Sweetwater County School District # 1

Transcription

1 Sweetwater County School District # 1 Post 65 Retiree Benefit Presentation June 7,

2 Agenda 01 Current plan options Grandfathered and Non-Grandfathered Plans What is changing? Post 65 Retirees UMR programs & helpful hints We are here to help 04 Premium Rates Current rates for the Plan Year 2

3 Current Plan Options Grandfathered & Non-Grandfathered Plans 3

4 Grandfathered Plan includes Medical, Pharmacy, Dental & Vision OV Copay: ER Surcharge: Urgent Care: * Deductible: Single Two Party Coinsurance: OOP Maximum: Single Two Party Pharmacy: Grandfathered Plan Plan Design In Network n/a $45 20% $400 Combined w/dental $800 Combined w/dental 20% $2,000 $4,000 $0 / 20% / 30% + $15 * Deductible: Single Two Party Diagnostic/Preventive Basic Services Major Services Orthodontic Annual Benefit Maximum Lifetime Ortho Maximum Eye Exam (1 per year) Lenses (1 set per year) Frames (1 pair per year) Elective Contacts (1x year) Dental $400 Combined w/medical $800 Combined w/medical 100% (ded waived) 80% 80% 80% $1,500 per person $1,500 per person Vision 100% 100% to $350 Max 100% to $125 Max $100 to $350 Max * Deductible: If you have two party coverage, any combination of covered members can help meet the maximum two party deductible, up to each person's individual amount. 4 4

5 Non-Grandfathered Plans includes Medical & Pharmacy Only Non Qualified Qualified High Deductible Qualified High Deductible Health Plan Health Plan Health Plan $1,000 PPO $1,500 HDHP $2,500 HDHP In Network OON In Network OON In Network OON ER Copay $150 $150 ER Copay n/a n/a ER Copay n/a n/a Deductible * Deductible ^ Deductible ^ Single $1,000 $2,000 Single $1,500 $5,000 Single $2,500 $5,000 Family $2,000 $4,000 Not Single $3,000 $10,000 Not Single $5,000 $10,000 Coinsurance 20% 50% Coinsurance 20% 50% Coinsurance 20% 50% OOP Maximum OOP Maximum OOP Maximum Single $4,000 $8,000 Single $4,500 $10,000 Single $6,000 $10,000 Family $8,000 $16,000 Not Single ^^ $9,000 $20,000 Not Single ^^ $12,000 $20,000 Pharmacy Retail $5/20% + $10/30% + $15 Pharmacy Retail 20% after deductible Pharmacy Retail 20% after deductible Pharmacy Mail $0/20%/30% + $15 Pharmacy Mail Program 20% after deductible Pharmacy Mail Program 20% after deductible Pharmacy Specialty Rx $5/20% + $10/30% + $15 Pharmacy Specialty Rx 20% after deductible Pharmacy Specialty Rx 20% after deductible 5 Preventative Procedures Covered at 100% In network Preventative Procedures Covered at 100% In network Preventative Procedures Covered at 100% In network Out of Pocket maximum includes deductibles Out of Pocket maximum includes deductibles Out of Pocket maximum includes deductibles and Medical and Pharmacy copays. Pharmacy counts for Medical and Pharmacy. Pharmacy counts for Medical and Pharmacy. Pharmacy counts towards in network only. towards in network only. towards in network only. * Deductible: If you have family coverage, any combination of covered family members can help meet the maximum family deductible, up to each person's individual amount. 5 ^ Deductible: If you have family coverage, any combination of covered family members can help meet the maximum family deductible. ^^ Not Single In Network Out of Pocket Maximum: $6,850 PPO Maximum amount that any one person will satisfy towards the annual family OOP in network only.

