SHARP 2015

Supplemental Healthcare, Adventist Retirement PlanLisa Turpen RN

Associate Administrator/SHARP Manager

What is SHARP?

� SHARP is a self-funded, NAD employer-sponsored healthcare plan for retirees of Participating employers of the North American Division.

� SHARP is not insurance.

� SHARP is governed by the Adventist Retirement Board.

Medicare and SHARP

� Medicare is primary for all of your medical services and treatments.

◦ At age 65 and retirement you must be enrolled in Medicare Part A and Part B.� This is referred to as Original Medicare

◦ If Medicare does not approve a service SHARP will not approve or pay on the service.

� Medicare Part A = Hospital, Skilled Nursing Facility etc.

� Medicare Part B = Outpatient services/Doctor services/Ancillary services such as x-ray or laboratory.

Medicare Assignment

� Assignment means that your doctor or provider agrees to accept the Medicare-approved amount.

◦ These providers are called “participating providers”.

� They agree to charge you only the Medicare deductible

and coinsurance amount. (80% paid by Medicare, 20% retiree coinsurance)

◦ They usually wait for Medicare to pay its share before asking you to pay your share.

� If you are enrolled in either the Base Option or the MCx Option, SHARP assists you with the Medicare deductible and coinsurance.

SHARP Eligibility

� SHARP is available at the time of retirement. The retiree must be a participant in the NAD Defined Benefit and/or Defined Contribution Plan.

◦ Eligibility is determined by your eligible NAD (church) Years of Service credit.

� 15 years is the minimum years of service credit required to be eligible to participate in SHARP

SHARP Open Enrollment

� Retiree has a one-time Open Enrollment. ◦ Calculated from the year of retirement.

• The three year open enrollment occurs in the fall of the year.• changes become effective January 1 of the following plan year.

Retired 6-1-2013

� Open Enrollment in the fall of 2016

� Changes become effective 1-1-2017

SHARP policy: if a retiree or spouse terminates any benefit it is a lifetime termination. SHARP will require written notice from the retiree. (see page 8; Requested Termination of Benefit in the 2015 Standard SHARP document)

Spouse Eligibility Post Retirement

� In January of 2014 the SHARP plan changed to allow a retiree who remarries after retirement to enroll the newly acquired spouse in SHARP.

◦ The retiree must notify SHARP within 30 days of the marriage.

◦ The spouse is not eligible for the earned credit.

◦ If the spouse is a full-time employee with healthcare offered by an employer that healthcare must be primary for the spouse. SHARP could be secondary.� (page 4)

SHARP Monthly Cost -2015

� Base Option $35/month/person

� MCx Option $145/month/person

� DVH Option $65/month/person

� RX Option $120/month/person

� Pre-Medicare Option $440/month/person

� Non-Medicare Option $138/month/person

SHARP Base & MCx Options –Page 15

� Base Option –secondary to Medicare

◦ $2100 deductible/person

� Medicare pays 80%

� Retiree pays 20%

◦ Once the $2100 deductible (retiree’s 20%) is met SHARP pays 100% of Medicare approved retiree coinsurance

� MCx Option –secondary to Medicare

◦ No Deductible◦ SHARP pays 100% of Medicare approved claim deductible and coinsurance

SHARP Base & MCx Options

� Includes One dental exam and cleaning paid at 100% each year

� Includes Foreign Travel Emergency Medical Coverage◦ $1000 deductible (not included in the Base Option deductible) - $50,000 limit/year

◦ Personal Travel 60 days or less

◦ Does not cover denominational sponsored travel

◦ You must pay the claim in the country you are visiting. Upon your return to the U.S. you submit your claim and receipts to ARM at the address listed on the back of your ID card.

Short Term Travel Insurance through ARM (Adventist Risk Management, Inc.� Phone: 1-888-951-4276

� Email: sttservice@adventistrisk.org

� ARM website: www.adventistrisk.org

SHARP DVH Option(Dental, Vision, Hearing)

The DVH Option is a standalone benefit in SHARP. (pages 18 & 19)� Dental Benefit: $2200.00 SHARP paid annual limit (exclusions are listed on page 18; cosmetic, TMJ, Orthodontia, experimental treatments, temporary services etc.)

� Vision Benefit: $400 SHARP paid annual limit

� Hearing Benefit: $2200.00 SHARP paid annual limit (look-back provision of one year to access unused benefits from the previous Plan year).

SHARP Rx Option is Express Scripts Medicare PDP

� All age 65 participants are required to be eligible for Medicare Part A or enrolled in Medicare Part B.

� The retiree Does Not enroll in a Medicare D plan on their own.

� The base Medicare D premium is paid by SHARP/Adventist Retirement Plan and not by the retiree.

� Welcome Kit from Express Scripts includes an Evidence of Coverage booklet.

SHARP Rx Three Tier Copay

Retail 30, 60, 90 day supply Home Delivery 90 day supply

� $12/30 day supply Generic

� $29/30 day supply Brand

� $45/30 day supply Non-Preferred

� A 60 day supply is 2 times the 30 day supply copay.

