Benefits Orientation

ATU Special Open Enrollment

Metropolitan CouncilBenefits

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Special Open Enrollment

During this Special Open enrollment, you may:Change from one medical plan to anotherAdd dependentsIf you currently waive medical coverage, you may enroll in a medical plan

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Special Open Enrollment

You may NOT:Drop medical coverageDrop coverage for any dependentsChange any other coverage (such as dental, vision, or flex)

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Medical Plans

HealthPartners PlansOpen AccessDistinctions IIIEmpower HRA

The Metropolitan Council offers three health plans through our insurer, Health Partners. The Open Access plan, Distinctions III plan and the Empower HRA plan.

All three plans offer benefits for in-network and out-of-network providers. A vast majority of our participants use in-network providers, so we will be focusing mostly on the in-network benefit.

Lets review some common terms before we proceed. 4

Medical Plans Common TermsLifetime MaximumTotal dollar amount payable under the planDeductibleAmount you pay of a medical charge before the health plan paysCopaysSpecific dollar amount that you pay for a specified service

Lifetime Maximum- The lifetime maximum is the dollar amount that is the maximum that HealthPartners would pay toward your claims in the time you are enrolled in that plan. The lifetime maximum is per individual person. For example, if the lifetime maximum is $2,000,000, HealthPartners would pay up to $2,000,000 in claims for you OR your spouse, OR for each of your children.Deductible A deductible is a dollar amount that you are responsible for on your claims before the HealthPartners coverage starts paying in any calendar year. This is very much like the deductible you have on your auto insurance. If you have an auto accident and your auto insurance has a $500 deductible, you have to pay the first $500 to repair damages from the accident. The medical insurance deductible is an amount per person with a maximum amount per family. For example if you have a $100 individual deductible with a $200 maximum per family, you would pay the first $100 in claims on any single person in your family before HealthPartners would pay anything on claims for that person. However, if you have a family, you would still pay no more the $100 per person, but no more the $200 per family toward that deductible in a calendar year. CoPays CoPays are specific dollar amounts that you pay for a specific service. For example, if you have a $25 copay for office visits, you will pay $25 to your doctors office when you have an office visit.

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Medical Plans Common TermsCoinsuranceThe percentage of the charge that you are responsible forOut of Pocket MaximumThe dollar maximum that you could potentially pay in a calendar year for covered medical expenses (includes deductible, copays and coinsurance)

Coinsurance Coinsurance is similar to copays, except it is a percentage. For example, if your plan covers 80% of an ambulance charge, the other 20% that you are responsible for is called coinsurance.

Out Of Pocket Maximum An out of pocket maximum is the maximum dollar amount that you could spend on covered medical expenses in a calendar year. This is an individual amount, with a family maximum. It includes the amount that you pay toward deductibles, copays and coinsurance. If your out of pocket maximum is $1,000 per individual and $2,000 per family, you would not pay more the $1,000 in a calendar year out of your pocket for any one person in your family, and no more than $2,000 for your entire family. Once the out of pocket maximum has been met, HealthPartners pays 100% of all covered charges for the rest of the calendar year.

You are still responsible for the full cost of service for any services not covered under the plan.

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Medical Plans Common TermsNetwork ProvidersDoctors and hospitals that contract with HealthPartnersNetwork DiscountsDiscounted amounts that HealthPartners negotiates with their network DoctorsFormularyA list of prescription drugs that are covered by HealthPartners health plans.

Network Providers - refers to those physicians, hospitals and ancillary care providers that contract with HealthPartners.

Network Discounts Network discounts are the discounts that HealthPartners has negotiated with medical providers within their network. All in-network services are billed from the medical providers to HealthPartners at their standard billing rate, and then they are discounted to the negotiated rate. For example, a doctor may normally charge $100 for a new patient office visit, but HealthPartners has negotiated a price of $75. When the provider bills the $100 charge to HealthPartners, HP reduces it to $75 and pays the normal benefits under your plan. If you have a $10 copay, you would pay the $10, HP would pay $65, and the doctors office would write off the $25 discount.

Formulary A formulary is a list of prescription drugs that are covered by HP health plans.

