Transcript Slide 1

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
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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
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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
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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
New for 2010-2011: The allowable
amount for non-contracting providers
will be limited to 50% of billed charges
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
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PPO Plan Overview (Network Level of Benefits)
Plan Features
ActiveCare 1-HD
ActiveCare 1
ActiveCare 2
ActiveCare 3
Deductible
(individual/family)
$2,400/$2,400
$1,200/$3,000
$500/$1,500
None
$3,000/$5,000
$2,000/$6,000
$2,000/$6,000
$1,000 per
individual
80% / 20%
80% / 20%
80% / 20%
80% / 20%
Out-of-Pocket
Maximum
(does not include
deductibles)
Coinsurance
(Plan pays/participant
pays)
New Deductibles
for 2010-2011
(per IRS rules)
ActiveCare 1-HD
and ActiveCare 1
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PPO Plan Overview (Network Level of Benefits)
Services
Office Visit Copay
Preventive Care
 Routine physicals*
 Well-woman exams*
 Routine
mammograms*
 Eye exams*
 Well-baby exams
 Immunizations
 Hearing exams
 PSA screenings
 Colorectal
screenings
 Osteoporosis
screenings
* Services
limited to one
per person per plan year
ActiveCare 1-HD
ActiveCare 1
ActiveCare 2
ActiveCare 3
20% after deductible
$30 for primary
$50 for specialist
$20 for primary
$30 for specialist
$0 copay up to $500
per person, per plan year
$30 for primary
$50 for specialist
$20 for primary
$30 for specialist
Remaining charges subject to
deductible and coinsurance
Includes all
preventive care
services billed
with an office visit
by a network
doctor
Includes all
preventive care
services billed with
an office visit by a
network doctor
New Copays
for 2010-2011
ActiveCare 2
Coinsurance
applies when no
office visit is billed
or when services
are performed
outside the office
(deductible
waived)
Coinsurance
applies when no
office visit is billed
or when services
are performed
outside
the office
(no deductible)
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ActiveCare 1-HD vs. ActiveCare 1
Plan Features
ActiveCare 1-HD
ActiveCare 1
Meets IRS definition of High
Deductible Health Plan
and offers opportunity to
contribute pretax dollars into a
Health Savings Account (HSA)
Yes, for all coverage
categories
(employee only, employee and
spouse, employee and
child(ren) and employee and
family)
Yes, for employee-only
coverage
No, for other coverage
categories
Deductible
$2,400 for employee only
$2,400 for family
$1,200 per individual
$3,000 per family
Maximum Coinsurance
$3,000 for employee only
$5,000 for family
$2,000 per individual
$6,000 per family
Out-of-Pocket Maximum
(includes deductibles)
$5,400 for employee only
$7,400 for family
$3,200 per individual
$9,000 per family
Lower premium than
ActiveCare 1
in all coverage categories
except employee and family
Higher premium than
ActiveCare 1-HD in all
coverage categories except
employee and family
Monthly Premium Cost
New for 2010-2011: Deductible and out-of-pocket maximum
amounts increased per IRS guidelines
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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
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Blue Distinction Centers for Bariatric Surgery
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
 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
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Blue Care Connection®
Total Care Approach to Health and Wellness
 Whether you decide to skip fast food, quit smoking,
or walk more, every day decisions can have a positive
impact on your health; Blue Care Connection
offers guidance at every level of health
Well Members
Low- Risk
Moderate- Risk
High-Risk
Complex / Catastrophic
< < < Wellness > > >
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Condition Management
If you have a chronic condition, we offer support.
• Support from 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
1-800-462-3275
• Establish goals with you and caregivers,
scheduling follow-ups as appropriate
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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
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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
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24/7 Nurseline
Advice anytime.
Round-the-clock health
and the wellness advice
from licensed
professionals
Advice isn’t just needed
from 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
24/7
1-800-581-0368
Available in English and Spanish
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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
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Personal Health Manager – Home Page
Read secure
messages
Take a Health Risk
Assessment
Review
member
alerts
Access Member
Care Profile
Use the
Interactive
Symptom
Checker
Explore
topics in the
Health
Information
and Care
Center
Ask a Question to a
certified Nurse,
Trainer, Dietitian or
Life Coach
Read the latest
health news, search
for specific health
topics or explore the
prescription drug
index
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“Ask A” Online Advisor
Ask the experts.
Expert advice from
licensed professionals
via the Personal Health
Manager
Expert advice at your fingertips.
