What is the difference between a dental reimbursement plan and dental insurance?

A dental insurance would most likely operate in a very similar way to medical insurance with a list of providers and covered services. The dental office would file the claim with the insurance provider and bill the patient for the amount the insurance won’t pay. Dental reimbursement with LISD has no list of providers – employees can see any licensed dentist and covers most dental services.

Will I receive a card for my Dental Reimbursement Plan coverage or do I just use my BlueCross BlueShield card?

Medical and dental are completely separate benefits. LISD Dental is not through the BCBS network. You will not receive a card since charges incurred with a dental provider are paid by the employee directly to the provider. Bring the LISD Dental Reimbursement Claim Form to a visit and have the provider complete the bottom portion of the form. Make sure to ask the dental office for a receipt that shows the work that was performed, the patient name, the amount paid and the date of payment.

How do I file for a Dental Reimbursement?

Mail, fax or bring by the completed Dental Reimbursement Claim Form along with the receipt to the Risk Management Department within 90 days of the date of payment. Reimbursements are direct deposited to the same account the employee has on record for monthly payroll. Checks, when cut, are mailed to the insured’s home address on record.

How much will I get back of what I spent?

Each covered person can spend $1,750 every dental year to receive back $1,000.

100% of the first $100 is reimbursed, 80% of the next $250 is reimbursed and 50% of the next $1,400 is reimbursed. Another way to look at it is:  First $100 = $100, next $250 = $200 then the next $1,400 = $700. 

Any other payment submitted in that Dental Reimbursement year will = $0.

When does the Dental year start over?

The Lubbock ISD Dental year runs from Jan 1^st through Dec 31st.

If I have work done in December but pay for it in January can I claim on the new Dental year?

Absolutely! Dental claims are entered by date of payment, not date of service.

Is there a lifetime orthodontic maximum?

No, there is not a separate orthodontic maximum amount. All reimbursements are applied to the same limit.

How long can I carry my dependent children?

Dependent children can be carried through the end of the month that they turn 26 unless they turn 26 on the first day of a month.

(Ex: 5/1/20 DOB coverage ends 5/1/20 OR 4/15/20 DOB coverage ends 5/1/20.)

Also, if a dependent is legally disabled then they are eligible to continue coverage past the dependent child age limit.

Can I or my family be covered on another dental insurance and the LISD Dental Reimbursement Plan? If yes, does that change how I file my claims?

Yes and yes! If you or a dependent have coverage with a dental insurance outside LISD and claims are filed with that coverage as primary then LISD must have an explanation of benefits or a ledger from the dental office showing what was paid by the other company before LISD will pay out their part. Dental office estimates of projected insurance payments cannot be accepted as proof.

Can I use my Flexible Spending Account (FSA) or Health Savings Account (HSA) to pay for my dental?

Actually, no in most instances you should not use your FSA or HSA cards to pay for dental because the pretax money in those accounts is for unreimbursed expenses.

(Ex: Spend $500 on HSA, LISD Dental reimburses employee $250, then $250 is ineligible for HSA usage.)

If the employee has already received the maximum annual Dental Plan amount and knows they will not have further reimbursements from the Dental Plan then it is safe to use FSA and HSA cards.

Does Lubbock ISD have paid maternity leave?

No. Accrued leave is used during an employee’s maternity absence but once it is exhausted then a dock period could be entered depending on each individual situation. Payroll usually handles leave situations and can give you more information at 1-806-219-0231.

Is there any paperwork I need to complete before I can take off work for maternity?

Yes. Please contact the Human Resources Department at 1-806-219-0040 or login on the Lubbock ISD Human Resources website and visit their department page. Human Resources can walk you through the completion of Family Medical Leave Act paperwork.

How late is too late to add my newborn and how do I do it?

Employees’ have a 31-day window from the date of birth to add a newborn to their coverage. Submit a Medical Plan Change Form from the Risk Management page.

I heard on the Bronze Plan I only have a $4,000.00 deductible but my provider called BlueCross BlueShield and reported it to be $6,650.00 – is that right?

BCBS is correct. The Bronze Plans do have a $6,650.00 deductible for in-network services. As of 2020 LISD still has an in-house claims process to reimburse up to $2,650.00 of maternity charges incurred on the Bronze Plans. All claims have to be filed with BCBS and confirmed by LISD. For more information, please contact 1-806-219-0283.

Where do I find the Wellness Maternity Video and the Bronze Maternity Deductible Reimbursement Form?

Maternity Video and Claim Forms

What is a deductible and how much do I have to spend to meet mine?

A deductible is the amount of expenses paid out of pocket before an insurer will pay any expenses. If an employee enrolls in the 2020 HMO or PPO Bronze Medical Plans the individual deductible is $6,650 and the family deductible is $13,300. The 2020 HMO & PPO Silver Medical Plans have a $4,000 individual deductible and $8,000 family deductible.

