Minimum Essential Coverage (MEC) & The RCI FREEDOM Plan Plus. An Affordable ACA Qualified & ERISA Health Plan Solution

Transcription

1 Minimum Essential Coverage (MEC) & The RCI FREEDOM Plus An Affordable ACA Qualified & ERISA Health Solution Sponsored by Small Business/Agency Cooperative, Inc. SERVICE FLEXIBILITY INTEGRITY Presented by: Regional Care, Inc. 905 W 27th Street Scottsbluff, NE regionalcare.com Maximizing savings and providing cung-edge soluons to help you effecvely manage your health care costs.

2 The Partners of The Freedom RCI serves over 200 clients with members in 48 states. RCI FAST FACTS Number of RCI Members: over 40,000 Largest Client: 3,500 members Smallest Client: 20 members Network Access: national networks and multiple regional networks Annual total number of claims processed on a monthly basis: over 54,000 Total number of RCI employees: 55 (at locations in Scottsbluff, Michigan, Colorado, Idaho, and eastern Nebraska) SERVE YOU RX Since 1987, SERVE YOU Rx has been the pharmacy benefit manager (PBM) of choice for employee benefit brokers and consultants, their clients, including employers, unions, coalitions and governmental entities, as well as third party administrators who are looking for a valuable partner to effectively manage prescription drug costs. SERVE YOU Rx offers: Stability Consistency Flexibility Customized plan designs Consultative clinical support Robust trend management programs and strategies Exceptionally focused member and client service Quality-driven, Serve You Rx owned and operated mail service and specialty pharmacies Over 66,000 pharmacies nationwide Privately owned and headquartered in Milwaukee, Wisconsin Wholly-owned mail order pharmacy The SB/A Coop is as a Non-Profit AGENCY Cooperave Corporaon that does not buy or sell products or services but acts as the Legal Collecve Agent of all the Cooperave Members to facilitate advantageous contractual relaonships for and between the members. The SB/A Coop may legally aggregate small employers together without becoming a Mulple Employer Welfare Associaon (MEWA) or acng as a Mulple Employer Trust (MET). The SB/A Coop will sponsor the unique ERISA Supplemental Health Care s that are ACA qualified when offered in tandem with a High Deducble Health (HDHP) or a Minimum Essenal Coverage (MEC). 2

3 The RCI MEC Freedom "An ERISA Health Solution The Small Business/Agency Cooperative Efficiency5 Savings5 Simplicity5 Freedom The SB/A Coop was formed in 2017 as a Non-Profit AGENCY Cooperave Corporaon to provide for Employer/Employee health care benefits in the small and large Group Employer marketplace. Each group employer Coop Member can sponsor a Parally Self-Funded ERISA Employer Welfare Benefit for the benefit of its Employees and their Dependents. Called The RCI MEC Freedom, it is a ERISA health plan for sponsoring employers offered in conjuncon with a Minimal Essenal Coverage (MEC). The Employer s claim exposure is protected via an Aggregate Stop Loss Fund (ASLF) owned by the SB/A Coop Employer Members. Each SB/A Coop Employer Member has its own RCI MEC Freedom funded claim account maintained by RCI, Inc., the Administrator. The Employer s maximum claim liability is limited to the 12-month level funding of its claim account. The Member Employer owns the funds and will receive 100% of any surplus following the Year runout at the end of the 15th month (12/15). Today s health benefits landscape is more challenging for employers to navigate than ever before. Yet, there s a reason why nearly 70% of employees who have health coverage in the U.S. are now enrolled in some sort of self-funded plan and why that number is growing they work. It s that simple. Companies of all sizes and types, including public enes, are finding this to be true as they make the switch from the more limited fully-insured plans to the added flexibility and customizable health benefit opons self-funding offers. We offer 4 plan opons which are illustrated in this document. To parcipate and take advantage of the RCI MEC Freedom opons, the following is required: Broker and employers must join the SB/A Coop complete the SB/A Coop Membership Agreement and pay the annual $24 membership fee Broker completes SB/A Coop Compensaon Form, Broker W-9, and Broker Informaon Form this is a one me requirement Employer completes the Group Informaon Form and Group W-9 Employees complete the RCI MEC Freedom plan Employee Enrollment Form for larger employer groups, employers can submit an electronic eligibility spreadsheet Talk with your SB/A Coop representave for more informaon and go to to download forms and learn more. 3

