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2019 Health BenefitsOpen Enrollment Benefits Over-view

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Health Insurance

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The Cost Containment You Need,The Compassionate Service You Want.

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We are excited to partner with Graff Financial, LLC in

providing cutting edge healthcare benefits

administration with a human touch.

We look forward to working with you and for you.

Welcome to Prairie States

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Seamless Integration

By keeping your health

management and administration

services in-house, we provide

seamless care and integration

throughout every step of your

personal health experience.

About Us

We provide benefits

administration for

customers across

the nation from our

offices in Chicago, IL

and Sheboygan, WI.

Your Services

Prairie States,

working with Self-

Funding Partners, will

administer the back

end of your Medical,

COBRA, FSA and

Health Management,

services effective

July 1, 2019.

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One Call for All the Answers

• Self-Funding Partners and Prairie States work together

to simplify communication, answer healthcare questions,

and ensure you get the most out of your benefits plan.

• Whenever you have a question or concern, simply

call. We are able to help you with:

• Reviewing medical claims

• Understanding eligibility

• Medical coverage and benefits

• Basic prescription coverage

• Pre-certification requirements

• Website assistance

• Taking advantage of preventive services

• Topics to discuss with your physician

• Referral to in-house nurses

• Choosing the right healthcare provider

Self-Funding Partners

(248) 566-6063

8:00 AM – 5:00 PM

Monday - Friday

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Your Prairie States Team

Service ContactMedical Claims Lori Copeland

ID Cards / Eligibility / COBRA Jess Voskuil

Flexible Spending Account (FSA) Amy Mullens

Pre-Certification Barb Laehn, LPN

Utilization Management Tami Stoffregen, BSN RN

Case Management Lisa Schmidt, BSN RN

Website Assistance Steve Godlewski

Prairie States Contact InformationPhone Number (800) 615-7020

Fax Number (920) 451-7023

My Prairie Online www.prairieontheweb.com

Business Hours 8:30 AM to 4:30 PM CST, Monday through Friday

Office Address 615 Pennsylvania Avenue, Sheboygan, WI 53081-4642

Mailing Address P.O. Box 23, Sheboygan, WI 53082-0023

Prairie States dedicated team of in-house professionals works closely

with Self-Funding Partners to get you the answers you need.

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Claims

Administration

Online

Tools

Case

Management

Transitions of

CareUtilization

Management

We Keep You

at the Center

Prairie States and the Continuum of Care

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Case

Management

Case Management helps

members with severe,

complex, and catastrophic

illnesses. Our nurses guide

you through the healthcare

system, answer questions,

and offer support.

Transitions of Care

Transitions of care helps

members after a hospital

stay, surgery or maternity

stay. We walk you through

discharge instructions, and

help you coordinate care.

Utilization

Management

Utilization Management and

Pre-Certification clinicians

work closely with you and

your providers to ensure

you receive appropriate

care and coverage in the

most appropriate and

cost-effective setting.

Health Management

Our clinicians have an average 23 years of experience.

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• All Hospitalization Services (over 23 hours)

• Chemotherapy and Radiation Therapy

(notification of oral agents)

• Clinical Trials

• Diagnostics (outpatient) - MRI, PET

• Dialysis

• Durable Medical Equipment (DME) -

All rentals. Purchases over $500.

• Genetic Testing

• Home Health / Home Infusion

• Hospice Services

• Pain Management Injections -

Epidural Steroid and Facet

• Specialty Medications covered under the

Medical Plan

• Surgical Procedures -

Inpatient and Outpatient

• Transplant Services

Pre-CertificationPenalty of $250

for Non-

Certification

Pre-certification is

required 7 days in

advance for scheduled

services, or 48 hours

after emergency

procedures/admissions

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Graff Financial, LLC - Plan Options

HSA HRA MECBenefit Plan Type: HDHP/HSA HDHP/HRA MEC

Non-Embedded Embedded

Deductible: Plan Individual \ Family Individual \ Family Individual \ Family

$2,000 \ $4,000 $5,000 \ $10,000 $0

$5,000 \ $10,000 $5,000 \ $10,000 $0

Deductible: Employee's Amount Individual \ Family Individual \ Family Individual \ Family

