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Frequently Asked
Questions about Benefits
 Q.
What is a co-pay?
Q.
What is a
deductible?
Q.
What is the
difference between the individual deductible and the family
deductible?
Q.
What is
coinsurance?
Q. What is an
Out-Of-Pocket Maximum?
Q. Do the charges I
pay for my prescriptions count toward my deductible or Out-of-Pocket
Maximum?
Q. How does the change in the
prescription drug plan work?
Q. How do I find the lowest
cost of prescriptions?
Q. What will I have to pay for
my surgery (childbirth)?
Q. What happens if I am in
the hospital on Dec. 31st?
Q.
I just took my child to the doctor and paid the office visit copay.
Why have I now received a bill for lab work done?
Q.
How do I add my new
baby to the Health Plan?
Q. I
just found out I am pregnant, are there any special programs
available to me?
Q. Does Irving ISD provide
discounts for gym memberships or lasik surgery?
Q. What is a Health Risk
Assessment and how do my family and I take it?
Answers:
Q.
What is a co-pay?
A.
A co-pay is a set dollar amount that is
your portion to pay for specific health care expenses such as for
doctor office visits: $30 on Base Plan, $50 for a Specialist.
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Q.
What is a deductible?
A. A
deductible is a dollar amount that you must meet by paying for
medical services before the insurance company will begin to pay for
your health care expenses. Our plans cover your expenses for an
office visit, after co-pay, without requiring you to first meet your
deductible.
For
the Base Plan
there is a $1000 Individual Deductible and a $2000 family
deductible. On the High
Plan there is a $250 In-Network Individual Deductible and a $500
In-Network Family Deductible. On the High Plan, if you use out of
network providers the Individual and Family Deductibles are $500 and
$1000 respectively.
The district’s plan has a
Calendar year deductible (Jan through Dec). On January 1 of each
year you will have a new deductible to satisfy before coinsurance
will begin.
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Q.
What is the difference between the
individual deductible and the family deductible?
A. Individual
deductibles is the amount of money that one person in your family
must meet (by paying for health care services) before the health
plan will begin paying a part of the charges. If there is more than
one person on your health plan, after two people have met their
deductible, all other individuals will be able to use the services
without meeting another deductible.
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Q.
What is coinsurance?
A. After
you have met your deductible, coinsurance is the percentage of
health care cost for which you are responsible (30% on Base Plan,
20% on High Plan) and also the percentage the health plan is
responsible for (70% Base Plan, 80% High Plan). You continue to pay
a percentage of all charges up to the Out-of-Pocket Maximum.
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Q.
What is an Out-Of-Pocket Maximum?
A.
The Out-of-Pocket Maximum (OOP) is the dollar amount that is the
greatest amount of coinsurance (% of bills) that you will have to
pay in one plan year. Your office visit, ER, Hospital and Urgent
Care copays do count toward your OOP. The OOP does not
include your deductible or
prescription expenses.
For the Base Plan, the OOP is $5000 for an individual and $10,000 for a family.
For the High Plan, the OOP
is $2000 for an individual and $4,000 for a family (In-Network).
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Q. Do the charges I pay for my
prescriptions count toward my deductible or Out-of-Pocket Maximum?
A.
No, your prescription charges do not count toward the deductible or
the out-of-pocket maximum. The only limit on the cost of
prescriptions is new $1000 threshold for each refill. Maximum you
pay per refill is 30, 40 or 50 percent of the first $1000 of cost of
the medication. This equates
to a maximum cost per refill of $300 for Generics, $400 for
Preferred Brand Drugs and $500 for Non-Preferred Brand Drugs.
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Q.
How does the prescription drug plan work?
A.
There is a limit to the amount employees have to pay each time they
fill a prescription. The limit is set at 30, 40 or 50% of the first
$1000 of cost for medications. This means that employees would pay
up to $300 for Generic;
$400 for Preferred Brand
Name
where no Generic is available and $500 for
Non-Preferred Brand
Name
medications where no Generic
is available.
