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Enrollment: August 1 - 18
2
What’s new? Changes for the 2017-2018 Plan Year
What’s New ActiveCare 1-HD ActiveCare Select or
ActiveCare Select Whole
Health
ActiveCare 2
Out-of-network
deductible
$5,000/$10,000 Not applicable – no
coverage for out-of-
network
$2,000/$6,000
Out-of-network out-of-
pocket maximum
$13,100/$26,200 Not applicable – no
coverage for out-of-
network
$14,300/$28,600
What’s Changing ActiveCare 1-HD ActiveCare Select or
ActiveCare Select Whole
Health
ActiveCare 2
In-network out-of-
pocket maximum
No change $7,150/$14,300 $7,150/$14,300
Emergency Room
copay
No change $200 copay plus 20% after
deductible
$200 copay plus 20% after
deductible
Cost of coverage Increase for all coverage
tiers
Increase for all coverage
tiers
Increase for all coverage
tiers
If you live in Fort Bend, Harris, Montgomery, Galveston and Brazoria counties, you will have a new
ActiveCare Select network available, effective Sept. 1, 2017
3
ActiveCare 1-HD – High Deductible
How the ActiveCare 1-HD plan works:
Deductible
You must meet a deductible before the plan starts to pay benefits, except for in-network preventive care. One family member or a combination of family
members may meet the deductible. However, benefits are not paid for any family member’s expenses until the entire deductible amount ($5,000 in-
network/$10,000 for out-of-network) is met (or $2,500 in-network/$5,000 out-of-network for a person with employee only coverage).
Coinsurance
Once the deductible is met, you pay a portion of your covered expenses. The plan pays a percentage of covered expenses (called coinsurance) and you pay a
certain percentage. Your share is less when you use in-network providers. To find them, go to www.trsactivecareaetna.com and click “Find a Doctor or
Facility” on the right side of the home page and follow the prompts. Note: Only in-network expenses will apply to meet the in-network deductible and only
out-of-network expenses will apply to meet the out-of-network deductible.
Out-of-pocket-maximum
The plan limits your out-of-pocket expenses. Once your share of expenses reaches the plan’s out-of-pocket maximum (in-network: $6,550 individual/$13,100
family; out-of-network: $13,100 individual/$26,200 family), the plan pays benefits at 100% for the rest of the plan year. The ActiveCare 1-HD out-of-pocket
maximum applies to each covered person individually, up to the maximum per family. The individual out-of-pocket maximum only includes covered expenses
incurred by that individual. After each covered person meets his/her individual out-of-pocket maximum, the plan pays 100% of the benefits for that person.
Note: Only in-network expenses will accumulate towards meeting the in-network out-of-pocket maximum and only out-of-network expenses will accumulate
towards meeting the out-of-network out-of-pocket maximum.
Is your doctor in the network?
To find in-network providers, go to www.trsactivecareaetna.com and click “Find a Doctor or Facility” on the right side of the home page and follow the
prompts.
Choose wisely, save money. Take advantage of plan features that offer care and services at no cost or low cost. For example:
• Certain generic preventive drugs are available at no cost. The deductible and coinsurance do not apply to certain generic preventive drugs that are available to you and your family at no cost. For a list
of these drugs, go to www.trsactivecareaetna.com www.trsactivecareaetna.com/coverage and click on “ActiveCare 1-HD.”
• Teladoc® lets you consult with a primary care physician by phone. Use this service for minor problems and save a trip to the doctor’s office (subject to the deductible). Each consult costs just $40.
4
ActiveCare 1-HD – High Deductible
In-network and Out-of-Network deductibles and out-of-pocket maximum
In-Network
• ActiveCare 1-HD meets IRS definition of a high deductible health plan for all coverage tiers
• May contribute pretax dollars into a health savings account (HSA) to help pay for current health expenses and save for
future qualified medical and retiree health expenses on a tax-free basis. Individuals can establish an HSA with banks and
credit unions. 2017 max contributions are $3400 for individual and $6750 for family. TRS does not administer an HSA.
• ActiveCare 1-HD has enhanced generic preventive drug coverage – deductible and coinsurance will be waived for certain
generic preventive drugs
Out-of-Network
• New out-of-network deductible and out-of-pocket maximum
• Out-of-network expenses will no longer count towards meeting the in-network deductible or accumulate towards reaching the in-
network out-of-pocket maximum
Out-of-Network 2017-2018 Plan Year
Deductible (employee only/family) $5,000/$10,000
Out-of-Pocket Maximum (individual/family) $13,100/$26,200* (includes deductibles of
5,000/$10,000, medical and prescription drug copays and
coinsurance)
*capped at $13,100 for each individual on a family plan
In-Network 2017-2018 Plan Year
Deductible (employee only/family) $2,500/$5,000
Out-of-Pocket Maximum (individual/family) $6,500/$13,100* (includes deductibles of 2,500/$5,000,
medical and prescription drug copays and coinsurance)
*capped at $6,550 for each individual on a family plan
5
ActiveCare 2
ActiveCare 2
With ActiveCare 2, you are free to receive care from any licensed doctor or other health care provider. When you choose providers who belong
to Aetna’s network, you will pay less out of your own pocket for covered services.
How the plan works
ActiveCare 2 has the same network as ActiveCare 1-HD, but there are notable differences.
• The deductible is lower.
• You pay a copay for most doctor visits.
• You may pay more in monthly premiums, compared to the other plans.
• You don’t have the option to establish a health savings account.
• You can participate in a Flexible Spending Account (not provided by TRS).
New Out-of-Network Deductible and Out-of-Pocket Maximum
There will be a separate in-network deductible and separate
out-of-network deductible. Only in-network expenses will apply
to meet the in-network deductible and only out-of-network
expenses will apply to meet the out-of-network deductible.
There will be a separate in-network out-of-pocket maximum and
separate out-of-network out-of-pocket maximum for the plan
year. Only in-network expenses will accumulate towards
meeting the in-network out-of-pocket maximum and only out-
of-network expenses will accumulate towards meeting the out-
of-network out-of-pocket maximum.
Is this plan for you?
You may want to consider ActiveCare 2 if you:
• want a lower deductible than with ActiveCare 1-HD
• want the freedom to use any health care provider and the
option to save with in-network providers
• prefer paying a flat dollar amount for doctors’ office visits.
6
ActiveCare 2
In-network and Out-of-Network deductibles and out-of-pocket maximum
Out-of-Network 2017-2018 Plan Year
Deductible (individual/family) $2,000/$6,000
Out-of-Pocket Maximum (individual/family) $14,300/28,600* (includes deductibles of
$2,000/$6,000, medical and prescription drug copays and
coinsurance)
In-Network 2017-2018 Plan Year
Deductible (individual/family) $1,000/$3,000
Out-of-Pocket Maximum (individual/family) $7,150/$14,300* (includes medical and prescription drug
deductibles, copays and coinsurance)
In-Network
Out-of-Network
• New out-of-network deductible and out-of-pocket maximum
• Out-of-network expenses will no longer count towards meeting the in-network deductible or
accumulate towards reaching the in-network out-of-pocket maximum
7
ActiveCare 1-HD and ActiveCare 2
(In-Network level of benefits)
8
Family deductible illustration
ActiveCare 1-HD with a $5,000 in-network family deductible
• The family deductible may be met by one or more people
• Plan pays benefits once entire $5,000 is met – there is no
individual deductible to meet
ActiveCare Select with a $1,200 in-network individual deductible and a $3,600 in-network family
deductible.
• Plan pays benefits for an individual as his/her deductible is met
• Everyone helps to meet the family deductible, but no one person
pays more than the individual amount
Amy Ted Bob Sue ChrisAmy covers a spouse and three dependents
$5,000
Amy
$1,200
Ted
$800
Bob
$600
Sue
$400
Chris
$200
9
Choice POS II Network for
ActiveCare 1-HD and ActiveCare 2
In-Network:
Statewide no need to:
– Select a Primary Care Physician
– Obtain referrals for specialist care
Receive highest level of benefits:
– Pay less for care
– No balance billing
No claim forms:
– Provider files claim for you
Out-of-Network:
• You pay more of the cost of
out-of-network benefits
• Higher deductibles, coinsurance
• Higher out-of-pocket maximum
• You may need to file your
own claim
• You could be balance
billed for amounts
over allowed amount
Always verify provider network status
10
How the medical plans work:
11
How the medical plans work: (continued)
12
ActiveCare Select/ ActiveCare Select Whole Health
NEW network Kelsey Select
(Network benefits ONLY plan*)
You will be automatically enrolled in a network based on where you live
If you live in one of these counties ActiveCare Select Whole Health Network
Ft. Bend
Harris
Montgomery
Memorial Hermann Accountable Care Network
or
Kelsey Select
Galveston
Brazoria (certain zip codes: 77511, 77512,
77578, 77581, 77583, 77584, 77588)
Kelsey Select
If you do not live in a county
listed above
Aetna Select Network
*Only pays for out-of-network care in a true medical emergency
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ActiveCare Select/ActiveCare Select Whole Health
In-network ONLY deductibles and out-of-pocket maximum
ActiveCare Kelsey Select
A new high performance network is available if you live in Ft. Bend, Harris, Montgomery, Galveston and certain areas* of Brazoria counties. If you are
presently enrolled in the ActiveCare Whole Health Select Memorial Hermann network, you must actively make a new enrollment election to change your
network to Kelsey Select.
