Transcript Flash Enrollment Tutorial - Blue Cross Blue Shield Association

Health Care
Coverage
For You And
Your Family!
Welcome
Agenda
●
What’s new this year
●
Who is eligible to enroll
●
Plan options
●
Cost of health coverage
●
How to enroll
●
Enrollment support
●
Questions
What’s New for 2004-2005?
●
ActiveCare 1, 2 and 3:
– Changes to prescription drug benefits for
ActiveCare 2 and 3
– No premium rate increase
●
HMOs:
– New rates
– Minor benefit changes
– New option in South Texas—Valley Baptist Health Plan
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 (including divorced) 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
●
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:
– Child is born on or after September 1, 2004, and
– Employee has “employee and family” or
“employee and child(ren)” coverage at the time of
birth
PPO Plan
Options
ActiveCare
1, 2 and 3
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
Network vs. Non-Network Providers
●
Network Providers
– Receive highest 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
Non-Network Providers
●
ParPlan Providers
– Receive non-network level of benefits
– No claims to file in most cases (ParPlan provider will
usually file the claims)
– No balance billing; ParPlan providers cannot bill for
costs exceeding the 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
Deductible: The amount of out-of-pocket expense that must be paid for
health care services before becoming payable by the health care plan
Coinsurance
ActiveCare 1
ActiveCare 2
ActiveCare 3
Network
NonNetwork
Network
NonNetwork
Network
NonNetwork
(after
deductible)
20%
40%
20%
40%
15%
35%
Plan Pays
80%
60%
80%
60%
You Pay
(no
deductible)
85%
65%
Coinsurance: The percentage of medical expenses that you and the health
plan share
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
Copayment (Copay): The amount paid at the time of service for certain
medical services and prescription drugs; copays depend on whether the
doctor is primary or a specialist
Specialist: Any physician other than a family practitioner, internist, OB/GYN, and
pediatricians
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
Copayment (Copay): The amount paid at the time of service for certain
medical services and prescription drugs; copays depend on whether the
doctor is primary or a specialist
Specialist: Any physician other than a family practitioner, internist, OB/GYN or
pediatrician
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
$3,000
per
Individual
per
Individual
Out-of-Pocket Maximum: When you reach your plan’s of out-of-pocket
maximum, the plan then pays 100% of any eligible expenses for the rest of
the plan year.
Preauthorization 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
●
2004-2005 plan year benefit changes
●
Retail pharmacy maintenance program
●
Home Delivery
●
Retail maintenance drug list
●
Copays
●
Prior authorization
●
Specialty Pharmacy and Dose Optimization
●
Online technology
●
Home Delivery tips
Prescription Drug Benefits
What’s New
●
Retail Pharmacy Maintenance Program
ActiveCare 2 and ActiveCare 3
– Retail copays for maintenance medications
– First two fills of maintenance medication at retail =
short-term copay
– Third (3rd) fill of maintenance medication at retail =
copay increase
– Copay for short-term medications at retail will not change
Prescription Drug Benefits
What’s New (continued)
●
Home Delivery
ActiveCare 2 and ActiveCare 3
– New copays for preferred and non-preferred brand
medications
– No change to copays for generic medications
– Home Delivery may save money vs. filling at retail
Prescription Drug Benefits
What’s New (continued)
●
Retail Maintenance Drug List
– Maintenance list includes most long-term medications
– Review list and price a medication –
www.trs.state.tx.us/trs-activecare
– Medco Health – www.medcohealth.com or call
Customer Service
– Notification – announcement letter and trigger letter
Prescription Drug Benefits
ActiveCare 1
Retail
Home Delivery
(up to 30-day supply)
(up to 90-day supply)
Network
Non-Network
You pay 100% of the
You pay 100% at the
discounted cost at
time of purchase and
the time of purchase will be reimbursed 80%
and will be reimbursed
by Blue Cross and
80% by Blue Cross
Blue Shield of Texas
and Blue Shield of
after your deductible
Texas after your
deductible
You pay 100% of the
discounted cost at the time
of purchase and will be
reimbursed 80% by
Blue Cross and Blue Shield
of Texas after
your deductible
Prescription Drug Benefits
ActiveCare 2
Retail Network
Home Delivery
(up to 30-day supply)
(up to 90-day supply)
Short-Term
Maintenance
Generic
$10
$15
$20
Preferred Brand
$25
$35
$62.50
Non-Preferred Brand
$45
$60
$112.50
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 Drug Benefits
ActiveCare 3
Retail Network
Home Delivery
(up to 30-day supply)
(up to 90-day supply)
Short-Term
Maintenance
Generic
$10
$15
$20
Preferred Brand
$25
$35
$62.50
Non-Preferred Brand
$40
