Maximize Your Benefits & Minimize Your Costs April 4, 2016 Joint - - PowerPoint PPT Presentation

Maximize Your Benefits & Minimize Your Costs

April 4, 2016

Joint Health Management Board

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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

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/

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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

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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

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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

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Tip #2 – Network Providers Can Reduce Your Costs You can find network providers on JHMB Health Connect

http://www.JHMBHealthConnect.com/locating-network-providers

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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

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Tip #2 – Network Providers Can Reduce Your Costs

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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

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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

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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

PlushCare Telehealth

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PlushCare Telehealth

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PlushCare Telehealth

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PlushCare Telehealth

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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

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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

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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

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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

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Tip #8 – Generics, Formulary, AND Mail Order

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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 PPO Plan Members (Envision Rx):

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

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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

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Tip #10 – Take Advantage of Flexible Spending Accounts (FSA’s)

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Annual Maximum Contribution Limits

$5,000

Dependent Care

$2,550

Health Care

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

FSA Eligible Expenses

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Health Care FSA

• Medical

– Copays – Deductibles – Prescriptions – Hospital costs – Acupuncture – Chiropractic

• Dental

– Deductible – Copays – Orthodontia

• Vision

– Prescription glasses – Sunglasses – Contact lenses – LASIK, PRK, etc. – Reading glasses

Dependent Care FSA

• Daycare centers
• In-home day care / Nanny / Au Pair
• Before or after school programs for children

under age 13

• Summer day camp
• Nursery school and Pre-school programs
• Elder care or dependents not capable of self-

care

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

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The scenarios below highlight potential tax savings available through the FSA program.

(1) For example purposes, taxes were estimated at 30.65%. The tax advantages you receive will vary depending on your annual

salary, tax filing status and annual contribution amount.

FSA Tax Savings Examples

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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- home Pay with FSA $614 $1,533

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.

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Tip #12 – Check Your EOBs

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Tip #13 – Get Preventive Care

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• Your health is your most important asset!
• Establish a good relationship with a primary

care physician and dentist and follow his/her recommendations on proactive preventive care

• Covered preventive care requires no copays, deductibles, cost share –

100% when using a network provider (Anthem and Kaiser)!

• Early intervention can avoid more serious treatment later
• http://www.jhmbhealthconnect.com/preventive-care-services

Tip #14 – Estimate Costs in Advance

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• Ask your doctor or dentist for an estimate of costs BEFORE the service

is provided.

• Through Kaiser, you can find estimate of what you’ll pay for many

common services – personalized for your benefit plan – kp.org/memberestimates – Or call 1-800-390-3507

Tip #14 – Estimate Costs in Advance

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• Dental too!
• Have your dentist obtain predetermination from Delta Dental for any

treatment over $300

• For procedures over $500, United Health Care recommends you

request a treatment plan from your dentist for submission to UHC

• Both dental plans will tell you in advance (if submitted) how much the

plan will pay and will identify your out-of-pocket costs

Tip #15 – Ask Questions

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• Delta Health Systems

800-807-0820

• Kaiser Permanente

800-464-4000

• Delta Dental PPO Plan

888-335-8227

• United Health Care HMO Dental

800-999-3367

• Envision Rx

800-361-4542

• Medical Eye Services

800-877-6372

• District’s Benefit Department

559-457-3520