ENROLLMENT GUIDE Health Plans

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1 ENROLLMENT GUIDE Health Plans

2 TABLE OF CONTENTS WELCOME 1 WHAT S NEW 2 HOW TO ENROLL Who Can Enroll in TRS-ActiveCare 4 How to Enroll in TRS-ActiveCare 7 Making Changes/Special Enrollment Events 9 SELECTING A HEALTH PLAN OPTION Choosing the Benefit Plan That s Right for You 10 Comparing a PPO to an HMO 12 Selecting a Health Plan Option 13 PPO Benefits Summaries and Plan Comparisons 14 HMO Benefits Summaries and Plan Comparisons 22 How the Plans Compare 30 Your Cost for Coverage 32 Understanding Your Benefits Terms to Know 34 Frequently Asked Questions 36 Limitations and Exclusions 38 Notices General Notice of Special Enrollment Rights and Preexisting Condition Exclusion 42 HIPAA Notice of Election of Exemption 43 Notice of Privacy Practices 43 Medicare Beneficiaries and Medicare Part D 43 Trs Group Long Term care insurance 44 Questions? Call Customer Service ActiveCare 1-HD ActiveCare 1 ActiveCare 2 (866) ActiveCare CT (Mon-Fri) (800) CT (Mon-Fri) (800) CT (Mon-Fri) (800) CT (Mon-Fri) (800) CT (Mon-Fri) TDD Number (for the hearing impaired) (800) This guide provides an overview of TRS-ActiveCare plan benefits. Your TRS-ActiveCare Benefits Booklet or your HMO s Evidence of Coverage provides a detailed description of your plan. The Benefits Booklet will be available online before September 1, 2009 and is the official TRS statement on benefits. HMO Evidence of Coverage documents will be available online and printed copies may be available from your HMO. TRS-ActiveCare benefits will be paid according to the Benefits Booklet or HMO s Evidence of Coverage and other legal documents governing the plan. This Enrollment Guide applies to the TRS-ActiveCare plan year and supersedes any prior version of the Enrollment Guide. However, prior versions of the Enrollment Guides remain in effect for the plan year to which they apply. In addition to TRS laws and regulations, the Enrollment Guide is TRS-ActiveCare s official statement about enrollment matters contained in the Guide and supersedes any other statement or representation made concerning TRS-ActiveCare enrollment, regardless of the source of that statement or representation. TRS-ActiveCare reserves the right to amend the Enrollment Guide at any time. 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. Prescription drug benefits for the ActiveCare 1-HD, 1, 2 and 3 plans are administered by Medco Health Solutions, Inc. HMO plans provided by: SHA, L.L.C. dba FirstCare Health Plans, Mercy Health Plans of Missouri, Inc., Scott and White Health Plan and Valley Baptist Insurance Company dba Valley Baptist Health Plans. Copyright 2009 Blue Cross and Blue Shield of Texas

3 welcome 1 Since 1937, the Teacher Retirement System of Texas (TRS) has served public education employees by delivering their retirement and related benefits and by managing the trust fund established to finance their benefits. On September 1, 2002, TRS introduced TRS-ActiveCare, a new statewide health coverage program for public education employees established by the 77th Texas Legislature. Today, participation in that program has grown to over 362,000 employees and dependents. Of the 1,256 districts/entities eligible to participate in TRS-ActiveCare, more than 86 percent, or 1,085, now do so. Along with four PPO plan options administered by Blue Cross and Blue Shield of Texas and Medco, there are four health maintenance organization (HMO) options offered under TRS-ActiveCare: FirstCare Health Plans, Mercy Health Plans, Scott & White Health Plan, and Valley Baptist Health Plans. These HMO options will provide additional plan choices to the employees of participating entities in areas served by these HMOs. These employees will be able to select TRS-ActiveCare coverage under one of the PPO plans or through the authorized HMO serving their part of the state. Accessible, affordable and quality health care has become increasingly important to all of us, and we at TRS are committed to providing that for you using all available resources. We hope that you ll take a few minutes to read through this booklet to learn more about your many TRS-ActiveCare benefits. How to use this guide This guide summarizes TRS-ActiveCare for the coming plan year, effective September 1, It provides details on all the health benefit plans offered through TRS-ActiveCare. The information will help you understand the different plans and give you the confidence to decide which option is best for you and your family. Throughout the guide, you ll find special sidebars with information to help you better understand your health care options. See Terms to Know on page 34 and the Frequently Asked Questions on page 36 for additional information. If you still have questions, log onto the TRS-ActiveCare Web site or call the health plan s toll-free Customer Service number for assistance. You ll have from April 13 - May 15 and August 1 - August 31 to enroll in or change your TRS-ActiveCare benefits for No plan changes will be accepted after August 31, For example, if you enroll in ActiveCare 2, you cannot change to ActiveCare 3 after August 31, 2009.

4 2 What s new What s new for ? If you plan to keep the same TRS-ActiveCare coverage, you do not need to submit an application form, unless you are transferring to a new participating district/entity. However, a form must be submitted to decline coverage, even if you declined TRS-ActiveCare coverage in No preexisting condition exclusions apply for plan or coverage changes you make unless you previously declined coverage. (Preexisting condition exclusions do not apply to HMO coverage.) Rates and/or benefits for every TRS-ActiveCare plan option have changed; please review the guide carefully. Note: The HMO option from Legacy Health Solutions will not be available for the plan year. All existing Legacy enrollees must select a new TRS-ActiveCare plan option. Benefit Changes for g Effective September 1, 2009 Plan Option Benefit(s) Change From Change To ActiveCare 1-HD New plan option! Meets IRS definition of high deductible health plan for all coverage categories Deductible (per plan year) N/A $2,300 employee-only coverage $2,300 employee and spouse, employee and child(ren), or employee and family coverage ActiveCare 1 ActiveCare 1-HD ActiveCare 1 ActiveCare 2 ActiveCare 3 Out-of-Pocket Maximum (per plan year) Deductible (per individual, per plan year) Bariatric surgery N/A Without deductibles: $3,000 employee-only coverage $5,000 employee and spouse, employee and child(ren), or employee and family coverage Including deductibles: $5,300 employee-only coverage $7,300 employee and spouse, employee and child(ren), or employee and family coverage $1,100 $1,150 (meets IRS definition of high deductible health plan for employee coverage only) Coverage is available at any location where the bariatric surgery is conducted Coverage under ActiveCare 1-HD, 1, 2 and 3 will be available only when the bariatric surgery is conducted at one of the Blue Distinction Centers for Bariatric Surgery; see page 15 for more information

