STATE EMPLOYEE HEALTH PLAN Open Enrollment for Plan Year 2013
HEALTH CARE COMMISSION (HCC) No employee & employer rate
increases No plan design changes for Plans A
and B Autism Spectrum Disorder Pilot– Benefit will be continued for 2013
OTHER HCC ACTION Plan Design Changes for Plan C– Lower premium– Deductible
• Single $2,500/ Family $5,000• Single family member only has to meet the
single deductible
– Network services for medical & pharmacy have 0% member Coinsurance
– State HSA Funding Increased• Maximum of $1,500 for single & $2,250 for
family• State pays HSA funding in a lump sum• All HSA accounts will be with US Bank
CHANGES DUE TO HEALTH REFORM
Preventive Care Coverage for Contraception–Medical coverage for implantable &
injectable contraceptives–Medical coverage for sterilization – Pharmacy coverage for prescription birth
control products• Must be on the Preferred Drug List• Does not include over the counter items
Preventive Care Coverage for Breastfeeding– Includes counseling and equipment
rental
NEW DOCUMENTS REQUIRED BY PPACA
Summary of Benefits & Coverage (SBC)– www.kdheks.gov/hcf/sehp/SBC.htm
Uniform Glossary of Health Coverage & Medical Terms*– www.kdheks.gov/hcf/sehp/download/U
niformGlossaryofHealthCoverageMedicalTerms.pdf
* Note: This is not specific to the SEHP Coverage
SELECTING YOUR HEALTH PLAN1. Pick a plan design (A, B or C)– Which plan design provides the coverage
you and your family need?– What is the total plan cost? What is the
member contribution?• Premiums + Deductible & Coinsurance = ?
2. Review the Provider Networks – Each of the medical plans uses a different
provider network
2013 SEHP MEDICAL PLANS
All are Preferred Provider Organizations (PPOs)– Plans A, B and C all use the same provider
networks & same basic coverages– 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
Plans A B CBlue Cross and Blue Shield of Kansas
X X X
Coventry/PHS X X X
UnitedHealthcare Company X X X
COVERED PREVENTIVE CAREServices Services
Well Baby Exams - includes newborn screenings & age-appropriate office visits.
Contraceptive Coverage – Designated prescription drugs, implantable & injectable contraceptives & sterilization procedures.
Well Woman, Man & Child Exams - includes an office visit & age-appropriate screenings, contraception services & counseling.
Ultrasonography for Aortic Aneurysm - Limited to one for men ages 65-75 with tobacco use history
Prenatal Screening & Counseling - Limited screening services.
Mammography – not limited to one.
Age-Appropriate Bone Density Screening
Vision Exam – one covered per person per year
Immunizations Routine Hearing Exam
Colonoscopy – not limited to one.
DEDUCTIBLE
A set amount of eligible expenses a covered person must pay out of their own pocket before the health plan will begin paying on their claims.
Network and Non Network Deductibles accumulate separately.
Deductible and “Not Covered” do not mean the same thing.
Deductible Example Claim Information
Plan C Deductible is $2,500
Network Dr. billed $600 for a covered service.
Health Plan allowance is $500.
Member has met $0 of their deductible this year
Claim Processing
$500 Allowed Charge-$500 Deductible $0 Paid by health plan
Your responsibility = $500
Plan Pays $0Member Pays $500 *
Dr. writes off $100* Members on Plan C have a Health Savings Account that could be
used to pay this deductible amount.
