TSHBP FAQ's
>TSHBP General Information
- What is the Texas Schools Health Benefits Program (TSHBP)?
- TSHBP is a regional rated program for Texas school districts. For the 2023-24 Plan Year, TSHBP is proud to offer two Directed Care Plans, the TSHBP High Deductible (HD) Plan and the TSHBP Copay Plan, and an Aetna Traditional PPO Plan, the Aetna Signature Plan. All plans are designed so members can easily navigate through their health medical needs. The TSHBP is a member-owned interlocal program, created in response to the needs of districts seeking long-term, cost-effective health benefits. The TSHBP health benefits program stabilizes and reduces the cost of group health coverage for employees while reducing their member out-of-pocket medical expenses. The Board of Trustees is made up of member districts from all areas of the State.
- How do I obtain a quotation from the TSHBP?
- Current FBS clients can obtain a quote by executing a Broker of Record (BOR). Contact your FBS Benefit Consultant or Account Executive for assistance. If you are not an FBS client, we will need current census information and a medical Broker of Record (BOR). Please contact TSHBP at 800-583-6908 for assistance.
- How does the TSHBP meet the school district’s purchasing requirements?
- Formed under the Interlocal Cooperation Act, Chapter 791 of the Texas Government Code, the TSHBP Interlocal Agreement enables Members to benefit from cost-saving agreements while meeting Texas Education Code section 44.031 Purchasing Contracts requirements.
- If our district joins the TSHBP for only one year, are we responsible for our runout claims liability?
- The TSHBP has a specific policy that pays for all individual members with over $500,000 in claims with unlimited coverage. This Aggregate Policy reimburses TSHBP for all eligible claims over expected loss funding level with a cumulative policy maximum of $2 million. The TSHBP utilizes an AM BEST A “Excellent” rated carrier with a financial size of XV ($2.0 billion or more).
- What measures are taken to protect the financial integrity of the program?
- The TSHBP Board of Directors has secured the services Heinfeld, Meech, & Co., P.C. to perform an independent audit of the program annually. The report is presented to the Board of Trustees for review and approval.
- Where does the “fund balance” in the TSHBP go?
- The Board of Trustees determines the use of the funds including monies to be returned to the participating districts or to provide member districts with additional services and programs.
>TSHBP Plan Information
- What are the advantages of TSHBP HD Plan?
- The TSHBP HDHP is an “embedded” deductible benefit plan. Once your deductible is met, the plan pays 100% of eligible charges. This allows a single family member access to medical benefits sooner. This can save families money if one family member incurs a large number of medical expenses.
- How does the TSHBP Copay Plan work?
- The TSHBP Copay Plan is a unique plan in that it has a $0 deductible. All services are subject to copays and all co-payments apply to the annual out-of-pocket maximum.
- Will deductibles carry over to TSHBP?
- No, there is no prior carrier credit. Deductibles (and other plan maximums) from the employee's prior health coverage do not carry over to TSHBP.
- What happens to the money I paid towards my deductible if I transfer to a different TSHBP participating district?
- Plan year deductibles, out-of-pocket maximums, and other accumulations will follow you and your dependents and will apply towards coverage at your new district.
- If I am in a medical emergency and seek treatment will my plan pay for the services?
- Medical emergencies will be paid by the plan regardless of the facility where you seek treatment. If you are on a Directed Care plan and have non-emergency medical services, reach out to the Care Coordinator to schedule services.
- Do I need to choose a Primary Care Provider (PCP)?
- None of the medical plans provided by TSHBP (Directed Care & Traditional PPO Plans) require you to choose a PCP or receive a referral to see a Specialist.
- I am at my doctor’s office, but I don’t have my card on me, what do I do?
- If you have misplaced or lost your TSHBP ID card, you can have your provider call the Care Coordinator to verify your benefits at 888-803-0081. Additionally, if you are at your local pharmacy and do not have your TSHBP ID card on you, you can have your pharmacist call Southern Scripts to verify benefits at 833-439-9618.