6 Non-Grandfathered Plans Medicare Supplemental-Type Plan Medical Only Medicare Supplemental Type Plan NEW Effective 10/01/2016 Plan Design No Network OV Copay: ER Surcharge: Urgent Care: n/a n/a n/a Deductible: Single Two Party n/a n/a Medicare Eligible Non Medicare Eligible Coinsurance: 0% 20% OOP Maximum: Medicare Eligible Non Medicare Eligible Single $0 $2,000 Two Party $0 $4,000 Note: The Plan will pay secondary to Medicare Services not covered by Medicare may be covered under this Plan, subject to the Medical Schedule of Benefits Post 65 Retirees electing this new plan will not be allowed to return to the Grandfathered Plan Pharmacy: No Benefit 6

7 Non-Grandfathered Plans Stand-Alone Dental & Vision * Deductible: Single Two Party Diagnostic/Preventive Basic Services Major Services Orthodontic Annual Benefit Maximum Lifetime Ortho Maximum Dental $50 $ % (ded waived) 80% 80% 80% $1,500 per person $1,500 per person Vision Eye Exam (1 per year) Lenses (1 set per year) Frames (1 pair per year) Elective Contacts (1x year) 100% 100% to $350 Max 100% to $125 Max $100 to $350 Max * Deductible: If you have two party coverage, any combination of covered members can help meet the maximum two party deductible, up to each person's individual amount. 7 7

8 What is changing? 8

9 What is changing? Grandfathered Plan will no longer be offered to Active Employees or Pre-65 Retirees after August 31, 2017 All active employees and Pre-65 retirees enrolled in the Grandfathered Plan will be enrolled in the $1,000 deductible PPO plan, optional Dental and optional Vision unless an election form is received requesting one of the other plan options or opting out of Dental and/or Vision by August 31, 2017 Those who enroll in a Qualified HDHP will also have an OptumBank account opened in their name and the District will deposit dollars into that account Grandfathered Plan will no longer be offered to Post-65 Retirees after August 31, 2018 Post 65 Retirees as of August 31, 2017 will be enrolled in the $1,000 deductible PPO plan, optional Dental and optional Vision unless an election form is received requesting one of the other plan options or opting out of Dental and/or Vision by August 31, 2018 Plan changes: All Non-Grandfathered Plans: Out-of-network coinsurance will change from 60% to 50% $1,000 Deductible PPO Plan: Emergency room copay will increase from $45 to $150 Generic copay will increase from $0 to $5 per script Preferred Brand copay will increase from $5 to $10 per script 9

10 All Medical Plans Preventive Services covered at 100% Grandfathered Plan Paid at 100% up to $500 per year 80% thereafter All Other Plans Paid at 100% in-network - No maximum Routine services include: Annual routine physical exams Immunizations Mammograms, including 3D mammograms Pap test PSA test / Prostate exams Colonoscopies, Sigmoidoscopy Preventive hearing exams Breast pumps Prenatal care Preventive diagnostic tests Female sterilizations 10

11 UMR programs & services 11

12 # 1 Utilization management Monitoring cases for appropriate care Prior authorization for medical necessity Determination and management of inpatient lengths-of-stay for medical and behavioral care Impact Reduced inpatient admissions and average length of stay Identification and steerage to care management programs Follows clinical guidelines with medical director oversight Registered nurses provide clinical oversight, coordination with facility & timely escalation of acute cases to case management nurses All programs interconnected and linked to claims system 12

13 Prior authorization Remember to call ahead # Prior authorization is required when you or a covered dependent need the following services: Inpatient stays in hospital or extended care facilities or residential treatment facilities Maternity deliveries longer than 48 hours normal delivery or 96 hours cesarean sections Transplants and related services Qualifying Clinical Trial Genetic testing Outpatient surgery for: Spinal surgery Nasal surgery Carpel tunnel surgery Heart catheterization Hysterectomy Herniorrhaphy 13

14 Prior authorization Remember to call ahead # PENALTY if a covered person receives services but does not obtain a prior authorization: a) Denial of claim or b) Penalty of 50% up to a maximum of $500 Does not apply to transplants, clinical trials or outpatient surgery Does not apply to services that are first covered by Medicare 14

