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 2020-21 plan year, the TSHBP is proud to offer a High Deductible Health Plan (HDHP) and our CoPay Plan (CPP). Both plans are designed so members can easily navigate through their health medical needs.

For the 2021-22 plan year, we enhanced our plans by offering Out-of-Network benefits, Welvie (a second opinion program), and Virta (a type-2 diabetes reversal program).

The TSHBP is a member-owned interlocal program, created in response to the needs of districts seeking a long-term, cost-effective health benefits. The TSHBP health benefits program stabilizes and reduces the cost of group health coverage for member’s employees.

The Board of Trustees is made up of member districts from all areas of the State.

>TSHBP Plan Information
  • What are the advantages of TSHBP HDHP?
    • 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 Co-Pay Plan work?
    • The TSHBP CoPay Plan is a unique plan where all services are subject to copays and all co-payments apply to the annual deductible.
  • 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 have non-emergency medical services, please reach out to the Care Coordinator to schedule services.
  • Do I need to choose a Primary Care Provider (PCP)?
    • On the TSHBP plans, you are not required 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
  • When should I reach out to the Care Coordinator?
    • If you need access to a facility or hospital for a service or procedure, then you are required to reach out to the Care Coordinator to pre-certify and/or coordinate services. These procedures could include a surgery, 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 utilizes 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.
  • If my doctor is not in the network, do I still have benefits?
    • A new benefit enhancement to the 2021-22 plan year is Out-of-Network benefits. If your physician of choice is not in-network, then you would just utilize out-of-network benefits. For example, on the Copay plan if your physician is not in the network, then your copay would be $40 instead of $35. Please present your ID card to your doctor to show them the new Out-of-Network benefits.
  • 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 under $670 are covered under the TSHBP Plan. Specialty Drugs over $670 are not covered under the TSHBP; however, the TSHBP does have 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.
  • 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.
>TSHBP Additional Plan Benefits
  • How does the TSHBP assist with Balance Billings?
    • 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, the TSHBP has retained legal support services to represent the member throughout the process. Ultimately, if the balance bill cannot be settled, the 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.
  • My doctor has told me that I require a surgical procedure. Does TSHBP offer second opinion program?
    • With the TSHBP plans, you have access to the Welvie My Surgery program at no added cost. With this program, you can explore your treatment options alongside your doctor and choose the best option for you or your dependents.
  • Does my TSHBP Medical Benefits come with Telehealth services?
    • Yes! We offer Telehealth services through Teladoc. If you are on the TSHBP CoPay plan, it is a $0 consultant fee. If you are on the TSHBP HD plan, it is a $30 consultant fee. For more information regarding Telehealth services, please visit the TSHBP website under Documents & Forms, 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, www.tshbp.org/virta-health/, for more information and how to join the program.
>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 13th, you should receive your TSHBP ID card by September 1st. If you enrolled between August 13th and August 24th, 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.
  • 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?
    • If your health care provider is contracted with the plan, services would be considered and applied to the In-Network benefits. If your healthcare provider is not contracted with the plan, services would be considered and applied to the Out-of-Network benefits. Please ensure to fill out the Transition of Care form located on the TSHBP website under Documents & Forms, www.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 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 is a Nationwide network, so you do not need to fill out a form to have a dependent covered for benefits. With Out-of-Network benefits being offered, if your dependent 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?
    • No, not at this time.
  • Can I cover a TRS-Care retiree as a dependent?
    • No, not at this time.