Plainview ISD Employee Benefit Guide

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2 Plainview ISD Employee Benefit Guide Enrollment assistance is available by calling: First Open enrollment July 1, 2016 August 12, Coverage effective date September 1, 2016

3 Benefit Contact Information Program Vendor Phone Number Website/ Plainview ISD Benefits First Financial Group of America (800) Plainview ISD Benefits Office (806) Medical Aetna First Care (800) (800) Dental Ameritas (800) Vision Eyetopia Superior Vision (830) (800) Group Life Insurance Dearborn National (800) Permanent Life Insurance Texas Life (800) MyHealthPass (formerly Teledoc) MyHealthPass (800) Health Savings Account First Financial Group of America (800) Flexible Spending Accounts First Financial Group of America (866) Long-Term Disability American Fidelity (800)

4 Benefit Contact Information Program Vendor Phone Number Website/ Accident Insurance American Fidelity (800) Cancer Insurance Allstate (800) Critical Illness Insurance Humana (800) om LegalShield LegalShield (512) InvestTrust 457 (b) First Financial Group of America (800)

5 Due to federal ACA Regulations, every employee (including active contributing member s and employees working 10 hours/week) is required to log in and complete the enrollment process, even if declining benefits. If you do not log in and enroll, you will not have these benefits in the 2016/17 plan year. For complete TRS medical information, visit the TRS website at or

6 Section 125 Plan What is a Cafeteria Plan and how does it work? As a district employee, you are eligible to participate in a Section 125 Flexible Benefit Plan. Enrollment opportunities are limited to the plan year dates for your district. Section 125 Flexible Benefit Plan allows you, the employee, to select from a list of available benefits that will meet your family s benefits needs. Certain benefit premiums are deducted from your gross earnings before federal with-holding taxes are calculated. The amount you elect to have deducted pre-tax actually lowers your taxable income. By implementing this plan, your employer is helping you reduce your taxes and increase your take home pay. You cannot change your benefit elections for the plan year unless it is within 30 days of certain IRS specified changes in family status such as: Marriage Divorce Birth/Adoption Death of a spouse/child Termination of spouse s employment You must notify Theressa Burns in the HR Benefits Office with 30 days of the date of the status change. If the Benefits Office is not notified within 30 days of the status change, no benefit change can be made until the next annual Open Enrollment. 6

7 Helpful Definitions Actively at Work You are performing your regular occupation for the employer on a full-time basis, either at the one of employer s usual places of business or at some location to which the employer s business requires you to travel. Annual Enrollment The period during which existing employees and their dependents are given the opportunity to enroll in or change their current elections. Annual Deductible The amount you pay each plan year or calendar year (dependent on your plan design) before the plan begins to pay covered expenses. Calendar Year January 1 st through December 31 st. Plan year definition next page. Co-insurance The percent of eligible charges that the plan pays and you pay after your deductible is met. 7

8 Guaranteed Issue The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial enrollment and other times as approved and is subject to limitations and exclusions. In-Network Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan. Out-of-Pocket Maximum The most an eligible or insured person can pay in coinsurance for Covered Expenses in their plan or calendar year (dependent on your plan design.) Plan Year September 1 st through August 31st. Pre-Existing Condition Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescription drugs or is under a health care provider s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services within the designated period immediately preceding the effective date of change.) This is only a list of generic definitions. The definitions in the certificate of coverage or policy will govern. 8

9 Who do I contact with Questions? Q & A For supplemental benefit questions, you can contact Ty Stovall, Plainview ISD s First Financial agent at or by ty.stovall@ffga.com. You may also call your Benefits/HR Department at For additional information please refer to the Benefit Contact page for this power point. For enrollment questions, contact FFGA at Where can I find forms? Go to your benefit website: Click on the benefit plan you need information about (i.e., Dental) and you can find a link for forms and phone numbers. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. You can login to the carrier website(dental, vision, Aetna, FirstCare) and print a temporary ID card or simply give your provider the insurance company s phone number. Your provider can call to verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier s customer service number to request another card. This is a general overview of your plan benefits. Additional details on covered expenses, limitations and exclusions are included in the summary plan description located on the 9