>Care Coordinator
- What is a Care Coordinator and what do they do?
- Under the Care Connect program, a Care Coordinator becomes a personal concierge for the members in the TSHBP. Today, most health plans require members to navigate a complicated maze of in-network confirmation requirements. With TSHBP, the Care Coordinator steps in on behalf of the member and fully supports the member through the process. The Care Coordinator will explain benefits, verify eligibility, answer questions, research quality on every encounter, schedule procedures, and negotiate with facilities for the best rates. For members enrolled in the TSHBP HD or TSHBP Copay Plan, the Care Coordinator is required to schedule and pre-certify services and/or procedures in a hospital or facility. For members enrolled in the Aetna Signature Plan, the Care Coordinator is not required but is available to members for use. Members could be eligible for the PPO+ Deductible/Coinsurance Credits.
- When should I reach out to the Care Coordinator?
- If you are on the Directed Care Plans and need access to a facility or hospital for a service or procedure, you are required to reach out to the Care Coordinator to pre-certify and/or coordinate services. You are encouraged to reach out as soon as you know you will need an admission or procedure; Care Coordinators require a minimum of 5 business days to secure necessary documentation and arrange payment to the provider. Procedures could include surgery, a high dollar diagnostic test (i.e., MRI or a colonoscopy), any inpatient or outpatient procedure (i.e., a delivery or getting your tonsils removed) are a few examples. When in doubt, reach out to our Care Coordinators to verify if a procedure needs to be pre-certified or services coordinated at 888-803-0081.
- What happens if I don’t call in to pre-certify or coordinate services required by the Care Connect Team?
- If you do not contact the Care Coordinator to pre-certify or coordinate services, benefits may not be covered, or a penalty could be applied.
- For an upcoming surgery, will I be able to keep my physician of choice?
- When reaching out to the Care Coordinator to schedule your procedure, the Care Coordinator will take into consideration your physician of choice, the hospitals/facilities your physician has admitting privileges to, quality scoring and if the facility is charging a fair price for your procedure. If the facility doesn't meet quality or plan standards, you may be asked to consider a different provider. If that happens, the Care Coordinator will discuss your options with you.
>TSHBP Network Information
- Who is the In-Network Provider for TSHBP?
- TSHBP Directed Care Plans utilize the HealthSmart National PPO Network to provide Physician and Ancillary Services access to all members. When asked what network you are on, say you are on the HealthSmart Network. Since procedures and admissions are handled through your Care Coordinator, there are no hospitals in the HealthSmart Network. The Aetna PPO Plan utilizes the Aetna Signature Administrators Network which includes Physician and Ancillary Services, as well as hospitals. When asked what network you are on, say you are on the Aetna Signature Network
- If my doctor is not in the network, do I still have benefits?
- The TSHBP Directed Care Plans provide coverage for both in and out-of-network providers. If your physician of choice is not in-network, then you would utilize out-of-network benefits. For example, on the TSHBP Copay Plan, if your physician is not in the network, then your copay would be $60 instead of $45. Please present your ID card to your doctor to provide details on the Out-of-Network benefits. The Aetna PPO Plans provide In-Network benefits only. There is no coverage for services provided by a non-Aetna network provider except in case of emergencies.
- If my doctor is not in the network, is there any way for me to add them?
- Yes, there is! If your provider is not in the network, you can nominate them to join the network at healthsmart.com/Service-Centers/Member-Center/Nominate-a-Provider. You will fill out a form where you would provide contact information for your provider and then we will start the process of reaching out to them to join the network.
- Do I have to meet both the In-Network and Out-of-Network deductibles before the plan pays 100%?
- You do not have to meet both the In-Network deductible and Out-of-Network deductible for the plan to pay 100%. Both In-Network and Out-of-Network will cross-apply, and a member would only have to meet $500 more in Out-of-Network benefits are being utilized.
