CSEBO 2017/18 Plan Year Overview SANTA PAULA UNIFIED SCHOOL - - PowerPoint PPT Presentation

CSEBO 2017/18 Plan Year Overview

SANTA PAULA UNIFIED SCHOOL DISTRICT AUGUST 23, 2017

2017/18 Plan Introductions

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Choose Your Preferred Network: Health Maintenance Organization (HMO)

 HMO 10 – new offering  HMO 30  HMO 10 – new offering  HMO 30

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Important Plan Terms Defined

 Copay

 The fee you pay for a doctor visit or

prescription refill

 Medical out-of-pocket maximum

(OOPM)

 Maximum you will pay for medical

expenses in a calendar year

 Prescription drug out-of-pocket

maximum

 Maximum you will pay for pharmacy

expenses in a calendar year

 Primary Care Physician (PCP)

 First point of contact for undiagnosed

health concerns; makes referrals to other providers/specialists

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CSEBO Medical Insurance HMO Comparison Effective 10/1/2017 - 9/30/2018

GENERAL PLAN INFORMATION Individual/Family Annual Medical Deductible Individual/Family Prescription Drug Deductible Per Individual Physician/Diagnostic Services Preventive Care Primary Care Office Visit Specialist Office Visit Diagnostic X-Ray and Lab Tests Advanced Imaging Inpatient Hospital Services Inpatient Hospitalization Outpatient Services Outpatient Surgery Outpatient Lab and Imaging Emergency Services Ambulance Services Emergency Room Urgent Care Urgent Care Visits $10 $30 $10 $30 $0 $100 per trip $50 per trip $50 per trip $50 copay, waived if admitted $200/visit, waived if admitted $50 copay, waived if admitted $100 copay, waived if admitted $0 30% $0 $0 $0 30% $10 per procedure $30 per procedure $0 30% $0 $0 $0 $0 $0 $0 $0 $100 per test $0 $0 $10 $30 $10 $30 $10 $40 $10 $30 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Annual Medical and Prescription Drug Combined Out-of-Pocket Limit $1,500/$4,500 $5,000/$10,000 $1,500/$3,000 $1,500/$3,000 PLAN NUMBER ANTHEM BLUE CROSS KAISER PERMANENTE HMO 10 HMO 30 HMO 10 HMO 30 In-Network In-Network In-Network In-Network

Prescription Drug Formulary

What is a formulary?

 List of plan-approved drugs  Varies by carrier and plan

Formulary tiers

 Tier 1

 Generic drugs, lowest cost share

 Tier 2

 Brand drugs on formulary, higher cost

share

 Tier 3

 Brand drugs not on formulary, higher

cost share

 Tier 4

 Specialty drugs, highest cost share

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CSEBO Medical Insurance HMO Comparison Effective 10/1/2017 - 9/30/2018

PRESCRIPTION DRUG BENEFITS Retail Generic Brand (Formulary/Preferred) Brand (Non-Formulary/Non-Preferred) Specialty Rx (Specialty Pharmacy Only; 30-day supply) Mail Order Generic Brand (Formulary/Preferred) Brand (Non-Formulary/Non-Preferred) $40 $100 $20 $30 90 days 90 days 100 days 100 days $20 $15 $10 $15 $40 $60 $20 $30 $20 $30 $20 $30 $20 $50 $20 $30 In-Network In-Network In-Network In-Network $20 30% (not to exceed $150) $20 30% (not to exceed $150) 30 days 30 days 30 days 30 days $10 $15 $10 $15 PLAN NUMBER ANTHEM BLUE CROSS KAISER PERMANENTE HMO 10 HMO 30 HMO 10 HMO 30

National 3-Tier National 4-Tier 3-Tier 4-Tier

Choose Your Plan Design: Preferred Provider Organization (PPO)

 PPO 90 – new, lower copays  PPO 80 – new plan offering  PPO 70 – new plan offering

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Important PPO Plan Terms Defined

 Deductible

 Your cost share to be paid in full before the plan pays  All deductibles run January 1 – December 31st  Waived for office visit copays and prescription drug refills on PPO’s

 Co-insurance

 Your cost share (percentage) for services after the deductible is met  The plan picks up the remainder

 Embedded Deductible/OOPM

 An individual within a family will not pay more than the individual

deductible/OOPM

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CSEBO Medical Insurance PPO Comparison Effective 10/1/2017 - 9/30/2018

