open enrollment 2012 non state employer groups. health care commission (hcc) approved employee &...
TRANSCRIPT
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Open Enrollment 2012Non State Employer Groups
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Health Care Commission (HCC) Health Care Commission (HCC)
Approved employee & employer rates◦NSG’s & Agency rates increased
12.5% on 7/1/10 15% on 7/1/11
◦NSG’s & Agency rates will increase 7.5% on 7/1/12
◦Return to the 95/55 employer contribution Coverage cost for employee-only will increase
◦Actual increase depends upon plan, tier and coverage level
Continue to provide a 55% contribution toward dependent coverage
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Other HCC ActionOther HCC Action
No plan design changes for Plans A and BPlan design changes for Plan C pharmacy
benefitAdded Stormont-Vail HealthCare as a
regional preferred lab vendor Quest will continue to offer a statewide
preferred lab optionAdded the HealthQuest Rewards Program
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Legislative ChangesLegislative Changes
Autism Spectrum Disorder Pilot◦Benefit will be continued for 2012
Limits placed on SEHP coverage for abortions◦Only covered to protect life of the mother
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2012 SEHP Medical Plans2012 SEHP Medical PlansAll plans are
Preferred Provider Organizations (PPOs)
◦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
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Vendor OptionsVendor Options
Plans A B C
Blue Cross and Blue Shield of Kansas
√ √ √
Coventry/PHS √ √ √
UnitedHealthcare Company √ √ √
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General practiceFamily practiceGeriatrics
Internal medicinePhysician extendersPediatrics
• Plans A & B only• PCPs have lower office visit copays • Member may have more than one
PCP• No referrals required
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Selecting a Medical PlanSelecting a Medical Plan
1. Pick a plan design (A, B or C)◦ Which plan design provides the coverage
you and your family need?
2. Review the Provider Networks ◦ Each of the medical plans uses a different
provider network
3. Review the other services each medical plan offers
4. Review the premiums
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Network Benefit* Plan A Plan B Plan C
Deductible$300 Single$600 Family
$150 Single$300 Family
$1,500 Single$3,000 Family
Coinsurance 20% 35% 20%
Coinsurance Maximum$1,400 Single$2,800 Family
$3000 Single $6000 Family
None
Out-of-Pocket Maximum None None $3,000 Single$6,000 Family
Office Visit – Primary Care Providers
$25 Copay $20 Copay – Adult$10 Copay -
Children < age 19
Deductible & Coinsurance
Office Visit - Specialist $45 Copay $40 Copay - Adult $25 Copay -
Children < age 19
Deductible & Coinsurance
Preferred Lab Benefit Yes Yes No
*Use of Non Network providers will increase your out-of-pocket cost.
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Covered Preventive CareCovered Preventive Care
Services Services
Well Baby Exams - includes newborn screenings and age-appropriate office visits.
Well Child Exam – includes office visit and age-appropriate screenings and counseling.
Well Woman Exam - includes office visit and age-appropriate screenings and counseling.
Well Man Exam - includes office visit and age-appropriate screenings and counseling.
Prenatal Screening & Counseling - Limited screening services. See benefit description for details.
Ultrasonography for Aortic Aneurysm - Limited to one for men ages 65-75 with history of tobacco use.
Age-Appropriate Bone Density Screening
Mammography – not limited to one.
Immunizations Routine Hearing Exam
Colonoscopy – not limited to one.
Vision Exam – one covered per person per year
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Quest DiagnosticsQuest Diagnostics
www.questdiagnostics.com
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Stormont-Vail HealthCareStormont-Vail HealthCare
Stormont-Vail HealthCare is a new regional preferred lab vendor in NE Kansas.
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.
Covered lab procedures are covered at 100%.◦Show your medical ID card to access benefit.
