Employee Presentation Cindy McGrath, Marketing and Communications Consultant

Transcription

1 Town of Marblehead Annual Enrollment April 4-May 2, 2018 Employee Presentation Cindy McGrath, Marketing and Communications Consultant 0

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3 Rising Health Care Costs Crowing Out Other Important Services Billions $25 $20 +$5.8B 42% Commonwealth of Massachusetts - Change in State Spending FY07 - FY17 Amounts in Billions (2016 inflation adjusted dollars) FY07 $15 FY17 $10 +$453M 9.1% +399M 5.4% +$203M $5 5.2% +$157M 7.6% -$59M -23.6% -$243M -8.4% -$521M -33% $0 Health Care Other Education Human Services Infrastructure, Housing & Economic Development Environment & Recreation Law & Public Safety Local Aid Source: Mass Budget and Policy Center 2

4 Why Are Health Care Costs Increasing? Two main drivers High cost providers and prevalent use of those providers Skyrocketing prescription drugs Other factors Aging population Mandates 3

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7 Skyrocketing Prescription Drug Costs Drug price inflation: double digit increases last four years (CVS Caremark) March 2018 U.S. Senate Committee Report on Medicare Part D Drugs: 20 drugs most widely prescribed drugs had cost increases averaging 12% per year between 2012 and 2017 Specialty spend=35% of all Rx costs and projected to be 50% in 2 years (American Journal of Managed Care) Delays of Patent Expirations: Loophole Helps Drug Makers Block Generics Boston Globe 3/23/18: $5.4 billion in lost savings annually Drug advertising increased by 30% past two years to $4.5 B 28% of U.S. residents ask their doctor about drug they saw advertised (Kaiser Family Foundation) 6

8 GIC Prescription Drug Procurement=Major Savings Low premium increase, no increase, or decrease for FY19! 7

9 Vendor Changes Prescription drugs moved to Express Scripts Download Express Scripts app and register for an account Check new drug formulary so you can plan in advance. Tufts Navigator and Spirit behavioral health benefits move to Tufts Find out if your providers are included! 8

10 All Employees Will Have Prescription Drug Coverage Through Express Scripts Effective July 1, 2018 Show the new prescription drug card to your pharmacy beginning July 1, Mail order and specialty drug services will move to Express Scripts and their specialty vendor, Accredo. If you have remaining mail order and specialty prescriptions, they will be transferred to Express Scripts. If you need a new mail order prescription, ask your physician to send it to Express Scripts. The copay tier of your brand name drug COULD change. So could drugs needing prior authorization. Check your drugs during AE. The 90-day mail order copay will apply if you use a CVS Pharmacy. 9

11 Annual Enrollment April 4-May 2 for Changes Effective July 1 Be Sure to Weigh Your Options! Gather a list of doctors, hospitals and medications Investigate your options. Contact the health plans you re considering to find out: Are your doctors and hospitals are in the network? What are the copay tiers for your specialists and hospitals? Are other services you might need covered? Weigh total expected copay costs and premiums before you decide to remain in the same health plan or change to another option. Choose your health plan no later than Wednesday, May 2. 10

12 Benefit Enhancements Fallon Select, Harvard Independence, and Tufts Navigator opened to new members Members 21 and under: $2,000 per hearing aid per impaired ear every 24 months No ambulance copay after deductible (new for Harvard, HNE, Tufts, UniCare) Prior authorization removed for hospice ACA Compliance: Dependents age may reside outside of health plan s service area. However, be aware of different coverage rules! UniCare PLUS network expanded to Martha s Vineyard, Nantucket, CT, and VT 11

13 Gather Your Provider and Medication List Why do you need a list of your doctors? To be sure they are in the health plan s network Why do you need a list of your hospitals? To be sure they are in the health plan s network To check the copay tiers Why do you need a list of your medications? To plan for July 1 formulary changes more on this later Don t Forget Your Family Members Providers! 12