4 $7,500/$15,000 RCI MEC Freedom MEC & The Freedom Covered Services Minimum Essenal Coverage (MEC ) The Freedom $7,500/$15,000 Annual Deducble None None Member Annual Out-of-Pocket Maximum None $3,750/$7,500 Co-insurance Percentage Covered (plan pays based on contracted amounts) 100% Inpaent/Outpaent Hospitalizaon, Inpaent/Outpaent Professional Services, All Medical & Surgical Professional Services, Emergency Room/ Urgent Care, Lab, X-ray and Imaging (other than Roune Well Care), Ambulance Service, Inpaent/Outpaent Psych & Substance Abuse Preventave Care Covered at 100% Covered by MEC Pharmacy Benefit 100% of ACA Mandated Prescripons, i.e. Birth Control TelaDoc - On-line & Telephonic Doctor Calls 100% - No Copayment Required Dental/Vision Discounted Benefits - Offered by Direct Dental s of America, Inc. Fee Schedule Annual Maximum of Covered Services No Annual Maximum $7,500/$15,000 Minimum Essenal Coverage (MEC) Roune Well Care As Provided Under the Affordable Care Act (ACA) Adult Preventave Services - Screenings & Services Covered at 100% Covered by MEC Woman Preventave Services - Screenings & Services Covered at 100% Covered by MEC Child Preventave Services - Screenings & Services Covered at 100% Covered by MEC The Combined MEC & Freedom s covers: ACA Preventave Care, Roune Checkups, Pap Smears, Flu Shots, Immunizaons, and More Primary Care, Specialist, & Urgent Care Visits Plus X-rays, CT & MRI Scans, Lab & Diagnosc Services Prescripon Drugs ACA at 100% (includes Birth Control) plus all others at 50% up to $7,500/$15,000 threshold limit using the SERVE YOU Rx pharmacy card at your favorite pharmacy Hospital, Surgical, & Ambulance Telemedicine (TelaDoc) and Dental & Vision Services (Direct Dental s of America, Inc.) Pharmacy benefits are eligible for SERVE YOU Rx discounts above the $7,500/$15,000 threshold 4

5 $7,500/$15,000 RCI MEC Freedom Plus $15,000/$30,000 Inpatient MEC & The Freedom Covered Services Minimum Essenal Coverage (MEC ) The Freedom $7,500/$15,000 + $15,000/$30,000 Inpaent Benefit Annual Deducble None None Member Annual Out-of-Pocket Maximum None $3,750/$7,500 Co-insurance Percentage Covered (plan pays based on contracted amounts) 100% Inpaent/Outpaent Hospitalizaon, Inpaent/Outpaent Professional Services, All Medical & Surgical Professional Services, Emergency Room/ Urgent Care, Lab, X-ray and Imaging (other than Roune Well Care), Ambulance Service, Inpaent/Outpaent Psych & Substance Abuse Inpaent Only Hospitalizaon and Professional Services Emergency Room/Urgent Care, Lab, X-ray and Imaging (if admiked) Ambulance Service (if admiked) Inpaent Psych & Substance Abuse (limited to 30 Days) Excludes Outpaent Drugs, Kidney Dialysis, Chemo Therapy, & All Other Infusion Therapy 100% of next $15,000 Preventave Care Covered at 100% Covered by MEC Pharmacy Benefit 100% of ACA Mandated Prescripons, i.e. Birth Control TelaDoc - On-line & Telephonic Doctor Calls Dental/Vision Discounted Benefits - Offered by Direct Dental s of America, Inc. Annual Maximum of Covered Services No Annual Maximum 100% - No Copayment Required Fee Schedule $7,500/$15,000 1st In/ Outpat services $15,000/ $30,000 next Inpat services Minimum Essenal Coverage (MEC) Roune Well Care As Provided Under the Affordable Care Act (ACA) Adult Preventave Services - Screenings & Services Covered at 100% Covered by MEC Woman Preventave Services - Screenings & Services Covered at 100% Covered by MEC Child Preventave Services - Screenings & Services Covered at 100% Covered by MEC 5

