RETIREE

ENROLLMENT GUIDE
2020/21 BENEFITS GUIDE FOR RETIRING EMPLOYEES

A PUBLICATION OF
THE OFFICE OF EMPLOYEE BENEFITS
Enrollment Guide for
Retiring Employees
2020 / 2021
Table of Contents
Getting Ready to Retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Your UT Financial Retirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Secure Retired Employee Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Retired Employee Insurance Plan Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Basic Coverage Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Optional Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Additional Action Items. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
UT SELECT and Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Special Circumstances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Returning to Work. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Dual Premium Sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Moving Out of Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Benefits Cost Worksheet for Retirees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Institution Resources | Retiree Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Identity Protection Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
UT SELECT Value Added Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
UT CONNECT (DFW only) Value Added Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Living Well Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Life Insurance Value Added Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

UT Benefits Contact List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Legal Notices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Uniform Summary of Benefits and Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
UT SELECT Medical Plan Opt Out of Certain Provisions of the Public Health Service (PHS) Act. . . . . . . . . . . . . 48
UT CONNECT Medical Plan Opt Out of Certain Provisions of the Public Health Service (PHS) Act . . . . . . . . . . 48
University of Texas System Notice of Privacy Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Medicare Part D Notice of Creditable Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) . . . . . . . . . . . . . . . 56
Nondiscrimination Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Accessibility Requirements Notice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Beneficiary Designation Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

This publication is provided as an overview of terms and conditions of the insurance and wellness pro-
grams for employees retiring from The University of Texas System. The University of Texas System reserves
the right to interpret the provisions of the Booklet and to amend any provisions thereof.
The current version of this publication may be found at:
www.utsystem.edu/offices/employee-benefits/forms-and-publications.
If there is any ambiguity or inconsistency between a printed copy of the document and the online version,
the terms of the online document shall control. However, to the extent that any provision in this publication
conflicts with applicable law, the applicable law shall control. You may request a printed copy of the latest
edition at any time. The University of Texas System reserves the right to amend, change or terminate the
health and welfare benefit plans, any underlying contracts or any other programs, at any time and without
notice, at its sole discretion, according to the terms of the applicable plans or programs.
Getting Ready to Retire
Congratulations on your upcoming retirement!

After years of hard work, you want to make sure that the transition to the next phase of
your life goes smoothly. There are many key factors to consider leading up to your official
retirement date.
This booklet was created to help you understand your UT insurance benefits as you make
the transition to retirement. One condition of UT insurance eligibility is formal retirement
under the Teacher Retirement System of Texas (TRS), Employees Retirement System
of Texas (ERS) or the Optional Retirement Program (ORP).

Before you get started

You must establish your legal status as a retired employee in order to receive
any UT Retired Employee insurance benefits. Retirement eligibility and eligibility for
UT insurance as a retired employee are not the same. Please see the appropriate contacts
listed on the next page for information on how to retire under TRS, ERS or ORP.
To make sure you’re on track, keep in close contact with your HR/Benefits Office well
before you plan to retire. Your institution is your main point of contact during this transition
although you may need to work with other agencies to complete various steps in the
process. Many institutions have special resources available to you including classes or
personal appointments to make sure you make this transition successfully. Institution
contact information is listed at the back of this book.

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Your UT Financial Retirement
TRS
The TRS website has a wealth of information available for you including checklists, forms
and the TRS Benefits Handbook. They also have group retirement informational sessions
and videos to help answer your questions.
www.trs.texas.gov | TRS Counseling Center (800) 223-8778, M-F 7 am – 6 pm CT

ERS
ERS Provides a very informative website to help you understand the retirement process
or even sign up to meet with a retirement counselor. You can also call ERS to speak with
someone and schedule an appointment.
www.ers.texas.gov | (877) 275-4377, M-F 8:00 am – 5:00 pm CT

ORP
If you are an ORP participant and you wish to retire, contact your HR/Benefits Office
to complete your Declaration of Retirement, and contact your ORP vendor(s) to discuss
distribution options.
Find ORP vendor contact information on the back page of this book.

UTSAVER TSA AND DCP PARTICIPATION

If you participated in either of the UTSaver Voluntary Retirement plans and want to begin
receiving distributions, contact your plan provider(s) approximately 3 months prior to your
anticipated retirement date to ensure a smooth transition. Also, prior to your final month
of employment cancel your contributions through the online resource Retirement Manager
or contact your HR/Benefits office to do so. Find UTSaver provider contact information on
the back page of this book.

Thank you for your years of service, and good luck!

THE OFFICE OF EMPLOYEE BENEFITS

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Secure Retired
Employee Insurance

Eligibility
RETIRED EMPLOYEE INSURANCE ELIGIBILITY
There are two sets of insurance eligibility requirements for UT System Retired Employees.
The requirements applicable to you depend on your employment status with UT System in
August 2003. System employees employed or eligible for Retired Employee insurance in
August 2003 are “grandfathered” under the eligibility requirements that were in place at
that time.
System employees who were not employed or eligible for Retired Employee insurance on
that date are subject to new requirements that took effect when the previous law was
amended. See eligibility details in the following pages of this section.
You must work with your institution's HR/Benefits office to complete your Retired
Employee insurance enrollment within 31 days of your retirement from TRS, ERS or ORP, or
wait until the next Annual Enrollment to enroll.

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 Are you Eligible?
Steps to Determine Eligibility for UT System Retired Employee Group Insurance**

STATUS IN AUGUST 2003?

EMPLOYED AS A NOT EMPLOYED WITH UT, BUT A NOT YET EMPLOYED AS A

BENEFITS ELIGIBLE FORMER BENEFITS ELIGIBLE BENEFITS ELIGIBLE RETIRED EMPLOYEE
EMPLOYEE++ EMPLOYEE++ EMPLOYEE++ FROM A UT INSTITUTION
WITH A UT INSTITUTION WITH A UT INSTITUTION WITH A UT INSTITUTION

MET RULE OF 80* OR 55/5+

ON 8/31/2003?

ELIGIBLE WHEN MEETING ELIGIBLE WHEN MEETING ELIGIBILITY CONTINUES

RULE OF 80* OR 55/5+ YES NO RULE OF 80* OR 65/10+ AS A RETIREE
(3 YEARS OF UT SERVICE REQUIRED) (10 YEARS OF UT SERVICE REQUIRED) EVEN IF RETURNING TO WORK

IMPORTANT NOTE:
+ FOR MORE DETAILED
55/5 OR 65/10 EMPLOYEE MUST ENROLL
*RULE OF 80 INFORMATION:
REPRESENTS THE MINIMUM WITHIN 31 DAYS OF
AGE + NUMBER OF YEARS OF
AGE / NUMBER OF YEARS OF RETIREMENT OR MUST WAIT SEE POLICY 220 IN THE OFFICE
CREDITABLE STATE SERVICE
CREDITABLE STATE SERVICE UNTIL THE NEXT ANNUAL OF EMPLOYEE BENEFITS
= AT LEAST 80
REQUIRED TO BE ELIGIBLE ENROLLMENT OR QUALIFYING ADMINISTRATIVE MANUAL.
CHANGE OF STATUS TO ENROLL.

**To qualify, most recent State of Texas Employment prior to retirement must be at a UT Institution (with limited
exceptions) and retire under TRS, ERS, or ORP.
Eligible to participate in the Group Insurance Program under Section 1601.101, Texas Insurance Code.
++

6 Secure RetiredEmployee Insurance | 2020-2021 Insurance Enrollment Guide for Retirees

 An individual who was employed at a UT System An individual who was NOT employed at a UT
institution in a benefits-eligible position or System institution in a benefits-eligible position
eligible to retire from UT in August 2003, and or eligible to retire from UT before or in August
subsequently retires from the System is eligible for 2003 is eligible for benefits as a Retired Employee if:
benefits as a Retired Employee if: • The individual meets the Rule of 80 (total of age
• The individual meets the Rule of 80 (total of age plus years of state service credit equals or exceeds
plus years of creditable state service equals or 80) with at least ten (10) years of creditable state
exceeds 80), or service, or
• the individual is at least age 55 with five (5) • is at least age 65 with ten (10) years of total
years of creditable state service; and state service credit; and
• The individual has at least three (3) years of service • The individual has at least ten (10) years of ser-
with the System for which the individual was vice with the System for which the individual was
eligible to participate in the UT Group Insurance eligible to participate in the UT Group Insurance
Program; and Program; and
• The individual’s last place of state employment • The individual’s last state employment before
before retirement was with a System institution; retirement was with a System institution; and
and • The individual retires from System under the juris-
• The individual retires from System under the diction of the Teacher Retirement System of Texas
jurisdiction of the Teacher Retirement System of (TRS); the Employees Retirement System of Texas
Texas (TRS); the Employees Retirement System of (ERS); or the Optional Retirement Program (ORP)
Texas (ERS); or the Optional Retirement Program established by Chapter 830, Government Code
(ORP) established by Chapter 830, Government or any other federal or state statutory retirement
Code or any other federal or state statutory program to which the System has made employer
retirement program to which the System has made contributions.
employer contributions.

A former System employee who terminated employment and subsequently worked for another state agency or state
institution of higher education and does not qualify for retiree insurance coverage under that state agency or institution
may be eligible to participate in the UT group insurance program if the former Employee meets the minimum applicable
requirements described above and does not meet the requirements for an annuitant under the Employees Retirement
System of Texas (ERS) group insurance program.
Individuals, regardless of age and years of service credit, who worked in a benefits-eligible position with UT and are
members of the Teacher Retirement System (TRS) and qualify for disability retirement may also qualify to participate in
the UT Benefits program. Individuals who are participants in the Optional Retirement Program (ORP) may also qualify for
disability retirement.
Complete details about Retired Employee insurance eligibility is available in the Office of Employee Benefits
Administrative Manual, Policy 220 in the Forms and Publications section of the OEB website.

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DEPENDENTS
You may enroll your eligible dependents for certain UT Benefits coverage. The definition of dependent for purposes of UT
group insurance is the same for Active and Retired Employees.
Eligibility to participate in certain UT Benefits coverage as a dependent is determined by law.

Eligible dependents are: Examples of dependents that are not eligible for UT
• Your spouse; Benefits include:
• your former spouse;
• Your children under age 26 regardless of their marital
status, including: • your child over age 26, if not medically incapacitated
and unable to provide their own support;
∙ biological children;
∙ stepchildren and adopted children; • foster children covered by another government
∙ grandchildren you claim as dependents for tax program, unless coverage is required by law or court
purposes; order;
∙ children for whom you are named a legal guardian • any dependent insured in the same plan type by
or who are the subject of a medical support order another UT employee or retired employee; and
requiring such coverage; and • any dependent insured by another plan that receives
∙ certain children over age 26 who are determined by State of Texas premium contributions.
OEB to be medically incapacitated and are unable to
provide their own support.

PREMIUM SHARING
As a Retired Employee, UT and the State of Texas will pay
100% of your premiums for the basic coverage package,
and up to 50% of the premiums for your dependents’
medical coverage. You are responsible for all optional
coverage premiums.
If you are a benefits-eligible Retired Employee with
coverage under another group health plan and elect to
waive the basic coverage package you are eligible to
receive 50% of the cost of the Basic Coverage Package to
purchase Dental and/or Vision Coverage. If you waive, you
will not be enrolled in Basic Group Life Insurance or be
eligible for the Living Well Program as those are a part of
the Basic Coverage Package.

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SURVIVING DEPENDENT BENEFITS
Dependents who are covered in a UT medical, dental and/or A surviving spouse may continue UT Benefits coverage for
vision insurance plan at the time of an Active Employee or the remainder of the surviving spouse’s life. A dependent
Retired Employee’s death may continue System insurance child may continue until the child loses his or her status as
as surviving dependents if: a dependent child.
• The employee/retiree had at least five years of Surviving dependents may only continue the coverage
creditable service with the Teacher Retirement System in place at the time of the deceased’s death. If surviving
(TRS) or Optional Retirement Program (ORP) prior to dependent coverage is ever terminated, it may not be
the time of death, AND reinstated and new coverage may not be added for a
• Three of the five years of service were with the surviving dependent at any time.
University of Texas System as a benefits-eligible Premium sharing is not available for surviving dependent
employee. coverage.

! In the event of a retired employee’s death, it is very important for someone to contact the institution from which
the employee retired within 31 days to update premium billing and coverage options. A helpful contact list for
your next-of-kin or other legal representative is provided in the resources section of this guide.

Enrollment
INITIAL PERIOD OF ELIGIBILITY FOR RETIRED EMPLOYEES
An individual must enroll in the program as a Retired Employee within 31 days of the date upon which the individual
retires from TRS, ERS or ORP. An individual who fails to enroll within the 31-day period may not enroll until:

(a) the next Annual Enrollment period; or (b) the occurrence of a qualified change of status event.

You may enroll in or make changes to benefits during your initial period of eligibility (when you first retire) through your
institution’s HR/Benefits Office.

WAITING PERIOD FOR RETIRED EMPLOYEES EVIDENCE OF INSURABILITY (EOI)

There is no waiting period for individuals who transition Evidence of insurability (EOI) is the record of a person’s
directly from active employment to retirement without a past and current health events. EOI is used by insurance
break in coverage. companies to verify whether a person meets the definition
An Employee who terminates employment without retiring of good health. Most people retire directly from active
and later applies for Retired Employee insurance will not be employment without a break in coverage and do not
eligible to participate in UT Basic Coverage (Medical with require EOI. However, an EOI form is required to add or
Prescription Drug Coverage and Basic Life Insurance) until increase voluntary life insurance for the Retired Employee
the first of the calendar month following 90 days after the or spouse. EOI must be submitted within 31 days of the
retirement date. There is no waiting period for enrollment change event date. Coverage subject to EOI will become
in optional coverages which are paid in full by the Retired effective on the EOI approval date, and your billing for the
Employee. coverage begins the first of the month after the approval
date. If the approval date is the first of a month, the
coverage and billing change is effective on that date. If EOI
is denied, the change in coverage will not take effect.

