retiree open enrollment choice notice basic and plus ... · changes in columbia public schools...

RETIREE Open Enrollment Choice Notice Basic and Plus Medical Plan

The Retiree Open Enrollment Choice is from November 3rd - November 17th, 2014 for Columbia Public School District’s Group Medical Plan. The retiree can choose either the Basic Plan or Plus Plan for an effective date of January 1, 2015. Current Basic Plan Participants: If you want to choose the Basic Plan, there is no action to take at this time. Your current enrollment will roll to the Basic Plan choice automatically. This choice will be good for the calendar year of 2015. Current Plus Plan Participants: Review the eligibility questions for the HSA on the Plus Plan Choice (yellow) form. If you answer TRUE to the HSA eligibility questions, you can continue to contribute to your HSA for 2015. If you answered TRUE to the HSA eligibility questions and want to stay on the Plus Plan for 2015, there is no action to take, your enrollment in the Plus Plan will roll to 2015 automatically. The plan choice will be good for the calendar year of 2015. If you answer FALSE to any of the HSA eligibility questions, you will likely not be eligible to contribute to a HSA for 2015. If you answered FALSE to the eligibility questions, you can choose to remain on the Plus Plan and not have the HSA, or you can move to the Basic Plan. If you answered FALSE on the eligibility questions and want to remain on the Plus Plan, there is no action to take at this time. If you choose to move to the Basic Plan, complete the “Your Open Enrollment Choice” (green) form enclosed. To Change Plans: Follow the instructions on the “Your Open Enrollment Choice” (green) form enclosed. Eligibility for the Plus Plan: Retirees and their currently covered spouse and children are eligible for the Plus Plan. Remember the Plus Plan is the medical plan, and the Health Savings Account (HSA) is a bank account. In order to contribute to a HSA, there are eligibility requirements. For some retirees, depending on their medical needs, the Plus Plan benefits, with its lower premium, may be more cost effective than the Basic Plan, even without utilizing a HSA. Example: A retiree is Medicare eligible and therefore does not meet the HSA contribution eligibility guidelines. If the Retiree has high prescription use on the Basic Plan and the prescriptions total greater than $1,400 for the year, the Plus Plan may be a better choice. Eligibility for the HSA & Medicare: Review the eligibility requirements for the HSA. If you become eligible for Medicare in 2015, you are not eligible to contribute to a HSA the month you become enrolled in Medicare, or for the months following Medicare enrollment. District Contribution to the HSA: The district will not be making a retiree HSA contribution in 2015. HSA Maximum contributions are set by the IRS: For 2015 the maximum annual contribution to HSAs are : Single maximum contribution is $3,350. The family contribution maximum is $6,650. Those age 55 and over can contribute an additional $1,000. Adding Dependents Notice: Retirees cannot add dependents to the medical or dental plans unless the retiree is in the first 12 months of their retirement. HealthLink Network Providers: No changes in network providers

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HSA Eligibility Map for Retirees

Participation Status Plus Plan

Eligibility If You Enroll In The Plus Plan:

HSA Eligibility & Contribution Limits - 2015 Retiree (not enrolled in Medicare)

Yes Yes for the HSA, $3,350 Maximum Contribution Plus $1,000 if the retiree is age 55 or over

Retiree and Spouse (neither enrolled in Medicare)

Yes Yes for the HSA, $6,650 Maximum Contribution Plus $1,000 for either or both participants if age 55 or over Spouse may be able to establish and contribute to his or her own HSA in order to accommodate both spouse’s, age 55 or over $1000 catch-up contributions. You may want to contact your tax advisor on how to set up and establish HSAs for both spouses.

Both Retiree and Spouse are Retirees (neither enrolled in Medicare)

Yes Yes for the HSA. The contribution limit for both HSAs combined is $6,650. Plus $1,000 for each retiree age 55 or over. The contributions to each HSA during the year, (including catch up contributions), is based on agreement between spouses and other rules. You can pay each other’s expense from either HSA.

Retiree (not enrolled in Medicare) Spouse (enrolled in Medicare)

Yes Yes for the HSA, $6,650 Family Maximum Contribution Plus $1,000 if the retiree is age 55 or over. The eligible spouse is not to make HSA contributions including any catch-up contributions because of Medicare coverage.

Retiree (enrolled in Medicare) Spouse (not enrolled in Medicare)

Yes Not eligible for the HSA, due to the Medicare enrollment of the retiree. If otherwise eligible, the spouse may be able to establish and contribute to his or her own HSA, if desired.

Retiree and Spouse (Both enrolled in Medicare)

Yes Not eligible for the HSA, due to Medicare enrollment

Retiree with a Spouse actively employed and participating in a Flexible Benefit Plan

Yes Not eligible to establish a HSA, because of the spouse’s traditional flexible benefit plan can potentially reimburse benefits on a first dollar basis.

Retiree (not enrolled in Medicare) Spouse is covered under a qualified HDHP and has a HSA Retiree has coverage w/CPS on self only

Yes Yes for the HSA The contribution limit for both HSAs combined is $6,650 ($3,325 each). Plus $1,000 for each spouse age 55 or over. The contributions to each HSA during the year (including catch up contributions), is based on agreement between spouses and other rules. You can pay each other’s expense from either HSA. You may want to contact your tax advisor on how to set up and establish HSAs for both spouses.

Note: If you are married, and both you and your spouse are retirees from the District and currently covered under the District’s medical plan, you can:

Each choose your own plan. One could have the Basic Plan and one could have the Plus Plan, although you give up the benefit of a family deductible if you are on the Basic Plan.

Each choose the Plus Plan and have individual deductibles of $1,400 each, instead of $2,800 together, or both choose the Basic Plan.

Enrollment Form Deadline: November 17, 2014

RETIREES - November 2014

Changes in Columbia Public Schools Health Care 2015

Deductibles and copays for the medical plans for 2015 will not change. No action is required if you want to “STAY” on the same plan you have now. Plus Plan participants should review HSA eligibility information on the (yellow) Plus Plan Choice – Retirees form. Premium Cost - 2015 This year’s medical premium cost increase is about 7.5%. While the average projected

increase for similar plans is about 6.5% for 2015, keep in mind the medical premiums

have remained the same for the past two years. Considering what other plans are

experiencing in terms of rising cost, our current benefits and rate levels continue to

allow us to meet our dual goals of maintaining excellent benefits while keeping cost

increases below national and regional trends. This has been and continues to be a team

effort, and we appreciate your efforts to become more engaged in the health care

purchasing process and wise use of your plan dollars.

