Frequently Asked Benefits Questions

I will be getting married/divorced soon. What do I need to do to change my name on my records and/or add/drop dependent(s) on my benefits?

You will need to apply for and obtain a new Social Security card reflecting your new name and provide a copy of the card to your departmental employment processor. Upon receipt of the appropriate paperwork from your department, your Human Resources office will update your personnel and payroll records. If you want to add or drop dependent(s), you will need to create a dependent event in Workday, add you new dependent (if adding) and complete the Benefit Event for dependent(s) for whom you are changing coverage. Verification documents will also be required to confirm the life event and to confirm the validity of the dependent.  You may also want to update your beneficiaries through Workday. If you participate in the Teacher Retirement System and you need to change your beneficiary designation, complete the TRS 15 form or contact TRS at (800) 223-8778 to request this form. If you participate in the Optional Retirement Program (ORP), Tax Deferred Annuity Program, or Deferred Compensation Plan, notify your vendor(s) of your new last name.

When is Open Enrollment?

Open Enrollment is July 10-31 each year. Any changes you make to your benefits during this time will be effective on September 1. Premium changes will be reflected on the first paycheck you receive for services you perform in the new fiscal year. For example, if you are paid monthly, premiums for your September coverage will be reflected on your October 1 paycheck.

What are the different types of Life Events and how do they impact my benefits?

Federal regulations define situations called Life Events that allow employees and retirees to change their Flexible Spending Account contributions or health, dental, vision or AD&D coverage during a plan year within 31 days of the Change in Status. Life Events include:

• Employee’s marriage, divorce or death of employee’s spouse
• Birth, adoption or death of a dependent child
• Child becoming ineligible for coverage due to reaching maximum age or other limitation such as marrying (age 26 for all coverage).
• Change in employee’s, spouse’s or dependent child’s employment status that affects eligibility for coverage
• Change in employee’s, spouse’s or dependent child’s residence that affects eligibility for coverage
• Employee’s receipt of a qualified medical child support order or letter from the Attorney General ordering the employee to provide (or allowing the employee to drop) medical coverage for a child
• Changes made by a spouse or a dependent child during his/her employer’s annual enrollment period
• The employee, spouse or dependent child becoming eligible or ineligible for Medicare or Medicaid due to plan age limitations or marrying or for premium assistance under Medicaid or child health plan
• Significant employer-initiated or carrier-initiated changes in or cancellation of the employee’s, spouse’s or dependent child’s coverage
• Change in day care cost due to a change in provider, change in provider’s fees (if the provider is not a relative) or change in number of hours the child needs care (for Dependent Day Care Spending Accounts)
• The employee or dependent child becomes eligible for premium assistance under Medicaid or child health plan

A court order against the spouse of an A&M System employee does not constitute a Life Event. Also, a change in income, which may affect coverage affordability, does not constitute a Life Event.

If you experience a Life Event and would like to change your benefit coverages, you may do so in Workday, within 31 days of the event occurrence. If it has been longer than 31 days since the Life Event occurred, you must wait until the next Open Enrollment period to make the change(s).

I need to change my beneficiaries. What do I do?

Beneficiary information may be updated any time of the year. You can change your beneficiary(ies) for Basic/Alternate Basic Life, Optional Life and/or Accidental Death and Dismemberment (AD&D) in Workday. If you participate in the Teacher Retirement System, complete the TRS 15 form or contact TRS at (800) 223-8778 to request this form. If you participate in the Optional Retirement Program (ORP), Tax Deferred Annuity Program or Deferred Compensation Plan, notify your vendor(s) of your new beneficiary.

Can I add my grandchild to my insurance coverages?

Yes. Your grandchild must be claimed on your income tax for the grandchild to be added. Verification documents are required.

I will be terminating employment soon. What forms do I need to complete and how can I continue my insurance coverage?

COBRA forms to continue health, dental and/or vision coverage will be sent to you through the mail by Navia, our COBRA billing vendor. Other coverages, such as Life and AD&D, may be continued through portability or conversion. Your Human Resources office will have this information and is a good resource for additional questions.

If I waive health coverage and certify that I have other health coverage, what other benefits can I buy using 1/2 the employer contribution?

You can use the employer contribution to pay for Alternate Basic life, Optional Accidental Death and Dismemberment, A&M Dental or DeltaCare USA Dental HMO, Superior Vision and Long-Term Disability coverage. The employer contribution will automatically be applied to any of these coverages in which you enroll in the order listed here. You can request that the employer contribution not be applied to your Long-Term Disability premiums because part or all of any benefits you receive from the plan will be subject to income taxes if part or all of your LTD premiums are paid by the employer contribution.

