Administrative Guide - Aetna · activecare/ 1// / / / / /!!! AdministrativeGuide July!2014! / / / /...

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www.trs.state.tx.us/trs-‐activecare 1

Administrative Guide July 2014

TRS-‐ActiveCare is administered by Aetna Life Insurance Company (Aetna). Aetna provides claims payment services, but does not assume any financial risk or obligation with respect to claims. Prescription drug benefits for TRS-‐ ActiveCare plans are administered by Caremark. HMO plans are provided by SHA, L.L.C. dba FirstCare Health Plans, Scott and White Health Plan and Allegian Insurance Company dba Allegian Health Plans, formerly Valley Baptist Health Plans. Enrollment, billing and COBRA administration services are provided by WellSystems LLC


Table of Contents Welcome • Your Guide to Successful Account Maintenance .............................................................................. 4 • Quick Reference Information ............................................................................................................ 5

• TRS-‐ActiveCare ............................................................................................................................. 5 • ActiveCare 1-‐HD, ActiveCare Select and ActiveCare 2 ................................................................. 6 • FirstCare Health Plans .................................................................................................................. 7 • Scott & White Health Plan ........................................................................................................... 7 • Allegian Health Plans (formerly Valley Baptist Health Plans) ...................................................... 7

• TRS-‐ActiveCare Service Teams ........................................................................................................... 8 • Aetna/Caremark/ActiveCare 1-‐HD, ActiveCare Select and ActiveCare 2 ................................... 10 • FirstCare Health Plans ................................................................................................................ 10 • Allegian Health Plans (formerly Valley Baptist Health Plans) .................................................... 10 • Scott & White Health Plan ......................................................................................................... 11

Eligibility • Employee Eligibility .......................................................................................................................... 12 • Dependent Eligibility ........................................................................................................................ 13 • Disabled Dependents ....................................................................................................................... 14 • Coverage Continuation while on Leave without Pay ....................................................................... 15 • Making Changes/Special Enrollment Events ................................................................................... 16

• New Dependents ....................................................................................................................... 16 • Loss of Coverage ........................................................................................................................ 17 • Dropping Coverage .................................................................................................................... 18

• Court-‐ordered Dependent Children ................................................................................................ 19 • Other Court-‐ordered Dependents ................................................................................................... 19 • Effective Date of Coverage .............................................................................................................. 20 • When Coverage Ends ....................................................................................................................... 26 • Reporting Terminations ................................................................................................................... 27 • Membership Processing Guidelines ............................................................................................... 29 • Request for Exceptions and Appeals ............................................................................................... 30 Enrollment • Enrollment Periods for the 2014-‐2015 Plan Year (July 21 – August 31) .......................................... 31 • WellSystems Enrollment Portal ....................................................................................................... 32 • Enrollment Application and Change Form ....................................................................................... 33 • How to Complete the Enrollment Application and Change Form ................................................... 34 • Pooling Funds/Split Premium .......................................................................................................... 37 • Changing Employment between Participating Entities and Rehires ............................................... 38 • Using the WellSystems Enrollment Portal ...................................................................................... 39 • Submitting Enrollment Application and Change Forms ................................................................... 39 • WellSystems Enrollment Portal Options .......................................................................................... 40


Transitional Care .............................................................................................................................. 41 TRS ActiveCare ID Cards ................................................................................................................... 43 Billing • Billing Summary ............................................................................................................................... 44 • Remittance ...................................................................................................................................... 45 • View Billing Summaries Online ........................................................................................................ 46 • Split Premium .................................................................................................................................. 46 Cost of Coverage • 2013-‐2014 Plan Year ........................................................................................................................ 47 • 2014-‐2015 Plan Year ........................................................................................................................ 48 COBRA Administration • COBRA Administrators ..................................................................................................................... 49 • Qualifying Events for COBRA Continuation Coverage ..................................................................... 50 • Eligibility .......................................................................................................................................... 50 • Notification ...................................................................................................................................... 51 • Employer Responsibilities ................................................................................................................ 51 • Cost and Payment of COBRA Coverage ........................................................................................... 53 • When COBRA Coverage Ends .......................................................................................................... 55 Online Resources • Website Features for Employees ..................................................................................................... 56 Supplies ............................................................................................................................................... 58 Exhibits ................................................................................................................................................ 60 • Forms

• Enrollment Application and Change Form • Application to Split Premium • COBRA Transmittal Form • Transitional Coverage Request Form • Request for Continuation of Coverage for Handicapped Child • Attending Physician’s Statement • District Representative Website Authorization

• Notices • COBRA Continuation Election Notice • Continuation Coverage Rights Under COBRA • Important Notices • Medicaid Subsidy (HIPP) Notice


Welcome Your Guide to Successful Account Maintenance Participation in TRS-‐ActiveCare, the statewide health coverage program for public education employees, has grown to over 463,999 employees and dependents. Of the 1,245 districts/entities eligible to participate in TRS-‐ActiveCare, 1,124 (90 percent), now do so. Along with three medical plan options administered by Aetna with prescription drug benefits administered by Caremark, there are three health maintenance organization (HMO) options offered under TRS-‐ActiveCare: FirstCare Health Plans, Scott & White Health Plan, and Allegian Health Plans, formerly Valley Baptist Health Plans. These HMO options will provide additional plan choices to the employees of participating entities in areas served by these HMOs. These employees will be able to select TRS-‐ActiveCare coverage under one of the medical plans or through an authorized HMO serving their part of the state. While the Teacher Retirement System of Texas (TRS) is responsible for developing rules and guidelines for administering TRS-‐ActiveCare, each participating district/entity is required to: • Assist in the administration of the TRS-‐ActiveCare program and plans according to TRS rules and guidelines. • Assist in account implementation and maintenance. • Collect enrollment applications and change forms and verify eligibility. • Report eligibility changes to WellSystems. • Review billing and audit summaries for accuracy on a monthly basis. • Pay monthly premiums in a timely manner to TRS (via TEXNET).

WellSystems has partnered with Aetna and will maintain all of the enrollment data for TRS-‐ActiveCare; ensure that Aetna, Caremark and the HMOs receive the most updated enrollment data available; generate monthly premium statements for districts/entities; and provide COBRA administration services (except for COBRA participants in the HMO plans). This administrative guide provides detailed information for implementing TRS-‐ActiveCare. The guide features tips on how to enroll new employees and communicate ongoing changes (adds / deletes / terminations). Eligibility rules, billing information, COBRA administration and answers to frequently asked questions are also included.


Quick Reference Information

TRS-ActiveCare Effective Date September 1, 2014

(Some districts/entities may begin participating in TRS-‐ActiveCare at a later date)

Plan Year September 1 through August 31

Eligibility and Billing

WellSystems is responsible for maintaining a consolidated enrollment database, sending enrollment files to Aetna, Caremark, and the HMOs and preparing the monthly bills sent to each district/entity.

Address for Enrollment Application and Change Forms

Use www.wellsystems-‐mesa.com OR WellSystems TRS Team P.O. Box 1390 Brandon, FL 33509-‐1390

Address for Dependent Child’s Statement of Disability

Aetna/Caremark P.O. Box 981106 El Paso, TX 79998-‐1106

Exception Requests Use online Exception Request form to submit requests and documentation to TRS; form is available at www.wellsystems-‐ea.com

Enrollment and Eligibility Use the www.wellsystems-‐ea.com OR WellSystems TRS Team P.O. Box 1390 Brandon, FL 33509-‐1390 Billing Use www.wellsystems-‐ea.com OR WellSystems TRS Team P.O. Box 1390 Brandon, FL 33509-‐1390

Formal Appeals See specific health plans for information on claim appeals

Enrollment and Eligibility TRS-‐ActiveCare Grievance Administrator 1000 Red River Street Austin, TX 78701 Fax : 512-‐542-‐6784 [email protected]

COBRA Administration Refer to specific health plan organization for COBRA administration

Websites www.trs.state.tx.us/trs-‐activecare WellSystems Enrollment: www.wellsystems-‐mesa.com Enrollment Eligibility/Billing Exceptions and Appeals: www.wellsystems-‐ea.com Aetna: www.trsactivecareaetna.com


ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 Aetna/Caremark

Policyholder Number 866325 Group Number 866325, 866343, 866344, 866345 Alpha Prefix ISD (as indicated on ID cards) TRS-‐ActiveCare Customer Service

Aetna/Caremark P.O. Box 981106 El Paso, TX 79998-‐1106 1-‐800-‐222-‐9205 8 a.m.-‐ 6 p.m. CT ( Mon – Fri)

Preauthorization Aetna 1-‐800-‐222-‐9205 8 a.m.-‐ 6 p.m. CT (Mon – Fri)

Aetna Care Advocate Team and Aetna Health Connections

1-‐800-‐222-‐9205

8 a.m.-‐ 6 p.m. CT (Mon – Fri)

Beginning Right Maternity Management Program

1-‐800-‐272-‐3531

8 a.m.-‐ 6 p.m. CT (Mon – Fri)

Address for Claim Forms and Claim Appeals

Aetna P.O. Box 981106 El Paso, TX 79998-1106

Transitional Care Forms Mail to: Aetna P.O. Box 981106 El Paso, TX 79998-1106

Fax to: 1-‐855-‐369-‐8891

COBRA Administration

WellSystems P.O. Box 1390 Brandon, FL 33509-‐1390 COBRA Payments: WellSystems P.O. Box 732513 Dallas, TX 75373-‐2513


FirstCare Health Plans

Group Number 82C000

Customer Service 1-‐800-‐884-‐4901 8 a.m.-‐ 6 p.m. CT (Mon – Fri)


FirstCare Health Plans ATTN: COBRA Administration 12940 N. Hwy 183 Austin, TX 78750 1-‐800-‐884-‐4901 8 a.m.-‐ 6 p.m. CT (Mon – Fri) Email: [email protected] Fax: 512-‐257-‐6031

Scott & White Health Plan

Group Number 008500

Customer Service 1-‐800-‐321-‐7947 24 hours a day, 7 days a week


CONEXIS 6191 North State Highway 161, Suite 400 Irving, TX 75038 Participant Services : 1-‐877-‐722-‐2667 Fax : 1-‐877-‐353-‐2948

Allegian Health Plans, formerly Valley Baptist Health Plans

Group Number H82CTP

Customer Service 855-‐463-‐7264, 8:00 a.m. – 5:00 p.m. CST (Mon. – Fri.) Email: [email protected]


Allegian Health Plans ATTN: COBRA Administration 1596 Whitehall Road Annapolis, MD 21409

Phone: 855-‐463-‐7264, 8:00 a.m. – 5:00 p.m. CST (Mon. – Fri.) Fax: 855-‐463-‐7269

COBRA Payments: Allegian Health Plans ATTN: COBRA Administration P.O. Box 732558 Dallas, TX 75373-‐2558


TRS-ActiveCare Service Teams Benefits-‐related inquiries should be directed to Customer Service at the specific health plan (see Quick Reference Information, pages 5-‐7). The following TRS-‐ActiveCare service teams have been established exclusively for Benefits Administrators and should not be used by health plan participants.

Aetna/ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 TRS-‐ActiveCare Customer Service (1-‐800-‐222-‐9205) is available to facilitate TRS-‐ActiveCare service and issues regarding the ActiveCare 1-‐HD, ActiveCare Select and ActiveCare 2 plans. Enrollment Coordinators at WellSystems are responsible for enrollment, billing and COBRA administration for all districts/entities within their assigned ESC Regions. Each Enrollment Coordinator is supported by a primary back-‐up as well as additional individuals within phone and email groupings. The WellSystems Enrollment Coordinator for each ESC Region are listed below along with their contact information. These individuals will be responsible for training and communicating important information to Benefits Administrators.

Contact Direct Phone Secure Fax Email Address

Region 1: Edinburg

WellSystems Daniel Claffey 1-‐855-‐820-‐8195 1-‐877-‐283-‐9167 [email protected]

Region 2: Corpus Christi


Region 3: Victoria


Region 4: Houston

WellSystems Jessica Morency 1-‐855-‐894-‐4987 1-‐877-‐258-‐5797 [email protected]

Region 5: Beaumont

WellSystems Jessica Morency 1-‐855-‐894-‐4987 1-‐877-‐258-‐5797 [email protected]

Region 6: Huntsville


Region 7: Kilgore

WellSystems Thomas Williams 1-‐855-‐820-‐8199 1-‐877-‐258-‐5798 [email protected]

Region 8: Mount Pleasant

WellSystems Thomas Williams 1-‐855-‐820-‐8199 1-‐877-‐258-‐5798 [email protected]


Region 9: Wichita Falls

WellSystems Julie Narubin 1-‐855-‐820-‐8192 1-‐877-‐283-‐9170 [email protected]

Region 10: Dallas

WellSystems Karanja Bighom 1-‐855-‐820-‐8194 1-‐877-‐358-‐4563 [email protected]

Region 11: Fort Worth

WellSystems Julie Narubin 1-‐855-‐820-‐8192 1-‐877-‐283-‐9170 [email protected]

Region 12: Waco

WellSystems Nicole Barrett 1-‐855-‐820-‐8201 1-‐877-‐283-‐9169 [email protected]

Region 13: Austin

WellSystems Nicole Barrett 1-‐855-‐820-‐8201 1-‐877-‐283-‐9169 [email protected]

Region 14: Abilene

WellSystems Mickey Hyden 1-‐855-‐894-‐4988 1-‐877-‐308-‐9436 [email protected]

Region 15: San Angelo


Region 16: Amarillo

WellSystems Jeremy Henderson 1-‐855-‐820-‐8193 1-‐877-‐280-‐2957 [email protected]

Region 17: Lubbock


Region 18: Midland


Region 19: El Paso


Region 20: San Antonio


Enrollment Coordinator Supporting All Regions as Back-‐up

WellSystems Cara Surdi 1-‐855-‐820-‐8198 1-‐877-‐383-‐9176 [email protected]


Caremark—ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 To administer the pharmacy program for ActiveCare 1-‐HD, ActiveCare Select and ActiveCare 2 plans, Caremark has established a Client Support Team (CST) to assist Benefits Administrators with questions and issues about prescription drug benefits, such as: • Research mail-‐order and retail pharmacy issues. • Conduct claims research and analysis. • Answer questions on drug coverage and drug plan benefits. • Order mail-‐order forms, drug plan brochures and claim forms in bulk. • Process stop payment and requests, and check re-‐issues.

Benefits Administrators may contact the CST by phone at 866-‐823-‐5182, Monday through Friday, from 7:00 a.m. – 7:00 p.m. CT or via e-‐mail at [email protected].


Entities Located In. . . Name Phone Number Email Address Abilene Whitney Hill 325-‐670-‐3885 [email protected] Amarillo Dana Nicklaus 806-‐584-‐5311 [email protected] Lubbock Dana Johnston 806-‐784-‐4326 [email protected] Waco Dan Mayfield 254-‐761-‐5802 [email protected] Questions/Comments [email protected]

Allegian Health Plans, formerly Valley Baptist Health Plans

Entities Located In. . . Name Phone Number Email Address

Cameron, Hidalgo, Starr and Willacy Counties

Lee Helm 956-‐389-‐2257 [email protected]



Region Address Account Representatives Regional Director Bryan/College Station

Scott & White Health Plan 3000 Briarcrest Dr. Suite 422 Bryan, TX 77802 979-‐268-‐7947 1-‐800-‐791-‐8777

Theresa Patino 979-‐268-‐7947 [email protected] Kathy Bean 979-‐268-‐7947 [email protected]

Cambi Bruegger 979-‐268-‐7947 [email protected]

Georgetown

Scott & White Health Plan 204 South IH 35 Suite 100 Georgetown, TX 78628 512-‐930-‐6040 1-‐800-‐758-‐3012

Liz Oberg 512-‐930-‐6044 [email protected] Nicole Stevens 512-‐930-‐6068 [email protected]

Davidica Blum 512-‐930-‐6060 [email protected]

San Angelo Scott & White Health Plan 1131 Knickerbocker Rd. Suite B San Angelo, TX 76903 325-‐659-‐1403

Cynthia Sutton 325-‐659-‐1390 [email protected] April Oden-‐Cortez 325-‐659-‐1403 [email protected]

Temple

Scott & White Health Plan 1206 West Campus Dr. Temple, TX 76502 254-‐298-‐3000 1-‐800-‐321-‐7947

Amy Heidbrink 254-‐298-‐3336 [email protected] Becky Johnson 254-‐298-‐3384 [email protected] Nancy Spencer 254-‐298-‐3368 [email protected]

Waco

Scott & White Health Plan American Plaza 200 West State Hwy 6 Suite 300 Waco, TX 76712 254-‐756-‐8000 1-‐800-‐684-‐7947

Mark Outlaw 254-‐756-‐8020 [email protected] Sharon Manchego 254-‐756-‐8029 [email protected]

Rose Mary Mayes 254-‐756-‐8015 [email protected]


Eligibility Employee Eligibility To be eligible for TRS-‐ActiveCare, an individual must be employed by a participating district/entity and be either an active, contributing TRS member or employed 10 or more regularly scheduled hours each week. Employees are not eligible for TRS-‐ActiveCare coverage if they are: • Receiving health care coverage as an employee or retiree under the Texas State College and University

Employees Uniform Insurance Benefits Act. Example: A school employee that has UT SELECT coverage as an employee with The University of Texas System

• Receiving health care coverage as an employee or retiree under the Texas Employees Uniform Group Insurance Benefits Act. Example: A school employee that has HealthSelect coverage as an employee with ERS

• A TRS retiree receiving, or who declined, coverage under TRS-‐Care, including a retiree who has returned to work*

Note: Although a retiree, a higher education employee or a state employee may not be covered as an employee of a participating district/entity, he or she can be covered as a dependent of an eligible employee. Employees covered as dependents by a higher education or state program may also be covered under TRS-‐ActiveCare as an employee. *If a TRS retiree has returned to work and has never been eligible for TRS-‐Care, he or she would be eligible for TRS-‐ActiveCare coverage, as long as the retiree meets all the TRS-‐ActiveCare eligibility requirements.

Who is eligible for TRS-‐ActiveCare coverage? Teachers, administrative personnel, substitutes, bus drivers, librarians, crossing guards, cafeteria workers, and high school or college students are all eligible for coverage, provided no exception applies, if they are employees of the district/entity, not volunteers, and are either active contributing TRS members or are employed by a participating district/entity for 10 or more regularly scheduled hours each week. Independent contractors and volunteers are not employees and are therefore not eligible for TRS-‐ActiveCare coverage. Note: The above eligibility guidelines apply only to TRS-‐ActiveCare and do not apply to eligibility for membership in the TRS pension plan. Only employees who are active contributing TRS members are eligible for funding provided under Chapter 1581, Texas Insurance Code.

Under Section 22.004, Texas Education Code, an employee who is participating in TRS-‐ActiveCare is entitled to continue participating in TRS-‐ActiveCare if the employee resigns after the end of the instructional year. TRS Rule, Section 41.38, Texas Administrative Code, will be applied by TRS-‐ActiveCare in determining the appropriate termination date of TRS-‐ActiveCare coverage.