HSAs Federal (IRS) guidelines have increased how much a participant of the Plus Plan can contribute to his or her HSA. If you are eligible for the HSA, the annual maximum amount you may contribute to your HSA for 2015 will be $3,350 for single coverage and $6,650 for family coverage. Catch-up contributions, (for those age 55 and over) will remain at $1,000 per year. Remember, you must be eligible to contribute to the HSA, according to IRS guidelines. Grandfathered health plans: What does that really mean? The Affordable Care Act (ACA) exempts “grandfathered” health plans from some, but

not all, of its more expensive provisions. For 2015, our plan options are still considered

“grandfathered” under the ACA. On one hand, this means that some, but not all,

provisions of health care reform currently impact our plans. On the other hand, our

plan’s structure and protection provided by relatively low deductibles and reasonable

out-of-pocket limits remain in place and have not changed significantly since the act

was passed in March of 2010.

There have been some ACA required changes for non-grandfathered status plans that

CPS has voluntarily implemented, or implemented early in prior years such as the

“unlimited lifetime maximum,” and allowing dependents to stay on the medical and

dental plans until age 26 regardless of employment status.

ACA also requires a number of administrative and compliance responsibilities that have

impacted, and will continue to impact, our plans and costs over time. For example, the

plan is required to include notice of “grandfathered status” to plan

participants. Additionally, two new taxes or fees related to health care reform

requirements are now paid by the plan on behalf of our plan participants.

While plan participants would prefer some provisions of ACA be immediately adopted,

such as the requirements to cover preventive benefits without employee out-of-pocket

expense, CPS has not made these additions at this time. The “grandfathered” election

was made in order to keep the annual cost of providing medical benefits at an

affordable amount for the Board of Education, employees and retirees, and to avoid

placing steps on the salary schedule in competition with improving benefits. A step on

the salary schedule gives each person the ability to make personal priority decisions,

while adding first dollar coverage and other provisions does not. Additionally, adding

preventive benefits could impact retiree and dependent premiums. This conversation

and annual consideration will continue.

Decision making tools: The district continues to provide tools and resources to help

you determine which plan (Basic Plan or Plus Plan) is the best choice for you and your

family. Elections are due in Business Services by November 17th.

Resources: Open enrollment packet:

A “How to Choose” communication piece , which highlights the pros and cons of each plan option. It also provides comparison examples based on a year of low, medium, and high claims.

Frequently asked questions about HSAs.

District Web site, www.cpsk12.org

Web links to MedTrak : For prescription drug information, go to www.medtrakservices.com. You will have access to a history of your prescription drug purchases, your costs and total cost of your prescriptions. This will help you carefully analyze your prescription use and cost.

Medical Plan Choice PowerPoint presentation.

Summary Benefit Comparison (SBC): A side by side comparison of the plans.

NOTE: Business Services is located in the Aslin Building, 1818 W. Worley St., Columbia, MO 65203. Questions? Contact Employee Benefits (573) 214-3710.

http://www.cpsk12.org/

http://www.medtrakservices.com/

Columbia Public Schools Business Services 1818 W. Worley St.

Columbia, MO 65203 Employee Benefits Office: (573) 214-3710

RETIREE 2015 Premium Schedule

Medical Premium Basic Plan Plus Plan

Retiree Medical $516 $466 Retiree Medicare Eligible $392 $353 Spouse of Retiree Medical $508 $458 Spouse Medicare Eligible $381 $342 One Child $237 $209 Children $403 $360 Dental Premium

Retiree $27.00 Spouse $24.00 Children $43.00 Note: Retirees cannot add dependents to the medical or dental plans unless the retiree is in the first 12 months of retirement.

PLEASE NOTE: The District website and email addresses have changed! Visit: www.cpsk12.org then click departments, then click Benefits!

Example: Jane Harmon, Benefits Manager: [email protected]

http://www.cpsk12.org/

mailto:[email protected]

Your Open Enrollment Choice RETIREES

If you want to STAY on the Basic Plan…. Your enrollment in the Basic Plan will automatically roll over to 2015. Any dependents who are

currently covered will continue coverage. There is NO further action to take at this time to stay on the Basic Plan.

If you want to remove any dependents from your medical plan, contact Employee Benefits at 214-3710 to request a separate change form.

OR If you want to STAY on the Plus Plan….

Go to the Plus Plan CHOICE yellow enrollment form for further instructions.

If you want to remove any dependents from your medical plan, contact Employee Benefits at 214-3710 to request a separate change form.

OR

If you want to move from the Basic Plan to the Plus Plan…. Go to the PLUS Plan CHOICE yellow enrollment form for further instructions.

OR

If you want to move from the Plus Plan to the Basic plan…

I am currently enrolled in the Plus Plan and want to switch to the Basic Plan for 2015. Sign and date this form, and return to Business Services no later November 17, 2014.

Currently enrolled dependents will move to the Basic Plan with you.

Note: If you want to remove any dependents from your medical plan, contact Employee Benefits at 214-3710 to request a separate change form. Forms must be returned by November 17, 2014.

You must not make any deposits to the HSA after December 31, 2014. Any unused HSA money in your account can be used for expenses incurred in 2014 or future years, even if you move to the Basic Plan.

Print Clearly: __________________________ _________________

Retiree Name Phone Number

_______________________________________________

Street Address City, State, Zip

______________________________________ _____________________

Retiree Signature DATE

Return this form to Business Services no later than November 17, 2014.

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TIP!

Can’t remember which plan you are on?

BASIC PLAN: The Basic Plan is the plan most like the “old”

plan the district had for years with a deductible and

prescription copays. Note: No changes in deductibles or

prescriptions are planned for 2015.

PLUS PLAN: The Plus Plan is the “newer” plan. The Plus Plan

is the plan with a high deductible. Participants pay 100% cost

of the prescriptions and other eligible expenses until the

deductible is met, then the plan pays 100% of eligible expenses

for in-network services. The Plus Plan also has a Health

Savings Account (HSA) option for those who meet the HSA

eligibility guidelines. Note: No changes in deductibles are

planned for 2015.

For further comparison information, see the enclosed “How to

Choose Coverage” comparison.

