Welcome to this presentation on the TRS-ActiveCare health coverage program. Information shared in this presentation is for the new health insurance

Transcription

1 Welcome to this presentation on the TRS-ActiveCare health coverage program. Information shared in this presentation is for the new health insurance program for SAISD employees in the plan year which becomes effective September 1,

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3 The agenda for this presentation includes: An overview of some interesting facts and figures about TRS-ActiveCare, followed by the highlights of the health plan options for and a summary of each plan s benefits and features. You will receive information on the eligibility rules for enrolling in the program and the cost of coverage for you and your family. You will also be given resources where you may access additional information. 3

4 TRS-ActiveCare is the statewide health care benefits program for Texas public education employees. It was established and signed into law by the Texas Legislature in The medical program is administered by Blue Cross and Blue Shield of Texas. Medco is the prescription drug company that administers the prescription drug program. To date 92% of districts in Texas participate in TRS-ActiveCare. 4

5 This is an overview of employees throughout the state and the plan they selected. There are four PPO plan options: ActiveCare 1-high deductible, 1, 2 and 3. ActiveCare 2 is the most popular plan in the state with 58% of the employees selecting this PPO option. There are three participating HMO carriers that collectively have approximately 5 percent of the membership in the state. The Scott & White HMO is the carrier for our district employees. 5

6 Let s look at the PPO medical plan options administered by Blue Cross and Blue Shield of Texas. We will cover the Scott & White HMO plan later in the presentation. 6

7 Administered by Blue Cross and Blue Shield of Texas, the PPO network for TRS-ActiveCare is the largest network of its kind in the state of Texas. Employees have the freedom to choose their own doctor at the point of service. No Primary Care Physician (PCP) or referrals are required!! Each time you or your dependent needs health care, you need to decide whether to see an in-network provider or a non-network provider. Network providers include Shannon and Community hospitals and most doctors in San Angelo; however, there are some that are not in the network and you should contact your physician to find out if he/she is in the network. When using in-network providers: you receive the highest level of benefits there are no claims for you to file in most cases (typically network providers file the claims for you) and there is also no balance billing; network providers cannot bill for costs that exceed the allowable amount When using non-network providers: you receive the non-network level of benefits (which is a reduced level from network benefits) you may have to file your own claims this will depend on the non-network provider and you may be billed for charges exceeding the BCBSTX allowable amount. Please be cautious and remember these things if you consider using a non-network provider. Network utilization is strongly encouraged whenever possible and that s what we will focus on as we discuss the PPO plan options. 7

8 The next few slides provide an overview of the 4 PPO plans. This information is also available on our SAISD website, the TRS website and in the enrollment guide pages 4 & 5. This chart illustrates benefits when network providers are used. As mentioned previously, nonnetwork benefits are also available and you may see the Enrollment Guide for information. Deductibles are the set amount of out-of-pocket expense, if applicable, that you must pay for health care services before the plan begins to share costs. For example, ActiveCare 1 has a $1,200 individual deductible and a $3,000 family deductible, which must be met before the plan pays any benefits. The ActiveCare 2 deductible is $750 per individual and $2,250 per family, and ActiveCare 3 has a $300 individual deductible to meet when using network providers for health care services and $900 for family. Let s consider the Out-of-Pocket Maximums: If you reach your plan s out-of-pocket maximum, the plan then pays 100% of any eligible expenses for the remainder of the plan year. Office visit copays continue after the out-of-pocket maximum is reached. As stated here, deductibles do not apply to the out-of-pocket maximums. For example: as an individual on ActiveCare 1, if you pay $1,200 for eligible medical expenses your individual deductible -- and then spend an additional $2,000 your out-of-pocket maximum -- the plan will then pay 100% of any eligible expenses for the rest of the plan year. So you must spend, $1,200 PLUS $2,000 for a total of $3,200 before the plan will pay 100%. Coinsurance is the percentage of medical expenses that you and the plan share. For example, the coinsurance amount when using network providers for all plans is "80/20." This means the plan pays 80% and you pay 20% after any applicable deductible. The 20% of coinsurance will count toward that out-of-pocket maximum. Copayments or -- Copays -- as we refer to them are the set amount you pay for certain medical 8