5 What s new 3 Benefit Changes for Continued g Effective September 1, 2009 Plan Option Benefit(s) Change From Change To FirstCare Health Plans Deductible Medical (per individual, per plan year) $400 $100 Legacy Health Solutions Mercy Health Plans Scott & White Health Plan Valley Baptist Health Plans Deductible Prescription Drugs (per individual, per plan year) Copays Non-maintenance medications, including insulin and diabetic medications Copays Maintenance medications, including insulin and diabetic medications (retail; after 2nd fill) Coinsurance Self-injectable medications Serious Mental Illness $0 $50 (Insulin and diabetic medications are not subject to deductible) $15/$30/$50 (retail) $45/$90/$150 (mail) $5/$25/$55 (retail) $15/$75/$165 (mail) $15/$30/$50 $10/$35/$70 20% (Tier IV, retail and mail) 20% (Tier V, retail and mail) $40 copay 60 visits maximum per plan year 15% (Tier IV, retail and mail) 35% (Tier V, retail and mail) $40 copay unlimited visits This HMO plan option is not available for the plan year. All existing enrollees must select a new TRS-ActiveCare plan option No changes Preventive care office visit, $25 copay $0 copay including well-child visits and immunizations Outpatient services, diagnostic/ $25 copay 20% of charges radiology procedures, outpatient surgery and allergy injections Hospital semi-private room and intensive care unit $200 copay per day to $1,000 maximum per admission Other hospital services $200 copay per day to $1,000 maximum per admission Inpatient serious mental illness and chemical dependency treatment $200 copay per day to $1,000 maximum per admission 20% plus $100 copay per day, up to $500 maximum per admission 20% of charges 20% plus $100 copay per day, up to $500 maximum per admission Emergency room $100 copay (waived if admitted) 20% plus $100 copay ($100 copay waived if admitted within 24 hours) Ambulance $40 copay (waived if transported) 20% plus $40 copay ($40 copay waived if transported) Skilled nursing facility $200 copay per day to $1,000 maximum per admission 20% plus $100 copay per day, up to $500 maximum Home infusion therapy $100 copay per day 20% plus $50 copay per day, up to $250 maximum Private duty nursing No charge 20% of charges Maximum plan year $3,000 per person $4,000 per person prescription benefit Drug deductible, per person, per None $50 plan year Preferred brand-name drug $25 copay (retail) $50 copay (mail, maintenance) 30% after drug deductible Non-preferred brand-name drug (retail) Non-preferred brand-name drug (mail, maintenance) Copays Outpatient specialty drugs (levels 1-4) No changes Lesser of $50 or 50% (formulary) Lesser of $100 or 50% (formulary); non-formulary, not available 50% after drug deductible (formulary) 50% after drug deductible $50/$100/$250/50% 10%/20%/30%/50% of charges

6 4 who can Enroll Who can enroll in TRS-ActiveCare? To be eligible for TRS-ActiveCare, you must be employed by a participating district/entity and be either an active, contributing TRS member or employed 10 or more regularly scheduled hours each week. You are not eligible for TRS-ActiveCare coverage if you are: Receiving health care coverage as an employee or retiree under the Texas State College and University Employees Uniform Insurance Benefits Act. Example: A school employee who has UT SELECT coverage as an employee with The University of Texas System. Receiving health care coverage as an employee or retiree under the Texas Employee Uniform Group Insurance Benefits Act. Example: A school employee who has HealthSelect coverage as an employee with ERS. A TRS retiree receiving, or who waived coverage under, TRS-Care, including a retiree who has returned to work.* * If a TRS retiree has returned to work and has never been eligible for TRS-Care, he or she would be eligible for TRS-ActiveCare coverage, as long as the retiree meets all the TRS-ActiveCare eligibility requirements. Note: Although a retiree, a higher education employee or a state employee may not be covered as an employee of a participating district/entity, he or she can be covered as a dependent of an eligible employee. Under Section , Texas Education Code, an employee who is participating in TRS-ActiveCare is entitled to continue participating in TRS-ActiveCare if the employee resigns after the end of the instructional year. TRS Rule 41.38, Texas Administrative Code, will be applied by TRS-ActiveCare in determining the appropriate termination date of TRS-ActiveCare coverage.

7 who can Enroll 5 Eligible dependents include: Your spouse (including a common law spouse) An unmarried (including divorced) child under the age of 25, such as: A natural or adopted child A stepchild A foster child A child under the legal guardianship of the employee Another child in a regular parent-child relationship with the employee, meaning: The child s primary residence is the household of the employee; The employee provides at least 50% of the child s support; Neither of the child s natural parents resides in that household; and The employee has the legal right to make decisions regarding the child s medical care An unmarried grandchild whose primary residence is the household of the employee and who is a dependent of the employee for federal income tax purposes An unmarried child of a covered employee, regardless of age, may be eligible for dependent coverage, provided that the child is either mentally retarded or physically incapacitated to such an extent to be dependent on the employee on a regular basis as determined by TRS, and meets other requirements as determined by TRS. (Siblings over age 25 or parents are not the children of an employee and do not meet the definition of an eligible dependent.) Note: It is against the law to elect coverage for an ineligible person. Violations may result in prosecution and/or expulsion from the plan for up to five years. TRS-ActiveCare eligibility audits may be conducted periodically. Audit notifications will be mailed to TRS-ActiveCare plan participants when TRS-ActiveCare needs to verify that participants or their covered dependents meet plan eligibility requirements. Please contact your Benefits Administrator immediately to submit an Enrollment Change Form if you have an ineligible person enrolled in TRS-ActiveCare. During an eligibility audit, you may be asked to provide proof of eligibility for yourself or your covered dependents and, if unsatisfactory, you will have a limited time to cancel coverage for the ineligible person(s) without incurring penalties that may include expulsion under TRS Rules published in the Texas Administrative Code and recovery of paid claims.

