slide1 n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
2010-2011 Plan Year Effective September 1, 2010 PowerPoint Presentation
Download Presentation
2010-2011 Plan Year Effective September 1, 2010

Loading in 2 Seconds...

play fullscreen
1 / 91

2010-2011 Plan Year Effective September 1, 2010 - PowerPoint PPT Presentation


  • 187 Views
  • Uploaded on

2010-2011 Plan Year Effective September 1, 2010. Agenda. TRS-ActiveCare Program Highlights Enrollment Summary Facts and Figures 2010-2011 Health Plan Options ActiveCare 1-HD, 1, 2 and 3 HMOs How to Enroll Who is Eligible to Enroll Cost of Coverage Enrollment Support.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about '2010-2011 Plan Year Effective September 1, 2010' - Anita


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
agenda
Agenda
  • TRS-ActiveCare Program Highlights
    • Enrollment Summary
    • Facts and Figures
  • 2010-2011 Health Plan Options
    • ActiveCare 1-HD, 1, 2 and 3
    • HMOs
  • How to Enroll
    • Who is Eligible to Enroll
    • Cost of Coverage
    • Enrollment Support
what is trs activecare
What is TRS-ActiveCare?
  • Established and signed into law in 2001 (Chapter 1579, Texas Insurance Code)
    • Blue Cross and Blue Shield of Texas selected to administer the program in January 2002 and 2008
    • Medco selected as PBM in January 2002 and 2008
    • Program effective date was September 1, 2002
    • HMO options added in 2003
  • A statewide health care benefits program for employees of school districts, charter schools, regional educational service centers and other educational districts
  • Law authorizes funding levels to help employees pay for coverage
enrollment summary employees by plan jan 2010
Enrollment Summary(Employees by Plan, Jan. 2010)

FirstCare Health Plans 2.5% Scott & White Health Plan 1.9% Valley Baptist Health Plans 0.1%

237,107 Contracts (Employees) • 398,099 Members

slide5

PPO Medical Plans

ActiveCare 1-HD, 1, 2 & 3 Plans

ppo network for activecare 1 hd 1 2 and 3
Network

There is no need to:

Select a Primary Care Physician

Obtain referrals for specialist care

Receive the highest level of benefits:

Pay less for care

No balance billing

No claim forms

Provider files claim for you

PPO Network for ActiveCare 1-HD, 1, 2 and 3

Always verify provider network status

Non-Network:

  • 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

New for 2010-2011: The allowable amount for non-contracting providers will be limited to 50% of billed charges

ppo plan overview network level of benefits
PPO Plan Overview (Network Level of Benefits)

New Deductiblesfor 2010-2011 (per IRS rules) ActiveCare 1-HD and ActiveCare 1

ppo plan overview network level of benefits1
PPO Plan Overview(Network Level of Benefits)

New Copaysfor 2010-2011ActiveCare 2

activecare 1 hd vs activecare 1
ActiveCare 1-HD vs. ActiveCare 1

New for 2010-2011: Deductible and out-of-pocket maximum amounts increased per IRS guidelines

New for 2010-2011: Deductible and out-of-pocket maximum amounts increased per IRS guidelines

health savings account hsa
Health Savings Account (HSA)
  • What is an HSA?
    • Special account owned by an individual and used to pay out-of-pocket expenses (such as deductibles) or to grow as savings
    • May be funded by the employee, the employer or both
    • Portable, meaning the HSA funds always belong to the individual
  • Who is eligible?Per IRS rules, any adult can contribute to an HSA if he/she:
    • Has coverage under an HSA-qualified high deductible health plan
    • Has no other first-dollar medical coverage
    • Is not enrolled in Medicare
    • Cannot be claimed as a dependent on someone else’s tax return
  • Does TRS offer an HSA?
    • No! But ActiveCare 1-HD qualifies as an HDHP for all coverage categories and ActiveCare 1 qualifies for employee-only coverage
    • Employees are not required to have an HSA to enroll in these plans
blue distinction centers for bariatric surgery
Blue Distinction Centers for Bariatric Surgery
  • List of Blue Distinction Centers for Bariatric Surgery is subject to change
  • Refer to the Doctors and Hospitals section of the Web site, www.bcbstx.com/trs or call Customer Service for most current list

