Make It Yours. It s time to picture how you ll benefit from your medical plan. Aon Active Health Exchange. Your 2015 Medical Plan User s Guide

Transcription

1 Aon Active Health Exchange It s time to picture how you ll benefit from your medical plan. Make It Yours Your 2015 Medical Plan User s Guide Bronze & Bronze Plus

2 THE BASICS When you enrolled, you decided that a Bronze or Bronze Plus coverage level gives you the right coverage at a cost you can afford. But choosing the right medical plan and insurance carrier was just the first step. You still need to know how to use it when you need it. Keep this Medical Plan User s Guide handy so you can make the most of your plan throughout the year. Protection You Need, Savings You ll Love Your coverage includes: A high-deductible medical plan that provides comprehensive medical coverage. Access to a Health Savings Account (HSA) that gives you a way to pay for current or future medical expenses. And, the HSA offers you tax advantages. How Your Medical Plan and Your HSA Work Together In-network preventive care is 100% covered you pay nothing. For other in-network expenses: YOU PAY YOU AND INSURANCE CARRIER PAY INSURANCE CARRIER PAYS 1. Annual deductible You pay the full cost of services and prescription drugs until you reach the deductible. 2. Coinsurance Once you reach the deductible, you and the insurance carrier share the cost of medical and prescription drug expenses. 3. After annual out-ofpocket maximum Once you reach the out-of-pocket maximum for the year, the insurance carrier pays 100% of eligible expenses. Health Savings Account You can use the money in your HSA to help pay the deductible and coinsurance. Or, you can save it and just pay for your expenses out of pocket. Let s take a closer look at each part of your coverage. Please note that the information provided in this guide is intended to be a summary of the most common plan designs offered across insurance carriers. It does not take into account how each insurance carrier covers any state-mandated benefits, its plan administration capabilities, or the approval from the state Department of Insurance on the benefits offered by the insurance carrier. If you have questions about a topic that isn t covered, please contact the insurance carrier for additional information. If there is a discrepancy between the information displayed in this guide and the official plan documents, the official plan documents will govern. Payless reserves the right to amend, suspend, or terminate the plan(s) or program(s) at any time. This overview does not constitute a contract of employment. Aon Active Health Exchange is a trademark of Hewitt Associates LLC. 1

3 Deductibles can seem scary, but they don t have to be. You just need to know what to expect. Are you covering anyone other than yourself under one of these plans? If so, be ready to pay the full family deductible before coinsurance kicks in even if only one of you has expenses. HOW YOUR MEDICAL PLAN WORKS There are three parts to your medical and prescription drug coverage. 1 Annual deductible This is what you pay out of your own pocket for medical and prescription drug expenses before your insurance begins to pay a share of your costs. It doesn t include copays or amounts taken out of your paycheck for health coverage. The in-network annual deductible amounts are: Bronze: $2,750 individual/$5,500 family Bronze Plus: $2,000 individual/$4,000 family Note: If you live in California and chose Kaiser Permanente or UnitedHealthcare as your insurance carrier, out-of-network care is not covered. Do you have family coverage? The entire family deductible must be met before your insurance will pay benefits for any covered family members. There is no individual deductible when you have family coverage. For example, if you have family coverage under the Bronze Plus plan and your spouse has a $2,300 expense to start off the year, you ll owe the full amount when you get the bill because the family deductible of $4,000 has not been met. Pay Nothing for Preventive Care In-network preventive care like annual physicals, wellness screenings, immunizations, and well-baby care is 100% covered without having to pay your deductible. Regular preventive care can also help your doctor find health issues before they become more serious and more expensive to treat. Many carriers follow the U.S. Preventive Services Task Force recommendations to determine which services are considered preventive services. Check with your insurance carrier for specifics. See page 11 for information about preventive drugs. No Double Dipping The coverage details within may not take into account how each plan covers any state-mandated benefits, its plan administration capabilities, or the approval from the state Department of Insurance of the benefits offered by the plan. If you have questions about a specific benefit, contact the insurance carrier for additional information. Out-of-network charges will not count toward your in-network annual deductible. The same goes for in-network charges they will not count toward your out-of-network deductible. 2