2020-2021 Insurance Enrollment Guide for Retirees | Enrollment Guide for Retiring Employees 9
DEPENDENT DOCUMENTATION BCBSTX life insurance Customer Service at (866) 628-2606
UT requires supporting documentation when you request (available Monday through Friday from 7 a.m. to 7 p.m.
to add a dependent to your plan. Be prepared to provide central time) for assistance.
proof of eligibility such as your marriage certificate, If you are a member of the Teachers Retirement System
your child(ren)’s birth certificates, appropriate adoption (TRS), you should download the TRS beneficiary designation
paperwork, federal tax forms or other documents that form and return the form directly to TRS. For more
support the dependent relationship. For medically information, go to the TRS website at www.trs.texas.gov
incapacitated dependents, proof of the incapacitating or call 1-800-223-8778.
condition and dependency must be submitted within 31
If you are a participant in the Optional Retirement Program
days of initial eligibility for enrollment of an incapacitated
(ORP), or the voluntary UTSaver Tax-Sheltered Annuity
dependent. This paperwork is required not only to support (TSA) or UTSaver Deferred Compensation Plan (DCP), you
the coverage of eligible dependents but also to support a should always be sure that a current beneficiary is on file
mid-year change of status such as marriage or birth of a
for each of these retirement accounts. You can download
child. Even if you have supplied this documentation to your the appropriate beneficiary designation form and return the
institution in the past, they may require another copy at completed form directly to your specific retirement provider.
retirement to update records. For more information, please see the Retirement Plan
Misrepresentation of benefit eligibility requirements section of the OEB website.
constitutes a violation of OEB’s official policy. A verified
misrepresentation by an Employee or Retired Employee ANNUAL ENROLLMENT
shall be reported by OEB to the appropriate institution for Annual Enrollment is the period of time during which you
investigation and possible sanctions. Possible sanctions may make changes to benefit elections for you and your
for such a violation range from a reprimand to dismissal. eligible dependents. Outside of Annual Enrollment, you
In addition, reimbursement may be required for any may only make changes if you have a qualified change
benefits paid to an ineligible individual. Deliberate of status event. UT System holds annual enrollment each
misrepresentation of dependent eligibility by an Employee summer, usually during the month of July. Prior to Annual
or Retired Employee may constitute criminal fraud and Enrollment, you will receive a reminder letter or email that
may result in a referral to a law enforcement office. informs you if any action is required on your part. During
Any ineligible dependent may be terminated from plan this time you may change your group insurance benefit
participation upon discovery of ineligibility. elections and add, update or remove dependents from
coverage using the My UT Benefits online system.
BENEFICIARY INFORMATION
Your Annual Enrollment elections become effective
It is important to designate beneficiaries for all of your
each September 1st after the Annual Enrollment period.
insurance and retirement accounts that require them. If you If coverage requires EOI, and EOI is not approved by
don’t, state laws may cause death benefits to be distributed September 1, that coverage will be effective on the EOI
differently than you had planned, may result in additional approval date (Voluntary Life Insurance) or the first of the
taxes, and may unnecessarily delay the process of finalizing
month following the approval date (all other coverage). If
payment to your loved ones. You should regularly review EOI is denied, the change in coverage will not take effect. If
and, if necessary, update your beneficiary designations. dependent documentation is not received or approved, the
For your UT Benefits group term life insurance (which you dependent’s coverage will not take effect.
receive even if you only have the basic coverage), you must
complete a new designation for Retired Employee coverage.
For your convenience, a copy of this form is included at the
back of this book. If you have questions, please contact

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QUALIFYING CHANGES OF STATUS RETIRED EMPLOYEE BILLING
You have 31 days from the date of certain qualified change If you will carry any insurance other than the Retired
of status event to notify your institution’s Benefits Office Employee only basic coverage and you need to pay monthly
and complete changes to your benefits that are consistent premiums, talk with your HR/Benefits office about how
with that event. If you do not make your eligible changes to set up your premium billing. Some institutions handle
during the 31-day status change period, your changes Retired Employee billing internally, and some handle it
cannot be made until the next Annual Enrollment in July, to through UT System Administration Benefits Billing.
be effective the following September 1. Confirm your contact information and update it (if
The list below includes common examples of qualified necessary). Always contact your HR/Benefits Office with
change of status events: any changes to your mailing address, email address and/or
• marriage, divorce, annulment, or spouse’s death; phone numbers.

• birth, adoption, medical child-support order, or TERMINATION OF COVERAGE

dependent’s death;
Failure to pay premium within 45 days of the due date will
• significant change in residence if the change affects result in cancellation of coverage retroactive to the first of
you or your dependents’ current plan eligibility; the month following the last month of paid coverage. An
• starting or ending employment, starting or returning individual whose coverage is cancelled for nonpayment
from FMLA, or other change of job status (e.g., from of premium is not eligible for coverage under COBRA. See
non-benefits eligible part-time to full-time) affecting the COBRA information in the Legal Notices section of this
eligibility; guide.
• change in dependent’s eligibility (e.g., reaching age 26
or gaining or losing eligibility for any other reason); or
• significant change in coverage or cost of other benefit
plans available to you and your family.
A Retired Employee whose dependent loses insurance
coverage under the Medicaid or CHIP program as a result
of loss of eligibility of either the employee or the dependent
or whose dependent becomes eligible for a premium
assistance subsidy under Medicaid or CHIP may enroll
this dependent in the basic coverage under UT Benefits,
as long as the dependent meets all other UT eligibility
requirements and is enrolled within 60 days from the date
of the applicable event. If enrollment of the dependent is
conditioned on enrollment of the Retired Employee, the
Retired Employee will also be eligible to enroll.
Note: EOI and dependent documentation may be required
for some benefit changes following a qualified change of
status event.
You may enroll in or make changes to benefits within the
required time frame through your institution HR/Benefits
office.

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Retired Employee
Insurance Plan Information
The insurance plan options for UT Retired Employees vary slightly from the Active
Employee insurance package. This section outlines the coverage options with
notes about how the coverage transitions. Contact information for all plan
vendors is located at the back of this book.

Basic Coverage Package

UT and the State of Texas pays 100% of your premiums for the Basic Coverage Package, and up to 50% of the
premiums for your dependents’ medical coverage. As a part of the Basic Coverage Package, you and your covered
dependents over age 18 are also eligible for the Living Well Wellness Program.

UT SELECT MEDICAL (WITH PRESCRIPTION DRUG)

The UT SELECT Medical If you have UT SELECT Medical as a Retired Employee, you and anyone
PPO plan for Retired covered on your plan that is eligible for Medicare will use Medicare as the
Employees is the same primary medical insurance. Medicare-eligible participants should be enrolled
plan as for Active in Medicare Parts A and B before you retire. Medicare-eligible retiree plan
Employees. participants are enrolled in the UT SELECT Part D plan for prescription drug
coverage. (See more in the Medicare section of this guide.) Non-Medicare
eligible plan participants continue in the same UT SELECT Medical and
Prescription Drug plan as Active employees.
If your address on file is outside of Texas, New Mexico, or Washington D.C.,
Out of Area benefits apply. See the UT SELECT Medical Plan Guide for more
information.

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 UT CONNECT MEDICAL (WITH PRESCRIPTION DRUG)

UT CONNECT ACO Medical Plan Effective September 1, 2018 the UT CONNECT

for Dallas/Fort Worth Area Accountable Care Organization (ACO) became available
See legal notices regarding the selection of Primary for UT Employees and non-Medicare eligible Retirees
Care Physicians. living in the designated service area. You can go online to
find out more information about the UT CONNECT plan:
www.utsystem.edu/offices/employee-benefits/ut-connect-
aco-medical-plan
The prescription drug coverage is the same as UT SELECT
medical participants.

BASIC GROUP TERM LIFE INSURANCE

$6,000 Group Term Life insurance is provided for each If you waive your Basic Coverage Package because you
Retired Employee as a part of the Basic Coverage have other medical coverage, you will not be enrolled in
Package. the Basic Group Term Life insurance.

LIVING WELL

Retired Employees and their dependents age 18 and If you waive or decline UT SELECT Medical or UT
over covered in the UT SELECT Medical Plan or UT CONNECT, you will not be eligible to participate in Living
CONNECT are automatically eligible for the Living Well Well. However, some institutions offer their own wellness
wellness program offered by UT System. resources regardless of enrollment in the UT SELECT or
Retired Employees and their spouse age 50 and above UT CONNECT Medical Plan.
are eligible for the SilverSneakers® Fitness program.
See Resources at the back of this book.

Optional Coverage
If you are a benefits-eligible Retired Employee with coverage under another group health plan and elect to waive the
basic coverage package, you are eligible to use 50% of the state premium sharing to purchase Dental and/or Vision
Coverage. If you waive the basic coverage, you will not be enrolled in Basic Group Life Insurance or be eligible for the
Living Well Program as those are a part of the Basic Coverage Package.

DENTAL

Retired Employees have the same dental plan options When you change from Active Employee status to Retired
as Active Employees. You may choose from UT SELECT Employee status, you may change your plan type.
Dental or UT SELECT Dental Plus PPO plans or the
DeltaCare Dental HMO Plan for yourself and your
dependents. You must be covered under the plan to
cover a dependent.

14 Enrollment Guide for Retiring Employees | 2020-2021 Insurance Enrollment Guide for Retirees
VISION

Retired Employees have the same vision plan options When you change from Active Employee status to Retired
as Active Employees. You may choose from Superior Employee status, you may change your plan type.
Vision or Superior Vision Plus for yourself and your
dependents. You must be covered under the plan to
cover a dependent.

UT FLEX

Retired Employees (including Return-to-Work Retired You may be reimbursed for expenses incurred through the
Employees) are not eligible for UT FLEX plans. Coverage time at which your coverage ends.
ends on the last day of the month in which you retire. If you have a balance in a Health Care Reimbursement
Account, you may continue that coverage through
COBRA. (Speak with your HR/Benefits representative to
verify if you are eligible to continue this coverage.)
If your coverage end date for the Health Care
Reimbursement Account is August 31(the last day of the
plan year), you may take advantage of the grace period
and incur expenses for reimbursement through November
15 of that same calendar year. The UT FLEX debit card is
not available for you to use during the grace period of the
plan year in which you retire.
All UT FLEX claims must be submitted by November
30 following the end of the plan year to be eligible for
reimbursement.

DISABILITY INSURANCE*

Disability Insurance is not available to Retired Return-to-work Retired Employees are not eligible for
Employees since it is meant to replace a portion of your Disability Insurance. Disability insurance is not portable
work pay if you become disabled. when you retire.

RETIRED EMPLOYEE VOLUNTARY GROUP TERM LIFE INSURANCE

Retired Employees may enroll in Voluntary Group If you retire without a break in coverage, you are guaran-
Term Life insurance in any of the following coverage teed coverage up to the amount of coverage you had in
amounts: place as an Active Employee, not to exceed $100,000.
$7,000 $10,000 $25,000 $50,000 $100,000 Any coverage in place as an Active Employee (minus the
Retired Employee coverage elected) may be converted
to a whole life policy within 31 days of retirement if you
retire without a break in coverage. Conditions Apply –
Contact BCBS of Texas for complete details.

2020-2021 Insurance Enrollment Guide for Retirees | Enrollment Guide for Retiring Employees 15
 RETIRED EMPLOYEE SPOUSE VOLUNTARY GROUP TERM LIFE INSURANCE

A spouse of a Retired Employee may elect $3,000 If you retire without a break in coverage and your spouse
Voluntary Group Term Life insurance if the Retired was enrolled in Voluntary Group Term Life insurance on
Employee is also enrolled in any amount of Retired your last day of active employment, the spouse may
Employee Voluntary Group Term Life insurance. enroll without completing Evidence of Insurability.
Spouse coverage in place when the employee retires may
be converted to a whole life policy. Conditions apply –
Contact BCBS of Texas for complete details.

ACCIDENTAL DEATH AND DISMEMBERMENT

Retired Employees (including Return-to-Work Retired Conversion and portability is not available for AD&D.
Employees) are not eligible for Accidental Death and
Dismemberment. Coverage ends on the last day of the
month in which you retire.

*If you are a Faculty member at one of the health institutions and your Disability insurance is through an alternative
benefit provided by your institution, please ask your HR/Benefits representative to discuss the options of those plans with
you.

Additional Action Items

Depending on your personal circumstances as you near retirement, you may need to take additional action to ensure
a smooth transition from active employment. Several important topics to think about are listed below. Related contact
information is listed at the end of this guide.

SOCIAL SECURITY PENSION

To determine whether you meet the guidelines for the social security pension plan please contact the Social Security
Administration directly. Keep in mind that setting up payments may take up to 3 months.

MEDICARE (FEDERAL HEALTH INSURANCE PROGRAM)

If you or any of your covered dependents are or will soon be eligible to receive the federal health insurance program
known as Medicare, you should reach out to the Social Security Administration office to determine your enrollment
requirements. See information on the following page for more information about Medicare and your insurance.

CONVERTING LIFE INSURANCE

If you wish to convert any of your Voluntary Group Term Life insurance to a whole life policy, contact the life insurance
vendor within a month after your employment ends.