10 What s new? ActiveCare 1-HD, ActiveCare 2 and ActiveCare Select plans will have higher out-of-pocket maximums for ActiveCare 1-HD out-of-pocket maximum will be capped for an individual to $6,550 ActiveCare 2 and ActiveCare Select retail maintenance copays will increase ALEX a benefits advisor tool that can help you decide the right plan for you! 10

11 ActiveCare 1-HD out-of-pocket maximum 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 Plan Year Plan Year Out-of-Pocket Maximum (employee only/family) $6,450/$12,900 (includes deductibles of $2,500/$5,000, medical and prescription drug copays and coinsurance) $6,550/$13,100* (includes deductibles of $2,500/$5,000, medical and prescription drug copays and coinsurance) *capped at $6,550 for each individual on a family plan 11

12 ActiveCare 2 out-of-pocket maximum Plan Year Plan Year Out-of-Pocket Maximum (individual/family) $6,600/$13,200 (includes medical and prescription drug deductibles, copays and coinsurance) $6,850/$13,700 (includes medical and prescription drug deductibles, copays and coinsurance) 12

13 ActiveCare Select/ActiveCare Select Whole Health out-of-pocket maximum Out-of-Pocket Maximum (employee only/family) Plan Year Plan Year $6,600/$13,200 (includes medical and prescription drug deductibles, copays and coinsurance) $6,850/$13,700 (includes medical and prescription drug deductibles, copays and coinsurance) 13

14 Out-of-Pocket (OOP) maximum illustration ActiveCare 1-HD with a $6,550 individual and $13,100 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 Amy Ted Bob Sue Chris $4,000 $5,000 $2,100 $1,000 $1,000 $1,000 $1,000 14

15 Family deductible illustration Amy covers a spouse and three dependents ActiveCare 1-HD with a $5,000 family deductible The family deductible may be met by one or more people Plan pays benefits once entire $5,000 is met there is no individual deductible to meet Amy Ted Bob Sue Chris $5,000 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 Amy Ted Bob Sue Chris $1,000 $800 $600 $400 $200 15

16 Choice POS II Network for ActiveCare 1-HD and ActiveCare 2 Network: Always verify provider network status Non-Network: Statewide 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 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 16

17 Choice POS II Plan overview (Network level of benefits) ActiveCare 1-HD ActiveCare 2 Deductible $2,500 employee only $5,000 family $1,000 individual $3,000 family Out-of-Pocket Maximum (includes medical and prescription drug copays/deductibles/coinsurance) $6,550 employee only $13,100 family $6,850 individual 13,700 family Coinsurance (Plan pays/participant pays) 80% / 20% 80% / 20% Office Visit Copay 20% after deductible $30 for primary $50 for specialist Primary means care provided by family practitioners, internists, OB/GYNs and pediatricians. All other physicians are specialists. 17

18 Choice POS II Plan overview (Network level of benefits) Preventive Care Clarification ActiveCare 1-HD ActiveCare 2 Preventive Care Plan pays 100% (deductible waived) Plan pays 100% (deductible waived; no copay required) Routine eye exam (one per plan year) Hearing exam 20% after deductible $30 for primary $50 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 18

19 Choice POS II Plan overview (Network level of benefits) Benefits (continued) Services ActiveCare 1-HD ActiveCare 2 High-tech Radiology (CT scan, MRI, nuclear medicine) 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) Emergency Room 20% after deductible $150 copay, plus 20% after deductible (copay waived if admitted) Outpatient Surgery 20% after deductible $150 copay per visit, plus 20% after deductible 19

20 Choice POS II Plan overview (Network level of benefits) Added Savings and Value with Quest Diagnostics Diagnostic Lab Services ActiveCare 1-HD ActiveCare 2 Quest Facility 20% after deductible Plan pays 100% (deductible waived) Other Facility 20% after deductible 20% after deductible 20

