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Health Care Coverage for You and Your Family!


Health Care Coverage for You and Your Family! Welcome Agenda Who is eligible to enroll Plan options and what s new Cost of health coverage How to enroll Enrollment ... – PowerPoint PPT presentation

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Title: Health Care Coverage for You and Your Family!

Health Care Coverage for You and Your Family!
  • Welcome

  • Who is eligible to enroll
  • Plan options and whats new
  • Cost of health coverage
  • How to enroll
  • Enrollment support
  • Questions

Who is Eligible to Enroll?
  • To be eligible for TRS-ActiveCare coverage, you
  • Be employed by a participating district/entity
  • 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
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
Eligible Dependents
  • Spouse (including a common law spouse)
  • Unmarried children under age 25
  • Natural child
  • Adopted child
  • Stepchild
  • Foster child
  • Other eligible dependents listed in
    Enrollment Guide
  • Grandchildren (unmarried)
  • Disabled children
    (unmarried, of any age)

  • Covered the first 31 days if employee has
  • 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
    newborns date of birth if
  • Employee has employee and family or employee
    and child(ren) coverage at the time of birth and
    at the time of enrollment

PPO Plan Options
  • ActiveCare 1, 2 and 3

Whats New for 2008-2009?
  • ActiveCare 1, 2 and 3
  • No premium increase
  • No benefit changes
  • Emphasis on health and wellness
  • New plan features available April 1, 2008
  • Blue Care Connection
  • 24/7 Nurseline
  • Personal Health Manager (PHM) online health and
    wellness resource
  • Live Chat secure, online real-time access for
    customer service inquiries

PPO Network for ActiveCare 1, 2 and 3
Need to locate a Network Provider?
Plan Overview
Illustrates benefits when network providers are
used. Non-network benefits are also available
see Enrollment Guide for more information.
Plan Overview
Illustrates benefits when network providers are
used. Non-network benefits are also available
see Enrollment Guide for more information.
Blue CareConnection
  • Health and Wellness Programs

TRS-ActiveCare is administered by Blue Cross and
Blue Shield of Texas, a Division of Health Care
Service Corporation, a Mutual Legal Reserve
Company, an Independent Licensee of the Blue
Cross and Blue Shield Association. Blue Cross
and Blue Shield of Texas provides claims payment
services only and does not assume any financial
risk or obligation with respect to claims.
24/7 Nurseline
Advice anytime. Round-the-clock health and the
wellness advice from licensed professionals
  • Advice isnt just neededfrom 9 to 5.24/7
    Nurseline is here to help.
  • Nurses provide health advice and information
    about high fevers, earaches, cuts and bruises and
  • Audio health library on topics such as kicking
    the smoking habit and ways to get a good nights

Available in English and Spanish
Personal Health Manager
  • Your online wellness experience begins here
  • Take a Health Risk Assessment
  • Improve your health with the Eat Right
    nutrition planner
  • Create a fitness plan to suit your personal
    health goals and needs with Get Fit

Click on the Personal Health Manager iconon Blue
Access for Members
Ask-A Online Advisor
Expert advice at your fingertips.Our Ask-A
feature is here to help.
Ask the experts. Expert advice from licensed
professionalsvia the Personal Health Manager
Ask a Trainer, Dietitian orLife Coach Send
questions about fitness, nutrition, or managing
Ask a Nurse Interact online with a Blue Care
Advisor on non-emergency, health-related
questions using the secure Ask a Nurse feature.
CONFIDENTIAL AND SECURE Receive a response within
one business day
Blue PointsSM Incentives
ActiveCare 1, 2 and 3 plan participants and their
covered dependents accumulate Blue PointsSM in
the Personal Health Manager.
Stay motivated. Earn Blue PointsSM in the
Personal Health Manager
  • Complete designated health and wellness
  • Report completed activities in the Personal
    Health Manager
  • Track your available balance
  • Redeem earned Blue PointsSM for a variety of

Weight Management and Tobacco Cessation
  • Self-Paced Approach
  • Online tools and resources via the Personal
    Health Manager
  • Secure e-mail outreach to keep members on track

Weight Management Program Support for a Healthier
Tobacco Cessation Program Support for members who
want to quit
  • Personalized Lifestyle Management Support
  • Counseling and coaching with licensed Wellness
  • Motivational toolkit
  • 24/7 Nurseline
  • Referrals when appropriate

Expecting? Special Beginnings Program
Live ChatSecure Online Customer Service
  • Send inquiries to customer service via e-mail
  • Immediate access to BCBSTX customer advocates
  • Available Monday Friday, 7 a.m. to 10 p.m. (CT)

What if I Have Questions?
  • Personalized Service
  • Call the TRS-ActiveCare customer service team
  • Claim questions/status
  • Network provider information
  • Membership and eligibility
  • Medical coverage questions
  • Inquiries (telephone and e-mail)
  • ID card requests
  • Transition of care information
  • Help with online tools!

