YOU MATTER! 2015 WOOD LANE EMPLOYEE HEALTH BENEFITS PLAN WELCOME: - - PowerPoint PPT Presentation

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YOU MATTER! 2015 WOOD LANE EMPLOYEE HEALTH BENEFITS PLAN WELCOME: - - PowerPoint PPT Presentation

Jan 13, 2023 227 likes •662 views

YOU MATTER! 2015 WOOD LANE EMPLOYEE HEALTH BENEFITS PLAN WELCOME: WOOD LANE EMPLOYEE HEALTH BENFITS PLAN Time for Change Separate Wood Lane from Residential Services Affordable Care Act (ACA) pushes and pulls Potential for

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SLIDE 1

YOU MATTER!

2015 WOOD LANE EMPLOYEE HEALTH BENEFITS PLAN

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SLIDE 2

WELCOME: WOOD LANE EMPLOYEE HEALTH BENFITS PLAN

  • Time for Change
  • Separate Wood Lane from Residential Services
  • Affordable Care Act (ACA) pushes and pulls
  • Potential for long-term budgetary savings
  • Buy Into Wellness Programming
  • Board of County Commissioners Serving as Plan Administrators
  • Mirrors Wood County’s Plan
  • Minor exceptions due to Affordable Care Act (ACA)
  • Long T

erm Strategy

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SLIDE 3

ABOUT THE PLAN

  • Plan Philosophy: Pay Now or Pay Later
  • Invest in Employees
  • Employer Sponsored Health Plan, Preferred Provider Organization

(PPO), Self-Insured, Non-Federal Governmental, Non-ERISA,

  • Trustees believe that this Plan is a “grandfathered” health plan

within the meaning of section 1251 of the Affordable Care Act (ACA)

  • Plan provides minimum essential coverage; and
  • Meets the minimum value standard for the benefits it provides
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SLIDE 4

FOUNDATION OF THE PLAN

Plan Administrators/ Trustees

Board of County Commissioners James Carter Doris Herringshaw Joel Kuhlman

Committee Members

Employee Health Benefits Wellness Sub-Committee Spousal Eligibility Exception Sub-Committee

Insurance Consultant

Jason Beaver

Third Party Administrators

Health: Stacey Kelley, Meritain Health Prescription: Tammie Wormley, PDMI Dental: Karen Chapman, Delta Dental

Administrative Support

Cheryl Albrecht, Rachel Richmond, Steve Puffer, Janese Diem, Pamela Boyer, Andrew Kalmar

Wood Lane Insurance Group Representative

Sue Dauer

Engaged Members

You

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SLIDE 5

PLAN FUNDING

Payment of Claims Employee

15%

Employer

85% Be an engaged consumer when pulling money out of our trust fund pocket. WOOD LANE INSURANCE TRUST

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SLIDE 6

2015 MONTHLY RATES

Coverage T

  • tal

Employer Employee* Health & Prescription $583.04 $495.59 $87.46 Vision $14.22 $12.08 $2.14 Dental $40.02 $34.02 $6.00 Life $14.60 $14.60 $0

T

  • tal Single

$651.88 $556.28 $95.60

2014 Rates $737.73 $627.71 $100.02

Health & Prescription $1,515.92 $1,288.54 $227.38 Vision $36.98 $31.44 $5.54 Dental $104.02 $88.42 $15.60 Life (employee only) $14.60 $14.60 $0

T

  • tal Family

$1,671.52 $1,423.00 $248.52

2014 Rates $2,178.36 $2,038.28 $293.08

Single Family

* Split between first and second pay dates of the month. May be deducted on a pre-tax basis. Employees are responsible to pay 15% of the total cost for

  • coverage. Spousal & Adult Child Premium rates are in addition to a family contract.
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SLIDE 7

IMPACT OF FEDERAL HEALTH CARE REFORM

  • Shared Responsibility
  • No requirement to change eligibility in 2015 (safe harbor)
  • Reporting requirement to Federal Government in 2016
  • Requires monthly eligibility and enrollment by SS# per employee
  • Certificate of Credible Coverage no longer needed
  • Summary of Benefits and Coverage (SBC) available on

employee intranet

  • ACA Fees
  • Patient-Centered Outcomes Research Institute Fee (PCORI through 2019):
  • Approx. $572 ($2 ea.)
  • Transitional Reinsurance Fee (TRF through 2016):
  • Approx. $18,018 ($63 ea.)
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SLIDE 8

