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Harrisonburg City Harrisonburg City Public SchoolsPublic Schools
Open Enrollment Open Enrollment 20142014
Harrisonburg City Harrisonburg City Public SchoolsPublic Schools
Open Enrollment Open Enrollment 20142014
Today’s AgendaToday’s Agenda
• Welcome
• Review Anthem Plan Effective 07/01/14– What’s Staying the Same– Why & What’s Changing– Claim Examples
• Q&A
WHAT’S STAYING THE SAME:KeyCare - Preferred Provider Organization (PPO) Plan
• PCP not required• No referrals needed• No claim forms needed when using network providers• Very large network of providers available both in Virginia and
throughout the U.S.• Out-of-network benefits available but at lower coverage
levels• Dependents covered until the end of the month in which they
reach age 26.• Annual eye exam - $15 copay (provided through Blue View
Vision)• Out of pocket maximum (in-network)-$3,000/$6,000
Plan OverviewPlan Overview
WHY & WHAT’S CHANGING:• WHY CHANGE:
• Health care costs are affected by:• Price inflation, utilization, legislation changes, new treatments, therapies
and technologies
• 8% is the national average rate increase…
• If HCPS made NO changes, our rate increase would be: 22.3%...this is not sustainable
• Solution: Change to a plan that is:• Considered a quality program in the market
• Cost effective and sustainable
Plan OverviewPlan Overview
WHY & WHAT’S CHANGING:
• WHAT’s CHANGING
• Benefits – plan is changing to KeyCare 25• Preventive services have been added as a result
of the Affordable Care Act
Plan OverviewPlan Overview
Preventive CarePreventive Care• Preventive Care Services covered at 100% in-network with
no member copay.• *Preventive care services are those services that meet the requirements of federal and
state law, including certain screenings, immunizations and physician visits, and include such services as:
Well Baby Visit with associated immunizations and screenings Well Woman Visit with associated gyn exam, pap smear, and mammogram. Medical
and Pharmacy contraceptives, 1 breast pump purchase or rental per pregnancy when purchased from a participating Durable Medical Equipment provider.
Routine Physical with associated immunizations and screenings Select OTC drugs with prescription from doctor (ex - iron supplements for children 0-12
months, aspirin for men age 45-79 and women age 55-79) Screening related to tobacco use including tobacco cessation products with
prescription from doctor
• *During the course of a routine screening procedure, abnormalities or problems may be identified that require immediate intervention or additional diagnosis. If this occurs, and your provider performs additional necessary procedures, the service will be considered diagnostic and/or surgical, rather than screening, depending on the claim for the services submitted by your provider, which will result in a member cost share.
Benefits Overview-KeyCare Benefits Overview-KeyCare 2525
In-network Services Current Plan KeyCare 25 Plan
Preventive Care Services No charge No charge
Doctor Visits – includes:•Office visits•Urgent care visits
$20 PCP$40 Specialist
$25 PCP$50 Specialist
•Spinal Manipulation (Chiropractic) visits-30 visits
$20 PCP$40 Specialist
$25/visit
Deductible(applies to all services with coinsurance)
None $500/person$1,000/family
You will pay the costs associated with your care until you have paid $500 in one calendar year. This is known as your deductible.
•If two people are covered, each will pay $500 ($1,000 total)•If three or more people are covered, together you will pay the first $1,000. The most one family member will pay is $500.
Benefits Overview-KeyCare Benefits Overview-KeyCare 2525
In-network Services Current Plan KeyCare 25 Plan
Diagnostic Labs & X-rays(provided in physician’s office, emergency room or facility)
Lab: no chargeX-rays-$40 copay
Advanced Diagnostic-$150
20%* after deductible
Emergency Room Facility $150 copay/visit, then 20%*
20%* after deductible
Outpatient Surgery $150 copay/visit, then 20%*
20%* after deductible
Inpatient Stays in a Network Hospital
$400/stay, then 20%* 20%* after deductible
*Anthem bases claim payment on the amount the health care providers in our network agree to accept for their services. This is called “allowable charge”. Network providers cannot balance bill for the difference in what we pay and what they charge.
