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.

Filing a Dental Expense Reimbursement Claim

Where do I find a dental claim form?

Before your dental visit, go to: www.LubbockISD.org, Staff, Insurance Information, Claim Forms (button), Claim Forms, Dental Expense Reimbursement Claim Form. 

How do I complete the dental claim form?

After the provider is paid, have them complete the bottom portion of the claim form, and attach a paid dental receipt with work performed, patient name, payment date and payment amount. The employee FULLY completes the top portion of the claim form. (Sometimes, if other dental insurance has not yet paid, you must wait to file the claim with Lubbock ISD.) Claims have a 90-day filing deadline unless a secondary insurance is involved. Claims will be processed within 30-days of submission as long as the claim is complete.

Reasons for claim rejections:
Missing employee signature.
Missing dental provider signature.
Missing receipt showing payment amount and payment date.
Claim submitted past the 90-day filing deadline.
Claim submitted without primary insurance explanation of benefits.

How do I submit the dental claim form and receipt?

By Fax to 806-766-1195.

By email to Lucinda.Lucero@LubbockISD.org.

By U.S. Postal Service to: Lubbock ISD Risk Mgmt, 1628 19th St, Lubbock, TX, 79401.

By school mail to: Risk Management, Attn: Dental.

Dropped off in a SEALED envelope at Central Office, West Building, Door #1 reception area.

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.

BCBS Wellness Claim Form for Gym Reimbursement

HIP Claim Form for Gym Reimbursement

What do I need to submit a gym claim?

• Employees with Lubbock ISD medical need:

1. BCBS Wellness Claim Form. (Completed and signed.)
2. Gym log of ten visits in a calendar month. (Visits on the same day 2 hrs apart.)
3. Receipt showing membership payment to the gym.

• Employees with Lubbock ISD Hospital Income Plan or HIP need:

1. HIP Claim Form. (Completed and signed.)
2. Gym log of ten visits in a calendar month. (Visits on the same day 2 hrs apart.)
3. Receipt showing membership payment to the gym.

Methods of submission:

• Fax: 1-806-766-1195, OR
• Mail: Lubbock ISD Risk Mgmt, 1628 19th Street, Lubbock, TX, 79401

How much will Lubbock ISD reimburse on a gym membership?

• $18 per month is the maximum reimbursement for an employee.

Is my spouse eligible?

• No, the gym membership reimbursement program is an employee only benefit.

How long do I have to file a gym claim?

• 30-day filing deadline
• Risk Management will process claims for the current and prior month only.

Can I submit for a weight loss program and the gym in the same month?

• No, an employee can claim one or the other but not both.

What if I participate in Weight Watchers and want to claim that instead of the gym?

• Weight Watchers requires 2 check-ins per month.
• Reciept showing payment for that month's membership,
• Screenshots showing two online participations in a calendar month,
• OR log book showing two weigh-in sessions in a calendar month,
• AND a completed claim form.

Living Better Diabetes Claim Form

What can I claim?

• Medications classified on the FDA Drug List for the treatment of diabetes management.
• Supplies for testing, meters, and pumps.
• $100 limit for eligible office visits.
• Diabetic labs.
• Eligible office visits include:
  • Diabetic office visit to treating physician.
  • Diabetic podiatrist visit.
  • Diabetic eye exams (not a regular eye exam, must be filed on medical.)

What do I need to submit a claim?

• Employees with Lubbock ISD medical need:

1. Living Better Diabetes Claim Form. (Completed and signed.)
2. Pharmacy slips showing the drug name, price, and date.
3. Explanations of Benefits for the Dates of Service.
4. Receipt showing payment to the physician or provider.
5. Monthly participation in the Living Better Diabetes Program. Contact iaWellness at 806-765-7265 for program participation details.

• Methods of submission:
  • Fax: 1-806-766-1195, OR
  • Mail: Lubbock ISD Risk Mgmt, 1628 19th Street, Lubbock, TX, 79401

What is the maximum I can get back in a calendar year?

• The annual reimbursement in a calendar year is $2,500 for 2020.

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 may be able to provide you with more information by calling 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 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 (FMLA) 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.  Failure to complete the required documents and provide proof within the 31-day window from birth of the child may result in denial of the addition to the plan/coverage. 

If there is a delay in receiving your child's birth certificate, please complete the enrollment process before the 31-day window lapses and include a copy of your newborn's hospital registration documents, hospital proof or certificate of birth from the hospital, etc. to ensure coverage begins asap and that your time to enroll your newborn does not lapse resulting in a denial of the additional family member under your plan/coverage.

(Please see the Qualifying Life Event section of Frequently Asked Questions for more details.)

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. For the current plan year, Lubbock ISD has an in-house claims process to reimburse up to $2,650.00 of approved maternity charges incurred on the Bronze Plans with completion of required documents and participation in the maternity program. All claims are to be filed with BCBS and confirmed by Lubbock ISD prior to reimbursement. For more information, please contact 806-219-0283.

