Mountain Home School District #193

Transcription

1 Mountain Home School District #193 Employee Benefits Enrollment Guide Plan Year:

2 HUB International Mountain States Limited Insurance Employee Benefits Wellness Welcome to Open Enrollment for your Benefits!! Elections you make during open enrollment will become effective September 1, Mountain Home School District #193 offers you and your eligible family members a comprehensive and valuable benefits program. We encourage you to take the time to educate yourself about your options and choose the best coverage for you and your family. Who is Eligible? If you are a full-time employee (working 20 or more hours per week) you are eligible to enroll in the benefits described in this guide. How to Enroll The first step is to review your current benefit elections. Verify your personal information and make any changes if necessary. Make your benefit elections. Once you have made your elections, you will not be able to change them until the next open enrollment period unless you have a qualified change in status. When to Enroll The open enrollment period runs from August 1, 2014, through August 31, The benefits you elect during open enrollment will be effective from September 1, 2014, through August 31, How to Make Changes Unless you have a qualified change in status, you cannot make changes to the benefits you elect until the next open enrollment period. Qualified changes in status include: marriage, divorce, legal separation, domestic partnership status, death of a spouse, child, or other qualified dependent, change in residence due to an employment transfer for you, your spouse or domestic partner, commencement or termination of adoption proceedings, or change in spouse s or domestic partner s benefits or employment status. 1

3 HUB International Mountain States Limited Insurance Employee Benefits Wellness Contact Information Tara Tandrow Broker Hana Waters Account Manager HUB International Pete Cavender Broker Tara Thompson Account Manager Carriers Medical Regence Blue Shield Customer Service Website Flexible Spending American Fidelity Dental Delta Dental Dental Vision Voluntary Life Employee and Dependent Blue Cross of Idaho (Willamette) Customer Service 24 Hour Nurse Line Website General Info LifeMap (VSP) Customer Service Website LifeMap Customer Service Website

4 HUB International Mountain States Limited Insurance Employee Benefits Wellness In-Network Benefits for Mountain Home School District #193 September 1, 2014 through August 31, 2015 Regence Blue Shield of Idaho Medical Deductible resets September 1 Deductible: $1,250 Individual / $2,500 Family Co-Insurance: 80% after deductible is met Max Out of Pocket: $4,250 Individual / $8,500 Family Physician Copay: $30 Rx Deductible: $250 (not on generic drugs) Rx Coverage: $10 */ $20* / $20** (*plus 20% coinsurance, **plus 25% coinsurance) LifeMap (VSP) Vision Service Frequencies: Exam / Lenses / Frame 12 mo / 12 mo / 24 mo Copays: Exam / Materials $10 / $25 Allowance: $130 frames OR contacts Delta Dental of Idaho Dental Deductible: None Preventative: 70% - 100% Basic: 50% Major: 50% Maximum Benefit: $1,000 per person per calendar year Orthodontic: Discount Program Only Blue Cross of Idaho (Willamette) Dental Deductible: No deductible, $15 office visit copay Preventative: 100% after copay Basic: Office visit copay - $50 Major: $50 - $150 Maximum Benefit: No Annual Maximum Orthodontic: $1,500 copay Voluntary Life and Accidental Death & Dismemberment - LifeMap Employees: Increments of $5,000 from $25,000 to a maximum of 5x your annual earnings, not to exceed $300,000 Spouse: Increments of $5,000 from $10,000 to a maximum of $300,000 Dependent Child(ren): Increments of $2,000 from $2,000 to a maximum of $10,000 This is a brief description of your coverage. For additional details on coverage definitions, exclusions, limitations and out of network benefits, please read your plan booklet carefully. 3

5 HUB International Mountain States Limited Insurance Employee Benefits Wellness Mountain Home School District # Insurance Rates REGENCE BLUE SHIELD OF IDAHO Effective September 1, 2014 $1,250 Deductible EE $2,500 Deductible Family RBS Single Employee 2nd Party Employee Voluntary Deductions Family Dual Emp Family 1-Child Children MEDICAL DELTA DENTAL EMPLOYEE Contribution EMPLOYER Contribution VSP (VISION) TOTAL Willamette Dental Cobra Administration Fee is 2% of premium 4