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Stormont-Vail Draw Sites Stormont-Vail Draw Sites Facility Address City/State
Stormont-Vail HealthCare Laboratory
1500 SW 10th Ave Topeka, KS
Cotton-O’Neil 901 Laboratory 901 SW Garfield Topeka, KS
Cotton-O’Neil 823 Laboratory 823 SW Mulvane Topeka, KS
Cotton-O’Neil Croco Laboratory 2909 SE Walnut Drive Topeka, KS
Cotton-O’Neil Urish Laboratory 6725 SW 29th Street Topeka, KS
Cotton-O’Neil Carbondale Laboratory
211 East Main Carbondale, KS
Emporia Medical Arts Clinic 1301 W 12th Avenue, Suite 401
Emporia, KS
Cotton-O’Neil Wamego Laboratory 1704 Commercial Circle Wamego, KS
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CaremarkCaremarkPlans A & B Prescription Drug BenefitPlans A & B Prescription Drug Benefit
Generic Drugs◦20% Coinsurance
Preferred Brand◦35% Coinsurance
Special Case Medications ◦25% to a max of $75 per 30-day supply
Non Preferred Brand◦60% Coinsurance
www2.caremark.com/kse
Up to a sixty (60) day supply of most drugs available
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2011Nasacort 3rd
QtrLevaquin 3rd
QtrTegretol XR 3rd QtrCaduet 4th
QtrLipitor 4th
QtrZyprexa 4th
Qtr
2012• Avalide 1st Qtr• Avandia 1st Qtr• Lexapro 1st Qtr• Lescol 2nd Qtr• Provigil 2nd Qtr• Plavix2nd Qtr• Actos 3rd Qtr• Diovan 3rd Qtr• Maxalt 4th Qtr• Singular 4th Qtr• Tricor4th Qtr
www2.caremark.com/kse
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Full-Time EmployeeEmployee
Only*Employee +
Dependents*Employer Contribution
$75.00 mo.($900 a yr)
$112.50 mo.($1,350 a yr)
EmployeeContribution
$25 to $91.66 $25 to $204.16
Maximum Annual HSA Contribution
$3,100 $6,250
*All columns represent 24 semi-monthly deductions •Each health plan uses a different HSA vendor•HSA vendor info – www.kdheks.gov/hcf/sehp/HSA.htm•Employees must open their HSA account by 1/1/12•HSA account and funds belong to the employee•Minimum contribution to HSA of $25 semi-monthly by the employee is required•See the Health Plan Comparison Chart for part-time information.
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CaremarkCaremarkPlan C Drug PlanPlan C Drug Plan
Plan C now has a Coinsurance Drug PlanDrugs are subject to the Deductible, then:
◦Generic 20% Coinsurance◦Preferred Brand 35% Coinsurance◦Non Preferred Brand 60% Coinsurance◦Special Case Drugs 25% Coinsurance to a
max of $75Generic Incentive ProvisionNot creditable coverage
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Plan C Chronic Care BenefitPlan C Chronic Care Benefit
Prescription Drugs for:
Prescription Drug Product
Member ResponsibilityPer 30-Day Supply
Diabetes
Generic Drug Deductible and then 10%to a maximum of $10
Preferred Brand Drug
Deductible and then 20% to a maximum of $20
Asthma
Generic Drug Deductible and then 10% to a maximum of $10
Preferred Brand Drug
Deductible and then 20% to a maximum of $20
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Deltal DentalDeltal DentalDental CoverageDental Coverage
Plan pays in full for two exams & cleanings per person per year
Plan Deductible◦Applies to Basic & Major Restorative Care◦$50 per person, maximum of 3 per family
Orthodontic benefit ◦$1,000 per person per lifetime
Annual benefit maximum◦$1,700 per person per year
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Dental BenefitDental Benefit
Benefit Level PPO PremierNon
Network
Preventive Services
Covered in full
Covered in full
Allowed amount
covered in full
Basic Benefit
Basic Restorative
Services50% 50% 50%
Enhanced BenefitBasic
Restorative Services
20% 40% 40%
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Superior Vision/Vision PlanSuperior Vision/Vision PlanBasic Plan includes
$25 Materials Copay then: 100% single vision, standard bifocal, trifocal
lenticular lenses Up to $100 allowance for frames
Elective Contact lens allowance $150 Office visit subject to $50 Copay
Enhanced Vision Plan includes Basic, plus… Contact Lens Fitting Fee subject to $35 Copay High index lenses or Poly-carbonate lenses up to $116 Progressive lenses up to $165 Scratch and UV coating
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Open EnrollmentOpen Enrollment
New Enrollment portal for NSE Group Members - http://employee.hrissuite.com
Here you can complete your enrollment◦Make health plan selections◦Add/drop dependents◦Declare tobacco status ◦Coverage effective January 1, 2012
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Required DocumentationRequired Documentation
If you are adding a dependent, documentation of eligibility is required. Provide copies of:◦Birth certificates ◦Marriage licenses◦Affidavit of common law marriage◦Social Security numbers required
Documents due by 10/31/11 to your HR office
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DefaultsDefaults
Members currently enrolled in UMR who do not make an enrollment election will have United HealthCare for 2012.
