Health Coverage for You and Your Family

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10 Δεκ 2013 (πριν από 3 χρόνια και 8 μήνες)

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Health Coverage for You and Your Family

Agenda


TRS
-
ActiveCare Program Highlights


Enrollment Summary


2013
-
2014 Health Plan Options


ActiveCare 1
-
HD, 2 and 3 PPO Plans


How to Enroll


Who is Eligible to Enroll


Cost of Coverage


Enrollment Support

2

Enrollment Summary

(Employees by Plan, Feb. 2013)

3

FirstCare Health Plans 2.5% Scott & White Health Plan 2.7% Valley Baptist Health Plans 0.5%

280,250 Employees
• 476,767 Members (Employees and Dependents)

PPO Plan Overview

ActiveCare

1
-
HD,
2
and 3 Plans

2013
-
2014
Plan
Year

New Deductible and Out
-
of
-
Pocket
Maximum for ActiveCare 1
-
HD

5


ActiveCare
1
-
HD meets IRS definition of a high deductible health
plan for all coverage tiers


May contribute pretax dollars into a health savings account
(HSA) to help pay for current health expenses and save for future
qualified medical and retiree health expenses on a tax
-
free basis


Individuals can establish an HSA with banks and credit unions





2012
-
2013 Plan Year

2013
-
2014 Plan Year

AC1

AC1
-
HD

AC1
-
HD

Deductible

(employee only/family)

$1,200/$3,000

$2,400/$2,400

$2,400/$4,800

Out
-
of
-
Pocket
Maximum

(employee only/family;

does not include
deductibles)

$2,000/$6,000

$3,000/$5,000

$3,850/$4,200

New Deductible and Out
-
of
-
Pocket
Maximum for ActiveCare 2

6

2012
-
2013 Plan Year

2013
-
2014 Plan Year

ActiveCare 2

ActiveCare 2

Deductible

(individual/family)

$750/$2,250

$1,000/$3,000

Out
-
of
-
Pocket Maximum

(individual/family;

does not include deductibles)

$2,000/$6,000

$4,000/$8,000

Family Deductible Illustration

Amy covers spouse and three dependents

7

$4,800

$1,000

$800

$400

Amy

Sue

Chris

Ted

Bob

Sue

ActiveCare
1
-
HD
with $
4
,
800
family deductible


The family deductible may be met by one or more
people


Plan pays benefits once entire $
4
,
800
is met
̶
there is
no individual deductible to meet


ActiveCare

2
with a $1,000 individual deductible and a $3,000 family deductible


Plan pays benefits for an individual as his/her deductible is met


Everyone helps to meet the family deductible, but no one person pays more than
the individual amount



Bob

$600

Amy

Ted

$200

Chris

Out
-
of
-
Pocket (OOP) Maximum Illustration

Amy covers spouse and three dependents

8

$4,200

$4,000

$
2
,
000

$600

Amy

Sue

Chris

Ted

Bob

Sue

ActiveCare
1
-
HD
with $
4
,
200
family OOP maximum


The family out
-
of
-
pocket maximum may be met by one
or more people


Plan pays benefits once entire $
4
,
200
is met
̶
there is
no individual amount to meet


ActiveCare

2
with a $4,000 individual and $8,000 family OOP maximum


Plan pays benefits for an individual as his/her OOP maximum is met


Everyone helps to meet the family OOP maximum, but no one person pays more
than the individual amount



Bob

$1,000

Amy

Ted

$400

Chris

PPO Network for ActiveCare

1
-
HD, 2 and 3

9

Non
-
Network:


You
pay more
of the cost
of out
-
of
-
network benefits


Higher deductibles,
coinsurance


You may need to

file your own claim


You could be

balance
billed

for amounts

over allowed

amount


Always verify provider network status

Network

Statewide

(all 254 counties)

No need

to
:


Select a Primary Care Physician


Obtain referrals for specialist care

Receive
highest level

of benefits:


