City of Canon City Benefit Information With Tools, Resources, and - - PowerPoint PPT Presentation

City of Canon City Benefit Information

With Tools, Resources, and Tips

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Benefits Overview

• Medical Benefits: Two PPO Plans, Plans A & B—A is now a “Buy Up” Option

(Medical is bundled with Dental and Vision) Plan Administered by Meritain (Meritain processes and pays claims, and provides customer service) The City utilizes the Aetna Choice POS II Network

• Meritain Pharmacy Solutions acts as the Pharmacy Benefit Manager (PBM)
• Dental Benefit: Administered by Meritain
• Vision/Hearing Benefit: Administered by Meritain
• Employer-paid Employee, Spouse, Dependent Life/AD&D: Mutual of Omaha
• Employee-Paid (Voluntary) Term Life/AD&D
• Employer-Paid Short Term Disability: Administered by Meritain
• Employer-Paid Long Term Disability: Lincoln Financial
• Flex: Rocky Mountain Reserve (Change from Meritain)

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Medical In-Network Deductible and Out of Pocket Max

(Former Amount in Parentheses)

Plan A Plan B Calendar Year Deductible Single Family $400 ($200) $1200 ($600) $1000 ($500) $3000 ($1500) Calendar Year Max Single Family $1500 $4500 $4000 ($1500) $12000 ($4500) (Max includes Deductible, Coinsurance and Copays – combined with Prescription Drug Card)

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In-Network Medical Benefits

(Former Amount in Parentheses) Plan A Plan B

Office Visit $20 ($15) $40 ($15) Specialist Visit $40 ($30) $80 ($30) Coinsurance (after deductible) 80% 75% (80%) Chiropractic/Spinal Manipulation (15 Visits) 80% After Deductible 75% After Deductible Emergency Services/ Emergency Room Services 80% After Deductible 75% After Deductible Diagnostic Testing, X-Ray and Lab (Outpatient) 100% of the first $100 per Calendar Year (Ded. waived), then subject to Ded., then 80% 100% of the first $100 per Calendar Year (Ded. waived), then subject to Ded., then 75% Hospital/Facility Expenses 80% After Deductible 75% After Deductible Mental/Substance Use Disorders (Outpatient) $20 ($15) $40 ($15)

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In-Network Medical Benefits, Continued

Plan A Plan B

Wellness Benefit Single 100% of the first $200 per Calendar Year (Ded. Waived), then Ded, then 80% 100% of the first $200 per Calendar Year (Ded. Waived), then Ded, then 75% Employee + 1 100% of the first $300 per Calendar Year (Ded. Waived), then Ded, then 80% 100% of the first $300 per Calendar Year (Ded. Waived), then Ded, then 75% Family 100% of the first $400 per Calendar Year (Ded. Waived), then Ded, then 80% 100% of the first $400 per Calendar Year (Ded. Waived), then Ded, then 75% Retail Pharmacy: 30-day supply, or 100 unit dose, whichever is a greater supply Generic: $20 Formulary: $50 Nonformulary: $75 (New) Specialty: $150 (New) Generic: $20 Formulary: $50 Nonformulary: $100 (New) Specialty: 25% Coin. (New) Mail Order Pharmacy: 90-day supply Generic: $40 Formulary: $100 Nonformulary: $150 (New) Generic: $40 Formulary: $100 Nonformulary: $200 (New)

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Monthly Employee Medical/Dental/Vision Premiums and City Contributions

Plan A Employee Plan A City Plan B Employee Plan B City

Employee

$130.62 $740.20 $80.99 $728.88

Employee + One

$277.36 $1571.70 $171.96 $1547.66

Family

$326.10 $1847.91 $202.18 $1819.65 Across the nation, the average percent an employee pays for single coverage is 18- 20%. The norm he/she pays for dependents is 30%. As a composite, employees typically pay about 25% of their health care premium. Medical inflation is pegged at about 6-8% per year, not even taking into account claims. Employers must try and control steadily rising health insurance costs each and every year, usually by reducing benefits and/or by increasing employee cost.

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Meritain Portal Aetna Choice POS II Provider Network

• Once you have your ID card, register at

meritain.com to open an account and gain access to Meritain Connect—there you can see what’s covered, see what you have paid/owe, and access tools and resources

• Access the portal from your cell phone/device
• Go to Aetna.com/docfind/custom/mymeritain to

do a quick search for participating doctors and facilities near you

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Deductible $50 Individual $150 Family Calendar Year Maximum Benefit $1000 Class A—Preventive and Diagnostic: (Ded waived) (Routine oral exams—cleaning, scaling, polishing, x-rays according to Schedule of Benefits, etc.) 100% Class B—Basic Services: (Extractions, oral surgery, fillings, etc.) 80% Class C—Major Services: (Root canals, crowns, cast and gold restorations, etc.) 50% IMPORTANT: A Pre-Determination of Benefits must be submitted prior to receiving any periodontic or prosthodontic services or appliances. If a Pre-Determination of Benefits is not received, benefits will be reduced by 50%, to a max reduction of $250.