New hires have 31 days from their actively-‐at-‐work date (the date they start to work) to enroll or decline coverage for themselves or their dependents. New hires may choose their actively-‐at-‐work date or the first of the month following their actively-‐at-‐work date as their effective date of coverage.


Dependent Eligibility An employee may also cover his or her eligible dependents at the same time he or she enrolls for coverage. No person may be covered under TRS-‐ActiveCare as both an employee and as a dependent, or as a dependent of more than one employee. Eligible dependents include: • A spouse (including a common law spouse) • A child under the age of 26, who is one of the following:

• 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” (other than those listed above) under the age of 26 in a regular parent-‐child relationship with the employee, meeting all four of the following requirements:

• 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, age 26 or over, of a covered employee 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 individual under 26 years of age who is either: (1) under the legal guardianship of an 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.

Note: It is against the law to elect coverage for an ineligible person. Violations may result in prosecution and/or expulsion from the TRS-‐ActiveCare program for up to five years. TRS-‐ActiveCare eligibility audits may be conducted periodically. Audit notifications will be mailed to TRS-‐ActiveCare plan participants when TRS-‐ActiveCare needs to verify participants or their covered dependents meet plan eligibility requirements. Please contact your Benefits Administrator immediately to submit an Enrollment Application and Change Form if you have an ineligible person enrolled in TRS-‐ActiveCare. During an eligibility audit, participants may be asked to provide proof of eligibility to the Benefits Administrator and, if unsatisfactory, the participant will have a limited time to cancel coverage for the ineligible person(s) without incurring penalties that may include expulsion under TRS rules published in the Texas Administrative Code and recovery of paid claims.


Disabled Dependents A child of a covered employee, age 26 and over, may be eligible for dependent coverage provided that the child is either mentally or physically incapacitated to such an extent as to be dependent on the employee on a regular basis as determined by TRS, and the child meets other requirements as determined by TRS. The employee (and the dependent's attending physician) must complete a Request for Continuation of Coverage for Handicapped Child Form and the Attending Physician’s Statement to provide satisfactory proof of the disability and dependency. The forms must be submitted no later than 31 days after the date the child turns age 26. To avoid any gap in coverage, the forms must be submitted and approved prior to the end of the month the child turns age 26. The employee must complete the Request for Continuation of Coverage for Handicapped Child Form along with the Attending Physician’s Statement and return it to: Aetna, P.O. Box 981106, El Paso, TX 79998-‐1106; Fax: 859-‐455-‐8650. The Request for Continuation of Coverage for Handicapped Child Form and the Attending Physician’s Statement are available on the Aetna TRS ActiveCare website www.trsactivecareaetna.com. See samples of the forms in the Exhibits section of this guide. Note: A sibling who is over age 26 may qualify as a disabled dependent. Parents and grandparents of the covered employee do not meet the definition of an eligible dependent.

Special Eligibility Situations • If an employee and spouse both work for a participating district/entity, the spouse may be covered as an

employee or as a dependent of an eligible employee. Only one parent may enroll dependent children for coverage.

• A child (under age 26) who is employed by a district/entity and is a contributing TRS member cannot be covered as a dependent on his or her parent's TRS-‐ActiveCare coverage. This child must be covered as an employee of the district/entity. If the child is not a contributing TRS member, the child may be covered as a dependent. Note: If the dependent child is going directly from their parents’ coverage to coverage as an employee, the dependent child’s effective date of coverage under the new district/entity should be the first of the month following their actively-‐at-‐work date, since their dependent coverage terminates at the end of the month and double coverage under TRS-‐ActiveCare is not allowed.

• If a TRS retiree has returned to work and has never been eligible for TRS-‐Care, he or she would be eligible for TRS-‐ActiveCare coverage, as long as the retiree meets all the TRS-‐ActiveCare eligibility requirements.

• If a participant has employee and spouse coverage and the spouse is hired by a participating district/entity, the employee may drop the spouse (unless restricted by district/entity’s Section 125 cafeteria plan rules), so that the spouse may enroll as a new hire. (Cancel reason–subscriber request)

• If a participant has employee-‐only or employee and child coverage and the spouse is hired by a participating district/entity, the employee cannot enroll the spouse simply because the spouse is a new hire; there must be a loss of other coverage. The employee may enroll the spouse within 31 days of the spouse’s event date for loss of other coverage.


Coverage Continuation while on Leave without Pay Employees must meet the participating district/entity's requirements for leave-‐without-‐pay status, including for the Family and Medical Leave Act (FMLA). Eligible employees may continue TRS-‐ActiveCare coverage while on leave without pay for a period not to exceed six months. For example, if your participating district/entity only allows three months for leave without pay, at which time his or her employment is terminated, the employee could continue coverage under TRS-‐ActiveCare for three months. If your participating district/entity allows 12 months for leave without pay, TRS-‐ActiveCare coverage will end after six months. Coverage for an individual on leave without pay ends the earlier of: • The last calendar day of the month for which premiums are paid; • The last calendar day of the month in which the employee's employment ends; • The last calendar day of the month in which an individual is no longer eligible for coverage due to

requirements unrelated to leave-‐without-‐pay-‐status; or • The last calendar day of the sixth month following the month in which coverage for leave without pay began.

Once the employee returns to active employment and meets eligibility requirements, he or she can re-‐enroll for TRS-‐ActiveCare coverage within 31 days. If the employee returns to active employment within the same plan year and chooses to re-‐enroll in TRS-‐ActiveCare, the employee must select the same plan option in which he or she was previously enrolled.

What happens to employees on leave without pay when their district/entity begins participation in TRS-‐ActiveCare? • Individuals who had health coverage provided through their employer on the day prior to the date the

district/entity begins participation in TRS-‐ActiveCare may enroll in TRS-‐ActiveCare. • Individuals who were not covered by their employer's health coverage plan on the day prior to the date

the district/entity began participation in TRS-‐ActiveCare cannot enroll until they return to work and meet eligibility requirements.

What happens if an employee enters into military service? If an employee enters into active, full-‐time military, naval or air service, he or she may continue TRS-‐ActiveCare coverage while on leave without pay. Employees on military leave without pay will be treated in the same manner as other employees on leave without pay in accordance with the participating district/entity’s requirements for leave-‐without-‐pay status, for a period not to exceed six months. An individual who elected coverage on or before December 9, 2004, may elect under the Uniformed Services Employment and Reemployment Rights Act (USERRA) to continue health coverage with his or her employer's plan for a maximum coverage period of 18 months. An individual who elected coverage on or after December 10, 2004, may elect under USERRA to continue health coverage with his or her employer's plan for a maximum coverage period of 24 months. Under most circumstances, the coverage period under COBRA and USERRA runs concurrently during the first 24 months. Coverage may be elected from USERRA or COBRA, but not both. Once the employee returns to active employment and meets eligibility requirements, he or she can re-‐enroll for TRS-‐ActiveCare coverage within 31 days. If the employee returns to active employment within the same plan year and chooses to re-‐enroll in TRS-‐ActiveCare, the employee must select the same plan option in which he or she was previously enrolled.


Making Changes/Special Enrollment Events An employee may be able to enroll for coverage, change plan options or change the dependents he or she covers during a plan year if the employee or the dependent has a special enrollment event under applicable law. Changes in employee and/or dependent coverage must be requested within 31 days after the special enrollment event. “Requested” is defined as processing the change in the WellSystems Enrollment Portal, processing the change in a third-‐party Enrollment Portal or submitting a completed, signed and dated Enrollment Application and Change Form. (Special rules apply to newborns; see information below.) If the employee does not request the appropriate changes during the applicable special enrollment period, the changes cannot be made until the next plan enrollment period or, if applicable, until another special enrollment event occurs. The change in coverage must be consistent with the family status change for special enrollment events. For example, if the employee gets married, the employee can change from employee-‐only coverage to employee and spouse coverage. The cost of coverage may change based on the selected coverage category. For most special enrollment events, the effective date of coverage will be the first of the month after the event date. Refer to the Effective Date of Coverage charts on pages 20-‐25 for more information.

New Dependents An employee may have a special enrollment event when a new dependent is added to his or her family as a result of marriage, birth, adoption or placement for adoption. A common law marriage is not considered a special enrollment event unless there is a Declaration of Common Law Marriage filed with an authorized government agency.

How are newborns covered by TRS-‐ActiveCare? TRS-‐ActiveCare automatically provides coverage for a newborn child of a covered employee for the first 31 days after the date of birth. To add coverage for the newborn, the employee must either enroll the child through the WellSystems Enrollment Portal or sign, date and submit an Enrollment Application and Change Form to the Benefits Administrator within 60 days after the date of birth. However, an employee has up to one year after the newborn's date of birth to add the newborn to coverage if the employee had employee and family or employee and child(ren) coverage with TRS-‐ActiveCare at the time of the newborn’s birth. The effective date of coverage for the newborn child is the date of birth. If the enrollment via WellSystems Enrollment Portal or completed Enrollment Application and Change Form is submitted after the enrollment period for the newborn child, the request to add coverage will be denied – even if there would be no change in premium. Note: Newborn grandchildren are not automatically covered by TRS-‐ActiveCare for the first 31 days; however, a covered employee may enroll eligible newborn grandchildren within 31 days after the newborn’s date of birth.

It is not necessary to wait for the newborn’s social security number to enroll. The employee should use the WellSystems Enrollment Portal or submit an Enrollment Application and Change Form without the social security number to add coverage, then update the enrollment record via the WellSystems Enrollment Portal or by submitting another Enrollment Application and Change Form once the number has been issued.

Even though the employee has more time to add a newborn to coverage as described immediately above, changing plans must be made within 31 days after the newborn’s date of birth (and the plan change becomes effective the first of the month following the date of birth).

A change request submitted through a Section 125 vendor (if applicable) will not automatically result in changes to an employee’s TRS-‐ActiveCare coverage. Changes to TRS-‐ActiveCare coverage can be submitted using the WellSystems Enrollment Portal or can be submitted to the Benefits Administrator using the Enrollment Application and Change Form.


Loss of Coverage Loss of coverage qualifies as a special enrollment event if: • The employee or dependent(s) lost other group coverage due to a loss of eligibility • The employee or dependent(s) elected to drop the other group health coverage because the employer

stopped all employer contributions toward the premium (including any employer-‐paid COBRA premium) • The employee and/or dependent(s) exhausted their COBRA continuation coverage

For TRS-‐ActiveCare, the loss of coverage from the following also qualifies as a special enrollment event: • Medicare • Medicaid • CHIP • HIPP • Individual coverage when outside the control of the individual. For example: the insurance company claims

bankruptcy, the insurance company withdraws from doing business in the state or the insurance company cancels the block of business

The following reasons for loss of other coverage do not qualify as special enrollment events: • An increase in the premium cost • A reduction in the employer’s contribution to the premium • Voluntary termination of coverage, including failure to pay premium • Any additional surcharge or benefit reduction for spouse coverage • Any reduction of benefits such as an increase in deductible or change in the coordination of benefits • A doctor or other health care provider no longer participates in the plan’s network Voluntary terminations of other coverage, such as dropping other coverage during a spouse’s enrollment period or a Section 125 cafeteria plan enrollment period due to premium or benefit changes, including spousal surcharges or coverage restrictions, are not special enrollment events for TRS-‐ActiveCare. In order to have a special enrollment event, when the employee or dependent of an employee loses other health coverage, the employee or dependent must have had other health coverage when coverage under TRS-‐ActiveCare was previously declined in writing. If the other coverage was COBRA continuation coverage, special enrollment can be requested only after the COBRA continuation coverage is exhausted. If the other coverage was not COBRA continuation coverage, special enrollment can be requested when the individual loses eligibility for the other coverage. If an employee enrolls via the WellSystems Enrollment Portal or submits an Enrollment Application and Change Form due to “loss of other coverage,” the employee’s original application must be checked to verify that coverage was declined (in section 6) due to other coverage. If section 6 was not completed or if no application exists, proof of coverage (such as a certificate of creditable coverage) in lieu of a declination of coverage on the enrollment application must be provided by the employee. If documentation is not made available, the employee’s request to add coverage will be denied.

TRS requires all new hires declining coverage to indicate their declination in the WellSystems Enrollment Portal or by completing an Enrollment Application and Change Form to be sent or faxed to the Benefits Administrator. There must be an electronic record or form on file with the Benefits Administrator for an employee to enroll later in TRS-‐ActiveCare due to loss of coverage.


Dropping Coverage TRS-‐ActiveCare participants may drop TRS-‐ActiveCare coverage during a plan year, unless restricted from doing so by their district/entity’s Section 125 cafeteria plan’s rules. Note: An employee cannot change plans when dropping a dependent from TRS-‐ActiveCare coverage.

Can coverage be dropped during the plan year? Unless restricted due to participation in an Internal Revenue Code Section 125 cafeteria plan, an employee can drop all coverage or drop dependent coverage. If coverage is dropped during the plan year, the individual will not be eligible to re-‐enroll in TRS-‐ActiveCare until the next plan enrollment period unless there is a special enrollment event. Note: An employee cannot elect to drop coverage retroactively; a future cancellation date is required. The cancellation must be received by WellSystems within the membership processing guidelines; see pages 29-‐30 for more information. What is a special enrollment event? This is an event, as defined by the Health Insurance Portability and Accountability Act (HIPAA), which provides a special enrollment period for employees and dependents when there is a loss of other group coverage or a gain of additional dependents, such as birth, adoption/placement for adoption and marriage. Can employees change plan options during the plan year? If an employee or dependent has a special enrollment event under applicable law, the employee may change plan options when exercising a special enrollment right. Plan changes are also permitted if the employee is directed by a court order or national medical support notice to provide health coverage for a dependent child or if the employee or dependent loses coverage because they no longer live, work or reside in an HMO service area.


Court-ordered Dependent Children If the participating district/entity receives a court order or national medical support notice that directs an employee to provide health coverage for a dependent child, the court-‐ordered dependent child will be automatically enrolled from the date the participating district/entity receives notification of the court order or national medical support notice. A court order or national medical support notice that directs anyone other than the employee to provide health coverage for a dependent child does not require TRS-‐ActiveCare to provide dependent coverage for the dependent child and is not a special enrollment event for the employee or any of the employee’s eligible dependents. The court order or national medical support notice that is directed to the employee is a special enrollment event for an employee, the employee’s spouse, and the employee’s dependent child(ren). Therefore, if an eligible employee is not covered by TRS-‐ActiveCare at the time the participating district/entity receives the court order or national medical support notice, the employee, the employee’s spouse and the employee’s dependent child(ren) may be enrolled for coverage in TRS-‐ActiveCare. With regard to any individuals who are not the subject of the court order or national medical support notice, normal eligibility and special enrollment event rules apply (for example, a request, along with supporting documentation, to enroll such individuals must be received within 31 days of the receipt by the participating district/entity of the court order or national medical support notice).

If a participating district/entity receives a court order or national medical support notice to add coverage for an employee’s dependent child(ren), the child(ren) may be added to the employee’s current TRS-‐ActiveCare plan if the employee is already enrolled; the employee may select a different plan at this time. If the employee is not covered and decides not to enroll in TRS-‐ActiveCare, the employee may select a plan for the dependent child(ren). If the employee refuses to sign an Enrollment Application and Change Form, the participating district/entity should consult with its legal counsel to determine what action it should take. If the participating district/entity determines it should enroll the child, the Benefits Administrator should note on the signature line of the Enrollment Application and Change Form that the employee refused to sign the application. A copy of the court order or national medical support notice should be attached when submitting the application to WellSystems. Note: Failure to comply with a court order or national medical support notice may subject the employer to penalties under state law. Consult with your legal counsel if you have questions concerning a particular court order or national medical support notice. Other Court-ordered Dependents A court order or national medical support notice that directs an employee to provide health coverage for a spouse, for an ex-‐spouse or for other dependents that are not eligible children under TRS-‐ActiveCare eligibility standards does not require TRS-‐ActiveCare to provide dependent coverage as a result of the court order or national medical support notice; additionally, a special enrollment event does not arise from such court order or national medical support notice. An ex-‐spouse is not eligible for TRS-‐ActiveCare coverage unless the ex-‐spouse is already covered as a COBRA continuation participant.

To enroll the employee’s dependent children for court-‐ordered coverage when the employee decides to not also enroll, either the WellSystems Enrollment Portal or Enrollment Application and Change Form must be completed. If only one child is being added, the child’s information should be submitted in Section 2. The child will be set up with a single ID number and the employee-‐only premium rate will be charged. If the employee is adding more than one child, the youngest child will be set up with an ID number and that child’s information should be submitted in Section 2 of the application. The other child(ren) will be listed as dependents (in Section 4) and the employee and child(ren) premium rate will be charged.


Effective Date of Coverage The effective date is the date TRS-‐ActiveCare coverage begins for a participant. See the chart below to help determine the effective date of coverage. Pre-‐existing condition waiting periods and creditable coverage no longer apply.

If . . . The employee's effective date is. . . The employee's eligible dependent's effective date is. . .

The district/entity first begins participation in TRS-‐ActiveCare on September 1, 2014, and the employee enrolls for coverage during summer enrollment

September 1, 2014 September 1, 2014

The district/entity begins participation in TRS-‐ActiveCare after September 1, 2014, and the employee enrolls for coverage

The date the district/entity first begins participation in TRS-‐ActiveCare

The same date as the employee's effective date of coverage

In no event will the dependent's coverage become effective prior to the employee's effective date

The employee enrolls for coverage during the 2014-‐2015 enrollment period and had originally declined coverage under TRS-‐ActiveCare

September 1, 2014 September 1, 2014

A new hire in a TRS-‐covered position who is a TRS member on his or her actively-‐at-‐work date enrolls for coverage within 31 days after the actively-‐at-‐work date

The employee's choice of: (1) his or her actively-‐at-‐work date, or (2) the first of the month following the employee's actively-‐at-‐work date Premium is billed for the full month in which coverage begins New hires must choose the effective date of coverage within 31 days after the actively-‐at-‐work date



A new hire in a non-‐TRS-‐covered position who is regularly scheduled to work 10 or more hours per week on his or her actively-‐at-‐work date enrolls for coverage within 31 days after the actively-‐at-‐work date

The employee's choice of: (1) his or her actively-‐at-‐work date, or (2) the first of the month following the employee's actively-‐at-‐work date Premium is billed for the full month in which coverage begins The employee must choose the effective date of coverage within 31 days after the actively-‐at-‐work date





An employee in a non-‐TRS-‐covered position who works less than 10 regularly scheduled hours per week becomes employed in a TRS-‐covered position and enrolls for coverage within 31 days after the date he or she becomes an eligible employee Note: If an employee who meets eligibility requirements as regularly scheduled to work 10 or more hours per week declines coverage, he or she may not elect coverage later during that plan year if changing status to a TRS member. (Changing TRS membership status is not an enrollment event)

The employee's choice of: (1) his or her eligibility date, or (2) the first of the month following the employee's eligibility date Premium is billed for the full month in which coverage begins The employee must choose the effective date of coverage within 31 days after the eligibility date



An employee in a non-‐TRS-‐covered position who works less than 10 hours per week begins to work 10 or more regularly scheduled hours per week and enrolls for coverage within 31 days after the date he or she becomes an eligible employee.

