2011-2012
City of Port Neches
Laura Bloss, Benefit Services Specialist
TML IEBP
(512) 719-6500
brett.bowers@tmliebp.org
TML IEBP Mission Statement
To provide excellent service and administrative
services to eligible municipalities in Texas by
utilizing innovative, affordable alternatives
while maintaining financial integrity.
Exclusive to Public Sector
Not-for-Profit
Member Equity
Public & Private
Sector Alliance
www.tmliebp.org
Find the Information You Need:
•Benefit Summaries
•Provider Search
•Online Customer Service
•Account Balances
•Consumer Driven Health Guides
•Claim Information
•Flex Forms
•Dependent Care
•Recurring Expense
•Important News
TML IEBP’s STATEWIDE NETWORK IS IMPROVING!
-
TML IEBP will access United Healthcare ‘s Choice PLUS Network
Not United Healthcare’s Options PPO Network
What does that mean besides better discounts?
TML IEBP will no longer have a Direct Network to supplement United’s Network
TML IEBP has worked with United to add most direct providers into Choice PLUS
How is the Preferred Lab network affected?
TML IEBP continues to offer the Preferred Lab Benefit
BUT QUEST is no longer in the network.
The Provider Search
Page will change after
1/1/2011. You may
preview the Choice
Plus network today.
2011-2012
NEW ID CARD: Please make certain to give providers a copy of
your new ID Card and tell them that you have a different network.
Benefit Assist Guide
BENEFIT ASSIST GUIDE
NOTIFICATION REQUIREMENTS
Notification enables clinical support and educations, such as:

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Perform pre-op education for the patient and ensure adherence to nationally recognized guidelines
in order to maximize quality and cost efficiency
Facilitate post-op discharge planning to optimize clinical outcomes
Refer patients to Centers of Excellence
Notification is required for the following admissions and/or procedures:
RVICE
NOTIFICATION
LATE NOTIFICATION PENALTY
Facility: twenty-four (24) hours after
actual admission or by 5 pm the next
business day for weekend/holiday
admissions
Facility: If admission Notification is
not received within seventy-two
(72) hours of the admission, a 50%
reduction will be applied to the
contracted benefit eligible rate.
INPATIENT ADMISSIONS
heduled Specialty Admissions
Orthopedic/Spine Surgeries (spinal surgeries, total
knee replacements, and total hip replacements)
Transplants: At least ten (10) working days prior to
any pre-transplant evaluation, the covered
individual or a family member must provide
Notification to Medical Care Management; failure
to do so will result in a Late Notification Penalty of
$400 or a reduction in benefits
Reconstructive/Potentially Cosmetic procedures
Bariatric Surgeries: Morbid Obesity Services (after
the approved six (6) month physician supervised
weight management treatment plan)
Congenital Heart Disease
her Inpatient Admissions
Skilled Nursing Facility
Psychiatric/Chemical Dependency Inpatient
Psychiatric/Chemical Dependency Residential
Treatment
Acute Care Hospital/Facility
Long Term Acute Care Facility
Acute Rehabilitation Facility
Scheduled Cesarean Section Delivery
patient Pregnancy/Maternity (Delivery Admission)
Vaginal Delivery admission in excess of forty-eight
(48) hours
Cesarean delivery admission in excess of ninety-six
(96) hours
All High Risk obstetrical or antepartum care or other
undelivered admission
Newborns who remain in the hospital after mother
is discharged
egnancy/Maternity
Sonogram/Ultrasound in excess of three (3)
Amniocentesis
Home Health (uterine monitoring)
Primary Physician/Healthcare
Professional: Prior to Admission
Primary Physician/Healthcare
Professional: If an advanced
admission Notification is not
received, a 100% reduction will be
applied to the contracted benefit
eligible rate.
Facility: twenty-four (24) hours after
actual admission or by 5 pm the next
business day for weekend/holiday
admissions
Facility: If admission Notification is
not received within seventy-two
(72) hours of the admission, a 50%
reduction will be applied to the
contracted benefit eligible rate.
Facility: twenty-four (24) hours after
actual admission or by 5 pm the next
business day for weekend/holiday
admissions
Facility: If admission Notification is
not received within seventy-two
(72) hours of the admission, a 50%
reduction will be applied to the
contracted benefit eligible rate.
Prior to commencement for
outpatient and Home Health
procedures, within forty-eight (48)
hours of multiple birth diagnosis
$200
TML Intergovernmental Employee Benefits Pool
Open Enrollment
When is Open Enrollment?
Open Enrollment is the month prior to the
new plan year.
Your group has an anniversary date of July 1,
2012 .
Open Enrollment would be during June,
2012.
2011-2012
What if I do not add my dependents during
the Open Enrollment period ?
•
They would have to wait until the following
year’s open enrollment period unless there is a
Qualifying Event:
1.
2.
3.
4.
5.
Marriage,
Birth or adoption of a child,
Loss of eligibility under Medicaid or SCHIPTermination of a
spouse’s employment,
Spouse changes from full-time to part-time or takes unpaid leave,
Significant change (10% or more) in the benefit coverage of your
spouse’s plan.
*Note: Dependents cannot be dropped during the plan year unless there is
a qualifying event. SCHIPS eligibility is NOT a qualifying event.
2011-2012
TML Intergovernmental Employee Benefits Pool
Healthcare Reform
in Action
2011-2012
Healthcare Reform (PPACA):
Standardization of Communication
 Compliance with standardization of the Explanation of Benefits (EOB’s)

