain age- and gender-specific preventive care services when network providers are usedMust be billed by provider as “preventive care”
10 PPO Plan Overview (Network Level of Benefits) Benefits (continued)ServicesActiveCare 1-HDActiveCare 2ActiveCare 3High-tech Radiology (CT scan, MRI, nuclear medicine)20% after deductible$100 copay per service, plus 20% after deductibleInpatient Hospital$150 copay per day, plus 20% after deductible($750 max copay per admission; $2,250 max/year)Emergency Room$150 copay, plus 20% after deductible(copay waived if admitted)$150 copay, plus 20% after deductible (copay waived if admitted)Outpatient Surgery$150 copay per visit, plus 20% after deductible$150 copay per visit, plus 20% after deductibleNo plan changes for these services other than the non-network allowable amount. A high-tech radiology copay is included for the ActiveCare 2 and 3 plans. The $100 copay is per service and applies to CT scans, MRIs and nuclear medicine when using network providers for these services. So, if a patient has a CT scan and an MRI on the same day, he/she will pay $200, plus deductible and coinsurance.The inpatient hospital copays for ActiveCare 2 and 3 are $150 copay per day, plus deductible and coinsurance. The maximum copay per admission for each plan is $750 and the maximum per plan year is $2,250.The emergency room and outpatient surgery copays for ActiveCare 2 and 3 are $150.
11 BVA New!! Effective Sept. 1, 2013 Benefits Value Advisor Help get benefits information and find network providers for:MRIsKnee surgeryCAT or CT ScansShoulder surgeryEndoscopy proceduresHip or joint replacement surgeryColonoscopy proceduresBariatric surgeryBack or spinal surgeryBenefits Value AdvisorUnderstanding benefits and how to best use themReal-time access to current cost and quality transparencyHere’s a new benefit to plan participants in ActiveCare 1-HD, 2 and 3 effective September 1, It’s called BVA: Benefits Value Advisor. BVAs will help plan participants maximize their benefit plan.For plan participants in the ActiveCare 1-HD, 2 and 3 plan options, a BVA can help you get benefits information and find contracting, in-network providers for a number of health care services such as:• CAT or CT Scans• MRIs• Endoscopy and Colonoscopy procedures• Back or spinal surgery• Knee surgery• Shoulder surgery• Hip or joint replacement surgery• Bariatric surgeryBenefits Value Advisors can also help you plan for your health care by:• Helping you better understand your benefits• Giving you a cost estimate for health care services or procedures• Scheduling a doctor or procedure appointment• Helping you get general health information about your condition• Helping you with preauthorization• Telling you about online educational toolsAppointment schedulingReferrals to condition management programsClinical decision support toolsPreauthorization coordinationOne-Call Solution: Customer Service
12 ActiveCare 1-HD, 2 & 3 2013-2014 Plan Year Prescription DrugsActiveCare 1-HD, 2 & Plan YearLet’s discuss the prescription drug benefits administered by Express Scripts for the ActiveCare 1-HD, 2 and 3 plans.
13 Your Prescription Drug Plan Express Scripts administers your prescription drug plans on behalf of TRSActiveCare 1-HD, 2, and 3 plansBenefit includes both a retail and mail componentExpress 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 suppliersExpress Scripts administers the prescription drug plan on behalf of TRS-ActiveCare. The program has both a retail and mail component. The retail coverage has over 65,000 pharmacies in network. And, of those, 4,700 pharmacies participate in the Retail-Plus network. Express Scripts also has a mail order facility. By filling your long-term medications through mail order or participating Retail-Plus maintenance pharmacies. Through the mail order pharmacy, participants can get up to a 90-day supply delivered directly to them at a lower copay. The mail order pharmacy is also staffed by pharmacists who have been specially trained in certain therapeutic categories. More on the Specialist Pharmacists later in the presentation.*Express Scripts’ mail-order pharmacies fill about 2 million prescriptions per week through a highly automated process that is % 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 FeaturesActiveCare 1-HDActiveCare 2ActiveCare 3Drug Deductible(per person, per plan year)Subject to plan year deductible$0 generic;$200 brand$75Retail 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)$25$50*$80*$45*$75*Mail Order andRetail-Plus(up to 90-day supply)$45$105*$180*Specialty Medications (retail or mail)20% coinsurance after deductible$200 per fillHere’s an overview of the prescription drug benefits for the ActiveCare 1-HD, 2 and 3 plans. This chart illustrates benefits when network providers are used. Non-network benefits are also available; see Enrollment Guide for more information.* 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.
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.As a result of the upcoming plan changes to Plans 1, 1-HD and 2, current participants of those plans will be issued replacement ID cards. A special card mailing will be completed for existing participants of these groups around the middle of August. If a move occurs to or from one these groups after the mailing, they will receive a new card based on their new coverage in that group.It’s important to note that the effective dates printed on the cards will be the more recent of either 9/1/2010 or the participant’s effective date with the plan. Example – if the participant's effective date is 1/1/2009, the date printed on the card will be 9/1/ If the participant's plan effective date is 1/1/2012, then 1/1/2012 will be printed on the card.
