VEHI Health Plans EFFECTIVE 1/1/2018
Overview New VEHI Health Plans All four plans: Cover the same benefit services Use the same national BCBS network Are supported by the VEHI wellness program (PATH) Have lower premiums than the current array of VEHI plans
Medical & Rx Services Categories of Essential Benefits Hospitalization: In-Patient/Out-Patient Care/Surgical Covered Physician Services Maternity Care Diagnostic & Therapy Services Physician Visits: Primary & Preventive Care, Physical Exams & Immunizations Specialty Care Diagnostic Care Physical/Speech/Occupational Therapies OB-GYN Care: Gynecological Care Prenatal & Post-Natal Care Current VEHI Plans Emergency Room & Urgent Care Facility Yes Yes Infertility Treatments Yes No Ambulance Service: To nearest facility in emergency Non-emergency transfers Home Care: Skilled Nursing Visits Private Duty Nursing Short-term Therapy in Home Chiropractic Care Yes Yes Medical Supplies & Equipment Yes Yes Mental Health & Substance Abuse Care: Inpatient / Outpatient Prescription Drugs: FDA-Approved Drugs and Antigens prescribed by doctor Diabetic Supplies, including test strips, insulin and syringes Vision Exams Yes Yes Yes Yes Yes Yes Yes (Sexual dysfunction drugs covered) Only in VHP Future VEHI Plans Yes Yes Yes Yes Yes Yes Yes (Sexual dysfunction drugs not covered) Yes now on all plans (adult and children)
National/International Network Same network for all plans in 2018 The Exclusive Provider Organization (EPO) Network provides you with the same great network in Vermont, as well as Access to any National and International BlueCard network provider Must use a BCBS provider, unless You are in an urgent or emergent situation You receive prior approval to see a non-network provider 96% of VEHI subscribers stayed within this network over the past year. Find a provider at: www.bcbsvt.com/findadoctor All members must designate a Primary Care Provider (PCP)
Final Approved Rates January 1, 2018 June 30, 2018 Monthly Rates FY 18 Single Parent/ Child(ren) Two-Person Family VEHI Platinum $657.55 $1,099.51 $1,315.10 $1,860.19 VEHI Gold $622.94 $1,042.53 $1,245.88 $1,763.38 VEHI Gold CDHP $523.29 $809.02 $982.75 $1,449.51 VEHI Silver CDHP $456.34 $769.27 $912.69 $1,298.60 Current Rates FY 17 Single Parent/ Child(ren) Two-Person Family VHP $752.41 n/a $1,478.99 $1,982.66
New tier level Parent/Child(ren) All of VEHI s new plans will now offer a Parent & Child(ren) coverage tier for employees with 1 or more children on the policy, who are not covering another adult on the policy Less expensive than a two-person or family tier VEHI/BCBSVT will automatically transition eligible employees and their children to these plans during the implementation; however, please let VEHI/BCBSVT know if anyone has been missed.
