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CSEBO 2017/18 Plan Year Overview SANTA PAULA UNIFIED SCHOOL - PowerPoint PPT Presentation

Oct 20, 2023 •439 likes •790 views

CSEBO 2017/18 Plan Year Overview SANTA PAULA UNIFIED SCHOOL DISTRICT AUGUST 23, 2017 2 2017/18 Plan Introductions Choose Your Preferred Network: 3 Health Maintenance Organization (HMO) HMO 10 new offering HMO 10 new

  1. CSEBO 2017/18 Plan Year Overview SANTA PAULA UNIFIED SCHOOL DISTRICT AUGUST 23, 2017

  2. 2 2017/18 Plan Introductions

  3. Choose Your Preferred Network: 3 Health Maintenance Organization (HMO)  HMO 10 – new offering  HMO 10 – new offering  HMO 30  HMO 30

  4. 4 Important Plan Terms Defined  Copay  The fee you pay for a doctor visit or prescription refill  Medical out-of-pocket maximum (OOPM)  Maximum you will pay for medical expenses in a calendar year  Prescription drug out-of-pocket maximum  Maximum you will pay for pharmacy expenses in a calendar year  Primary Care Physician (PCP)  First point of contact for undiagnosed health concerns; makes referrals to other providers/specialists

  5. CSEBO Medical Insurance HMO Comparison 5 Effective 10/1/2017 - 9/30/2018 ANTHEM BLUE CROSS KAISER PERMANENTE PLAN NUMBER HMO 10 HMO 30 HMO 10 HMO 30 GENERAL PLAN INFORMATION In-Network In-Network In-Network In-Network Annual Medical and Prescription Drug Combined Out-of-Pocket Limit Individual/Family $1,500/$4,500 $5,000/$10,000 $1,500/$3,000 $1,500/$3,000 Annual Medical Deductible Individual/Family $0 $0 $0 $0 Prescription Drug Deductible Per Individual $0 $0 $0 $0 Physician/Diagnostic Services $0 Preventive Care $0 $0 $0 Primary Care Office Visit $10 $30 $10 $30 $40 $30 Specialist Office Visit $10 $10 $0 Diagnostic X-Ray and Lab Tests $0 $0 $0 Advanced Imaging $0 $100 per test $0 $0 Inpatient Hospital Services Inpatient Hospitalization $0 30% $0 $0 Outpatient Services Outpatient Surgery $0 30% $10 per procedure $30 per procedure Outpatient Lab and Imaging $0 30% $0 $0 Emergency Services Ambulance Services $0 $100 per trip $50 per trip $50 per trip $50 copay, waived if $200/visit, waived if $50 copay, waived if $100 copay, waived if Emergency Room admitted admitted admitted admitted Urgent Care Urgent Care Visits $10 $30 $10 $30

  6. 6 Prescription Drug Formulary What is a formulary? Formulary tiers  Tier 1  List of plan-approved drugs  Generic drugs, lowest cost share  Varies by carrier and plan  Tier 2  Brand drugs on formulary, higher cost share  Tier 3  Brand drugs not on formulary, higher cost share  Tier 4  Specialty drugs, highest cost share

  7. 7 CSEBO Medical Insurance HMO Comparison Effective 10/1/2017 - 9/30/2018 ANTHEM BLUE CROSS KAISER PERMANENTE PLAN NUMBER HMO 10 HMO 30 HMO 10 HMO 30 PRESCRIPTION DRUG BENEFITS In-Network In-Network In-Network In-Network Retail 30 days 30 days 30 days 30 days Generic $10 $15 $10 $15 $20 $30 $20 $30 Brand (Formulary/Preferred) $20 $50 $20 $30 Brand (Non-Formulary/Non-Preferred) Specialty Rx (Specialty Pharmacy Only; $20 30% (not to exceed $150) $20 30% (not to exceed $150) 30-day supply) Mail Order 90 days 90 days 100 days 100 days Generic $20 $15 $10 $15 $40 $60 $20 $30 Brand (Formulary/Preferred) Brand (Non-Formulary/Non-Preferred) $40 $100 $20 $30 National 3-Tier National 4-Tier 3-Tier 4-Tier

  8. 8 Choose Your Plan Design: Preferred Provider Organization (PPO)  PPO 90 – new, lower copays  PPO 80 – new plan offering  PPO 70 – new plan offering

  9. 9 Important PPO Plan Terms Defined  Deductible  Your cost share to be paid in full before the plan pays  All deductibles run January 1 – December 31 st  Waived for office visit copays and prescription drug refills on PPO’s  Co-insurance  Your cost share (percentage) for services after the deductible is met  The plan picks up the remainder  Embedded Deductible/OOPM  An individual within a family will not pay more than the individual deductible/OOPM