8 6 who can Enroll Who is eligible for TRS-ActiveCare coverage? Teachers, administrative personnel, permanent substitutes, bus drivers, librarians, crossing guards, cafeteria workers, and high school or college students are all eligible for coverage, provided no exception applies, if they are employees of the participating district/entity, not volunteers, and are either active contributing TRS members or are employed by a participating district/entity for 10 or more regularly scheduled hours each week. True on-call substitutes, independent contractors, and volunteers are not employees and are therefore not eligible for TRS-ActiveCare coverage. Note: Only employees who are active, contributing TRS members are eligible for funding under Chapter 1581, Texas Insurance Code. What is CHIP and is it available to my family? Currently, families may qualify for low-cost children s health insurance through the TexCare Partnership and Children s Health Insurance Program (CHIP). To apply, call TexCare Partnership at (800) or log on to Note: A child cannot receive coverage under both TRS-ActiveCare and CHIP.

9 HOW TO Enroll 7 How to Enroll Follow these steps to enroll: 1 Choose the health plan option that s right for you 2 Complete the Enrollment Application and Change Form (if required), available from your Benefits Administrator or on the TRS-ActiveCare Web site. Even if you are not accepting available coverage through TRS-ActiveCare, please complete sections 2 and 9 of the Enrollment Application and Change Form and note that you are declining health coverage for yourself and/or your dependents 3 Submit the completed, signed and dated form to your Benefits Administrator within the required enrollment period(s). Note: Some districts/entities may offer electronic enrollment through an interactive voice response (IVR) or Web-based system. If so, you may not need to submit an Enrollment Application and Change Form. See your Benefits Administrator for details. Please keep a copy of any confirmation of coverage you receive from the electronic enrollment system for your records. Enrollment Application Available Online Type your application online by visiting and completing three steps: 1 Input your information in the application file 2 Print the application 3 Sign, date and submit the form to your Benefits Administrator Enroll Now! The plan enrollment periods for the plan year are: April 13 - May 15 (Spring Enrollment) August 1- August 31 (Summer Enrollment) During the plan enrollment periods, you may select a plan option, make plan changes, and add or delete dependents from your health coverage without a special enrollment event. Note: You should choose your plan carefully. You may not change plans during a plan year, and there may be restrictions to making plan changes in future plan years.

10 8 how to Enroll Who needs to submit an Enrollment Application and Change Form For employees already enrolled in TRS-ActiveCare: If you are not making any changes to your current health benefit plan or adding/dropping dependents, you do not need to re-enroll unless you want to: Change your TRS-ActiveCare plan option, or Add or drop the dependents you cover, or Choose to cancel and/or decline coverage under TRS-ActiveCare, or Enroll for TRS-ActiveCare coverage with a different participating district/entity, or Change your name or address and/or correct your date of birth or Social Security number Remember, you must submit an Enrollment Application and Change Form if you change employment during the plan year and enroll for TRS-ActiveCare coverage with another participating district/entity. Forms should be returned to your Benefits Administrator. If you do not return your enrollment form, you will automatically be enrolled in the same plan you elected for at the same level of coverage unless you are transferring to a new participating district/entity. Please pay close attention to any benefit changes from last year as you make your plan choices. Your premium will be adjusted to reflect any rate change on September 1, For employees enrolling in TRS-ActiveCare for the first time: New hires may choose their actively-at-work date (the date they start to work) or the first of the month following their activelyat-work date as their effective date of coverage. If choosing the actively-at-work date, full premium for the month will be due; premiums are not pro-rated. You will need to sign and submit an Enrollment Application and Change Form to your Benefits Administrator before the later of: The end of the plan enrollment period 31 calendar days after your actively-at-work date 31 calendar days after a special enrollment event (Special rules apply to adding newborns; see page 9 for more information) What if I choose not to enroll in TRS-ActiveCare? TRS believes it is very important that everybody should have health coverage. Please keep in mind that if you decline coverage, you won t be able to elect coverage during the year unless you have a special enrollment event, such as a marriage, divorce, birth or adoption of a child, or a loss of other coverage. If you submit an Enrollment Application and Change Form due to loss of other coverage, your original application will be checked to verify that coverage was declined (in section 9) due to other coverage. If section 9 was not completed or if no application exists, proof of coverage (such as a certificate of creditable coverage) in lieu of a declination of coverage on the enrollment application must be provided to your Benefits Administrator. If documentation is not made available, your request to add coverage will be denied. So it is very important that you complete and submit a form even if you are declining coverage. Note: Any decision you make, including the decision not to enroll, stays in effect for the entire plan year, unless you have a special enrollment event. Refer to the Making Changes/Special Enrollment Events section of this guide for more information. To decline coverage: Complete sections 1, 2 and 9 of the Enrollment Application and Change Form to voluntarily decline coverage for yourself and any of your dependents and to provide the reason for declining. Submit the form to your Benefits Administrator. If you are currently covered by TRS-ActiveCare but want to decline coverage for , you must sign and submit an Enrollment Application and Change Form during the plan enrollment period to terminate coverage at the end of the plan year by checking the boxes for Cancel Enrollee and Decline Coverage for the new plan year. If I m already enrolled and not making any changes, do I have to complete an Enrollment Application and Change Form? No, unless you declined coverage in If you are not making any changes to your current health benefit plan or adding or dropping dependents, or transferring to a different participating district/entity, you do not need to re-enroll. You will automatically be enrolled in the same plan you elected for at the same level of coverage, and your premium will be adjusted to reflect any rate change on September 1, You should review any benefit changes, as well as rate changes, for your current plan. If you declined coverage in and wish to decline coverage again in , you must resubmit an Enrollment Application and Change Form to your Benefits Administrator indicating you are declining coverage. Note: If you are an HMO participant with Legacy Health Solutions, you must select a new plan option for the plan year.

