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Importance of Your Decisions

State of Tennessee Group Insurance Program New Employee Benefits Orientation Higher Education Employees - 2014. Importance of Your Decisions. The decisions you make now as a new employee will have lasting effects on your benefits

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Importance of Your Decisions

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  1. State of TennesseeGroup Insurance ProgramNew Employee Benefits Orientation Higher Education Employees - 2014

  2. Importance of Your Decisions • The decisions you make now as a new employee will have lasting effects on your benefits • Please note: some of your decisions can only be made during the new hire period • Please make sure that you are aware of all the options available to you and that you make an informed decision • Submit any questions to your Agency Benefits Coordinator (ABC) or Benefits Administration www.partnersforhealthtn.gov1-800-253-9981

  3. Resource Materials For more detailed information, refer to the Eligibility and Enrollment Guide provided by your ABC. You will also be provided with an Employee Checklist to confirm that you have been informed of important benefits information www.partnersforhealthtn.gov1-800-253-9981

  4. Resource Materials The Summary of Benefits Coverage (SBC) describes your health coverage options. You can print a copy on the Benefits Administration website, or ask your ABC for a copy. www.partnersforhealthtn.gov1-800-253-9981

  5. About the Plan • The State Group Insurance Program (also called the Plan) covers three different populations: • State and Higher Education Employees • Local Education Employees • Local Government Employees • We spend about $1.3 billion annually and cover nearly 300,000 members • The health plan is self-insured, meaning that the State, not an insurance company, pays claims from premiums collected from members and their employers • The Division of Benefits Administration manages the State Group Insurance Program and works with your Agency Benefits Coordinator (ABC) to serve our Plan members www.partnersforhealthtn.gov1-800-253-9981

  6. Who is Eligible for Coverage? • Generally, full time employees are eligible for health insurance coverage as well as their dependents, who may include: • Legally married spouses • Children up to age 26, including natural, adopted or step-children or children for whom the employee is the legal guardian • There are special circumstances for employees with disabled dependents that may allow for coverage of these dependents after age 26 • For more information about disabled dependents, refer to the Eligibility and Enrollment Guide or consult your ABC www.partnersforhealthtn.gov1-800-253-9981

  7. Notice to TennCare Enrollees • You must contact your caseworker at the TennCare within 10 days of your date of employment • Report to TennCare your new job, salary and that you have access to medical insurance with your new employer • Employees cannot be enrolled in both TennCare and a State Group Health Insurance plan www.partnersforhealthtn.gov1-800-253-9981

  8. Adding Coverage • There are only three times you may add health coverage: • As a new employee • During the fall Annual Enrollment • If you experience a special qualifying event • A specific life change, such as marriage, the birth of a baby or something that results in loss of other coverage • Must submit paperwork within 60 days of the event or loss of other coverage • A complete list is provided on page three of the enrollment application www.partnersforhealthtn.gov1-800-253-9981

  9. Annual Enrollment • During Annual Enrollment, you may: • Add health insurance coverage • Change health insurance carriers • Choose a different PPO or health insurance carrier • Cancel health insurance coverage • Changes are effective January 1 of the following year • Add, cancel or make changes to optional benefits during Annual Enrollment Annual Enrollment occurs each year during the fall, usually around October. www.partnersforhealthtn.gov1-800-253-9981

  10. Canceling Coverage • You may only cancel health, dental or vision coverage for yourself or your dependents: • During Annual Enrollment • If you become ineligible to continue coverage • If you experience a qualifying event listed on the Insurance Cancel Request Application • You cannot cancel coverage during the plan year, outside of Annual Enrollment, unless you have a qualifying event or lose eligibility under the plan www.partnersforhealthtn.gov1-800-253-9981

  11. Definitions • Premiums are the amount you pay each month for your coverage regardless of whether or not you receive health services • A copay is a flat dollar amount you pay for services and products, like office visits and prescriptions • A deductible is a set dollar amount that you pay out-of-pocket each year for services • Co-insurance is a form of payment where you pay a percentage of the cost for a service, after meeting your deductible www.partnersforhealthtn.gov1-800-253-9981