Customer Service 1-866-355-5999
Blue Access for MembersOnline Member Management
  • Online member management tool.
  • Check claim status, view and download EOBs
    (Explanations of Benefits)
  • Order additional ID cards, and print temporary ID
  • Send secure e-mail messages to BCBS Customer
  • Monthly health articles
  • Links to health information and wellness tools
    and resources

Prescription Drugs
  • ActiveCare 1, 2 and 3

Your Medco Prescription Drug Plan
  • Your TRS-ActiveCare health plan has two
    prescription drug components
  • Blue Cross and Blue Shield of Texas manages your
    medical plan expenses, including prescription
    drug expenses under ActiveCare 1
  • Medco manages your prescription drug plan
    expenses for ActiveCare 2 and 3

Your Medco Prescription Drug Plan
  • Medco has its own mail-order pharmacy Medco By
    Mail which delivers medications to your home at
    a lower cost
  • Medcos mail-order pharmacies fill about 2
    million prescriptions per week through a highly
    automated process that is 99.9997 accurate and
    is 23 times more accurate than a retail pharmacy

Dispensing Error Rate in a Highly Automated
Mail-Service Pharmacy Practice Nov. 2007,
Pharmacology, a peer-reviewed journal of the
American College of Clinical Pharmacy
Specific Rx Benefit Information
  • If you are taking a long-term medication, filling
    your prescriptions through Medcos mail-order
    pharmacy provides several benefits
  • You receive a 90-day supply of your medication at
    a lower copay
  • You have access to Specialist Pharmacists who
    receive additional training in conditions such as
    asthma, diabetes, heart disease and more
  • While retail pharmacists know the medications you
    fill at one pharmacy, Medcos Specialist
    Pharmacists have a complete view of all of your
    medications so they know if there are potential
    safety issues and will contact you and your
    doctor to discuss these issues
  • You have access to specialist pharmacists whether
    you fill your prescription at a retail pharmacy
    or at Medco By Mail
  • Your medication questions can be answered by
    calling 1-866-355-5999

Prescription Drug Benefits
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
Prescription Drug Benefits
  • Once the deductible is satisfied, the member pays
    the applicable copay
  • Member-paid cost differences between a brand-name
    drug and a generic equivalent do not apply to the
  • Member cost share will not exceed the cost of the

Prescription Drug Benefits
  • Once the deductible is satisfied, the member pays
    the applicable copay
  • Member-paid cost differences between a brand-name
    drug and a generic equivalent do not apply to the
  • Member cost share will not exceed the cost of the

Information Resources
  • TRS Web site
  • Pharmacy Benefit Highlights
  • List of maintenance medications
  • FAQs
  • Download forms
  • Medco Member Web site
  • Prior Authorization List
  • Formulary Information
  • Locate a Participating Pharmacy
  • Health and Wellness Information
  • My Rx Choices / Price a Medication
  • Online Ordering
  • Download forms
  • Customer Service Number 1-866-355-5999
  • Benefits Booklet

My Rx Choices Your online savings tool
  • Lower your cost for prescriptions with My Rx
  • Features include
  • Personal assessment of cost-saving opportunities
    based on your prescription plan and medications
    that you or covered family members take on an
    ongoing basis.
  • Best-value alternatives based upon greatest cost
    savings to you presented in order from highest
    value to member
  • Brand-to-generic and retail-to-mail compare
    options available
  • Easy-to-understand explanations of complicated
  • The average amount saved by My Rx Choices users
    is 294!
  • Your doctor knows which medications are right for
    you but you may not know how much they cost. My
    Rx Choices provides you with available lower-cost
    options so that you and your doctor can make the
    most informed decisions based on health and cost.
  • Simply visit Youll to take
    a moment to register before using this service.
    You can also call 1-866-355-5999.

