Transcript 2010 Employee Benefits Option Presentation

2014 Benefit Options
Presentation
Plan Year January 1 through December 31, 2014
This publication is issued by the Office of Management and Enterprise
Services as authorized by Title 62, Section 34. Copies have not been printed
but are available through the agency website. This work is licensed under a
Creative Attribution-NonCommercial-NoDerivs 3.0 Unported License.
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2949
The Employee Benefit
Options Guide
How to access the Guide:
• View the Guide on the EGID website
at www.sib.ok.gov or
www.healthchoiceok.com
• Complete the online request to get
one by mail
• Contact your Insurance Coordinator
• Contact EGID Member Services
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Topics
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•
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2014 Plan Changes
Health Plans
Dental Plans
Vision Plans
HealthChoice Life Insurance Plan
Eligibility
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For More Information
• 2014 Employee Benefit Options Guide
• Frequently Asked Questions at
www.sib.ok.gov or
www.healthchoiceok.com
• Plan websites and customer service
representatives
• Your Insurance Coordinator
• EGID Member Services
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Index
Click the links below to access a
particular section of this presentation.
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2014 Plan Changes
HealthChoice Health Plans
HMO Health Plans
Dental Plans
Vision Plans
HealthChoice Life Insurance Plan
Eligibility
End Presentation
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2014 PLAN
CHANGES
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Eligibility Changes
Enrolling a newborn:
• HealthChoice and HMO plan members
must enroll the newborn for the
month of birth if dependent coverage
is desired
• Premium for month of birth must be
paid
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HealthChoice Plan Changes
HealthChoice High and USA Plans
• Calendar year out-of-pocket maximum is
being increased to $3,300 for an
individual/Network and $3,800 for an
individual/non-Network
HealthChoice High Alternative Plan
• Calendar year out-of-pocket maximum is
being increased to $3,550 for an
individual/Network and $4,050 for an
individual/non-Network
• Calendar year out-of-pocket maximum is
being decreased to $8,400 for a family
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HealthChoice Plan Changes
HealthChoice S-Account Plan
• Copays for physician office visits for
general practitioners, etc., and VA,
Military and Indian Clinics is being
reduced to $30
• Copay for specialist office visit will
remain $50
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HMO Plan Changes
CommunityCare HMO
• Calendar year out-of-pocket is being
increased to $4,000 for an individual and
$8,000 for a family
• Copay for hospital inpatient admission
increased to $750
• Copay for hospital outpatient visit increased
to $500
• Copay for mental health or substance abuse
inpatient admission increased to $750
• No referral needed for most specialist visits
• Visit state.ccok.com to view benefits, claims,
EOBs, and more
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HMO Plan Changes
GlobalHealth HMO
• Copay for specialty scans will be $750
• Copay for outpatient visits in free-standing
facility will be $250 and $750 in a hospital
facility
• Copay for emergency health care facility visit
increased to $300
• Durable medical equipment – 20%
coinsurance
• Occupational or speech therapy and physical
therapy/physical medicine limit: 60
combined inpatient and outpatient visits per
acute illness or injury
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Dental Plan Changes
HealthChoice Dental
• 12-month waiting period will apply to
all members, including those who had
previous group dental coverage
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Dental Plan Changes
CIGNA Dental
• Cost for sealant increased to $17 per tooth
• Cost for amalgam, one surface increased to
$23
• Cost for a root canal, anterior, increased to
$375
• Cost for periodontal/scaling/root planing,
1-3 teeth, increased to $75
• Out-of-pocket for children through 18
increased to $2,472
• Out-of-pocket for adults increased to
$3,384
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Dental Plan Changes
Delta Dental
• Delta Dental Premier is now Delta Dental
PPO Plus Premier
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Vision Plan Changes
Primary Vision Care Services (PVCS)
• Discounts offered through nJoy Vision,
previously TLC, call PVCS for details
Vision Services Plan
• $25 copay on contact lenses
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HealthChoice Life
Insurance Plan Changes
Dependent Life Insurance
• Dependent life benefit for birth to 6
months of age is being eliminated
• Dependent children eligible for Low,
Standard, or Premier Option from live
birth to age 26
Return to Index
End Presentation
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HEALTHCHOICE
HEALTH PLANS
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Available Plans
• HealthChoice High
• HealthChoice High Alternative
• HealthChoice Basic
• HealthChoice Basic Alternative
• HealthChoice S-Account
• HealthChoice USA
Using a HealthChoice Network Provider
will lower your out-of-pocket costs.
