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Benefits under State Health Benefit Plan

Benefits under State Health Benefit Plan. GASPA May 6, 2009. Presented by Bill Tierney. DCH Mission. RESPONSIBLE. HEALTHY. ACCESS. Access to affordable, quality health care in our communities. Responsible health planning and use of health care resources.

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Benefits under State Health Benefit Plan

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  1. Benefits under State Health Benefit Plan GASPA May 6, 2009 Presented by Bill Tierney

  2. DCH Mission RESPONSIBLE HEALTHY ACCESS Access to affordable, quality health care in our communities Responsible health planning and use of health care resources Healthy behaviors and improved health outcomes

  3. DCH InitiativesFY 2008 and FY 2009 FY 2009 FY 2008 Medicaid Transformation Health Care Consumerism Financial Integrity Health Improvement Solutions for the Uninsured Medicaid Program Integrity Workforce Development PeachCare for KidsTM Program Stability Customer Service Medicaid Transformation Health Care Consumerism Financial Integrity Solutions for the Uninsured Medicaid Program Integrity Workforce Development PeachCare for Kids Program Stability Customer Service and Communication

  4. State Health Benefit Plan Overview • Plan Options-Focus on Health Reimbursement Account (HRA) • When Member Retires-Focus on Medicare Advantage (MA) • Retiree Changes

  5. SHBP Plan Options – January 1, 2009(for active employees and retirees) Vendors: CIGNA and UnitedHealthcare – each offer: - Health Reimbursement Arrangement (HRA) - High Deductible Health Plan (HDHP) - Preferred Provider Organization (PPO) - Health Maintenance Organization (HMO) - Medicare Advantage Private-Fee-For-Service with Prescription Drug Plan (MAPD PFFS) (retirees age 65 or older and/or their spouses or those determined to be disabled by Social Security who are eligible for Medicare)

  6. Why Should You Consider a HRA? • Low employee premiums • SHBP provides dollar credits to use for all of your medical and pharmacy expenses and reduces your deductible and maximum out-of-pocket expenses • Unused dollar credits roll over to the next year • 100 percent coverage of preventive care and not charged against your HRA account • Unlimited provider choice • No Primary Care Physician designation, or specialistreferrals required

  7. HRA Plan Design • Health Reimbursement Account (HRA) • *$ 500 – Employee • *$1,000 – Employee + Spouse • *$1,000 – Employee + Child(ren) • *$1,500 – Employee + Spouse + Child(ren) • *Plus $125 for annual physical and completing a health assessment. Employee and spouse can each earn this. • SHBP credits your account each year to help pay covered medical expenses • HRA amount pro-rated if effective date after 1/1

  8. How an HRA Works – Single Coverage Health Coverage SHBP pays 90/60% up to $2,000 Out-of-pocket maximum ----$1,000 Deductible----- $500 Member Responsibility Preventive Care $500 Health Reimbursement Account – funded by SHBP

  9. How an HRA Works – Year Two • Member only had $200 • of non-preventive care • medical expenses in • year 1 • $300 of non-used HRA • dollars rolls over to • year 2 • SHBP credits another • $500 to HRA • HRA balance at beginning • of year 2 is $800 • Member responsibility to • meet deductible is now • only $200 Health Coverage SHBP pays 90/60% up to $2,000 Out-of-pocket maximum ----$1,000 Deductible----- $200 Member Responsibility Preventive Care $800 Health Reimbursement Account – funded by SHBP

  10. Winners & Losers Analysis • This analysis compares the out-of-pocket costs of two plans. Out-of-pocket costs include the member’s deductible, co-payments, coinsurance and employee contribution • In 2008, the HRA plan provided a better financial result for 75 percent of all members versus those in the HMO. The HRA plan provided a better financial result for 95 percent of all members versus those in the PPO

  11. When Member Retires Member may continue coverage at retirement if: • Eligible to receive and are receiving a monthly benefit from a Georgia-sponsored retirement system and • Enrolled in the SHBP at time of retirement − If the retiree wants to cover dependents (including spouse), they must be covered at the time of retirement NOTE: Retiree cannot continue health insurance if a lump sum distribution is taken from his/her Georgia-sponsored retirement system and retiree does not receive a monthly retirement benefit

  12. Changing Options • When the retirement benefit doesn’t cover premiums • When eligible for Medicare • Retiree may change to single coverage at any time • Retiree may drop SHBP at anytime (the retiree will not be able to get the coverage back unless the retiree returns to work in a benefits eligible position)

  13. Eligibility Questions Any questions regarding eligibility should be referred to: SHBP Call Center: 404-656-6322 800-610-1863 Note: This presentation is a summary and does not outline every situation where a member can make changes in coverage.

  14. Retirement and Medicare- under age 65 Retirees and/or their dependents not enrolled in Medicare: • SHBP is the primary insurer • Premiums are the same as active employees • Options under CIGNA and UHC are: * HRA * HDHP * HMO * PPO

  15. Age 65? If Continuing to Work- in a SHBP benefits eligible position past age 65, SHBP will pay primary benefits on the employee and all dependents regardless if covered by Medicare.

