Learn with Anthem. Understanding PPO Plans Travel Coverage Nurseline

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1 Learn with Anthem Understanding PPO Plans Travel Coverage Nurseline

2 Network Advantage Visit any licensed provider Provider Networks where you live, where you work or where you travel Largest network with 780,000 providers and 5,800 hospitals International coverage with BlueCard Worldwide o Worldwide access to 899 hospitals and 6,819 physicians in 200 different countries Significantly more of U.S. News and World Report s Best Hospitals (95%) Quality Networks for Transplants, Bariatric*, Cardiac and Cancer through Blue Distinction Network Cost Efficiency Network through Blue Precision for 12 different specialties including: Cardiovascular/Cardiology, Orthopedics, General Surgery, Gastroenterology, Neurology/ Neurosurgery, Otolaryngology, Urology, Pulmonary, OBGYN, Oncology, Dermatology and Opthalmology 2

3 What is BlueCard Worldwide? Enables Blue Cross and Blue Shield Plan members traveling or living abroad to obtain medical assistance and inpatient, outpatient and professional services from a network of healthcare providers worldwide. 3

4 Benefits to Members Peace of mind for members traveling or living overseas Single point of contact for medical assistance services 24x7x365 Worldwide network of healthcare providers Access to provider information through BlueCard Access Line BLUE (2583) Centralized administration Easy program to use 4

5 World Access - Medical Assistance Provide referral to doctor or hospital Facilitate verbal translations between provider and member Perform medical monitoring of inpatient cases Review the care and treatment rendered Includes World Access staff speaking with: the member the treating medical officer the member s family and/or member s primary physician 5

6 Understanding Your PPO Plans PPO 90/10 PPO 80/20

7 Understanding Key Components of Your PPO Plans Copay: Flat fees paid for services that include office visits, ER, Urgent Care and Pharmacy. Deductible: A set amount that you pay before your plan starts paying for certain covered services. Coinsurance: You and the plan share the cost of covered services after you have met your deductible. Out-of Pocket Maximum: The most you pay for covered health services each year. This maximum includes your deductible, coinsurance and copays. This does not include your premium or contributions to any spending accounts. Premium: The amount you pay to be enrolled in the plan. 7

8 Blue Access 80/20 Plan Benefits In-network Out-of-network Calendar Year Deductible $250/$500 $500/$1,000 Co-insurance 80%/20% after deductible 60%/40% after deductible Out-of-Pocket Maximum $1,750/$3,500 $3,500/$7,000 Inpatient Hospital Deductible then 20% Deductible then 40% Outpatient Deductible then 20% Deductible then 40% Preventive (Age Appropriate screenings) Covered in Full Deductible then 40% Emergency Room $200 copay $200 copay Urgent Care $40 copay Deductible then 40% Office Visit (PCP) $20 copay Deductible then 40% Specialist Visit $30 copay Deductible then 40% Pharmacy 30-day Retail - Generic Formulary-- $8 - Brand Formulary -- $25 - Non-Formulary -- $40 90 days Mail Order Generic Formulary -- $12 Brand Formulary -- 10% ($22 Min) Non-Formulary -- 10% ($60 Min) 30-day Retail 50% coinsurance ($40 Min copay) 90 days Mail Order Non-Network Mail Order is not covered. 8

9 Blue Access 80/20 Plan Claim Example Claim #1 Information Plan Component PPO 80/20 Echocardiogram (echo) Copay $0 $972 (allowed amount) Deductible $250 Coinsurance $ (20% of $722) Patient Total $ WSU Plan Total $ Claim #2 Information Plan Component PPO 80/20 Outpatient Laparoscopic Surgery Facility Copay $0 $12,866 (allowed amount) Deductible $0 $1, Coinsurance (20% of claim up to OOPM) Patient Total $1, WSU Plan Total $11,

10 Blue Access 90/10 Plan Benefits In-network Out-of-network Calendar Year Deductible $125/$250 $250/$500 Co-insurance 90%/100% after deductible 70%/30% after deductible Out-of-Pocket Maximum $1,000/$2,000 $2,000/$4,000 Inpatient Hospital Deductible then 10% Deductible then 30% Outpatient Deductible then 10% Deductible then 30% Preventive (Age Appropriate screenings) Covered in Full Deductible then 30% Emergency Room $200 copay $200 copay Urgent Care $40 copay Deductible then 30% Office Visit (PCP) $15 copay Deductible then 30% Specialist Visit $25 copay Deductible then 30% Pharmacy 30-day Retail - Generic Formulary-- $8 - Brand Formulary -- $25 - Non-Formulary -- $40 90 days Mail Order Generic Formulary -- $12 Brand Formulary -- 10% ($22 Min) Non-Formulary -- 10% ($60 Min) 30-day Retail 50% coinsurance ($40 Min copay) 90 days Mail Order Non-Network Mail Order is not covered

11 Blue Access 90/10 Plan Claim Example Claim #1 Information Plan Component PPO 90/10 Echocardiogram (echo) Copay $0 $972 (allowed amount) Deductible $125 Coinsurance $84.70 (40% of $847) (40% of allowed amount) Patient Total $ WSU Plan Total $ Claim #2 Information Plan Component PPO 90/10 Outpatient Laparoscopic Surgery Facility Copay $0 $12,866 (allowed amount) Deductible $0 $ Coinsurance (10% of claim up to OOPM) Patient Total $ WSU Plan Total $12,