Important:

Bariatric surgery 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 procedure will not be covered by TRS-ActiveCare

blue care connection
Blue Care Connection®
  • Whether you decide toskip fast food, quit smoking, or walk more, every day decisions can have a positive impact on your health; Blue Care Connectionoffers guidance at every level of health

Total Care Approach to Health and Wellness

Well Members

Low- Risk

Moderate- Risk

High-Risk

Complex / Catastrophic

< < < Wellness > > >

condition management
Condition Management

If you have a chronic condition, we offer support.

  • Supportfrom Blue Care Advisors—clinical professionals who can help you manage chronic health conditions such as: asthma, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disorder and other health conditions
  • Understanding and following your physician’s orders
  • Review medications, side effects, compliance, refills and current services
  • Establish goals with you and caregivers, scheduling follow-ups as appropriate

1-800-462-3275

tobacco cessation and weight management
Tobacco Cessation and Weight Management
  • Self-Paced Approach
    • Online program and resources available in the Personal Health Manager
    • Secure e-mail outreach to keep members on track
  • Lifestyle Management Support
    • Counseling and coaching with licensed Wellness Coaches
    • 24/7 Nurseline
    • Referrals when appropriate

1-800-462-3275

special beginnings
Special Beginnings®

Special Beginnings helps expectant mothers and their babies get off to a healthy start by providing prenatal and postnatal health education and guidance at no additional cost

  • Once enrolled in the program, plan participants receive:
  • Pregnancy risk assessment and ongoing communication/monitoring
  • Educational material covering pregnancy and infant care topics
  • Frequent, personal contact with program staff from early pregnancy through six weeks after delivery
  • Assistance in managing high-risk conditions such as gestational diabetes and preeclampsia
  • Program components are available in English and Spanish

1-888-421-7781

24 7 nurseline
24/7 Nurseline
  • Advice isn’t 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 more
    • Audio health library on topics such as kicking the smoking habit and ways to get a good night’s rest

Advice anytime.

Round-the-clock health and the wellness advice from licensed professionals

24/7

1-800-581-0368

Available in EnglishandSpanish

personal health manager phm
Personal Health Manager (PHM)
  • Your online wellness experience begins with the Personal Health Manager
  • Features include:
    • Lifestyle Management tools:
      • Weight Management
      • Tobacco Cessation
      • Fitness and Nutrition Plans
      • Stress Reduction
    • Health Risk Assessment
    • “For Your Health” features
    • Blue PointsSM Rewards
    • “Ask-A” feature – health and wellness questions via secure e-mail
    • Online health encyclopedia
    • Interactive symptom checker
personal health manager home page
Personal Health Manager – Home Page

Read secure messages

Take a Health Risk Assessment

Review member alerts

Access MemberCare Profile

Ask a Question to a certified Nurse, Trainer, Dietitian or Life Coach

Use the Interactive Symptom Checker

Read the latest health news, search for specific health topics or explore the prescription drug index

Explore topics in the Health Information and Care Center

ask a online advisor
“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 Nurse:

Interact online with a Blue Care Advisor on non-emergency, health-related questions using the secure “Ask A Nurse” feature.

Ask A Trainer, Dietitian orLife Coach:

Send questions about fitness, nutrition, or managing stress.

Confidential and Secure – Receive an e-mail response within one business day

health risk assessment easy to use
Health Risk Assessment – Easy To Use

1

2

3

  • Choose your assessment topic:
    • Health & well-being*
    • Sleep
    • Stress management
    • Nutrition
    • Fitness & physical activity
    • Back & joint health
  • *We recommend completingthe Health & Well-beingassessment first.

