Transcript Flash Enrollment Tutorial - Health Insurance Texas | Blue

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:
www.trs.state.tx.us/trs-activecare
– 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 2003-2004?
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
FIRSTCARE
ActiveCare 2
Mercy Health Plans
ActiveCare 3
Scott and White Health Plan
What’s New for 2003-2004?
• 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 2003-2004?
• 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
Employees Eligible to Enroll
Active
contributing
TRS member?
If Yes
You may be eligible
If No
Regularly work
10 or more
hours per week?
If No
You are
not eligible
If Yes
You may be eligible
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 1-800-647-6558 or log on to
www.texcarepartnership.com
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 1
Network
Non-Network
$1,000 Individual
$3,000 Family
ActiveCare 2
Network
Non-Network
$500 Individual
$1,500 Family
ActiveCare 3
Network
Non-Network
None
$500 Individual
$1,500 Family
Coinsurance
ActiveCare 1
ActiveCare 2
ActiveCare 3
Network
Non-Network
Network
Non-Network
Network
Non-Network
Plan Pays
(after
deductible)
80%
60%
80%
60%
85%
65%
You Pay
20%
40%
20%
40%
15%
35%
Office Visit Copay
ActiveCare 1
ActiveCare 2
ActiveCare 3
Network
NonNetwork
Network
NonNetwork
Network
NonNetwork
20% after
deductible
40% after
deductible
$25/$35
per visit
40% after
deductible
$20/$30
per visit
35% after
deductible
Preventive Care Copay
ActiveCare 1
Network
$15
per visit
(up to $500 per
person, per
plan year)
NonNetwork
40% after
deductible
ActiveCare 2
Network
$25/$35
per visit
(up to $500 per
person, per
plan year)
ActiveCare 3
NonNetwork
Network
NonNetwork
40% after
deductible
$20/$30
per visit
35% after
deductible
Out-of-Pocket Maximum
(excludes copays and deductibles)
ActiveCare 1
Network
Non-Network
$2,000 Individual
$6,000 Family
ActiveCare 2
Network
Non-Network
$2,000 Individual
$6,000 Family
ActiveCare 3
Network
Non-Network
$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
Retail
(up to 30-day supply)
Network
Non - Network
You pay 100% of the
discounted cost at the
time of purchase, and
will be reimbursed 80%
after your deductible
You pay 100% at the
time of purchase, and
will be reimbursed 80%
after your deductible
Home Delivery
(up to 90-day supply)
You pay 100% of the discounted
cost at the time
of purchase, and will be
reimbursed 80% after
your deductible
Prescription Drugs—ActiveCare 2
Retail
(up to 30-day supply)
Network
$10 generic
$25 preferred
$45 non-preferred
Home Delivery
(up to 90-day supply)
Non - Network
Pay cost
Submit claim*
$20 generic
$50 preferred
$90 non-preferred
*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 3
Retail
(up to 30-day supply)
Network
$10 generic
$25 preferred
$40 non-preferred
Home Delivery
(up to 90-day supply)
Non - Network
Pay cost
Submit claim*
$20 generic
$50 preferred
$80 non-preferred
*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
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).
Example
Full price of brand-name
$ 120
Full price of generic
-
70
(Difference)
$
50
Plus retail generic copay
+
10
You pay
$
60
Online Technology- www.trs.state.tx.us/trs-activecare
Online services available prior
Additional online services available
to enrollment:
after enrollment:
• Access pharmacy benefits
highlights
• Request refills and renewals
through home delivery pharmacy
• Compare pricing and coverage
for brand name and generic
medication for both home delivery
and retail
• Check status of orders
• Locate network participating retail
pharmacies
• Find drug information
• 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
$ 150 per day ($750 maximum)
Emergency room
$ 75 (waived if admitted)
Urgent care
$ 25
Out-of-pocket maximum
2x total plan year cost of coverage
FIRSTCARE — Prescription Drugs
Retail
(up to 30-day supply)
Mail Order
(up to 90-day supply)
$10 generic
$20 preferred
$40 non-preferred
$20 generic
$40 preferred
$80 non-preferred
FIRSTCARE — Prescription Drugs
If a brand-name prescription is dispensed when a
generic is available
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).
Example
Full price of brand-name
$ 120
Full price of generic
-
70
(Difference)
$
50
Plus retail generic copay
+
10
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
Benefit
Copay
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)
Mercy Health Plans—Prescription Drugs
Retail
(up to 30-day supply)
Mail Order
(up to 90-day supply)
$5 generic
$20 preferred
$35 non-preferred
$10 generic
$40 preferred
$70 non-preferred
Infertility drugs are covered at 50%
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
Benefit
Copay
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
Retail
(up to 30-day supply)
Generic
Preferred
Non-preferred
Non-formulary
$5
$20
lesser of $50
or 50% copay
50% copay
Mail Order
(up to 90-day supply)
Generic
Preferred
Non-preferred
Non-formulary
$10
$40
lesser of $100
or 50% copay
N/A
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
Part-Time
Employees
Professional
Employees
30 or more hours
each week
Less than 30 hours
each week
Administrative or
over $50K annually
District
(minimum)
$150.00
$150.00
$150.00
State of Texas
$ 75.00
$ 75.00
$ 75.00
Supplemental
Compensation
$ 41.66
$ 20.83
$
$266.66
$245.83
$225.00
Funding
Sources
Total Monthly
Funding
0.00
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 3
1.866.355.5999
(Blue Cross and Blue Shield of Texas and Medco Health)
• FIRSTCARE
1.800.884.4901
• Mercy Health Plans
1.800.617.3433
• Scott and White Health Plan
1.800.321.7947
What’s Available Online?
www.trs.state.tx.us/trs-activecare
• Enrollment guide
(English and Spanish, large print)
• Application tutorial
• Downloadable forms
(enrollment application, split premium, etc.)
• Provider locator
• Frequently asked questions
Questions