14 Investigate Your Options 13

15 Where Do You Find Which Providers Participate, Provider Tiers, and Rx Formulary? Website Telephone GIC Health Fair 14

16 Weigh Plan Types Indemnity: access to any licensed doctor or hospital throughout the United States and outside of the country. Be aware about out of Massachusetts provider balance billing practices. Use the plan s national network to avoid these potential charges. PPO (Preferred Provider Organization): provides coverage by network doctors, hospitals, and other health care providers. It allows treatment by out-ofnetwork providers, but at a lower level of coverage. EPO (Exclusive Provider Organization) = HMO without PCP and referral requirements. POS (Point of Service): provides coverage for treatment by a network of doctors, hospitals, and other health care providers. Selection of a Primary Care Provider (PCP) is required and members must get a referral to a specialist to get the lowest out-ofpocket costs. HMO (Health Maintenance Organization): Provides coverage for treatment by a network of doctors, hospitals, and other health care providers within a certain geographic area. HMOs do not offer out-of-network benefits, with the exception of emergency care. Selection of a PCP is required. 15

17 Weigh Plan Networks Network: Group of doctors, hospitals and other health care providers that contract with the plan. If you are in a plan that offers both network and nonnetwork coverage (i.e., PPO and POS), you will the highest benefit level and lowest out-of-network cost when you are treated by network providers. National Network UniCare Indemnity Plan/Basic (Indemnity) Broad Network Fallon Health Select Care (HMO) Harvard Pilgrim Independence Plan (POS) Tufts Navigator (POS) UniCare/PLUS (PPO-type) 16

18 Weigh Plan Networks (continued) Limited and Regional Network Plan: a less expensive health plan that offers essentially the same benefits as more expensive wider network plans, but with fewer physicians, hospitals, and other providers. Regional Network Health New England (HMO without referral requirement) Neighborhood Health Plan (HMO) Limited Network Fallon Health Direct Care (HMO) Harvard Pilgrim Primary Choice (HMO) Tufts Health Plan Sprit (EPO) UniCare/Community Choice (PPO-type) 17

19 Copay, Deductible, and Out-of-Pocket Maximum Copay: a set dollar amount you pay for network doctors office visits, prescription drugs, inpatient hospital care, outpatient surgery, and emergency room care. Deductible: a set dollar amount your are responsible for paying to your provider(s) for certain services before the plan will pay for these services. Deductibles reset each July 1. Out-of-pocket maximum: The maximum amount of medical, prescription drug, and behavioral health copays, coinsurance, and deductibles a member will pay for covered expenses within a fiscal year. 18

20 What s Subject to the Deductible? Not Usually Office visits including for mental health Medically necessary wigs Hearing Aids Pap smears EKGs Colonoscopies Usually Emergency room visits Inpatient hospitalization Surgery Lab and blood test X-rays and radiology Durable Medical Equipment 19

21 Most Copays Are The Same for All Plans Preventive Services no copay Specialist Office Visit: $30/$60/$75 Retail Clinic and Urgent Care Visit: $20 Outpatient Behavior Health Visit: $20 Emergency Room: $100 Outpatient Surgery: $250 (Exceptions UniCare PLUS: $110/$110/$250 and UniCare Community Choice: $110) High Tech Imaging Scans: $100 Prescription Drugs: $10/$30/$65 (retail) $25/$75/$165 (mail order) 20

22 Broad Network Copays PCP Visit Harvard Independence and Tufts Navigator ($10 Tier 1/ $20 Tier 2/ $40 Tier 3) Fallon Select $20 UniCare PLUS $15 (Centered Care) and $20 Inpatient Hospital Care is Tiered $275 Tier 1/ $500 Tier 2/ $1,500 Tier 3 Note that the UniCare Indemnity Plan/Basic has a $275 copay 21

23 Copay Changes Effective July 1, 2018 Tier 3 copays for specialists will decrease to $75 per visit: $30/$60/$75 (Tier 3 doesn t apply for Harvard Primary Choice) Telehealth copays will decrease to $15. Secure two-way video chats 24 hours/day. Download the app and register in advance. Helpful for: Allergies, upper respiratory infection, flu Earache, skin rash, urinary tract infection, conjunctivitis Sinus infection, upset stomach and behavioral health consultations Tufts Spirit inpatient hospital copay will decrease to $275/$500 22