12 Out of Network

13 What happens if I go out of network? The PPO plans provide benefits for out of the network providers of service; however nonnetwork providers may balance bill you. Example: Dr. Smith is an out of network provider, he bills Anthem $1,000 for a procedure Total charge - $1,000 The Usual and Customary Rate (UCR) for the procedure is $800 Anthem applies your non-network benefits based on a percentage of the $800 UCR rate The non-network provider can bill you for the amount above the UCR. Network providers agree to accept negotiated fees and do not balance bill patients for covered network services 13 13

14 Blue Access Out of Network PPO 80/20 Claim Example Claim #1 Information Plan Component Patient Responsibility WSU Plan Responsibility PPO 80/20 Echocardiogram (echo) $2, Total Charge $972 Allowed Amount $ % UCR applied to Claim $1, Balance Bill $1, Copay $0 Deductible $500 Coinsurance $ (40% of $277.60) Patient Total $2, $ (60% of $277.60) WSU Plan Total $

15 Access to Registered Nurses Any time of the day or night

16 24/7 NurseLine 24/7 NurseLine provides access to a registered nurse over the phone 24/7, anytime, anywhere. Helps members understand their symptoms Increases understanding of medical condition or prescribed course of treatment Helps ensure members access the right care in the right setting 16 16

17 24/7 NurseLine: Key Features The 24/7 NurseLine program features include: A skilled clinical team RN license Bilingual RNs, language line, and hearing impaired services Immediate physician support, as needed Comprehensive Audiohealth Library Quality assurance Clinical record reviews Satisfaction surveys 17 17

18 24/7 Nurseline Member feedback Your nurse was unbelievable in her knowledge of what to do and how to get the right care. She is a real asset to your health care system. She was also so friendly and kind you are lucky to have her as an employee and your clients are lucky she is there to help them. Very helpful. I probably wouldn't have gone to the hospital on my own, but both times the nurse instructed me to the hospital and I agreed it was the best decision. It helped me get the urgent care I needed immediately and couldn't get elsewhere. The last nurse that I It is spoke great with to have was a reliable wonderfully source caring to call and when helpful. I need it It is great to have a reliable source to call when I need it often when my primary physician isn t always available. Nurse was fantastic in demeanor and knowledge. I always enjoyed talking to the 24/7 nurses. All of the nurses are very pleasant which aids in the discussions about my health concerns. That really helps the situations (when help is needed). After describing my symptoms I was told to get It has to helped the emergency my family room. understand There I was my condition diagnosed and with provided an appendicitis. knowledge to I had help them arrived to prevent before having it ruptured the same thank condition you to in NurseLine. the future. Source: Quarterly 24/7 Member Satisfation 1Q14 Customer Viewpoint Program

19 Pharmacy Coverage

20 Refill a script on-the-go: New mobile access to your prescription information Find a Mobile ID card (medical + pharmacy) Find a pharmacy Search and view medications Compare medication costs Order home delivery refills Check order status Schedule dosing reminders 20 20

21 Pharmacy Benefits Page 21 21

22 Wright State University Flex Spending Account (FSA) Education Session February 2015

23 Healthcare FSA Details o Eligibility No medical plan required Not eligible if you OR your spouse are contributing to an HSA o Provides employees with pre-tax benefits to pay for healthcare expenses Federal/State/Local* Income Tax (*not all local taxes) FICA (Social Security & Medicare) o Funds can be used to pay expenses of yourself, your legal spouse and your dependent children o Maximum contribution is $2, Enhancement includes ability to carry forward $500 balance to 2016 o Per pay contributions made on from 1/1/15 12/31/15 Elections must be made at initial enrollment Limited events allow changes Use it or lose it account Employee Benefits Consulting Wealth Management Life & Disability Insurance 23 23

24 Healthcare FSA Details o Qualified Expenses (Please refer to IRS Publication 213(d): Annual physical exams Ambulance service Chiropractor Contact lenses and supplies Eye exams Eyeglasses Hospital services Orthodontia Prescription medications Therapy Imaging (MRI, PET, X-ray) Dental o Reimbursement Funds are available on the date you enter the plan File a claim with My Cafeteria Plan / phone fax Direct Deposit Reimbursed weekly Employee Benefits Consulting Wealth Management Life & Disability Insurance 24 24

25 Dependent Care FSA Details o Eligibility No medical plan required o Provides employees with pre-tax benefits to pay for dependent care expenses Federal/State/Local* Income Tax (*not all local taxes) FICA (Social Security & Medicare) o Funds can be used to pay dependent care expenses Children up to age 13 Adults meeting IRS requirements o Maximum contribution $5,000 if filing jointly $2,500 if married filing separate *Amounts can be deducted for DCFSA or Child Care Credit on your taxes, but not both. o Per pay contributions made on from 1/1/15 12/31/15 Elections must be made at initial enrollment Limited events allow changes Use it or lose it account Employee Benefits Consulting Wealth Management Life & Disability Insurance 25 25

26 Dependent Care FSA Details o Qualified Expenses (Please refer to IRS Publication 503): Care inside/outside the home Care Centers Expenses must allow you to work or look for work Care provider is not eligible if they are: Dependent for whom you claim as an exemption Dependent under the age of 19 Your spouse o Reimbursement Funds are available as deposited File a claim with My Cafeteria Plan Phone: / Online: Mail: mycafeteriaplan, 432 East Pearl St., Miamisburg, OH Fax: claims@mycafeteriaplan.com Direct Deposit Reimbursed weekly Employee Benefits Consulting Wealth Management Life & Disability Insurance 26 26