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 pharmacistOnline ToolsClosing gaps in careMy Rx Choices®Mobile AppOther available resourcesRecognizing that the rising cost of health care is a topic on everyone’s mind. Let’s take a look at how specialization and participant engagement can help control costs and ensure the highest quality of care.
17 Extremely Satisfied/Very Satisfied with overall counseling experience Specialist Pharmacists are an integral part of the healthcare continuum97% of patientsExtremely Satisfied/Very Satisfied with overall counseling experienceSpecialist Pharmacists are specially trained to counsel patients about their conditions and connect with physicians and healthcare coachesAverage patient call lasts 12 minutesCalls are monitored and recorded for trainingPharmacists spend their time focused on a single conditionAdvanced tools let pharmacists see the “whole patient” along with their drug regimen across prescribers and pharmaciesThe Therapeutic Resource Centers (TRC’s) help manage the needs of chronically and complexly ill patients. As we discussed earlier, the specialist pharmacists, who staff the TRC’s, are an integral part of the healthcare continuum, particularly for patients who are on multiple medications to treat ongoing and often numerous conditions.The difference between a specialist pharmacist and a conventional pharmacist is in the training and resources available to them. The specialist pharmacists have over 400 hours of additional training in a particular disease state, and they only handle medications associated to that condition. And they use this additional training to ensure that prescriptions have the most thorough review prior to filling.The chronic and complex conditions serviced by the Therapeutic Resource Centers represent nearly all the pharmacy costs. This pharmacy practice model allows Express Scripts to place added focus on the overall health of the plan and its participation. The specialist pharmacists are able to spend the time to perform counseling, and are given access to tools that allow them to see information about the “whole patient" – their drug regimen across prescribers and pharmacies.When a pharmacist counsels a patient, the discussion lasts an average of 12 minutes and involves a dialog that helps pinpoint the challenges that face the patient, helps the pharmacist gain an understanding of the side effects the patient may be having, and helps patients resolve concerns or issues. Counseling involves listening to the patient as much as talking to them about their medications.“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 Not Using Controller Medication for Asthma Express Scripts’ online tools and mobile apps help connect patients and their caregiversOnline prescription management:Refills, renewals and order statusWorry-free Fills ®Transfer to mailClaims, balances and historyLocate a pharmacyPreferencesBenefit education and management:Benefit highlightsForms and cardsPricing and coverage detailsNew! Accessibility featuresThe Express Scripts participant website empowers and educates plan participants by providing the personalized information they need to make better-informed health decisions regarding prevention and treatment. It also enables participants to make better-informed financials decisions regarding the cost of their medication. It is a one-stop shopping tool for all prescription-related items. And, it’s available anytime.Let’s go over some of the capabilities in more detail.Gap In Care Alerts Help participants identify and address potential safety issues with their prescriptionsOmissionNot Using Controller Medication for Asthma18
19 Pharmacy Care Online Alerts AdherenceOmissionA main driver of increased health care costs is medication adherence. The World Health Organization estimates that only about half of patients on maintenance medications take their drugs as directed. Poor adherence results in up to hundreds of billions of dollars in medical expenses each year.Express Scripts focuses on closing the critical gaps in a patient’s care by monitoring and improving adherence to essential medication and optimizing therapies and doses to protect plan and patient costs. A critical concept is recognizing the value of engaging and empowering patients with the right tools. Online alerts make patients aware of important therapy adherence and omission concerns. These alerts allow patients to take action and close their own gaps in care.On track
20 Close-up: Sample Alert Message Information about the alert and why it’s importantAbility for patients to self-close gaps as appropriateAlerts contain therapy-specific video clips, content that helps patients understand why it’s important, links to additional resources such as the American Diabetes Association, National Heart, Lung and Blood Institute, and printable information for patients to take to their doctors. There is also access to Express Scripts pharmacists as well as a "click-to-call" capability to request a call back from an Express Scripts pharmacist. These alerts were designed to give participants access to content, tools and information that educate and inform.Video clips relevant to each alertLinks to additional resourcesAccess toExpress Scripts pharmacistsPrintable information to take to the doctor
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 usePrint a kit to help your doctor better understand the economic impact of different medication alternativesAlternative medications are based upon greatest cost savings to you presented in order, starting with the highest valueBrand-to-generic and retail-to-mail comparisons are shownSimply visit You’ll need to take a moment to register before using this service. You can also callYou have to shop your benefit. Prices can vary at different retail pharmaciesMy Rx Choices is a tool on the express-scripts.com website that allows participants to comparison shop appropriate therapies to determine which is the most cost effective medication for them. Results include the best-cost therapy in each particular class with associated pricing information and annualized savings for the selected drug and other lower-cost alternatives.After reviewing their options, users are given the choice to print a report to take to their next doctor visit. The report shows specific copay amounts.Unless allowed by law, a prescription will not be changed without approval from the prescriber.My Rx Choices can also be accessed by calling customer service.
