Presentation Transcript

1. 2014 Benefit Options Presentation Plan Year January 1 through December 31, 2014 This publication is issued by the Office of Management and Enterprise Services as authorized by Title 62, Section 34. Copies have not been printed but are available through the agency website. This work is licensed under a Creative Attribution-NonCommercial-NoDerivs 3.0 Unported License. 2949
2. The Employee BenefitOptions Guide How to access the Guide: View the Guide on the EGID website at www.sib.ok.gov or www.healthchoiceok.com Complete the online request to get one by mail Contact your Insurance Coordinator Contact EGID Member Services
3. Topics 2014 Plan Changes Health Plans Dental Plans Vision Plans HealthChoice Life Insurance Plan Eligibility
4. For More Information 2014 Employee Benefit Options Guide Frequently Asked Questions at www.sib.ok.gov or www.healthchoiceok.com Plan websites and customer service representatives Your Insurance Coordinator EGID Member Services
5. Index Click the links below to access a particular section of this presentation. 2014 Plan Changes HealthChoice Health Plans HMO Health Plans Dental Plans Vision Plans HealthChoice Life Insurance Plan Eligibility
6. 2014 PLAN CHANGES
7. Eligibility Changes Enrolling a newborn: HealthChoice and HMO plan members must enroll the newborn for the month of birth if dependent coverage is desired Premium for month of birth must be paid
8. HealthChoice Plan Changes HealthChoice High and USA Plans Calendar year out-of-pocket maximum is being increased to $3,300 for an individual/Network and $3,800 for an individual/non-Network HealthChoice High Alternative Plan Calendar year out-of-pocket maximum is being increased to $3,550 for an individual/Network and $4,050 for an individual/non-Network Calendar year out-of-pocket maximum is being decreased to $8,400 for a family
9. HealthChoice Plan Changes HealthChoice S-Account Plan Copays for physician office visits for general practitioners, etc., and VA, Military and Indian Clinics is being reduced to $30 Copay for specialist office visit will remain $50
10. HMO Plan Changes CommunityCare HMO Calendar year out-of-pocket is being increased to $4,000 for an individual and $8,000 for a family Copay for hospital inpatient admission increased to $750 Copay for hospital outpatient visit increased to $500 Copay for mental health or substance abuse inpatient admission increased to $750 No referral needed for most specialist visits Visit state.ccok.com to view benefits, claims, EOBs, and more
11. HMO Plan Changes GlobalHealth HMO Copay for specialty scans will be $750 Copay for outpatient visits in free-standing facility will be $250 and $750 in a hospital facility Copay for emergency health care facility visit increased to $300 Durable medical equipment – 20% coinsurance Occupational or speech therapy and physical therapy/physical medicine limit: 60 combined inpatient and outpatient visits per acute illness or injury
12. Dental Plan Changes HealthChoice Dental 12-month waiting period will apply to all members, including those who had previous group dental coverage
13. Dental Plan Changes CIGNA Dental Cost for sealant increased to $17 per tooth Cost for amalgam, one surface increased to $23 Cost for a root canal, anterior, increased to $375 Cost for periodontal/scaling/root planing, 1-3 teeth, increased to $75 Out-of-pocket for children through 18 increased to $2,472 Out-of-pocket for adults increased to $3,384
14. Dental Plan Changes Delta Dental Delta Dental Premier is now Delta Dental PPO Plus Premier
15. Vision Plan Changes Primary Vision Care Services (PVCS) Discounts offered through nJoy Vision, previously TLC, call PVCS for details Vision Services Plan $25 copay on contact lenses
16. HealthChoice Life Insurance Plan Changes Dependent Life Insurance Dependent life benefit for birth to 6 months of age is being eliminated Dependent children eligible for Low, Standard, or Premier Option from live birth to age 26 Return to Index
17. HEALTHCHOICEHEALTH PLANS
18. Click here to view HealthChoice plan changes Available Plans HealthChoice High HealthChoice High Alternative HealthChoice Basic HealthChoice Basic Alternative HealthChoice S-Account HealthChoice USA Using a HealthChoice Network Provider will lower your out-of-pocket costs.
19. HealthChoice Plan Changes Tobacco-free Attestation To remain enrolled in the HealthChoice High or Basic Plan, you must attest that you and your covered dependents are tobacco-free Due to HealthChoice by Nov. 15, 2013 The Attestation is available: On the EGID website Through a mobile app, or By calling HealthChoice Member Services
20. HealthChoice Plan Changes If you cannot complete the Attestation, you must either: Enroll in the quit tobacco program AND complete three coaching calls, or Provide a letter from your doctor indicating it is not medically advisable for you or your dependent to quit tobacco. If you do not complete the Attestation or complete one of the reasonable alternatives as defined previously, you will be enrolled in the HealthChoice High Alternative or Basic Alternative Plan with a higher deductible and out-of-pocket maximum.