ELIGIBILITY

EMPLOYEE  SPOUSE  DEPENDENTS

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SLIDE 9

EMPLOYEE ELIGIBILITY

  • Eligibility Guide
  • Initial Eligibility
  • Permanent employee (working 35 hours per week)
  • Grandfathering employees currently on coverage
  • Ongoing Eligibility
  • Continued permanent status working 35 hours per week
  • Full active pay status the first working day of the month
  • Full active pay status 30 days prior or following the first day of

the month, unless protected by FMLA

  • Qualifying Events offering Special Enrollment
  • Reported within 30 days of event
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SLIDE 10

SPOUSAL ELIGIBILITY

  • Lawful spouses may be covered on

Vision and Dental

  • Spousal eligibility for primary coverage is based upon spouses’ annual

adjusted gross income and must be certified on an annual basis in a form acceptable to the Plan

  • 2015 eligibility is based on tax return documenting 2013 income completed

in 2014

  • Less than $26,700 • Spouse can remain as primary,

a spousal premium will not apply.

  • $26,700 to $58,400 • Spouse can remain as primary,

a spousal premium will apply.

  • Greater than $58,400 • Spouse may remain as secondary at no additional cost.

No primary coverage available.

  • Employees may request an exception of their spousal eligibility after the

initial review based on reduction of income. Forms for the Eligibility Review Process available on the employee website.

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SLIDE 11

DEPENDENT ELIGIBILITY: HEALTH AND PRESCRIPTION

ELIGI ELIGIBLE: Unmarried Unmarried Natural, st Natural, step, or adopt ep, or adopted child of em child of emplo ployee Resident sident of Ohio or a full time student

  • f Ohio or a full time student

No Not eligible f t eligible for r their o their own n em emplo ployer er sponsore sponsored gr group health plan

  • up health plan

No Not eligible under t eligible under Me Medicare or Medicaid dicare or Medicaid Em Emplo ployees must elect t ees must elect to continue benef continue benefits ts for co r covere red depe depend ndents within 30 da ts within 30 days ys

  • f attaining age 26.
  • f attaining age 26.

Adult Child Premium Applies ult Child Premium Applies ELIGI ELIGIBLE: Biological son or daughter Adopted son or daughter (includes placement for adoption) Stepson or daughter NO NOT E T ELIG IGIB IBILE: ILE: The spouse of dependent The child of dependent CANNO NNOT C T COND NDITIO ITION E N ELIG IGIB IBILIT ILITY O Y ON: Student Status Marital Status Residence with employee Financial dependence on employee Eligibility in other employer sponsored group health plan Coverage by other parent

Bir Birth Age 26* e 26* Ag Age 2 26 Age 28* e 28* Federal La ederal Law w Stat State La e Law w * T

  • birthdate
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SLIDE 12

DEPENDENT ELIGIBILITY: VISION & DENTAL

  • Must mee

Must meet Plan rules as list Plan rules as listed ed on

  • n

lef left

  • Full time

ll time student at an accred student at an accredit ited ed school school until the end of the calend until the end of the calendar ar year in ar in which the which they rea reach the h the limiting limiting age of 23 age of 23

  • Full-time student co

ll-time student coverage continues rage continues

  • nly bet

between s een semest ster ers/quar arters if if the student is enr the student is enrolled lled as a full-time as a full-time student in the ne student in the next regular xt regular semest ster/q er/quar uarter er.

  • Natural, legally adopted children or children placed in

anticipation of adoption who are:

  • Unmarried
  • Not employed on a regular full time basis
  • Not covered under the Plan as an employee
  • Dependent on the covered employee or the covered

employee’s Spouse for more than 50% of their financial support

  • Dependent claimed for tax exemption purposes under

Section 152 of the Internal Revenue Code

  • Includes a stepchild or child under legal guardianship of a

covered employee or covered employee’s spouse who:

  • Meets all the requirements listed above
  • Lives in the covered employee’s home for more than half
  • f each calendar year in a regular parent-child relationship
  • Is wholly dependent on the covered employee for financial

support

  • Is claimed by the employee as a dependent for tax

exemption purposes under Section 152 of the Internal Revenue Code

Bir Birth Ag Age 1 19* Ag Age 1 19 Age 23* e 23* * T

  • end of calendar year

Plan R Plan Rules les Plan R Plan Rules les

Depende Dependent childre t children with with a a totally tally disabling ph disabling physical handicap or ysical handicap or de developmental disability ma lopmental disability may q y qualify alify. See Plan See Plan Document f Document for additional r additional inf information. rmation.

