STATE EMPLOYEE HEALTH PLAN Open Enrollment for Plan Year 2013

HEALTH CARE COMMISSION (HCC) No employee & employer rate

increases No plan design changes for Plans A

and B Autism Spectrum Disorder Pilot– Benefit will be continued for 2013

OTHER HCC ACTION Plan Design Changes for Plan C– Lower premium– Deductible • Single $2,500/ Family $5,000• Single family member only has to meet the

single deductible– Network services for medical & pharmacy

have 0% member Coinsurance– State HSA Funding Increased• Maximum of $1,500 for single & $2,250 for

family• State pays HSA funding in a lump sum• All HSA accounts will be with US Bank

CHANGES DUE TO HEALTH REFORM

Preventive Care Coverage for Contraception–Medical coverage for implantable &

injectable contraceptives–Medical coverage for sterilization – Pharmacy coverage for prescription birth

control products• Must be on the Preferred Drug List• Does not include over the counter items

Preventive Care Coverage for Breastfeeding– Includes counseling and equipment

rental

NEW DOCUMENTS REQUIRED BY PPACA

Summary of Benefits & Coverage (SBC)– www.kdheks.gov/hcf/sehp/SBC.htm

Uniform Glossary of Health Coverage & Medical Terms*– www.kdheks.gov/hcf/sehp/download/U

niformGlossaryofHealthCoverageMedicalTerms.pdf

* Note: This is not specific to the SEHP Coverage

SELECTING YOUR HEALTH PLAN1. Pick a plan design (A, B or C)– Which plan design provides the coverage

you and your family need?– What is the total plan cost? What is the

member contribution?• Premiums + Deductible & Coinsurance = ?

2. Review the Provider Networks – Each of the medical plans uses a different

provider network

2013 SEHP MEDICAL PLANS

All are Preferred Provider Organizations (PPOs)– Plans A, B and C all use the same provider

networks & same basic coverages– Claims paid based on the network status– Network Providers accept the plan

allowance as payment in full– Non Network Providers can balance bill– All plans include preventive care

Plans A B CBlue Cross and Blue Shield of Kansas

X X X

Coventry/PHS X X X

UnitedHealthcare Company X X X

COVERED PREVENTIVE CAREServices Services

Well Baby Exams - includes newborn screenings & age-appropriate office visits.

Contraceptive Coverage – Designated prescription drugs, implantable & injectable contraceptives & sterilization procedures.

Well Woman, Man & Child Exams - includes an office visit & age-appropriate screenings, contraception services & counseling.

Ultrasonography for Aortic Aneurysm - Limited to one for men ages 65-75 with tobacco use history

Prenatal Screening & Counseling - Limited screening services.

Mammography – not limited to one.

Age-Appropriate Bone Density Screening

Vision Exam – one covered per person per year

Immunizations Routine Hearing Exam Colonoscopy – not limited to one.

 

DEDUCTIBLE A set amount of eligible expenses

a covered person must pay out of their own pocket before the health plan will begin paying on their claims.

Network and Non Network Deductibles accumulate separately.

Deductible and “Not Covered” do not mean the same thing.

Deductible Example Claim Information

Plan C Deductible is $2,500Network Dr. billed $600 for a covered service.

Health Plan allowance is $500.Member has met $0 of their deductible this year

Claim Processing $500 Allowed Charge-$500 Deductible $0 Paid by health planYour responsibility = $500Plan Pays $0Member Pays $500 *

Dr. writes off $100* Members on Plan C have a Health Savings Account that could be

used to pay this deductible amount.

COINSURANCE A cost sharing formula for health

care services Coinsurance is expressed as a

percentage of the allowed charge that will be paid by the member and the balance paid by the Plan

You must meet the deductible before coinsurance is applied

Coinsurance ExampleClaim Information

Member has Plan ANetwork Dr. billed $125 for servicePlan allowed $100 for serviceMember has met their $300 DeductibleMember Coinsurance is 20%

Claim Processing

$100 allowed by Plan20% Coinsurance $20 Paid by MemberPlans pays the other 80%Plan Pays $80Member Pays $20 $100 Dr. writes off $25

Network Benefits

Plan A Plan B Plan C

Deductible $300 Single$600 Family

$150 Single$300 Family

$2,500 Single$5,000 Family

Coinsurance 20% 35% 0%

Annual Coinsurance

$1,400 Single$2,800 Family

$3,000 Single$6,000 Family

None

Total Deductible & Coinsurance

$1,700 Single$3,400 Family

$3,150 Single$6,300 Family

$2,500 Single$5,000 Family

Pharmacy Covered under separate policy

Covered under separate policy

Included with Medical

Preferred Lab Yes Yes NoOffice Visits

Adults (age 19+)