6 HUB International Mountain States Limited Insurance Employee Benefits Wellness THIS PAGE IS INTENTIONALLY LEFT BLANK FOR DOUBLE SIDED PRINTING 5

7 Regence BlueShield of Idaho: Preferred Coverage Period: 09/01/ /31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling 1 (888) Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out-ofpocket limit on my expenses? What is not included in the out-of-pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $1,250 member / $2,500 family per calendar year. Doesn t apply to certain preventive care or outpatient mental health and substance abuse. Copayments or amounts in excess of the allowed amount do not count toward the deductible. Yes. $250 per member for prescription drug coverage. There are no other specific deductibles. Yes. Preferred and participating providers: $4,250 member / $8,500 family per calendar year. Non-participating providers: $5,000 member / $10,000 family per calendar year. Premiums, balance-billed charges, and health care this plan doesn t cover. Yes. See or call 1 (888) for lists of preferred or participating providers. No. You don t need a referral to see a specialist. Yes. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-ofpocket limit. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call 1 (888) or visit us at Page 1 If you aren t clear about any of the underlined terms used in this form, see the Glossary. 6 MOUNTAIN HOME SCHOOL DISTRICT 193 You can view the Glossary at or call 1 (888) to request a copy. II0114SPRFX

8 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use preferred and participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/ screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Generic drugs Preferred brand drugs Your Cost If You Use a Preferred Provider Your Cost If You Use a Participating Provider Your Cost If You Use a Nonparticipating Provider $30 copay / visit $45 copay / visit 40% coinsurance $30 copay / visit, and 20% coinsurance 20% coinsurance for complementary care - acupuncture, chiropractor care and naturopathic services $45 copay / visit, and 40% coinsurance 50% coinsurance for complementary care - acupuncture, chiropractor care and naturopathic services 40% coinsurance 50% coinsurance for complementary care - acupuncture, chiropractor care and naturopathic services No charge No charge 40% coinsurance 20% coinsurance 40% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 40% coinsurance 20% coinsurance after $10 copay / retail prescription $10 copay / mail order prescription 20% coinsurance after $20 copay / retail prescription 20% coinsurance after $40 copay / mail order prescription Limitations & Exceptions Copayment applies to each preferred or participating office visit only, deductible waived. All other services are covered at the coinsurance specified, after deductible. Coverage is limited to 20 complementary care visits / year. Coinsurance does not apply to the out-ofpocket limit for non-participating providers. No charge for childhood immunizations from non-participating providers. none Coverage is limited to a 30-day supply retail or 90-day supply mail order. Deductible does not apply to generic drugs, certain preventive drugs, women s 7 Page 2 MOUNTAIN HOME SCHOOL DISTRICT 193 II0114SPRFX

9 Common Medical Event More information about prescription drug coverage is available at If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant Services You May Need Non-preferred brand drugs Specialty drugs Your Cost If You Use a Preferred Provider Your Cost If You Use a Participating Provider Your Cost If You Use a Nonparticipating Provider 25% coinsurance after $20 copay / retail prescription 25% coinsurance after $40 copay / mail order prescription Refer to generic, preferred brand and non-preferred brand drugs above. Limitations & Exceptions contraceptives and immunizations at a participating pharmacy. You are responsible for the difference in cost between a dispensed brand-name drug and the equivalent generic drug, in addition to the copayment and/or coinsurance. Facility fee (e.g., ambulatory surgery 20% coinsurance 40% coinsurance 40% coinsurance none center) Physician/surgeon fees 20% coinsurance 40% coinsurance 40% coinsurance none Emergency room services Emergency medical transportation Urgent care 20% coinsurance after $100 copay 20% coinsurance after $100 copay 20% coinsurance after $100 copay Copayment applies to the facility charge for each visit (waived if admitted), whether or not the deductible has been met. 20% coinsurance 20% coinsurance 20% coinsurance none Covered the same as the If you visit a health care provider s office or clinic or If you have a test Common Medical Events. none Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance 40% coinsurance none Physician/surgeon fee 20% coinsurance 40% coinsurance 40% coinsurance none Mental/Behavioral health outpatient No charge 20% coinsurance 40% coinsurance services Mental/Behavioral 20% coinsurance 20% coinsurance 40% coinsurance health inpatient services none Substance use disorder outpatient services No charge 20% coinsurance 40% coinsurance Substance use disorder inpatient services 20% coinsurance 20% coinsurance 40% coinsurance Prenatal and postnatal Maternity services for children are not 20% coinsurance 40% coinsurance 40% coinsurance care covered. 8 Page 3 MOUNTAIN HOME SCHOOL DISTRICT 193 II0114SPRFX

