Embed Size (px)
Citation preview
Missouri Department of Missouri Department of Transportation & Missouri State Transportation & Missouri State
Highway Patrol Employee Benefits Highway Patrol Employee Benefits Meeting for 2007Meeting for 2007
2
What is New for the What is New for the MoDOT/MSHP Medical Plan MoDOT/MSHP Medical Plan
for 2007?for 2007?
Employees will have one plan design effective January 01, 2007.
The plan will be called Open Access III (OAIII) Plan, but benefits will change
All active employees will have the same out-of-pocket premium structure.
3
Why is MoDOT/MSHP Not Why is MoDOT/MSHP Not Offering the 100% Coverage Offering the 100% Coverage
Plan under OAIIIPlan under OAIII
The current OAIII plan is not self-supporting and would require large increases in the monthly out-of-pocket premium for our members.
As of June 30, 2006, this plan has a deficit of $1,000,000+.
That means the claims paid is $1 million greater than the premiums collected for this plan.
4
Rates Required to Maintain Rates Required to Maintain Current 100% Coverage PlanCurrent 100% Coverage Plan
OUT-OF-POCKET RATES
CURRENT
2007 Sub only $51 $216 Sub/spouse $234 $564 Sub/family $308 $811 Sub/child $173 $503 Sub/2 children $256 $632
5
COMPARING SPOUSE COMPARING SPOUSE CONTRIBUTION PLAN RATESCONTRIBUTION PLAN RATES
Spouse contribution plans are plan categories where both the subscriber and spouse work for MoDOT or MSHP.
They receive additional state share contributions.
Comparison of current 2006 out-of-pocket monthly premium costs to 2007 as follows:
CURRENT 2007
Sub/spouse $0 $252
Sub/family $2 $499
6
MoDOT/MSHP’s Plan for 2007 is MoDOT/MSHP’s Plan for 2007 is HealthLink Open Access III Plan HealthLink Open Access III Plan with Freedom Network Selectwith Freedom Network Select
In-Network Benefits
Deductible -$300/individual/CY, $900 maximum per family).
Coinsurance – 10% coinsurance after
deductible is met
Office Visit - $15 co-payment for office
visit only. Other services applied to
deductible and coinsurance
Out-of-Pocket Maximums
Individual coverage $750
Family coverage $2,000.
Other co-pays which may apply $75 ER $15 urgent care (office visit only)
Out-of-Network Benefits
Deductible -$300/individual/CY, $900 maximum per family).
Coinsurance – 20% coinsurance after deductible is met
Office Visit – 20% coinsurance of allowed amount after deductible
.Out-of-Pocket Maximum –
Individual coverage $1,500
Family coverage $4,500.
UCR – For out-of-network services you may
be billed by the provider for any charges
above usual, reasonable & customary.
7
OUT-OF-POCKET COST OUT-OF-POCKET COST COMPARISONCOMPARISON
Out-of-Pocket Premium Costs to Maintain Current 100% Coverage Plan for 2007
Sub Only - $216 x 12 = $2,592 Sub/family - $811 x 12 = $9,732 Sub/spouse - $564 x 12 = $6,768 Sub/child - $503 x 12 = $6,036 Sub/2child - $632 x 12 = $7,584
Spouse Contribution Categories
Sub/family - $499 x 12 = $5,988 Sub/spouse - $252 x 12 = $3,024
Total Out-of-Pocket Costs for Covered Medical Services for 2007 Plan
Utilizing in-network providers
Deductibles/CY - $300 Medical & $75 RX
10% Coinsurance – $750 max Potential CY out-of-pocket costs
(excluding co-pays for office visit, urgent care or ER, which you currently pay) are:
$1,125/individual $3,125/family of 3 or sub/2child $2,250/sub/spouse or sub/1child Does not include increase from 20%
to 30% for prescription drugs
8
Pharmacy Benefit ChangesPharmacy Benefit Changes
$75 Deductible per participant per CY
After the deductible is met, the participant pays a 30% coinsurance or a minimum $5 co-pay (not both).
9
Pharmacy Benefits That Will Pharmacy Benefits That Will Not Change From Your Not Change From Your
Current CoverageCurrent Coverage 30-day starter quantity if the drug is a new
medication, has not been purchased in the past 6 months or the strength of the drug has changed.
Mandatory generic policy that requires generic drugs be used, unless a generic is not available or the individual has a Prior Authorization (PA) to use the brand over the generic.