16 Enrollment Guide for Retiring Employees | 2020-2021 Insurance Enrollment Guide for Retirees
UT SELECT and Medicare
Different parts of Medicare cover different services. You may hear about four parts of Medicare: Part A, Part B, Part C, and
Part D. Parts A, B, and D work in conjunction with UT SELECT. Part C is typically not useful or necessary if you are enrolled
in UT SELECT and could conflict with the UT SELECT plan.
Original Medicare is administered directly by the federal government. It is the way participants in UT SELECT get their
Medicare medical coverage. It has two parts:
1. Part A (Hospital Insurance) covers most medically 2. Part B (Medical Insurance) covers most medically
necessary hospital, skilled nursing facility, home health, necessary doctors’ services, preventive care, durable
and hospice care. medical equipment, hospital outpatient services,
laboratory tests, x-rays, mental health care, and some
home health and ambulance services.
Medicare Part D (outpatient Prescription Drug Insurance) is the part of Medicare that provides outpatient prescription
drug coverage. Part D is provided to Medicare-eligible UT SELECT participants through the Express Scripts Medicare®
(PDP)* for UT SELECT (aka UT SELECT Part D). It is never provided directly by the government (like Original Medicare is).
*Prescription Drug Plan
Note: Certain retirees that will return-to-work in a modified or phased capacity may have additional options. To learn
about those guidelines please reach out to your institution’s HR/Benefits office for details.

RETIRED EMPLOYEES
When you retire (and are not working in a benefits-eligible position for 20 or more hours per week) any Medicare-eligible
person covered on your plan including you should:
As a retired employee, if you or your Medicare-eligible
Enroll in Part A (typically inpatient coverage)
dependent have declined Medicare Part B, UT SELECT
AND Medical will reduce your claim payment by the benefit that
Enroll in Part B coverage, (typically office visits and would have been available to you under Medicare Part B
doctor fees) (usually 80%), and then pay the remaining claim amount
under the terms of your health plan. Medical bills can
AND
quickly climb to tens or hundreds or thousands of dollars.
Decline Part D (prescription drug coverage) plans Eighty percent of a hospital stay or outpatient procedure
offered by private carriers could have a lasting financial impact to you and your
family.
Contact your Social Security office 3 months prior to your
The University of Texas System urges all retired
retirement date, if possible. If your dependents are also
employees and dependents to enroll in Medicare
eligible, they will need to do the same. A delay in signing up
Parts A and B when they become eligible at age 65, or
could leave you covered at only 20% for medical expenses.
earlier if they are eligible due to a disability such as
End Stage Renal Disease. Retired Employees, or soon-to- For prescription benefits, UT System will automatically
be Retired Employees, or their dependents who are eligible enroll Medicare-eligible retirees and Medicare-eligible
for Medicare must have Medicare Parts A and B to receive dependents of retirees into the UT SELECT Part D plan. The
the maximum benefits available from the UT SELECT plan. UT SELECT Part D plan maintains the familiar copays and
other benefits of the employee prescription plan.

2020-2021 Insurance Enrollment Guide for Retirees | Enrollment Guide for Retiring Employees 17
Enrollment in a separate Part D plan or Medicare Advantage MEDICARE PARTS A AND B COORDINATION
plan with prescription drug coverage will conflict with UT OF BENEFITS
SELECT Part D coverage because the Centers for Medicare In most instances, if you are eligible for Medicare and are
and Medicaid Services (CMS) only allows enrollment in working at UT in a benefits-eligible position for at least
one Medicare plan. For current enrollees in the UT SELECT 20 hours per week such as during phased retirement or if
Part D plan, the annual prescription deductible will reset on you have returned to work, your UT medical plan will be
January 1. Other deductibles and out-of-pocket maximums primary for you and your covered dependents, regardless
for the UT Benefits program will reset on September 1, as of age, and Medicare will be secondary. Medicare may
usual. be primary for some Medicare-eligible active employees
The Centers for Medicare and Medicaid Services (CMS) or their dependents with certain medical conditions such
will send you prescription drug plan materials, including as end stage renal disease (ESRD) or amyotrophic lateral
detailed benefits information and a new ID card. Non- sclerosis (ALS). Consult with your local Social Security
Medicare-eligible UT SELECT plan participants with retiree Administration office to learn what illnesses qualify for
coverage will continue to be enrolled in “the commercial Medicare coverage prior to turning age 65.
plan”—the same plan that insures participants with Once you are retired and also eligible for Medicare,
coverage through active employment. Medicare becomes your primary payer and pays your
medical claims first; UT SELECT pays second. If you choose
INCOME-BASED MEDICARE COSTS a doctor who accepts Medicare assignment, you will not
Medicare-eligible participants with UT SELECT retiree be responsible for any difference between the billed charge
coverage with income above a certain level may be and the Medicare allowed amount.
subject to an Income Related Medicare Adjustment
PLEASE NOTE: Effective September 1, 2018 the UT
Amount (IRMAA). This fee is paid to Medicare and is not a
CONNECT Accountable Care Organization (ACO)
premium paid to the UT SELECT plan. The Social Security
became available for UT Employees and non-Medicare
Administration (SSA) makes initial determinations whether
the income-related monthly adjustment amount (IRMAA) eligible Retirees living in the designated service area.
applies to Medicare beneficiaries with Part B, or Medicare If you participate with UT CONNECT ACO and then
prescription drug coverage (or both if enrolled in both at become eligible for Medicare, you will be switched to
UT SELECT as of the effective date of your Medicare
the time a determination is made) using IRS data. SSA
eligibility.
sends a notice with information about the determination
and appeal rights when they make an initial IRMAA
determination.
Conversely, if your income qualifies you for extra help to
pay for your Medicare prescription drug coverage such
as your monthly premium, annual deductible and copays,
you will receive information on this from the Medicare
prescription drug plan.

18 Enrollment Guide for Retiring Employees | 2020-2021 Insurance Enrollment Guide for Retirees
If you or your dependents are enrolled in Medicare
If a service is normally not covered by UT SELECT or
and your doctor accepts Medicare assignment
is subject to limitations (such as the 20 visit limit on
• The doctor may be in or out of the UT SELECT Network; physical therapy), the service beyond plan limitations
• The participant may be in or out-of-area; and exclusions will not be covered. All regular UT
• UT SELECT will pay 100% of benefits approved but SELECT exclusions and limitations apply regardless
not paid by Medicare (subject to UT SELECT plan of Medicare enrollment. See the UT SELECT Medical
provisions); Plan Guide for complete details on plan limits and
exclusions.
• There are no deductibles, copayments or coinsurance
(subject to UT SELECT plan provisions); and To ensure claims are correctly processed, you and your
dependents should alert your medical providers of
• When you or your dependents are at an inpatient
changes including:
facility that accepts Medicare assignment, UT SELECT
will pay the Medicare inpatient deductible, and the When you first retire (and Medicare becomes primary)
$100 per day Copay ($500 maximum) will not apply. When you first enroll in Medicare (if after retirement)
If your doctor does not accept Medicare assignment When you return to work in a benefits-eligible position
• Network and Out-of-Network benefits apply; (and Medicare becomes secondary)

• UT SELECT will coordinate with Medicare; and

• Deductibles, copayments and coinsurance may apply.

2020-2021 Insurance Enrollment Guide for Retirees | Enrollment Guide for Retiring Employees 19
This chart shows you how UT SELECT Medical coordinates benefits with Medicare Parts A and B when Medicare is
primary.
Please Note: Medicare eligible retirees are eligible to participate with UT SELECT medical plan only.

PROVIDER
BCBSTX SERVICE UT SELECT PAYS
ACCEPTS UT SELECT
IN-NETWORK COVERED MEDICARE PAYS (SUBJECT TO PLAN
MEDICARE MEMBER PAYS
PROVIDER BY MEDICARE LIMITATIONS)
ASSIGNMENT

Y Y Y 80% MC Allowed 20% MC Allowed No Charge

Y N Y 80% MC Allowed 20% MC Allowed No Charge

100% after Copay

or 80% of BCBS Copay or 20% of BCBS
Allowed after Allowed after $350
Y Y N 0
$350 Deductible, Deductible, whichever is
whichever is applicable
applicable

$750 Deductible + 40%

60% of BCBS of BCBS Allowed +
Y N N 0 Allowed after $750 Difference between
Deductible Billed Charge and BCBSTX
Allowed

100% after Copay or

20% of allowed
After MC Deductible Copay or $350 Deductible
charges2 after $350
N Y Y is satisfied 80% MC and 20% coinsurance,
Deductible,
Limiting Charge1 whichever is applicable
whichever is
applicable

After MC Deductible 20% of allowed

$750 Deductible and 40%
N N Y is satisfied 80% MC charges2 after $750
coinsurance
Limiting Charge Deductible

100% after Copay or

Copay or 20% of BCBS
20% of BCBS Allowed
Allowed after $350
N Y N 0 after $350 Deductible,
Deductible, whichever is
whichever is
applicable
applicable

$750 Deductible + 40%

60% of BCBS Allowed of BCBS Allowed +
N N N 0
After $750 Deductible Difference between Billed
Charge and BCBSTX Allowed
1
Provider who does not participate with Medicare may not bill more than the Medicare Limiting Charge (115% of MC Allowed).
2
Allowed charges are the lesser of the Medicare Limiting Charge or the Blue Cross and Blue Shield allowed amount. If the Blue Cross and Blue
Shield allowed amount is less, the member may be billed the difference.

20 Enrollment Guide for Retiring Employees | 2020-2021 Insurance Enrollment Guide for Retirees
COORDINATION OF BENEFITS WITH UT SELECT, MEDICARE AND A THIRD COVERAGE
Special rules are mandated by federal law when coordinating benefits between UT SELECT Medical, Medicare and
another coverage. The following examples show the proper coordination of benefits for some common insurance
situations. If you have questions about coordination of benefits, contact the Office of Employee Benefits or Medicare.

EXAMPLE A John and his wife may wish to consider

John is 68, continues to have a full-time 1. UT SELECT whether the reimbursements received as
position at UT, and is covered as a dependent a dependent on his wife’s plan justify their
2. MEDICARE
under his wife’s retiree plan with ABC additional premium costs. In many instances,
Company. John’s claims will be paid in this
3. ABC COMPANY Medicare’s secondary payment will cover
order: the out-of-pocket costs remaining after the
primary insurer pays.

EXAMPLE B Although Linda has returned to work after

Linda is 67, has retired from UT and returned 1. MEDICARE retiring, her position is not benefits-eligible;
to work in a position working less than 20 2. UT SELECT therefore, her insurance benefits are obtained
hours per week. Linda’s husband also covers as a result of retirement, not employment. Her
her under his retiree plan with XYZ Company.
3. XYZ COMPANY prescription drug benefit is provided through
Linda’s claims will be paid in this order: the UT SELECT Part D plan.

EXAMPLE C 1. UT SELECT It is important to inform your providers and

Meredith is 72 and has UT SELECT as 2. SPOUSE’S EMPLOYER health plan carriers of all the insurances
a Retired Employee. During her phased 3. MEDICARE in which you are enrolled. Understanding
retirement, she returns to teach for the Fall Her prescription drug benefit is the same as correct coordination of benefits will help to
semester, from September 1 through January that of an active, non-retired employee— ensure timely and accurate claims payments.
15. She is covered by her husband’s medical the UT SELECT “commercial” plan. If you have questions regarding your specific
plan through his active employment. insurance situation, please contact your
During the semester that Meredith has For the remainder of the year, when institution Benefits Office or the UT System
returned to a benefits-eligible position at UT, Meredith is not teaching, her claims are Office of Employee Benefits.
her claims are paid in this order: paid as follows:
1. SPOUSE’S EMPLOYER
2. MEDICARE
3. UT SELECT

For more information on UT SELECT and Medicare, please see the Legal Notices section of this guide.

2020-2021 Insurance Enrollment Guide for Retirees | Enrollment Guide for Retiring Employees 21
Special Circumstances
Returning to Work
If you are a TRS Retired Employee returning to work with a TRS agency, Texas law restricts
your ability to work at other employers that participate in TRS and how much you can
work. Consult with TRS and your hiring agency before returning to work after retirement.
ORP Retired Employees do not have the same restrictions.
Returning to work in any capacity could affect your Social Security Benefits so contact the
Social Security Administration to learn how those changes may affect your benefits.

YOUR TRS ANNUITY

GENERAL INFORMATION
If you plan to work in Texas public education after service or disability retirement, you
should carefully review all requirements that apply to such work.
If you do not effectively terminate employment because you do not wait long enough
to return to work or to arrange your return to work, your service or disability retirement
can be totally revoked and you can be required to pay back annuity payments you have
already received.
If you comply with all of the requirements and your retirement is effective, but you work
more than the law allows while receiving your monthly benefit, you lose monthly service
or disability annuity payments for months in which your work exceeds the allowable
amount.
To work after service or disability retirement without revocation of retirement or loss of
benefits, a retiree must:
• terminate all employment with a TRS-covered employer (see "Termination of
Employment Before Retirement" and "Negotiation for Return to Employment" in the
TRS handbook),
• wait to negotiate a return to employment as permitted under law,
• not work for a TRS-covered employer during the required break in service after the
effective retirement date, and
• work only the amount of time permitted.

2020-2021 Insurance Enrollment Guide for Retirees | Special Circumstances 23

These requirements above apply to all retirees, service and disability, and both normal-age and early-age. However, there
are some differences in how the requirements are applied, depending on retirement circumstances. In addition, these
requirements may be affected by changes to state law and TRS regulations. For additional information, a full explanation
of the requirements, see the TRS Employment After Retirement brochure, which can be found on the TRS website at
www.trs.texas.gov or can be obtained by calling TRS.