  12. Definitions • The out-of-pocket co-insurance maximum is the limit on the amount of money you will have to pay each year in deductibles and co-insurance • The out-of-pocket copay maximum limits how much you pay for certain in-network services that require copays • A network is a group of doctors, hospitals and other health care providers contracted with a health insurance plan to provide services to members at pre-negotiated (and usually discounted) fees • The maximum allowable charge (MAC) is the most a plan will pay for a service For a complete list of definitions, see the Eligibility and Enrollment Guide or visit our website. www.partnersforhealthtn.gov1-800-253-9981

  13. Choosing Your Health Insurance Options    • Choose between Two Preferred Provider Organization (PPO) Options • Partnership PPO • Standard PPO • Choose an Insurance Carrier • BlueCross BlueShield of Tennessee • Cigna - Open Access Plus or LocalPlus Networks (LocalPlus is available in Middle Tennessee only) • Choose between Four Premium Levels • Employee • Employee + child(ren) • Employee + spouse • Employee + spouse + children After the initial new hire period, changes can only be made if you experience a special qualifying event or during Annual Enrollment in the fall. www.partnersforhealthtn.gov1-800-253-9981

  14. PPO Options • There are two health insurance options available to you: • Partnership PPO • Standard PPO • Both of these options are Preferred Provider Organizations (PPOs) • How a PPO Works: • Visit any doctor or hospital you want • However, the PPO has a list of in-network doctors, hospitals and other providers that you are encouraged to use • These in-network providers have agreed to take lower fees so you pay less for services • You will pay more for non-emergency services from out-of-network providers www.partnersforhealthtn.gov1-800-253-9981

  15. Partnership PPO Rewards members for taking an active role in their health Commitment to Partnership Promise is required Comparing Your PPO Options  Step 1: Choose Your PPO Option • Standard PPO • No incentives for healthy behaviors • Members pay a greater share of costs Both options cover the same services and treatments. However, you will always pay less for services if you are enrolled in the Partnership PPO. www.partnersforhealthtn.gov1-800-253-9981

  16. Partnership PPO • Healthways administers the Partnership Promise • Partnership PPO members pay much lower premiums • The Partnership Promise is an annual commitment • In order to remain in the Partnership PPO, members and covered spouses must complete the Partnership Promise each year • The Partnership Promise requirements may change from one year to the next www.partnersforhealthtn.gov1-800-253-9981

  17. Partnership Promise – 2014 New Members • 2014 new members and covered spouses must: • Complete the online Well-Being Assessment (WBA) • Get a biometric health screening • * Both requirements must be completed within 120 days of your insurance coverage effective date www.partnersforhealthtn.gov1-800-253-9981

  18. Partnership Promise Online Well-Being Assessment (WBA) • Summarizes your overall health and offers steps you can take to improve • By completing the confidential assessment online, you will learn more about your physical, emotional and social health and how your lifestyle habits affect your overall well-being • Go to www.partnersforhealthtn.gov and create an online well-being account to access the assessment You (and your covered spouse) will have 120 days from your coverage effective date to complete the Well-Being Assessment (WBA). 17 www.partnersforhealthtn.gov1-800-253-9981

  19. Partnership Promise Biometric Health Screening • A biometric health screening is required within 120 days of your insurance coverage effective date • Screening includes height, weight, waist circumference, blood sugar, blood pressure and cholesterol levels • There are two ways to get a screening in 2014: • At a worksite screening • Go to www.partnersforhealthtn.gov, and in the QuickLinks box, click on Complete Your Biometric Screening to register for a worksite screening in your area • At your doctor’s office • You may use screening results from a doctor’s visit within the last 12 months • Ask your doctor to complete the Physician Screening Form. Go to www.partnersforhealthtn.gov, and in the QuickLinks box, click on Complete Your Biometric Screening to download the form www.partnersforhealthtn.gov1-800-253-9981

