[WKU HUMAN RESOURCES:Employee Benefits]

KTRS Medical Insurance and Prescription Drug Program

Eligibility

Member Coverage - As a retired member of the Kentucky Teachers' Retirement System, you may choose to be covered by the KTRS medical insurance policy if you are age fifty-five (55) with at least five (5) years KTRS service; you have twenty-seven (27) years of service; or you are on disability retirement (please see the special condition in the Benefits section).

 Your coverage is in force at 12:01 a.m. on the date your retirement is effective unless you are in the hospital at that time. In that event, coverage is delayed until the end of that hospitalization or until the end of a six month period, whichever is the earliest date.

 If you retired with less than 27 Kentucky years of service and are less than age 55 (reciprocity retiree), you will not have insurance coverage until July 1 following your 55th birthday.

 Spouse Coverage - Spouses of members who joined KTRS prior to July 1, 1978 will pay according to the length of service of the KTRS retired member. Spouses of members who joined KTRS for the first time on July 1, 1978 or later will pay the full premium amount.

Spouses of retired members who marry after retirement and after January 1, 1984 will pay the full premium amount.

 If a spouse is not covered by KTRS medical insurance at the time of the retired member's death, the spouse may not be able to obtain coverage at any future time. (Please see "Waiver of Evidence of Insurability".)

 Spouses of deceased members are not eligible to continue their coverage in the event of remarriage.

 Dependent Child Coverage - Currently a child may be covered at no charge only if he/she is unmarried, dependent and under age 19. A child who is a full-time college student may not enroll in this plan if he/she is age 19 or older at the time of your retirement.

 

Evidence of Insurability

If you retire but do not enroll in the KTRS medical insurance program, you and/or your spouse may enroll in the insurance program only after having provided KTRS satisfactory evidence of your medical insurability. If the retired member does not qualify, no family member will be permitted entry into the plan.

 Retirees, spouses and other eligible family members who elect insurance coverage at retirement and continuously retain no break in medical coverage through KTRS are not required to prove evidence of insurability.

 Waiver of Evidence of Insurability Requirement - If a member or spouse canceled or elected out of the KTRS medical insurance program because they had other medical coverage, KTRS can consider waiving the evidence of insurability requirement provided the other medical coverage has been continuous since the electing out and is lost under these qualifying events:

  1. Employer of retiree or spouse goes out of business
  2. Death of retiree or spouse
  3. Divorce of retiree or spouse
  4. Layoff of retiree or spouse
  5. Retirement of retiree or spouse
  6. Termination of employment for retiree or spouse.
Retirees and /or spouses must notify KTRS in writing within 60 days of the qualifying event in order to be considered for coverage and avoid proving evidence of insurability. It is the responsibility of the retiree and/or spouse to prove other medical coverage and qualifying events necessary to be considered to regain KTRS coverage.

 Coverage in the KTRS medical insurance plan is through the retiree. If the spouse is not covered by KTRS medical insurance at the time of the retiree's death and is eligible to apply for coverage through the waiver of insurability process, he or she may do so only during the 60 day period following the death of the retiree.

 

Cost

Determined by years of service.  Please see www.ktrs.state.ky.us for current information.

 

Coordination With Other Plans

The purchase of additional medical insurance coverage is your individual decision based on your needs. Where other "group plans" exist, the KTRS plan will not reimburse expenses paid by another "group plan." Certain indemnity type insurance policies that pay the insured for periods of hospitalization on a daily or weekly basis without regard to specific services rendered are not coordinated with the KTRS plan.

 

Effect of Medicare for Eligible Retired Members and Dependents

The federal Medicare program, which provides for persons 65 and over and certain disability retirees below age 65, is composed of two parts, Part A - Hospitalization Benefits and Part B - Physicians Benefits. Part A is automatically extended if you are eligible for Social Security benefits. Part B must be applied for, and you must agree to pay the required monthly contribution. You are not expected, however, to enroll and pay the Medicare Part B premium.

 You should carefully read the pamphlet describing Medicare benefits available at your Social Security Office. Any benefits payable, or which would be payable, under Medicare, whether or not you have enrolled under Part B will be deducted from the medical expenses covered under the KTRS plan before the benefits of the KTRS plan are determined. This is based upon the earliest date that any coverage under Medicare can become effective for an individual.

 We cannot emphasize too strongly the importance of enrolling in Part B of Medicare at the time you become eligible. Your medical insurance is incomplete without this coverage.

 You should contact your local Social Security Office at least 45 days prior to the month in which your 65th birthday occurs, or upon approval for disability retirement, for details regarding enrollment. It is important that this be done in order that you may enroll for Medicare when you first become eligible to do so.

 

Medicare B Direct

KTRS retired members and spouses who are enrolled in Medicare Part B are encouraged to take advantage of a time-saving program called Medicare B Direct. This program authorizes Medicare to forward your non-hospital claims directly to Aetna and eliminates the necessity for you to file the claim again. Currently this service is available to all retired members residing in Kentucky and 40 other selected states. Enrollment forms for this program must be obtained from the KTRS office. Generally, members who have insurance coverage other than Aetna and Medicare are not advised to enroll in this program.

