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State Employee Health Plan

State Employee Health Plan. Open Enrollment 2011. State of the Plan. Claim expense continues to outpace revenue Plan reserves are low Bill passed requiring claim audits Audits to recover claims paid in error $9 million removed from health care fund 7/1/10 Health Care Commission voted to:

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State Employee Health Plan

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  1. State Employee Health Plan Open Enrollment 2011

  2. State of the Plan • Claim expense continues to outpace revenue • Plan reserves are low • Bill passed requiring claim audits • Audits to recover claims paid in error • $9 million removed from health care fund 7/1/10 • Health Care Commission voted to: • Increase employee and employer rates • Agencies will see a 15% increase • Employee rates increase up to 8% • Plan design changes for Plan A & B

  3. Medical Plan Changes for 2011 • Plan A • Network Deductible increased to $300/$600 • Network Coinsurance maximum increased $1,400/$2,800 • Office visit Copays • Primary Care Provider $25 • Specialist $45 • Plan B • Network Deductible added $150/$300 • Network Coinsurance increased 5% to 35% • Network Coinsurance maximum increased to $3000/$6000 • No changes for Plan C

  4. Legislative Changes • Senate Subs. For House Bill 2160 Requires a one-year pilot to provide coverage for: • Autism spectrum disorder • Birth to 7 years - not to exceed $36,000 • Age 7 to 19 - not to exceed $27,000 • Covered services subject to applicable deductible, coinsurance and copays • Services must be medically necessary • Report due to the legislature March 2012 • Oral cancer medications • Requires coverage of oral drugs in the same manner as IV cancer medications.

  5. Patient Protection & Affordable Care Act • Signed into law on March 23, 2010 • Incorporates modifications of the Health Care and Education Reconciliation Act of 2010 • Signed into law on March 30, 2010 • Jointly referred to as Health Reform • Complex law • Implementation is in phases

  6. Key Provisions for 2010 • Mandates coverage for children to age 26 • No school or support requirements • Can be married – (no coverage for spouses) • Requirement effective for SEHP on 1/1/11 • Enroll your dependents during Open Enrollment • Prohibits lifetime maximums on “essential services” for medical plans

  7. Key Provisions for 2010 • Authorizes the FDA to approve generic versions of biologic drugs • 12-year exclusivity period on biologic drugs • Provides temporary reinsurance program for early non Medicare retirees (age 55-65) • Limited to $5 billion dollars • Reimburses the health plan for amount spent on high cost claims of early retirees • Temporary expires in 2014 • SEHP has applied for the program • Requires coverage without cost sharing for preventive services

  8. Covered Preventive Care

  9. Key Provisions for 2011 • Excludes over the counter (OTC) products without a prescription as eligible expenses: • Health Care Flexible Spending Account (FSA) • Plan C - Health Savings Account (HSA) • Increases the taxes on HSA funds not used for medical purposes • Employers required to disclose value of health benefits on W-2 form

  10. 2011 SEHP Medical Plans • Standardized Plan designs: • All plans include preventive care • All plans are Preferred Provider Organizations (PPO) • Claims paid based on the network status • Network providers accept the plan allowance as payment in full • Non Network Providers can balance bill

  11. Vendor Options

  12. Selecting a Medical Plan • Pick a plan design (Plan A, B or C) • Which plan design provides the coverage you and your family need? • Review the Provider Networks • Each of the medical plans uses a different provider network • Not all providers are in the network • Review the other services each medical plan offers • Websites, discount programs, etc. 4. Review the premiums

  13. Plan A – Network Providers • Preventive Care Covered at 100% • 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 • Quest Lab Card Benefit

  14. Plan B – Network Providers • Preventive Care Covered at 100% • Primary Care Office Visits • $20 Adult Copay • $10 Children age 18 and under Copay • Specialist Office Visits • $40 Adult Copay • $25Children age 18 and under Copay • $150/$300 Deductible • 35% Coinsurance • Coinsurance maximum $3,000/$6,000 • Quest Lab Card benefit

  15. Plans A & B Non Network Providers • $500/$1,500 Deductible • 50% Coinsurance • Coinsurance Max $3,650/$7,300 • Preventive care not covered