9 services and prescription drugs at the time of service. Please Note: There are no copays in the ActiveCare 1-HD or ActiveCare 1 plans. In ActiveCare 2 and 3, the copay depends on whether the doctor is a primary care physician or a specialist. Primary means care provided by family practitioners, internists, OB/GYNs, and pediatricians. All other physicians are considered specialists. #

10 Please note: The deductible year for TRS-ActiveCare is September 1 through August 31. SAISD s current deductible year is January through December. Unfortunately, TRS requires us to begin our new deductible on September 1 st. There is no carryover provision for any deductible previously met in the SAISD selffunded plan. This is unfortunate; however, SAISD will no longer be the insurance provider and we are subject to the state plan requirements. 9

11 Some people may be confused by the ActiveCare 1-HD and ActiveCare 1 plans because they appear to be very similar. This chart illustrates the differences between the two plans. The chart and a detailed explanation is included in the Frequently Asked Questions document. ActiveCare 1-HD meets the Internal Revenue Service definition of a high deductible health plan for all four coverage categories (employee only, employee/spouse, employee/child(ren) and employee/family). ActiveCare 1 meets the definition for employee-only coverage (not for dependents or families). Meeting the IRS definition of a high deductible health plan offers the opportunity to contribute pretax dollars into a health savings account also referred to as an HSA. TRS and SAISD do not offer health savings accounts; however, this presentation includes information about HSAs that you may wish to consider as an option. 10

12 An HSA or Health Savings Account is a special account owned by an individual used to pay for current and future medical expenses. It combines a high deductible health plan with a tax-free Health Savings Account that the participant and covered family members can use to pay out-of-pocket expenses such as copays and deductibles, or leave unspent to grow as savings. Each year, the HSA can be funded up to the IRS maximum. The participant controls the HSA, providing the flexibility to decide how, when and where to spend health care dollars. And the HSA is portable, which means you keep the funds even if you change health plans, take a new job or retire. An HSA is different than a Flexible Spending Account. Both are used for medical expenses; however, the IRS rules for each are different. The IRS has a use it or lose it rule for Flexible Spending Accounts. HSA funds carryover every year and may grow as savings. TRS-ActiveCare and SAISD DO NOT offer an HSA - - But ActiveCare 1-HD and ActiveCare 1 meet the IRS definition for eligibility. Employees are not required to have an HSA to enroll in these plans, but you may seek an HSA administrator on your own to establish an account. Many banks local and national banks offer this service. To learn more about HSAs, please visit the U. S. Treasury s website. *It is Important to Note that HSAs have tax and legal ramifications. TRS, Blue Cross and Blue Shield and SAISD do not provide legal or tax advice, and nothing in this presentation is to be construed as legal or tax advice. You should seek advice based on your particular circumstances from an independent tax advisor regarding the tax consequences. 11

13 As we continue with our benefit overview, this slide shows that the TRS-ActiveCare PPO plans provide 100% coverage for certain preventive care services when network providers are used. However, not all preventive care benefits are covered at 100%, routine eye and vision exams and hearing exams are not part of the benefits for preventive care. Some examples of preventive care services covered 100% when using network providers are: Routine annual physicals (one per plan year) Immunizations Well-child care Routine mammograms (one per plan year) Routine colonoscopies Bone density tests Screening for prostate cancer Smoking cessation counseling services Healthy diet counseling and obesity screening 12