Plus Plan Choice - Retirees

I am currently enrolled in the Plus Plan and want to KEEP the Plus Plan

I am currently enrolled in the Basic Plan and want to MOVE to the Plus Plan

STEP 1: Eligibility for the Health Savings Account (HSA) In order to determine if you are eligible to contribute

to the HSA for 2015, circle True or False for each of the following questions:

HSA Eligibility Questions:

True/False I am choosing to enroll in the Plus Plan for 2015. True/False In 2015, I will not be covered by another plan that has a deductible lower than $1,300 for single coverage

or $2,600 for family coverage. True/False In 2015, I will not be covered by another health plan with first dollar coverage or benefits such as

prescription copays or office visit copays. True/False I am not covered by Medicare now, and will not be covered by Medicare in 2015. True/False My spouse is not enrolled in a Traditional Flex plan (Cafeteria Plan or Flex Spending Account) for 2015.

Current participants keeping the Plus Plan New participants enrolling in the Plus Plan

Decision: Each year you are responsible for making sure you qualify for the HSA by

answering the eligibility questions in Step 1. If you answered True to all the HSA eligibility questions and want to continue your Plus Plan enrollment for 2015, please review the Step 2 information. No further action on your part is necessary; there are no forms to return if you still meet the HSA eligibility guidelines and want to stay on the Plus Plan. If you answered False to any of the HSA eligibility questions:

You are not eligible for the HSA for 2015. (See Medicare note below) You must not make any deposits to the HSA after December 31, 2014. Any unused HSA money in your account can be used for expenses incurred in

2014 or future years, even if you move to the Basic Plan. If you will become eligible for Medicare in 2015, you can contribute to the

HSA in the months prior to your birth month, but not after. You must decide if you want to continue on the Plus Plan without the HSA or

move to the Basic Plan.

You can stay on the Plus Plan for 2015 without the HSA benefit, or you can move to the Basic Plan by completing the enclosed “Your Open Enrollment Choice” (green) form indicating your choice to move to the Basic Plan.

Employee opens HSA account at any bank. Enter your Date of Birth: ______________ Get your account opened by December 10, 2014. Do not make contributions until after January 1, 2015. Read the enclosed frequently asked questions, and proceed to Step 2 and Step 3.

STEP 2: Review HSA Contribution Maximums for 2015

The federal HSA deposit limits for 2015 are:

Plus Plan single coverage: $3,350

Plus Plan family coverage: $6,650

Retirees over age 55 can contribute an extra $1,000

***If you answered true to the eligibility questions above, no further action is required for current

participants keeping the Plus Plan.***

STEP 3: Signature and form required only for those participants who are “NEW” to the Plus Plan:

Check One: Previously I was enrolled in the Basic Plan, and am choosing now to enroll in the Plus Plan for 2015. OR I am not eligible for the HSA, but am choosing to enroll in the Plus Plan for 2015. _________________________________________________ _____________________________ Employee Signature DATE “PRINT NAME Clearly” Here

_________________________________________________________ _______________________ Street Address City, State, Zip Code Phone Number

If you want to REMOVE any dependents, contact Employee Benefits at

214-3710 to request a separate change form.

Return this form to Business Services no later than November 17, 2014

Circle

T/F

Retiree Medical Plan Choice The District offers you the choice of two health care plans – The Basic Plan and the Plus Plan – with different levels of coverage, costs and funding structures. The Basic Plan is a “traditional PPO” Plan. The Plus Plan is an alternative that provides the participant an option to contribute to a health care savings account (HSA).

The HSA can be used to help pay for out-of-pocket health care expenses. The HSA allows you to roll unused funds over from one year to the next so that you can build a real nest egg to use for medical expenses for yourself and your dependents.

Both plans have different levels of benefits depending upon the health care provider you choose. You will receive greater benefits, and your health care dollars will go farther when you receive care from a provider in the network. There is a How to Choose Health Coverage comparison enclosed that will be helpful in your decision process.

Because there will be minimal change to the plan in 2015, the District believes that both plans are still considered “grandfathered” under the Affordable Care Act (ACA). This means that some, but not all, provisions of health care reform currently impact our plan.

Changes in 2015 Premium costs for the medical plan will increase,

see enclosed premium schedule.

There are no changes in copays, deductibles, or out-of-pocket maximums in 2015.

Maximum contribution limits for HSA owners will increase in 2015 to $3,350 for single coverage and

$6,650 for family coverage. There will still be a $1,000 catch-up contribution allowed for those participants age 55 and over.

Deductibles & Out of Pocket Limits: Depending on your actual medical expenses, your out-of-pocket limit could be lower under the Plus Plan. Additionally, under the Plus Plan, the cost for prescription drugs is included in the out-of-pocket limits. Under the Basic Plan, your cost for prescription drug copays are in addition to your annual out-of-pocket limits. You should decide how you could reasonably budget for the deductible amount and out-of-pocket limit under either plan option if you were faced with a large health care claim. Your deductibles and out-of-pocket limits under both plans will continue to be based on a calendar year. Note that if you have family coverage under the Plus Plan, the full $2800 deductible must be met before any benefits are covered.

You Must Be Eligible to contribute to a HSA: Review the eligibility list on the Plus Plan enrollment form.

Tax-Free Vehicle: You can make tax deductible contributions by making in person deposits to Landmark Bank. (You get the tax benefit on these dollars when you file your income taxes). Federal guidelines for the HSA contribution maximums for 2015 are $3,350 for single coverage and $6,650 for family coverage. Additional catch-up contributions up to $1,000 are allowed for those age 55 and older. You may use the money in your HSA to reimburse yourself for eligible medical expenses, including, but not limited to plan deductible and coinsurance. You may even be able to save enough in your HSA over time, because of the carryover feature, to cover more than the entire amount of your deductible and/or out-of-pocket limit. HSAs generally earn a competitive interest rate and offer a triple tax advantage to you, contributions are tax deductible, earnings are tax free, and payments from the HSA are tax exempt if you use them for qualified medical expenses. The Plus Plan with the HSA option remains a great tax advantaged vehicle for those who are eligible for the HSA.

Using the HSA: Use a debit card or checkbook to pay for your qualified expenses. Keep all documentation of receipts in the event of an IRS audit. Be sure to read the enclosed FAQ about HSAs for additional information on using a HSA and for a list of qualified expenses. Additional information is also available at www.irs.gov.