ORP RETIRED EMPLOYEES YOUR INSURANCE AND

RETURNING TO WORK
Unlike the Teacher Retirement System, retirees from the
If you return to work for another Texas State Agency or
Optional Retirement Program (ORP) do not have the same
Institution of Higher Learning you may be able to enroll
limitations on employment after retirement. However,
in their active employee benefits plans, but you may not
ORP retirees who later return to employment in Texas
receive premium sharing from more than one state group
public institutions of higher education are not eligible to
insurance program either as the Subscriber (covered
participate in ORP, with the following exceptions:
enrollee) or a dependent.
• ORP retirees who enrolled in retiree group insurance on
Inform your new employer's HR/Benefits office if you
or before June 1, 1997;
are a Return-to-Work Retired Employee.
• Employees who elected ORP in lieu of ERS at the
Texas Higher Education Coordinating Board (THECB) IMPORTANT: If you return to work at UT in a benefits-
and who, after terminating employment with the eligible position 20 hours or more per week, Medicare
THECB and enrolling in retiree group insurance as an becomes secondary and the UT SELECT medical plan
ORP retiree from the THECB, subsequently become becomes primary for any Medicare-eligible person on
employed in an ORP-eligible position at a Texas public your plan, including you. You and your dependents are
institution of higher education; also enrolled in the "commercial" prescription drug
• Employees who elected ORP in lieu of TRS and who, plan--the plan for active employees.
after terminating employment with all Texas public
institutions of higher education and enrolling in retiree
group insurance as an ORP retiree from a Texas public
institution of higher education, subsequently become
employed in an ORP-eligible position at the THECB; and
• ORP retirees who enroll in retiree group insurance as a
part of a phased retirement program, as defined in 19
Texas Administrative Code Chapter 25.
You are not eligible to participate in TRS or ORP.
You can participate in the UTSaver Voluntary Retirement
plans. If you did not end your contributions to a UTSaver
TSA or DCP Plan when you retired, those contributions may
resume when you return to work.
You will continue to have insurance as a Retired Employee
only. You will not be eligible to enroll in insurance available
only to Active Employees (Disability and higher amounts of
Voluntary Group Term Life insurance) or to participate in UT
FLEX.

24 Special Circumstances | 2020-2021 Insurance Enrollment Guide for Retirees

Dual Premium Sharing
You may not receive premium sharing from more than for Optional Coverage offered by System. If you currently
one state group insurance program (ERS or A&M) either cover a dependent that is also enrolled in one of these
as the Subscriber (covered employee) or a dependent. You plans, please choose to have that person covered under
must either be the Subscriber (covered employee) or the only one plan and make the appropriate enrollment
dependent. If you or your spouse waive the Basic Coverage, changes as soon as possible.
neither of you will receive one-half of the premium sharing

Moving Out of Area

When your address on record with your retiring institution UT CONNECT ACO only provides benefits for UT
changes to one that is outside of Texas, New Mexico, or Employees and non-Medicare eligible Retirees living in the
Washington, D.C., your UT SELECT Medical Insurance designated service area. You can go online to find out more
applies Out of Area benefits. If you and your dependents information about the UT CONNECT plan:
are also enrolled in Medicare, this will have little to no www.utsystem.edu/offices/employee-benefits/ut-
effect on your out-of-pocket expenses. If you or any of your connect-aco-medical-plan
dependents are not eligible for Medicare, your benefits
change to apply mostly deductible and coinsurance.
Please review the UT SELECT Medical Plan Guide Out of
Area Benefits or the UT SELECT Medical Plan Summary
of Benefits and coverage for details. These documents are
available on the UT System Office of Employee Benefits
website or by contacting the Office of Employee Benefits.

2020-2021 Insurance Enrollment Guide for Retirees | Special Circumstances 25

Resources
In addition to the robust UT Benefits, additional resources are available to help
you stay physically and financially healthy.

UT RESOURCES
Benefits Cost Worksheet for Retirees
Institution Resources – Retiree Associations
Identity Protection Services

UT SELECT VALUE ADDED BENEFITS

Enhanced Concierge-level Customer Service – Omada
Health Advocacy Solutions (HAS) Livongo
Virtual Doctor Visits - MD LIVE NEW! Ovia Health: A Digital support program
Hinge Health NEW! Seasons of Life

UT CONNECT VALUE ADDED BENEFITS

Enhanced Customer Service NEW! Ovia Health: A Digital support program
Virtual Doctor Visits - MD LIVE NEW! Seasons of Life

LIVING WELL RESOURCES

Naturally Slim Silver Sneakers
Employee Assistance Program Lifestyle Management
Condition Management 24/7 Nurseline
Specialist Pharmacists Tobacco Cessation
Onsite Health Checkups Onsite Flu Shots
UT System Activity Challenges

LIFE INSURANCE VALUE ADDED BENEFITS

Travel Benefits Beneficiary Resources
Will Preparation Accelerated Death Benefit

UT BENEFIT CONTACT LIST

2020-2021 Insurance Enrollment Guide for Retirees | Resources 27

Benefits Cost Worksheet for Retirees
PLAN YEAR 2020-2021

This is NOT an enrollment form. You must enroll through your institution’s Benefits Office.
Please remember that this form only provides you (the subscriber) with an estimate of your total out-of-pocket cost per month
based on state-appropriated funds and contracted premium rates. Be sure to review available benefits materials for more
information on the plans listed.
For each section, figure the correct cost and enter it in the TOTAL boxes to the right of each section.

MEDICAL OUT-OF-POCKET COST PER MONTH Retired Employees BLUE CROSS BLUE SHIELD OF TEXAS
Subscriber Subscriber & Subscriber & Subscriber &
Plan Available – Worldwide
Only Spouse Child(ren) Family
UT SELECT
$0 $270.42 $282.82 $532.52
(OUT-OF-POCKET)
UT CONNECT (OUT-OF-POCKET)
$0 $243.38 $254.54 $479.26
DALLAS-FORT WORTH AREA ONLY
PREMIUM SHARING
(PAID BY STATE OF TEXAS AND $628.06 $957.26 $838.70 $1,169.88 MEDICAL
YOUR UT INSTITUTION) TOTAL

Medical Plan Rates include: Prescription benefit coverage + $6,000 Life $

OR
TOBACCO PREMIUM PROGRAM (TPP)

Tobacco User(s) Non-user Subscriber Spouse Child(ren) TPP TOTAL2

Tobacco User(s) Cost $0 $30.00 $30.00 $30.001 $

1 Maximum cost of $30 per month regardless of how many covered dependent children use tobacco.
2 Maximum cost per family is $90 per month.

DENTAL OUT-OF-POCKET COST PER MONTH DELTA DENTAL

Subscriber Subscriber & Subscriber & Subscriber &
Plans Available
Only Spouse Child(ren) Family
NATIONWIDE
UT SELECT Dental $28.52 $54.14 $59.66 $84.84
UT SELECT Dental Plus $61.40 $116.60 $128.66 $183.30
DENTAL
CERTAIN AREAS IN TEXAS TOTAL
DeltaCare Dental HMO $8.80 $16.74 $18.50 $26.40 $

VISION OUT-OF-POCKET COST PER MONTH SUPERIOR VISION

Subscriber Subscriber & Subscriber & Subscriber &
Plans Available
Only Spouse Child(ren) Family
VISION
Superior Vision $5.90 $9.30 $9.52 $15.10 TOTAL
Superior Vision Plus $9.00 $14.08 $15.08 $21.30 $

28 Resources | 2020-2021 Insurance Enrollment Guide for Retirees

LIFE OUT-OF-POCKET COST PER MONTH DEARBORN NATIONAL
Enter Elected Coverage Amount:
Select from the following options and enter here (see1 below).
$7,000
$10,000
$25,000 A
$50,000
$100,000
Note: For those Retired Employees of the UT System who retired through the 1993 one-time retirement option, enter the
amount of coverage currently in place.
Divide total in A by 1,000 to determine units of $1,000 for premium calculation. Enter here. B

Refer to Retiree Rate Chart below. Enter the rate that corresponds with your age on September 1, 2020. C

To determine the premium cost per month, multiply B x C. D

The remainder of the Life Out-of-Pocket calculation section relates to the eligible spouse of a Retired Employee.
Dependent children of Retirees are not eligbile for Life coverage.

If you are electing the $3,000 Family Coverage option, enter $1.83 (see2 below). Otherwise, enter zero. E

To determine total Life premium cost per month, add D + E. Otherwise, enter zero. LIFE TOTAL $
RETIREE RATE CHART

AGE OF SUBSCRIBER ON 9/01/20 RATE PER $1,000 COVERAGE

15 - 34 $0.037
35 - 39 $0.047
40 - 44 $0.063
45 - 49 $0.097
50 - 54 $0.150
55 - 59 $0.233
60 - 64 $0.364
65 - 69 $0.650
70 - 74 $0.752
75 - 79 $0.932
80 and over $1.634
1
If you are increasing your Life coverage amount, Evidence of Insurability (EOI) is required.
2
To elect Spouse Life coverage, EOI may be required. Contact your institution Benefits Office for assistance.

ESTIMATED TOTAL MONTHLY OUT-OF-POCKET

(Add ALL boxes and enter total) $

2020-2021 Insurance Enrollment Guide for Retirees | Resources 29

Institution Resources | Retiree Associations
INSTITUTION
www.uta.edu/hr/retireesclub/

UT ARLINGTON Dr. Shirley Theriot, President Dr. Josie O’Quinn, Secretary

retireesclub@uta.edu josieloq@att.net
UT Retired Faculty-Staff Association sites.utexas.edu/rfsa/
Eleanor Moore, RFSA President Carol Barrett, RFSA Coordinator
UT AUSTIN
512-840-5657
carol.barrett@texasexes.org

UT DALLAS www.utdallas.edu/ra/ www.utdallas.edu/ra/contact.htm

No retiree association, but you may join the Alumni Valerie Herrera
Association: alumni.utep.edu 915-747-8318
UT EL PASO
vrherrera@utep.edu

UT HSC HOUSTON www.uthro.org/

makelivesbetter.uthscsa.edu/arfa
UT HSC SAN ANTONIO
Contact Cindi Adcock for more information: AdcockC@uthscsa.edu or (210) 567-2003

UT HEALTH TYLER No retiree association at this time.

UT MD ANDERSON www.mdanderson.org/about-us/for-employees/employee-resources/retirees-association/index.html
CANCER CENTER MDARetiree@yahoo.com

UTMB Retirees Association

UTMB GALVESTON hr.utmb.edu/retirees/ 301 University Blvd., Galveston TX 77555-0947
(409) 747-4878

UT PERMIAN BASIN No retiree association at this time.

UT RIO GRANDE VALLEY No retiree association at this time.

provost.utsa.edu/rfa/
UT SAN ANTONIO Retired Faculty Association
provost@utsa.edu

UT SOUTHWESTERN
No retiree association at this time.
MEDICAL CENTER

UT SYSTEM
UT System Administration Retired Employees may join the UT Austin Retired Faculty-Staff Association.
ADMINISTRATION

UT TYLER www.uttyler.edu/human-resources/retired-employees/retirees-association.php

30 Resources | 2020-2021 Insurance Enrollment Guide for Retirees

Identity Protection Services
As a value-added service, Blue Cross and Blue Shield of NOTE: If you have not previously registered with Blue
Texas (BCBSTX) provides employees, retirees and their Access for Members (BAM), you will need to do so in order
families who are covered under the UT SELECT or the UT to access the link to sign up for free Identity Protection
CONNECT Medical Plan (both administered by BCBSTX) the services. Your Benefits Identification number (or BID)
opportunity to enroll in identity protection services. is an 8-character unique identifier used for all of your
These services are intended to give you some additional UT Benefits coverage which can be found on your Blue
peace of mind. They are intended to protect health and Cross and Blue Shield of Texas ID card. The "Identification
personal information. Provided by Experian – at no cost Number" requested during registration for BAM includes
to you – these services complement the security and data the leading "0" on your BCBSTX ID card plus your
protection measures BCBSTX already has in place. 8-character BID.

The services offered at no cost to you include features such

as credit monitoring, fraud resolution, and identity theft
insurance for adults and a selection of services for minor
dependent children. Please note, that under the terms of
this value added program, you will be required to re-enroll
annually.
To enroll in this free program, you should log into your
Blue Access for Members (BAM) account at www.bcbstx.
com/ut (for UT SELECT participants) or www.bcbstx.com/
utconnect (for UT CONNECT participants). Once logged in,
please look for the "Identity Protection" link in the "Quick
Links" section on the left side of the page.

2020-2021 Insurance Enrollment Guide for Retirees | Resources 31

UT SELECT
Value Added Services
HEALTH ADVOCACY SOLUTIONS (HAS)
Get coordinated help and personal health care support from a team of experts. Features
include:
• Help with understanding your care options & benefits;
• Help finding network providers & scheduling appointments;
• Ability to speak to the same health advocate for follow-up questions and discussions;
and
• Coordinated help from your health advocate and other experts to connect you with the
resources you need, when you need them.
You can contact a Health Advocate at (866) 882-2034 or you can chat live either
online (bcbstx.com/ut) or via the BCBSTX app (bcbstx.com/mobile)

MDLIVE: VIRTUAL DOCTOR VISITS - $0 COPAYMENT

Care when and where you need it, at no cost to you, through MDLIVE – available 24 hours
a day, seven days a week, 365 days a year. Features include:
• Physicians with expertise in primary care, pediatrics, & more;
• Treatment for many non-emergency medical conditions, including: colds and flu, fever
(age 3+), sinus infections, ear problems (age 12+), allergies, etc.; and
• Behavioral health services (by appointment and with video connection only).
Visit mdlive.com/bcbstx for more information and to activate your account.