The employee's choice of: (1) his or her eligibility date, or (2) the first of the month following the employee's eligibility date

Premium is billed for the full month in which coverage begins The employee must choose the effective date of coverage within 31 days after the eligibility date



The employee is enrolled in an approved HMO and loses eligibility because he or she no longer lives, works or resides in that HMO service area, the employee may enroll in another approved HMO (if applicable) or ActiveCare 1-‐HD, ActiveCare Select or ActiveCare 2 within 31 days after losing eligibility.

Please note: If an employee enrolled in the ActiveCare Select (Aetna Whole Health) network moves out of the Aetna Whole Health network area, he or she will remain in the ActiveCare Select plan and may choose providers in the ActiveCare Select (Open Access) network. A new ID card will be sent indicating the network change.

The first of the month following the event date





The employee returns from military service and enrolls (or re-‐enrolls) in TRS-‐ActiveCare within 31 days after his or her actively-‐at-‐work date If the employee returns to active employment within the same plan year and chooses to re-‐enroll in TRS-‐ActiveCare, the employee must select the same plan option in which he or she was previously enrolled




The employee returns from leave-‐without-‐pay status and enrolls (or re-‐enrolls) for coverage within 31 days after his or her actively-‐at-‐work date If the employee returns to active employment within the same plan year and chooses to re-‐enroll in TRS-‐ActiveCare, the employee must select the same plan option in which he or she was previously enrolled




A covered employee has a newborn child, the employee may enroll:

(1) newborn only, or (2) spouse only, or (3) spouse and the newborn

Other eligible dependents can also be added at this time The employee has 60 days after the newborn’s date of birth to enroll the newborn for coverage. If the employee has employee and child(ren) or employee and family coverage at the time of the newborn’s birth and at the time of enrollment, the employee has up to one year after the newborn’s date of birth to add the newborn to coverage The spouse and other eligible dependents can only be added within 31 days after the newborn’s date of birth

The newborn’s date of birth If only enrolling the newborn, premium is waived for the first calendar month if the date of birth is other than the first of the month If enrolling any other eligible dependent, premium is billed for the full month in which coverage begins TRS-‐ActiveCare automatically provides coverage for a newborn child of a covered employee for the first 31 days after the date of birth, but this coverage ends unless the newborn is added to the employee’s coverage



An eligible, but not covered employee, has a newborn child, the employee may enroll: (1) employee only, or (2) employee and spouse, or (3) employee and newborn, or (4) employee, spouse and newborn The employee has 60 days after the newborn’s date of birth to enroll the newborn for coverage. The employee, spouse and other eligible dependents can only be added within 31 days after the newborn’s date of birth

The newborn’s date of birth

Premium is billed for the full month in which coverage begins

The newborn’s date of birth

Premium is billed for the full month in which coverage begins

A covered employee adopts a child and chooses to enroll within 31 days after the date of adoption or date on which the child to be adopted is placed with the employee, the employee may enroll: (1) the adopted child only, or (2) spouse only, or (3) spouse and the adopted child

Other eligible dependents can also be added at this time

The date of adoption or the date on which the child to be adopted is placed with the employee If only enrolling the adopted child, premium is waived for the first calendar month if the date of the adoption is other than the first of the month If enrolling any other eligible dependent, premium is billed for the full month in which coverage begins

An eligible, but not covered employee, adopts a child and chooses to enroll within 31 days after the date of adoption or date on which the child to be adopted is placed with the employee, the employee may enroll: (1) employee only, or (2) employee and spouse, or (3) employee and adopted child, or (4) employee, spouse and adopted child Other eligible dependents can also be added at this time

The date of adoption or date on which the child to be adopted is placed with the employee Premium is billed for the full month in which coverage begins

The date of adoption or the date on which the child to be adopted is placed with the employee Premium is billed for the full month in which coverage begins



A covered employee becomes a legal guardian of an eligible dependent child and chooses to enroll the dependent within 31 days after the date the legal guardianship is granted Other eligible dependents can also be added at this time An award of legal guardianship is not a special enrollment event for a non-‐covered employee or his or her dependents

The date the guardianship is granted Premium is waived for the first calendar month if the date of notification is other than the first of the month

A covered employee adds a court-‐ordered eligible dependent child after the participating district/entity receives notice of the court order or national medical support notice Other eligible dependents can also be added at this time A court order on the spouse (or ex-‐spouse) of a covered employee does not require TRS-‐ActiveCare to provide dependent coverage

The date the participating district/entity receives notification of the court order or national medical support notice Premium is waived for the first calendar month if the date of notification is other than the first of the month

An eligible, but not covered employee adds a court-‐ordered eligible dependent child after the participating district/entity receives notice of the court order or national medical support notice Other eligible dependents can also be added at this time A court order is a special enrollment event for the employee. If the employee chooses to enroll himself and other eligible dependents, he or she has 31 days after the date the participating district/entity receives notice of the court order or national medical support notice to enroll

The date the participating district/entity receives notification of the court order or national medical support notice Premium is billed for the full month in which coverage begins

The date the participating district/entity receives notification of the court order or national medical support notice Premium is billed for the full month in which coverage begins

A covered employee adds an eligible newborn grandchild or another newborn child who is in a regular parent-‐child relationship with the employee within 31 days after the date of birth

The newborn’s date of birth Premium is waived for the first calendar month if the date of birth is other than the first of the month



A covered employee adds an eligible grandchild or another child who is in a regular parent-‐child relationship with the employee within 31 days after the child qualifies as a dependent

Adding a grandchild or another child who is in a regular parent-‐child relationship with the employee is not a special enrollment event for a non-‐covered employee or his or her dependents

First of the month following the date the child qualifies as a dependent

A covered employee gets married and chooses to enroll within 31 days after the date of marriage, the employee may enroll: (1) spouse only (2) spouse’s eligible children, or (3) spouse and spouse’s eligible children


The first of the month following the date of marriage

An eligible, but not covered employee gets married and chooses to enroll within 31 days after the date of marriage, the employee may enroll: (1) employee only, or (2) employee and spouse, or (3) employee and spouse’s eligible children, or (4) employee, spouse, and spouse’s eligible children




An employee receives an Insurance Enrollment Notification letter from the Texas Health and Human Services agency, regarding eligibility for HIPP

The first of the month following the date of the notification letter

The first of the month following the date of the notification letter

The employee makes changes to coverage due to other special enrollment events within 31 days after the qualifying event

The first of the month following the event date.

The first of the month following the event date


When Coverage Ends TRS-‐ActiveCare employee coverage will end: • The last day of the month the employee's employment ends unless otherwise provided by TRS rules or law • The last day of the month the employee is expelled from the TRS-‐ActiveCare program • The last day of the month in which an employee is no longer eligible for TRS-‐ActiveCare coverage (such as the

employee’s TRS retirement date or as allowed by TRS Rule 41.38) • When the employee stops making the required premium contribution payments • The last day of the month in which the employee enters into active, full-‐time military, naval or air service except

as provided under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) or other applicable law

• The last day of the month in which eligibility for COBRA continuation coverage expires • If a participating district/entity fails to make all premium payments for a period of a least 90 days • When the TRS-‐ActiveCare program is terminated

A dependent’s coverage will end: • When the employee's coverage ends • The last day of the month in which he or she loses their status as an eligible dependent (for example, a spouse's

coverage will end if an employee gets divorced) • If a dependent child becomes eligible as an employee who is an active contributing TRS member • The last day of the month in which he or she enters into active, full-‐time military, naval, or air service except as

provided under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) or other applicable law

• The last day of the month in which eligibility for COBRA continuation coverage expires • When the employee stops paying required contributions for dependent coverage

Note: When coverage ends, participating districts/entities are responsible for reporting timely cancellations for employees and dependents in the WellSystems Enrollment Portal or on the Enrollment Application and Change Form, including the reason for termination of coverage from the choices provided. Exceptions may be granted for extraordinary circumstances constituting “good cause.” Exceptions are not a guarantee of coverage reinstatement, billing credit or enrollment. The definition of “good cause” means that a person’s failure to act was not because of a lack of diligence to reasonably take prompt and timely action. If an employee or Benefits Administrator submits an exception and it does not meet guidelines as noted on page 30, the request will be denied.

Benefits Administrators should enter future termination dates for retirees using the WellSystems Enrollment Portal.

www.trs.state.tx.us/trs-activecare 27

Reporting Terminations When reporting a termination in the WellSystems Enrollment Portal or through submission of an Enrollment Application and Change Form, Benefits Administrators should use the actual event date such as the actual date of the divorce, the date of death, the last day worked for a terminating employee or the actual date of the loss of eligibility. Coverage will continue through the last day of the month in which the event occurred. In some instances, Benefits Administrators are incorrectly reporting the first of the month following the event date as the actual event date. This results in the individual incorrectly having an additional 30 days of coverage as an employee, with the premium billed to the participating district/entity. For accurate billing and claims processing, be sure to report the actual event date. For example, if the last day worked for a terminating employee is November 30, report November 30, not December 1, as the event date. The reason for terminating coverage should also be listed on the Enrollment Application and Change Form. Note: Refer to page 37 for information on reporting terminations for employees set up under a split premium arrangement.

When is a dependent child no longer eligible for coverage? Coverage for a dependent child terminates at the end of the month the child turns 26 or enters into active, full-time military service, whichever occurs first, unless eligible as a disabled dependent. If a child becomes an employee and is a contributing TRS member, the child’s coverage will also terminate. (A child under age 26 who is employed by a district/entity and is a contributing TRS member cannot be covered as a dependent on his or her parent's TRS-ActiveCare coverage.) Refer to the COBRA Administration section of this guide for information on how to assist the child in applying for COBRA/continuation coverage following termination after reaching age 26. If an employee has a disabled dependent child, age 26 or over, the child may be eligible for dependent coverage provided that the child is either mentally or physically incapacitated to such an extent as to be dependent on the employee on a regular basis and the child meets other requirements as determined by TRS. The employee (and the dependent’s attending physician) must complete a Request for Continuation of Coverage for Handicapped Child Form along with the Attending Physician’s Statement to provide satisfactory proof of the disability and dependency. The form must be submitted within 31 days after the date the child turns 26. To avoid any gap in coverage, the form must be submitted and approved prior to the end of the month the child turns 26. Note: No action is required by the Benefits Administrator to cancel coverage for an over-age dependent. The coverage for the dependent child will be terminated systematically at the end of the month the child turns 26. Auto-cancel does not apply to a dependent over the age of 26 that has already been approved for extended coverage as a disabled dependent. When applicable, the Benefits Administrator will see an adjustment in the employee’s premium on the district/entity’s billing. The employee will receive a certificate of creditable coverage for the dependent child, and separately, the dependent child will receive information on COBRA continuation coverage.

http://www.trs.state.tx.us/trs-activecare


How to report terminations to WellSystems There are two options to communicate terminations to WellSystems. The WellSystems Enrollment Portal allows for termination of coverage to be reflected on the monthly bill up to two business days prior to the billing date, as specified on page 44. Benefits Administrators may also submit terminations using the Enrollment Application and Change Form, which can be faxed directly to their Enrollment Coordinator using their secure direct fax. Any Enrollment Application and Change Form received up to two business days prior to the monthly billing date will be reflected on the bill. When reporting any termination, the reason for termination must be noted.

Reporting Terminations: Cancel Reasons Enrollment Application and Change Form WellSystems Enrollment Portal

Employee

Death Deceased

Loss of Eligibility Insufficient Hours Worked

Terminated Employment/Retirement Left Employment

Non-‐Payment of Premium* Account Request*

Leave of Absence Period Expired Leave of Absence

Dropped Coverage (Employee Request)* Subscriber Request*

Other (Annual Enrollment)* Subscriber Request*

Dependent

Divorce/Legal Separation Divorce

Death Deceased

Loss of Eligibility Eligibility Requirements Not Met

Dropped Coverage (Employee Request)* Subscriber Request*

Other (Annual Enrollment)* Subscriber Request*

*COBRA/continuation coverage is not available; individuals terminating coverage for these reasons will not receive a COBRA packet. When canceling an employee or dependent in the WellSystems Enrollment Portal, enter the first of the month following the event date shown on the Enrollment Application and Change Form. Example: Employee terminates May 15; enter June 1 as the termination date in the portal. To ensure billing is as accurate as possible, enter all terminations in the WellSystems Enrollment Portal two business days prior to the published bill date each month for the change to be reflected on that month’s bill. Example: Employee terminates on May 8 and the termination is entered in the WellSystems Enrollment Portal on May 25. The district/entity will see the change on the June 1 bill. If the termination is entered on June 5, the change will show on the July 1 bill with a credit for June premium. Note: If you are processing a termination online and the actual termination date exceeds the processing guidelines, you should still process the termination with the earliest date the system will allow. For example, a June 1 termination received September 25 can be entered in the WellSystems Enrollment Portal as a September 1 termination date, which stops the premium billing for the individual terminating coverage.


Membership Processing Guidelines All new enrollments and changes in enrollment as a result of a qualifying event must be submitted to WellSystems through the WellSystems Enrollment Portal or via a signed and dated Enrollment Application and Change Forms by the end of the plan enrollment period or within 31 days after the qualifying event date. (Special rules apply to newborns; see box on page 16 for more information.) If a form is not signed and dated within the appropriate timeframe, it should not be submitted for processing.

Participating districts/entities should report enrollments, cancellations and other changes to WellSystems in a timely manner. The charts below provide the deadlines for submitting and processing membership transactions.

Membership Processing Guidelines Apply to all transactions except for dropping coverage (see next page) All transactions must be signed and dated within the appropriate timeframe

For transactions effective this month. . .

The Benefits Administrator must process the transaction through the WellSystems Enrollment Portal or submit an Enrollment Application and Change Form (or the AEP file) to WellSystems by. . .

Or. . . for coverage changes related to newborns, the change must be completed through the WellSystems Enrollment Portal or by submitting an Enrollment Application and Change Form (or the AEP file) to WellSystems by. . .

08/2014 09/15/2014 11/17/2014 09/2014 10/16/2014 12/15/2014 10/2014 11/17/2014 01/15/2015 11/2014 12/16/2014 02/17/2015 12/2014 01/15/2015 03/16/2015 01/2015 02/17/2015 04/15/2015 02/2015 03/16/2015 05/15/2015 03/2015 04/15/2015 06/15/2015 04/2015 05/15/2015 07/15/2015 05/2015 06/15/2015 08/17/2015 06/2015 07/15/2015 09/15/2015 07/2015 08/17/2015 10/15/2015 08/2015 09/15/2015 11/16/2015 09/2015 10/15/2015 12/15/2015 10/2015 11/16/2015 01/15/2016 11/2015 12/15/2015 02/16/2016 12/2015 01/15/2016 03/15/2016 01/2016 02/16/2016 04/15/2016

If the transaction is not processed in the WellSystems Enrollment Portal or the Enrollment Application and Change Form (or AEP file) is not received by this date, WellSystems will process the transaction as follows: Adds: Form will be returned to the district/entity, the district/entity can request an exception through the WellSystems Exception and Appeals portal. Terminations: Form will be processed within the guidelines. Example: A 6/01/15 termination is received 9/24/15 and will be processed as 9/01/15. The district/entity can request an exception through the WellSystems Exception and Appeals portal to process a 6/01/15 effective date.

If the form (or AEP file) is not received by this date, WellSystems will return the application to the district/entity. The district/entity can request an exception through the WellSystems Exception and Appeals portal.


Request for Exceptions Exceptions may be granted for extraordinary circumstances constituting “good cause.” Exceptions are not a guarantee of coverage reinstatement, billing credit or enrollment. The definition of “good cause” means that a person’s failure to act was not because of a lack of diligence to reasonably take prompt and timely action. If an employee or Benefits Administrator submits an exception and it does not meet guidelines as noted above, it will be denied. Please do not submit an exception if it does not meet the guidelines stated above. Employees and Benefits Administrators from participating districts/entities will be held accountable for their decisions and must abide by TRS Rules and the TRS-‐ActiveCare membership processing guidelines.

WellSystems will coordinate exception requests with TRS through its Exception and Appeals portal at www.wellsystems-‐ea.com. You will be required to log in using the same user name and password as the WellSystems Enrollment Portal. Passwords for the two portals are maintained separately for security purposes. If you change one password you will have to also change the password for the other portal. Once logged in, the portal will direct you to complete a number of mandatory fields, such as Exception Reason and important dates. There is also a section for documenting the “good cause” reason for the exception. Where appropriate, supporting documentation should be imaged and attached. In no event will retroactive coverage be effective on a date earlier than the beginning of the current plan year or twelve (12) calendar months, whichever occurred first.

TRS will notify WellSystems when an exception request is approved. WellSystems will process the request and notify the Benefits Administrator when an exception request is completed.

Request for Appeal If an enrollment exception request is denied, the employee may file an Appeal, including additional explanations or documentation. That appeal can be initiated from the WellSystems Exception and Appeals portal by simply clicking on the link [email protected] link. You should provide additional information or documentation to support the appeal. All appeals will be handled by the TRS-‐ActiveCare Grievance Administrator. Responses will be provided directly to the employee.

What are the processing guidelines for dropping coverage for non-‐payment of premium? If a district/entity is canceling coverage for an employee due to non-‐payment of premium, the cancellation will be effective in the month in which the termination is processed in the WellSystems Enrollment Portal or an Enrollment Application and Change Form (or AEP file) is received by WellSystems. For example, if the cancellation is received in April, it will be effective April 1 regardless of the date requested on the form. The district/entity can request an exception through the WellSystems Exception and Appeals portal.

What happens if an employee voluntarily drops coverage? An employee cannot elect to drop coverage retroactively; a future cancellation date is required. The employee’s signature date will be used to determine the cancellation date. For example, if the form is signed in August for a September 1 cancellation date, the cancellation will be effective September 1. If the form is signed in September for a September 1 cancellation date, the cancellation will be effective October 1. The cancellation must be processed in the WellSystems Enrollment Portal or received by WellSystems within the membership processing guidelines. Note: If coverage is voluntarily dropped during the plan year, the individual will not be eligible to re-‐enroll in TRS-‐ActiveCare until the next enrollment period unless there is a special enrollment event.

What if additional information is needed to complete processing? If WellSystems receives an incomplete web enrollment or Enrollment Application and Change Form, the Benefits Administrator will be contacted by phone or email by your Enrollment Coordinator. If the information is not readily available or is not provided to the Enrollment Coordinator within three business days, the Benefits Administrator will receive a letter, summarizing the missing information. To process the transaction by the requested effective date, the information must be received by WellSystems within 45 calendar days after the date on the letter.


