How to Use YourCVUSD Health Benefits Effectively

Why the presentation?

• Education– A better understanding of our system– A better understanding of the funding– Empower you to be a better health care

consumer• We are in NO WAY are telling to avoid the

doctor• Trying to be smarter about usage of benefits

Funding• CVUSD collects contributions from members and pays out of the general fund into

the health benefits fund – This year it is $14,273 per employee in PPO. 963 employees enrolled in PPO.– Anthem Blue Cross HMO for singles $5,871; $12,045 for double; $17,908 for

families. 231 HMO employees enrolled.

• CVUSD pays Kaiser an amount per employee for their coverage.– We negotiate each year with Kaiser for the amount charged.– Singles- $5,346; $10,692 double; $15,129 for families– 315 employees enrolled

• CVUSD pays Blue Cross to “rent” their insurance pool.– The money in the CVUSD health benefits fund pays for PPO claims that are processed

through Anthem Blue Cross.– EACH time you go to the doc or have something done, CVUSD gets a bill from Blue Cross for the agreed-upon amount.

• It is paid out of CVUSD’s Health Fund– If any claims go above $260,000 we have an insurance plan called “Stop/Loss” that covers all medical costs in excess of that amount.

• Approximately $78K per month

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 est$17,600,000

$17,800,000

$18,000,000

$18,200,000

$18,400,000

$18,600,000

$18,800,000

$18,234,425

$18,688,407

$18,304,501

$17,969,115

$18,083,634$18,155,377

Total Cost of Health Benefits

Premium payments added this year

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 est10

10.2

10.4

10.6

10.8

11

11.2

11.4

10.65

11.18 11.211.28 11.27

11.25

Health benefits as % of budget

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 est1400

1450

1500

1550

1600

1650

1700

1750

1800

1850

1900

18561840 1837

1761

1636

1509

Employees and retirees enrolled in insurance

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 est1400

1450

1500

1550

1600

1650

1700

1750

1800

1850

1900

1856 1840 1837

1761

1636

1509

Employees enrolled in insurance

In short

• Total costs dropped, but on the rise– Employee contributions helped flatten the trend out– Fewer employees– As the budget decreases health care becomes a larger

share.• Costs per employee up and costs TO employee up

– Premium increases– More usage– Doc fee increases– Plan modifications

Preventative Care• Affordable Care Act (aka “Health Care Reform” or “Obamacare”)

– Should not cost you anything out-of-pocket (IN-NETWORK ONLY)– No more co-pays for preventive check ups– Cost of appointment to plan not applied to deductible

• The key is to set the appointment the correct way. – When you set the appointment make sure you ask for a “preventive

care” screening. – Once in the appointment, do not ask for a diagnosis of another issue

or ask for a prescription, or Rx renewal. – Adding a diagnosis and/or prescription makes it a diagnostic

appointment and then no longer qualifies as preventive screening. – The doctor may make a diagnosis or give a prescription

as a result of the screening, but that should be his/her decision, not your request.

– Remind your doc that lab coding must be for preventative care – not with a diagnosis code.

Who pays for preventative care?• You don’t pay anything, intent is to

encourage you to go to the doc for the check-up

• Intent to save money over the long-term because issues will be caught early

• District (health plan) DOES pay the full amount.

Prescriptions- same for in and out-of-network• Going to the pharmacy

– 30 Day Supply• $15 for generic• $30 for brand name

• Mail Order – 90 Day Supply

• $30 generic• $60 brand

Monthly Premium Payments - CVUSD

Additional programs to help• Anthem 360

– Not a scam– Disease management for high risk issues

• Diabetes, coronary artery disease, asthma, etc.

• Future Moms (Anthem)– Must call in– Nurse help

• Nurseline (Anthem)– 800-337-4770

• Kaiser:Kaiser after-hours advice: 1-888-576-6225

• Conejo Cares (everybody)– Mix It Up– Thrive Across America– Waverly Wellness

• Know Your Numbers– Costs $20– if you have it done at Los Robles it can be as high as $600

• Health Risk Assessments• Classes

District Website- Under Departments/Employee Benefits

Emergency Room Visits

• 213 total last year• $429,714 in total claims• $1,471 per visit average• Of the 213 visits, only 2 were

admitted to the hospital

What’s the difference?!• Approximate emergency room costs (national avg. ER visit $1,349):

– To YOU:• $100 Co-Pay• 20%- $249.80

– To the PLAN (the district)• 80% of remaining- $997

• Approximate cost of urgent care visit ($100 national avg.)– To YOU:

• Co-pay- $20• 20%- $16

– To the PLAN:• 80% of remaining- $64

Emergency Room Visits

Monday

Tuesday

Wednesd

ay

Thursday

Friday

Satu

rday

Sunday

05

10152025303540

# of Visits

# of Visits

Anthem ER Alt

If you are having an emergency- go to the ER

• Urgent care is for ear infections, sometimes stitches, tummy aches,

sore throats, etc.

If you’re having chest pain GO TO THE ER!

If you do have an emergency

• If you get checked into a non-network hospital– Anthem will pay as if you are in-network

UNTIL YOU ARE STABILIZED

• Once you are stabilized, you begin to pay out-of-network rates

• Get to an in-network hospital ASAP

Top 5 chronic conditions HMO

1. Cancer2. Depression3. Asthma4. CAD5. Hyperlipidemia

Top 5 HMO Conditions PMPM

Suppl Class Digestive Infectious Neoplasms Mental Disorders

42.69

16.59

11.26 10.438.72

Current Year

Nationwide trend of usage

% of employees % of claims0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

5

53

10

25

35

19

50

3

Parting thoughts• Eat right• Exercise• REST• Do preventive appointments

– Better to catch things early– “I save the plan money because I never go to the

doctor”- DOESN’T SAVE MONEY• Go to the dentist• Get an annual eye exam• Encourage each other for better health• Participate in the programs that have been

created like Conejo Cares Wellness Plan.• ASK QUESTIONS