11 Making Changes 9 Making Changes/Special Enrollment Events The plan options and coverage levels you select during the plan enrollment periods will remain in effect from September 1, 2009 through August 31, You cannot add or change covered persons during the year unless you have a special enrollment event (family status change) such as: You marry (a common law marriage is not considered a special enrollment event unless there is a certificate of common law marriage filed with an authorized government agency) You divorce (if the divorce results in a loss of other coverage) A child is born, adopted, or is placed with you for adoption A child marries or reaches age 25 A court orders you to provide health coverage for your child (does not apply to court-ordered coverage for a spouse) You involuntarily lose other health insurance coverage (and you originally declined TRS-ActiveCare coverage in writing because of coverage under another health benefit plan) Your eligible dependent involuntarily loses other health insurance coverage (and you originally declined TRS-ActiveCare dependent coverage in writing for the individual(s) losing other coverage because of coverage under another health benefit plan). Note: You can add the dependent only if you are already covered by ActiveCare 1-HD, 1, 2 or 3. If you live, work or reside in an HMO service area, you and your dependent can enroll in HMO coverage. TRS-ActiveCare participants may drop TRS-ActiveCare coverage during a plan year, unless restricted from doing so by their district/ entity s Section 125 cafeteria plan s rules. Voluntary terminations of other coverage, such as dropping other coverage due to premium or benefit changes, including spousal surcharges or coverage restrictions, are not special enrollment events. Call Customer Service before you make any changes to other coverage you may have. The change in coverage must be consistent with the family status change for special enrollment events as defined by TRS-ActiveCare plan rules. For example, if you get married, you can change from employee-only coverage to employee and spouse coverage. The cost of coverage may change based on the selected coverage category. Changes in employee and/or dependent coverage must be made within 31 calendar days after the special enrollment event. (Special rules apply to adding newborns; see below for more information.) It is YOUR responsibility to meet any such deadlines. If you do not request the appropriate changes during the applicable special enrollment period, the changes cannot be made until the next plan enrollment period or, if applicable, another special enrollment event. A preexisting condition waiting period may apply at that time. For most special enrollment events, the effective date of coverage will be the first of the month after the event date. Note: Even if you have a special enrollment event, change employment to another participating district/entity or leave and become re-employed by your same district/entity, you may not make plan changes during a plan year unless specifically permitted by TRS Rules. An employee may not add dependents during the plan year unless there is a special enrollment event. If coverage is dropped during the plan year, an individual will not be eligible to re-enroll in TRS-ActiveCare until the next plan enrollment period even if there is a special enrollment event, including a loss of other coverage. A change request submitted through your Section 125 vendor (if applicable) will not automatically result in changes to your TRS-ActiveCare coverage. All changes to TRS-ActiveCare coverage must be submitted to your Benefits Administrator, using the TRS-ActiveCare Enrollment Application and Change Form. How are newborns covered by TRS-ActiveCare? TRS-ActiveCare automatically provides coverage for a newborn child of a covered employee for the first 31 days after the date of birth. To add coverage for the newborn, the employee must sign, date and submit an Enrollment Application and Change Form to the Benefits Administrator within 60 days after the date of birth. However, an employee has up to one year after the newborn s date of birth to add the newborn to coverage if the employee has employee and family or employee and child(ren) coverage with TRS-ActiveCare at the time of the newborn s birth and at enrollment. The effective date of coverage is the date of birth. If the application is submitted after the enrollment period for the newborn child, the request to add coverage will be denied even if there would be no change in premium. Note: It is not necessary to wait for the newborn s Social Security number. You should submit an Enrollment Application and Change Form without the newborn s Social Security number to add coverage and re-submit another form once the number has been issued.

12 10 Selecting a Health Plan Option Choosing the Health Plan That s Right for You TRS-ActiveCare offers many different health plan options. The following pages feature an overview of benefits for all TRS-ActiveCare health plan options. Not all health plan options are available in all areas of the state. The charts to the right display the options available by county (or by ZIP code in some areas). See your Benefits Administrator or log onto the TRS-ActiveCare Web site to find out which options are available in your area. ActiveCare 1- HD, 1, 2 and 3 options, administered by Blue Cross and Blue Shield of Texas and Medco, are available to districts/ entities in all Texas counties. To be eligible for an HMO, you must live, work or reside within the HMO service area. County ActiveCare 1-HD, 1, 2 & 3 FirstCare Health Plans Andrews Armstrong Mercy Health Plans Scott & White Health Plan Austin o Bailey Bastrop Bell Blanco Borden Bosque Brazos Briscoe Burleson Burnet Caldwell o Callahan Valley Baptist Health Plans Cameron Carson Castro Childress Cochran Coke o Coleman o Collingsworth Comanche Concho Coryell Cottle Crane Crockett Crosby Dallam Dawson Deaf Smith Dickens Donley Duval Eastland Ector Edwards Erath o Falls Fisher Floyd Gaines Garza Glasscock Gray Grimes o Hale Hall Hamilton

