Transcript deductible - Children`s Home Society of Florida

Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions
Children’s Home
Society of Florida
2013 Open Enrollment
Agenda
1. 2013 Medical Benefits
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2.
3.
4.
5.
HRA (Health Reimbursement Arrangement) Health Network Only
HRA (Health Reimbursement Arrangement) Health Network Option
Incentives
Tools and resources
Dental PPO plan
Life & Disability, EAP plan
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Changes for 2013
• Women’s Health – Covered at 100% for Gestational Diabetes screening, HPV, and
several other screenings and counseling. (See benefit plan design for more details).
• 100% coverage for Pre-Natal Maternity care.
• 100% coverage for tubal ligation and generic contraceptives.
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Components of HRA
Preventive Care Covered at 100%
All Other Care
1
3
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FUND for covered
medical expenses
You pay medical
expenses until
you meet
DEDUCTIBLE
MEDICAL BENEFITS
provide traditional
coverage
Out-of-Pocket Maximum
Information and Decision Support Tools
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Components of HRA
Preventive
Preventive
Care
Care
The
Fund
The
Deductible
Medical
Benefits
• Preventive care covered at 100% - no
deductible in-network
• Preventive Care includes routine
physicals, mammograms, pap smears,
child immunizations, flu shots,
colorectal cancer screenings and more
(subject to guidelines)
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Components of HRA
Preventive
Care
The
Fund
• Provided by CHS at 100%
• Fund used first; pays 100% of covered
expenses (medical only, Rx not covered by
fund)
• Fund Amount $750/$1,500
The
Deductible
Medical
Benefits
• Earn an additional $50/$100 through
incentives
• Fund dollars do not roll over to following year
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Components of HRA
Preventive
Care
The
Fund
The
Deductible
Medical
Benefits
• Increase your fund by $50 per employee and
$50 per spouse. To be eligible for the
incentive*:
• Employee and covered spouse must
complete the health risk assessment
(Simple Steps)
PLUS
• Complete one Online Wellness Program
*Survey no longer required for payout of incentive
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Components of HRA
Preventive
Care
The
Fund
The
Deductible
• Deductible includes the fund, plus
the amount you pay (member
responsibility) after your fund is
exhausted and before your medical
benefits begin
Medical
Benefits
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Components of HRA
Preventive
Care
The
Fund
The
Deductible
• After fund and member responsibility
(deductible) exhausted
• Member pays coinsurance until out-of-pocket
maximum is reached.
• Plan pays 100% after out-of-pocket maximum
is met
Medical
Benefits
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Aetna Health Fund (HRA)
Aetna Health Network ONLY
Plan Design Feature
CHS-Provided HRA Fund
HRA Incentive Program
Deductible
Preventive Care
Office Visits
Emergency Room
Inpatient Hospital Stay
Prescription Drug
Annual Out-of-Pocket
Preferred Provider
$750
$1,500
$50/$100
$2,000 Individual
$4,000 Family
$0; no deductible
25%; after deductible
$25% after $250 copay; after deductible
25%; after deductible
Not subject to deductible
or Fund
$20/$45/$65
$4,500 Individual
$9,000 Family
Benefit Exclusions and limitations apply. See your plan design summary for more information.
*Benefits exclusions and limitations apply. See your plan design summary for more
information.
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Aetna Health Fund (HRA)
Aetna Health Network OPTION
Plan Design Feature
CHS-Provided HRA Fund
HRA Incentive Program
Deductible
Preventive Care
Office Visits
Emergency Room
Inpatient Hospital Stay
Prescription Drugs
Annual Out-of-Pocket
Maximum
Preferred Provider
Non-Preferred Provider
$750 Employee Only
$1,500 Family
$50/$100
$2,000 Individual
$4,000 Family
0%; No deductible
25%; after deductible
25%; after $250 copay; after
deductible
25%; after deductible
Not subject to deductible or
Fund
$20/$45/$65
$4,500 Individual
$9,000 Family
$4,000 Individual
$8,000 Family
Limited Coverage
45%; after deductible
Same as Preferred Benefit
45%; after deductible
Not Covered
$8,000 Individual
$16,000 Family
Benefit Exclusions and limitations apply. See your plan design summary for more information.
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Prescription Terms to Know
Generics – Prescriptions identified as a generic and
subject to the lowest prescription copay.
Formulary Brand-Name – Prescriptions identified as a
brand name drug that are on Aetna’s preferred drug list
(Aetna’s preferred drug list (Formulary)can be
accessed on the website at the following link
http://www.aetna.com/FSE/planType.do?businessSectorCode=CM).
These prescriptions are covered at the middle RX
copay.
Non Formulary Brand-Name – Prescriptions that are
not on Aetna’s preferred drug list. These prescriptions
are covered at the highest copay.
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Prescription Drug Benefit
Retail
Generic Formulary:
$20
Brand Formulary:
$45
Non-Formulary:
$65
Mail Order Drug Benefit:
$40/$90/$130 for up to 90-day supply
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How does it work?
You wake up one morning with sudden
cold-like symptoms. You call your doctor, but he’s booked
until next Tuesday. Instead, you:
Step 1.
Step 2.
Step 3.
Contact Teladoc.
Talk with a doctor.
Resolve the issue.
You simply log on to their
account or call Teladoc, 24/7,
to request either a telephone
or video consult (video consults
are not available in TX).
