Q. What's Scott and White Health Plan's role in my medical plan?
A. Scott and White Health Plan (SWHP) administers all three Baylor Scott & White Health medical plans — the Select Exclusive Quality Alliance (SEQA)/Exclusive Quality Alliance (EQA), Preferred Provider Organization (PPO) and Health Savings Account (HSA). Baylor Scott & White funds the entire cost of its employee medical coverage. This means the System assumes the financial risk of providing medical benefits to its employees and their covered dependents. SWHP has been hired to manage claims, deliver customer service and provide overall administration of our medical plans.
Q. When should I expect to receive my new ID card?
A. Medical ID cards will be mailed to your home address or mailing address if one is on file and it's different than your home address. The target date to have a medical ID card to you is by Jan. 1. You can also log in to the SWHP Member Portal at bswh.swhp.org to request additional medical ID cards or print and save a temporary copy of your medical ID card. Employees may need to create an account if new hire or has not set up a Member Portal account. You can also view your medical ID card on MyBSWHealth app and add to Apple wallet. To log in, use the same user name and password you use for the SWHP Member Portal. Or you can also contact SWHP Customer Advocacy at 844-843-3229! to request additional ID cards.
Q. What's the SWHP Customer Advocacy phone number?
A. SWHP has set up a dedicated customer service number for Baylor Scott & White employees and covered dependents: 844-843-3229. The customer advocates can answer a wide range of questions and check with a subject matter expert on questions they can't resolve. SWHP Customer Advocacy Department hours are 7 a.m. - 8 p.m. CT, Monday - Sunday.
Q. What is Prior Authorization?
A. Our prior authorization process requires your physician or any other health care provider to secure pre-approval for certain procedures, services, or mediation to determine medical necessity and ensure the request is appropriate and safe for the patient.
Q. Which procedures need to be pre-authorized by my provider?
A. You can find the prior authorization list on the SWHP Member Portal at bswh.swhp.org.. From the home page, select Tools and Resources to get to the Prior authorization list. Make sure you and your doctor review the list to confirm if Prior authorization is needed.
Q. Where can I find a list of what services are subject to prior authorization? Is this my responsibility or my provider's responsibility?
A. The prior authorization list can be found at bswh.swhp.org under Tools and Resources. It is the provider's responsibility to handle the prior authorization process, but you should confirm your provider has approval on file before you receive care for services that require prior authorization.
Q. Why doesn't my doctor show up when I use the provider search tool?
A. The provider search tool refreshes every 2 to 4 weeks. Some doctors may still be in the contracting process with SWHP. While most doctors in the Baylor Scott & White Quality Alliance (BSWQA) are contracted with SWHP, some aren't. Even if your doctors are part of the BSWQA, check the provider search tool at bswh.swhp.org to be sure they participate in our Tier 1 BSWQA Network or Tier 2 Cigna National Network.
Q. What should I do if my doctors show up in the provider search results but say they are not part of the network?
A. Your provider's office staff may not be aware they are part of the network for Baylor Scott & White medical plans — either through direct contracts with SWHP or our Tier 2 Cigna National Network. If this situation arises with one of your doctors, please ask them to call our Provider Services at 844-769-3994 to verify their network participation for Baylor Scott & White Employee Plan.
Q. How do I make sure the doctors who care for me in the hospital will be in network?
A. Hospital-based physicians (radiologists, anesthesiologists, pathologists, emergency providers, neonatologists and hospitalists) will not be part of the searchable provider options as they may be independent contractors. If you receive care from any of these physicians at any Tier 1 BSWQA Network facility, they will be paid at the Tier 1 BSWQA Network benefit level of the usual and customary rate. There
may be instances a non-contracted physician may balance bill you if they do not
agree with the reimbursement rate applied to your claim/s. If this happens,
contact SWHP Customer Advocacy at 844-843-3229 for assistance.