How is Out-of-Pocket Calculated? All copayments, deductible and co-insurance are counted toward the annual out-ofpocket maximum. If the maximum is reached, all out-of-pocket costs stop for the rest of the calendar year. Deductible Copayments Co-insurance Out-of-pocket Maximum
Out-of-pocket Maximum Ranges (per calendar year) Single Family Federal Allowance 2017 $7,150 $14,300 VEHI OOPM Range 2018 $2,500 - $4,000 $5,000 - $8,000 VHC OOPM Range 2017 $2,500 - $7,150 $5,000 - $14,300
Health Plans Member Cost Share Member Cost Share Member Cost Share Cost Share HRA or HSA Compatible HRA HRA HRA/HSA HRA/HSA Medical Deductible $500/$1,000 $1,200/$2,400 $1,800/$3,600 (aggregate) $3,000/$6,000 Medical Out of Pocket Maximum $1,500/$3,000 $1,800/$3,600 $2,500/$5,000 (aggregate) $4,000/$8,000 Prescription Deductible $0 $0 Included in medical deductible Included in medical deductible Prescription Out of Pocket Maximum $1,300/$2,600 $1,300/$2,600 $1,300/$2,600 (aggregate) (included in Medical OOPM) $1,300/$2,600 (aggregate) (included in Medical OOPM) Total Out of Pocket Exposure (Medical and Rx) $2,800/$5,600 $3,100/$6,200 $2,500/$5,000 (aggregate) $4,000/$8,000 Preventive PCP Visit $0 $0 $0 $0 Primary Care Physician / Mental Health or Substance Abuse Visit $25 $25 Deductible, then 20% coinsurance Deductible, then 20% coinsurance Specialist Visit $35 $35 Deductible, then 20% coinsurance Deductible, then 20% coinsurance Urgent Care Facility $75 Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Emergency Room $250 Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Inpatient, Outpatient, Radiology, DME, Ambulance, etc. Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Generic tier 1 / tier 2 / Brand / NP Brand $4 / $10 /$20 / 50% $4 / $10 /$20 / 50% Deductible, then 20% coinsurance Deductible, then 20% coinsurance Wellness Prescriptions $4 / $10 /$20 / 50% $4 / $10 /$20 / 50% No member cost No member cost
VEHI Platinum & Gold All copayments, deductible and co-insurance are counted toward the annual out-of-pocket maximum. In these plans, medical costs and pharmacy costs are tracked separately. If the maximum is reached for medical care, all medical out-of-pocket costs stop for the rest of the calendar year. If the maximum is reached for pharmacy, all pharmacy out-of-pocket costs stops for the rest of the calendar year. Deductible Rx Copayments Rx Co-insurance Copayments Co-insurance Medical Out-of-pocket Maximum Prescription Out-of-pocket Maximum
VEHI Platinum Member Cost Share Medical Deductible $500 / $1,000 Medical Out of Pocket Maximum $1,500 / $3,000 Prescription Deductible $0 Prescription Out of Pocket Maximum $1,300 / $2,600 Total Out of Pocket Exposure (Medical and Rx) $2,800 / $5,600 Preventive PCP Visit $0 Primary Care Physician / Mental Health or Substance Abuse Visit $25 Specialist Visit $35 Urgent Care $75 Emergency Room $250 Inpatient, Outpatient, Radiology, DME, Ambulance, etc. Deductible, then 20% coinsurance Generic tier 1 / Generic tier 2 (new) $4 / $10 Preferred / Non-Preferred Brand $20 / 50% Monthly Rates Single Two Person (Two Adults) Parent & Child(ren) (new) Family VEHI Platinum (FY 18) $657.55 $1,315.10 $1,099.51 $1,860.19 VEHI VHP (FY 17 ) $752.41 $1,478.99 n/a $1,982.66
VEHI Gold Member Cost Share Medical Deductible $1,200 / $2,400 Medical Out of Pocket Maximum $1,800 / $3,600 Prescription Deductible $0 Prescription Out of Pocket Maximum $1,300 / $2,600 Total Out of Pocket Exposure (Medical and Rx) $3,100 / $6,200 Preventive PCP Visit $0 Primary Care Physician / Mental Health or Substance Abuse Visit $25 Specialist Visit $35 Urgent Care Emergency Room Inpatient, Outpatient, Radiology, DME, Ambulance, etc. Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Generic tier 1 / Generic tier 2 (new) $4 / $10 Preferred / Non-Preferred Brand $20 / 50% Monthly Rates Single Two Person (Two Adults) Parent & Child(ren) (new) Family VEHI Gold ( FY 18) $622.94 $1,245.88 $1,042.53 $1,763.38 VEHI VHP (FY 17) $752.41 $1,478.99 n/a $1,982.66 VEHI $1,200 (FY 17) $601.91 $1,183.12 n/a $1,586.30