If you live in Galveston county or certain areas* of Brazoria county and are presently in the ActiveCare Select plan, you will automatically be placed in the
Kelsey Select network for the 2017-2018 plan year. You will no longer be in the ActiveCare Select nationwide network. Since this is a network-only plan, if
you have dependents that do not live with you, you may want to consider enrolling in a different plan.
*Brazoria Zip Code areas 77511, 77512, 77578, 77581, 77583, 77584, 77588
How the plan works:
• For most doctor’s office visits, you pay a flat dollar amount.
• Charges not subject to doctors’ office copay, are subject to the plan deductible and/or other applicable copays. For many services, this is a flat dollar
amount plus a percentage of the billed charge.
• The plan pays benefits only when you and your covered dependents use in-network providers (except in a true emergency). If you seek care outside
the network that applies to you (see network chart), you will pay all billed charges out of your own pocket.
• Once your out-of-pocket expenses reach the plan’s out-of-pocket maximum, the plan pays
• 100% of covered expenses for the rest of the plan year.
In-Network ONLY 2017-2018 Plan Year
Deductible
(individual/family)
$1,200/$3,600
Out-of-Pocket
Maximum
(individual/family)
$7,150/$14,300 (includes medical and
prescription drug deductibles, copays and
coinsurance)
In-Network Only Plan:
No need to:
• Select a Primary Care Physician
• Obtain referrals for specialist care
Two Networks:
• Aetna Whole Health
• Aetna Select
Receive highest level of benefits:
• Pay less for care
• No balance billing
No claim forms:
• Provider files claim for you
No out of network coverage
except in a true emergency
Is this plan for you?
You may want to consider the this plan if you:
• Understand which ActiveCare Select network you will be placed in
• Do not expect to use out-of-network providers
• Do not cover dependents who live outside your plan’s network area
• Want a lower deductible and a lower premium cost for coverage
14
ActiveCare Select/
ActiveCare Select Whole Health Plan overview
(Network benefits ONLY plan*)
*If enrolled in ActiveCare Kelsey
Select, you must use Kelsey lab
services, not Quest labs.
15
Teladoc may be a potential and more affordable alternative to emergency room and
urgent care. Many common medical issues can be resolved through the convenience of
just a phone call or NEW! this year - a video chat – 24/7/365
Highlights include….
• Copays waived for and ActiveCare Select/ActiveCare Select Whole Health and ActiveCare 2 plans;
only $40 consultation fee for ActiveCare 1-HD plan.
• Board certified providers specializing in family practice, internal medicine and pediatrics.
• Common diagnosis and treatment of common conditions such as sinusitis, upper respiratory
infection, urinary tract infection, bronchitis, ear infections, influenza and the common cold.
• Consults available wherever the patient is – at home, at work, or travelling within the
United States.
• Guaranteed member call or video chat back within 60 minutes! The average call back time is 20-30
minutes or schedule a call back at a specific time.
• Diagnosis, recommended treatment and prescriptions ordered when appropriate.
• A copy of the consult record will be sent to the member’s PCP upon request.
Teladoc
16
16©2017 Aetna Inc.
Go to the Right Place for Care
• Knowing your options for
medical care can help you
save time and money.
• Follow this path to get the
right level of care at the right
place for the lowest cost.
• Login to your secure member
website at www.aetna.com to
find your closest options.
• Avoid freestanding emergency
rooms, if possible. These
facilities have “emergency” in
the name, but they are not
physically attached to a
hospital.
1717
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Your Prescription Drug Plan
• Caremark administers your prescription drug plans
on behalf of TRS
– ActiveCare 1-HD, ActiveCare Select and
ActiveCare 2 plans
• Benefit includes both a retail and mail component
• ActiveCare 1-HD will have enhanced generic
preventive drug coverage. Certain generic
preventive drugs are available at no cost. Go to
www.trsactivecareaetna.com/coverage to view
the list.
• Caremark has its own mail-order pharmacy where
specialist pharmacists focus on compliance and
lower cost options for the patient, and the
automated filling system ensures the prescription
is filled accurately
19
Prescription Drug Maintenance Medications– network level
*If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference between the brand-name drug
and the generic drug. Chart illustrates benefits when network pharmacies are used. Non-network benefits are also available; see Enrollment Guide for more information. Go to
www.trsactivecareaetna.com/coverage to view the list of generic preventive drugs)
**You can fill 32-day to 90-day supply through mail order.
Features ActiveCare 1-HD ActiveCare Select /ActiveCare Select Whole Health Active Care 2
Drug Deductible
(per person, per plan year)
Subject to
plan year deductible
$0 generic;
$200 brand
$0 generic;
$200 brand
Short-Term Supply at a Retail Location
(up to 31-day supply)
Tier 1 (Generic)
Tier 2 (Preferred Brand)
Tier 3 (Non-Preferred Brand)
20% coinsurance
after deductible
(deductible and
coinsurance waived for
certain generic
preventive drugs)
$20 for a 1- to 31-day supply
$40 for a 1- to 31-day supply*
50% coinsurance for a 1- to 31-day supply*
$20 for a 1- to 31-day supply
$40 for a 1- to 31-day supply*
$65 for a 1- to 31-day supply*
Extended-Day Supply at Mail Order or
Retail-Plus Pharmacy Location
(up to 60- to 90-day supply)**
Tier 1 (Generic)
Tier 2 (Preferred Brand)
Tier 3 (Non-Preferred Brand)
$45 for a 60- to 90-day supply
$105 for a 60- to 90-day supply*
50% coinsurance for a 60- to 90-day supply*
$45 for a 60- to 90-day supply
$105 for a 60- to 90-day supply*
$180 for a 60- to 90-day supply*
Specialty Medications 20% coinsurance
after deductible
20% coinsurance per fill
$200 per fill (up to 31-day supply)
$450 per fill (32- to 90-day supply)
Features ActiveCare 1-HD ActiveCare Select /ActiveCare Select Whole Health ActiveCare 2
Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply) - The second time a participant fills a short-term supply of a maintenance medication at a retail pharmacy,
they will pay a convenience fee. They will be charged the coinsurance and copays in the row below the second time they fill a short-term supply of a maintenance medication. Participants can avoid
paying the convenience fee by filling a larger day supply of a maintenance medication through mail order or at a Retail-Plus location.
Tier 1 (Generic)
Tier 2 (Preferred Brand)
Tier 3 (Non-Preferred Brand)
20% coinsurance
after deductible
(deductible and coinsurance
waived for certain generic
preventive drugs)
$35 for a 1- to 31-day supply
$60 for a 1- to 31-day supply*
50% coinsurance for a 1- to 31-day supply*
$35 for a 1- to 31-day supply
$60 for a 1- to 31-day supply*
$90 for a 1- to 31-day supply*
20
Diabetic Meter and Supplies – network level
Features ActiveCare 1-HD
ActiveCare Select/ActiveCare
Select Whole Health
Active Care 2
Preferred brand glucose meter Free Free
Free
Short-term retail supplies
Copays waived for needles
and syringes only if purchased
same day as insulin and
insulin processed first.
Copays waived for needles and syringes
only if purchased same day as insulin and
insulin processed first.
Copays waived for needles and
syringes only if purchased same day
as insulin and insulin processed first.
Dispense as written penalty does not
apply to waived copays.
90-day supply at Retail-Plus
or mail-order service
Copays waived for needles,
syringes and alcohol swabs
regardless of whether
processed on same day as
insulin and regardless of
brand. To receive test strips
and lancets at no cost, you
must use the preferred brand.
Copays waived for needles, syringes and
alcohol swabs regardless of whether
processed on same day as insulin and
regardless of brand. To receive test strips
and lancets at no cost, you must use the
preferred brand.
Copays waived for needles, syringes
and alcohol swabs regardless of
whether processed on same day as
insulin and regardless of brand. To
receive test strips and lancets at no
cost, you must use the preferred
brand.
Dispense as written penalty does not
apply to waived copays.
