Frequently Asked Benefits Questions

Below you will find frequently asked questions about the various insurance plans offered by the Texas A&M University System. If you cannot find your answer here, contact your Human Resources Office.

Accidental Death and Dismemberment

I’m a foreign national, and my visa requires that I have medical evacuation and repatriation coverage. Do I meet this requirement under the AD&D or Life Plan?

If you have health coverage and Basic Life, then you automatically have medical evacuation coverage. This is provided through Redpoint WTP LLC under the vendor Minnesota Life.

Benefit Changes

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), complete a Dependent Enrollment Form/ Certification. Verification documents will also be required. Documentation is required to add a new dependent. You may also want to update your beneficiaries through iBenefits under Single Sign On or you can complete a Beneficiary Designation Form to change beneficiary(ies) for Basic/Alternate Basic Life, Optional Life and/or Accidental Death and Dismemberment (AD&D). 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 1-July 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 Changes in Status and how do they impact my benefits?

Federal regulations define situations called Changes in Status 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 60 days of the Change in Status. Changes in Status are:

  • 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 health care), age 25 for all other 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 Change in Status. Also, a change in income, which may affect coverage affordability, does not constitute a Change in Status.

If you experience a Change in Status and would like to change your benefit coverages, complete a Benefit Change Form, if applicable, a Dependent Enrollment Change Formwithin 60 days of the Change in Status. If it has been longer than 60 days since the Change(s) in Status occurred, you must wait until the next Annual 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 iBenefits or by completing a Beneficiary Designation Form.Verification documents will be required. 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 living in your home and you must provide proof of this to your Human Resources office in order for this 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 or provided to you at your “exit interview”. 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, EyeMed Vision Care 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.

Dental Insurance

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

The most up-to-date list of participating dentists is online at

http://deltadentalins.com/tamus/. You can also call Delta at (800) 336-8264.

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

No. All dental services 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 does not have a maximum cost benefit for any type of treatment, including orthodontia. For each service you receive, you pay the copayment listed on the schedule, and DeltaCare USA pays the rest, no matter how many services you receive in a year.

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

To find a DeltaCare USA dentist, go to http://deltadentalins.com/tamus/. 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?

You must choose a network general dentist, but you can change to another network general dentist up to four times a year by calling DeltaCare USA. Each covered family member can have a different dentist. You must get treatment from your network general dentist, unless your network general dentist refers you to a network specialist.

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. You and your network dentist agree on the treatment, and you pay the copayment for that treatment. DeltaCare USA will pay the remaining cost for whichever treatment you choose, even if a less expensive treatment is available.

How is Delta Dental PPO different from DeltaCare USA HMO?

The plans have different benefits, provider networks and requirements. With 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). 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 Network 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 PPO dentist to receive benefits. Dental PPO 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 dentists to receive benefits, you must be referred by your general dentist to dental specialists and the specialist must be in the network. You pay a set fee for each dental service you receive.

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?

DeltaCare USA plan covers two cleanings per year (one cleaning every six months), while the A&M Dental 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. To get a periodontal cleaning covered for preventive care, you will need to provide information to Delta that you have previously had other periodontal work done such as 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?

One way to be sure you know what your cost will be is to ask your dentist what services he/she is recommending. 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.

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.

Express Scripts

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 on 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.

Direct Billing and Cobra Billing Services - P&A Group

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

The A&M System contracts with P&A Group to provide billing services and collect payments for insurance premiums. This impacts Retirees, Survivors, Fellows, Leave without pay employees who are being billed for their premiums, 9-month employees who have elected billing for their summer premiums, and COBRA participants who have continued insurance with the A&M System.

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

P&A offers multiple payment options:

  1. ACH Payment – If not already established, you may authorize an ACH automatic debit from your checking or savings account by completing an online request through your member account. Alternatively, you can setup an ACH automatic debit from your checking or savings account by completing the ACH authorization form and return the completed form to the P&A Group by mail or fax. With either of these options, you will still need to make an initial payment while this ACH process is setup.
    Please Note: If you are already set up with ACH debit transactions through the A&M System, the information will be transferred to P&A and will require no further action from you. If you need to change or update your account, please work with P&A directly
  2. Secure Online Payment – To make a one-time payment or set-up recurring monthly payments, create an online account on the P&A Group website www.padmin.com
  3. IVR (Integrated Voice Response) or Pay By Phone – To make a one-time payment or set-up recurring monthly payments, call P&A Group at (800) 688-2611.
  4. Check or Money Order – Pay by check or money order by mailing your payment to P&A Group: Dept 652, PO Box 8000, Buffalo, NY 14267-8000.

