Presentation on theme: "Health Care Coverage for You and Your Family! Welcome."— Presentation transcript:
Health Care Coverage for You and Your Family! Welcome
2 Agenda Who is eligible to enroll Plan options and whats new Cost of health coverage How to enroll Enrollment support Questions
3 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 Health care coverage for public school employees and their families
4 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 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.
5 Eligible Dependents Spouse (including a common law spouse) Unmarried children under age 25 –Natural child –Adopted child –Stepchild –Foster child Other eligible dependents listed in Enrollment Guide –Grandchildren (unmarried) –Disabled children (unmarried, of any age)
6 Newborns Covered the first 31 days if employee has coverage To continue coverage, employee must add newborn within 60 days after the date of birth However, an employee has up to one year after the newborns 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
ActiveCare 1, 2 and 3 PPO Plan Options
8 Whats New for ? ActiveCare 1, 2 and 3 No premium increase No benefit changes Emphasis on health and wellness New plan features available April 1, 2008 –Blue Care Connection –24/7 Nurseline –Personal Health Manager (PHM) online health and wellness resource –Live Chat secure, online real-time access for customer service inquiries
9 PPO Network for ActiveCare 1, 2 and 3 Largest PPO network in the state Includes over 50,000 physicians and over 400 hospitals in Texas Available in all 254 Texas counties Advantages to using network providers Receive highest level of benefits No claims to file No balance billing Need to locate a Network Provider?
10 Plan Overview ActiveCare 1ActiveCare 2ActiveCare 3 Deductible (individual/family) $1,100/$3,000$500/$1,500None Out-of-Pocket Maximum (individual/family) $2,000/$6,000 $1,000 per individual Coinsurance (Plan pays/participant pays) 80%/20% Office Visit Copay 20% after deductible $25 for primary $35 for specialist $20 for primary $30 for specialist Illustrates benefits when network providers are used. Non-network benefits are also available; see Enrollment Guide for more information.
11 Plan Overview ActiveCare 1ActiveCare 2ActiveCare 3 Preventive Care Routine physicals* Well-woman exams* Routine mammograms * Eye exams* Well-baby exams Immunizations Hearing exams PSA screenings Colorectal screenings Osteoporosis screenings * Services limited to one per person per plan year $0 copay up to $500 per person, per plan year Remaining charges subject to deductible and coinsurance $25 for primary $35 for specialist Includes all preventive care services billed with an office visit by a network doctor Coinsurance applies when no office visit is billed or when services are performed outside the office (deductible waived) $20 for primary $30 for specialist Includes all preventive care services billed with an office visit by a network doctor Coinsurance applies when no office visit is billed or when services are performed outside the office (no deductible) Illustrates benefits when network providers are used. Non-network benefits are also available; see Enrollment Guide for more information.
TRS-ActiveCare is administered by Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of Texas provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Blue Care Connection ® Health and Wellness Programs
13 Advice anytime. Round-the-clock health and the wellness advice from licensed professionals 24/7 Nurseline Advice isnt just needed from 9 to 5. 24/7 Nurseline is here to help. Nurses provide health advice and information about high fevers, earaches, cuts and bruises and more Audio health library on topics such as kicking the smoking habit and ways to get a good nights rest Available in English and Spanish 24/ New!
14 Personal Health Manager New! Your online wellness experience begins here: Take a Health Risk Assessment Improve your health with theEat Right nutrition planner Create a fitness plan to suit your personal health goals and needs with Get Fit Click on the Personal Health Manager icon on Blue Access ® for Members
15 Ask the experts. Expert advice from licensed professionals via the Personal Health Manager Ask-A Online Advisor Expert advice at your fingertips. Our Ask-A feature is here to help. Ask a Trainer, Dietitian or Life Coach: Send questions about fitness, nutrition, or managing stress. Ask a Nurse: Interact online with a Blue Care Advisor on non-emergency, health-related questions using the secure Ask a Nurse feature. CONFIDENTIAL AND SECURE Receive a response within one business day
16 Stay motivated. Earn Blue Points SM in the Personal Health Manager Blue Points SM Incentives ActiveCare 1, 2 and 3 plan participants and their covered dependents accumulate Blue Points SM in the Personal Health Manager. Complete designated health and wellness activities Report completed activities in the Personal Health Manager Track your available balance Redeem earned Blue Points SM for a variety of items!