4 2 Coinsurance Coinsurance is the percentage you pay after you meet the deductible. If you have family coverage, coinsurance won t kick in for any family member until the entire family deductible is met. Once the deductible is met, you pay 20% of the negotiated cost for in-network medical and prescription drug expenses. Negotiated costs are the fees providers (doctor, hospital, lab, etc.) have agreed to accept for a particular service in exchange for being a part of your insurance carrier s network. When It s Time to Pay Remember, you can use the HSA to help pay your deductible and coinsurance. We ll address the HSA in just a little bit. 3 Annual out-of-pocket maximum This is the most you would have to pay in a year for medical and prescription drug costs. Generally, the deductible and coinsurance amounts you pay will count toward your annual out-of-pocket maximum. It doesn t include amounts taken out of your paycheck for health coverage or amounts paid for services that are not covered by the plan. Note: If you enrolled in Kaiser Permanente, your prescription drug copays will not count toward your annual out-of-pocket maximum. The in-network annual out-of-pocket maximum amounts are: Bronze: $5,950 individual/$11,900 family Bronze Plus: $5,000 individual/$10,000 family No Double Dipping Out-of-network charges will not count toward your in-network outof-pocket maximum. The same goes for in-network charges they will not count toward your out-of-network out-of-pocket maximum. Remember: If you live in California and chose Kaiser Permanente or UnitedHealthcare as your insurance carrier, out-of-network care is not covered. Do you have family coverage? The entire family out-of-pocket maximum must be met before your insurance will pay the full cost of covered charges for any covered family members. There is no individual out-of-pocket maximum when you have family coverage. For example, if you have family coverage under the Bronze Plus plan and your spouse has a $5,500 out-of-pocket expense to start off the year, you ll owe the full amount when you get the bill because the family out-of-pocket maximum of $10,000 has not been met. 3

5 PAYING FOR MEDICAL CARE When you receive medical care, you may want to pay with your HSA, or out of pocket so you can save your HSA money for future expenses. Either way, just follow these easy steps when it s time to get care: Never Postpone Care Step 1: Meet with your provider. Don t forget you ll probably pay a lot less when you see in-network providers. Step 2: Present your medical plan ID card. You should receive your ID card by January 1. If you don t receive it or you need additional cards for your covered dependents, call your insurance carrier. Your ID card has key information about you and your coverage. You and your covered dependents should each keep a card in your wallet or purse so you have it when you need it. When you visit your doctor, hospital, or other health care provider, remember to show them the card so they know how to bill for the services they are providing you. In-network providers will submit the claim to your carrier for you and you will be billed later. Out-of-network providers may have you submit the claim to your carrier and, in some cases, ask you to pay when you receive care. Step 3: Review the Explanation of Benefits (EOB). An EOB is not a bill. It s simply a statement from your insurance carrier that shows when you received care and how much it cost. An EOB is typically mailed to you after your visit (unless you ve registered on your medical insurance carrier s website and opted to receive electronic communication). It will show: Your provider s charges The negotiated amount your insurance carrier agreed to pay How much is covered (if any) Your payment responsibility (remember, if you haven t met your deductible, you could owe the entire negotiated amount) Keep the EOB for your records because you will need it for the last step. Step 4: Review your provider s bill. A provider s bill typically arrives in your mailbox after the EOB arrives. The amount you owe on your provider s bill should match what s on the EOB. Keep reading to learn what to do if the numbers don t match. Step 5: Pay your provider. You can pay your provider out of pocket, or check out the couple of ways you can use your HSA to pay for qualified health care expenses on page 9. It is never healthy to postpone getting care you need because you want to avoid paying out of your pocket. Get Registered Online Be sure to register on your carrier s website so you can get information when you need it. You can review your claims, check to see if you ve met your deductible, take advantage of tools and resources, and much more. See page 13 for contact information. 4