PLAN NUMBER GENERAL PLAN INFORMATION In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Annual Medical Out-of-Pocket Limit1 Individual $2,000 $4,500 $3,000 $7,500 $5,000 $12,500 Two-Party $4,000 $9,000 $6,000 $15,000 $10,000 $25,000 Family $6,000 $13,500 $9,000 $22,500 $12,700 $31,750 Individual/Family Annual Medical Deductible1 Individual $500 $1,000 $750 $1,500 $1,000 $2,000 Two-Party $1,000 $2,000 $1,500 $3,000 $2,000 $4,000 Family $1,500 $3,000 $2,250 $4,500 $3,000 $6,000 Prescription Drug Deductible Per Individual Physician/Diagnostic Services Preventive Care $0 Not Covered $0 Not Covered $0 Not Covered Primary Care Office Visit $10 30% $20 40% $30 50% Specialist Office Visit $10 30% $30 40% $40 50% Diagnostic X-Ray and Lab Tests 10% 30% 20% 40% 30% 50% Advanced Imaging 10% 30% 20% 40% 30% 50% Inpatient Hospital Services Inpatient Hospitalization 10% ($250/non- compliance ded) 30% ($250/non- compliance ded) 20% ($250/non- compliance ded) 40% ($250/non- compliance ded) 30% ($250/non- compliance ded) 50% ($250/non- compliance ded) Outpatient Services Outpatient Surgery 10% ($250/non- compliance ded) 30% ($250/non- compliance ded) 20% ($250/non- compliance ded) 40% ($250/non- compliance ded) 30% ($250/non- compliance ded) 50% ($250/non- compliance ded) Outpatient Lab and Imaging 10% ($250/non- compliance ded) 30% ($250/non- compliance ded) 20% ($250/non- compliance ded) 40% ($250/non- compliance ded) 30% ($250/non- compliance ded) 50% ($250/non- compliance ded)

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$0 $0 $0 Annual Prescription Drug Out-of-Pocket Limit $5,150/$8,300 $3,850/$4,700 $1,000/$1,000 PPO 90 PPO 80 PPO 70

Advanced Imaging Example: Before Plan Deductible is Met

PPO 90

• $230 specialist office visit, $10

specialist office visit copay paid at POS; plan pays the rest

• $1,000 billed for imaging by

provider

• $500 applied to individual

deductible

• 10% coinsurance of remaining

$500, $50

• Total for Service: $560

PPO 80

• $230 specialist office visit, $30

specialist office visit copay paid at POS; plan pays the rest

• $1,000 billed for imaging by

provider

• $750 applied to individual

deductible

• 20% coinsurance of remaining

$250, $50

• Total for Service: $830

PPO 70

• $230 specialist office visit, $40

specialist office visit copay paid at POS; plan pays the rest

• $1,000 billed for imaging by

provider

• $1,000 applied to individual

deductible

• Deductible is met
• Total for Service: $1,040

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For informational purposes only, not an actual claim.

Advanced Imaging Example: After Plan Deductible is Met

PPO 90

• $230 specialist office visit, $10

specialist office visit copay paid at POS; plan pays the rest

• $1,000 billed for imaging by

provider

• 10% coinsurance of $1,000,

$100

• Total for Service: $110

PPO 80

• $230 specialist office visit, $30

specialist office visit copay paid at POS; plan pays the rest

• $1,000 billed for imaging by

provider

• 20% coinsurance of $1,000,

$200

• Total for Service: $230

PPO 70

• $230 specialist office visit, $40

specialist office visit copay paid at POS; plan pays the rest

• $1,000 billed for imaging by

provider

• 30% coinsurance of $1,000,

$300

• Total for Service: $340

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For informational purposes only, not an actual claim.

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CSEBO Medical Insurance PPO Comparison Effective 10/1/2017 - 9/30/2018

PLAN NUMBER PRESCRIPTION DRUG BENEFITS In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Retail Generic $10 $10 Brand (Formulary/Preferred) $20 $20 Brand (Non-Formulary/Non-Preferred) $35 $35 Specialty Rx (Specialty Pharmacy Only; 30-day supply) Same as Retail Brand Same as Retail Brand 20% up to $150 max copay Mail Order Generic $5 $20 $20 Brand (Formulary/Preferred) $5 $40 $40 Brand (Non-Formulary/Non-Preferred) $5 $70 $70 Specialty Rx (Specialty Pharmacy Only; 30-day supply) $5 $70 20% up to $150 max copay PPO 90 PPO 80 PPO 70 30 days 30 days 30 days Paper claim submission required Paper claim submission required Paper claim submission required $5 min copay/ or 20% up to a $25 max copay Paper claim submission required Paper claim submission required Paper claim submission required 90 days 90 days 90 days

