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2019 Health BenefitsOpen Enrollment Benefits Over-view
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Health Insurance
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The Cost Containment You Need,The Compassionate Service You Want.
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We are excited to partner with Graff Financial, LLC in
providing cutting edge healthcare benefits
administration with a human touch.
We look forward to working with you and for you.
Welcome to Prairie States
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Seamless Integration
By keeping your health
management and administration
services in-house, we provide
seamless care and integration
throughout every step of your
personal health experience.
About Us
We provide benefits
administration for
customers across
the nation from our
offices in Chicago, IL
and Sheboygan, WI.
Your Services
Prairie States,
working with Self-
Funding Partners, will
administer the back
end of your Medical,
COBRA, FSA and
Health Management,
services effective
July 1, 2019.
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One Call for All the Answers
• Self-Funding Partners and Prairie States work together
to simplify communication, answer healthcare questions,
and ensure you get the most out of your benefits plan.
• Whenever you have a question or concern, simply
call. We are able to help you with:
• Reviewing medical claims
• Understanding eligibility
• Medical coverage and benefits
• Basic prescription coverage
• Pre-certification requirements
• Website assistance
• Taking advantage of preventive services
• Topics to discuss with your physician
• Referral to in-house nurses
• Choosing the right healthcare provider
Self-Funding Partners
(248) 566-6063
8:00 AM – 5:00 PM
Monday - Friday
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Your Prairie States Team
Service ContactMedical Claims Lori Copeland
ID Cards / Eligibility / COBRA Jess Voskuil
Flexible Spending Account (FSA) Amy Mullens
Pre-Certification Barb Laehn, LPN
Utilization Management Tami Stoffregen, BSN RN
Case Management Lisa Schmidt, BSN RN
Website Assistance Steve Godlewski
Prairie States Contact InformationPhone Number (800) 615-7020
Fax Number (920) 451-7023
My Prairie Online www.prairieontheweb.com
Business Hours 8:30 AM to 4:30 PM CST, Monday through Friday
Office Address 615 Pennsylvania Avenue, Sheboygan, WI 53081-4642
Mailing Address P.O. Box 23, Sheboygan, WI 53082-0023
Prairie States dedicated team of in-house professionals works closely
with Self-Funding Partners to get you the answers you need.
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Claims
Administration
Online
Tools
Case
Management
Transitions of
CareUtilization
Management
We Keep You
at the Center
Prairie States and the Continuum of Care
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Case
Management
Case Management helps
members with severe,
complex, and catastrophic
illnesses. Our nurses guide
you through the healthcare
system, answer questions,
and offer support.
Transitions of Care
Transitions of care helps
members after a hospital
stay, surgery or maternity
stay. We walk you through
discharge instructions, and
help you coordinate care.
Utilization
Management
Utilization Management and
Pre-Certification clinicians
work closely with you and
your providers to ensure
you receive appropriate
care and coverage in the
most appropriate and
cost-effective setting.
Health Management
Our clinicians have an average 23 years of experience.
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• All Hospitalization Services (over 23 hours)
• Chemotherapy and Radiation Therapy
(notification of oral agents)
• Clinical Trials
• Diagnostics (outpatient) - MRI, PET
• Dialysis
• Durable Medical Equipment (DME) -
All rentals. Purchases over $500.