Benefits Overview-KeyCare Benefits Overview-KeyCare 2525
In-network Services Current Plan KeyCare 25 Plan
Out of Pocket Maximum(once you meet your OOP Max, the plans pays 100% for the remainder of the calendar year)
$3,000/person$6,000/family
$3,000/person$6,000/family
What counts toward this maximum:•medical copays (example - $25 PCP visit)
•deductible under KeyCare 25•your coinsurance amounts (20% of allowable charge)
What doesn’t count toward this maximum:•prescription drug copays
•vision plan copay•cost of care when benefit limits are reached
Benefits Overview-KeyCare Benefits Overview-KeyCare 2525
Out of Network Services (services provided by providers who are not part of the Anthem
KeyCare network)
Current Plan KeyCare 25 Plan
Deductible* $500/person$1,000/family
$750/person$1,500/family
Coinsurance Plan Pays: 70%You Pay: 30%
Plan pays: 60%You Pay: 40%
Out of Pocket Maximum* $4,500/person$9,000/family
$4,500/person$9,000/family
*Deductibles and out-of-pocket maximums do not cross accumulate between in-network and out of network. Anthem bases claim payment on the amount the health care providers in our network agree to accept for their services. This is called “allowable charge”. Non-Network providers can balance bill for the difference in what we pay and what they charge.
Benefits OverviewBenefits Overview
Prescription Drug Benefits Current Plan KeyCare 25 Plan
Express Scripts, Inc (ESI) is the Pharmacy Company that Anthem uses
Up to a 30 day medication supply at participating Retail pharmacies
Tier 1 - $10 Tier 2 - $30Tier 3 - $50
Tier 1 - $10 Tier 2 - $40Tier 3 - $75
Up to a 90 day medication supply through ESI home delivery pharmacy
Tier 1 - $20 Tier 2 - $60Tier 3 - $100
Tier 1 - $20 Tier 2 - $80Tier 3 - $150
Meet Carol Lewis | Employee Only Meet Carol Lewis | Employee Only CoverageCoverageClaim Examples/Starting July 1, 2014Claim Examples/Starting July 1, 2014
Carol’s Services Date of Service
Anthem’s Allowable
Charge
Anthem Claim Payment
Carol’s Payment to Providers
Amount toward OOP
that Carol has met
Preventive Ob/GYN visit & lab tests
7/10/14 $300-visit$150-lab
$300-visit$150-lab
$0 $0
Diagnostic visit to PCP & lab work for strep throat
9/30/14 $350-visit$100-lab
$325-visit($350-$25 copay)
$0-lab(deductible not
met)
$25 copay-visit$100- lab
($100 toward deductible)
$125
MRI for knee injury
10/1/14 $1,000 $480($1,000-$400
(deductible owed=$600 x 80%)
$520($400 remainder of deductible + $120 which is 20% of $600)
$645($125 + $520)
Meet Carol Lewis | Employee Only Meet Carol Lewis | Employee Only CoverageCoverage
Claim Examples (continuedClaim Examples (continued))Carol’s Services Date of
ServiceAnthem’s Allowable
Charge
Anthem Claim Payment
Carol’s Payment to Providers
Amount toward OOP
that Carol has met
Outpatient Surgery for knee injury
10/15/14 $12,000 $9,600($12,000 x 80%)
$2,355(20% of $12K
would be $2400, but OOP would
be met)
$3,000($645 + $2355)
Follow-up visit with Specialist who did knee surgery
11/1/14 $150 $150 $0 OOP has been met for
2014*
*For the remainder of 2014, Anthem pays 100% of any remaining medical charges.Carol continues to pay for any prescriptions and/or routine vision exam.
Meet Carol Lewis | Employee Only Meet Carol Lewis | Employee Only CoverageCoverageClaim Examples/Starting January 1, 2015Claim Examples/Starting January 1, 2015
Carol’s Services Date of Service
Anthem’s Allowable
Charge
Anthem Claim Payment
Carol’s Payment to Providers
Amount toward OOP
that Carol has met
Confirmation of pregnancy at OB/GYN’s office
01/01/15 $200-visit$100-lab
$150-visit($200-$50 copay)
$0-lab(deductible not
met)
$50/visit$100 lab
($100 toward deductible)
$150
Pregnancy Related Ultrasound at GYN’s office
03/01/15 $400 $0(deductible not
met)
$400(remainder of deductible)
$550($150 + $400)
Pregnancy Related Ultrasound at GYN’s office
06/01/15 $400 $320($400 x 80%)
$80($400 x 20%)
$630($550 + $80)
Maternity-Delivery and Global Bill from GYN
09/01/15 $7600 $6,080($7600 x 80%)
$1,520($7600 x 20%)
$2,150($550 + $1520)
Questions