15 # 2 Case management Coordinating complex and catastrophic cases Nurse case managers act as advocates for patient: Facilitate communication and coordinate care between physicians and other care providers Provide expertise handling complex cases Excel in patient care while keeping plan s costs in mind Intensively manage case from diagnosis to conclusion Promote patient self-management Interfacing with providers, EAP, etc. Assist you during a hospital stay Support you after you are released Arrange home care when needed 15

16 # 3 Disease management Mitigating impact of chronic medical conditions Focus on the most prevalent condition(s): Asthma Diabetes Hypertension COPD Heart disease Congestive heart failure Depression (co-morbidity) Personal health coaching Targeted messaging HealtheNotes Member engagement campaigns Educational information 16 Online resources

17 Disease management Disease management nurses: Follow evidence-based guidelines to help patients with a chronic conditions Match interventions with identified risks to foster patient self-management Educate on primary care/prevention, behavior modification and maintaining successful lifestyle changes Excel in patient advocacy and care How do I enroll? Call

18 # 4 NurseLine SM Steering members to appropriate care 24/7 health care advice Audio health education library Language line translation service Live online Nurse Chat service on umr.com What number would I call? 18 Call (on the back of your ID card)

19 Helpful Hints & Tools Connect to tools for better health 19

20 Helpful Hints Choose the right health care setting Where you go for medical care can make a big difference in what you pay and how long you wait to see a health care provider 20

21 Helpful Hints UnitedHealth Premium program The UnitedHealth Premium program evaluates doctors using evidence-based medicine and national standardized measures. Just go to umr.com and click on Find a Provider 21

22 Online services Easy access for members Members can: View claims (EOBs) Determine benefits & coverage Find a provider Check accounts and balances Order, print and fax ID cards Access health information (tools and videos) Access to mobile-friendly site Link to OptumRx site Additional resources available YouTube Videos Health Education Library Other Insurance Accident Details 22

23 Easy access on desktop or mobile devices There s nothing to download, our sites are mobile ready! Fewer clicks Access key information in 2 clicks or less Charts and icons Make it easy to find and understand information Mobile or desktop Consistent navigation between sites 23

24 myhealthcare Cost Estimator Empowering members myhce Makes it easy for members to research treatments, get cost estimates before a visit, plus view recommended care options Get cost estimates View quality rating information for providers and facilities Helps manage health care costs 24

25 Customer First Representatives Got questions? We have answers. Contact us by phone Available Monday - Friday 8:00 a.m. to 8:00 p.m. MDT Nurseline /7 Contact us online Nurseline Live Chat 25

26 Premium Rates Current rates for the Plan Year 26

27 Premium Rates Post 65 Retirees Monthly Contributions Current rates for the Plan Year Retiree Medicare premiums will be calculated based on the eligibility of each individual or dependent separately (beginning September 1, 2017) Grandfathered Plan Single $553 Two-Party $967 Includes Medical, Pharmacy, Dental & Vision $1,000 Deductible PPO Plan Single $456 Two-Party $799 Includes Medical & Pharmacy Qualified HDHP $1,500 Qualified HDHP $2,500 Single $406 Two-Party $711 Includes Medical & Pharmacy Single $339 Two-Party $593 Includes Medical & Pharmacy Medicare Supplemental-type Plan Single $211 Two-Party $370 Includes Medical only (Rates include a one-time incentive of $44 Single or $75 Two-Party) 27

28 Premium Rates Post 65 Retirees Monthly Contributions Current rates for the Plan Year Retiree Medicare premiums will be calculated based on the eligibility of each individual or dependent separately (beginning September 1, 2017) Stand-Alone Dental Single $ 54 Two-Party $ 94 Stand-Alone Vision Single $ 37 Two-Party $ 65 28

29 Questions? 29