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HealthChoice Plan Changes
Tobacco-free Attestation
• To remain enrolled in the HealthChoice
High or Basic Plan, you must attest that
you and your covered dependents are
tobacco-free
• Due to HealthChoice by Nov. 15, 2013
The Attestation is available:
• On the EGID website
• Through a mobile app, or
• By calling HealthChoice Member Services
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HealthChoice Plan Changes
If you cannot complete the Attestation, you
must either:
• Enroll in the quit tobacco program AND
complete three coaching calls, or
• Provide a letter from your doctor indicating
it is not medically advisable for you or your
dependent to quit tobacco.
If you do not complete the Attestation or
complete one of the reasonable alternatives as
defined previously, you will be enrolled in the
HealthChoice High Alternative or Basic
Alternative Plan with a higher deductible and
out-of-pocket maximum.
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High
When using a Network Provider:
• $30 copay for primary care office visits
• $50 copay for specialist office visits
• Annual deductible $500 for an
individual or $1,500 for a family
• Plan pays 80% and member pays 20%
of Allowed Charges up to the out-ofpocket maximum of $3,300 for an
individual or $8,400 for a family
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High Alternative
When using a Network Provider:
• Benefits the same as High Plan except
deductible and out-of-pocket maximum
• Annual deductible $750 for an
individual or $2,250 for a family
• Plan pays 80% and member pays 20%
of Allowed Charges up to the out-ofpocket maximum of $3,550 for an
individual or $8,400 for a family
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Basic
When using a Network Provider:
• Office visit copays do not apply
• Plan pays first $500 then member pays
next $500 as deductible; $1,000
deductible for a family of two or more
• Plan then pays 50% until the out-ofpocket maximum is met; $5,500 for an
individual or $11,000 for a family
• Plan then pays 100% of Allowed
Charges
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Basic Alternative
When using a Network Provider:
• Office visit copays do not apply
• Plan pays first $250 then member pays
next $750 as deductible; $1,500
deductible for a family of two or more
• Plan then pays 50% until the out-ofpocket maximum is met; $5,750 for an
individual or $11,500 for a family
• Plan then pays 100% of Allowed
Charges
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S-Account
Plan designed for members with a Health
Savings Account (HSA)
When using a Network Provider:
• Combined $1,500 deductible for an
individual and $3,000 for a family*
• Entire deductible must be met before
benefits are paid (including prescriptions)
• $30/$50 copay for office visits
• The calendar year out-of-pocket maximum
is $3,000 for an individual or $6,000 for a
family
*Individual deductible does not apply if two or more family members are covered.
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USA
• For members who live and work
outside of Oklahoma and Arkansas for
more than 90 consecutive days
• Benefits are the same as the
HealthChoice High Plan
• Members have access to the USA
Plan’s nationwide provider network
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Network Pharmacy Benefits
• Prescriptions can be filled at
HealthChoice Network Pharmacies
• Benefits are the same for all plans; SAccount members must meet the Plan
deductible before benefits are paid
• You are responsible for the cost
difference when choosing a brandname if a generic is available
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Network Pharmacy Benefits
When purchasing up to a 30-day supply:
• Generic – Up to $10
• Preferred brand-name – Up to $45
• Non-Preferred brand-name – Up to
$75
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Network Pharmacy Benefits
When purchasing up to a 90-day supply:
• Generic – Up to $25
• Preferred brand-name – Up to $90
• Non-Preferred brand-name – Up to
$150
90-day fill does not apply to medications
with quantity or dosage limits
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Network Pharmacy Benefits
• Certain prescription tobacco cessation
medications for a $0 copay
• A calendar year pharmacy out-of-pocket
maximum of $2,500/individual, $4,000/
family (does not apply to S-Account
Plan)
• Specialty medications must be
purchased through Accredo Health, the
HealthChoice specialty care, delivery
service pharmacy
Return to Index
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HMO
PLANS
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HMO Plans
• You must live or work within the ZIP
Code service area of the HMO
• Copay system for services and supplies
• Primary Care Physician (PCP) is required
• Select your providers from the network
designated by your plan for the State of
Oklahoma
You must select another provider within
your HMO’s network in the event your
provider leaves the network.