My Rx Choices Available through Customer
Service or on
  • The My Rx Choices home page allows the user to
  • Select a patient (pre-populated with all covered
    household members)
  • Select a drug to compare from a pre-populated
    list of prescriptions for the user.
  • Your potential savings are clearly presented.

My Rx Choices
Medco can facilitate on generic equivalents
received through mail order
My Rx Choices
Members may print a kit to discusslower-cost
alternatives with their doctor
More about Your Rx Benefits
  • Refill your medication at when you
    use Medco By Mail
  • Sign-up for Refill Reminders at
  • Speak to a specialist pharmacist about the
    medications you are taking for a specific
  • Send e-mails to Customer Service and to Medco
    pharmacists through the Medco member Web site

Medco Tour of Champions
  • An endorsement campaign featuring six Olympic
    gold medalists each with a chronic or complex
  • Promotes Specialist Pharmacists as providing a
    higher level of care for people with chronic
    and complex conditions like asthma and diabetes
  • Campaign runs through 12/08

HMO Plan Options
  • 2008-2009 Plan Year

  • HMO Plan Option

FirstCare Health PlansService Area
92 counties across Texas
FirstCare Health Plans
  • No claim forms
  • No preexisting limitations
  • Emphasis on preventive health care
  • No referrals required
  • Extensive provider network
  • Local hospitals and doctors
  • Nationwide network through Texas True Choice and
    PHCS (outside Texas)
  • Worldwide emergency care

FirstCare Health PlansMember Satisfaction
  • Timely Customer Service
  • Minimum automation calls answered in Lubbock,
  • Limited wait time to talk to a live
  • High member satisfaction for claims processing
  • Web site accessibility for information 24 hours a
  • Regional offices in Abilene, Amarillo, Lubbock
    and Waco to serve local communities

FirstCare Health PlansWhats New for 2008-2009
  • 400 deductible not applicable on most office
    visit services see Plan Summary
  • Out-of-pocket maximum reduced to 3,500 per
  • 100 copay on radio-nuclide stress test
  • 100 copay on non-pregnancy ultrasound tests
  • 40 copay on bone mass measurement test
  • Limited dental-related services have a maximum
    allowance of 10,000
  • External prosthetics devices have a lifetime
    maximum allowance of 10,000
  • 10 copay on preferred diabetic testing supplies
  • No copay on preferred glucose monitors
  • Premium increase of approximately 9.9

FirstCare Health PlansWhats New for 2008-2009
  • 24/7 NurseLine available
  • Access a Registered Nurse with your medical
  • Staying Healthy Questions
  • Minor Injuries
  • Routine Illnesses
  • Medication Questions
  • Understanding Your Treatment Options
  • Access Their Web site (
  • Health Assessments
  • Health Topics

FirstCare Health Plans
FirstCare Health Plans
10,000 maximum prescription benefit per person
per plan year
Excludes insulin and allergy serum Not subject
to 10,000 benefit maximum
FirstCare Health PlansMember Portal
  • Link from the TRS-ActiveCare Web site for easy
    access to
  • Change PCP
  • Request ID Cards
  • Print temporary ID Cards
  • Change address
  • Check status of claims
  • Check status of authorizations

Legacy Health Solutions
  • HMO Plan Option

Legacy Health SolutionsService Area
18 counties West Texas
Legacy Health Solutions
  • HMO Network Expansion
  • 389 Physicians in Legacy HMO Network
  • Added physicians of West Texas Medical Associates
    to our HMO
  • Members like HMO features
  • Predictable medical expense
  • No deductibles
  • No coinsurance
  • Coverage for preexisting conditions
  • No referrals needed for specialists
  • In CAHPS Customer Satisfaction Survey, members
    ranked Legacy HMO in 93
  • Local management means timely feedback for
    participant questions, concerns, medical

Legacy Health Solutions
  • Emergencies covered anywhere
  • 24 Hour Nurse Hotline
  • Health Advisory Tools customized to each member
  • Online Personal Health Record
  • Out-of-area care for dependents
  • LHS network has 349 physicians representing over
    43 specialties throughout West Texas
  • Disease and case management for chronic

Legacy Health SolutionsWhats New for 2008-2009
  • 300 copay per day for inpatient hospital(1,500
    maximum per admission)
  • 300 copay for outpatient hospital
  • 3,000/9,000 out-of-pocket maximum per
  • 150 copay for emergency room care within 48
    hours (copay waived if admitted)
  • 35 copay for preferred brand-name drug(retail
    up to 30-day supply)
  • 70 copay for preferred brand-name drug(mail up
    to 90-day supply)
  • Premium increase of approximately 5

