Clear Creek Amana Community School District

Transcription

1 Clear Creek Amana Community School District

2 Clear Creek Amana CSD Plan Comparison Plan Design Purchasing Plan Buy Down Option 1: Wellmark Alliance Select Wellmark Alliance Select Buy Down Option 2: Wellmark Alliance Select Option 3: Wellmark HDHP- HSA Network In Out In Out In Out In Out Deductible Individual $6,000 $500 $1,000 $1,000 $2,000 $3,000 $6,000 Family $12,000 $1,000 $2,000 $2,000 $4,000 $6,000 $12,000 Coinsurance 0/0 0/0 80/20 60/40 80/20 60/40 100/0 70/30 Out of pocket maximum Individual $6,350 $1,000 $2,000 $2,000 $4,000 $3,000 $10,000 Family $12,700 $2,000 $4,000 $4,000 $8,000 $6,000 $20,000 Copays Prescription drugs Preventative Care $0 $0 $0 $25 Office visit - PCP Office visit - non-pcp ER Tier 1 Tier 2 Tier 3 Tier 4 $15 $15 $15 $15 20% coinsurance 20% coinsurance $25 $25 $40 $40 $100 $100 $15 $15 20% coinsurance $10 $10 $10 $25 $40 $100 30% coinsruance This comparison summarizes certain provisions of the plan(s) illustrated. Complete plan information is included in the legal documents and brochures that govern each plan.

3 Why would an employer use this strategy to fund a health plan? There are several reasons an employer uses this strategy. First, it should generate cost savings over time. Second, it allows for more flexibility in plan design & third, it allows the employer to capture relevant data about the total cost, utilization trends, and distribution of claims which can be used in negotiating renewals. How does the process work? You will go to your medical provider and present your card just as you always have. If a copay is due, you ll pay that. If the claim is applied to the deductible, then the Insurance Company will pay their share, the self funded plan (administered through a TPA) will pay their share, and you pay the difference. How will I know everything is being processed correctly? When you have a claim that applies to the deductible, you ll get an Explanation of Benefits (EOB) from the Insurance Company. Shortly following, you will receive another EOB from the TPA explaining how the self-funded plan processed the claim. Who determines how the claim is processed? Claims are processed according to the language in your Insurance Company Plan Document. If you have a question about how a claim was handled, you should contact the Insurance Company. After the Insurance Company has made a determination on a claim, then the TPA will process the claim according to the self-funded portion of the plan. If you have a question on how the TPA processed a claim, please contact them. Will this be confusing? This is a different process than what you are used to and there will certainly be questions. To contact your Insurance Company-refer to your ID Card. To contact the TPA-call Auxiant at (800)

4 How Partial Self-Funding Works Your employer has entered into a Partial Self-Funded arrangement in order to better manage the cost of the Health Insurance Plan. What does that mean? The plan provided to the employees and their dependents and the plan purchased from the Insurance Company are different. Your employer has elected to self-fund portions of the deductible, coinsurance & out of pocket maximum. Your employer has contracted with a Third Party Administrator (TPA) to process the claims that fall between the benefits you receive and the benefit plan that is purchase from the Insurance Company. Refer to the attached Frequently Asked Questions for additional information. Generally, the Partially Self-Funded plan only applies to the deductible, coinsurance & out of pocket maximum. Do not make a payment to your provider based upon any EOB. These are not bills. They are simply Explanations of Benefits. You will receive a bill from your health care provider based upon the adjusted EOB from the TPA. If you have any questions about your EOBs or bills, please contact: 1. Insurance Company Refer to your ID Card 2. Auxiant Customer Service (800) To the right is a flow chart to help better explain this new process. The Participant visits a Health Care Provider who provides the services and then codes the claim and submits it to the Insurance Company for processing. The Insurance Company processes the claim and sends an Explanation of Benefits (EOB) to the Provider, TPA and participant reflecting the higher deductible, coinsurance & out of pocket maximum. When the TPA receives the EOB from the Insurance Company, they reprocess that EOB and adjust the EOB to reflect the lower deductible, coinsurance & out of pocket maximum. The TPA sends the revised EOB to the provider and the participant. The Participant should retain both the Insurance Company EOB & TPA EOB. The Provider may receive payment from both the Insurance Company & TPA. The Provider will then send a bill to the participant for their portion of the deductible and/or coinsurance.

