Transcript Benefits Orientation

Metropolitan Council
Benefits
ATU SPECIAL OPEN
ENROLLMENT
Special Open Enrollment
During this Special Open enrollment, you may:
 Change from one medical plan to another
 Add dependents
 If you currently waive medical coverage, you
may enroll in a medical plan
Special Open Enrollment
You may NOT:
 Drop medical coverage
 Drop coverage for any dependents
 Change any other coverage (such as dental,
vision, or flex)
Medical Plans
 HealthPartners Plans
 Open Access
 Distinctions III
 Empower HRA
Medical Plans
Common Terms
 Lifetime Maximum
 Total dollar amount payable under the plan
 Deductible
 Amount you pay of a medical charge before the health plan
pays
 Copays
 Specific dollar amount that you pay for a specified service
Medical Plans
Common Terms
 Coinsurance
 The percentage of the charge that you are responsible for
 Out of Pocket Maximum
 The dollar maximum that you could potentially pay in a
calendar year for covered medical expenses (includes
deductible, copays and coinsurance)
Medical Plans
Common Terms
 Network Providers
 Doctors and hospitals that contract with HealthPartners
 Network Discounts
 Discounted amounts that HealthPartners negotiates with
their network Doctors
 Formulary
 A list of prescription drugs that are covered by
HealthPartners health plans.
Medical Plans
Common Traits
Common Traits Between Plans
 All plans cover preventive services at 100%
 Same large network of doctors/facilities
 No referrals
 CIGNA network gives in-network benefits when
out of area
 All in-network coverage provides an unlimited
lifetime maximum
Medical Plans
Open Access Plan
Medical Plans
Open Access Plan
 Richest Benefits=Highest Cost
 No Calendar Year Deductible (in-network)
 $10 Office Visit Copay
 $40 Urgent Care Copay
 $50 Emergency Room Copay
Prescription Drug Copay:
 $12 (generic or brand name)
 Mail order available
Medical Plans
Distinctions III Plan
Medical Plans
Distinctions III
 Three Tiers (Levels) of In Network Providers
 Tiers assigned by HealthPartners based on many
factors, some of which are:
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Patient outcomes
Overall cost of treatment
Use of technology
Patient Satisfaction
Medical Plans
Distinctions III
 Who is Tiered?
Primary Care
 Cardiology
 Ear, Nose and Throat (ENT)
 Orthopedics
 Ob/Gyn
 Hospital
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 Specialties not tiered default to level 2
Medical Plans
Distinctions III
 Providers re-evaluated every calendar year
 Lowest out of pocket costs when you use highest
level of provider (level 1)
 You have coverage for all providers
 Look up providers levels on
www.healthpartners.com or call HealthPartners
customer service at (952) 883-5000
Medical Plans
Distinctions III
 Tiering is done individually
 Same clinic does not mean same tier or level
 Primary Care may be level 2
 Cardiologist in same clinic may be level 1, 2, or 3
Medical Plans
Distinctions III Office visits: $15 copay (level 1), $25 copay (level
2), $35 copay (level 3); no deductible
 Inpatient Hospital: $100 copay (level 1), $250
copay (level 2), $500 copay (level 3); deductible
applies
 Outpatient Care: $30 copay (level 1), $40 copay
(level 2), $70 copay (level 3); deductible applies
 Urgent Care: $25 copay; no deductible
Medical Plans
Distinctions III Behavioral Health and Convenience Care visits:
$15 copay all levels; no deductible
 Emergency Room: $75 copay; no deductible
 Prescription Drugs: $8 copay for generic, $18
copay for brand name; mail order available
Medical Plans
Distinctions 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
Medical Plans
Empower HRA Plan
Medical Plans
Empower HRA
 High Deductible Health Plan combined with a
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Health Reimbursement Account (HRA)
Employer contribution to HRA account
Contribution fully funds deductible
Contribution not pro-rated, regardless of entry
date into plan
HRA account reimburses out of pocket expenses
Medical Plans
Empower HRA
Health Reimbursement Account
 Employer contribution is tax-free
 Balance carries over year after year
 Balance is yours even if you switch plans, terminate
employment or retire
 Interest bearing
 Metropolitan Council pays admin fee as long as you
are enrolled in Empower HRA plan
Medical Plans
Empower HRA
Health Reimbursement Account
 Only Metropolitan Council can contribute to HRA
account
 Eligible expenses for reimbursement from HRA
account:
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Deductible
Copays
Coinsurance
IRS 213D list (Flexible Spending Account List)
Medical Plans
Empower HRA- Health Plan Benefits
 Unlimited Lifetime Maximum
 Preventive 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
Medical Plans
Empower HRA- Prescriptions
 Prescription drugs paid at 80% after deductible
 Debit card for prescription drugs only
 Compare drug costs with the drug cost calculator at
www.healthpartners.com/pharmacy
Medical Plans
Empower HRA
Medical Claims
Processing
Go to
doctor,
show ID
card
Doctor office
bills HP,
HP processes
claim
HealthPartners sends
explanation of benefits,
submits to HRA processing
You deposit
check,
pay provider
If funds are
adequate,
check
for balance
due is sent
to you
Medical Plans
Bring prescription
to network
pharmacy,
show HealthPartners
card
Empower HRA
Prescription Claims
Processing
Pharmacy runs claim
through the plan,
determine the
amount
you owe
Use your HP debit
card to pay
balance.
If no HRA funds,
you pay with your
own funds
 Reimbursement from HRA account sent to you
(check or direct deposit)
 Benefits from the health plan sent directly to
provider of services
 Automatic reimbursement is called Crossover
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MUST turn off crossover if there is other insurance coverage
MAY turn off crossover if you have an FSA
Medical Plans
 Scenario #1- single coverage
 $1,000 contribution- 2011
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$1,000 contribution- 2012 (new balance $1,900)
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1 office visit -$100 (discounted amount)= $900 balance
2 office visits -$200 (discounted amount) = $1,700 balance
$1,000 contribution- 2013 (new balance $2,700)
Medical Plans
 Scenario #1- continued
 HRA account balance $2,700
 $200,000 hospital bill (discounted amount)
 $2,500 calendar year out of pocket maximum
 HealthPartners 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%
Medical Plans
 Scenario #2- family coverage
 $2,000 contribution- 2011
Several office visits and prescriptions
 $2,200 in total expenses (discounted amount)
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$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
How To Choose
 Look at past medical history
 Current health
 Include premiums in your cost calculations
 Worst case scenario- combine annual premiums
with out of pocket maximum
 Premiums are inevitable; deductibles, copays and
coinsurance only apply if you have claims
Metropolitan Council
Benefits
WRAP-UP
Forms Due
 Special 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
Forms Due
 Submitting forms earlier is better
 If 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”.
Questions
Any Questions?
Benefits Contact Information:
Email: [email protected]
Benefits-One Line (651) 602-1601