Pay less for care


No balance billing

No claim forms


Provider files claim for you

PPO Plan Overview

(Network Level of Benefits)

10

ActiveCare 1
-
HD

ActiveCare 2

ActiveCare 3

Deductible


$2,400 employee only

$4,800 family

$1,000 individual

$3,000 family

$300 individual

$900 family

Out
-
of
-
Pocket
Maximum

(does not include copays
or deductibles)

$3,850 employee only

$4,200 family

$4,000 individual

$8,000 family

$1,000 per individual

Coinsurance

(Plan pays/

participant pays)

80% / 20%

80% / 20%

80% / 20%

Office Visit Copay

20% after deductible

$30 for primary

$50 for specialist

$20 for primary

$30 for specialist

Primary

means care provided by
family practitioners, internists, OB/GYNs

and

pediatricians.


All other physicians are specialists.

PPO Plan Overview

(Network Level of Benefits)

11

Preventive Care Clarification

Services

ActiveCare 1
-
HD

ActiveCare 2

ActiveCare 3

Preventive Care

Plan pays 100%

(deductible waived)

Plan pays 100%

(no copay required)

Plan pays 100%

(no copay required)

Routine eye exam
(one per plan year)

Hearing exam

20% after deductible

$30 for primary

$50 for specialist

$20 for primary

$30 for specialist


100% coverage for certain age
-

and gender
-
specific preventive
care services when network providers are used


Must be billed by provider as “preventive care”

PPO Plan Overview

(Network Level of Benefits)

12

Benefits (continued)

Services

ActiveCare 1
-
HD

ActiveCare 2

ActiveCare 3

High
-
tech
Radiology

(CT scan, MRI,

nuclear medicine)

20% after deductible

$100 copay per
service, plus 20%

after deductible

$100 copay per
service, plus 20%

after deductible

Inpatient Hospital

20% after deductible

$150 copay

per day, plus 20%

after deductible

($750 max copay per
admission; $2,250
max/year)

$150 copay


per day, plus 20%

after deductible

($750 max copay per
admission; $2,250
max/year)

Emergency Room

20% after deductible

$150 copay, plus 20%

after deductible

(copay waived

if admitted)

$150 copay, plus 20%
after deductible


(copay waived

if admitted)

Outpatient Surgery

20% after deductible

$150 copay

per visit, plus 20%

after deductible

$150 copay


per visit, plus 20%
after deductible

13

New!! Effective Sept.
1
,
2013


MRIs


CAT or CT Scans


Endoscopy procedures


Colonoscopy procedures


Back
or spinal surgery


Knee
surgery


Shoulder
surgery


Hip
or joint replacement surgery


Bariatric surgery

B
enefits
V
alue Advisor

Real
-
time access to
current cost and
quality transparency

Appointment
scheduling

Clinical decision

support tools

Understanding
benefits and
how to best use
them

Referrals to condition
management programs

Preauthorization

coordination

Help get benefits information

and find network providers for:

One
-
Call Solution: 1
-
866
-
355
-
5999 Customer Service

Prescription
Drugs

ActiveCare

1
-
HD,
2 & 3

2013
-
2014
Plan
Year

Your Prescription Drug Plan

15


Express Scripts administers your prescription
drug plans on behalf of TRS


ActiveCare 1
-
HD, 2, and 3 plans


Benefit includes both a retail and mail
component


Express Scripts has its own mail
-
order
pharmacy where specialist pharmacists focus
on compliance and lower cost options for the
patient, and the automated filling system
ensures the prescription is filled accurately.*
Express Scripts buys medication from the
most reputable suppliers

*Express Scripts’ mail
-
order pharmacies fill about 2 million prescriptions per week through a highly automated process that is
99.9997% accurate and is 23 times more accurate than a retail pharmacy

“Dispensing Error Rate in a Highly Automated Mail
-
Service Pharmacy Practice”; Nov. 2007,
Pharmacology
, a peer
-
reviewed

journal of the American College of Clinical Pharmacy

Prescription Drug Benefits



Network Level

16

*

If you obtain a brand
-
name drug when a generic equivalent is available, you are responsible for the generic copayment plus th
e cost difference
between the brand
-
name drug and the generic drug. Chart illustrates benefits when network pharmacies are used. Non
-
network ben
efits are also
available; see Enrollment Guide for more information.