Complete the assessment in as little as10 to 15 minutes

  • Receive Personalized report and next steps:
    • Report provides member with summary of health risks and areas where they could improve
    • Recommended ‘next steps’ and suggestions to make positive changes to your lifestyle.
health risk assessment hra
Health Risk Assessment (HRA)

Be informed about your overall health and well-being

  • A Health Risk Assessment helpsassess your health risks, interests and readiness to change
    • Examines your overall health and well-being
    • Provides a detailed report with overall health and well-being score and sub-scores for:
      • Medical health, job satisfaction,life load, risk and lifestyle, mood, nutrition, sleep, stress, pain and body weight
    • Recommends areas for improvement
    • Confidential and secure (results are not shared with employers)

Earn Blue PointsSM

blue points sm incentives
Blue PointsSMIncentives

TRS-ActiveCare PPO plan participants and their covered dependents accumulate Blue Points in the Personal Health Manager

Stay motivated.

Earn Blue Points in the Personal Health Manager

  • Complete designated health and wellness activities
  • Report completed activities in the Personal Health Manager
  • Track your available balance
  • Redeem earned Blue Points for a variety of items!
slide23

www.bcbstx.com/trs

Available online

Enrollment Video Application Form Enrollment GuideBenefits Booklet

24/7 Nurseline, Lifestyle and Condition ManagementandSpecial Beginnings phone numbers

blue access for members
Blue Access® for Members
  • Online member management tool
    • Check claim status, view claim summaries and print EOBs (Explanations of Benefits)
    • Order additional ID cards, and print temporary ID
    • Monthly health articles
    • Links to health information and wellness tools and resources, including the Personal Health Manager

Send secure e-mail messages to BCBS Customer Advocates

available Monday thru Friday, 7 a.m. to 10 p.m. (CT)

what if i have questions
What if I Have Questions?

Personalized Service

  • Call TRS-ActiveCare customer service for:
    • 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 Service1-866-355-5999

prescription drugs

Prescription Drugs

ActiveCare 1-HD,1, 2 & 3

your medco prescription drug plan
Your Medco Prescription Drug Plan
  • Medco administers your prescription drug plans on behalf of TRS
    • ActiveCare 1-HD, 1, 2, and 3 plans
  • Benefit includes both a retail and mail component
  • Medco has its own mail-order pharmacy – Medco By Mail – where specialist pharmacist focus on compliance and lower cost options for the patient, and the automated filling system ensures the prescription is filled accurately.*
  • Medco’s 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
prescription drug benefits network level
Prescription Drug Benefits - Network Level

* 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.

specific rx benefit information
Specific Rx Benefit Information
  • Retail pharmacies are ideal for acute (short-term) and new medication you may be trying for the first time

In compliance with SB 0704, 81 (R) Texas Legislature, TRS will make available through Medco a retail maintenance network effective September 1, 2010.  Retail pharmacies who choose to participate in this network will be able to dispense up to a 90-day supply of medication.  Please contact Medco customer service for more information on pharmacies that may choose to participate in the retail maintenance network. Medco is in the process of soliciting this network. We will not know which pharmacies will choose to participate until later this summer.

specific rx benefit information1
Specific Rx Benefit Information
  • If you are taking a long-term medication, filling your prescriptions through Medco’s mail-order pharmacy provides several benefits:
    • You can receive up to a 90-day supply of your medication at a lower copay
    • Prescriptions are delivered directly to you and you can order refills online and check the status of your orders
    • You have access to specialist pharmacists
      • Specifically trained in specific conditions
      • Review all of your incoming prescriptions for potential safety issues and will contact you and your doctor to discuss any issue
    • Medco only buys medication from the most reputable suppliers

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

getting the right drug to the right person at the right time
Getting the right drug, to the right person, at the right time

Specialization and member engagement are critical components to controlling health care costs and driving quality clinical outcomes:

  • Specialist pharmacist
  • Personalized medicine offering
  • Research-driven protocols
  • My Rx Choices®
  • Other available resources
personalized medicine
Personalized Medicine
  • What is it?
    • A science that examines the inherited variations in genes that dictate drug response (whether a drug will be effective or safe)
    • Personalizing drug therapy based on each patient's genetic variability
  • In 2009, TRS began providing this service toTRS-ActiveCare patients if both the doctor and patient wish to take the test
  • How patients metabolize drugs can have significant impacts on both medication choice and dosage
  • Testing consists of a cheek swab…what do you have to lose?
high level process flow
High-level Process Flow
  • Prescription comes in for a pharmacy claim for a product with an associated test through the prescription. Fill the prescription, then…

Identification

Communication

  • Contact physician for approval to test patient
  • Contact patient to discuss program and test kit mailing
  • 800 number provided for questions

Intervention

  • Cheek swab completed by patient and mailed to lab
  • Lab processes test, sends results and interpretation to physician and Medco TRC pharmacist
  • Therapy change made if applicable

Follow-up

  • Monitor lab outcomes and follow-up as needed
my rx choices your online savings tool
My Rx Choices®Your online savings tool
  • Lower your cost for prescriptions with My Rx Choices®
    • Features include:
      • Personal assessment of cost-saving opportunities based on your prescription plan and the medications you use
      • Print a kit to help your doctor better understand the economic impact of different medication alternatives
      • Alternative medications are based upon greatest cost savings to you presented in order, starting with the highest value
      • Brand-to-generic and retail-to-mail comparisons are shown
      • The average amount saved by My Rx Choices® users is $294!
  • Simply visit www.medco.com/save. You’ll need to take a moment to register before using this service. You can also call 1-866-355-5999
  • You have to shop your benefit. Prices can vary at different retail pharmacies
my rx choices available through customer service or on www medco com
My Rx Choices®Available through Customer Service or on www.medco.com
  • The My Rx Choices® home page allows the user to:
    • Select a patient within a household (pre-populated with all under age 18 dependents and spouse information will be shown if authorization has been given)
    • Select a drug to compare from a pre-populated list of prescriptions for the user.
  • Your potential savings are clearly presented
  • Members may print a kit to discuss with their doctor
  • Generic alternatives are provided
generic dispensing is important
Generic Dispensing is important…

Generic Waiver

Program

First phase January-March 2010

My Rx Choices®

Approximately 6,000 web hits per month

Cost Difference

Average cost of generic prescription is just over $15 as compared to $151 for a brand

Savings

For every 1% of increase generic usage, TRS could save millions of dollars

Next waiver period will be June – August 2010

* Annual savings based upon initial waiver period performance and an 80% refill rate.

information resources
Information Resources
  • TRS Web site – www.trs.state.tx.us/trs-activecare
    • Pharmacy Benefit Highlights
    • List of maintenance medications
    • FAQs
    • Download forms
  • Medco Member Web site – www.medco.com
    • Prior authorization list
    • Formulary information
    • Locate a participating pharmacy
    • Health and wellness information
    • My Rx Choices® / Price a Medication
    • Online ordering
    • Order Medco By Mail refills
    • Download forms
    • Medco widget
  • Customer Service 1-866-355-5999
  • Benefits Booklet
hmo plan options

HMO Plan Options

2010-2011 Plan Year

firstcare health plans

FirstCare Health Plans

HMO Plan Option

company overview
Company Overview

We have been part of the TRS-ActiveCare program since 2003 and currently cover more than 11,000 school employees and their dependents.

We are a hospital-based health plan, founded in 1985 and are owned by Covenant Health System in Lubbock, Texas and Hendrick Medical Center in Abilene, Texas.

We focus exclusively on the Texas market and have offices in Abilene, Amarillo, Lubbock, and Waco.

Our local presence in each of our regions enables us to provide the level of service you and your family deserve.