PCP $25 CopaySpecialist $45

Copay

PCP $20 CopaySpecialist $40

Copay

Deductible & 0% Coinsurance

Children (< age 19)

PCP $25 CopaySpecialist $45

Copay

PCP $10 Copay Specialist $25

Copay

Deductible & 0% Coinsurance

QUEST DIAGNOSTICS Statewide & nationwide preferred lab vendor 100% coverage for eligible outpatient lab

tests – For non-emergency outpatient lab work only– Testing must be performed and billed by Quest

Available on Plans A and B only Your Doctor can draw the sample

- or- Visit Quest’s website for collection sites– Online appointment scheduling available

Use Your Quest ID card or medical ID card

www.labcard.com

STORMONT-VAIL HEALTHCAREStormont-Vail HealthCare is the regional preferred lab vendor in NE Kansas100% coverage for eligible outpatient lab testsAll Plan A and B members may use the Stormont-Vail draw site locationsLabs drawn at other Cotton-O’Neil locations may be included if by network providersShow your medical ID Card to access benefit

PLANS A & B DRUG BENEFITGeneric Drugs– 20% Coinsurance

Preferred Brand– 35% Coinsurance

Non Preferred Brand– 60% Coinsurance

Special Case Medications – 25% to a max of $75 per 30-day

supply Coinsurance Maximum is $2,580

per person for Generic, Preferred Brand & Special Case medications.

www2.caremark.com/kse

GENERIC LAUNCHES 2012

Actos 3rd QtrDiovan3rd QtrSingulair 3rd QtrMaxalt 4th QtrMaxalt MLT 4th QtrTricor 4th QtrRequip XL 4th Qtr

2013Reclast 1st QtrZomig 2nd QtrZomig ZMT 2nd QtrAdvicor 2nd QtrNiaspan 3rd QtrAciphex 4th QtrCymbalta 4th Qtr

www2.caremark.com/kse

PLAN C Network Coverage for Medical & Pharmacy – $2,500/$5,000 Deductible– 0% Coinsurance– $2,500/$5,000 Total Deductible & Coinsurance– Preventive Care Services paid at 100%

Non Network Coverage– $2,500/$5,000 Deductible – 20% Coinsurance– $4,000/$8,000 Total Deductible & Coinsurance– Preventive Care is not covered

Does not include dental or optional vision plan

PLAN C DRUG PLAN Same Preferred Drug List as Plans A & B Covered drugs are subject to the

Network Plan C deductible After the deductible, the plan pays

covered prescription drugs at 100% 100% coverage for contraceptives on

the PDL Discount Tier drugs are not covered

drugs– Only eligible for Caremark’s negotiated

discount Plan C is a creditable drug plan

PLAN C - AT A GLANCEPlan C Network Benefits

Single Family

Deductible $2,500 $5,000Coinsurance 0% 0% Total Member Pays $2,500 $5,000

HSA Account Single Family

State Maximum HSA Contribution $1,500 $2,250

Minimum $25 EE Contribution $600 $600

Total Annual HSA Contribution $2,100 $2,850

WHAT IS A HEALTH SAVING ACCOUNT?

An employee-owned bank account for saving money to pay for current or future medical expenses for members enrolled in a qualified high deductible health plan

Unspent HSA funds roll over and accumulate year to year and can be invested

Portable - The account and the money belong to you

HSA ELIGIBILITY REQUIREMENTS The following members are not eligible for an

HSA:– Enrolled in Medicare – Receiving Social Security benefits– Enrolled in TRICARE or TRICARE for Life– Enrolled with the Veteran’s Administration (VA)

and/or have received VA medical services within a three-month period immediately preceding their enrollment in Plan C

– Covered as a dependent under another plan that isn’t a QHDHP

– Can be claimed as a dependent on another individual’s tax return (e.g., Parents)

– Spouse has Health Care Flexible Spending AccountSee page 12 of the OE Book

STATE INCREASES HSA FUNDING

State will pay HSA contribution as a lump sum

Payment date depends on HCFSA:– Account funded in January if no

HCFSA in 2012 or if all money has been used by 12/31/12

– Account funded after March 15, 2013, if enrolled in HCFSA in 2012 and you have funds during the grace period

HSA CONTRIBUTIONS Full Time Employee - (24 semi-monthly deductions)

Single FamilyEmployer (ER) Contribution

$1,500 $2,250

Employee (EE) Contribution

$25 to $72.91

$25 to $175

Maximum Annual HSA Contribution (ER+EE)