21
Fill 90-Day Supplies of Maintenance Medications
to Save Money
• You may be paying higher out-of-pocket costs for maintenance
medications
• When it comes to medications that are taken regularly, there are
two easy ways to save time and money:
• Retail-Plus pharmacies that fill 90-day supplies of maintenance
drugs.
– Use the Retail-Plus pharmacy locator online at
http://info.caremark.com/trsactivecare.
• 90-day refills by Caremark’s mail-order services.
– There’s no cost for shipping and Caremark will deliver anywhere
you like.
– Caremark will contact the doctor for a new prescription and
handle all the details.
– You can set up mail order by visiting Caremark.com/mailservice.
You can fill a 90-day supply through mail order, and break up your coinsurance
or copay into three monthly payments. For example, you can pay $15 per
month to satisfy your $45 copay for a 90-day supply of a maintenance
medication when using the mail-order service.
22
Caremark’s online tools and mobile apps
help connect patients and their caregivers
Prescription Alerts - Alerts you to refills available at mail or retail,
remaining refills, last refill, past due refills; add to cart right there
Savings Opportunities - Displays savings for each member of the family,
with ability to request a medication change online
Recent Orders - Provides capability to track orders and alerts members
of any changes to status
Refill and Manage - Family prescriptions can be managed in one place
with a few clicks
Only PBM to offer native pre-log in functions for iPhone and Android
• Scan to refill multiple Rx checkout
• Pill identifier
• Drug interaction checker
After log in functions available
• Find drug costs
• Find a pharmacy in network
• View digital ID card
• See prescription orders and history
• Refill prescriptions
23
What if I have questions?
• Call TRS-ActiveCare customer service for:
– Claim questions/status
– Network provider information
– Medical and Rx coverage questions
– Inquiries (telephone and email)
– ID card requests
– Transition of care information
– Help with online tools
www.trsactivecareaetna.com
Personalized Service
TRS-ActiveCare Customer Service
1-800-222-9205
24
TRS-ActiveCare Aetna website
www.trsactivecareaetna.com
2525
26
Who is eligible/not 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
Also an individual, who is not receiving health care coverage as an employee or retiree under (i) the Texas State
College and University Employees Uniform Insurance Benefits Act (e.g., coverage offered by The University of
Texas System or the Texas A & M University System), (ii) the Texas Employees Uniform Group Insurance Benefits
Act (e.g., coverage offered by ERS); or (iii) TRS-Care.
NOT eligible for TRS-ActiveCare coverage:
• State of Texas employees or retirees
• Higher education employees or retirees
• TRS retirees, receiving or who declined coverage under TRS-Care
Health care coverage for public school employees and their families
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.
27
Enrolling in the Plan
• Enrollment Period for 2017-2018 Plan Year is August 1 – 18
• Use the Enrollment Guide and Provider Directories to pick a plan and coverage that is right for you
• Premium adjusted to reflect any rate change, effective on the September 5 pay check
Enrolling for the first time:
Forms are due to the Benefits Administrator before: The end of the plan enrollment period, or 31 calendar days after your actively-at-work
date, or 31 calendar days after a special enrollment event. New hires may choose their effective date of coverage Actively-at-work date, or
First of the month following their actively-at-work date
If you are a returning enrollee and you want to change your benefit plan coverage for 2017-2018, must actively enroll:
• Add or drop dependents
• Select a different TRS-ActiveCare plan option
• Cancel and/or decline coverage
• Update name, address or any other demographic information
Enrollees may be able to enroll for coverage, change plan options or change the dependents covered during the plan year within 31 days
after a special enrollment event occurs
• New dependent - Marriage, birth, adoption or placement for adoption *Special rules apply to newborns
• Loss of other coverage
Newborn Coverage:
• Covered first 31 days, if you have coverage - Does not apply to newborn grandchildren
• You must add newborn within 31 days after the newborn’s date of birth
• Plan changes must be made within 31 days after the newborn’s date of birth
• Not necessary to wait for newborn’s SSN - Submit application without SSN to enroll then Re-submit another form after SSN is issued
28
Dependent eligibility & Dependent w/ Disability
• A dependent does not include a brother or sister of an employee unless the sibling is an unmarried individual under 26 years of age who is either: (1) under the legal
guardianship of the employee, or (2) in a regular parent-child relationship with the employee and meets the “any other child” criteria
• Parents and grandparents of the covered employee do not meet the definition of an eligible dependent
Dependent Disability Process:
Dependent Child’s Statement of Disability:
• A letter will be sent to the employee advising the loss of coverage for the dependent on their birthday unless they provide
details of their disability
• Employee completes the Request for Continuation of Coverage for Disabled Child form and requests physician to complete
the Attending Physicians Form
• Completed forms are to be faxed or mailed along with any supporting documentation the physician includes for review.
Fax # /address for submission are noted on the forms.
Spouse, including common law spouse
A child under age 26: a natural child, an adopted child (or a child who is lawfully placed for legal adoption), stepchild, foster
child, or child under legal guardianship of the employee
“Any other child” under the age of 26 (unmarried) in a regular parent-child relationship with the employee – Must meet
residency and support criteria
A grandchild under age 26
Unmarried disabled dependent (age 26+) – Must live with employee
If notification from Aetna is not provided advising Approval of Disability, the dependent’s enrollment will be
terminated on the last day of the month in which the 26th birthday occurs.
29
Special Eligibility & Split Premium Process
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 26) employed by a district/entity can be covered as a dependent:
• If the child is a contributing TRS member, they are not eligible for split or pooled billing
Split Premium Form – Online only:
• New – the paper Application to Split Premium form will no longer be available. Instead each employee and Benefits
Administrator must complete their portion of the online Application to Split Premium form.
• The Split Funded arrangement will remain in effect for the next year, unless your district/entity requires you to complete a
new form yearly
• Must be employed by districts/entities participating in TRS-ActiveCare
• The cost for TRS-ActiveCare coverage will be split between the two employers
• One employee must decline coverage
• The Benefits Administrator must also sign and approve the form
3030
31
Cost of Coverage
This is the MONTHLY amount you will owe each month after the employer contributes to their coverage.
The bottom box is your ANNUAL cost.
Amount You Pay
with the $225 district
contribution
ActiveCare 1 - HD ActiveCare
Select/ActiveCare Select
Whole Health
ActiveCare 2
Individual $126 $289 $489
+ Spouse $766 $1039 $1469
+Children $446 $609 $837
+Family $1091 $1364 $1779
Amount You Pay
with the $225 district
contribution
ActiveCare 1 - HD ActiveCare
Select/ActiveCare Select
Whole Health
ActiveCare 2
Individual $1512 $3468 $5868
+ Spouse $9192 $12,468 $17,628
+Children $5352 $7308 $10,044
+Family $13,092 $16,368 $21,348
Monthly
Cost
Yearly
Cost
Funding to Help Offset the Cost of TRS-ActiveCare Coverage
Funding applies to active, contributing TRS members
District/Entity (minimum) $150
State of Texas $75
Total Per Month $225
32
Split premium & ID Cards
Split Premiums
• Married couples working for different participating entities may “pool” funds
• Optional
• Requires an online Application to Split Premium form to be completed by both employees and employers
• Form available online
ID Cards
• Medical plans (ActiveCare 1-HD, ActiveCare Select/ActiveCare Select Whole Health and ActiveCare 2)
Separate cards for medical and prescription drugs
Aetna
Caremark
New enrollees will receive new ID cards
Returning enrollees making a plan change (including coverage level, or adding or deleting a dependent) will
receive new ID cards. If you are not making a plan change, you will not receive new ID cards.