VEHI Gold & Silver CDHP All copayments, deductible and co-insurance are counted toward the annual out-ofpocket maximum. Medical and pharmacy costs are tracked together, although the pharmacy has a lower, embedded cap. If the maximum is reached, all out-of-pocket costs stop for the rest of the calendar year. Medical & Rx Deductible Medical & Rx Co-insurance $20 Vision Copay Out-of-pocket ------Rx Out-of-Pocket Maximum-------- Maximum
VEHI Gold CDHP (default plan) Member Cost Share Medical Deductible (Aggregate) $1,800 / $3,600 Medical Out of Pocket Maximum $2,500 / $5,000 Prescription Deductible Prescription Out of Pocket Maximum Included in medical deductible $1,300 / $2,600 (included in Medical OOPM) Total Out of Pocket Exposure (Medical and Rx) $2,500 / $5,000 Preventive PCP Visit $0 Primary Care Physician / Mental Health or Substance Abuse Visit Specialist Visit Urgent Care, Emergency Room Inpatient, Outpatient, Radiology, DME, Ambulance, etc. Generic or Brand drugs Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Wellness drugs (new) Monthly Rates Single Two Person (Two Adults) No member cost Parent & Child(ren) (new) Family VEHI Gold CDHP (FY 18) $523.29 $982.75 $809.02 $1,449.51 VEHI VHP (FY 17) $752.41 $1,478.99 n/a $1,982.66 VEHI $1,800 (FY 17) $601.91 $1,183.12 n/a $1,586.30
VEHI Silver CDHP Member Cost Share Medical Deductible $3,000 / $6,000 Medical Out of Pocket Maximum $4,000 / $8,000 Prescription Deductible Prescription Out of Pocket Maximum Included in medical deductible $1,300 / $2,600 (included in Medical OOPM) Total Out of Pocket Exposure (Medical and Rx) $4,000 / $8,000 Preventive PCP Visit $0 Primary Care Physician / Mental Health or Substance Abuse Visit Specialist Visit Urgent Care, Emergency Room Inpatient, Outpatient, Radiology, DME, Ambulance, etc. Generic or Brand drugs Wellness drugs (new) Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance No member cost Monthly Rates Single Two Person (Two Adults) Parent & Child(ren) (new) Family VEHI Silver CDHP (FY 18) $456.34 $912.69 $769.27 $1,298.60 VEHI VHP (FY 17) $752.41 $1,478.99 n/a $1,982.66 VEHI $1,800 (FY 17) $601.91 $1,183.12 n/a $1,586.30
Out-of-pocket Costs Out-of-pocket Costs (OOP) (eg: copayments, deductibles and coinsurance) are present in all four plans- but in differing amounts and for different benefit services. Higher premium plans have lower medical out-of-pocket maximums. OOP costs apply only when health care benefit services are used. OOP costs are capped on a calendar year basis - there is a maximum OOP cost in medical and pharmacy for each plan. The family pharmacy OOP maximum is the same across plans, while the medical OOP maximum differs. (Pharmacy OOP is aggregate on the CDHPs) There is no out-of-pocket cost sharing for preventive services in any of the plans. There is no out-of-pocket cost sharing for wellness prescriptions in the Gold CDHP or Silver CDHP. There is no out-of-pocket cost sharing for diabetic medications or supplies in any of the plans.
Payment for services Services that require copayments are expected to be paid at the time of service. Pharmacy copayments or deductible/coinsurance are also expected at the time of sale. Deductibles and coinsurance are normally collected after the claim has been processed and adjudicated by BCBSVT. A remittance advice is sent to the provider An Explanation of Benefits is sent to the member The provider then bills the member for the service based on the allowed amount, and the amount of the member s cost-share The provider may ask for some payment up front if they confirm that the member has a large deductible to meet. If an HRA or HSA with automatic payment to the provider is in place, the member should work with the provider to wait for the claim to process.