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Q.
How do I find the lowest cost of prescriptions?
A.
The amount you have to pay for prescriptions depends on what the
medication is and where you choose to shop.
Take a look at the
Prescription Drug List to determine what your medication is
classified as. If it is a Non-Preferred Brand Name drug, review the
list to see if there are any Generic or Preferred Brand Name
alternatives available. Also, take the list to the Doctor’s office
and ask them to see if there are alternatives that would cost you
less. (BCBS Prescription Drug
List)
To shop around to find
the lowest price for your medications, you can call
BCBS Customer Service 1-800-521-2227
to get assistance in pricing your medication at area pharmacies or
you can log into
www.bcbstx.com
to search prices at area
pharmacies. More ideas on pricing are available on our website at (Where
to Shop for RX).
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Q.
What will I have to pay for my surgery (childbirth)?
A.
The amount you will have to pay for a surgery or child birth will
depend on the charges billed by the hospital and physicians
involved. The most you would be responsible for would be your
Deductible and Out-of-Pocket Maximum (combined total of
$6000).
The lower the cost of the surgery, the lower your payment
responsibility will be.
If you are planning a
surgery that will be performed in a Hospital, you will be
responsible for meeting the following payments.
Base Plan Example:
$20,000
surgery and hospital stay charges
You Pay
$1000 Deductible
+ $500 Admission copay (counts
toward your Out of Pocket Maximum)
$1500
$20,000 -
$1500 = $18,500 remaining charges
You Pay
30% of $18,500 = $5,550 your coinsurance
Max
Coinsurance on plan = $5,000
Total paid for
$20,000 surgery: $1000 + $5,000 = $6,000
You would still owe for
office visit copays and/or prescription expenses incurred though the
rest of the year.
Base
Plan Example: (CHILDBIRTH EXAMPLE)
$50 OBGYN Office Visit Copay (Initial visit to confirm pregnancy)
$10,000
surgery and hospital stay charges
You Pay
$1000 Deductible
+ $500 Admission copay
$1500
$10,000 -
$1500 = $8,500 remaining charges
You Pay
30% of $8,500 = $2,550 your coinsurance
Max Out
of Pocket $5,000
Total paid for
$10,000 surgery: $1000 + $2,550 = $3,550
(not counting office visit copays or prescriptions)
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Q.
What happens if I am in the hospital at the end of the year on Dec. 31st?
A. Your hospital charges will apply to the
deductible and coinsurance of the year you were admitted for the entire length of your stay.
As soon as you are released from the hospital, all future
charges/medical needs will be applied to the new year’s deductible
and out-of-pocket maximum.
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Q. I
just took my child to the doctor and paid the office visit copay.
Why have I now received a bill for lab work done?
A.
Many doctors’ offices will process
their own blood work, urine analysis and possibly their own x-rays.
Sometimes they must send these tests out but will charge for all
services under their own billing. If the doctor’s office sends the
lab work or x-rays off and they are billed separately through the
other vendor (hospital, Quest, etc.), you will be responsible for the
charges. These charges will work to satisfy part of your
deductible and/or out-of-pocket maximum.
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Q.
How do I add my new baby to the Health
Plan?
A.
Contact the Benefits Office by calling
972-215-5241 or emailing Maria G. Perez
mgperez@irvingisd.net .
You must provide a copy of the baby’s birth certificate (or copy of
the birth facts provided at the Hospital). Your premium deductions
will be adjusted to reflect any additions if needed. You will also
receive an id card on the new baby within two (2) weeks of adding
the child.
You have 31 days from the date of birth/adoption to get your baby
added to the District’s Insurance. You must contact the District’s
Benefits Office within this timeframe to have the child added.
Babies are only covered automatically for 31 days, after that, their
coverage is terminated unless the Office has received proper
documentation.
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