Preferred 3-Tier Preferred 3-Tier Preferred 4-Tier

Health Savings Accounts (HSA) Basics

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Choose Your Preferred Network:

 HSA 80 – new offering  HSA 60  DHMO HSA 8966

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HSA Contribution Maximums

2017 Maximums

Tier Under 55 Over 55 Individual $3,400 $4,400 Family $6,750 $7,750

2018 Maximums

Tier Under 55 Over 55 Individual $3,450 $4,450 Family $6,900 $7,900

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Investing your HSA

Anthem

 Administered through HealthEquity  Like a traditional bank, you earn

standard interest on your investment

 Low-risk Yield Plus yields higher interest

rates, but cash remains liquid

 Varying risk mutual funds

 Requires a $1,000 minimum balance

Kaiser

 Administered through HealthCare

Bank

 Like a traditional bank, you earn

standard interest on your investment

 Varying risk mutual funds

 Requires a $2,000 minimum balance

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CSEBO Medical Insurance Health Savings Account (HSA) Plan Comparison Effective 10/1/2017 - 9/30/2018

GENERAL PLAN INFORMATION In-Network Out-of-Network In-Network Out-of-Network Individual/Family $5,000/$10,000 $10,000/$20,000 $6,550/$13,100 $12,700/$25,400 Individual/Family $1,500/$3,0001 $4,500/$9,000 $2,600/$5,200 $5,000/$10,000 Preventive Care $0 40% $0 50% Primary Care Office Visit 20% 40% $45 50% Specialist Office Visit 20% 40% $45 50% Diagnostic X-Ray and Lab Tests 20% 40% 40% 50% Advanced Imaging 20% 40% 40% 50% Inpatient Hospitalization 20% 40% up to $1,000 maximum 40% 50% up to $1,000 maximum Outpatient Surgery 20% 40% up to $350 maximum 40% 50% up to $350 maximum Outpatient Lab and Imaging 20% 40% up to $350 maximum 40% 50% up to $350 maximum Ambulance Services Emergency Room Urgent Care Visits 20% 40% $45 50% 10% Outpatient Services - After Plan Deductible is Met 10% 10% Emergency Services - After Plan Deductible is Met 20% 40% 10% 20% 40% ($250 deductible) 10% Urgent Care - After Plan Deductible is Met 10% Inpatient Hospital Services - After Plan Deductible is Met In-Network Only Annual Medical and Prescription Drug Combined Out-of-Pocket Limit $3,000/$6,000 Annual Medical Deductible and Prescription Drug Deductible - Plan deductible applies unless otherwise stated $1,500/$3,0001 Physician/Diagnostic Services - After Plan Deductible is Met $0 10% 10% 10% 10% PLAN NUMBER ANTHEM BLUE CROSS KAISER PERMANENTE HSA 80 HSA 60 DHMO HSA #8966

Advanced Imaging Example: Before Plan Deductible is Met

Anthem HSA 80

• $230 specialist office visit
• $1,000 billed for imaging by

provider

• Total for Service: $1,230

Anthem HSA 60

• $230 specialist office visit
• $1,000 billed for imaging by

provider

• Total for Service: $1,230

KP DHMO HSA 8966

• $230 specialist office visit
• $1,000 billed for imaging by

provider

• Total for Service: $1,230

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For informational purposes only, not an actual claim.

Advanced Imaging Example: After Plan Deductible is Met

Anthem HSA 80

• $230 specialist office visit
• $1,000 billed for imaging by

provider

• 20% coinsurance of $230

specialist office visit, $46

• 20% coinsurance of $1,000

imaging, $200

• Total for Service: $246

Anthem HSA 60

• $230 specialist office visit
• $1,000 billed for imaging by

provider

• $45 copay for specialist office

visit; plan pays the rest

• 40% coinsurance of $1,000

imaging, $400

• Total for Service: $445

KP DHMO HSA 8966

• $230 specialist office visit
• $1,000 billed for imaging by

provider

• 10% coinsurance of $230

specialist office visit, $23

• 10% coinsurance of $1,000

imaging, $100

• Total for Service: $123

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For informational purposes only, not an actual claim.