 External Appeal Language
 Ombudsmen Information
1.1.12
» Non English language declinations based on county specific 10% or more
of the population residing in the claimant’s county who are literate only in
the same non-English language as determined based on American
Community Survey data published by the US Census Bureau.
» Diagnosis Code upon request
» Procedure Codes upon request
» Translation Request upon request in County Specific non-English
2011-2012
TML Intergovernmental Employee Benefits Pool
Medical Plan
Please refer to the
Medical Benefits
Booklet for complete
details on your
medical benefit
program.
2011-2012
Notification Requirements
Service
Notification
Late Notification
Penalty
Emergency Admissions
One (1) business day following an emergency or as soon
as reasonably possible
$400
Scheduled Admissions
• Includes Psychiatric / Chemical Dependency Intensive
Five (5) days prior to a non-emergency admission
$400
Pregnancy Maternity
Sonogram (in excess of three),Amnio, Home
Health, Multiple Birth Diagnosis
Within (48) hours
Prior to Commencement for Outpatient and Home Health
Procedures
$200
Newborn/Pregnancy Maternity
C-Section
Within (48) Hours
Within (96) hours
$400
Transplant & Morbid Obesity
(10) Working Days prior to initial evaluation
$400
Outpatient Surgery
(3) Working Days prior to procedure
$200
MRI, PET, CAT, MRA, Chemotherapy, Radiation
Therapy, Oral Oncology, Hyperbaric Oxygen
Therapy, Cochlear Device/Implantation, Hospice,
Home Health, Physician Home Visit, Convalescent
Nursing Home for Rehab, Dialysis, Durable
Medical Equipment for Charges in Excess of
$1,000, Infusion Therapy, Dental Injury &
Reconstructive Surgical Procedure, Testing for
Genetic Markers
Prior to Commencement
$200
Outpatient Treatment
2011-2012
Medical Plan
2011-2012 Benefit Changes / Choice Plus Network
MEDICAL CARE MANAGEMENT FEATURES
SERVICE
NOTIFICATION
LATE NOTIFICATION PENALTY
Facility: twenty-four (24) hours
after actual admission or by 5 pm
the next business day for
weekend/holiday admissions
$400Facility: If admission
Notification is not received
within seventy-two (72) hours of
the admission, a 50% reduction
will be applied to the contracted
benefit eligible rate.
INPATIENT ADMISSIONS
Scheduled Specialty Admissions
 Orthopedic/Spine Surgeries (spinal surgeries,
total knee replacements, and total hip
replacements)
 Transplants: At least ten (10) working days
prior to any pre-transplant evaluation, the
Covered Individual or a family member must
provide Notification to Medical Care
Management; failure to do so will result in a
Late Notification Penalty of $400 or a
reduction in benefits
 Reconstructive/Potentially Cosmetic
procedures
 Bariatric Surgeries: Morbid Obesity Services
(after the approved six (6) month physician
supervised weight management treatment
plan)
 Congenital Heart Disease
Primary Physician/Healthcare
Professional: Prior to Admission
Primary Physician/Healthcare
Professional: If an advanced
admission Notification is not
received, a 100% reduction will
be applied to the contracted
benefit eligible rate.
2011-2012
Medical Plan Changes
2011-2012 Benefit
Major Medical
 2012 Calendar Year preventive/routine benefit expands
 Speech Therapy
No notification required:
 Occupational Therapy