6 What If Billing mistakes happen. It s an unfortunate fact of life. If you have questions about your coverage, you should start by contacting your insurance carrier directly. They know their plans best and have the final say on all claims and billing disputes. Sometimes you need more help than your insurance carrier can provide. If you run into trouble with a billing issue, health care advocates are available through the Payless Benefits Center. They are experts in handling claims and billing disputes, and they are dedicated to finding solutions that offer lasting peace of mind. Find more information about health care advocates here. If you aren t satisfied with the resolution of a claim or billing dispute, you can file an appeal through your insurance carrier, who will be able to direct you through that process. Keep in mind that Payless does not have any influence on the outcome because your medical plan is fully insured. This means the insurance carrier not Payless is responsible for the cost of claims. Make Your Money Last Use these tips to save more and stretch your dollars even further: Stay in network You can check the provider directory through the Payless Health Exchange at or refer to your insurance carrier s website. If you go to an out-of-network provider, consider the following: There is no discount on the amount the provider charges, and your medical insurance carrier will pay much less leaving you to pay the rest. For example, you could pay more through a higher deductible, higher coinsurance, and any amounts above what s considered reasonable and customary (R&C). The R&C amount is typically based on the amount Medicare pays. If you use out-of-network providers, make sure to find out what percentage of Medicare your carrier pays it makes a big difference. For example, let s say you have an out-of-network surgery that costs $5,000, and Medicare would pay $2,000. If your carrier pays 100% of what Medicare would pay (that is, the amount your carrier will use to calculate benefits), you would owe the full amount over $2,000, which is $3,000 ($5,000 $2,000 = $3,000). If your carrier pays 120% of what Medicare would pay, you would owe the amount over $2,400 ($2,000 x 120% = $2,400), or in this case, $2,600 ($5,000 $2,400 = $2,600). The higher the percentage of Medicare your carrier pays, the less you will owe for out-of-network services. If you live in California and chose Kaiser Permanente or UnitedHealthcare as your insurance carrier, out-of-network care is not covered. Questions? Don t worry. You have backups. When you face a billing issue: 1. Start with your insurance carrier. 2. Contact the Payless Benefits Center at to connect with a health care advocate if you need help. 3. File an appeal if you re not satisfied with the final outcome. Get the Best Care Possible Many carriers have done some homework for you to determine who provides the highest-quality, lowestcost care. Take advantage by first checking to see whether your doctor is in network, then take it a step further by looking for doctors and specialists who meet the carrier s high standards. Avoid Surprises If your doctor is out of network and you still want to see him or her, check the cost with your doctor before you get care. Then, ask your doctor to confirm the portion that will be covered by your medical insurance carrier and the portion for which you will be responsible. That way you ll be prepared for any potentially significant costs and avoid surprises later. 5

7 Go to the right place for care When you or a loved one is sick or hurt, your priority is getting the care you need. But a trip to the emergency room may not be the best choice. Your costs will be higher than any of your other options for care, and you may wait hours to see a doctor if you go there for non-emergency care. If it isn t a true emergency,* here are a few options to consider: Retail health clinic Found in pharmacy and retail stores, these clinics are staffed by medical professionals who can provide basic medical services. Urgent care center (also called Convenience Care or Walk-in Centers ) A facility with doctors available to treat conditions that should be looked at right away, but aren t life threatening (conditions such as flu symptoms, migraine headaches and minor burns or fractures). Doctor s office Your doctor knows you best and can help coordinate your care. * If a situation seems life-threatening, contact 911 or your local emergency number right away. You should seek emergency room care if you experience serious injury, severe pain or infection, uncontrollable bleeding, poisoning, chest pain, major burns, difficulty breathing or broken bones. Build a relationship with your doctor Studies show that a better doctor-patient relationship may actually improve your care and lead to saving money. Here are a few tips for preparing for your next visit: Make a list of the drugs you take on a regular basis. Be sure to include prescription drugs, over-the-counter drugs, vitamins, and supplements. Make a note of any health issues or major life events you ve had since your last doctor visit. Think about your eating, drinking, sleeping, exercising, smoking, and other lifestyle habits have they changed? Jot down any changes to your family health history. And if you have a chronic health condition (for example, diabetes or high blood pressure), write down whether there have been any changes, whether you re experiencing any new symptoms, and whether you ve been following your treatment plan. Write down questions you have for your doctor. During your visit, if you don t understand your doctor s answer, ask for a simple explanation. Your doctor can also help you understand your treatment options and their costs. If you re concerned about a procedure, ask for a second opinion. Remember your ID card. Your doctor s office staff needs it to verify your coverage and make a copy for their records. COST n Doctor s Office or Retail Health Clinic n Urgent Care n ER Care Not Sure Where to Go? Many insurance carriers offer 24/7 access to registered nurses who can help you find the right place to get care. Check with your insurance carrier to see if a NurseLine is available. Need Preapproval? Before getting certain types of care, you or your doctor may be required to run it by your insurance carrier first. Getting prior review (also referred to as prior authorization or precertification) allows the carrier to verify you re eligible for the services, to make sure you re getting care that makes sense for your condition, and to confirm how the bill is going to be paid. When prior review is required and you don t get preapproved, you could get stuck paying a lot more. For that reason, it s always in your best interest to ask your doctor whether you need to do anything in advance and confirm that services you need will be covered by your insurance carrier. 6