• Genetic Testing
• Home Health / Home Infusion
• Hospice Services
• Pain Management Injections -
Epidural Steroid and Facet
• Specialty Medications covered under the
Medical Plan
• Surgical Procedures -
Inpatient and Outpatient
• Transplant Services
Pre-CertificationPenalty of $250
for Non-
Certification
Pre-certification is
required 7 days in
advance for scheduled
services, or 48 hours
after emergency
procedures/admissions
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Graff Financial, LLC - Plan Options
HSA HRA MECBenefit Plan Type: HDHP/HSA HDHP/HRA MEC
Non-Embedded Embedded
Deductible: Plan Individual \ Family Individual \ Family Individual \ Family
$2,000 \ $4,000 $5,000 \ $10,000 $0
$5,000 \ $10,000 $5,000 \ $10,000 $0
Deductible: Employee's Amount Individual \ Family Individual \ Family Individual \ Family
In-Network: $2,000 \ $4,000 $500 \ 1,000 $0
Out-Of-Network: $5,000 \ $10,000 $500 \ $1,000 $0
Deductible: Employer HRA Individual\Family
In-Network: $0 $4,500 \ $9,000 $0
Out-Of-Network: $0 $4,500 \ $9,000 $0
Co-Insurance
In-Network: 100% 90% up to $1,000\Individual and $2,000\Family 100%
Out-Of-Network: 70% 70% up to $2,000\Individual and $4,000\Family Not covered
Out of Pocket Max (Includes Ded.) Individual \ Family Individual \ Family Individual\ Family
In-Network: $4,000 \ $8,000 $7,350 \ $14,700 N/A
Out-Of-Network: Unlimited Unlimited N/A
Employee Max In-Network $4,800 / $8,000 $2,850 / $5,700 N/A
Lifetime Max: Unlimited Unlimited Unlimited
Office Visit:*
PCP (In-Network): Subj. to Ded. & Coins. $25 copay/office visit then 0% N/A
Specialist (In-Network): Subj. to Ded. & Coins. $25 copay/office visit then 0% N/A
Out of Network: Subj. to Ded. & Coins. Subj. to Ded. & Coins. N/A
Teladoc $45 Consult Fee $0 N/A
Urgent Care (Stand Alone Clinic ):* Subj. to Ded. & Coins. $50 copay, Ded. Waived N/A
ER (In and Out of Network): Subj. to Ded. & Coins. $150 copay, Ded. Waived N/A
Routine Care:
In-Network: Covered at 100% Covered at 100% Covered at 100%
Out-Of-Network: 70% after Ded. 70% after Ded. Not Covered
Prescription Drugs:* Retail Mail Order (In Network) Retail/Mail Order (In Network) Retail/Mail Order
Generic:Retail: $10 copay after deductible
Mail Order: $20 copay after deductible
Retail: $20 copay
Mail Order: $40 copay
100%: Drugs required by the ACA for
preventive services
Preferred Brand:Retail: $25 copay after deductible
Mail Order: $50 copay after deductible
Retail: $50 copay
Mail Order: $100 copay
100%: Drugs required by the ACA for
preventive services
Non Preferred Brand:Retail: $40 copay after deductible
Mail Order: $80 copay after deductible
Retail: $80 copay
Mail Order: $160 copay
100%: Drugs required by the ACA for
preventive services
Preferred Specialty:Retail: $50 copay after deductible
Mail Order: Not CoveredSee applicable tier above
100%: Drugs required by the ACA for
preventive services
Non-Preferred Specialty $75 / $150
Hospital In Patient/Out Patient:
In-Network: Subj. to Ded. & Coins. Subj. to Ded. & Coins. N/A
Out-Of-Network: Subj. to Ded. & Coins. Subj. to Ded. & Coins. N/A
This benefit comparison will not replace the benefit summary furnished (SBC). Please see Summary for complete details.
* Office Visit Copays and Prescription Drug Copays apply to Out of Pocket Maximums but not Deductibles.
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What is an HSA, Benefits of an HSA, Contribution Limits
• A health savings account (HSA) is an account that you can use to pay
qualified medical expenses, per the IRS.
• Must be in conjunction with a high-deductible health plan (HDHP).
• Funds rollover each year, so you can use your HSA to save tax-free money for medical expenses
after retirement.
• You own the account, even if you leave the company.