Stacked vs Aggregate Deductibles Family Gold Policy Deductible Examples $4,000 $3,500 Annual Family Ded $3,600 No per-member cap $3,000 $2,500 $2,000 $1,500 $3,600 Annual Family Ded $2,400 Capped at $1,200 per member $600 $600 $1,000 $500 $1,200 $0 Gold CDHP (Aggregate) Gold (Stacked)
Claim Example: VEHI Gold CDHP (Aggregate) VEHI Silver CDHP (Stacked) In this example our Member is on twoperson plan and incurs a $10,000 claim. The Dependent of the Member later has a $1,500 claim. $1,800/$3,600 deductible $2,500/$5,000 out-of-pocket max Member has $10,000 claim Member meets the $3,600 aggregate deductible Member is responsible for 20% of the remaining $6,400 (up to $1,400) = $1,280 Member has paid $4,880 toward the outof-pocket maximum Dependent of Member later has a $1,500 claim The Member had met the entire deductible, and most of the out-of-pocket maximum. Dependent of Member only has to pay 20% on their claim up to $120 to meet the family aggregate out-of-pocket maximum. All further claims for either member or dependent would be covered at 100% for the remainder of the calendar year. Total out-of-pocket cost $5,000 $3,000/$6,000 deductible $4,000/$8,000 out-of-pocket max Member has $10,000 claim Member meets the $3,000 stacked deductible Member is responsible for 20% of the remaining $7,000 (up to $1,000) = $1,400 Member has paid $4,000 toward their outof-pocket maximum All further claims for the Member would be covered at 100% for the remainder of the year. Dependent of Member later has a $1,500 claim The Dependent has not met their deductible, so the entire $1,500 claim goes toward their $3,000 deductible. The Dependent would still be responsible for their claims until their deductible was met, and then would be responsible for 20% up to the out-of-pocket maximum. With an additional exposure of $2,500. Total out-of-pocket cost $5,500
Prescription out-of-pocket maximums On the VEHI Platinum and Gold copayment-style plans: your out-of-pocket maximum for prescriptions is stacked (no one member has to pay more than $1,300 in a calendar year) On the VEHI Gold CDHP and Silver CDHP plans: the prescription benefits are always aggregate even on the Silver plan this does not apply to the single plan, only the two-person, parent/child(ren) and family plans two-person, parent/child(ren) and family plans must meet the entire $2,600 before the out-of-pocket maximum is met, and the entire family will receive 100% prescription coverage for the remainder of the calendar year the prescription benefits are aggregate to meet IRS requirements of HSA eligibility
Wellness Prescriptions Applicable to the Gold CDHP & Silver CDHP plans only Prescription drugs on the Wellness Rx list are not subject to deductible, and are covered at 100% coverage Categories on the Wellness Rx list include: Asthma/COPD Diabetes Hyperlipidemia Hypertension Osteoporosis Prenatal Please note that not all prescriptions under the categories are covered at 100% A full list of 100% covered Wellness medications can be found at www.bcbsvt.com/wellnessrx Please note: Platinum/Gold non-cdhp plans are subject to copay/coinsurance except for diabetic medications
Pre-2018 Coverage for Diabetes VHP JY Plan Comprehensive CDHP $1,800 Diabetic Medications obtained through the prescription drug benefit Diabetic supplies ( e.g. Test strips, Insulin and Syringes) obtained through the prescription drug benefit Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Diabetic Durable Medical Equipment (DME) (e.g. Pump, Continuous Glucose Monitor) Covered at 100% Covered at 100% Subject to ded/coins Subject to ded/coins
Post-2018 Coverage for Diabetes Diabetic Medication on the Wellness Rx list Diabetic Medication NOT the on Wellness Rx list Diabetic supplies ( e.g. Test Strips, Insulin and Syringes) obtained through the prescription drug benefit Diabetic Durable Medical Equipment (e.g. Pump, Continuous Glucose Monitor) VEHI Platinum VEHI Gold VEHI Gold CDHP VEHI Silver CDHP Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100% Subject to ded/coins Subject to ded/coins
Preventive Care Coverage The Affordable Care Act (ACA) expanded the coverage of preventive care below are examples of benefits that are covered at 100% on all VEHI health plans. For example: Annual exam for all family members Well-baby and well child office visits Immunizations Colorectal screening Services for women also include: Annual OBGYN exam and pap test Screening mammogram Generic oral birth control, as well as implantable and injectable contraceptives Standard breast pump from a durable medical equipment network provider Lactation support from a network lactation consultant For a full list of covered services, please see www.bcbsvt.com/preventive, scroll down to step 3 and you ll find the link to the ACA preventive care list
Primary Care Provider vs Specialist Primary Care Provider A provider who was selected by a member of a managed care team to manage all aspects of his or her health care. The following types of providers are eligible to be a PCP: general practice, internal medicine, family practice, pediatrician, geriatrics, naturopath, or nurse practitioner. Specialist A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care. Important note: if your PCP is unavailable, there should be a cross-covering provider made available to you. Seeing another PCP (who is not designated to cross-cover) will process as a Specialist Visit.
