Transcript Slide 1

Health Care
Coverage for You
and Your Family!
Welcome
Agenda
•
•
•
•
•
•
Who is eligible to enroll
Plan options and what’s new
Cost of health coverage
How to enroll
Enrollment support
Questions
2
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
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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.
4
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)
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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
newborn’s 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
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PPO Plan Options
ActiveCare 1, 2 and 3
What’s New for 2008-2009?
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
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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
Need to locate a
Network Provider?
www.trs.state.tx.us/trs-activecare
www.bcbstx.com/trs
providers
 Receive highest level of benefits
 No claims to file
 No balance billing
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Plan Overview
ActiveCare 1
ActiveCare 2
ActiveCare 3
Deductible
(individual/family)
$1,100/$3,000
$500/$1,500
None
Out-of-Pocket Maximum
(individual/family)
$2,000/$6,000
$2,000/$6,000
$1,000 per
individual
80%/20%
80%/20%
80%/20%
20% after
deductible
$25 for primary
$35 for specialist
$20 for primary
$30 for specialist
Coinsurance
(Plan pays/participant pays)
Office Visit Copay
Illustrates benefits when network providers are used. Non-network benefits are also available; see
Enrollment Guide for more information.
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Plan Overview
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
ActiveCare 1
ActiveCare 2
ActiveCare 3
$0 copay up to
$500 per person,
per plan year
$25 for primary
$35 for specialist
$20 for primary
$30 for specialist
Includes all preventive
care services billed
with an office visit by a
network doctor
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)
Coinsurance applies
when no office visit is
billed or when services
are performed outside
the office
(no deductible)
Remaining charges
subject to deductible
and coinsurance
Illustrates benefits when network providers are used. Non-network benefits are also available; see
Enrollment Guide for more information.
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Blue Care
Connection®
Health and Wellness Programs
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.
24/7 Nurseline
Advice anytime.
Round-the-clock health
and the wellness advice
from licensed
professionals
Advice isn’t 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 night’s rest
24/7
1-800-581-0368
Available in English and Spanish
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Personal Health Manager
Your online wellness experience
begins here: www.bcbstx.com/trs
• Take a Health Risk
Assessment
• Improve your health with the
“Eat 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
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“Ask-A” Online Advisor
Expert advice at your fingertips.
Ask the experts.
Expert advice from
licensed professionals
via the Personal Health
Manager
Our “Ask-A” feature is here to help.
Ask a Nurse:
Interact online with a
Blue Care Advisor on
non-emergency,
health-related
questions using the
secure “Ask a Nurse”
feature.
Ask a Trainer,
Dietitian or
Life Coach:
Send questions
about fitness,
nutrition, or
managing stress.
CONFIDENTIAL AND SECURE
Receive a response within one business day
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Blue Points Incentives
SM
Stay motivated.
Earn Blue Points in the
Personal Health
Manager
SM
ActiveCare 1, 2 and 3 plan
participants and their covered
dependents accumulate
Blue PointsSM 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 PointsSM
for a variety of items!
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Weight Management and
Tobacco Cessation
Tobacco Cessation
Program
Support for members
who want to quit
Self-Paced Approach
• Online tools and
resources via the
Personal Health Manager
• Secure e-mail outreach to
keep members on track
Weight Management
Program
Support for a Healthier
You
Personalized Lifestyle
Management Support
• Counseling and coaching
with licensed Wellness
Coaches
• Motivational toolkit
• 24/7 Nurseline
• Referrals when
appropriate
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Expecting?
Special Beginnings® Program
1-800-462-3275
Special Beginnings is a confidential, fullfeatured 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:
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Baby bath and soap samples
Cleansing cloths
Nursing pads
Coupons for baby products
• Magazines that help you learn more about
pregnancy and parenting
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Live Chat
Secure Online Customer Service
• Send inquiries to customer
service via e-mail
• Immediate access to
BCBSTX customer
advocates
• Available Monday – Friday,
7 a.m. to 10 p.m. (CT)
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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 e-mail)
• ID card requests
• Transition of care information
• Help with online tools!
Customer Service
1-866-355-5999
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Blue Access® for Members
Online Member Management Tool
Online member
management tool.
