Non State GroupsOpen Enrollment for Plan Year 2013

No employee & employer rate increases

No plan design changes for Plans A and B

Autism Spectrum Disorder Pilot– Benefit will be continued for 2013

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

– In Network services for medical & pharmacy have NO member Coinsurance

– Employer HSA Funding Increased• Maximum of $1,500 for single & $2,250 for family• Employer may pays HSA funding in a lump sum• All HSA accounts will be with US Bank

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

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/

UniformGlossaryofHealthCoverageMedicalTerms.pdf

* Note: This is not specific to the SEHP Coverage

1. 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

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

networks & same basic coverage– 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

Services ServicesWell 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.

 

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 $2,500

Network 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 plan

Your responsibility = $500

Plan 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.

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 Example

Claim Information

Member has Plan A

Network Dr. billed $125 for service

Plan allowed $100 for service

Member has met their $300 Deductible

Member Coinsurance is 20%

Claim Processing

$100 allowed by Plan20% Coinsurance $20 Paid by Member

Plans 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 No

Office 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

100% Coverage of eligible outpatient lab tests

Two vendors– Quest Diagnostics– Stormont-Vail

Cannot be used for:– Hospital outpatient or inpatient lab

services– Labs needed on a STAT basis

Statewide & nationwide preferred lab vendor

Testing must be performed and billed by Quest

Your Doctor can draw the sample and call for specimen pick up

For draw site locations visit: www.labcard.com- Online appointment scheduling available

Use Your Quest ID card or medical ID card

Stormont-Vail HealthCare is the regional preferred lab vendor in NE Kansas

100% coverage for eligible outpatient lab tests

All Plan A and B members may use the Stormont-Vail draw site locations

Labs drawn at other Cotton-O’Neil locations may be included if by network providers

Show your medical ID Card to access benefit

Generic 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

Caremark Prescription Drug Benefit –

Plans A & B

2012Actos 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 QtrAchiphex 4th QtrCymbalta 4th Qtr

www2.caremark.com/kse

Network Coverage for Medical & Pharmacy – $2,500/$5,000 Deductible– No 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

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 credible drug plan

Plan C Network Benefits

Single Family

Deductible $2,500 $5,000

Coinsurance 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

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

The following members are not eligible for an HSA:– Enrolled in Medicare – 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

– Receiving benefits from Social Security– Covered as a dependent under another plan

that isn’t a QHDHP– Can be claimed as a dependent on another

individual’s tax return (i.e. Parents)– Spouse has Health Care Flexible Spending

AccountSee page 12 of the OE Book

Employer may 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

Full Time Employee - (24 semi-monthly deductions)

Single Family

Employer (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 Account 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. •Members over age 55 can contribute additional funds to “catch up”

26

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

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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 processes 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

28

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

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

Benefit Level PPO PremierNon

Network

Preventive Services

Covered in full

Covered in full

Allowed amount

covered in full

Basic BenefitBasic

Restorative50% 50% 50%

Enhanced Benefit

Basic Restorative

20% 40% 40%

$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

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

Requirements for 2014 incentive discount– Complete the required online health

questionnaire(10 Credits)

– Earn 20 additional credits

HQ Rewards deadline is July 31, 2013

Non Tobacco usage is worth 10 credits– Non Tobacco Use declaration is now online at:

www.kansashealthquest.com– You may complete declaration at anytime

before the deadline.

Tobacco cessation program is no longer required for tobacco users.

Enroll online: https://hrissuite.com–Make health plan selections

– Add/drop dependents• Dependent documentation required by

October 31.

– Coverage effective January 1, 2013

Coventry/PHS and UHC are issuing new ID cards for Plan C members

Delta Dental is issuing new ID cards for all

For all others, new cards will only be issued if the member makes a plan/coverage change

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

Hold for link to the health plan tool that will be on our web site soon

www.kdheks.gov/hcf/sehp

US Bank Tool place holder

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

Questions?

Option Slides

Primary Care Providers (PCPs)• General practice• Family practice• Geriatrics

• Internal medicine• Physician extenders• Pediatrics

• Plans A & B only• PCPs have lower office visit copays • Member may have more than one

PCP• No referrals required

Facility Address CityStormont-Vail HealthCare Laboratory

1500 SW 10th Ave. Topeka

Cotton-O’Neil 901 Laboratory

901 SW Garfield Topeka

Cotton-O’Neil 823 Laboratory

823 SW Mulvane Topeka

Cotton-O’Neil Croco Laboratory

2909 SE Walnut Dr.

Topeka

Cotton-O’Neil Urish Laboratory

6725 SW 29th St. Topeka

Cotton-O’Neil Carbondale Laboratory

211 East Main Carbondale

Emporia Medical Arts Clinic

1301 W 12th Ave. Suite 401

Emporia

Cotton-O’Neil Wamego Laboratory

1704 Commercial Circle

Wamego

Network vs. Non NetworkPlan A - Non Network

Provider 

Service on 1/2/2013Plan Pays

Member Pays

Provider Write-

Off

Billed Charge $1,500      

Allowed Charge $1,400   $100 $0

$500Deductible ($500)   $500  

50% Coinsurance $900 $ 450 $450  

Total   $450 $1,050 $0

Plan A - Network Provider

 

Service on 1/2/2013Plan Pays

Member Pays

Provider Write-Off

Billed Charge $1,500      

Allowed Charge $1,400     $100

$300 Deductible ($300)   $300  

20% Coinsurance $1,100 $880 $220  

Total   $880 $520 $100

Office Visit Copays– $25 for Primary Care Office Visits– $45 for Specialist Office Visits

$300/$600 Deductible 20% Coinsurance Coinsurance Max $1,400/$2,800 Preventive Care Services paid at

100% Lab Card Benefit

Primary Care Office Visits– $20 Copay for Adults – $10 Copay for Children <age 19

Specialist Office Visits– $40 Copay for Adults– $25 Copay for Children <age 19

$150/$300 Deductible 35% Coinsurance Coinsurance max $3,000/$6,000• Preventive Care Services paid at 100%

Lab Card benefit

$500/$1,500 Deductible 50% Coinsurance Coinsurance Max $3,650/$7,300 Non Network Providers can

balance bill Preventive care not covered

Covered in full:– Prophylaxis/cleanings – twice per year.– Oral examinations – twice per year.– Bitewing x-rays – • adults – 1 x a year • children under 18 - 2 x a year

– Full mouth x-rays – once each five (5) years.

– Limited coverage for children only:• Sealants• Space maintainers• Topical fluoride

– Ancillary – emergency relief of pain.