Enrollment Enrollment Period for the 2014-2015 Plan Year ( July 21-August 31) During the plan enrollment periods, employees may select a plan option, make plan changes, and add or delete dependents from their health coverage without a special enrollment event.

For plan enrollment, who needs to enroll via the WellSystems Enrollment Portal or via an Enrollment Application and Change Form?

For employees already enrolled in TRS-‐ActiveCare: If the employee is not making any changes to his or her current health benefit plan, there is no need to re-‐enroll. The employee only needs to use the WellSystems Enrollment Portal or complete and return an Enrollment Application and Change Form if he or she wants to: • Change TRS-‐ActiveCare plan options, or • Add or drop dependents, or • Choose to cancel coverage under TRS-‐ActiveCare for the employee and dependents, or • Enroll for TRS-‐ActiveCare coverage with a different participating district/entity ,or • Change name or address and/or correct date of birth or social security number

Enrollment via the WellSystems Enrollment Portal or via the Enrollment Application and Change Form requires a review by the Benefits Administrator. Reviewing applications and changes submitted through the WellSystems Enrollment Portal is quick and easy. For instructions, please refer to the Benefits Administrator Approving an Enrollment Request guide included on the TRS website. Once signed on the Benefits Administrator will be provided with a list of employees who have submitted an application for enrollment or change which are pended for Benefits Administrator approval. Each transaction can be reviewed and approved, at which time it is routed to WellSystems to upload to the enrollment database. A district/entity is able to use Enrollment Application and Change Forms completed by employees to enter enrollment applications and changes via the WellSystems Enrollment Portal. For instructions, refer to the Benefits Administrator Updating Enrollment guide on the TRS website. For instructions if the employee is new, please refer to the Benefits Administrator Enrolling a New Hire guide included on the TRS website.

If a district/entity continues to send enrollment activity to WellSystems via an Enrollment Application and Change Form, it is the responsibility of the Benefits Administrator to review each form for completeness, signature and date. Forms can be sent to WellSystems via mail at WellSystems TRS Team, P.O. Box 1390, Brandon, FL 33509-‐1390 or can be securely faxed to district’s/entity’s Enrollment Coordinator using the number listed on pages 8-‐9.

If no form is returned, the employee will automatically be enrolled in the same plan elected for 2013-‐2014 at the same level of coverage, unless the employee is transferring to a new participating district/entity. The premium will be adjusted to reflect any new rate on September 1, 2014. Note: If employees were enrolled in ActiveCare 3 for 2013-‐2014, they will be automatically enrolled in ActiveCare 2. They must enroll and select another plan if they do not want coverage in ActiveCare 2.

For employees enrolling in TRS-‐ActiveCare for the first time: New hires may choose their actively-‐at-‐work date (the date they start to work) or the first of the month following their actively-‐at-‐work date as their effective date of coverage. If choosing the actively-‐at-‐work date, full premium for the month will be due; premiums are not pro-‐rated. An Enrollment Application and Change Form should be submitted to the Benefits Administrator before the later of: • The end of the plan enrollment period • 31 days after a new hire’s actively-‐at-‐work date • 31 days after a special enrollment event (Special rules apply to newborns; see box on page 16 for more

information)


Note: TRS does not offer, nor does it endorse, any form of supplemental coverage for any of the health coverage plans available under TRS-‐ActiveCare. To obtain information about any coverage that is purported to be a companion or supplement to any TRS-‐ActiveCare plan, employees should contact the organization making such offerings and/or the Texas Department of Insurance (TDI) at www.tdi.state.tx.us or the TDI Consumer Helpline at 1-‐800-‐252-‐3439. WellSystems Enrollment Portal The simplest way to apply for coverage or make changes to existing coverage is to utilize the WellSystems Enrollment Portal (www.wellsystems-‐mesa.com). If a district/entity chooses this option, WellSystems will provide the district/entity Benefits Administrators with a letter and guide for completing enrollment using the portal. Employees with existing TRS-‐ActiveCare coverage should receive the Employees Currently Enrolled for TRS-‐ActiveCare Benefits guide included on the WellSystems Enrollment Portal. Information maintained by WellSystems, including names, relationships, social security numbers, addresses and currently chosen plan has already been loaded. If there are no changes, the employee can indicate such. If they wish to make any changes, they are able to update all information on covered individuals, change coverage or decline coverage. In all cases, they will be able to print a confirmation of the enrollment, which includes all of the information and choices shown in the portal. New employees and those previously declining coverage should receive the New Hire and Previously Declined guide included on the TRS website. In this case, they will need to enter names, relationships, social security numbers, addresses and benefit selections. The WellSystems Enrollment Portal can be used to process all of the following types of enrollment transactions: • Apply for coverage. • Add a dependent. • Cancel enrollment. • Cancel dependent coverage. • Change coverage. • Change address. • Change name. • Decline coverage. • Correct social security number. • Print an enrollment or declination confirmation.

All enrollments and changes completed by employees will be pended for Benefits Administrator review and approval. Once signed on to the WellSystems Enrollment Portal as an Administrator, the Benefits Administrator will be provided with a list of employees that have completed enrollment or changes. Records can be reviewed and approved by clicking on the individual, reviewing the information submitted by the employee, and either approving or re-‐pending the transaction.

All new hires are required to either utilize the WellSystems Enrollment Portal or complete an Enrollment Application and Change Form – even if declining coverage for themselves and/or dependents. Annual declination forms from eligible, but not covered, employees are not required. If the WellSystems Enrollment Portal is used, the record of declination will be maintained by WellSystems. If using the Enrollment Application and Change Form, Benefits Administrators should maintain copies of the declination forms. Do not send declination forms. However, please keep them for your files.


Enrollment Application and Change Form Another option for districts/entities to enroll or make changes in TRS-‐ActiveCare is through the use of the Enrollment Application and Change Form. Completed forms must be submitted to WellSystems via mail or fax within the membership processing guidelines on pages 29-‐30. (Do not send applications to the TRS address in Austin, Texas; this delays processing.) As a Benefits Administrator of a participating district/entity, you will be responsible for collecting Enrollment Application and Change Forms from your employees, verifying eligibility, and ensuring forms are complete and accurate. Missing information could result in delays. Applications should be completed in blue or black ink, or they can be entered through the WellSystems Enrollment Portal.

Social security numbers are required Effective immediately, social security numbers are required for all employees and dependents enrolling in TRS-‐ActiveCare. Note: It is not necessary to wait for a newborn’s social security number. The employee should submit an Enrollment Application and Change Form without the newborn’s social security number to add coverage and re-‐submit another form once the number has been issued.

New Optional Enrollment Fields In an effort to facilitate enhanced care management programs, TRS and Aetna have added three optional data fields in the WellSystems Enrollment Portal and on the Enrollment Application and Change Form. These are: Email Address: This is the address where the employee and/or dependents wish to receive communication from Aetna Care Managers, including invitations to join programs and preventive care reminders. Primary Language: To help eliminate language barriers and effectively communicate, the employee should pick from the list of languages or input another language not listed.


How to Complete the Enrollment Application and Change Form The following chart describes each section of the Enrollment Application and Change Form. Section Why this section is important/How to complete Eligibility This section contains two questions to determine eligibility for TRS-‐ActiveCare. At

least one of the questions must be answered "Yes" for an employee to be eligible for coverage. If both questions are checked "No," the employee is not eligible and the form should not be submitted.

Section 1 – Enrollment/Change Transaction Type

This section identifies the participating district/entity and captures the reason the employee is enrolling, changing or declining coverage. • Check "New Employee" if the employee is initially enrolling in TRS-‐ActiveCare. • Check "Add Dependent" if an employee currently enrolled in TRS-‐ActiveCare is

adding coverage for a dependent. • Indicate if enrollment is due to an annual enrollment or a special enrollment

event. If a special enrollment event, check the event and indicate the event date.

• A new hire must select when they want coverage to begin:

• Their actively-‐at-‐work date (the day the employee begins work) • The first of the month following the employee’s actively-‐at-‐work date

• Check "Change Only" to indicate a plan/coverage change, an address change or name change.

• Check "Decline Coverage" to decline employee coverage If an employee is currently covered by TRS-‐ActiveCare but wants to decline coverage for the new plan year, he or she may submit one Enrollment Application and Change Form during the plan enrollment period to terminate coverage at the end of the current plan year and decline coverage for the new plan year. The employee should check the “Cancel Enrollee” box and enter the event date; the employee should also check the “Decline Coverage” box and complete sections 2 and 6 of the form.

• For Terminations/Cancellation requests, select a reason from the options provided, or check “Other” and write the reason in the space provided.

Note: The actual event date such as the actual date of the divorce, the date of death, the last date of employment for a terminating employee or the actual date of the loss of eligibility should be used when reporting terminations on an Enrollment Application and Change Form. Coverage terminates at the end of the month in which the event occurred. (When reporting the termination on the WellSystems Enrollment Portal, enter the first of the month following the event date shown on the Enrollment Application and Change Form.)


Section Why this section is important/How to complete For District Use Only This section is used to verify eligibility and the effective date of coverage. The

Benefit Administrator must insert the following information to expedite processing: • TRS District number for the participating district/entity • Employee’s actively-‐at-‐work date • Employee's effective/change date of coverage (If the employee chooses the

actively-‐at-‐work date for coverage to begin, both dates will be the actively-‐at-‐work date.)

• Employer approval signature

Note: Benefit Administrators are responsible for administering the eligibility requirements established by TRS. Do not enroll an employee whose Enrollment Application and Change Form was not signed, dated and submitted within the enrollment period. The employee must submit a written request to TRS for an exception to the eligibility requirements to add coverage. Changing an employee’s signature or hire date to meet membership processing guidelines is an act of fraud. An Enrollment Application and Change Form submitted improperly will be returned to the participating district/entity. A request for exception can be made through TRS.

Section 2 – Employee Information

Section 2 must always be completed – even by employees who decline coverage.

Section 3 – Coverage Selection

Section 3 must always be completed to select a benefits plan and coverage category. Note: HMO enrollees must live, work or reside within the HMO service area to be eligible for HMO coverage. Check the TRS-‐ActiveCare website, www.trs.state.tx.us/trs-‐activecare and click on “Plan Options available by County” to view eligible counties and ZIP codes.

Section 4 – Dependent Information

This section must be completed for all dependents that an employee is adding to or dropping from TRS-‐ActiveCare coverage. If there are more than five children, attach a separate Enrollment Application and Change Form and complete Sections 1, 2 and 4 on the second form. Mark the attachment "page 2 of 2" at the top of the form.

The child's relationship to the employee must be indicated for each dependent child enrolling for coverage. Section 7 outlines the conditions for enrollment in TRS-‐ActiveCare. No additional documentation is required. It is against the law to elect coverage for an ineligible person.


Section Why this section is important/How to complete Section 5 – Disabled Dependents Over Age 26

This section is to be completed only when an employee applies for dependent coverage for a disabled child, age 26 or over. A Request for Continuation of Coverage for Handicapped Child Form along with the Attending Physician’s Statement must be completed and submitted to Aetna at the address shown on the form. The Request for Continuation of Coverage for Handicapped Child Form and the Attending Physician’s Statement are available on the website at www.trsactivecareaetna.com.

Section 6 – Declination of Coverage

This section must be completed if an employee is declining coverage for himself and/or any of his dependents. If the employee is enrolling for coverage, but is declining coverage for any dependents (to be listed by name on the form), the employee must complete this section and sign and date the form.

This section is required to be completed if the employee experiences a special enrollment event and wants to enroll or add coverage for a dependent.

If Section 6 is not completed or if no application exists, proof of coverage (such as a certificate of creditable coverage) in lieu of a declination of coverage on the enrollment application must be provided to the participating district/entity’s Benefit Administrator.

Section 7 – Coverage Conditions

This section outlines the conditions to apply for TRS-‐ActiveCare coverage. This section must always be signed and dated.

Section 8– Special Notes Regarding My Enrollment

This section is for any additional notes. This section may also be used to enter dependent termination information (see Section 2).

What options are available to a husband and wife who both work for a participating district/entity? • Each can choose employee-‐only coverage and select the same or different plans • One can select employee and spouse coverage, and the spouse must decline coverage • One can choose employee-‐only coverage, and the spouse can choose the same or different plan for

employee and child(ren) coverage • One can select employee and family coverage, and the spouse must decline coverage • Each can decline coverage


Pooling Funds/Split Premium Married employees who are active contributing TRS members may "pool" their local district and state funding to use toward the cost of TRS-ActiveCare coverage. If a husband and wife both work for a participating district/entity, funds may be pooled when: • One employee selects employee and spouse coverage, and the spouse declines coverage; or • One employee selects employee and family coverage, and the spouse declines coverage.

If a husband and wife work for different participating districts/entities and wish to pool funds, an Application to Split Premium Form 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 percent of the total cost of coverage. The participating district/entity employing the spouse who declined coverage will consider the employee as covered under a group health plan for funding purposes and the participating district/entity’s premium billing statement will list the employee under their spouse’s ID number. Each employee and their Benefits Administrator must complete their portion of the Application to Split Premium Form. This form should be submitted to WellSystems via fax or e-mail at the same time as either (i) an enrollment or change processed through the WellSystems Enrollment Portal is approved or (ii) an Enrollment Application and Change Form is mailed or faxed. A sample Application to Split Premium Form is included in the Exhibits section of this guide and is also posted on the TRS website. Note: Both participating districts/entities need to have the same effective date of coverage for married employees to split premium except for the following: If an employee already has employee and family coverage and the spouse is hired by another participating district/entity, the spouse can decline coverage and complete an Application to Split Premium to be effective on the first of the month following the spouse’s actively-at-work date. Requests for split premium must be signed, dated and submitted to the Benefits Administrator within the plan enrollment period and received by WellSystems within the membership processing guidelines. Requests for exceptions can be made through the WellSystems Exception and Appeals Portal (www.wellsystems-ea.com). Important: If either employee changes employment to another participating district/entity, a new Application to Split Premium Form will be required.

How are terminations of coverage handled under a split premium arrangement? If the employee that declined coverage terminates employment, the Benefits Administrator should complete Section 5 of the original Application to Split Premium Form and re-submit to WellSystems to cancel the split premium arrangement. Otherwise, the cost of coverage will continue to be split between and billed to the two employers. The spouse’s district will be notified in writing by WellSystems that the split premium arrangement has been cancelled. If the employee that is carrying the coverage terminates, the Benefits Administrator needs to either submit the termination through the WellSystems Enrollment Portal or submit an Enrollment Application and Change Form to WellSystems to terminate the coverage, which will automatically cancel the split premium arrangement. In this situation, the employee that declined coverage will be able to elect TRS-ActiveCare coverage through their entity due to the loss of coverage (he or she must enroll within 31 days of the special enrollment event).



Changing Employment between Participating Entities and Rehires When a covered employee changes employment to another participating district/entity, both entities must utilize the WellSystems Enrollment Portal or complete an Enrollment Application and Change Form. The Benefits Administrator of the prior employing district/entity must submit a termination at the time the employee terminates. The employee's coverage will terminate at the end of the month in which termination occurs. The employee will need to enroll through the WellSystems Enrollment Portal or complete a new Enrollment Application and Change Form to be submitted to the new employer when hired. Because they are switching districts/entities, their original enrollment information (names, relationships, social security numbers, addresses, etc.) will not automatically populate as it is linked to the original district/entity for security purposes. As such they will need to enroll as if they were a New Employee as shown in the New Hire or Previous Declination guide included on the WellSystems Enrollment Portal. Rehires will need to re-‐enroll through the WellSystems Enrollment Portal or complete an Enrollment Application and Change Form. There is no break in coverage if the individual is employed by a new participating district/entity (or rehired by the same participating district/entity) no later than the last day of the next calendar month following the month in which employment terminated. The employee must elect coverage within 31 days after his or her actively-‐at-‐work date and elect coverage to be effective on the actively-‐at-‐work date. If the employee elects his or her effective date to be the first of the month following the actively-‐at-‐work date, there will be a gap in coverage, and no benefits will be available for that period of time (unless the employee elects COBRA continuation coverage).

For example, John Doe terminates with ABC district on October 15. His coverage continues through October 31. John Doe begins working for XYZ district on November 12. He elects his actively-‐at-‐work date as his effective date of coverage. He is responsible for the entire employee contribution for a full month of coverage. In this example, there is no gap in coverage. However, if John Doe elects December 1 to be his effective date, there will be no coverage for the month of November unless he elects COBRA continuation coverage.

An employee changing employment to another participating district/entity (or rehired by the same entity) must enroll via the WellSystems Enrollment Portal or submit a new Enrollment Application and Change Form and choose the same plan. The employee cannot change his or her current plan option for the remainder of the plan year unless a special enrollment event occurs. Dependents cannot be added to coverage unless a special enrollment event or plan enrollment period occurs. Plan year deductibles, out-‐of-‐pocket maximums and other accumulations will follow and apply to the employee (and his or her covered dependents). Note: TRS rules do not allow double coverage under TRS-‐ActiveCare. If WellSystems receives an enrollment or change through its portal or an Enrollment Application and Change Form from a new hire (or from a dependent now eligible as an employee) currently enrolled in TRS-‐ActiveCare at another participating district/entity, coverage will be set up at the new employing entity. TRS-‐ActiveCare coverage elected at the prior district/entity will be terminated as of the effective date of the new coverage. WellSystems will notify the prior district/entity with the date the coverage was terminated. If the coverage should have been terminated on any other date, it is the responsibility of the Benefits Administrator at the prior district/entity to report the correct termination date to WellSystems. (If a dependent is going directly from dependent coverage to coverage as an employee, the dependent’s effective date of coverage under the new entity will be the first of the month following their actively-‐at-‐work date.)


Using the WellSystems Enrollment Portal The WellSystems Enrollment Portal is intuitive and very easy to use, and can be accessed at www.wellsystems-‐mesa.com/TRS. Step-‐by-‐step instructions for different users and different tasks are included on the TRS website as the following Guides:

User Description of Task Guide Title Benefits Administrator Approving new enrollments, Annual

Enrollment changes, other changes and coverage termination transactions completed by employees using the portal

“Benefits Administrator Approving an Enrollment Request”

Benefits Administrator Entering new enrollments completed by employees using the Enrollment Application and Change Form

“Benefits Administrator Enrolling a New Hire”

Benefits Administrator Entering updates to existing records from information provided by employees through the Enrollment Application and Change Form or other means of communication

“Benefits Administrator Updating Enrollment”

Existing TRS-‐ActiveCare Enrollee

An existing TRS-‐ActiveCare participant entering changes to demographic (name, relationship, social security number, address, etc.) and/or coverage information (ActiveCare Plan, HMO or coverage type)

“Employee Currently Enrolled with TRS-‐ActiveCare Changes to Current Information or Enrollment”

New Hire or Employee Previously Declining Coverage

A new hire or participant previously declining coverage enrolls for coverage through the portal

“New Employee or Previously Declined Coverage New Enrollment”

Submitting Enrollment Application and Change Forms Some districts/entities may continue to utilize Enrollment Application and Change Forms for the 2014-‐2015 Enrollment Period. Completed forms can be submitted to WellSystems via the secure fax number for your Enrollment Coordinator listed on page 8-‐9 or can be mailed to: WellSystems TRS Team, P.O. Box 1390, Brandon, FL 33509-‐1390. The mailing address for overnight mail is: WellSystems TRS Team, 1315 Oakfield Drive, #1390, Brandon, FL 33509-‐1390. Note: Never mail or fax an Enrollment Application and Change Form to the HMOs; all membership processing is handled by WellSystems. Do not send declination forms to WellSystems unless requested to do so due to a special enrollment request. Note: Some participating districts/entities may offer electronic enrollment. If so, you do not need to submit Enrollment Application and Change Forms to WellSystems; however, you must still comply with TRS membership processing guidelines and signature dates. Employees should keep copies of their confirmation of coverage from the electronic enrollment system. If you are considering offering an electronic enrollment for third-‐party vendor, you must contact your Enrollment Coordinator at WellSystems at least 60 days prior to implementation.