21 ActiveCare Select Plan/ActiveCare Select Whole Health Network Only Plan: Statewide no need to: Select a Primary Care Physician Obtain referrals for specialist care Always verify provider network status Non-Network: No coverage except in a true emergency Two Networks: Aetna Whole Health (ACO) Aetna Select (Open Access) Receive highest level of benefits: Pay less for care No balance billing No claim forms: Provider files claim for you Is this plan for you? You may want to consider the this plan if you: Understand which ActiveCare Select network you will be placed in Do not expect to use out-of-network providers Do not cover dependents who live outside your plan s network area Want a lower deductible and a lower premium cost for coverage 21

22 ActiveCare Select/ActiveCare Select Whole Health Plan overview (Network benefits ONLY plan*) You will be automatically enrolled in a network based on where you live If you live in one of these counties Aetna Whole Health Network Bexar Comal Collin Dallas Denton Ellis Ft. Bend Harris Montgomery Hays Travis Williamson Guadalupe Kendall Parker Rockwall Tarrant Baptist Health System and HealthTexas Medical Group Baylor Scott & White Quality Alliance Memorial Hermann Accountable Care Network Seton Health Alliance If you do not live in a county listed above Aetna Select Open Access Network *Only pays for out-of-network care in a true medical emergency 22

23 ActiveCare Select/ActiveCare Select Whole Health Plan overview (Network benefits ONLY plan*) Preventive Care Clarification Services ActiveCare Select Preventive Care Plan pays 100% (no copay required) Routine eye exam (one per plan year) Hearing exam $30 for primary $60 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 *Only pays for out-of-network care in a true medical emergency 23

24 ActiveCare Select/ActiveCare Select Whole Health Plan overview (Network benefits ONLY plan*) Benefits (continued) Services High-tech Radiology (CT scan, MRI, nuclear medicine) Inpatient Hospital ActiveCare Select $100 copay per service, plus 20% after deductible $150 copay per day, plus 20% after deductible ($750 maximum copay per admission) Emergency Room Outpatient Surgery $150 copay, plus 20% after deductible (copay waived if admitted) $150 copay per visit, plus 20% after deductible *Only pays for out-of-network care in a true medical emergency 24

25 ActiveCare Select/ActiveCare Select Whole Health Plan overview (Network benefits ONLY plan*) Added Savings and Value with Quest Diagnostics Diagnostic Lab Services Facility Quest Facility ActiveCare Select Plan pays 100% (deductible waived) Other Facility 20% after deductible *Only pays for out-of-network care in a true medical emergency 25

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27 Teladoc Teladoc is an affordable alternative to emergency room and urgent care. Many common medical issues can be resolved through the convenience of just a phone call 24/7/365 Highlights include. Copays waived for ActiveCare 2 and ActiveCare Select plans; only $40 consultation fee for ActiveCare 1-HD plan. Board certified providers specializing in family practice, internal medicine and pediatrics. Common diagnosis and treatment of common conditions such as sinusitis, upper respiratory infection, urinary tract infection, bronchitis, ear infections, influenza and the common cold. Consults available wherever the patient is at home, at work, or travelling within the United States. Guaranteed member call back within 60 minutes! The average call back time is minutes or schedule a call back at a specific time. Diagnosis, recommended treatment and prescriptions ordered when appropriate. A copy of the consult record will be sent to the member s PCP upon request. 27

28 Health and wellness resources For personal help with health conditions, challenges and goals Simple Steps To A Healthier Life Aetna Health Connections Beginning Right Maternity Program Aetna Care Advocate Team National Medical Excellence Program 24-Hour Nurse Information Line Live Healthy Challenge SM 28

29 Aetna Health Concierge A single source for help and information Answers to benefits questions Help to find care and services Information about helpful programs and resources A personal guide to Aetna Navigator 29

30 Aetna discount programs For savings on a wide variety of health needs Fitness memberships and equipment Hearing aids and exams Vision care Weight management programs Natural products and services 30

31 TRS-ActiveCare Aetna website 31

32 Your secure member website Aetna Navigator Check benefits and claims Search for doctors in the network Order additional ID cards, or print a temporary ID card Cost of Care tools Know the cost before you go Take a confidential health assessment 32

33 Choose wisely save money Aetna Member Payment Estimator Helps you make smarter care choices Compares costs for common procedures and treatments Know the cost of the care before you go 33