8 Save with an HSA now, thank yourself later. An HSA is a smart way to set yourself up for success. You can use it to pay for expenses now, or have a leg up on savings the following year if you don t use all your HSA money now. HOW THE HSA WORKS Your HSA is a personal bank account that works with your medical plan. It allows you to set aside tax-free money to pay for qualified health care expenses, like money you pay toward coinsurance and deductibles. You decide how much money you want to save in your HSA, and you can change it at any time. And, if you don t need that much health care, your money stays in your account and earns tax-free interest. It s a great way to save for future expenses. Your HSA is yours to keep even if you change plans, leave the company, or retire. Time for a Change? To change your HSA contributions during the year, log on to the Payless Health Exchange. From the home page, click Enroll Now and follow the prompts to enter your new HSA contribution amount per paycheck. What s Great About the HSA? While no one likes to take money out of their paycheck, the HSA offers several tax advantages: It s tax-free when it goes in. You can put money into your HSA on a before-tax basis through convenient payroll deductions. It s tax-free as it grows. You earn tax-free interest on your money. The interest you earn even earns interest! It s tax-free when you spend it. When you spend your HSA on qualified health care expenses, you don t pay any taxes. That means you re saving money on things like your medical, dental, and vision coinsurance and deductibles. 7

9 Attention First Timers! Is this your first time enrolling in an HSA through Your Spending Account (YSA), your HSA administrator? When you enrolled and elected to contribute money to an HSA, your information was sent to YSA to begin setting up your account. Make sure to also: Get your debit card Once your account is open, you ll receive a welcome letter and HSA debit card in the mail. The debit card gives you instant access to your HSA dollars. Just sign the back of the card and follow the instructions to activate it. If you don t receive your HSA debit card by January 1, contact YSA to request one be mailed to you. Already Have a Debit Card? If you already have an active debit card from YSA, go ahead and continue using it. A new card will not be issued unless your current card will soon expire. Manage your HSA throughout the year You re in complete control of your HSA you decide how and when to use it. Log on to YSA s website at to track your HSA balance, see how much you ve paid toward your deductible, use tools, view claims, change your HSA contributions and much more. Growing Your HSA You can use your HSA to get a head start on saving for the future. In fact, you can grow your HSA into a 401(k)-like nest egg for health care. Here are three ways: 1 Your contributions For 2015, you can save up to $3,350 if you re covering just yourself, or $6,550 if you re covering yourself and family. Most people take advantage of saving on a before-tax basis, but you can also set aside money after taxes. You won t get a tax break on after-tax savings, but once your account reaches $1,000 total in beforeand after-tax savings, you can invest the money in your account. That could help your account balance grow even faster. If you re age 55 or older, you can also make additional before-tax catch-up contributions to your HSA up to $1, Interest Already Have an HSA? If you currently have money in an HSA, you can still use it to pay for qualified health care expenses. Since your new HSA is managed by a different company, though, you may decide to transfer your funds to your new account. You will receive information on how to transfer your funds at the end of your enrollment period. After your plan begins, you can also log on to YSA s website at for directions on how to transfer funds. Your account earns tax-free interest. Over time, the interest you earn even earns interest! 3 Any investment earnings You can invest your HSA balance once it reaches $1,000. This is a great way to put your money to work for you and grow your HSA more quickly. For more information on your investment options, log on to YSA s website at or contact them at Note: You may not be able to use part or all of your invested HSA balance to pay yourself back for qualified expenses. Your Spending Account is a trademark of Hewitt Associates LLC. 8