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

Maternity Video and Maternity Bronze Plan Claim Form

Who Is Eligible for Health Benefits at LISD?

• Employee/Subscriber - is a full-time or half-time Employee of LISD on monthly payroll who resides/lives in the service area and a bona fide employee entitled to participate in the health care benefit program. Temporary and hourly employees must work 130 hours per month for a six-month period to qualify for benefits prior to enrollment. In a month where it is not possible to work 130 hours (due to district hours) then the employee is given credit for that month.
  
  
• The Employee/Subscriber may enroll his/her family into the benefits program if they are considered Dependents of the Employee/Subscriber and who must be described as:
  
  
• • Spouse - a legal spouse is eligible for coverage if they are able to submit upon request a certified copy of their marriage certificate or a declaration of informal marriage certificate filed with the county clerk's office
    
    
  • Child of Subscriber/Employee - a child means a natural child, a stepchild, eligible foster child, an adopted child - under twenty-six (26) years of age; this could include a child with whom the Subscriber/Employee has proof of legal guardianship or court order for coverage to be provided for the minor child; a child of your child who is your dependent under federal income tax purposes at the time of application for coverage of the child is made
    
    
  • Children - a child of any age as noted above but who is and continues to be incapable of sustaining employment by reason of mental or physical handicap and is chiefly dependent upon Subscriber/Employee for economic support and maintenance.  A Dependent Child's Statement of Disability form including medical certification of disability may be required to be submitted within thirty-one (31) days of the date of medical certification and may be required to be provided at the time of application for enrollment and as often as once a year
    
    
  • Newborn Children Coverage - coverage will be automatic for Subscriber/Employee's (or covered Employee's spouse's) newborn child for the first thirty-one (31) days following the date of birth; coverage will continue for the newborn beyond the thirty-one (31) days only if the child is a dependent and the necessary forms and required contributions are completed/made by the Employee/Subscriber with the Risk Management Office to ensure further coverage for the newborn
    
    
  • Newly Adopted Children - coverage will be automatic for a newly-adopted child of Subscriber/Employee for the first thirty-one (31) days from the date the Subscriber/Employee is in a suit for adoption or thirty-one (31) days from the date of the adoption is final.  Coverage will continue beyond the thirty-one (31) days only if the child is an eligible dependent and the necessary forms and required contributions are completed/made by the Employee/Subscriber with the Risk Management Office to ensure further coverage of the adopted child
    
    
    
  The Risk Management Office will be performing random or for cause/questionable coverage request(s) audits as part of an ongoing plan verification process relating to dependent coverage relating to enrollment for the 2021 benefits year and thereafter.  If you are notified by the Risk Management Office requesting/requiring a copy of a marriage certificate, proof of dependent child legal custody order, birth certificates, federal income tax form showing dependent child claim/allowance, etc., please respond as soon as possible to ensure ongoing coverage for your dependent.  Failure to submit the required/requested documentation could result in non-coverage of that dependent until receipt of the requested documentation is received and verified by the Risk Management Office.  Failure to follow the enrollment guidelines and enrolling someone that does not qualify for coverage under the plan policies may also result in a denial of the claim accordingly.
   
  Should you have any questions, please give Vaun (ext 0283) or Lisa (ext 0235) a call.  Thanks!

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 HIPAA?

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. (See the Qualifying Life Event section of Frequently Asked Questions for more details.)

What is a Qualifying Life Event?

See the Qualifying Life Event section in Frequently Asked Questions.

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. 

Are any pharmacies out of the Lubbock ISD coverage network?

Currently, Walgreens pharmacy locations are out of the Lubbock ISD pharmacy network.

If I take a prescription each month - do I need to do anything special?

Monthly maintenance prescriptions should be filled through CVS retail pharmacy locations or through mail order for a 90-day supply.

I heard there are free medications?

Yes, there are prescriptions that are $0 cost to employees. Two avenues are available for $0 cost medications:

CVS Prescription coverage $0 cost preventive generics. For additional information click on this LINK.

United Pharmacy $0 Copay Generics if the medication is prescribed by a $0 Copay Clinic provider. For additional information click on this LINK.

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.

Employees may make a change outside of the normal open enrollment period if the proper steps are taken inside a 31-day window from the event.

What proof should I submit with my Qualifying Life Event?

Here are the documents required for proof of a  Qualifying Life Event:

Birth - a birth certificate (if there is a delay in receiving the birth certificate, please provide proof of birth within the 31-day window by providing copies of the newborn's hospital registration documents, hospital certificate of birth, etc.).  Failure to provide the required change/add form along with proof of birth within the 31-day window will result in denial of the addition to health plan.