22 Managing prescription with ease: Transfer to mail online conversion program This dedicated tool helps patients lower their drug costs by enabling them to conveniently transfer medications to home delivery. The participant can select which drugs to transfer and Express Scripts will contact the patient’s physician on his or her behalf. Once the doctor approves the switch, the patient will receive their first order within 7 to 14 days.
23 New! Accessibility Features Spanish-speaking participants can view all site content in Spanish. For participants who are sight-impaired, content can be read by screen readers. These features can be accessed from every page of the site.
24 Unique functionality not available anywhere in healthcare today Innovation that can help participants make better decisions for healthier outcomesBoost compliance and adherenceSave moneyEnable informed decisionsImprove careManage Refills and RenewalsThe Express Scripts mobile application (app) can help participants make better decisions for healthier outcomes. The app is available to anyone with an iPhone, BlackBerry®, or Android™ smartphone, regardless of wireless carrier.The app includes these six features:Refills and RenewalsEnables participants to quickly and easily refill and renew their home delivery prescriptionsOrder StatusParticipants can quickly and easily track their home delivery prescription orders right from their phone.My Rx Choices®View lower-cost options availableView medication coverage limitations any time, including when in the doctor’s officeDrug safety alerts to avoid disruptionPharmacy Care AlertsParticipants can review personalized alerts to help ensure they are following their prescribed treatment planMedicine CabinetSends reminders to the user’s smartphone when it’s time to take prescription medications and OTC drugs, or to request refillsAlerts notify participants if there’s a possible health risk related to their medications.Lets participants add OTC medications, vitamins, and supplements to check for possible interactions with their prescriptions.Loads and updates medication history automatically.Virtual Prescription ID CardAuto populate with personalized informationUpdate in real-timeUnique functionality not available anywhere in healthcare today
25 Information Resources TRS Website –Pharmacy Benefit HighlightsList of maintenance medicationsFAQsDownload formsExpress Scripts Participant Website –Prior authorization listFormulary informationLocate a participating pharmacyGenerics Rx AdvantageMy Rx Choices® / Price a MedicationHealth and wellness informationMobile AppCheck prescription statusOrder mail order refillsExpress Scripts widgetCustomer Service –Benefits Booklet
27 Company OverviewWe have been part of the TRS-ActiveCare program since and currently cover more than 13,000 school employees and their dependentsWe are a hospital-based health plan, founded in 1985 and are owned by Covenant Health System in Lubbock and Hendrick Medical Center in AbileneWe focus exclusively on the Texas market and have offices in Abilene, Amarillo, Lubbock, and WacoFirstCare’s mission is to provide members with comprehensive health care coverage at an affordable priceFirstCare has experienced steady membership growth over the past 9 years. Currently, we cover over 13,000 school employees and their dependents making us the largest HMO provider for TRS.FirstCare believes one of the main reasons for our membership growth is because we’re a hospital-based health plan. FirstCare is owned by two Texas hospitals – Covenant Health Systems in Lubbock and Hendrick Medical Center in Abilene. Considering that our owners are hospitals, they instill in us the need to put patient care first with the understating that healthcare decisions are made by local health providers; not by someone on the phone in a different state.FirstCare is committed to our communities by having local offices where members can come by and ask questions. Our local offices are active in promoting healthy lifestyle programs by sponsoring health education classes within their communities. If you would like for us to participate in a health fair at your school, please let us know.Finally, our company’s mission is to provide members with comprehensive health care coverage at an affordable price. As been discussed by several of today’s presenters, health care cost have been rapidly increasing due to new technology, drugs, and increase in utilization. That is why we have partnered with some of the largest health providers in our service area, to help control those costs. Those partnerships have allowed us to keep our rate increase minimal, while making no changes to our benefits for the plan year.
28 Rate OverviewThe national average increase for health insurance premiums is 9 to 11 percent per yearFor plan year 2013, the overall rate increase is less than percentCoverage CategoryEmployee Only$391.50Employee and Spouse$985.06Employee and Child(ren)$622.62Family$994.84As discussed in the company overview slide, our mission is to provide comprehensive coverage at an affordable price. As illustrated, we have been able to maintain premium increases below the national average.
29 Benefit Highlights No referrals to network specialists No routine claim formsNo pre-existing limitationsCollege-age dependents living outside our service area have full coverage (address must be on file)NOTE: Care must be accessed through our affiliate provider networksSecure online access to membership and claim information atIf members need to see a participating specialist, they can go directly to one or coordinate through their primary care physician. We encourage members to develop a relationship with a primary care physician. In many instances, a primary care physician can resolve the issue or help guide them to the appropriate specialist. Also, by accessing care through a primary care physician, members will have a lower office visit copayment. Our provider network includes more than 2,400 specialists in 92 counties throughout the north, west, and central regions in Texas. A complete listing of providers is available at under the "Find a Physicians" tab. Look for the TRS-ActiveCare directory.When members access care from participating providers, all they have to do is show their ID card. FirstCare will coordinate payment directly with providers thus eliminating the need to file routine claim forms.Our policy does not include a preexisting condition exclusion. If an enrollee has a medical condition that is covered under the policy, it is covered as of the enrollee’s effective date with FirstCare. This provides peace of mind that an enrollee can switch to FirstCare and have covered services beginning on day one.Many of our members have college-age dependents that reside outside our service area. No problem. They are covered for all services, including routine, non-emergency care as long as the care is provided by a doctor or facility that is contracted with FirstCare or one of our affiliated networks. In order to receive this comprehensive level of benefits, the student’s out-of-area address must be on file with FirstCare. This can be done by simply calling our Customer Service Department atFirstCare members have access to a robust secure website. Members can review claim and benefit information, request new ID cards, and research ways to promote a healthy lifestyle.