Physical Therapy
No notification required:
$500
12 visits
Combined
18 visits
 Ambulance Ground
$1,500
 Ambulance Air
$9,000
 Obesity- follow up treatment is eligible benefit if surgery received prior to
being covered under this plan
2011-2012
Healthcare Reform (PPACA):
Evidence Based Medicine
Evidence Based Medicine is a process of external expert medical
evaluation to ensure clinically appropriate healthcare. It seeks to
assess the quality of evidence of the risks and benefits of treatments
(including lack of treatment).
TML IEBP contracts with a multitude of Specialty
Review Medical Consultants to work with your
attending physician to achieve the most effective
treatment outcome using evidence based medicine
approaches for benefit plan coverage.
2011-2012
2012 Healthy Initiatives Incentive
PROCEDURE
Health Power Assessment
Questionnaire
Preventive Office Visit
Lipid Panel
Basic or Comprehensive
Metabolic Blood Panel
TSH
PSA
Fecal Occult
Bone Density Study
Mammogram
PAP
Female Female Female Female Female Male
Male Male
18 - 35 36 - 39 40-50 51- 65
66 + 18 - 39 40 - 50 51+
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X 40-50
X
X
X 40-50
X
X 40-50
X
X
X
X
X
X
X
To comply with national Standards, TML IEBP is changing ages to
40-50 for Fecal Occult Test & Mammograms
Please refer to 2011-20112Medical Book, Schedule of Benefits and Summary of Benefit Changes for specific plan details.
2011-2012
Medical Plan
2011-2012 Benefit Changes
• Population Health Management will replace
Outreach. A Professional Health Coach is
available to all eligible enrollees.
• You can reach a health coach by calling:
1-888-818-2822 or by calling the number on
your ID Card to reach your coach directly.
BeWellat TML IEBP
Contact a Professional Health Coach
1-888-818-2822
Discuss your health concerns,
understand medications, develop
healthy habits and more...
2011-2012
TML Intergovernmental Employee Benefits Pool
Prescription Benefits
2011-2012
Medication Therapy Management Program (MTMP)
8 ways to Purchase Prescription Drugs
Lowest
Cost
$
$$
$$$
Over the Counter Equivalence:
Retail
Copay
$0.00
Value Tiered 34 day generic dispensement
Value Tiered 84-90 day generic dispensement
Generic
Best Brand Price List
$0.00
$9.00
$10.00
$38.00
N/A
N/A
$25.00
$95.00
Non-Best Brand Price List
$60.00
$150.00
Cost Share
$120.00
$300.00
Mac A
Non-Sedating Antihistamines (Claritin, Alavert)
Stomach and Ulcer (Prilosec)
Allergy Medication (Zyrtec)
Smoking Cessation (Nicorette Gum) Limit - 3 boxes
Allegra and Allegra-D
Specialty/Biotech Prescriptions
Highest
Cost
Mail Order Copay
N/A
$100.00
for 34 day dispensement
CVS Caremark will continue to administer mail order / Biotech.
2011-2012
Align Pharmacy Network
New Pharmacies are being added each month
Medication Therapy Management Program
The Value Tiered/Align Network Pharmacy Extension includes:
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Boomtown Drug
Brookshire Brothers
Chapel Hill Pharmacy
City Market Pharmacy
Cody Drug
Cody Pharmacy
Collingsworth Pharmacy
Cub Pharmacy
Davis City Pharmacy
Diamond Pharmacy
Dillon Stores
Doc's Drugstore of Brownwood
Doc's Drugstore of Early
Dominick’s
Eagle Lake Pharmacy
Farm Fresh 
Fikes Pharmacy
Fred Meyer