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

P&A offers you full access to your billing account information online. You can easily verify payments have been received by checking your account online at www.padmin.com. From there, you may also print a receipt. Alternatively, Customer Service Representatives are also available Monday through Friday from 7:30am to 9pm CST at (800) 688-2611.

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

Late Notices are sent out approximately the 15th of each month for that month. If your payment for that month is not received or postmarked by the end of the month, 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)?

No, you will not receive ongoing monthly invoices. If there is a change in your draft amount, you will receive advance notification accordingly.

How can I change my tobacco-user status as a COBRA participant?

You should contact P&A to let them know of the change in tobacco-user status. They can adjust your bill for the coming month.

COBRA

What is P&A Group’s role in COBRA coverage?

Effective April 1, 2017, P&A Group will manage the COBRA coverage process for The Texas A&M University System. Once an employee or dependent is eligible for COBRA, P&A will send the required explanation of rights, election forms, and, if applicable, insurance application forms. If the COBRA eligible individual wishes to elect COBRA coverage, he/she will complete and return the necessary documentation to P&A Group to be enrolled in COBRA continuation coverage. The first payment will be due at time of election and after that, a bill will be sent every month by P&A. It is critical that COBRA premiums be paid timely to keep coverage in place. COBRA coverage cannot be reinstated upon cancelation.

What are my payment options for COBRA premium?

Payment should be made directly to P&A Group which offers multiple payment options:

  • Log in to your My Benefits account and set up an ACH withdrawal, which is an automatic withdrawal from your chosen bank account.
  • Call the P&A Group automated telephone system at (800) 688-2611, where you can make a payment over the phone.
  • Mail a personal check or money order to P&A Group, 17 Court Street Suite 500, Buffalo, NY 14202.
  • Contact the P&A customer service department at (800) 688-2611 x6705 to make a one-time online payment.

When is my COBRA payment due?

Payments are due on the first day of each month. If your payment is not received by the first of the month, P&A will send  a Late Notice. Late Notices are sent out approximately the 15th of each month for that month. If your payment for that month is not received or postmarked by the end of the month, your coverage will be terminated for non-payment, back to the end of the last month for which you made payment. Once cancelled, your COBRA coverage cannot be reinstated.

During my initial COBRA election, can I switch health plan coverage so COBRA payments are cheaper?

No, you are not eligible to change your insurance plans as you are required to stay in the health or dental plan that you were in at the time of your COBRA qualifying event. The only time you can make a change is during the annual open enrollment period, or if you have an appropriate Life Change Event.

My dependent or former dependent received a COBRA packet – what needs to be done?

P&A Group sends a COBRA packet to qualified dependents when they experience a COBRA qualifying event and are no longer eligible to be covered under your insurance (such as reaching maximum age). If your dependent wishes to elect COBRA continuation, they will need to complete the COBRA election form and any applications necessary. All the paperwork should be filled out by the enrolling dependent. The parent’s information does not need to be on the forms.

Can I cancel my COBRA coverage?

Yes. You may cancel your COBRA coverage at any time. However, once it is cancelled, it cannot be reinstated. You must submit your request to cancel coverage to P&A in writing. You should include your name, your employer (or previous employer), and the effective date you want the coverage cancelled. You can submit that information through your P&A Group My Benefits online account, mail, or fax. Within the “My Benefits” page, you can view your insurance coverage, cancel coverage online, and make payments. In addition, you can view your COBRA start and end dates, make demographic changes, and view your invoice and payment history.

What happens when my COBRA coverage ends?

Your COBRA coverage will end once you have reached the maximum period of coverage (either 18 or 36 months). At that point, you may be able to convert your COBRA coverage to individual coverage with your current insurance carrier or purchase a new policy through a public or private health insurance exchange. To find out more about any conversion rights you may have when your COBRA coverage ends, please contact your carrier directly.

Flexible Spending Accounts

Am I better off using the child care tax credit on my income tax return or the Dependent Day Care Spending Account?