Our “Ask A” feature is here to help.
Ask A Nurse:
Interact online with a Blue
Care Advisor on nonemergency, healthrelated questions using
the secure “Ask A Nurse”
feature.
Ask A Trainer,
Dietitian or
Life Coach:
Send questions about
fitness, nutrition, or
managing stress.
Confidential and Secure – Receive an
e-mail response within one business day
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Health Risk Assessment – Easy To Use
1
2
Choose your
assessment topic:
• Health & well-being*
• Sleep
• Stress management
• Nutrition
• Fitness & physical
activity
• Back & joint health
Complete the
assessment in
as little as
10 to 15 minutes
3
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.
*We recommend completing
the Health & Well-being
assessment first.
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Health Risk Assessment (HRA)
Be informed about your overall health and well-being
A Health Risk Assessment helps
assess 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
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Blue PointsSM Incentives
Stay motivated.
Earn Blue Points in the
Personal Health Manager
TRS-ActiveCare PPO plan
participants and their covered
dependents accumulate 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!
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www.bcbstx.com/trs
Available online
Enrollment Video
Application Form
Enrollment Guide
Benefits Booklet
24/7 Nurseline,
Lifestyle and
Condition
Management and
Special Beginnings
phone numbers
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)
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What if I Have Questions?
Personalized Service
 Call TRS-ActiveCare customer service for:
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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
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Prescription Drugs
ActiveCare 1-HD,1, 2 & 3
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
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Prescription Drug Benefits - Network Level
Features
Drug Deductible
(per person, per plan year)
ActiveCare 1-HD
ActiveCare 1
ActiveCare 2
ActiveCare 3
Subject to plan
year deductible
Subject to plan
year deductible
$50
$50
$10
$25*
$45*
$10
$25*
$40*
$15
$35*
$60*
$15
$35*
$55*
$20
$62.50*
$112.50*
$20
$62.50*
$100*
Retail Short-Term
(up to 30-day supply)
Generic/Preferred Brand/NonPreferred Brand
Retail Maintenance
(after second fill, up to
30-day supply)
Generic/Preferred Brand/NonPreferred Brand
Medco by Mail
(up to 90-day supply)
Generic/Preferred Brand/NonPreferred Brand
20% coinsurance
after deductible
* 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.
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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.
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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
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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
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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 to
TRS-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?
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High-level Process Flow
Identification
 Prescription comes in for a pharmacy claim for a
product with an associated test through the
prescription. Fill the prescription, then…
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
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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
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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 (prepopulated with all under
age 18 dependents and
spouse information will
be shown if
authorization has been
given)
– Select a drug to
compare from a prepopulated 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
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Generic Dispensing is important…
Generic Waiver
Program
My Rx Choices®
Cost Difference
Savings
First phase January-March 2010
Approximately 6,000 web hits per month
Average cost of generic prescription is just
over $15 as compared to $151 for a brand
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.
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Information Resources
 TRS Web site – www.trs.state.tx.us/trs-activecare
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Pharmacy Benefit Highlights
List of maintenance medications
FAQs
Download forms
 Medco Member Web site – www.medco.com
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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
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HMO Plan Options
2010-2011 Plan Year
TRS-ActiveCare
Participating HMOs
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FirstCare Health Plans
HMO Plan Option
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.
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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.
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Benefit Highlights
 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)
NOTE: Care must be accessed through one of our
affiliate provider networks
 Secure online access to your membership and claim
information at www.firstcare.com
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New for 2010-2011
 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
Coverage Category
2010-2011
Employee Only
$351.36
Employee and Spouse
$870.48
Employee and Child(ren)
$558.82
Family
$874.02
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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
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New for 2010-2011
2009-2010
2010-2011
Deductible
$100 per individual
no family maximum
Deductible
$250 per individual
$500 per family
A family of four can save $100!
Out-of-Pocket Maximum
$3500 per individual
no family maximum
Out-of-Pocket Maximum
$3000 per individual
$6000 per family
A family of four can save $8,000!
Lifetime Maximum
Unlimited
Lifetime Maximum
$2 million
The plan included various levels of
copayments for each service in addition to
the annual deductible.
Benefits are simplified to now include a flat
copayment after deductible.
Ex. 20% copayment for outpatient ER visits
10% copayment for inpatient services
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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 510
Abilene, 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
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Amarillo Region Provider Network
FirstCare has a comprehensive network
of local physicians, hospitals, and
pharmacies that offer a full range of
medical services.