Members currently enrolled in Preferred Health Systems who do not make an enrollment election will have Coventry/PHS for 2012.
If you fail to make a tobacco use election you will be defaulted to paying the base rates in 2012.
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Identification CardsIdentification Cards
All medical plans are issuing new ID cards.Delta Dental is issuing new ID cards.
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ResourcesResources
Review the Open Enrollment (OE) booklet
?’s: Call the health plan customer service◦Phone numbers in the front of the OE booklet
Visit the website: www.kdheks.gov/hcf/sehp.htm◦Benefit descriptions available◦Provider directory listings◦Preferred drug list
Email ?’s to SEHP: [email protected]
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Thank You for Attending Thank You for Attending
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Questions?Questions?
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Option SlidesOption Slides
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General practiceFamily practiceGeriatrics
Internal medicinePhysician extendersPediatrics
• Plans A & B only• PCPs have lower office visit copays • Member may have more than one PCP• No referrals required
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Network vs. Non NetworkNetwork vs. Non Network
Plan A - Non Network Provider
Service on 1/2/2011 Plan Pays Member PaysProvider Write-
Off
Billed Charge $1,500
Allowed Charge $1,400 $100 $0
$500 Deductible ($500) $500
50% Coinsurance $900 $ 450 $450
Total $450 $1,050 $0
Plan A - Network Provider
Service on 1/2/2011 Plan Pays Member PaysProvider 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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Plan A – Network ProvidersPlan A – Network Providers
Office Visit Copays◦$25 for Primary Care Office Visits◦$45 for Specialist Office Visits
$300/$600 Deductible 20% CoinsuranceCoinsurance Max $1,400/$2,800• Preventive Care Services paid at 100%
Lab Card Benefit
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Plan B – Network ProvidersPlan B – Network Providers
Primary Care Office Visits◦$20 Copay for Adults ◦$10 Copay for Children <age 18
Specialist Office Visits◦$40 Copay for Adults◦$25 Copay for Children <age 18
$150/$300 Deductible35% CoinsuranceCoinsurance max $3,000/$6,000• Preventive Care Services paid at 100%
Lab Card benefit
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Plans A & B Non Network ProvidersPlans A & B Non Network Providers$500/$1,500 Deductible50% CoinsuranceCoinsurance Max $3,650/$7,300Non Network Providers can balance billPreventive care not covered
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Plan C w/ Health Savings AccountPlan C w/ Health Savings AccountNetwork Provider Coverage
◦$1,500/$3,000 Deductible◦20% Coinsurance◦$3,000/$6,000 Out-of-Pocket Maximum◦Preventive Care Services paid at 100%
Non Network Provider Coverage◦$2,000/$4,000 Deductible ◦50% Coinsurance◦$3,650/$7,300 OOP Maximum ◦Preventive Care is not covered
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Dental Preventive CareDental Preventive CareCovered 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.
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Dental Restorative ServicesDental Restorative ServicesBasic Restorative
◦Regular restorative dentistry – fillings◦Oral surgery◦Endodontics – root canals ◦Periodontics – treatment of gum & bone disease◦Additional diagnostic X-Rays
Major Restorative◦Special restorative dentistry – crowns◦Prosthodontics – bridges, implants, dentures◦TMJ Treatment – Requires prior authorization
Restorative care is subject to a $50 deductible
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Dependent Eligibility ChangeDependent Eligibility Change
Effective 1/1/11, dependents are eligible to be covered on the plan to age 26 even if:◦they do not live with you◦they are not a student◦they are not dependent on you for support, or◦are married
Spouses of dependents are not eligible. Grandchildren are only eligible under limited
circumstances. You can add coverage for your eligible
dependents during this Open Enrollment.