non state groups open enrollment for plan year 2013
TRANSCRIPT
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Non State GroupsOpen Enrollment for Plan Year 2013
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No employee & employer rate increases
No plan design changes for Plans A and B
Autism Spectrum Disorder Pilot– Benefit will be continued for 2013
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Plan Design Changes for Plan C– Lower premium– Deductible
• Single $2,500/ Family $5,000• Single family member only has to meet the single
deductible
– In Network services for medical & pharmacy have NO member Coinsurance
– Employer HSA Funding Increased• Maximum of $1,500 for single & $2,250 for family• Employer may pays HSA funding in a lump sum• All HSA accounts will be with US Bank
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Preventive Care Coverage for Contraception–Medical coverage for implantable &
injectable contraceptives–Medical coverage for sterilization – Pharmacy coverage for prescription birth
control products• Must be on the Preferred Drug List• Does not include over the counter items
Preventive Care Coverage for Breastfeeding– Includes counseling and equipment rental
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Summary of Benefits & Coverage (SBC)– www.kdheks.gov/hcf/sehp/SBC.htm
Uniform Glossary of Health Coverage & Medical Terms*– www.kdheks.gov/hcf/sehp/download/
UniformGlossaryofHealthCoverageMedicalTerms.pdf
* Note: This is not specific to the SEHP Coverage
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1. Pick a plan design (A, B or C)– Which plan design provides the coverage
you and your family need?– What is the total plan cost? What is the
member contribution• Premiums + Deductible & Coinsurance = ?
2. Review the Provider Networks – Each of the medical plans uses a different
provider network
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All are Preferred Provider Organizations (PPO)– Plans A, B and C all use the same provider
networks & same basic coverage– Claims paid based on the network status– Network Providers accept the plan
allowance as payment in full– Non Network Providers can balance bill– All plans include preventive care
Plans A B CBlue Cross and Blue Shield of Kansas
X X X
Coventry/PHS X X X
UnitedHealthcare Company X X X
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Services ServicesWell Baby Exams - includes newborn screenings & age-appropriate office visits.
Contraceptive Coverage – Designated prescription drugs, implantable & injectable contraceptives & sterilization procedures.
Well Woman, Man & Child Exams - includes an office visit & age-appropriate screenings, contraception services & counseling.
Ultrasonography for Aortic Aneurysm - Limited to one for men ages 65-75 with tobacco use history
Prenatal Screening & Counseling - Limited screening services.
Mammography – not limited to one.
Age-Appropriate Bone Density Screening
Vision Exam – one covered per person per year
Immunizations Routine Hearing Exam Colonoscopy – not limited to one.
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A set amount of eligible expenses a covered person must pay out of their own pocket before the health plan will begin paying on their claims.
Network and Non Network Deductibles accumulate separately.
Deductible and “Not Covered” do not mean the same thing.
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Deductible Example Claim Information
Plan C Deductible is $2,500
Network Dr. billed $600 for a covered service.
Health Plan allowance is $500.
Member has met $0 of their deductible this year
Claim Processing
$500 Allowed Charge-$500 Deductible $0 Paid by health plan
Your responsibility = $500
Plan Pays $0Member Pays $500 *
Dr. writes off $100
* Members on Plan C have a Health Savings Account that could be used to pay this deductible amount.
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A cost sharing formula for health care services
Coinsurance is expressed as a percentage of the allowed charge that will be paid by the member and the balance paid by the Plan
You must meet the deductible before coinsurance is applied
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Coinsurance Example
Claim Information
Member has Plan A
Network Dr. billed $125 for service
Plan allowed $100 for service
Member has met their $300 Deductible
Member Coinsurance is 20%
Claim Processing
$100 allowed by Plan20% Coinsurance $20 Paid by Member
Plans pays the other 80%
Plan Pays $80Member Pays $20 $100
Dr. writes off $25
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Network Benefits
Plan A Plan B Plan C
Deductible $300 Single$600 Family
$150 Single$300 Family
$2,500 Single$5,000 Family
Coinsurance 20% 35% 0%
Annual Coinsurance
$1,400 Single$2,800 Family
$3,000 Single$6,000 Family
None
Total Deductible & Coinsurance
$1,700 Single$3,400 Family
$3,150 Single$6,300 Family
$2,500 Single$5,000 Family
Pharmacy Covered under separate policy
Covered under separate policy
Included with Medical
Preferred Lab Yes Yes No
Office Visits
Adults (age 19+)
PCP $25 CopaySpecialist $45
Copay
PCP $20 CopaySpecialist $40
Copay
Deductible & 0% Coinsurance
Children (< age 19)
PCP $25 CopaySpecialist $45
Copay
PCP $10 Copay Specialist $25
Copay
Deductible & 0% Coinsurance
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100% Coverage of eligible outpatient lab tests
Two vendors– Quest Diagnostics– Stormont-Vail
Cannot be used for:– Hospital outpatient or inpatient lab
services– Labs needed on a STAT basis
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Statewide & nationwide preferred lab vendor
Testing must be performed and billed by Quest
Your Doctor can draw the sample and call for specimen pick up
For draw site locations visit: www.labcard.com- Online appointment scheduling available
Use Your Quest ID card or medical ID card
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Stormont-Vail HealthCare is the regional preferred lab vendor in NE Kansas
100% coverage for eligible outpatient lab tests
All Plan A and B members may use the Stormont-Vail draw site locations
Labs drawn at other Cotton-O’Neil locations may be included if by network providers
Show your medical ID Card to access benefit
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Generic Drugs– 20% Coinsurance
Preferred Brand– 35% Coinsurance
Non Preferred Brand– 60% Coinsurance
Special Case Medications – 25% to a max of $75 per 30-day supply
Coinsurance Maximum Is $2,580 per person for Generic, Preferred Brand & Special Case medications.