What does the term ‘out of pocket’ mean and once I satisfy my deductible do I have to pay anything else?

‘Out of pocket’ refers to the share of the expenses the insured party must pay directly to the health care provider. The 2020 HMO & PPO Bronze Medical Plans have no co-insurance. After deductible, the 2020 HMO & PPO Silver Medical Plans begin to pay at a rate of 80% while the employee continues to pay 20% until their co-insurance limit is met. The 2020 HMO & PPO Silver Medical Plans have an individual co-insurance of $3,050 and a family co-insurance of $6,100. LISD will pay 100% of eligible in-network medical expenses after the deductible and co-insurance for the individual or family.

What are copays and do I have any?

Copays are small fixed amounts required by a health insurer and paid by the insured for each outpatient visit or drug prescription. The 2020 HMO & PPO Bronze Medical Plans have no copays because all costs for medical treatment and prescriptions go toward the deductible.  The 2020 HMO & PPO Silver Medical Plans have prescription coverage with a yearly prescription deductible for each covered person and designated copays for generic, formulary brand name and non-formulary brand name.

What is the difference between ‘In-Network’ and ‘Out-of-Network’ fees, charges or providers?

In-network - All physicians, specialists, hospitals, and other providers who have agreed to provide medical care to PPO members under terms of the contract with the PPO.

Out-of-network services -Health care services from providers not in a HMO´s or a PPO´s network. Except in certain situations, HMOs will only pay for care received from within its network. If you´re in a PPO plan, you will have to pay more to receive services outside the PPO´s network.

*Source information on in-network versus out-of-network from TDI.texas.gov.*

As an employee new to LISD when would my Medical coverage begin?

For new hires, the coverage can begin on the first day of duty with a premium due in full OR the 1^st of the month following the employee’s actively at work date.  What that means is, if an employee begins work 8/13 they may begin their coverage for Medical on that day and pay two full medical premiums in September when they receive the first check of the assignment.  Employees may elect to begin Medical the first day of the month of the first check instead and pay only one premium.

If I resign or retire from LISD when does my medical coverage end? Can I take it with me?

In general, when an employee’s medical coverage ends is based on when the last check is received with premiums deducted. If an employee retires and receives their last check with premiums deducted in May or June then they are covered as an active employee on LISD medical until the end of May or June. If an employee resigns they could, depending on their assignment dates, receive pay through the end of August and their medical would cease as an active employee after the last day of that month. Coverage for medical and dental can be extended after employment through COBRA.

Separation Checklist (Benefits)

What is COBRA and how can I get it if I want it?

Consolidated Omnibus Budget Reconciliation Act is a Federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event occurs. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.  Click HERE for the HealthCare.gov site.  Currently, BCBS sends out offers to COBRA eligible persons to their last known home address.

Where can I go to find out information about the Affordable Care Act?

A good site to visit is the government page entitled HealthCare.gov.

How long can I carry my dependent children?

Dependent children can be carried through the end of the month that they turn 26 unless they turn 26 on the first day of a month. (Ex: 5/1/20 DOB coverage ends 5/1/20 OR 4/15/20 DOB coverage ends 5/1/20.)  Click HERE for more information regarding dependents posted on the HealthCare.gov site.  This information is also in the handbook for the medical policies posted on the Risk Management Department web page.

What is HIPPA?

HIPAA stands for the Health Insurance Portability and Accountability Act of 1996.  For more information regarding HIPAA please see the Risk Management web page.

What does EOB stand for?

EOB is short for Explanation of Benefits.  If a provider is seen and a claim is filed then you will receive an explanation of the claim in the mail to your home address unless your have chosen the paperless option online.  Each claim explanation tells how much the total fee charged was, how much of an in-network discount is applied if applicable and all eligible payments made.  Most EOB’s also tell you the dollar amount applied to your deductible and co-insurance and how much you could owe a provider.

When can I make changes to my medical plan?

The open enrollment period for Lubbock ISD Medical is normally in the month of November for an effective date of January 1^st. Unless there is a Qualifying Life Event (QLE) outside of the normal open enrollment period and the appropriate paperwork is submitted within 31 days of the event no changes to medical will be allowed.

What is a Qualifying Life Event?

A Qualifying Life Event would be a birth/adoption, death, marital status change, spouse or dependent employment change or a coverage loss.

If I have medical through another source can I waive my benefits?

It is not necessary to waive medical benefits since LISD supplies a free supplemental coverage called HIP, (Hospital Income Plan), that does not interfere with other medical coverage.

What does HIP do for me?

This supplemental policy provided free by LISD pays $250 per day that employees are confined to the hospital. Claims are submitted and processed in the Risk Management Department.

Will I have to pay anything if I see the doctor for Wellness/Preventive services?

Claims are filed with procedure codes. These procedure codes tell insurance companies what services were performed during a visit. If the provider files the claim with a primary diagnosis code for an eligible routine wellness procedure then the charge should be paid at one hundred percent, provided it is in-network.