14 In ActiveCare 2 and 3 plans, a high-tech radiology copay is included. The $100 copay is per service and applies to CT scans, MRIs and nuclear medicine when using network providers. So, if a patient has a CT scan and an MRI on the same day, he/she will pay $200, plus deductible and coinsurance. The inpatient hospital copays for ActiveCare 2 and 3 are $150 copay per day, plus deductible and coinsurance. The maximum copay per admission for each plan is $750 and the maximum per plan year is $2,250. The emergency room and outpatient surgery copays for ActiveCare 2 and 3 are $

15 In the Blue Cross and Blue Shield plans, Blue Distinction is a designation awarded to medical facilities that have demonstrated expertise in delivering quality health care. All bariatric surgical procedures for weight loss, such as lap band and gastric bypass, must be performed at one of the Blue Distinction Centers for Bariatric Surgery or the expenses will not be covered by TRS-ActiveCare. Travel expenses to and from the Blue Distinction Centers will not be covered by the plan. The list of Blue Distinction Centers for Bariatric Surgery is subject to change without notice. Refer to the Blue Cross website or contact Customer Service for doctors and the benefit costs. 14

16 TRS-ActiveCare requires advance approval (preauthorization) by Blue Cross and Blue Shield of Texas for certain services. Preauthorization establishes in advance (or within 48 hours following an emergency hospital admission) the medical necessity of certain care and services covered under TRS-ActiveCare. The following types of services require preauthorization: All inpatient admissions; treatment of all serious mental illness, mental health care and chemical dependency; extended care, such as in a skilled nursing facility, through home health care or through hospice; and home infusion therapy. Blue Cross and Blue Shield of Texas will review the medical necessity of your treatment prior to the final benefit determination. If the treatment or service is not medically necessary, benefits will be denied. There is a $250 penalty for failure to preauthorize a medically necessary admission to a non-network hospital. When using non-network providers, YOU are responsible for obtaining preauthorization. Network physicians will preauthorize services for you; however, it is always in your best interest to verify this with your physician. You are encouraged to call the 800# on your ID card or on the website. 15

17 Benefits for prescription drugs is always of interest to employees. 16

18 Medco administers the prescription drug plan on behalf of TRS-ActiveCare. The program has both a retail and mail-order component. The retail coverage has over 65,000 pharmacies in network. And, of those, 4,700 pharmacies participate in the Retail-Plus network. Medco also has a mail order facility. By filling your long-term medications through the Medco Pharmacy, you can get up to a 90-day supply delivered directly to you at a lower copay. You can order refills, comparison shop medications, check the status of your orders online, or you can call the toll-free number. 17

19 This is an overview of the prescription drug benefits for the ActiveCare 1-HD, 1, 2 and 3 plans. The chart illustrates benefits when network providers are used. Nonnetwork benefits are also available and you may refer to the Enrollment Guide for more information on pages 3, 6 & 7. ActiveCare 2 has a $200 plan year deductible for brand name prescriptions and the deductible is waived for generic medications. There is a $75 deductible in the ActiveCare 3 plan. The plan allows one maintenance prescription fill before you pay the retail maintenance penalty. This means that a higher copay will be assessed on the second fill of a maintenance prescription, unless it is filled through the Medco Pharmacy or a participating Retail-Plus network pharmacy. To help control costs, TRS has implemented the Generics Rx Advantage Program, a copay waiver program for generics and selected brands that will become generic in the near future. All waived copays are fully funded by Medco. To get started in the program, you simply enroll online. 18

20 In the PPO Plans of ActiveCare 1, 1HD, 2 & 3 the MedCo Network has local pharmacies at 18 locations: Baptist, Community, CVS, Food Basket, HEB, Lowe s, Medical Arts, Medi-Mart, Myers, Sam s, Sav-on, Shannon, Walgreens, Wal-Mart For a 90-day supply of your maintenance drug you may get this by mail-order from Medco OR at HEB for the same benefit. 19

21 In compliance with the 2010 Patient Protection and Affordable Care Act, TRS offers coverage for certain recommended preventive medications at no cost to you. Beginning September 1, 2012, coverage of certain contraceptive products will also be made available to women at no cost. 20