34 Mobile apps and tools Aetna Mobile Secure Site Log-in Required Find a network doctor Check your plan coverage Check on a claim Show you ID card Contact TRS-ActiveCare Customer Service itriage Check a symptom Look up a conditions Find the right doctor Check on ER wait times Teladoc 24/7/365 access to doctors by phone Get treatment for colds, allergies, ear infections and much more MyQuest Schedule a lab appointment Find a lab near you Check you results 34

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36 Your Prescription Drug Plan Caremark administers your prescription drug plans on behalf of TRS ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 plans Benefit includes both a retail and mail component Caremark 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 36

37 Prescription Drug benefits network level Features ActiveCare 1-HD ActiveCare Select ActiveCare 2 Drug Deductible (per person, per plan year) Retail Short-Term (up to 31-day supply) Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Retail Maintenance (after first fill, up to 31-day supply) Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Mail Order or Retail-Plus (up to 90-day supply) Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Specialty Medications (retail or mail) Subject to plan year deductible 20% coinsurance after deductible 20% coinsurance after deductible $0 generic; $200 brand $20 $40* 50% coinsurance* $35 $60* 50% coinsurance* $45 $105* 50% coinsurance* 20% coinsurance per fill $0 generic; $200 brand * 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. $20 $40* $65* $35 $60* $90* $45 $105* $180* $200 per fill (up to 31-day supply) $450 per fill (32-to 90-day supply) 37

38 Caremark s online tools and mobile apps help connect patients and their caregivers Prescription Alerts Alerts you to refills available at mail or retail, remaining refills, last refill, past due refills; add to cart right there Savings Opportunities Displays savings for each member of the family, with ability to request a medication change online Recent Orders Provides capability to track orders and alerts members of any changes to status Refill and Manage Family prescriptions can be managed in one place with a few clicks 38

39 Innovation that can help participants make better decisions for healthier outcomes Only PBM to offer native pre-log in functions for iphone and Android Scan to refill multiple Rx checkout Pill identifier Drug interaction checker After log in functions available Find drug costs Find a pharmacy in network View digital ID card See prescription orders and history Refill prescriptions 39

40 Specialist Pharmacists are an integral part of the health care continuum The Caremark Specialty Pharmacy provides not only your specialty medicines, but also personalized pharmacy care management services: Access to a team of clinical experts that are specially trained in your condition On-call pharmacist 24 hours a day, seven days a week Coordination of care with you and your doctor Convenient delivery to the address of your choice, including your doctor s office Medicine- and condition-specific education and counseling Insurance and financial coordination assistance Confidential and empathetic care Online support and resources through including condition-specific information and the specialty pharmacy drug list 40

41 Information resources TRS Website Pharmacy Benefit Highlights List of maintenance medications FAQs Download forms Caremark Participant Website 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 Caremark widget Customer Service Benefits Booklet 41

42 What if I have questions? Personalized Service Call TRS-ActiveCare customer service for: Claim questions/status Network provider information Medical and Rx coverage questions Inquiries (telephone and ) ID card requests Transition of care information Help with online tools TRS-ActiveCare Customer Service

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44 Company overview FirstCare Health Plans joined TRS-ActiveCare program in 2003; currently covers over 28,000 school employees and their dependents. Hospital-based health plan owned by Covenant Health in Lubbock and Hendrick Medical Center in Abilene. Focuses exclusively on the Texas market, serving over 108 counties with offices in Abilene, Amarillo, Austin and Lubbock. For a complete list of plan changes, please refer to your evidence of coverage and schedule of benefits. 44

45 Rate overview Coverage Category Premiums Employee Only $ Employee and Spouse $1, Employee and Child(ren) $ Family $1, For a complete list of plan changes, please refer to your evidence of coverage and schedule of benefits. 45

46 Benefit highlights 100% preventive care coverage $0 PCP office visit copayments for dependents, age 19 and under Maximum out-of-pocket includes medical and Rx deductibles, copayments & coinsurance No Rx deductible for generic drugs $0 copayment for some generic drugs *Example shown is for individual deductible For a complete list of plan changes, please refer to your evidence of coverage and schedule of benefits. 46