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• $35 office visit copay for PCP
• $50 office visit copay for specialist
• $750 copay for hospital and mental
health or substance use disorder
admission
• $200 copay each emergency room visit
• $50 copay for after-hours urgent care
• Out-of-pocket maximum of $4,000 for
an individual or $8,000 for a family
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Pharmacy
Benefits
• 30-day supply per copay
• $0 copay for select generics
• Up to a $10 copay for formulary generic
medications
• Up to a $40 copay for formulary brandname medications
• Up to a $65 copay for all other
medications
• Some medications have quantity limits
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• $25/$50 office visit copay for PCP/specialist
• $300 copay each emergency room visit
• $25 copay for after-hours urgent care PCP;
$50 copay for all others
• $250 copay for free-standing outpatient
facility or $750 for a hospital facility
• No copay for x-ray and lab services
• MRI, PET, CAT, or nuclear scan – copay of
$250 for free-standing facility or $750 for
hospital facility
• Out-of-pocket maximum of $3,000 for an
individual or $5,000 for a family
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Pharmacy
Benefits
• 30-day supply per copay
• $4 copay for select generics
• Up to a $10 copay for formulary generic
medications
• Up to a $50 copay for formulary brandname medications
• Up to a $75 copay for all other
medications
• Some medications have quantity limits
Return to Index
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DENTAL
PLANS
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Dental Plans Available
• Assurant Freedom Preferred
• Assurant Heritage Plus with SBA
(Prepaid)
• Assurant Heritage Secure (Prepaid)
• CIGNA Dental Care Plan (Prepaid)
• Delta Dental PPO
• Delta Dental PPO Plus Premier
• Delta Dental PPO – Choice
• HealthChoice Dental
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Dental Benefits
All the dental plans have the same core
benefits which are divided into four
different classes:
• Preventive Care includes cleanings,
bitewing x-rays, and routine oral exams
• Basic Care includes fillings, extractions,
root canals, endodontics, and
periodontics
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Dental Benefits
• Major Care includes dentures,
bridgework, crowns, and implants
• Orthodontic Care* is covered for
members under age 19 and members
age 19 or older with
temporomandibular joint dysfunction
(unless otherwise noted)
*Assurant Freedom Preferred has a 12-month waiting period
for orthodontic care; waived if proof of continuous dental
insurance is provided.
HealthChoice has a 12-month waiting period for orthodontic
care.
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Freedom Preferred
Dental Plan
• Preventive Care is covered at 100%
• A $25 deductible applies to Basic and
Major Care
After the deductible:
• Basic Care is covered at 85%
• Major Care is covered at 60%
• Orthodontic Care under age 19 is covered
at 60%; lifetime maximum benefit $2,000
• All other services have a combined
$2,000 maximum annual benefit
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Heritage Plus
with SBA
Dental Plan
• No deductible or annual maximum for
general dentist
• You must select a Primary Care Dentist
for each covered person
• Preventive Care is covered at 100%
• Copay schedule applies to other services
• Orthodontic Care for children and adults
• The Special Benefit Amendment provides
an additional discount for network
specialists
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Heritage Secure
Dental Plan
• No deductible or annual maximum with
general dentist
• You must select a Primary Care Dentist
for each covered person
• Preventive Care is covered at 100%
• Copay schedule applies to other
services
• Orthodontic Care for children and
adults
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Dental Care
Plan
• No deductible or maximum annual
benefit
• You must select a Primary Care Dentist
for each covered person
• After a $5 copay, routine cleanings, x-rays,
and evaluations are covered at 100%
• A copay schedule applies to other
services, including specialist care
• Orthodontic Care for children and adults
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Delta
Dental PPO
• Preventive Care is covered at 100%
• $25 annual deductible for Basic and
Major Care
• Basic Care is covered at 85%
• Major Care is covered at 60%
• Orthodontic Care for children and adults
is covered at 60% with a $2,000 lifetime
maximum benefit
• $2,500 maximum annual benefit for
other services
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Delta
Dental PPO
Plus Premier
• A $50 combined deductible applies to
Diagnostic, Preventive, Basic, and Major
Care
• Preventive Care is covered at 100%
• Basic Care is covered at 70%
• Major Care is covered at 50%
• Orthodontic Care for children and adults
is covered at 60% with a lifetime
maximum of $2,000
• $3,000 maximum annual benefit
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Delta Dental
