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Health Care Coverage For You And Your Family! PowerPoint Presentation
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Health Care Coverage For You And Your Family!

Health Care Coverage For You And Your Family!

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Health Care Coverage For You And Your Family!

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Presentation Transcript

  1. Health Care CoverageFor You And Your Family! Welcome

  2. Agenda • What’s new this year • Who is eligible to enroll • Plan options • Cost of health coverage • How to enroll • Enrollment support • Questions

  3. What’s New for 2004-2005? • ActiveCare 1, 2 and 3: • Changes to prescription drug benefits for ActiveCare 2 and 3 • No premium rate increase • HMOs: • New rates • Minor benefit changes • New option in South Texas—Valley Baptist Health Plan

  4. Employees Eligible to Enroll Active contributing TRS member? You may be eligible If Yes If No Regularly work 10 or more hours per week? You may be eligible If Yes If No You are not eligible

  5. Employees NOT Eligible to Enroll • State of Texas employees or retirees • Higher education employees or retirees • TRS retirees, including those back at work • These individuals are not eligible to enroll for TRS-ActiveCare coverage as employees, but they can be covered as a dependent of an eligible employee

  6. Eligible Dependents • Spouse (including a common law spouse) • Unmarried (including divorced) children under age 25 • Natural child • Adopted child • Stepchild • Foster child

  7. More Eligible Children • A child under the legal guardianship of the employee • Another child in a regular parent-child relationshipwith the employee: • The child's primary residence is the household ofthe employee • The employee provides at least 50% of the child's support • Neither of the child's natural parents resides in that household • The employee has the legal right to make decisions regarding the child's medical care • A grandchild whose primary residence is the household of the employee and who is a dependent of the employee for federal income tax purposes

  8. More Eligible Dependents • Unmarried children (any age) mentally retarded or physically incapacitated • Any other dependents required to be covered under applicable law

  9. Newborns • Covered the first 31 days if employee has coverage • To continue coverage, employee must add newborn within 60 days after the date of birth • However, an employee has up to one year after the newborn’s date of birth if: • Child is born on or after September 1, 2004, and • Employee has “employee and family” or “employee and child(ren)” coverage at the time of birth

  10. PPO Plan Options ActiveCare1, 2 and 3

  11. PPO Features ActiveCare 1, ActiveCare 2 and ActiveCare3 • Administered by Blue Cross and Blue Shield of Texas and Medco Health • No primary care physician (PCP) required; no referrals required to see a specialist • Select any provider for care within the PPO network or outside the network • When you receive care inside the network, you receive the highest level of benefits • When you receive care outside the network, you still have coverage but you may pay more of the cost • Worldwide coverage for emergency and non-emergency care

  12. Network vs. Non-Network Providers • Network Providers • Receive highest level of benefits • No claims to file • No balance billing • Non-Network Providers • Receive non-network level of benefits • Must file own claims • May be billed for charges exceeding allowable amount

  13. Non-Network Providers • ParPlan Providers • Receive non-network level of benefits • No claims to file in most cases (ParPlan provider will usually file the claims) • No balance billing; ParPlan providers cannot bill for costs exceeding the allowable amount

  14. Coverage Outside Texas • BlueCard PPO Program(for enrollees living or traveling outside of Texas) • Access to more than 624,000 physicians and 6,000 hospitals nationwide • PPOs can be found in 49 states, District of Columbia and Puerto Rico • Network level of benefits • Claims filed by providers • No balance billing

  15. Deductibles (Plan Year) Deductible: The amount of out-of-pocket expense that must be paid for health care services before becoming payable by the health care plan

  16. Coinsurance Coinsurance: The percentage of medical expenses that you and the health plan share

  17. Office Visit Copay Copayment (Copay): The amount paid at the time of service for certain medical services and prescription drugs; copays depend on whether the doctor is primary or a specialist Specialist: Any physician other than a family practitioner, internist, OB/GYN, and pediatricians

  18. Preventive Care Copay Copayment (Copay): The amount paid at the time of service for certain medical services and prescription drugs; copays depend on whether the doctor is primary or a specialist Specialist: Any physician other than a family practitioner, internist, OB/GYN or pediatrician

  19. Out-of-Pocket Maximum(excludes copays and deductibles) Out-of-Pocket Maximum: When you reach your plan’s of out-of-pocket maximum, the plan then pays 100% of any eligible expenses for the rest of the plan year.

  20. Preauthorization Required • All inpatient hospital stays • Treatment of all serious mental illness, mental health care and chemical dependency • Home health care • Hospice • Skilled nursing facility • Home infusion therapy

  21. Prescription Drug Benefits ActiveCare1, 2 and 3

  22. Prescription Drug Benefits • 2004-2005 plan year benefit changes • Retail pharmacy maintenance program • Home Delivery • Retail maintenance drug list • Copays • Prior authorization • Specialty Pharmacy and Dose Optimization • Online technology • Home Delivery tips

  23. Prescription Drug Benefits What’s New • Retail Pharmacy Maintenance Program ActiveCare 2 and ActiveCare 3 • Retail copays for maintenance medications • First two fills of maintenance medication at retail = short-term copay • Third (3rd) fill of maintenance medication at retail = copay increase • Copay for short-term medications at retail will not change

  24. Prescription Drug Benefits What’s New (continued) • Home Delivery ActiveCare 2 and ActiveCare 3 • New copays for preferred and non-preferred brand medications • No change to copays for generic medications • Home Delivery may save money vs. filling at retail

  25. Prescription Drug Benefits What’s New (continued) • Retail Maintenance Drug List • Maintenance list includes most long-term medications • Review list and price a medication – www.trs.state.tx.us/trs-activecare • Medco Health – www.medcohealth.com or call Customer Service • Notification – announcement letter and trigger letter

  26. Prescription Drug Benefits

  27. Prescription Drug Benefits Note: When using a non-network pharmacy, you must pay the entire cost and submit a claim form to Medco Health. You will be reimbursed the amount that would have been charged by a network pharmacy, less the required copayment.