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SLIDE 13

13

ELIGIBILITY CERTIFICATION PROCESS

  • Spousal Certification Required for Primary Coverage

Vision/Dental

  • Requires Tax Return and Forms from 2013 (filed in 2014)
  • Dependent Certification Required for Dependents

20 to 27 years old in 2015 Plan Year

  • Required for All Types of Coverage
  • Student Certification
  • Based on Type of Coverage and Age
  • Health/Prescription:

26 to 28 (birthdate) if living outside of Ohio

  • Vision/Dental:

19 to 23 (end of calendar year)

  • Adult Child Premium applies for Ages 26 and 27
  • Refer to the Summary Plan Description for Rates
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SLIDE 14

ELIGIBILITY

  • Coordination of Benefits
  • Contract Holder is Primary on their coverage, secondary on
  • ther coverage
  • Children use birthday rule if dual coverage
  • Report Other Insurance
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SLIDE 15

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ELIGIBILITY QUESTION & ANSWER SESSIONS

  • One-on-One Assistance
  • November 24 at 10 a.m. – Room 2 & 3
  • November 24 at 3 p.m. – Room 2 & 3
  • Use Eligibility Guide to Assist with Navigation of Eligibility

Rules and Required Forms

  • Enrollment in Life Insurance is mandatory
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SLIDE 16

COVERAGE

HEALTH  PRESCRIPTION  VISION  DENTAL  LIFE

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SLIDE 17

COVERAGE SUMMARY

  • Health & Prescription Benefits
  • Similar Schedule of Benefits & Plan Design
  • Expanded Network of Providers
  • Free Over-the Counter (OTC) Medications
  • New

Vision Benefits

  • Dental Benefit
  • Expanded Network of Providers
  • Wellness Benefits
  • Designed for Early Detection/Prevention
  • Free Confidential Wellness Screening with Wellness Coaching
  • Wellness Programming with Rewards
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SLIDE 18

HEALTH INSURANCE Third Party Administrator: Meritain Health Network: FrontPath Health Coalition

Schedule of Benefits In-Network Out-of-Network

Annual Deductible $200 single $400 family $400 single $800 family Annual Co-Insurance $1,500 single $3,000 family $10,000 single $20,000 family Co-Payments $10 $25 ambulance $50 ER If Co-Payment applied, charge is not subject to deductible or co-insurance

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SLIDE 19

HEALTH INSURANCE Third Party Administrator: Meritain Health Network: FrontPath Health Coalition

Service In-Network Out-of-Network

Well Care Visits Children & Adults $10 Co-Payment 50% Well Child Immunizations (lab 20% out of network) $0 Co-Payment 50% Medically Necessary Office Visits/Chiropractic, Physical, Occupational, Speech Therapy $10 Co-Payment 50% Routine T esting/Screenings (PAP , Mammogram, PSA, etc.) 20% 20% ER – Charge for use of ER $50 Co-Payment, waived if admitted Outpatient Medically Necessary Lab, T esting, X-ray 20% 20% Other Covered Services 20% 50% Refer to the Summary Plan Description or Plan Document for complete information.

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SLIDE 20

Allen Allen Branch Crawford De Kalb Defiance Erie Fulton Hancock Henry Hillsdale Huntington Huron Jackson Lagrange Lenawee Monroe Noble Ottawa Paulding Putnam Sandusky Seneca Steuben Van Wert Washtenaw Whitley Williams Wood Wyandot Lucas

FrontPath's service area includes:

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SLIDE 21

TAKE ACTION

  • Have a Primary Care Physician
  • Provide preventative care and teach healthy lifestyle choices
  • Identify and treat common medical conditions
  • Assess the urgency of your medical problems and direct you to the

best place for that care

  • Make referrals to medical specialists when necessary
  • How to find a Primary Care Physician
  • FrontPath provides directory of physicians
  • Wood County Community Health & Wellness Center

(Wood County Health District)

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SLIDE 22

TAKE ACTION

  • Pre-Certification is the ultimate responsibility of the member
  • n the following services
  • Hospital Care – Inpatient (including Mental Disorders and Substance

Use Disorders)

  • Emergency room visit that leads to inpatient care
  • Birth of baby
  • Extended Care Facility/Skilled Nursing Facility
  • Outpatient Occupational or Physical Therapy - after 15 visits/year
  • Transplant
  • Chemotherapy or Radiation - recommended
  • Inpatient, Outpatient, or Physician’s Office
  • Penalty applied for non-compliance
  • 50% if found medically necessary
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SLIDE 23

KNOW YOUR PLAN

200 400 600 800 1000 1200 1400 1600 Doctor Visit Urgent Care Emergency Room Sample Costs

ER - Treatment must be rendered within 72 hours of onset of

  • symptoms. Refer to

the Plan Document for a definition of Medical Emergency.