That depends on your personal situation. You may want to consult a tax advisor.

If I have braces put on and pay the full cost up front, can I be reimbursed the full amount from my account?

Orthondontia services are the only type of services that can be considered “incurred” when you make a prepayment. You must be reimbursed in the plan year in which the payment was made with the understnding that the services will begin at that time.

Are there limitations on the kind of expenses I can claim through my Flexible Spending Account?

Yes. IRS publications 502 and 503 list most of the services that can be claimed.

Once I sign up for Spending Accounts, do I have to keep contributing the same amount each year?

No. In fact, you must re-enroll each year even if you want to contribute the same amount as in past years. Each year during Annual Enrollment, you decide whether to participate and how much, if any, to put into each account. If you want to participate one year and drop out the next, you can do it. However, you cannot change your decision in the middle of a plan year unless you have a Change in Status.

Why do I have to re-enroll in the Spending Accounts each year even if I want my contribution amount to stay the same?

This requirement is not part of the law that governs Spending Accounts, but most employers have this rule. Because contributions can’t be changed during the plan year unless you have a Change in Status, it’s important that you make the right decision up front so you won’t forfeit unused contributions. Since your needs may change from year to year, you need to carefully consider how much you will need to contribute each year.

I’m going to enroll in the Spending Accounts for the first time this year. If I have an expense the first week in September, can I get reimbursed immediately?

You can submit any expense that you incur on or after September 1. All of the money you will contribute during the plan year is available from the beginning of the year for the Health Care Spending Account. You can be reimbursed from the Dependent Day Care Spending Account only for an amount you have already contributed to the account.

Leave

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 will need to complete a Benefit Change Form and a Dependent Enrollment Change Form, if applicable, to cancel the coverage you do not want to continue. 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. The bank draft form is available from your Human Resources office. 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 without providing evidence of good health or having pre-existing condition limitations by completing a new Benefit Change Form and Dependent Enrollment Change Form within 60 days.

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 will need to complete a Benefit Change Form and a Dependent Enrollment Change Form, if applicable, to cancel any coverage you do not want to continue. 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 new Benefit Change Form and Dependent Enrollment Change Form 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.

Life Insurance

Do I need to provide evidence of insurability to enroll in Optional Life coverage?

If you enroll in Optional Life after your first 60 days of employment, you will need to provide evidence of insurability (good health), unless you have a Change in Status. If you have a Change in Status, you may enroll in Optional Life coverage of one-half or one times pay without providing evidence of insurability, but you will need to provide evidence of insurability to enroll in higher levels of coverage.

How does the automatic Dependent Basic Life coverage work?

Employees and retirees who have Basic Life or Alternate Basic Life coverage automatically have $5,000 of life insurance coverage on all eligible dependent children. This benefit does not include spouses. You do not have to specifically enroll your children. They are automatically covered. The coverage cannot be waived.

What is the difference between Basic Life/Basic AD&D, Alternate Basic Life and Optional Life?

Basic Life/Basic AD&D is automatically provided to those who enroll in an A&M System health plan, and the employer contribution pays the premium. Those who do not take System health coverage and do not certify that they have other health coverage may buy Basic Life/Basic AD&D, but must pay for it themselves. Alternate Basic Life is available to employees and retirees who do not enroll in an A&M System health plan, but certify that they have other health coverage. Because they certify that they have other health coverage, they can use half of the employer contribution to buy other coverages, including Alternate Basic Life, which has a maximum coverage level of $50,000. Optional Life is available to all employees except those in Alternate Basic Life, but the employer contribution may not be used to pay the premiums. Those eligible for Alternate Basic Life may choose to buy either Optional Life or Alternate Basic Life, but not both.

If I increase my Optional Life coverage during Annual Enrollment, when is the increase effective?

After completing and submitting your evidence of good health application, the increase becomes effective on the first of the month following approval of your application or September 1, whichever is later.

Why set up an Alternate Basic Life plan if anyone can buy Optional Life?

When some employees are allowed to use state money to buy life insurance in a plan, then anyone who is in the same plan and has more than $50,000 in coverage must pay income tax on the cost of the coverage in excess of $50,000. To keep from increasing many employees’ tax bills, we must prohibit using the employer contribution to buy life insurance through the Optional Life plan. However, we want employees eligible for half the employer contribution to be able to buy up to $50,000 of life insurance with that money. That’s why we set up a separate plan just for them. To avoid any extra taxes for that group, we limited the amount of life insurance that could be purchased through Alternate Basic Life to $50,000.

