State of Maine Employee Health & Benefits

1. State of Maine Employee Health & Benefits Insurance Update Revised 02/06/2013

2. 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

3. Who does what…..

4. Point of Service Plan: “Self-Insured ” 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.

5. 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

6. Types of medical expenses you pay for and those you don’t…. • 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

7. Types of providers

8. 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

9. 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)

10. 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

11. Thank you for attending! Questions?

12. Appendix

13. 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%

14. 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

15. 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

16. Summary of Plan Design Changes: Comparison 8/1/11 to 7/1/12 Any amount paid towards your 2012 deductible or coinsurance through June 30th will be applied to the new limits for July 1st.

17. 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

18. 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

19. 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.) www.maine.gov/deh

20. 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