47 Benefit highlights Local offices; Texas-based customer service Comprehensive network of quality physicians No referral to network specialists Coverage for dependents living outside service area* Expecting the Best maternity program Secure online access to membership and claim information at FirstCare.com/TRS *Care must be accessed through our affiliate provider networks For a complete list of plan changes, please refer to your evidence of coverage and schedule of benefits. 47

48 Medical benefits for Overview/Changes No PCP Copay for Dependents (Age 19 & under) Deductible $500 per individual/$1,500 per family Out-of-Pocket Maximum includes medical/drug deductible, copayments & coinsurance $6,000 per individual/$12,000 per family Office Visit Primary Care $20 Primary Care visits for dependents $0 age 19 and under Specialist $60 Inpatient/Outpatient 25% after deductible (member share) For a complete list of plan changes, please refer to your evidence of coverage and schedule of benefits. 48

49 Pharmacy benefits for No Rx deductible for Tiers 1 & 2 and $0 copay for select generics (Tier 1) Deductible $100 per individual/$300 per family Not applicable for Tiers 1 & 2 Rx Out-of-Pocket Maximum Now part of overall Plan s Out-of-Pocket Maximum Copayments Select Generic/ACA Tier 1 $0 Preferred Generic Tier 2 $15 Preferred Brand/ Non-Preferred Generic Non-Preferred Brand/ Non-Preferred Generic *after deductible Tier 3 $40* Tier 4 $100* Specialty/Injectables Tier 5 20%* For a complete list of plan changes, please refer to your evidence of coverage and schedule of benefits. 49

50 FirstCare Service Area 108 counties across Texas To be eligible to enroll in a FirstCare plan, you must live or work in one of the shaded counties. 50

51 Abilene Region Provider Network FirstCare has a comprehensive network of local physicians, hospitals, and pharmacies that offer a full range of medical services. A complete list of network providers is available at FirstCare.com/TRS. Local FirstCare Contact Whitney Hill whill@firstcare.com Abilene Hospital: Hendrick Medical Center Other Regional Hospitals: Anson General Hospital Ballinger Memorial Hospital Coleman County Medical Center Comanche County Medical Center Eastland Memorial Hospital Fisher County Hospital Hamlin Memorial Hospital Haskell Memorial Hospital Heart of Texas Memorial Hospital Hendrick Medical Center Knox County Hospital Mitchell County Hospital North Runnels Hospital Rolling Plains Memorial Hospital Stamford Memorial Hospital Stephens Memorial Hospital Stonewall Memorial Hospital Throckmorton County Memorial Hospital 51

52 Amarillo Region Provider Network FirstCare has a comprehensive network of local physicians, hospitals, and pharmacies that offer a full range of medical services. A complete list of network providers is available at FirstCare.com/TRS. Local FirstCare Contact Dana Nicklaus dnicklaus@firstcare.com Amarillo Hospitals: Baptist St. Anthony s Hospital (BSA) Plum Creek Specialty Hospital Other Regional Hospitals: Childress Regional Medical Center Collingsworth General Hospital Coon Memorial Hospital Golden Plains Community Hospital Hansford County Hospital Hardeman County Memorial Hospital Hemphill County Hospital Hereford Regional Medical Center Moore County Hospital District Ochiltree Hospital District Pampa Regional Medical Center Parkview Hospital Parmer County Community Hospital Shamrock General Hospital Swisher Memorial Hospital 52

53 Lubbock Region Provider Network FirstCare has a comprehensive network of local physicians, hospitals, and pharmacies that offer a full range of medical services. A complete list of network providers is available at FirstCare.com/TRS. Local FirstCare Contact Dana Johnston djohnston@firstcare.com Lubbock Hospitals: Covenant Health System University Medical Center Other Regional Hospitals: Brownfield Regional Medical Center Cochran Memorial Hospital Cogdell Memorial Hospital Covenant Health System Crane Memorial Hospital Crosbyton Clinic Hospital HealthSouth Rehabilitation Hospital Iraan General Hospital District Lamb Healthcare Center Lynn County Martin County McCamey Hospital Medical Arts Hospital Medical Center Hospital Midland Memorial Hospital Muleshoe Area Medical Center Pecos County Memorial Permian Regional Medical Center Plains Memorial Hospital Rankin County Hospital Reeves County Hospital Seminole Memorial Hospital Winkler County Memorial Hospital W J Mangold Memorial Hospital Yoakum County Hospital 53

