State Employee Health State Employee Health PlanPlan
Non State GroupOpen Enrollment 2010
Changes for 2010Changes for 2010Medical Plans
Plan changes for Plan ADeductible increased to $150/$300Coinsurance maximum increased to $1,200/$2,400Quest LabCard added
No plan changes for Plan B and Plan C
Prescription Drug PlanAdding Performance Drug List
Dental Plan Deductible increased to $50/$150 New value-based plan design
Medical Plan Options Plan OptionsPlan A Plan B Plan C
Blue Cross and Blue Shield of Kansas √ √
CoventryHealth Care √ √ √
Preferred Health Systems √ √ √
UMRa UnitedHealthcare Co.
√ √ √
Medical PlanMedical Plan
Standardized Plan designs:All plans include preventive care Not all services are covered
Review the benefit descriptionQuestions - contact plan’s customer service
Differences:Provider networks
All plans are Preferred Provider Organizations (PPO)
RatesAdditional services/discounts offered on Medical Plan’s websites
Selecting a Medical PlanSelecting a Medical Plan1. Pick a plan design (Plan A, B or C)2. Review the Provider Networks
● Each of the medical plans uses a different provider network
3. Review the other services each medical plan offers
4. Review the premiums
PPO ProvidersPPO Providers
Claims paid based on the network statusNetwork providers accept the plan allowanceNon Network Providers can balance bill
Non Network Providers may work at Network Facilities - examples:
PathologistsEmergency Room ProvidersAnesthesiologistsRadiologistsLaboratory Technicians
Plan A - Network Provider
Service on 1/2/2010
Plan Pays
Member Pays
Provider
Write Off
Billed Charge $1,500
Allowed Charge $1,400 $100
$150 Deductible ($150) $150
20% Coinsurance $1,250 $1000 $250
Total $1,00
0 $400 $100
Plan A - Non Network Provider
Service on 1/2/2010
Plan Pays
Member Pays
Provider
Write Off
Billed Charge $1,500
Allowed Charge $1,400 $100 $0
$500Deductible ($500) $500
50% Coinsurance $900 $ 450 $450
Total $450 $1050 $0
Primary Care ProvidersPrimary Care Providers
General practiceFamily practiceGeriatrics
Internal medicine
Physician extenders
Pediatrics
● Primary Care Providers (PCPs) are defined as:
● Use a network provider ● Referrals not required by the medical plan
Preventive CarePreventive Care
Physical ExamsWell WomanWell ManWell BabyWell Child
Immunizations Over age 60 – shingles vaccineFlu shots
Vision ExamHearing ExamBone Density ScreeningMammogramColonoscopy
Plan A – Network ProvidersPlan A – Network Providers
Preventive Care Covered at 100%Office Visit Copays
$20 for Primary Care Office Visits$40 for Specialist Office Visits
$150/$300 Deductible 20% CoinsuranceCoinsurance Max $1,200/$2,400Quest LabCard Benefit
Quest LabCardQuest LabCardOptional benefit
You will need to request tests are sent to Quest or.. Use a Quest collection siteThe decision is up to you and your provider
100% coverage of eligible outpatient lab testsSaves you and the plan money For non-emergency outpatient lab work onlyTesting must be performed and billed by Quest
You will receive a Quest ID cardQuest logo will also be on your medical card
Plan B – Network ProvidersPlan B – Network ProvidersPreventive Care Covered at 100%Primary Care Office Visits
$20 Adult Copay$10 Children age 18 and under Copay
Specialist Office Visits$40 Adult Copay $25 Children age 18 and under Copay
No Deductible30% CoinsuranceCoinsurance maximum $2,200/$4,400Quest LabCard benefit
Quest Lab Card SavingsQuest Lab Card Savings
Current Lab Fees
Billed $194.83Allowed: $155.86Coinsurance 80%Plan pays $124.69Member pays
$31.17
LabCard Fees
Total Charges $35.33
Coinsurance 100%
Plan Pays $35.33
Member Pays $0
Charges on a typical lab claim for: CBC, Lipid Panel, TSH & Basic Metabolic Panel
Plan saves $89.36 and Employee saves $31.17
Source: Quest Diagnostics, Inc.