13 Selecting a 11 Health Plan Option County ActiveCare 1-HD, 1, 2 & 3 FirstCare Health Plans Mercy Health Plans Scott & White Health Plan Valley Baptist Health Plans County ActiveCare 1-HD, 1, 2 & 3 FirstCare Health Plans Mercy Health Plans Scott & White Health Plan Valley Baptist Health Plans Hansford Hartley Haskell Hays o Hemphill Hildalgo Hill Hockley Hutchinson Irion Jim Hogg Jones Kent Kimble o King Kinney Knox Lamb Lampasas Lee o Leon o Limestone o Lipscomb Llano o Loving Lubbock Lynn Madison Martin Mason o McCulloch McLennan Menard Midland Milam Mills Mitchell Moore Motley Nolan Ochiltree Oldham Parmer Pecos Potter Randall Reagan o Reeves Roberts Robertson Runnels o San Saba o Schleicher Scurry Shackelford Sherman Somervell o Starr o Stephens Sterling o Stonewall Sutton Swisher Taylor Terry Tom Green Travis Upton Val Verde Walker o Waller o Ward Washington o Webb Wheeler Willacy Williamson Winkler Yoakum Zapata All Other Texas Counties o Partial counties covered as follows: Austin All of 77452, 77833, and Portions of ZIP codes 77418, and Caldwell All of 78610, 78616, 78622, 78640, 78644, 78655, 78656, and Portions of ZIP codes and Coke All of 76905, 76933, 76945, and Portions of ZIP code Coleman All of 76828, 76834, 76873, 76878, 76882, 76884, 76888, and Portions of ZIP codes 76443, 76801, 76823, and Erath All of 76436, and Portions of ZIP codes 76401, and Grimes All of 77363, 77830, 77831, 77861, 77868, 77869, and Portions of ZIP codes and Hays All of 78610, 78619, 78620, 78640, 78652, 78667, 78676, 78736, and Portions of ZIP code Kimble All of 76841, 76849, 76854, 76856, and Portions of ZIP codes 76883, and Lee All of 76578, 77853, 78621, 78659, 78942, and Portions of ZIP code Leon All of and Portions of ZIP codes 75833, and Limestone All of 76624, 76635, 76642, 76648, 76653, 76664, 76667, 76673, 76678, 76686, and Portions of ZIP codes and Llano All of 76831, 76885, 78607, 78609, 78639, 78643, and Portions of ZIP code Mason All of 76820, 76825, 76842, and Portions of ZIP code Reagan All of Portions of ZIP codes and Runnels All of 76821, 76861, 76865, 76875, 76882, 76933, 79519, 79538, and Portions of ZIP code San Saba All of 76824, 76832, and Portions of ZIP code Starr All of 78536, and Somervell All of 76033, 76043, 76048, 76070, and Portions of ZIP code Sterling All of Portions of ZIP code Walker All of 77334, 77340, 77341, 77342, 77343, 77344, 77348, and Portions of ZIP codes 75862, 77320, and Waller All of and Portions of ZIP codes and Washington All of 77426, 77833, 77834, and Portions of ZIP codes and 78946

14 12 Comparing a PPO to an HMO If you have the opportunity to select between a PPO option and an HMO option, there are several factors you should consider when making a decision, including cost, choice, access to providers and your own lifestyle. Preferred Provider Organization (PPO) Generally speaking, a PPO plan offers more choice than an HMO plan. When you enroll in a PPO plan, you do not have to select a primary care physician (PCP), nor do you have to obtain a referral to see a specialist. You have the freedom of visiting any physician or hospital you choose. A PPO plan offers two levels of benefits network and non-network. When you seek care from a network physician or hospital, the PPO plan pays a larger portion of your health care costs than it pays for services by a non-network provider. However, when you receive care outside the network, you still have coverage, but you may pay more of the cost. If enrolled in a PPO plan, there may be a plan year deductible to meet before the plan begins paying benefits, and you may pay a copayment or coinsurance when you utilize health care services. Preexisting condition exclusions may also apply. (Prior creditable coverage may offset any preexisting condition waiting period.) Although the out-of-pocket costs are potentially higher than HMO plans, a PPO plan offers enrollees more choice and more flexibility than an HMO plan. Health Maintenance Organization (HMO) HMO plans offer prepaid health care for you and your covered dependents. In most instances you will pay only a copayment for your medical services, including prescriptions. A copayment is a set dollar amount that you pay a provider when utilizing services. To be eligible for an HMO plan, you must live, work or reside within the HMO service area. HMO plans offer a network of providers within a defined service area. Except for emergencies, which are covered worldwide, you and your dependents must use network providers to receive HMO plan benefits. Preexisting condition exclusions do not apply to HMO plans. When you enroll in an HMO plan, you will be asked to select a primary care physician. This physician will coordinate all of your health care, and provide referrals to specialty care if needed. Females may also select a network OB/GYN and may schedule an appointment with that physician without a referral from a PCP. When you are comparing the merits of a PPO plan or an HMO plan, be sure to compare the providers in all plans. If your physician is within an HMO network, you may find that an HMO plan is a cost-effective way to receive comprehensive medical benefits. TRS-ActiveCare has given you the opportunity to take control of your health care. Please review the Benefits Summaries and Plan Comparisons on pages to decide which plan option meets the needs of your family and your lifestyle.

