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Health Care Coverage for You and Your Family! 2009-2010 Plan Year Welcome Agenda TRS-ActiveCare Program Highlights – Enrollment Summary – Facts and Figures What’s New for 2009-2010 – ActiveCare 1, 2 and 3, plus new 1-HD option – HMOs How to Enroll – Who is Eligible to Enroll – Cost of Coverage – Enrollment Support 2 Enrollment Summary Percentage of Employees by Plan • February 2009 ActiveCare 3 15,062 7% HMO Plans 10,488 5% ActiveCare 1 39,841 18% ActiveCare 2 151,505 70% 216,896 Employees • 361,918 Members 3 Facts and Figures 2006-2007 2007-2008 Percent Increase Billed Charges $2.1 billion $2.5 billion 19% Medical Claims Transactions 2.9 million 3.2 million 10% Pharmacy Claims Transactions 2.7 million 3.0 million 11% Paid Claims— Medical $656 million $783 million 19% Paid Claims— Prescription Drugs $151 million $176 million 17% 4 What’s New for 2009-2010? ActiveCare 1, 2 and 3 4.5 percent premium increase Continued emphasis on health and wellness One benefit change: Bariatric surgery New Option! ActiveCare 1-HD Basically same as ActiveCare 1, but – Higher deductible (meets IRS definition of a high deductible health plan—all coverage categories) – Slightly lower premium cost (for most coverage categories) 5 PPO Network for ActiveCare 1-HD, 1, 2 and 3 Largest PPO network in the state Includes over 50,000 physicians and over 400 hospitals in Texas Available in all 254 Texas counties Advantages to using network Need to locate a Provider? www.trs.state.tx.us/trs-activecare www.bcbstx.com/trs providers Receive highest level of benefits No claims to file No balance billing 6 Plan Overview – Network Level of Benefits Plan Features ActiveCare 1-HD ActiveCare 1 ActiveCare 2 ActiveCare 3 Deductible (individual/family) $2,300/$2,300 $1,150/$3,000 $500/$1,500 None $3,000/$5,000 $2,000/$6,000 $2,000/$6,000 $1,000 per individual 80% / 20% 80% / 20% 80% / 20% 80% / 20% Out-of-Pocket Maximum (does not include deductibles) Coinsurance (Plan pays/participant pays) Illustrates benefits when network providers are used. Non-network benefits are also available; see Enrollment Guide for more information. Plan Overview – Network Level of Benefits Services Office Visit Copay Preventive Care Routine physicals* Well-woman exams* Routine mammograms* Eye exams* Well-baby exams Immunizations Hearing exams PSA screenings Colorectal screenings Osteoporosis screenings * Services limited to one per person per plan year ActiveCare 1-HD ActiveCare 1 ActiveCare 2 ActiveCare 3 20% after deductible $25 for primary $35 for specialist $20 for primary $30 for specialist $0 copay up to $500 per person, per plan year $25 for primary $35 for specialist $20 for primary $30 for specialist Remaining charges subject to deductible and coinsurance Includes all preventive care services billed with an office visit by a network doctor Includes all preventive care services billed with an office visit by a network doctor Coinsurance applies when no office visit is billed or when services are performed outside the office (deductible waived) Coinsurance applies when no office visit is billed or when services are performed outside the office (no deductible) Non-network benefits are also available; see Enrollment Guide for more information. 8 Plan Overview – ActiveCare 1-HD vs. ActiveCare 1 Plan Features ActiveCare 1-HD ActiveCare 1 Meets IRS definition of High Deductible Health Plan and offers opportunity to contribute pretax dollars into a Health Savings Account (HSA) Yes, for all coverage categories (employee only, employee and spouse, employee and child(ren) and employee and family) Yes, for employee-only coverage No, for other coverage categories Deductible $2,300 for employee only $2,300 for family $1,150 per individual $3,000 per family Maximum Coinsurance $3,000 for employee only $5,000 for family $2,000 per individual $6,000 per family Out-of-Pocket Maximum (includes deductibles) $5,300 for employee only $7,300 for family $3,150 per individual $9,000 per family Monthly Premium Cost Less expensive than ActiveCare 1 in all coverage categories except employee and family More expensive than ActiveCare 1-HD in all coverage categories except employee and family Note: The amounts shown for “family” refer to the coverage categories for employee and spouse, employee and child(ren) and employee and family. 