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State Employee Health Plan

State Employee Health Plan . Open Enrollment 2012. Health Care Commission (HCC) . Approved employee & employer rates Agency composite rates increases 12.5% on 7/1/10 15% on 7/1/11 7.5% on 7/1/12 Return to the 95/55 employer contribution C overage cost for employee-only will increase

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State Employee Health Plan

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  1. State Employee Health Plan Open Enrollment 2012

  2. Health Care Commission (HCC) • Approved employee & employer rates • Agency composite rates increases • 12.5% on 7/1/10 • 15% on 7/1/11 • 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

  3. Other HCC Action • No plan design changes for Plans A and B • Plan design changes for Plan C pharmacy benefit • Added Stormont-Vail HealthCare as a regional preferred lab vendor • Quest will continue to offer a statewide preferred lab option • Added the HealthQuest Rewards Program

  4. Legislative 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

  5. 2012 SEHP Medical Plans • 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 • All plans include preventive care

  6. Covered Preventive Care

  7. Vendor Options

  8. *Use of Non Network providers will increase your out-of-pocket cost.

  9. Selecting a Medical Plan • Pick a plan design (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 • Review the other services each medical plan offers 4. Review the premiums

  10. Quest Diagnostics • Statewide & nationwide preferred lab vendor • 100% coverage for eligible outpatient lab tests • For non-emergency outpatient lab work only • Testing must be performed and billed by Quest • Available on Plans A and B only • Your Doctor can draw the sample - or- • Visit a Quest website for collection sites • Online appointment scheduling available • Use Your Quest ID card or medical id card www.labcard.com

  11. Stormont-Vail HealthCare • Stormont-Vail HealthCare is a new regional preferred lab vendor in NE Kansas. • 100% coverage for eligible outpatient lab tests • 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.

  12. Stormont-Vail Draw Sites

  13. Plans A & B 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 Up to a sixty (60) day supply of most drugs available www2.caremark.com/kse

  14. Generic Launches • 2012 • Avalide 1st Qtr • Avandia 1st Qtr • Lexapro 1st Qtr • Lescol 2nd Qtr • Provigil 2nd Qtr • Plavix 2nd Qtr • Actos 3rd Qtr • Diovan 3rd Qtr • Maxalt 4th Qtr • Singular 4th Qtr • Tricor 4th Qtr 2011 • Nasacort 3rd Qtr • Levaquin 3rdQtr • Tegretol XR 3rdQtr • Caduet 4th Qtr • Lipitor 4th Qtr • Zyprexa4thQtr • nn www2.caremark.com/kse

  15. *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.

  16. Plan C Drug Plan • Plan C now has a Coinsurance Drug Plan • Drugs 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 $75 • Generic Incentive Provision • Not creditable coverage

  17. Plan C Chronic Care Benefit

  18. Dental 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

  19. Dental Benefit

  20. Vision Plan Basic 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 or Poly-carbonate lenses up to $116 • Progressive lenses up to $165 • Scratch and UV coating

  21. Flexible Spending Accounts • Health Care Flexible Spending Account • For Plan A and B members only • Dependent Care Flexible Spending Account • Pre-tax contributions • Up to $5,000 per account per year • Grace period for Health Care FSA • Details on eligible expenses available at: www.asiflex.com

  22. Optional HCFSA Debit Card • Visa card to access funds • Documentation may still be required by ASI • Debit card election form is mailed to you • You pay a $12 nonrefundable service fee per year • Debit card enrollment rolls from year to year • Current debit card users must contact ASI to cancel debit card enrollment www.asiflex.com

  23. Limited FSA for Plan C • Can set aside funds for dental and vision expenses only • Cannot be used for medical expenses • HSA account is designed for that purpose • “Use it or lose it” applies to this account • Funds must be used by December 31 each year

  24. Open Enrollment • Enroll online: • Make health plan selections • Add/drop dependents • Declare tobacco status • Enroll in Flexible Spending Accounts • Enroll in HealthyKIDS • Families at 250% of poverty level • State pays 90% of children’s premium • Enroll at:https://khap.kdhe.state.ks.us/hkapplication/ • Coverage effective January 1, 2012

  25. Required 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 • Document due by 10/31/11 to HR office

  26. Defaults • 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.

  27. Identification Cards • All medical plans are issuing new ID cards. • Delta Dental is issuing new ID cards. • Vision and Drug are not issuing new car

  28. 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 website: www.kdheks.gov/hcf/sehp.htm • Benefit descriptions available • Provider directory listings • Preferred drug list • Information on the HSA and FSA accounts • Email ?’s to SEHP:benefits@kdheks.gov

  29. Questions?

  30. Option Slides

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

  32. Network vs. Non Network

  33. Plan A – Network Providers • 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 • Preventive Care Services paid at 100% • Lab Card Benefit

  34. Plan B – Network Providers • Primary Care Office Visits • $20 Copay for Adults • $10 Copay for Children <age 18 • Specialist Office Visits • $40 Copay for Adults • $25Copay for Children <age 18 • $150/$300 Deductible • 35% Coinsurance • Coinsurance max $3,000/$6,000 • Preventive Care Services paid at 100% • Lab Card benefit

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

  36. Preferred Lab Benefit Expanded • Available on Plans A and B only • 100% coverage for eligible outpatient lab tests • Two vendors participating in the program • Quest Diagnostics -- Statewide/Nationwide access • Stormont Vail Healthcare -- Regional access

  37. Stormont-Vail HealthCare • Stormont-Vail HealthCare is a new regional preferred lab vendor in NE Kansas. • Cotton O’Neil patients will automatically participate • Non Cotton O’Neil patients in Plans A or B may visit one of the 8 draw site locations • Take your Medical ID card • Photo ID • Doctor’s Lab orders • Covered lab procedures are covered at 100%.

  38. Plan C w/ Health Savings Account • 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 OOP Maximum • Preventive Care is not covered

  39. Dental Preventive Care • Covered 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.

  40. 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

  41. 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.

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