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SLIDE 24

PRESCRIPTION: Pharmacy Benefits Direct, Inc. (PDMI)

  • Pharmacy Network Required
  • Includes all area chain pharmacies – Meijer, WalMart, RiteAid, CVS, WalGreens, etc.
  • Retail Pharmacy Co-Payments per Rx (Max 34 day supply)
  • Select OTC

$0

  • Generic - Tier 1

$5

  • Brand Name Formulary- Tier 2

$15 plus 20% of the AWP $35 max out-of-pocket

  • Brand Name Non-Formulary -Tier 3

$15 plus 20% of the AWP $50 max out-of-pocket

  • Mail Order
  • MedVantX
  • 30-day script must be filled at pharmacy prior to using 90-day mail order
  • Co-Payments per Rx (Max 90 day supply)
  • Select OTC

$0

  • Generic - Tier 1

$10

  • Brand Name Formulary - Tier 2

$30 plus 20% of the AWP: $70 max out-of-pocket

  • Brand Name Non-Formulary - Tier 3

$30 plus 20% of the AWP: $100 max out of pocket

AWP = Average Wholesale Price

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SLIDE 25

TAKE ACTION

  • Price Shop for Prescriptions
  • Use Free OTC or Lower Tier Formulary
  • RxEOB
  • Website offer price comparisons
  • Use the Mail order for refills on maintenance drugs
  • 3 months for the price of 2
  • Take Advantage of Pharmacy Marketing
  • Free or $4/$10 generics at pharmacy
  • List of prescriptions varies by pharmacy
  • Present your insurance card to check for drug interactions
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SLIDE 26

VISION Wood County Commissioners

  • Reimbursement Program
  • Payable only as primary (no coordination of benefits)
  • No restriction on access
  • Requires original receipt and claim form with patient and

services clearly identified

  • Benefit Period and Reimbursement Limit
  • $100 per participant during 2015
  • Covers
  • Exams
  • Prescription glasses/frames and contacts
  • Refractive Surgery
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SLIDE 27

DENTAL Third Party Administrator: Delta Dental

  • Delta Dental Premier or Preferred Network
  • $100 Annual Deductible / $1,500 Annual Maximum per person
  • Class I: Covered annually at 100% of the Usual, Customary and Reasonable (UCR) fee.

Not subject to the deductible: 2 cleanings, 2 fluoride treatments, 1 set of bitewing radiographs, Sealants for children under 14 (limited)

  • Class II: Covered annually at 80% of the UCR fee after the deductible has been met:

Radiographs (Full mouth x-rays every five years), Oral Surgery, Minor Restorative Services, Periodontics, Endodontics

  • Class III: Covered at 50% of the UCR fee after the deductible has been met:

Prosthodontics, Major Restorative Services, Orthodontics ($1,500 per child-per lifetime, to the end of the year in which they turn 19 - not subject to deductible)

  • Useful Tip:
  • Can use two cleanings anytime during the year
  • Predetermination of benefits recommended for services over $200
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SLIDE 28

LIFE INSURANCE: METLIFE

  • Term Insurance
  • Value based on one times annual salary
  • Benefits Terminate at Separation of Employment
  • Conversion Opportunities
  • Accelerated Death Benefit
  • Waiver of Premium
  • Life Certificate Available on Employee Intranet
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SLIDE 29

WELLNESS PROGRAMS

SCREENINGS  CHALLENGES  REIMBURSEMENT PROGRAMS

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SLIDE 30

TAKE ACTION: ENGAGE IN YOUR HEALTH Are you happy with your current health status?

Catastrophic Disease Management Lifestyles Screenings

Generally more difficult to start from the top and work down Generally easier to manage health issues at an early state

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SLIDE 31

YOU MATTER! WHAT YOU DO IS YOUR CHOICE

  • Participate in Wellness Programs and be Entered to Win

Quarterly Prizes

  • Earn a $100 Deductible Credit for 2016 Health Care
  • 1. Know

Your Numbers

  • 2. Stay Informed
  • Attend Annual Insurance Meeting for the 2016 Plan

Year in 2015

  • 3. Get Engaged -You Pick Categories
  • Complete one program in three of the following four categories:
  • Exercise/Fitness Program
  • Diet/Nutrition Program
  • Stress Reduction/Well-Being Program
  • T
  • bacco T

ermination

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SLIDE 32

WELLNESS PROGRAM ELIGIBILITY

  • Available to employees and their family members eligible for

coverage regardless of enrollment

  • You already pay for programming in your premiums, so

participate and get money back

  • Part time employees encouraged to participate
  • Prizes
  • Drawings
  • Deductible credit if you become eligible for benefits
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SLIDE 33