6 $10,000/$20,000 RCI MEC Freedom Plus $15,000/$30,000 Inpatient MEC & The Freedom Covered Services Minimum Essenal Coverage (MEC ) The Freedom $10,000/$20,000 + $15,000/$30,000 Inpaent Benefit Annual Deducble None None Member Annual Out-of-Pocket Maximum None $5,000/$10,000 Co-insurance Percentage Covered (plan pays based on contracted amounts) 100% 50% Co-ins on 1st $10,000 Inpaent/Outpaent Hospitalizaon, Inpaent/Outpaent Professional Services, All Medical & Surgical Professional Services, Emergency Room/ Urgent Care, Lab, X-ray and Imaging (other than Roune Well Care), Ambulance Service, Inpaent/Outpaent Psych & Substance Abuse 50% Co-ins on 1st $10,000 Inpaent Only Hospitalizaon and Professional Services Emergency Room/Urgent Care, Lab, X-ray and Imaging (if admiked) Ambulance Service (if admiked) Inpaent Psych & Substance Abuse (limited to 30 Days) Excludes Outpaent Drugs, Kidney Dialysis, Chemo Therapy, & All Other Infusion Therapy 100% of next $15,000 Preventave Care Covered at 100% Covered by MEC Pharmacy Benefit 100% of ACA Mandated Prescripons, i.e. Birth Control 50% Co-ins on 1st $10,000 TelaDoc - On-line & Telephonic Doctor Calls Dental/Vision Discounted Benefits - Offered by Direct Dental s of America, Inc. Annual Maximum of Covered Services No Annual Maximum 100% - No Copayment Required Fee Schedule $10,000/$20,000 1st In/ Outpat services $15,000/ $30,000 next Inpat services Minimum Essenal Coverage (MEC) Roune Well Care As Provided Under the Affordable Care Act (ACA) Adult Preventave Services - Screenings & Services Covered at 100% Covered by MEC Woman Preventave Services - Screenings & Services Covered at 100% Covered by MEC Child Preventave Services - Screenings & Services Covered at 100% Covered by MEC 6

7 $25,000/$50,000 RCI MEC Freedom Plus $25,000/$50,000 Inpatient MEC & The Freedom Covered Services Minimum Essenal Coverage (MEC ) (PPO) The Freedom $25,000/$50,000 + $25,000/$50,000 Inpaent Benefit (PPO) Annual Deducble None None Member Annual Out-of-Pocket Maximum None $7,250/$14,500 Co-insurance Percentage Covered (plan pays based on contracted amounts) 100% 80% of next $17,500 Inpaent/Outpaent Hospitalizaon, Inpaent/Outpaent Professional Services, All Medical & Surgical Professional Services, Emergency Room/ Urgent Care, Lab, X-ray and Imaging (other than Roune Well Care), Ambulance Service (if admiked), Psych & Substance Abuse 80% of next $17,500 Inpaent Only Hospitalizaon and Professional Services Emergency Room/Urgent Care, Lab, X-ray and Imaging (if admiked) Ambulance Service (if admiked) Inpaent Psych & Substance Abuse (limited to 30 Days) 100% of next $25,000 Excludes Outpaent Drugs, Kidney Dialysis, Chemo Therapy, & All Other Infusion Therapy Preventave Care Covered at 100% Covered by MEC Pharmacy Benefit TelaDoc - On-line & Telephonic Doctor Calls Dental/Vision Discounted Benefits - Offered by Direct Dental s of America, Inc. Annual Maximum of Covered Services 100% of ACA Mandated Prescripons, i.e. Birth Control No Annual Maximum 80% of next $17,500 No Coverage Above 1st $25, % - No Copayment Required Fee Schedule $25,000/$ st In/Outpaent Services $25,000/$50,000 next Inpaent Services Minimum Essenal Coverage (MEC) Roune Well Care As Provided Under the Affordable Care Act (ACA) Adult Preventave Services - Screenings & Services Covered at 100% Covered by MEC Woman Preventave Services - Screenings & Services Covered at 100% Covered by MEC Child Preventave Services - Screenings & Services Covered at 100% Covered by MEC 7