3333
34
Information resources
• TRS Website – www.trs.state.tx.us/trs-activecare
– Pharmacy Benefit Highlights
– List of maintenance medications
– FAQs
– Download forms
• Caremark Participant Website – www.caremark.com/trsactivecare
– Prior authorization list
– Formulary information
– Locate a participating pharmacy
– Generics Rx Advantage
– My Rx Choices® / Price a Medication
– Health and wellness information
– Mobile App
– Check prescription status
– Order mail order refills
– Download forms
– Caremark widget
• Customer Service – 1-800-222-9205
• Benefits Booklet
35
Mobile apps and tools
Aetna Mobile Secure Site – Log-in Required
• Find a network doctor
• Check your plan coverage
• Check on a claim
• Show you ID card
• Contact TRS-ActiveCare Customer Service
Teladoc
• 24/7/365 access to doctors by phone
• Get treatment for colds, allergies, ear
infections and much more
MyQuest
• Schedule a lab appointment
• Find a lab near you
• Check you results
36
Aetna Savings, Navigator & Payment Estimator
For savings on a wide variety of health needs
• Fitness memberships and equipment
• Hearing aids and exams
• Vision care
• Weight management programs
• Natural products and services
Aetna Navigator – www.aetnanavigator.com
• Check benefits and claims
• Search for doctors in the network
• See the cost and patient ratings of providers
• Order additional ID cards, or print a temporary ID card
• Cost of Care tools – Know the cost before you go
• Take a confidential health assessment
Aetna Member Payment Estimator
• Helps you make smarter care choices
• Compares costs for common procedures and treatments
• Know the cost of the care before you go

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TRS Active Care Presentation

  • 2. 2 What’s new? Changes for the 2017-2018 Plan Year What’s New ActiveCare 1-HD ActiveCare Select or ActiveCare Select Whole Health ActiveCare 2 Out-of-network deductible $5,000/$10,000 Not applicable – no coverage for out-of- network $2,000/$6,000 Out-of-network out-of- pocket maximum $13,100/$26,200 Not applicable – no coverage for out-of- network $14,300/$28,600 What’s Changing ActiveCare 1-HD ActiveCare Select or ActiveCare Select Whole Health ActiveCare 2 In-network out-of- pocket maximum No change $7,150/$14,300 $7,150/$14,300 Emergency Room copay No change $200 copay plus 20% after deductible $200 copay plus 20% after deductible Cost of coverage Increase for all coverage tiers Increase for all coverage tiers Increase for all coverage tiers If you live in Fort Bend, Harris, Montgomery, Galveston and Brazoria counties, you will have a new ActiveCare Select network available, effective Sept. 1, 2017
  • 3. 3 ActiveCare 1-HD – High Deductible How the ActiveCare 1-HD plan works: Deductible You must meet a deductible before the plan starts to pay benefits, except for in-network preventive care. One family member or a combination of family members may meet the deductible. However, benefits are not paid for any family member’s expenses until the entire deductible amount ($5,000 in- network/$10,000 for out-of-network) is met (or $2,500 in-network/$5,000 out-of-network for a person with employee only coverage). Coinsurance Once the deductible is met, you pay a portion of your covered expenses. The plan pays a percentage of covered expenses (called coinsurance) and you pay a certain percentage. Your share is less when you use in-network providers. To find them, go to www.trsactivecareaetna.com and click “Find a Doctor or Facility” on the right side of the home page and follow the prompts. Note: Only in-network expenses will apply to meet the in-network deductible and only out-of-network expenses will apply to meet the out-of-network deductible. Out-of-pocket-maximum The plan limits your out-of-pocket expenses. Once your share of expenses reaches the plan’s out-of-pocket maximum (in-network: $6,550 individual/$13,100 family; out-of-network: $13,100 individual/$26,200 family), the plan pays benefits at 100% for the rest of the plan year. The ActiveCare 1-HD out-of-pocket maximum applies to each covered person individually, up to the maximum per family. The individual out-of-pocket maximum only includes covered expenses incurred by that individual. After each covered person meets his/her individual out-of-pocket maximum, the plan pays 100% of the benefits for that person. Note: Only in-network expenses will accumulate towards meeting the in-network out-of-pocket maximum and only out-of-network expenses will accumulate towards meeting the out-of-network out-of-pocket maximum. Is your doctor in the network? To find in-network providers, go to www.trsactivecareaetna.com and click “Find a Doctor or Facility” on the right side of the home page and follow the prompts. Choose wisely, save money. Take advantage of plan features that offer care and services at no cost or low cost. For example: • Certain generic preventive drugs are available at no cost. The deductible and coinsurance do not apply to certain generic preventive drugs that are available to you and your family at no cost. For a list of these drugs, go to www.trsactivecareaetna.com www.trsactivecareaetna.com/coverage and click on “ActiveCare 1-HD.” • Teladoc® lets you consult with a primary care physician by phone. Use this service for minor problems and save a trip to the doctor’s office (subject to the deductible). Each consult costs just $40.
  • 4. 4 ActiveCare 1-HD – High Deductible In-network and Out-of-Network deductibles and out-of-pocket maximum In-Network • ActiveCare 1-HD meets IRS definition of a high deductible health plan for all coverage tiers • May contribute pretax dollars into a health savings account (HSA) to help pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis. Individuals can establish an HSA with banks and credit unions. 2017 max contributions are $3400 for individual and $6750 for family. TRS does not administer an HSA. • ActiveCare 1-HD has enhanced generic preventive drug coverage – deductible and coinsurance will be waived for certain generic preventive drugs Out-of-Network • New out-of-network deductible and out-of-pocket maximum • Out-of-network expenses will no longer count towards meeting the in-network deductible or accumulate towards reaching the in- network out-of-pocket maximum Out-of-Network 2017-2018 Plan Year Deductible (employee only/family) $5,000/$10,000 Out-of-Pocket Maximum (individual/family) $13,100/$26,200* (includes deductibles of 5,000/$10,000, medical and prescription drug copays and coinsurance) *capped at $13,100 for each individual on a family plan In-Network 2017-2018 Plan Year Deductible (employee only/family) $2,500/$5,000 Out-of-Pocket Maximum (individual/family) $6,500/$13,100* (includes deductibles of 2,500/$5,000, medical and prescription drug copays and coinsurance) *capped at $6,550 for each individual on a family plan
  • 5. 5 ActiveCare 2 ActiveCare 2 With ActiveCare 2, you are free to receive care from any licensed doctor or other health care provider. When you choose providers who belong to Aetna’s network, you will pay less out of your own pocket for covered services. How the plan works ActiveCare 2 has the same network as ActiveCare 1-HD, but there are notable differences. • The deductible is lower. • You pay a copay for most doctor visits. • You may pay more in monthly premiums, compared to the other plans. • You don’t have the option to establish a health savings account. • You can participate in a Flexible Spending Account (not provided by TRS). New Out-of-Network Deductible and Out-of-Pocket Maximum There will be a separate in-network deductible and separate out-of-network deductible. Only in-network expenses will apply to meet the in-network deductible and only out-of-network expenses will apply to meet the out-of-network deductible. There will be a separate in-network out-of-pocket maximum and separate out-of-network out-of-pocket maximum for the plan year. Only in-network expenses will accumulate towards meeting the in-network out-of-pocket maximum and only out- of-network expenses will accumulate towards meeting the out- of-network out-of-pocket maximum. Is this plan for you? You may want to consider ActiveCare 2 if you: • want a lower deductible than with ActiveCare 1-HD • want the freedom to use any health care provider and the option to save with in-network providers • prefer paying a flat dollar amount for doctors’ office visits.