How do I find a Delta Network or Premier dentist in my area?

The most up-to-date list of participating dentists on the TAMUS Delta website. You can also call Delta Dental at (800) 521-2651.

Are there any pre-existing conditions that won’t be covered immediately under the DeltaCare USA Dental HMO?

No. All dental services noted on the DeltaCare USA schedule will be covered under the DeltaCare USA Dental HMO as soon as your coverage becomes effective.

If I enroll in DeltaCare USA, will my benefits be reduced if I go to a dentist who is not in the DeltaCare USA network?

DeltaCare USA will not pay benefits for treatment from a non-HMO dentist. You will pay the full cost.

Why doesn’t DeltaCare USA have an office visit copayment of $30 like most of the health plans?

The DeltaCare USA plan allows you to pay a set fee (copayment) for each service. The fee varies according to the service, rather than being the same fee for all services, as with some health plans. For preventive care, you pay a copayment of $5 and the plan pays the rest. You must receive services from the dental office to whom you have been assigned. You can change dental offices by calling Delta Dental at (800) 336-8264. Other copayments are higher. To receive any type of dental service for a $20 or $25 copayment would require higher premiums than most employees would be willing to pay.

What’s the maximum benefit DeltaCare USA will pay in a year? Is it different for orthodontia?

DeltaCare USA plan does not have an annual maximum limitation. Instead, for each service you receive, you pay the copayment listed on your DeltaCare schedule.

How do I find a DeltaCare USA dentist in my area?

To find a DeltaCare USA dentist, go to the TAMUS Delta website. You can also call DeltaCare USA at (800) 422-4234. However, because the A&M System is rural-based, network dentists are not available in all areas where we have employees and retirees.

In DeltaCare USA, do I have to get all treatment from a single dentist?

When you enroll in the DeltaCare USA plan you will be assigned a DeltaCare USA general dentist. Contact DeltaCare USA to become assigned to your selected network dental office. You must get treatment from your assigned network general dentist, unless your network general dentist refers you to a network specialist. If you would like to change your network general dentist, you may do so by calling DeltaCare USA at 800-422-4234. All changes must be requested by the 21st of the month in order to take effect the first of the following month. Each covered family member can have a different dentist.

Last year, my dentist recommended some treatment, and the A&M Dental plan said it would pay only for a less expensive treatment. Does DeltaCare USA have that same rule?

No, the plan does not have an alternate treatment provision that would require payment for the less expensive treatment. You and your network dentist agree on the treatment, and you pay the copayment for that treatment as shown in your DeltaCare USA schedule. If the service is not listed in your DeltaCare USA schedule, it is not a covered benefit.

How is Delta Dental PPO different from DeltaCare USA HMO?

The plans have different benefits, provider networks and requirements. With Delta Dental PPO, you can see any dentist you wish and receive benefits, and you can go directly to any dental specialists without a referral. Preventive care is covered at 100% of reasonable and customary fees (as determined by Delta Dental). For other services, you pay an annual $75 deductible and then a percentage of the cost of what the dentist charges for the service. If you use a Delta PPO or Premier dentist, you will likely pay less because Delta has contracted with these dentists to provide services at reduced prices. However, you do not have to use a network dentist to receive benefits, but costs may be higher with a non-Delta Dental network dentist. The Dental PPO plan also has an annual benefit maximum of $1,500 per covered person and an additional $1,500 lifetime limit per covered person for orthodontic care.

With DeltaCare USA HMO, you must use DeltaCare USA network dentists to receive benefits, you must be referred by your general dentist to see dental specialists and the specialist must be in the network. You pay a set fee for each dental service you receive on the DeltaCare HMO plan. These fees are noted in your DeltaCare USA Schedule.

I am under the care of a periodontist and have my teeth cleaned twice a year at the periodontist’s office and twice a year at my regular dentist’s office. Will the plan cover all of my cleanings?

The DeltaCare USA plan covers two cleanings per year (one cleaning every six months). The Dental PPO plan covers three cleaning per year. The cleanings can be done at a regular dentist’s office or a periodontist’s office. If you have your teeth cleaned more often, you must pay the cost of the additional cleanings. Periodontal cleanings are only covered for those that have an established history of periodontal services (such as the scaling and root planing).