Changing Plans: You will be allowed to choose between the plans each year during open enrollment. If you enroll in the Plus Plan for 2015, accumulate a balance in your HSA, and decide at a subsequent open enrollment that you wish to switch to the Basic Plan, you may do so. Once the money is in your HSA, it belongs to you, and you can use the HSA money for future expenses. If you switch to the Basic Plan, you cannot make contributions to the HSA while covered under the Basic Plan.

How to Compare: Based on your actual medical expenses, the Plus Plan may in fact, be the lower cost option. If you are on the Basic Plan, add up how many prescription copays and other medical costs you may have in the calendar year. Compare your annual out of pocket expense with the Plus Plan deductible, and if you are eligible for the HSA, don’t forget to count the potential tax savings. Finally, you will want to consider Basic and Plus Plan premium costs in your comparison.

How to Choose Health Coverage

Effective January 1,2015

RETIREES

Columbia Public Schools

Instead of a one-size-fits-all plan, the district’s health care coverage features two plan options—the

Basic Plan and the Plus Plan. The following chart gives you a very brief outline of the two plans and

their benefit levels.

Basic Plan

“Traditional” Flex plan compatible

Plus Plan HSA and “Limited” Flex plan compatible

In-network Out-of-network In-network Out-of-network

Deductible (individual/family) $500/$1,000 $600/$1,200 $1,400/$2,800* $1,400/$2,800*

Coinsurance 80% after deductible 70% after deductible 100% after deductible 70% after deductible

Out-of-pocket limit (individual/family)

$1,500/$3,000 $2,100/$4,200 $1,400/$2,800 $4,800/$8,400

Lifetime maximum Unlimited Unlimited

Prescription drugs Prescription copays

Retail copays: $15/$30/$45 Mail order copays: $25/$55/$90

Covered as other medical expenses, subject to deductible

*If you are on the Plus Plan and have family coverage, the full $2,800 deductible must be met before any benefits are paid

Basic Plan

Pros: Cons:

100% coverage for Rx after small copays

Allows you to more easily budget for health care costs in the

earlier months of the year

Out-of-pocket limits provide excellent protection against

catastrophic loss

Retiree & Dependent premiums are higher

Higher out-of-pocket limit for in-network services

Rx copay costs are in addition to the out-of-pocket limit

Rx costs do not accumulate toward the deductible

Plus Plan with HSA

Pros: Cons:

Retiree & Dependent premiums are significantly lower

Lowest potential out-of-pocket expense per year—for in-

network services

The plan pays 100% after the deductible is met for services

provided within the PPO network (HealthLink)

Rx costs count toward the deductible and out-of-pocket limits

The HSA can be used to pay for your deductible and

coinsurance, or it can be used for other medical services like

dental, glasses, and eye exams, etc.

The HSA can also be used to pay expenses for your spouse

and dependents not on the plan

You “own” the HSA

You can contribute to your HSA by making in-person deposits

at Landmark Bank

Unused HSA money rolls over and is available to you the next

year

You may have to budget for the deductible in the first

few months of the calendar year, depending on the

timing of your health care expenses

Highest plan deductible

Higher out-of-pocket maximum for out-of-network

services

Rx copay benefits are not available

If covered under family coverage, no one in the family is

eligible for benefits until the entire $2,800 family

deductible has been met for in-network services.

Coverage under the

Plus Plan is more

affordable than under

the Basic Plan (see

enclosed rates).

The HSA remains a

great tax-free vehicle

for a retiree to pay

for qualified medical

expenses.

2015 Federal

guidelines for HSA

contribution

maximums: Retirees

can contribute up to

$3,350 to their HSA

for single coverage,

or $6,650 for family

coverage, and an

extra $1,000 for a

retiree and/or spouse

age 55 or over.

This information is

designed to help you

make the best

decision for you and

your family. Here are

some of the pros and

cons.

How to Choose Health Coverage page 3

page 2


Comparison of the Basic Plan and Plus Plan: Are you a minimal user?

Here are three examples of how benefits of the Basic Plan and the Plus Plan would work and the

resulting out-of-pocket cost. Expenses shown are estimated to be after PPO and Rx network

discounts are applied. All examples are based on single coverage.

Example 1: Minimal

annual health care costs Basic Plan Plus Plan with HSA

Medical expenses

$75 (subject to $500 deductible

and 80% coinsurance to $1,500) =

$75 out-of-pocket expense

$75 (subject to $1,400 deductible

and 0% coinsurance) =


Prescription drug expenses $30 copay cost

(no out-of-pocket limit)

$210 Rx cost without copays

(subject to same $1,400 deductible)

Total participant medical cost $75 + $30 = $105 $75 + $210 = $285

Net out-of-pocket cost for

participant $75 + $30= $105 cost

$285 cost* *using HSA pre-tax dollars

Example 2: Average


Medical expenses

$450 (subject to $500 deductible



$450 (subject to $1,400 deductible



Prescription drug expenses $160 copay cost


$844 Rx cost without copays


Total participant medical cost $450 + $160 = $610 $450 + $844 = $1,294


participant $450 + $160 = $610 cost

$1,294 cost** ** $106 away from deductible

and100% coverage

for the rest of the year

Example 3: High


Medical expenses

$36,300 (subject to $500 deductible


$1,500 out-of-pocket expense

$36,300 (subject to $1,400 deductible


$1,400 out-of-pocket expense

Prescription drug expenses $2,600 copay cost


$18,584 Rx cost without copays


Total participant medical cost $1,500 + $2,660 = $4,160 $1,200 + $0 = $1,400


participant $4,100 - $0 = $4,160 cost $1,400 cost

As you look at these examples and think about which plan choice is best for you, consider these factors:

Basic Plan You must pay a $500

deductible Your out-of-pocket

expense limit, including the deductible, is $1,500

Rx copays are helpful to budget for this expense, but the cost of copays is in addition to your out-of-pocket limits

Plus Plan You must pay a

$1,400 deductible Your out-of-pocket

expense limit, including the deductible, is $1,400

You must pay Rx costs (not just the copays), but this cost will count toward the deductible and out-of-pocket limits

Check each year if you are eligible for HSA contributions

Use your HSA tax-free money to pay for your qualified medical expenses

Review the

enclosed

Frequently Asked

Questions About

HSAs

for a

representative

list of

HSA-qualified

expenses

Money you deposit in a HSA is tax deductible. Use HSA money to pay for

deductibles, glasses, contacts, and other qualified medical expenses. You can

accumulate dollars in the HSA to be used for future year expenses.