  • 6. 6 ActiveCare 2 In-network and Out-of-Network deductibles and out-of-pocket maximum Out-of-Network 2017-2018 Plan Year Deductible (individual/family) $2,000/$6,000 Out-of-Pocket Maximum (individual/family) $14,300/28,600* (includes deductibles of $2,000/$6,000, medical and prescription drug copays and coinsurance) In-Network 2017-2018 Plan Year Deductible (individual/family) $1,000/$3,000 Out-of-Pocket Maximum (individual/family) $7,150/$14,300* (includes medical and prescription drug deductibles, copays and coinsurance) In-Network Out-of-Network • New out-of-network deductible and out-of-pocket maximum • Out-of-network expenses will no longer count towards meeting the in-network deductible or accumulate towards reaching the in-network out-of-pocket maximum
  • 7. 7 ActiveCare 1-HD and ActiveCare 2 (In-Network level of benefits)
  • 8. 8 Family deductible illustration ActiveCare 1-HD with a $5,000 in-network family deductible • The family deductible may be met by one or more people • Plan pays benefits once entire $5,000 is met – there is no individual deductible to meet ActiveCare Select with a $1,200 in-network individual deductible and a $3,600 in-network family deductible. • Plan pays benefits for an individual as his/her deductible is met • Everyone helps to meet the family deductible, but no one person pays more than the individual amount Amy Ted Bob Sue ChrisAmy covers a spouse and three dependents $5,000 Amy $1,200 Ted $800 Bob $600 Sue $400 Chris $200
  • 9. 9 Choice POS II Network for ActiveCare 1-HD and ActiveCare 2 In-Network: Statewide no need to: – Select a Primary Care Physician – Obtain referrals for specialist care Receive highest level of benefits: – Pay less for care – No balance billing No claim forms: – Provider files claim for you Out-of-Network: • You pay more of the cost of out-of-network benefits • Higher deductibles, coinsurance • Higher out-of-pocket maximum • You may need to file your own claim • You could be balance billed for amounts over allowed amount Always verify provider network status
  • 10. 10 How the medical plans work:
  • 11. 11 How the medical plans work: (continued)
  • 12. 12 ActiveCare Select/ ActiveCare Select Whole Health NEW network Kelsey Select (Network benefits ONLY plan*) You will be automatically enrolled in a network based on where you live If you live in one of these counties ActiveCare Select Whole Health Network Ft. Bend Harris Montgomery Memorial Hermann Accountable Care Network or Kelsey Select Galveston Brazoria (certain zip codes: 77511, 77512, 77578, 77581, 77583, 77584, 77588) Kelsey Select If you do not live in a county listed above Aetna Select Network *Only pays for out-of-network care in a true medical emergency
  • 13. 13 ActiveCare Select/ActiveCare Select Whole Health In-network ONLY deductibles and out-of-pocket maximum ActiveCare Kelsey Select A new high performance network is available if you live in Ft. Bend, Harris, Montgomery, Galveston and certain areas* of Brazoria counties. If you are presently enrolled in the ActiveCare Whole Health Select Memorial Hermann network, you must actively make a new enrollment election to change your network to Kelsey Select. If you live in Galveston county or certain areas* of Brazoria county and are presently in the ActiveCare Select plan, you will automatically be placed in the Kelsey Select network for the 2017-2018 plan year. You will no longer be in the ActiveCare Select nationwide network. Since this is a network-only plan, if you have dependents that do not live with you, you may want to consider enrolling in a different plan. *Brazoria Zip Code areas 77511, 77512, 77578, 77581, 77583, 77584, 77588 How the plan works: • For most doctor’s office visits, you pay a flat dollar amount. • Charges not subject to doctors’ office copay, are subject to the plan deductible and/or other applicable copays. For many services, this is a flat dollar amount plus a percentage of the billed charge. • The plan pays benefits only when you and your covered dependents use in-network providers (except in a true emergency). If you seek care outside the network that applies to you (see network chart), you will pay all billed charges out of your own pocket. • Once your out-of-pocket expenses reach the plan’s out-of-pocket maximum, the plan pays • 100% of covered expenses for the rest of the plan year. In-Network ONLY 2017-2018 Plan Year Deductible (individual/family) $1,200/$3,600 Out-of-Pocket Maximum (individual/family) $7,150/$14,300 (includes medical and prescription drug deductibles, copays and coinsurance) In-Network Only Plan: No need to: • Select a Primary Care Physician • Obtain referrals for specialist care Two Networks: • Aetna Whole Health • Aetna Select Receive highest level of benefits: • Pay less for care • No balance billing No claim forms: • Provider files claim for you No out of network coverage except in a true emergency Is this plan for you? You may want to consider the this plan if you: • Understand which ActiveCare Select network you will be placed in • Do not expect to use out-of-network providers • Do not cover dependents who live outside your plan’s network area • Want a lower deductible and a lower premium cost for coverage
  • 14. 14 ActiveCare Select/ ActiveCare Select Whole Health Plan overview (Network benefits ONLY plan*) *If enrolled in ActiveCare Kelsey Select, you must use Kelsey lab services, not Quest labs.
  • 15. 15 Teladoc may be a potential and more affordable alternative to emergency room and urgent care. Many common medical issues can be resolved through the convenience of just a phone call or NEW! this year - a video chat – 24/7/365 Highlights include…. • Copays waived for and ActiveCare Select/ActiveCare Select Whole Health and ActiveCare 2 plans; only $40 consultation fee for ActiveCare 1-HD plan. • Board certified providers specializing in family practice, internal medicine and pediatrics. • Common diagnosis and treatment of common conditions such as sinusitis, upper respiratory infection, urinary tract infection, bronchitis, ear infections, influenza and the common cold. • Consults available wherever the patient is – at home, at work, or travelling within the United States. • Guaranteed member call or video chat back within 60 minutes! The average call back time is 20-30 minutes or schedule a call back at a specific time. • Diagnosis, recommended treatment and prescriptions ordered when appropriate. • A copy of the consult record will be sent to the member’s PCP upon request. Teladoc
  • 16. 16 16©2017 Aetna Inc. Go to the Right Place for Care • Knowing your options for medical care can help you save time and money. • Follow this path to get the right level of care at the right place for the lowest cost. • Login to your secure member website at www.aetna.com to find your closest options. • Avoid freestanding emergency rooms, if possible. These facilities have “emergency” in the name, but they are not physically attached to a hospital.
  • 17. 1717
  • 18. 18 Your Prescription Drug Plan • Caremark administers your prescription drug plans on behalf of TRS – ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 plans • Benefit includes both a retail and mail component • ActiveCare 1-HD will have enhanced generic preventive drug coverage. Certain generic preventive drugs are available at no cost. Go to www.trsactivecareaetna.com/coverage to view the list. • Caremark has its own mail-order pharmacy where specialist pharmacists focus on compliance and lower cost options for the patient, and the automated filling system ensures the prescription is filled accurately
  • 19. 19 Prescription Drug Maintenance Medications– network level *If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug. Chart illustrates benefits when network pharmacies are used. Non-network benefits are also available; see Enrollment Guide for more information. Go to www.trsactivecareaetna.com/coverage to view the list of generic preventive drugs) **You can fill 32-day to 90-day supply through mail order. Features ActiveCare 1-HD ActiveCare Select /ActiveCare Select Whole Health Active Care 2 Drug Deductible (per person, per plan year) Subject to plan year deductible $0 generic; $200 brand $0 generic; $200 brand Short-Term Supply at a Retail Location (up to 31-day supply) Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) 20% coinsurance after deductible (deductible and coinsurance waived for certain generic preventive drugs) $20 for a 1- to 31-day supply $40 for a 1- to 31-day supply* 50% coinsurance for a 1- to 31-day supply* $20 for a 1- to 31-day supply $40 for a 1- to 31-day supply* $65 for a 1- to 31-day supply* Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (up to 60- to 90-day supply)** Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) $45 for a 60- to 90-day supply $105 for a 60- to 90-day supply* 50% coinsurance for a 60- to 90-day supply* $45 for a 60- to 90-day supply $105 for a 60- to 90-day supply* $180 for a 60- to 90-day supply* Specialty Medications 20% coinsurance after deductible 20% coinsurance per fill $200 per fill (up to 31-day supply) $450 per fill (32- to 90-day supply) Features ActiveCare 1-HD ActiveCare Select /ActiveCare Select Whole Health ActiveCare 2 Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply) - The second time a participant fills a short-term supply of a maintenance medication at a retail pharmacy, they will pay a convenience fee. They will be charged the coinsurance and copays in the row below the second time they fill a short-term supply of a maintenance medication. Participants can avoid paying the convenience fee by filling a larger day supply of a maintenance medication through mail order or at a Retail-Plus location. Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) 20% coinsurance after deductible (deductible and coinsurance waived for certain generic preventive drugs) $35 for a 1- to 31-day supply $60 for a 1- to 31-day supply* 50% coinsurance for a 1- to 31-day supply* $35 for a 1- to 31-day supply $60 for a 1- to 31-day supply* $90 for a 1- to 31-day supply*
  • 20. 20 Diabetic Meter and Supplies – network level Features ActiveCare 1-HD ActiveCare Select/ActiveCare Select Whole Health Active Care 2 Preferred brand glucose meter Free Free Free Short-term retail supplies Copays waived for needles and syringes only if purchased same day as insulin and insulin processed first. Copays waived for needles and syringes only if purchased same day as insulin and insulin processed first. Copays waived for needles and syringes only if purchased same day as insulin and insulin processed first. Dispense as written penalty does not apply to waived copays. 90-day supply at Retail-Plus or mail-order service Copays waived for needles, syringes and alcohol swabs regardless of whether processed on same day as insulin and regardless of brand. To receive test strips and lancets at no cost, you must use the preferred brand. Copays waived for needles, syringes and alcohol swabs regardless of whether processed on same day as insulin and regardless of brand. To receive test strips and lancets at no cost, you must use the preferred brand. Copays waived for needles, syringes and alcohol swabs regardless of whether processed on same day as insulin and regardless of brand. To receive test strips and lancets at no cost, you must use the preferred brand. Dispense as written penalty does not apply to waived copays.
  • 21. 21 Fill 90-Day Supplies of Maintenance Medications to Save Money • You may be paying higher out-of-pocket costs for maintenance medications • When it comes to medications that are taken regularly, there are two easy ways to save time and money: • Retail-Plus pharmacies that fill 90-day supplies of maintenance drugs. – Use the Retail-Plus pharmacy locator online at http://info.caremark.com/trsactivecare. • 90-day refills by Caremark’s mail-order services. – There’s no cost for shipping and Caremark will deliver anywhere you like. – Caremark will contact the doctor for a new prescription and handle all the details. – You can set up mail order by visiting Caremark.com/mailservice. You can fill a 90-day supply through mail order, and break up your coinsurance or copay into three monthly payments. For example, you can pay $15 per month to satisfy your $45 copay for a 90-day supply of a maintenance medication when using the mail-order service.