How can I find out exactly what my cost will be for my dental care under the A&M Dental plan?

For the Dental PPE Plan, ask your dentist what services h/she is recommending and ask that they send in a pre-treatment estimate. This will allow Delta Dental to provide and estimate of coverage based on the benefits available at that time. You can then send your dentist’s suggested treatment plan to Delta, and Delta will tell you what your share of the cost will be. For the DeltaCare USA plan, members are responsible for the copay listed in their DeltaCare USA Schedule. Ask the dentist for the procedure codes that they are recommending and use those to see the cost in the DeltaCare USA schedule.

The A&M Dental plan has a $1,500 per person maximum benefit each plan year and a $1,500 per person lifetime maximum on orthodontic care. When I have orthodontic care, do the expenses apply to both maximums or only the orthodontic maximum?

Those expenses will apply only to the orthodontic lifetime maximum.

What is the Diabetes Care Value Program?

The Diabetes Care Value Program combines a quality-based pharmacy network and a holistic approach to diabetes patient care. The program applies to all A&M Care health plan members who purchase oral and injectable diabetes drugs as well as the diabetes blood glucose test strips. For the prescription to be covered under the A&M Care health plan, the program requires that:

• diabetes-related prescriptions be filled with a 90-day supply rather than a 30-day supply, and
• diabetes-related prescriptions be filled through Express Scripts Home Delivery (mail-order) or a Walgreens pharmacy (retail)

When did the Diabetes Care Value Program begin?

The program began on March 1, 2017.

Why is the Diabetes Value Care Program being implemented?

The two main goals of the program are better patient outcomes and control of rapidly increasing costs. Aside from specialty medications used to treat debilitating diseases such as multiple sclerosis or HIV, spending on diabetic medications is the next highest spend and over the next three years it is expected to increase by 52%. Controlling health plan costs helps offset premium increases and benefit reductions.

One of the greatest problems that diabetic patients experience is not taking their prescribed medication. Express Scripts estimates that being non-adherent with diabetes medications on average increases total healthcare costs by $4,690 per diabetic patient, per year. When receiving a 90-day supply of medicine, members:

• Are less likely to miss a dose,
• Have fewer refills to remember to order, and
• Have a savings of one copayment for each prescription filled by Express Scripts Home Delivery.

In addition to financial terms, limiting the network for diabetic medications to Express Scripts Home Delivery and Walgreens offers the following benefits:

• With Express Scripts Home Delivery, you will be able to speak with a pharmacist 24/7 if you have questions about your medicine. You can also talk with specialist pharmacists in the Express Scripts Diabetes Therapeutic Resource Center who have advanced training on medicines used to treat diabetes and get answers about drug interactions, administration techniques, side effects and even food interactions.
• Walgreens pharmacists will reach out to members that start or transfer a diabetes medication for a phone consultation to provide one-on-one counseling.

Do I need to get a new prescription from my doctor for my diabetic medications?

Express Scripts Home Delivery will contact your physician’s office to get a new prescription. Walgreens can tell you if your prescription can be transferred from your current pharmacy or assist with securing a new prescription.

Does this mean I can only use specific pharmacies to get my diabetes drugs?

Yes, you can only use Express Scripts Home Delivery (mail-order) or Walgreens (retail). If you live in a rural area and there is no access to a Walgreens pharmacy, you can use an alternate retail pharmacy (see this specific list of additional approved pharmacies).

Am I required to get a 90-day supply and fill the prescription through Express Scripts Home Delivery or a Walgreens pharmacy for my other long-term medications?

No, this program is only for diabetes-related medications.

How will my copayments work?

If you use Express Scripts Home Delivery to fill your prescription, you will be charged two copayments for a 90-day supply. If you use a Walgreens to fill your prescription, you will be charged three copays for a 90-day supply.

What if I am newly diagnosed with diabetes and it takes a few times before my doctor and I find a diabetes maintenance medication that works for me?

Each member taking diabetes medication will be allowed up to two 30-day fills at a retail provider for new diabetes maintenance medication prescriptions.

I can’t afford to pay more than one copay at a time. What can I do?

You can use Express Scripts Home Delivery and the Extended Payment Program. This program allows you to spread out your payments over three installments using a credit or debit card. There is no service fee.

How do I get my medicine delivered from Express Scripts Home Delivery?