Columbia Public Schools RETIREES FREQUENTLY ASKED QUESTIONS ABOUT HSAs

INFORMATION What is a Health Savings Account (HSA)? A HSA is an account that can be funded with your pre-tax dollars to help pay for eligible medical expenses not covered by the District insurance plan, including deductibles and coinsurance. Who is eligible for a HSA? Anyone, who is:

Covered by a “qualified” High Deductible Health Plan (HDHP); and

Not covered under another health plan (other coverage) that is not a HDHP.

Not enrolled in Medicare /Medicaid/ Tri-care or recently received Veteran’s Benefits.

Not eligible to be claimed as a dependent on another person’s tax return.

The employee and / or spouse must not be enrolled in a traditional Flex (Section 125 or Cafeteria Plan).

What is a “qualified” High Deductible Health Plan (HDHP)? The District’s Plus Plan is a qualified High Deductible Health Plan that satisfies the IRS standard requirements for deductibles..

Type of Coverage

2015 Annual Deductible In-network

Single $1,400 Family $2,800

If your family is covered under the Plus Plan, no one in the family is eligible for benefits until the entire family deductible is satisfied.

How does a HSA work?

Part 1 HDHP (Plus Plan)

Intended to cover eligible expenses primarily for illness and injury after

the deductible has been met.

Part 2 HSA

Pays for out-of-pocket qualified medical expenses not paid or not covered by your insurance plan.

Step 1. Participant funds the HSA account. Step 2. Participant seeks medical services. Step 3. Medical services are paid by the HDHP (Plus Plan), subject to a deductible and coinsurance. Step 4. Participant may choose to seek reimbursement from their HSA account for amounts paid toward deductible, coinsurance, and other eligible expenses not covered by the HDHP. Step 5. Once the deductible and out-of-pocket maximum is satisfied, the participant is covered for all additional eligible plan expense under the Plus Plan during the year at 100%.

When do I use my HSA? After visiting a physician, facility, or pharmacy, your medical claim will be submitted to your HDHP for payment. Your HSA dollars can be used to pay your out-of-pocket expenses (deductibles and coinsurance) billed by the provider or pharmacy. Alternatively, you can choose to save your HSA dollars for a future medical expense. Where can I obtain information, monthly statements and bank forms for my HSA? By calling Landmark Bank (573) 499-7335. What income tax forms will I need to file when I have a HSA? You’ll need to file IRS form 8889, along with your form 1040 individual income tax return, to report any contributions made to your HSA as well as any distributions from your HSA. For contributions, you’ll receive form 1099-SA and for distributions you’ll receive form 5498-SA. If you do not make contributions or distributions during the year, you will not receive these forms. If you have excess contributions to your HSA, you must also file form 5329.

CONTRIBUTIONS How do I make contributions to my HSA? You can contribute directly to your HSA at the Bank by contributing online, mailing deposits, or making deposits in person.

When should I contribute to my HSA? Do not make any contributions to the HSA until covered by a HDHP. Only medical expenses incurred after your HDHP effective date and the date your HSA is established are considered eligible expenses. How much can I contribute to a HSA? Your contributions cannot be more than the IRS annual limits stated. For 2015, the IRS guidelines state that HSA contributions are tax-deductible up to $3,350 for single coverage participants and $6,650 for those with family coverage. Eligible individuals who are 55 or older may contribute an additional $1,000 per year to help maximize tax advantages. Consult a tax advisor for advice on your circumstances. What happens if my total contribution for the year exceeds the IRS limits? Contact Landmark Bank for specific instructions. If you receive a distribution of the excess contribution on or before April 15 (following the year in which you mistakenly withdrew funds), there is no penalty. Earnings on the excess amount are taxable. Generally, the 6 percent excise tax will not apply as long as the excess contributions and earnings are returned to you before the due date (including extensions) for filing your tax return. For additional questions, contact Landmark Bank and/or your tax advisor. How much tax will I have to pay on contributions over the IRS limits? Excess contributions are subject to a 6% excise tax. What if I have contributed the maximum annual amount and am no longer covered by a high deductible health plan (HDHP)? If you are no longer covered by a HDHP later in the year and have contributed the maximum annual amount, you will have excess contributions. Contact Landmark Bank and / or your tax advisor. Once I am eligible, how can I make “catch up” contributions – all at once or over time? For eligible individuals age 55 or over, either method can be used. For specifics, refer to IRS guidelines or consult a tax advisor.

WITHDRAWING FUNDS

What information do I need to keep when I withdraw funds? Save all receipts and records of withdrawals to substantiate reporting to the IRS. If you use your funds for non-health related expenses, you must report those withdrawals. You are responsible for maintaining all disbursement documentation associated with your HSA – not the District or Landmark Bank. What happens if I withdraw too much and don’t spend it on qualified medical expense? If you use your HSA funds for anything other than a qualified medical expense as illustrated in IRS Publication 502, the amount withdrawn is subject to both income tax and a 20 percent penalty, unless you are age 65. If you are age 65 or older, the amount you withdraw for non-medical purposes is treated as retirement income, and is subject to normal income tax, but not subject to the 20 percent penalty. Can I return funds to my HSA if I withdraw them by mistake? Withdrawals made for what you thought were qualified medical expenses, but turned out not to be, can be returned to the HSA if you made the withdrawal in error. Contact Landmark Bank for specifics. How do I designate an additional card holder for my account (authorized user) and/or request that someone other than me be allowed to receive information about my HSA? You can add an additional debit card holder (authorized user) and/or an individual who is authorized to receive information about your account by downloading forms online. However, because the HSA is an individually held account, additional debit card holders and/or individuals authorized for information cannot request certain changes to your account. For further information, contact Landmark Bank.

FREQUENTLY ASKED QUESTIONS ABOUT HSAs (Continued) RETIREES WITHDRAWING FUNDS (Continued) What happens if my account becomes overdrawn and I do not make a deposit to bring my account current? For information, contact Landmark Bank. How and when can I invest my HSA funds? For information, contact Landmark Bank. What if I am no longer covered by a HDHP? If you are no longer covered by a HDHP, you cannot continue to contribute funds to your HSA. However, the money in your HSA is yours to keep at Landmark Bank, or yours to transfer to another HSA account custodian. If you choose to transfer your HSA to another qualifying account, you must do so within 60 days of withdrawing the funds from Landmark Bank to avoid taxes and penalty. HSA funds can be used tax-free for eligible medical expenses for a tax dependent at any time, regardless of enrollment in a HDHP.

