Experience & Trends determines the District Insurance Rates. Claims are processed through our TPA and PBM = BCBSTX/Prime

Transcription

1 Open Enrollment Meeting Plan Year Self-Funded Medical and Rx Plan Experience & Trends determines the District Insurance Rates Claims are processed through our TPA and PBM = BCBSTX/Prime AISD Contributions and Employee Premiums fund the entire plan for the District 1

2 Claims A claim is the result of a documented outcome of your office visit submitted to the insurance company by a Provider. Claim Factors New Patient, Existing Patient, Follow-up, etc. Lab Work, Imaging, Procedures, etc. Severity/Risk Claims How Claims are Paid Employee Visits Provider Provider Bills Patient Provider Files Claim Provider is Paid by BCBS BCBS Processes Claim 2

3 PPO Medical/Rx Plan Changes Current $10 Care Today Copay $35 PCP Copay No Max Out-of-Pocket Individual Family Non-Preferred Brand Rx 30 Day = $60 90 Day = $160 Mail Order - $150 Specialty Formulary = $100 Non-Formulary = $100 Next Year $15 Care Today Copay $30 PCP Copay ACA Mandated Limits Individual $6,350 Family $12,700 Non-Preferred Brand Rx 30 Day = $80 90 Day = $240 Mail Order - $200 Specialty Formulary = $80 Non-Formulary = $ Rx Care Management Changes Increased Step Therapy for new prescriptions Anti-Depressants Non-Steroid/Anti-Inflammatory Type II Diabetes Cholesterol & Triglycerides Anemia & MDS Multiple Sclerosis Prior Authorization for current and new drugs in 20 different categories to ensure they are used within FDA labeling Prescribed for Approved Symptoms Maximum Time Allowance for Treatment 3

4 PPO An office visit may cost more than the copay Covered Under Copay Consultation Diagnostic Labs and X-rays Not Covered Under Copay Injections Procedures Rapid Tests, Stitches, Wart/Mole Removal, Broken Bones, etc. Non-Preventative Labs Sonograms/Ultrasounds 2 nd Opinion Radiologist reviewing X-Rays/Ultrasounds PPO Prescription Tiers Set on Drug History, Cost and Utilization Tier 1 - Generic drugs; Features the lowest copayment Tier 2 - Preferred brand-name products based on safety, efficiency and cost; Generic not available; Second lowest copayment Tier 3 Non-Preferred brand-name drugs for which alternatives are available in Tier 1 or Tier 2; or Not used typically as a first line of treatment Tier 4 - Specialty Drugs require special dosing or administration, are typically prescribed by a specialist and are more expensive than most medications. 4

5 PPO Prescriptions and Co-Pays DO NOT Guarantee Coverage Step Therapy may be required Try Generic Rx first Samples or Discount Cards Provided Samples of Brand Name drugs typically are not covered prior to participating in Step Therapy (ex. Nexium) Discount cards may not coordinate with insurance coverage If Provider or employee prefers a drug in a higher tier when a generic is available, based upon approval, you will pay the copay + difference RX Change 20 mg moves to Over-the-Counter LATE MAY 40 mg moves to Over-the-Counter SEPTEMBER 5

6 HDHP Consumer Driven Health Plan Shop for the best price for medical procedures and Rx Pay 100% of discounted price for Medical Visits/Procedures/Rx Covered at 100% after reaching deductible What s the Catch? Pay actual discounted cost rather than copays Keep receipts Medical Flex Account cannot be used Not excluded from Rx Step Therapy and Case Management MUST KNOW AND UNDERSTAND YOUR PLAN HDHP How Can HDHP Work For You? Annual Wellness Exam/Well-Child Visit is Free Use Blue Access for Members to research the best pricing on procedures or imaging. Free and Low-Cost Medications United Supermarket provides free Antibiotics Wal-Mart and Target provide maintenance medications for $4 and $10 dollar list (and goes towards deductible) Not every Provider s Office knows how a Consumer Driven Health Plan works. 6

7 Cost of PPO v. HDHP with Employee Only Premiums PPO Baby $420 + $5,500 = $5,920 Knee Scope $420 + $5,500 = $5,920 Imaging (CT/MRI) $420 + $ = $1,320 Allergy T/T $420 + $3,000 + $600 = $4,020 PCP Office Visit/Rx $420 + $ = $465 No Health Issues $420 HDHP (CDHP) Baby $ = $3,060 Knee Scope $ = $3,060 Imaging (CT/MRI) $60 + $ = $960 Allergy T/T $60 + $3,000 = $3,060 PCP Office Visit/Rx $60 + $ = $295 No Health Issues $60 Two Medical Plans PPO Preferred Provider Organization (Individual) Office Copay - $30/$50 Rx Copay Based on Tier Deductible Co-Insurance Out-of-Pocket Max Deductible = $3,000 Coinsurance = $2,500 Copay = $850 Potential Max = $6,350 Additional Premiums = $420 TOTAL = $6,770 HDHP High Deductible Health Plan (Individual) Deductible Office Visits Procedures Rx Potential Max - $3,000 Premium = $60 TOTAL = $3,060 7

8 Wellness Credits March 29 th September 27th Measurement National Institute of AISD Credit for Health Level Plan Level Meeting Criteria Blood Pressure 120/80 Less than 140/90 $100 Body Mass Index Less than 25kg/m Less than 30kg/m $100 LDL Cholesterol Less than 100 mg/dl Less than 130 mg/dl $100 Tobacco/Nicotine None Detected None Detected $100 Online HA Completed $100 Credits are applied to your deductible as you near $3,000 Shows as a credit and not a deduction. Only visible after applied towards claims. Rates HDHP BSA Network Medical / Rx Monthly Rates PREMIUM Non-Tobacco User Incentive Credit Biometric Screening Participant Incentive Credit Premium After Credits Employee Only $ $ $9.00 $ 5.00 Employee + Spouse $ $ $9.00 $ Employee + Children $ $ $9.00 $ Employee + Family $ $ $9.00 $ PPO BSA Network Employee Only $ $ $9.00 $ Employee + Spouse $ $ $9.00 $ Employee + Children $ $ $9.00 $ Employee + Family $ $ $9.00 $ District Contribution $ Per Month 8

9 Dental Reimbursement Plan, not Insurance 80% of the first $250 50% of the next $1,600 Reimbursement amounts start over July 1 st No lifetime maximum for Orthodontia 6 Month waiting period on new enrollees through Open Enrollment Rates will remain the same for Vision - VSP Option I $10 Basic Exam $25 Materials Copay $120 Allowance for Frames or Contacts Option II $10 Basic Exam $25 Materials Copay $250 Allowances on Frames or Contacts Rates will remain the same for

10 Life and LTD Purchase additional Term Life Insurance Purchase Dependent Life Buy-up to 60% or 67% LTD Rates will remain the same for FFGA Provide greater vendor options Ability to provide affordable Voluntary Benefits to employees Single Source Provider for Flex and Voluntary Benefits Appointments on all campuses will occur during May 10

11 Open Enrollment Open Enrollment Meeting Schedule Date Time Where Monday, May 5 th 4:30 PM Caprock HS Auditorium Tuesday, May 6 th 4:30 PM Travis MS Auditorium Wednesday, May 7 th 4:30 PM Tascosa HS Auditorium Thursday, May 8 th 4:30 PM Bonham MS Auditorium Monday, May 12 th 4:30 PM Palo Duro HS Auditorium Tuesday, May 13 th 4:30 PM Crockett MS Auditorium Thursday, May 15 th 5:15 PM ESC - Board Room Online PeopleSoft enrollment open through May 18 th 11