24 Deductibles and Out-of-Pocket Maximum Changes Deductibles Limited Network Plan (Fallon Direct, Harvard Primary Choice, Health New England, Tufts Spirit and UniCare Community Choice) deductibles decreasing to $400/$800 Fallon Select deductible will now match other wide networks: $500/$1000 Fallon Direct and Select will add Rx deductibles to match other carriers: $100/$200 Out-of-Pocket Maximums Out-of-Pocket Maximums for health/behavioral health and Rx will be combined to match other plans for UniCare Basic, Community Choice, PLUS: $5,000/$10,000 23

25 Regional and Limited Network Plans are Significantly Less Expensive Lower monthly premiums Lower deductible by $100 single/$200 family coverage (exception NHP) Lower inpatient hospital copays: $275/admission no tiering (Health New England, Neighborhood Health Plan, Fallon Health Direct, and UniCare/Community Choice) $275 Tier 1, $500 Tier 2, No Tier 3 (Harvard Pilgrim Primary Choice and Tufts Spirit) 24

26 GIC Health Plan Rates FISCAL YEAR 2019 MONTHLY RATES EFFECTIVE JULY 1, 2018 FOR TOWN OF MARBLEHEAD ENROLLEES RATES INCLUDE THE 0.35% ADMINISTRATIVE FEE Active Employees, Retirees and Survivors without Medicare Employee and Non-Medicare Retiree/ Survivor Pays Monthly Health Plan % Individual Coverage Family Coverage Fallon Health Direct Care 17% $96.27 $ Fallon Health Select Care (RE-OPENED 17% TO NEW MEMBERS) Harvard Pilgrim Independence Plan (RE- 17% OPENED TO NEW MEMBERS) Harvard Pilgrim Primary Choice Plan 17% Health New England 17% NHP Prime (Neighborhood Health Plan) 17% Tufts Health Plan Navigator (RE-OPENED 17% TO NEW MEMBERS) Tufts Health Plan Spirit 17% UniCare State Indemnity Plan/Basic with 35% CIC (Comprehensive) UniCare State Indemnity Plan/Basic 35% without CIC (Non-Comprehensive) UniCare State Indemnity Plan/Community 17% Choice UniCare State Indemnity Plan/PLUS 17%

27 Choose Your Plan No Later Than Wednesday, May 2 Send completed forms to Your Municipal Coordinator. Forms are available: On the GIC s website: Mass.gov/gic/forms Through your GIC Coordinator At GIC health fairs 26

28 Keep in Mind Once you choose a health plan, you cannot change health plans during the year unless: Retire and become Medicare eligible Move out of plan s service area 27

29 All New Benefit Effective July 1, 2018 Employee Assistance Program Three visits/incident no cost counseling benefit Unlimited, 24/7 access to master s-level specialists for mental health and substance abuse challenges and concerns including: Child and elder care Convenience services including travel assistance and pet care Relationships, separation and divorce Financial and legal issues Work challenges Professional development Workplace concerns By phone, online, video, or at worksite Critical incident response services Benefit navigation Training programs, such as How to parent teens and Wills and estate planning 28

30 Additional Information Automatic enrollment with benefits for: All employees and their families Managers and supervisors No fees or additional premiums premium included in health plan rates Communications of program begin in May including details on: Phone number Website Mobile application e-mindful website 29

31 Final Reminders - Lower Your Out-of-Pocket Health Care Costs Work with your Primary Care Provider to navigate the system. Use urgent care facilities, retail minute clinics and telehealth. Seek care from Tier 1 and Tier 2 specialists. Access by phone app the prescription drug formulary at all doctor visits. If you are in a tiered hospital plan and have a planned hospital admission, talk with your doctor about whether a Tier 1 hospital would make sense. Use your health plan s cost estimator for health care procedure shopping UniCare, Fallon, and Neighborhood Health Plan will send members a check if they shop for and then visit a low-cost provider. Eat healthy, exercise regularly, don t smoke, and find ways to destress. 30