10 Spending Your HSA When it s time for you to pay for care or prescription drugs, there are two ways to use your HSA to pay: 1 Use your HSA debit card Just swipe it when you re ready to pay for qualified medical expenses and the funds will be taken directly from your account. Just make sure you only use the card on eligible expenses, and that you have enough money in your HSA to cover it. Log on to YSA s website at to check your balance beforehand. 2 Pay out of pocket If you prefer, you can pay for your qualified expenses up front and pay yourself back through your HSA later. To get started, just log on to YSA s website at or contact YSA. You ll be able to transfer money from your HSA to your regular bank account. Eligible Expenses You can find a complete list of eligible expenses at Keep in mind, if you use money from your HSA to pay for nonqualified expenses such as child care, cosmetic surgery, health club fees, teeth whitening products, or vitamins you ll pay taxes on that money and pay an additional 20% penalty tax if you re under age 65. Keep Receipts Always remember to save your receipts when you make payments from your HSA, in case you need to provide proof of your eligible expenses to the IRS. 9

11 SUCCESS STORIES The following profiles show different ways you can use the HSA to pay for expenses and save for the future. They are for illustrative purposes only. Using the HSA Debit Card This is Ken s first year in the Bronze plan. He would like to start saving for future health care expenses, but right now he s focused on his immediate health care expenses. Ken uses the HSA debit card to pay for medication. He also uses it to pay the bill after visiting the doctor s office. By the end of the year, he has used up most of his account. The remaining money rolls over to the following year so he can use it to pay future expenses. Can I Use an HSA? To be eligible to contribute to an HSA, you must enroll in a Bronze or Bronze Plus medical coverage level. If you re covered by a second medical coverage, it must also be a high-deductible medical plan for you to be eligible for an HSA. For example, if you re also enrolled in your spouse s coverage, that plan must be a high-deductible medical plan too. You can t contribute to an HSA if: You re enrolled in Medicare or a veteran s medical plan. You re claimed as a dependent on someone else s federal tax return. You or your spouse have a general purpose Health Reimbursement Account (HRA) or participate in a general purpose Health Care Flexible Spending Account (Health Care FSA). Paying Yourself Back Later Karen started contributing to her HSA in January. Her account balance is growing, but it s not large enough (yet) to pay for an emergency she just had. Karen knows that by the end of the year, her HSA will have more than enough money to pay for the emergency. So, she decides to pay for the expense out of pocket now, and reimburse herself from her HSA later. When her account balance is large enough, Karen will just log on to YSA s website at to request that money is transferred from her HSA to her regular bank account. Karen knows she has the option to increase her contributions at any time to be able to reimburse herself more quickly but she would prefer to keep her contributions the same for now. In general, you can t have an HSA and use a Health Care FSA for medical expenses at the same time. If you have an HSA and Health Care FSA: Your Health Care FSA will be limited to paying for qualified dental and vision expenses[, and medical expenses after you have met the combined medical and prescription drug deductible. Your HSA can be used for medical, dental, and vision expenses. If you currently have money in a Health Care FSA, use it before you begin contributing to your HSA. This includes any grace period that applies during a new plan year (generally before March 15). Although you can enroll your children up to age 26 in your medical coverage, you can t use money from your HSA to pay their health care expenses unless you claim them as dependents on your federal income taxes (generally children up to age 18 or age 22 if they are full-time students). 10

