Health care coverage for you and your family! Welcome

Agenda TRS-ActiveCare What’s new this year Who is eligible to enroll Plan options Cost of health coverage How to enroll Enrollment support Questions

Key Points to Remember TRS-ActiveCare is good health coverage and TRS is proud to offer it Dedicated Customer Service Dedicated Web site: –Online application tutorial –Online application –Online provider and pharmacy searches –FAQs

What is TRS-ActiveCare? TRS-ActiveCare established by Chapters 1579, Texas Insurance Code A statewide health care benefits program for employees of school districts, charter schools, regional education service centers, and other educational districts Chapters 1580 and 1581, Texas Insurance Code established funding to help pay for health coverage

What’s New for ? Everyone will have access to these three TRS-ActiveCare preferred provider organization (PPO) plans …And many people will also have access to one or two of these three TRS-ActiveCare health maintenance organizations (HMOs) ActiveCare 1 ActiveCare 2 ActiveCare 3 FIRSTCARE Mercy Health Plans Scott and White Health Plan

What’s New for ? Supplemental Compensation –$500 (paid in monthly installments) for full-time, non-professional employees –$250 (paid in monthly installments) for part-time, non-professional employees –$0 for professionals

What’s New for ? 90-Day Waiting Period for TRS Membership, Supplemental Compensation and $75 State Funding –Applies to new hires beginning employment on or after September 1, 2003 who are not TRS members on first day of employment –No required waiting period for TRS-ActiveCare coverage –New hires may delay effective date of coverage until the first of the month in which TRS membership begins –Waiting period does not apply to contributing TRS members

Regularly work 10 or more hours per week? Active contributing TRS member? You are not eligible If No You may be eligible If Yes Employees Eligible to Enroll

Employees NOT Eligible to Enroll State of Texas employees or retirees Higher education employees or retirees TRS retirees, including those back at work 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

Eligible Dependents Spouse (including a common law spouse) Unmarried children under age 25 –Natural child –Adopted child –Stepchild –Foster child

More Eligible Children A child under the legal guardianship of the employee Another child in a regular parent-child relationship with the employee: –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 –The employee has the legal right to make decisions regarding the child's medical care A grandchild whose primary residence is the household of the employee and who is a dependent of the employee for federal income tax purposes

More Eligible Dependents Unmarried children (any age) mentally retarded or physically incapacitated Any other dependents required to be covered under applicable law Newborns are automatically covered by TRS-ActiveCare for the first 31 days after birth. An Enrollment Application and Change Form must be signed and submitted within 60 calendar days after the date of birth to continue coverage for the newborn.

CHIP Program Families may qualify for low cost children’s health insurance through the TexCare Partnership and Children’s Health Insurance Program (CHIP) Benefits include doctor/hospital visits, prescriptions, coverage for preexisting conditions, dental, eye care and more Call TexCare Partnership at or log on to A child cannot receive coverage under both an employer-sponsored health care plan such as TRS-ActiveCare and CHIP

Selecting a Plan Option

Selecting a Health Plan Option Do you have access to other health coverage? How do the cost and provisions compare with TRS-ActiveCare? Is your current physician in one of the networks? Are you willing to change physicians if your current physician is not in the network?

PPO Features ActiveCare 1, ActiveCare 2 and ActiveCare 3 Administered by Blue Cross and Blue Shield of Texas and Medco Health No primary care physician (PCP) required; no referrals required to see a specialist Select any provider for care within the PPO network or outside the network When you receive care inside the network, you receive the highest level of benefits When you receive care outside the network, you still have coverage but you may pay more of the cost Worldwide coverage for emergency and non-emergency care

HMO Features FIRSTCARE, Mercy Health Plans, and Scott & White Health Plan Live, work or reside within the HMO service area Primary Care Physician (PCP) must coordinate care to receive benefits Choose a different PCP for each family member or select the same one for the entire family Females may choose a network OB/GYN and schedule appointments with that physician without a PCP referral Worldwide coverage for emergency care No preexisting condition exclusions apply

What Plan Options Are Available In Your Area?