  16. Quest Lab Card • Optional Lab Card Program • Benefits: • 100% coverage of eligible outpatient lab tests • Saves you and the plan money • For non-emergency outpatient lab work only • Testing must be performed and billed by Quest • You will need to request to use Quest Or • Visit a Quest collection site • The decision is up to you and your provider • You have a Quest ID card • Your medical card ID also works

  17. Quest Lab Card Savings Charges on a typical lab claim for: CBC, Lipid Panel, TSH & Basic Metabolic Panel Plan saves $89.36 and Employee saves $31.17 Source: Quest Diagnostics, Inc. Current Lab Fees Billed $194.83 Allowed: $155.86 Coinsurance 80% Plan pays $124.69 Member pays $31.17 Lab Card Fees Total Charges $35.33 Allowed: $35.33 Coinsurance 100% Plan pays $35.33 Member pays $0

  18. True or False • My doctor’s office said I had to use Quest for lab services or I would have no lab coverage. False. Quest is an optional program. You are not required to use it and you do have coverage at other labs. • My provider said that I had to transport my pap smear specimen to a Quest site to have coverage. False. Preventive care services such as a pap smears are covered at 100% when provided by a network provider. Quest is one of the network providers.

  19. Plan A & B Drug Benefit Generic Drugs • 20% Coinsurance Preferred Brand • 35% Coinsurance Special Case Medications • $75 per 30-day Supply Non Preferred Brand • 60% Coinsurance Discount Tier • 100% Member Responsibility More information: www2.caremark.com/kse

  20. Generic Launches 2010 • Flomax • Cardizem La • Skelaxin • Cozaar • Hyzaar • Yaz • Arimidex • Effexor XR • Amerge • nn • 2011 • Aricept 2nd Qtr • Levaquin 2nd Qtr • Nasacort AQ 2nd Qtr • Serevent Diskus 3rd Qtr • Tegretol XR 3rd Qtr • Xeloda 3rd Qtr • Femara 4th Qtr • Lipitor 4th Qtr • Zyprexa 4th Qtr

  21. Plan C – QHDHP w/ HSA • Network 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 Out-of-Pocket Maximum • Preventive Care is not covered

  22. Plan C – QHDHP Drug Plan • Drugs are subject to the Deductible then: • Generic $10 Copayment • Preferred Brand $30 Copayment • Non Preferred Brand $55 Copayment • Copayment is per 31-day supply • Generic Incentive Provision • Uses Caremark Preferred Drug List • Not “creditable” drug coverage for Medicare

  23. Dental Coverage • Plan pays in full for two cleanings and oral exams each year for each member • 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

  24. Basic Benefit • If you have NOT had a preventive exam or office visit for exam or cleaning of the teeth in the preceding 12-month period:

  25. Enhanced Benefits • If you have had at least one preventive or office visit for cleaning or exam of the teeth in the preceding 12-month period:

  26. Vision Plan • Basic Plan • Eye exams subject to $50 Copay • $25 Materials Copay then: • 100% single-vision, standard bifocal, trifocal lenticular lenses • Up to $100 allowance for frames • Elective Contact lens allowance $150 • Enhanced Vision Plan includes Basic PLUS… • Progressive lenses up to $165 • High index lenses or Poly-carbonate lenses up to $116 • Scratch and UV coating • Contact Lens Fitting Fee - subject to $35 Copay

  27. Flexible Spending Accounts • Health Care Flexible Spending Account • Deductibles, Copays & Coinsurance • Eyeglasses, contacts, orthodontics & hearing aids • Optional Debit Card for health care FSA • Dependent Care Flexible Spending Account • Day care services & Pre-school or Babysitters • Pre-tax contributions • Up to $5,000 per account per year • Extended grace period for Health Care FSA • Details on eligible expenses available at: www.asiflex.com

  28. Optional HCFSA Debit Card • Optional Debit Card for health care FSA • Information will be sent to you to elect debit card • You pay a $12 service fee per year • Non refundable fee is charged at the beginning of the year • Debit cards roll from year to year • Current debit card users must contact ASI to cancel debit card enrollment • Must notify ASI no later than December 15, 2010 to avoid the $12 fee for 2011