$55
$100
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 Drug Benefits
ActiveCare 2 and 3: Member pays the difference
●
You pay the difference if a brand-name prescription is dispensed
when a generic is available
●
You pay the generic copay plus the difference in cost between the
brand-name prescription and what the cost would be if the generic
drug had been purchased, regardless of doctor DAW (Dispense As
Written)
Example:
Full price of brand-name drug
$120
Full price of generic
$ 70
(Difference)
$ 50
Plus retail generic copay
$ 10
You pay
$ 60
Prescription Drug Benefits
Drug Formulary
●
Preferred and Non-Preferred Medications
– Copays
– Preferred Prescriptions Drug List
– Generic Medications
– My Doctor Visits
Prescription Drug Benefits
Prior Authorization
●
Program designed to ensure the safety of participants and
help contain costs
●
May review some or all of the following information to
assure an appropriate coverage decision:
–
–
–
–
–
–
Patient diagnosis
Indications for prescribed drug use
Dosing
Duration of therapy
Patient drug profile
Drug interactions
Prescription Drug Benefits
Other new programs
●
Specialty Pharmacy
– Designed to help participants obtain high cost pharmaceuticals that
require injection, unique administration, refrigeration and or special
handling
– Eligible participants will receive information on the program
●
Dose Optimization
– A clinically-based program that encourages participant convenience
and cost-savings when therapeutically appropriate
– Participant communications included in program
Prescription Drug Benefits
Online Technology: www.trs.state.tx.us/trs-activecare
Online services
available prior to
enrollment
Additional online
services available
after enrollment
•
Compare pricing and coverage for brand-name and
generic medication for both home delivery and retail
•
View Retail Maintenance List
•
Locate participating retail network pharmacies
•
Access pharmacy benefits highlights
•
•
Locate drug information
Request refills and renewals through home delivery
pharmacy
•
Check status of orders
•
Review “My Doctor Visits”
•
Access health and wellness information
•
Order supplies
Prescription Drug Benefits
Home Delivery Tips
●
New prescriptions may be required for new enrollees
●
To use Home Delivery Pharmacy Service (long-term
maintenance medications) have your doctor to write two
prescriptions:
– One for a 14-day supply (to eliminate interruption of therapy)
– One for a 90-day supply
●
Easy Rx
●
Have your doctor call 1.888.327.9791 to obtain fax instructions
●
For retail prescriptions (short-term acute medications) only one
prescription is needed
HMO Plan
Options
2004-2005 Plan Year
HMO Features
●
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
FIRSTCARE
HMO Plan Option
FIRSTCARE
Service Area
85 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
Specialist office visit
Preventive care
Outpatient surgery facility
Inpatient hospital
Emergency room
$15
$30
$15
$150
$150 per day ($750 maximum)
$75 (waived if admitted)
Urgent care
Out-of-pocket maximum
$35
2x total plan year cost of
coverage
FIRSTCARE
What’s new for 2004-2005:
● 4 counties added to the service area
● $50 copay for surgical procedures performed in
physician’s office
● $30 copay per visit for short-term mental services
● $250 copay per device for prosthetics/orthotics/
implantable devices
● Injectable medication copay now subject to a $2,500
injectable drug out-of-pocket maximum
FIRSTCARE
What’s new for 2004-2005:
• Hospice services will no longer require a copayment
• $35 copay for minor emergency or urgent care center
visits
•
25% copay for self-injectable and high technology
medications (excludes diabetic medications and allergy
serum)
FIRSTCARE
Prescription Drugs
Retail
Mail Order
(up to 30-day
supply)
$10
(up to 90-day
supply)
$20
Preferred Brand
$20
$40
Non-Preferred Brand
Self-Injectable and High
Technology Drugs*
$40
25%
$80
25%
Generic
*Excludes insulin and allergy serum
FIRSTCARE
●
If a brand-name prescription is dispensed when a
generic is available, the enrollee pays the generic copay
plus the difference in cost between the brand-name
prescription and what the cost would be if the generic
drug had been purchased, regardless of doctor DAW
(Dispense As Written)
Example:
Full price of brand-name drug
$120
Full price of generic
$ 70
(Difference)
$ 50
Plus retail generic copay
$ 10
Enrollee pays
$ 60
Mercy Health
Plans
HMO Plan Option
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
Mercy Health Plans
Referrals
●
To visit a specialist, a PCP referral is required; 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
●
No benefits available for non-emergency care outside
the network or for a specialist visit without a referral from
a PCP
Mercy Health Plans
Benefit
Copay
PCP/Specialist office visit
Preventive care
Outpatient surgery facility
Inpatient hospital
Emergency room
$10
$10
$0
$0
$50 (waived if admitted)
Urgent care
Out-of-pocket maximum
