state of maine employee health & benefits insurance update revised 02/06/20131
TRANSCRIPT
State of Maine Employee Health & Benefits
Insurance Update
Revised 02/06/2013 1
What we’ll cover today...
Explain how your health plan works Help you maximize your health benefits Provide overview of resources available to
you Answer your questions
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Who does what…..
State Employee Health Commission
• 24 members• Employees &
Retirees• Labor/management• Design plan
features• Set premium rates• Contract with
vendors
Aetna
• Third-party administrator (TPA)
• Process medical claims
• Maintain a network of doctors & hospitals
• Care management
Division of Employee Health & Benefits
• Administrative support to the Health Commission
• Process benefit applications
• Maintain payroll records for insurance premiums for State employees
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Point of Service Plan: “Self-Insured ”
Health Plan
Employee Paid
Premiums
Employer Paid
Premiums
Medical Providers
Copays, Deductibles
& Coinsurance
Premiums are collected from plan participants, the State of Maine and ancillary employer groups. Those funds are used to pay for services provided by doctors, hospitals, prescriptions, etc.
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Where does flat funding come from? Why is it important?
The Point of Service (POS) health plan was flat funded as part of the budget passed by the State of Maine Legislature for fiscal years 2012 and 2013
The funding for the POS plan cannot exceed the premium rates in effect for fiscal year 2011
Premium rates must remain the same for both the employees/retirees and the employer paid premiums (e.g. State of Maine); the two primary funding sources to pay for medical claims
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Types of medical expenses you pay for and those you don’t….
• Office visit• Prescription• Emergency room visit• MRI, CT scan
Copay (flat dollar amount)
• Lab work• X-ray• Procedure• Surgery
Deductible (owed before plan covers)
• Lab work• X-ray• Procedure• Surgery
Coinsurance (percentage after deductible)
Provided at no cost to you
• Routine physical exams• Immunizations• Routine gynecological exams• Routine mammograms• Routine eye exams• Colonoscopies
no copay | no deductible | no coinsurance
Refer to your Benefit Overview for out-of-network coverage.
See appendix for more information 6
Types of providers
Preferred Providers
Referred Providers
Non-Participating Providers
• Primary care doctors• Hospitals
• Primary care doctors• Hospitals• Pharmacies• Specialists
• Primary care doctors• Hospitals• Pharmacies• Specialists
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Maximize the Benefits of Your Health Plan
Choose a primary care doctor (“PCP”) Get a referral from your selected PCP
• Specialty services• Tests• Procedures
Preferred providers• Highest level of benefit• Least out of pocket expense
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What to do if you receive a denial of your claim….
You have options! Carefully review your explanation of benefits Call Aetna Member Services to review your claim
with you (1-855-850-0039) Aetna appeal process Appeal to the State Employee Health
Commission Independent external review administered by the
Maine Bureau of Insurance (1-800-300-5000)
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Resources to Assist You Aetna
• Member Services 1-855-850-0039• www.AetnaStateOfMaine.com
• Aetna Navigator• DocFind
Division of Employee Health & Benefits• (207) 287-6780 or 1-800-422-4503• www.maine.gov/deh
Maine Bureau of Insurance• 1-800-300-5000• www.maine.gov/pfr/insurance/index.shtml
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Thank you for attending!
Questions?
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Appendix
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What is driving the increase in plan expenses?
FY2012 (7/1/11-6/30/12): 6% increase or an extra $13.4 million in plan expenses (medical claims)
FY2013 (7/1/12-6/30/13): 10% projected increase or an extra $22 million in plan expenses• The FY13 10% increase is a direct result of:
• Cost of medical care is going up• Hospital in-patient services up 14.4%• Hospital out-patient services up 7.8%
• Increased utilization• Up 3.5%
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Copay, Deductible & Coinsurance Defined
Copay: A flat dollar amount paid for certain health expenses
Deductible: The amount you pay before the health plan provides coverage
Coinsurance: A shared expense between you and the health plan
*Deductible + Coinsurance = Calendar year out-of-pocket maximum limit
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Co-pay Amounts
Co-pay amounts will remain the same• Primary Care office visit $0 or $20• Specialist office visit $25• Prescription Drug Copays
• 30-day supply - $10/$30/$45/$50 • 90-day supply - $15/$45/$70/$75 Generic/Name-brand formulary/Non-formulary/Lifestyle
• Emergency Room $100 & Walk-In Clinic $25• Advanced Imaging $50
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Summary of Plan Design Changes: Comparison 8/1/11 to 7/1/12
Tier 1Preferred Level
Tier 2Referred Level
Tier 3Self-Referred
8/1/11 7/1/12 8/1/11 7/1/12 8/1/11 7/1/12
DeductibleIndividual
Family
$0
$0
$300
$600
$200
$400
$1,500
$3,000
$300
$600
$2,500
$5,000
CoinsuranceMember
Plan
5%
95%
5%
95%
15%
85%
20%
80%
25%
75%
40%
60%
Out-of-Pocket Max
Individual
Family
$500
$1,000
$1,100
$2,200
$1,000
$2,000
$3,000
$6,000
$2,100
$4,200
$5,000
$10,000
Any amount paid towards your 2012 deductible or coinsurance through June 30th will be applied to the new limits for July 1st.
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Aetna’s On-Line Tools Customized website for the State of Maine “Express Lane”
www.AetnaStateOfMaine.com • Find a Provider• Benefit Overview• Discount Programs (Fitness, weight management, vision, hearing,
etc) Secure member website – Aetna Navigator
• Look up a claim• Order/print an ID card• Keep track of health care costs• Change your primary care doctor
Aetna Mobile• Mobile web• App for Android & iPhone
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Includes all types of providers – PCP’s, specialists, hospitals, walk-in clinics, etc.
Participates with Aetna Preferred status (based on results from the
Maine Health Management Coalition)• See www.GetBetterMaine.org for more information
Find out additional information about your Doctor…certification status, language spoken, handicap access, accepting new patients, etc.
Aetna DocFind
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Division of Employee Health & Benefits: 1-800-422-4503
Each of you have access to a designated Benefits Specialist:
Our Specialists can assist you with questions regarding eligibility, payroll deductions for premiums and general plan guidance. (Reminder: The best resource for questions regarding medical claims is Aetna Member Services 1-855-850-0039.)
If your last name begins with….
Your Benefits Specialist is….
Contact Information
A – DOT Doris Pietroski [email protected]
DOU – KZ June Soucy [email protected]
LA – PL Erica Ouellette [email protected]
PO – Z Emily Charlton [email protected]
www.maine.gov/deh 19
Additional Resources
www.GetBetterMaine.org – the Maine doctor and hospital ratings
www.leapfroggroup.org/cp - hospital safety scores
www.maine.online.Staywell.com – Your personal wellness program
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