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Fry’s Food & Drug
Graham Pharmacy
HealthMart Pharmacy (Access Health)
HEB
Hico Pharmacy
Holmes Pharmacy
Hughes Pharmacy
Kenjura Pharmacy
King Soopers
Kmart
Kroger 
Luna's Friendly Pharmacy
Maloney Pharmacy
Med Shop Pharmacy
Medical Arts Drug (Waldie's Pharmacy)
Medicine Shoppe of Henderson
Overton Pharmacy
Plaza Pharmacy
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Quality Food Centers
Ralph’s
Randall’s 
Safeway
Sam’s Club
Shopko
Smiths 
Star Markets 
Target
The Medicine Shoppe of Jasper
Tom Thumb
Troup Pharmacy
Vons Companies Inc.
Vista Pharmacy
Waldie's Pharmacy
Walmart
Walter's Pharmacy
Whitehouse Pharmacy
2011-2012
Cost Share Drugs
Evidence Based Drug Formulary
Cost Share Copay Drugs
Cost Share Drugs
Antibiotics: Anti-Infective Agents
Impacts utilization on: Adoxa®, Doryx®, Dynacin®,
Monodox®, Periostat®, Solodyn®, Oraxyl®, Oracea®
Alternative Drugs
Generic
Generic
Minocycline® (for Dynacin®, Solodyn®)
Doxycycline® (for Adoxa®, Doryx®,
Monodox®, Periostat®, Oracea®,
Oraxyl®)
Central Nervous System: Sedative Hypnotics
Generic
Impacts utilization on: Ambien®, Ambien CR®,
Edluar®, Lunesta®, Rozerem®, Sonata®, Zolpidem ER® Generic
Zolpidem® Immediate Release (for
Ambien®)
Zaleplon® (for Sonata®)
Stomach Ulcer/Reflux
Drugs/Gastrointestinal/Stomach: Proton Pump
Inhibitors
Impacts utilization on: Aciphex®, Dexilant® (formerly
Kapidex®), Nexium®, Lansoprazole®, Prevacid®,
Prilosec®, Protonix®, Vimovo®
OTC
OTC
OTC
Generic
Generic
Prevacid®
Prilosec®
Zegerid®
Omeprazole®
Pantoprazole®
Respiratory/Allergy/Asthma: Antihistamines
Impacts utilization on: Fexofenadine®, Clarinex®,
Xyzal®
OTC
OTC
OTC
Generic
Generic
Allegra®
Zyrtec®
Claritin®
Loratidine®
Cetirizine®
Generic Cost Share Drugs
2011-2012
Cost Share Drugs
Cost Share Copay Drugs
Evidence Based Drug Formulary
Cost Share Drugs
Alternative Drugs
Nasal Steroids
Impacts utilization on: Beconase AQ®, Flonase® (brand),
Nasacort AQ®, Nasalide® (brand), Nasarel®, Nasonex®,
Omnaris®, Rhinocort AQ®, Veramyst®
Generic
Generic
Fluticasone® (for Flonase®)
Flunisolide® (for Nasalide®)
ADHD
Impacts utilization on: Adderall®, Adderall XR®,
Metadate/CD®, Ritalin®, Methylphenidate® extended release
(Concerta®)
Generic
Generic
BRAND
BRAND
BRAND
Methylphenidate®
Amphetamine®
Straterra®
Vyvanse®
Focalin XR®
Osteoporosis Drugs
Generic
Impacts utilization on: Actonel®, Actonel® w/Calcium, Atelvia®,
Boniva®, Fosamax®, Fosamax-D®
Alendronate® (for Fosamax®)
Migraine Headaches
Impacts utilization on: Amerge®, Axert®, Frova®, Imitrex®
(brand), Relpax®, Treximet®, Zomig®, Zomig ZMT®
Generic
Brand
Sumatriptan® (for Imitrex®)
Maxalt®
Overactive Bladder Drugs
Impacts utilization on: Detrol®, Detrol LA®, Ditropan® (brand),
Ditropan XL®, Gelnique®, Enablex®, Oxytrol® Patches,
Sanctura®, Toviaz®, Vesicare®
Generic
Oxybutynin® Immediate Release (for
Ditropan®)
2011-2012
Clinical Prior Authorization
The list of conditions below may change as appropriate for the plan. For prior authorization requests, please have your doctor/prescription prescriber call
RxResults at (888) 871-4002. Your doctor/prescription prescriber will be asked a series of questions and RxResults will then approve or deny the authorization
request.
ANTIBIOTICS