How does the Living Access benefit work?

The Living Access benefit is designed to give you access to part of your Basic, Optional or Alternate Basic Life benefit if you have a terminal condition. Often those who are terminally ill need the extra money that can be provided by this benefit. To qualify for a Living Access benefit, you must be covered under Basic Life, Optional Life or Alternate Basic Life and a doctor must certify that you have less than 24 months to live. You can receive 50% of your total coverage amount. If your spouse and/or covered children have Dependent Life coverage, they are also eligible for the Living Access benefit.

If I sign up for Dependent Life, are all of my eligible dependents automatically covered?

No. You must list each dependent you wish to cover when you enroll. You must provide evidence of insurability (good health) to add a spouse, unless you enrolled him/her within 60 days of when you first became eligible for coverage or within 60 days of a Change in Status.

What is the portability provision in the life insurance program?

Under the portability provision, you may continue the same amount of Life coverage without providing evidence of good health. The premiums will be higher than those paid by active employees, but much lower than those for the conversion policy. Some provisions, such as the Living Access Benefit, that are available to active employees are not included in the portability program.

How do I change my beneficiaries?

You may change your beneficiaries at any time through Workday. When you change your beneficiary, your new beneficiary designations will supersede all previous designations.

Long Term Disability

Do I need to provide evidence of insurability to enroll in Long-Term Disability (LTD)?

You do not have to provide evidence of insurability (good health) to enroll, but you must be actively at work on the day your coverage is scheduled to go into effect or coverage will be delayed. If you are not actively at work, coverage will become effective on the first subsequent day you report to work. When you enroll, you must indicate whether you are, or are not, a tobacco user. You will have the opportunity to enroll without evidence of insurability during each Annual Enrollment period. However, pre-existing condition limitations will apply.

What are the pre-existing condition limitations for LTD coverage?

A pre-existing condition is one for which you had symptoms, received medical treatment, consultation, care or services, or took prescribed drugs or medicines during the three months before your LTD coverage began. You cannot receive LTD benefits for a pre-existing condition if your period of disability begins during your first 12 months of plan coverage.

If I become disabled, will my LTD benefit be taxed?

If you are paying the full premium, your benefit will not be taxed. However, if you have waived health coverage and are using part of the employer contribution to pay your LTD premiums, your LTD benefits will be taxed. That’s because the premiums are paid with after-tax dollars if you pay them and non-taxed dollars if the state pays them. The IRS looks at coverage paid for by the state as deferred income that is subject to taxation when received.

Why is our LTD benefit offset by other retirement or disability benefits we receive?

The purpose of LTD coverage is to ensure you have a source of income in case you are unable to work due to a disability. However, the plan also wants to encourage you to return to productive employment as soon as possible. By guaranteeing a percentage of your pay, the plan ensures you will have a certain level of income, although it may come from various sources. While 65% of pay may not sound like enough to live on, keep in mind that you do not pay Social Security or federal income tax (in most cases) on your LTD benefits and on some other potential disability benefits. Also, you will not have many work-related expenses, such as commuting costs, while you are not working, so you may not need as much income. If the plan were to always pay 65% regardless of other benefits, the premiums would be much higher. Also, some disabled employees might receive more than 100% of their pay from various sources, providing little incentive for them to return to work. This would further increase plan costs and premiums.

What kinds of other benefits offset my LTD benefit?

The benefits that offset the LTD benefit include those under individual and family Social Security, any group LTD plan (including those through professional associations), A&M System leave programs, Railroad Retirement Act, Jones Act, workers’ compensation, occupational disease law, compulsory benefit act or law, and similar plans or laws. Your LTD benefit will not be offset by any disability or retirement benefits from an employer-sponsored retirement plan, including TRS and ORP, unless you actually receive those benefits.

Why is the Long-Term Disability benefit period for mental-health-related disabilities limited to 24 months?