• HSAs can only be offered with a high-deductible health plan with the below minimum
deductibles and out of pocket maximums:
• Minimum deductible for network providers:
• $1,350 single, $2,700 family (2019 limits established by the IRS)
• Maximum annual out-of-pocket for network providers:
• $6,750 single, $13,500 family (2019 limits established by the IRS)
• HSA Contribution Limits:
• 2019
• $3,500 for individual coverage
• $7,000 for family coverage
• $1,000 Catch-up (For individuals ages 55-plus, IRS allows additional $1,000
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Who is Eligible for an HSA & HSA Distribution Rules
• Anyone who is:
• Covered by a HDHP
• Not enrolled in Medicare
• Not covered under other health insurance*
• Not another person’s dependent
*Other health insurance does not include: specific disease or illness insurance, accident,
disability, dental care, vision care and long-term care insurance.
• HSA distributions can be taken for qualified medical expenses for the following people:
• The account holder (person covered by the HDHP)
• Spouse of that individual
• Even if not covered by the HDHP
• IRS eligible Dependents of that individual
• Even if not covered by the HDHP
• Distributions from your HSA are tax-free if they are taken for “qualified medical expenses.”
• The IRS defines expenses that are considered “qualified medical expenses” for HSA distributions. Expenses
must be primarily to treat or prevent a physical or mental defect or illness.
• Your HSA can only be used for expenses that are incurred on or after the date the HSA was established.
However, HSA funds can be used for expenses from a prior year, as long as the expenses incurred on or
after the date the HSA was established.
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A welcome letter is being mailed to your home with instructions for setting up your Teladoc® account, completing your medical history and requesting a consult. Once you're set up, a Teladoc doctor is just a call or click away.
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Teladoc gives you access 24 hours, 7 days a week to a U.S. board-certified doctor through the convenience of phone, video or mobile app visits. Set up your account today so when you need care now, a Teladoc doctor is just a call or click away.
Go to Teladoc.com and
click “set up account”.
Download the app and
click “Activate account”.
Visit teladoc.com/mobile
app to download the app.
Teladoc can help you
register your account
over the phone.
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Teladoc
Teladoc is a convenient and affordable option for quality care when you need care now, if you’re considering the ER or urgent care for non-emergency issues, or if you’re away from home. Call 1-800-Teladoc for on-demand access, day or night, to board-certified doctors.
How Do I Choose?By knowing where to get care, you can make smarter decisions for your health and healthcare expenses.
Primary Care Physician
Whether you are looking for preventive or wellness services, or guidance and care in managing a condition or other health issue, your Primary Care Physician is in the best position to provide a comprehensive plan and coordination of care for your needs.
Urgent Care
Urgent Care facilities are typically stand-alone clinics that do not carry the expensive costs of an ER. If you can’t get into your own doctor and the health issue can’t wait, have a need outside of regular office hours, or are traveling outside of your hometown, Urgent Care is a great alternative to fill this patient need.
Emergency Care
Emergency Room departments are located within hospitals and are prepared to care for patients suffering true emergencies such as heart attacks, serious motor vehicle accidents, strokes, and other life threatening conditions.
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PPO Networks and Rx Program
Preferred Provider Organization (PPO)
Prescription Benefit Manager (PBM) Rx Program
Outside of Michigan
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• You will receive new Member ID Cards from Prairie States.
• The ID cards will be mailed to your home.
• Please destroy your old ID cards when you receive the new version.
• To ensure proper handling of your claims, beginning July 1, 2019 present your Prairie States Member ID card.
• If you do not yet have your ID card as of July 1, 2019, simply call (248) 566-6063, and we will give you and/or your physicians the information needed at the time of your appointment.
ID Cards
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This section provides a brief
overview of how claims were
paid for a specified period of
time, as well as the portion
providers may bill you after
your health plan benefits are
paid.
The Prairie States EOB is
not a bill.
This section shows payment
details for each claim.
How to Read Your EOB
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Claims are also shown
individually including
service code, procedure
description, applicable
co-pay, payment
amount, etc.
The Accumulator
Description Section lists
year to date amounts
paid toward Individual
and/or Family
Deductibles and Out-of-
Pocket amounts.
Details on how to file an
appeal are provided at
the bottom of your EOB.
This section provides
service code
descriptions for claims
processed.