ASTHMA
INHALERS
Requests may be granted to patients who have
demonstrated compliance to an inhaled steroid
and/or satisfied additional clinical criteria as
determined by the prior authorization review.
Treatment Plan Adherence is required for
authorization to be approved.
 ADVAIR®
 BROVANA®
 DULERA®
 FORADIL®
 PERFOROMIST®
 SEREVENT®
 SYMBICORT®
ASTHMA

NON INHALERS 


GENERAL



Note:
ZYVOX®
XOLAIR® Injection
ACCOLATE®
SINGULAIR®*
ZYFLO®
Covered only for asthma as a second-line
drug, after an inhaled steroid. Use is
excluded for allergies and/or allergic rhinitis.
Requests may be granted to patients who
have demonstrated compliance to an inhaled
steroid and/or satisfied additional clinical
criteria as determined by the prior
authorization review. Treatment Plan
Adherence is required for authorization to be
approved.
Attention Deficit Disorder ADHD (For
individuals 17 years of age or older)
These medications may be reimbursed
following satisfaction of clinical criteria as
determined by prior authorization review.
Narcolepsy Medications (For individuals 17
years of age or older)
Acne Medications (For individuals 26 years
of age and older)
MAJOR BIOTECH
PRESCRIPTION
CATEGORIES
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Blood Cell Deficiency
Crohn’s Disease
Cystic Fibrosis
Growth Hormones
Hemophilia
Hepatitis C
HIV/Immune Deficiency Medications
Multiple Sclerosis
Oncology Oral
Osteoarthritis
Psoriasis
Pulmonary Arterial Hypertension
Renal Disease
Rheumatoid Arthritis
All Others
TESTOSTERONE
ALL PRODUCTS

ANDROGEL® (covered only for hormone
replacement not for erectile dysfunction)
ANDRODERM® TESTIM®
Actual lab results defining the testosterone
level will be required. The lab report will
indicate whether the level is low or within
normal ranges.
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DIABETES
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OSTEOPOROSIS

JANUVIA®/JANUMET® (covered for diabetes
only)
SYMLIN®
BYETTA®
VICTOZA®
ONGLYZA®
KOMBIGLYZE®
TRAJENTA®
These medications may be reimbursed
following satisfaction of clinical criteria as
determined by prior authorization review.
FORTEO®
All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change without notice to accommodate new drug
entries to the marketplace and adjustments in established medical and pharmacy practice guidelines.
2011-2012
Step Therapy
TML IEBP Step Therapy Drug Categories
ASTHMA
HIGH BLOOD PRESSURE (ANGIOTENSIN RECEPTOR BLOCKERS/ARB’S)
Required for members <40 years of age who have not
demonstrated adherence to an inhaled corticosteroid (ICS)
(90 days of therapy in the past 120 days).
If the member fills a medication in Category B, they will NOT need to
start with Category A, unless they haven’t used the medication for 100
days.
If the member is beginning therapy (regardless of age), only an
inhaled steroid will be approved unless otherwise approved by
RxResults.
Category A

Inhaled Corticosteroid (ICS) - Member must demonstrate
adherence to an inhaled steroid and/or satisfy specific clinical
criteria as determined by RxResults prior to obtaining a
Category B medication.
Category A
 Any generic ACE inhibitor or ACE-combination
 Losartan®/Losartan HCTZ®
Category B (Only after failure with a Category A medication)