Important Reminders Employees may enroll in any of the four VEHI health plans and can switch plans once per year during the employer s open enrollment period. Enrollment information for 1/1/18 is needed from the school district by 11/15/17 If enrollment information is not received by 11/15/17, employees will be moved to the VEHI Gold CDHP Plan Employees can also switch health plans mid-year if they have a life event (marriage, birth, adoption) New Parent & Child(ren) tier comes into effect for 1/1/18 *If negotiated
Cost Exposures
Combined Cost Exposure for a Single Plan Single Plans $12,000 $10,000 $8,000 $2,800 $3,100 $2,500 $4,000 $6,000 $4,000 $2,000 $7,891 $7,475 $6,279 $5,476 $0 VEHI Platinum VEHI Gold VEHI Gold CDHP VEHI Silver CDHP Premium Out of Pocket Exposure
Combined Cost Exposure for a Two-Person Plan $25,000 Two-Person Plans $20,000 $5,600 $6,200 $15,000 $5,000 $8,000 $10,000 $5,000 $15,781 $14,951 $11,793 $10,952 $0 VEHI Platinum VEHI Gold VEHI Gold CDHP VEHI Silver CDHP Premium Out of Pocket Exposure
Combined Cost Exposure for a Parent/Child(ren) Plan $20,000 $18,000 $16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 Parent/Child(ren) Plans $5,600 $6,200 $8,000 $5,000 $13,194 $12,510 $9,708 $9,231 VEHI Platinum VEHI Gold VEHI Gold CDHP VEHI Silver CDHP Premium Out of Pocket Exposure
Combined Cost Exposure for a Family Plan $30,000 Family Plans $25,000 $5,600 $6,200 $20,000 $5,000 $8,000 $15,000 $10,000 $22,322 $21,161 $17,394 $15,583 $5,000 $0 VEHI Platinum VEHI Gold VEHI Gold CDHP VEHI Silver CDHP Premium Out of Pocket Exposure
VEHI Member Claims Data NO CLAIMS 8% $4000+ 28% $2500-$3999 10% $1800-$2499 8% $1500-$1799 4% $0.01-$1499 42% Information is based on all VEHI membership (subscribers and their dependents). Claims incurred in calendar year 2015, paid through February 2016. Call customer service for your personalized claims history at 1-800-247-2583. Or visit our Member Resource Center at www.bcbsvt.com/member
Healthcare Spending Accounts
Tax-Favored Funding Arrangements Available Health Savings Account (HSA) Health Reimbursement Arrangement (HRA) Flexible Spending Account (FSA) VEHI does not in any way endorse specific health care plan options or cost-sharing arrangements. Decisions about health care plans, funding arrangements, costsharing mechanisms, and related salary considerations are made through collective bargaining between school districts and local unions. VEHI shares information about the use of HRAs, HSAs and FSAs in order to ensure parties have access to information about the options available and to secure cost-effective pricing for administering these plans through a third-party vendor.
Health Savings Account (HSA) Must be paired with a Consumer-Directed Health Plan (or CDHP) per IRS regulations Can be funded by the employee and/or employer, if negotiated. Money deposited pre-tax, grows pre-tax and withdrawn pre-tax for qualified expenses HSA dollars can be used to pay for member s share of cost Accounts and funds belong to the employee (No use it or lose it ) Accounts stay with employee even after employment ends
Health Reimbursement Arrangement (HRA) Eligible to be paired with any health plan Employer owned account Promise to pay funded by the employer pre-tax Can cover deductibles, copayments or coinsurance as determined in collective bargaining
Flexible Spending Account (FSA) Generally funded by the employee Election done before the beginning of the plan year plan accordingly Typically has use it or lose it provisions Medical FSAs can be used in conjunction with an HRA Limited-purpose FSAs can be used in conjunction with an HSA (covers dental, eye-glasses or contacts)
More Information on VEHI Website Including Health Care Spending Accounts Webinars