Health insurance

YOUR BENEFITS

Health insurance

The state offers health insurance coverage to both active and retired school employees. Many larger districts offer local health insurance for active employees, rather than the state plan.

Active employee health insurance (TRS-ActiveCare)

The state plan for active school employees has four levels of coverage. For 2020-21, enrollment in the highest level of coverage, ActiveCare 2, is limited to only those who were enrolled in that level in 2019-20. ActiveCare is administered by Blue Cross Blue Shield, with pharmacy benefits managed by CVS Caremark.

Funding

All districts and eligible employees, regardless of whether they participate in the state plan, are included in the funding contributed for school employee health insurance (unless the employee has waived coverage). The term “eligible employees” includes part-time employees working at least 10 hours per week. The state provides $75 per month for each participating employee for health insurance coverage, and districts must contribute at least $150 per month per employee.

Participation

All school districts are eligible to participate in the statewide plan. Participation for districts with 500 or fewer employees is mandatory; those that are self-funded or participating in a co-op/risk pool were given the opportunity to opt out when the program first began. Districts with more than 500 employees can opt in to the program. Districts choosing not to participate must still provide access to health insurance. The funding arrangement ($75 per month per participating employee from the state and at least $150 per month per employee from the district) will still apply. Individual employees may choose to waive coverage. A school employee married to another school employee can decide whether to be treated under the district health insurance plan as the primary employee or a dependent. Pursuant to the U.S. Supreme Court’s ruling in Obergefell v. Hodges in June 2015, TRS extends spousal benefits to same-sex spouses.

Portability of insurance/continuing coverage

Legislation initiated by TCTA requires a school district not participating in the state plan to provide for portability of insurance coverage, an essential benefit for employees transferring from one school district to another. This ensures that the employee cannot be refused coverage for a pre-existing condition if the employee has had insurance under another qualifying plan for at least 12 months and applies for coverage under the district plan no more than 63 days after coverage is terminated under the former coverage. (A 2009 TCTA-initiated law prohibits TRS from opting out of federal law that requires coverage of pre-existing conditions, thus maximizing portability 58 2020-21 ACTIVECARE RATES*

ActiveCare Plans Primary HD Primary+ 2**

Employee only $386 $397 $514 $937 Employee & spouse $1,089 $1,120 $1,264 $2,222 Employee & child(ren) $695 $715 $834 $1,393 Employee & family $1,301 $1,338 $1,588 $2,627 *Rates and benefits under locally provided plans or stateapproved HMOs will vary. **Enrollment in ActiveCare 2 is limited to employees who were enrolled in ActiveCare 2 in 2018-19. Note: The premium costs listed do not take into account the required $75/month contribution from the state and $150/ month from the district (some districts contribute more). Actual premium costs for employees will be lower than the amounts in this chart.

between private sector/local district coverage and TRSActiveCare. The federal Patient Protection and Affordable Care Act passed in 2010 also restricts the ability of a health care plan sponsor to opt out of the provisions of federal law that ensure portability.) Other TCTA-initiated legislation requires that districts continue to provide insurance coverage and funding through the summer months for employees who resign after the end of the instructional year.

COVID-19 coverage

The TRS-administered plans are providing special COVIDrelated benefits, including free testing for many eligible enrollees. See the TRS website (https://www.trs.texas.gov/ Pages/news_coronavirus.aspx) for details.

Coverage options

TRS has approved three HMOs as an option for employees in participating districts. The benefits offered under these HMOs are significantly different from benefits in the ActiveCare Blue Cross Blue Shield plan, and details are available on the TRS website in the Active Members > TRS-ActiveCare section. Employees in the Panhandle and parts of West and Central Texas can participate in Blue Essentials West Texas; those in portions of the Rio Grande Valley can opt for Blue Essentials South Texas; Central Texas employees and those in some North Texas counties can choose the Scott & White Health Plan.

Retiree health insurance (TRS-Care)

Details of the state’s health care coverage for retirees are available at trs.texas.gov. Beginning Jan. 1, 2018, a retiree who is age 65 and eligible for Medicare will be enrolled in a Medicare Advantage Plan with Medicare Part D prescription drug coverage. A retiree under age 65 will be enrolled in a high deductible plan. See trs.texas.gov for complete details.

TRS-ACTIVECARE PLAN HIGHLIGHTS* (effective Sept. 1, 2020-Aug. 31, 2021)

SERVICE Deductible In-Network Deductible Out-of-Network Out-of-Pocket Max In-Network Out-of-Pocket Max Out-of-Network PRIMARY

$2,500 individual $5,000 family No out-of-network coverage with this plan. $8,150 individual $16,300 family No out-of-network coverage with this plan.

HD

$2,800 individual $5,600 family $5,500 individual $11,000 family $6,900 individual $13,800 family $20,250 individual $40,500 family

PRIMARY+

$1,200 individual $3,600 family No out-of-network coverage with this plan. $6,900 individual $13,800 family No out-of-network coverage with this plan. 2 (no new enrollees)

$1,000 individual $3,000 family $2,000 individual $6,000 family $7,900 individual $15,800 family $23,700 individual $47,400 family

Coinsurance

Office Visit

Diagnostic Lab

Preventive Care Urgent Care

Emergency Care Outpatient Costs

30% after deductible

$30 copay/primary care $70 copay/specialist

Office/Independent Lab: You pay $0. Outpatient: 30% after deductible

Plan pays 100%

$50 copay

30% after deductible

30% after deductible 20% after deductible for in-network provider 40% after deductible for out-of-network provider 20% after deducible for primary/specialist for in-network provider 40% after deducible for primary/specialist for out-of-network provider 20% after deductible for in-network provider 40% after deductible for out-of-network provider Plan pays 100%

20% after deductible for in-network provider 40% after deductible for out-of-network provider 20% after deductible

20% after deductible for in-network provider 40% after deductible for out-of-network provider 20% after deductible

$30 copay/primary care $70 copay/specialist

Office/Independent Lab: You pay $0. Outpatient: 20% after deductible

Plan pays 100%

$50 copay

20% after deductible

20% after deductible 20% after deductible for in-network provider 40% after deductible for out-of-network provider $30 copay/primary care $70 copay/specialist

40% after deductible for any out-of-network provider

Office/Independent Lab: You pay $0. Outpatient: 20%/40% after deductible

Plan pays 100%

$50 copay for in-network provider 40% after deductible for out-of-network provider $250 copay + 20%

$150 copay + 20% after deductible in-network $150 copay + 40% after deductible out-of-network

Inpatient Hospital

30% after deductible 20% after deductible for in-network provider 40% after deductible for out-of-network 20% after deductible $150/day + 20% after deductible in-network $500/day + 40% after deductible out-of-network

Freestanding ER

$500 copay plus 30% after deductible $500 copay plus 20%/40% after deductible $500 copay plus 20% after deductible $500 copay plus 20%/40% after deductible

TRS Virtual Health

$0 per consultation $30 per consultation $0 per consultation $0 per consultation

Prescription Drugs Deductible

Generic Drugs

(30-day / 90-day supply Integrated with medical deductible

$15 / $45 copay $0 for certain generics Integrated with medical deductible

20% after deductible $0 for certain generics $200 brand deductible

$15 / $45 copay $200 brand deductible

$20 / $45 copay

Preferred Brand

30% after deductible 25% after deductible 25% after deductible 25% after deductible*

Non-preferred Brand

50% after deductible 50% after deductible 50% after deductible 50% after deductible*