ADVAIR®

BROVANA®

DULERA®

FORADIL®

PERFOROMIST®

SEREVENT®

SYMBICORT®
Category B (Only after failure with a Category A medication) The
prescribing provider must provide documentation from the Covered
Individual’s medical record indicating that prior treatment with an ACE
inhibitor resulted in a cough or angioedema.
 ATACAND®/ATACAND HCT®
 AVAPRO®/AVALIDE®
 BENICAR®/BENICAR HCT®
 COZAAR®/HYZAAR® (Brand only)
 DIOVAN®/DIOVAN HCT®
 EDARBI®
 EXFORGE®/EXFORGE HCT®
 MICARDIS®/MICARDIS HCT®
 TEKTURNA®/TEKTURNA HCT®
 TEKAMLO®
 TEVETEN®/TEVETEN HCT®
 TRIBENZOR®
 TWYNSTA®
 VALTURNA®
 AZOR®
Treatment Plan Adherence is required for authorization to be
approved.
Note:
All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change
without notice to accommodate new drug entries to the marketplace and adjustments in established medical
and pharmacy practice guidelines.
2011-2012
Restat Website
www.restat.com
Member Login
RESTAT Website
Drug Pricing Lookup
Drug Name
Medical Condition
Dosage
Drug Form/ Quantity
Zipcode
Shop & Compare
RESTAT Website
Drug Pricing Lookup
RESTAT Website
Drug Pricing Lookup
2011-2012
Medication Therapy Mangement Program:
Is based on Evidence Based Medicine.
Converts Patients from costly drugs to therapeutically equivalent,
cost effective alternatives.
Ask your Dr. to contact Rx Results, (the number is on your ID Card)
Look up drug prices at www.restat.com
2011-2012
TML Intergovernmental Employee Benefits Pool
Medical Plans
Medical Plan Options – Port Neches
Plan
Copay
Individual
Deductible
Individual
Out of Pocket
(2 x Family)
(2 x Family)
$30.00
$200.00
$2,500.00
30%
$0.00
$3,000.00
20%
$500.00
$2,000.00
20%
$500.00
$3,000.00
20%
$750.00
$3,000.00
20%
$1,000.00
$3,000.00
P85-150-40*
$1,500.00
$4,000.00
HSA Eligible
(IRS: High Deductible Health Plan)
(IRS: High Deductible Health Plan)
P85-20-25
HRA Eligible
P75-0-30
HRA Eligible
P85-50-20
HRA Eligible
P85-50-30
HRA Eligible
P85-75-30
HRA Eligible
P85-100-30
HRA Eligible
P85-250-30*
$2,500.00
$3,000.00
HSA Eligible
(IRS: High Deductible Health Plan)
(IRS: High Deductible Health Plan)
Medical Plan Options – Port Neches
► Employee & Dependents must enroll on same plan
► Employee can change plans at open enrollment or with qualifying event
 Should an employee select a plan that is more expensive than the amount pledged , an
optional pretax payroll deduction would allow them to “buy-up” to a more expensive plan.
 Should an employee select a plan that is less expensive than the amount pledged, they can
“buy-down”. The balance of remaining dollars can be used to offset the monthly cost of
dependent coverage or if not applied to coverage, can be deposited in a pre-tax account
PRE-TAX
Health Reimbursement Account (HRA)- Employees that “buy-down” to a less expensive
PPO plan (not one of the two IRS High Deductible Plans) are able to have the excess money
deposited into a Health Reimbursement Account.
High Deductible Health Savings Account (HSA) - Employees that “buy-down” to one of
the two IRS High Deductible Plans are able to have the excess money deposited into a Health
Savings Account.
HIGH DEDUCTIBLE HEALTH PLANS
The High Deductible Health Plans (HDHP) are IRS designed plans that have a
number of features that make them very different from a traditional PPO:
As you receive non-preventive medical care, you must meet the plan deductible
before the health plan pays benefits.
Enrollees must pay all diagnosis related expenses (non-preventive) until the
deductible is met. This include preferred lab charges and prescription drug charges.
Preventive prescription drugs can be purchased with a copay (or at no cost for
certain generic drugs). However, non-preventive prescriptions are not eligible for
a copay (or no cost) until the deductible is met (A list of preventive drugs is
available).
Both healthcare and prescription drug expenses can accumulate to the
deductible and out of pocket max.
Once the deductible & out-of-pocket max is met, eligible, in-network services
and eligible prescriptions will be paid at 100%.
HDHP Preventive Drug List
HIGH DEDUCTIBLE HEALTH PLANS
How does this work with Section 125 (FLEX) plan? It
becomes a Limited Post Deductible Section 125 Plan
 Flex money cannot be used until the HDHP deductible is satisfied. (H.S.A.
money in your H.S.A bank account can!)
 Flex money can be used for dental or vision expenses.
HIGH DEDUCTIBLE HEALTH PLANS
What if I have money in my HRA today?
 HRA money cannot be used until the deductible is satisfied. (HSA money can!)
 HRA money can be used for dental or vision expenses.
HRA money can be used once the HDHP deductible is satisfied. Current
Flex/Debit card de-activated 09/30/2011. Paper receipts must be filed for
reimbursement.
What if I have satisfied some or all of my yearly
deductible? Do I get credit for monies spent?
 Per IRS, deductible credit cannot be given if you used HRA money.
 You will get credit for any portion of the deductible that was satisfied without