  29. Over the Counter Drugs • Effective January 1, 2011, over the counter drugs will require a physician prescription to be eligible under an HFSA. • Change due to the Patient Protection and Affordable Care Act • For a list of OTC drugs that require a prescription go to:www.asiflex.com • Debit card may not be used for OTC drugs after 1/1/11

  30. Limited FSA for Plan C • New limited FSA available for members on Plan C. • Can set aside funds for dental and vision expenses only • Cannot be used to fund medical expenses • HSA account is designed for that purpose • Debit card not available for use with this account • Contribution limit same as Health Care FSA • “Use it or lose it” applies to this account as well

  31. HealthQuest • Health Screenings & Online Health Assessment • $50 gift card for completion • 24/7 Nurse Line • Lifestyle Health Coaching • Condition Management Programs • Tobacco Cessation Program • Employee Assistance Program (EAP) • 24/7 confidential support • Personal counseling & referrals • HealthQuest Website, Portal, Newsletter & Blog • Wellness Presentations • Wellness Champion Network http://www.sehbp.org/healthquest

  32. Non Tobacco Users Discount • You must disclose your tobacco status • Discount available for: • Non tobacco user - or - • Tobacco users agreeing to enroll and complete the HealthQuest tobacco cessation program • You may begin the tobacco cessation program now! • You must complete 5 tobacco discussions by May 1, 2011 • Discount is based oncompletingthe program

  33. Paying the Base Rate in 2011 • The following will NOT be receiving the discount: • Elects not to disclose Tobacco status • Tobacco users not enrolled in the tobacco cessation program • Failed to enroll online and disclose tobacco status • Members who enroll but fail to complete the tobacco cessation program by May 1, 2011 will lose their discount for the remainder of 2011.

  34. Annual Open Enrollment • October 1 – October 31, 2010 • Enroll online: • Declare tobacco status (Annual enrollment required) • Make health plan selections • Add/drop dependents • Enroll in Flexible Spending Accounts • Enroll in HealthyKIDS • Families at 250% of poverty level • State pays 90% of children’s premium • Same coverage Must enroll every year • Coverage effective January 1, 2011

  35. Dependent 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

  36. Required Documentation • If you are adding a dependent, documentation of eligibility is required • Birth certificates • Marriage licenses • Affidavit of common law marriage • Social Security numbers required • Document due by 11/1/10 • If documentation is not received, dependents will not be added to your plan for 2011

  37. Identification Cards • To receive a new ID card, your address in SHARP must be accurate. • Last year we received over 15 tubs of returned mail due to incorrect member addresses • ID cards delayed due to manual look-up required • Plan A members will be getting new health plan ID cards • Dental and Vision members will get new cards • If you need a new ID card, call the vendor

  38. Resources • Review the Open Enrollment (OE) booklet • ?’s call the health plan customer service • Phone numbers in the front of the OE booklet • Visit the KHPA website: www.sehbp.org • Benefit descriptions available • Provider directory listings • Preferred drug list • Information on the HSA and FSA accounts • Email ?’s to SEHP: benefits@khpa.ks.gov

  39. Open Enrollment Checklist • Enrollment Online: • Consider enrolling your dependent children under age 26 • Review health plan selections • Must declare tobacco status • Enroll in HealthyKIDS • Enroll in flexible spending accounts • Confirmation statements • Available online 12/15/10

  40. Questions?

  41. Option Slides

  42. Network vs. Non Network

  43. Primary Care Providers (PCPs) • General practice • Family practice • Geriatrics • Internal medicine • Physician extenders • Pediatrics • PCPs have lower office visit copays • Plans A & B only • Member may have more than one PCP • No referrals required

  44. Dental Preventive Care • Covered in full: • Prophylaxis/cleanings – twice per year. • Oral examinations – twice per year. • Bitewing x-rays – • adults - 1x 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.

  45. Dental Restorative Services • Basic 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

  46. Claiming Your Flex Funds • Optional Debit Card for health care FSA • Information will be sent to you to elect debit card • You pay a $12 service fee per year • Fee is charged at the beginning of the year • You may still need to send documentation to ASI • Reimbursements by check or direct deposit available • Fill out a claim form, attach receipts, and mail or fax to ASI. • Fill out form electronically, attach electronic copies of receipts, and email to: claims@asiflex.com

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