Understanding Group Health Insurance Anthem KeyCare 15+ Plan

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1 Understanding Group Health Insurance Anthem KeyCare 15+ Plan January 12, 2010 Although it is the intent of the University to continue current benefit plans, the University reserves the right to modify, amend or terminate any benefit plan, with or without notice. This summary describes only the major features of the plan. In the event of any inconsistency between this summary and the legal plan documents, the legal plan documents (located in Human Resources) will govern.

2 W&L s plan In-network and out-of-network summary Preventive Wellness ER Care Pre-Natal Care Mental Health and Substance Abuse Ongoing Conditions Hospital Stays Prescription Drug Benefit Vision Benefit Common Procedures Excluded Services FAQ s Resources Subsidy Rates AGENDA

3 The University offers eligible employees and their families enrollment in Anthem BC/BS s KeyCare 15+ plan. This plan includes both in-network and out-of-network benefits as well as coverage for prescription drugs. Employees select individual membership, a membership for self and one legal dependent or family membership. Same and opposite sex domestic partner benefits are available. The University currently contributes 66% of the premium and offers to reduce, upon request and eligibility, the employee s share of premium so that an eligible employee won t pay more than 10% of family income. Members can access care with any physician or hospital, but there are financial advantages to using in-network physicians and hospitals. In-network doctors and hospitals file claims so there s no paperwork for you to deal with and innetwork doctors/hospitals cannot balance bill. Since Anthem is known nationwide you can access care outside of our local area. Through BlueCard PPO you can directly access doctors and hospitals who participate in other BC/BS plans throughout the country and in many places throughout the world. Tip: If traveling outside the US, call Anthem for a list of providers in the country you ll be visiting. New employees enroll within 31 days of employment. All employees can enroll or make changes during open enrollment or within 31 days of a qualifying life event. Children can be covered through the calendar year in which they turn age 25. At the point they are no longer considered tax dependents the portion you pay for them is taxable. Coverage can be extended longer for children with mental or physical challenges that prevent them from living alone. Employees are responsible for letting HR know when either of these situations occur. Summary

4 Visit Anthem s website for in-network providers Calendar Year Deductible: none Out of Pocket Maximum: $1,500 individual; $3,000 family. This total includes medical co-pays and coinsurance (Rx and Vision co-pays are excluded) Office visit co-pays: $15 PCP; $30 Specialist Preventive Wellness: No copay covered at 100% Inpatient Hospital Copay/Coinsurance: $200 per admission + Outpatient Surgical Copay/Coinsurance: $100 per visit + ER Visits: $100 +; waived if admitted to hospital Vision (one routine preventative eye exam per calendar year): $15 copay Visit the HR website for additional information: % pdf. Review of Current In-Network Benefits

5 Calendar Year Deductible: $200 individual; $400 family Out of Pocket Maximum: $2,750 individual; $5,500 family. This total includes medical co-pays and coinsurance (Rx and Vision co-pays are excluded) Note on Out of Pocket Maximum: In-network and Out-of-Network maximums are not combined, but considered separately. For out-of-network services, deductibles and coinsurance apply to allowable charges. Members are responsible for non-allowed charges at 100%. Benefit level: 80% after deductible Office visit co-pays: 80% after deductible Preventive Wellness: 80% after deductible Inpatient Hospital Coinsurance: 80% after deductible Outpatient Surgical Coinsurance: 80% after deductible ER Visits: 80% after deductible Vision (one routine preventative eye exam per calendar year): $30 allowance (not subject to deductible) Visit the HR website for additional information: complete information: pdf. Review of Current Out of Network Benefits

6 A good diet and exercise can go along way toward contributing to your overall health - so can regular checkups and screenings covered at 100% in most cases! Children, birth through age six, are covered for preventive checkups and screenings as recommended by the AAP and Virginia s Commissioner of Health. Coverage guidelines for children over age 7 and adults are based on the AMA and include annual checkups, immunizations, labs and x-rays done in connection with an annual checkup, mammograms for members age 35 and older, annual gynecological exams, annual PSA testing and prostate exams for men age 40 and older, and colorectal cancer screenings Check out Health Channels, a feature of for more information including a library of more than 30,000 articles on self-care, medications, conditions, tests and treatments. Type in preventive care guidelines on Anthem s website and download preventive care guidelines for children and adults. Following these recommendations not only helps with your overall wellness but saves you money. Also available through are weekly e-newsletters, health risk assessments and discount offers. Preventive Wellness (an apple a day )

7 Not only does personal wellness and early prevention help you, it helps the entire W&L community. Premiums, for the most part, are driven by claims experience. This means, generally, the healthier our population, the lower our claims costs, the less premium increase we see. How does Preventive Wellness help us?