WHAT EXPENSES ARE ELIGIBLE FOR REIMBURSEMENT FROM A HSA? A HSA may reimburse qualified medical expenses incurred by you the account holder, your legal spouse and your qualified dependents as described in Section 213(d) of the IRS Code. A partial list of qualified medical expenses can be found in IRS Publication 502. These expenses must not have been reimbursed previously by any other coverage, such as a Flex Spending Account. In general, the IRS requires that expenses must be for the diagnosis, cure, mitigation, treatment or prevention of disease, and for treatments affecting any part or function of the body. Specifically, the expense has to be primarily for the prevention or alleviation of a physical or mental defect or illness. The determination often hangs on the word “primarily.” A determination of whether an expense is for “medical care” is based on all the relevant facts and circumstances. Generally, insurance premiums paid are not eligible HSA reimbursements, however, the following insurance premiums may be reimbursed from a HSA:

COBRA premiums,

Health insurance premiums while receiving unemployment benefits,

Qualified long term care premiums (annual amounts subject to age limits), and

Premiums paid for the District’s retiree coverage for those who are age 65 or over. For further questions, you should contact Landmark Bank and/or your tax advisor. The following lists provide examples of eligible and ineligible medical expenses for disbursement from a HSA. This list is not all-inclusive. Remember, the IRS may modify its list of eligible expenses from time to time. As always, consult your tax advisor should you require specific tax advice.

ELIGIBLE HSA MEDICAL EXPENSES MAY INCLUDE:

Acupuncture

Alcoholism treatment

Ambulance

Artificial limb

Artificial teeth

Breast reconstruction surgery (mastectomy related)

Chiropractor

Contact lenses and solutions

Cosmetic surgery (if due to trauma or disease)

Dental treatment (X-rays, fillings, braces, extractions, etc.)

Diagnostic devices (such as blood sugar test kits for diabetics)

Doctor’s office (including physicians, surgeons, specialists or other medical practitioners) visits and procedures

Drug addiction treatment

Drugs, prescription

Eyeglasses and exams

Eye surgery (such as laser eye surgery or radial keratotomy)

Fertility enhancements

Hearing aids (and batteries for use)

Hospital services

Laboratory fees

Long-term care (for medical expenses and premiums)

Nursing home

Nursing services

Operations/surgery (excluding unnecessary cosmetic surgery)

Osteopath

Over the counter (OTC) medical expense for items used solely to treat a medical condition (such as aspirin, pain relievers, decongestants, cough suppressants, etc.), but only if prescribed by a physician.

Physical Therapy

Psychiatric care

Psychologist

Special education (for learning disabilities)

Speech Therapy

Stop-smoking programs (including nicotine gum or patches)

Vasectomy

Weight-loss program (to treat a specific disease diagnosed by a physician)

Wheelchairs

WHAT EXPENSES ARE NOT ELIGIBLE FOR TAX FAVORED REIMBURSEMENT FROM A HSA?

Advance payment for future medical care

Amounts reimbursed from any other source (such as other health coverage or a Flexible Spending Account)

Babysitting, child care and nursing services for a normal, healthy baby

Betting (including lottery, gaming, chips, or track wagers)

Cosmetic surgery (unless due to trauma or disease)

Diaper service

Electrolysis or hair removal

Expenses incurred prior to the date the HSA was established

Funeral expenses

Gasoline

Health club dues

Household help

Illegal operations and treatments

Maternity clothes

Meals

Nutritional supplements

Over-the-counter drugs and medicines other than those used exclusively for medical purposes or those not prescribed by a physician.

Personal use items (such as toothbrush , toothpaste)

Premiums for Medicare supplemental policies

Swimming lessons

Teeth-whitening

Weight loss program (unless prescribed to treat a specific disease)

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Columbia Public Schools: Basic Plan Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: PPO

Questions: Call 1-800-990-9058 or visit us at www.mycoresource.com If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-800-866-487-2365 to request a copy.

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.mycoresource.com or by calling 1-800-990-9058. The Uniform Glossary can be accessed at: www.dol.gov/ebsa/healthreform.

Important Questions Answers Why this Matters:

What is the overall deductible?

In-network: $500/person, $1,000/family. Out-of-network

$600/person, $1,200 maximum/family. Prescription copays do not count toward the deductible.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other

deductibles for specific services?

No. You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out–of–pocket limit on my expenses?

Yes. In-network:$1,500/person, $3,000/family. Out-of-network: $2,100/ person, $4,200/family.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in

the out–of–pocket limit?

Premiums, balance-bill charges, health care this plan does not cover and all copayments

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Is there an overall annual limit on what the plan pays?

No. The chart starting on page 2 describes specific coverage limits, such as limits on the number of office visits.

Does this plan use a network of providers?

Yes. See www.healthlink.com or call 1-800-624-2356 for a list of In-network providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes. Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

http://www.mycoresource.com/

http://www.dol.gov/ebsa/healthreform

http://www.myfmh.com/


http://www.healthlink.com/

2 of 8



Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.

The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

This plan may encourage you to use In-Network providers by charging you lower deductibles, copayments and coinsurance amounts.

Common

Medical Event Services You May Need

Your cost if you use an

In-Network Provider

Your cost if you use an Out-of-

Network Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

Deductible, then 20% coinsurance


–––––––––––none–––––––––––

Specialist visit Deductible, then 20% coinsurance


–––––––––––none–––––––––––

Other practitioner office visit Deductible, then 20% coinsurance


–––––––––––none–––––––––––

Preventive care/screening/immunization



No charge for immunizations from birth to age 5. Baseline mammograms at age 35, annual mammograms beginning at age 40, and annual well woman exams are covered subject to deductible, then coinsurance.

If you have a test

Diagnostic test (x-ray, blood work) Deductible, then 20% coinsurance


Coverage for medical conditions only. Diagnostic tests for preventive or wellness screenings are not covered.

Imaging (CT/PET scans, MRIs) Deductible, then 20% coinsurance


Must be medically necessary



3 of 8



Common



In-Network Provider


Network Provider


If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.medtrakrx.com by calling 800-771-4648.