10 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost If You Use a Preferred Provider Your Cost If You Use a Participating Provider Your Cost If You Use a Nonparticipating Provider Limitations & Exceptions Delivery and all inpatient services 20% coinsurance 40% coinsurance 40% coinsurance Home health care 20% coinsurance 40% coinsurance 40% coinsurance Coverage is limited to 130 visits / year. Rehabilitation services 20% coinsurance 40% coinsurance 40% coinsurance Coverage is limited to 20 outpatient visits / year. Coverage for neurodevelopmental therapy is limited to 28 outpatient visits / year. Habilitation services 20% coinsurance 40% coinsurance 40% coinsurance Coverage for neurodevelopmental therapy is limited to services for members through age 6. Skilled nursing care 20% coinsurance 40% coinsurance 40% coinsurance Coverage is limited to 30 inpatient days / year. Durable medical equipment 20% coinsurance 40% coinsurance 40% coinsurance none Hospice service No charge 40% coinsurance 40% coinsurance Coverage is limited to 14 respite days / lifetime. Eye exam Not covered Not covered Not covered none Glasses Not covered Not covered Not covered none Dental check-up Not covered Not covered Not covered none 9 Page 4 MOUNTAIN HOME SCHOOL DISTRICT 193 II0114SPRFX

11 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Bariatric surgery Cosmetic surgery, except congenital anomalies Dental care (Adult) Hearing aids Infertility treatment Long-term care Private-duty nursing Routine eye care (Adult) Routine foot care Vision hardware Weight loss programs except for nutritional counseling Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Chiropractic care Non-emergency care when traveling outside the U.S. 10 Page 5 MOUNTAIN HOME SCHOOL DISTRICT 193 II0114SPRFX

12 Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1 (888) You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866) or or the U.S. Department of Health and Human Services at 1 (877) x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact the plan at 1 (888) or visit You may also contact your state insurance department at 1 (800) or or the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866) or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? In order for certain types of health coverage (for example, individually purchased insurance or job-based coverage) to qualify as minimum essential coverage, the plan must pay, on average, at least 60 percent of allowed charges for covered services. This is called the minimum value standard. This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al 1 (888) Having a baby (normal delivery) To see examples of how this plan might cover costs for a sample medical situation, see the next page. About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. 11 Don t use these examples to estimate your actual costs Amount owed to providers: $7,540 Plan pays: $4,920 Patient pays: $2,620 Page 6 MOUNTAIN HOME SCHOOL DISTRICT 193 II0114SPRFX

13 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $1,250 Copays $20 Coinsurance $1,200 Limits or exclusions $150 Total $2,620 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays: $3,700 Patient pays: $1,700 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $670 Copays $440 Coinsurance $550 Limits or exclusions $40 Total $1, Page 7 MOUNTAIN HOME SCHOOL DISTRICT 193 II0114SPRFX

14 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call 1 (888) or visit us at Page 8 If you aren t clear about any of the underlined terms used in this form, see the Glossary. 13 MOUNTAIN HOME SCHOOL DISTRICT 193 You can view the Glossary at or call 1 (888) to request a copy. II0114SPRFX