30 Medical Benefits for 2013-2014 No Plan Changes! Deductible$600 per individual$1,500 per familyOut-of-Pocket Maximum$4,000 per individual$8,000 per familyOffice VisitPrimary Care – $25Specialist – $60Inpatient / Outpatient25% after deductible(member share)This chart outlines some of the changes in the medical plan. Please refer to the Schedule of Benefits and Evidence of Coverage for a complete overview of coverage.
31 Rx Benefit Comparison for 2013-2014 Deductible$100 per Individual$300 per FamilyRx Yearly MaximumUnlimitedCopaymentTier 1 (Generic) – $10Tier 2 (Preferred Brand Name) – $30Tier 3 (Non-Preferred Brand Name) – $60Tier 4 (Specialty)* – 20%*After $4,000 member out-of-pocket expense, cost is covered 100% by FirstCareThis chart outlines some of the changes to the prescription drug plan. Please refer to the Schedule of Benefits and Evidence of Coverage for a complete overview of coverage.
32 Service Area – 93 Counties Across Texas TRS-ActiveCareService AreaIn order to be a member in our plan, members must live, reside or work in one of the shaded areas. FirstCare’s service area includes 93 counties, thus providing the largest service area for those wanting to enroll in an HMO.Within our 93 counties there are over 1,600 Primary Care Physicians and 2,400 Specialists including some of the most well respective hospitals. Before seeking care, remember to check your provider’s participation status.The next couple of slides outline some of the providers participating in our network.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 address for TRS-ActiveCare members and Benefit Administrators –One of the many benefits of participating in the TRS ActiveCare program is theopportunity for school employees to chose from several outstanding healthcarecompanies. FirstCare is proud to be part of such a program. Our participation inTRS-ActiveCare spans nine years insuring more than 13,000 school employees and their dependents.We are a Texas hospital-based health plan, who believes medical decisions aremade locally by physicians who understand how health care is delivered in theircommunities; not by someone on the phone in a different state.We have local representation available to conduct meetings at your school to make sure employees are informed on how our benefits work.In addition, our Texas-based Customer Service Department is available to answer questions.This year we have set up a dedicated address for TRS-ActiveCare members and Benefit Administrators at The address is constantly monitored and a great way to request ID cards, research claims, and ask benefit questions.Thank you for the opportunity to present our health plan. I’m available to answeryour questions and look forward to visiting with you over the next couple of weeks.
34 FirstCare Health Plans Contact UsYou may submit your questions or commentsvia toYou can also write or call customer service at:FirstCare Health Plans1901 West Loop 289Suite #9Lubbock, TX 79407
36 Who is Eligible to Enroll? To be eligible for TRS-ActiveCare coverage, you must:Be employed by a participating district/entity andBe an active, contributing TRS member orBe employed 10 or more regularly scheduled hours each weekWho can enroll in TRS-ActiveCare?To be eligible for TRS-ActiveCare, you must be employed by a participating entity. Then, ask yourself these questions:(1) Are you an active, contributing TRS member?(2) Are you employed for 10 or more regularly scheduled hours each week?If the answer is yes to either question, then you are eligible for TRS-ActiveCare coverage.Health care coverage for public school employees and their families
37 Employees NOT Eligible to Enroll State of Texas employees or retireesHigher education employees or retireesTRS retirees, receiving or who declined coverage under TRS-CareThese individuals are not eligible to enroll for TRS-ActiveCare coverage as employees, but they can be covered as a dependent of an eligible employee.Employees that are not eligible to enroll in TRS-ActiveCare include individuals:Receiving health care coverage as an employee or retiree under the Texas State College and University Employees Uniform Insurance Benefits Act, for example, a school employee that has UT SELECT coverage as an employee with The University of Texas System.Receiving health care coverage as an employee or retiree under the Texas Employee Uniform Group Insurance Benefits Act, for example, a school employee that has HealthSelect coverage as an employee with ERSA TRS retiree receiving, or who waived coverage, under TRS-Care, including a retiree who has returned to work. Note: If a retiree has returned to work and has never been eligible for TRS-Care, he or she would be eligible for TRS-ActiveCare coverage, as long as the retiree meets all the TRS-ActiveCare eligibility requirements.Basically, employee coverage is not available from two state sources.However, these individuals–retirees, higher education and state of Texas employees–while they are not eligible to enroll for TRS-ActiveCare coverage as employees, they can be covered as a dependent of an eligible employee.