8 Sometimes it s hard to decide if your situation is truly an emergency. Anthem defines emergency as the sudden onset of a medical condition with such severe symptoms that a person with an average knowledge of health and medicine would seek medical care immediately because there may be serious risk to mental or physical health, danger or significant impairment of body functions, significant harm to organs, danger to the health of a baby or pregnant woman. Rule of thumb: Keep Danger to Life or Limb in mind. Always get the help you need. Many times, family doctors are better equipped and more cost-effective for minor aches and pains. By going to your doctor s office instead of the ER or a Specialist, you help keep W&L s claims experience down and this helps limit the rise of future premium costs. If your ER visit leads to a hospital stay, notify Anthem within 48 hours. Emergency Care

9 With Future Moms, you have access to 24-hour telephone support from OB/GYN registered nurses who, with the support of on-site medical directors, pharmacists and dieticians, are trained to work with you when questions arise. When you sign up for this program, you receive a book that tells you what to expect each week of your pregnancy, and guidance on questions to ask your doctor during visits. In-network: you ll pay a global fee for your doctor s services and $200 for an in-network in-hospital co-pay. Out of network: After you pay the deductible, Anthem pays 80% of allowable charges. Prenatal Care Programs and Resources

10 If you or a covered family member is struggling with emotional issues or addiction, you know the toll it takes on the family. Anthem provides assistance through their Behavioral Health Unit staffed by licensed professionals trained to help with these issues. Call for assistance. Our Employee Assistance Plan is also available at Mental Health or Substance Abuse Issues

11 Chronic conditions can really impact the quality of your life. The ConditionCare program helps members deal with asthma, diabetes, allergies, depression, stress, certain heart disease conditions and other chronic illnesses. Includes 24 hour/day access to specially-trained nurses for help with questions and information on treatments Ongoing Conditions

12 Anthem offers members an opportunity to compare hospitals based on criteria you choose such as (how often does a particularly hospital perform a certain procedure, what are the rates of complication, etc.) Quality Hospital Incentive Program (Q-HIP) rewards hospitals for adopting higher level standards of quality for the best patient outcomes. Pre-authorizations are required for inpatient hospitalizations and certain medical procedures. Innetwork providers normally obtain these for you. Please be mindful that it never hurts to double check. You may do so by calling Anthem s Customer Service department or by logging into your own personal Anthem account. Hospital Stays

13 30 day supply: $10 for tier 1, $30 for tier 2, $50 for tier 3 90 day supply through Anthem s mail order: $10 for tier 1, $60 for tier 2, $150 for tier 3 Visit Anthem s website to check the cost of prescription drugs using your prescription drug card. Check with your pharmacy most offer prescriptions at discounted prices. Current Prescription Drug Benefit

14 sources/bvvision_va_ppo_exam_only.pdf Current Vision Benefits

15 Colonoscopy cancer screening. You ll pay less in an internist s office compared to an outpatient hospital setting. In addition, there may be cases in which a Preventive screening reveals something that needs to be treated right away or needs further diagnostic testing. When this occurs, if your doctor bills the service as diagnostic instead of a wellness screenings, your payment responsibility increases. Flu shots Immunizations Maternity Benefit global fee Diabetic equipment Common Procedures

16 Please refer to your Anthem booklet for a complete list of services not covered by Anthem. Some non-covered services include acupuncture, cosmetic surgery or procedures, dental services, family planning services, preventive hearing care or hearing aids, investigative/experimental procedures, some medical equipment and supplies, paternity testing, smoking cessation services, workrelated injuries. While these services are excluded from the medical coverage through Anthem, some of these services can be covered through medical flexible spending accounts. Also, remember that if you are injured at work, coverage for services received is through our Workers Compensation policy, not your group health insurance through Anthem. Services Excluded from Coverage

17 Do I need a referral to see a specialist? No Must I call Anthem if I m in the ER? No, but we suggest (for peace of mind) that you call within 48 hours. Is pre-authorization required? If it is and you are using in-network physicians and hospitals, they will take are of this. Again, for peace of mind you may want to call. Pre-Existing Conditions Pre-Existing Conditions are not excluded from coverage. What if I m now eligible for Medicare? As long as you are actively at work, Anthem is your primary coverage. There isn t any need to sign up for Part B Medicare until you retire. Ambulance travel Covers professional ambulance services to/from nearest hospital/provider. If billed through the facility, covered the same as all other facility services Air ambulance services are also covered when pre-authorized or in cases of threatened loss of life. You will pay 10% of the cost charged by the provider. When do I use Anthem health for dental services? Situations such as accidental injury to permanent, sound and natural teeth or the surgical removal of impacted wisdom teeth may be covered through group health rather than dental. Frequently Asked Questions

18 HR Website Health Advocate 24/7 Nurse Hotline ( ) Anthem.com Member services: Resources

19 The University made a commitment in 2006 to assist lower-paid employees with their health insurance premium by subsidizing part of the premium cost. Employees who think they may be eligible should bring their most recent tax return to HR to apply. Subsidy

20 As mentioned, rates are subject to change in July. What can we do to influence rates? Take advantage of wellness programs, stay healthy by maintaining a healthy diet and exercising. Early detection and prevention is key. Current Rates

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