  16. Retirement and MedicareRetiree/and or dependent 65 or older • It is important that retiree enrolls in Medicare Parts A and B when eligible • Medicare Part B can purchased even if the retiree has not worked enough quarters to qualify • Retiree and spouse can purchase Medicare Part B if they are U.S. Citizens, reside in the U.S., age 65 or older (or a legal non-citizen, age 65 or older, who resides and has lived in the U.S. for at least 5 years)

  17. July 1, 2009 SHBP Retiree Policy Change • Retirees and/or their spouses 65 or older who are NOT enrolled in Medicare Part B will see a substantial increase in premiums • SHBP has sent numerous communications to these individuals without Medicare Part B notifying them of this change and urging them to enroll

  18. January 1, 2010 SHBP Retiree Policy Change Mandatory Medicare Advantage (MA) enrollment for all retirees and their covered spouses eligible for Medicare Retirees not enrolled in Medicare Part B will lose the 75 percent state subsidy and will pay the full premium Retirees can elect other SHBP options but will pay the full cost for the coverage

  19. Medicare Advantage Private-Fee-For-Service with Prescription Drug Coverage (MAPD PFFS) • These plans are custom for SHBP retirees and have enriched benefits that are structured to reduce/limit retirees out-of-pocket expenses • Sometimes called Medicare Part C Plans and are approved and partially funded by the U.S. Government • These plans take the place of the retiree’s original Medicare • Includes Part D prescription drug benefit • If a retiree purchases an individual Part D plan and is enrolled in our MAPD PFFS option, they will lose their coverage with SHBP

  20. MAPD PFFS Plan Benefits No deductibles $1,000 annual out-of-pocket maximum (medical) Primary Care Physician co-pays - $20 per visit Specialist co-pays - $25 per visit Inpatient hospital -$190 per day co-pay for days 1-4 then 100 percent coverage Worldwide emergency room coverage - 100 percent after $50 co-pay Annual physicals - 100 percent coverage after office visit co-pay

  21. MAPD PFFS Plan Benefits Routine Podiatry (6 visits per calendar year) Annual routine eye exams- $25 co-pay per visit Routine glasses, contact lenses and frames ($125 maximum every 2 years) Routine hearing exams and hearing aid benefit ($1,000 maximum every 4 years) Unlimited home health care visits Prescription drug coverage- $10/$25/$50/$50

  22. MAPD PFFS Plan Benefits(Prescription Drugs ) Most Medicare Part D plans have a deductible and what’s called a coverage gap commonly referred to as the “doughnut hole” There is no deductible under the SHBP MAPD PFFS prescription drug benefit and no “doughnut hole” Retirees will only pay their co-pay amount until they reach $4,350 out of pocket Once this limit is reached, the retiree will pay the greater of 5 percent coinsurance or reduced co-pays for generics and brand drugs ($2.40 -$6.00) for the remainder of the calendar year

  23. How the MAPD PFFS Options Work Simplicity because the retiree has one ID card, one customer service number and one Web site for his/her medical and pharmacy needs 100 percent coverage for covered medical expenses once the retiree’s low out-of-pocket maximum has been met for the Plan year No more coordination of benefits with Medicare as this is an all-inclusive plan in place of ‘traditional’ Medicare

  24. How the MAPD PFFS Options Work (Medical) Retirees: Are not required to use a specific network of doctors Can choose any Deemed Provider (a provider who is eligible to receive payment from Medicare and who agrees to the CIGNA Medicare Access Plus Rx or UnitedHealthcare Medicare Direct terms, conditions and payment rate) to receive care Simply need to show CIGNA or UnitedHealthcare ID card at every visit to receive service

  25. How the MAPD PFFS Options Work • Offered nation wide • No PCP required • No referrals • No prior authorizations

  26. Medicare Advantage MAPD PFFS Options - Provider Participation If the retiree’s doctor or hospital does not agree to be a Deemed Provider, any services received will not be covered under the Medicare Advantage MAPD PFFS options Retirees can receive assistance in finding an eligible provider at any time. He/she can call CIGNA's or United Healthcare's Customer Service toll free number

  27. Enrollment in MAPD PFFS Plans • Retirees must be enrolled in Medicare Parts A and B to enroll in the MAPD PFFS Plans • Enrollment in the MAPD PFFS Plans is based on CMS approval • Once CMS approves the members enrollment the information will be sent to SHBP • The effective date of coverage under the MAPD PFFS Plans will be determined by CMS Note: SHBP will expand the MAPD PFFS Plans to include “Part B Only” to accommodate retirees not enrolled in Part A Medicare 1/1/2010

  28. SHBP members who want specific information about the MAPD PFFS options should call the vendor directly at: More Information Eligibility questions - call the SHBP Call Center 404-656-6322 or 1-800-610-1863

  29. More Information www.dch.georgia.gov/shbp Numerous communications are available at the Web site above that will be helpful to active employees or retirees. Some of the items available are: Summary Plan Descriptions, Forms, prescription drug lists (PDL), Decision Guides, Fact Sheets.

  30. Important Coverage must be continuous from active into retirement!!! Retiree cannot re-enroll!

  31. Questions??

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