22 For additional information, you may refer to these websites, contact the customer service office or consult your benefits booklet. 21

23 In addition to the ActiveCare plans, TRS offers participating members an option of an HMO plan. The HMO is through the Scott and White Health Plan. As you may know, an HMO provides members lower costs as an incentive to use only one network. To receive benefits in this plan, you may only use physicians and medical facilities associated with Scott & White. 22

24 Scott and White Health Plan is available in 48 counties across Central and West Texas. The green dots on the map represent hospital providers throughout the service area. In Tom Green County, Shannon Health System and multiple physicians from West Texas Medical Associates are in the Scott & White network. 23

25 Scott and White Health Plan benefits are not subject to pre-existing conditions. PCP and maternity visits are covered with a $20 copay. Preventive care services for adults and children are covered at no charge. Scott and White also includes 1 refraction eye exam annually at no charge. Scott and White does not require PCP designations nor referrals to Specialists. See Enrollment Guide for full list of benefits on pages 10 &

26 The Scott & White HMO prescription drug plan includes NO deductible on generic prescriptions. A $100 deductible applies to preferred brand, nonpreferred brand and non-formulary prescriptions. If you purchase your prescription drugs through a retail pharmacy, you pay $3 for generic medications with no deductible. For preferred brand drugs you pay 30% after your deductible. For non-preferred brand-name drugs, you pay 50% after the deductible. The cost of non-formulary drugs is the greater of $50 or 50% after deductible. If a brand-name prescription is dispensed when a generic is available, a copay of 50% applies after your prescription deductible. Prescription drugs purchased through mail order with a Scott and White pharmacy are $6 for generic with no deductible and 30% after deductible for mail order preferred brand. For non-preferred brand drugs, the cost is 50% after the deductible. Non-formulary drugs are not available by mail order with this plan. 25

27 With this plan, prescriptions may be filled at most major retail pharmacies. A 90-day supply of your maintenance drug is only available through mail-order. 26

28 If you have difficulty scheduling an appointment with a local network provider, help is available. Shannon Patient Access Coordinators are available to help you find a physician that best meets your needs. 27

29 This portion of the presentation will provide a summary of enrolling in the plan. 28

30 To be eligible for TRS-ActiveCare (1) you must be an active, contributing TRS member or (2) be employed for 10 or more regularly scheduled hours each week If you are a retiree, please contact the Human Resources Department for information regarding eligibility requirements. 29

31 This slide shows the rules for eligible dependents, which may be: A spouse (including a common law spouse) A child under the age of 26 as detailed in the slide "Any other child" unmarried and under age 26 in a regular parent-child relationship with the employee A child age 26 or older may be eligible for dependent coverage, provided that the child is either mentally or physically incapacitated to such an extent to be dependent on the employee on a regular basis as determined by TRS, and meets other requirements as determined by TRS. A dependent does not include a brother or a sister of an employee unless the brother or sister 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 an employee, as defined in the "any other child" category above. Parents and grandparents of the covered employee do not meet the definition of an eligible dependent. 30

32 If an employee and spouse both work for a district or entity that participates in TRS-ActiveCare: each employee may elect their own coverage as employee-only OR one employee may decline coverage and be covered as a spouse on the other employee s plan More information will be covered later in this presentation. Only one parent may enroll dependent children for coverage If a child (under age 26) is employed by a district/entity and is a contributing TRS member, this child cannot be covered as a dependent on his or her parent's TRS-ActiveCare coverage. The child must be covered as an employee. If the child is not a contributing TRS member, the child may then be covered as a dependent. 31