2020-2021 Insurance Enrollment Guide for Retirees | Resources 33

HINGE HEALTH NEW! OVIA HEALTH: A DIGITAL SUPPORT
A new approach to help you conquer chronic pain without PROGRAM
surgery or drugs. Features include: Ovia Health provides maternity and family apps to support
you through your entire parenthood journey. These apps
• At-home exercise therapy and behavioral coaching
are included in your UT SELECT health plan, offered
program for chronic back and knee pain based on
through Blue Cross and Blue Shield of Texas (BCBSTX).
proven, non-surgical care guidelines;
With Ovia, you’ll have access to enhanced, personalized
• Delivered remotely using mobile & wearable technology
health and wellness features:
provided at no cost to you;
• Health assessment and symptom tracking | Receive
• Programs for chronic hip, shoulder, and neck pain
alerts and predictive, personal coaching when Ovia
available beginning January 1, 2020; and
detects a potential medical issue.
• No out-of-pocket cost.
• More than fifty physician-developed clinical
Visit hingehealth.com/UTS for more information. programs to help you be as healthy as possible |
Engage with personalized health and wellness programs
OMADA to help you navigate infertility, sexual health, birth
Clinically proven to help reduce the risk of Type 2 diabetes planning, preterm delivery, mental health, breastfeeding,
and help participants lose weight. Features include: and more.
• Core 16-week program includes wireless smart scale, • Unlimited 1-on-1 coaching | Message instantly
weekly online lessons, and a health coach and focuses on with Registered Nurse health coaches to ask all your
nutrition, physical activity, and behavioral change with questions.
• Researched curriculum paired with professional health • Career and return-to-work programs | Find coaching
coaches; and and career advice for preparing for maternity leave,
• No out-of-pocket cost. returning to work, and being a working parent.
Visit omadahealth.com/UTS for more information. Download the app that’s right for you:
Ovia Fertility – Health & Fertility
LIVONGO
Ovia Pregnacy – Pregnancy & Postpartum
Simplified new approach to diabetes management, for
those living with Type 1 or Type 2. Features include: Ovia Parenting – Family & working parents
• Unlimited support, strips & lancets; To create an account, choose “I have Ovia Health as a
benefit” before tapping “Sign up” and make sure to select
• 24/7 support from Certified Diabetes Educators; and
BCBSTX as your health plan and enter your employer name.
• No out-of-pocket cost.
You can also contact a health advocate at (866) 882-2034
Visit welcome.livongo.com to learn more for more information or should you have any questions.

34 Resources | 2020-2021 Insurance Enrollment Guide for Retirees

NEW! SEASONS OF LIFE
Seasons of Life is a proactive outreach program offered
through your UT SELECT benefits and Blue Cross and Blue
Shield of Texas (BCBSTX) that provides personalized claims
resolution assistance to you and your dependents who may
be dealing with the death of a loved one.
When BCBSTX learns of a death, a specially trained
customer advocate will send a handwritten sympathy card.
This advocate will become your single point of contact
for the duration of the program. You and/or your family
can then contact the customer advocate at a time that
is convenient for you to discuss any insurance-related
matters.
BCBSTX will conduct a full review of the deceased’s
reimbursement history, claims status and customer service
history before contacting you and/or your family, so the
customer advocate can anticipate needs and ensure that
compassionate help is available when it’s needed most.
While the Seasons of Life program is launched proactively
based on information provided to BCBSTX, please know
that you and/or your dependents can contact a health
advocate for assistance if needed.
Simply call (866) 882-2034.

2020-2021 Insurance Enrollment Guide for Retirees | Resources 35

UT CONNECT (DFW only) Value Added Services
ENHANCED CUSTOMER SERVICE NEW! OVIA HEALTH: A DIGITAL SUPPORT
Providing personalized support to: PROGRAM
Ovia Health provides maternity and family apps to support
• Help with understanding your care options & benefits;
you through your entire parenthood journey. These apps
• Help finding network providers & scheduling are included in your UT CONNECT health plan, offered
appointments; and through Blue Cross and Blue Shield of Texas (BCBSTX).
• Help find ways to save even more on out-of-pocket With Ovia, you’ll have access to enhanced, personalized
expenses for care. health and wellness features:
This service offers a single phone number to reach • Health assessment and symptom tracking | Receive
CONNECT navigators and nurses who have access to UT alerts and predictive, personal coaching when Ovia
Southwestern Medical directors: (888) 372-3398. detects a potential medical issue.
• More than fifty physician-developed clinical
MDLIVE: VIRTUAL DOCTOR VISITS - $0
COPAYMENT programs to help you be as healthy as possible |
Care when and where you need it, at no cost to you, Engage with personalized health and wellness programs
through MDLIVE – available 24 hours a day, seven days a to help you navigate infertility, sexual health, birth
week, 365 days a year. Features include: planning, preterm delivery, mental health, breastfeeding,
and more.
• Physicians with expertise in primary care, pediatrics, &
more; • Unlimited 1-on-1 coaching | Message instantly
with Registered Nurse health coaches to ask all your
• Treatment for many non-emergency medical conditions,
questions.
including: colds and flu, fever (age 3+), sinus infections,
ear problems (age 12+), allergies, etc.; and • Career and return-to-work programs | Find coaching
and career advice for preparing for maternity leave,
• Behavioral health services (by appointment and with
returning to work, and being a working parent.
video connection only).
Download the app that’s right for you:
Visit mdlive.com/bcbstx for more information and to
activate your account. Ovia Fertility – Health & Fertility
Ovia Pregnacy – Pregnancy & Postpartum
Ovia Parenting – Family & working parents
To create an account, choose “I have Ovia Health as a
benefit” before tapping “Sign up” and make sure to select
BCBSTX as your health plan and enter your employer
name.
You can also contact a health advocate at (888) 372-3398
for more information or should you have any questions.

36 Resources | 2020-2021 Insurance Enrollment Guide for Retirees

NEW! SEASONS OF LIFE
Seasons of Life is a proactive outreach program offered
through your UT CONNECT benefits and Blue Cross and
Blue Shield of Texas (BCBSTX) that provides personalized
claims resolution assistance to you and your dependents
who may be dealing with the death of a loved one.
When BCBSTX learns of a death, a specially trained
customer advocate will send a handwritten sympathy card.
This advocate will become your single point of contact
for the duration of the program. You and/or your family
can then contact the customer advocate at a time that
is convenient for you to discuss any insurance-related
matters.
BCBSTX will conduct a full review of the deceased’s
reimbursement history, claims status and customer service
history before contacting you and/or your family, so the
customer advocate can anticipate needs and ensure that
compassionate help is available when it’s needed most.
While the Seasons of Life program is launched proactively
based on information provided to BCBSTX, please know
that you and/or your dependents can contact a health
advocate for assistance if needed.
Simply call (888) 372-3398.

2020-2021 Insurance Enrollment Guide for Retirees | Resources 37

Living Well Resources
The UT System Living Well program provides a variety of resources to
enable employees, retirees, and dependents of the UT SELECT and UT
CONNECT medical plans to take charge of their health and develop their
own personal wellness program. Our mission is to improve the health
and well-being of Texans through achieving optimal performance level
of University of Texas System employees, retirees and dependents at all
Institutions.
Learn more about all of these programs at our Living Well website:
www.livingwell.utsystem.edu

NATURALLY SLIM
Naturally Slim is an online program that helps you lose weight, plus improve your overall
health -- all while eating the foods you love. With Naturally Slim, you’ll learn that you don’t
have to starve yourself or count calories to be healthy, lose weight and keep it off forever.

SILVER SNEAKERS
Silver Sneakers is offered to retirees and their spouses (age 50+), providing access to local
fitness facilities. (Available for UT SELECT only.)

UT SYSTEM ACTIVITY CHALLENGES

Team up with your institution for the UT System-wide Physical Activity Challenge. You’ll
work toward the challenge goal to earn rewards and can team up with colleagues to earn
your institution the coveted Traveling Trophy.

EMPLOYEE ASSISTANCE PROGRAM

The Employee Assistance Program (EAP) can help you resolve problems that affect your
personal life or job performance.

2020-2021 Insurance Enrollment Guide for Retirees | Resources 39

24/7 NURSELINE TOBACCO CESSATION
Get answers to your health care questions, information The medical plan offers members a variety of tobacco
about major medical issues, chronic illness support, and cessation resources at no out-of-pocket cost. These
lifestyle change support. Call toll-free: (888) 315-9473, 24 resources include professional counseling and
hours a day, 7 days a week. pharmaceutical therapy.

SPECIALIST PHARMACISTS
If you take medications to treat high cholesterol, diabetes,
or one of several other conditions, specialist pharmacists
can answer your questions and offer improvements in
the quality and affordability of your pharmacy care. Learn
more: (800) 818-0155.

40 Resources | 2020-2021 Insurance Enrollment Guide for Retirees

BLANK PAGE

2020-2021 Insurance Enrollment Guide for Retirees | Resources 41

Life Insurance Value
Added Benefits
If you are enrolled in any Blue Cross Blue Shield of Texas (BCBSTX) life
insurance plan, you have access to additional benefits listed below.
TRAVEL BENEFITS
Travel Resource Services provided by Europ Assistance (EA) USA, Inc. in partnership with
BCBSTX is a 24-hour emergency service that can help you access emergency assistance
when you are traveling 100 or more miles away from home. Services include medical evac-
uation, return of mortal remains, traveling companion assistance, and more.

WILL PREPARATION
To help reduce the effort in preparing a legal will, BCBSTX offers Online Will Preparation.
Online Will Preparation offers:
• A simple, easy process to create wills • Wills are valid in the state in which the
online insured resides
• Online access means users can create • Users create wills at no cost to them
wills at their convenience, any time of
the day or night

BENEFICIARY RESOURCES
Unlimited 24/7 phone consultation Referrals and support services
Grief counselors, legal assistance and Counselors provide compassionate
financial advisors are available by phone for support throughout the process, including
up to one year. referrals to qualified grief counselors and
Five face-to-face sessions financial and legal consultants within BDA’s
Sessions can be used with one grief nationwide network of professionals.
counselor or legal advisor. Time may also Counselors Follow Up by Telephone
be split between a grief counselor and legal Counselors will initiate follow-up calls for
advisor. A one-hour financial consultation up to one year when necessary.
on the phone is also available.

ACCELERATED DEATH BENEFIT

An Employee, Retired Employee or covered spouse with a life expectancy of less than 24
months due to a Terminal Condition may be eligible for advanced payment of 50% of their
Basic and Voluntary Term Life insurance amount in-force on the date that proof of loss is
determined.
2020-2021 Insurance Enrollment Guide for Retirees | Resources 43
UT BENEFITS CONTACT LIST | Complete the form on the next page to provide to people who will handle your UT
Benefits in case you are unable to do so.

NOTE: You may also want to print your latest benefits summary from the most recent annual enrollment period.
UT Benefits Contact List
In case of an emergency, if I am unable to care for my personal matters, please use the contact information to ensure that
my benefits are handled correctly.

My Benefits ID Number is
BID

My Institution’s HR/Benefits Office

NAME

PHONE

EMAIL

My institution will assist with updating my address and coverage and filing claims.

INSURANCE PROVIDERS
Blue Cross Blue Shield of TX | (866) 882–2034 UT SELECT
UT SELECT MEDICAL INSURANCE
www.bcbstx.com/ut Group Number 071778

Blue Cross Blue Shield of TX | (888) 372–3398 UT CONNECT

UT CONNECT MEDICAL INSURANCE
www.bcbstx.com/utconnect Group Number 241132

Express Scripts | (800) 818-0155 Group Number

PRESCRIPTION DRUG INSURANCE
www.express-scripts.com/ut UTSYSRX

Express Scripts | (800) 860-7849 Group Number

PART D PRESCRIPTION DRUG
TTY (800) 716-3231 24 hrs/day, 7 days/week 7454MDRX
INSURANCE
utbenefits.link/RetiredEmployeeRX

Delta Dental | (800) 893-3582 PPO Group Number 5968

DENTAL INSURANCE
www.deltadentalins.com/universityoftexas HMO Group Number 6690

Blue Cross Blue Shield of Texas Ancillary | Group Number

LIFE INSURANCE (866) 628-2606 GFZ71778
www.bcbstx.com/ancillary -ut/

RETIREMENT PROVIDERS (SELECT THE BOX FOR YOUR PROVIDER(S))

FIDELITY INVESTMENTS (800)343–0860 www.netbenefits.com/ut

VOYA FINANCIAL (866)506-2199 https://utexas.prepare4myfuture.com

LINCOLN FINANCIAL GROUP (800)454-6265 *8 www.lfg.com/ut

TIAA-CREF (800)842-2776 www.tiaa-cref.org/utexas

AIG Retirement Services (800)448-2542 www.valic.com/utexasorp

2020-2021 Insurance Enrollment Guide for Retirees | Resources 45

Legal Notices
You have the right to obtain a printed copy free of charge of any or all of
these notices at any time by contacting the Office of Employee Benefits at
benefits@utsystem.edu or 512-499-4616.

IMPORTANT IF YOU (AND/OR YOUR DEPENDENTS) HAVE MEDICARE OR WILL BECOME

ELIGIBLE FOR MEDICARE IN THE NEXT 12 MONTHS, A FEDERAL LAW GIVES YOU MORE
CHOICES ABOUT YOUR PRESCRIPTION DRUG COVERAGE. PLEASE SEE THE MEDICARE
PART D NOTICE FOR MORE DETAILS.

Uniform Summary of Benefits and

Coverage
The uniform Summary of Benefits and Coverage (SBC) provision of the Affordable Care Act
requires all insurers and group health plans to provide consumers with an SBC to describe
key plan features in a mandated format, including limitations and exclusions. The provision
also requires that consumers have access to a uniform glossary of terms commonly used in
health care coverage.
The UT insurance SBCs are available online.
UT SELECT PPO or Out-of-Area coverage:
www.bcbstx. com/ut/coverage
UT CONNECT coverage:
www.bcbstx.com/utconnect/coverage
You can view the glossary at
www.utsystem.edu/documents/docs/publication/2018/glossary- health-coverage-and-
medical-terms

To request a copy of these documents free of charge, you may call the SBC Hotline at
1-855-756-4448.