41

service area 93 counties across texas
Service Area – 93 counties across Texas

TRS

Service Area

To be eligible to enroll in FirstCare, you must live, reside or work in one of the shaded counties.

benefit highlights
Benefit Highlights
  • NOTE: Care must be accessed through one of our affiliate provider networks

43

No referrals to network specialists

No routine claim forms

Worldwide emergency care

No preexisting limitations

College-age dependents living outside our service area have full coverage (address must be on file)

Secure online access to your membership and claim information at www.firstcare.com

new for 2010 2011
New for 2010-2011

44

The national average increase for health insurance premiums is 7 to 11 percent per year

FirstCare has lowered premiums for two years in a row to help you combat the rising cost of health care

new for 2010 20111
New for 2010-2011
  • Preventive care is now covered at 100%. No office visit copayments and the deductible is waived*
    • Well woman exam
    • Screening mammograms including X-ray, digital, and ultrasound
    • Routine physicals
    • Immunizations
    • Routine sight, speech, and hearing screenings
    • Routine lab and X-ray
  • Primary Care Physician office visit copayment is $25
  • Specialist office visit copayment is $40

*Exception: Colorectal Cancer Procedure has a $50 copayment

abilene region provider network
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 www.firstcare.com.

Our Abilene office is located at:

2 Village Drive, Suite 510Abilene, TX 79606(325) 670-3525

Come visit us and meet the staff.

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

47

amarillo region provider network
Amarillo Region Provider Network

Amarillo Hospitals:

Northwest Texas Healthcare System

Northwest Texas Surgery Center

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

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 www.firstcare.com.

Our Amarillo office is located at:

600 S Tyler St Box# 12019Amarillo, TX 79101(806) 356-5265

Come visit us and meet the staff.

48

lubbock region provider network
Lubbock Region Provider Network

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 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

Ward Memorial Hospital

Winkler County Memorial Hospital

W J Mangold Memorial Hospital

Yoakum County Hospital

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 www.firstcare.com.

Our Lubbock office is located at:

1901 W. Loop 289 Suite# 9Lubbock, TX 79407(806) 784-4300

Come visit us and meet the staff.

49

waco bryan college station region provider network
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 www.firstcare.com.

Our Waco office is located at:

1105 Wooded Acres Dr. Suite # 404Waco, TX 76710(254) 761-5800

Come visit us and meet the staff.

Waco Hospitals:

Hillcrest Baptist Medical Center

Providence Health Center

Bryan/College Station Hospitals:

College Station Medical Center

St. Joseph Regional Health 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

King’s Daughters Hospital

Lake Whitney Medical Center

Limestone 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

50

why choose firstcare
Why Choose FirstCare?
  • We have experience with TRS-ActiveCare benefits. In fact, we cover more than 11,000 school employees and their dependents.
  • We are a hospital based health plan that supports
  • our local communities.
  • Medical decisions are made locally by physicians
  • who understand how health care is delivered in your area.
  • A dedicated FirstCare representative is available in
  • your area to answer questions.
  • FirstCare values Texas teachers, administrators,
  • and school employees. We are proud to serve you.

51

contact us
You may submit your questions or comments

via e-mail to cservice@firstcare.com

You can also write or call customer service at:

FirstCare Health Plans

1901 West Loop 289

Suite #9

Lubbock, TX 79407

800-884-4901

http://www.trs.state.tx.us/trs-activecare

Contact Us

52

service area
Service Area

Hospital Locations

54

hospital providers
Hospital Providers

Central Texas Hospitals

Parkview Regional Hospital-New!

Limestone County Medical Center

Burleson St. Joseph Health Center

Coryell Memorial

Glen Rose Medical Center

Goodall-Witcher Healthcare

Grimes St. Joseph Health Center

Hamilton General Hospital

Hillcrest Medical Health Center

Johns Community Hospital

King’s Daughter’s Hospital

Lakeside Hospital

Llano Memorial Hospital

Madison, St. Joseph Health Center

Metroplex Hospital

Providence Health Center

Richards Memorial Hospital

Rollins Brook Community Hospital

Scott & White Healthcare-Round Rock

Scott & White Hospital

St. Joseph Regional Health Center

The Hospital at Westlake Medical Center

Trinity Medical Center

55

hospital providers1
Hospital Providers

West Texas Hospitals

New! Ballinger Memorial Hospital

Ballinger, TX

Shannon Medical Center

San Angelo, TX

Reagan Memorial Hospital

Big Lake, TX

Coleman County Medical Ctr.