Dental Plan Design

(Subject to Usual and Customary Charges)

Dental Plan Administered by Meritain

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Benefit Description Benefit Vision/Hearing Care 100% Combined Calendar Year Maximum Benefit $300

Vision Plan Design

Vision/Hearing Care Administered by Meritain

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For you (Eligibility requirement of 30 hours worked per week): $150,000 For your spouse: $20,000 For your Children: Six months and older, $5,000; 14 days to less than six months, $5,000; less than 14 days, $1000 Accidental Death & Dismemberment (AD&D) Benefit Amount The Principal Sum amount is equal to the amount of your life insurance benefit Living Care/Accelerated death benefit 80% of the amount of the life insurance benefit is available to you if terminally ill, not to exceed $100,000

Employer-Paid Life and AD&D Insurance

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Travel Assistance Assistance for travels over 100 miles away from home or outside the country Employee Assistance Program (EAP) Access for you and your loved ones to trained professionals and resources for assistance with personal and workplace issues Hearing and Discount Program Access for you and your family to discounted hearing products, including hearing aids and batteries Will Prep Discounted online will preparation tools through “Willing.” Create a customized plan to protect your family and property

Free Value Adds Included with Life/AD&D Coverage

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For you (Eligibility requirement of 30 hours worked per week): Minimum of $10,000; GI 5 times annual salary, up to $100,000; Maximum of $500,000, in increments of $10,000, but no more than five times annual salary For your spouse: Minimum of 5,000; GI 100% of employee’s benefit, up to $50,000; Maximum of 100% of employee’s benefit, up to $250,000 For your Children: Minimum of $2,000; GI 100% of employee’s benefit; Maximum

• f 100% of employee’s benefit, up to $10,000

Accidental Death & Dismemberment (AD&D) Benefit Amount For you, your spouse, and your dependent children. The Principal Sum amount is equal to the amount of your life insurance benefit Living Care/Accelerated death benefit 80% of the amount of the life insurance benefit is available to you if terminally ill, not to exceed $100,000

Voluntary Life and AD&D Insurance

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Short Term Disability

(Administered by Meritain)

• Eligibility: 20 hours/week
• Waiting Period: Benefits not paid during this

waiting period: Accident and illness, 14 calendar days

• Daily Benefit: 1/7 of Weekly Benefit
• Weekly Benefit: 100% of Basic Weekly

Compensation (Basic weekly rate of pay of the employee prior to the date of the disability. Does not include commissions, overtime pay, bonuses, and any other compensation not received as basic wages or salary.)

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Long Term Disability

(Through Lincoln Financial Group)

• Eligibility: All full-time active employees

working 20 or more hours per week in an eligible class

• Maximum Monthly Benefit: 66.67% of salary,

up to $6,000 per month

• Maximum Benefit Duration: Later of age 65 or

SSNRA

• Own occupation period: 60 months
• Elimination period: 180 days

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Flex

(through Rocky Mountain Reserve)

• Moving 1/1/20 from Meritain to Rocky

Mountain Reserve

• Healthcare FSA with debit card: 2020 maximum
• f $2750
• Dependent Care FSA: 2020: $2500 per parent if

married and filing separately; $5000 if married and filing a joint return

• $500 carryover allowed on healthcare FSA—will

carry over from 2019 to 2020 with vendor change

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Measures to Take Advantage of Health Plan and Cut Costs:

• Self Advocacy
• Prevention & Free Offerings
• Network, Portal Usage
• Precertifying
• Generics
• Teladoc

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Self Advocacy

It’s your health and your pocketbook— no one has more incentive than you to take care of both!