You can choose between these easy options:

• Go to http://www.express-scripts.com/ (if you don’t already have an account set up, you will have to set up your account with a user id and password), review the medications that are on file (the medications you have previously filled at retail pharmacies will be listed) and choose the medicine you want delivered, add it to your cart, then checkout.
• Call the Patient Customer Service number on the back of your Express Scripts ID card (866.544.6970) and tell the representative you would like to set up a prescription to be sent through home delivery.

Whichever you choose, Express Scripts will work with your doctor to get you set up and there is no additional cost to you. Your medicine will be delivered in a confidential, tamper-proof, weather-resistant package.

How long does it take to receive a prescription ordered from Express Scripts Home Delivery?

Orders are usually processed 48 hours from when received. Your medicine should be delivered in about 8 days (10 – 14 days if it’s a new prescription). You can check your order status by going online anytime. You also have the option to set up automatic refills for your long-term medications.

How can I find the closest Walgreens?

Go to http://www.express-scripts.com/ (if you don’t already have an account set up, you will have to set up your account with a user id and password). Once online in the Express Scripts website, click on “Manage Prescriptions” on the ribbon at the top of the page. Then click on “Locate a Pharmacy” from the drop down menu and follow the directions.

I get my diabetes maintenance medications at Walmart for $4. Can I still get them at Walmart?

Yes, you can continue to get your diabetes maintenance medication at Walmart (or any other similar program at another retail or grocery store). Provide them with your Express Scripts member ID card to process your claim. The claim will be rejected for payment by Express Scripts, but it will still process through Express Scripts’ clinical review system checking for any drug allergies or drug interactions and you will still receive the lower price.

How do I pay my premiums if I am not receiving a paycheck?

The A&M System provides billing services and collect payments for insurance premiums. This impacts Retirees, Survivors, Fellows, Leave without pay employees who are being billed for their premiums, and 9-month employees who have elected billing for their summer premiums.

How and where do I send/make my insurance premium payment?

The System Insurance Billing office offers multiple payment options:

1. TRS Annuity deduction – You can elect TRS Deduction, if you are receiving monthly retirement funds from TRS. Your premiums are deducted from your monthly annuity before it is deposited to your bank account, the same way that Medicare premiums are deducted from your social security check. TRS annuity deductions are the easiest and most convenient premium payment option for TRS retirees, providing consistency and peace of mind.  To start deductions from your TRS annuity payment we need your authorization signature on the Deduction from TRS Annuity for Retiree Insurance Premiums (HR 115) form. You will be placed in a paper bill status until a copy of the TRS Annuity Retirement confirmation letter is received by the SBA Insurance Billing office for processing.
2. ACH Payment – You may authorize an ACH automatic debit from your checking or savings account by completing Bank Draft Authorization form for Group Insurance Payment Election (HR 116). You may still need to make an initial payment while this ACH process is setup.
3. Check or Money Order – Pay by check or money order by mailing your payment to Texas A&M System Benefits Administration, Insurance Billing Office, 1117 TAMU, College Station, TX 77843-1117. Please add UIN and payment Month in memo line.
4. To pay by credit card only (no debit) while in a paper bill payment type or past due status, log into the Insurance Billing Application located on your Single Sign On (SSO) menu, https://sso.tamus.edu. You may view your invoices by clicking on My Billing, selecting the invoice, click the Pay Online button and follow the prompts on the screen.  You may also click on the How to Pay button for instructions on using the TAMUS Invoice Payment Portal.

Return all completed forms with original signature (not digital) to the Insurance Billing office by email or mail as indicated on the form.  If you need to change or update your account, please visit https://www.tamus.edu/benefits/benefits-administration/system-insurance-billing-department/ to download the appropriate form.

Where can I check to see if my insurance premium payment was received?

System Insurance Billing offers you access to your billing account information online. You can easily verify payments received by checking your account. To view your Insurance Billing information you may log into the Insurance Billing Application located on your Single Sign On (SSO) menu, https://sso.tamus.edu. Click on My Billing to view invoices. From there, you may also print a receipt. Alternatively, Customer Service Representatives are also available Monday through Friday from 8am to 5pm CST at (979) 845-0015.

What happens if my insurance premium payment is late or not received by the 1st of the month?

Late Notices are sent out initially at 30 days past due and a final notice is sent at 45 days past due. If your payment is 60 days past due, your coverage will be terminated at that time, back to the last day of the month for which payment was received. Any claims paid after the last paid through date will not be honored.

Will I receive an invoice if I am on automated bank draft (ACH) or TRS deduction?