  20. If You Cover Your Spouse • Same PPO Option • Your spouse must also commit to the 2014 Partnership Promise • Exception: If you and your spouse both work for a Participating Employer you can choose different PPO options • Partnership Promise is not required for covered children www.partnersforhealthtn.gov1-800-253-9981

  21. Standard PPO • The Standard PPO offers the same services as the Partnership PPO, but you will pay more for monthly premiums, annual deductibles, pharmacy copays, medical care co-insurance and out-of-pocket maximums • Members enrolled in the Standard PPO are not required to fulfill the Partnership Promise - but these members do have access to the ParTNers for Health Wellness Program www.partnersforhealthtn.gov1-800-253-9981

  22. Choosing an Insurance Carrier • Once you choose your PPO, you have a choice of two carriers: • BlueCross BlueShield of Tennessee offers Network S • Cigna offers Open Access Plus (statewide) or LocalPlus (middle TN only) • The Cigna LocalPlus network is a pilot program • Cigna LocalPlus has a narrower network than Cigna Open Access Plus • You may choose between these two carriers, regardless of the PPO option you select • Check the networks carefully to make sure your preferred doctors and hospitals are in the network you choose  Step Two: Choosing an Insurance Carrier www.partnersforhealthtn.gov1-800-253-9981

  23. Choosing an Insurance Carrier • Each carrier has its own network of preferred doctors, hospitals and other health care providers • Check the networks for each carrier carefully when making your decision • Provider directories are available • Online • By calling the carrier’s customer service phone line • From your ABC www.partnersforhealthtn.gov1-800-253-9981

  24. Choosing an Insurance Carrier • Carrier costs vary by grand division • In East and Middle Tennessee • Cigna Open Access Plus costs $20 more per month for employee only coverage and $40 more per month for all other tiers • In Middle Tennessee, Cigna LocalPlus costs the same as BCBST • In West Tennessee, BlueCross BlueShield costs $20 more per month for employee only coverage and $40 more per month for all other premium tiers Each carrier offers statewide and national networks, regardless of the region where you live www.partnersforhealthtn.gov1-800-253-9981

  25. Choosing Your Premium Level • The amount you pay in premiums depends on the PPO you choose and the number of people you cover under the plan • There are four premium levels (tiers) available: • Employee Only • Employee + Child(ren) • Employee + Spouse • Employee + Spouse + Child(ren)  Step Three: Choosing Your Premium Level Remember: The Partnership PPO premiums are lower than the premiums for the Standard PPO. www.partnersforhealthtn.gov1-800-253-9981

  26. Choosing Your Premium Level • If your spouse works for a participating employer, you have another option: • Choose premium level (dependent on your situation either employee-only or employee + child or children), PPO and insurance carrier separately • If you and your spouse are both State and Higher Education employees: • You may each want to consider enrolling in employee only coverage or employee + children, if you have children, to ensure that you receive the maximum life insurance benefit. However, an individual may only be covered under one policy www.partnersforhealthtn.gov1-800-253-9981

  27. Premiums: Higher Education Plan • Employee Share of Monthly Premiums* • *Premiums shown are for the least expensive carrier in the region. A complete chart is available in the Eligibility and Enrollment Guide and the ParTNers for Health website. The State pays 80% of the total premium cost for active employees. www.partnersforhealthtn.gov1-800-253-9981

  28. Covered Services • The Partnership PPO and the Standard PPO both cover the same services, treatments and products, including the following: • Preventive care • Primary care • Specialty care • Hospitalization and surgery • Laboratory and x-rays • A comparison chart that lists covered services and their costs is available in the Eligibility and Enrollment guide and on the ParTNers for Health website www.partnersforhealthtn.gov1-800-253-9981

  29. Copays www.partnersforhealthtn.gov1-800-253-9981

  30. Free In-Network Preventive Care • Annual preventive care check-up offered to members at no cost • Lab work related to the preventive care visit covered at 100% • You need to visit an in-network provider to receive preventive care services at no cost Regular preventive care is one of the most important things you can do to stay healthy. www.partnersforhealthtn.gov1-800-253-9981