54 Waco/Bryan-College Station Region Provider Network FirstCare has a comprehensive network of local physicians, hospitals, and pharmacies that offer a full range of medical services. A complete list of network providers is available at FirstCare.com/TRS. Local Representative Contact Claudia Rojas crojas@firstcare.com Waco Hospitals: Providence Health Center Bryan/College Station Hospitals: St. Joseph Regional Health Center College Station Medical Center Other Regional Hospitals: Burleson St. Joseph Health Center Central Texas Hospital Coryell County Memorial Hospital East Texas Medical Center Crockett & Fairfield Falls Community Hospital Goodall-Witcher Hospital Grimes St. Joseph Health Center Hamilton General Hospital Hill Regional Hospital Huntsville Memorial Hospital Lake Whitney Medical Center Little River Medical Center Llano Memorial Hospital Madison St. Joseph Health Center Metroplex Adventist Hospital Parkview Regional Hospital Rollins Brook Community Hospital Seton Highland Lakes Texas Health Harris Methodist Hospital Stephenville Trinity Medical Center 54

55 Why choose FirstCare? Local offices; Texas-based customer service Comprehensive network of quality physicians No referral to network specialists Coverage for dependents living outside service area* Worldwide emergency care Expecting the Best TM maternity program Participating in the TRS-ActiveCare program since 2003 Serves 108 Texas counties *Care must be accessed through our affiliate provider networks For a complete list of plan changes, please refer to your evidence of coverage and schedule of benefits. 55

56 Contact us You may submit your questions or comments via to You can also write or call customer service at: FirstCare Health Plans 1901 West Loop 289 Suite 9 Lubbock, TX For a complete list of plan changes, please refer to your evidence of coverage and schedule of benefits. 56

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58 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 58

59 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. 59

60 Dependent eligibility 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 60

61 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 61

62 Annual enrollment Enrollment Period for Plan Year: July 1 August 22 (Annual Enrollment) Use the Enrollment Guide and Provider Directories to pick a Plan and coverage that is right for you Your current plan election will carry forward to the new plan year (September 1, 2016 to August 31, 2017). You do not have to actively enroll for coverage this year, unless your district/entity requires you enroll each year. Premium adjusted to reflect any rate change, effective September 1 62

63 Enrolling for the first time The enrollment must be completed before: The end of the plan enrollment period, or 31 calendar days after the employee s actively-at-work date, or 31 calendar days after a special enrollment event New hires may choose their effective date of coverage Actively-at-work date, or First of the month following their actively-at-work date Full premium for the month will be due if choosing actively-at-work date; premiums are not pro-rated 63

64 Making changes/special enrollment events Enrollees may be able to enroll for coverage, change plan options or change the dependents covered 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. 64

65 Part-time to full-time special enrollment Employees who move from part-time to full-time employees during the plan year may enroll in coverage within 31-days from the date they became a full-time employee for: Employee Eligible dependents This enrollment opportunity exists even if enrollment was previously declined by the employee. 65

66 Newborn coverage Covered first 31 days, if you have coverage Does not apply to newborn grandchildren You must add newborn within 31 days after the newborn s date of birth 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 (SSN) Submit application without SSN to enroll Re-submit another form after SSN is issued 66

67 Dependent disability process Dependent Child s Statement of Disability: A letter will be sent to the employee advising the loss of coverage for the dependent on their birthday unless they provide details of their disability Employee completes the Request for Continuation of Coverage for Handicapped Child form and requests physician to complete the Attending Physicians Form Completed forms are to be faxed or mailed along with any supporting documentation the physician includes for review. Fax # /address for submission are noted on the forms. If notification from Aetna is not provided advising Approval of Disability, the dependent s enrollment will be terminated on the last day of the month in which the 26 th birthday occurs. 67

