Maximize Your Benefits & Minimize Your Costs April 4, 2016 Joint Health Management Board
Maximize Your Benefits & Minimize Your Costs • Health Care is very expensive • Health Insurance is very expensive • Complex world that is growing more complex and more and every year! • Many programs available through JHMB, that maximize your dollars • Being a good consumer helps you get the most from your benefit programs – and reduces your out-of-pocket expenses 2
Tip #1 – Understand Your Benefits • Do not wait until you are sick to learn about your health care benefits • There is a wealth of information online • JHMB HealthConnect can be a primary source of information and very helpful http://www.jhmbhealthconnect.com/ 3
Tip #2 – Network Providers Can Reduce Your Costs • Preferred Provider Organization (PPO) – Freedom to use or not use PPO network providers – Higher benefit for using network – Decision made at the time of health care service – May go directly to specialists without a referral – Anthem PPO (Medical Plans A & B) – California Only – Delta Dental (Premiere and PPO Networks) – Medical Eye Services Vision (MES) – Take charge of your provider choice: • Laboratories, x-rays • Specialists 4
Tip #2 – Network Providers Can Reduce Your Costs • PPO Network Providers have agreed to a negotiated discount in exchange for being a part of the network • Since you pay a portion of that fee, your cost should also be less • And … .network providers have agreed to accept the benefit plan allowance – you should not be billed for amounts over that allowance 5
Tip #2 – Network Providers Can Reduce Your Costs Jane Uses Anthem PPO Network Provider to have lab work – Billed charges for lab work: $310 – Lab bill with Anthem PPO discount: $210 – Jane is in Medical Plan A and has met her deductible, so she would pay 20% coinsurance on $210 allowance: • Out of pocket cost is $43.40 Jane does NOT use an Anthem PPO Network Provider to have lab work – Billed charges for lab work: $310 – Allowed amount for lab work: $250 – Jane would pay 40% coinsurance on $250 allowance – And, she would pay the difference in cost between $310 and $250: • Out of pocket cost is $160 6
Tip #2 – Network Providers Can Reduce Your Costs You can find network providers on JHMB Health Connect http://www.JHMBHealthConnect.com/locating-network-providers 7
Tip #2 – Network Providers Can Reduce Your Costs • Two Dental Networks • Premier dentists have agreed to Delta Dental allowance – (Approximately 97% of all dentists) – No balance billing over what plan allows – May or may not be PPO dentists – Deductible and coinsurance subject to PPO network status • PPO dentists have also agreed to the allowance, AND they are paid at a higher benefit – (Approximately 75% of Fresno dentists) – Have also agreed to a deeper negotiated discount than other dentists 8
Tip #2 – Network Providers Can Reduce Your Costs 9
Tip #3 – HMO’s Help You Manage Your Out-of-Pocket Costs • Health Maintenance Organization (HMO) – Member must use the HMO network of providers – Emergency care covered worldwide – Otherwise, no benefits for going outside the network – To see specialists, member must obtain a referral from the plan/primary care – Kaiser Permanente HMO Medical Plan C – Pacific Union Dental/United Healthcare – Dental HMO – HMO medical plans are very good at keeping you in-network and under their medical supervision • Less financial worry for you • You have less control over your healthcare decisions 10
Tip #3 – HMO’s Help You Manage Your Out-of-Pocket Costs • Dental Health Maintenance Organization (HMO) – High level of benefit – Low copays for each service – No annual maximum benefit – No deductibles – Lower out-of-pocket costs • However … . – Fewer network providers – Must use a network provider – Be careful of “upselling” to services not covered by the plan 11
Tip #4 – Consider Telehealth • Medical treatment via secure video or phone • 24/7/365 physician consultations • Fast and convenient access • Lower out-of-pocket costs 12
PlushCare Telehealth 13
PlushCare Telehealth 14
PlushCare Telehealth 15
PlushCare Telehealth 16
Tip #5 – Generic Drugs Are Less Expensive • Generic drugs are the same as brand-name drugs in: – Dosage – Safety – Strength – Quality – The way it works – The way it is taken – The way it should be used • National average monthly cost per prescription: – Brand - $240 – Generic - $16 17
