1 High Deductible Health Plan Enrollment and Administration HBR Training September 2014
2 Presentation Overview Eligibility Reminders Administration Information Plan Benefit Design Additional Member Benefits Employee/Employer Rates Enrollment Materials Enrollment and Billing Portal Preview 2
3 ACA Plan Requirements Who is Eligible for Coverage? To avoid tax penalties under section 4980H of the Internal Revenue Code (the Code) large employers must offer coverage that is affordable, and is at least minimal value to all full-time employees. Employing units are responsible for determining whether or not an employee is a fulltime employee. This includes all non-permanent employees. Non-permanent employees are currently not offered coverage through the State Health Plan. Employees are considered full-time, and thus required to be offered employersponsored health care, if they are reasonably expected to work 30 hours per week. Employers have flexibility in determining an employee s status and may use a safe harbor which utilizes a measurement and stability period for determining eligibility and offering coverage. If the safe harbor is not used then employee status is determined every month. The State Health Plan will be offering a High Deductible Health Plan for those nonpermanent employees determined to be full-time by the employing units. The State Health Plan is not able to provide guidance to employing units regarding eligibility for employees. Additional information is posted on the Plan s website under the HBR tab. Click Health Care Reform/Affordable Care Act Information 3
4 Open Enrollment Reminders During Open Enrollment you are able to: Enroll in the State Health Plan Add or remove dependents without a qualifying life event An eligible dependent of a covered employee includes: Legal spouse Children up to age 26, including natural, legally adopted, foster children, children for which the employee has legal guardianship and stepchildren of the employee Coverage for such children (described above) who are covered by the Plan when they turn age 26 to the extent that they are physically or mentally incapacitated on the date that they turn age 26. A child is physically or mentally incapacitated if they are incapable of earning a living due to a mental or physical condition. Coverage continues for such children as long as the incapacity exists or the date coverage would otherwise end, whichever is earlier. It is essential that dependent verification documentation is maintained on all dependents (e.g., birth certificate, marriage certificate, court orders) Outside of Open Enrollment you may not add or remove dependents or disenroll from the State Health Plan unless you experience a qualifying life event, such as marriage, birth, death or retirement, and those changes must be made within 30 days of the event. 4
5 Administration Information Members in this plan will have access to the MedCost PPO Provider Network for medical services. Go to Medcost.com and click Find a Provider and select MedCost/MedCost ULTRA The Pharmacy benefit will be managed by Express Scripts and will use Express Scripts 2015 National Preferred Formulary. Members will be sent a monthly bill for their premium, which will be sent by COBRAGuard, the Plan s direct billing administrator. Eligible members will not use eenroll to enroll in this plan. HBRs will have to load eligible members into the Enrollment and Billing portal provided by COBRAGuard. 5
6 High Deductible Health Plan Summary Plan Features In-Network (Individual Coverage In-Network (Family Coverage) Out-of-Network (Individual Coverage Out-of-Network (Family Coverage) Medical Coverage Deductible $5,000 $10,000 $10,000 $20,000 Coinsurance 50% 50% 60% 60% Out-of-Pocket Maximum (Medical and Pharmacy) $6,450 $12,900 $12,900 $25,800 ACA Preventive Care Services $0 (covered at 100%) $0 (covered at 100%) 60% after deductible 60% after deductible Office Visits 50% after deductible 50% after deductible 60% after deductible 60% after deductible Specialist Visit 50% after deductible 50% after deductible 60% after deductible 60% after deductible Inpatient Hospital 50% after deductible 50% after deductible 60% after deductible 60% after deductible Prescription Coverage 2015 Express Scripts National Formulary Covered Prescription Drugs HDHP ACA Preventive Medications 50% after deductible 50% after deductible 50% after deductible 50% after deductible $0 (covered at 100%) With a Prescription $0 (covered at 100%) With a Prescription $0 (covered at 100%) With a Prescription $0 (covered at 100%) With a Prescription 6
7 High Deductible Health Plan Summary-Con t. Instead of copays, members will pay a 50% coinsurance after meeting the deductible for in-network medical and pharmacy expenses, except for ACA preventive services and medications. The deductible and coinsurance (medical and pharmacy) are included in the out-of-pocket maximum. ACA Preventive Services and Medications ACA medical preventive services are covered at 100% ACA preventive medications are covered at 100% with a prescription A list of these services and medications will be available on the Plan s website at 7
8 High Deductible Health Plan Pharmacy Benefit Members will pay in full for prescription drugs if the deductible has not been met. Pay in full means you will pay 100% of the covered prescription drug cost Once the deductible is met, members will pay a 50% coinsurance for prescriptions until the out-of-pocket maximum has been met. This pharmacy benefit will use the 2015 Express Scripts National Preferred Formulary (preferred drug list) and includes their broad retail pharmacy network Express Scripts National Preferred Formulary (preferred drug list) will be posted on the State Health Plan s website. 8