Plans A & B - Non Network Plans A & B - Non Network ProvidersProviders
$500/$1,500 Deductible50% CoinsuranceCoinsurance Max $3,650/$7,300Preventive care not covered
Drug PlanDrug PlanGeneric Drugs
20% CoinsurancePreferred Brand
35% CoinsuranceSpecial Case Medications
$75 per 30-day supplyNon Preferred Brand
60% CoinsuranceDiscount Tier
100% Member responsibility
Drug PlanDrug PlanPrint out the PDL and take it with you
Preferred Drug List (PDL) available on website
PDL is updated quarterly
Talk to your doctor about prescription drug optionsUsing Generics will save you moneySpecialty, Special Case and injectables lists
on the websitewww.khpa.ks.govwww2.caremark.com/kse/
Performance Drug List Performance Drug List Three drug classes of Performance Drug List:
ACE/ARBs – Blood pressure loweringHMGs – Cholesterol lowering PPIs – Stomach acid reducers
Must try a Generic before using a Non Preferred Brand Name Drug
Claim system will review member’s history
Generic and Preferred Brands not effectedThose using a Non Preferred drug will be notified by Caremark
Performance Drug ListPerformance Drug ListPreferred ACE/ARBs
Genericbenazepril & benazepril HCTcaptopril & captopril HCTenlapril & enlapril HCTfosinopril & fosinopril HCTlisinopril & lisinopril HCTmoexipril & moexipril HCTquinapril & quinapril HCTramipriltrandolapril
Preferred BrandsBenicar & Benicar HCTMicardis & Micardis HCT
Non Preferred ARBs
Diovan & Diovan HCTTeveten & Teveten HCTTekturna & Tekturna HCT
Angiotensin Converting Enzyme Inhibitors (ACEs)
Angiotensin II Receptor Antagonists (ARBs) &
Direct Renin Inhibitors & Combinations
Blood Pressure Lowering
Performance Drug ListPerformance Drug List
Preferred HMGs
Genericsimvastatinpravastatinlovastatin
Preferred BrandsLipitorCrestor
Non Preferred HMGsVytorinLescolLescol XLAltoprevPravacholZocor
Cholesterol Lowering Agents
HMG-CoA Reductase Inhibitors (HMGs or Statins)/Combinations
Performance Drug ListPerformance Drug List
Preferred PPIs
Genericomeprazolepantoprazole
Preferred BrandsPrevacidNexium
Non Preferred PPIsAciphexPrilosec
Stomach Acid Reducers
Proton Pump Inhibitors (PPIs)
Home DeliveryHome DeliveryConvenient and easyTiming of orders
New orders process within 10-14 daysReorders process in 5-7 days
Up to a 60-day supply availableSame Coinsurance requirementsConvenient re-orders
Online @ Caremark.comPhone: 1.800.294.6324
Projected Generic Launches Projected Generic Launches 4th Qtr. 2009
Prevacid
Pulmicort Inhalation Suspension
Valtrex
1st & 2nd Qtr. 2010
ArimidexFlomax 24 hour ER
HyzaarEffexor XR
http://www.khpa.ks.gov/sehp/2009_providers.html
3rd & 4th Qtr. 2010
• Aricept
• Cozaar
• Namenda
Specialty & Biotech DrugsSpecialty & Biotech DrugsDesigned for conditions that are difficult to treat with traditional therapy
Treatments for: cancer, MS, hemophilia, hepatitis C, rheumatoid arthritis and growth hormoneSelf-administered drugs for home useOvernight shipping
Available only at Caremark Specialty Pharmacy
Call Caremark Connect: 1.800.237.2767
Coordinates patient care with provider
List of Specialty & Biotech drugs available:
http://www.khpa.ks.gov/sehp/2009_providers.html
Plan C – QHDHP w/ HSAPlan C – QHDHP w/ HSA
QHDHP is the medical & drug planHSA is the health savings account You are not eligible to enroll for an HSA if:
Anyone covered by MedicareCovered by another health plan that is not a QHDHPCovered by a health care flexible spending account Covered by TRICARE or TRICARE For LifeEligible to receive VA medical services
Plan C - QHDHP Plan C - QHDHP
Network Provider Coverage$1,500/$3,000 Deductible
20% Coinsurance$3,000/$6,000 Out-of-Pocket MaximumPreventive Care Services paid at 100%
Non Network Provider Coverage$2,000/$4,000 Deductible 50% Coinsurance$3,650/$7,300 Out-of-Pocket Maximum Preventive Care is not covered
Plan C – QHDHP Drug PlanPlan C – QHDHP Drug Plan
Drugs are subject to the Deductible then:Generic $10 Copayment Preferred Brand $30 CopaymentNon Preferred Brand $55 Copayment
Copayment is per 31-day supplyGeneric Incentive ProvisionUses Caremark Preferred Drug List, Performance Drug list and Specialty PharmacyNot “creditable” drug coverage for Medicare
Plan C – Health Savings Account Plan C – Health Savings Account (HSA)(HSA)
Employer contribution to your HSA
$75.00 per pay month for single$112.50 per pay month for family
Member contribution to HSARequire contribution of $50 per month
HSA bank depends on medical plan vendor selected
http://www.khpa.ks.gov/SEHBP/benlink.htm
HSA funds can be used to pay: Deductible, Coinsurance, Copayments
Dental CoverageDental CoverageYou have access to two PPO provider networks
Delta Dental PPODelta Dental Premier
Plan DeductibleApplies to Basic & Major Restorative Care$50 per person, $150 per family
Orthodontic benefit $1,000 per person per lifetime
Annual benefit maximum$1,700 per person per year
Dental Preventive Care Dental Preventive Care Covered in full:
Prophylaxis/cleanings – twice per year.Oral examinations – twice per year.Bitewing x-rays –
adults – 1 x a year children under 18 - 2 x a year
Full mouth x-rays – once each five (5) years.Limited coverage for children only:
SealantsSpace maintainersTopical fluoride