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Flexible Spending Account Review
• Flexible Spending Accounts allows employees to put money away on a pre-tax
basis, through payroll deductions to pay for:
• Un-reimbursed Medical, Dental and Vision eligible expenses:• Health Plan Deductible, Co-insurance
• Dental and Vision eligible expenses
• Over the counter medications are only eligible with a prescription from your physicians
• Dependent Care eligible expenses:• The day care provider must file taxes and be willing to write you a receipt for services
• Dependents must be less than 13 years of age and claimed on your taxes
• Dependent Care may also apply to physically or mentally challenged spouse or family
member for whom you are legally responsible and claim as an exemption on your taxes.
• Tax Advantage:
• 25% - 30% of the contributions based on employee tax bracket
• No Federal, State or FICA taxes taken on deduction amount
• Enrollment in June of every year for July 1 effective date.
• Determine an annual amount to cover your potential out-of-pocket eligible
expenses for the new year.
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Flexible Spending Account Review
• Maximum election amount allowed per Calendar Year for
Medical FSA has been increased to $2,700 and it is available
to you on July 1.
• Maximum election amount allowed per Calendar Year for
Dependent FSA is $5,000 ($2,500 if you and your spouse
both have a DCSA).
• Dependent FSA – Member can only request reimbursement
for the amount that has accumulated in Dependent FSA
account.
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Flexible Spending Account Review
Limited Scope
• If you participate in the High Deductible Health Plan and have an HSA
(Health Savings Account), you may participate in a Limited Scope FSA:
• Dental and Vision eligible expenses ONLY
• Different from the regular FSA, in that medical expenses are not
eligible as you would have the HSA for those amounts for deductible
and out-of-pocket eligible expenses.
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FSA
Reminders
• Be conservative – under the IRS Regulations the Health FSA, Dependent
FSA and Limited Scope FSA are a Use it or Lose it account. Any
unused funds at the end of the year are forfeited.
• Claims must be incurred between July 1 and June 30.
• Claims must be filed for reimbursement within 90 days following the end
of the plan year or prior to September 30.
• You cannot change the Annual Election unless you have a qualifying
event per the IRS regulations.
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FSA
Claim Submissions
• Direct Deposit Option:
• Complete the Direct Deposit form on Self-Funding Partners Portal
• Include a voided check or savings deposit ticket
• EFT’s are released on Wednesdays.
• Manual Claim submission:
• Submit a Reimbursement Form, found self-Funding Partners Portal,
along with copy of bill, receipt or statement from the provider of
service, prescription stub or print out from pharmacy. A paper form is
also available on Self-Funding Partner’s portal with mail, fax, email
instructions.
• Physical checks are mailed on Fridays.
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My Prairie Online Portal
• Medical and Rx Claims
• Eligibility Information
• PPO and PBM Links
• Explanation of Benefits (EOB) View
• Single-sign-on access:
• Wellness Portal
• Cost Transparency Tools
• Request an ID card
• Pre-Authorizations
• Out-of-area student action plan
• At-a-glance dashboard for current
deductible and out-of-pocket totals
• Mobile-enabled – full functionality
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Health Insurance Questions?
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Voluntary BenefitsDental, Vision, Life, STD, LTD
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Guardian Life
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Guardian Life
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Guardian Life
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Guardian Life
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Guardian Life
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Guardian Life
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Guardian Life
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Voluntary Benefits Questions?
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Graff Group’s Team
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Service ContactMedical Claims
Self-Funding Partners
Graff Group Advocate Team
Elizabeth (Liz) Wivo, Regional Advocate
Point of Service Issue Resolution
ID Cards / Eligibility / COBRA
Enrollment changes
Flexible Spending Account (FSA)
Health Savings Account (HSA)
Guardian Benefits
(Dental, Vision, Life, ST-D / LT-D)
Website Assistance
Self-Funding PartnersPhone Number (248) 566-6063
Self-Funding Portal www.self-fundingpartners.com/graff
Business Hours 8:00 AM to 5:00 PM, Monday through Friday
Office Address 4150 Grange Hall Rd, Holly, MI 48442