� A 90 day supply is 3 times the 30 day supply copay.

� $29/90 day supply Generic

� $70/90 day supply Brand

� $110/90 day supply Non-Preferred

How it works in 2015

Initial Stage

• You pay the copay until your Medicare D drug spend reaches $2960.00 (gross drug cost paid by you, SHARP and the manufacturer)

Coverage Gap Stage

• You continue to pay the copay until your Medicare D spend reaches $4700.00 (TrOOP, your true out of pocket costs, paid in this phase)

Catastrophic Stage

• After your costs reach $4700.00 you pay• Either 5% coinsurance or• $2.65 for generic• $6. 60 for brand

Coverage Gap Out-of-Pocket Limit

Brand drugs in the Coverage Gap of a Medicare D program include a manufacturer discount of 50%.

• The amount the retiree pays in copayment counts toward your true out-of-pocket (TrOOP) costs in the Coverage Gap.

• SHARP pays the remainder.

• SHARP’s payment does not count toward the retiree/spouse yearly out-of-pocket limit.

Generic drugs in the Coverage Gap of a Medicare D program include a retiree copay.

• SHARP pays the remaining price of the drug.

• The amount SHARP pays for generic drugs in the Coverage Gap does not count toward the retiree yearly out-of-pocket limit.

Penalties

The Centers for Medicare and Medicaid Services (CMS) established a penalty in the Medicare D program for retirees with high incomes. CMS looks at the past two years of tax returns and Social Security income.

High Income Earner penalty = retiree pays the penalty fee directly to CMS. SHARP does not assist with this fee.

� Tax return for a single of $85,000/year or

� Tax return for a family of $170,000/year.

SHARP RX Option

• Each enrolled participant will receive a list of participating pharmacies in their demographic region. (Evidence of Coverage booklet)

• The Medicare Rx Option retiree/eligible spouse will have a yearly opt out period: November – December

• There are individual prescription drug ID cards.

Medication Management Therapy

� The Express Scripts Medicare PDP program offers you assistance with managing your medications.

◦ This is voluntary program

◦ Work with you and your physician

◦ Information on enrollment can be found in the Evidence of Coverage booklet in chapter

Medicare and the Affordable Care Act

� The healthcare act has placed a few requirements on Medicare.◦ Quality review process for providers.

◦ Durable Medical Equipment regional supplier bidding rule changes.

◦ Mental health parity: Medicare pays the same as medical services.

◦ Manufacturer prescription drug discounts in Medicare D plans Coverage Gap.

◦ Medicare began reducing the cost of generic drugs in the Coverage Gap by providing a subsidy of 7%. This will increase each year by 7% until the retiree cost sharing portion is reduced from 47.5% to 25%.

◦ Medicare began in 2013 to pay a portion of the cost of Brand name drugs in the coverage gap/donut hole (25% federal subsidy) and by 2020 the retiree cost sharing portion in the coverage gap is reduced to 25%.

The ACA rules regarding healthcare exchanges and taxes/fines do not apply to the SHARP retiree with Medicare primary.

Medicare Part B Premium Reimbursement-Page 12

� SHARP assists the retiree and eligible spouse with Defined Benefit Plan service with the Medicare Part B premium in 2015 of $104.90. This is a separate line item on your January statement of benefits.

◦ This is a non-taxable benefit item

Medicare Part B Table: 2014 $104.90

Category A 35+ Years 90% $94.41

Category B 30-34 Years 80% $83.92

Category C 25-20 Years 70% $73.43

Category D 20-24 Years 60% $62.94

Category D 15-19 Years 50% $52.45

Earned Credit - 2015

2015 Earned Credit

Retirement Plan Service Credit

35 +Yrs.30-34 Yrs.

25-29 Yrs.

20-24 Yrs.

15-19 Yrs.

8-14 Yrs.**

5-7 Yrs.**

Category A B C D E F G

Standard SHARP (Eligible Retiree and Eligible Spouse)

$220 $200 $175 $155 $130 $110 $90

Pre-Medicare SHARP (Eligible Retiree and Eligible Spouse)

$440 $385 $330 $275 $220 $170 $110

Non-Medicare SHARP (eligible dependent children)

$138 $121 $104 $86 $69 $52 $35

Sample Monthly SHARP Cost

� Base Option $35.00

� DVH Option $65.00

� Rx Option $120.00

Total of selections: $220.00

Less the Earned Credit: - $200.00 (category B, 30-35 years)

Total/Month : $20.00

Retirement Website

� The current SHARP plan document

� Summary of Coverage and Benefits

� Notice of Privacy practices

� Reflections Newsletter

� Creditable Coverage notice for Pre-Medicare/Non-Medicare members

◦ www.adventistretirement.org

SHARP Department

Gayle Fell/SHARP Assistant

(Retiree last name A-K)

Vernon Roger/SHARP Assistant

(Retiree last name L-Z)

Lisa Sharpe/SHARP Assistant

(Express Scripts Liaison)