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CSEBO Medical Insurance Health Savings Account (HSA) Plan Comparison Effective 10/1/2017 - 9/30/2018

PRESCRIPTION DRUG BENEFITS In-Network Out-of-Network In-Network Out-of-Network Retail - After Plan Deductible is Met Generic $20 Brand (Formulary/Preferred) $45 Brand (Non-Formulary/Non-Preferred) $60 Specialty Rx (Specialty Pharmacy Only; 30- day supply) 20% (not to exceed $150) Mail Order - After Plan Deductible is Met Generic $40 Brand (Formulary/Preferred) $90 Brand (Non-Formulary/Non-Preferred) $120 Specialty Rx (Specialty Pharmacy Only; 30- day supply) 20% (not to exceed $150) $60 20% (not to exceed $150) $30 20% (not to exceed $150) 90 days 90 days 100 days 20% (not to exceed $250) Paper claim submission required Paper claim submission required $20 $60 In-Network Only 30 days 30 days 30 days 20% (not to exceed $250) 40% 50% $10 $30 PLAN NUMBER ANTHEM BLUE CROSS KAISER PERMANENTE HSA 80 HSA 60 DHMO HSA #8966

Preferred 4-Tier Preferred 4-Tier 4-Tier

SPUSD Contributions to HSA’s

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2017/18 Plan Year District Contributions

Tier Anthem HSA 80 Anthem HSA 60 KP DHMO HSA Single $3,400 $3,400 $3,400 Two-Party $2,000 $2,000 $3,320 Family $2,000 $2,000 $2,000

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Worst Case Scenario, Individual:

Tier Anthem HSA 80 Anthem HSA 60 KP DHMO HSA Deductible 10/1 – 12/31/2017 1/1 – 9/30/2018 10/1 – 12/31/2017 1/1 – 9/30/2018 10/1 – 12/31/2017 1/1 – 9/30/2018 Individual Meet deductible, 20% until $5,000 OOPM Meet deductible, 20% until $5,000 OOPM Meet deductible, 40% until $6,550 OOPM Meet deductible, 40% until $6,550 OOPM Meet deductible, 10% until $3,000 OOPM Meet deductible, 10% until $3,000 OOPM District Contribution ($3,400) Exhausted ($3,400) Exhausted ($3,000) ($400) Worst Case Total: $1,600 $5,000 $3,150 $6,550 $0 $2,600

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Annual Cost by Plan Comparison

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Annual Employee Contributions

Tier PPO 90 PPO 80 PPO 70 HSA 80 HSA 60 DHMO HSA ABC HMO 10 ABC HMO 30 KP HMO 10 KP HMO 30 EE- Only $1,600 $1,350 $1,100 $750 $0 $0 $1,100 $500 $750 $400 2-Party $3,750 $3,150 $2,500 $1,250 $0 $0 $2,500 $1,750 $1,500 $800 Family $7,000 $5,500 $5,000 $2,500 $1,500 $0 $5,000 $4,000 $4,000 $2,250

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OOPM for 10/1 – 12/31/2017 & 1/1 – 9/30/2018

Tier PPO 90 PPO 80 PPO 70 HSA 80 HSA 60 DHMO HSA ABC HMO 10 ABC HMO 30 KP HMO 10 KP HMO 30 EE-Only $4,000 $6,000 $10,000 $10,000 $13,100 $6,000 $3,000 $10,000 $3,000 $3,000 2-Party $8,000 $12,000 $20,000 $20,000 $26,200 $12,000 $6,000 $20,000 $6,000 $6,000 Family $12,000 $18,000 $25,400 $20,000 $26,200 $12,000 $9,000 $20,000 $6,000 $6,000

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OOPM + EE Contribution – ER HSA Contribution

Tier PPO 90 PPO 80 PPO 70 HSA 80 HSA 60 DHMO HSA ABC HMO 10 ABC HMO 30 KP HMO 10 KP HMO 30 EE-Only $5,600 $7,350 $11,100 $7,350 $9,700 $2,600 $4,100 $10,500 $3,750 $3,400 2-Party $11,750 $15,150 $22,500 $19,250 $24,200 $8,680 $8,500 $21,750 $7,500 $6,800 Family $19,000 $23,500 $30,400 $20,500 $25,700 $10,000 $14,000 $24,000 $10,000 $8,250

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Lowest cost plan

Decision Support Tool

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QUESTIONS?

Trever Hansen Health Benefits Manager Coastal Schools Employee Benefits Organization (805) 437-1508 trhansen@vcoe.org

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Resources

 Anthem Formulary Link (searchable):

 https://www11.anthem.com/ca/pharmacyinformation/

 HealthEquity:

 http://healthequity.com/

 Kaiser Permanente Formulary:

 www.kp.org/formulary

 Kaiser Permanente HSA

 www.kp.org/healthpayment

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