Features

ActiveCare

1
-
HD

ActiveCare 2

ActiveCare 3

Drug Deductible

(per person, per plan year)

Subject to

plan year deductible

$0 generic;

$200 brand

$75

Retail Short
-
Term

(up to 31
-
day supply)

Tier 1 (Generic)

Tier 2 (Preferred Brand)

Tier 3 (Non
-
Preferred Brand)

20% coinsurance

after deductible




$20


$40*


$65*




$15


$35*


$60*

Retail Maintenance

(after
first
fill, up to

31
-
day supply)

Tier 1 (Generic)

Tier 2 (Preferred Brand)

Tier 3 (Non
-
Preferred Brand)





$25


$50*


$80*




$20


$45*


$75*

Mail Order and

Retail
-
Plus

(up to 90
-
day supply)

Tier 1 (Generic)

Tier 2 (Preferred Brand)

Tier 3 (Non
-
Preferred Brand)



$45

$105*

$180*



$45

$105*

$180*

Specialty Medications
(retail or mail)

20% coinsurance

after deductible

$200 per fill

$200 per fill

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 enroll.


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.


17

Specialized Care is the Key to

Quality Outcomes

Specialization and participant engagement are critical components
to controlling health care costs and driving quality clinical outcomes:



Specialist pharmacist



Online Tools



Closing gaps in care



My Rx Choices
®



Mobile App



Other available resources

18

Extremely Satisfied/Very Satisfied
with overall counseling experience

Specialist Pharmacists are specially trained to
counsel patients about their conditions and
connect with physicians and healthcare
coaches


Average patient call lasts 12 minutes


Calls are monitored and recorded for training


Pharmacists spend their time focused on a
single condition


Advanced tools let pharmacists see the
“whole patient” along with their drug

regimen across prescribers and pharmacies

97
% of
patients

Specialist Pharmacists are an integral

part of the healthcare continuum

19

“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

20

Omission

Not Using Controller
Medication for Asthma

Express Scripts’ online tools and mobile apps
help connect patients and their caregivers

Online prescription management:


Refills, renewals and order status


Worry
-
free Fills

®



Transfer to mail


Claims, balances and history


Locate a pharmacy


Preferences

Benefit education and management:


Benefit highlights


Forms and cards


Pricing and coverage details


New!
Accessibility features

Gap In Care Alerts

Help participants identify

and address potential safety issues with their
prescriptions

Pharmacy Care Online Alerts

21

Adherence

Omission

On track

Close
-
up: Sample Alert Message

22



Ability for patients
to self
-
close gaps
as appropriate



Information about
the alert and why
it’s important



Printable
information to take
to the doctor



Access to

email Express
Scripts pharmacists



Links to
additional
resources



Video clips
relevant to
each alert

My Rx Choices
®


Your online savings tool


Lower your cost for prescriptions with My Rx Choices
®


Features include:


Personal assessment of cost
-
saving opportunities based on your prescription
plan and the medications you use


Print a kit to help your doctor better understand the economic impact of different
medication alternatives


Alternative medications are based upon greatest cost savings to you presented
in order, starting with the highest value


Brand
-
to
-
generic and retail
-
to
-
mail comparisons are shown


Simply visit
www.express
-
scripts.com
. You’ll need to take a
moment to register before using this service. You can also call