15 Glossary of Health Coverage and Medical Terms This glossary has many commonly used terms, but isn t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.) Bold blue text indicates a term defined in this Glossary. See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real life situation. Allowed Amount Maximum amount on which payment is based for covered health care services. This may be called eligible expense, payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.) Appeal A request for your health insurer or plan to review a decision or a grievance again. Balance Billing When a provider bills you for the difference between the provider s charge and the allowed amount. For example, if the provider s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. Co-insurance Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. Jane pays Her plan pays You pay co-insurance 20% 80% plus any deductibles (See page 4 for a detailed example.) you owe. For example, if the health insurance or plan s allowed amount for an office visit is $100 and you ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. Co-payment A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service. Deductible The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins Jane pays Her plan pays to pay. For example, if 100% 0% your deductible is $1000, your plan won t pay (See page 4 for a detailed example.) anything until you ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics. Emergency Medical Condition An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm. Emergency Medical Transportation Ambulance services for an emergency medical condition. Complications of Pregnancy Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren t complications of pregnancy. Emergency Room Care Emergency services you get in an emergency room. Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse. OMB 14 Control Numbers , , and Glossary of Health Coverage and Medical Terms Page 1 of 4

16 Excluded Services Health care services that your health insurance or plan doesn t pay for or cover. Grievance A complaint that you communicate to your health insurer or plan. Habilitation Services Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Health Insurance A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium. Home Health Care Health care services a person receives at home. Hospice Services Services to provide comfort and support for persons in the last stages of a terminal illness and their families. Hospitalization Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care. Hospital Outpatient Care Care in a hospital that usually doesn t require an overnight stay. In-network Co-insurance The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance. In-network Co-payment A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments. Medically Necessary Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine. Network The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. Non-Preferred Provider A provider who doesn t have a contract with your health insurer or plan to provide services to you. You ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Out-of-network Co-insurance The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Outof-network co-insurance usually costs you more than innetwork co-insurance. Out-of-network Co-payment A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network co-payments. Out-of-Pocket Limit The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, Jane pays Her plan pays 0% 100% balance-billed charges or (See page 4 for a detailed example.) health care your health insurance or plan doesn t cover. Some health insurance or plans don t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. Physician Services Health care services a licensed medical physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine) provides or coordinates. 15 Glossary of Health Coverage and Medical Terms Page 2 of 4

17 Plan A benefit your employer, union or other group sponsor provides to you to pay for your health care services. Preauthorization A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn t a promise your health insurance or plan will cover the cost. Preferred Provider A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also participating providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more. Premium The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. Prescription Drug Coverage Health insurance or plan that helps pay for prescription drugs and medications. Prescription Drugs Drugs and medications that by law require a prescription. Primary Care Physician A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient. Provider A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law. Reconstructive Surgery Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions. Rehabilitation Services Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings. Skilled Nursing Care Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home. Specialist A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care. UCR (Usual, Customary and Reasonable) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount. Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Primary Care Provider A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services. 16 Glossary of Health Coverage and Medical Terms Page 3 of 4

18 How You and Your Insurer Share Costs - Example Jane s Plan Deductible: $1,500 Co-insurance: 20% Out-of-Pocket Limit: $5,000 January 1 st Beginning of Coverage Period December 31 st End of Coverage Period Jane pays 100% Her plan pays 0% more costs Jane pays 20% Her plan pays 80% more costs Jane pays 0% Her plan pays 100% Jane hasn t reached her $1,500 deductible yet Her plan doesn t pay any of the costs. Office visit costs: $125 Jane pays: $125 Her plan pays: $0 Jane reaches her $1,500 deductible, co-insurance begins Jane has seen a doctor several times and paid $1,500 in total. Her plan pays some of the costs for her next visit. Office visit costs: $75 Jane pays: 20% of $75 = $15 Her plan pays: 80% of $75 = $60 Jane reaches her $5,000 out-of-pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year. Office visit costs: $200 Jane pays: $0 Her plan pays: $ Glossary of Health Coverage and Medical Terms Page 4 of 4

19 STAYING WELL Regence BlueShield of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association Preventive Care Coverage Wondering what preventive care your plan covers? Our plans cover the kind of services that: Screen for serious conditions Prevent infectious diseases Help you stay well 18