ActiveCare 1, 2 and 3 PPO Plans Statewide Service Area

FIRSTCARE HMO Plan Service Area: Panhandle, West Texas and Central Texas

Mercy Health Plans HMO Plan Service Area: South Texas

Scott & White Health Plan HMO Plan Service Area: Central Texas

PPO Plan Options ActiveCare 1, 2 and 3

Coverage Features Network Providers –Receive highest level of benefits –No claims to file –No balance billing ParPlan Providers –Receive non-network level of benefits –No claims to file –No balance billing Non-Network Providers –Receive non-network level of benefits –Must file own claims –May be billed for charges exceeding allowable amount

Coverage Outside Texas BlueCard PPO Program (for enrollees living or traveling outside of Texas) Access to more than 624,000 physicians and 6,000 hospitals nationwide PPOs can be found in 49 states, District of Columbia and Puerto Rico Network level of benefits Claims filed by providers No balance billing

Deductibles (Plan Year) ActiveCare 1ActiveCare 2ActiveCare 3 NetworkNon-NetworkNetworkNon-NetworkNetworkNon-Network $1,000 Individual $3,000 Family $500 Individual $1,500 Family None $500 Individual $1,500 Family

Coinsurance ActiveCare 1ActiveCare 2ActiveCare 3 NetworkNon-NetworkNetworkNon-NetworkNetworkNon-Network Plan Pays (after deductible) 80%60%80%60%85%65% You Pay 20%40%20%40%15%35%

Preventive Care Copay ActiveCare 1ActiveCare 2ActiveCare 3 Network Non- Network Network Non- Network Network Non- Network 20% after deductible 40% after deductible $25/$35 per visit 40% after deductible $20/$30 per visit 35% after deductible Office Visit Copay ActiveCare 1ActiveCare 2ActiveCare 3 Network Non- Network Network Non- Network Network Non- Network $15 per visit (up to $500 per person, per plan year) 40% after deductible $25/$35 per visit (up to $500 per person, per plan year) 40% after deductible $20/$30 per visit 35% after deductible

Out-of-Pocket Maximum (excludes copays and deductibles) ActiveCare 1ActiveCare 2ActiveCare 3 NetworkNon-NetworkNetworkNon-NetworkNetworkNon-Network $2,000 Individual $6,000 Family $2,000 Individual $6,000 Family $1,000 per Individual $3,000 per Individual

Precertification Required All inpatient hospital stays Treatment of all serious mental illness, mental health care and chemical dependency Home health care Hospice Skilled nursing facility Home infusion therapy

Prescription Drug Benefits ActiveCare 1, 2 and 3

Prescription Drug Benefits Retail and Home Delivery pharmacy benefits Some drugs may require prior authorization New written prescriptions are required for Home Delivery for new enrollees Online technology

Prescription Drugs—ActiveCare 1 You pay 100% at the time of purchase, and will be reimbursed 80% after your deductible You pay 100% of the discounted cost at the time of purchase, and will be reimbursed 80% after your deductible You pay 100% of the discounted cost at the time of purchase, and will be reimbursed 80% after your deductible Non - NetworkNetwork Home Delivery (up to 90-day supply) Retail (up to 30-day supply)

*Note: When using a non-network pharmacy, you must pay the entire cost and submit a claim form to Medco Health. You will be reimbursed the amount that would have been charged by a network pharmacy, less the required copayment. Prescription Drugs—ActiveCare 2 Pay cost Submit claim* $20 generic $50 preferred $90 non-preferred $10 generic $25 preferred $45 non-preferred Non - NetworkNetwork Home Delivery (up to 90-day supply) Retail (up to 30-day supply)

Prescription Drugs—ActiveCare 3 Pay cost Submit claim* $20 generic $50 preferred $80 non-preferred $10 generic $25 preferred $40 non-preferred Non - NetworkNetwork Home Delivery (up to 90-day supply) Retail (up to 30-day supply) *Note: When using a non-network pharmacy, you must pay the entire cost and submit a claim form to Medco Health. You will be reimbursed the amount that would have been charged by a network pharmacy, less the required copayment.