Questions?7

Medical Plans Common TraitsCommon Traits Between Plans

All plans cover preventive services at 100% Same large network of doctors/facilitiesNo referrals CIGNA network gives in-network benefits when out of areaAll in-network coverage provides an unlimited lifetime maximum

Now lets talk about the Health Plans themselves

A common traits for all plans are they all use the same large network of doctors. There are no referrals required by the plan; you may see any doctor you choose. Your physician may require or suggest a referral, but per the plan, you can go to whoever you want.

All plans cover preventive care at 100%.

You have in-network benefits even if you are out of area if you see a CIGNA Network doctor. This is a good option if you are traveling within the United States, or have family members or students in other states. CIGNA providers can be found online at Healthpartners.com or by calling the number on the back of your card. 8

Medical PlansOpen Access Plan

Now lets talk about the Open Access Plan.9

Medical PlansOpen Access PlanRichest Benefits=Highest CostNo Calendar Year Deductible (in-network)$10 Office Visit Copay$40 Urgent Care Copay$50 Emergency Room CopayPrescription Drug Copay:$12 (generic or brand name)Mail order available

The Open Access plan has the richest benefits and is the highest cost plan. The in-network level of benefits has an unlimited lifetime maximum. There is no calendar year deductible for ATU. ATU calendar year out of pocket maximums are $1,000 per person and $2000 per family.

In-network preventive care is covered at 100%. You pay a $10 copayment for office visits for illness or injury, behavioral health care, allergy injection and urgent care visits. There is a $50 Emergency room copay under ATU.

You pay 20% of the discounted amount of MRIs/CAT/PET scans, Ambulance and Durable Medical Equipment charges, and all other covered services are covered by HealthPartners at 100%.

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Medical Plans Distinctions III Plan

Now lets talk about the next plan offering Distinctions III

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Medical PlansDistinctions III

Three Tiers (Levels) of In Network ProvidersTiers assigned by HealthPartners based on many factors, some of which are:Patient outcomesOverall cost of treatmentUse of technologyPatient Satisfaction

The Distinctions III plan is a plan where there are three levels or tiers of in-network coverage.

The level or tier that a particular doctor is in is determined by HealthPartners. The criteria they use includes:Patient OutcomesOverall cost of treatmentUse of TechnologyPatient SatisfactionTreatmentStandardsCostAnd more

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Medical PlansDistinctions IIIWho is Tiered?Primary CareCardiology Ear, Nose and Throat (ENT)OrthopedicsOb/GynHospital Specialties not tiered default to level 2

HealthPartners tiers Primary care, Cardiology, Ear, Nose and Throat care, Orthopedics, OB/GYN and Hospitals.

Any other type of provider (such as oncologist, ophamologist) are not tiered and default to level 2.

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Medical Plans Distinctions IIIProviders re-evaluated every calendar yearLowest out of pocket costs when you use highest level of provider (level 1)You have coverage for all providersLook up providers levels on www.healthpartners.com or call HealthPartners customer service at (952) 883-5000

Every provider is re-evaluated each calendar year, so the level a provider is in will be the level they will remain in for a full calendar year, but could change in the next calendar year.

Utilizing benefits level 1 providers gives you the least out of pocket costs. But it is important to remember that you have coverage for all providers, regardless of which level or tier they are in.

You can find what level your provider is in, or find a new provider, on HealthPartners website at www.healthpartners.com of by calling HP customer service at 852-883-500014Medical PlansDistinctions III

Tiering is done individuallySame clinic does not mean same tier or levelPrimary Care may be level 2Cardiologist in same clinic may be level 1, 2, or 3

Provider tiering is on an individual doctor and specialty. All doctors at a single clinic location may not be the same level. You may chose a primary care doctor that is in level 2, but if they send you to a cardiologist within the same clinic, the cardiologist may be level 1,2 or 3.

PROVIDE SOME EXAMPLES USING THE DISTINCTIONS III BOOKLET.15

Medical Plans Distinctions III- Office visits: $15 copay (level 1), $25 copay (level 2), $35 copay (level 3); no deductibleInpatient Hospital: $100 copay (level 1), $250 copay (level 2), $500 copay (level 3); deductible appliesOutpatient Care: $30 copay (level 1), $40 copay (level 2), $70 copay (level 3); deductible appliesUrgent Care: $25 copay; no deductible

The Distinctions III in-network level of benefits has an unlimited lifetime maximum.