>Prescription Benefits
- Who administers the prescription drug program for my plan?
- Southern Scripts manages the TSHBP Prescription Drug for the plans. They offer a full prescription service to deliver significant savings to our TSHBP members through straight-forward pricing models and management.
- What are Specialty Drugs and how are they covered under the plans?
- Specialty Drugs are classified as high-cost, high complexity drugs and are often biologics - "Drugs derived from lining cells" that are often injectable or infused. They are used to treat complex or rare chronic conditions such as cancer. Specialty Drugs are covered under the TSHBP Plan; however, the TSHBP does require participation in a patient assistance program in place for members requiring Specialty Drugs. Please review our Prescription Drug Benefit page to see how we assist members with their Specialty Drug needs. Please contact Southern Scripts to see if your medication qualifies at (833) 439-9618.
- Does TSHBP offer Mail Order?
- TSHBP does offer an option for Mail Order Services for a 90 Day Supply. If you are wanting to Mail Order your prescriptions, you can find the Mail Order Form here, Mail Order Form.
>RxCompass
- What is the RxCompass program?
- RxCompass is a drug management solution that provides significant savings on specialty and high-cost medications. Our comprehensive pharmacy drug savings program guides you through various drug savings pathways to maximize savings. In most instances you will have zero out-of-pocket costs. If you are on a High Deductible plan, you will be subject to your plan requirements first.
- How will I know which medication will have to go through RxCompass?
- You can search for various medications using the “Search” feature at tshbp.org to see if a medication falls under the RxCompass program. Additionally, RxCompass may contact members who need access to these medications.
- Why can’t I get my medication from my current pharmacy?
- The designated drugs are covered under the RxCompass program. RxCompass Care Navigators will help you to source your medication through our various lower cost pathways. They will also assess the level of medication you have on hand and may approve additional fills at your current pharmacy if needed.
- Will all my other medications be affected?
- Only drugs on the RxCompass list are affected by this program.
- Do all RxCompass drugs need a prior authorization?
- Not every drug requires approval through the authorization process.
- Does the RxCompass program replace our current prescription plan?
- This is a program that works alongside your current prescription plan.
- Will I have to pay more money to be in the RxCompass program?
- In most instances, you will have a zero out-of-pocket cost, if you are enrolled in a High Deductible Health (HDHP) Plan, you will be subject to the required deductible amounts.
- How do I enroll?
- A highly trained Care Navigator will be assigned to you and assist you every step of the way through your transition to a new dispensing pharmacy. They will determine if you have enough medication on hand while they assist you. If you are short on medication, they will allow an additional fill at your current pharmacy.
- Why do I have to fill my new medication locally first instead of using one of the RxCompass pathways?
- When taking a new-to-you medication a minimum of a 30-day trial is required in which initial counseling could be received from a local pharmacy. This ensures that you know how to properly take the medication and are aware of possible side effects. The trial also ensures there are no adverse reactions to the medication and that your physician has determined it is appropriate to continue therapy prior to ordering a three-month supply.
- What is the maximum amount of medication I can order?
- Using the RxCompass pathways, you may be able to order up to a 90-day supply of medication. This is dependent on a written prescription from your physician, who determines the amount of the medication (up to a 90-day supply) that will be dispensed.
- Will the medication be exactly the same as what I currently take?
- All medications sourced through the RxCompass pathways are FDA approved and as safe and effective as the medications from your local pharmacy.
- How do you ensure my safety?
- All medications are delivered in the original sealed package supplied from the brand-name manufacturer’s approved facility.
- Who pays the shipping costs?
- There are no individual shipping charges. All shipping costs are covered by the program.
- Do I have to sign for my package?
- Typically, there is no requirement for signature upon delivery, however, certain delivery vendors may require a signature, this is left to their discretion. You will receive a tracking number allowing you to monitor your shipments’ progress. Some of these medications are highly perishable, sitting for an extended period in high or low temperatures can render them unusable which is why a signature is recommended.
