UT Benefits for Retired Employees: Plan Year 2013-2014

UT SELECT Medical Plan

AE Highlights

  • Slight coverage increase (see below)
  • No changes to copayments, deductibles, or out-of-pocket maximums
  • UTSW Network option will continue to provide greatly reduced or no out-of-pocket cost for UT SELECT members who receive services from a UTSW physician at a UTSW facility

New monthly Out-of-Pocket Cost for FULL TIME Employees

  • Employee Only: $0 (No change)
  • Employee& Spouse: $214.22 ($6.24 increase)
  • Employee & Child(ren): $224.05 ($6.53 increase)
  • Employee & Family: $421.86 ($12.29 increase)
  • Tobacco Premium Program: $0 to $90 per month based upon tobacco user status

UT offers UT SELECT, a self-funded medical PPO plan, administered by Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

Choice of Doctors Each Time You Need Health Care

When you enroll in UT SELECT, you can receive care from any licensed doctor you choose; no referrals are required.  If you use a network doctor, you will receive the highest level of benefits, pay less out-of-pocket, and will usually not have to file any claims. If you use an out-of-network doctor, you will still be covered, but your out-of-pocket costs for health care services will be substantially higher.

NETWORK - Network benefits are available to UT SELECT participants living in Texas, New Mexico and Washington, D.C. who receive services from providers who have a network contract agreement with BCBSTX. Network benefits may also be available when services are rendered by providers outside of Texas if that provider has a network contract agreement with the Blue Cross and Blue Shield plan in the state where services were rendered. Network providers have agreed to charge only up to the BCBSTX allowed amount. You are responsible for applicable deductibles, copays and/or coinsurance.

UTSW Network Pilot Program- As an additional network option, OEB would like to introduce a new collaborative pilot program between The University of Texas Southwestern Medical Center and UT System OEB called the UTSW Network.  If any In-Area UT SELECT member receives medical care from a UTSW physician or at a UTSW facility, the out-of-pocket cost will be greatly reduced or eliminated.  Benefits include $10 primary care and $10 specialist copayment, no out-of-pocket cost for inpatient or outpatient care, no deductible, and no coinsurance.

Physician fees for services performed at affiliated hospitals are included in this benefit. However, the benefit does not include facility charges for other hospitals (e.g. Children’s Medical Center, VA North Texas Health Care System, Parkland Health & Hospital System, Baylor, and Texas Health Resources) even when a UTSW physician refers you to a non-UTSW facility. For Dallas and surrounding counties, UTSW has a clinically affiliated physician program (UTSCAP) in which UTSW selectively partners with quality internal medicine and family practice community physicians who are included in the UTSW Network. More information is available at http://www.bcbstx.com/ut/important.html or by contacting BCBSTX Customer Service.

OUT-OF-NETWORK – Out-of-network benefits are available to UT SELECT participants living in Texas, New Mexico and Washington, D.C. who receive services from providers who do not have a network contract agreement with BCBSTX. When receiving services from out-of-network providers, you will be responsible for applicable deductibles, copays and/or coinsurance, as well as any amounts exceeding the BCBSTX allowed amount.

OUT-OF-AREA - Out–of-Area benefits apply only to those UT SELECT participants whose residence of record is outside of Texas, New Mexico and Washington, D.C.

Preventive Care

Preventive care services are offered at no out-of-pocket cost. Eligible services are outlined in the federal regulations based on U.S. Preventive Service Task Force Recommendations.

To view a list of preventive care benefits offered through the UT SELECT Medical plan as well as information on preventive care benefits as required by the Affordable Care Act (healthcare reform), go to the Living Well: Make it a Priority website at www.livingwell.utsystem.edu/myhealth.htm#preventive.

Please be aware that you may incur some cost if the preventive service is not the primary purpose of the visit or if your doctor bills for services that are not preventive.