Prescription Drugs—ActiveCare 2 & 3 If a brand-name prescription is dispensed when a generic is available Example You pay: Generic copay plus the difference in cost between the brand-name prescription and what the cost would be if you had purchased the generic, regardless of doctor DAW (Dispense As Written). Full price of brand-name Full price of generic (Difference) Plus retail generic copay You pay $ $ $60

Online Technology- Online services available prior to enrollment: Access pharmacy benefits highlights Compare pricing and coverage for brand name and generic medication for both home delivery and retail Locate network participating retail pharmacies Find drug information Additional online services available after enrollment: Request refills and renewals through home delivery pharmacy Check status of orders Access health and wellness information

HMO Plan Option FIRSTCARE

FIRSTCARE Service Area 81 counties across Texas

FIRSTCARE No claim forms or deductibles Coverage for preexisting conditions Emphasis on preventive health care Extensive provider network Direct access to designated OB/GYN Worldwide emergency care Regional offices

FIRSTCARE Benefit Copay PCP office visit$15 Specialist office visit$30 Preventive care$15 Outpatient surgery $150 Inpatient hospital$150per day ($750 maximum) Emergency room $75(waived if admitted) Urgent care $25 Out-of-pocket maximum2x total plan year cost of coverage

FIRSTCARE — Prescription Drugs $20 generic $40 preferred $80 non-preferred $10 generic $20 preferred $40 non-preferred Mail Order (up to 90-day supply) Retail (up to 30-day supply)

FIRSTCARE — Prescription Drugs If a brand-name prescription is dispensed when a generic is available Example You pay: Generic copay plus the difference in cost between the brand name prescription and what the cost would be if you had purchased the generic, regardless of doctor DAW (Dispense As Written). Full price of brand-name Full price of generic (Difference) Plus retail generic copay You pay $ $ $60

HMO Plan Option Mercy Health Plans

Mercy Health Plans Service Area 4 Texas counties: –Webb –Jim Hogg –Zapata –Duval

Mercy Health Plans No annual deductibles or coinsurance No claim forms No lifetime maximum No preexisting condition limitations

Mercy Health Plans Low out-of-pocket expense Emergencies covered anywhere Case management –Diabetes mellitus –Hypertension –Asthma –Other chronic diseases CuraScript Injectable Program

Mercy Health Plans Mercy Health Plans ranked #1 on Consumer Assessment Health Plans Survey (CAHPS)* on the following: How people rated their plan Getting care that is needed How well doctors communicate Courtesy, respect, helpfulness of office staff * Office of Public Insurance Council

Referrals To visit a specialist, a referral is required from your PCP; however referrals are not required for the following: –Women may self refer to a designated OB/GYN –Ophthalmologist/optometrist (annual eye exam) –Orthopedic surgeon –Dermatologist If you receive non-emergency care outside the network or for a specialist without a referral from your PCP, you receive no benefit

Mercy Health Plans BenefitCopay PCP/Specialist office visit$10 Preventive care$10 Outpatient surgery $ 0 Inpatient hospital$ 0 Emergency room$50 (waived if admitted) Urgent care$25 Out-of-pocket maximum$1,000maximum (individual) $2,000maximum (family)

Infertility drugs are covered at 50% Mercy Health Plans—Prescription Drugs $10 generic $40 preferred $70 non-preferred $5 generic $20 preferred $35 non-preferred Mail Order (up to 90-day supply) Retail (up to 30-day supply)

HMO Plan Option Scott & White Health Plan

Scott & White Health Plan Service Area 34 counties across Texas

Scott & White Health Plan No claim forms Coverage for preexisting conditions Worldwide emergency care Prescription drug benefit Direct access to OB/GYN and ophthalmology Regional customer service centers in Georgetown, Temple, Bryan/College Station, and Waco. 24 hour Nurse ON CALL