2020-2021 Insurance Enrollment Guide for Retirees | Legal Notices 47

UT SELECT Medical UT CONNECT Medical
Plan Opt Out of Certain Plan Opt Out of Certain
Provisions of the Public Provisions of the Public
Health Service (PHS) Act Health Service (PHS) Act
Group health plans sponsored by State governmental Group health plans sponsored by State governmental
employers, such as UT System must generally comply with employers, such as UT System must generally comply with
certain requirements in title XXVII of the federal Public certain requirements in title XXVII of the federal Public
Health Services Act. However, the Act also permits State Health Services Act. However, the Act also permits State
governmental employers that sponsor “self-funded” health governmental employers that sponsor “self-funded” health
plans (rather than provide coverage through a health plans (rather than provide coverage through a health
insurance policy) to elect to exempt the self-funded plan insurance policy) to elect to exempt the self-funded plan
from such requirements. UT System has elected to exempt from such requirements. UT System has elected to exempt
the UT SELECT Medical plan, which is self-funded, from the the UT CONNECT Medical plan, which is self-funded, from
following requirements: the following requirements:
1. Standards related to benefits for mothers and
1. Standards related to benefits for mothers and newborns.
newborns.
2. Parity in the application of certain limits to mental
2. Parity in the application of certain limits to mental
health benefits.
health benefits.
3. Required coverage for reconstructive surgery following
3. Required coverage for reconstructive surgery following
mastectomies.
mastectomies.
4. Coverage of dependent students on medically necessary
4. Coverage of dependent students on medically
leave of absence.
necessary leave of absence.
The exemption from these federal requirements will be in
The exemption from these federal requirements will be in
effect for the 2020-2021 plan year. The election may be
effect for the 2020-2021 plan year. The election may be
renewed for subsequent plan years.
renewed for subsequent plan years.
However, UT System currently voluntarily provides
However, UT System currently voluntarily provides coverage that substantially complies with the requirements
coverage that substantially complies with the requirements of the Newborn and Mother’s Protection Act and the
of the Newborn and Mother’s Protection Act and the WHCRA. Information about coverage available to
WHCRA. Information about coverage available to newborns and mothers after delivery and coverage for
newborns and mothers after delivery and coverage for reconstructive surgery can be found in the UT CONNECT
reconstructive surgery can be found in the UT SELECT Medical plan guide.
Medical plan guide.

48 Legal Notices | 2020-2021 Insurance Enrollment Guide for Retirees

University of Texas System Notice of Privacy Practices
Revised Effective August 1, 2018
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. PURPOSE OF THIS NOTICE

This Notice of Privacy Practices (this “Notice”) describes Specifically, this Notice describes how System may use
the privacy practices of the UT SELECT, UT CONNECT, UT or disclose your medical information (see Section II), your
SELECT Dental and Dental Plus and UT FLEX Self-funded rights concerning your medical information (see Section III),
Group Health Plans (“the Plans”) which are funded by The how you may contact System regarding System’s privacy
University of Texas System and administered by the Office policies (see Section VI), and System’s right to revise this
of the Employee Benefits (OEB) within the University of Notice (see Section VII).System will abide by the terms of
Texas System Administration (System). Federal law requires this Notice as long as it is in effect. This Notice applies to
System to make sure that any medical information that any use or disclosure of your medical information occurring
it collects, creates or holds on behalf of the Plans that on or after the effective date written at the top of this
identifies you remains private. Federal law also requires page, even if System created or received the information
System to maintain this Notice of System’s legal duties and before the effective date. This Notice will no longer apply
privacy practices with respect to your medical information. once a revised version of this Notice becomes effective.

II. HOW SYSTEM MAY USE OR DISCLOSE YOUR MEDICAL INFORMATION

System may use or disclose your medical information only as described in this Section II.
A. Treatment. System may disclose your medical addition, System may contact you to give you
information to a health care provider for your information about treatment alternatives or other
medical treatment. health-related services that may interest you.
B. Payment. System may use or disclose your medical System may also disclose your medical information
information in order to determine premiums, to a health care provider or other health plan that
determine whether System is responsible for is involved with your health care, as needed for
payment of your health care, and make payments that person’s quality-related medical information to
for your health care. For example, before paying evaluate the performance of participating providers
a doctor’s bill, System may use your medical in the Plans’ networks, and System may disclose
information to determine whether the terms of your your medical information to an auditor who will
Plan cover the medical care you received. System make sure that a third party administrator of a Plan
may also disclose your medical information to a is complying with contracts and applicable laws.
health care provider or other person as needed for D. Required by Law. System will use or disclose your
that person’s payment activities. medical information if a federal, state, or local law
C. Health Care Operations. System may use or requires it to do so.
disclose your medical information in order to E. Required by Military Authority. If you are a member
conduct “health care operations.” Health care of the Armed Forces or a foreign military, System
operations are activities that federal law considers may use or disclose your medical information if the
important to System’s successful operation. As appropriate military authorities require it to do so.
examples, System may use your medical information F. Serious Threat to Health or Safety. System may use
complying with contracts and applicable laws. In or disclose your medical information if necessary
2020-2021 Insurance Enrollment Guide for Retirees | Legal Notices 49
 because of a serious threat to someone’s health or activities authorized by law;
safety. • Law enforcement officials if they need the
G. Limited Data Set. System may use or disclose your information to investigate a crime or to identify
medical information for purposes of health care or locate a suspect, fugitive, material witness, or
operations, research, or public health activities missing person;
if the information is stripped of direct identifiers • Health oversight agencies, if authorized by law,
and the recipient agrees to keep the information in order to monitor the health care system,
confidential. government benefit programs, or compliance with
H. Disclosure to You. System may disclose your civil rights laws;
medical information to you or to a third party to • Persons authorized by law to receive public health
whom you request us in writing to disclose your information, including reports of disease, injury,
medical information. birth, death, child abuse or neglect, food problems,
I. Disclosures to Individuals Involved with Your Health or product defects;
Care. System may use or disclose your medical • Persons authorized by law to receive the
information in order to tell someone responsible for information under a court order, subpoena,
your care about your location or condition. System discovery request, warrant, summons, or similar
may disclose your medical information to your process;
relative, friend, or other person you identify, if the
• Persons who need the information to comply with
information relates to that person’s involvement
workers’ compensation laws or similar programs
with your health care or payment for your health
providing benefits for work-related injuries or
care.
illnesses;
J. Disclosures to Business Associates. System may
• Governmental agencies authorized to receive
contract or otherwise arrange with other entities
reports of abuse if you are a victim of abuse,
or System offices to perform services on behalf of
neglect, or domestic violence;
the Plans. System may then disclose your medical
information to these “Business Associates,” and • Coroners or medical examiners, after your death, to
these Business Associates will use or disclose your identify you, to determine your cause of death, or as
medical information only to the extent System otherwise authorized by law;
would be able to do so under the terms of this • Funeral directors, after your death, who need the
Section II. These Business Associates are also information;
required to comply with federal law that regulates
• The Secretary of Health and Human Services, a
your medical information privacy. To the extent that
federal agency that investigates compliance with
System offices serve as Business Associates to other
federal privacy law.
institutions within The University of Texas System
that are Covered Entities, those offices will comply L. Incidental Uses and Disclosures. Uses and
with those institutions’ Privacy Policies and Notices disclosures that occur incidentally with a use or
of Privacy Policies as to those institutions’ Protected disclosure described in this Section II are acceptable
Health Information (PHI) they maintain, access or if they occur notwithstanding System’s reasonable
use as their Business Associates. safeguards to limit such incidental uses and
disclosures.
K. Other Disclosures. System may also disclose your
medical information to: M. Written Authorization. System may use or disclose
your medical information under circumstances that
• Authorized federal officials for intelligence,
are not described above only if you provide permission
counterintelligence, and other national security

50 Legal Notices | 2020-2021 Insurance Enrollment Guide for Retirees

 by “written authorization.” After you provide written longer use or disclose your medical information under
authorization, you may revoke that authorization, in the circumstances permitted by that authorization.
writing, at any time by sending notice of the revocation However, System cannot take back any disclosures
to the Privacy Officer identified in Section VI of this already made under that authorization.
Notice. If you revoke an authorization, System will no

III. RESTRICTIONS
A. System will not use your medical information for communications for which the Plan receives no
fundraising purposes. remuneration such as refill reminders, treatment
B. System will never use your genetic medical plans, alternatives to treatment, case management,
information about you for underwriting purposes. value added services provided in connection with a
Using or disclosing your genetic information is Plan, and other purposes related to treatment and
prohibited by federal law. health care operations. “Marketing” also excludes
promotional gifts of nominal value provided by the
C. System does not use your medical information for
Plan.
marketing purposes. “Marketing” does not include
face to face communications with you, or any D. System does not sell your medical information.

IV. YOUR RIGHTS CONCERNING YOUR MEDICAL INFORMATION

You have the following rights associated with your medical information:
A. Right To Request Restrictions. Although System B. Right To Confidential Communications. You
is generally permitted to use or disclose your medical have the right to request that System communicate
information for treatment, payment, health care your medical information to you by a certain method
operations, and notification to individuals involved (for example, by e-mail) or at a certain location (for
with your health care, you have the right to request example, at a post office box). You must make your
that System limit those uses and disclosures of medical request in writing to the Privacy Officer. Your request
information. You must make your request in writing must include the method or location desired. If your
to the Privacy Officer. Your request must state (1) request would impact payment, you must describe how
the information you want to limit, (2) to whom you payment will be handled. Your request must indicate
want the limit to apply, (3) the special circumstances why disclosure of your medical information by another
that support your request for a restriction on Plan method or to another location could endanger you.
disclosures, and (4) if your request would impact C. Right To Inspect and Copy. You have the right,
payment, how payment will be handled. System will in most cases, to inspect and copy your medical
consider your request but does not have to agree to information maintained by or for System. You must
it. If System does agree, System will comply with your make your request in writing to the Privacy Officer. If
request (unless the disclosure is for your emergency System denies your request, you may have the right
treatment or is required by law) until you or System to have the denial reviewed by a licensed health
cancels the restriction. There is a form you can use to care professional selected by System. If System (or a
make this request which is available on the System licensed health care professional performing the review
website or by contacting the Privacy Officer or the on behalf of System) grants your request System will
Benefits Office at The University of Texas System provide you with the requested access. You may
institution that you contact for assistance with your request copies of such information but System may
System insurance benefits. charge may charge you a reasonable fee.

2020-2021 Insurance Enrollment Guide for Retirees | Legal Notices 51

D. Right to Amend. If you feel that medical information • Disclosures made under your written authorization;
System has about you is incorrect or incomplete, you and
may ask System to amend the information. You have • In certain circumstances, disclosures to law
the right to request an amendment for as long as the enforcement officials or health oversight agencies.
information is kept by or for System. You must make You must make your request in writing to the
your request in writing to the Privacy Officer, and you Privacy Officer. Your request must state the time
must give a reason that supports your request. If period during which the disclosures were made,
System denies your request for an amendment, System which may not include dates more than six years
will explain to you its reasons for denial and your prior to the request. System may charge you a fee
appeal rights following denial. for the list of disclosures if you request more than
E. Right to an Accounting of Disclosures. You have one list within 12 months.
the right to request a list of disclosures of your medical F. Right to Make a Complaint. If you believe your
information that have been made by System and its privacy rights have been violated, you may file a
Business Associates. OEB does not have to list the written complaint with System’s Privacy Officer or
following disclosures: with the federal government’s Department of Health
• Disclosures for treatment; and Human Services. System will not penalize you or
• Disclosures for payment; retaliate against you in any way if you file a complaint.

• Disclosures for health care operations; G. Right to a Paper Copy of This Notice. You have the
right to request a paper copy of this Notice, even if you
• Disclosures of a limited data set for health care
have received this Notice electronically. You may make
operations, research, or public health activities;
your request to the Privacy Officer.
• Disclosures to you;
• Disclosures to individuals involved with your health
care;
• Disclosures to authorized federal officials for
national security activities;
• Disclosures that occur incidentally with other
permissible uses and disclosures;

V. BREACH NOTIFICATIONS
System makes every effort to secure your health information, including the use of encryption whenever possible. In the
event that any of your medical information that has not been encrypted is the subject of a breach, System will provide you
with a written or electronic notification about the breach as required by federal law.

VI. WHOM TO CONTACT REGARDING SYSTEM’S PRIVACY POLICIES

a. System’s Privacy Officer. To obtain a copy of Privacy Officer c/o
the most current Notice, to exercise any of your Systemwide Compliance Office
rights described in this Notice, or to receive further The University of Texas System
information about the privacy of your medical 210 West 7th Street
information, you may contact System’s Privacy Austin, Texas 78701-2902
Officer at: (512) 852-3264
Email: Privacyofficer@utsystem.edu

52 Legal Notices | 2020-2021 Insurance Enrollment Guide for Retirees

 b. Department of Health and Human Services. c. Electronic Copy of This Notice. You may obtain
To obtain further information about the federal an electronic copy of the most current version of
privacy rules or to submit a complaint to the this Notice at the following website: https://www.
Department of Health and Human Services, you utsystem.edu/documents/docs/hipaa/hipaa-notice-
may contact the Department by telephone at 1 800 privacy-practices.
368 1019, by electronic mail at (ocrmail@hhs.gov),
or by regular mail addressed to:
Regional Manager
Office of Civil Rights
US Department of Health and Human Services
1301 Young Street
Dallas, TX 75202
(800) 368-1019
TDD (800) 537-7697

VII. SYSTEM’S RIGHT TO REVISE THIS NOTICE

System reserves the right to change the terms of this Notice at any time. System also reserves the right to make the
revised notice effective for medical information System already has about you as well as any information OEB receives
while such notice is in effect. Within 60 days of a material revision to this Notice, System will provide the revised notice to
all individuals then covered by a Plan. If you want to make sure that you have the latest version of this Notice, you may
contact the Privacy Officer.