  31. Co-Insurance Prior authorization is required for inpatient care, advanced x-ray, scans and imaging, inpatient therapy and certain medical equipment. www.partnersforhealthtn.gov1-800-253-9981

  32. Annual Deductibles You pay the annual deductible before co-insurance benefits kick in. But, any costs you pay toward your deductible will apply to your out-of-pocket maximum. www.partnersforhealthtn.gov1-800-253-9981

  33. Out-of-Pocket Maximums *Members are responsible for 100% of non-emergency out-of-network provider charges above the maximum allowable charge (MAC). *Out-of-Pocket copay maximum does not apply to out-of-network providers. www.partnersforhealthtn.gov1-800-253-9981

  34. Take Note! • Deductibles and out-of-pocket maximums for in-network and out-of-network services add up separately • Services received in-network count toward your in-network deductible and out-of-pocket maximum • Services received out-of-network count toward your out-of-network deductible and out-of-pocket maximum Ineligible expenses, including non-covered services and expenses over the MAC don’t count toward deductibles and out-of-pocket maximums. www.partnersforhealthtn.gov1-800-253-9981

  35. Pharmacy Benefits • Your health plan also includes pharmacy benefits • The covered drug list is the same for both the Partnership PPO and Standard PPO, although copays differ between the two • There is a $3,750 in-network pharmacy out-of-pocket copay maximum • Pharmacy benefits are administered by CVS Caremark, one of the largest pharmacy benefits managers in the country with over 1,600 in-network pharmacies statewide www.partnersforhealthtn.gov1-800-253-9981

  36. Pharmacy Benefits • Copay amounts are based on three different factors: the type of pharmacy you use, your PPO option and the drug level (tier) of the medication • There are three drug levels: • Generic Drug (tier one) is a generic medicine that is FDA-approved and equal to the brand-name product in safety, effectiveness, quality and performance • Least expensive option • Preferred Brand (tier two) is a brand-name drug included on the drug list • More expensive option • Non-preferred Brand (tier three) is a brand-name drug not on the drug list • Most expensive option www.partnersforhealthtn.gov1-800-253-9981

  37. Prescription Drug Copays www.partnersforhealthtn.gov1-800-253-9981

  38. Employee Assistance Program (EAP) • Provided at no cost to all benefits eligible employees and your benefits eligible dependents • ParTNers Employee Assistance Program (EAP) helps you and your family members deal with problems we all experience during our daily lives • Up to five no-cost sessions per incident • Your EAP can handle issues related to: • Stress, depression and anxiety • Family, relationship or marital issues • Child and elder care • Grief and loss • Your EAP also offers no cost financial and legal consultations www.partnersforhealthtn.gov1-800-253-9981

  39. Employee Assistance Program (EAP) • All services are confidential and available at no cost to members 24/7 • You and your eligible dependents may get up to five, no cost counseling sessions per problem episode, per year • Your EAP also offers work-life services, financial and legal services, assistance finding eldercare and dependent care services and much more • Contact ParTNers EAP: • Toll Free 24/7 at 1.855.HERE4TN (1.855.437.3486) • Or at www.Here4TN.com www.partnersforhealthtn.gov1-800-253-9981

  40. Mental Health and Substance Abuse Treatment • Members and dependents who are enrolled in health coverage are enrolled in the Mental Health and Substance Abuse services • Services generally include: • Outpatient assessment and treatment • Inpatient assessment and treatment • Alternative care such as partial hospitalization, residential treatment and intensive outpatient treatment • Treatment follow-up and aftercare • Costs are based on your health plan • Prior authorization is required for some services www.partnersforhealthtn.gov1-800-253-9981