9 Health Savings Account (HSA) What is an HSA? – Special account owned by an individual and used to pay out-of-pocket expenses (such as deductibles) or to grow as savings – May be funded by the employee, the employer or both – Portable, meaning the HSA funds always belong to the individual Who is eligible? Per IRS rules, any adult can contribute to an HSA if he/she: – Has coverage under an HSA-qualified high deductible health plan – Has no other first-dollar medical coverage – Is not enrolled in Medicare – Cannot be claimed as a dependent on someone else’s tax return Does TRS offer an HSA? – No! But ActiveCare 1-HD qualifies as an HDHP for all coverage categories and ActiveCare 1 qualifies for employee-only coverage – Employees are not required to have an HSA to enroll in these plans 10 What You Need to Know Participating districts/entities in TRS-ActiveCare are not expected or required to offer HSAs – You may seek an HSA administrator on your own – No integration with Blue Cross or Medco systems – No tax or legal advice available from TRS or TRS-ActiveCare customer service; HSA inquiries should be directed to your tax or legal counsel and/or your HSA administrator ActiveCare 1-HD is not for everyone – You need to look beyond the premium cost – Premium savings may not be enough to justify the additional deductible and out-of-pocket expenses 11 Benefit Change – Bariatric (Weight Loss) Surgery Important: Effective September 1, 2009, coverage for bariatric surgery will be available only when performed at one of the Blue Distinction Centers for Bariatric Surgery List is subject to change: Check online or call Customer Service for most current list 12 Health and Wellness Programs ActiveCare 1-HD, 1, 2 & 3 Plans Wellness Coaches Personalized Support. Motivational and lifestyle coaching by clinical professionals Lifestyle and condition management can be challenging Our Wellness Coaches are here to help • Personalized telephonic support • Motivational and behavioral coaching • Personalized and coordinated goal-setting with action plans • Communications via US mail • Monitoring compliance and tracking outcomes 1-800-462-3275 14 Condition Management Programs Voluntary programs designed for those diagnosed with: asthma, diabetes, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disorder, metabolic syndrome (high blood pressure, high cholesterol and obesity), lower back pain, rare conditions or depression Enrolling in a program can help: – – – – Decrease the intensity and frequency of symptoms Enhance self-management skills Minimize missed days at work Enrich quality of life Call to enroll or ask questions – Condition management telephone number is also listed on ID cards 1-800-462-3275 15 Weight Management and Tobacco Cessation Tobacco Cessation Program Support for members who want to quit Self-Paced Approach • Online tools and resources via the Personal Health Manager • Secure e-mail outreach to keep members on track Personalized Lifestyle Management Support • Counseling and coaching with licensed Wellness Coaches • Motivational toolkit • 24/7 Nurseline • Referrals when appropriate Weight Management Program Support for a Healthier You 16 Special Beginnings® Special Beginnings helps expectant mothers and their babies get off to a healthy start by providing prenatal and postnatal health education, and guidance from pregnancy to six weeks after delivery Once enrolled in the program, plan participants receive: • Pregnancy risk assessment by an experienced obstetric registered nurse to determine risk level of pregnancy and level of outreach needed • A welcome packet full of product samples, coupons and magazines • Educational materials on a variety of topics • Frequent, personal contact with a nurse case manager who helps coordinate care with the mom’s physician • Immunization schedules Program components are available in English and Spanish 1-800-462-3275 17 Personal Health Manager (PHM) Your online wellness experience begins with the Personal Health Manager Features include: Lifestyle Management tools: Weight Management Tobacco Cessation Fitness and Nutrition Plans Stress Reduction Health Risk Assessment “For Your Health” features Blue PointsSM Rewards “Ask-A” feature – health and wellness questions via secure e-mail Online health encyclopedia Interactive symptom checker 18 Personal Health Manager – Home Page Read secure messages Take a Health Risk Assessment Review member alerts Access Member Care Profile Use the Interactive Symptom Checker Explore topics in the Health Information and Care Center Ask a Question to a certified Nurse, Trainer, Dietitian or Life Coach Read the latest health news, search for specific health topics or explore the prescription drug index 19 Health Risk Assessment (HRA) Be informed about your overall health and well-being A Health Risk Assessment helps assess your health risks, interests and readiness to change Examines your overall health and well-being Provides a detailed report with overall health and well-being score and sub-scores for: Medical health, job satisfaction, life load, risk and lifestyle, mood, nutrition, sleep, stress, pain and body weight Recommends areas for improvement Confidential and secure 20 “Ask-A” Online Advisor Expert advice at your fingertips. Ask the experts. Expert advice from licensed professionals via the Personal Health Manager Our “Ask-A” feature is here to help. Ask a Nurse: Interact online with a Blue Care Advisor on non-emergency, health-related questions using the secure “Ask a Nurse” feature. Ask a Trainer, Dietitian or Life Coach: Send questions about fitness, nutrition, or managing stress. CONFIDENTIAL AND SECURE Receive a response within one business day 21 Blue PointsSM Incentives Stay motivated. Earn Blue Points in the Personal Health Manager TRS-ActiveCare PPO plan participants and their covered dependents accumulate Blue Points in the Personal Health Manager Complete designated health and wellness activities Report completed activities in the Personal Health Manager Track your available balance Redeem earned Blue Points for a variety of items! 22 24/7 Nurseline Advice anytime. Round-the-clock health and the wellness advice from licensed professionals Advice isn’t just needed from 9 to 5. 24/7 Nurseline is here to help. Nurses provide health advice and information about high fevers, earaches, cuts and bruises and more Audio health library on topics such as kicking the smoking habit and ways to get a good night’s rest 24/7 1-800-581-0368 Available in English and Spanish 23 Learn more about the Blue Care Connection health and wellness programs online www.bcbstx.com/trs 24 Blue Access® for Members Online member management tool Check claim status, view and download EOBs (Explanations of Benefits) Order additional ID cards, and print temporary ID Monthly health articles Links to health information and wellness tools and resources, including the Personal Health Manager Send secure e-mail messages to BCBS Customer Advocates available Monday thru Friday, 7 a.m. to 10 p.m. (CT) 25 What if I Have Questions? Personalized Service Call TRS-ActiveCare customer service for: – – – – – – – – Claim questions/status Network provider information Membership and eligibility Medical coverage questions Inquiries (telephone and e-mail) ID card requests Transition of care information Help with online tools! Customer Service 1-866-355-5999 26 Prescription Drugs ActiveCare 1-HD,1, 2 & 3 Your Medco Prescription Drug Plan Medco administers your prescription drug plans on behalf of TRS – ActiveCare 1, 2, and 3 and now the new 1-HD plan Benefit includes both a retail and mail component Medco has its own mail-order pharmacy – Medco By Mail – where specialist pharmacist focus on compliance and lower cost options for the patient, and the automated filling system ensures the prescription is filled accurately.