8 Minimum Essential Coverage (MEC) Annual Benefit MEC Covered Services Minimum Essential Coverage (MEC ) Annual Deductible None Member Annual Out-of-Pocket Maximum None Co-insurance Percentage covered ( Pays Based on Contracted Amounts) 100% Preventative Care Covered at 100% Pharmacy Benefit Annual Maximum of Covered Services 100% of ACA mandated prescriptions, i.e. Birth Control No Annual Maximum Routine Well Care As Provided Under the Affordable Care Act (ACA) Adult Preventative Services -- Screenings & Services Listed Below are Eligible 1. Abdominal Aortic Aneurysm 9. Diet Counseling Covered at 100% 2. Alcohol Misuse 10. Obesity Covered at 100% 3. Aspirin 11. Sexually Transmitted Infection (STI) Covered at 100% 4. Blood Pressure 12. Syphilis Covered at 100% 5. Cholesterol 13. HIV Covered at 100% 6. Colorectal Cancer 14. Tobacco Use Covered at 100% 7. Depression 15. Immunization Vaccines Covered at 100% 8. Type 2 Diabetes Covered at 100% Woman Preventative Services - Screenings & Services Listed Below are Eligible 1. Anemia 12. Gestational Diabetes Covered at 100% 2. Bacteriuria Urinary Tract 13. Gonorrhea Covered at 100% 3. BRCA 14. Hepatitis B Covered at 100% 4. Breast Cancer Mammography 15. Human Immunodeficiency Virus (HIV) Covered at 100% 5. Breast Cancer Chemoprevention 16. Human Papillomavirus (HPV) DNA Test Covered at 100% 6. Breastfeeding 17. Osteoporosis Covered at 100% 7. Cervical Cancer 18. Rh Incompatibility Covered at 100% 8. Chlamydia Infection 19. Tobacco Use Covered at 100% 9. Contraception 20. Sexually Transmitted Infections (STI) Covered at 100% 10. Domestic and interpersonal Violence 21. Syphilis Covered at 100% 11. Folic Acid Supplements 22. Well-Woman Visits Covered at 100% Child Preventative Services - Screenings & Services Listed Below are Eligible 1. Alcohol and Drug Use 14. Hematocrit or Hemoglobin Covered at 100% 2. Autism 15. Hemoglobinopathies or Sickle Cell Covered at 100% 3. Behavioral 16. HIV Covered at 100% 4. Blood Pressure 17. Immunization Vaccines Covered at 100% 5. Cervical Dysplasia 18. Iron Supplements Covered at 100% 6. Congenital Hypothyroidism 19. Lead Exposure Covered at 100% 7. Depression 20. Medical History Covered at 100% 8. Developmental 21. Obesity Covered at 100% 9. Dyslipidemia 22. Oral Health Covered at 100% 10. Fluoride Supplements 23. Phenylketonuria (PKU) Covered at 100% 11. Gonorrhea 24. Sexually Transmitted Infection Covered at 100% 12. Hearing 25. Tuberculin Testing Covered at 100% 13. Height, Weight and Body Mass Index 26. Vision Covered at 100% 8

9 Provisions Plus Inpatient Benefit $7,500/$15,000 RCI MEC Freedom Plus $15,000/$30,000 Inpaent: ACA Preventave Care, Roune Checkups, Pap Smears, Flu Shots, Immunizaons, and More Primary Care, Specialist, & Urgent Care Visits Plus X-rays, CT & MRI Scans, Lab & Diagnosc Services Prescripon Drugs ACA at 100% (includes Birth Control) plus all others at 50% up to $7,500/$15,000 threshold limit using the SERVE YOU Rx pharmacy card at your favorite pharmacy Telemedicine (TelaDoc) and Dental & Vision Services (Direct Dental s of America, Inc.) Pharmacy benefits are eligible for SERVE YOU Rx discounts above the $7,500/$15,000 threshold Exclusions from coverage under $15,0000/$30,000 Inpaent Benefit: Outpaent Drugs, Kidney Dialysis, Chemo Therapy, and All Other Infusion Therapy $10,000/$20,000 RCI MEC Freedom Plus $15,000/$30,000 Inpaent: ACA Preventave Care, Roune Checkups, Pap Smears, Flu Shots, Immunizaons, and More Primary Care, Specialist, & Urgent Care Visits Plus X-rays, CT & MRI Scans, Lab & Diagnosc Services Prescripon Drugs ACA at 100% (includes Birth Control) plus all others at 50% up to $10,000/$20,000 threshold limit using the SERVE YOU Rx pharmacy card at your favorite pharmacy Telemedicine (TelaDoc) and Dental & Vision Services (Direct Dental s of America, Inc.) Pharmacy benefits are eligible for SERVE YOU Rx discounts above the $10,000/$20,000 threshold Exclusions from coverage under $15,000/$30,000 Inpaent Benefit: Outpaent Drugs, Kidney Dialysis, Chemo Therapy, and All Other Infusion Therapy $25,000/$50,000 RCI MEC Freedom Plus $25,000/$50,000 Inpaent: ACA Preventave Care, Roune Checkups, Pap Smears, Flu Shots, Immunizaons, and More Primary Care, Specialist, & Urgent Care Visits Plus X-rays, CT & MRI Scans, Lab & Diagnosc Services Prescripon Drugs ACA at 100% (includes Birth Control) plus all others at 50% and 20% up to $25,000/$50,000 threshold limit using the SERVE YOU Rx pharmacy card at your favorite pharmacy Telemedicine (TelaDoc) and Dental & Vision Services (Direct Dental s of America, Inc.) Pharmacy benefits are eligible for SERVE YOU Rx discounts above the $25,000/$50,000 threshold Exclusions from coverage under $25,000/$50,000 Inpaent Benefit: Outpaent Drugs, Kidney Dialysis, Chemo Therapy, and All Other Infusion Therapy Inpaent Benefit Provisions: Enhanced benefits in addion to base benefits Inpaent Psych/Substance Abuse benefits limited to 30 days per year Addional Annual Maximum benefit is limited to $15,000/$30,000 or $25,000/$50,000 per year Inpaent Only Hospitalizaon and Professional Services Emergency Room/Urgent Care, Lab, X-ray and Imaging (if admiked) Ambulance Service (if admiked) Inpaent Psych & Substance Abuse (limited to 30 Days) Addional Inpaent Benefit provision is effecve 60 days amer the effecve date of the member Any hospital confinement that began on or before the effecve date is excluded from plan coverage Outpaent Drugs, Kidney Dialysis, Chemo Therapy, and All Other Infusion Therapy is excluded from coverage under Inpaent Provision 9