  • 22. 22 Caremark’s online tools and mobile apps help connect patients and their caregivers Prescription Alerts - Alerts you to refills available at mail or retail, remaining refills, last refill, past due refills; add to cart right there Savings Opportunities - Displays savings for each member of the family, with ability to request a medication change online Recent Orders - Provides capability to track orders and alerts members of any changes to status Refill and Manage - Family prescriptions can be managed in one place with a few clicks Only PBM to offer native pre-log in functions for iPhone and Android • Scan to refill multiple Rx checkout • Pill identifier • Drug interaction checker After log in functions available • Find drug costs • Find a pharmacy in network • View digital ID card • See prescription orders and history • Refill prescriptions
  • 23. 23 What if I have questions? • Call TRS-ActiveCare customer service for: – Claim questions/status – Network provider information – Medical and Rx coverage questions – Inquiries (telephone and email) – ID card requests – Transition of care information – Help with online tools www.trsactivecareaetna.com Personalized Service TRS-ActiveCare Customer Service 1-800-222-9205
  • 25. 2525
  • 26. 26 Who is eligible/not 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 Also an individual, who is not receiving health care coverage as an employee or retiree under (i) the Texas State College and University Employees Uniform Insurance Benefits Act (e.g., coverage offered by The University of Texas System or the Texas A & M University System), (ii) the Texas Employees Uniform Group Insurance Benefits Act (e.g., coverage offered by ERS); or (iii) TRS-Care. NOT eligible for TRS-ActiveCare coverage: • State of Texas employees or retirees • Higher education employees or retirees • TRS retirees, receiving or who declined coverage under TRS-Care Health care coverage for public school employees and their families 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.
  • 27. 27 Enrolling in the Plan • Enrollment Period for 2017-2018 Plan Year is August 1 – 18 • Use the Enrollment Guide and Provider Directories to pick a plan and coverage that is right for you • Premium adjusted to reflect any rate change, effective on the September 5 pay check Enrolling for the first time: Forms are due to the Benefits Administrator before: The end of the plan enrollment period, or 31 calendar days after your actively-at-work date, or 31 calendar days after a special enrollment event. New hires may choose their effective date of coverage Actively-at-work date, or First of the month following their actively-at-work date If you are a returning enrollee and you want to change your benefit plan coverage for 2017-2018, must actively enroll: • Add or drop dependents • Select a different TRS-ActiveCare plan option • Cancel and/or decline coverage • Update name, address or any other demographic information Enrollees may be able to enroll for coverage, change plan options or change the dependents covered during the plan year within 31 days after a special enrollment event occurs • New dependent - Marriage, birth, adoption or placement for adoption *Special rules apply to newborns • Loss of other coverage Newborn Coverage: • Covered first 31 days, if you have coverage - Does not apply to newborn grandchildren • You must add newborn within 31 days after the newborn’s date of birth • Plan changes must be made within 31 days after the newborn’s date of birth • Not necessary to wait for newborn’s SSN - Submit application without SSN to enroll then Re-submit another form after SSN is issued
  • 28. 28 Dependent eligibility & Dependent w/ Disability • A dependent does not include a brother or sister of an employee unless the sibling is an unmarried individual under 26 years of age who is either: (1) under the legal guardianship of the employee, or (2) in a regular parent-child relationship with the employee and meets the “any other child” criteria • Parents and grandparents of the covered employee do not meet the definition of an eligible dependent Dependent Disability Process: Dependent Child’s Statement of Disability: • A letter will be sent to the employee advising the loss of coverage for the dependent on their birthday unless they provide details of their disability • Employee completes the Request for Continuation of Coverage for Disabled Child form and requests physician to complete the Attending Physicians Form • Completed forms are to be faxed or mailed along with any supporting documentation the physician includes for review. Fax # /address for submission are noted on the forms. Spouse, including common law spouse A child under age 26: a natural child, an adopted child (or a child who is lawfully placed for legal adoption), stepchild, foster child, or child under legal guardianship of the employee “Any other child” under the age of 26 (unmarried) in a regular parent-child relationship with the employee – Must meet residency and support criteria A grandchild under age 26 Unmarried disabled dependent (age 26+) – Must live with employee If notification from Aetna is not provided advising Approval of Disability, the dependent’s enrollment will be terminated on the last day of the month in which the 26th birthday occurs.
  • 29. 29 Special Eligibility & Split Premium Process 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 26) employed by a district/entity can be covered as a dependent: • If the child is a contributing TRS member, they are not eligible for split or pooled billing Split Premium Form – Online only: • New – the paper Application to Split Premium form will no longer be available. Instead each employee and Benefits Administrator must complete their portion of the online Application to Split Premium form. • The Split Funded arrangement will remain in effect for the next year, unless your district/entity requires you to complete a new form yearly • Must be employed by districts/entities participating in TRS-ActiveCare • The cost for TRS-ActiveCare coverage will be split between the two employers • One employee must decline coverage • The Benefits Administrator must also sign and approve the form
  • 30. 3030
  • 31. 31 Cost of Coverage This is the MONTHLY amount you will owe each month after the employer contributes to their coverage. The bottom box is your ANNUAL cost. Amount You Pay with the $225 district contribution ActiveCare 1 - HD ActiveCare Select/ActiveCare Select Whole Health ActiveCare 2 Individual $126 $289 $489 + Spouse $766 $1039 $1469 +Children $446 $609 $837 +Family $1091 $1364 $1779 Amount You Pay with the $225 district contribution ActiveCare 1 - HD ActiveCare Select/ActiveCare Select Whole Health ActiveCare 2 Individual $1512 $3468 $5868 + Spouse $9192 $12,468 $17,628 +Children $5352 $7308 $10,044 +Family $13,092 $16,368 $21,348 Monthly Cost Yearly Cost Funding to Help Offset the Cost of TRS-ActiveCare Coverage Funding applies to active, contributing TRS members District/Entity (minimum) $150 State of Texas $75 Total Per Month $225
  • 32. 32 Split premium & ID Cards Split Premiums • Married couples working for different participating entities may “pool” funds • Optional • Requires an online Application to Split Premium form to be completed by both employees and employers • Form available online ID Cards • Medical plans (ActiveCare 1-HD, ActiveCare Select/ActiveCare Select Whole Health and ActiveCare 2) Separate cards for medical and prescription drugs Aetna Caremark New enrollees will receive new ID cards Returning enrollees making a plan change (including coverage level, or adding or deleting a dependent) will receive new ID cards. If you are not making a plan change, you will not receive new ID cards.
  • 33. 3333
  • 34. 34 Information resources • TRS Website – www.trs.state.tx.us/trs-activecare – Pharmacy Benefit Highlights – List of maintenance medications – FAQs – Download forms • Caremark Participant Website – www.caremark.com/trsactivecare – Prior authorization list – Formulary information – Locate a participating pharmacy – Generics Rx Advantage – My Rx Choices® / Price a Medication – Health and wellness information – Mobile App – Check prescription status – Order mail order refills – Download forms – Caremark widget • Customer Service – 1-800-222-9205 • Benefits Booklet
  • 35. 35 Mobile apps and tools Aetna Mobile Secure Site – Log-in Required • Find a network doctor • Check your plan coverage • Check on a claim • Show you ID card • Contact TRS-ActiveCare Customer Service Teladoc • 24/7/365 access to doctors by phone • Get treatment for colds, allergies, ear infections and much more MyQuest • Schedule a lab appointment • Find a lab near you • Check you results
  • 36. 36 Aetna Savings, Navigator & Payment Estimator For savings on a wide variety of health needs • Fitness memberships and equipment • Hearing aids and exams • Vision care • Weight management programs • Natural products and services Aetna Navigator – www.aetnanavigator.com • Check benefits and claims • Search for doctors in the network • See the cost and patient ratings of providers • Order additional ID cards, or print a temporary ID card • Cost of Care tools – Know the cost before you go • Take a confidential health assessment Aetna Member Payment Estimator • Helps you make smarter care choices • Compares costs for common procedures and treatments • Know the cost of the care before you go

Editor's Notes

  1. Minor benefit changes to the maximum out of pocket and emergency room copays for ActiveCare Select /ActiveCare Select Whole Health and ActiveCare 2. All plans will have increases in the cost of coverage for all coverage tiers (employee only; employee and spouse; employee and child(ren); employee and family) New Out-of-network bucket TRS wants you to make the most of your benefits and use in-network providers. We contract with Aetna for access to high-quality providers and want you to use the providers in the network. Creating separate out-of-network deductibles and out-of-pocket maximums allowed TRS to preserve benefits as much as possible and not increase premiums. AC-1HD and AC 2 will now have separate out-of-network deductibles and out-of-pocket maximums, so it will be important for participants to stay in network. If you see an out-of-network provider, those out-of-pocket costs will accumulate toward your out-of-network deductible and out-of-network out-of-pocket maximum. It will not apply to your in-network deductible and in-network out-of-pocket maximum. Note to Presenter:: Please delete the last item on the slide If you do not have employees who live in Fort Bend, Harris, Montgomery, Galveston and Brazoria counties.