Q. What if I have dependent children out of state on my plan?
A. Employees and dependents who live 40 or more miles from the nearest Tier 1 BSWQA Network hospital should consider either the Preferred Provider Organization (PPO) plan or Health Savings Account (HSA) plan because of their expanded provider network. To find out if there are network providers who practice in the location where you or your dependent(s) live, check the provider search tool at bswh.swhp.org. Or if you or your dependent had the OOA coverage activated but no longer live 40 or more miles from a Tier 1 BSWQA Network hospital, contact SWHP to deactivate this coverage.
Q. Under the SEQA/EQA plans, are out-of-area dependents covered at all?
A. Under the SEQA/EQA plans, the only coverage for out-of-area dependents would be for care that is urgent or emergency. If you have kids out of state, you should look at the PPO or HSA plans.
Q. What access to coverage do we have for travel outside of Texas/outside of the country?
A. If you are traveling out of state and need emergency care, your copay is $250 if you enroll in the SEQA/EQA or PPO plan. If you enroll in the HSA, your member responsibility is 10% after your deductible. If you are admitted, the copay under the SEQA/EQA and PPO will be waived, and the applicable inpatient benefit will apply based on the facility network status. For example, under the PPO and HSA plans, if the facility is Tier 2, the Tier 2 inpatient benefit will apply. If the facility is Tier 3, inpatient services will be paid at the Tier 2 benefit level. Coverage for out of the country is only available for emergency services and the benefit is at the applicable member cost share based on the plan you elect for 2019. Please visit the benefits website at www.BSWHbenefits.com for complete details about your cost and coverage under each plan option.
Q. Are Baylor Scott & White facilities and affiliated entities covered under Tier 1 BSWQA Network?
A. Baylor Scott & White facilities are part of the Tier 1 BSWQA Network. For those affiliated entities they must be contracted with Scott and White Health Plan and BSWQA to be considered Tier 1 BSWQA Network. Employees are encouraged to use the provider search tool at bswh.swhp.org to confirm provider network status prior to accessing service.
Q. When I need urgent care, which facilities are covered by our plan?
A. Our provider networks include many urgent care locations in the Tier 1 BSWQA Network and Tier 2 Cigna National Network. Tier 1 BSWQA Network urgent care locations include Concentra, PrimaCare, Cook Children's Urgent Care, MedPost Urgent Care, NextCare Urgent Care, etc. All our urgent care providers are listed in the provider search tool at bswh.swhp.org. We're continuing to review and expand our urgent care network as needed. Please use the provider search tool for a complete list.
Q. What is the benefit if I use of a non-contracted urgent care provider?
A. If you elect the SEQA or EQA plan, you are only responsible to pay the applicable Tier 1 copay. If you elect the PPO or HSA plan, the benefit is the applicable Tier 2 member cost share. Please visit the benefits website at www.BSWHbenefits.com for complete details about your cost and coverage under each plan option.
Q. Because Tier 1 BSWQA Network is limited geographically, do we receive a deeper discount on services?
A. Tier 1 BSWQA Network provides a higher quality of care and the plan covers a greater share of the cost for facilities/providers.
A. Scott & White Medical Center – Temple, LabCorp, Quest Diagnostics, ClearPoint Diagnostic, Central Texas Pathology, etc. are in Tier 1 BSWQA Network. In addition, some HTPN clinics have their own in-house lab services and are considered Tier 1 BSWQA Network. Many providers have arrangements with multiple lab services and may be able to send your lab work to LabCorp, Quest, and ClearPoint if you request it. Lab tests that are part of preventive care services are always covered at 100% in Tier 1 BSWQA Network and Tier 2 Cigna National Network (if enrolled in the PPO or HSA medical plans) and must be billed with a preventive care diagnosis. For a complete list of lab locations, visit our provider search tool at bswh.swhp.org.