Coleman, TX

Schleicher County Medical Ctr.

El Dorado, TX

Kimble Hospital

Junction, TX

Lillian M. Hudspeth Memorial Hospital

Sonora, TX

Concho County Hospital

Eden, TX

56

what s new for 2010 2011
What’s New for 2010-2011
  • Our plan still has a $0 medical deductible
  • Wereducedthe annual out-of-pocket maximum from $3,000 down to $2,000 for an individual
    • Copays and medical expenses count toward your out-of-pocket max
  • The family out-of-pocket maximum remains unchanged at $6,000
  • Your annual prescription drug benefit is now unlimited!
    • We removed the annual cap, which was previously set at $4,000 per person

57

what s new for 2010 2011 cont d
What’s New for 2010-2011 (cont’d)

Wereducedthe primary care office visit copay to $20 per visit — last year it was $25

The specialty office visit copay is now $35 per visit

For allergy serum you pay 20%

Outpatient surgery, $100 copay plus 20%

58

0 medical deductible 20 pcp office visit
$0 Medical Deductible, $20 PCP Office Visit

See Enrollment Guide for full list of benefits.

59

unlimited rx benefit
Unlimited Rx Benefit

*If a brand-name prescription is dispensed when a generic is available, a copay of 50% applies after deductible

60

scott white health plan accolades
Scott & White Health Plan Accolades

Scott & White Health Plan has been named one of the Highest Ranked Health Plans in Texas by U.S. News & World Report 1 for the fifth year in a row.2

Scott & White Health Plan has also earned an “Excellent Accreditation” from the National Committee for Quality Assurance (NCQA) for both Commercial and Medicare products (2000-2009)

This is our 10th consecutive year with “Excellent Accreditation.”

The NCQA is a private, not-for-profit organization that evaluates how well a health plan operates along with the results it delivers to members in terms of care, service and efficiency.

1U.S. News/NCQA America’s Best Health Plans 2009-10. “America’s Best Health Plans” is a

trademark of U.S. News & World Report.

2Previous rankings posted on www.usnews.com.

61

online lifestyle management programs
Online Lifestyle Management Programs

64

  • Balance
    • Weight Management
  • Overcoming Binge Eating
    • Compulsive Eating
  • Breathe
    • Smoking Cessation
  • Care for Your Health
    • Chronic Condition Guidance
  • Relax
    • Stress Management
  • Overcoming Depression
    • Depression Guidance
  • Care for your Back
    • Back Care
  • Overcoming Insomnia
    • Sleep Problems
  • Move
    • Physical Activity
  • Nourish
    • Healthy Eating
  • Succeed
    • Health Risk Assessment
personalized service
Personalized Service

65

24-hour Nurse Advice Line

1-800-975-6612

Available to all SWHP members

VitalChat

Instant Message with a nurse online and have your questions answered

Customer Service Advocate

1-800-321-7947

we are texas friendly
We are Texas Friendly

66

Simple

Helpful

Honest

valley baptist health plans1
Valley Baptist Health Plans

Service Area

  • Rio Grande Valley
  • Counties
    • Cameron
    • Hidalgo
    • Starr (partial)
    • Willacy
  • Provider Network
    • More than 870 providers
    • 12 hospitals Valley-wide
valley baptist health plans2
Valley Baptist Health Plans
  • Low deductibles
  • No claim forms
  • No preexisting condition limitations
  • Controllable costs
valley baptist health plans3
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
  • 99% member satisfaction (employer group survey)
  • 97% of our providers would recommend our plan to their patients (provider survey)
valley baptist health plans4
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 plans5
Valley Baptist Health Plans

What’s New for 2010-2011

  • Approximately 9.0% premium decrease
  • $2 million lifetime maximum
  • New copays for outpatient services, ER, ambulance and urgent care
valley baptist health plans7
Valley Baptist Health Plans