2020-2021 Insurance Enrollment Guide for Retirees | Legal Notices 53

Medicare Part D Notice of Creditable Coverage
Please read this notice carefully and keep it where therefore considered Creditable Coverage. Because
you can find it. This notice has information about your your existing coverage is Creditable Coverage, you
current prescription drug coverage with The University of can keep this coverage and not pay a higher premium
Texas System and about your options under Medicare’s (a penalty) if you later decide to join a Medicare drug
prescription drug coverage. This information can help you plan.
decide whether or not you want to join a Medicare drug
You can join a Medicare drug plan when you first
plan.
become eligible for Medicare and each year from
Medicare-eligible retirees and their Medicare-eligible October 15th to December 7th. However, if you lose
dependents covered under the UT medical plans are your current creditable prescription drug coverage,
automatically enrolled in the UT SELECT PDP Employer through no fault of your own, you will also be eligible
Group Waiver Plan (EGWP), also known as UT SELECT for a two (2) month Special Enrollment Period (SEP) to
Part D. Active employees and retirees working in a join a Medicare drug plan.
benefits-eligible position at a UT institution, as well as
What Happens to Your Current Coverage If You
their dependents, who are covered under the UT medical
Decide to Join a Medicare Drug Plan?
plans are enrolled in the UT prescription drug plan (non-
Medicare) regardless of Medicare eligibility. If you are For participants in the UT prescription drug plan (non-
considering enrolling in a Medicare Part D plan or an Medicare), you are not required to drop your UT medical
Advantage Plan with prescription drug coverage that is and prescription plan coverage if you choose to join a Part
not affiliated with UT, you should compare your current D plan not affiliated with UT. Your UT prescription drug
coverage through UT, including which drugs are covered benefits will coordinate with your outside Part D coverage.
at what cost, with the coverage and costs of the Medicare
plans available to you. Information about where you can For participants in the UT SELECT Part D plan, enrollment
get help with making decisions about your prescription in a Medicare Part D or Advantage plan not affiliated with
drug coverage is included at the end of this notice. UT will conflict with your UT SELECT Part D coverage. You
will need to choose either a UT or non-UT plan, then take
There are two important things you need to know further action to disenroll from the other. Failure to do so
about your current coverage and Medicare’s may result in automatic disenrollment from the plan of
prescription drug coverage: your choice or a disruption in your coverage.
1. Medicare prescription drug coverage became available If you do decide to join a Medicare drug plan and drop or
in 2006 to everyone with Medicare. You can get this lose your current UT medical plan coverage, be aware that
coverage if you join a Medicare Prescription Drug you and your dependents will be able to get this coverage
Plan or join a Medicare Advantage Plan (like an HMO back during annual enrollment or following a qualified
or PPO) that offers prescription drug coverage. All change of status event.
Medicare drug plans provide at least a standard level
of coverage set by Medicare. Some plans may also When Will You Pay a Higher Premium (Penalty) to Join
offer more coverage for a higher monthly premium. a Medicare Drug Plan?
You should also know that if you drop or lose your current
2. The University of Texas System Office of Employee coverage with the UT medical plan and don’t join a
Benefits has determined that the coverage offered by Medicare drug plan within 63 continuous days after your
the UT prescription drug plan is, on average for all plan current coverage ends, you may pay a higher premium (a
participants, expected to pay out as much as standard penalty) to join a Medicare drug plan later.
Medicare prescription drug coverage pays and is
54 Legal Notices | 2020-2021 Insurance Enrollment Guide for Retirees
If you go 63 continuous days or longer without creditable Call 1-800-MEDICARE (1-800-633-4227). TTY users
prescription drug coverage, your monthly premium may should call 1-877-486-2048.
go up by at least 1% of the Medicare base beneficiary
If you have limited income and resources, extra help paying
premium per month for every month that you did not
for Medicare prescription drug coverage is available. For
have that coverage. For example, if you go nineteen
information about this extra help, visit Social Security on
months without creditable coverage, your premium may
the web at www.socialsecurity.gov, or call them at
consistently be at least 19% higher than the Medicare
1-800-772-1213 (TTY 1-800-325-0778).
base beneficiary premium. You may have to pay this
higher premium (a penalty) as long as you have Medicare Remember: Keep this Creditable Coverage notice. If you
prescription drug coverage. In addition, you may have to decide to join one of the Medicare drug plans, you may
wait until the following October to join. be required to provide a copy of this notice when you join
to show whether or not you have maintained creditable
For More Information About This Notice Or Your coverage and, therefore, whether or not you are required
Current Prescription Drug Coverage to pay a higher premium (a penalty).Medicare prescription
Contact your institution Benefits Office for additional drug coverage is available. For information about this
information. NOTE: You’ll get this notice each year and if extra help, visit Social Security on the web at www.
this coverage changes through the UT medical plans. You socialsecurity.gov, or call them at 1-800-772-1213 (TTY
also may request a copy of this notice at any time from 1-800-325-0778).
The Office of Employee Benefits or your institution Benefits
Office.

For More Information About Your Options Under

Medicare Prescription Drug Coverage
More detailed information about Medicare plans that
offer prescription drug coverage is in the “Medicare &
You” handbook. You’ll get a copy of the handbook in the
mail every year from Medicare. You may also be contacted
directly by Medicare drug plans.

For more information about Medicare prescription drug

coverage, visit www.medicare.gov.

Call your State Health Insurance Assistance Program (see

the inside back cover of your copy of the “Medicare & You”
handbook for their telephone number) for personalized
help.

2020-2021 Insurance Enrollment Guide for Retirees | Legal Notices 55

Premium Assistance Under Medicaid and the Children’s
Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or If you or your dependents are eligible for premium
CHIP and you’re eligible for health coverage from your assistance under Medicaid or CHIP, as well as eligible
employer, your state may have a premium assistance under your employer plan, your employer must allow
program that can help pay for coverage, using funds from you to enroll in your employer plan if you aren’t already
their Medicaid or CHIP programs. If you or your children enrolled. This is called a “special enrollment” opportunity,
aren’t eligible for Medicaid or CHIP, you won’t be eligible and you must request coverage within 60 days of being
for these premium assistance programs but you may be determined eligible for premium assistance. If you have
able to buy individual insurance coverage through the questions about enrolling in your employer plan, contact
Health Insurance Marketplace. For more information, visit the Department of Labor at www.askebsa.dol.gov or
www.healthcare.gov. call 1-866- 444-EBSA (3272).
If you or your dependents are already enrolled in If you live in one of the following states, you may
Medicaid or CHIP and you live in a State listed below, be eligible for assistance paying your employer
contact your State Medicaid or CHIP office to find out if health plan premiums. The following list of states is
premium assistance is available. current as of January 31, 2019. Contact your State
If you or your dependents are NOT currently enrolled for more information on eligibility –
in Medicaid or CHIP, and you think you or any of
your dependents might be eligible for either of these
programs, contact your State Medicaid or CHIP office or
dial 1-877-KIDS NOW or www.insurekidsnow.gov to
find out how to apply. If you qualify, ask your state if it
has a program that might help you pay the premiums for
an employer-sponsored plan.

ALABAMA – Medicaid COLORADO – Health First Colorado

Website: myalhipp.com/ (Colorado’s Medicaid Program) & Child Health Plan
Phone: 1-855-692-5447 Plus (CHP+)
Health First Colorado Website:
ALASKA – The AK Health Insurance Premium
www.healthfirstcolorado.com
Payment Program
Health First Colorado Member Contact Center:
Website: myakhipp.com/ Phone 1-866-251-4861
1-800-221-3943/ State Relay 711
Email: CustomerService@MyAKHIPP.com
CHP+:
Medicaid Eligibility: dhss.alaska.gov/dpa/Pages/medicaid/
www.colorado.gov/pacific/hcpf/childhealth-plan-plus
default.aspx
CHP+ Customer Service: 1-800-359-1991/ State Relay
ARKANSAS – Medicaid 711
Website: myarhipp.com
FLORIDA – Medicaid
Phone: 1-855-MyARHIPP (855-692-7447)
Website: flmedicaidtplrecovery.com/hipp
CALIFORNIA – Medicaid Phone: 1-877-357-3268
Website:
www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont. aspx
Phone: 1-800-541-5555

56 Legal Notices | 2020-2021 Insurance Enrollment Guide for Retirees

GEORGIA – Medicaid MISSOURI – Medicaid
Website: medicaid.georgia.gov/health-insurancepremium- Website:
payment-program-hipp www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 1-678-564-1162 ext. 2131 Phone: 1-573-751-2005
INDIANA – Medicaid MONTANA – Medicaid
Healthy Indiana Plan for low-income adults 19-64: Website:
Website: www.in.gov/fssa/hip / Phone: 1-877-438-4479 dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
All other Medicaid: Phone: 1-800-694-3084
Website: www.indianamedicaid.com
NEBRASKA – Medicaid
Phone: 1-800-403-0864
Website: www.ACCESSNebraska.ne.gov
IOWA – Medicaid Phone: 1-855-632-7633
Website: www.dhs.iowa.gov/ime/members Lincoln: (402) 473-7000
Phone: 1-800-338-8366 Omaha: (402) 595-1178
KANSAS – Medicaid NEVADA – Medicaid
Website: www.kdheks.gov/hcf/ Website: dhcfp.nv.gov
Phone: 1-785-296-3512 Phone: 1-800-992-0900
KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid
Kentucky Integrated Health Insurance Premium Payment Website: www.dhhs.nh.gov/oii/hipp.htm
Program (KI-HIPP) Website: chfs.ky.gov/agencies/dms/ Phone: 1-603-271-5218
member/ Pages/kihipp.aspx Toll-Free number for the HIPP program: 1-800-852-3345,
Phone: 1-855-459-6328 ext 5218
Email: KIHIPP.PROGRAM@ky.gov
NEW JERSEY – Medicaid and CHIP
KCHIP Website: kidshealth.ky.gov/Pages/index.aspx
Medicaid Website:
Phone: 1-877-524-4718
www.state.nj.us/humanservices/dmahs/clients/medicaid
Kentucky Medicaid Website: chfs.ky.gov
Medicaid Phone: 1-609-631-2392
LOUISIANA – Medicaid CHIP Website: www.njfamilycare.org/index.html
Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp CHIP Phone: 1-800-701-0710
Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-
NEW YORK – Medicaid
5488 (LaHIPP)
Website: www.health.ny.gov/health_care/medicaid/
MAINE – Medicaid Phone: 1-800-541-2831
Website: www.maine.gov/dhhs/ofi/public-assistance/
NORTH CAROLINA – Medicaid
index.htm Phone: 1-800-442-6003 TTY Maine relay 711
Website: dma.ncdhhs.gov
MASSACHUSETTS – Medicaid and CHIP Phone: 1-919-855-4100
Website: www.mass.gov/eohhs/gov/departments/
NORTH DAKOTA – Medicaid
masshealth Phone: 1-800-862-4840
Website: www.nd.gov/dhs/services/medicalserv/medicaid/
MINNESOTA – Medicaid Phone: 1-844-854-4825
Website: mn.gov/dhs/people-we-serve/children-and-
OKLAHOMA – Medicaid and CHIP
families/ health-care/health-care-programs/programs-
Website: www.insureoklahoma.org
and-services/ medical-assistance.jsp (Under ELIGIBILITY
Phone: 1-888-365-3742
tab, see “what if I have other health insurance?”)
Phone: 1-800-657-3739
2020-2021 Insurance Enrollment Guide for Retirees | Legal Notices 57
OREGON – Medicaid WISCONSIN – Medicaid
Website: healthcare.oregon.gov/Pages/index.aspx Website:
www.oregonhealthcare.gov/index-es.html www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-699-9075 Phone: 1-800-362-3002
PENNSYLVANIA – Medicaid WYOMING – Medicaid
Website: www.dhs.pa.gov/provider/medicalassistance/ Website: health.wyo.gov/healthcarefin/medicaid/
healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-307-777-7531
Phone: 1-800-692-7462
To see if any more States have added a premium
RHODE ISLAND – Medicaid
assistance program since January 31, 2020, or for more
Website: www.cohhs.ri.gov/
information on special enrollment rights, you can contact
Phone: 1-855-697-4347, or 401-462-0311 (Direct Rite
either:
Share Line)
SOUTH CAROLINA – Medicaid U.S. Department of Labor
Website: www.scdhhs.gov Employee Benefits Security Administration
Phone: 1-888-549-0820 www.dol.gov/ebsa
1-866-444-EBSA (3272)
SOUTH DAKOTA – Medicaid
Website: dss.sd.gov U.S. Department of Health and Human Services
Phone: 1-888-828-0059 Centers for Medicare & Medicaid Services
www.cms.hhs.gov
TEXAS – Medicaid 1-877-267-2323, Menu Option 4, Ext. 61565
Website: www.gethipptexas.com/
Phone: 1-800-440-0493
UTAH – Medicaid and CHIP
Medicaid: medicaid.utah.gov
CHIP: health.utah.gov/chip
Phone: 1-877-543-7669
VERMONT– Medicaid
Website: www.greenmountaincare.org/
Phone: 1-800-250-8427
VIRGINIA – Medicaid and CHIP
Website: www.coverva.org/hipp
Medicaid Phone: 1-800-432-5924
CHIP Phone: 1-855-242-8282
WASHINGTON – Medicaid
Website: www.hca.wa.gov/
Phone: 1-800-562-3022
WEST VIRGINIA – Medicaid
Website: mywvhipp.com
Phone: 1-855-MyWVHIPP (1-855-699-8447)

58 Legal Notices | 2020-2021 Insurance Enrollment Guide for Retirees

Nondiscrimination Notice
Discrimination is Against the Law If you believe that the UT System Office of Employee
The University of Texas System Office of Employee Benefits Benefits has failed to provide these services or
complies with applicable Federal civil rights laws and does discriminated in another way on the basis of race, color,
not discriminate on the basis of race, color, national origin, national origin, age, disability, or sex, you can file a
age, disability, or sex. The UT System Office of Employee grievance with: The UT System Office of Human Resources,
Benefits does not exclude people or treat them differently 210 W. 7th Street, Austin, Texas 78701, (512) 499-4587,
because of race, color, national origin, age, disability, or sex. (512) 499-4395, esc@utsystem.edu. You can file a
grievance in person or by mail, fax, or email. If you need
The UT System Office of Employee Benefits provides:
help filing a grievance, the UT Office of Human Resources is
Free aids and services to people with disabilities to available to help you.
communicate effectively with us, such as:
You can also file a civil rights complaint with the U.S.
• Qualified sign language interpreters, and Department of Health and Human Services, Office for Civil
• Written information in other formats (large print, audio, Rights, electronically through the Office for Civil Rights
accessible electronic formats, other formats). Complaint Portal, available at https://ocrportal.hhs.gov/ocr/
portal/lobby.jsf, or by mail or phone at:
Free language services to people whose primary language
is not English, U.S. Department of Health and Human Services
such as: 200 Independence Avenue, SW
Room 509F, HHH Building
• Qualified interpreters, and
Washington, D.C. 20201
• Information written in other languages. 1-800-368-1019, 800-537-7697 (TDD)
If you need these services, contact the UT System Office of Complaint forms are available at
Human Resources. www.hhs.gov/ocr/office/file.