www2.caremark.com/kse
Caremark Prescription Drug Benefit –
Plans A & B
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2012Actos 3rd QtrDiovan3rd QtrSingulair 3rd QtrMaxalt 4th QtrMaxalt MLT 4th QtrTricor 4th QtrRequip XL 4th Qtr
2013Reclast 1st QtrZomig 2nd QtrZomig ZMT 2nd QtrAdvicor 2nd QtrNiaspan 3rd QtrAchiphex 4th QtrCymbalta 4th Qtr
www2.caremark.com/kse
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Network Coverage for Medical & Pharmacy – $2,500/$5,000 Deductible– No Coinsurance– $2,500/$5,000 Total Deductible & Coinsurance– Preventive Care Services paid at 100%
Non Network Coverage– $2,500/$5,000 Deductible – 20% Coinsurance– $4,000/$8,000 Total Deductible & Coinsurance– Preventive Care is not covered
Does not include dental or optional vision plan
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Same Preferred Drug List as Plans A & B Covered drugs are subject to the
Network Plan C deductible After the deductible, the plan pays
covered prescription drugs at 100% 100% coverage for contraceptives on
the PDL Discount Tier drugs are not covered
drugs– Only eligible for Caremark’s negotiated
discount Plan C is a credible drug plan
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Plan C Network Benefits
Single Family
Deductible $2,500 $5,000
Coinsurance 0% 0%
Total Member Pays $2,500 $5,000
HSA Account Single Family
State Maximum HSA Contribution
$1,500 $2,250
Minimum $25 EE Contribution $600 $600
Total Annual HSA Contribution $2,100 $2,850
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An employee-owned bank account for saving money to pay for current or future medical expenses for members enrolled in a qualified high deductible health plan
Unspent HSA funds roll over and accumulate year to year and can be invested
Portable - The account and the money belong to you
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The following members are not eligible for an HSA:– Enrolled in Medicare – Enrolled in TRICARE or TRICARE for Life– Enrolled with the Veteran’s Administration
(VA) and/or have received VA medical services within a three-month period immediately preceding their enrollment in Plan C
– Receiving benefits from Social Security– Covered as a dependent under another plan
that isn’t a QHDHP– Can be claimed as a dependent on another
individual’s tax return (i.e. Parents)– Spouse has Health Care Flexible Spending
AccountSee page 12 of the OE Book
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Employer may pay HSA contribution as a lump sum
Payment date depends on HCFSA:– Account funded in January if no
HCFSA in 2012 or if all money has been used by 12/31/12
– Account funded after March 15, 2013 if enrolled in HCFSA in 2012 and you have funds during the grace period
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Full Time Employee - (24 semi-monthly deductions)
Single Family
Employer (ER) Contribution
$1,500 $2,250
Employee (EE) Contribution
$25 to $72.91
$25 to $175
Maximum Annual HSA Contribution (ER+EE)
$3,250 $6,450
Over age 55 “Catch up” amount
$1,000 $1,000•HSA Contributions are governed by the Internal Revenue Service (IRS).•Eligibility criteria for HSA Account is on Page 12 of the Open Enrollment Book•Minimum contribution of $25 semi-monthly by the employee is required•Contributions may be made with pre- or post-tax funds. •Members over age 55 can contribute additional funds to “catch up”
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All Plan C options will have the same HSA vendor: – US Bank
A file with the members who enroll in Plan C will be sent by SEHP to US Bank
Employees receive “welcome” notification via email –Letter if no email
Employee completes online enrollment process–Must accept the Terms and Conditions–Order additional cards for dependents–Select account beneficiaries
Online Tools to manage your account
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Use your HSA Bank Card at a Pharmacy – Fill a prescription– Swipe your HSA Bank Card for payment– Save a copy of receipt for your records
Use your HSA Bank Card for Medical Services– Health plan processes claim & sends you an
Explanation of Benefits (EOB) – Pay the provider using your HSA Bank Card– Save a copy of the bill or EOB for your records
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You Pay the Provider through Bill Pay– You go online and use Bill Pay to issue
payment to the provider of service
Reimburse yourself for expenses paid out of your pocket– With Bill Pay you can send a direct
deposit reimbursement to your checking or savings account for health care services
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Plan pays in full for 2 exams & cleanings
$50 Plan Deductible max of 3 per family
Implant Coverage– 50% Coinsurance to a max of $1,250 per
year – Benefit subject to annual benefit max
Annual benefit maximum– $1,700 per person per year
$1,000 Lifetime Orthodontic benefit
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Benefit Level PPO PremierNon
Network
Preventive Services
Covered in full
Covered in full
Allowed amount
covered in full
Basic BenefitBasic
Restorative50% 50% 50%
Enhanced Benefit
Basic Restorative
20% 40% 40%
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$25 Materials Copay then:– 100% single vision, standard bifocal,
trifocal lenticular lenses– Up to $100 frame allowance
Elective Contact lens allowance $150
Office visit subject to $50 Copay
Contact Lens Fitting Fee subject to $35 Copay
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Includes Basic benefits plus…– Frame allowance of up to $150– Contact Lens Fitting Fee subject to $35
Copay– High index or Poly-carbonate lenses up
to $116– Progressive lenses up to $165 – Scratch and UV coating
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Requirements for 2014 incentive discount– Complete the required online health
questionnaire(10 Credits)
– Earn 20 additional credits
HQ Rewards deadline is July 31, 2013
Non Tobacco usage is worth 10 credits– Non Tobacco Use declaration is now online at:
www.kansashealthquest.com– You may complete declaration at anytime
before the deadline.