In-network preventive care is covered at 100% with no deductible.

You will pay a $100 copayment at a level 1 facility for inpatient hospital care, $250 copayment at a level 2 facility, and $500 copy at a level 3 facility. The deductible does apply to inpatient care, so if you havent met your deductible for the calendar year, your first hospital stay will be the deductible plus the copay. For any inpatient stays after that, you will be only the copay amount, your deductible has been met for the calendar year.

Outpatient Care also applies the calendar year deductible and have copays of $30 for level 1, $40 for level 2, and $70 for level 3.

Urgent care has a $25 copay for all levels of providers and deductible does not apply.

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Medical Plans Distinctions III- Behavioral Health and Convenience Care visits: $15 copay all levels; no deductibleEmergency Room: $75 copay; no deductiblePrescription Drugs: $8 copay for generic, $18 copay for brand name; mail order available

For ATU, there is a $200 per person, $400 per family calendar year deductible, and the out of pocket maximum is $1,000 per person or $2,000 per family.

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Medical PlansDistinctions III- $200 per person/$400 per family calendar year deductible (does not apply to every benefit)$1,000 per person/ $2,000 per family out of pocket maximum per calendar year

See benefits chart for more information

Prescriptions drug copays are based on whether the drug is generic or brand name, and the deductible does not apply.

For ATU, generic drugs have a $8 copay, while brand drugs have a $18 copay.

You can also use HealthPartners mail order pharmacy to get a 90 day supply of generic drugs for $16 copay, or a 90 supply of a brand name drug for a $36 copay.

See your benefits chart for more information

QUESTIONS? 18

Medical PlansEmpower HRA Plan

Now lets talk about the third plan being offered. EMPOWER HRA19

Medical Plans Empower HRA

High Deductible Health Plan combined with a Health Reimbursement Account (HRA)Employer contribution to HRA accountContribution fully funds deductibleContribution not pro-rated, regardless of entry date into planHRA account reimburses out of pocket expenses

The Employer HRA plan is a high deductible health plan combined with a health reimbursement account.

This plan has an in network calendar year deductible of $1,000 individual and $2,000 family. However, Metropolitan Council funds the deductible by depositing $1,000 for people who elect single coverage , or $2,000 for people who elect family coverage into a trust account to reimburse you for medical expenses.

This deposit occurs every calendar year that you are enrollment in the Empower HRA plan.

It is NOT pro-rated for new employees. Newly eligible employees who enroll in the Empower HRA plan get the entire employer contribution, even if their coverage is effective near the end of the calendar year.

The HRA account reimburses you for any out of pocket medical expenses.20

Medical Plans Empower HRAHealth Reimbursement AccountEmployer contribution is tax-freeBalance carries over year after yearBalance is yours even if you switch plans, terminate employment or retireInterest bearing Metropolitan Council pays admin fee as long as you are enrolled in Empower HRA plan

The HRA contribution is fully tax free and will carry over into the next year or years if it is not used. These dollars are yours to use to reimburse out of pocket medical expenses, even if you switch plans at open enrollment, terminate employment or retire.

They are in an interest bearing trust fund and Metropolitan Council pays the administration fee for that account for as long as you are a participant in the plan.

If you switch plans, retire or terminate, a $4 per month administrative fee is deducted from you HRA balance, until the entire account is depleted.

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Medical PlansEmpower HRAHealth Reimbursement AccountOnly Metropolitan Council can contribute to HRA accountEligible expenses for reimbursement from HRA account:DeductibleCopaysCoinsuranceIRS 213D list (Flexible Spending Account List)

Only the Metropolitan Council can contribute to your HRA account; You cannot add to the funds.

Your HRA can be used to reimburse expenses for any active employees or dependents, and includes deductible, coinsurance and copays for medical and dental expenses.