20 What you need to know about preventive care As you probably know, the federal health care reform law passed in 2010 requires insurers to cover specific preventive care services. We support that initiative. In fact, our plans already covered many preventive care services, as we have long believed that preventive care and early detection are key to the long-term health and well-being of our members. This brochure explains who s eligible for preventive care and shows which services are available to you and the family members covered by your plan. Who s eligible for these preventive services? To be eligible for these preventive services, you must first be covered by a current Regence policy. Benefits for the federally required preventive services: Are not required in grandfathered policies, which are essentially policies that were in effect on March 23, 2010, as long as few or no benefit changes have been made to them. (We have chosen to retain grandfathered status for a very limited number of policies.) May be covered by grandfathered plans that have chosen to include the benefit. May apply to retiree-only plans. What preventive services are covered? Regence follows government guidelines to determine which preventive services we cover. 1 These guidelines are updated periodically to reflect new scientific and medical advances. Also, current services could be revised and may have limitations. Benefits are subject to change. New recommendations must be implemented no later than the first plan or policy year that is at least one year after the recommendation s publication. You can learn more details about these services at healthcare.gov, including recommended child and adolescent immunization schedules. What is the coinsurance/copay for these preventive services? The services listed in this brochure will be paid at 100% (no deductibles, coinsurance or copays) when you see preferred or participating providers (Category 1 or Category 2) or in-network providers. Deductibles and/or coinsurance may apply when you see other providers. Services may require pre-authorization or have to meet medical policy criteria. 1. Evidence-based preventive guidelines are developed and validated by the following government entities: United States Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA). 19

21 Covered preventive services Men Women Pregnant Women Children (0-17) Health screenings, counseling and services for: Adult abdominal aortic aneurysm Alcohol misuse Suggested guidelines Screening is covered once per lifetime for men age 65 and over if they have ever smoked. Screening and behavioral counseling intervention covered for adults age 18 and older. Anemia (iron deficiency) Screening covered up to age 21, and pregnant women. ü ü ü ü Bacteriuria (urinary tract infection) Screening for asymptomatic pregnant women. ü Blood pressure Screening covered for adults age 18 and older. ü ü Breast cancer Screening for women age 40 and older and those at increased risk. Mammograms only. ü Breast cancer chemoprevention Counseling for women at increased risk. ü Breastfeeding equipment Manual and electric breastfeeding pumps are covered when purchased or rented from a licensed provider. Hospital-grade pumps are not covered. ü ü Breastfeeding - lactation support and counseling Lactation support and counseling are covered when provided by a licensed provider. Breastfeeding supplies Initial breastfeeding supplies provided with a breastfeeding pump. ü ü Cervical cancer Screening for sexually active women. ü Chlamydia infection Screening for infection. ü Cholesterol Screening for men age 35 and older and men ages who are at increased risk for coronary heart disease. Screening for women age 45 and older and those ü ü ü who are at increased risk for coronary heart disease. Colorectal cancer Screening for those age 50 and older, once every 5 years for a sigmoidoscopy and every 10 years for a colonoscopy, fecal occult blood testing annually. ü ü Congenital hypothyroidism Screening for newborns. ü Contraceptive education and training Education and training on contraceptive methods. See Note 1. ü ü Contraceptive devices - implants, cervical caps, intrauterine devices (IUDs), diaphragms Generic contraceptive devices are covered. When no generic exists, a brand is covered. If a generic becomes available, the brand will no longer be covered under Preventive Care. See Note 1. Depression screening Screening during wellness exams. ü ü ü Diabetes (Type 2) Screening for adults with sustained high blood pressure. ü ü Diabetes (Gestational) Screening for pregnant women between 24 and 28 weeks of gestation and the first pre-natal visit for pregnant women at high risk for diabetes. ü Diet behavioral counseling Counseling for adults with hyperlipidemia and other risk factors. ü ü Genetic risk assessment and BRCA (breast cancer susceptibility) mutation For women with family risk of breast and ovarian cancer. ü counseling and testing Gonorrhea medication Preventive medication for the eyes of newborns. ü Gonorrhea screening Screening for males up to age 21 and all females. ü ü ü Hearing One screening in the first year of life for newborns. ü Hepatitis B Screening for pregnant women. ü Hepatitis C Screening for those at increased risk, and a one-time screening for adults born between 1945 and ü ü ü ü ü ü ü ü ü ü 20