The 24-month limit applies only to non-organic mental-health-related disabilities. Benefits for organic mental illnesses, such as schizophrenia, bipolar disorder and Alzheimer’s, are paid the same as for physical disabilities. The potential length of non-organic mental-health-related disability claims is difficult to determine, so large reserves must be kept to cover these disabilities. This causes LTD plan costs, and therefore premiums, to increase. For that reason, payment periods for non-organic mental-health-related disabilities are limited by most employers. The 24-month limit is in line with the industry standard for LTD coverage and should help reduce our claims costs and keep premiums low for everyone.

Health Insurance

What is a primary care physician and what is a specialist?

Under the A&M Care and Graduate Student health plans, a primary care physician (PCP) is a general or family practitioner, an internal medicine doctor, a pediatrician or an obstetrician/gynecologist. All other doctors under these plans are considered specialists.

I understand that there is a 60-day waiting period for the employer contribution for medical insurance coverage for new faculty. Would there be a waiting period for my wife and stepchildren after the wedding?

No, there is no new waiting period when you add a new dependent to your coverage,

If I’m a graduate student, do I have to enroll in the Graduate Student Health Plan to have health coverage?

No. You can choose between the Graduate Student Health Plan and the A&M Care plan.

Does the Graduate Student Health Plan’s repatriation benefit meet the visa requirements for foreign nationals?

Yes, the Graduate Student Health Plan is the only A&M System health care plan that offers repatriation benefits, and those benefits do meet the visa requirement for foreign nationals. However, the Basic Life plan also offers repatriation benefits, so if you enroll in any health plan through the A&M System you will have Basic Life and therefore medical evacuation and repatriation coverage.

My doctor has prescribed a particular medicine for me, but my health plan says it’s not on the plan’s formulary. What does that mean?

All of our health plans use formularies. Formularies are lists of drugs the health plan prefers that you take for various illnesses. Each health plan has its own formulary, so a drug may be on the formulary of one plan, but not on another. These drugs cost less for the health plan to dispense because they are purchased in bulk with special discounted pricing from the manufacturer. A&M System health plans have a three or four-tier copayment system. These consists of three or four copayment levels with the lowest copayment for a generic drug, a higher copayment for a brand-name drug on the formulary, and a higher copayment for a brand-name drug not on the formulary, and in some cases, a coinsurance amount for very expensive injectables or biogenetic drugs.The formulary may change during the year, but the Texas Department of Insurance now requires health plans to notify you 90 days in advance if they will be removing a drug you are taking from the formulary list, so you will have a chance to try another drug or request an appeal.

If I’m an A&M Care plan participant, can I get prescriptions filled at my favorite pharmacy?

The ExpressScripts network is a nationwide network of more than 55,000 pharmacies, so the chances are good that your pharmacy is participating. To see if your pharmacy belongs to the ExpressScripts network, or to locate a participating pharmacy near you, call ExpressScripts toll-free at (866) 544-6970, or access ExpressScripts web site at www.express-scripts.com.

What happens if I use an out-of-network pharmacy?

As an A&M Care plan member, you must pay, up front, the full cost of a prescription if you use a pharmacy that is out of ExpressScripts network of pharmacies. You must then file a claim with ExpressScripts to be reimbursed for covered medications. After you’ve met your deductible, your copayment is deducted and then ExpressScripts will reimburse you 75% of the remaining reasonable and customary cost. Contact your Human Resources office for out-of-network claim forms or call ExpressScripts toll-free at (866) 544-6970.

Under the A&M Care plan, how do I determine whether to have my prescriptions filled at my local pharmacy or the mail-order pharmacy?

Your local pharmacy should be used for short-term or acute medications such as antibiotics or pain relief medications. For long-term or maintenance medications, you should use the mail-order pharmacy, ExpressScripts By Mail. Using the mail-order pharmacy, you can get up to a 90-day supply of your medication for only two copayments. Be sure your physician writes the prescription for 90 days worth of medicine, plus any needed refills. However, if you are getting a brand-name drug when a generic is available, you will have to pay the cost difference between the generic and brand-name in addition to the copayments. The only exception is if, before you submit the prescription, your doctor sends ExpressScripts a completed prior authorization form, available at www.express-scripts.com, explaining why it is medically necessary for you to have the brand-name drug. ExpressScripts must approve the request.

If Medicare is primary, do I have to use network doctors and hospitals?

No. In the A&M Care plan, you will receive the same benefits no matter which doctors and hospitals you use.