21. High When using a Network Provider: $30 copay for primary care office visits $50 copay for specialist office visits Annual deductible $500 for an individual or $1,500 for a family Plan pays 80% and member pays 20% of Allowed Charges up to the out-of-pocket maximum of $3,300 for an individual or $8,400 for a family
22. High Alternative When using a Network Provider: Benefits the same as High Plan except deductible and out-of-pocket maximum Annual deductible $750 for an individual or $2,250 for a family Plan pays 80% and member pays 20% of Allowed Charges up to the out-of-pocket maximum of $3,550 for an individual or $8,400 for a family
23. Basic When using a Network Provider: Office visit copays do not apply Plan pays first $500 then member pays next $500 as deductible; $1,000 deductible for a family of two or more Plan then pays 50% until the out-of-pocket maximum is met; $5,500 for an individual or $11,000 for a family Plan then pays 100% of Allowed Charges
24. Basic Alternative When using a Network Provider: Office visit copays do not apply Plan pays first $250 then member pays next $750 as deductible; $1,500 deductible for a family of two or more Plan then pays 50% until the out-of-pocket maximum is met; $5,750 for an individual or $11,500 for a family Plan then pays 100% of Allowed Charges
25. S-Account Plan designed for members with a Health Savings Account (HSA) When using a Network Provider: Combined $1,500 deductible for an individual and $3,000 for a family* Entire deductible must be met before benefits are paid (including prescriptions) $30/$50 copay for office visits The calendar year out-of-pocket maximum is $3,000 for an individual or $6,000 for a family *Individual deductible does not apply if two or more family members are covered.
26. USA For members who live and work outside of Oklahoma and Arkansas for more than 90 consecutive days Benefits are the same as the HealthChoice High Plan Members have access to the USA Plan’s nationwide provider network
27. Network Pharmacy Benefits Prescriptions can be filled at HealthChoice Network Pharmacies Benefits are the same for all plans; S-Account members must meet the Plan deductible before benefits are paid You are responsible for the cost difference when choosing a brand-name if a generic is available
28. Network Pharmacy Benefits When purchasing up to a 30-day supply: Generic – Up to $10 Preferred brand-name – Up to $45 Non-Preferred brand-name – Up to $75
29. Network Pharmacy Benefits When purchasing up to a 90-day supply: Generic – Up to $25 Preferred brand-name – Up to $90 Non-Preferred brand-name – Up to $150 90-day fill does not apply to medications with quantity or dosage limits
30. Network Pharmacy Benefits Certain prescription tobacco cessation medications for a $0 copay A calendar year pharmacy out-of-pocket maximum of $2,500/individual, $4,000/ family (does not apply to S-Account Plan) Specialty medications must be purchased through Accredo Health, the HealthChoice specialty care, delivery service pharmacy Return to Index
31. HMOPLANS
32. HMO Plans Click here to view HMO Plan Changes You must live or work within the ZIP Code service area of the HMO Copay system for services and supplies Primary Care Physician (PCP) is required Select your providers from the network designated by your plan for the State of Oklahoma You must select another provider within your HMO’s network in the event your provider leaves the network.
33. $35 office visit copay for PCP $50 office visit copay for specialist $750 copay for hospital and mental health or substance use disorder admission $200 copay each emergency room visit $50 copay for after-hours urgent care Out-of-pocket maximum of $4,000 for an individual or $8,000 for a family
34. Pharmacy Benefits 30-day supply per copay $0 copay for select generics Up to a $10 copay for formulary generic medications Up to a $40 copay for formulary brand-name medications Up to a $65 copay for all other medications Some medications have quantity limits
35. $25/$50 office visit copay for PCP/specialist $300 copay each emergency room visit $25 copay for after-hours urgent care PCP; $50 copay for all others $250 copay for free-standing outpatient facility or $750 for a hospital facility No copay for x-ray and lab services MRI, PET, CAT, or nuclear scan – copay of $250 for free-standing facility or $750 for hospital facility Out-of-pocket maximum of $3,000 for an individual or $5,000 for a family
36. Pharmacy Benefits 30-day supply per copay $4 copay for select generics Up to a $10 copay for formulary generic medications Up to a $50 copay for formulary brand-name medications Up to a $75 copay for all other medications Some medications have quantity limits Return to Index
37. DENTALPLANS
38. Dental Plans Available Assurant Freedom Preferred Assurant Heritage Plus with SBA (Prepaid) Assurant Heritage Secure (Prepaid) CIGNA Dental Care Plan (Prepaid) Delta Dental PPO Delta Dental PPO Plus Premier Delta Dental PPO – Choice HealthChoice Dental
39. Dental Benefits All the dental plans have the same core benefits which are divided into four different classes: Preventive Care includes cleanings, bitewing x-rays, and routine oral exams Basic Care includes fillings, extractions, root canals, endodontics, and periodontics
40. Dental Benefits Major Care includes dentures, bridgework, crowns, and implants Orthodontic Care* is covered for members under age 19 and members age 19 or older with temporomandibular joint dysfunction (unless otherwise noted) *Assurant Freedom Preferred has a 12-month waiting period for orthodontic care; waived if proof of continuous dental insurance is provided. HealthChoice has a 12-month waiting period for orthodontic care.