$25
$1,000 maximum (individual)
$2,000 maximum (family)
Mercy Health Plans
Prescription Drugs
Retail
Mail Order
(up to 30-day
supply)
$5
(up to 90-day
supply)
$10
Preferred Brand
$20
$40
Non-Preferred Brand
$35
$70
Generic
Infertility drugs are covered at 50%
*
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
Williamson
Robertson
Madison
Brazos
Milam
Georgetown
Burleson
Blanco
Grimes
Lee
Travis
Hays
Walker
College Station
Washington
Bastrop
Waller
Austin
Caldwell
Regional Office
Scott & White Approved TRS Service Area
Scott and 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 and White Health Plan
●
A not-for-profit HMO with a network of more
than 650 physicians in 56 specialties
●
A 478-bed hospital
●
A network of regional clinics in Central Texas
●
“Excellent” status with 3 year accreditation by
NCQA, 2003
●
“A-” rating by AM Best, 2004
Scott and White Health Plan
Changes for 2004-2005:
●
Ambulance transportation – No copay
●
Ambulance with no transportation - $40 copay
●
Weight reduction programs excluded (including
gastric bypass surgery)
Scott and White Health Plan
Benefit
Copay
PCP/Specialist office visit
Preventive care
Outpatient surgery facility
Inpatient hospital
Emergency room
$25
$25
$100
$200 per day ($1,000 maximum)
$100 (waived if admitted)
Urgent care
Out-of-pocket maximum
$40
$2,000 maximum per individual
Scott and White Health Plan
Prescription Drugs
Generic
Preferred Brand
Non-Preferred Brand
Non-Formulary
Retail
Mail Order
(up to 34-day
supply)
$5
(up to 90-day
supply)
$10
$20
$40
lesser of $50
or 50% copay
lesser of $100
or 50% copay
50% copay
N/A
$2,000 maximum benefit per person per plan year
Scott and White Health Plan
●
$2,000 plan year maximum per person
●
If a brand-name prescription is dispensed when
a generic is available, enrollees pays:
– 50% of brand-name cost
Valley Baptist
Health Plan
HMO Plan Option
Valley Baptist Health Plan
Service Area:
Rio Grande Valley
Provider Network:
• More than 800 providers
• 7 hospitals Valley-wide
Valley Baptist Health Plan
Local Plan
● Locally owned and operated in Harlingen, Texas
● What this means for you: You can come by our office
if you prefer to discuss your benefits face-to-face
Predictable Costs
● Lab/radiology is covered in full; copays for office visits,
ER, hospitalizations and day surgery
● What this means for you: You will know ahead of time
your out-of-pocket expense
Valley Baptist Health Plan
Deductibles
● None
● What this means for you: You will not have to meet an
out-of-pocket expense before your health care services
are covered
Coinsurance
● None
● What this means for you: You will not be responsible
for 20% of hospital fees, lab, etc. – all you have to do is
pay your copay
Valley Baptist Health Plan
Benefit
Copay
PCP office visit
Specialist office visit
Preventive care
Outpatient surgery facility
Inpatient hospital
Emergency room
$25
$35
$25 PCP/$35 Specialist
$500
$1,500*
$150 (waived if admitted)
Urgent care
*Out-of-pocket maximum
for hospital admissions
$35
$3,000 maximum (individual)
$6,000 maximum (family)
Valley Baptist Health Plan
Prescription Drugs
Retail
(up to 30-day
supply)
$15
Mail Order
(up to 90-day
supply)
$30
Preferred Brand
$25
$50
Non-Preferred Brand
Self-Injectable and High
Technology Drugs*
$45
25%
$90
25%
Generic
*Excludes insulin and allergy serum
*
Valley Baptist Health Plan
Value Added Services
● Valley Healthy Partners
– Diabetes Management Program – provides support to
diabetic members through prevention, early
detection, education and self-care
– FREE diabetic supplies for program participants
● Valley Healthy Baby
– Maternity Program – provides guidance towards a
healthy pregnancy and delivery
– Baby Line – 24 hour support line for counseling and
education at (800) 395-2229
Cost for Health
Coverage
2004-2005 Plan Year
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
●
If you enrolled in 2003-2004 and do not wish to make
changes to your current health benefit plan, you do not
need to submit an enrollment application
●
You must complete an application if declining coverage –
even if you previously declined coverage
Sign, date and submit forms to your Benefits Administrator
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,
2005 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
Your TRS-ActiveCare ID card will
be mailed to your home
●
New ID cards with unique identification numbers
(no Social Security Numbers) will be issued to
all participants
●
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
– Mercy Health Plans
– Scott and White Health Plan
1.800.884.4901
1.800.617.3433
1.800.321.7947
– Valley Baptist Health Plan
1.800.829.6440
Enrollment Support
●
Available Online
www.trs.state.tx.us/trs-activecare
– Enrollment guide
(English and Spanish)
– Application and plan comparison tutorials
– Downloadable forms
(enrollment application, split premium, etc.)
– Provider locator
– Frequently asked questions
Questions
Thank you for
attending