17 Weight Management Program Support for a Healthier You Tobacco Cessation Program Support for members who want to quit Weight Management and Tobacco Cessation Self-Paced Approach Online tools and resources via the Personal Health Manager Secure outreach to keep members on track Personalized Lifestyle Management Support Counseling and coaching with licensed Wellness Coaches Motivational toolkit 24/7 Nurseline Referrals when appropriate
18 Expecting? Special Beginnings ® Program Special Beginnings is a confidential, full- featured program helping you to better understand and manage your pregnancy. A pregnancy risk assessment to determine the risk of your pregnancy and provide you with close monitoring through a series of follow-up calls from an experienced obstetrical nurse. A welcome packet full of congratulatory gifts including: –Baby bath and soap samples –Cleansing cloths –Nursing pads –Coupons for baby products Magazines that help you learn more about pregnancy and parenting
19 Live Chat Secure Online Customer Service Send inquiries to customer service via Immediate access to BCBSTX customer advocates Available Monday – Friday, 7 a.m. to 10 p.m. (CT) New!
20 What if I Have Questions? Personalized Service Call the TRS-ActiveCare customer service team for: Claim questions/status Network provider information Membership and eligibility Medical coverage questions Inquiries (telephone and ) ID card requests Transition of care information Help with online tools! Customer Service
21 Online member management tool. Check claim status, view and download EOBs (Explanations of Benefits) Order additional ID cards, and print temporary ID Send secure messages to BCBS Customer Advocates Monthly health articles Links to health information and wellness tools and resources Blue Access ® for Members Online Member Management Tool
Prescription Drugs ActiveCare 1, 2 and 3
23 Your Medco Prescription Drug Plan Your TRS-ActiveCare health plan has two prescription drug components –Blue Cross and Blue Shield of Texas manages your medical plan expenses, including prescription drug expenses under ActiveCare 1 –Medco manages your prescription drug plan expenses for ActiveCare 2 and 3
24 Your Medco Prescription Drug Plan Medco has its own mail-order pharmacy – Medco By Mail – which delivers medications to your home at a lower cost Medcos 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
25 Specific Rx Benefit Information If you are taking a long-term medication, filling your prescriptions through Medcos mail-order pharmacy provides several benefits: –You receive a 90-day supply of your medication at a lower copay –You have access to Specialist Pharmacists who receive additional training in conditions such as asthma, diabetes, heart disease and more –While retail pharmacists know the medications you fill at one pharmacy, Medcos Specialist Pharmacists have a complete view of all of your medications so they know if there are potential safety issues and will contact you and your doctor to discuss these issues You have access to specialist pharmacists whether you fill your prescription at a retail pharmacy or at Medco By Mail Your medication questions can be answered by calling
26 Prescription Drug Benefits ActiveCare 1ActiveCare 2ActiveCare 3 Drug Deductible (per person, per plan year) Subject to $1,100 plan year deductible $50 Retail Short-Term (up to 30-day supply) Generic/Preferred Brand/Non- Preferred Brand 100% of the discounted cost at the time of purchase; 80% will be reimbursed by Blue Cross and Blue Shield of Texas after deductible $10 $25* $45* $10 $25* $40* Retail Maintenance (after second fill, up to 30-day supply) Generic/Preferred Brand/Non- Preferred Brand $15 $35* $60* $15 $35* $55* Medco by Mail (up to 90-day supply) Generic/Preferred Brand/Non- Preferred Brand $20 $62.50* $112.50* $20 $62.50* $100* * 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.
27 Prescription Drug Benefits ActiveCare 2 and 3: Applying the Deductible Example 1Claim cost less than $50 Deductible Once the deductible is satisfied, the member pays the applicable copay Member-paid cost differences between a brand-name drug and a generic equivalent do not apply to the deductible Member cost share will not exceed the cost of the medication Total Cost Deductible Applied Copay Deductible Remaining First Fill$37 $13 Second Fill$37$13$13 + copay$0
28 Prescription Drug Benefits ActiveCare 2 and 3: Applying the Deductible Example 2Claim cost more than $50 Deductible Total CostDeductible Applied CopayDeductible Remaining First Fill$100$50$25$0 Next Fill$100$0$25$0 Once the deductible is satisfied, the member pays the applicable copay Member-paid cost differences between a brand-name drug and a generic equivalent do not apply to the deductible Member cost share will not exceed the cost of the medication.