$3,250 $6,450

Over age 55 “Catch up” amount

$1,000 $1,000•HSA Contributions are governed by the Internal Revenue Service (IRS).•Eligibility criteria for HSA is on Page 12 of the Open Enrollment Book•Minimum contribution of $25 semi-monthly by the employee is required•Contributions may be made with pre- or post-tax funds. •HSA Contribution amounts can be changed anytime during the year.•Members over age 55 can contribute additional funds to “catch up”

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• All Plan C options will have the same HSA vendor: – US Bank

• A file with the members who enroll in Plan C will be sent by SEHP to US Bank

• Employees receive “welcome” notification via email – Letter if no email

• Employee completes online enrollment process– Must accept the Terms and Conditions– Order additional cards for dependents– Select account beneficiaries

• Online Tools to manage your account

HSA ENROLLMENT IS EASY

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USING YOUR HSA FUNDS • Use your HSA Bank Card at a Pharmacy – Fill a prescription– Swipe your HSA Bank Card for payment– Save a copy of receipt for your records

• Use your HSA Bank Card for Medical Services– Health plan adjudicates claim & sends you an

Explanation of Benefits (EOB) – Pay the provider using your HSA Bank Card– Save a copy of the bill or EOB for your

records

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ADDITIONAL WAYS TO PAY WITH YOUR HSA• You Pay the Provider through Bill Pay– You go online and use Bill Pay to issue

payment to the provider of service• Reimburse yourself for expenses paid

out of your pocket– With Bill Pay you can send a direct

deposit reimbursement to your checking or savings account for health care services

DENTAL COVERAGE Plan pays in full for 2 exams &

cleanings $50 Plan Deductible max of 3 per

family Implant Coverage– 50% Coinsurance to a max of $1,250 per

year – Benefit subject to annual benefit max

Annual benefit maximum– $1,700 per person per year

$1,000 Lifetime Orthodontic benefit

DENTAL BENEFIT

Benefit Level PPO PremierNon

Network

Preventive Services

Covered in full

Covered in full

Allowed amount

covered in full

Basic BenefitBasic

Restorative 50% 50% 50%Enhanced Benefit

Basic Restorative 20% 40% 40%

BASIC VISION PLAN $25 Materials Copay then:– 100% single vision, standard bifocal,

trifocal lenticular lenses– Up to $100 frame allowance

Elective Contact lens allowance $150

Office visit subject to $50 Copay Contact Lens Fitting Fee subject

to $35 Copay

ENHANCED VISION PLAN Includes Basic benefits plus…– Frame allowance of up to $150– Contact Lens Fitting Fee subject to $35

Copay– High index or Poly-carbonate lenses up

to $116– Progressive lenses up to $165 – Scratch and UV coating

FLEXIBLE SPENDING ACCOUNTS Health Care Flexible Spending Account– For Plan A and B members only – Limited to $2,500 – Debit Card available

Limited FSA for Plan C members– Dental and vision expenses only– Cannot be used for medical expenses

Dependent Care Flexible Spending Account– For child care expenses – Limited to $5,000

www.asiflex.com

HEALTHQUEST (HQ) REWARDS Requirements for 2014 incentive

discount– Complete the health assessment– Earn 20 additional credits

HQ Rewards deadline is July 31, 2013 Non Tobacco usage is worth 10 credits– Certification is now online at:

www.kansashealthquest.com– You may complete the certification anytime

before the deadline. Tobacco cessation program is no longer

required for tobacco users.

OPEN ENROLLMENT Enroll online:–Make health plan selections– Add/drop dependents• Dependent documentation required by

October 31.– Enroll in Flexible Spending Accounts– Apply for HealthyKIDS

• Families at 250% of poverty level• State pays 90% of children’s premium• Enroll at:

https://khap.kdhe.state.ks.us/hkapplication/– Coverage effective January 1, 2013

IDENTIFICATION CARDS Coventry/PHS and UHC Plan C are

issuing new ID cards Delta Dental is issuing new ID cards Plans A and B, BCBS Plan C, Lab,

Vision & Drug are not issuing new cards unless the member makes a plan/coverage change

RESOURCES Review the Open Enrollment (OE) booklet ?’s: Call the health plan customer service– Phone numbers in the front of the OE booklet

Visit www.kdheks.gov/hcf/sehp.htm– Benefit descriptions, Provider directories, &

Preferred drug list available– Information on the HSA and FSA accounts

Summary of Benefits & Coverage (SBC) Email ?’s to SEHP: benefits@kdheks.gov

BENEFIT DECISION MAKING TOOLS

Two tools are available at: www.kdheks.gov/hcf/sehp/default.htm– SEHP Tool – US Bank Plan Comparison Tool

There is a Payroll Calculation tool available at http://www.kansas.gov/employee/

Questions?