Generic drugs Retail: $15/Rx, Mail: $25/Rx

Retail: $15/Rx*, Mail: $25/Rx*

Covers up to a 30-day supply (retail prescription), 90 day supply (mail order prescription. See your plan document Schedule A for a list of exclusions, limitations, and formulary information. *Out-of-network may also require payment of charges over the “in-network” allowed amount.

Preferred brand drugs Retail: $30/Rx, Mail: $55/Rx


Non-preferred brand drugs

Retail: $45/Rx, Mail: $90/Rx


Specialty drugs

Retail: $45/Rx, Mail: $90/Rx


Pre-authorization required. *Out-of-network may also require payment of charges over the “in-network” allowed amount.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)



Services must be medically necessary. See your plan document for information about excluded services. Physician/surgeon fees



If you need immediate medical attention

Emergency room services Deductible, then 20% coinsurance


–––––––––––none–––––––––––

Emergency medical transportation



Local ambulance services to the nearest hospital, not to exceed 150 miles. Transportation services to the US from outside the US are not covered services under this plan.

Urgent care Deductible, then 20% coinsurance


–––––––––––none–––––––––––

If you have a hospital stay

Facility fee (e.g., hospital room) Deductible, then 20% coinsurance


See your plan document for information about excluded services.



4 of 8



Common



In-Network Provider


Network Provider


Physician/surgeon fee Deductible, then 20% coinsurance


If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services



See your plan document for information about excluded services. Group counseling is not covered by this plan. Only one-on-one services are covered.

Mental/Behavioral health inpatient services



Limited to 90 days per Calendar Year. See your plan document for information about excluded services.

Substance use disorder outpatient services



Group counseling is not covered by this plan. See your plan document for information about excluded services.

Substance use disorder inpatient services



Limited to 30 days per Calendar Year. Group counseling is not covered by this plan. Only one-on-one services are covered. See your plan document for additional information about excluded services.

If you are pregnant

Prenatal and postnatal care Deductible, then 20% coinsurance


No maternity coverage for dependent children. See plan document for enrollment rules on adding newborns. Delivery and all inpatient services



If you need help recovering or have other special health needs

Home health care Deductible, then 20% coinsurance


Coverage limited to expenses that are medically necessary. Custodial care is not covered.

Rehabilitation services Deductible, then 20% coinsurance


There must be a medically necessary treatment plan prescribed by a physician and subject to case management review.

Habilitation services Deductible, then 20% coinsurance




5 of 8



Common



In-Network Provider


Network Provider


Skilled nursing care Deductible, then 20% coinsurance


Coverage limited to 60 days per Calendar Year.

Durable medical equipment Deductible, then 20% coinsurance


Equipment must be medically necessary.

Hospice service




If your child needs dental or eye care

Eye exam Not Covered Not Covered –––––––––––none–––––––––––

Glasses Not Covered Not Covered –––––––––––none–––––––––––

Dental check-up Not Covered Not Covered –––––––––––none–––––––––––

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Acupuncture

Cosmetic surgery

Dental care

Immunizations over age 5

Massage therapy

Hearing aids

Infertility treatment

Long-term care

Well child visits

Private-duty nursing

Routine eye care

Routine foot care

Weight loss programs

Routine well visits and related lab work

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Annual well woman exams

Office visits for illness and related lab work

Immunizations birth to age 5

Specialist visit charges for illness and related lab work

Mammograms and colonoscopies (see limits and exclusions)

Chiropractic care



6 of 8



Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health

coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you

pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact Employee Benefits at 573-214-3710. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877- 267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For

questions about your rights, this notice, or assistance, you can contact:


Business Services Office – Attn: Employee Benefits

1818 W. Worley Street

Columbia, Missouri 65203

573-214-3710

Or you may contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) at 1-866-444-EBSA (3272) through EBSA’s website at www.dol.gov/ebsa/healthreform.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––



http://www.dol.gov/ebsa,

http://www.cciio.cms.gov/


7 of 8



Having a baby (normal delivery)

Managing type 2 diabetes (routine maintenance of

a well-controlled condition)

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Amount owed to providers: $7,540 Plan pays $5,790 Patient pays $1,750

Sample care costs:

Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Patient pays:

Deductibles $500

Copays $100

Coinsurance $1,000

Limits or exclusions $150

Total $1,750


Sample care costs:

Prescriptions $2,900

Medical Equipment and Supplies $1,300

Office Visits and Procedures $700

Education $300



Total $5,400

Patient pays:

Deductibles $500

Copays $200

Coinsurance $380


Total $1,260

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples.



8 of 8



Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?

Costs don’t include premiums.

Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

The patient’s condition was not an excluded condition.

The patient’s coverage tier in the “Having a baby” example is assumed to be “family coverage” and “single coverage” in the “Managing type 2 diabetes” example.

The “Having a baby” example assumes that the baby’s expenses are for “well baby services” and that the baby was enrolled in the plan within 31 days of the birth. If the baby is sick, the baby will incur their own expenses subject to a separate deductible.

All services and treatments started and ended in the same coverage period.

There are no other medical expenses for any member covered under this plan.

Out-of-pocket expenses are based only on treating the condition in the example.

The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples.

The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of

Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium

you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to a flexible spending arrangement (FSA) that helps you pay out-of-pocket expenses on a tax favored basis.



1 of 8

Columbia Public Schools: Plus Plan Coverage Period: 01/01/2015- 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: PPO


This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan document at www.mycoresource.com or by calling 1-800-990-9058. The Uniform Glossary can be accessed at: www.dol.gov/ebsa/healthreform.

Important Questions Answers Why this Matters:

What is the overall deductible?

$1,400 for those with single coverage, $2,800 for those with family coverage.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other

deductibles for specific services?

No. You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out–of–pocket limit on my expenses?

Yes. In-network: $1,400 for those with single coverage, $2,800 for those with family coverage. Out-of-network: $4,200 for single and $8,400 for family.

The out-of-pocket limit is the most you could pay for claims incurred during a calendar year for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in

the out–of–pocket limit?

Premiums, balance-bill charges, and health care this plan does not cover.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Is there an overall annual limit on what the plan pays?

No. The chart starting on page 2 describes specific coverage limits, such as limits on the number of office visits.

Does this plan use a network of providers?