5 EXPLANATION OF BENEFITS If it s not a bill, then what is it? AN EXPLANATION OF BENEFITS (EOB) IS A RECAP OF WHAT YOUR INSURANCE HAS PAID FOR. How much your provider charged for each service How much your health insurance company paid for each service How much you saved by staying in-network How much you are responsible for paying out-of-pocket Remember, your EOB is not a bill. If your EOB shows that you are responsible for some of the cost, your provider will bill you separately. When you receive your EOB it is important to review your statement to make sure that you are getting the most value out of your health care spending. HERE ARE THREE TIPS THAT COULD HELP REDUCE THE AMOUNT YOU PAY OUT-OF-POCKET: EOB TIP Select an in-network provider. Use the Find a Doctor or Hospital tool on Wellmark.com to find an in-network provider, so you can get the best savings from your health plan. TIP Compare charges. If you receive a bill from your provider, compare charges on your EOB to charges listed on the provider bill to confirm that services and charges listed are correct. TIP Register for mywellmark. Review your health plan information online, so you are familiar with your plan. mywellmark is your personalized site to make the most of your coverage. LEARN MORE

6 HOW TO READ YOUR EXPLANATION OF BENEFITS PATIENT NAME: YOUR NAME HERE ISSUE DATE: 06/10/14 ➊ ➋ ➌ ➍ ➎ ➏ ➐ ➑ Date of Service 05/19/ Physician Name Patient Account Number Health Care Provider Claim Number Type of Service Amount Charged Network Savings Amount Paid by Health Plan Deductible Copayment Coinsurance Amount Not Covered Notes Office Medical Care $ $5.00 $82.00 $0.00 $15.00 $0.00 $0.00 Office Laboratory $36.00 $15.00 $21.00 $0.00 $0.00 $0.00 $0.00 Office Laboratory $30.00 $20.00 $10.00 $0.00 $0.00 $0.00 $0.00 Claim Total: $ $40.00 $ $0.00 $15.00 $0.00 $0.00 1,2 Other Insurance Paid: $ Wellmark provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims. (Z110) 2 - We have settled this claim directly with your provider. (Z195) ➒ ➓ You are responsible for $15.00 Helpful terms found on your EOB: ➊ PATIENT ACCOUNT NUMBER: Your account number with your health care provider. ➋ AMOUNT CHARGED: The total amount charged by a health care provider for services you received, whether or not the services are covered under your health plan. ➌ NETWORK SAVINGS: The amount you saved by receiving services from a health care provider within the Wellmark Blue Cross and Blue Shield provider network or the BlueCard Preferred Provider Organization (). ➍ AMOUNT PAID BY HEALTH PLAN: The amount paid to you or your health care provider. ➎ DEDUCTIBLE: The fixed dollar amount you pay for certain covered services before benefits are available. Your health care provider may bill you for these charges. ➏ COPAYMENT: The fixed dollar amount you pay for certain covered services. Your health care provider may require this payment when you receive services. ➐ COINSURANCE: The amount, calculated using a fixed percentage, you pay for certain covered services. Your health care provider may bill you for these charges. ➑ AMOUNT NOT COVERED: The portion of the charges not covered under your health plan. Examples of Amount Not Covered include any of the following: Amounts for services that are not medically necessary. Amounts for services that are not covered by your health plan. Amounts for services that have reached contract or benefit maximums. If you receive services from a non-participating health care provider, any difference between the amount charged and the maximum allowable fee for the service. Maximum allowable fee is the amount we establish for covered services or supplies. Benefit reductions for services that are not properly pre-certified, if required. Benefit reductions for receiving inpatient hospital services from a non-network hospital. ➒ OTHER INSURANCE PAID: If you have coverage with another health plan, this is the amount that the other plan has agreed to pay. ➓ YOU ARE RESPONSIBLE FOR: Your share of the cost for the services shown on the EOB. You should use this information to coordinate your payment(s) to your providers. Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield and the Cross and Shield symbols are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans. Wellmark is a registered mark of Wellmark, Inc Wellmark, Inc. M /14