  2. ActiveCare 1-HD meets the IRS definition of a high deductible health plan (HDHP) for all tiers of coverage (employee only, employee and spouse, employee and child(ren), and employee and family), and offers you the opportunity to contribute pretax dollars into a health savings account (HSA). An HSA allows you to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis. You can establish an HSA with banks and credit unions. Employers may set up plans for employees as well, in which case the employer will generally be arranging the HSA for the employee. TRS does not administer health savings accounts, but some entities participating in TRS-ActiveCare do provide this option to their employees. You can also establish an HSA by working directly with financial institutions offering this product. Many banks and credit unions offer custodial account services for individuals wishing to establish an HSA. TRS does not have a list of these institutions and does not endorse any particular HSA product. Please contact financial institutions serving your area to obtain further information. Once an individual meets their in-network out-of-pocket maximum of $6,550, the plan will start paying benefits at 100% for that individual. Certain generic preventive drugs are available at no cost. The deductible and coinsurance will not apply to these generic medications. Go to www.trsactivecareaetna.com/coverage and click on “ActiveCare 1-HD” to view the list.
  3. ActiveCare 1-HD meets the IRS definition of a high deductible health plan (HDHP) for all tiers of coverage (employee only, employee and spouse, employee and child(ren), and employee and family), and offers you the opportunity to contribute pretax dollars into a health savings account (HSA). An HSA allows you to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis. You can establish an HSA with banks and credit unions. Employers may set up plans for employees as well, in which case the employer will generally be arranging the HSA for the employee. TRS does not administer health savings accounts, but some entities participating in TRS-ActiveCare do provide this option to their employees. You can also establish an HSA by working directly with financial institutions offering this product. Many banks and credit unions offer custodial account services for individuals wishing to establish an HSA. TRS does not have a list of these institutions and does not endorse any particular HSA product. Please contact financial institutions serving your area to obtain further information. Once an individual meets their in-network out-of-pocket maximum of $6,550, the plan will start paying benefits at 100% for that individual. Certain generic preventive drugs are available at no cost. The deductible and coinsurance will not apply to these generic medications. Go to www.trsactivecareaetna.com/coverage and click on “ActiveCare 1-HD” to view the list.
  4. The Affordable Care Act changed the way an out-of-pocket limit is calculated. As in the previous plan year, the 2017-2018 plan year out-of-pocket maximum does include the amount you pay out of your pocket to meet the medical and prescription drug deductibles and any medical and prescription drug copays/coinsurance. (however, the copay for Bariatric Surgery does not count towards the out-of-pocket maximum). The maximums are increasing this year.
  5. The Affordable Care Act changed the way an out-of-pocket limit is calculated. As in the previous plan year, the 2017-2018 plan year out-of-pocket maximum does include the amount you pay out of your pocket to meet the medical and prescription drug deductibles and any medical and prescription drug copays/coinsurance. (however, the copay for Bariatric Surgery does not count towards the out-of-pocket maximum). The maximums are increasing this year.
  6. Plan overview. Let’s take a look at the two Choice POS II plans. This chart illustrates benefits when network providers are used. As mentioned previously, out-of-network benefits are also available but new this year you will need to meet a separate out-of-network deductible and out-of-pocket maximum; see the Enrollment Guide for information. 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. Out-of-Pocket Maximum: If you reach your plan’s out-of-pocket maximum, the plan then pays 100% of any eligible expenses for the remainder of the plan year. (Please note under the ActiveCare 2 plan, the bariatric surgery copay does NOT apply to the out-of-pocket maximum) Coinsurance: The percentage of medical expenses that you and the plan share. For example, the coinsurance amount when using network providers for all plans is “80/20.” This means that the plan pays 80% and you pay 20% after any applicable deductible. Copayments: The set amount you pay for certain medical services and prescription drugs at the time of service. Note: For ActiveCare 2, the copay depends on whether the doctor is “primary" or a specialist. Primary means care provided by family practitioners, internists, OB/GYNs, and pediatricians. All other physicians are specialists.
  7. Family Deductibles and the Differences between Plans A deductible is the amount of out-of-pocket expense that must be paid for health care services by the plan participant before becoming payable by the health plan. For ActiveCare 1-HD, before the plan pays for any of your family’s covered medical expenses, the entire amount of the deductible must be met. It can be met by one family member or a combination of family members; however, there are no benefits until covered expenses equaling the deductible amount ($5,000) have been incurred. For ActiveCare 2 and ActiveCare Select/ActiveCare Select Whole Health the deductible applies to each covered person individually, up to the maximum per family. For example, under ActiveCare Select the plan has a $1,200 individual and $3,600 family deductible. If Amy incurs $1,200 in medical bills, her deductible is met and the plan will pay any subsequent medical bills for her for the year even though the family deductible of $3,600 has not been met yet.
  8. Before we talk about the plan options, let’s review the provider network of doctors and hospitals for the ActiveCare 1-HD and ActiveCare 2 plans. Administered by Aetna, the Choice POS II network for TRS-ActiveCare is one of the largest nationwide networks of its kind in the state of Texas. It offers access to over 45,800 physicians and more than 660 hospitals and over 26,000 other providers in Texas. Employees have the freedom to choose their own doctor at the point of service. No Primary Care Physician (PCP) or referrals are required. Each time you or your eligible dependent needs health care, you will need to decide whether to see a network provider or an non-network provider. With network providers: Receive highest level of benefits No claims to file in most cases (network provider will usually file the claims) • No balance billing; network providers cannot bill for costs exceeding the allowable amount With non-network providers: Receive non-network level of benefits (reduced level from network) May have to file own claims May be billed for charges exceeding the Aetna allowable amount
  9. The Affordable Care Act changed the way an out-of-pocket limit is calculated. As in the previous plan year, the 2017-2018 plan year out-of-pocket maximum does include the amount you pay out of your pocket to meet the medical and prescription drug deductibles and any medical and prescription drug copays/coinsurance. (however, the copay for Bariatric Surgery does not count towards the out-of-pocket maximum). The maximums are increasing this year. There is no coverage for out-of-network care except for a true emergency.
  10. The Affordable Care Act changed the way an out-of-pocket limit is calculated. As in the previous plan year, the 2017-2018 plan year out-of-pocket maximum does include the amount you pay out of your pocket to meet the medical and prescription drug deductibles and any medical and prescription drug copays/coinsurance. (however, the copay for Bariatric Surgery does not count towards the out-of-pocket maximum). The maximums are increasing this year. There is no coverage for out-of-network care except for a true emergency.
  11. Kelsey Select A new high performance local network is available if you live in Ft. Bend, Harris, Montgomery, Galveston and certain areas of Brazoria counties. If you are presently enrolled in the ActiveCare Whole Health Select-Memorial Hermann network, you must actively make a new enrollment election to change your network to Kelsey Select. If you live in Galveston or certain areas of Brazoria county and are presently in the ActiveCare Select plan, you will automatically be placed in the Kelsey Select network for the 2017-2018 plan year. You will no longer be in the ActiveCare Select national network. Since this is a network-only plan, if you have dependents that do not live with you, you may want to consider enrolling in a different plan. Note to presenter – delete this slide if you do not have employees living in Fort Bend, Harris, Montgomery, Galveston of Brazoria counties.
  12. The Affordable Care Act changed the way an out-of-pocket limit is calculated. As in the previous plan year, the 2017-2018 plan year out-of-pocket maximum does include the amount you pay out of your pocket to meet the medical and prescription drug deductibles and any medical and prescription drug copays/coinsurance. (however, the copay for Bariatric Surgery does not count towards the out-of-pocket maximum). The maximums are increasing this year. There is no coverage for out-of-network care except for a true emergency.
  13. The TRS-ActiveCare Select plans provide 100% coverage for certain preventive care services when network providers are used. However, not all preventive care benefits are covered at 100%, including routine eye and vision exams and hearing exams. For example: Although age-specific vision “screenings” are covered 100% in the network provider’s office, routine eye and vision “exams,” such as those performed by an optometrist or an ophthalmologist, are subject to applicable copayment, deductible, and coinsurance. Sample preventive care services covered 100% when using network providers: Routine annual physicals (one per plan year) Immunizations Well-child care Routine mammograms (one per plan year) Routine colonoscopies Bone density test Smoking cessation counseling services Healthy diet/obesity screening/counseling
  14. With Teladoc you have phone access and NEW this year video chat - to a national network of physicians for non-emergency medical assistance. Teladoc physicians include general practitioners, internists and pediatricians. They can diagnose, treat and prescribe medication for many common medical issues such as the flu, colds and other infections. When your doctor’s office is closed or you can’t get to a doctor because of your work schedule or location, Teladoc is available by phone, 24 hours a day, 7 days a week. And you’ll save money too! Covered 100% in ActiveCare Select/ActiveCare Select Whole Health and ActiveCare 2; $40 consultation fee (applies to deductible and out-of-pocket maximum) for ActiveCare 1-HD.