Yes. See www.healthlink.com or call 1-800-624-2356 for a list of In-Network providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes. Some of the services this plan doesn’t cover are listed on page 5. See your plan document for additional information about excluded services.





http://www.healthlink.com/

2 of 8



Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.

The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

This plan may encourage you to use In-Network providers by charging you lower deductibles, copayments and coinsurance amounts.

Common



In-Network Provider


Network Provider


If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

Deductible, then no charge


–––––––––––none–––––––––––

Specialist visit Deductible, then no charge


–––––––––––none–––––––––––

Other practitioner office visit Deductible, then no charge


–––––––––––none–––––––––––

Preventive care/screening/immunization

Not covered Not covered No charge for immunizations from birth to age 5. Baseline mammograms at age 35, annual mammograms beginning at age 40, and annual well woman exams are covered subject to deductible, then no charge.

If you have a test

Diagnostic test (x-ray, blood work) Deductible, then no charge


Coverage for medical conditions only. Diagnostic tests for preventive or wellness screenings are not covered.

Imaging (CT/PET scans, MRIs) Deductible, then no charge


Must be medically necessary



3 of 8



Common



In-Network Provider


Network Provider


If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.medtrakrx.com by calling 800-771-4648.

Generic drugs


Deductible, then no

charge* Covers up to a 30-day supply (retail prescription), 90 day supply (mail order prescription. See your plan document Schedule A for a list of exclusions, limitations, and formulary information. *Out-of-network may also require payment of charges over the “in-network” allowed amount.

Preferred brand drugs


Deductible, then no

charge*

Non-preferred brand drugs Deductible, then no charge

Deductible, then no

charge*

Specialty drugs


Deductible, then no

charge*

Pre-authorization required. *Out-of-network may also require payment of charges over the “in-network” allowed amount.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)



Services must be medically necessary. See your plan document for information about excluded services. Physician/surgeon fees



If you need immediate medical attention

Emergency room services Deductible, then no charge


–––––––––––none–––––––––––

Emergency medical transportation



Local ambulance services to the nearest hospital, not to exceed 150 miles. Transportation services to the US from outside the US are not covered services under this plan.

Urgent care Deductible, then no charge


–––––––––––none–––––––––––

If you have a hospital stay

Facility fee (e.g., hospital room) Deductible, then no charge


See your plan document for



4 of 8



Common



In-Network Provider


Network Provider


Physician/surgeon fee Deductible, then no charge


information about excluded services.

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services



See your plan document for information about excluded services. Group counseling is not covered by this plan. Only one-on-one services are covered.

Mental/Behavioral health inpatient services



Limited to 90 days per Calendar Year. See your plan document for information about excluded services.

Substance use disorder outpatient services



Group counseling is not covered by this plan. See your plan document for information about excluded services.

Substance use disorder inpatient services



Limited to 30 days per Calendar Year. Group counseling is not covered by this plan. Only one-on-one services are covered. See your plan document for additional information about excluded services.

If you are pregnant

Prenatal and postnatal care Deductible, then no charge


No maternity coverage for dependent children. See plan document for enrollment rules on adding newborns. Delivery and all inpatient services



If you need help recovering or have other special health needs

Home health care Deductible, then no charge


Coverage limited to expenses that are medically necessary. Custodial care is not covered.

Rehabilitation services Deductible, then no charge



Habilitation services Deductible, then no charge




5 of 8



Common



In-Network Provider


Network Provider


Skilled nursing care Deductible, then no charge


Coverage limited to 60 days per Calendar Year.

Durable medical equipment Deductible, then no charge


Equipment must be medically necessary.

Hospice service




If your child needs dental or eye care

Eye exam Not Covered Not Covered –––––––––––none–––––––––––

Glasses Not Covered Not Covered –––––––––––none–––––––––––

Dental check-up Not Covered Not Covered –––––––––––none–––––––––––

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Acupuncture

Cosmetic surgery

Dental care

Immunizations over age 5

Massage therapy

Hearing aids

Infertility treatment

Long-term care

Well child visits

Private-duty nursing

Routine eye care

Routine foot care

Weight loss programs

Routine well visits and related lab work

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Annual well woman exams

Office visits for illness and related lab work

Immunizations birth to age 5

Specialist visit charges for illness and related lab work

Mammograms and colonoscopies (see limits and exclusions)

Chiropractic care



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Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health

coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you

pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact Employee Benefits at 573-214-3710. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877- 267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For

questions about your rights, this notice, or assistance, you can contact:


Business Services Office – Attn: Employee Benefits

1818 W. Worley Street

Columbia, Missouri 65203

573-214-3710

Or you may contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) at 1-866-444-EBSA (3272) through EBSA’s website at www.dol.gov/ebsa/healthreform.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––



http://www.dol.gov/ebsa,

http://www.cciio.cms.gov/


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Columbia Public Schools: Plus Plan Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: PPO


Having a baby (normal delivery)

Managing type 2 diabetes (routine maintenance of

a well-controlled condition)

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.


Sample care costs:

Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900


Prescriptions $200

Radiology $200


Total $7,540

Patient pays:

Deductibles $2,800

Copays $0

Coinsurance $0


Total $2,950


Sample care costs:

Prescriptions $2,900

Medical Equipment and Supplies $1,300

Office Visits and Procedures $700

Education $300



Total $5,400

Patient pays:

Deductibles $1,400

Copays $0

Coinsurance $0


Total $1,580

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples.



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Columbia Public Schools: Plus Plan Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: PPO


Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?

Costs don’t include premiums.

Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

The patient’s condition was not an excluded condition.

The patient’s coverage tier in the “Having a baby” example is assumed to be “family coverage” and “single coverage” in the “Managing type 2 diabetes” example.

The “Having a baby” example assumes that the baby’s expenses are for “well baby services” and that the baby was enrolled in the plan within 31 days of the birth. If the baby is sick, the baby will incur their own expenses subject to a separate deductible.

All services and treatments started and ended in the same coverage period.

There are no other medical expenses for any member covered under this plan.

Out-of-pocket expenses are based only on treating the condition in the example.

The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples.

The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of

Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium

you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance.

Are there other considerations?

Yes. Because this plan is a qualified high

deductible health plan (HDHP), you should also consider the district contribution of $600 per year to an active individual’s health savings account (HSA). Additionally, you should consider contributing to your HSA if you are eligible to do so.



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