22 Covered preventive services Men Women Pregnant Women Children (0-17) HIV Screening for adolescents and adults ages 15 to 65 years, and younger adolescents and older adults who are at increased risk. Also includes all pregnant women, including those who present in labor who are untested and whose HIV status is ü ü ü ü unknown. HPV Screening for women from age 30, every 3 years. ü Interpersonal and domestic violence Screening and counseling during wellness exams. ü Lead screening Screening up to age 21. ü ü ü Metabolic screening Screening up to age 2 months. ü Obesity Screening and (if obese) counseling age 6 and older. ü ü ü Oral health Risk assessment for preschool children. ü Osteoporosis Screening for women age 65 and older and all women at increased risk. ü Phenylketonuria (PKU) Newborn screening for genetic disorders. ü Prevention of falls Physical therapy for adults age 65 or older residing independently in the community who are at increased risk for falls. ü ü RH(D) incompatibility Screening for pregnant women. ü Sexually transmitted infection (STI) Counseling during wellness exams. ü ü ü Sickle cell Screening for children up to 12 months old. ü Skin cancer Counseling for children, adolescents and young adults ages 10 to 24. ü ü ü Sterilization Sterilization is covered. See Note 1. ü Syphilis Screening for those at increased risk and those up to age 21; also includes pregnant women. ü ü ü ü Tobacco use Counseling and interventions. Does not include programs or classes. See also Tobacco use below. ü ü ü ü Tuberculosis Skin test for children. ü Vision Screening for children age 3 up to age 5. ü Immunization vaccines - please consult your physician for frequency Diphtheria, pertussis, tetanus (DPT) ü ü ü Haemophilus influenzae type b (Hib) ü Hepatitis A ü ü ü Hepatitis B ü ü ü Herpes zoster (shingles) Age 60 and older. ü ü Human papillomavirus (HPV) Up to age 27. ü ü ü Inactivated poliovirus ü Influenza ü ü ü Measles, mumps, rubella (MMR) ü ü ü Meningococcal ü ü ü Pneumococcal ü ü ü Rotavirus ü Varicella ü ü ü 21

23 Covered preventive services Men Women Pregnant Women Children (0-17) Prescription medications Only the types of prescription medications listed below are covered under Preventive Care. Medications require a prescription. Get the most value for your health care dollar with preferred medications. Learn more at regencerx.com/learn/covered. Aspirin use for the prevention of For men age and women age cardiovascular disease ü ü Contraceptive injectables Generic contraceptive injectables. See Note 1. ü ü Contraceptive pills Generic contraceptive pills. See Note 1. ü ü Contraceptive products-topical Diaphragms and patches. See Notes 1 and 2. ü ü Emergency contraceptive products Generic contraceptive pills. See Notes 1 and 2. ü ü Fluoride supplements For children 6 months through age 6 without sufficient fluoride ü Folic acid supplements For all women planning or capable of pregnancy. ü ü Iron supplements For children age 6-12 months at increased risk - drops only. ü Tobacco use Generic tobacco cessation medications. ü ü Vitamin D supplement For adults age 65 or older residing independently in the community who are at increased risk for falls. ü ü Wellness exams Suggested guidelines Well-child exams For children through 17 years of age. ü Annual physical exams Ages 18 and over. ü ü Notes: 1. This benefit may not be available to members of groups who have applied for a religious exemption from contraceptive coverage. 2. When no generic exists in the medication category, a formulary brand is covered. 22

24 HUB International Mountain States Limited Insurance Employee Benefits Wellness THIS PAGE IS INTENTIONALLY LEFT BLANK FOR DOUBLE SIDED PRINTING 23