9 Health Savings Account Compatible The HDHP is compatible with a Health Savings Account (HSA). An HSA is a tax-deductible savings account with tax-free withdrawals for qualified medical and pharmacy expenses. Having an HSA is not required to be enrolled in this plan. An HSA can be helpful in reaching the deductible and ease the out-of-pocket burden on an HDHP. Enrolled members will be responsible for setting up their own HSA. 9
10 Additional Member Services Teladoc 24/7- Access to consultations over the phone or online (where available) with board certified physicians for common conditions such as allergies, infections, etc. The out-of-pocket cost to the member for this service will be $40.00 per use of service. A welcome kit from Teladoc will be sent to enrolled members. HealtheReports - Online provider search, cost and quality tool Personal Care Management - Customized health education and oneon-one nurse mentoring and coaching to encourage self-empowerment and self-management. Includes transitional care management. Personal Health Suite - Online suite of health and wellness tools and information, including Health and Productivity Assessment (HPA), Healthy Living Programs, personal health record/portal and health trackers 10
11 Monthly Premium Rates for High Deductible Health Plan (HDHP) Coverage Type Employer Share Employee Monthly Premium Dependent Monthly Premium Total Monthly Employee Premium Employee-only $ $92.38 N/A $92.38 Employee + Child(ren) $ $92.38 $ $ Employee + Spouse $ $92.38 $ $ Employee + Family $ $92.38 $ $
12 Open Enrollment Guide HBRs will be sent a pdf of the Enrollment Guide for eligible members. HBRs are responsible for sending the guide to eligible members. The guide will not include enrollment dates, so you will need to promote when your employing unit will be hosting Open Enrollment for this plan. The initial Open Enrollment is set for Oct. 6-31, 2014 Groups that are not able or ready for the scheduled enrollment dates are able to add members for the initial enrollment just as they do for any new hire. The State Health Plan s website will have one page dedicated to this plan in which the following materials will be available soon. To access this information, employees will need to visit and click High Deductible Health Plan. ACA Preventive Services List HDHP ACA Preventive Medication List 2015 Express Scripts National Preferred Formulary (preferred drug list) Benefit Booklet HDHP Summary 12
13 Member ID Cards Member ID cards will be sent to enrolled members prior to their benefit effective date. Below is a sample of the card they will receive for themselves and their enrolled dependents. 13
15 HBR Administration Site ncshp.hr.hrissuite.com If multiple locations are available the HBR will need to select the needed location.
16 Requests submitted for approval by the administrator will show on this screen once they have been approved.
17 Requests that have not yet been approved will show on the Active Requests tab.
18 Search function to locate a specific employee. Employee ID and Medicare Number will be removed from the search options.
19 Main screen showing employee info. The HBR may upload supporting documentation on this screen. If a newly eligible dependent needs to be added please select Add Family Member and input the dependent s information.
20 The Employment tab shows the selected employee s employment status (active or COBRA), start date, end date and department.
21 The Benefits tab will show active benefits the selected employee is enrolled in, once elections are made. If dependents need to be added to benefits due to a Qualifying Event please select Edit Benefits to process the request.
22 The HBR will review the supporting QE documentation provided by the employee, upload the documentation and submit the request to add the dependent(s).
25 Once the dependent s information has been entered and the needed QE documentation is attached to the request the new dependent will show on the Member & Family tab.
26 To manually add an employee select Create Member and enter the requested information.
28 The Upload File option will be added to the menu below the Create Member option.
29 The Report function pulls an Excel file showing all active employees and dependents (if selected) enrolled in benefits as of a specific date.
31 If dependents are to be included, Include Dependents would be selected.
32 HDHP Employer and Member Billing Invoices by department will be included on the portal. Member invoices will be integrated on the member portal (shphdhp.com) Invoices are generated on the 10 th of each month. Invoices are viewable online under the Invoices Menu Option. Once an invoice is opened in the system, it will show two options to pay the bill: Mail a check to the lockbox Click to pay online via ACH Once payment is received the invoice will be satisfied. The satisfied invoice will be viewable under the Invoice Tab. Billing reports are included in the system. If the member payment is not received by the end of the grace period the member will be terminated and the employer portion will be refunded on the next invoice.
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