In-Network: $2,000 \ $4,000 $500 \ 1,000 $0

Out-Of-Network: $5,000 \ $10,000 $500 \ $1,000 $0

Deductible: Employer HRA Individual\Family

In-Network: $0 $4,500 \ $9,000 $0

Out-Of-Network: $0 $4,500 \ $9,000 $0

Co-Insurance

In-Network: 100% 90% up to $1,000\Individual and $2,000\Family 100%

Out-Of-Network: 70% 70% up to $2,000\Individual and $4,000\Family Not covered

Out of Pocket Max (Includes Ded.) Individual \ Family Individual \ Family Individual\ Family

In-Network: $4,000 \ $8,000 $7,350 \ $14,700 N/A

Out-Of-Network: Unlimited Unlimited N/A

Employee Max In-Network $4,800 / $8,000 $2,850 / $5,700 N/A

Lifetime Max: Unlimited Unlimited Unlimited

Office Visit:*

PCP (In-Network): Subj. to Ded. & Coins. $25 copay/office visit then 0% N/A

Specialist (In-Network): Subj. to Ded. & Coins. $25 copay/office visit then 0% N/A

Out of Network: Subj. to Ded. & Coins. Subj. to Ded. & Coins. N/A

Teladoc $45 Consult Fee $0 N/A

Urgent Care (Stand Alone Clinic ):* Subj. to Ded. & Coins. $50 copay, Ded. Waived N/A

ER (In and Out of Network): Subj. to Ded. & Coins. $150 copay, Ded. Waived N/A

Routine Care:

In-Network: Covered at 100% Covered at 100% Covered at 100%

Out-Of-Network: 70% after Ded. 70% after Ded. Not Covered

Prescription Drugs:* Retail Mail Order (In Network) Retail/Mail Order (In Network) Retail/Mail Order

Generic:Retail: $10 copay after deductible

Mail Order: $20 copay after deductible

Retail: $20 copay

Mail Order: $40 copay

100%: Drugs required by the ACA for

preventive services

Preferred Brand:Retail: $25 copay after deductible

Mail Order: $50 copay after deductible

Retail: $50 copay

Mail Order: $100 copay

100%: Drugs required by the ACA for

preventive services

Non Preferred Brand:Retail: $40 copay after deductible

Mail Order: $80 copay after deductible

Retail: $80 copay

Mail Order: $160 copay

100%: Drugs required by the ACA for

preventive services

Preferred Specialty:Retail: $50 copay after deductible

Mail Order: Not CoveredSee applicable tier above

100%: Drugs required by the ACA for

preventive services

Non-Preferred Specialty $75 / $150

Hospital In Patient/Out Patient:

In-Network: Subj. to Ded. & Coins. Subj. to Ded. & Coins. N/A

Out-Of-Network: Subj. to Ded. & Coins. Subj. to Ded. & Coins. N/A

This benefit comparison will not replace the benefit summary furnished (SBC). Please see Summary for complete details.

* Office Visit Copays and Prescription Drug Copays apply to Out of Pocket Maximums but not Deductibles.

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What is an HSA, Benefits of an HSA, Contribution Limits

• A health savings account (HSA) is an account that you can use to pay

qualified medical expenses, per the IRS.

• Must be in conjunction with a high-deductible health plan (HDHP).

• Funds rollover each year, so you can use your HSA to save tax-free money for medical expenses

after retirement.

• You own the account, even if you leave the company.