WellSystems Enrollment Portal Options WellSystems provides real-‐time, online enrollment capabilities for participating districts/entities in TRS-‐ActiveCare to simplify and enhance the enrollment experience. There are two options available to a district/entity for using the WellSystems Enrollment Portal:

• The district’s/entity’s employees can be provided with “self-‐service” enrollment and change, through access to the portal. Through a secure sign-‐on, the employee will be guided through the enrollment and change process, with edits and reminders included if they incorrectly enter information or do not enter required fields. Once they have completed their enrollment they can submit and print a confirmation of the information provided and their enrollment choices. The transaction is pended for review and approval by the district/entity Benefits Administrator prior to receipt by WellSystems; or

• The district/entity can continue to utilize the Enrollment Application and Change Form, with the Benefits Administrator accessing the WellSystems Enrollment Portal to enter new enrollments and changes.

Districts/entities choosing to utilize the “self-‐service” option must notify WellSystems in advance so that employee sign-‐on privileges can be established. Make sure you have the employee’s completed Enrollment Application and Change Form before updating the employee’s records. If you enroll an employee or update an employee’s records using WellSystems for Employers, do not submit the employee’s Enrollment Application and Change Form to Aetna or WellSystems. You must keep the form for your records. Note: Benefits Administrators are responsible for administering the eligibility requirements established by TRS. Online access for account maintenance may be revoked for misuse.


Transitional Care

ActiveCare 1-HD, ActiveCare Select or ActiveCare 2 Aetna/Caremark

Transitional care applies only to initial enrollees as of the date the district/entity begins participating in TRS-‐ActiveCare; transitional care does not apply to new hires. If an employee or covered dependent is undergoing a course of medical treatment at the time of enrolling in ActiveCare 1-‐HD, ActiveCare Select or ActiveCare 2 and the participant's doctor is not in the network, ongoing care with the current doctor may be requested for a period of time. Transitional care benefits may be available if being treated for any of the following conditions by a non-‐network doctor: • Pregnancy (third trimester or high risk) • Newly diagnosed cancer • Terminal illness • Recent heart attack • Other ongoing acute care

To request transitional care benefits, the employee must complete a Transition Coverage Request Form. A copy of this form is available in the Exhibits section of this guide and is also posted on www.trsactivecareaetna.com. Instructions for submitting the request to Aetna are on the form. All requests are subject to approval. If the transitional care request is approved, the participant may continue to see his or her non-‐network doctor and receive the network level of benefits from their selected TRS-‐ActiveCare plan. If the transitional care request is denied, the participant may still continue to see their current doctor, but benefits will be paid at the non-‐network level. If the participant's doctor is in the network, a Transition Coverage Request Form is not required.


FirstCare Health Plans If an employee or covered dependent is undergoing a course of treatment at the time of the effective date of coverage, and the treating physician is not a participating FirstCare Health Plans provider, one of the following will take place: 1. The PCP and FirstCare Health Plans will transition the care to a FirstCare Health Plans network provider if at all

possible; or 2. If the treatment or condition is such that the care cannot be transitioned to a FirstCare Health Plans network

provider, FirstCare Health Plans may authorize the use of a non-‐network provider. If a non-‐network provider is used, the patient will be responsible for the charges over and above the usual, reasonable and customary rates paid by FirstCare Health Plans, in addition to the applicable copayment.

Scott & White Health Plan If the employee (or covered dependent) is under the care of a specialist who is a non-‐network specialist, the employee will need to contact Scott & White Health Plan Customer Service for assistance in transitioning care within the Scott & White Health Plan-‐approved system. Authorization of non-‐network care is reviewed on an individual case-‐by-‐case basis.

Allegian Health Plans, formerly Valley Baptist Health Plans If an employee or covered dependent is undergoing a course of treatment at the time of the effective date of coverage, and the treating physician is not a participating Allegian Health Plans provider, one of the following will take place: 1. The PCP and Allegian Health Plans will transition the care to a Allegian Health Plans network provider if at all

possible; or 2. If the treatment or condition is such that the care cannot be transitioned to an Allegian Health Plans network

provider, Allegian Health Plans may authorize the use of a non-‐network provider. If a non-‐network provider is used, the patient will be responsible for the charges over and above the usual, reasonable and customary rates paid by Allegian Health Plans, in addition to the applicable copayment.


TRS-ActiveCare ID Cards

ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 Aetna/ Caremark

TRS-‐ActiveCare ID cards for ActiveCare 1-‐HD, ActiveCare Select and ActiveCare 2 medical plans will be mailed to the employee's mailing address provided on the Enrollment Application and Change Form. The employee's name will appear on the card. Employees will receive family ID cards – with up to five covered family members listed on the card. If there are more than four covered dependents, an additional card will be provided displaying the other covered dependents. Once the initial cards are received, employees may call TRS-‐ActiveCare Customer Service to request additional cards or request additional cards on Aetna Navigator at www.trsactivecareaetna.com. Employees may also call TRS-‐ActiveCare Customer Service to report incorrect information listed on the ID card or replace lost or damaged cards. There is no charge for additional ID cards.

FirstCare Health Plans, Scott & White Health Plan, and Allegian Health Plans For the Scott & White Health Plan and the FirstCare Health Plans options, the employee and each covered dependent will receive their own ID card. For the Allegian Health Plans option, the employee will receive one ID card with all covered dependents listed on it. To request additional ID cards, employees may call the HMO health plan’s Customer Service number or visit the HMO plan’s website. Will enrollees receive new ID cards for the 2014-‐2015 plan year?

Existing Enrollees

New Enrollees

ActiveCare 1-‐HD Yes Yes ActiveCare Select Yes Yes ActiveCare 2 Yes Yes FirstCare Health Plans Yes Yes Scott & White Health Plan No Yes Allegian Health Plans No Yes

Separate ID Cards for Medical and Prescription Drug Benefits — ActiveCare 1-‐HD, ActiveCare Select and ActiveCare 2 Plan participants enrolled in the ActiveCare 1-‐HD, ActiveCare Select and ActiveCare 2 plans will have two ID cards — one from Aetna for the medical benefits and a separate card from Caremark for the pharmacy/ prescription drug benefits.


Billing Billing Summary WellSystems will generate each participating district/entity’s billing summary on the 1st of each month. If the 1st is not a business day, the bill will be produced on the first business day after the 1st. The chart below shows the billing dates through the end of the 2014-‐2015 plan and January 2016.

For transactions effective this month. . .

Billing will generate on. . .

And payment will be due by. . .

08/2014 8/1/2014 8/15/2014 09/2014 9/1/2014 9/15/2014 10/2014 10/1/2014 10/15/2014 11/2014 11/3/2014 11/14/2014 12/2014 12/1/2014 12/15/2014 01/2015 1/2/2015 1/15/2015 02/2015 2/2/2015 2/13/2015 03/2015 3/2/2015 3/13/2015 04/2015 4/1/2015 4/15/2015 05/2015 5/1/2015 5/15/2015 06/2015 6/1/2015 6/15/2015 07/2015 7/1/2015 7/15/2015 08/2015 8/3/2015 8/14/2015 09/2015 9/1/2015 9/15/2015 10/2015 10/1/2015 10/15/2015 11/2015 11/2/2015 11/13/2015 12/2015 12/1/2015 12/15/2015 01/2016 1/4/2016 1/15/2016

For example, if a new hire is effective on August 5, 2014 and the enrollment application has been received and processed up to two business days prior to August 1st or July 30, 2014, that employee will be included on the district’s August 2014 bill. If the application for this employee was received or processed after July 30, 2014, the employee will not appear on the billing summary until September (which will include an adjustment for August). Billing will be based on covered enrollees in all TRS-‐ActiveCare plan options – including HMOs – as of the date the bill is produced. Participating districts/entities will not receive a separate bill for employees enrolled in one of the HMO options. The billing summary will list employee names, social security numbers, type of coverage and premiums due for the billing period.

Note: You can download and/or print a copy of your billing statement through the WellSystems Enrollment Portal as soon as you receive notice that a bill has been produced, but no later than the first business day of each month.


Remittance Payment will be due by the 15th of the month. If the 15th of the month is not a business day, payment is due by the last business day prior to the 15th. Please contact your WellSystems Enrollment Coordinator at their direct toll-‐free number listed on pages 8-‐9 if you need copies of your billing statement or to discuss any proposed adjustments to the bill such as coverage changes, terminations or new enrollees. Remit via TEXNET the total amount due to TRS-‐ActiveCare by the due date. Contact TRS at 512-‐542-‐6396 if you have any questions about payment of this bill. Approved adjustments will be reflected on a future bill.

What happens if payment is not made by the due date or the amount paid is different than the billed amount? You must pay the amount billed by the due date. Any delay in the timely deposit of your other regular monthly payroll contributions to TRS does not apply to the amount due requirement for TRS-‐ActiveCare premiums. You should make a separate TEXNET deposit for the TRS-‐ActiveCare amount due if necessary to make timely payment. TRS participates in the warrant hold program administered by the Comptroller of Public Accounts. If you do not pay the amount billed for TRS-‐ActiveCare or do not pay by the due date, TRS will request that the Comptroller release no further warrants (funds) to your district/entity until the indebtedness to TRS for TRS-‐ActiveCare is fully satisfied.


View Billing Summaries Online Each month, on the first work day of the month (the billing dates are listed on page 44), the district/entity Benefits Administrator will receive an email indicating that the district/entity’s monthly bill is available. Clicking on the link in the e-‐mail will bring the Benefits Administrator to the WellSystems Enrollment Portal where the electronic bill can be downloaded. Please note that all bills from September 2014 to the current month will be available for download and may be converted to an Excel format for analysis and reconciliation by the district/entity. Split Premium This applies only to married employees working for different participating entities. The cost for TRS-‐ActiveCare coverage will be split between and billed to the two employers. Each employer will be billed 50 percent of the total cost of the TRS-‐ActiveCare plan and coverage category selected. The participating district/entity employing the spouse who declined coverage will consider the employee as covered under a group health plan for funding purposes. Benefits Administrators will be able to identify employees electing to split premium on the monthly billing summaries. How are terminations of coverage handled under a split premium arrangement? If the employee who declined coverage terminates employment, the Benefits Administrator needs to call their Enrollment Coordinator at the direct toll free line shown on pages 8-‐9 or complete Section 5 of the original Application to Split Premium Form and fax to WellSystems at the direct fax number listed on pages 8-‐9 to cancel the split premium arrangement. Otherwise, the cost of coverage will continue to be split between the two employers. The spouse’s district will be notified in writing by WellSystems that the split premium arrangement has been cancelled. If the employee that is carrying the coverage terminates, the Benefits Administrator needs to utilize the WellSystems Enrollment Portal or submit an Enrollment Application and Change Form to terminate the coverage, which will automatically cancel the split premium arrangement. In this situation, the employee that declined coverage will be able to select TRS-‐ActiveCare coverage through his or her entity due to the loss of coverage (must enroll within 31 days of the special enrollment event).


Cost of Coverage

Total Monthly Costs 2013-‐2014 Plan Year

Effective September 1, 2013 through August 31, 2014

PPO Plans

ActiveCare 1-‐HD

ActiveCare 2

ActiveCare 3

Coverage Category Total Cost* Total Cost* Total Cost* Employee Only $325.00 $529.00 $796.00 Employee and Spouse $794.00 $1,203.00 $1,810.00 Employee and Child(ren) $572.00 $841.00 $1,269.00 Employee and Family $1,060.00 $1,323.00 $1,990.00

HMO Plans

FirstCare

Health Plans


Allegian Health Plans

(formerly Valley Baptist Health Plans)

Coverage Category Total Cost* Total Cost* Total Cost*

Employee Only $391.50 $418.42 $387.06 Employee and Spouse $985.06 $945.10 $941.04 Employee and Child(ren) $622.62 $664.00 $607.86 Employee and Family $994.84 $1,048.54 $960.14

*District and state funds are provided each month to active contributing TRS members to use toward the cost of TRS-‐ActiveCare coverage. State funding is subject to appropriation by the Texas Legislature. Note: New hires may choose their actively-‐at-‐work date (the date they start to work) or the first of the month following their actively-‐at-‐work date as their effective date of coverage. If choosing the actively-‐at-‐work date, full premium for the month will be due; premiums are not pro-‐rated.


Total Monthly Costs 2014-‐2015 Plan Year

Effective September 1, 2014 through August 31, 2015

Medical Plans

ActiveCare 1-‐HD

ActiveCare Select

ActiveCare 2

Coverage Category Total Cost* Total Cost* Total Cost* Employee Only $325.00 $450.00 $555.00 Employee and Spouse $850.00 $1,044.00 $1,287.00 Employee and Child(ren) $572.00 $709.00 $875.00 Employee and Family $1,145.00 $1,238.00 $1,323.00

HMO Plans

FirstCare

Health Plans



Coverage Category Total Cost* Total Cost* Total Cost* Employee Only $390.14 $452.80 $400.20 Employee and Spouse $977.76 $1,020.08 $969.60 Employee and Child(ren) $618.94 $717.32 $627.14 Employee and Family $987.44 $1,131.50 $989.22

*District and state funds are provided each month to active contributing TRS members to use toward the cost of TRS-‐ActiveCare coverage. State funding is subject to appropriation by the Texas Legislature. Note: New hires may choose their actively-‐at-‐work date (the date they start to work) or the first of the month following their actively-‐at-‐work date as their effective date of coverage. If choosing the actively-‐at-‐work date, full premium for the month will be due; premiums are not pro-‐rated.



Health Plan

Contacts for Applications and Inquiries

ActiveCare 1-‐HD, ActiveCare Select and ActiveCare 2 Plans

For enrollment questions and other information: WellSystems ATTN: TRS Team P.O. Box 1390 Brandon, FL 33509-‐1390 For payments: WellSystems P.O. Box 732513 Dallas, TX 75373-‐2513


FirstCare Health Plans ATTN: COBRA Administration 12940 N. Hwy 183 Austin, TX 78750 1-‐800-‐884-‐4901 8 a.m. – 6 p.m. CT (Mon – Fri) Email: [email protected] Fax: 512-‐257-‐6031


CONEXIS 6191 North State Highway 161, Suite 400 Irving, TX 75038 Participant Services Phone: 1-‐877-‐722-‐2667 Participant Services Fax: 1-‐877-‐353-‐2948

Allegian Health Plans (formerly Valley Baptist Health Plans)

Allegian Health Plans ATTN: COBRA Administration 1596 Whitehall Road Annapolis, MD 21409

Phone: 855-‐463-‐7264, 8:00 a.m. – 5:00 p.m. CST (Mon. – Fri.) Fax: 855-‐463-‐7269 Email: [email protected]

COBRA Payments: Allegian Health Plans ATTN: COBRA Administration P.O. Box 732558 Dallas, TX 75373-‐2558


Qualifying Events for COBRA Continuation Coverage The Consolidated Omnibus Budget Reconciliation Act (COBRA) passed by the 99th Congress provides that when employees and covered dependents lose their eligibility for group medical insurance coverage because of any of the events listed below, they may elect to continue group medical plan participation. The continued coverage can remain in effect for a maximum period of either 18, 29 or 36 months, depending on the reason the coverage terminated.

Qualifying Events for 18-‐Month Continuation

• Loss of eligibility due to reduction of employee work hours

• Voluntary employee termination including retirement (early or disability)

• Employee layoff for economic reasons

• Employee discharge, except for discharge for gross misconduct, or

• Failure of a participating district/entity to pay all premiums for at least 90 days


• Loss of coverage by employee or dependent if determined by the Social Security Administration to be disabled at any time during the first 60 days after the initial COBRA qualifying event date

To receive the additional 11 months of COBRA continuation coverage, the plan’s COBRA administrator must receive a copy of the Social Security Administration’s (SSA) determination letter before the end of the 18-‐month period of COBRA continuation coverage


• Death of an employee

• Divorce or legal separation of an employee, so long as the spouse was previously enrolled as a covered participant

• Employee becomes eligible for Medicare, leaving dependents without group medical coverage (as in the case of an employee who reaches age 65, retires and begins Medicare coverage), or

• Children who lose coverage due to plan provisions (for example, reaching the maximum age)

Note: Non-‐payment of premiums is not a qualifying event for COBRA continuation coverage. Eligibility Employees and dependents covered by TRS-‐ActiveCare on the day before the qualifying event are eligible to continue coverage. Employees or dependents not previously enrolled cannot elect to begin coverage. Note: Employees may not make plan changes during a plan year unless there is a special enrollment event–even if changing from active to COBRA status.


Notification The COBRA notification process includes the following steps: • The WellSystems Enrollment Portal or the Enrollment Application and Change Form must be utilized by the

Benefits Administrator to report a termination of coverage. • If the WellSystems Enrollment Portal is utilized, the termination date and reason for the termination must be

entered. When submitted it will be delivered automatically to your Enrollment Coordinator. • If the Enrollment Application and Change Form is utilized, the termination date and reason must be entered, and

the form must be mailed or faxed to WellSystems. • WellSystems will process the change. If the qualified participant was enrolled in the ActiveCare 1-‐HD, ActiveCare

Select, or ActiveCare 2 Plans, the Qualifying Event Notice will be automatically mailed to the participant. If the qualified participant was enrolled with an HMO, the COBRA administrator for each will be notified of the termination date and reason. Those COBRA administrators will mail the Qualifying Event Notice to HMO qualifying participants.

• The Qualifying Event Notice will include:

• Explanation of Group Health Continuation Under COBRA (sample attached in the Exhibits section of this guide)

• COBRA election form with premium information, and • Return envelope.