In fact, you may use that fund to reimburse any expenses that are on the IRS 213D list, which is the same list as used to determine eligible expenses on the Flexible Spending account, so it also includes items such as eyeglasses, hearing aids, and durable medical equipment. 22

Medical PlansEmpower HRA- Health Plan BenefitsUnlimited Lifetime MaximumPreventive services covered at 100%All other services 80% after deductible$1,000 individual/$2,000 family calendar year deductible$2,500 individual/$5,000 family out of pocket maximum per calendar year

The Empower HRA plan has an unlimited lifetime maximum in-network. Preventive care is covered at 100%. All other services, including prescription drugs, is paid at 80% after the calendar year deductible.23

Medical Plans Empower HRA- Prescriptions

Prescription drugs paid at 80% after deductibleDebit card for prescription drugs onlyCompare drug costs with the drug cost calculator at www.healthpartners.com/pharmacy

HealthPartners does supply Empower HRA participants with a debit card to be used at the pharmacy for prescription drugs only. This debit card takes money directly from your HRA fund to pay for the prescriptions.

Using the drug cost calculator on healthpartners.com, you can find the negotiated prices of your prescription from several pharmacies in your area. The cost difference between two pharmacies can be amazing, and worth the trip to another pharmacy. 24

Medical PlansEmpower HRAMedical Claims Processing

Here is how the HRA claims process works.

When you see an in-network medical provider, you show your ID card, and they bill HealthPartners. Generally you are not asked for any payment at the front desk.HealthPartners processes the bill, applies the network discount, then either applies the balance to your deductible, or if your deductible is met, pays 80% of the negotiated rate.HealthPartners sends an explanation of benefits (EOB) to your doctors office and to you.At the same time HP sends the claim to their HRA processing center, which checks your balance due for that claim against your HRA account balance. If there are adequate funds, they send you a check for the out of pocket amount. You deposit the check and pay the doctor

For example: if this was your first visit of the calendar year, and the doctors bill was $100; then HP would first apply the negotiated discount, (lets say that was $25), then apply the remaining $75 to your deductible. You would get an EOB that you owe the doctor $75, and then get a check for $75 from HP a few days later. This check is the reimbursement from your HRA account. You deposit the check and pay the bill.25

Medical PlansEmpower HRAPrescription ClaimsProcessing

Here is how prescriptions claims are handled

You show your HealthPartners ID card, and the pharmacy will submit for benefits as they fill your prescription. The prescription amount may go toward your deductible, be paid at 80% or, if you have met your out of pocket maximum, be paid in full.Any amount that you owe for the prescription can be paid using your HP debit card, unless youve already used your entire HRA balance. If the amount is depleted you must pay from your own funds.Note: if you have a flex account, you may want to use your flex debit card to pay for the prescription, saving your HRA funds. 26Reimbursement from HRA account sent to you (check or direct deposit)Benefits from the health plan sent directly to provider of servicesAutomatic reimbursement is called CrossoverMUST turn off crossover if there is other insurance coverageMAY turn off crossover if you have an FSA

Medical Plans

Because the HRA account is a reimbursement account, the reimbursement will always go to you, either in paper check form, or you can sign up for direct deposit. You cannot request it to be sent directly to the medical provider.

However, benefits payable under the health plan, such as the 80% payment HP would make after you meet your deductible, do go directly to the provider.

The automatic reimbursement of out of pocket expenses from your HRA account is called crossover. It happens automatically, unless you send HP a form to turn off crossover. Once the crossover is turned off, you can manually submit claims for the proper out of pocket expense reimbursement.

You MUST turn off the crossover if you or anybody in your family has other insurance coverage. Both insurance companies must process your claim before your financial responsibility is determined for that service.

You may also choose to turn off crossover if you are also enrolled in a Flexible Spending Account. Since FSA money is lost if not used during the calendar year, you will want to deplete that account before using your HRA contributions.

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Medical Plans Scenario #1- single coverage$1,000 contribution- 20111 office visit -$100 (discounted amount)= $900 balance$1,000 contribution- 2012 (new balance $1,900)2 office visits -$200 (discounted amount) = $1,700 balance$1,000 contribution- 2013 (new balance $2,700)

Because unspent HRA account dollars carry over from year to year, you have the potential to save enough to cover any out of pocket expenses, even with the most catastrophic of health problems.