12 Each prescription drug company covers prescription drugs differently. Want to know how your prescription will be covered? Do your homework and ask questions. HOW YOUR PRESCRIPTION PLAN WORKS Your prescription drug coverage is provided through your medical insurance carrier s pharmacy benefits manager. When you buy drugs through an in-network retail pharmacy or mail order, you pay 20% of the cost after you meet the combined medical and prescription drug deductible. Keep in mind that the cost of your prescription depends on how your medication is classified by your insurance carrier either Tier 1, Tier 2, or Tier 3. The higher the tier, the more you ll pay. You should contact your carrier to find out how your specific drug is classified. You may even find out there s a cheaper alternative available. Using mail-order service can also save you money. Paying for Prescription Drugs When you need to fill a prescription, you choose whether to use an in-network retail pharmacy or mail order. Below are the steps to fill a prescription. 1 Get a prescription from your doctor If you re going to fill your prescription at an in-network retail pharmacy, get a 30-day prescription from your doctor. To use mail-order service, get a 90-day prescription from your doctor. 2 Fill your prescription If you re at an in-network retail pharmacy, simply present your ID card to the pharmacist along with your prescription. You ll use the same ID card for both medical and prescription drug expenses. If you re using mail order, log on to your insurance carrier s website and follow the instructions to get mail-order service set up. You may even be able to set up automatic refills so that a new 90-day supply is mailed to you when you need it. Do You Take Preventive Drugs? If so, you may not have to pay anything. That s because the Affordable Care Act requires that certain preventive care drugs are covered at 100% when you fill them in network but each insurance carrier determines which drugs it considers preventive. You should contact your carrier to see whether your drug is on their preventive drug list. Note: You must have a doctor s prescription for the medication even for over-the-counter preventive care drugs and you must use an in-network retail pharmacy or mailorder service. Follow the Directions Think skipping a few pills is a good way to save money? Think again. The effects could be dangerous and lead to other health problems and costs. Always take your prescription drugs as directed. It does make a difference! 3 Pay the balance You have to meet a combined annual deductible for medical and prescription drugs before the plan begins to share in the cost of prescription drugs. If you haven t met your deductible, you ll have to pay the full price of the drug s discounted rate. 11

13 Make Your Money Last Use these tips to save more and stretch your dollar even further: Fill prescriptions with drugs on the formulary. A formulary is a list of generic and brand name drugs that are approved by the Food and Drug Administration (FDA) and are covered under your prescription drug plan. Be sure to check whether your drug is listed on the formulary before you fill it. If it isn t, you ll pay more. You can access your plan s formulary by checking with your insurance carrier. You can find contact information on page 13. Go generic. Generic drugs meet the same standards as brand name drugs, but they typically cost less. And, because brand name drugs are so expensive, some prescription drug companies don t cover them at all if a generic is available. Ask your doctor if a generic is available to you. Note: While generics will cost less most of the time, insurance carriers can classify higher-cost generics as Tier 2 or Tier 3 drugs, which means you ll pay the Tier 2 or Tier 3 price for certain generic drugs. Shop around. Where you shop can be just as important as what you buy. Some retail pharmacies fill certain prescription drugs (e.g., generic drugs) for a lower price. See if any retailers near you offer special deals on your prescription drugs. Use mail order for ongoing medications. Mail-order service can save you a trip to the pharmacy and may reduce your costs. To set up mail order with a new medical insurance carrier, you ll likely need a new 90-day prescription from your doctor. And, because mail order can take a few weeks to establish, it s a good idea to ask your doctor for a 30-day prescription to fill at a retail pharmacy in the meantime. In Some Cases You could also get a 90-day supply at an in-network retail pharmacy. It won t save you money like mail order might, but you ll get the benefit of convenience. 12

14 RESOURCES TO HELP YOU Medical Insurance Carrier Medical coverage and claims information Prescription drug coverage Setting up mail order for maintenance medications Health Savings Account (HSA) HSA balance Change HSA contributions Transfer money from your HSA Invest your HSA Payless Benefits Center Questions about your benefits or enrollment Connect with a health care advocate for help with a benefits or billing issue Internal Revenue Service (IRS) List of qualified HSA and FSA expenses Flexible Spending Accounts (FSAs) Health Care FSA claims and questions Aetna Website: Phone Number: Dean / Prevea360 Website: Phone Number: Health Net Website: Phone Number: Kaiser Permanente Website: Phone Numbers: CA: CO: GA: DC, MD, VA: OR AND WA: UnitedHealthcare National Website: Phone Number: UnitedHealthcare of CA Website: Phone Number: Your Spending Account (YSA) Website: Phone Number: Hours of Operation: 9:00 a.m. to 6:00 p.m., ET Website: Phone Number: Hours of Operation: 9:00 a.m. to 6:00 p.m., ET HSA: FSA: Your Spending Account (YSA) Website: Phone Number: Hours of Operation: 9:00 a.m. to 6:00 p.m., ET 13