If the applicable COBRA administrator receives the COBRA election and initial premium payment within the time periods specified in the Qualifying Event Notice, the participant's coverage will be reinstated and they will receive monthly premium bills. If the COBRA Election Form and all premiums due are not received within the time periods specified in the Qualifying Event Notice, the qualifying participant will be notified they are unable to continue and their check will be returned. Once a qualified beneficiary has enrolled and paid premiums to date, new ID cards will be generated and mailed to the participant. Employer Responsibilities While TRS has contracted with WellSystems to administer COBRA eligibility and membership processing for TRS-‐ActiveCare, the participating employers retain certain obligations under federal law. Recent changes to COBRA may impact your participating district/entity. For example: Notice of unavailability of continuation coverage is required of employers. This is different from the Notice of Continuation Coverage Rights under COBRA provided by TRS-‐ActiveCare. The use of a notice of unavailability by the employer may be appropriate in situations including, but not necessarily limited to, the following:

• Failure to notify the employer or COBRA administrator within 60 days of the qualifying event • Coverage was cancelled due to non-‐payment of premium • Voluntary termination of coverage by the employee • Termination of employment due to gross misconduct

TRS recommends that participating districts/entities obtain their own legal counsel regarding their responsibilities under COBRA and any other applicable state or federal law.


What happens if an employee terminates within two months before the entity begins participating in TRS-ActiveCare? Terminated employees who are in their 60-day election period for COBRA continuation coverage on the date the district/entity begins participation in TRS-ActiveCare must receive a COBRA packet from the entity's current COBRA administrator and one from WellSystems for TRS-ActiveCare. The district/entity's Benefits Administrator should report the employee's termination to both administrators. The individual then has two options: 1. For continuous coverage, the individual must elect COBRA continuation coverage under the current

plan, pay the premium due and then elect TRS-ActiveCare as of the effective date of the entity's participation in TRS-ActiveCare; or

2. The individual may choose only to elect TRS-ActiveCare as of the date the entity begins participation in

TRS-ActiveCare. If the employee chooses this option, the individual will not have coverage from the date coverage ended under the current plan until coverage begins under TRS-ActiveCare.

How will COBRA participants enroll in TRS-ActiveCare? • Districts/Entities currently participating in TRS-ActiveCare (2013-2014 Plan Year): COBRA participants

will receive an enrollment kit in July. The kit will include a cover letter with rates (TRS cost plus 2%), an enrollment guide, a COBRA enrollment application and a return envelope. The COBRA participants will have a choice of selecting ActiveCare 1-HD, ActiveCare Select, ActiveCare 2 plans or an HMO option, if available.

• Districts/Entities beginning participation in TRS-ActiveCare (2014-2015 Plan Year): A COBRA

Transmittal Form has been developed to assist Benefits Administrators in gathering information on current COBRA participants. A copy of the Transmittal Form is in the Exhibits sections of this guide and is posted on the website. Benefits Administrators may mail, fax or email the information. (The contact information is on the form.) The district/entity’s current COBRA administrator may have a report that can be used for this purpose. Once the list of the COBRA participants is received, an enrollment kit will be distributed in July to the COBRA participants. The kit will include a cover letter with rates, an enrollment guide, a COBRA enrollment application and a return envelope. The COBRA participants will have a choice of selecting ActiveCare 1-HD, ActiveCare Select, ActiveCare 2 plans or an HMO option, if available.

Benefits Administrators should not receive COBRA applications. If a COBRA application is received in error, it should be forwarded immediately to the appropriate COBRA administrator as listed on pages 6-7.

After September 1, COBRA participants will receive system-generated notifications and applications from their specific TRS-ActiveCare health plan.



Cost and Payment of COBRA Coverage Any eligible individual electing to continue TRS-‐ActiveCare coverage must pay the full premium rate for active employees plus a 2% administrative fee.* The COBRA participant will be billed monthly and will remit premiums directly to the COBRA administrator (WellSystems for the ActiveCare 1-‐HD, ActiveCare Select and ActiveCare 2 plans or the applicable HMO health plan). The COBRA administrator will send all notifications of premium changes, health care benefit changes and the COBRA coverage termination date to the participant. Premium payments are due the first of each month. Premium payments must be postmarked within 30 days of the premium due date (grace period) or COBRA coverage will be terminated. If premium payment is not received by the 20th of the month, a reminder notice will be sent to the COBRA participant. Note: Until a COBRA payment is received each month, the participant’s record will reflect a termination date representing the last day of the month for which premium has been received. The coverage record will be updated upon receipt of payment and any denied claims may be resubmitted for consideration. Benefits for COBRA participants will be the same as those for active employees. COBRA participants must elect the same plan they had at termination. COBRA participants will have the same rights as active employees at the next plan enrollment period. The rate charged for COBRA coverage will be determined as follows: • Any spouse, dependent child or employee continuing coverage as an individual will be charged the rate for

employee-‐only coverage • An employee and spouse continuing coverage will be charged the rate for employee and spouse coverage • Any adult continuing coverage with dependent children will be charged the rate for employee and child(ren)

coverage • If the entire family continues coverage, they will be charged the rate for employee and family coverage • If more than one child continues coverage (without an adult), the coverage will be set up under the youngest

child's identification number and they will be charged the rate for employee and child(ren) coverage

*Disability extension: Qualified medical plan beneficiaries, who have been determined by the Social Security Administration to be disabled and are eligible for the 11-‐month disability extension of COBRA coverage, will be charged 150% of the applicable cost during the additional months of COBRA coverage (up to 11 months). Individuals with HMO coverage should consult their HMO’s Evidence of Coverage for information regarding COBRA coverage.


2013-‐2014 Plan Year

Total Monthly Cost of COBRA Coverage*

ActiveCare 1-‐HD ActiveCare 2 ActiveCare 3

Coverage Category Total Cost** Total Cost** Total Cost** Employee Only $331.50 $539.58 $811.92 Employee and Spouse $809.88 $1,227.06 $1,846.20 Employee and Child(ren) $583.44 $857.82 $1,294.38 Employee and Family $1,081.20 $1,349.46 $2,029.80




(formerly Valley Baptist Health Plans)

Coverage Category Total Cost* Total Cost* Total Cost* Employee Only $394.22 $421.69 $389.70 Employee and Spouse $999.66 $958.90 $954.76 Employee and Child(ren) $629.98 $672.18 $614.92 Employee and Family $1,009.64 $1,064.41 $974.24

2014-‐2015 Plan Year

Total Monthly Cost of COBRA Coverage*

ActiveCare 1-‐HD ActiveCare Select ActiveCare 2

Coverage Category Total Cost** Total Cost** Total Cost** Employee Only $331.00 $459.00 $566.00 Employee and Spouse $867.00 $1,064.00 $1,312.00 Employee and Child(ren) $583.00 $723.00 $892.00 Employee and Family $1,167.00 $1,262.00 $1,349.00




Coverage Category Total Cost* Total Cost* Total Cost* Employee Only $390.30 $454.21 $408.05 Employee and Spouse $989.66 $1,032.83 $988.84 Employee and Child(ren) $623.68 $724.02 $639.53 Employee and Family $999.54 $1,146.48 $1,008.85

*Includes 2% administrative fee **Includes 2% administrative fee; qualified medical plan beneficiaries, who have been determined by the Social Security Administration to be disabled and are eligible for the 11-‐month disability extension of COBRA coverage, will be charged 150% instead of 102% of the applicable cost during the additional 11 months of COBRA coverage.


When COBRA Coverage Ends COBRA continuation coverage ends if: • The benefits continuation period expires (COBRA participants will receive an End of Eligibility Notice 60 days prior

to the expiration of their continuation period). • Premiums are not paid within 30 days of the due date. • The COBRA participant becomes covered under another group health plan either as an employee, spouse or

dependent. • The COBRA participant becomes entitled to Medicare benefits. • TRS-‐ActiveCare no longer provides group medical coverage for public school employees.

There is no conversion privilege available for any of the TRS-‐ActiveCare medical or HMO plans.


Online Resources Website Features You can access helpful information and administrative forms from Aetna, WellSystems and HMOs through the TRS-‐ActiveCare website, www.trs.state.tx.us/trs-‐activecare. Aetna, WellSystems, Caremark, FirstCare Health Plans, Scott & White Health Plan and Allegian Health Plans are solely responsible for the accuracy and security of information maintained on or through their websites. The chart below highlights online capabilities and features available by plan option for Benefits Administrators to use for TRS-‐ActiveCare enrollment and plan maintenance. To get to a specific website, go to www.trs.state.tx.us/trs-‐activecare and select the desired website.

Teacher Retirement System of Texas (TRS) Health Benefits For Benefits Administrators

Provider Locator Frequently Asked Questions Enrollment Guide Enrollment Application and Change Form

TRS-‐ActiveCare WellSystems Enrollment Portal Enrollment Orientation Presentation Enrollment Orientation Videos Exception and Appeals Portal Current and Historical Monthly Bills Forms Employee Communication Campaign (Health and Wellness Communications)

ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 Aetna and Caremark

Health Benefits Pharmacy Benefits www.trsactivecareaetna.com Aetna Navigator

Find a Doctor or Hospital Enrollment Guide Forms Benefits Booklet Contact Information Request ID Cards Complete a Health Assessment Personal Health Record View Claim History Member Payment Estimator

Pharmacy Benefits Retail Pharmacy Locator Drug Name Search Preferred Drug List Access Claims and Balances Maintenance Drug List Mail-‐Order Forms Online Refills


FirstCare Health Plans Health Benefits Pharmacy Benefits

Forms Provider Locator Evidence of Coverage Schedule of Copayments Participant Handbook ID Card Request PCP Change View Claims Contact Information

Pharmacy Benefits Retail Pharmacy Search Drug Name Search Copays Preferred Drug List Formulary Alternatives


Health Benefits Pharmacy Benefits Provider Locator Summary of Benefits Evidence of Coverage Explanation of Benefits (EOB) Enrollee Handbook Medicare Notice Online Suite of Lifestyle Management Programs

Health Risk Assessment, Weight Management, Nutrition, Care for Your Back, Smoking Cessation, Stress, Depression and Much More

VitalCare 24-‐hour Nurse Advice Line The Dialog Center Complex Care Guidance Audio Library (more than 200 health topics) Disease and Condition Management Tools ID Card Request PCP Change Contact Information View Claims Educational Materials and Tools Research Health Conditions Preventive Health Guidelines Online Member Newsletters Cancer Prevention and Care Maternity Related Topics

Pharmacy Benefits Pharmacy FAQs Retail Pharmacy Locator Formulary Copays Pharmacy Refills Pharmacy Claim Information Drug Pricing Drug Information

Allegian Health Plans, formerly Valley Baptist Health Plans Health Benefits Pharmacy Benefits

Forms Provider Locator Evidence of Coverage ID Card Request PCP Change View Claims Contact Information

Pharmacy Benefits Retail Pharmacy Search Drug Name Search Copays Preferred Drug List Formulary Alternatives


Supplies Enrollment Guides will be available online. Printed copies are not available. Benefits Booklets for the ActiveCare 1-‐HD, ActiveCare Select and ActiveCare 2 medical plans will be available online. Printed copies are not available. The online version of the Benefits Booklet is the official TRS statement on benefits. TRS-‐ActiveCare benefits will be paid according to the Benefits Booklet and other legal documents governing the plan. Post-‐enrollment and additional materials for HMO coverage should be obtained directly from the HMO. Contact your HMO account manager for assistance.

2014-2015 Health Plans

Exhibits


Forms

Enrollment Application and Change Form

ELIGIBILTY: Are you an active employee and making monthly contributions to TRS? ☐ Yes ☐ No If no, are you regularly scheduled to work 10 or more hours per week? ☐ Yes ☐ No

(If no to both, you are not eligible for TRS-ActiveCare coverage)

SECTION 1: ENROLLMENT/CHANGE TRANSACTION TYPE

□ Annual Enrollment ☐ New Employee ☐ Add Dependent ☐ Special Enrollment

□ For New Employee (check one):☐Effective on Actively at Work ☐Effective 1st day of month following

For District Use Only

TRS District #

Actively at Work Date:

Special Enrollment Event Date: __ /__ /____ ☐Marriage ☐Court Order ☐Birth/Adoption

☐ Loss of Coverage ☐Other: Effective/Change Date:

Change Only: ☐ Name

☐Address

☐Plan/Coverage

Decline Coverage: ☐Yes (Complete Section 6) ☐N/A

Cancel Employee ☐Death ☐Loss of Eligibility ☐Retirement/Terminated ☐Non-Payment ☐Other: _____________

Cancel Dependent ☐Divorce ☐Death ☐Loss of Eligibility ☐Dropped Coverage ☐Other: ____________

Employer Approval:

Effective Date of Change/Cancel _____ / _____ / _________

Were you covered by another district? ☐ Yes ☐ No

If so, which: _______________ SECTION 2: EMPLOYEE INFORMATION Last Name: First Name: MI: Social Security #: Mailing Address: City: State: Zip: Home Phone Number: Cell Phone Number: Email: Date of Birth: Sex: ☐M ☐F Language: ☐ English ☐Spanish Ethnicity: Do you have a disability affecting your ability to communicate or read? ☐Yes (Please complete Section 8) ☐ No

Is the Employee Covered By Other Insurance? ☐Yes Carrier/Plan: ☐No

Is the Employee Covered by Medicare? ☐Yes ☐Part A ☐Part B ☐Part C ☐Part D Effective: ☐No

Reason for Medicare Coverage: ☐ Entitlement Age ☐ Disability ☐End Stage Renal Disease (ESRD) SECTION 3: COVERAGE SELECTION (Please select a Plan of Coverage – Plan or HMO - and Coverage Type) Plan Selection: ☐ActiveCare 1-HD ☐ActiveCare Select ☐ActiveCare 2 HMO Selection: ☐FirstCare Health Plans ☐Scott & White Health Plan ☐Allegian Health Plans (formerly Valley Baptist Health Plans)

Coverage Type Selected: ☐Employee Only ☐Employee + Spouse ☐Employee + Child(ren) ☐Employee + Family SECTION 4: DEPENDENT INFORMATION (Use additional form for additional dependents)

SPOUSE Last Name: First Name: MI: Street Address: ☐Same as Employee

City: State: Zip: Phone Number:

Sex: ☐M ☐F Date of Birth: Social Security #: Other Insurance: ☐Yes. Carrier/Plan ☐No ☐Medicare: ☐Part A ☐Part B ☐Part C ☐Part D CHILD Last Name: First Name: MI:

☐Natural/Adopted ☐Stepchild ☐Foster Child ☐Grandchild ☐Legal Guardian ☐Disabled ☐ Other Street Address: ☐Same as Employee City: State: Zip Code: Phone Number:

Date of Birth: Social Security #: Sex: ☐M ☐F Other Insurance: ☐Yes. Carrier/Plan ☐No ☐Medicare: ☐Part A ☐Part B ☐Part C ☐Part D

CHILD Last Name: First Name: MI: ☐Natural/Adopted ☐Stepchild ☐Foster Child ☐Grandchild ☐Legal Guardian ☐Disabled ☐ Other

Street Address: ☐Same as Employee City: State: Zip Code: Phone Number:


PLEASE CONTINUE ON NEXT PAGE

Applicant Signature: __________________________________________________________________ Date: ________________________

SECTION 8: SPECIAL NOTES REGARDING MY ENROLLMENT (Please indicate any special information regarding my enrollment for Aetna, Caremark or my selected HMO)

CHILD Last Name: First Name: MI:

☐Natural/Adopted ☐Stepchild ☐Foster Child ☐Grandchild ☐Legal Guardian ☐Disabled ☐ Other Street Address: ☐Same as Employee City: State: Zip Code: Phone Number:


CHILD Last Name: First Name: MI: ☐Natural/Adopted ☐Stepchild ☐Foster Child ☐Grandchild ☐Legal Guardian ☐Disabled ☐ Other

Street Address: ☐Same as Employee City: State: Zip Code: Phone Number: Date of Birth: Social Security #: Sex: ☐M ☐F: Other Insurance: ☐Yes. Carrier/Plan ☐No ☐Medicare: ☐Part A ☐Part B ☐Part C ☐Part D

SECTION 5: DISABLED DEPENDENTS OVER AGE 26 ☐Request for Continuation of Coverage for Handicapped Child form and Attending Physician’s Statement

Please note that a Request for Continuation of Coverage for Handicapped Child form and Attending Physician’s Statement are required for coverage of a disabled child over age 26. See your Benefits Administrator for the forms, which must be completed in full and submitted to your Benefits Administrator.

SECTION 6: DECLINATION OF COVERAGE This is to certify that the available coverage has been explained to me. I have been given the opportunity to apply for the coverage available to me and my dependents and have voluntarily elected to decline the coverage as elected below.

Name: SSN: ☐Employee Reason: ☐Other Coverage ☐Other: Name: ☐Spouse Reason: ☐Other Coverage ☐Other: Name: ☐Child Reason: ☐Other Coverage ☐Other: Name: ☐Child Reason: ☐Other Coverage ☐Other: Name: ☐Child Reason: ☐Other Coverage ☐Other: Name: ☐Child Reason: ☐Other Coverage ☐Other:

SECTION 7: COVERAGE CONDITIONS • I am employed by the Employer named in this Enrollment Application and Change Form. I am eligible to participate in the coverage(s) offered by the

TRS-ActiveCare program which is administered by Aetna, with HMO benefits provided by SHA, L.L.C. dba FirstCare Health Plan, Scott and White Health Plan, and Allegian Insurance Company dba Allegian Health Plans. On behalf of myself and any dependents listed on their Enrollment Application and Change Form, I apply for those coverage(s) for which I am eligible. o If I am enrolling a grandchild in Section 4, I certify that my household is the grandchild’s primary residence and the grandchild is my dependent

for federal income tax purposes for the reporting year in which coverage of the grandchild is in effect. o If I am enrolling a child as an “other Child” in Section 4, I certify that my household is the child’s primary residence, that I provide at least 50% of

the child support, that neither of the children’s natural parents reside in my household, and that I have the legal right to make decisions regarding the child’s medical care.

• Only those coverage(s) and amount for which I am eligible will be available to me. I understand that if this Enrollment Application and Change Form is accepted, the coverage(s) will become effective in accordance with the provisions or the TRS-ActiveCare program.

• I understand that by enrolling for coverage with Employer named in the Enrollment Application and Change Form that any TRS-ActiveCare coverage I previously elected under another TRS-ActiveCare participating district/entity will be terminated under TRS Rules.

• I authorize necessary payroll deduction by my Employer, if any, to cover the cost of my coverage(s). I agree that my Employer acts as my agent. All notices given to my Employer are binding upon me. I also agree that my participation in the coverage(s) is subject to any future amendments.

• I understand that by declining TRS-ActiveCare coverage now or by terminating TRS-ActiveCare coverage during the plan year, I am not eligible to re-enroll in TRS-ActiveCare until the next plan year, unless I experience a special enrollment event.

• I state that the information given on the Enrollment Application and Change Form is true and correct. I understand and agree that any incorrect statements material to the risk and knowingly made by me will invalidate my coverage(s).

Application to Split Premium

Submit to: WellSystems Via Your Enrollment Coordinator's Dedicated Fax or E-Mail

Please Print in Blue or Black Ink.