* • Medco’s mail-order pharmacies fill about 2 million prescriptions per week through a highly automated process that is 99.9997% accurate and is 23 times more accurate than a retail pharmacy “Dispensing Error Rate in a Highly Automated Mail-Service Pharmacy Practice”; Nov. 2007, Pharmacology, a peer-reviewed journal of the American College of Clinical Pharmacy 28 Prescription Drug Benefits - Network Level Features Drug Deductible (per person, per plan year) ActiveCare 1-HD ActiveCare 1 ActiveCare 2 ActiveCare 3 Subject to $2,300 plan year deductible Subject to $1,150 plan year deductible $50 $50 $10 $25* $45* $10 $25* $40* $15 $35* $60* $15 $35* $55* $20 $62.50* $112.50* $20 $62.50* $100* Retail Short-Term (up to 30-day supply) Generic/Preferred Brand/NonPreferred Brand Retail Maintenance (after second fill, up to 30-day supply) Generic/Preferred Brand/NonPreferred Brand Medco by Mail (up to 90-day supply) Generic/Preferred Brand/NonPreferred Brand 20% coinsurance after deductible * If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug. Chart illustrates benefits when network pharmacies are used. Non-network benefits are also available; see Enrollment Guide for more information. 29 Specific Rx Benefit Information Retail pharmacies are ideal for acute (short-term) and new medication you may be trying for the first time If you are taking a long-term medication, filling your prescriptions through Medco’s mail-order pharmacy provides several benefits: – You receive a 90-day supply of your medication at a lower copay – Prescriptions are delivered directly to you and you can order refills online and check the status of your orders – You have access to specialist pharmacists • Specifically trained in specific conditions • Review all of your incoming prescriptions for potential safety issues and will contact you and your doctor to discuss any issue – Medco only buys medication from the most reputable suppliers You have access to specialist pharmacists whether you fill your prescription at a retail pharmacy or at Medco By Mail • Your medication questions can be answered by calling 1-866-355-5999 30 Patient Centric Care Different members have different needs Well Acute Chronic Complex Wrinkles, baldness, contraception, vitamins Colds and flu, strep throat, ear infection, headache, sprains Heart disease, diabetes, arthritis, high blood pressure, high cholesterol, dementia, chronic back pain Cancer, AIDS, pulmonary hypertension, multiple chronic conditions such as heart failure and diabetes 31 Specialist Pharmacists An industry leading platform to better care Rare & Specialty Oncology Immunology Diabetes Cardiovascular Pulmonary Neurology Psychiatry Gastrointestinal Specialist pharmacists have special training and unparalleled experience A unique model and scale that enables each Medco pharmacy to specialize in a particular disease Proprietary data capabilities bring specialist services to members Medco’s specialist pharmacists create a patient experience which improves the quality of member care and increases savings for our clients 32 Medco’s Therapeutic Resource Centers provide specialized pharmacy services • > 59% of TRS-AC members have chronic & complex needs • > 96% of Rx cost is for members with chronic & complex conditions Complex 9.1% of members and 41.3% of FY08 costs 9% 41% Chronic 49.8% of members and 55.1% of FY08 costs Well 19.2% of members and <1% of FY08 costs 817 patients 1,832 patients 13.5%RxRxcost cost 4.9% Oncology Immunology 3,668 patients 6.4% Rx cost Diabetes 16,109 patients 18.0% Rx cost Cardiovascular 39,091 patients 25.3% Rx cost Pulmonary 39,465 patients 15.1% Rx cost Neurology Psychiatry 54,353 patients 17.0% Rx cost Gastrointestinal 5,539 patients 1.2% Rx cost 50% Acute 21.9% of members and 3.1% of FY08 costs Rare & Specialty 22% 55% 19% % Members % Rx Cost FY’08 TRS data Complex & Chronic patients 33 Focus on right drug at right time for the right person The future of medicine lies in specialization: Specialist Pharmacist Personalized Medicine offering My Rx Choices® Other Available Resources 34 Personalized Medicine What is it? – A science that examines the inherited variations in genes that dictate drug response (whether a drug will be effective or safe) – Personalizing drug therapy based on each patient's genetic variability New this year, TRS is providing this service to TRS-ActiveCare patients if both the doctor and patient wish to take the test Out with the old….drugs aimed at processes or diseases In with the new….. drugs designed for specific interventions