1
-
866
-
355
-
5999


You have to shop your benefit. Prices can vary at different retail
pharmacies

23

Managing prescription with ease: Transfer

to mail online conversion program


24

25

New!
Accessibility Features

Innovation that can help
participant
s make

better decisions for healthier outcomes

26

Save money


Enable informed decisions

Auto populate with
personalized information

Update in real
-
time

Improve care

Boost compliance and
adherence

Manage Refills and
Renewals

Unique functionality not available anywhere in healthcare today

Information Resources


TRS Website


www.trs.state.tx.us/trs
-
activecare


Pharmacy Benefit Highlights


List of maintenance medications


FAQs


Download forms


Express Scripts Participant Website


www.express
-
scripts.com


Prior authorization list


Formulary information


Locate a participating pharmacy


Generics Rx Advantage


My Rx Choices® / Price a Medication


Health and wellness information


Mobile App


Check prescription status


Order mail order refills


Download forms


Express Scripts widget


Customer Service


1
-
866
-
355
-
5999


Benefits Booklet

27

How to Enroll

2013
-
2014
Plan Year

How to Enroll

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

29

Health care coverage for public school employees and their families

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

30

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.

Dependent Eligibility

31

Spouse, including common law spouse

A child under age 26: a natural child, an adopted child (or a child who is
lawfully placed for legal adoption), foster child, or child under legal
guardianship of the employee

“Any other child” under the age of 26 (unmarried) in a regular parent
-
child
relationship with the employee


Must meet residency and support criteria

A grandchild under age 26

Unmarried disabled dependent (age 26+)


Must live with employee


A dependent does not include a brother or sister of an employee unless the
sibling is an unmarried individual under 26 years of age who is either:

(1) under the legal guardianship of the employee, or (2) in a regular parent
-
child relationship with the employee and meets the “any other child” criteria


Parents and grandparents of the covered employee do not meet the
definition of an eligible dependent

Special Eligibility Situations


If employee and spouse both work for a participating
district/entity:


A spouse may be covered as an employee or as a dependent of an
employee


Only one parent can cover dependent children


A child (under age
26
) employed by a district/entity and a
contributing TRS member cannot be covered as a dependent


The child must be covered as an employee


If the child is not a contributing TRS member, the child may be covered

as a dependent

32

Three Steps to Enroll

33

2

Complete your enrollment as
instructed by your district’s
benefits department

1

Choose your
health plan

Enrollment


Enrollment Periods for 2013
-
2014 Plan Year:


April 30


May 20 (Spring Enrollment)


August 1


August 30 (Summer Enrollment)


No pre
-
existing condition exclusion applies
except

for those who
previously declined coverage (may be reduced by prior
creditable coverage)


Passive enrollment


If no plan or coverage changes, then no
form required




Premium adjusted to reflect any rate change, effective
September 1

34

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 selects a different TRS
-
ActiveCare plan option or
terminates coverage

Pre
-
existing Condition Exclusions

35


Pre
-
existing condition exclusions
will not apply:


To any individual
under the age of 19


To employees that initially enroll when the district/entity begins participating
in TRS
-
ActiveCare


To new hires who enroll within 31 days after their actively
-
at
-
work date


To HMO enrollees




A 12
-
month pre
-
x waiting period may apply to employees or
dependents enrolling in the
ActiveCare

PPO plans due to:


A special enrollment event


A transfer to another participating district/entity (or rehire by the same
participating district/entity), if the employee or any covered dependent has
any remaining pre
-
existing waiting period or a gap in coverage of 63 or

more consecutive days.

Exception:
If a participant has been covered at any time since 2002, pre
-
x may
apply if employee is hired by another participating district/entity (or rehired by same
district/entity)

Making Changes/Special Enrollment Events

36

Enrollees
may be able to
enroll for coverage, change plan
options, or change the dependents he or she covers
during the
plan year
within
31
days
after a special enrollment event occurs



New dependent


Marriage, birth, adoption or placement for adoption


Special rules apply to newborns


Loss of other
coverage

Changing districts/entities is not considered a special enrollment event

Newborns


Covered first 31 days if employee has coverage


Does not apply to newborn grandchildren


Must add newborn within 60 days after the date of birth or up to
one year after the date of birth if:


Employee has “employee and family” or “employee and child(ren)” coverage
at the time of birth and at the time of enrollment


Plan changes must be made within 31 days after the newborn’s
date of birth


Not necessary to wait for newborn’s Social

Security number


Submit application without SSN to enroll


Re
-
submit another form after SSN is issued

37

Cost for Health Coverage

2013
-
2014
Plan
Year

Cost of Coverage

39

Funding to Help Offset the Cost of

TRS
-
ActiveCare

Coverage

District/Entity (minimum)

$150

State of Texas

$75

Total Per Month

$225

Funding applies to active, contributing TRS members

Cost charts illustrate the monthly gross premiums

Monthly Cost for Coverage

40


See page 17 of

Enrollment Guide



$225 in district/entity

and state funds to

help pay for coverage

Application to

Split Premium

41


Married couples working

for
different

participating

entities may “pool” funds


Optional


Requires an
Application

to Split Premium

form to

be completed by both

employees and employers


Form available online

ID Cards (mailed to your home)


PPO plans (ActiveCare
1
-
HD,
2
and
3
)


Separate cards for medical and prescription drugs


Blue Cross and Blue Shield of Texas


Express Scripts


BCBSTX will reissue ID cards to existing plan participants transitioning from
AC
1
-
HD to ActiveCare
1
(medical plan ID cards do not expire)


Prescription drug ID cards will be reissued by Express Scripts for

ActiveCare
1
-
HD and ActiveCare
2
plan participants

42

Online Enrollment Support

Available online


www.trs.state.tx.us/trs
-
activecare

and www.bcbstx.com/trs


Enrollment guide


Summary of Benefits and Coverage (SBC)


Downloadable forms (application and change form,

application to split premium, claim form, etc.)


Provider locator


Enrollment presentation


43

44

www.bcbstx.com/trs



Enrollment Info



Blue Access for
Members

Blue Access for Members
SM

45

Online member management tool


Research health conditions


View claims history and print

Explanation of Benefits (EOB) statements






Locate a network doctor or hospital


Order additional ID cards,

or print a temporary ID


Take a confidential health assessment

Send secure

email messages

to BCBSTX

Customer
Advocates

Monday thru Friday

7 a.m. to 10 p.m. (CT)

EOBs are available online; you must log in
and elect to receive paper copies

Blue Access

Mobile
SM

46

Public Site



No log
-
in required


Health Care 101


Find a Doctor or Hospital


Blue Access for Members Log
-
in


Contact Information

Provider Finder App

For iPhone
®

and Android
®

phones

A claim has been paid. Please
log in to Blue Access for
Members for details.
A claim has been paid. Please
log in to Blue Access for
Members for details.
A claim has been paid. Please
log in to Blue Access for
Members for details.
Blue Access for Members
SM

Secure Site


Log
-
in Required


ID Card


My Coverage


Benefits / Eligibility


Visits and Claims


Health and Wellness


Diabetes, Obesity, Nutrition, Fitness, Metabolic
Syndrome, Maternity Care, Member Care Profile


User Profile


Register for Blue Access for Members

Text Messaging

Static



One
-
Way SMS
Messaging

Diabetes
Management, Claim Status
Notification Alerts

Dynamic



Two
-
Way
Messaging
member initiates
text with keyword

(ID Card
Management)

What if I Have Questions?


Call TRS
-
ActiveCare customer service for:


Claim questions/status


Network provider information


Membership and eligibility


Medical and Rx coverage questions


Inquiries (telephone and email)


ID card requests


Transition of care information


Help with online tools!

47



Customer Service


1
-
866
-
355
-
5999

Personalized Service

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.
Prescription drug benefits for
ActiveCare

1
-
HD,
2
and
3
plans are
administered by Express Scripts, Inc. HMO plans provided by:
SHA, L.L.C.
dba

FirstCare

Health Plans, Scott and White Health
Plan, and Valley Baptist Insurance Company
dba

Valley Baptist
Health Plans.