41. Freedom Preferred Dental Plan Preventive Care is covered at 100% A $25 deductible applies to Basic and Major Care After the deductible: Basic Care is covered at 85% Major Care is covered at 60% Orthodontic Care under age 19 is covered at 60%; lifetime maximum benefit $2,000 All other services have a combined $2,000 maximum annual benefit
42. Heritage Plus with SBA Dental Plan No deductible or annual maximum for general dentist You must select a Primary Care Dentist for each covered person Preventive Care is covered at 100% Copay schedule applies to other services Orthodontic Care for children and adults The Special Benefit Amendment provides an additional discount for network specialists
43. Heritage Secure Dental Plan No deductible or annual maximum with general dentist You must select a Primary Care Dentist for each covered person Preventive Care is covered at 100% Copay schedule applies to other services Orthodontic Care for children and adults
44. Dental Care Plan No deductible or maximum annual benefit You must select a Primary Care Dentist for each covered person After a $5 copay, routine cleanings, x-rays, and evaluations are covered at 100% A copay schedule applies to other services, including specialist care Orthodontic Care for children and adults
45. Delta Dental PPO Preventive Care is covered at 100% $25 annual deductible for Basic and Major Care Basic Care is covered at 85% Major Care is covered at 60% Orthodontic Care for children and adults is covered at 60% with a$2,000 lifetime maximum benefit $2,500 maximum annual benefit for other services
46. DeltaDental PPO Plus Premier A $50 combined deductible applies to Diagnostic, Preventive, Basic, and Major Care Preventive Care is covered at 100% Basic Care is covered at 70% Major Care is covered at 50% Orthodontic Care for children and adults is covered at 60% with a lifetime maximum of $2,000 $3,000 maximum annual benefit
47. Delta Dental PPO – Choice You must select a Primary Care Dentist for each covered person No deductible for Preventive or Basic Care $100 deductible for Major Care Copay schedule for all other services Orthodontic Care for children and adults has a maximum lifetime benefit of $1,800 $2,000 maximum annual benefit for Preventive, Basic, and Major Care
48. Dental When using a Network Provider: Preventive Care is covered at 100% A $25 deductible applies to Basic and Major Care Basic Care is covered at 85% Major Care is covered at 60% Orthodontic Care is covered at 50% —no lifetime maximum, 12-month waiting period applies A $2,500 calendar year maximum applies to all other services Return to Index
49. VISIONPLANS
50. Vision Plans Available Humana CompBenefitsVisionCare Plan Primary Vision Care Services (PVCS) Superior Vision Plan UnitedHealthcare Vision Vision Service Plan (VSP)
51. Vision Plans Overview Each vision plan has its own provider network A copay schedule for services and materials The toll-free number and website address of each plan is listed in the Employee Benefit Options Guide Contact each vision plan for specific benefit questions
52. Humana/CompBenefits When using an in-network provider: $10 copay for an annual eye exam $25 copay for lenses and frames; one pair per year Discounts are available for other vision services and lens options Contact lenses are available instead of glasses; $130 allowance Discount through TLC for laser surgery
53. Primary Vision Care Services When using an in-network provider: There is no copay or limit on the number of eye exams Lenses and frames are sold at wholesale cost There is no limit on the number of pairs of glasses Benefits available for contact lenses Discount through nJoy for laser surgery
54. Superior Vision When using an in-network provider: $10 copay for eye exams; one per year $25 copay for lenses and frames; one pair per year Contact lenses – available instead of glasses; $25 copay/standard fitting then plan pays 100% or $50 copay/specialty fitting then plan pays up to $50 Discounts available for other vision services and lens options, including laser vision correction
55. UnitedHealthcare Vision When using an in-network provider: $10 copay for eye exams; one per year $25 copay for lenses and frames; one pair per year Lens UV coating and tints are covered in full Contact lenses are available instead of glasses Discounts available for other vision services and lens options including laser vision correction
56. VSP When using an in-network provider: $10 copay for eye exams; one per year $25 copay for lenses and frames; one pair per year No copay for contact lens exam with network provider Contact lenses are available instead of glasses Discounts are available for glasses and other vision benefits, including laser vision correction Return to Index
57. LIFE INSURANCE PLAN