COINSURANCE A cost sharing formula for health
care services Coinsurance is expressed as a
percentage of the allowed charge that will be paid by the member and the balance paid by the Plan
You must meet the deductible before coinsurance is applied
Coinsurance Example
Claim Information
Member has Plan A
Network Dr. billed $125 for service
Plan allowed $100 for service
Member has met their $300 Deductible
Member Coinsurance is 20%
Claim Processing
$100 allowed by Plan20% Coinsurance $20 Paid by Member
Plans pays the other 80%
Plan Pays $80Member Pays $20 $100
Dr. writes off $25
Network Benefits
Plan A Plan B Plan C
Deductible $300 Single$600 Family
$150 Single$300 Family
$2,500 Single$5,000 Family
Coinsurance 20% 35% 0%
Annual Coinsurance
$1,400 Single$2,800 Family
$3,000 Single$6,000 Family
None
Total Deductible & Coinsurance
$1,700 Single$3,400 Family
$3,150 Single$6,300 Family
$2,500 Single$5,000 Family
Pharmacy Covered under separate policy
Covered under separate policy
Included with Medical
Preferred Lab Yes Yes No
Office Visits
Adults (age 19+)
PCP $25 CopaySpecialist $45
Copay
PCP $20 CopaySpecialist $40
Copay
Deductible & 0% Coinsurance
Children (< age 19)
PCP $25 CopaySpecialist $45
Copay
PCP $10 Copay Specialist $25
Copay
Deductible & 0% Coinsurance
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 Quest’s website for collection sites– Online appointment scheduling available
Use Your Quest ID card or medical ID card www.labcard.com
STORMONT-VAIL HEALTHCARE
Stormont-Vail HealthCare is the regional preferred lab vendor in NE Kansas100% coverage for eligible outpatient lab testsAll Plan A and B members may use the Stormont-Vail draw site locationsLabs drawn at other Cotton-O’Neil locations may be included if by network providersShow your medical ID Card to access benefit
PLANS A & B DRUG BENEFIT
Generic Drugs– 20% Coinsurance
Preferred Brand– 35% Coinsurance
Non Preferred Brand– 60% Coinsurance
Special Case Medications – 25% to a max of $75 per 30-day
supply Coinsurance Maximum is $2,580
per person for Generic, Preferred Brand & Special Case medications.
www2.caremark.com/kse
GENERIC LAUNCHES 2012
Actos 3rd QtrDiovan3rd QtrSingulair 3rd QtrMaxalt 4th QtrMaxalt MLT 4th QtrTricor 4th QtrRequip XL 4th Qtr
2013Reclast 1st QtrZomig 2nd QtrZomig ZMT 2nd QtrAdvicor 2nd QtrNiaspan 3rd QtrAciphex 4th QtrCymbalta 4th Qtr
www2.caremark.com/kse
PLAN C Network Coverage for Medical &
Pharmacy – $2,500/$5,000 Deductible– 0% Coinsurance– $2,500/$5,000 Total Deductible & Coinsurance– Preventive Care Services paid at 100%
Non Network Coverage
– $2,500/$5,000 Deductible – 20% Coinsurance– $4,000/$8,000 Total Deductible & Coinsurance– Preventive Care is not covered
Does not include dental or optional vision plan
PLAN C DRUG PLAN Same Preferred Drug List as Plans A & B Covered drugs are subject to the
Network Plan C deductible After the deductible, the plan pays
covered prescription drugs at 100% 100% coverage for contraceptives on
the PDL Discount Tier drugs are not covered
drugs– Only eligible for Caremark’s negotiated
discount Plan C is a creditable drug plan
PLAN C - AT A GLANCEPlan C Network Benefits
Single Family
Deductible $2,500 $5,000
Coinsurance 0% 0%
Total Member Pays $2,500 $5,000
HSA Account Single Family
State Maximum HSA Contribution $1,500 $2,250
Minimum $25 EE Contribution $600 $600
Total Annual HSA Contribution $2,100 $2,850
WHAT IS A HEALTH SAVING ACCOUNT?
An employee-owned bank account for saving money to pay for current or future medical expenses for members enrolled in a qualified high deductible health plan
Unspent HSA funds roll over and accumulate year to year and can be invested
Portable - The account and the money belong to you
HSA ELIGIBILITY REQUIREMENTS The following members are not eligible for an
HSA:– Enrolled in Medicare – Receiving Social Security benefits– Enrolled in TRICARE or TRICARE for Life– Enrolled with the Veteran’s Administration (VA)
and/or have received VA medical services within a three-month period immediately preceding their enrollment in Plan C
– Covered as a dependent under another plan that isn’t a QHDHP
– Can be claimed as a dependent on another individual’s tax return (e.g., Parents)
– Spouse has Health Care Flexible Spending AccountSee page 12 of the OE Book
STATE INCREASES HSA FUNDING
State will pay HSA contribution as a lump sum
Payment date depends on HCFSA:– Account funded in January if no
HCFSA in 2012 or if all money has been used by 12/31/12
– Account funded after March 15, 2013, if enrolled in HCFSA in 2012 and you have funds during the grace period
HSA CONTRIBUTIONS Full Time Employee - (24 semi-monthly deductions)