38 Dependent Eligibility Spouse, including common law spouseA 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 criteriaA grandchild under age 26Unmarried disabled dependent (age 26+) – Must live with employeeHere are the rules for eligible dependents:A spouse (including a common law spouse)*A child under the age of 26 such as:A natural childAn adopted child or a child who is lawfully placed for legal adoptionA stepchildA foster childA child under the legal guardianship of the employee"Any other child" under age 26 (unmarried) in a regular parent-child relationship with the employee(other than a child described in the category immediately above), meaning:The child's primary residence is the household of the employee;The employee provides at least 50% of the child's support;Neither of the child's natural parents resides in that household; andThe employee has the legal right to make decisions regarding the child's medical careA grandchild under age 26 whose primary residence is the household of the employee and who is a dependent of the employee for federal income tax purposes for the reporting year in which coverage of the grandchild is in effectA child of a covered employee, age 26 or over, may be eligible for dependent coverage, provided that the child is either mentally or physically incapacitated to such an extent to be dependent on the employee on a regular basis as determined by TRS, and meets other requirements as determined by TRS.A dependent does not include a brother or a sister of an employee unless the brother or sister 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 an employee, as defined in the "any other child" category above. Parents and grandparents of the covered employee do not meet the definition of an eligible dependent.*A common law marriage is not considered a special enrollment event unless there is a Declaration of Common Law Marriage filed with an authorized government agency.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” criteriaParents 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 employeeOnly one parent can cover dependent childrenA child (under age 26) employed by a district/entity and a contributing TRS member cannot be covered as a dependentThe child must be covered as an employeeIf the child is not a contributing TRS member, the child may be covered as a dependentIf an employee and spouse both work for a participating district/entity:Each employee can applyEach employee can choose employee-only coverage and select the same or different plansOne employee can select employee and spouse coverage, and the spouse must decline coverageOne employee can choose employee-only coverage, and the spouse can choose the same or different plan for employee and child(ren) coverage.One employee can select employee and family coverage, and the spouse must decline coverage.Only one parent may enroll dependent children for coverage.What if a child works for a participating entity?A child (under age 26) who is employed by a district/entity and is a contributing TRS member cannot be covered as a dependent on his or her parent's TRS-ActiveCare coverage. This child must be covered as an employee. If the child is not a contributing TRS member, the child may be covered as a dependent.
40 2 Complete an Enrollment Application and Change Form Three Steps to Enroll2 Complete an Enrollment Application and Change FormAvailable from your Benefits Administrator3 Sign, date and submit form to your Benefits Administrator1 Choose your health plan
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 requiredPremium adjusted to reflect any rate change, effective September 1The plan enrollment periods for the plan year are: April 22 - May 24 (Spring Enrollment) and August 1- August 31 (Summer Enrollment). No pre-existing condition waiting period applies for plan or coverage changes made this year except for those who previously declined coverage. If an employee previously declined coverage and wishes to enroll, a 12-month pre-existing condition waiting period will apply to any employee and dependent enrolling in ActiveCare 1-HD, 2 or 3. (May be reduced by prior creditable coverage.) If no form is returned, the employee will automatically be enrolled in the same plan elected for at the same level of coverage. The premium will be adjusted to reflect any rate change that will become effective September 1, 2013.There is one exception to the passive enrollment: The ActiveCare 1 plan option will be discontinued for the plan year. If an employee is currently enrolled in ActiveCare 1, he or she will be transitioned into ActiveCare 1-HD at the same level of coverage effective September 1, If the employee does not want to be enrolled in ActiveCare 1-HD, he or she must submit an Enrollment Application and Change Form during the plan enrollment periods to select a different TRS-ActiveCare plan option or terminate TRS-ActiveCare coverage.HMO coverage does not contain preexisting condition exclusions, and pre-x does not apply to individuals under the age of 19.Employees should be encouraged to read the enrollment guide and review the plans carefully. Rates and/or benefits for every TRS-ActiveCare plan option have changed.Clarification: If an employee is already enrolled in TRS-ActiveCare and changes employment to a new participating district/entity, the employee needs to complete and return a new enrollment form.Note to Benefits Administrators: If you have a third party vendor administering your Section 125 cafeteria plan, be sure the vendor communicates the processing guidelines correctly to the employees. All changes to TRS-ActiveCare must be submitted to the Benefits Administrator on an Enrollment Application and Change Form. Making a change through a third party vendor for a Section 125 cafeteria plan does not automatically generate a change to TRS-ActiveCare.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 Who needs to submit a form?New hiresEnrolling or declining TRS-ActiveCare coverageEnrolling for TRS-ActiveCare coverage with a different participating district/entityALL current employees:In an effort to get everything correct from the start, everyone must completea new enrollment form; even if you decline coverage.Who needs to submit an Enrollment Application and Change Form?New hiresEnrolling or declining TRS-ActiveCare coverageEnrolling for TRS-ActiveCare coverage with a different participating district/entityEmployees already enrolled, but making changes such as:Changing to a different TRS-ActiveCare plan optionAdding or dropping dependentsChoosing to cancel and/or decline coverage under TRS-ActiveCare (cancellations and declinations must be completed on two separate forms)Changing name or address and/or correcting date of birth or Social Security numberRemember, employees must submit an Enrollment Application and Change Form if they change employment during the plan year and enroll for TRS-ActiveCare coverage with another participating