Q. How do I know if I am receiving care from a Tier 1 provider if I am in an emergency room?
A. If you receive care from any hospital-based physicians at any Tier 1 BSWQA Network facility, they will be paid at the Tier 1 BSWQA Network benefit level of the usual and customary rate. If you are balance billed, please contact SWHP Customer Advocacy at: 844-843-3229 for assistance
Q. I'm enrolled in the HRA plan. What do I do now?
A. If you were previously enrolled in the HRA plan and do not enroll in a new plan, you will be auto-enrolled in the PPO plan for 2019. Make sure you go through Annual Enrollment between Oct. 29 – Nov. 9 to enroll in the plan of your choice. You must log in to PeoplePlace to complete your Annual Enrollment.
Q. What happened to my HRA dollars?
A. The HRA plan will be discontinued, but if you have unused HRA dollars remaining in your account, you can still use them to help pay for eligible expenses if you are enrolled in the SEQA/EQA or PPO plans. To review your HRA balance, log in to the SWHP Member Portal at bswh.swhp.org. You can also view your HRA balance on MyBSWHealth app. To log in, use the same user name and password you use for the SWHP Member Portal.
Q. What happens to my HRA dollars if I move to the HSA?
A. If you previously had a HRA and enroll in the HSA your HRA funds would be forfeited.
Q. I understand that HRA funds rollover...is there an expiration of these total funds? Will they roll over year after year until depleted?
A. The HRA rollover is part of a multi-year strategy. We do not have a defined end date for when this funds will expire.
Q. For 2019, can the HRA funds be used for all medical-related expenses, including prescriptions, hospital stays, etc.?
A. HRA funds can only be used for eligible medical expenses incurred in Tier 1 and non-Tier 1 urgent and emergency care. Rx is still excluded.
Q. If I enroll in the SEQA/EQA plan, can I use HRA rollover funds towards non-Tier 1 expenses i.e. doctors/clinics/hospitals?
A. The SEQA/EQA plans only have one network – the Tier 1 BSWQA Network. Unless the care is urgent, emergency or authorization is provided, out-of-network care would not be covered by your rollover funds.
Q. Will Discovery still be the vendor for the HRA?
A. Discovery Benefits will continue to be the vendor for the HRA and will continue to make payments directly to providers on your behalf.
Q. In the past, the HRA plan had a $2,000 deductible, and the company provided $1,000 to help with the cost. How does this benefit translate into the new plans?
A. Coverage offered under the new SEQA/EQA plans is more affordable and predictable. That means you will only pay a fixed copay for most services instead of having to meet a higher deductible upfront. The EQA does require you to meet a deductible for certain services such as durable medical equipment, home healthcare, etc. but your deducible is only $500 for employee only, compared to $2,000 under the HRA.
Q. How are ED/radiologists paid at a Baylor Scott & White facility versus Tier 2 Cigna National Network or Tier 3?
A. If you received care by any of these physicians at a Tier 1 BSWQA Network facility, their claims will process/pay at the Tier 1 BSWQA Network benefit level of the usual and customary rate if the physician is Tier 3. If you received care from any of these physicians at a Tier 2 Cigna National Network or Tier 3 facility, Tier 2 Cigna National Network physicians are paid at a contracted rate and Tier 3 physicians are paid at the usual and customary rate. Tier 3 physicians may balance-bill you for charges not reimbursed by the plan. If you are balance-billed, please contact SWHP Customer
Advocacy at 844-843-3229 for assistance.
Q: Under the SEQA/EQA plan will we be required to use a BSWH pharmacy?
A: You will still have the option to use BSWH pharmacies as well as contracted pharmacies. The BSWH pharmacy (retail or mail order) is the only way to fill a 90 day supply of a medication, or a specialty drug.
Q: For the EQA plan what are the benefits for an outpatient surgery?
A: Outpatient care requires a copay of $150, then the rest is covered at 100%.
Q: How is chiropractic care covered under the SEQA/EQA plans?
A: Coverage is provided for charges for detection and correction by manual or mechanical means of nerve interference resulting from or related to misalignment or partial dislocation of or in the vertebral column. Coverage includes initial consultation and treatment. Benefits under each option are limited to 20 visits per person per calendar year. The copay would be the applicable specialty visit copay.