KNOW YOUR NUMBERS

  • Identify High Risk Areas
  • Positive changes reduce risk of developing chronic disease
  • Free and Confidential
  • On-Site Appointments
  • Required to enroll in benefits
  • We pay if you keep appointment
  • Included Screenings (fasting required)
  • Health Risk Assessment
  • Blood Pressure
  • Coronary Risk Profile (cholesterol with HDL, LDL, and Triglyceride)
  • Blood Sugar (A1C)
  • Occult Blood
  • Bone Density
  • Personalized one-on-one results with wellness coach
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SLIDE 34

PROGRAM EXAMPLES

  • Couch to 5K
  • Set a goal to walk or run a 5k
  • Catch Some ZZZs Challenge
  • Sleep is an important part to maintaining a healthy

lifestyle

  • Sleep Hygiene can help maximize the hours you spend

sleeping and improve immune system

  • Get Fit for Fall: Stretch and Flex Challenge
  • 10 week program using Active for Life website
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SLIDE 35

ACTION ITEMS

APPLICATION  ONGOING REPORTING  INFORMATION

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SLIDE 36

ACTION ITEMS

  • Employees must re-enroll for 2015 coverage
  • Enrollment Period: Nov. 14 to Dec. 3
  • Review Summary Plan Description for Plan Information
  • Complete enrollment process by December 3
  • Utilize the writable application on the intranet
  • Pre-taxed payroll deduction election
  • Section 125 Premium Only Plan
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SLIDE 37

ACTION ITEMS

  • Universal Application Required to Enroll in Coverage
  • Life Insurance is Mandatory
  • Must elect or waive other coverage options
  • Health/Prescription, Vision, Dental
  • Include necessary Eligibility Certification Forms
  • Spousal
  • Dependent/Student
  • Report Legal Names/Numbers as listed on Social Security

Cards

  • Used for federal reporting
  • Report Secondary Coverage
  • If seeking secondary coverage for dependents, must report

primary coverage information on application

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SLIDE 38

ACTION ITEMS

  • December 3: Deadline to Make Application

to the Plan

  • Sue Dauer -Wood Lane Insurance Group Representative
  • Sign-Off on Privacy Practices, Wellness Waiver, and

Summary Plan Description – Due Nov. 14

  • Additional meetings available for questions on eligibility

and enrollment

  • November 24
  • 10 a.m. and 3 p.m.
  • Room 2 & 3
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SLIDE 39

ACTION ITEMS - ONGOING

  • Report Changes within 30 days
  • Changes in primary/secondary coverage
  • Coordination of Benefits
  • Birth/Adoption
  • Address Changes
  • Marriages
  • Name Changes
  • Divorce
  • See Summary Plan Description for additional reporting

requirements

  • Always review Individual Enrollment

Verification to ensure accuracy of information

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SLIDE 40

TRANSITION TIMELINE

Annual Eligibility Certification Period Spousal Primary Dependents (19-27) Students OBRA

  • Aug. 15 – Sept. 15
  • Nov. 7

Distribute Summary Plan Description

  • Dec. 12

Spousal Exception Applications Due

  • Nov. 14

Employee Insurance Meetings

  • Nov. 14 --------------------------- Dec. 3

Enrollment Period Opportunity to Waive or Elect Coverage

  • Jan. 17

2015 Individual Enrollment Verification Sign-off Due

  • Jan. 1

Coverage Effective

  • Jan. 10 -------------– March 20

Complete Wellness Screening

  • Nov. 24

Individual Meetings to Discuss Eligibility APPLICATIONS DUE

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SLIDE 41

WEBSITE:

WWW.CO.WOOD.OH.US/EMPLOYEE

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SLIDE 42

QUESTIONS?

  • Commissioners’ Office Staff
  • Cheryl Albrecht
  • Rachel Richmond
  • Steve Puffer
  • Janese Diem
  • Pamela Boyer
  • Jason Beaver, Insurance Consultant
  • Stacey Kelley, Meritain Health
  • Tammie Wormley, Pharmacy Benefit

Direct, Inc. (PDMI)

  • Karen Chapman, Delta Dental
  • Sue Dauer, Wood Lane Insurance

Group Representative

APPLICATIONS DUE: DECEMBER 3 by 4:30 p.m. to Sue Dauer

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SLIDE 43

YOU MATTER!

WE LOOK FORWARD TO MANAGING YOUR CONFIDENTIAL PLAN!