district/entity.Note: Because the ActiveCare 1 plan option is being discontinued, current enrollees in ActiveCare 1 will automatically be enrolled in ActiveCare 1-HD at the same level of coverage, effective September 1, The employee must submit an Enrollment Application and Change Form during the plan enrollment periods to select a different plan option or to terminate TRS-ActiveCare 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, or31 calendar days after the employee’s actively-at-work date, or31 calendar days after a special enrollment eventNew hires may choose their effective date of coverageActively-at-work date, orFirst of the month following their actively-at-work dateWhat does the employee need to do to enroll in TRS-ActiveCare for the first time?The employee will need to sign and submit an Enrollment Application and Change Form to the Benefits Administrator before:The end of the plan enrollment period, or31 calendar days after the employee’s actively-at-work date, or31 calendar days after a special enrollment event (Special rules apply to adding newborns; see page 19 for more information)New hires may choose as their effective date of coverage their actively-at-work date (the date they start to work) or the first of the month following their actively-at-work date. When choosing the actively-at-work date, the full premium for the month will be due; premiums are not pro-rated.Full premium for the month will be due if choosing actively-at-work date; premiums are not pro-rated
44 Pre-existing Condition Exclusions Pre-existing condition exclusions will not apply:To any individual under the age of 19To employees that initially enroll when the district/entity begins participating in TRS-ActiveCareTo new hires who enroll within 31 days after their actively-at-work dateTo HMO enrolleesA 12-month pre-x waiting period may apply to employees or dependents enrolling in the ActiveCare PPO plans due to:A special enrollment eventA 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)Pre-existing condition exclusions do not apply to any individual under age 19, employees that initially enroll when the district/entity begins participating in TRS-ActiveCare or to new hires who enroll within 31 days after their actively-at-work date. Exception: If the employee was covered under TRS-ActiveCare at any point in time since its inception in 2002 and has been hired by a different participating district/entity (or rehired by the same participating district/entity), pre-existing limitation exclusions may apply. A 12-month pre-existing condition waiting period may apply to employees or dependents enrolling in ActiveCare 1-HD, 2 or 3 due to:A special enrollment eventA 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.Prior creditable coverage may be used to offset a pre-existing condition waiting period unless followed by a gap in coverage of 63 or more consecutive days. Most health coverage is creditable coverage, including, but not limited to, coverage under a group health plan, HMO, an individual health policy, COBRA, Medicaid, or Medicare. It is important that information about prior coverage be provided by attaching a certificate of creditable coverage to the Enrollment Application and Change Form. Gaps in prior coverage may impact creditable coverage. If the certificate of coverage reveals a gap in coverage exceeding 63 days, it cannot be counted toward the pre-existing condition waiting period.
45 Making Changes/Special Enrollment Events 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 occursNew dependentMarriage, birth, adoption or placement for adoptionSpecial rules apply to newbornsLoss of other coverageChanging districts/entities is not considered a special enrollment eventAn employee may be able to enroll for coverage, change plan options, or change the dependents he or she covers during a plan year if the employee or dependent has a special enrollment event. Changes in employee and/or dependent coverage must be made within 31 days after the special enrollment event. (Special rules apply to newborns; see page 19 of the Enrollment Guide—and next slide—for more information.) If the employee does not request the appropriate changes during the applicable special enrollment period, the changes cannot be made until the next plan enrollment period or, if applicable, until another special enrollment event occurs.One example of a special enrollment event is gaining a new dependent as a result of marriage, birth, adoption, or placement for adoption. Note that a common law marriage is not considered a special enrollment event unless there is a Declaration of Common Law Marriage filed with an authorized government agency.Another example of a special enrollment event is loss of other coverage. Loss of coverage qualifies as a special enrollment event if:The employee and/or dependent(s) lost other coverage due to a loss of eligibilityThe employee and/or dependent(s) elected to drop the other group health coverage because the employer stopped all employer contributions toward the premium (including any employer-paid COBRA premium)The employee and/or dependent(s) exhausted their COBRA continuation coverageChanging districts/entities is not considered a special enrollment event under TRS-ActiveCare.
46 Newborns Covered first 31 days if employee has coverage Does not apply to newborn grandchildrenMust 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 enrollmentPlan changes must be made within 31 days after the newborn’s date of birthNot necessary to wait for newborn’s Social Security numberSubmit application without SSN to enrollRe-submit another form after SSN is issuedNo rule changes, but always worth mentioning: Throughout the Administrative Guide and the new Enrollment Guide, you’ll see references to "Special rules apply to newborns" with information about making changes/adding coverage. Here are the rules for newborns: TRS-ActiveCare automatically provides coverage for a newborn child of a covered employee for the first 31 days after the date of birth. To add coverage for the newborn, the employee must sign, date and submit an Enrollment Application and Change Form to the Benefits Administrator within 60 days after the date of birth. However, an employee has up to one year after the newborn's date of birth to add the newborn to coverage if the employee has employee and family or employee and child(ren) coverage with TRS-ActiveCare at the time of the newborn’s birth and at the time of enrollment.Even though the employee has more time to add a newborn to coverage as described above, changing plans must be made within 31 days after the newborn’s date of birth.Note: It is not necessary to wait for the newborn’s Social Security number to enroll. The employee should submit an Enrollment Application and Change Form without the Social Security number to add coverage and re-submit another form or use Blue Access for Employers once the number has been issued.