If I have Medicare as my primary carrier, do I have to precertify with Blue Cross and Blue Shield?

No.

If my doctor submits evidence that I must have a drug not on the formulary list for medical reasons, can I get the nonformulary drug by paying the formulary copayment?

If your doctor provides documentation to ExpressScripts before the prescription is filled stating that you have tried the formulary drug and you must have the nonformulary drug for medical reasons, and if ExpressScripts approves the substitution, you will pay only the formulary copayment. Formulary information is available at www.express-scripts.com or from your Human Resources office.

Under the A&M Care plans, how long will it take to get prescriptions filled through the mail-order program?

Once ExpressScripts By Mail receives a prescription and order form with all of the required information, your prescription is filled and mailed, on average, within three days for orders that do not require intervention. Orders sent by regular mail usually take an additional two to five days to arrive. If you want to ensure faster delivery, you may pay more for overnight delivery.

What is a formulary list?

The formulary is a list of preferred brand-name drugs that have been compared and evaluated with other brands and provide maximum quality and value. Many therapeutic categories (for example, ulcer medications) have two or more brand-name drugs that are used for the same purpose.To maximize your savings, you should present the list to your physician each time you are to receive a prescription and, when possible, ask your physician to consider the use of generically equivalent alternatives. You are not required to use the drugs on this list, and they are not the only drugs covered by the plan. If a drug you are using is not on the list, you may still have your physician prescribe that drug for your use, but you will pay a higher copayment.

How will I know if my prescription will be filled with a brand-name or a generic medication?

Generic alternatives will be dispensed by the pharmacist whenever available and legally permitted, unless your physician specifically indicates on the prescription “dispense as written.” The generic version of a drug has the same chemical compound as its brand-name counterpart. The use of generic drugs offers a simple and safe alternative to help reduce your prescription drug costs. If a generic drug is available and you have your prescription filled with a brand-name drug, the plan will pay only the cost of the generic. You will be responsible for paying the difference, plus the brand-name copayment. You pay only the brand-name copayment when no generic is available.

Under the A&M Care plans, I understand some medications may be limited or require prior authorization. Which drugs are these?

Generally, the A&M Care plans will cover drugs that are prescribed for the medically necessary treatment of an injury, illness or disease. The plans do not cover drugs prescribed for fertility treatment or cosmetic purposes, including hair growth agents.To obtain some drugs, you must first have your physician fax or mail documentation of the medical necessity of the drug using the preauthorization form available on the ExpressScripts web site, www.express-scripts.com. ExpressScripts will then determine whether to authorize coverage for the drug. If ExpressScripts does not authorize coverage, you may still obtain the drug, but you will pay the full cost.Some drugs are restricted to certain ages, dosages or diagnoses and may require prior authorization.Call ExpressScripts at (866) 544-6970 (toll free), or visit the web site at www.express-scripts.com, if you have a question about whether a medication is covered, requires prior authorization or is restricted.

Why don’t retirees eligible for Medicare have to use network providers?

Medicare has already set the amount a doctor who accepts assignment may charge for services for those on Medicare. These rates are greatly reduced from what the doctor normally charges. In addition, since the A&M Care plan generally pays after Medicare, the balance due is relatively small. Consequently, making Medicare-eligible retirees use network doctors would generate little or no savings for the A&M Care plans

If I choose not to enroll in Medicare, will my benefits be paid the same way as an active employee’s are paid?

The answers depends on whether you are actively employed or retired. If you are actively employed with the A&M System, which is defined as working at the A&M System at least 50% time (20 hours a week) for at least 4½ consecutive months, you may postpone enrolling in Medicare until you retire. In this case, your benefits will be paid the same as other active employees. If you are retired and eligible for Medicare, the A&M Care plan will pay benefits as if you are enrolled in Parts A and B of Medicare, even if you are not actually enrolled. To get full health benefits, you must enroll in both parts of Medicare as soon as you become eligible.

I turned 65 this year. Does that mean I should enroll in 65 PLUS?

Not necessarily. You still have the choice of enrolling in the A&M Care plan. However, the 65 PLUS plan generally provides the best health care value for eligible retirees.

If I buy a brand-name drug, do I just pay the formulary or nonformulary copayment?