 

When to File a Claim With Aetna

The initial claim for benefits for each calendar year can be made as soon as the bills for covered expenses of one family member exceed the deductible. Therefore, bills should be submitted monthly, or more often if necessary. If you have Medicare, a claim should be filed with Medicare first. A copy showing what Medicare paid must be attached to your Aetna claim form. As soon as your bills for "Covered Expenses" under the KTRS plan exceed your Medicare benefits and your deductible, you should file a claim with Aetna.

Before hospital admittance, you or your doctor are required to pre-certify your stay with Aetna by calling the following number: In Louisville 423-6150 In Kentucky 1-800-633-7050 Outside the State 1-800-874-0054. In an emergency you, your doctor or the hospital must call within 48 hours after your admission to the hospital. If you do not pre-certify, the plan will cover your hospital and board expenses at only 50% rather than the usual 80%.

Pre-certification is designed to cut hospital costs by avoiding unnecessary hospital admissions. This saves money for you and KTRS.

 

To Whom Benefits May be Paid

Benefits for hospital expenses will be paid directly to you if you file a claim submitting your hospital bill. However, you may request that the benefits be paid directly to the hospital. You may also request that benefits for your physician's expenses be paid directly to him/her at the time you file a claim. Benefits for other expenses will always be paid directly to you. Upon retirement you will receive two packets: one from Aetna for hospital and other medical expenses and one from PAID Prescriptions with your ID card and mail service information.

 

Retail Drug Program

Allows a 30 day supply of medication at one time. $75 deductible each year. Once $75 deductible is met, retiree pays 20% of KTRS cost of the drug when using a participating pharmacy. No claims to file when your card is presented. The retail program is easy to utilize. Simply present your PAID Prescriptions ID card to any KTRS-PPO participating pharmacy. The pharmacist will fill your prescription(s), collect the appropriate co-payment, and ask you to sign a log to indicate that the drugs were received. Retail Program: 1-800-272-7243 Monday through Friday, 8:30 a.m. to 5:00 p.m. This program serviced by: PAID Prescriptions 1900 Pollitt Drive, Fair Lawn, New Jersey 07410.

 

Mail Service Drug Program

Allows a 90 day supply of medication at one time. $3 cost for each generic prescription. $10 cost for each brand name prescription. No deductible to meet or claims to file. In order for you to receive a 90 day supply of medication from National Rx, your doctor must prescribe the proper quantity. For example, if you take one table per day, your doctor must write a prescription for 90 tablets. If you take two tablets per. day, your doctor must write a prescription for 180 tablets, etc. Mail Service Program: 1-800-282-2881. Monday through Friday, 8 a.m. to 8:00 p.m., or Saturday 8:00 a.m. to 12:00 noon, Eastern Time. Emergency pharmacy consultation is available 7 days a week, 24 hours a day. This program serviced by: National Rx Services, Inc. P.O. Box 182050, Columbus, Ohio 43218-2050.

 

Claim Instructions

For medical claim forms, please submit completed Aetna forms to: Aetna Life and Casualty Group Claims Department P.O. Box 35890 10401 Linn Station Road, Louisville, Kentucky 40232. To obtain Aetna claim forms, please call (502)426-7130. Note: Remember, there will be no claims to file if you take your card to a participating pharmacy. For prescription drugs please submit completed PAID forms to: PAID PRESCRIPTIONS, INC. Post Office Box 6121, Fair Lawn, New Jersey 07410-0999. To obtain PAID PRESCRIPTION claim forms, please call 1-800-272-7243.

Provisions Subject to Change

These provisions and premium charges are subject to periodic review, and changes may be made in the future.

 

Cost of Insurance Coverage

Effective September 1, 1992, the following cost sharing schedule went into effect: Members - A monthly charge is being implemented for all members to cover a portions of the health insurance cost. The charge is based on the years of service as a career teacher and the following percentages of the premium cost will apply: The monthly premium for the health insurance during 1993-94 will be $130 for persons age 65 and over and $270 for persons under age 65. The portion to be paid by members and spouses July 1, 1994 through June 30, 1995 will be as follows: Members age 65 and over - Members age 64 and under Eligible Spouses: The current monthly charge for the spouse is based on the retiree's length of service as a career teacher. The following percentages of the premium cost will apply: Eligible Spouses of Retirees: Age 65 and older 20+ yrs. service $58.50 15-19 yrs. service $71.50 10-14 yrs. service $84.50 less than 10 yrs. service $97.50.

Age 64 and under

Spouse of members who joined KTRS on July 1, 1978 or later will pay the following full premium rate for 1994-95: under age 65 - $270/month; over age 65 - $130/month.

 The KTRS Board of Trustees and staff regret the necessity of retirees having to pay any part of the cost of their health insurance. Faced with the fact that the amount of funds in the Medical Insurance Fund would not cover the expenses, the KTRS Board determined that the above cost sharing plan was the best available solution. KTRS supported increases in minimum payments and cost of living increases during 1994-96 that will more than offset the insurance cost for most retirees. Proposed changes in medical insurance coverage at the national level for all employees including active and retired teachers cold bring changes to coverage for KTRS retirees before the close of the 1994-96 biennium.

For more information on any of the above topics, please see www.ktrs.state.ky.us

 Comments or questions about this section of Western Online should be directed to Beth Littrell
Last Modified: September 22, 1998
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Western Kentucky University.