15 Selecting a Health Plan Option 13 Take the time to review the Benefits Summaries and Plan Comparisons. Think about which plan works best for you and your family. Before you make your choice, consider: Do you have access to health coverage other than what is provided by TRS-ActiveCare? If so, how do the costs and provisions of that coverage compare? If you have a choice of provider networks, which one is nearest to you? Is your current physician in one of the networks? If your doctor is in a PPO and an HMO network, and if you are eligible for the PPO and the HMO, you might want to evaluate your anticipated out-of-pocket costs for all of the options available to you. Are you willing to change physicians if your current physician is not in the network? What specific benefits do you or your family use most frequently? Preventive? Maintenance prescriptions? Behavioral health? Make sure you look at the corresponding line in the comparison chart to see which plan would work best. Whom do you need to cover? Where do they live? Do you or members of your family travel? Make sure you understand how treatment is received outside of your local area. Also when choosing a health plan, be sure to consider the total cost of your options, including: Coinsurance: The percentage of medical expenses that you and the plan share. For example, if the network coinsurance amount is 80/20, that means the plan pays 80 percent and you pay 20 percent. Copayments: The set amount you pay for certain medical services and prescription drugs at the time of service. Deductibles: The set amount of out-of-pocket expense, if applicable, that must be paid for health care services by the covered person before the plan begins to share costs. For example, ActiveCare 1 has a $1,150 deductible, which must be met before the plan pays any benefits. Employee contributions: The expense paid by the employee for coverage through the TRS-ActiveCare program. Plan options and preferred brand-name prescription drugs All TRS-ActiveCare plan options include prescription drug benefits. As you select a plan option, you should know that the prescription drug benefits differ. To find out if and how your medication is covered by TRS-ActiveCare, check the Web site or call the specific health plan s toll-free Customer Service number listed on the inside front cover of this guide. Important Notice TRS does not offer, nor does it endorse, any form of supplemental coverage for any of the health coverage plans available under TRS-ActiveCare. To obtain information about any coverage that is purported to be a companion or supplement to any TRS-ActiveCare plan, employees should contact the organization making such offerings and/or the Texas Department of Insurance (TDI) at or the TDI Consumer Helpline at (800)

16 14 ppo benefits summaries and plan comparisons What s new for ? 4.5% premium increase for the ActiveCare 1, 2 and 3 plans New plan option ActiveCare 1-HD meets IRS definition of high deductible health plan for employees and families Bariatric surgery to be covered only when performed at designated Blue Distinction Centers for Bariatric Surgery What s the difference between ActiveCare 1-HD and ActiveCare 1? The two plans are similar, but ActiveCare 1-HD features the highest deductible, the amount that must be met first before the plan pays benefits. Other key differences are highlighted below: Feature 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) Deductible (per plan year) Yes, for all coverage categories: employee-only, employee and spouse, employee and child(ren) and employee and family $2,300 for employee only $2,300 for family The family deductible amount may be satisfied by one participant or a combination of two or more participants Yes, for employee-only coverage No, for other coverage categories $1,150 per individual $3,000 per family In this plan, the deductible applies to you and each covered person in your family individually; up to the maximum per family Maximum coinsurance (per plan year) Out-of-pocket maximum (per plan year; includes deductibles) $3,000 for employee only $5,000 for family Coinsurance is the percentage of covered medical expenses that you and the plan share; once you and/or your family members have met your applicable deductible, the plan pays 80% of your benefits and you pay 20% up to the maximum amount shown $5,300 for employee only $7,300 for family When your or your family s combined deductible and coinsurance expenses satisfy the out-of-pocket maximum, the plan pays 100% of the allowable amount of covered medical expenses for the remainder of the plan year $2,000 per individual $6,000 per family After deductible, the plan pays 80% of your covered medical expenses and you pay 20% up to the maximum amount shown for individual/family $3,150 per individual $9,000 per family In this plan, the out-of-pocket maximum applies to you and each covered person in your family, up to the maximum per family. Once the out-of-pocket maximum is reached, the plan pays 100% of the allowable amount of covered medical expenses for the remainder of the plan year Preventive services Same as ActiveCare 1 When using network providers, plan pays 100% up to the first $500 per individual, per plan year; remaining charges will be subject to deductible and coinsurance All other services and prescription drugs Same as ActiveCare 1 After deductible, plan pays 80% and you pay 20% when using network providers (60%/40% for non-network) Monthly Premium Costs (see page 33 for Cost of Coverage) Less expensive than ActiveCare 1 in all coverage categories, except employee and family Employee and family coverage is more expensive for this plan than ActiveCare 1 because the deductible and out-of-pocket maximum amounts for family are less and the plan may begin paying benefits sooner More expensive than ActiveCare 1-HD in all coverage categories, except employee and family Employee and family coverage is less expensive for this plan than ActiveCare 1-HD because the deductible and out-of-pocket maximum amounts for family are greater and it will take longer to accumulate the medical expenses to satisfy these amounts Note: The amounts shown for family refer to the coverage categories for employee and spouse, employee and child(ren) or employee and family.