• Check claim status, view
and download EOBs
(Explanations of Benefits)
• Order additional ID cards,
and print temporary ID
• Send secure e-mail
messages to BCBS
Customer Advocates
• Monthly health articles
• Links to health information
and wellness
tools and resources
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Prescription Drugs
ActiveCare 1, 2 and 3
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
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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
• Medco’s 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
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Specific Rx Benefit Information
• If you are taking a long-term medication, filling your
prescriptions through Medco’s 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, Medco’s 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
1-866-355-5999
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Prescription Drug Benefits
Drug Deductible
(per person, per plan year)
ActiveCare 1
ActiveCare 2
ActiveCare 3
Subject to $1,100
plan year
deductible
$50
$50
$10
$25*
$45*
$10
$25*
$40*
$15
$35*
$60*
$15
$35*
$55*
$20
$62.50*
$112.50*
$20
$62.50*
$100*
Retail Short-Term
(up to 30-day supply)
Generic/Preferred Brand/NonPreferred Brand
Retail Maintenance
(after second fill, up to 30-day supply)
Generic/Preferred Brand/NonPreferred Brand
Medco by Mail
(up to 90-day supply)
Generic/Preferred Brand/NonPreferred 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
* 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.
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Prescription Drug Benefits
ActiveCare 2 and 3: Applying the Deductible
Example 1—Claim cost less than $50 Deductible
Total
Cost
Deductible
Applied
Copay
Deductible
Remaining
First Fill
$37
$37
$37
$13
Second Fill
$37
$13
$13 + copay
$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
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Prescription Drug Benefits
ActiveCare 2 and 3: Applying the Deductible
Example 2—Claim cost more than $50 Deductible
Total
Cost
Deductible
Applied
Copay
Deductible
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.
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Information Resources
• TRS Web site – www.trs.state.tx.us/trs-activecare
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Pharmacy Benefit Highlights
List of maintenance medications
FAQs
Download forms
• Medco Member Web site – www.medco.com
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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 1-866-355-5999
• Benefits Booklet
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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 www.medco.com/save. You’ll to take a moment to register
before using this service. You can also call 1-866-355-5999.
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My Rx Choices
Available through Customer Service or on www.medco.com
• The My Rx Choices
home page allows the
user to:
- Select a patient (prepopulated with all
covered household
members)
- Select a drug to
compare from a prepopulated list of
prescriptions for the
user.
• Your potential savings
are clearly presented.
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My Rx Choices
Medco can
facilitate on
generic
equivalents
received
through mail
order
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My Rx Choices
Members may
print a kit to
discuss
lower-cost
alternatives
with their
doctor
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More about Your Rx Benefits
• Refill your medication at www.medco.com when
you use Medco By Mail
• Sign-up for “Refill Reminders” at www.medco.com
• Speak to a specialist pharmacist about the
medications you are taking for a specific condition
• Send e-mails to Customer Service and to Medco
pharmacists through the Medco member Web site
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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
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HMO Plan Options
2008-2009 Plan Year
FirstCare
HMO Plan Option
FirstCare Health Plans
Service Area
92 counties
across Texas
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FirstCare Health Plans
•
•
•
•
•
No claim forms
No preexisting limitations
Emphasis on preventive health care
No referrals required
Extensive provider network
– Local hospitals and doctors
– Nationwide network through Texas True Choice
and PHCS (outside Texas)