using HRA monies.
2011-2012
TML Intergovernmental Employee Benefits Pool
Health Reimbursement
Account (HRA)
2011-2012
HRA
Healthcare Reform in Action
All Over-the-Counter medicines or drugs
must be prescribed by a physician.
The following are examples of some of the OTC items that will remain available
without a doctor's prescription:
• Band Aids
• Braces & Supports
• Contact Lens Supplies & Solutions
• Diagnostic Tests & Monitors
• First Aid Supplies
• Ostomy Products
• Wheelchairs, Walkers, Canes
• Birth Control
• Catheters
• Denture Adhesives
• Elastic Bandages & Wraps
• Insulin & Diabetic Supplies
• Reading Glasses
FAQ: If I get a doctor’s prescription for an OTC medication, can I still use my Benefits Debit Card?
No. The Benefits Debit Card cannot be used to pay for any OTC medications after December 31, 2010. However, you
may use another form of payment and submit a FSA/HRA/HSA Claim Form with a doctor’s prescription for
reimbursement.
2011-2012
Availability of Funds
• HRA funds are only available as they are
deposited by the employer.
• When using the debit card only the amount
available will be approved.
• Example: Claim totals $250, but only $249.99 is
available; debit card transaction will be denied. A claim of
$249.99 would be approved and the remaining $0.01
should be paid through alternate means (cash or personal
credit card)
2011-2012
HRA Funds are NOT Use it or Lose It
HRA Funds can be used to:
1. Purchase eligible medical expenses per the IRS
guidelines and Plan Document
2. Offset cost of Dependent Coverage
3. Purchase Voluntary Products (i.e, vision/dental)
or
4. Can accumulate year to year and later be
converted to a Retiree Reimbursement Account
2011-2012
Debit Card Guidelines
• In many cases, the software will substantiate procedures for
Debit Card Claims
• Receipts should always be maintained by participant (keep a
folder with all the receipts and documentation!)
• Even though it’s called a “Debit” card, there is no PIN# so you
must select “Credit” when swiping the card
2011-2012
TML Intergovernmental Employee Benefits Pool
Prompt Pay
2011-2012
SB 418 ~ Prompt Pay
Healthcare Reform in Action
Governor Perry signed into law SB 418 to support prompt payments for network providers.
Claim Methodology
Paper Claim (5 days after claim is mailed)
Electronic Claim or overnight receipt
Affirmative adjudicated Pharmacy Claim
Payment Timeline
45 days
30 days
21 days
* Claims that are not paid within
the timeline will revert back to the
billed amount and may lose the
discounts of the contracted
amount.
Requesting Additional Information and Impact on Claim Payment Timeline
Many network provider contracts, including Baylor Medical System, stipulate that payors requesting
additional information from someone other than the Prompt Pay Provider will not stop the claim
payment timeline. Thus, getting the requested information from the covered individual, in a timely
manner, is critical to ensure that penalties are avoided. Below are examples of information that a claim
could be pended/denied for while awaiting information from the covered individual:
1. Other Insurance,
2. Pre-existing Condition Inquiry,
If the information is not
3. Verification of dependent eligibility
received, the covered
4. Right of Recovery Investigation,
individual may be balance
5. Coordination of Benefits.
billed.
2011-2012
Accident / Injury Questionnaire
Accident / Injury Questionnaire
Return to:
TML Intergovernmental Employee Benefits Pool
PO Box 149190
Austin, TX 78714-9190
Fax: (512) 719-6539
TML Intergovernmental Employee Benefits Pool (TML IEBP) received a claim for the services that suggests you
may have had an accident or injury. This form must be completed and signed by you (or a parent or guardian if the
injured person is under 18 years of age). The information you provide is important as it helps TML IEBP find out if
medical benefits are available from other sources. Please complete any and all relevant sections even if the services
are not accident or injury related. Return promptly to the above address to avoid further delays in the processing of
your claims.
Information on Patient:
Information on Covered Employee:
Name:
Name:
Address:_____________________________________
Employer’s Name:
____________________________________________
Enrollee ID:
Address:
Daytime Phone #:
Daytime Phone #:
Section A ~ Treatment Information: (“NOT APPLICABLE” or “N/A” ARE NOT PROPER ANSWERS)
1.
Please provide a brief description of why treatment was necessary____________________________________
________________________________________________________________________________________
Date of event that caused the injury/illness__________________
Address or location of event________________________________________________________________
Please give a brief description of what happened. (We need a description of the cause of the event even if no one
else was involved.)
