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Insurance Insights

Provider Negotiations

The Relationship of Providers, Insurers and Employers.
Rising health care costs and the impact to UT SELECT PPO health plan members is always a concern as the UT System Office of Employee Benefits strives to ensure that all UT SELECT members have timely access to quality, affordable health care. While providers, insurance companies, and employers share the ultimate goal of ensuring that care is accessible and comprehensive, differing interests can sometimes lead to confusion or disagreements about what the best choices are in delivering on that ultimate goal. For example, network providers’ participation and reimbursement rates require complex and often lengthy negotiations. In the case of UT SELECT, such negotiations may involve medical providers practicing within UT System Health Institutions and affiliated hospitals.

Although UT SELECT is a self-funded medical plan, the UT System Office of Employee Benefits contracts with Blue Cross and Blue Shield of Texas (BCBSTX) to serve as the UT SELECT Third Party Administrator. This means that BCBSTX, not the UT System Office of Employee Benefits, negotiates network issues including reimbursement rates with UT SELECT providers. BCBSTX is contractually obligated to provide a network of providers who agree to provide services at reimbursement levels comparable to other network providers practicing in the same specialty in the same geographic area that offer the same services. This practice maintains a level playing field for providers in the same market by avoiding giving any particular provider or group of providers a price advantage over others in the area. Network negotiations are designed to maximize outcomes that are in the best interests of UT SELECT members and the plan as a whole.

For members who are concerned about a potential loss of access to a specific network provider with whom they have an established history or relationship, it is important to remember that the UT SELECT plan does allow members the freedom to choose any qualified provider regardless of whether or not they are in or out of the network. Every effort will be made to avoid a situation where members will be forced to change physicians or hospitals due to network contract negotiations or other provider issues. In the event that a provider chooses not to remain in the BCBSTX network, members have the option to utilize these providers as out of network providers for additional out-of-pocket costs or may choose to find another physician providing comparable services who remains in the network. All UT SELECT members have the power to make these types of personal decisions regarding the choice of providers based on each unique situation and may personally balance all of the factors that are most important in managing their own individual health care.

Changing Your Group Insurance Benefits Mid-Year

As a UT System benefits eligible employee, retiree or dependent, you may make changes to your group insurance benefits during Annual Enrollment each year or following a qualified “change of status” event.

The Internal Revenue Service specifies that a “life event” or a “change of status” event can be the basis for an employee, retiree or eligible dependent to revoke an existing benefit election and make a new election mid-year.

Once it is established that the life event qualifies as a change of status event, you have 31 days from the date of the event to notify your institution’s Benefits Office and change your benefit elections. If you do not make the election changes during the 31-day status change period, your changes cannot be made until the next Annual Enrollment period in July, to be effective the following September 1. Note: Evidence of Insurability may be required for some benefit changes if you wait until Annual Enrollment instead of enrolling during the 31-day status change period.

The list below includes common examples of qualified Change of Status events:

Your benefit changes must be consistent with your change of status event. For questions regarding changes of status, please refer to OEB Policy 310 or contact your Institution Benefits Office.

UT FLEX Grace Period: September 1, 2008 through November 15, 2008

The UT FLEX Grace Period allows UT FLEX Medical Expense Reimbursement Account participants an additional 2 ˝ months each year (September 1 through November 15) to incur eligible expenses at the end of the plan year. By incurring eligible health related purchases or services during the grace period, UT FLEX medical participants can avoid forfeiting any leftover funds from the 2007-2008 plan year that ended on August 31, 2008.

Notice for Medical Expense Reimbursement Account Members: The grace period for your 2007-2008 UT FLEX Medical Expense Reimbursement Account will end on Saturday, November 15, 2008. To make the payment process during the grace period simpler and easier to understand, PayFlex Systems USA, Inc. (PayFlex) has implemented improvements that allow all expenses incurred during the grace period to automatically be paid out of the “prior” plan year balance, thereby helping you to “use up” your prior plan year balance first. Once the prior plan year balance is exhausted, the remaining claims will be applied toward the current plan year. On the PayFlex website, you will find a detailed description of this process.

Notice for Day Care Reimbursement Account Members: The grace period does not apply to the Dependent Day Care Account.

IMPORTANT: All claims for the 2007-2008 plan year (which ended August 31, 2008), including those incurred during the additional 2 ˝ month grace period for the Medical Expense Reimbursement Account, must be filed no later than November 30, 2008, or they will not be eligible for reimbursement.

For additional information regarding the grace period, filing deadline, claims status or account balances, please visit the PayFlex website at or contact PayFlex customer service at (866) 887-3539.

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