• Worldwide emergency care
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FirstCare Health Plans
Member Satisfaction
• Timely Customer Service
– Minimum automation; calls answered in Lubbock, Texas
– Limited wait time to talk to a live representative
• High member satisfaction for claims processing (90%)
• Web site accessibility for information 24 hours a day
• Regional offices in Abilene, Amarillo, Lubbock and
Waco to serve local communities
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FirstCare Health Plans
What’s New for 2008-2009
• $400 deductible – not applicable on most office visit
services; see Plan Summary
• Out-of-pocket maximum reduced to $3,500 per person
• $100 copay on radio-nuclide stress test
• $100 copay on non-pregnancy ultrasound tests
• $40 copay on bone mass measurement test
• Limited dental-related services have a maximum allowance
of $10,000
• External prosthetics devices have a lifetime maximum
allowance of $10,000
• 10% copay on preferred diabetic testing supplies
• No copay on preferred glucose monitors
• Premium increase of approximately 9.9%
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FirstCare Health Plans
What’s New for 2008-2009
• 24/7 NurseLine available
– Access a Registered Nurse with your medical
questions
•
•
•
•
•
•
Staying Healthy Questions
Minor Injuries
Routine Illnesses
Medication Questions
Understanding Your Treatment Options
Access Their Web site (www.healthforums.com)
– Health Assessments
– Health Topics
1-800-981-7912
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FirstCare Health Plans
Benefit
Copay
PCP office visit
$20 (no deductible)
Specialist office visit
$40 (no deductible)
Preventive care
$20 (no deductible)
Outpatient surgery facility
$150
Inpatient hospital
$150 per day ($750 maximum)
Emergency room
$100 (waived if admitted)
Urgent care
$40
Out-of-pocket maximum
$3,500 per member
43
FirstCare Health Plans
Prescription Drugs
Retail
Mail Order
(up to 30-day supply)
(up to 90-day supply)
Generic
$15
$45
Preferred Brand
$30
$90
Non-Preferred Brand
$50
$150
Self-Injectable and High
Technology Drugs *†
20%
20%
$10,000 maximum prescription benefit per person per plan year
*Excludes insulin and allergy serum
†Not
subject to $10,000 benefit maximum
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FirstCare Health Plans
Member Portal
• Link from the TRS-ActiveCare Web site for easy
access to:
– Change PCP
– Request ID Cards
– Print temporary ID Cards
– Change address
– Check status of claims
– Check status of authorizations
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Legacy Health Solutions
HMO Plan Option
Legacy Health Solutions
Service Area
18 counties
West Texas
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Legacy Health Solutions
• HMO Network Expansion
– 389 Physicians in Legacy HMO Network
– Added physicians of West Texas Medical Associates to our HMO
• Members like HMO features
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Predictable medical expense
No deductibles
No coinsurance
Coverage for preexisting conditions
No referrals needed for specialists
• In CAHPS Customer Satisfaction Survey, members ranked
Legacy HMO in 93%
• Local management means timely feedback for participant
questions, concerns, medical appointments
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Legacy Health Solutions
•
•
•
•
•
•
Emergencies covered anywhere
24 Hour Nurse Hotline
Health Advisory Tools customized to each member
Online Personal Health Record
Out-of-area care for dependents
LHS network has 349 physicians representing over
43 specialties throughout West Texas
• Disease and case management for chronic
conditions
49
Legacy Health Solutions
What’s New for 2008-2009
• $300 copay per day for inpatient hospital
($1,500 maximum per admission)
• $300 copay for outpatient hospital
• $3,000/$9,000 out-of-pocket maximum per individual/family
• $150 copay for emergency room care within 48 hours
(copay waived if admitted)
• $35 copay for preferred brand-name drug
(retail; up to 30-day supply)
• $70 copay for preferred brand-name drug
(mail; up to 90-day supply)
• Premium increase of approximately 5%
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Legacy Health Solutions
Claim Messaging
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Legacy Health Solutions
Pharmacy Savings Messaging
$3,835.46
Potential Savings:
$1,235.55/yr
How to Save
Talk to your doctor about switching from Nexium to Prilosec OTC or another comparable drug.