That depends. If no generic equivalent is available, you pay the formulary copayment if you buy a brand-name drug on the formulary and the nonformulary copayment if you buy a brand-name drug not on the formulary. However, many plans have mandatory generic substitution. If a generic is available, many plans require that you pay more if you do not want to take the available generic. If you are covered by one of the A&M Care plans, your doctor can submit medical evidence that you need the brand-name drug because you can’t take the generic drug, and ExpressScripts|Medco, the A&M Care drug plan administrator, may approve payment of the brand-name formulary or nonformulary copayment.

Can I add or drop dependents from my health plan during the plan year?

If you have a Change in Status, you may add or drop the dependent affected by the change to or from your health, dental or vision plan within 60 days of the change. Otherwise, you may not add or drop dependents except during Annual Enrollment (effective Sept. 1). Changes in Status are:

  • 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 age 26
  • 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
  • The employee/retiree or dependent child loses coverage under the State Medicaid or Child Health Plan or becomes eligible for premium assistance under the 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)

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

Are the A&M Care plans the same as the Blue Cross Blue Shield (BCBSTX) plans?

Yes. BCBSTX administers the A&M Care plans for the A&M System.

What are the key phone numbers for Blue Cross Blue Shield of Texas?

Member services: (866) 295-1212 Precertification: (800) 441-9188 Mental health precertification: (800) 528-7264 BlueCard (for network physician information outside Texas): (800) 810-BLUE Both precertification numbers can be dialed directly or accessed by calling member services. Member services representatives will be available from 8 a.m. until 8 p.m., Monday through Friday.

How do I know if I live in a Blue Cross and Blue Shield network area?

Blue Cross and Blue Shield of Texas (BCBSTX) has networks in all 50 states and provides coverage worldwide.

What network benefits are available for employees and retirees living or traveling outside Texas?

A&M System employees and retirees have access to network doctors nationwide through BlueCross BlueShield’s BlueCard program. Your ID card has a toll-free number you can call to get information on providers in your area. Unless you are eligible for Medicare and not working for the A&M System, you must use a network provider to receive the highest level of benefits.

How do the network and out-of-network deductibles and out-of-pocket maximums work together if I sometimes go to network doctors and sometimes to out-of-network doctors?

Out-of-network provider expenses will apply only to the out-of-network deductible and out-of-pocket maximum. Network expenses will apply only to the network deductible and network out-of-pocket maximum.

Why are out-of-network deductibles more than network and non-network deductibles?

A&M Care participants pay the higher, out-of-network deductible when they choose to visit a care provider not in the network. This provision encourages plan participants to visit network providers, with whom BlueCross BlueShield of Texas has contracted to provide certain services at lower costs, and helps hold down the premium costs for all employees.

How do I get prescription medicine through the A&M Care plans?

ExpressScripts is the drug plan administrator for the A&M Care plans. If you enroll in one of the A&M Care plans, you will receive a ExpressScripts drug card. You can use this card at more than 55,000 chain and independent pharmacies throughout the U.S. for a 30-day supply of medicine. You pay a $50 deductible on your first prescription drug purchases each year for each covered family member. Then you pay $10 for each generic prescription, $35 for each brand-name formulary prescription and $60 for each brand-name nonformulary prescription if you buy drugs at a local pharmacy. You can also order up to a 90-day supply of maintenance medications through ExpressScripts mail-order program, ExpressScripts By Mail. If you use the mail-order program, you pay two copayments for a 90-day supply after the $50 annual deductible. If you buy a brand-name drug when a generic is available, you pay the difference in cost in addition to the $35 or $60 brand-name copayment, unless your doctor provides information in advance that you cannot take the generic drug for a documented medical reason and PharmaCare approves the brand-name drug. For more information on obtaining prescription medicines, call ExpressScripts toll-free at (866) 544-6970.

Under the A&M Care plans, do I need to file a claim to get reimbursed for short-term drugs?

Under the A&M Care plans, do I need to file a claim to get reimbursed for short-term drugs?You file a claim only if you use a pharmacy that is not in ExpressScripts network. Out-of-network pharmacies require you to pay the full cost of the drug at the time of purchase.

Where can I get more information about wellness exams?

You can find a Q&A document about wellness exams here.

Where can I get more information about tobacco premiums?

You can find a Q&A document about tobacco premiums here.

Vision Insurance

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.