based on your genetics 35 Your Genes: Which dose is right for you? Old: Trial and error 100mg New: Pharmacogenomics-driven 500mg 100mg 10mg Daily dose has been “personalized” Source: http://www.fda.gov/cder/genomics/presentations.htm; August 26, 2005 36 High-level Process Flow Identification Identify pharmacy claim indicating warfarin or tamoxifen were dispensed Communication Contact physician for approval to test patient Contact patient to discuss program and test kit mailing 800 number provided for questions Intervention Cheek swab completed by patient and mailed to lab Lab processes test, sends results and interpretation to physician and Medco TRC pharmacist Therapy change made if applicable Follow-up Monitor lab outcomes and follow-up as needed 37 Personalized Medicine Patients in Need The ability to determine how patients metabolize drugs can have significant impacts on financial and clinical outcomes Avoiding breast cancer re-occurrence, severe bleeding events, and strokes is possible with a cheek swab test STOP 49 patients Tamoxifen Users 373 New Warfarin Users 620 Prevents Action $96,000/re-occurrence estimated to receiving no benefit from Tamoxifen STOP Action Prevents $13,800/severe bleed $39,500/stroke 372 patients estimated to need dosing adjustment The avg. cost/patient tested is $1,000-$1,500 less than those NOT tested Testing could result in significant quality of life improvement 38 My Rx Choices® Your online savings tool Lower your cost for prescriptions with My Rx Choices – Features include: • Personal assessment of cost-saving opportunities based on your prescription plan and the medications you use • Print a kit to help your doctor better understand the economic impact of different medication alternatives • Alternative medications are based upon greatest cost savings to you presented in order, starting with the highest value • Brand-to-generic and retail-to-mail comparisons are shown • The average amount saved by My Rx Choices users is $294! Simply visit www.medco.com/save. You’ll to take a moment to register before using this service. You can also call 1-866-355-5999 You have to shop your benefit. Prices can vary at different retail pharmacies 39 My Rx Choices Medco can facilitate on generic equivalents received through mail order 40 Information Resources TRS Web site – www.trs.state.tx.us/trs-activecare – – – – Pharmacy Benefit Highlights List of maintenance medications FAQs Download forms Medco Member Web site – www.medco.com – – – – – – – – Prior Authorization List Formulary Information Locate a Participating Pharmacy Health and Wellness Information My Rx Choices® / Price a Medication Online Ordering Order Medco By Mail Refills Download forms Customer Service Number 1-866-355-5999 Benefits Booklet 41 HMO Plan Options 2009-2010 Plan Year TRS-ActiveCare Participating HMOs 43 How to Enroll 2009-2010 Plan Year Who is Eligible to Enroll? To be eligible for TRS-ActiveCare coverage, you must: Be employed by a participating district/entity and – Be an active, contributing TRS member or – Be employed 10 or more regularly scheduled hours each week Health care coverage for public school employees and their families 45 Employees NOT Eligible to Enroll State of Texas employees or retirees Higher education employees or retirees TRS retirees, receiving or who declined coverage under TRS-Care These individuals are not eligible to enroll for TRS-ActiveCare coverage as employees, but they can be covered as a dependent of an eligible employee. 46 Eligible Dependents Spouse (including a common law spouse) Unmarried children under age 25 – Natural child – Adopted child – Stepchild – Foster child Other eligible dependents listed in Enrollment Guide – Grandchildren (unmarried) – Disabled children (unmarried, of any age) 47 Special Eligibility Situations If employee and spouse both work for a participating district/entity: – A spouse may be covered as an employee or as a dependent of an employee – Only one parent can cover dependent children A child (under age 25) employed by a district/entity and a contributing TRS member cannot be covered as a dependent The child must be covered as an employee If the child is not a contributing