Tobacco cessation program is no longer required for tobacco users.
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Enroll online: https://hrissuite.com–Make health plan selections
– Add/drop dependents• Dependent documentation required by
October 31.
– Coverage effective January 1, 2013
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Coventry/PHS and UHC are issuing new ID cards for Plan C members
Delta Dental is issuing new ID cards for all
For all others, new cards will only be issued if the member makes a plan/coverage change
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Review the Open Enrollment (OE) booklet ?’s: Call the health plan customer service– Phone numbers in the front of the OE booklet
Visit www.kdheks.gov/hcf/sehp.htm– Benefit descriptions, Provider directories, &
Preferred drug list available– Information on the HSA and FSA accounts
Summary of Benefits & Coverage (SBC) Email ?’s to SEHP: [email protected]
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Hold for link to the health plan tool that will be on our web site soon
www.kdheks.gov/hcf/sehp
US Bank Tool place holder
There is a Payroll Calculation tool available at http://www.kansas.gov/employee/
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Questions?
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Option Slides
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Primary Care Providers (PCPs)• General practice• Family practice• Geriatrics
• Internal medicine• Physician extenders• Pediatrics
• Plans A & B only• PCPs have lower office visit copays • Member may have more than one
PCP• No referrals required
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Facility Address CityStormont-Vail HealthCare Laboratory
1500 SW 10th Ave. Topeka
Cotton-O’Neil 901 Laboratory
901 SW Garfield Topeka
Cotton-O’Neil 823 Laboratory
823 SW Mulvane Topeka
Cotton-O’Neil Croco Laboratory
2909 SE Walnut Dr.
Topeka
Cotton-O’Neil Urish Laboratory
6725 SW 29th St. Topeka
Cotton-O’Neil Carbondale Laboratory
211 East Main Carbondale
Emporia Medical Arts Clinic
1301 W 12th Ave. Suite 401
Emporia
Cotton-O’Neil Wamego Laboratory
1704 Commercial Circle
Wamego
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Network vs. Non NetworkPlan A - Non Network
Provider
Service on 1/2/2013Plan Pays
Member Pays
Provider Write-
Off
Billed Charge $1,500
Allowed Charge $1,400 $100 $0
$500Deductible ($500) $500
50% Coinsurance $900 $ 450 $450
Total $450 $1,050 $0
Plan A - Network Provider
Service on 1/2/2013Plan Pays
Member Pays
Provider Write-Off
Billed Charge $1,500
Allowed Charge $1,400 $100
$300 Deductible ($300) $300
20% Coinsurance $1,100 $880 $220
Total $880 $520 $100
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Office Visit Copays– $25 for Primary Care Office Visits– $45 for Specialist Office Visits
$300/$600 Deductible 20% Coinsurance Coinsurance Max $1,400/$2,800 Preventive Care Services paid at
100% Lab Card Benefit
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Primary Care Office Visits– $20 Copay for Adults – $10 Copay for Children <age 19
Specialist Office Visits– $40 Copay for Adults– $25 Copay for Children <age 19
$150/$300 Deductible 35% Coinsurance Coinsurance max $3,000/$6,000• Preventive Care Services paid at 100%
Lab Card benefit
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$500/$1,500 Deductible 50% Coinsurance Coinsurance Max $3,650/$7,300 Non Network Providers can
balance bill Preventive care not covered
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Covered in full:– Prophylaxis/cleanings – twice per year.– Oral examinations – twice per year.– Bitewing x-rays – • adults – 1 x a year • children under 18 - 2 x a year
– Full mouth x-rays – once each five (5) years.
– Limited coverage for children only:• Sealants• Space maintainers• Topical fluoride
– Ancillary – emergency relief of pain.