  10. CSEBO Medical Insurance PPO Comparison 10 Effective 10/1/2017 - 9/30/2018 PPO 90 PPO 80 PPO 70 PLAN NUMBER GENERAL PLAN INFORMATION In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Annual Medical Out-of-Pocket Limit 1 Individual $2,000 $4,500 $3,000 $7,500 $5,000 $12,500 Two-Party $4,000 $9,000 $6,000 $15,000 $10,000 $25,000 Family $6,000 $13,500 $9,000 $22,500 $12,700 $31,750 Annual Prescription Drug Out-of-Pocket Limit $5,150/$8,300 $3,850/$4,700 $1,000/$1,000 Individual/Family Annual Medical Deductible 1 Individual $500 $1,000 $750 $1,500 $1,000 $2,000 Two-Party $1,000 $2,000 $1,500 $3,000 $2,000 $4,000 Family $1,500 $3,000 $2,250 $4,500 $3,000 $6,000 Prescription Drug Deductible Per Individual $0 $0 $0 Physician/Diagnostic Services Preventive Care $0 Not Covered $0 Not Covered $0 Not Covered Primary Care Office Visit $10 30% $20 40% $30 50% Specialist Office Visit $10 30% $30 40% $40 50% Diagnostic X-Ray and Lab Tests 10% 30% 20% 40% 30% 50% Advanced Imaging 10% 30% 20% 40% 30% 50% Inpatient Hospital Services Inpatient Hospitalization 10% ($250/non- 30% ($250/non- 20% ($250/non- 40% ($250/non- 30% ($250/non- 50% ($250/non- compliance ded) compliance ded) compliance ded) compliance ded) compliance ded) compliance ded) Outpatient Services Outpatient Surgery 10% ($250/non- 30% ($250/non- 20% ($250/non- 40% ($250/non- 30% ($250/non- 50% ($250/non- compliance ded) compliance ded) compliance ded) compliance ded) compliance ded) compliance ded) Outpatient Lab and Imaging 10% ($250/non- 30% ($250/non- 20% ($250/non- 40% ($250/non- 30% ($250/non- 50% ($250/non- compliance ded) compliance ded) compliance ded) compliance ded) compliance ded) compliance ded) or

  11. 11 Advanced Imaging Example: Before Plan Deductible is Met PPO 90 PPO 80 PPO 70 $230 specialist office visit, $10 $230 specialist office visit, $30 $230 specialist office visit, $40 • • • specialist office visit copay specialist office visit copay specialist office visit copay paid at POS; plan pays the rest paid at POS; plan pays the rest paid at POS; plan pays the rest $1,000 billed for imaging by $1,000 billed for imaging by $1,000 billed for imaging by • • • provider provider provider $500 applied to individual $750 applied to individual $1,000 applied to individual • • • deductible deductible deductible 10% coinsurance of remaining 20% coinsurance of remaining Deductible is met • • • $500, $50 $250, $50 Total for Service: $1,040 • Total for Service: $560 Total for Service: $830 • • For informational purposes only, not an actual claim.

  12. 12 Advanced Imaging Example: After Plan Deductible is Met PPO 90 PPO 80 PPO 70 $230 specialist office visit, $10 $230 specialist office visit, $30 $230 specialist office visit, $40 • • • specialist office visit copay specialist office visit copay specialist office visit copay paid at POS; plan pays the rest paid at POS; plan pays the rest paid at POS; plan pays the rest $1,000 billed for imaging by $1,000 billed for imaging by $1,000 billed for imaging by • • • provider provider provider 10% coinsurance of $1,000, 20% coinsurance of $1,000, 30% coinsurance of $1,000, • • • $100 $200 $300 Total for Service: $110 Total for Service: $230 Total for Service: $340 • • • For informational purposes only, not an actual claim.

  13. 13 CSEBO Medical Insurance PPO Comparison Effective 10/1/2017 - 9/30/2018 PPO 90 PPO 80 PPO 70 PLAN NUMBER PRESCRIPTION DRUG BENEFITS In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Retail 30 days 30 days 30 days Generic $5 min copay/ or $10 $10 Brand (Formulary/Preferred) Paper claim $20 Paper claim $20 Paper claim 20% up to a $25 Brand (Non-Formulary/Non-Preferred) submission $35 submission $35 submission max copay Specialty Rx (Specialty Pharmacy Only; Same as Retail required Same as Retail required 20% up to $150 required 30-day supply) Brand Brand max copay Mail Order 90 days 90 days 90 days Generic $5 $20 $20 Brand (Formulary/Preferred) $5 Paper claim $40 Paper claim $40 Paper claim Brand (Non-Formulary/Non-Preferred) $5 $70 $70 submission submission submission Specialty Rx (Specialty Pharmacy Only; 20% up to $150 required required required $5 $70 30-day supply) max copay Preferred 3-Tier Preferred 4-Tier Preferred 3-Tier

  14. 14 Health Savings Accounts (HSA) Basics

  15. 15

  16. 16 Choose Your Preferred Network:  HSA 80 – new offering  DHMO HSA 8966  HSA 60

  17. 17 HSA Contribution Maximums 2017 Maximums 2018 Maximums Tier Under 55 Over 55 Tier Under 55 Over 55 Individual $3,400 $4,400 Individual $3,450 $4,450 Family $6,750 $7,750 Family $6,900 $7,900

  18. 18 Investing your HSA Anthem Kaiser  Administered through HealthEquity  Administered through HealthCare Bank  Like a traditional bank, you earn standard interest on your investment  Like a traditional bank, you earn standard interest on your investment  Low-risk Yield Plus yields higher interest rates, but cash remains liquid  Varying risk mutual funds  Varying risk mutual funds  Requires a $2,000 minimum balance  Requires a $1,000 minimum balance

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