This form is to be completed by both husband and wife who wish to split the cost of employee and spouse or employee and family coverage while being employed by different districts/entities participating in TRS-ActiveCare. The Employee identified in SECTION 1 is required to select a plan under TRS-ActiveCare. The employee's spouse, identified in SECTION 3, is required to decline (waive) TRS-ActiveCare coverage. The employing district/entity for EACH person must also complete SECTIONS 2, 4 and 5 as appropriate. The cost for TRS-ActiveCare coverage will be split between the two employers. Each employer will be billed 50 percent of the total cost of the TRS-ActiveCare plan selected by the employee in SECTION 1. The entity employing the spouse who declined coverage will consider the employee as covered under a group health plan for funding purposes. SECTION 1- TO BE COMPLETED BY THE EMPLOYEE that has elected employee and spouse or employee and family coverage Employee Last Name First Name MI

Employee Social Security Number

- -

I have elected employee and spouse or employee and family coverage , and I elect to split the cost of coverage 50/50 with my spouse. Employee Signature: ______________________________________________________________ Date: ______________________________ SECTION 2 – TO BE COMPLETED BY EMPLOYER of the employee in Section 1 District/Entity Name TRS Reporting Number

Health Benefits Plan (Check One)

Plan: □ActiveCare 1-HD □ActiveCare Select □ActiveCare 2

HMO: □FirstCare Health Plans □Scott & White Health Plan □Allegian Health Plans (formerly Valley Baptist Health Plans) I confirm this employee is an active employee enrolled for TRS-ActiveCare coverage. I understand that the cost of this employee's coverage will be split 50/50 between our district/entity and the participating district/entity of the employee's spouse. Employer Verification Signature: ___________________________________________________________Date: ________________________ SECTION 3 – TO BE COMPLETED BY EMPLOYEE that will be declining coverage Employee Last Name First Name MI

Employee Social Security Number

- -

I elect to split the cost of coverage 50/50 with my spouse. I have declined TRS-ActiveCare coverage under my participating district/entity and will be covered as a dependent of my spouse as listed in Section 1. Employee Signature: ______________________________________________________________ Date: ______________________________ SECTION 4 – TO BE COMPLETED BY EMPLOYER of the employee in Section 3 District/Entity Name TRS Reporting Number

I confirm this employee is an active employee who has declined TRS-ActiveCare coverage. I understand that 50 percent of the cost of coverage elected by this employee's spouse will be billed to our district/entity. Employer Verification Signature: ___________________________________________________________Date: ________________________

SECTION 5 – TO BE COMPLETED BY EMPLOYER of the employee in Section 3 to TERMINATE SPLIT PREMIUM District/Entity Name TRS Reporting Number

Please terminate the split premium funding arrangement for this employee. Effective Date:

Employer Verification Signature: _____________________________________________________________________ Date: ___________________________

COBRA Transmittal Form

If you have any questions about how to complete this form, please contact your WellSystems Enrollment Coordinator. Hours of operation are Monday – Friday, 8:00am – 5:00pm (EST).

Please return completed form and any additional documentation to your Enrollment Coordinator via fax or email.

Information About Your District/Entity www.trs.state.tx.us/trs-activecare

1. District/Entity Name: ______________________________________________________________

2. TRS Report Number:

3. Effective Date with TRS-ActiveCare:

MM DD YYYY

4. Address: Street Address City State Zip Code

5. Benefits Administrator Name: ________________________________________________________

6. Benefits Administrator Phone Number: (_____) ______________ Fax Number (____) ____________

7. Internet/Email Address (if available) __________________________________________________ 8. Attach a complete list of COBRA participants or dependents, including all information listed below.

ELECTING BENEFICIARY ELECTING BENEFICIARY DEPENDENT(S)

Name Address Social Security Number Date of Birth Qualified Event Date Qualified Event Reason Most recent payment and amount date Current paid-to date of COBRA premiums Type of coverage elected

Name Address (if different) Social Security Number Date of Birth Type of coverage elected

9. Name/Contact of Prior COBRA Administrator (if applicable):

___________________________________________________________________________________ Signature: __________________________________________________________Date: _____________

(Form Completed By)

Transition Coverage Request Personal and confidential Fully insured commercial members in California should not use this form

On the other side of this form, you’ll find answers to commonly asked questions about transition-of-care coverage. Please read them before filling out this form.

This is a request for Aetna to cover ongoing care at the highest level of benefits from: • An out-of-network doctor • A doctor whose Aexcel,® or plan sponsor specific network status has changed • Certain other health care providers who have treated you Once we review your completed form, we will send you a letter explaining our decision regarding your request for transition-of-care coverage. Step 1: Fill out these sections:

1. Section 1 (Group or employer information) 2. Section 2 (Subscriber and patient information): Aetna plan information is on the front of the Aetna ID card. 3. Section 3 (Authorization): Read the authorization, then sign and date the form.

Step 2: Give the form to the doctor/health care provider to complete Section 4, including the diagnostic and treatment information requested on page 4.

Step 3: Fax the completed form to Aetna for review. Note: Complete one form for each health care provider.

Note: A request for transition-of-care coverage does not apply if your provider is in Aetna’s network (participating) or is part of your plan’s highest benefit tier. Our DocFind® online provider directory is at www.aetna.com. It can tell you if your doctor is in the network or help you find a participating provider for your Aetna plan. You can also call us at the phone number on your Aetna ID card.

Fax medical and mental health/substance abuse requests to:

TRS-ActiveCare Customer Service at 1-855-369-8891

Be sure to complete all fields on pages 3 and 4 before you submit this request form. It will speed up processing of your transition-of-care request.

GC-16440 (6-14)

Aetna transition-of-care coverage questions and answers Q. What is transition-of-care (TOC) coverage? A. TOC coverage is temporary coverage. You can receive TOC when you become a new member of an Aetna medical benefits plan or change

your current Aetna medical plan, and you are being treated by a doctor who: • Is not in the Aetna network • Is not included in Aexcel, tier 1 (for tiered network plans) or plan sponsor specific networks, and your benefits change to include one of

these networks TOC coverage can also apply to you even if you do not change your current Aetna medical plan, but your treating doctor leaves the Aetna network or changes network status, which affects your benefits. TOC coverage is not for primary care physicians (PCPs) who are not in the Aetna network, except when the PCP leaves the Aetna network during your plan year and you are receiving treatment, or if certain laws or regulations apply. Approved TOC coverage allows a member who is receiving treatment to continue the treatment for a limited time at the highest plan benefits level. TOC coverage is only for the requested doctor. Except in New York, TOC coverage does not include health care facilities, durable medical equipment (DME) vendors or pharmaceutical items (also see second question below). If the TOC coverage is approved, the doctor must use a health care facility, DME vendor or pharmacy vendor in the Aetna network. If you want to request coverage for a vendor or facility outside the Aetna network, call the Member Services phone number on your Aetna member ID card and ask for a nonparticipating request form.

Q What is an active course of treatment? A. An active course of treatment means you have begun a program of planned services with your doctor to correct or treat a diagnosed condition. The start date is the first date of service or treatment. An active course of treatment covers a certain number of services or period of treatment for special situations. Some active course-of-treatment examples may include, but are not limited to:

• Members who enroll with Aetna after 20 weeks of pregnancy, unless there are specific state or plan requirements (Members less than 20 weeks pregnant whom Aetna confirms as high risk are reviewed on a case-by-case basis.)

• Members who have completed 14 weeks of pregnancy or more and are receiving care from an Aetna participating practitioner whose network status changes.

• Members in an ongoing treatment plan, such as chemotherapy or radiation therapy • Members with a terminal illness who are expected to live six months or less • Members who need more than one surgery, such as cleft palate repair • Members who have recently had surgery • Members who receive outpatient treatment for a mental illness or for substance abuse (The member must have had at least 1 treatment

session within 30 days before the status of the member or the participating health care provider changed.) • Members with an ongoing or disabling condition that suddenly gets worse • Members who may need or have had an organ or bone marrow transplant To be considered for TOC coverage, treatment must have started before the enrollment or re-enrollment date, or before the date your doctor left the Aetna network, or before the date a doctor’s network status changed.

Q. What other types of providers, besides doctors, can be considered for TOC coverage? A. This includes health care professionals such as physical therapists, occupational therapists, speech therapists and agencies that provide skilled

home care services, such as visiting nurses. TOC is considered for participating hospitals only when the facility is not designated as a tier 1 facility for plans that include tiered networks. TOC does not apply to other health care facilities (for example, skilled nursing facility), DME vendors or pharmaceutical items.

Q. If I am currently receiving treatment from my doctor, why wouldn’t my request for TOC coverage be approved? A. If you are currently receiving treatment, the procedure or service must be a covered benefit. Your doctor must also agree to accept the terms outlined on the TOC request form. Q. My PCP is no longer an Aetna provider. If my plan requires me to select a PCP, can I still see my doctor? A. If you are currently receiving treatment, you may still be able to visit your PCP, even if he/she leaves the network. In all states, except Texas

and New Jersey, you may need to select a PCP in the Aetna network. In Texas and New Jersey, TOC may apply to PCPs. Talk to your PCP so that he/she can help you with your future health care needs.

Q. How long does TOC coverage last? A. Usually, TOC coverage lasts 90 days, but this may vary based on your condition (for example, pregnancy). We will tell you if your TOC

coverage request is approved and how long the coverage will last. Q. How do I sign up for TOC coverage? A. Contact your employer or benefits department. You must submit a TOC request form to Aetna:

• Within 90 days of when you enroll or re-enroll • Within 90 days of the date the health care provider left the Aetna network • Within 90 days of a doctor’s network status change You or your doctor can send in the request form.

Q. How will I know if my request for TOC coverage is approved? A. We will send you a letter via U.S. mail. The letter will say whether or not you are approved. Q. Does TOC coverage apply to the Traditional Choice® or Medicare Advantage PPO ESA (extended service area) plans? A. No. Q. What if I have an Aexcel or plan sponsor specific network plan? A. If TOC coverage is approved, you may still receive care at the highest benefits level for a certain time period. If you continue treatment with this

doctor after the approved time period, your coverage would follow what is stated in your plan design. This means you may have reduced benefits or no benefits.

Q. What if I have more questions about TOC coverage? A. Call the Member Services phone number on your Aetna ID card. If you have questions about TOC mental health services, you can call the

Member Services phone number on your Aetna ID card or, if listed, the mental health or behavioral health number. GC-16440 (6-14)


Medical Mental Health/Substance Abuse

Please indicate above whether this request is for medical treatment or mental health/substance abuse treatment. 1. Group or employer information (Note: Complete a separate form for each member and/or provider.) Group or employer’s name (Please print)

TRS-ActiveCare Plan control number

Plan effective date (Required)

2. Subscriber and patient information Subscriber’s name (Please print)

Subscriber’s Aetna ID number

Subscriber’s address (Please print)

Patient’s name (Please print)

Birthdate (MM/DD/YYYY)

Patient’s address (Please print)

Telephone number

Plan type/product

Telephone number for patient/subscriber submitting request (Business hours, 9 a.m. – 5 p.m.)

Last date of treatment before beginning Aetna coverage (as applicable)

3. Authorization I request approval for coverage of ongoing care from the health care provider named below for treatment started before my effective date with Aetna, or before the end of the provider’s contract with the Aetna network, or before the provider’s network status change. If approved, I understand that the authorization for coverage of services stated below will be valid for a certain period of time. I give permission for the health care provider to send any needed medical information and/or records to Aetna so a decision can be made. Patient’s signature (Required if patient is age 17 or older)

Date (MM/DD/YYYY)

Parent’s signature (Required if patient is age 16 or younger)

Date (MM/DD/YYYY)

4. Provider information (Note: Provide all specific information to avoid delay in the processing of this request.) Name of treating doctor or other health care provider (Please print)

Telephone number

Contact name of office personnel to call with questions

Address of treating doctor or other health care provider (Please print)

Tax ID number

Signature of treating doctor or other health care provider

Date (MM/DD/YYYY)

The above-named patient is an Aetna member as of the effective date indicated above. We understand you are not or soon will not be a participating provider in the Aetna network. The patient has asked that we cover your care for a specific time period. This is because of a condition, such as pregnancy, that is considered an active course of treatment. An active course of treatment is defined as: “A program of planned services starting on the date the provider first renders a service to correct or treat the diagnosed condition and covering a defined number of services or period of treatment and includes a qualifying situation.” Please include a brief statement of the patient’s current condition and treatment plan. For pregnancies, please indicate the estimated date of confinement (EDC). If we approve this request, you agree:

• To provide the patient’s treatment and follow-up • Not to seek more payment from this patient other than the patient responsibility under the patient’s plan of benefits

(for example, patient’s copayment, deductibles or other out-of-pocket requirements) • To share information on the patient’s treatment with us

You also agree to use the Aetna network for any referrals, lab work or hospitalizations for services not part of the requested treatment. In New York State, the provider completing the form may not be leaving the network, but may request continuing care to be provided by a hospital that is leaving the network.

GC-16440 (6-14)


Patient’s name (Please print)

Birthdate (MM/DD/YYYY)

Provider: Please complete the diagnostic and treatment information below describing the active course of treatment.

Description of all medical and behavioral health-related diagnoses (for example, pregnancy, cancer, depression, post-operative). Include all ICD codes:

Description of all treatment and procedures. Include all CPT codes:

Date of original surgery, if applicable:

Date care was initiated:

Dates of current treatment: (Please provide copies of medical records from the last office visit.)

Number of additional visits needed : (For pregnancy, please include EDC.)

GC-16440 (6-14)

Misrepresentation Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Attention Alabama Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Attention Arkansas, District of Columbia, Rhode Island and West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention California Residents: For your protection California law requires notice of the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Attention Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Attention Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Attention Kansas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Attention Louisiana Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application is guilty of a crime and may be subject to fines and confinement in prison. Attention Maine and Tennessee Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. Attention Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention Missouri Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, denial of insurance and civil damages, as determined by a court of law. Any person who knowingly and with intent to injure, defraud or deceive an insurance company may be guilty of fraud as determined by a court of law. Attention New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy or knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Attention New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. Attention North Carolina Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and subjects such person to criminal and civil penalties. Attention Ohio Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Attention Oklahoma Residents: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Attention Oregon Residents: Any person who with intent to injure, defraud, or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Attention Puerto Rico Residents: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. Attention Texas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose of misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention Vermont Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention Virginia Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and civil penalties. Attention Washington Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

GC-16440 (6-14)

Request for Continuation of Coverage for Handicapped Child

Employee Instructions: • Complete sections 1 through 8 on this form. • Please print the information requested, with the exception of the

signature section. • Ask your physician to complete the Attending Physician's

Statement and return the form to you. • Send or fax this completed form along with the completed

Attending Physician's Statement to: Aetna PO Box 981106 El Paso, TX 79998-1106 FAX: 859-455-8650 You and your employer will be notified of the denial or approval of this request.

Note: Aetna has the right to: • Require proof of the continuation of the handicap. • Examine or require examination of your child (at his/her/your

own expense) as often as needed while the handicap continues.

• Require an exam no more than each year after 2 years from the date your child reached the maximum age.

Continuation of coverage will cease on the first to occur of: • Cessation of handicap. • Failure to give proof that the handicap continues. • Failure to have any required exam. • Termination of your dependent child coverage for a reason

other than reaching the maximum age. 1. Employee

Information Name

Aetna ID Number

Address (street, city, state, zip code)

2. Employer Information

Name

Policy Number

Effective Date of Coverage

3. Prior Plan Information

Was the dependent previously covered under the employee’s plan? No Yes If Yes, date prior plan

started ended

Name and Telephone Number of Prior Carrier

4. Employee Statement

I represent that, to the best of my knowledge and beliefs, the statement and answers made by me on this form are complete and correct. I understand that continuation of coverage for a handicapped dependent is subject to approval by Aetna based on the applicable health benefits plan and the documentation submitted to Aetna in support of this request for continuation of coverage. Employee's Signature Date

5. Physician Information

Attending Physician's Name Attending Physician's Address (street, city, state, zip code) Attending Physician's Telephone Number

6. Employee Signature and Release

To all providers of health care: You are authorized to provide Aetna Life Insurance Company or one of its affiliated companies (“Aetna”), and any independent claims administrators, consulting health professionals and utilization review organizations with whom Aetna has contracted, information concerning health care advice, treatment or supplies provided to the patient (including that relating to mental illness and/or AIDS/ARC/HIV). This information will be used to evaluate a request for coverage. This authorization is valid for the term of the plan under which a claim has been submitted. I know that I have a right to receive a copy of this authorization upon request and agree that a photographic copy of this authorization is as valid as the original. Employee's Signature Date

7. Dependent Information

Name

Birth Date (MM/DD/YYYY)

Social Security Number

Relationship to Employee:

8. Handicap Child Information

When did the incapacity start? Mental Incapacity Date Physical Incapacity Date

Schools or Jobs

Has this dependent been attending school or a training facility since reaching the limiting age of the plan?

Yes No Education Level Reached

List Schools/Facilities Attended Dates (mm/dd/yyyy) Custodial Care Name of School/Facility From To Facility Yes No Yes No Yes No

GC-463 (1-14) A-POD Page 1 of 3

Work History

Has dependent been working? Yes No If Yes, provide the name of the employer and the dates of employment: Hours Hourly

Name Dates of Employment worked weekly Wage Description of duties If No, how does the dependent's incapacity prevent employment?

Living Arrangements

Does dependent live at home?

Yes No If No, where does the dependent live? Financial Support

Do you regularly provide more than one-half the financial support for this dependent? Yes No If No, please explain:

Do you claim this person as a dependent for Federal Income Tax purposes?

Yes No Is this dependent eligible for any other privately or publicly funded health benefits?

Yes No If Yes, please explain: 9. Misrepresentation Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Attention Alabama Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Attention Arkansas, District of Columbia, Rhode Island and West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention California Residents: For your protection California law requires notice of the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Attention Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Attention Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Attention Kansas and Missouri Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Attention Louisiana Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application is guilty of a crime and may be subject to fines and confinement in prison. Attention Maine and Tennessee Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. Attention Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy or knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Attention New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. Attention North Carolina Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and subjects such person to criminal and civil penalties. Attention Ohio Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Attention Oklahoma Residents: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Attention Oregon Residents: Any person who with intent to injure, defraud, or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Attention Puerto Rico Residents: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. Attention Texas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose of misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention Vermont Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention Virginia Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and civil penalties. Attention Washington Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

GC-463 (1-14) Page 2 of 3

GC-463 (1-14) Page 3 of 3

Handicapped Child Attending Physician's Statement/ Behavioral Health Attending Physician’s Statement Please print the information requested, with the exception of the signature section.

Employee Instructions: Attending Physician Instructions: � Complete sections 1-3. � Complete sections 4-6 and return the completed form to the employee.

1. Employer Information

Name (as shown on ID card)

Policy/Group Number

2. Employee Information

Name

ID Number


3. Dependent Child Information

Name


4. Physician’s Statement

For medical conditions, please complete section A below. For behavioral health conditions, please complete sections A and B below. For all conditions, you may refer to section C below, Use of the Social Security Disability Guidelines, to quantify an individual’s disability or handicap.