58. Employee Life Basic and Supplemental Life for You First $20,000 of life coverage (Basic Life) All additional coverage is known as Supplemental Life $500,000 of Supplemental Life coverage is available with an approved Life Insurance Application Basic Life and the first $20,000 of Supplemental Life include Accidental Death and Dismemberment (AD&D) benefits
59. Employee Life During initial enrollment: You can enroll in Guaranteed Issue (two times your annual salary rounded up to the next $20,000) without a Life Insurance Application You can apply for amounts above Guaranteed Issue; a Life Insurance Application is required
60. Employee Life During Option Period: You can enroll in Basic Life You can enroll in Supplemental Life You can enroll in up to $500,000 of Supplemental Life insurance coverage An approved Life Insurance Application is required
61. Beneficiary Designation Keep your beneficiary designation up-to-date Beneficiaries can be changed at any time Review your beneficiaries if you have a change, such as a marriage, divorce, death of a family member, or birth of a child Beneficiary Designation Forms are available online, from your Insurance Coordinator, or by calling EGID Member Services
62. Dependent Life You must be enrolled in Basic Life coverage to enroll your eligible dependents in Dependent Life. Premier Option Spouse $20,000 Child $10,000 Standard Option Spouse $10,000 Child $5,000 Low Option Spouse $6,000 Child $3,000 No coverage for a stillbirth. Return to Index
63. ELIGIBILITY
64. Eligible Employees An education employee must be: Currently employed, eligible for TRS, and working at least four hours a day or 20 hours a week A local government employee must be: Currently employed, regularly scheduled to work 1,000 hours or more per year, and cannot be listed as a temporary or seasonal employee
65. Eligible Dependents Eligible dependents include: Your legal spouse (including common-law) Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child, or child legally placed with you for adoption up to age 26, whether married or unmarried Disabled dependents over age 26 with approved documentation
66. Eligible Dependents If you insure one dependent, all eligible dependents must be insured You can exclude dependents who do not reside with you, are married, are not financially dependent on you for support, have other group insurance, or are eligible for Indian or military benefits A spouse can be excluded by signing the Spouse Exclusion Certification statement on the back of the form
67. Other Dependent Children Other unmarried dependent children up to age 26, upon completion of an Application for Coverage for Other Dependent Children Guardianship papers or a tax return showing dependency can be provided in lieu of the application Dependents cannot include your parents or grandparents
68. Midyear Qualifying Events Certain qualifying events allow you to make a midyear change, examples include: Marriage Divorce Adoption Death Childbirth* Gain or loss of other group insurance *Must be added the first of the month of birth. Notify your Insurance Coordinator within 30 days of the event or wait until the next annual Option Period.
69. Deadlines for Forms Option Period Enrollment/Change Form: Your Insurance Coordinator will provide the deadline Insurance Enrollment Form: Return your form to your Insurance Coordinator within 30 days Insurance Change Form: Return your form to your Insurance Coordinator within 30 days of a qualifying event
70. Deadlines for Forms Tobacco-free Attestation: Must be completed as part of the Option Period enrollment process The Attestation can be completed online or returned to your Insurance Coordinator Deadline is November 15, 2013
71. Confirmation Statements EGID mails you a Confirmation Statement when you enroll or make changes to coverage If your Confirmation Statement is incorrect, contact your Insurance Coordinator immediately
72. Confirmation Statements If you do not make changes during the annual Option Period and are not automatically enrolled in a HealthChoice alternative plan, no Confirmation Statement will be sent; keep your enrollment form as verification of coverage
73. Reminders Option Period is the only time you can make changes to coverage with a qualifying event HealthChoice High and Basic require a completed tobacco-free Attestation To enroll in dental or life coverage, you must have group health insurance If excluding your spouse, your spouse must sign the Spouse Exclusion Certification Return signed and dated forms to your Insurance Coordinator by the set deadline Notify your Insurance Coordinator if you have a change of address
74. Questions The 2014 Employee Benefit Options Guide Plan websites and toll-free numbers available in your Option Period packet The FAQ section of the EGID website EGID Member Services at 1-405-717-8780 or toll-free 1-800-752-9475; TDD users call 1-405-949-2281 or toll-free 1-866-447-0436 Your Insurance Coordinator Return to Index