UT SELECT and Medicare

Active Employees

In most cases, an active employee or dependent of an active employee enrolled in UT SELECT should enroll in Medicare Part A and decline Parts B and D once eligible, typically at age 65. Once you retire, you and your Medicare-eligible dependent(s) should then enroll in Part B without penalty and continue to waive Part D. In most instances, if you are eligible for Medicare and are working at UT in a benefits-eligible position for at least 20 hours per week, your UT medical plan will be primary for you and your covered dependent, regardless of age, and Medicare will be secondary. Medicare may be primary for some Medicare-eligible active employees with certain medical conditions such as end stage renal disease (ESRD). Consult with your local Social Security Administration office to learn what illnesses qualify for Medicare coverage prior to turning age 65.

Retired Employees

When you or your covered dependent(s) become eligible for Medicare, you and your Medicare-eligible dependents should enroll in Part A (typically inpatient coverage) and Part B coverage (typically office visits and doctor fees). The University of Texas System urges all retired employees and dependents to enroll in Medicare Parts A and B when they become eligible at age 65, or earlier if they are eligible due to a disability such as end stage renal disease. Retired employees, or soon-to-be retired employees, or their dependents who are eligible for Medicare must have Medicare Parts A and B to receive the maximum benefits available from the UT SELECT plan. It is your responsibility to inform your institution Benefits Office if your covered dependents are Medicare-eligible.

In most instances, if you are eligible for Medicare and are working in a position for at least 20 hours per week, your UT medical plan will be primary, and Medicare will be secondary. Medicare may be primary for some Medicare-eligible active employees with certain medical conditions such as End Stage Renal Disease. Consult with your local Social Security Administration office to learn what illnesses qualify for Medicare coverage prior to turning age 65.
If you are retired and also eligible for Medicare, Medicare becomes your primary payer and pays your medical claims first; UT SELECT pays second. If you choose a doctor who accepts Medicare assignment, you will not be responsible for any difference between the billed charge and the Medicare allowed amount.

If you decline Part B, you will have to pay a higher premium if you ever re-apply for Medicare coverage. As a retired employee, if you or your Medicare-eligible dependent have declined Medicare Part B and fail to re-apply, you will be required to pay the portion that Medicare Part B would have paid as primary insurer for Part B-covered items for yourself and any Medicare-eligible dependents.

To ensure claims are correctly processed, you should contact Blue Cross and Blue Shield of Texas and report your or your dependent’s Medicare Health Insurance Claim (HIC) number and the effective dates of Medicare Parts A and B immediately upon enrollment.

If you or your dependents are enrolled in Medicare and your doctor accepts Medicare assignment

  • The doctor may be in or out of the UT SELECT Network;
  • UT SELECT will pay 100% of benefits approved but not paid by Medicare (subject to UT SELECT plan limitations);
  • There are no deductibles, copayments or coinsurance; and
  • When you or your dependents are an inpatient at a facility that accepts Medicare assignment, UT SELECT will pay the Medicare inpatient deductible, and the $100 per day Copay ($500 maximum) will not apply.

If your doctor does not accept Medicare assignment

  • Network and Out-of-Network benefits apply;
  • UT SELECT will coordinate with Medicare; and
  • Deductibles, copayments and coinsurance may apply.

This chart shows you how UT SELECT coordinates benefits with Medicare. All benefits are subject to plan limitations.

 

Provider Accepts Medicare Assignment

BCBSTX In-Network Provider

Service Covered by Medicare

Medicare Pays

UT SELECT Pays (Subject to plan limitations)

UT SELECT
Member Pays

Y

Y

Y

80% MC Allowed

20% MC Allowed

No Charge

Y

N

Y

80% MC Allowed

20% MC Allowed

No Charge

Y

Y

N

0

80% of BCBS Allowed after $350 Deductible or 100% after Copay, whichever is applicable

20% of BCBS Allowed after $350 Deductible or 100% after Copay, whichever is applicable

Y

N

N

0

60% of BCBS Allowed after $750 Deductible

$750 Deductible + 40% of BCBS Allowed + Difference between Billed Charge and BCBSTX Allowed

N

Y

Y

After MC Deductible is satisfied, 80% MC Limiting Charge1

20% of allowed charges2 after $350 Deductible or 100% after Copay, whichever is applicable