25 ONLINE RESOURCES Regence.com Get everything you need to know about your plan Looking for a claim or a doctor? Want to compare treatment costs? Visit regence.com for all that and more. Your complete source of health and wellness information You can find everything you need to know about your health plan and ways to take care of yourself all in one place: regence.com. Consider health care decisions and explore treatment options to help you plan your budget: Compare cost and quality of hospitals, clinics and providers. Research treatment options and out-of-pocket cost estimates. Learn about medical conditions and medications. Explore health articles and videos. Discover tools that help you track your coverage and make informed decisions about your health care: Review details about your coverage. Regence BlueShield of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association Manage your claims online and eliminate paper Explanation of Benefits. Find a doctor or specialist and read patient reviews. Healthy living has its own rewards, but Regence Rewards points can help: Earn points for completing a General Health Assessment. Receive points for healthy everyday activities such as eating fruits and veggies and walking the dog, or joining an online wellness program. Redeem points for a $25 gift card. 24

26 To get started, just follow these steps: 1. Go to regence.com and click Register. 2. Complete the required Plan Information fields. The name, member ID and group numbers you enter must match your member card. 3. Complete the Account Information fields. 4. Create a user name and secure password. 5. Review your information, accept the User Agreement and click Approve. You re automatically enrolled for Rewards after you register. You get Rewards points for the following: Taking a confidential General Health Assessment. Learn how you ve been managing your health to date, and get practical tips on how to improve your health and well-being. Managing stress and getting into shape. Reach for a healthy lifestyle with wellness programs on weight loss, nutrition, stress relief, smoking cessation and more. What are you waiting for? Register now at regence.com! WELL TIP Anyone in your family age 13 and older can register for an account and qualify for the Rewards program id/ Regence BlueShield of Idaho 25

27 From Be a Wise Health Care Consumer: Reduce your prescription drug costs You can cut costs by up to 90 percent by becoming an informed consumer and using the same buying techniques that you use when shopping for other goods and services. As more individuals comparison shop for drugs, more retailers will compete to win their business, which will drive prices lower. These strategies can help you become a savvy prescription drug consumer. Price comparisons. Drug prices are not uniform; you can save a considerable amount of money by shopping around Drug substitution. When your doctor prescribes a drug, ask if a cheaper alternative is available. Mail-Order Pharmacies. Mail-order and Internet pharmacies offer the best deals on prescription drugs, especially for patients with chronic conditions. Pill-splitting. Many prescription drugs are available at increased dosages for similar costs as smaller dosages. Prescribing half as many higher-strength pills and having the patient split them to achieve the desired dosage can reduce the cost of some medications as much as 50 percent. However, pill splitting is not safe for all medications. If a pill is FDA-approved for pill splitting, it will say so on the label or informational insert that comes with the prescription. The FDA recommends pills only be split if FDA-approved and after consulting with your doctor to ensure it is safe. Over-the-counter drugs (OTC). Ask your doctor if an OTC drug will work just as well as a prescription drug. Today there are hundreds of OTC drugs that were previously only available by prescription. Generic medications. Generic medications work as well as brand name drugs and can cost 20 to 80 percent less. This applies for both prescriptions and OTC drugs. Pharmaceutical company assistance programs/state drug assistance. Many drug companies and states offer drug assistance programs for the elderly, lowincome and /or people with disabilities. Medicare drug plans. Seniors can combine smart shopping techniques with the Medicare drug plan. All the information you need is available at Samples. Drug companies give thousands of samples to doctors every year. Your doctor may be able to provide you with weeks worth of the medication at no charge. Stay on your meds. If you take medication regularly, don t skip doses or go off your meds to save money. Sticking to your medication schedule will help you avoid health complications that will cost more money in the future. Discount prescription cards. Look into a discount card, either through a drugstore chain or a national plan. They can provide additional discounts on your prescriptions for a small monthly or annual fee. Bulk buying. As you may know from your everyday shopping, it s cheaper to buy in bulk. The same is true for drugs. Buying larger quantities at a time generally reduces the per dose cost of drugs. This is especially true for generics purchased by mail. This article is provided by HUB International Mountain States Limited. It is to be used for informational purposes only and is not intended to replace the advice of an insurance professional. Visit us at , 2013 Zywave, Inc. All rights reserved. 26