29 Information Resources TRS Web site – –Pharmacy Benefit Highlights –List of maintenance medications –FAQs –Download forms Medco Member Web site – –Prior Authorization List –Formulary Information –Locate a Participating Pharmacy –Health and Wellness Information –My Rx Choices ® / Price a Medication –Online Ordering –Download forms Customer Service Number Benefits Booklet
30 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 medications that you or covered family members take on an ongoing basis. –Best-value alternatives based upon greatest cost savings to you presented in order from highest value to member –Brand-to-generic and retail-to-mail compare options available –Easy-to-understand explanations of complicated concepts –The average amount saved by My Rx Choices users is $294! Your doctor knows which medications are right for you but you may not know how much they cost. My Rx Choices provides you with available lower-cost options so that you and your doctor can make the most informed decisions based on health and cost. Simply visit Youll to take a moment to register before using this service. You can also call
31 My Rx Choices Available through Customer Service or on The My Rx Choices home page allows the user to: - Select a patient (pre- populated with all covered household members) - Select a drug to compare from a pre- populated list of prescriptions for the user. Your potential savings are clearly presented.
32 My Rx Choices Medco can facilitate on generic equivalents received through mail order
33 My Rx Choices Members may print a kit to discuss lower-cost alternatives with their doctor
34 Refill your medication at when you use Medco By Mail Sign-up for Refill Reminders at Speak to a specialist pharmacist about the medications you are taking for a specific condition Send s to Customer Service and to Medco pharmacists through the Medco member Web site More about Your Rx Benefits
35 Medco Tour of Champions An endorsement campaign featuring six Olympic gold medalists – each with a chronic or complex condition Promotes Specialist Pharmacists as providing a higher level of care for people with chronic and complex conditions like asthma and diabetes Campaign runs through 12/08
Plan Year Cost for Health Coverage
37 Coverage Categories Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
38 Monthly Cost of Coverage Page 35 of the Enrollment Guide
39 Application to Split Premium 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 both employers
Plan Year How to Enroll
41 How to Enroll 2 Complete an Enrollment Application and Change Form Available in the Enrollment Guide Also available online 1 Choose your health plan 3 Sign, date and submit form to your Benefits Administrator
42 How to Enroll If you do not wish to make changes to your current health benefit plan, you do not need to submit an enrollment application form –You will be enrolled in the same plan you selected for at the same level of coverage To decline coverage: You must complete and submit a form – even if you have declined coverage before
43 Can Changes in Coverage Be Made After Your Application Has Been Submitted? Changes can be made up to the end of your enrollment period Plan choices will remain in effect through August 31, 2009 unless theres a special enrollment event such as: –Marriage or divorce –Birth, adoption or placement for adoption of a child –A child marries or reaches age 25 –A court order to provide health coverage for an eligible child –Loss of coverage Changes must be made within 31 days after the event date (special rules apply to newborns) New application must be submitted for any change
44 Cafeteria Plan Vendor(s) Making a change through the Section 125 vendor does not automatically generate a change to coverage under TRS-ActiveCare All changes to TRS-ActiveCare must be signed, dated and submitted on an Enrollment Application and Change Form
45 Are There Preexisting Condition Exclusions? Pre-x does not apply to 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 If 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) unless gap in coverage is less than 63 days and the employee has proof of prior creditable coverage A 12-month pre-x condition waiting period may apply due to: –A special enrollment event –A future plan enrollment period (to be determined by TRS for each plan enrollment period) –A transfer to another participating district/entity (or rehire) if the employee or any covered dependent has any remaining preexisting waiting period or a gap in coverage greater than 63 days Pre-x waiting period may be reduced by creditable coverage
46 Important Notice Supplemental Coverage TRS does not offer or endorse any supplemental coverage for any of the health coverage plans available under TRS-ActiveCare To obtain information about any coverage that claims to be a companion or supplement to any TRS-ActiveCare plan, employees should contact: –The organization making such offering and/or –The Texas Department of Insurance (TDI) or the TDI Consumer Helpline (800)
47 Your TRS-ActiveCare ID card will be mailed to your home ActiveCare 1, 2 and 3 –New ID cards will not be issued to current participants unless changing plans; new enrollees will receive new cards HMO plans –All HMO participants will receive new cards (except for Scott and White Health Plans) –Each individual covered under the plan will receive a card
48 Enrollment Support Dedicated Customer Service ActiveCare 1, 2 or (Blue Cross and Blue Shield of Texas and Medco) FirstCare Health Plans Legacy Health Solutions Mercy Health Plans Scott and White Health Plan Valley Baptist Health Plans
49 Enrollment Support Available Online Enrollment guide (English and Spanish) Downloadable forms (enrollment application, split premium, claim form, etc.) Provider locator Frequently asked questions