Q. On the SEQA plan for Inpatient, there are 5 Days at $150. If one must stay longer than 5 days, how is this handled?
A. After the max of 5 days, care is covered at 100%.
Q. If I choose the SEQA plan, what coverage could be expected for DME or specifically a C-Pap machine?
A. There is no deductible, so this would just be subject to a 10% coinsurance.
Q. What happens if a get a bonus or a promotion after I enroll? Will my medical premiums go up on the date of my pay change?
A. Your hourly rate of Sept. 30, 2018 will be used to determine your medical premiums. Even if you have changes throughout the year (increases or decreases), your rate for medical coverage will stay the same. The only time your rate would change is if you go from full time to part time, or vice versa.
Q. For preventive screening, how do we know if anesthesia providers are covered?
A. If the provider bills as preventive services and they meet the criteria for preventive services, the services are paid at 100% for Tier 1 BSWQA Network and Tier 2 Cigna National Network (if enrolled in the PPO or HSA medical plans).
Q. How is the cost of medical premiums determined for salaried employees? When will the 2019 medical premium paycheck deductions take effect for salaried employees?
A. Your hourly rate as of Sept. 30, 2018, will be used to determine your medical premiums. Our 2019 medical premium rates go into effect Jan. 1, 2019 and deductions will begin in the first paycheck of the year, which is on Jan 11, 2019.
Q. How are EMS services billed and why don't we get to choose which Tier the provider comes from? Or is there a more efficient way to get emergency transport?
A. EMS services are processed/paid at the Tier 1 BSWQA Network benefit level of the usual and customary rate if the provider is not contracted. It is an industry standard that EMS providers are normally not contracted with any insurance company. If a provider does not agree with the payment they receive from SWHP and you are balance-billed, contact SWHP Customer Advocacy at 844-843-3229 and let them know you are being balance-billed. SWHP will work with the provider to try and negotiate a single case agreement.
Q. For a "routine" preventive care procedure such as a colonoscopy, will it be covered free of cost if a previous one (done three years ago) was routine but resulted in a procedure (polyp removal)?
A. Preventive screening for Sigmoidoscopy is every five years; colonoscopy is every 10 years; and fecal occult blood test (FOBT) is every year starting at age 50 years and continuing until age 85 years. If screening resulted in a procedure (polyp removal), the claim can also result in a medical diagnostic, which means, you
would have a member cost share.
Q. What is considered high-cost, low-value medication on the Rx plan?
A. This year, we're moving to a new drug list called the Group Value Formulary, which is reviewed and approved by BSWH physicians and healthcare providers. High-cost, low-value drugs have been removed from formulary and drugs and Tiers 1-3 have been expanded. Drugs not listed on the formulary require prior authorization. If the drug is approved, you'll pay the applicable nonpreferred or specialty copay. This change doesn't mean less coverage. It means more affordability! Click here to view a complete list of formulary drugs.
Q. What is the new copay to see a specialist?
A. Your member cost share for an office visit to a specialist will vary based on the plan you elect for 2019. For example, a specialist copay is $40 in the SEQA plan and $50 in the EQA plan. Please visit the benefits website at www.BSWHbenefits.com for complete details about your cost and coverage under each plan option.
Q. Is there a list of contracted pharmacies available? Is there additional cost for employees to use pharmacies that are not under BSWH?
A. Please visit the Member Portal at bswh.swhp.org to find a list of contracted pharmacies under each plan. Your member cost share for prescriptions filled at non-BSWH pharmacies is higher and will depend on the type of medication you are prescribed (e.g. generic, preferred, etc.) and the plan you elect for 2019. Please visit the benefits website at www.BSWHbenefits.com for complete details about your pharmacy coverage.
Q. Are lab costs covered at 100% under "preventive care"?
A. If the labs are billed as preventive and send to an in-network lab, they will be covered at 100%.
Q. In 2018, birth control was considered as preventive and $0.00 cost. Would this be the same in the SEQA?
A. There are no changes to this benefit.
Q. Is there a copay for labs on either of these plans (SEQA/EQA) or just the 20% charge of labs and $75 per x-ray?
A. Member cost share for labs is 20% coinsurance under the SEQA and 30% under the EQA. If it's an x-ray, it would be a $75 copay for SEQA/EQA. Please visit the benefits website at www.BSWHbenefits.com for complete details about your cost and coverage under each plan option.