Maximum plan year prescription benefit is $10,000 per individual

how to enroll

How to Enroll

2010-2011 Plan Year

who is eligible to enroll
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

employees not eligible to enroll
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.

eligible dependents
Eligible Dependents
  • Spouse (including a common law spouse)
  • Unmarried children under age 25
    • Natural child
    • Adopted child
    • Stepchild
    • Foster child
  • Other eligible dependents listed inEnrollment Guide
    • Grandchildren (unmarried)
    • Disabled children (unmarried, of any age)
special eligibility situations
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 25) 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
enrollment
Enrollment
  • Enrollment Periods for 2010-2011 Plan Year:
    • April 19 - May 21 (Spring Enrollment)
    • August 1 - August 31 (Summer Enrollment)
  • Preexisting condition exclusion applies to those that previously declined coverage; may be reduced by prior creditable coverage
  • Passive enrollment; no need to enroll unless you want to:
    • Change TRS-ActiveCare plan option
    • Add or drop dependents
    • Cancel and/or decline coverage
    • Enroll for TRS-ActiveCare coverage with a different participating district/entity
    • Change name or address or correct date of birth or Social Security number
preexisting condition waiting period and creditable coverage
Preexisting Condition Waiting Period and Creditable Coverage
  • 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
  • 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 of 63 or more consecutive days
  • Pre-x waiting period may be reduced by creditable coverage

Exception: If a participant has been covered by TRS-ActiveCare at any time since 2002, pre-x may apply if employee is hired by another participating district/entity (or rehired by same district/entity)

cost for health coverage

Cost for Health Coverage

2010-2011 Plan Year

monthly cost for coverage
Monthly Costfor Coverage
  • See page 27 of Enrollment Guide
  • $225 in district/entityand state funds to help pay for coverage
cost of coverage cont d
Cost of Coverage (Cont’d)

Employee and family coverage for ActiveCare 1-HD is more expensive than ActiveCare 1 because the deductible and out-of-pocket maximum amounts for family are less and the plan may begin paying 100% benefits sooner

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

Application to Split Premium
can changes in coverage be made after your application has been submitted
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, 2011 unless there’s a special enrollment event such as:
    • Marriage or divorce
    • Birth, adoption or placement for adoption of a child
    • A child marries or reaches age 25
    • A court order to provide health coverage for an eligible child
    • Loss of coverage
  • Changes must be made within 31 days after the event date (special rules apply to newborns)
  • New application must be submitted for any change
newborns
Newborns
  • Covered first 31 days if employee has coverage
  • Must add newborn within 60 days after the date of birth or up to one year after the 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
  • Not necessary to wait for newborn’s Social Security number
    • Submit application without SSN to enroll
    • Re-submit another form after SSN is issued
your trs activecare id card will be mailed to your home
Your TRS-ActiveCare ID card will be mailed to your home
  • Enroll by May 19 to receive ID card by September 1
  • ActiveCare 1-HD, 1, 2 and 3
    • All enrollees, including existing plan participants, will receive new ID cards
    • New! Separate cards for medical and prescription drugs
      • Blue Cross and Blue Shield of Texas
      • Medco
  • HMO plans
    • All HMO participants will receive new cards (except for Valley Baptist Health Plans)
    • Each individual covered under the plan will receive a card
enrollment support
Enrollment Support

Dedicated Customer Service

  • ActiveCare 1-HD,1, 2 or 3 866-355-5999(Blue Cross and Blue Shield of Texas and Medco)
  • FirstCare Health Plans 800-884-4901
  • Scott and White Health Plan 800-321-7947
  • Valley Baptist Health Plans 800-829-6440
enrollment support1
Available Online

Enrollment guide (English and Spanish)

Downloadable forms(enrollment application, split premium, claim form, etc.)

Provider locator

Frequently asked questions

Enrollment Support

www.trs.state.tx.us/trs-activecare

questions

Questions

Thank you for attending