• HSAs can only be offered with a high-deductible health plan with the below minimum

deductibles and out of pocket maximums:

• Minimum deductible for network providers:

• $1,350 single, $2,700 family (2019 limits established by the IRS)

• Maximum annual out-of-pocket for network providers:

• $6,750 single, $13,500 family (2019 limits established by the IRS)

• HSA Contribution Limits:

• 2019

• $3,500 for individual coverage

• $7,000 for family coverage

• $1,000 Catch-up (For individuals ages 55-plus, IRS allows additional $1,000

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Who is Eligible for an HSA & HSA Distribution Rules

• Anyone who is:

• Covered by a HDHP

• Not enrolled in Medicare

• Not covered under other health insurance*

• Not another person’s dependent

*Other health insurance does not include: specific disease or illness insurance, accident,

disability, dental care, vision care and long-term care insurance.

• HSA distributions can be taken for qualified medical expenses for the following people:

• The account holder (person covered by the HDHP)

• Spouse of that individual

• Even if not covered by the HDHP

• IRS eligible Dependents of that individual

• Even if not covered by the HDHP

• Distributions from your HSA are tax-free if they are taken for “qualified medical expenses.”

• The IRS defines expenses that are considered “qualified medical expenses” for HSA distributions. Expenses

must be primarily to treat or prevent a physical or mental defect or illness.

• Your HSA can only be used for expenses that are incurred on or after the date the HSA was established.

However, HSA funds can be used for expenses from a prior year, as long as the expenses incurred on or

after the date the HSA was established.

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A welcome letter is being mailed to your home with instructions for setting up your Teladoc® account, completing your medical history and requesting a consult. Once you're set up, a Teladoc doctor is just a call or click away.

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Teladoc gives you access 24 hours, 7 days a week to a U.S. board-certified doctor through the convenience of phone, video or mobile app visits. Set up your account today so when you need care now, a Teladoc doctor is just a call or click away.

Go to Teladoc.com and

click “set up account”.

Download the app and

click “Activate account”.

Visit teladoc.com/mobile

app to download the app.

Teladoc can help you

register your account

over the phone.

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Teladoc

Teladoc is a convenient and affordable option for quality care when you need care now, if you’re considering the ER or urgent care for non-emergency issues, or if you’re away from home. Call 1-800-Teladoc for on-demand access, day or night, to board-certified doctors.

How Do I Choose?By knowing where to get care, you can make smarter decisions for your health and healthcare expenses.

Primary Care Physician

Whether you are looking for preventive or wellness services, or guidance and care in managing a condition or other health issue, your Primary Care Physician is in the best position to provide a comprehensive plan and coordination of care for your needs.

Urgent Care

Urgent Care facilities are typically stand-alone clinics that do not carry the expensive costs of an ER. If you can’t get into your own doctor and the health issue can’t wait, have a need outside of regular office hours, or are traveling outside of your hometown, Urgent Care is a great alternative to fill this patient need.

Emergency Care

Emergency Room departments are located within hospitals and are prepared to care for patients suffering true emergencies such as heart attacks, serious motor vehicle accidents, strokes, and other life threatening conditions.

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PPO Networks and Rx Program

Preferred Provider Organization (PPO)

Prescription Benefit Manager (PBM) Rx Program

Outside of Michigan

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• You will receive new Member ID Cards from Prairie States.

• The ID cards will be mailed to your home.

• Please destroy your old ID cards when you receive the new version.

• To ensure proper handling of your claims, beginning July 1, 2019 present your Prairie States Member ID card.

• If you do not yet have your ID card as of July 1, 2019, simply call (248) 566-6063, and we will give you and/or your physicians the information needed at the time of your appointment.

ID Cards

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This section provides a brief

overview of how claims were

paid for a specified period of

time, as well as the portion

providers may bill you after

your health plan benefits are

paid.

The Prairie States EOB is

not a bill.

This section shows payment

details for each claim.

How to Read Your EOB

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Claims are also shown

individually including

service code, procedure

description, applicable

co-pay, payment

amount, etc.

The Accumulator

Description Section lists

year to date amounts

paid toward Individual

and/or Family

Deductibles and Out-of-

Pocket amounts.

Details on how to file an

appeal are provided at

the bottom of your EOB.

This section provides

service code

descriptions for claims

processed.