17 ppo benefits summaries and plan comparisons 15 What is a Health Savings Account (HSA)? An HSA is a special account owned by an individual used to pay for current and future medical expenses. It combines a high deductible health plan with a tax-free Health Savings Account that you and your covered family members can use to pay out-of-pocket expenses such as copays and deductibles, or leave to grow as savings. Each year, the HSA can be funded up to the IRS maximum by you, your employer or both. You control the HSA, giving you the flexibility to decide how, when and where to spend your health care dollars. And the HSA is portable, which means you keep the funds even if you change health plans, take a new job or retire.* Who is eligible for an HSA? 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 (other types of insurance such as specific injury or accident, disability, dental, vision or long-term care are permitted) Is not enrolled in Medicare Cannot be claimed as a dependent on someone else s tax return Does TRS-ActiveCare offer an HSA? No, but ActiveCare 1-HD meets the IRS definition of a high deductible health plan for all coverage categories, and ActiveCare 1 meets the IRS definition of a high deductible health plan for employee-only coverage. You are not required to have an HSA to enroll in these plans, but if desired, you can seek an HSA administrator on your own to establish an account. How do I learn more about an HSA? The U.S. Treasury s Web site has additional information on HSAs, including answers to frequently asked questions, related IRS forms and publications, technical guidance, and links to other helpful Web sites. Visit the Treasury s Web site at and click on Health Savings Accounts. * Important Note: Health Savings Accounts (HSAs) have tax and legal ramifications. Neither The Teacher Retirement System of Texas or Blue Cross and Blue Shield of Texas provide legal or tax advice, and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used or relied on, for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection to the matter(s) addressed by these materials. You should seek advice based on your particular circumstances from an independent tax advisor regarding the tax consequences of specific health insurance plans or products. Blue Distinction Centers for Bariatric Surgery Blue Distinction is a designation awarded by Blue Cross and Blue Shield to medical facilities that have demonstrated expertise in delivering quality health care, resulting in better overall outcomes for bariatric patients. Effective September 1, 2009, all medically necessary bariatric surgical procedures, such as lap band and gastric bypass for weight loss, will be covered only if performed at one of the facilities listed below: Blue Distinction Centers for Bariatric Surgery Baylor Regional Medical Center of Plano Baylor University Medical Center Del Sol Medical Center Doctors Hospital Houston Northwest Medical Center Memorial Hermann Hospital Mother Frances Hospital Presbyterian Hospital of Dallas Providence Memorial Hospital Rio Grande Regional Hospital Scott & White Memorial Hospital The Methodist Hospital Trinity Medical Center United Regional Health Care System, Inc. UT Southwestern Zale Lipshy Hospital Wadley Regional Medical Center Location Plano Dallas El Paso Dallas Houston Houston Tyler Dallas El Paso McAllen Temple Houston Carrollton Wichita Falls Dallas Texarkana Coverage restrictions apply to all bariatric surgery procedures performed on or after September 1, 2009, including those with predeterminations and preauthorizations issued for bariatric surgery prior to September 1, Any bariatric procedures performed September 1, 2009, or after must be performed at one of the Blue Distinction Centers for Bariatric Surgery or the expenses will not be covered by TRS-ActiveCare. Travel expenses to and from the Blue Distinction Centers will not be covered by the plan. Blue Distinction Centers for Bariatric Surgery provide a full range of bariatric surgery care services, including inpatient care, post-operative care, outpatient follow-up care and patient education. Each facility meets stringent clinical criteria, developed in collaboration with expert physicians and medical organizations, and is subject to periodic reevaluation as criteria continue to evolve. Note: The list of Blue Distinction Centers for Bariatric Surgery is subject to change without notice. Refer to the Doctors and Hospitals section of the Web site, to search for current Blue Distinction Centers for Bariatric Surgery or contact Customer Service.

18 16 ppo benefits summaries and plan comparisons Need to locate a network or ParPlan physician or hospital? Log on to: or call Customer Service for assistance at (866) Freedom of Choice How the ActiveCare 1-HD, 1, 2 and 3 PPO Plans Work Service Area Statewide Customer Service (866) a.m. to 8 p.m. (Central Time) Monday through Friday If you need to Visit a doctor or specialist A specialist is any physician other than a family practitioner, internist, OB/GYN or pediatrician Receive preventive care Receive emergency care Be admitted to the hospital Receive behavioral health or chemical dependency services Network: You pay lower out-of-pocket costs if you choose network care Visit any network doctor or specialist Pay the office visit copay (not applicable for ActiveCare 1-HD or ActiveCare 1) Pay any coinsurance and deductible Your doctor cannot charge more than the allowable amounts for covered services Visit any network doctor or specialist Pay the preventive care copay (not applicable for ActiveCare 1- HD or ActiveCare 1) Pay any coinsurance and deductible Your doctor cannot charge more than the allowable amounts for covered services Call 911 or go to any hospital or doctor immediately; you will receive network benefits for emergency care Pay any copay (waived if admitted) Pay any coinsurance and deductible Call the preauthorization number on your ID card within 48 hours Your network doctor will preauthorize your admission Go to the network hospital Pay any coinsurance and deductible Call the behavioral health number on your ID card first to authorize all care See a network doctor or health care professional, or go to any network hospital or facility Pay any coinsurance and deductible Non-Network: (Including ParPlan) You pay higher out-of-pocket costs if you choose non-network care Payment for non-network services is limited to the allowable amount as determined by Blue Cross and Blue Shield of Texas. ParPlan providers accept the allowable amount. You are responsible for all charges billed by non-parplan Providers which exceed the allowable amount. Visit any licensed doctor or specialist Pay for the office visit File a claim and get reimbursed for the visit minus any coinsurance and deductible Your costs will be based on allowable amounts; the non-network doctor you receive services from may require you to pay any charges over the allowable amounts determined by Blue Cross and Blue Shield of Texas Visit any licensed doctor or specialist Pay for the preventive care visit File a claim and get reimbursed for the visit minus any coinsurance and deductible Your costs will be based on allowable amounts; the non-network doctor you receive services from may require you to pay any charges over the allowable amounts determined by Blue Cross and Blue Shield of Texas Call 911 or go to any hospital or doctor immediately; you will receive network benefits for emergency care Pay any copay (waived if admitted) Pay any coinsurance and deductible Call the preauthorization number on your ID card within 48 hours You, a family member, your doctor or the hospital must preauthorize your admission Go to any licensed hospital Pay any coinsurance and deductible each time you are admitted Call the behavioral health number on your ID card first to authorize all care See any licensed doctor or health care professional, or go to any licensed hospital or facility Pay any coinsurance and deductible File a claim Claims will be filed for you You may need to file the claim yourself Get prescription drugs ActiveCare 1-HD and ActiveCare 1: Take prescription to a network retail pharmacy or mail order service Pay the required coinsurance and deductible ActiveCare 2 and ActiveCare 3: Take prescription to a network retail pharmacy or mail order service Pay the required prescription drug deductible and copay ActiveCare 1-HD and ActiveCare 1: Take prescription to any licensed pharmacy Pay the total cost of the drug File a claim with Medco and get reimbursed the amount that would have been charged by a network pharmacy less any coinsurance and deductible ActiveCare 2 and ActiveCare 3: Take prescription to any licensed pharmacy Pay the total cost of the drug File a claim with Medco and get reimbursed the amount that would have been charged by a network pharmacy less the required prescription drug deductible and copay Even if you visit a non-network doctor, you may still save money using a ParPlan physician Blue Cross and Blue Shield of Texas contracts with many non-network doctors and hospitals. These providers accept the Blue Cross and Blue Shield of Texas allowable amounts for covered services and cannot bill you more. In most cases they will file claims, too. Look for participating doctors and hospitals on the TRS-ActiveCare Web site under Provider Locator; select Blue Cross and Blue Shield of Texas, then select ParPlan.