Q. What is the difference between an HMO and the new SEQA/EQA plans?
A. HMO plans may require you to get a referral from your PCP to see a specialist and the SEQA/EQA does not require referrals. You can see any provider in Tier 1 BSWQA Network without a referral.
Q. What is the maternity coverage under the SEQA/EQA plans?
A. Prenatal care is covered at 100% if billed as a prenatal visit. Your delivery is $150 per day max of 5 days, then coverage is 100%.
Q. What is the mental/behavioral health coverage under the SEQA/EQA plans?
A. Coverage is at the applicable copay based on the place of service (i.e. office visit, outpatient, or inpatient). Please visit the benefits website at www.BSWHbenefits.com for complete details about your cost and coverage under each plan option.
Q. How do you meet the EQA deduxctible if you don't need durable medical equiement, private duty nursing, etc?
A. If you don't need these services, you wouldn't run into a situation where you would go into deductible. Most services have a fixed copay, then the plan pays 100% (labs are 30% consinsurance).
Q. Where can I find a list of Tier 1 proiders for Tarrant County and surrounding counties?
A. Click here to access the 2019 Find a Provider function for SEQA & EQA or 2019 Find A Provider PPO & HSA.
Q. What happens if I go to a Tier 1 BSWQA Network facility and the radiology who reads my x-ray results is contracted and not in Tier 1?
A. If you received care at a Tier 1 BSWQA Network facility, claims will be processed at the Tier 1 benefit level of the usual and customary rate. If you are balance billed, please contact SWHP Customer Advocacy at 844-843-3229 for assistance.
Q. Are prescriptions applied to the deductible of the SEQA/EQA and/or PPO plans?
A. For each of the plans listed above, prescriptions are not applied to the deductible. The HSA plan does have a design where prescriptions are subject to deductible and coinsurance.
Q. What happens to my spouse's medical insurance coverage when he or she turns 65 and is eligible for Medicare?
A. We do not have a requirement that states your spouse must be removed from the plan. You may contineu to cover them on your plan even though they are eligible and may have Medicare.
Q. The annual deductible says "employee + family." Is there an annual deductible specific to "employee + children" only?
A. No, the deductible is the same. The EQA and PPO plans have embedded deductibles, which means the plan provdiers after-deductible coverage once an individual with family coverage meets the individual deductible, even if the family deductible has not been met. This does not apply to the HSA plan.
Q. Does MetLife PPO Plus cover local dentists?
A. This network is quite expansive and includes many dentists. To locate dental providers in the MetLife network, go to metlife.com, enter your ZIP code and chose the PDP network.
Q. What is the dental maximum for the PPO plan vs. the PPO Plus plan with MetLife?
A. Under the PPO plan, the annual maximum benefit is $1,250. On the PPO Plus plan, the annual maximum is $2,500. The Plus plan includes coverage for implants and orthodontia.
Q. Is there a maximum age for orthodontia on the PPO Plus plan?
A. Orthodontia is offered to both children and adults on the Plus plan. There is a $2,000 lifetime maximum for this benefit.
Q. How are implants covered on the PPO Plus plan?
A. Implants are covered as a major service. Deductible would apply first, then the plan would pay 50%. This would apply to the annual maximum.
Q. Will I receive a new card for vision due to the switch to EyeMed?
A. Yes, you will receive a new ID card from EyeMed. The goal is to have this to you no later than Jan.1.
Q. What is covered and what local optometrists can we access with EyeMed?
A. Please use this link for more details on what is covered by the vision plan and a list of providers that accept EyeMed: www.bswhbenefits.com/vision.
Q: If my pay rate increases during the year, will the plan premium cost automatically change at that time or will the costs remain the same until the next plan year?