33 Pre-existing condition exclusions do not apply to: any individual under age 19, employees that initially enroll when the district/entity begins participating in TRS- ActiveCare (like SAISD is doing now) to HMO enrollees to new hires who enroll within 31 days after their actively-at-work date. However, there is an exception: If you were covered under TRS-ActiveCare at any point in time since its inception in 2002 and you have been hired by a different participating district/entity, pre-existing limitation exclusions may apply. Please contact the TRS-ActiveCare customer service for details. 32

34 There are basically 2 steps to enroll: 1 st you are encouraged to review each plan and consider your health care needs then select a plan that best meets your needs 2 nd you must complete an enrollment application. You will complete your application electronically on the SAISD Employee Access Center. 33

35 Your link to the electronic enrollment will be on the district s Employee Access Center. As you know, this is the center on the district s website where your benefits and pay information is located. Simply access the SAISD webpage, select the Favorites, Employee Favorites at the top left corner of the homepage, click on the Employee Acccess Center and log in. You will see the link entitled FFenroll which is the electronic enrollment platform for our TRS-ActiveCare plans. 34

36 When you select FFenroll on the Employee Access Center, this screen will appear. To log in, enter your SAISD employee ID number or your Social Security number. Your PIN is the last 4 digits of your Social Security number plus the last 2 digits of your year of birth. You may wish to make a note of this information and have it accessible when you are ready to enroll. 35

37 The enrollment screen will appear. You will complete the information and click Enroll. If you are covering dependents, a screen will appear and you will enter the dependents information. 36

38 You will select the plan in which you are enrolling and select I wish to apply for this coverage. If you are declining or waiving coverage perhaps you have coverage through another family member or entity, you will select I wish to DECLINE this coverage. You will then click Next. If you receive an error message, perhaps you didn t complete all the information required on prior screens. If you leave your screen before completing the election, the information you entered will remain until you go back to the screen and complete the process. 37

39 SAISD s enrollment period this year is: April 30 - May 25 In order to have coverage in our new health plan through TRS, you must enroll electronically and you must complete your enrollment no later than May 25. It is critical that you enroll during the enrollment period. TRS has very strict deadlines and is not lenient if you fail to meet the deadline. If you are declining coverage, you also must go to the Employee Access Center and access the enrollment form and select the decline coverage option. Even if you decline coverage, you must complete the electronic process. There is also a paper document required by TRS. You may contact the Human Resources Department for that form. Again, it is strongly encouraged that you read the enrollment guide and review the plans carefully. Rates and benefits for every plan option are in the guide. Enrollment for the Section 125 Cafeteria Plan voluntary/supplemental benefits (dental, vision, cancer, disability, etc. and the flexible spending accounts) has not changed. The open enrollment for those plans is 38

40 November - December for a January effective date. #

41 An employee may be able to enroll for coverage, change plan options, or change the dependents he or she covers during a plan year if the employee or dependent has a special enrollment event. Changes in employee and/or dependent coverage must be made within 31 days after the special enrollment event. (Special rules apply to newborns; see page 19 of the Enrollment Guide and next slide for more information.) If the employee does not request the appropriate changes during the applicable special enrollment period, the changes cannot be made until the next plan enrollment period or, if applicable, until another special enrollment event occurs. TRS has very strict deadlines and makes few exceptions. One example of a special enrollment event is gaining a new dependent as a result of marriage, birth, adoption, or placement for adoption. Please note that a common law marriage is not considered a special enrollment event unless there is a Declaration of Common Law Marriage filed with an authorized government agency. Another example of a special enrollment event is loss of other coverage. Loss of coverage qualifies as a special enrollment event if: The employee and/or dependent(s) lost other coverage due to a loss of eligibility The employee and/or dependent(s) elected to drop the other group health coverage because the employer stopped all employer contributions toward the premium (including any employer-paid COBRA premium) The employee and/or dependent(s) exhausted their COBRA continuation coverage Changing districts/entities is not considered a special enrollment event under TRS- 39

42 ActiveCare. #

43 Detailed information about coverage for newborns is in our Frequently Asked Questions #26 and in the Enrollment Guide on page