Tip #6 – Be Aware of the Envision Rx Formulary • Effective January 1, 2016, the Envision Rx plan implemented a formulary • Affects PPO Medical Plan A & B Members Covered by Envision Rx – Does not affect Medicare members – Does not affect Kaiser HMO members • A formulary is a list of drugs organized into group or “Tiers” – Tier 1 ($10 copay) – drugs are generic drugs and are the first choice whenever possible – Tier 2 ($35 copay) – drugs are a set of preferred brand-name drugs – Tier 3 ($50 copay) – drugs are non-preferred brand-name drugs 18
Tip #6 – Be Aware of the Envision Rx Formulary • Discuss the list of drugs on the formulary with your doctor before your prescription is written. Your doctor may see that there is a preferred drug that is appropriate for you. • You can look up the formulary to find out which medications are preferred by going to envisionrx.com and selecting ‘Resource Tools’ > ‘Formulary’ > ‘Preferred Drug List’ • As a first-time visitor to envisionrx.com, please take a moment to register with your member ID number 19
Tip #7 – There are Lower Copays Through Mail Order • If you are taking long-term medications for chronic conditions, consider mail order • Lower copays • Fast and convenient delivery to home • Available to PPO Plan, Kaiser HMO and Medicare members 20
Tip #8 – Generics, Formulary, AND Mail Order PPO Plan Members (Envision Rx): Kaiser HMO Members: Retail per 30 days: $10 copay per generic; $35 copay per brand name Mail Order per 100 days: $20 copay generic; $70 copay brand name 21
Tip #9 – Be MES Vision Savvy • Using MES PPO network means a higher benefit • Ask provider what selection of frames and lenses are covered by your plan 22
Tip #9 – Be MES Vision Savvy • Be aware of the Maximum Out-of-Pocket Schedule (MOOP) • Using PPO Provider can limit your MOOP for certain services that normally cost extra 23
Tip #10 – Take Advantage of Flexible Spending Accounts (FSA’s) An FSA is a pretax benefit, which allows employees to set aside a specific pretax dollar amount for unreimbursed medical, dental, vision and dependent care expenses. • FSA Plan Year: January 1 through December 31 • Open Enrollment Once per Year (October-November) • Depending on the type of FSA you have (Health Care FSA or Dependent Care FSA), you can contribute up to an annual maximum level per plan year Annual Maximum Contribution Limits $5,000 $2,550 Dependent Care Health Care 24
FSA Eligible Expenses Health Care FSA Dependent Care FSA • Medical • Daycare centers – Copays • In-home day care / Nanny / Au Pair – Deductibles • Before or after school programs for children – Prescriptions under age 13 – Hospital costs • Summer day camp – Acupuncture • Nursery school and Pre-school programs – Chiropractic • Elder care or dependents not capable of self- care • Dental – Deductible – Copays – Orthodontia • Vision – Prescription glasses – Sunglasses – Contact lenses LASIK, PRK, etc. – – Reading glasses 25
FSA Benefit Plan Rules • Subject to IRS “use it or lose it” provisions • Employee contributions are deducted from your paycheck pre-tax and deposited in your FSA • Contribution changes are not allowed unless an eligible change in family status has occurred such as: – Marriage / divorce – Birth / adoption – Death of a dependent – Loss / gain of coverage 26
FSA Tax Savings Examples The scenarios below highlight potential tax savings available through the FSA program. Single Person Family of Four Without FSA With FSA Without FSA With FSA Annual Salary $36,000 $36,000 $80,000 $80,000 Annual Pre-tax Contribution $0 $2,000 $0 $5,000 Taxable Income $36,000 $34,000 $80,000 $75,000 Taxes Withheld (1) ($11,038) ($10,424) ($24,528) ($22,995) Annual After Tax Expenses ($2,000) $0 ($5,000) $0 Annual Take-home Pay $22,962 $23,576 $50,472 $52,005 Increase in Annual Take- $614 $1,533 home Pay with FSA salary, tax filing status and annual contribution amount. (1) For example purposes, taxes were estimated at 30.65%. The tax advantages you receive will vary depending on your annual 27
Tip #11 – Check Your Bills • Think health care providers do not make mistakes? • A large majority of hospital bills in particular have errors, which can cost you additional money • Just as you would with any other kind of bill, check to ensure that: – Each service that is billed was actually provided to you – Check the dates – Question the provider if you are unsure • If you plan has already paid benefits, contact Delta Health Systems for assistance. 28
Tip #12 – Check Your EOBs 29
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