Legacy Health Solutions Claim Messaging
Legacy Health SolutionsPharmacy Savings Messaging
Potential Savings
How to Save Talk to your doctor about switching
from Nexium to Prilosec OTC or another comparable
Print Report
Legacy Health Solutions Web Tools
  • Best in class tools to help members understand
    and manage their health and health care finances

Legacy Health Solutions
Legacy Health Solutions
Injectable Prescription Drugs - 25 of charges
Mercy Health Plans
  • HMO Plan Option

Mercy Health PlansService Area
  • 4 Texas counties
  • Webb
  • Jim Hogg
  • Zapata
  • Duval

Mercy Health Plans
  • 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
  • How people rated their plan
  • How people rated their health care
  • How people rated their doctor
  • How people rated their specialist
  • How people rated the efficiency and helpfulness
    of customer service

Office of Public Insurance Council
Mercy Health PlansReferrals
  • 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 PlansWhats New for 2008-2009
  • Office visit copay changes from 10 to 20
  • 10 coinsurance for inpatient, outpatient and
    diagnostic services
  • Prescription drug copays change from
  • Retail
  • 5 to 10 generic
  • 20 to 25 preferred brand (formulary)
  • 35 to 45 non-preferred brand (non-formulary)
  • Mail Order
  • Copays 2x retail copays
  • Approximately 10 premium increase

Mercy Health Plans
Mercy Health Plans
Infertility drugs are covered at 50 2,000
maximum prescription drug benefit per person per
plan year
Scott White Health Plan
  • HMO Plan Option

Scott and White Health PlanService Area
32 counties across Texas
Scott and White Health Plan
  • Named one of the Highest Ranked Health Plans in
    Texas by U.S. News World Report (2007) for the
    third year in a row
  • No claim forms, no deductibles
  • Coverage for preexisting conditions
  • Worldwide emergency care
  • Direct access to OB/GYN and ophthalmology
  • Regional customer service centers in
    Georgetown,Temple, Bryan/College Station and
  • 24-hour Nurse Advice Line 1-800-975-6612

Scott and WhiteNew Cancer Treatment Center
Temple Campus
First phase of work is underway Estimated
completion date is 1QTR 2009
Scott and White Health PlanExpanding Network of
  • Hospital Additions
  • Hillcrest Baptist Medical Center/Waco
  • Grimes St. Joseph Hospital/Navasota
  • Physician Group Additions
  • SW Wells Branch Clinic March 2008
  • Kings Daughters Clinic March 2008
  • SW Salado Clinic September 2008
  • Expansions/additions proposed in 2008 for
    Williamson, Travis and Bastrop counties
  • Pharmacy Additions
  • SWHP Canyon Creek Pharmacy Temple April 2008
  • SWHP Salado Pharmacy September 2008

Scott and White Health PlanWhats New for
  • Prescription benefit maximum
  • Increasing from 2,000 to 3,000 per person
  • Diabetic test strips
  • Preferred brand 5
  • Non-preferred brand 25
  • Home infusion therapy benefit
  • 100 per day
  • 500 maximum copayment per course of treatment
  • Premium increase of approximately 9

Scott and White Health Plan
Scott and White Health Plan
3,000 maximum benefit per person per plan
year If a brand-name prescription is dispensed
when a generic is available, enrollee pays 50 of
brand-name cost
Scott and White Health PlanOnline Wellness Tools
  • Succeed Health risk appraisal
  • Breathe Smoking cessation
  • Balance Weight management
  • Relax Stress management
  • Nourish Nutrition
  • CareTM for Your Back Back pain management
  • CareTM for Your Health Healthy living program
  • OvercomingTM Depression Depression management
Valley Baptist Health Plans
  • HMO Plan Option

Valley Baptist Health PlansService Area
  • Rio Grande Valley
  • Counties
  • Cameron
  • Hidalgo
  • Starr (partial)
  • Willacy
  • Provider Network
  • More than 780 providers
  • 11 hospitals Valley-wide

Valley Baptist Health Plans
  • No deductibles or coinsurance
  • No claim forms
  • No lifetime maximum
  • No preexisting condition limitations
  • Predictable costs

Valley Baptist Health Plans
  • Free diabetic supplies available
  • Worldwide emergency care
  • Locally owned and operated in the Rio Grande
    Valley by Valley Baptist Health System