TRS member, the child may be covered as a dependent 48 Enrollment Enrollment Periods for 2009-2010 Plan Year: – April 13 - May 15 (Spring Enrollment) – August 1 - August 31 (Summer Enrollment) Preexisting condition exclusion applies to those that previously declined coverage; may be reduced by prior creditable coverage Passive enrollment; no need to enroll unless you want to: – – – – Change TRS-ActiveCare plan option Add or drop dependents Cancel and/or decline coverage Enroll for TRS-ActiveCare coverage with a different participating district/entity – Change name or address or correct date of birth or Social Security number The HMO option from Legacy Health Solutions will not be available for 2009-2010 plan year. All existing Legacy enrollees must select a new TRS-ActiveCare plan option. 49 Cost for Health Coverage 2009-2010 Plan Year Monthly Cost for Coverage Page 33 of the Enrollment Guide 51 Cost of Coverage PPO Plans ActiveCare 1-HD ActiveCare 1 Total Cost Total Cost Employee Only $245 $278 Employee and Spouse $600 $633 Employee and Child(ren) $382 $443 Employee and Family $785 $697 Family Deductible $2,300 $3,000 Family Out-of-Pocket Maximum $7,300 $9,000 Coverage Category Employee and family coverage for ActiveCare 1-HD is more expensive than ActiveCare 1 because the deductible and out-of-pocket maximum amounts for family are less and the plan may begin paying benefits sooner 52 Application to Split Premium Married couples working for different participating entities may “pool” funds Optional Requires an Application to Split Premium form to be completed by both employees and employers Form available online 53 Can Changes in Coverage Be Made After Your Application Has Been Submitted? Changes can be made up to the end of your enrollment period Plan choices will remain in effect through August 31, 2010 unless there’s a special enrollment event such as: – – – – – Marriage or divorce Birth, adoption or placement for adoption of a child A child marries or reaches age 25 A court order to provide health coverage for an eligible child Loss of coverage Changes must be made within 31 days after the event date (special rules apply to newborns) New application must be submitted for any change 54 Newborns Covered first 31 days if employee has coverage Must add newborn within 60 days after the date of birth or up to one year after the date of birth if: – Employee has “employee and family” or “employee and child(ren)” coverage at the time of birth and at the time of enrollment Not necessary to wait for newborn’s Social Security number – Submit application without SSN to enroll – Re-submit another form after SSN is issued 55 Cafeteria Plan Vendor(s) Making a change through the Section 125 vendor does not automatically generate a change to coverage under TRS-ActiveCare All changes to TRS-ActiveCare must be signed, dated and submitted on an Enrollment Application and Change Form 56 Important Notice Supplemental Coverage TRS does not offer or endorse any supplemental coverage for any of the health coverage plans available under TRS-ActiveCare To obtain information about any coverage that claims to be a companion or supplement to any TRS-ActiveCare plan, employees should contact: – The organization making such offering and/or – The Texas Department of Insurance (TDI) http://www.tdi.state.tx.us or the TDI Consumer Helpline (800) 252-3439 57 Your TRS-ActiveCare ID card will be mailed to your home Enroll by May 15 to receive ID card by September 1 ActiveCare 1-HD, 1, 2 and 3 – New ID cards will not be issued to current participants unless changing plans – New enrollees will receive new cards 58 Enrollment Support Dedicated Customer Service ActiveCare 1-HD,1, 2 or 3 1.866.355.5999 (Blue Cross and Blue Shield of Texas and Medco) FirstCare Health Plans Mercy Health Plans Scott and White Health Plan Valley Baptist Health Plans 1.800.884.4901 1.800.617.3433 1.800.321.7947 1.800.829.6440 59 Enrollment Support Available Online Enrollment guide (English and Spanish) Downloadable forms (enrollment application, split premium, claim form, etc.) Provider locator Frequently asked questions www.trs.state.tx.us/trs-activecare 60 Questions Thank you for attending