PPO – Choice
• You must select a Primary Care Dentist
for each covered person
• No deductible for Preventive or Basic
Care
• $100 deductible for Major Care
• Copay schedule for all other services
• Orthodontic Care for children and adults
has a maximum lifetime benefit of $1,800
• $2,000 maximum annual benefit for
Preventive, Basic, and Major Care
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Dental
When using a Network Provider:
• Preventive Care is covered at 100%
• A $25 deductible applies to Basic and
Major Care
• Basic Care is covered at 85%
• Major Care is covered at 60%
• Orthodontic Care is covered at 50% —no
lifetime maximum, 12-month waiting
period applies
• A $2,500 calendar year maximum applies
to all other services
Return to Index
End Presentation
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VISION
PLANS
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Vision Plans Available
• Humana CompBenefits VisionCare
Plan
• Primary Vision Care Services (PVCS)
• Superior Vision Plan
• UnitedHealthcare Vision
• Vision Service Plan (VSP)
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Vision Plans Overview
• Each vision plan has its own provider
network
• A copay schedule for services and
materials
• The toll-free number and website
address of each plan is listed in the
Employee Benefit Options Guide
• Contact each vision plan for specific
benefit questions
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Humana/CompBenefits
When using an in-network provider:
• $10 copay for an annual eye exam
• $25 copay for lenses and frames; one
pair per year
• Discounts are available for other vision
services and lens options
• Contact lenses are available instead of
glasses; $130 allowance
• Discount through TLC for laser surgery
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Primary Vision Care
Services
When using an in-network provider:
• There is no copay or limit on the
number of eye exams
• Lenses and frames are sold at wholesale
cost
• There is no limit on the number of pairs
of glasses
• Benefits available for contact lenses
• Discount through nJoy for laser surgery
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Superior Vision
When using an in-network provider:
• $10 copay for eye exams; one per year
• $25 copay for lenses and frames; one pair
per year
• Contact lenses – available instead of
glasses; $25 copay/standard fitting then
plan pays 100% or $50 copay/specialty
fitting then plan pays up to $50
• Discounts available for other vision
services and lens options, including laser
vision correction
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UnitedHealthcare
Vision
When using an in-network provider:
• $10 copay for eye exams; one per year
• $25 copay for lenses and frames; one pair
per year
• Lens UV coating and tints are covered in
full
• Contact lenses are available instead of
glasses
• Discounts available for other vision
services and lens options including laser
vision correction
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VSP
When using an in-network provider:
• $10 copay for eye exams; one per year
• $25 copay for lenses and frames; one
pair per year
• No copay for contact lens exam with
network provider
• Contact lenses are available instead of
glasses
• Discounts are available for glasses and
other vision benefits, including laser
vision correction
Return to Index
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LIFE INSURANCE
PLAN
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Employee Life
Basic and Supplemental Life for You
• First $20,000 of life coverage (Basic Life)
• All additional coverage is known as
Supplemental Life
• $500,000 of Supplemental Life coverage
is available with an approved Life
Insurance Application
• Basic Life and the first $20,000 of
Supplemental Life include Accidental
Death and Dismemberment (AD&D)
benefits
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Employee Life
During initial enrollment:
• You can enroll in Guaranteed Issue
(two times your annual salary rounded
up to the next $20,000) without a Life
Insurance Application
• You can apply for amounts above
Guaranteed Issue; a Life Insurance
Application is required
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Employee Life
During Option Period:
• You can enroll in Basic Life
• You can enroll in Supplemental Life
• You can enroll in up to $500,000 of
Supplemental Life insurance coverage
• An approved Life Insurance Application
is required
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Beneficiary Designation
• Keep your beneficiary designation up-todate
• Beneficiaries can be changed at any time
• Review your beneficiaries if you have a
change, such as a marriage, divorce,
death of a family member, or birth of a
child
• Beneficiary Designation Forms are
available online, from your Insurance
Coordinator, or by calling EGID Member
Services
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Dependent Life
You must be enrolled in Basic Life coverage to
enroll your eligible dependents in Dependent
Life.