Adoption - relevant court documents

Spouse or Dependent Employment Change - a letter of creditable coverage from the prior insurer

Marriage - marriage certificate

Divorce or Legal Separation - relevant court documents

Coverage Loss - a letter of creditable coverage from the prior insurer

What forms are required for a Qualifying Life Event?

It depends upon the plans an employee wishes to change. See below for examples:

Medical Plan Change Form - complete this form to make a change to medical.

Dental Plan Change Form - complete this form to make a change to dental. (90-day waiting period to file a dental claim if the QLE is not birth or marriage.)

Eyetopia Plan Change Form - complete this form to make a change to Eyetopia Vision through First Financial.

Superior Plan Change Form - complete this form to make a change to Superior Vision through First Financial.

*HSA Contribution Form - no QLE required, but the form should be submitted to the Risk Management Department by the 10th of each month to stop, start, or change Health Savings Account contribution amounts.

**Post Tax Cancellation Form - some post tax coverages such as disability or life insurance do not require a QLE, but they do require a form to make the desired cancellation.

***Sun Life EOI Application - some post tax coverages such as disability or life insurance do not require a QLE, but they do require a form to make the desired change. Sun Life Optional Life Insurance requires Evidence of Insurability paperwork with the coverage application.

How do I submit a Qualifying Life Event?

Here are the steps to submit a Qualifying Life Event:

Go to the "Change Forms" button.

Under "Change Forms" see the necessary coverage forms and instructions for Qualifying Life Event entry.

Complete the necessary forms and gather the proof required.

Log on to the Employee Service Center.

Follow the Qualifying Life Event entry instructions to enter the change request.

Attach scanned documents to the Qualifying Life Event.

Who Is Eligible for Health Benefits at LISD?

• Employee/Subscriber - is a full-time or half-time Employee of LISD on monthly payroll who resides/lives in the service area and a bona fide employee entitled to participate in the health care benefit program. Temporary and hourly employees must work 130 hours per month for a six-month period to qualify for benefits prior to enrollment. In a month where it is not possible to work 130 hours (due to district hours) then the employee is given credit for that month.
  
  
• The Employee/Subscriber may enroll his/her family into the benefits program if they are considered Dependents of the Employee/Subscriber and who must be described as:
  
  
• • Spouse - a legal spouse is eligible for coverage if they are able to submit upon request a certified copy of their marriage certificate or a declaration of informal marriage certificate filed with the county clerk's office
    
    
  • Child of Subscriber/Employee - a child means a natural child, a stepchild, eligible foster child, an adopted child - under twenty-six (26) years of age; this could include a child with whom the Subscriber/Employee has proof of legal guardianship or court order for coverage to be provided for the minor child; a child of your child who is your dependent under federal income tax purposes at the time of application for coverage of the child is made
    
    
  • Children - a child of any age as noted above but who is and continues to be incapable of sustaining employment by reason of mental or physical handicap and is chiefly dependent upon Subscriber/Employee for economic support and maintenance.  A Dependent Child's Statement of Disability form including medical certification of disability may be required to be submitted within thirty-one (31) days of the date of medical certification and may be required to be provided at the time of application for enrollment and as often as once a year
    
    
  • Newborn Children Coverage - coverage will be automatic for Subscriber/Employee's (or covered Employee's spouse's) newborn child for the first thirty-one (31) days following the date of birth; coverage will continue for the newborn beyond the thirty-one (31) days only if the child is a dependent and the necessary forms and required contributions are completed/made by the Employee/Subscriber with the Risk Management Office to ensure further coverage for the newborn
    
    
  • Newly Adopted Children - coverage will be automatic for a newly-adopted child of Subscriber/Employee for the first thirty-one (31) days from the date the Subscriber/Employee is in a suit for adoption or thirty-one (31) days from the date of the adoption is final.  Coverage will continue beyond the thirty-one (31) days only if the child is an eligible dependent and the necessary forms and required contributions are completed/made by the Employee/Subscriber with the Risk Management Office to ensure further coverage of the adopted child
    
    
    
  The Risk Management Office will be performing random or for cause/questionable coverage request(s) audits as part of an ongoing plan verification process relating to dependent coverage relating to enrollment for the 2021 benefits year and thereafter.  If you are notified by the Risk Management Office requesting/requiring a copy of a marriage certificate, proof of dependent child legal custody order, birth certificates, federal income tax form showing dependent child claim/allowance, etc., please respond as soon as possible to ensure ongoing coverage for your dependent.  Failure to submit the required/requested documentation could result in non-coverage of that dependent until receipt of the requested documentation is received and verified by the Risk Management Office.  Failure to follow the enrollment guidelines and enrolling someone that does not qualify for coverage under the plan policies may also result in a denial of the claim accordingly.
   
  Should you have any questions, please give Vaun (ext 0283) or Lisa (ext 0235) a call.  Thanks!