Understanding Your TRS-ActiveCare Plan

This is the monthly amount you pay for health care coverage.

This is the amount you pay annually for covered health care services before your health plan starts to pay. Keep in mind that your health plan covers certain preventive benefits at 100%, even before you meet your deductible. See a complete list of covered preventive care and screenings.

There’s an individual deductible and a family deductible. For all TRS-ActiveCare plans, individuals only need to meet their own deductible before the plan begins to pay their coinsurance. That means individuals don’t have to wait for the family to meet the family deductible before the health plan starts paying benefits.

Here’s How Deductibles Work:

Claims that count toward an individual’s deductible also count toward the family’s deductible. Once an individual meets their deductible, they then only pay coinsurance or copays, which don’t count toward the family deductible.

After the family deductible is met by any combination of family members, the entire family only pays coinsurance and copays for medical care and prescriptions for the rest of the year.

Coinsurance is the portion you’re required to pay for services after you meet your deductible. It’s often a specified percentage of the costs. For example, you pay 30% in coinsurance and your health plan pays 70%.

A copay is the set amount you pay for a covered service at the time you receive it. This amount can vary by the type of service or provider. For example, you may pay $30 to see your regular doctor, and you may pay $70 to see a specialist like an endocrinologist.

MOOP is the maximum amount you’ll pay each plan year for medical costs. After reaching your MOOP, your health plan pays 100% of allowable charges for covered services for the rest of the plan year. Just like with deductibles, there is an individual MOOP and a family MOOP.

An individual’s deductible, copays and coinsurance count toward both the individual and family MOOPs. Once an individual meets their MOOP, their allowable expenses are covered at 100% for the rest of the plan year. After the family MOOP is met by any combination of family members, the entire family’s medical care and prescriptions are covered at 100% for the rest of the plan year.

A PCP is the provider you choose to be your primary source for medical care. Your PCP coordinates all your medical care and treatment, including hospital admissions and referrals to specialists.

The TRS-ActiveCare Primary and TRS-ActiveCare Primary+ plans require you to have a PCP. We encourage you to have a PCP even if you’re not enrolled in one of those plans because it can benefit your health and budget.

A referral is a written authorization from your PCP to see a different contracted provider, specialist or facility.

If you’re enrolled in the TRS-ActiveCare Primary plan or the TRS-ActiveCare Primary+ plan, you’re required to have a referral to see almost any provider other than your PCP.

Blue Cross and Blue Shield of Texas (BCBSTX) requires approval for certain medical services or treatment before you have them or within 48 hours of emergency treatment. You or your doctor will need to get prior authorization for these services for them to be covered by your plan.

Possibly the most important factor to understand about your health plan is its network. You can save a substantial amount of money by using only in-network providers. These providers are contracted with your health plan to provide medical services and treatment at a negotiated rate.

It’s important to know with the TRS-ActiveCare Primary and TRS-ActiveCare Primary+ plans, you won’t have coverage at all if you don’t use in-network providers. That means you’ll pay all expenses out of your own pocket. Make sure you’re always in network by using Provider Finder® to search for doctors and hospitals in your plan’s network.

To find out your specific copays, coinsurance, deductibles and MOOPs, check your plan’s Resource Guide or Benefits Booklet. You can also call a Personal Health Guide (PHG) at 1-866-355-5999 or chat with a PHG in the BCBSTX APP.

• Download the BCBSTX App from the Apple App Store
• Download the BCBSTX App from the Google Play Store