- Will medications sent from countries like Canada, Australia, United Kingdom, and New Zealand look the same as the medication currently dispensed from my local pharmacy?
- Sometimes pharmaceutical companies use different names for the same medication internationally so the medication may not be called the same as it is in the USA. Also, the appearance of the medication and packaging can differ between countries for the same medication. These medications are all FDA approved.
- How long will it take for the plan member to receive their order?
- It depends on the RxCompass pathway. However, as a guideline you will receive your medication within 10-15 working days of the order shipping. We do recommend that you have a 30-day supply on hand of the medication you are ordering, prior to the placement of the first order. Our Care Navigators will help with getting additional refills as needed.
- What happens if I run out of medication while I am waiting?
- Your Care Navigator will work closely with you to make sure you have enough medication on hand while we are sourcing medication through the RxCompass pathways. During our initial communication with you we will determine how much medication you have on hand and will approve an additional fill if necessary.
>TSHBP Additional Plan Benefits
- How does the TSHBP assist with Balance Billings?
- For the Directed Care Plans, in the event a member receives a balance bill for a covered service, the TSHBP has engaged a patient advocacy firm who will work in coordination with the TSHBP’s Care Connect Program on the member’s behalf to support the member and work directly with the provider or medical facility to negotiate an agreeable balance bill settlement. Unfortunately, the balance bill support process can become lengthy due to a medical facility refusing to accept a fair and reasonable payment negotiation as settlement for the balance bill. In those circumstances, TSHBP has retained legal support services to represent the member throughout the process. Ultimately, if the balance bill cannot be settled, TSHBP has purchased a service which may be used to settle balance bills on behalf of the members. The member will not be responsible for more than the amount stated as their out-of-pocket costs on the Explanation of Benefits they receive from the plan.
- Do my TSHBP Medical Benefits come with Telehealth services?
- Yes! We offer Telehealth services through Teladoc. For more information regarding Telehealth services, please visit the TSHBP website under Documents & Forms, https://tshbp.org/documents-forms/.
- Does TSHBP offer any specific programs for members with Type-2 Diabetes?
- For TSHBP members living with Type 2 Diabetes, Virta Health is an option for you. It is a program that helps reverse Type 2 Diabetes, available to members between ages 18-79. Please visit the TSHBP Virta Health page on our website, tshbp.org/virta-health/, for more information and how to join the program.
- What is Hinge Health?
- Hinge Health is a digital musculoskeletal management program with custom physical therapy programs designed by physicians and led by board certified Health coaches. Hinge Health is a service provided at no extra cost to you! Please visit our website, https://www.hingehealth.com/for/texasschoolshealthbenefits/, for additional information on Hinge Health and to join.
- What is TSHBeFit?
- TSHBeFit is a Wellness Program to help members achieve their personal health and well-being. TSHBeFit has partnered with WellRight to provide you resources to achieve and maintain good health through health and wellness challenges, educational modules and easy tracking through their interactive dashboard. The WellRight platform is fully HIPAA compliant which means all personal health data you provide with the system will never be shared. TSHBeFit is available to our members at no additional cost, and dependents can utilize the program as well!
- Who do I contact if I have issues with logging into TSHBeFit?
- If you are having issues with logging into WellRight or have questions, please reach out to support@wellright.com.
>Eligibility & Enrollment
- What is the plan year?
- The plan year begins September 1 and ends August 31. Accumulations toward satisfying any required deductible and/or out-of-pocket maximum must be incurred within that period. In some circumstances, the initial plan year may be less than 12 months.
- When will I receive my TSHBP ID card?
- If you enrolled in a TSHBP plan before August 4th, you should receive your TSHBP ID card by September 1st. If you enrolled between August 5th through August 18th, you should receive your TSHBP ID card approximately around September 1st.
If you are a New Hire, you will receive your TSHBP ID card with 2-3 weeks of enrollment.