$350 Deductible and 20% coinsurance or Copay, whichever is applicable

N

N

Y

After MC Deductible is satisfied, 80% MC Limiting Charge

20% of allowed charges2 after $750 Deductible

$750 Deductible and 40% coinsurance

N

Y

N

0

80% of BCBS Allowed after $350 Deductible or 100% after Copay, whichever is applicable

20% of BCBS Allowed after $350 Deductible or 100% after Copay, whichever is applicable

N

N

N

0

60% of BCBS Allowed After $750 Deductible

$750 Deductible + 40% of BCBS Allowed + Difference between Billed Charge and BCBSTX Allowed

1 Provider who does not participate with Medicare may not bill more than the Medicare Limiting Charge (115% of MC Allowed).
2 Allowed charges are the lesser of the Medicare Limiting Charge or the Blue Cross and Blue Shield allowed amount. If the Blue Cross and Blue Shield allowed amount is less, the member may be billed the difference.

COORDINATION OF BENEFITS WITH UT SELECT, MEDICARE AND A THIRD COVERAGE

Special rules are mandated by federal law when coordinating benefits between UT SELECT, Medicare and another coverage. Generally, the law states that Medicare is primary to retiree plans.

Medicare is secondary when

  • The Beneficiary has group plan coverage through active employment
  • The Beneficiary is eligible for Medicare due to age (65) or disability; AND
  • The Beneficiary has Medicare Part A or Parts A and B.

The following examples show the proper coordination of benefits for some common insurance situations:

EXAMPLE A John is 68, continues to have a full-time position at UT, and is covered as a dependent under his wife’s retiree plan with ABC Company. John’s claims will be paid in this order:

  • UT SELECT
  • Medicare
  • ABC Company

John and his wife may wish to consider whether the reimbursements received as a dependent on his wife’s plan justify their additional premium costs. In many instances, Medicare’s secondary payment will cover the out-of-pocket costs remaining after the primary insurer pays.

EXAMPLE B Linda is 67, has retired from UT and returned to work in a position working less than 20 hours per week. Linda’s husband also covers her under his retiree plan with XYZ Company.  Linda’s claims will be paid in this order:

  • Medicare
  • UT SELECT
  • XYZ Company

Although Linda has returned to work after retiring, her position is not benefits-eligible; therefore, her insurance benefits are obtained as a result of retirement, not employment. 

EXAMPLE C Meredith is 72 and has retired from UT. During her phased retirement, she returns to teach for the Fall semester, from September 1 through January 15. She is covered by her husband’s employer. During the semester that Meredith has returned to a benefits-eligible position at UT, her claims are paid in this order:

  • UT SELECT
  • Spouse’s Employer
  • Medicare

For the remainder of the year, when Meredith is not teaching, her claims are paid as follows:

  • Spouse’s Employer
  • Medicare
  • UT SELECT

It is important to inform your providers and health plan carriers of all the insurances in which you are enrolled. Understanding correct coordination of benefits will help to ensure timely and accurate claims payments. If you have questions regarding your specific insurance situation, please contact your institution Benefits Office, the UT System Office of Employee Benefits, or your health care administrator.

For more information on UT SELECT and Medicare, please see the Important Notices section of this handbook. You may also request a copy from your institution Benefits Office.

Your Health Care Benefits Travel with You

Your UT SELECT Medical ID card features the Blue Cross and Blue Shield symbols and the PPO in a suitcase logo telling providers that you are part of the BlueCard program. This means you and your covered dependents have access to Blue Cross and Blue Shield network providers throughout the United States and around the world. To receive the network (highest) level of benefits when you need to seek care, please call 1-800-810-BLUE (2583) printed on your Medical ID card.

Transitional Benefits

If you or a covered dependent are being treated for certain chronic or ongoing medical conditions at the time you enroll in UT SELECT, and your doctor is not in the UT SELECT PPO network, ongoing care with your current doctor for up to three months may be requested.

Transitional benefits are subject to approval. To request transitional benefits, complete a “Transitional Benefits Form”available from your institution Benefits Office or online at www.bcbstx.com/ut.

 

 

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