2.
3.
Please check all boxes that apply to the reason for treatment:
Injury at work
Injury involving an automobile
Injury at the patient’s place of residence
Sports injury (include waiver or name and address of sport organization)
Assault
Other Injury
Treatment not related to an Accident/Injury
Is this related to a motor vehicle accident?
Work vehicle involved during working hours?
Was a Police Report Filed?
YES
YES
NO, (if no, move to question 4)
YES
NO
NO (if yes, please attach a copy)
Please list the name, address and phone number of the owner and driver of the vehicle the injured person was
riding in at the time of the accident.
Name
Address
Telephone
Owner:
Driver:
Owner 2:
Driver 2:
List the make, year and license number of vehicle the injured person was riding in or driving.
Vehicle Make
Vehicle Year
Vehicle License Number
Do I have to submit the Accident/Injury
Questionnaire even if I was not in an
accident?
Yes! The information requested can affect
the way your claims are processed. Because
of this, all claims related to this accident or
injury will be put on hold until TML IEBP
receives your completed Accident/Injury
Questionnaire. If TML IEBP does not receive
your completed Accident/Injury
Questionnaire, you may be balanced billed
by your medical care provider(s). Once the
questionnaire is received, claims will be
released for processing.
2011-2012
Other Coverage Inquiry
Understanding Your
Explanation of Benefits
1
2
3
4
5
1.
Date of Service - Date the service was
incurred.
2.
Total Charge - The amount your
provider is charging for services.
3.
Ineligible - Any amounts listed in this
column may not be covered under the
terms of your benefit plan and may be
your responsibility to pay.
4.
Remark Code - The code used
regarding payment. The code is
defined under Remark Code
description.
5.
Type of Service - The numeric code
for type of service rendered. The code
is defined under Type of Service
rendered.
6.
Cost Management Savings - You are
not responsible for this amount
because you received services from
an In Network provider or from a
provider that was willing to negotiate
his or her fee. The discount was
negotiated with the provider of service
on your behalf. The affiliation, if
shown, indicates the provider
organization through which the
discounts were negotiated.
6
7
8
9
10
11
12
7.
Copay - The amount shown represents
either the copay you paid at the time of
service or the copay amount that you
will be responsible to pay. This amount
usually does not apply towards the
satisfaction of your deductible or out of
pocket maximum. Copays are
described in your Benefit Book and on
your Schedule of Medical Expense
Benefits.
8.
Deductible Amount - The amount
shown is the amount applied to toward
the patient’s deductible. The deductible
is your responsibility to pay.
Deductibles are described in your
Benefit Book and on your Schedule of
Medical Expense Benefits.
9.
Covered Expenses - The amount
shown is the amount that is considered
for payment by your benefit plan.
10. Balance - The amount shown is the
amount charged minus the ineligible,
cost management savings, copay and
deductible amount.
11. Pay % - The amount shown is the
benefit percentage that was paid by
your benefit plan.
12. Amount Payable - The amount shown
is the benefit amount paid by your
benefit plan.
13. Out of Pocket - This is the portion of
the Covered Expenses that is the
patient’s responsibility. Non Network
amounts may not apply to the
cumulative out of pocket depending on
plan design.
13
14
15
14. Patient’s Total Responsibility - If there
is no Other Payment Adjustment
amount, the Patient’s Total
Responsibility equals the Total Charge
less Cost Management Savings less
Other less Total Benefit. Note: The
Patient’s Total Responsibility will not be
shown if there is an Other Payment
Adjustment amount or if this EOB is for
an adjusted claim.
15. Other - This is the total of any charges
listed in the Ineligible column for which
we are awaiting documentation or for
which we have determined the provide
may have inappropriately coded this
service or for which we determined the
amount was a duplicate. Upon receipt
of the requested information, a decision
will be made to determine which, if any,
of these charges are eligible expenses.
If the provider believes that the charges
were appropriately coded and billed,
supporting documentation must be
submitted for further review to
determine if any additional allowance is
warranted. If the amount is for a
duplicate, no action is necessary.
2011-2012
SUPERIOR VALUE
• Preferred labs pay at 100% for eligible laboratory tests…
remember Quest labs are not a network provider!
• No Cost for many Generic Drugs at Align Pharmacies
• $150 Incentive for completing Annual Tests
– No cost (network) + $300 for wellness (2011) increases to $500
(201 - Calendar Year).
• Professional Health Coaches
– You can reach a health coach by calling: 1-888-818-2822