There are some drugs that are not covered. Examples include: Drugs for weight loss, hair loss,
fertility and impotence
10
Pharmacy Benefits That Will Pharmacy Benefits That Will Not Change From Your Not Change From Your
Current CoverageCurrent Coverage Participants can fill a 90 day prescription at
both retail or mail order participating pharmacies.
Some drugs are paid at a $50 maximum co-payment.
Some drugs require a prior authorization (PA) Most PA’s must be renewed on an annual
basis. examples include: Cox inhibitors, hypertensive agents,
anti-migraine agents and some asthma drugs
11
Pharmacy BenefitsPharmacy Benefits
The PBM has their own network of pharmacies that participants of the plan must use when purchasing their prescriptions.
A retail or mail order pharmacy may be used when purchasing maintenance drugs.
12
Pharmacy BenefitsPharmacy Benefits
The Medical Board is currently in the process of finalizing the bid process for the 2007 pharmacy benefits manager (PBM).
Once the PBM is selected you can access their website to verify if your pharmacy is participating.
Plan participants will receive a new prescription card that must be presented each time they have a prescription filled at a local retail pharmacy.
13
PREVENTIVE BENEFITS PREVENTIVE BENEFITS FOR 2007FOR 2007
Preventive Benefits will remain the same except for your dependent children for 2007:
Non-Medicare Subscriber $350 Non-Medicare Spouse $350 Non-Medicare Child $200
14
MoDOT/MSHP’s Plan for 2007 is MoDOT/MSHP’s Plan for 2007 is HealthLink Open Access III Plan HealthLink Open Access III Plan with Freedom Network Selectwith Freedom Network Select
The Network Scenario is as follows:
In-Network Benefits – When you seek services from a provider that participates with HealthLink HMO and/or PPO Network, Freedom Network Select (western MO), AHI-HealthLink (Texas only) & Quincy Tri-State Coalition Network.
Out-of-Network Benefits – When you seek services from a provider that falls outside the service area of the networks mentioned above including those providers that participate with Freedom Network only.
15
Advantages of one Advantages of one Consolidated Health Plan for Consolidated Health Plan for the MODOT/MSHP Employeesthe MODOT/MSHP Employees
Precertification requirements have been simplified to only include inpatient precertification.
Employees currently in the Open Access – HMO Plan will have premium reductions effective January 01, 2007.Exception may be spouse contribution plan
members Out of Network Benefits have improved in the 2007
MODOT/MSHP Plan as it compares to the current Open Access – HMO Plan.
16
DO I NEED TO DO ANYTHING DO I NEED TO DO ANYTHING TO ENROLL IN THE NEW TO ENROLL IN THE NEW
MEDICAL PLAN?MEDICAL PLAN? NO You and any participants currently enrolled in
the 2006 OAIII medical plan will be automatically enrolled in the new OAIII medical plan for 2007
New ID cards will be issued Only requires action if you are making a plan
change such as terminating coverage, etc. or have a qualifying event to add dependents, etc.
17
Benefits of one Benefits of one Consolidated Health Plan Consolidated Health Plan
for MoDOT/MSHP for MoDOT/MSHP EmployeesEmployees
Additional provider network savings to the MODOT/MSHP plan.
All employees will have access to the MedCall – 24 hour nurse & the Maternicall Program.
19
GOOD NEWSGOOD NEWS
The eligibility of a dependent is changing for 2007
Unmarried dependents can now be covered up to age 23 without full time student verification
They must meet the definition of a dependent.
20
How to Find a HealthLink Open How to Find a HealthLink Open Access IIIAccess III
or Freedom Network Select or Freedom Network Select provider?provider?
HealthLink’s website is www.healthlink.com.
Freedom Network Select’s website is www.phpkc.com. (For Western MO)
HealthLink’s Customer Service (CS) number is (888) 724-9395.
When calling the CS number, specifically ask for Freedom Select if you live in their network area.
21
Meritain HealthMeritain Health
The third party claims administrator for the MoDOT/MSHP Medical Plan.
Meritain continues to be your main contact for information regarding benefits, claims and eligibility questions.
22
Meritain HealthMeritain Health
Meritain’s toll-free number is (888) 306-6681.
Meritain’s Customer Service Representatives are available Monday through Friday from 8:00 am – 5:00 pm.
23
CONTACT INFORMATIONCONTACT INFORMATION
Employee Benefit’s toll free # is 877-863-9406
Look under “Benefits” on the MoDOT intranet site.
www.modot.mo.gov/newsandinfo/benefits.htm
Contact your local insurance representative in your district, division or troop
24
May we answer your May we answer your questions?questions?