Single Family
Employer (ER) Contribution
$1,500 $2,250
Employee (EE) Contribution
$25 to $72.91
$25 to $175
Maximum Annual HSA Contribution (ER+EE)
$3,250 $6,450
Over age 55 “Catch up” amount
$1,000 $1,000•HSA Contributions are governed by the Internal Revenue Service (IRS).•Eligibility criteria for HSA is on Page 12 of the Open Enrollment Book•Minimum contribution of $25 semi-monthly by the employee is required•Contributions may be made with pre- or post-tax funds. •HSA Contribution amounts can be changed anytime during the year.•Members over age 55 can contribute additional funds to “catch up”
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• All Plan C options will have the same HSA vendor: – US Bank
• A file with the members who enroll in Plan C will be sent by SEHP to US Bank
• Employees receive “welcome” notification via email – Letter if no email
• Employee completes online enrollment process– Must accept the Terms and Conditions– Order additional cards for dependents– Select account beneficiaries
• Online Tools to manage your account
HSA ENROLLMENT IS EASY
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USING YOUR HSA FUNDS • Use your HSA Bank Card at a Pharmacy – Fill a prescription– Swipe your HSA Bank Card for payment– Save a copy of receipt for your records
• Use your HSA Bank Card for Medical Services– Health plan adjudicates claim & sends you
an Explanation of Benefits (EOB) – Pay the provider using your HSA Bank Card– Save a copy of the bill or EOB for your
records
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ADDITIONAL WAYS TO PAY WITH YOUR HSA• You Pay the Provider through Bill Pay– You go online and use Bill Pay to issue
payment to the provider of service• Reimburse yourself for expenses paid
out of your pocket– With Bill Pay you can send a direct
deposit reimbursement to your checking or savings account for health care services
DENTAL COVERAGE Plan pays in full for 2 exams &
cleanings $50 Plan Deductible max of 3 per
family Implant Coverage– 50% Coinsurance to a max of $1,250 per
year – Benefit subject to annual benefit max
Annual benefit maximum– $1,700 per person per year
$1,000 Lifetime Orthodontic benefit
DENTAL BENEFIT
Benefit Level PPO PremierNon
Network
Preventive Services
Covered in full
Covered in full
Allowed amount
covered in full
Basic BenefitBasic
Restorative50% 50% 50%
Enhanced Benefit
Basic Restorative
20% 40% 40%
BASIC VISION PLAN $25 Materials Copay then:– 100% single vision, standard bifocal,
trifocal lenticular lenses– Up to $100 frame allowance
Elective Contact lens allowance $150
Office visit subject to $50 Copay Contact Lens Fitting Fee subject
to $35 Copay
ENHANCED VISION PLAN Includes Basic benefits plus…– Frame allowance of up to $150– 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
FLEXIBLE SPENDING ACCOUNTS Health Care Flexible Spending Account– For Plan A and B members only – Limited to $2,500 – Debit Card available
Limited FSA for Plan C members– Dental and vision expenses only– Cannot be used for medical expenses
Dependent Care Flexible Spending Account– For child care expenses – Limited to $5,000
www.asiflex.com
HEALTHQUEST (HQ) REWARDS Requirements for 2014 incentive
discount– Complete the health assessment– Earn 20 additional credits
HQ Rewards deadline is July 31, 2013 Non Tobacco usage is worth 10 credits– Certification is now online at:
www.kansashealthquest.com– You may complete the certification
anytime before the deadline. Tobacco cessation program is no longer
required for tobacco users.
OPEN ENROLLMENT Enroll online:–Make health plan selections– Add/drop dependents• Dependent documentation required by
October 31.
– Enroll in Flexible Spending Accounts– Apply for 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, 2013
IDENTIFICATION CARDS Coventry/PHS and UHC Plan C are
issuing new ID cards Delta Dental is issuing new ID cards Plans A and B, BCBS Plan C, Lab,
Vision & Drug are not issuing new cards unless the member makes a plan/coverage change
RESOURCES Review the Open Enrollment (OE) booklet ?’s: Call the health plan customer service– Phone numbers in the front of the OE booklet
Visit www.kdheks.gov/hcf/sehp.htm– Benefit descriptions, Provider directories, &
Preferred drug list available– Information on the HSA and FSA accounts
Summary of Benefits & Coverage (SBC) Email ?’s to SEHP: [email protected]
BENEFIT DECISION MAKING TOOLS
Two tools are available at: www.kdheks.gov/hcf/sehp/default.htm– SEHP Tool – US Bank Plan Comparison Tool
There is a Payroll Calculation tool available at http://www.kansas.gov/employee/
Questions?