Dental Restorative Dental Restorative ServicesServices
Basic RestorativeRegular restorative dentistry – fillingsOral surgeryEndodontics – root canals Periodontics – treatment of gum & bone disease Additional Diagnostic X-Rays
Major RestorativeSpecial restorative dentistry – crownsProsthodontics – bridges, implants, denturesTMJ Treatment – Requires prior authorization
Restorative care is subject to a $50 deductible
Value Based Plan DesignValue Based Plan Design
Basic BenefitBasic BenefitIf You have NOT had one preventive or office visit for cleaning or exam of the teeth in the preceding 12-month period:
Benefit Level PPO Premier Non Network
Preventive CareCovered in
full
Covered in full
Allowed amount
covered in full
Basic Restorative
Services50% 50% 50%
Major Restorative
Services50% 50% 50%
Enhanced BenefitEnhanced Benefit
If You have had at least one preventive or office visit for cleaning or exam of the teeth in the preceding 12-month period :
Benefit Level PPO Premier Non Network
Preventive Services
Covered in full
Covered in full
Allowed amount covered in full
Basic Restorative
Services20% 40% 40%
Major Restorative
Services50% 50% 50%
Exams subject to $50 Copay$25 Materials Copay then:
100% single-vision, standard bifocal, trifocal lenticular lensesUp to $100 allowance for frames
Elective Contact lens allowance $150Home delivery: SVcontacts.com
Basic Vision PlanBasic Vision Plan
Enhanced Vision PlanEnhanced Vision Plan
Includes Basic Plan Coverage PLUS…Progressive lenses up to $165 High index lenses or Poly-carbonate lenses up to $116 Scratch and UV coatingContact Lens Fitting Fee
Subject to $35 CopayLimited Coverage
Enhanced benefits not available from Non Network Providers
Non Tobacco Users DiscountNon Tobacco Users DiscountYou must complete enrollment form and declare tobacco status to get the discount!$40 discount per monthMust be a non tobacco user
- or -
Tobacco users agreeing to enroll in the HealthQuest tobacco control program beginning 1/1/10
Tobacco Control ProgramTobacco Control Program1. Enroll in the tobacco control program between
1/1/2010 and 1/31/2010 2. Complete an assessment with a Quit Coach by
1/31/2010 3. Complete a minimum of four remaining telephone
discussions with a Quit Coach by 5/31/20104. Call the toll free number from 7 AM – 2 AM any time
you need to speak with a Quit Coach.5. Quit for Life will notify the SEHP once you have
completed and you will receive a congratulatory letter from the SEHP. Additionally, employees will be requested to complete a survey to give their feedback on the program.
Paying the Base Rate in Paying the Base Rate in 20102010
The following will NOT be receiving the discount:Elects not to disclose Tobacco statusTobacco users not enrolled in the tobacco control program Failed to enroll and declare tobacco statusMembers who enroll but fail to complete the tobacco control course within the required timeline will be notified of the loss of the non tobacco discount
Every 6.5 seconds someone around the world dies from tobacco use. In fact, it is the only legal consumer product that kills when used as intended. Tobacco use is the second leading cause of death around the globe; it causes more death globally than AIDS, illegal drugs, motor vehicle accidents, murder, and suicide combined.Source: National Business Group on Health – Tobacco the Business of Quitting
ResourcesResources
Review the Open Enrollment (OE) bookletCall the health plan customer service
Phone number in the front of the OE booklet
Visit the KHPA website: http://www.khpa.ks.gov/SEHP/Active.htm
Benefit descriptions availableCaremark PDLProvider listingsInformation on HSA accounts
Email ?’s to SEHP: [email protected]
HealthQuestHealthQuestHealth Screenings & Online Health Assessment
$50 gift card for completion
Health CoachingOnline Wellness NewsletterHealthQuest Website and BlogWellness PresentationsLIFELINE Employee Assistance Program
1-800-284-757524/7 supportConfidential, personal counseling & referrals
http://www.khpa.ks.gov/healthquest/default.htm
Annual Open EnrollmentAnnual Open EnrollmentOctober 1 – October 31, 2009
Enroll: Using enrollment form
Declare tobacco statusMake changesAdd/drop dependents
Paper enrollment forms required:New employees hired after September 10, 2009
Coverage effective January 1, 2010
Required DocumentationRequired DocumentationIf you are adding a dependent, documentation of eligibility is required
Birth certificates Marriage licensesAffidavit of common law marriageSocial Security numbers for all covered members
Documentation must accompany enrollment formIf documentation is not received dependents will not be added to your plan for 2010
Identification CardsIdentification Cards
Make sure your address is up-to-date Plan A members will get new health plan id cardAll Plan A members will get a LabCard id cardDelta Dental will be issuing everyone new id cardsNew cards for new/changed memberships only
Superior VisionCaremarkPlans B and C
If you lose your card, call the health plan
Open Enrollment ChecklistOpen Enrollment Checklist
Enrollment: Use enrollment formMust declare tobacco status Review health plan selections
Questions?Questions?