Scenario #1

You enroll in single coverage and MC contributed $1,000 to you HRA account. You have a great year, only needing to see a doctor once, using $100 of your funds, leaving a $900 balance that carries into the next year.In January of that next year, you get another $1,000 contribution bringing your balance to $1,900. This year you require two office visits, using $200 of your funds. $1,700 carried over into the next year.When combined with the third year contribution, brings your total to $2,700

28Medical PlansScenario #1- continuedHRA account balance $2,700$200,000 hospital bill (discounted amount)$2,500 calendar year out of pocket maximumHealthPartners pays $197,500$2,500 is reimbursed to you from your HRA account- you pay hospital$200 balance in account, all claims for the rest of the calendar year paid at 100%

Now that 3rd year is not so good.

You have a major accident right at the beginning of the year which results on a $200,000 hospital bill. HP processes the claim, applying your deductible and coinsurance. However, your individual out of pocket maximum is $2,500. HP then reimburses you $2,500 from you HRA account.

HP pays the hospital $197,500 You now have a balance of $200 in your HRA account and, since you met your out of pocket maximum, HP pays any additional claims for the rest of the calendar year at 100%.

You paid $0 in out of pocket expenses this year. 29

Medical Plans Scenario #2- family coverage$2,000 contribution- 2011Several office visits and prescriptions$2,200 in total expenses (discounted amount)$2,000 deductible reimbursed from HRA account (balance is now $0)Remaining $200 is paid under the health plan at 80%. You pay $40. Total paid out of your pocket- $40

Not all scenarios are that drastic. Lets look at a second scenario.

Scenario #2

You enroll in family coverage, and MC contributed $2,000 to your HRA account. Throughout the year, your family has several office visits and prescriptions, totaling $2,200 in expense.

The calendar year family deductible is $2,000, which is reimbursed from your HRA contribution.

The other $200 in expenses is paid under the HP health plan at 80%, leaving you to pay the 20%, or $40 out of your pocket.

Your total medical expenses paid out of your pocket in this calendar year is $40.

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How To ChooseLook at past medical historyCurrent healthInclude premiums in your cost calculationsWorst case scenario- combine annual premiums with out of pocket maximumPremiums are inevitable; deductibles, copays and coinsurance only apply if you have claims

So now you have seen all three medical plans, each of which is a very good plan. How do you choose which one to select?

Look at the monthly premiums for each health plan. These premiums can be found in your packet. Note that the Open Access plan, which is the richest plan, is the most expensive. The HRA plan, which has the highest deductible is usually the least expensive plan.

Look back at the last several years of your medical history. How often do you and your family use medical services?

What is your current state of health? Do you take prescriptions? DO you have a chronic health condition? Are you generally healthy?

Many people worry that even if they are very healthy, something catastrophic could happen. To determine the worst case scenario, combine the yearly premiums for your plan with the out of pocket maximum for that plan. And remember for HRA you get a contribution from MC. Use the single amount of you would enroll in single coverage and the family amount if you would enroll in family coverage.

Premiums are inevitable: deductibles, copays and coinsurance only apply if you have claims.

Notes: The plan with the lowest out of pocket expenses could actually be the highest costing plan when you add the monthly premiums that you pay for that plan. Remember that the premiums you pay for the plan you choose are the same every month, if you utilize medical care or not, so take into consideration that the higher copay or coinsurance that is only applied if you incur those services may be worth the lower premiums.

31Wrap-UpMetropolitan CouncilBenefits

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Forms DueSpecial Open Enrollment forms must received in Benefits no later June 10, 2011 (fax, email, interoffice mail, regular mail)You must submit proof of eligibility for dependents you are enrolling - see the back of the form

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Forms DueSubmitting forms earlier is betterIf you do not submit your forms in time, you will not be able to enroll in a plan or change dependents until the next open enrollment, unless you have a qualified family status change.

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QuestionsAny Questions?Benefits Contact Information:Email: benefits@metc.state.mn.usBenefits-One Line (651) 602-1601

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