  41. Optional Dental Benefits • Eligible employees can choose between two dental options: • Each year during Annual Enrollment, eligible employees can enroll in or transfer between dental options • Unlike health insurance where a portion of the premium is paid by the employer, dental insurance is paid 100% by the employee • AssurantPrepaid Plan • Participating dentists only • Fixed copays • Delta Dental PDO Plan • Coinsurance and deductible • Any dentist • Pay less with network providers www.partnersforhealthtn.gov1-800-253-9981

  42. Prepaid Plan • Prepaid Plan Administered by Assurant Employee Benefits • The network is DentiCare • Predetermined copay amounts (reduced fees) for dental treatments • There are no deductibles to meet, no claims to file, no waiting periods for covered members, no annual dollar maximum and pre-existing conditions are covered • Referrals are not required • To receive benefits, you must select a dentist from the Prepaid Plan list • Note: There are some areas in the state where Assurant network dentists are not available www.partnersforhealthtn.gov1-800-253-9981

  43. Preferred Dental Organization • The Preferred Dental Organization (PDO) is administered by Delta Dental of Tennessee • Use Delta Dental’s PDO network • You pay co-insurance for covered services • A deductible applies for out-of-network dental care • Referrals are not required • You or your dentist will file claims for covered services • Some services require waiting periods and limitations/exclusions apply • To find a dentist in Delta Dental’s network, visit the dental section of the ParTNers for Health website or call the number listed on the inside cover of the Eligibility and Enrollment Guide www.partnersforhealthtn.gov1-800-253-9981

  44. Dental Premiums Dental services for both the Prepaid Plan and the Dental PDO include: www.partnersforhealthtn.gov1-800-253-9981

  45. Optional Vision Benefits • Eligible employees can choose between two State vision plans • Full list of vision benefits is available in the Eligibility and Enrollment Guide and on the ParTNers for Health website • Administered by EyeMed Vision Care • Members have access to EyeMed’s Select Network Basic Plan • Discounted rates • Allowances • Expanded Plan • Co-pays • Allowances • Discounted rates 44 www.partnersforhealthtn.gov1-800-253-9981

  46. Vision Premiums • Both plans offer the same services: Each year during Annual Enrollment, eligible employees can enroll in or transfer between vision options. www.partnersforhealthtn.gov1-800-253-9981

  47. Additional Benefits • Higher Education employees are also eligible for: • ParTNers for Health Wellness Program • Life Insurance • Long-Term Care Insurance Did You Know? All State employees have access to the ParTNers for Health Wellness Program even if enrolled in the Standard PPO. www.partnersforhealthtn.gov1-800-253-9981

  48. ParTNers for Health Wellness Program • The Wellness Program is designed to provide opportunities to manage and improve your health • Services are free to all members enrolled in health coverage and their spouses and dependents enrolled in the health plan • The Nurse Advice Line gives you medical information and support 24/7 • Health coaching offers professional support to create and meet goals to improve your health • Well-Being Connect,the ParTNers for Health Web Portal,links you to powerful online tools and health information at your fingertips (look for My Wellness Login) www.partnersforhealthtn.gov1-800-253-9981

  49. ParTNers for Health Wellness Program • An online Well-Being Assessment (WBA) is available to help you learn more about your health and identify any potential health risks • Sign up for weekly health tips by email to receive a short email with each week’s healthy living tip. • Fitness center discounts are available to plan members for fitness centers across the state • To access any of the services listed here, visit the wellness webpage on the ParTNers for Health website www.partnersforhealthtn.gov1-800-253-9981

  50. Working for a Healthier Tennessee • The goal of Working for a Healthier Tennessee is to encourage and enable State employees and our plan members to lead healthier lives • Initiative implemented under the leadership of Governor Bill Haslam and is supported by the ParTNers for Health Wellness Program and the ParTNers Employee Assistance Program • Some of our agencies will have Site Champions who provide ideas and activities to help employees improve in three key areas: • Physical activity • Healthy eating • Tobacco cessation • All Higher Education plan members have access to ParTNers for Health tools and resources like Well-Being Connect, the Well-Being Assessment (WBA) and Nutrition and Fitness Challenges www.partnersforhealthtn.gov1-800-253-9981

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