10 RCI MEC Freedom Pricing $7,500/$15,000 Fixed Cost Claim Funding Monthly Funding Cost Employee Only $ $ = $ Employee + Spouse $ $ = $ Employee + Child(ren) $ $ = $ Employee & Family $ $ = $ $7,500/$15,000 Plus $15,000/$30,000 Inpaent Benefit Fixed Cost Claim Funding Monthly Funding Cost Employee Only $ $ = $ Employee + Spouse $ $ = $ Employee + Child(ren) $ $ = $ Employee & Family $ $ = $ $10,000/$20,000 Plus $15,000/$30,000 Fixed Cost Claim Funding Monthly Funding Cost Employee Only $ $ = $ Employee + Spouse $ $ = $ Employee + Child(ren) $ $ = $ Employee & Family $ $ = $ $25,00/$50,000 Plus $25,000/$50,000 Fixed Cost Claim Funding Monthly Funding Cost Employee Only $ $ = $ Employee + Spouse $ $ = $ Employee + Child(ren) $ $ = $ Employee & Family $ $ = $ ACA Qualified MEC No medical underwring required and no pre-exisng condion limitaons apply SB/A Coop Membership required Mulple PPO Networks are available, i.e. PHCS, First Health, Mul, etc. 10

11 The Freedom Cost Calculator Group Name: Agent Name: $7,500/$15,000 RCI MEC Freedom Enrollment Fixed + Claim Funding Cost Per Selecon Employee Only X $275 ($175 + $100) = Employee + Dependents X $450 ($210 + $240) = Total Employees Total Monthly Funding MONTHLY FUNDING X 12 = ANNUAL FUNDING $7,500/$15,000 RCI MEC Freedom Plus $15,000/$30,000 Inpaent Benefit Enrollment Fixed + Claim Funding Cost Per Selecon Employee Only X $325 ($175 + $150) = Employee + Dependents X $500 ($210 + $290) = Total Employees Total Monthly Funding MONTHLY FUNDING X 12 = ANNUAL FUNDING $10,000/$20,000 RCI MEC Freedom Plus $15,000/$30,000 Inpaent Benefit Enrollment Fixed + Claim Funding Cost Per Selecon Employee Only X $375 ($185 + $190) = Employee + Dependents X $600 ($220 + $380) = Total Employees Total Monthly Funding MONTHLY FUNDING X 12 = ANNUAL FUNDING $25,000/$50,000 RCI MEC Freedom Plus $25,000/$50,000 Inpaent Benefit Enrollment Fixed + Claim Funding Cost Per Selecon Employee Only X $485 ($195 + $290) = Employee + Dependents X $735 ($230 + $505) = Total Employees Total Monthly Funding MONTHLY FUNDING X 12 = ANNUAL FUNDING Authorized Group Contact Acceptance Signature: Printed Name and Title: Date of Acceptance: Effecve Date: 11