A: If someone's pay increases during a plan year (not due to a status change like from FT to PT or vice versa), the medical plan premium would not change; however, life insurance changes accordingly.
Q: For the EQA plan what is applied to the $500?
A: You meet your deductible with durable medical equipment expenses, private duty nursing, hearing aids, skilled nursing, home health and hospice care. After the deductible, you have a 10% coinsurance for these services.
Q: Can you verify that prescriptions do not get applied to the deductible regardless of what plan is chosen (for SEQA, EQA, PPO)?
A: For each of the plans listed above, prescriptions do not get applied to the deductible. The HSA plan however does have a design where prescriptions are subject to deductible and coinsurance.
Q: I currently have the MetLife Plus Dental Plan. Since the maximum will increase 25% in 2019, will the increase be applied if I begin orthodontia work in this calendar year? In other words, will the dental plan (if I maintain the exact same plan) honor a work in progress?
A: The orthodontia maximum has not changed for 2019. This is a separate limit from the annual maximum that increased.
Q. Can an employee waive coverage and still enroll the dependents?
A. No, employee coverage must be issued for dependent spouse and/or child coverage to become effective.
Q. Is there a Pre-Existing Condition Limitation? A. No, there is not a Pre-Existing Condition Limitation on the accidental injury or critical illness plans.
Q. Is there a benefit waiting period?
A. No, there is no benefit waiting period. Coverage is effective immediately.
Q. How often can a covered person be paid a benefit for the Health Screening Benefit or Wellness Benefit?
A. The benefit is payable one time per covered person per calendar year.
Q. What value-add services are included with these products and is there an additional cost?
A. There are no additional costs to the employee for these services. Value-added services include:
Q: What diagnoses/conditions are covered for the new accident injury and critical illness plans? What is not covered? What percentages, if any, are paid by the employee?
A: Please visit www.BSWHbenefits.com. Under "other benefits" we have a new page dedicated to these plans.
Q: Can you be covered under STD and accident injury/critical illness at the same time?
A: Yes, you can be covered by all of these plans because they are individual offerings
Q. Is it possible to buy different plans for different family members?
A. No, it is not possible to purchase different plans for different family members.
Q. I didn't sign up for short term disability during my new hire period. What do I need to do to elect this benefit during Annual Enrollment?
A. You don't have to do anything. This year, we are auto-enrolling all benefit-eligible employees in short-term disability (STD) coverage.
Q. Is Ask ALEX available to help me decide which plan is right for me and my family?
A. Alex is live now at www.myalex.com/bswh/2019.
Q. Does the LTD plan have a time limit? For example, 26 weeks, 52 weeks, indefinitely?
A. LTD will continue to make payments up until Social Security retirement age as long as someone continues to meet the definition of disability under the plan.
Q. Will funds in a general-purpose FSA card be transferred onto OPTUM cards after 12/31/18?
A. No, you will spend down your 2018 account with WageWorks. With the grace period, you can incur eligible expenses until 3/15/19. Any monies contributed in 2019 will go into your Optum Bank account.
Q: I have an employee that will be on maternity leave during annual enrollment. How does she enroll in benefits?
A: Employees on leave of absence can enroll in the PeoplePlace system. They should follow the instructions below:
Q: Where can we find pricing information for the STD, LTD, and AD&D?
A: Pricing information for STD, and LTD can be found in the PeoplePlace enrollment system. AD&D pricing can be found on www.BSWHbenefits.com.
Q: Does adoption leave apply to any children under the age of 18?
A: Adoption leave is only applicable to the adoptive parent who legally adopts a child (not biologically related to either parent) under the age of 18.
Q: If an employee does not currently have BSWH insurance, do they need to complete Thrive?
A: While it's certainly encouraged to still take part in Thrive, it's not required. You only pay the $30 extra per pay period if you don't complete the requirements, and have BSWH insurance.
Q. Does my spouse have to submit the Thrive paperwork/physical? And does it cost me the $30 per pay check if he or she does not do this?
A. Spouses are not required to complete Thrive.