68 Split Premium Process Split Premium Form: The Split Premium Form must be completed and signed by both employees who wish to split the cost of employee and spouse or employee and family The Split Funded arrangement will remain in effect for the next year, unless your district/entity requires you to complete a new form yearly Must be employed by different districts/entities participating in TRS-ActiveCare The cost for TRS-ActiveCare coverage will be split between the two employers One employee must decline coverage The Benefits Administrator must also sign and approve the form The employee who declined coverage is considered as being covered under a group health plan 68

69 Making changes/special enrollment events Enrollees may be able to enroll for coverage, change plan options or change the dependents covered 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. 69

70 Part-time to full-time special enrollment Employees who move from part-time to full-time employees during the plan year may enroll in coverage within 31-days from the date they became a full-time employee for: Employee Eligible dependents This enrollment opportunity exists even if enrollment was previously declined by the employee. 70

71 Newborn coverage Covered first 31 days, if you have coverage Does not apply to newborn grandchildren You must add newborn within 31 days after the newborn s date of birth 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 (SSN) Submit application without SSN to enroll Re-submit another form after SSN is issued 71

72 Dependent disability process Dependent Child s Statement of Disability: A letter will be sent to the employee advising the loss of coverage for the dependent on their birthday unless they provide details of their disability Employee completes the Request for Continuation of Coverage for Handicapped Child form and requests physician to complete the Attending Physicians Form Completed forms are to be faxed or mailed along with any supporting documentation the physician includes for review. Fax # /address for submission are noted on the forms. If notification from Aetna is not provided advising Approval of Disability, the dependent s enrollment will be terminated on the last day of the month in which the 26 th birthday occurs. 72

73 Split Premium Process Split Premium Form: The Split Premium Form must be completed and signed by both employees who wish to split the cost of employee and spouse or employee and family. The Split Funded arrangement will remain in effect for the next year, unless your district/entity requires you to complete a new form yearly Must be employed by different districts/entities participating in TRS-ActiveCare The cost for TRS-ActiveCare coverage will be split between the two employers One employee must decline coverage The Benefits Administrator at each district must also sign and approve the form The employee who declined coverage is considered as being covered under a group health plan 73

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75 ActiveCare 1HD TRS Amount Plainview ISD Contribution EE Premium Employee Only $341 $341 $0 Employee & Spouse $914 $341 $573 Employee & Children $615 $341 $274 Employee & Family $1,231 $341 $890 Employee Pool/Split $1,231 $341 $ ActiveCare Select TRS Amount Plainview ISD Contribution EE Premium Employee Only $484 $341 $143 Employee & Spouse $1,147 $341 $806 Employee & Children $779 $341 $438 Employee & Family $1,361 $341 $1,020 Employee Pool/Split $1,361 $341 $ ActiveCare 2 TRS Amount Plainview ISD Contribution EE Premium Employee Only $645 $341 $304 Employee & Spouse $1,552 $341 $1,211 Employee & Children $1,042 $341 $701 Employee & Family $1,597 $341 $1,256 Employee Pool/Split $1,597 $341 $ FirstCare TRS Amount Plainview ISD Contribution EE Premium Employee Only $ $341 $132 Employee & Spouse $1, $341 $ Employee & Children $ $341 $ Employee & Family $1, $341 $ Employee Pool/Split $1, $341 $

76 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 Form available online New Termination of Split Premium 76

77 ID cards (mailed to your home) Medical plans (ActiveCare 1-HD, ActiveCare Select and ActiveCare 2) Separate cards for medical and prescription drugs Aetna Caremark New enrollees will receive new ID cards Returning enrollees making a plan change (including coverage level, or adding or deleting a dependent) will receive new ID cards HMO plans Only new enrollees will receive ID cards 77

78 TRS-ActiveCare is administered by Aetna Life Insurance Company (Aetna). Aetna 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, ActiveCare Select and ActiveCare 2 plans are administered by Caremark. HMO plans provided by: SHA, L.L.C. dba FirstCare Health Plans, Scott and White Health Plan, and Allegian Insurance Company dba Allegian Health Plan. 78