  28. Prescription Drug Benefits Note: When using a non-network pharmacy, you must pay the entire cost and submit a claim form to Medco Health. You will be reimbursed the amount that would have been charged by a network pharmacy, less the required copayment.

  29. Prescription Drug Benefits ActiveCare 2 and 3: Member pays the difference • You pay the difference if a brand-name prescription is dispensed when a generic is available • You pay the generic copay plus the difference in cost between the brand-name prescription and what the cost would be if the generic drug had been purchased, regardless of doctor DAW (Dispense As Written)

  30. Prescription Drug Benefits Drug Formulary • Preferred and Non-Preferred Medications • Copays • Preferred Prescriptions Drug List • Generic Medications • My Doctor Visits

  31. Prescription Drug Benefits Prior Authorization • Program designed to ensure the safety of participants and help contain costs • May review some or all of the following information to assure an appropriate coverage decision: • Patient diagnosis • Indications for prescribed drug use • Dosing • Duration of therapy • Patient drug profile • Drug interactions

  32. Prescription Drug Benefits Other new programs • Specialty Pharmacy • Designed to help participants obtain high cost pharmaceuticals that require injection, unique administration, refrigeration and or special handling • Eligible participants will receive information on the program • Dose Optimization • A clinically-based program that encourages participant convenience and cost-savings when therapeutically appropriate • Participant communications included in program

  33. Prescription Drug Benefits

  34. Prescription Drug Benefits Home Delivery Tips • New prescriptions may be required for new enrollees • To use Home Delivery Pharmacy Service (long-term maintenance medications) have your doctor to write two prescriptions: • One for a 14-day supply (to eliminate interruption of therapy) • One for a 90-day supply • Easy Rx • Have your doctor call 1.888.327.9791 to obtain fax instructions • For retail prescriptions (short-term acute medications) only one prescription is needed

  35. HMO Plan Options 2004-2005 Plan Year

  36. HMO Features • Live, work or reside within the HMO service area • Primary Care Physician (PCP) must coordinate care to receive benefits • Choose a different PCP for each family member or select the same one for the entire family • Females may choose a network OB/GYN and schedule appointments with that physician without a PCP referral • Worldwide coverage for emergency care • No preexisting condition exclusions apply

  37. FIRSTCARE HMO Plan Option

  38. FIRSTCARE Service Area 85 counties across Texas

  39. FIRSTCARE • No claim forms or deductibles • Coverage for preexisting conditions • Emphasis on preventive health care • Extensive provider network • Direct access to designated OB/GYN • Worldwide emergency care • Regional offices

  40. FIRSTCARE

  41. FIRSTCARE What’s new for 2004-2005: • 4 counties added to the service area • $50 copay for surgical procedures performed in physician’s office • $30 copay per visit for short-term mental services • $250 copay per device for prosthetics/orthotics/ implantable devices • Injectable medication copay now subject to a $2,500 injectable drug out-of-pocket maximum

  42. FIRSTCARE • What’s new for 2004-2005: • Hospice services will no longer require a copayment • $35 copay for minor emergency or urgent care center visits • 25% copay for self-injectable and high technology medications (excludes diabetic medications and allergy serum)

  43. FIRSTCARE *Excludes insulin and allergy serum

  44. FIRSTCARE • If a brand-name prescription is dispensed when a generic is available, the enrollee pays the generic copay plus the difference in cost between the brand-name prescription and what the cost would be if the generic drug had been purchased, regardless of doctor DAW (Dispense As Written)

  45. Mercy Health Plans HMO Plan Option

  46. Mercy Health Plans Service Area 4 Texas counties: • Webb • Jim Hogg • Zapata • Duval

  47. Mercy Health Plans • No annual deductibles or coinsurance • No claim forms • No lifetime maximum • No preexisting condition limitations

  48. Mercy Health Plans • Low out-of-pocket expense • Emergencies covered anywhere • Case management • Diabetes mellitus • Hypertension • Asthma • Other chronic diseases • CuraScript Injectable Program

  49. Mercy Health Plans • Mercy Health Plans ranked #1 on Consumer Assessment Health Plans Survey (CAHPS)* on the following: • How people rated their plan • Getting care that is needed • How well doctors communicate • Courtesy, respect, helpfulness of office staff * Office of Public Insurance Council

  50. Mercy Health Plans Referrals • To visit a specialist, a PCP referral is required; however, referrals are not required for the following: • Women may self refer to a designated OB/GYN • Ophthalmologist/optometrist (annual eye exam) • Orthopedic surgeon • Dermatologist • No benefits available for non-emergency care outside the network or for a specialist visit without a referral from a PCP