A complete list of network providers is
available at www.firstcare.com.
Our Amarillo office is located at:
600 S Tyler St
Box# 12019
Amarillo, TX 79101
(806) 356-5265
Come visit us and meet the staff.
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
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Lubbock Region Provider Network
FirstCare has a comprehensive network
of local physicians, hospitals, and
pharmacies that offer a full range of
medical services.
A complete list of network providers is
available at www.firstcare.com.
Our Lubbock office is located at:
1901 W. Loop 289
Suite# 9
Lubbock, TX 79407
(806) 784-4300
Come visit us and meet the staff.
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
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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 # 404
Waco, 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
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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.
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Contact Us
You may submit your questions or comments
via e-mail to [email protected]
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
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Scott & White Health Plan
HMO Plan Option
Service Area
Hospital Locations
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Hospital Providers
Central Texas Hospitals
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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 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
 Our plan still has a $0 medical deductible
 We reduced the 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)
 We reduced the 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
Benefit
Copay
Medical Deductible
$0
Primary Care Physician
$20
Specialist Office Visit
$35
Preventive Care
$0
Outpatient Surgery Facility
Inpatient Hospital
Emergency Room
Urgent Care
$100 copay plus 20%
$100 copay per day ($500 max) plus 20%
$100 copay per visit plus 20%
($100 copay waived if admitted within 24 hours)
$40 copay per visit plus 20%
Out-of-Pocket Maximum
$2,000 individual/$6,000 family
See Enrollment Guide for full list of benefits.
59
Unlimited Rx Benefit
Prescription Drugs
Retail
(up to 34-day supply
Rx Maximum
Mail Order
(up to 90-day supply)
Unlimited
Rx Deductible
Applies to brand and
non-preferred
$50
$50
Generic
$5
$10
Preferred Brand*
30% after deductible
30% after deductible
Non-Preferred Brand
50% after deductible
50% after deductible
Non-Formulary
greater of $50 or 50%
after deductible
N/A
*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 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
Find a Provider Online – www.swhp.org
62
Login to MyPlan
63
Online Lifestyle Management Programs
 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
64
64
Personalized Service
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
65
We are Texas Friendly
Simple
Helpful
Honest
66
66
Valley Baptist Health Plans
HMO Plan Option
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
68
Valley Baptist Health Plans




Low deductibles
No claim forms
No preexisting condition limitations
Controllable costs
69
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)
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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
71
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
72
Valley Baptist Health Plans
Benefit
Copay
PCP office visit
$25
Specialist office visit
$35
Preventive care
$25 PCP/$35 Specialist
Outpatient surgery facility
20% after deductible
Inpatient hospital
20% after deductible
Emergency room
20% after deductible (waived if
admitted)
$75 copay (deductible waived)
Urgent care
Out-of-pocket maximum
$3,000 maximum (individual)
$6,000 maximum (family)
73
Valley Baptist Health Plans
Prescription Drugs
Retail
Mail Order
(up to 30-day supply)
(up to 90-day supply)
Generic
$10
$30
Preferred Brand
$30
$90
Non-Preferred Brand
$60
$180
Maximum plan year prescription benefit is $10,000 per individual
74
How to Enroll
2010-2011 Plan Year
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
76
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.
77
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)
78
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
79
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
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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
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)
 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
81
Cost for Health Coverage
2010-2011 Plan Year
Monthly Cost
for Coverage
 See page 27 of
Enrollment Guide
 $225 in district/entity
and state funds to
help pay for coverage
83
Cost of Coverage (Cont’d)
PPO Plans
ActiveCare 1-HD
ActiveCare 1
Total Cost
Total Cost
Employee Only
$262
$297
Employee and Spouse
$642
$677
Employee and Child(ren)
$409
$474
Employee and Family
$840
$746
Family Deductible
$2,400
$3,000
Family Out-of-Pocket
Maximum
$7,400
$9,000
Coverage Category
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
84
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
85
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
86
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
87
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
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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
 Scott and White Health Plan
 Valley Baptist Health Plans
800-884-4901
800-321-7947
800-829-6440
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Enrollment Support
Available Online
 Enrollment guide
(English and Spanish)
 Downloadable forms
(enrollment application,
split premium, claim form,
etc.)
 Provider locator
 Frequently asked
questions
www.trs.state.tx.us/trs-activecare
90
Questions
Thank you for attending