44 This section of the presentation addresses the cost of coverage. 41

45 The Texas Insurance Code authorizes funding to help active employees who are TRS members pay for TRS-ActiveCare coverage. Each district is required to contribute a minimum of $225 per month to help employees pay for this coverage. San Angelo ISD contributes well above the minimum required contribution at $350 per employee per month. That equals $4,200 per year. This amount significantly reduces the amount that employees will owe per month for the TRS-ActiveCare plan selected. Please note that the rates shown in the Enrollment Guide on page 21 are the gross monthly premiums and do not reflect the SAISD contribution. 42

46 The Employee Cost Comparison for each plan is available on our district website for you to review more closely. The rates on this slide and on the Employee Cost Comparison on the website reflect employee cost and is not the total cost of each plan. We have subtracted the district s $350 contribution so you may see the actual cost to you. Please note that the plan costs quoted in the Enrollment Guide on page 21 are the total cost of the plan. The enrollment guide is for every participating district in the state; therefore, it is not going to reflect our district s $350 contribution. A question that has been posed several times involves the cost of employee and family coverage for ActiveCare 1-HD and ActiveCare in which the high deductible plan is more expensive than employee and family coverage for ActiveCare 1. This is because the deductible and out-of-pocket maximum amounts for family are less and the plan may begin paying 100% benefits sooner. So for ActiveCare 1, employee and family coverage is less expensive than ActiveCare 1-HD because the deductible and out-of-pocket maximum amounts for family are greater and it will take longer to accumulate the medical expenses to satisfy these amounts. 43

47 TRS offers a special benefit if both you and your spouse work for SAISD and need family coverage. You have the option to pool the funds contributed to your plan: You may decline coverage and be covered on your spouse s plan In this case, your spouse would elect family dual coverage on the enrollment screen and this will cover you, your spouse and your children. Although you decline coverage, you still must complete the electronic enrollment and check the box indicating you are declining coverage. If this is the option you elect, SAISD is required to contribute on behalf of both you and your spouse equaling a contribution from SAISD of $700 to the spouse s plan that elects the family dual coverage. This is a great advantage. Please contact the SAISD Human Resources Department if this applies to you and you need help enrolling. 44

48 If you and your spouse work for different participating entities (2 districts or a district and the service center) you have the option to split funds contributed on your behalf. You must complete the Application to Split Premium and the employer cost of coverage will be split and paid by the two employers, making your cost much less. If you and your spouse work for different participating entities please contact the SAISD Human Resources Department for more information and instructions on completing the form. 45

49 When enrolling in the plan by May 25, 2012, you will receive your ID card by September 1, For the medical benefits, administered by Blue Cross and Blue Shield of Texas, employees with "employee-only" coverage will receive one card; employees with dependent coverage will receive two cards. Additional cards may be ordered from Customer Service at no charge. You will have a separate prescription card from Medco. The Scott & White HMO plan has only 1 card for both medical and prescription drugs. All ID cards include a unique identification number instead of a Social Security Number. 46

50 The Web is an excellent source for additional information. You may access: The enrollment guide in English and Spanish and Large Print Forms Provider locator And frequently asked questions and answers 47

51 Blue Access for Members is a secure portion of the BCBSTX website that ActiveCare 1-HD, 1, 2 and 3 plan participants can use to access their personal membership and claims information. My Benefits is the online tool for the Scott & White HMO plan. This is where you: check the status of a claim and view claim summaries print Explanations of Benefits - - EOB are not mailed order additional or replacement ID cards and print a temporary ID card 48

52 If you elect one of the PPO plans, there is a customer service team available to answer your questions about claims, medical coverage, prescription drug coverage, and eligibility. They can also assist you with ID card requests, transition of care information and help with online tools. 49

53 Thank you for participating in this session. You may submit questions through our district website or call the Human Resources Department at x517 or x