Premier Option
Spouse
$20,000
Child
$10,000
Standard Option
Spouse
$10,000
Child
$5,000
Low Option
Spouse
$6,000
Child
$3,000
No coverage for a stillbirth.
Return to Index
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ELIGIBILITY
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Eligible Employees
An education employee must be:
• Currently employed, eligible for TRS,
and working at least four hours a day
or 20 hours a week
A local government employee must be:
• Currently employed, regularly
scheduled to work 1,000 hours or
more per year, and cannot be listed
as a temporary or seasonal employee
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Eligible Dependents
Eligible dependents include:
• Your legal spouse (including commonlaw)
• Your daughter, son, stepdaughter,
stepson, eligible foster child, adopted
child, or child legally placed with you
for adoption up to age 26, whether
married or unmarried
• Disabled dependents over age 26 with
approved documentation
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Eligible Dependents
• If you insure one dependent, all
eligible dependents must be insured
• You can exclude dependents who do
not reside with you, are married, are
not financially dependent on you for
support, have other group insurance,
or are eligible for Indian or military
benefits
• A spouse can be excluded by signing
the Spouse Exclusion Certification
statement on the back of the form
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Other Dependent Children
• Other unmarried dependent children
up to age 26, upon completion of an
Application for Coverage for Other
Dependent Children
• Guardianship papers or a tax return
showing dependency can be provided
in lieu of the application
• Dependents cannot include your
parents or grandparents
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Midyear Qualifying Events
Certain qualifying events allow you to
make a midyear change, examples include:
•
•
•
•
•
•
Notify your Insurance
Marriage
Coordinator within 30 days
Divorce
of the event or wait until the
Adoption
next annual Option Period.
Death
Childbirth*
Gain or loss of other group insurance
*Must be added the first of the month of birth.
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Deadlines for Forms
Option Period Enrollment/Change Form:
• Your Insurance Coordinator will
provide the deadline
Insurance Enrollment Form:
• Return your form to your Insurance
Coordinator within 30 days
Insurance Change Form:
• Return your form to your Insurance
Coordinator within 30 days of a
qualifying event
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Deadlines for Forms
Tobacco-free Attestation:
• Must be completed as part of the
Option Period enrollment process
• The Attestation can be completed
online or returned to your Insurance
Coordinator
• Deadline is November 15, 2013
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Confirmation Statements
• EGID mails you a Confirmation
Statement when you enroll or make
changes to coverage
• If your Confirmation Statement is
incorrect, contact your Insurance
Coordinator immediately
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Confirmation Statements
If you do not make changes during the
annual Option Period and are not
automatically enrolled in a HealthChoice
alternative plan, no Confirmation
Statement will be sent; keep your
enrollment form as verification of
coverage
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Reminders
• Option Period is the only time you can
make changes to coverage with a
qualifying event
• HealthChoice High and Basic require a
completed tobacco-free Attestation
• To enroll in dental or life coverage, you
must have group health insurance
• If excluding your spouse, your spouse must
sign the Spouse Exclusion Certification
• Return signed and dated forms to your
Insurance Coordinator by the set deadline
• Notify your Insurance Coordinator if you
have a change of address
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Questions
• The 2014 Employee Benefit Options
Guide
• Plan websites and toll-free numbers
available in your Option Period packet
• The FAQ section of the EGID website
• EGID Member Services at 1-405-7178780 or toll-free 1-800-752-9475; TDD
users call 1-405-949-2281 or toll-free
1-866-447-0436
• Your Insurance Coordinator
Return to Index
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