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Flexible Spending Account Review

• Flexible Spending Accounts allows employees to put money away on a pre-tax

basis, through payroll deductions to pay for:

• Un-reimbursed Medical, Dental and Vision eligible expenses:• Health Plan Deductible, Co-insurance

• Dental and Vision eligible expenses

• Over the counter medications are only eligible with a prescription from your physicians

• Dependent Care eligible expenses:• The day care provider must file taxes and be willing to write you a receipt for services

• Dependents must be less than 13 years of age and claimed on your taxes

• Dependent Care may also apply to physically or mentally challenged spouse or family

member for whom you are legally responsible and claim as an exemption on your taxes.

• Tax Advantage:

• 25% - 30% of the contributions based on employee tax bracket

• No Federal, State or FICA taxes taken on deduction amount

• Enrollment in June of every year for July 1 effective date.

• Determine an annual amount to cover your potential out-of-pocket eligible

expenses for the new year.

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Flexible Spending Account Review

• Maximum election amount allowed per Calendar Year for

Medical FSA has been increased to $2,700 and it is available

to you on July 1.

• Maximum election amount allowed per Calendar Year for

Dependent FSA is $5,000 ($2,500 if you and your spouse

both have a DCSA).

• Dependent FSA – Member can only request reimbursement

for the amount that has accumulated in Dependent FSA

account.

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Flexible Spending Account Review

Limited Scope

• If you participate in the High Deductible Health Plan and have an HSA

(Health Savings Account), you may participate in a Limited Scope FSA:

• Dental and Vision eligible expenses ONLY

• Different from the regular FSA, in that medical expenses are not

eligible as you would have the HSA for those amounts for deductible

and out-of-pocket eligible expenses.

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FSA

Reminders

• Be conservative – under the IRS Regulations the Health FSA, Dependent

FSA and Limited Scope FSA are a Use it or Lose it account. Any

unused funds at the end of the year are forfeited.

• Claims must be incurred between July 1 and June 30.

• Claims must be filed for reimbursement within 90 days following the end

of the plan year or prior to September 30.

• You cannot change the Annual Election unless you have a qualifying

event per the IRS regulations.

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FSA

Claim Submissions

• Direct Deposit Option:

• Complete the Direct Deposit form on Self-Funding Partners Portal

• Include a voided check or savings deposit ticket

• EFT’s are released on Wednesdays.

• Manual Claim submission:

• Submit a Reimbursement Form, found self-Funding Partners Portal,

along with copy of bill, receipt or statement from the provider of

service, prescription stub or print out from pharmacy. A paper form is

also available on Self-Funding Partner’s portal with mail, fax, email

instructions.

• Physical checks are mailed on Fridays.

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My Prairie Online Portal

• Medical and Rx Claims

• Eligibility Information

• PPO and PBM Links

• Explanation of Benefits (EOB) View

• Single-sign-on access:

• Wellness Portal

• Cost Transparency Tools

• Request an ID card

• Pre-Authorizations

• Out-of-area student action plan

• At-a-glance dashboard for current

deductible and out-of-pocket totals

• Mobile-enabled – full functionality

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Health Insurance Questions?

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Voluntary BenefitsDental, Vision, Life, STD, LTD

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Guardian Life

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Guardian Life

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Guardian Life

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Guardian Life

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Guardian Life

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Guardian Life

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Guardian Life

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Guardian Life

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Voluntary Benefits Questions?

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Graff Group’s Team

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Service ContactMedical Claims

Self-Funding Partners

Graff Group Advocate Team

Elizabeth (Liz) Wivo, Regional Advocate

ewivo@self-fundingpartners.com

Point of Service Issue Resolution

ID Cards / Eligibility / COBRA

Enrollment changes

Flexible Spending Account (FSA)

Health Savings Account (HSA)

Guardian Benefits

(Dental, Vision, Life, ST-D / LT-D)

Website Assistance

Self-Funding PartnersPhone Number (248) 566-6063

Self-Funding Portal www.self-fundingpartners.com/graff

Business Hours 8:00 AM to 5:00 PM, Monday through Friday

Office Address 4150 Grange Hall Rd, Holly, MI 48442