19 PPO Benefits Summaries 17 and Plan Comparison Online resources for your health Through Blue Access for Members, you and your family have access to online resources where you will find practical and useful information. For example, you can research specific health conditions and get advice on how to start a program for exercise, smoking cessation or weight loss. With Blue Access for Members, you can also: Check the status of a claim Confirm who is covered under your plan View and print detailed claim history and information (Explanation of Benefits) Locate a physician in your network that meets your needs Sign up to receive notifications of new claim activity Request a new or replacement ID card or print a temporary ID card Access the Personal Health Manager and earn Blue Points Take a Health Risk Assessment and gain immediate access to Customer Service with questions about your ActiveCare 1-HD, 1, 2 and 3 benefits and claims through Live Chat To register for Blue Access for Members, you ll need your group and member identification number, found on your TRS-ActiveCare ID card. Upon authentication, you ll be asked to create a user name and password that you ll use for all future visits to Blue Access for Members. Complete a Health Risk Assessment and receive an individualized report with guidance and suggestions on the next steps to improving your health Receive targeted wellness information via to help manage specific medical conditions, including alerts for screening tests, and set up reminders for medical appointments and medication refills Request fitness and weight loss advice with Ask A Dietitian Receive help on managing stress, workplace conflicts or other issues with Ask A Life Coach Ask registered nurses health-related questions online with the Ask A Nurse feature Receive exercise and fitness advice with the Ask A Trainer feature Blue Points SM Earn Blue Points each time you: track a fitness workout; report a meal you have eaten; or take advantage of any other component of the For Your Health section within the Personal Health Manager Redeem Blue Points for reward items within the Personal Health Manager More resources to help you achieve a healthier life 24 7 Nurseline Call 24 hours a day, seven days a week for answers to health related questions, (800) Talk to registered nurses for free advice on health conditions such as high fevers, earaches, rashes, cuts and bruises, and more Access audio library, featuring over 1,200 pre-recorded health messages, including: Kicking the smoking habit Managing high blood pressure Ways to get a good night s rest Getting a grip on stress Having a baby? Special Beginnings is a voluntary program for covered participants who are expecting a baby. This program helps expectant mothers and their babies get off to a healthy start by providing prenatal and postnatal health education, pregnancy risk assessment, educational materials and follow-up monitoring from pregnancy to six weeks after delivery. Special Beginnings coordinates with the mother s physician to provide case management services to help reduce the chance of low birth-weight infants and/or premature delivery. Condition Management Voluntary, health improvement programs that can help members with: cancer, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, asthma, diabetes, metabolic syndrome (high cholesterol, high blood pressure and obesity) and low back pain. Obesity/Weight Management and Tobacco Cessation Programs Behavioral coaching, clinical coaching, education and condition management to help those who want to lose weight or stop smoking. Enroll Today To enroll or ask questions about the voluntary health and wellness programs available to you at no additional cost, please call toll-free at (800)

20 18 PPO Benefits Summaries and Plan Comparisons Type of Service ActiveCare 1-HD ActiveCare 1 General Provisions Network Non-Network Network Non-Network Deductible (per plan year) Individual You pay No primary care physician required $2,300 for employee only (meets IRS definition of a high deductible health plan) Family You pay $2,300 (meets IRS definition of a high deductible health plan) Out-of-pocket maximum (per plan year) No primary care physician required $1,150 (meets IRS definition of a high deductible health plan) $3,000 (does not meet IRS definition of a high deductible health plan) Individual You pay $3,000 plus deductible for employee only $2,000 plus deductible Family You pay $5,000 plus deductible $6,000 plus deductible Maximum Lifetime Benefit Unlimited Unlimited Unlimited Unlimited Doctor and Lab Services Doctor office visits You pay 20% after deductible 40% after deductible 20% after deductible 40% after deductible Allergy injections You pay 20% after deductible 40% after deductible 20% after deductible 40% after deductible Office surgery You pay 20% after deductible 40% after deductible 20% after deductible 40% after deductible Outpatient surgery You pay 20% after deductible 40% after deductible 20% after deductible 40% after deductible Maternity care (doctor charges only; see Hospital/Facility Services for inpatient charges) You pay 20% after deductible 40% after deductible 20% after deductible 40% after deductible Inpatient doctor visits You pay 20% after deductible 40% after deductible 20% after deductible 40% after deductible Contraceptive devices You pay 20% after deductible 40% after deductible 20% after deductible 40% after deductible Preventive Care Doctor office visits Services limited to one per person per plan year: routine physicals, OB/GYN well-woman exams, routine mammograms, and eye exams. Other services include well-baby exams, immunizations, hearing exams, and PSA, colorectal cancer, osteoporosis screenings Plan pays 100% up to the first $500 per individual, per plan year; remaining charges will be subject to deductible and coinsurance 40% after deductible Plan pays 100% up to the first $500 per individual, per plan year; remaining charges will be subject to deductible and coinsurance 40% after deductible Hospital/Facility Services Inpatient hospital and other inpatient charges You pay 20% after deductible (preauthorization required) 40% after deductible (preauthorization required) 20% after deductible (preauthorization required) 40% after deductible (preauthorization required) Outpatient surgery You pay 20% after deductible 40% after deductible 20% after deductible 40% after deductible Outpatient hospital/facility You pay 20% after deductible 40% after deductible 20% after deductible 40% after deductible Emergency room care You pay 20% after deductible 20% after deductible

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