A. Medical and Behavioral Health conditions:

I. Diagnosis(es):

II. Date of onset of the handicap:

III. Objective findings that substantiate impairment:

IV. Please provide any additional clinical information that supports how the individual’s handicap prevents employment (applicable to individuals over age 18):

B. Behavioral Health conditions , please provide:

I. The individual’s IQ score and,

II. A functional assessment. Include communication ability, presence of intrusive psychiatric symptoms, stability,

response to treatment and prognosis (continue on a separate page if necessary):

C. Use of the Social Security Disability Guidelines: To quantify an individual’s disability or handicap, refer to the Social Security disability guidelines found at: www.ssa.gov/disability/professionals/bluebook/ChildhoodListings.htm (for dependents age 18 and younger) OR www.ssa.gov/disability/professionals/bluebook/AdultListings.htm (for dependents over age 18).

Using the appropriate set of guidelines, select the individual’s affected body system(s). If your patient qualifies, please document the corresponding “listing” from the guidelines under which the handicap(s) falls. Note: Satisfying the Social Security listing level impairment requirements does not ensure a determination of disability or handicap under the individual’s Aetna plan. These Guidelines are only offered as a means to solicit submission of appropriate clinical information.

Documentation on this form should include:

I. Diagnosis(es):

II. Listing number(s):

Documents and medical records showing how the individual qualifies under a Social Security Disability listing must be submitted with this form.

5. Attending Physician Contact Information (required) Attending Physician's Name, Telephone Number and Address (include street, city, state, zip code)

Attending Physician's Signature (required)

Date

6. Other Treating Physicians

Please list the name, address and telephone number of other physicians or other health care providers you are aware of who are currently treating this

individual for his or her mental or physical incapacity.

GC-464 – 2-14) A-POD

7. Misrepresentation

Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Attention Alabama Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Attention Arkansas, District of Columbia, Rhode Island and West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention California Residents: For your protection California law requires notice of the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Attention Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Attention Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Attention Kansas and Missouri Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Attention Louisiana Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application is guilty of a crime and may be subject to fines and confinement in prison. Attention Maine and Tennessee Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. Attention Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy or knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Attention New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. Attention North Carolina Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and subjects such person to criminal and civil penalties. Attention Ohio Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Attention Oklahoma Residents: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Attention Oregon Residents: Any person who with intent to injure, defraud, or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Attention Puerto Rico Residents: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. Attention Texas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose of misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention Vermont Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention Virginia Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and civil penalties. Attention Washington Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

GC-464 (2-14)

DISTRICT/ENTITY REPRESENTATIVE WEBSITE AUTHORIZATION

Authorized district/entity representatives can be granted access to WellSystems’ secure web portals for coverage inquiries/updates and Exception and Appeals processing. Each user’s access must be authorized by the district’s/entity’s Benefits Administrator.

To request website access, please provide the names and email addresses of the representatives from your district/entity and type of access requested. Please note any district/entity currently using an online enrollment vendor will have read-only access to the employee coverage/update portal.

A welcome email with username and login instructions will be provided to the email address listed.

AUTHORIZED DISTRICT/ENTITY REPRESENTATIVE

First Name:

Last Name:

Title:

Email Address:

Phone:

Access to Employee Coverage Portal (Y/N) Access to Exception and Appeal Portal (Y/N)


First Name:

Last Name:

Title:

Email Address:

Phone:


*If additional representatives are needed, please use the back of this form.

Benefits Administrator or Authorized Representative Signature: __________________________________________

Date: ______________________

Region: _____________________ District/Entity: ____________________


First Name:

Last Name:

Title:

Email Address:

Phone:



First Name:

Last Name:

Title:

Email Address:

Phone:



First Name:

Last Name:

Title:

Email Address:

Phone:



Notices

1

COBRA Continuation Coverage Election Notice IMPORTANT INFORMATION: COBRA Continuation Coverage and other Health Coverage Alternatives Dear: This notice has important information about your right to continue your health care coverage in the [enter name of group health plan] (the Plan), as well as other health coverage options that may be available to you, including coverage through the Health Insurance Marketplace at www.HealthCare.gov or call 1-800-318-2596. You may be able to get coverage through the Health Insurance Marketplace that costs less than COBRA continuation coverage. Please read the information in this notice very carefully before you make your decision. If you choose to elect COBRA continuation coverage, you should use the election form provided later in this notice. Why am I getting this notice? You’re getting this notice because your coverage under the Plan will end on [date] due to: End of employment Reduction in hours of employment Death of employee Divorce or legal separation Entitlement to Medicare Loss of dependent child status Federal law requires that most group health plans (including this Plan) give employees and their families the opportunity to continue their health care coverage through COBRA continuation coverage when there’s a “qualifying event” that would result in a loss of coverage under an employer’s plan. What’s COBRA continuation coverage? COBRA continuation coverage is the same coverage that the Plan gives to other participants or beneficiaries who aren’t getting continuation coverage. Each “qualified beneficiary” (described below) who elects COBRA continuation coverage will have the same rights under the Plan as other participants or beneficiaries covered under the Plan. Who are the qualified beneficiaries?

http://www.healthcare.gov/

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Each person (“qualified beneficiary”) in the category(ies) checked below can elect COBRA continuation coverage: Employee or former employee Spouse or former spouse

Dependent child(ren) covered under the Plan on the day before the event that caused the loss of coverage Child who is losing coverage under the Plan because he or she is no longer a dependent

Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other more affordable coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You should compare your other coverage options with COBRA continuation coverage and choose the coverage that is best for you. For example, if you move to other coverage you may pay more out of pocket than you would under COBRA because the new coverage may impose a new deductible. When you lose job-based health coverage, it’s important that you choose carefully between COBRA continuation coverage and other coverage options, because once you’ve made your choice, it can be difficult or impossible to switch to another coverage option. If I elect COBRA continuation coverage, when will my coverage begin and how long will the coverage last? If elected, COBRA continuation coverage will begin on [date] and can last until [date]. Continuation coverage may end before the date noted above in certain circumstances, like failure to pay premiums, fraud, or the individual becomes covered under another group health plan. Can I extend the length of COBRA continuation coverage?

If you elect continuation coverage, you may be able to extend the length of continuation coverage if a qualified beneficiary is disabled, or if a second qualifying event occurs. You must notify WellSystems of a disability or a second qualifying event within a certain time period to extend the period of continuation coverage. If you don’t provide notice of a disability or second qualifying event within the required time period, it will affect your right to extend the period of continuation coverage. For more information about extending the length of COBRA continuation coverage, visit http://www.dol.gov/ebsa/publications/cobraemployee.html.

http://www.dol.gov/ebsa/publications/cobraemployee.html

3

How much does COBRA continuation coverage cost? COBRA continuation coverage will cost: Other coverage options may cost less. If you choose to elect continuation coverage, you don’t have to send any payment with the Election Form. Additional information about payment will be provided to you after the election form is received by the Plan. Important information about paying your premium can be found at the end of this notice. You may be able to get coverage through the Health Insurance Marketplace that costs less than COBRA continuation coverage. You can learn more about the Marketplace below. What is the Health Insurance Marketplace? The Marketplace offers “one-stop shopping” to find and compare private health insurance options. In the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums and cost-sharing reductions (amounts that lower your out-of-pocket costs for deductibles, coinsurance, and copayments) right away, and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll. Through the Marketplace you’ll also learn if you qualify for free or low-cost coverage from Medicaid or the Children’s Health Insurance Program (CHIP). You can access the Marketplace for your state at www.HealthCare.gov. Coverage through the Health Insurance Marketplace may cost less than COBRA continuation coverage. Being offered COBRA continuation coverage won’t limit your eligibility for coverage or for a tax credit through the Marketplace. When can I enroll in Marketplace coverage?

You always have 60 days from the time you lose your job-based coverage to enroll in the Marketplace. That is because losing your job-based health coverage is a “special enrollment” event. After 60 days your special enrollment period will end and you may not be able to enroll, so you should take action right away. In addition, during what is called an “open enrollment” period, anyone can enroll in Marketplace coverage.

To find out more about enrolling in the Marketplace, such as when the next open enrollment period will be and what you need to know about qualifying events and special enrollment periods, visit www.HealthCare.gov.

If I sign up for COBRA continuation coverage, can I switch to coverage in the Marketplace? What about if I choose Marketplace coverage and want to switch back to COBRA continuation coverage?

If you sign up for COBRA continuation coverage, you can switch to a Marketplace plan during a Marketplace open enrollment period. You can also end your COBRA continuation coverage early and switch to a Marketplace plan if you have another qualifying event such as marriage or

https://www.healthcare.gov/do-i-qualify-for-medicaid

https://www.healthcare.gov/are-my-children-eligible-for-chip



4

birth of a child through something called a “special enrollment period.” But be careful though - if you terminate your COBRA continuation coverage early without another qualifying event, you’ll have to wait to enroll in Marketplace coverage until the next open enrollment period, and could end up without any health coverage in the interim.

Once you’ve exhausted your COBRA continuation coverage and the coverage expires, you’ll be eligible to enroll in Marketplace coverage through a special enrollment period, even if Marketplace open enrollment has ended.

If you sign up for Marketplace coverage instead of COBRA continuation coverage, you cannot switch to COBRA continuation coverage under any circumstances.

Can I enroll in another group health plan? You may be eligible to enroll in coverage under another group health plan (like a spouse’s plan), if you request enrollment within 30 days of the loss of coverage. If you or your dependent chooses to elect COBRA continuation coverage instead of enrolling in another group health plan for which you’re eligible, you’ll have another opportunity to enroll in the other group health plan within 30 days of losing your COBRA continuation coverage. What factors should I consider when choosing coverage options? When considering your options for health coverage, you may want to think about:

• Premiums: Your previous plan can charge up to 102% of total plan premiums for COBRA coverage. Other options, like coverage on a spouse’s plan or through the Marketplace, may be less expensive.

• Provider Networks: If you’re currently getting care or treatment for a condition, a change in your health coverage may affect your access to a particular health care provider. You may want to check to see if your current health care providers participate in a network as you consider options for health coverage.

• Drug Formularies: If you’re currently taking medication, a change in your health coverage may affect your costs for medication – and in some cases, your medication may not be covered by another plan. You may want to check to see if your current medications are listed in drug formularies for other health coverage.

• Severance payments: If you lost your job and got a severance package from your former employer, your former employer may have offered to pay some or all of your COBRA payments for a period of time. In this scenario, you may want to contact the Department of Labor at 1-866-444-3272 to discuss your options.

• Service Areas: Some plans limit their benefits to specific service or coverage areas – so if you move to another area of the country, you may not be able to use your benefits. You may want to see if your plan has a service or coverage area, or other similar limitations.

• Other Cost-Sharing: In addition to premiums or contributions for health coverage, you probably pay copayments, deductibles, coinsurance, or other amounts as you use your benefits. You may want to check to see what the cost-sharing requirements are for other

5

health coverage options. For example, one option may have much lower monthly premiums, but a much higher deductible and higher copayments.

For more information This notice doesn’t fully describe continuation coverage or other rights under the Plan. More information about continuation coverage and your rights under the Plan is available in your summary plan description or from the COBRA Administrator COBRA Administrator. If you have questions about the information in this notice, your rights to coverage, or if you want a copy of your summary plan description, contact: WellSystems TRS Team P.O. Box 1390 Brandon, FL 33509-1390 (855) 748-2654 For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, visit the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) website at www.dol.gov/ebsa or call their toll-free number at 1-866-444-3272. For more information about health insurance options available through the Health Insurance Marketplace, and to locate an assistant in your area who you can talk to about the different options, visit www.HealthCare.gov. Keep Your Plan Informed of Address Changes To protect your and your family’s rights, keep the COBRA Administrator informed of any changes in your address and the addresses of family members. You should also keep a copy of any notices you send to the COBRA Administrator.

http://www.dol.gov/ebsa


6

Important Information About Payment First payment for continuation coverage You must make your first payment for continuation coverage no later than 45 days after the date of your election (this is the date the Election Notice is postmarked). If you don’t make your first payment in full no later than 45 days after the date of your election, you’ll lose all continuation coverage rights under the Plan. You’re responsible for making sure that the amount of your first payment is correct. You may WellSystems to confirm the correct amount of your first payment. Periodic payments for continuation coverage After you make your first payment for continuation coverage, you’ll have to make periodic payments for each coverage period that follows. The amount due for each coverage period for each qualified beneficiary is shown in this notice. The periodic payments can be made on a monthly basis. Under the Plan, each of these periodic payments for continuation coverage is due [Date] for that coverage period You may instead make payments for continuation coverage for the following coverage periods, due on the following dates:. If you make a periodic payment on or before the first day of the coverage period to which it applies, your coverage under the Plan will continue for that coverage period without any break. The Plan will send periodic notices of payments due for these coverage periods. Grace periods for periodic payments Although periodic payments are due on the dates shown above, you’ll be given a grace period of 30 days after the first day of the coverage period to make each periodic payment. You’ll get continuation coverage for each coverage period as long as payment for that coverage period is made before the end of the grace period If you pay a periodic payment later than the first day of the coverage period to which it applies, but before the end of the grace period for the coverage period, your coverage will be suspended as of the first day of the coverage period and then retroactively reinstated (going back to the first day of the coverage period) when the periodic payment is received. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. If you don’t make a payment before the end of the grace period for that coverage period, you’ll lose all rights to continuation coverage under the Plan. Your first payment and all periodic payments for continuation coverage should be sent to:

WellSystems

PO Box 732513 Dallas, TX 75373-2513 Overnight: JP Morgan Chase (TX1-0029) Attn: WellSystems PO Box 732513 14800 Frye Road, 2nd FL Fort Worth, TX 76155

1

** Continuation Coverage Rights Under COBRA**

Introduction You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct.

2

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:

• The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross

misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.”

When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:

• The end of employment or reduction of hours of employment; • Death of the employee; • Teacher Retirement System (TRS) Commencement of a proceeding in bankruptcy with

respect to the employer;]; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to the Teacher Retirement System (TRS) and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

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Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to:

WellSystems TRS Team P.O. Box 1390 Brandon, FL 33509-1390 (855) 748-2654

How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

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Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov. Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan contact information WellSystems TRS Team P.O. Box 1390 Brandon, FL 33509-1390 (855) 748-2654


TRS-AC Rev. 3-2013

Important Notices I. Initial Notice about Special Enrollment Rights in Your Group Health Plan

A federal law called Health Insurance Portability and Accountability Act (HIPAA) requires that we notify you about s very important provision in the plan. Under the plan’s “special enrollment provision” if you acquire a new dependent or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons.

A. SPECIAL ENROLLMENT PROVISIONS

Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program) If you are declining enrollment for yourself or your eligible dependents (including your spouse) because of other available health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if you move out of an HMO service area, or the employer stops all contributions towards other coverage for you and your dependents). However, you must request enrollment, and Blue Cross and Blue Shield of Texas (BCBSTX) must receive your request, within 31 days after coverage ends for you or your dependents (or you move out of the prior plan’s HMO service area, or after the employer stops all contributions toward the other coverage, including employer paid COBRA paid premiums). Loss of Coverage for Medicaid or a State Children’s Health Insurance Program If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under the Texas Children’s Health Insurance Program (CHIP) is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment, and BCBSTX must receive your request, within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program. Loss of Coverage as a Result of a Lifetime Limit on All Benefits You or your spouse or dependents may also have special enrollment rights in this plan at the time a claim is denied by another group health plan as a result of a lifetime limit on all benefits in the other group health plan. However, you must request enrollment, and BCBSTX must receive your request, within 31 days after the claim has been denied by the other group health plan. New Dependent by Marriage, Birth, Adoption, or Placement for Adoption If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment, and BCBSTX must receive your request, within 31 days after the marriage, birth*, adoption, or placement for adoption. *Special rules apply to newborns; refer to your TRS-ActiveCare Benefits Booklet or the HMO’s Evidence of Coverage.

Eligibility for State Premium Assistance for Enrollees (HIPP) of Medicaid or a State Children’s Health Insurance Program If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment, and BCBSTX must receive your request, within 60 days after the determination is made concerning eligibility for such assistance for you or your dependents’. Additional Information To request special enrollment or obtain more information, call Customer Service at the phone number on the back of your TRS-ActiveCare ID card.

Medicaid Subsidy (HIPP Notice)

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage, using funds from their Mediciaid or CHIP programs. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs, but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you are not already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor electronically at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of January 31, 2014. You should contact your State for further information on eligibility.

ALABAMA – Medicaid Website: http://www.medicaid.alabama.gov Phone: 1-855-692-5447 ALASKA – Medicaid Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 ARIZONA – CHIP Website: http://www.azahcccs.gov/applicants Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437

COLORADO – Medicaid Medicaid Website: http://www.colorado.gov/ Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943 FLORIDA – Medicaid Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268 GEORGIA – Medicaid Website: http://dch.georgia.gov/ Click on Programs, then Medicaid Phone: 1-800-869-1150


http://www.askebsa.dol.gov/

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IDAHO – Medicaid and CHIP Medicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/PremiumAssistance/tabid/1510/Default.aspx Medicaid Phone: 1-800-926-2588 INDIANA – Medicaid Website: http://www.in.gov/fssa Phone: 1-800-889-9949 IOWA – Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884 KENTUCKY – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 LOUISIANA – Medicaid Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447 MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-977-6740 TTY: 1-800-977-6741 MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120 MINNESOTA – Medicaid Website: http://www.dhs.state.mn.us/ Click on Health Care, then Medical Assistance Phone: 1-800-657-3629 MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005 MONTANA – Medicaid Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml Phone: 1-800-694-3084 NEBRASKA – Medicaid Website: www.ACCESSNebraska.ne.gov Phone: 1-800-383-4278

NEVADA – Medicaid Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900 NEW HAMPSHIRE – Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY – Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 1-609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEW YORK – Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA – Medicaid and CHIP Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604 OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON – Medicaid and CHIP Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462 RHODE ISLAND – Medicaid Website: www.ohhs.ri.gov Phone: 401-462-5300 SOUTH CAROLINA – Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

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TEXAS – Medicaid Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493 UTAH – Medicaid and CHIP Website: http://health.utah.gov/upp Phone: 1-866-435-7414 VERMONT– Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.dmas.virginia.gov/rcp-HIPP.htm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.famis.org/ CHIP Phone: 1-866-873-2647

WASHINGTON – Medicaid Website: http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA – Medicaid Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN – Medicaid Website: http://www.badgercareplus.org/pubs/p-10095.htm Phone: 1-800-362-3002 WYOMING – Medicaid Website: http://health.wyo.gov/healthcarefin/equalitycare Phone: 307-777-7531

To see if any more States have added a premium assistance program since January 31, 2013, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565 OMB Control Number 1210-0137 (expires 10/31/2016)

http://www.dol.gov/ebsa

http://www.cms.hhs.gov/

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