- If you enrolled in a TSHBP plan before August 4th, you should receive your TSHBP ID card by September 1st. If you enrolled between August 5th through August 18th, you should receive your TSHBP ID card approximately around September 1st.
- Are there separate ID cards for Medical and RX benefits?
- Your TSHBP ID card is for both your Medical and Prescription benefits.
- How many TSHBP ID cards will I receive?
- It depends on the tier that you are enrolled. If you are on the Employee Only tier, you will receive only one card. If you are on the Employee + Spouse, Employee + Child(ren) or Family tier, you will only receive two TSHBP ID cards. If you would like to order more TSHBP ID cards, you can order more on the TSHBP Member Portal website, https://portal.90degreebenefits.com/Logon/.
- Prior to joining TSHBP, I was undergoing treatment for a serious illness, can I continue to use the same health care provider?
- TSHBP understands that Transition of Care is critically important to members who are participating in ongoing treatment for a serious illness. Please ensure to fill out the Transition of Care form located on the TSHBP website under Documents & Forms, tshbp.org/documents-forms/, and reach out to the Care Coordinator with any questions.
- Can an employee or dependent drop coverage throughout the plan year?
- Yes, unless such action is restricted due to participation in an Internal Revenue Code § 125 cafeteria plan. However, an employee cannot drop his or her coverage without also dropping coverage for all dependents. The change will take effect on the first day of the following month. If a given individual drops coverage, that individual will not be eligible to re-enroll in the TSHBP until the next annual enrollment period, unless the individual experiences a Qualifying Event.
- How long can a dependent child have TSHBP coverage?
- Coverage for a dependent child ends at the end of the month that the child turns 26. However, if the child is either mentally or physically incapacitated to such that they are dependent on the employee on a regular basis and meet other requirements for eligibility, you may be able to continue coverage for the dependent child who meets the requirements. If you cover a disabled child who will turn 26 soon, contact TSHBP for information on keeping him or her on your coverage.
- Does a child have to be enrolled in school to be eligible for dependent coverage?
- There is no full-time student requirement to be eligible for TSHBP.
- Can I add dependents throughout the plan year?
- You may add dependents during the plan year if you experience a Qualifying Event, such as a marriage or the birth of a child. You must enroll the dependent within 31 days of the special enrollment event. The coverage takes effect on the first of the month following the date of enrollment under the special enrollment event. Newborn coverage is effective on the date of birth.
- I have a child that is going to school out of state. Do I need to fill out an Out-of-State Attestation form for them to receive coverage?
- The TSHBP HealthSmart Network and the Aetna Signature Administrators Network are Nationwide networks. You do not need to fill out a form to have a dependent covered for benefits. With Out-of-Network benefits being offered on the Directed Care Plans, if your dependent is seeing a provider that is not in the network, those services could go to your Out-of-Network deductible.
- Is a common law spouse eligible for dependent coverage?
- A common law spouse is eligible for dependent coverage as long as there is a Declaration of Common Law Marriage filed with an authorized government agency. In the event of a common law marriage is dissolved, a legal divorce is needed in the State of Texas.
- Does TSHBP offer COBRA Benefits?
- COBRA benefits are administrated and managed by 90 Degree Benefits. You will receive your COBRA packet within 2-3 weeks after the date of your termination. Please call the Care Coordinator at 888-803-0081 if you have any questions regarding COBRA benefits.
- Can Retirees join TSHBP?
- Yes, retirees can join TSHBP if they meet their district’s eligibility.
- Can a grandchild have TSHBP coverage?
- Yes, a grandchild under 26 whose primary residence is the household of the employee and who is a dependent of the employee for federal income tax purposes for the reporting year in which coverage of the grandchild is in effect is considered an eligible dependent. An employee must have legal guardianship of the grandchild for the dependent to be covered by TSHBP. Coverage will begin the first of the month following the date the child qualifies as a dependent.