No, you will not receive ongoing monthly invoices. To view your Insurance Billing information you may log into the Insurance Billing Application located on your Single Sign On (SSO) menu, https://sso.tamus.edu. Click on My Billing to view invoices.

I have exhausted all my paid sick leave and I am still unable to return to work. What are my options?

If you have also exhausted all your vacation and compensatory time, if applicable, and need additional paid sick leave, your employer’s sick leave pool may be available to you for a catastrophic illness or injury affecting you or a family member if you meet certain requirements. Review the System Regulation 31.06.01, Sick Leave Pool Administration. To apply, contact your Human Resources office for the appropriate form. If you are not eligible for the sick leave pool or have exhausted your sick leave pool time, you may be granted up to 12 months of unpaid leave.

I have been notified that my absence from work is covered under the Family and Medical Leave Act (FMLA); however, I have exhausted all paid leave. What are my options now?

Under FMLA you may take a total of 12 weeks of paid and/or unpaid leave each fiscal year. Once you exhaust all paid leave (vacation, sick leave, sick leave pool, if eligible), you will be placed on leave without pay until you return to work. Sick leave may be taken only in situations when such leave would normally be permitted. If you must be on leave without pay while you are on FMLA leave, your job protection and the employer contribution toward your insurance premiums will continue. If you wish to continue your insurance coverage you must continue to pay your share of the premiums. You should discuss these options with your benefits office and should also receive an “event” in your Workday inbox to complete to complete to drop or continue benefit coverage. You will be billed each month you are on leave without pay for the premiums, or you may elect automatic bank draft for payment of the premiums.  You may make Health Care Spending Account contributions directly to the spending account administrator while on unpaid leave. When you return from FMLA leave without pay, you may re-enroll in any coverage you dropped while on LWOP without pre-existing condition limitations by completing a new Benefit Event within 31-days from returning from leave. If you were enrolled in Optional Life or Spouse Life and dropped it while on leave without pay, Evidence of Insurability will be required to reinstate coverage.

I am not eligible for FMLA, but want to take a leave of absence due to the birth of my baby. What are my choices?

If you are not eligible for FMLA leave, you are entitled to parental leave for up to 12 weeks immediately following the birth of a child or adoption or foster care placement of a child younger than three years. You must use your paid leave and FLSA and state compensatory time, if any. Once your paid leave and compensatory time are exhausted, you will be placed on leave without pay until you return to work. If you must be on leave without pay, your job protection will continue, but you will not receive the employer contribution toward your insurance coverage. If you wish to continue your insurance coverage you must pay the full premium. . You should discuss these options with your benefits office and should also receive an “event” in your Workday inbox to complete to drop or continue benefit coverage. You will be billed each month you are on leave without pay for the premiums. You may make Health Care Spending Account contributions directly to the spending account administrator while on unpaid leave. When you return from parental leave without pay, you may re-enroll in any coverage you dropped without providing evidence of good health or having pre-existing condition limitations by completing a newBenefit Event within 60 days.

How will my leave without pay affect my state service for longevity pay and vacation accrual purposes?

Except for military leave without pay, any full calendar month in which you are on leave without pay will not count as state service for purposes of longevity or hazardous duty pay, vacation accrual or retirement benefits. You also will not earn vacation or sick leave for any such month.

If I have vision coverage through my health plan and through Superior Vision, how do the benefits coordinate?

You should submit your vision care expenses first to your health plan. Then submit your Explanation of Benefits from your health plan to Superior Vision. Superior pays secondary to your health plan and will pay its benefits based on what you’ve already received from your health plan.

Where can I get a list of Superior Vision network providers?

Contact Superior Vision at (844) 549-2603 or search for providers on the Superior Vision website, http://superiorvision.com. Choose the “National” network in the drop down box.

I wear trifocal lenses. Are these covered by Superior Vision for the $15 copayment, or do I have to pay extra?

Single vision, bifocal, trifocal and lenticular lenses are all covered for a $15 copayment when you use a network provider. The copayment also covers scratch coating. You pay extra only when you buy other elective features. The plan pays limited benefits if you use a non-network provider.

Under Superior Vision, what will I have to pay for contact lenses?

The plan will pay 100% of the cost for standard contact lenses at a network provider. For conventional disposable contact lens, the plan will pay up to $150 at a network provider. The plan will pay 100% for medically necessary contacts. If you go to a non-network provider the plan will pay up to $150 for elective contacts and up to $210 for medically necessary contacts. Any contact lens benefit replaces the eyeglass frames and lenses benefit.