28 HUB International Mountain States Limited Insurance Employee Benefits Wellness THIS PAGE IS INTENTIONALLY LEFT BLANK FOR DOUBLE SIDED PRINTING 27

29 Mountain Home School District #193 GENERAL BENEFIT PLAN SUMMARY Selected Benefits and Percentages PPO Premier Contract Effective Date: 09/01/2014 Preventive & Diagnostic Services: % % Group Number: Deductible: Per Person Per Family No Deductible Examinations, x-rays, teeth cleaning PPO Premier Basic Services: % % NA NA Fillings, root canals, extractions, minor oral surgery NA NA Major Services: Crowns, onlays, bridges, dentures 50% 50% Maximum Benefit: $1,000 $1,000 Implants: 50% 50% Per eligible person per benefit year. Value-Added Orthodontic Discount Program Delta Dental of Idaho subscribers and their eligible dependents can receive a discounted fee for adult and child orthodontia treatment if they obtain services from a Delta Dental Discount Program orthodontist in Idaho. Please see your employer for additional information. This value-added service is not insurance. Additional Benefits / Limitations Class I Preventive and Diagnostic Services Examinations once every 6 months; Cleanings once every 6 months (restricts against periodontal cleaning within the same time period); Fluoride once every 12 months for dependent children under age 19; Sealants once per tooth every 3 years; Full mouth series or panoramic x-rays once every 5 years; Bitewing x-rays once every 12 months; Space maintainers under age 18 once a lifetime per permanent tooth. Class II Basic Services Periodontal cleanings once every 6 months (restricts against basic cleaning within the same time period); Full mouth debridement (4355) is a benefit if no cleanings within 12 months of the service date (an additional cleaning is allowed within 60 days of the full mouth debridement); Scaling and root planning (4341, 4342) covered once every 24 months per quadrant (no limit as to the number of quadrants per visit); Root Canals, Extractions, Periodontics; Fillings restricted to same tooth/surface once every 24 months; Posterior fillings are paid as composites; Composite fillings are not downgraded to amalgam; Nitrous oxide is not covered. Dependents Eligible children must be under age 26. Class III Major Restorative Services Crowns, Build-ups, stainless steel crowns, onlays, or bridges on same tooth once every 7 years; For dependent children under age 16, benefits are limited to plastic or stainless steel crowns on same tooth once every 24 months; Prosthetic services pay on the prep date; Occlusal guards are covered for bruxism only once in 24 months; Missing tooth clause does not apply; TMJ is not a covered benefit; Partials, or dentures 1 time per arch every 7 years, eligible for partials at age 16. Late enrollee waiting period is 24 months. Implants Implants are a covered benefit per tooth with a maximum lifetime benefit of $900 (including crown) applied to the annual individual maximum benefit. Value-Added Orthodontic Discount Program Delta Dental of Idaho subscribers and their eligible dependents can receive a discounted fee for adult and child orthodontia treatment if they obtain services from a Delta Dental Discount Program orthodontist in Idaho. Please see your employer for additional information. This value-added service is not insurance. This is only a general summary of benefits. It provides a brief description about the important features of this policy and does not constitute a contract or guarantee of payment. Full terms and conditions are set forth in the policy provisions. If you have any questions about your benefit plan's coverage detail and benefits or would like to submit a predetermination before services are performed, please call one of our friendly Delta Dental customer service advisors at (208) You may also log onto our website, for benefit and eligibility information or up-to-date claim status. Once you have logged onto our website, simply click onto the Subscriber Online Connection. Or, if you have a fax machine, you may access your eligibility and claim information by calling Delta Dental's ProFax number at (208) DELTA DENTAL OF IDAHO PO BOX 2870 Eligibility: (208) Fax: (208) Boise, ID Claims Questions: (208) DDI - GENSUM909 Page 1 of 1