  15. Know where to go for care Use the emergency room (ER) for life-threatening emergencies only – Life-threatening emergencies warrant a trip to the closest ER. For non-emergency care, there are other options. Use an urgent care center or walk-in clinic for non-life-threatening emergencies – If it is not a true emergency but you need help in a hurry, please consider visiting an urgent care center or walk-in clinic. You can find them by using the DocFind online provider directory. (Note to presenter: Kelsey Select participants will not have coverage for walk-in clinics) Go to www.trsactivecareaetna.com and click “Find a Doctor or Facility” on the home page. Not sure where to go? Call the 24-Hour Nurse Information Line at 1-800-556-1555 to get guidance from a trained nurse.   About freestanding emergency rooms: Freestanding emergency rooms (ERs) are owned by independent groups or individuals and provide many of the same services as hospital-based ERs. Unfortunately, they also bill like regular ERs. This means your non-emergency visit can cost a great deal more than an urgent care center for the same services.  
  16. Let’s discuss the prescription drug benefits administered by Caremark for the ActiveCare 1-HD and ActiveCare Select/ActiveCare Select Whole Health and ActiveCare 2.
  17. Caremark administers the prescription drug plan on behalf of TRS-ActiveCare. The program has both a retail and mail component. The retail coverage has over 65,000 pharmacies in network. And, of those, 4,700 pharmacies participate in the Retail-Plus network. Caremark also has a mail-order facility. By filling your long-term medications through mail order or participating Retail-Plus maintenance pharmacies. Through the mail-order pharmacy, you can get up to a 90-day supply delivered directly to you at a lower copay. The mail-order pharmacy is also staffed by pharmacists who have been specially trained in certain therapeutic categories. Certain preventive drugs are available at no cost. The deductible and coinsurance will not apply to these generic medications. Go to www.trsactivecareaetna.com/coverage and click on ActiveCare 1-HD to view the list.
  18. Here’s an overview of the prescription drug benefits for the ActiveCare 1-HD and ActiveCare Select/ActiveCare Select Whole Health plans. This chart illustrates benefits when network providers are used. Non-network benefits are also available; see Enrollment Guide for more information. How to save on prescription costs Ask your doctor for a generic prescription. For long-term maintenance medications – use the Mail Order service or Retail-Plus pharmacy and you will save you both time and money! ActiveCare 1-HD will waive the deductible and coinsurance for certain generic preventive drugs. Go to www.trsactivecareaetna.com/coverage to view the list. 
  19. If you have diabetes, you may qualify for a preferred brand blood glucose meter at no cost to you. Your prescription benefit plan has a value-added program that gives you meters at no cost to you. Participants enrolled in ActiveCare Select/ActiveCare Select Whole Health and ActiveCare 2 can also get diabetics supplies at no cost. For more details, please contact the CVS Caremark® Member Services Diabetic Meter Team at 1-800-588-4456.
  20. Save time and money with a 90-day supply – When it comes to medications that are taken regularly, there are two easy ways to save time and money: Retail- Plus pharmacies that sell 60- to 90-day supplies of maintenance drugs. 90-day refills by Caremark’s mail-order services. There’s no cost for shipping and Caremark will deliver anywhere you like. Caremark will contact the doctor for a new prescription and handle all the details. You can set up mail order by visiting Caremark.com/mailservice.
  21. The Caremark website empowers you by providing the personalized information you need to make better-informed health decisions regarding prevention and treatment. It also enables you to make better-informed financial decisions regarding the cost of medication. It is a one-stop shopping tool for all prescription-related items. And, it’s available anytime.
  22. Questions? The ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 customer service team can help answer your questions about your claims, medical coverage and prescription drug coverage. They can also assist you with ID card requests, transition of care information and help with online tools such as Aetna Navigator, the cost of care tools as well as the new online health assessment.
  23. Aetna has a custom website for TRS-ActiveCare medical plan participants. There you will have access to all the tools and resources Aetna has to offer – from finding an network doctor to reaching a Health Concierge to discuss a complex health condition. It is all there in one convenient place at www.trsactivecareaetna.com.
  24. Who can enroll in TRS-ActiveCare? To be eligible for TRS-ActiveCare, you must be employed by a participating entity. Then, ask yourself these questions: (1) Are you an active, contributing TRS member? (2) Are you employed for 10 or more regularly scheduled hours each week? If the answer is yes to either question, then you are eligible for TRS-ActiveCare coverage.
  25. First, you must register in the WellSystems Enrollment Portal and establish a user name and password. Log in to the portal and complete the fields. (The field marked with a red* are mandatory.) If you are changing plans for 2017-2018, you must actively enroll or you will be continued in your present 2017-2018 plan coverage. Now is the time you can make changes, add or cancel dependents, decline coverage and/or update any demographic information.
  26. Eligible dependents can include: A spouse (including a common law spouse)* A child under the age of 26 such as: A natural child An adopted child or a child who is lawfully placed for legal adoption A stepchild A foster child A child under the legal guardianship of the employee “Any other child” under age 26 (unmarried) in a regular parent-child relationship with the employee (other than a child described in the category immediately above), 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 A grandchild under age 26 whose primary residence is the household of the employee and who is a dependent of the employee for federal income tax purposes for the reporting year in which coverage of the grandchild is in effect. A child of a covered employee, age 26 or over, may be eligible for dependent coverage, provided that the child is either mentally 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. A dependent does not include a brother or a sister of an employee unless the brother or sister is an unmarried individual under 26 years of age who is either: (1) under the legal guardianship of the employee, or (2) in a regular parent-child relationship with an employee, as defined in the “any other child” category above. Parents and grandparents of the covered employee do not meet the definition of an eligible dependent. *A common law marriage is not considered a special enrollment event unless there is a Declaration of Common Law led with an authorized government agency.
  27. What does the employee need to do to for the Split Premium process? The paper application is no longer available. Each employee and Benefits Administrators must complete their portion of the online form. The employees must be employed by districts that are participating in TRS-ActiveCare. The cost of the premium will be split between the two employers. One of the employees must decline coverage.
  28. In order for plan cost estimator function in ALEX to work, employees will need to have information on how much they end up paying for their benefits and then multiply that by how many checks they get.
  29. If a husband and wife work for different participating entities and wish to “pool” funds, an Application to Split Premium must be completed. For the husband and wife who choose this option, the cost of coverage will be split between and billed to the two employers. Each employer will be billed 50% of the total cost of coverage. The entity employing the spouse who declined coverage will consider the employee as covered under a group health plan for funding purposes. Each employee and their Benefits Administrator must complete their portion of the online Application to Split Premium form. This form should be submitted with the Enrollment Application and Change Form. This form should not be used by employees working for the same entity.
  30. Mobile apps put health and benefits features and functionality right into your hands. It’s the information you need, the way you want to access it. Aetna Mobile lets you pull up Aetna Navigator on your smartphone or other device. You can look up a doctor, show your member ID card, check a claim payment, look at your Personal Health Record, and much more. Aetna Mobile works with Apple mobile digital devices and Android-powered phones. Teladoc, gives you 24/7/365 access to board-certified doctors by phone who can diagnosis and treat conditions like colds, ear infections and much more. MyQuest, app lets you search for a Quest lab near you, schedule an appointment, check your results and share your results. (Note to presenter: Kelsey Select participants will not use MyQuest app for lab services. They must use Kelsey lab services. They can visit kelsey-seybold.com/trs to find providers.)
  31. Aetna Navigator is a secure portion of the Aetna site that TRS-ActiveCare participants can use to access their personal membership and claims information. Once enrolled and registered you can: Check the status of a claim and view claim summaries Search for network providers Confirm who is covered under your plan Request a replacement ID card or print a temporary one Get cost estimates on services before you go Take the health assessment View your personal health record Get started with Aetna wellness programs Connect with a Health Concierge It has recently been redesigned along with being the go-to spot for coverage and benefits information, helpful tools, wellness programs and more. Now it also offers: A fresh new look with easier navigation to guide participants to relevant tools An enhanced provider search with office visit costs and patient ratings and reviews Improved cost transparency with streamlined design and patient ratings and reviews Greater benefits details in simpler terms Easy-to-find wellness and health program information A step-by-step guide to claims A consistent experience across devices and tools