Print Report
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Legacy Health Solutions Web Tools
• Best in class tools to help members understand
and manage their health and health care finances
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Legacy Health Solutions
Benefit
Copay
PCP office visit
$20
Specialist office visit
$35
Preventive care
PCP $20 / Specialist $35
Outpatient surgery facility
$300
Inpatient hospital
$300 per day (5-day maximum)
Emergency room
$150 (waived if admitted)
Urgent care
$25
Out-of-pocket maximum
$3,000 (individual)
$9,000 (family)
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Legacy Health Solutions
Prescription Drugs
Retail
Mail Order
(up to 30-day supply)
(up to 90-day supply)
Generic
$8
$16
Preferred Brand
$35
$70
$200 or 50% of
charges, whichever is
less
N/A
Non-Preferred Brand
Injectable Prescription Drugs - 25% of charges
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Mercy Health Plans
HMO Plan Option
Mercy Health Plans
Service Area
4 Texas counties:
Webb
Jim Hogg
Zapata
Duval
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Mercy Health Plans
• No claim forms
• No lifetime maximum
• No preexisting condition limitations
58
Mercy Health Plans
• Low out-of-pocket expense
• Emergencies covered anywhere
• Case management
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Diabetes mellitus
Hypertension
Asthma
Other chronic diseases
• CuraScript Injectable Program
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Mercy Health Plans
• Mercy Health Plans ranked #1 on Consumer
Assessment Health Plans Survey (CAHPS)* on the
following:
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How people rated their plan
How people rated their health care
How people rated their doctor
How people rated their specialist
How people rated the efficiency and helpfulness of
customer service
* Office of Public Insurance Council
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Mercy Health Plans
Referrals
• To visit a specialist, a PCP referral is required; however,
referrals are not required for the following:
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Women may self refer to a designated OB/GYN
Ophthalmologist/optometrist (annual eye exam)
Orthopedic surgeon
Dermatologist
• No benefits available for non-emergency care outside the
network or for a specialist visit without a referral from a PCP
61
Mercy Health Plans
What’s New for 2008-2009
• Office visit copay changes from $10 to $20
• 10% coinsurance for inpatient, outpatient and
diagnostic services
• Prescription drug copays change from:
– Retail
• $5 to $10 generic
• $20 to $25 preferred brand (formulary)
• $35 to $45 non-preferred brand (non-formulary)
– Mail Order
• Copays = 2x retail copays
• Approximately 10% premium increase
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Mercy Health Plans
Benefit
Copay
PCP/Specialist office visit
$20
Preventive care
$20
Outpatient surgery facility
10% coinsurance
Inpatient hospital
10% coinsurance, after $500 plan year
deductible
Emergency room
$50 (waived if admitted)
Urgent care
$25
Out-of-pocket maximum
$1,000 maximum (individual)
$2,000 maximum (family)
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Mercy Health Plans
Prescription Drugs
Retail
Mail Order
(up to 30-day supply)
(up to 90-day supply)
Generic
$10
$20
Preferred Brand
$25
$50
Non-Preferred Brand
$45
$90
Infertility drugs are covered at 50%
$2,000 maximum prescription drug benefit per person per plan year
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Scott & White
Health Plan
HMO Plan Option
Scott and White Health Plan
Service Area
32 counties across
Texas
Somervell
Erath
Hill
Bosque
Waco
Hamilton
Mills
McLennan
Coryell
Falls
Lampasas
Leon
San Saba
Temple
Bell
Burnet
Llano
Robertson
Milam
Williamson
Madison
College Station
Burleson
Blanco
Grimes
Lee
Travis
Hays
Walker
Brazos
Georgetown
Washington
Bastrop
Waller
Austin
Caldwell
Regional Office
Scott & White Approved TRS Service Area
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Scott and White Health Plan
• Named one of the Highest Ranked Health Plans in
Texas by U.S. News & World Report (2007) for the
third year in a row
• No claim forms, no deductibles
• Coverage for preexisting conditions
• Worldwide emergency care
• Direct access to OB/GYN and ophthalmology
• Regional customer service centers in Georgetown,
Temple, Bryan/College Station and Waco
• 24-hour Nurse Advice Line 1-800-975-6612
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Scott and White
New Cancer Treatment Center – Temple Campus
First phase of work is
underway
Estimated completion
date is 1QTR 2009
68
Scott and White Health Plan
Expanding Network of Providers
• Hospital Additions
– Hillcrest Baptist Medical Center/Waco
– Grimes St. Joseph Hospital/Navasota
• Physician Group Additions
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–
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S&W Wells Branch Clinic – March 2008
King’s Daughters Clinic – March 2008
S&W Salado Clinic – September 2008
Expansions/additions proposed in 2008 for Williamson, Travis and
Bastrop counties
• Pharmacy Additions
– SWHP Canyon Creek Pharmacy – Temple – April 2008
– SWHP Salado Pharmacy – September 2008
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Scott and White Health Plan
What’s New for 2008-2009
• Prescription benefit maximum
– Increasing from $2,000 to $3,000 per person
• Diabetic test strips
– Preferred brand $5
– Non-preferred brand $25
• Home infusion therapy benefit
– $100 per day
– $500 maximum copayment per course of treatment