2020-2021 Insurance Enrollment Guide for Retirees | Legal Notices 59

Accessibility Requirements Notice
Spanish
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al .
UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D

Vietnamese
CHÚ Ý: Nếu bạn nói Tiếng Việt , có các dị ch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số
UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D

Chinese
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 。
UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D

Korean
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 번으로 전화해 주십시오
UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D

Arabic
UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D
‫ اتصل برقم‬.‫ فإن خدمات املساعدة اللغویة تتوافر لك باملجان‬،‫ إذا كنت تتحدث اذكر اللغة‬:‫ملحوظة‬

Urdu
UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D
‫ تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کریں‬،‫ اگر آپ اردو بولتے ہیں‬:‫خربدار‬

Tagalog
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa .
UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D

French
UT SELECT Medical

ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le UT SELECT Prescription Drug
UT SELECT Medicare Part D
.

Hindi
ध्यान दें: यदि आप हिदं ी बोलते हैं तो आपके िलए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D
पर कॉल कर।

Laotian
ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລກ
ິ ານຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ .
UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D

Persian (Farsi)
‫ تسھیالت زبانی بصورت رایگان برای شام فر‬،‫ اگر بھ زبان فارسی گفتگو می کنید‬:‫توجھ‬
.‫متاس بگیر ید‬ UT SELECT Medical
‫ با‬.‫اھم باشد‬
UT SELECT Prescription Drug
UT SELECT Medicare Part D

German
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer .
UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D

Gujarati
ચુચના: જો તમે ગુજરાતી બોલતા હો, તો િન:શુલ્કુ ભાષા સહાય સેવાઓ તમારા માટ ઉપલબ્ધ છ. ફોન કરો .
UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D

Russian
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D .

Japanese
注意事項：日本語を話される場合、
無料の言語支援をご利用いただけます。 まで、
お電話にてご連絡ください。
UT SELECT Medical
UT SELECT Prescription Drug
UT SELECT Medicare Part D

UT SELECT Medical 1-866-882-2034

UT CONNECT Medical 1-888-372-3398
UT SELECT Prescription Drug 1-800-818-0155
UT SELECT Medicare Part D 1-800-860-7849 (TTY: 1-800-716-3231)
UT SELECT Dental 1-800-893-3582
UT FLEX 1-844-887-3539
 .
BENEFICIARY DESIGNATION FORM
TEAR HERE

Group Term Life (GTL) and Accidental Death and Dismemberment (AD&D)
The University of Texas System GFZ71778
INSTRUCTIONS (PLEASE PRINT, SIGN AND DATE THIS FORM IN BLACK INK)
Employee/Retired Employee Name SSN or Benefits ID No. Date of Birth Home Telephone Number

Home Address City State Zip

Indicate below which University of Texas System institution (U.T. Institution) you are with as an Employee or a Retired Employee
 U.T. Arlington  U.T. Tyler  U.T. M.D. Anderson Cancer Center Houston
 U.T. Austin  U.T. HSC Tyler  U.T. Medical Branch Galveston
 U.T. San Antonio  U.T. HSC Houston  U.T. Southwestern Medical Center Dallas
 U.T. Dallas  U.T. HSC San Antonio  U.T. System Administration Austin
 U.T. Rio Grande Valley  U.T. Permian Basin  U.T. El Paso
DEFINITIONS & STATEMENTS
Primary Beneficiary means the person or persons who will receive the benefits in the event of the Insured’s death. Proceeds will be
divided in equal shares if multiple primary beneficiaries are named, unless otherwise indicated. If percentages are listed, the total of
the combination must equal 100%.
Contingent Beneficiary means the person or persons who will receive the benefits if the primary beneficiary is not living at the time
of the Insured’s death.
Will or Trust as Beneficiary Designation can be done by using the following written statement: “To [name of trustee], trustee of the
[name of trust], under a trust agreement dated [date of trust].” If you wish to designate a testamentary trust as beneficiary (i.e. created
by will), you should recognize the possibility that your will which was intended to create a trust may not be admitted to probate
(because it is lost, contested or suspended by a later will). Claim payment delays can result if the beneficiary designation does not
provide for this situation. **
Minors as Beneficiary Designation can be done by using this document. However, please note if your beneficiary is a minor at the
time of claim, payments may be delayed due to special issues raised by these designations. ** Dependent Beneficiary – In the event
a dependent dies, the employee is the beneficiary of their life insurance proceeds.
Please note: Under Texas Law current employees/retirees of The University of Texas are unable to list an institution of The University
of Texas System as a primary and or contingent beneficiary. This prohibition does not apply if the beneficiary is a non-profit
organization that is a separately managed and uniquely taxable entity from a UT System institution.
**This information is not intended as legal advice. Always consult an attorney before making your beneficiary designation.
BENEFICIARY DESIGNATION FOR ALL EMPLOYEE/RETIRED EMPLOYEE LIFE BENEFITS (GTL and AD&D)
Primary Beneficiary Birth Date Relationship Social Security # Address %

Contingent Beneficiary Birth Date Relationship Social Security # Address %

The Blue Cross and Blue Shield of Texas (BCBSTX) provides this form, which asks that you provide your Social Security
number. As required by BCBSTX , Employees/Retired Employees of The University of Texas System must submit this
completed form with Social Security numbers to BCBSTX. Further disclosure of your Social Security number by BCBSTX
and The University of Texas System is governed by the Public Information Act (Chapter 552 of the Texas Government
Code) and other applicable law.

Employee/Retired Employee Signature_______________________________________ Date_________________

Important Note For Married Employees: If you reside in AZ, CA, ID, LA, NV, NM, TX, WA or WI, and you name someone
other than your spouse as primary beneficiary, your spouse's consent will be necessary to allow your spouse to waive
his or her rights to any community property interest in the benefits. We have provided a space below for your spouse's
signature. Payment of benefit may be delayed or disputed unless your spouse signs.
Spousal Consent for Community Property States Only: I hereby consent to the Primary Beneficiary designated by my
spouse and understand that this consent supersedes any prior spousal consent under this plan.
Spouse Signature ______________________________________________ Date ____________  Employee has no legal spouse
TEAR HERE

Return this completed form to: BCBSTX - Beneficiary Processing Center - 701 E. 22nd Street, Lombard, IL 60148
- Ph 866-628-2606 - Fax 877-361-7661
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance
Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross
and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
R040119 I X6053_UT
UT Institutions Plan Administrators
UT ARLINGTON UT MEDICAL BRANCH UT SELECT MEDICAL LIVING WELL HEALTH
Office of Human Resources AT GALVESTON (Blue Cross and Blue Shield of Texas) PROGRAM
(817) 272- 5554 Employee Benefits Services Group: 71778 livingwell@utsystem.edu.
Fax: (817) 272-5810 (409) 772-2630, Option “0” (866) 882-2034 www.livingwell.utsystem.edu
benefits@uta.edu Toll Free: (866) 996-8862 M-F 8:00 AM-6:00 PM CT
Fax: (409) 772-2754 www.bcbstx.com/ut UT SELECT DENTAL
UT AUSTIN benefits.services@utmb.edu UT SELECT DENTAL PLUS
Human Resources PRESCRIPTION PLAN (Delta Dental)
(512) 471-4772 or UT PERMIAN BASIN (Express Scripts) Group: 5968
Toll Free: (800) 687-4178 Human Resources Group: UTSYSRX (800) 893-3582
Fax: (512) 232-3524 (432) 552-2752 (800) 818-0155 M-F 6:15 AM-6:30 PM CT
HRSC@austin.utexas.edu Fax: (432) 552-3747 24hrs a day 7 days a week www.deltadentalins.com/
hernandez_c@utpb.edu www.express-scripts.com/ut universityoftexas
UT DALLAS
Office of Human Resources UT RIO GRANDE VALLEY MEDICARE PART D DELTACARE USA
(972) 883-2221 Brownsville PRESCRIPTION DENTAL HMO
Fax: (972) 883-2156 Office of Human Resources-Benefits (Express Scripts) (Delta Dental)
benefits@utdallas.edu (956) 882-8205 Group: 7454MDRX Group: 6690
Fax: (956) 882-6599 (800) 860-7849 (800) 893-3582
UT EL PASO benefits@utrgv.edu 24hrs a day 7 days a week M-F 7:00 AM-8:00 PM CT
Office of Human Resources Edinburg www.express-scripts.com/ut www.deltadentalins.com/
(915) 747-5202 Office of Human Resources-Benefits universityoftexas
Fax: (915) 747-5815 (956) 665-2451 UT CONNECT MEDICAL
benefits@utep.edu Fax: (956) 665-3289 (Blue Cross and Blue Shield of Texas) SUPERIOR VISION
benefits@utrgv.edu Dallas / Fort Worth area only Group: 26856
UT HEALTH SCIENCE Group: 241132 (800) 507-3800
CENTER HOUSTON UT SAN ANTONIO (888) 372-3398 M-F 7:00 AM-8:00 PM CT
Employee Benefit Services Human Resources M-F 8:00 AM-6:00 PM CT Sat 10:00 AM-3:30 PM CT
(713) 500-3935 (210) 458-4250 www.bcbstx.com/utconnect www.superiorvision.com/ut
Fax: (713) 500-0342 hr@utsa.edu
benefits@uth.tmc.edu UT FLEX GROUP TERM LIFE,
UT SOUTHWESTERN (Maestro Health) AD&D, AND DISABILITY
UT HEALTH SAN MEDICAL CENTER (844) UTS-FLEX (887-3539) (Blue Cross Blue Shield of Texas)
ANTONIO Human Resources Benefits Division M-F 7:00 AM-7:00 PM CT Group: GFZ71778
Office of Human Resources (214) 648-9830 Sat 9:00 AM-2:00 PM CT (866) 628-2606
(210) 567-2600 Fax: (214) 648-9881 www.myutflex.com M-F 7:00 AM-7:00 PM CT
Fax: (210) 567-6791 benefits@utsouthwestern.edu www.bcbstx.com/ancilliary
ben-admin@UTHSCSA.EDU
UT SYSTEM
UT HEALTH SCIENCE ADMINISTRATION AIG TIAA
CENTER AT TYLER Office of Talent & Innovation (800) 448-2542 (800) 842-2776
Office of Human Resources (512) 499-4587 M-F 8:00 AM-7:00 PM CT TDD (800) 842-2755
(903) 877-7784 Fax: (512) 499-4395 www.valic.com/utsystem M-F 7:00 AM-9:00 PM
Fax: (903) 877-5394 grp-hrsp@utsystem.edu Sat 8:00 AM-5:00 PM CT
benefits@uthct.edu FIDELITY INVESTMENTS www.tiaa.org/public/tcm/
UT TYLER (800) 343-0860 utexas/home
UT MD ANDERSON Office of Human Resources M-F 7:00 AM-11:00 PM CT
CANCER CENTER (903) 566-7434 www.netbenefits.com/ut VOYA FINANCIAL
Human Resources Benefits Fax: (903) 565-5690 (800) 584-6001
(713) 745-6947 humanresources@uttyler.edu LINCOLN FINANCIAL M-F 7:00 AM-9:00 PM CT
Fax: (713) 745-7167 GROUP Sat 7:00 AM-3:00 PM CT
MyHR@mdanderson.org (800) 454-6265 * 8 utsaver.com/voya
M-F 7:00 AM-7:00 PM CT
Physicians Referral Service (PRS) www.lfg.com/ut
(713) 792-7600
Fax: (713) 794-4812
prsfacbensrvs@mdanderson.org
OFFICE OF EMPLOYEE BENEFITS © 2020

benefits@utsystem.edu

Office of Employee Benefits | The University of Texas System

210 W. 7th Street | Austin, TX 78701

The Office of Employee Benefits (OEB) leads in designing, implementing

and administering high quality, cost-effective benefit programs for
employees and retirees of The University of Texas System.

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