Valley Baptist Health Plans
  • 99 member satisfaction (employer group survey)
  • 97 of our providers would recommend our plan to
    their patients (provider survey)

Valley Baptist Health Plans
  • PCP will refer you to a specialist
  • No referral needed for a designated OB/GYN
  • Case management services for diabetes mellitus

Valley Baptist Health PlansWhats New for
  • No plan changes
  • Approximately 8.5 premium increase

Valley Baptist Health Plans
Valley Baptist Health Plans
Cost for Health Coverage
  • 2008-2009 Plan Year

Coverage Categories
  • Employee Only
  • Employee and Spouse
  • Employee and Child(ren)
  • Employee and Family

Monthly Costof Coverage
Page 35 of the Enrollment Guide
Application to Split Premium
  • Married couples working for different
    participating entities may pool funds
  • Optional
  • Requires an Application to Split Premium form to
    be completed by both employees and both employers

How to Enroll
  • 2008-2009 Plan Year

How to Enroll
  • 2 Complete an Enrollment Application and Change
  • Available in the Enrollment Guide
  • Also available online

3 Sign, date and submit form to your Benefits
1 Choose your health plan
How to Enroll
  • If you do not wish to make changes to your
    current health benefit plan, you do not need to
    submit an enrollment application form
  • You will be enrolled in the same plan you
    selected for 2007-2008 at the same level of
  • To decline coverage You must complete and
    submit a form even if you have declined
    coverage before

Can Changes in Coverage Be Made After Your
Application Has Been Submitted?
  • Changes can be made up to the end of your
    enrollment period
  • Plan choices will remain in effect through August
    31, 2009 unless theres a special enrollment
    event such as
  • Marriage or divorce
  • Birth, adoption or placement for adoption of a
  • 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

Cafeteria Plan Vendor(s)
  • Making a change through the Section 125 vendor
    does not automatically generate a change to
    coverage under TRS-ActiveCare
  • All changes to TRS-ActiveCare must be signed,
    dated and submitted on an Enrollment Application
    and Change Form

Are There Preexisting Condition Exclusions?
  • Pre-x does not apply to employees that initially
    enroll when the district/entity begins
    participating in TRS-ActiveCare or to new hires
    who enroll within 31 days after their
    actively-at-work date
  • If covered at any time since 2002, pre-x may
    apply if employee is hired by another
    participating district/entity (or rehired by same
    district/entity) unless gap in coverage is less
    than 63 days and the employee has proof of prior
    creditable coverage
  • A 12-month pre-x condition waiting period may
    apply due to
  • A special enrollment event
  • A future plan enrollment period (to be determined
    by TRS for each plan enrollment period)
  • A transfer to another participating
    district/entity (or rehire) if the employee or
    any covered dependent has any remaining
    preexisting waiting period or a gap in coverage
    greater than 63 days
  • Pre-x waiting period may be reduced by creditable

Important NoticeSupplemental Coverage
  • TRS does not offer or endorse any supplemental
    coverage for any of the health coverage plans
    available under TRS-ActiveCare
  • To obtain information about any coverage that
    claims to be a companion or supplement to any
    TRS-ActiveCare plan, employees should contact
  • The organization making such offering and/or
  • The Texas Department of Insurance (TDI)
    http// or the TDI Consumer
    Helpline (800) 252-3439

Your TRS-ActiveCare ID card will be mailed to
your home
  • ActiveCare 1, 2 and 3
  • New ID cards will not be issued to current
    participants unless changing plans new enrollees
    will receive new cards
  • HMO plans
  • All HMO participants will receive new cards
    (except for Scott and White Health Plans)
  • Each individual covered under the plan will
    receive a card

Enrollment Support
  • Dedicated Customer Service
  • ActiveCare 1, 2 or 3 1.866.355.5999(Blue Cross
    and Blue Shield of Texas and Medco)
  • FirstCare Health Plans 1.800.884.4901
  • Legacy Health Solutions 1.877.410.2432
  • Mercy Health Plans 1.800.617.3433
  • Scott and White Health Plan 1.800.321.7947
  • Valley Baptist Health Plans 1.800.829.6440

Enrollment Support
  • Available Online
  • Enrollment guide (English and Spanish)
  • Downloadable forms(enrollment application, split
    premium, claim form, etc.)
  • Provider locator
  • Frequently asked questions
  • Thank you for attending