47 Cost for Health Coverage Your Cost for CoverageChapter 1581, Texas Insurance Code, authorizes funding to help active employees who are TRS members—those making retirement contributions to the Teacher Retirement System of Texas—pay for TRS-ActiveCare coverage. Each district is required to contribute at least $150 per month per active TRS member for coverage. The state will contribute $75 per month per active TRS member. That’s a minimum of $225 per month to help you pay for health coverage.Plan Year
48 Funding to Help Offset the Cost of TRS-ActiveCare Coverage Cost of CoverageFunding to Help Offset the Cost of TRS-ActiveCare CoverageDistrict/Entity (minimum)$198.33State of Texas$75Total Per Month$273.33Funding applies to active, contributing TRS membersCost charts illustrate the monthly gross premiumsChapter 1581, Texas Insurance Code, authorizes funding to help active employees who are TRS members—those making retirement contributions to the Teacher Retirement System of Texas—pay for TRS-ActiveCare coverage. Currently, each district/entity is required to contribute at least $150 per month per active TRS member for coverage. (Your participating district/entity may contribute more.) The state currently contributes $75 per month per active TRS member. That’s a minimum of $225 per month to help employees pay for health coverage. This amount significantly reduces what employees will owe per month for the TRS-ActiveCare plan that they choose.State funding is subject to appropriation by the Texas Legislature. The rates shown in the Administrative Guide and the Enrollment Guide are the gross monthly premiums and do not include any funding amounts. Benefits Administrators are encouraged to develop cost sheets that help employees determine their net monthly costs.
49 Monthly Cost for Coverage See page 17 of Enrollment Guide$ in district/entity and state funds to help pay for coverageThis chart appears on page 17 of your Enrollment Guide. It shows the total cost for each of the TRS-ActiveCare plan options.Chapter 1581, Texas Insurance Code, authorizes funding to help active employees who are TRS members—those making retirement contributions to the Teacher Retirement System of Texas—pay for TRS-ActiveCare coverage. Currently, each district/entity is required to contribute at least $150 per month per active TRS member for coverage. (Your participating district/entity may contribute more.) The state currently contributes $75 per month per active TRS member. That’s a minimum of $225 per month to help employees pay for health coverage. This amount significantly reduces what employees will owe per month for the TRS-ActiveCare plan that they choose.State funding is subject to appropriation by the Texas Legislature. The rates shown in the Enrollment Guide are the gross monthly premiums and do not include any funding amounts. See your Benefits Administrators to determine your net monthly cost.Note: New hires may choose their actively-at-work date (the date they start to work) or the first of the month following their actively-at-work date as their effective date of coverage. If choosing the actively-at-work date, the full premium for the month will be due; premiums are not pro-rated.
50 Application to Split Premium Married couples working for different participating entities may “pool” fundsOptionalRequires an Application to Split Premium form to be completed by both employees and employersForm available onlineIf a husband and wife work for different participating entities and which to “pool” funds, an Application to Split Premium must be completed. For the husband and wife who choose this option, the cost of coverage will be split between and billed to the two employers. Each employer will be billed 50% of the total cost of coverage. The entity employing the spouse who declined coverage will consider the employee as covered under a group health plan for funding purposes.Each employee and their Benefits Administrator must complete their portion of the Application to Split Premium form which is available on the TRS-ActiveCare website, This form should be submitted to Blue Cross and Blue Shield of Texas with the Enrollment Application and Change Form.This form should not be used by employees working for the same entity.
51 ID Cards (mailed to your home) PPO plans (ActiveCare 1-HD, 2 and 3)Separate cards for medical and prescription drugsBlue Cross and Blue Shield of TexasExpress ScriptsBCBSTX 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 participantsHMO plansAll HMO participants will receive new cardsEach individual covered under the plan will receive a cardID CardsIf an employee submits an Enrollment Application and Change Form by May 24, 2013, he or she will receive a new ID card by September 1, If an employee submits an application or change after May 24, he or she may not receive an ID card until October 1.Since there were no medical plan changes affecting the information on the medical plan ID cards, existing plan participants in the ActiveCare 1-HD, 2 and 3 plans will not receive new ID cards unless changing plans. (ID cards do not expire.)All HMO enrollees will receive new identification cards for the plan year.ActiveCare 1-HD, 2 and 3: For the medical benefits, administered by Blue Cross and Blue Shield of Texas, employees with "employee-only" coverage will receive one card; employees with "employee and spouse" or "employee and children" or "family" coverage will receive two cards. Additional cards may be ordered from Customer Service at no charge.The cards should begin mailing in early August and be received before the effective date of coverage (September 1, 2013).All ID cards include a unique identification number instead of a Social Security Number (SSN). New cards will be mailed to employees by September 1, Multiple cards may be received. For example: If a plan participant receives a new ID card and subsequently makes a change during the summer (August) enrollment period, an updated card will be sent after the change is processed.