• Participate and collaborate with your doctor
• Take a proactive role in your health care
• Demonstrate assertiveness
• Do your homework on referrals

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Self Advocacy Includes “Lifestyle as Medicine”:

• Feet= Physical Activity
• Forks= Healthy Diet
• Fingers= Not Smoking
• Sleep= Quantity and Quality
• Stress= Dealing with it Effectively
• Love= Strong Social Connections

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Take Advantage of Free Annual Wellness Visit

• The ACA provides us one free

preventive/wellness visit a year

• Establish a relationship with a Primary Care

Provider (PCP) and a baseline for health

• Detecting health problems at early stages may

make them easier and less expensive to treat, not to mention less painful

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The CDC Recommends the Following Immunizations for Adults

(Talk to Your Healthcare Professional About These Vaccines)

Flu, Td/Tdap, Shingles, Pneumococcal, Meningococcal, MMR, HPV, Chickenpox, Hep A/B, Hib Haemophilus Influenza Type B

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Examples of Free Screenings and Interventions for Adults

(Ask your doctor for any recommendations)

• Breast cancer
• Cervical cancer
• Colon cancer
• Diabetes
• Genetic counseling
• HIV
• Osteoporosis
• Prostate

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Remember: Stay Informed through the Meritain Portal

• Create an account on the Meritain portal: meritain.com
• Track your EOB, Deductible, Max, Claims online
• If you have any questions about claims, call the Customer

Service number on the back of your ID card: 800-925-2272

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Precertify to Avoid a Reduction in Benefits

• Some benefits might be reduced without prior authorization
• Call if you have any questions about precertification well before any
• utpatient care or hospital stay
• From the back of your card:
• Call for plan required prior authorization: 800-542-6355

FAILURE TO CALL FOR PRIOR AUTHORIZATION MAY REDUCE BENEFITS

• ALSO—MAKE SURE CLAIMS ARE SUBMITTED TO Meritain NOT Aetna (claims

address on back of medical ID card). You are NOT an Aetna member; the city utilizes the Aetna network only. Any claims submitted to Aetna will be DENIED.

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Stay in Network

• Avoid higher OOP max costs on Plan B

($4000/$12000 versus $8000/$16000)

• Best pricing takes place in network, with

established provider contracts

• Avoid balance billing
• Pharmacy benefits out of network are

reimbursed at the amount that would have been paid to a participating provider, less the applicable copay, potentially leaving you with added costs

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Continuum of Care Costs

In 2007, Harvard University reported that 62% of personal bankruptcies were caused by medical expenses Know where to go to get the appropriate and most affordable care:

• A doctor’s office is the best place to go for routine or

preventive care, to keep track of medications, and for immunizations and screenings

• Urgent Care Centers and Emergency Rooms are useful in more

urgent situations

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Facts about Urgent Care vs Emergency Room Care

• ER patients have no way of knowing just how high their bills will be
• ERs must treat patients with even minor emergencies because

federal law requires them to offer care to every patient and turn no

• ne away
• Research suggests that approximately 60% of ER patients could be

seen at Urgent Care centers

• The average ER visit can cost a patient at least $795, while the same

exact treatment at an Urgent Care facility generally costs around $200.

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Using Urgent Care versus ER

Urgent Care centers treat conditions that are non urgent, like:

• Fever
• Broken bones
• Allergy
• Animal bites
• Flu

Emergency Rooms treat life threatening injuries/ illnesses/medical conditions, like:

• Stroke
• Heart attack
• Severe burns
• Poisoning
• Seizures

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Generic versus Brand Name Medications

• Generic drugs approved by the FDA are as safe and effective

as their brand name counterparts, but cost less

• According to the FDA, Generic drugs are often 80 to 85%

cheaper than brand name drugs

• Ask your doctor to prescribe a generic medication

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Mail Order Maintenance Medications

Opt for 90-day mailed delivery of maintenance medication. To set up this feature:

• Ask your doctor to send an

electronic prescription

• Or Call 877-468-6592 and speak with a

Customer Service Representative

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Take Advantage of Convenient Teladoc 24/7/365

• Talk to a doctor anytime, for free!
• A doctor will listen, diagnose and potentially

write a script for issues like cold, flu, allergies, ear infection, respiratory infection, pink eye, etc.

• MyDr.Consult.com or 1-800-362-2667
• Mobile app through the App Store,
• r Google Play

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Important Contact Information

• Medical/Dental/Vision: Meritain 1-800-925-2272
• Aetna Choice POS II Provider Network:

1-800-343-3140

• Meritain Health Pharmacy Solutions: 1-866-475-7589
• Precertification with Meritain: 1-800-242-1199
• Teladoc: 1-800-362-2667
• Life/Dependent Life/Voluntary Life: Mutual of Omaha

1-800-228-7104

• Flex: Rocky Mountain Reserve 1-866-557-0109
• STD/LTD: Please see HR regarding claim forms/needs

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Please complete an enrollment form if you are adding or changing coverage. Open Enrollment runs from November 5 – 19th Please see the HR department if you have any questions

What Now?

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Conclusion and Action Items

• Sign up for any desired benefits
• Schedule your wellness visit today
• Research network options, before

appointment

• Create a Meritain portal account today
• Ask for generic medications

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