• Premium increase of approximately 9%
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Scott and White Health Plan
Benefit
Copay
Deductible
$0
PCP/Specialist office visit
$25
Preventive care
$25
Outpatient surgery facility
$100
Inpatient hospital
$200 per day ($1,000 maximum)
Emergency room
$100 (waived if admitted)
Urgent care
$40
Out-of-pocket maximum
$3,000 maximum per individual
$6,000 maximum per family
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Scott and White Health Plan
Prescription Drugs
Retail
(up to 34-day supply)
Mail Order
(up to 90-day supply)
None
None
Generic
$5
$10
Preferred Brand
$25
$50
lesser of $50
or 50% copay
lesser of $100
or 50% copay
greater of $50 or
50% copay
N/A
Rx Deductible
Non-Preferred Brand
Non-Formulary
$3,000 maximum benefit per person per plan year
If a brand-name prescription is dispensed when a generic is available, enrollee pays 50% of
brand-name cost
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Scott and White Health Plan
Online Wellness Tools
•
•
•
•
•
•
•
•
Succeed® – Health risk appraisal
Breathe® – Smoking cessation
Balance® – Weight management
Relax® – Stress management
Nourish® – Nutrition
CareTM for Your Back – Back pain management
CareTM for Your Health – Healthy living program
OvercomingTM Depression – Depression management
www.trs.state.tx.us/trs-activecare
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Valley Baptist
Health Plans
HMO Plan Option
Valley Baptist Health Plans
Service Area
• Rio Grande Valley
• Counties
–
–
–
–
Cameron
Hidalgo
Starr (partial)
Willacy
• Provider Network
– More than 780 providers
– 11 hospitals Valley-wide
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Valley Baptist Health Plans
•
•
•
•
•
No deductibles or coinsurance
No claim forms
No lifetime maximum
No preexisting condition limitations
Predictable costs
76
Valley Baptist Health Plans
• Free diabetic supplies available
• Worldwide emergency care
• Locally owned and operated in the Rio Grande
Valley by Valley Baptist Health System
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Valley Baptist Health Plans
• 99% member satisfaction (employer group survey)
• 97% of our providers would recommend our plan to
their patients (provider survey)
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Valley Baptist Health Plans
• PCP will refer you to a specialist
• No referral needed for a designated OB/GYN
• Case management services for diabetes mellitus
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Valley Baptist Health Plans
What’s New for 2008-2009
• No plan changes
• Approximately 8.5% premium increase
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Valley Baptist Health Plans
Benefit
Copay
PCP office visit
$25
Specialist office visit
$35
Preventive care
$25 PCP/$35 Specialist
Outpatient surgery facility
$250
Inpatient hospital
$300 per day ($1,500 maximum)
Emergency room
$150 (waived if admitted)
Urgent care
$25
Out-of-pocket maximum
$3,000 maximum (individual)
$6,000 maximum (family)
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Valley Baptist Health Plans
Prescription Drugs
Retail
Mail Order
(up to 30-day supply)
(up to 90-day supply)
Generic
$15
$30
Preferred Brand
$25
$50
Non-Preferred Brand
$45
$90
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Cost for Health
Coverage
2008-2009 Plan Year
Coverage Categories
•
•
•
•
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
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Monthly Cost
of Coverage
Page 35 of the
Enrollment Guide
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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
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How to Enroll
2008-2009 Plan Year
How to Enroll
2
Complete an
Enrollment
Application and
Change Form
•Available in the
Enrollment Guide
1 Choose your
health plan
•Also available
online
3 Sign, date and
submit form to
your Benefits
Administrator
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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 2007-2008 at the same level of
coverage
• To decline coverage: You must complete and
submit a form – even if you have declined
coverage before
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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 there’s 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
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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
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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-atwork 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
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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)
http://www.tdi.state.tx.us or the TDI Consumer
Helpline (800) 252-3439
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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
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Enrollment Support
Dedicated Customer Service
• ActiveCare 1, 2 or 3
1.866.355.5999
(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
1.800.884.4901
1.877.410.2432
1.800.617.3433
1.800.321.7947
1.800.829.6440
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Enrollment Support
Available Online
• Enrollment guide (English
and Spanish)
• Downloadable forms
(enrollment application, split
premium, claim form, etc.)
• Provider locator
• Frequently asked questions
www.trs.state.tx.us/trs-activecare
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Questions
Thank you for attending