Scott & White Health Plan A multi-specialty group practice with more than 500 physicians A 478-bed hospital A network of regional clinics in Central Texas “Excellent” status with 3 year accreditation by NCQA, 2000 “A-” rating by AM Best, 2002 Scott and White named one of Nations Top 100 Cardiovascular Hospitals* “Best of the Best” in Texas for overall health care, overall health plan and doctors that communicate well.** *Solucient 100 Top Hospitals® Cardiovascular Benchmarks for Success 2002 **1999 UltraLink National Satisfaction Survey

Scott & White Health Plan BenefitCopay PCP/Specialist office visit$ 25 Preventive care$ 25 Outpatient surgery $100 Inpatient hospital$200 per day ($1,000 maximum) Emergency room$100 (waived if admitted) Urgent care$ 40 Out-of-pocket maximum$2,000 per individual

Scott & White Health Plan — Prescription Drugs Generic$10 Preferred$40 Non-preferredlesser of $100 or 50% copay Non-formularyN/A Generic$5 Preferred$20 Non-preferredlesser of $50 or 50% copay Non-formulary50% copay Mail Order (up to 90-day supply) Retail (up to 30-day supply)

Scott & White Health Plan — Prescription Drugs $2,000 plan year maximum per person If a brand-name prescription is dispensed when a generic is available: –You pay: 50% of brand-name cost

Cost for Health Coverage

Funding Sources Full-Time Employees 30 or more hours each week Part-Time Employees Less than 30 hours each week Professional Employees Administrative or over $50K annually District (minimum) $ State of Texas$ Supplemental Compensation $ 41.66$ 20.83$ 0.00 Total Monthly Funding $266.66$245.83$225.00

Coverage Categories Employee Only Employee and Spouse Employee and Child(ren) Employee and Family

Choosing a Coverage Category If employee and spouse both work for a participating entity: –A spouse may be covered as an employee or as a dependent of an employee –Only one parent can cover dependent children

Choosing a Coverage Category A child (under age 25) employed by a participating entity and a contributing TRS member cannot be covered as a dependent The child must be covered as an employee of the participating entity If the child is not a contributing TRS member, the child may be covered as a dependent

Total Monthly Cost of Coverage

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 employers

How to Enroll

Who Needs to Enroll For new coverage or changes, complete an Enrollment Application and Change Form You must complete an application if declining coverage

How to Enroll Fill out entire paper Enrollment Application and Change Form, including all dependent information Print in blue or black ink and write clearly, or download form from Web site to type information and print Sign and return to Benefits Administrator You must complete an application to decline coverage.

Effective Date of Coverage If your district/entity begins participation in TRS-ActiveCare after September 1, 2003, your choices of effective date are: –The date the district/entity first begins participation in TRS-ActiveCare, or –The first of the month in which your TRS membership begins If you are a new hire of a participating district and you begin employment on or after September 1, 2003, your choices of effective date are: –Actively-at-work date (premium is due for the entire month) –The first of the month following your actively-at-work date, or –The first of the month in which your TRS membership begins

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, 2004 unless there’s a qualified status change such as: –Marriage –Divorce –Birth or adoption of a child, or –Loss of coverage from another group plan New application must be submitted for any change

Your TRS-ActiveCare ID card will be mailed to your home ActiveCare 1, 2 and 3 –Employee only: one card –All other coverage categories: two cards –Call Customer Service for additional cards HMO plans –Each individual covered under the plan will receive a card

Enrollment Support

Dedicated Customer Service ActiveCare 1, 2 or (Blue Cross and Blue Shield of Texas and Medco Health) FIRSTCARE Mercy Health Plans Scott and White Health Plan

What’s Available Online? Enrollment guide (English and Spanish, large print) Application tutorial Downloadable forms (enrollment application, split premium, etc.) Provider locator Frequently asked questions

Questions