52 Online Enrollment Support Available online –andEnrollment guideSummary of Benefits and Coverage (SBC)Downloadable forms (application and change form, application to split premium, claim form, etc.)Provider locatorEnrollment presentationThe Web is an excellent source for additional information. We have placed a link on the TRS-ActiveCare home page for Benefits Administrators. Log on to view the following:Enrollment guide (English and Spanish)Benefits summaries/highlightsDownloadable forms (application, split premium, claim form, etc.).Provider locatorFrequently asked questionsYour Administrative Guide—pages 56 to 57—contains a reference chart of website features and provides details for navigating the site, including key links to all the available health plans.Also available: Enrollment Presentation. The employee enrollment presentation with speaker notes is available online. The presentation is done in PowerPoint and is available on the website (under the "For Benefits Administrators" link) for you to download and customize for your district/entity.
53 Blue Access for Members Enrollment InfoBlue Cross and Blue Shield of Texas has a custom website for TRS-ActiveCare PPO plan participants and all Benefits Administrators. By selecting Blue Cross and Blue Shield of Texas or the For Benefits Administrators links on the TRS-ActiveCare website, you’ll be directed to the BCBSTX home page for TRS-ActiveCare. (You can also access the site directly through From this page, you can select the For Benefits Administrators tab and access information just for you.53
54 Blue Access for MembersSM Online member management toolResearch health conditionsView claims history and print Explanation of Benefits (EOB) statementsLocate a network doctor or hospitalOrder additional ID cards, or print a temporary IDTake a confidential health assessmentSend secure messages to BCBSTX Customer AdvocatesMonday thru Friday7 a.m. to 10 p.m. (CT)EOBs are available online; you must log in and elect to receive paper copiesBlue Access for Members is a secure portion of the BCBSTX website that ActiveCare 1-HD, 2 and 3 plan participants can use to access their personal membership and claims information.Plan participants may:check the status of a claim and view claim summariesprint Explanations of Benefitsreceive notification when claims are filedconfirm covered dependentsorder additional or replacement ID cards and print a temporary ID cardsend an inquiry to Customer Service with Live Chat. Send secure messages directly to BCBS Customer Advocates. Live Chat is available Monday through Friday from 7 a.m. to 10 p.m., Central Time.Blue Access is also the doorway to other health benefits tools, such as:Cost EstimatorWell onTarget wellness portal, where you can take a confidential health assessment.
55 Blue Access MobileSMBlue Access for MembersSM Secure Site – Log-in RequiredID CardMy Coverage – Benefits / EligibilityVisits and ClaimsHealth and Wellness – Diabetes, Obesity, Nutrition, Fitness, Metabolic Syndrome, Maternity Care, Member Care ProfileUser ProfileRegister for Blue Access for MembersText Messaging Static – One-Way SMS Messaging Diabetes Management, Claim Status Notification AlertsDynamic – Two-Way Messaging member initiates text with keyword (ID Card Management)Public Site – No log-in requiredHealth Care 101Find a Doctor or HospitalBlue Access for Members Log-inContact InformationProvider Finder App For iPhone® and Android® phonesNow members can connect to information wherever they are.Mobile features accessible for everyone – from a web-enabled phone, and personal information for registered BAM members plus texting on any phone with text capabilities – no web required.Find a Doctor or Hospital: Locate in-network providers by name / specialty, find nearest urgent care by city or by ZIPBlue Access for Members Log-in: Allows members to log into secure mobile site or register directly from mobile phoneContact Us: Phone and mail contact informationProvider Finder Smartphone App For iPhone® and Android® phones:Locate in-network providers by name / specialtyLink to map and directionsAdd provider information to contactsLocate nearest urgent care facility by ZIP or using phone’s GPS locationiPhone App can be downloaded on the iPad®Blue Access for MembersID Card: Instant digital membership card Coverage effective date, ID number, member IDCoverage: Benefits and eligibility – deductibles, coinsurance, copays, covered dependents, out-of-pocket maximumsClaims: Claim status by patient, date or statusHealth and Wellness articles and information: Diabetes, Obesity, Nutrition, Fitness, Metabolic Syndrome, Maternity Care, Member Care Profile
56 What if I Have Questions? Personalized ServiceCall TRS-ActiveCare customer service for:Claim questions/statusNetwork provider informationMembership and eligibilityMedical and Rx coverage questionsInquiries (telephone and )ID card requestsTransition of care informationHelp with online tools!Questions? The ActiveCare 1-HD, 2 and 3 customer service team can help answer your questions about your claims, medical coverage, prescription drug coverage, and eligibility. They can also assist you with ID card requests, transition of care information and help with online tools such as Blue Access for Members, the cost estimator tool and the new Benefits Value Advisor benefit as well as the new online health assessment.Customer Service