A board-certified doctor licensed
in their state reviews their
Electronic Health Record (EHR)
and provides a consult over the
phone or through video, just like
an in-person visit.
The doctor recommends the
right treatment for your medical
issue. If a prescription is
necessary, it’s phoned into your
pharmacy of choice.
Step 4.
Step 5.
Settle up.
Smile.
You pay your member
responsibility amount on a debit
card, credit card, or ACH, and
Teladoc submits a claim to Aetna
for the remainder, if applicable.
Your medical issue gets resolved
a fraction of the time and cost.
22 Minute
Average
Response Time
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Transparency and
Web Decision Support
Tools
Confidential disclaimer or title of presentation here, edit in View/slide master
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Aetna Navigator
Aetna Navigator – Secure Member Website
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Aetna Navigator – Secure Member Website
Aetna Navigator (www.aetna.com)
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Transactions, Decision Support and Health Information
Check claims, balances, enrollment
DocFind®
Hospital Comparison Tool
Estimate the Cost of Care
Price-A-DrugSM
Simple Steps To A Healthier Life Health Risk Assessment®
Personal Health Record
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Simple Steps- Confidential Website
Key Program Features
• Health Risk Questionnaire
• Available for all employees
• Healthy Living Programs
• $50 incentive per
employee and spouse
($100 per family) for Aetna
enrolled members only
• Tailored Health Reports
• Personalized Action Plan
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What Does Transparency Look Like?
Price-A-Drug
Hospital Comparison
Physician Unit Price
Estimate Costs on Conditions
Specialist
Quality & Efficiency
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Procedure-Based
Site of Service
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Ashton, Richard K., MD
123 Sunny Street
Hartford, CT 12345
(860) 124-4567
Black, John B., MD
123 Sunny Street
Hartford, CT 12345
(860) 124-4567
Select ‘Provider Details’ for a specific doctor
Black, Susan V., MD
123 Sunny Street
Hartford, CT 12345
(860) 124-4567
Clay, John B., MD
123 Sunny Street
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Black, John B., MD
123 Sunny Street
Hartford, CT 12345
(860) 124-4567
Select ‘View Rates for Aetna Members’ or
‘View Clinical Quality and Efficiency’
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Physician Unit Price
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Actual
negotiated
rate
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Up to 30 most
common
doctor’s
services, by
specialty
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Nearly 700
distinct
services
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Estimate the cost of care tool*
• Provides cost and health related
information to help members
make more informed health care
decisions
• Helps members better plan for
their health care expenses
• Provides cost information for
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Dental procedures
Diagnostic tests and vaccines
Office visits
Surgical and scope procedures
Diseases and conditions
Prescription drugs (Price-A-DrugSM)
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Member Payment Estimator
•Estimates based on member’s actual
benefits plan (including deductible,
coinsurance, copayments, and plan limits).
•Allows members to:
– Compare up to ten in-network providers
or facilities and view estimates for certain
out-of-network physician services
–Generate estimates for themselves and
their covered dependents
• Provides estimates for “service bundles”
– Multiple services typically performed
together as one procedure or visit (for
example, office visit, colonoscopy) with
the option to view details
• Uses member-friendly terminology
instead of industry language
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Key information and features
• Available to all Aetna Navigator®
registered subscribers
• Provides estimated average costs for
approximately 200 medical and dental
procedures, tests, office visits, diseases
and conditions
• Access to Price-A-Drug with costs for
approximately 9,000 prescription drugs
• Illustrates potential cost advantage of
using in-network providers
• Uses data sourced directly from
Aetna’s systems
• Available at no additional cost to
members or plan sponsors
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Price-A-Drug
Cost and decision-support information
for prescription drugs
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Estimated member
out-of-pocket costs
•
Mail-order savings
•
Drug information links
•
Generic alternatives
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Aetna Mobile App
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The Aetna Mobile App works with iPhone,
Blackberry Smartphone, and Android
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Features of Aetna Mobile
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Find a doctor
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Check benefits and coverage information
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Search claims
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Track your health and claims
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Pull up you medical ID card information
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Urgent care finder
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Contact Aetna
Visit your phone’s app store and Download
the App for free today
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Discount Programs
•Natural Alternatives Discount
Program
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Chiropractic
Acupuncture
Massage Therapy
Nutritional Counseling
Mail Order Vitamins/Herbs
• Eyewear Discount Program & Lasik
• Hearing Discounts (HearPo)
• Fitness Discount Program
(Globalfit.com)
• Jenny Craig Discounts
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Managing Your Health
Informed Health Line
• Speak to a registered nurse
1-800-556-1555
• 24/7 availability
• Confidential
• Health & Wellness Information
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PPO Dental Plan
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Your dentist…your choice
When you visit a dentist in the dental
PPO network…
• Meet your deductible
• Coinsurance
• No claim forms
When you see any other licensed
dentist…
• Out-of-pocket expenses may be
higher
• You may have to file a claim form
• You may be subject to balance billing
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Dental Active High PPO
In-Network
•Deductible $50/$100
Out-of-Network
•Deductible $50/$100
•Preventive Care 100%
•Preventive Care 100%
•Basic Care 80%
•Basic Care 60%
•Major Care 60%
•Major Care 40%
•Annual Benefit Max
$1,500
•Annual Benefit Max
$1,500
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Dental Active Low PPO
In-Network
•Deductible $0/$0
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Out-of-Network
Deductible $200/$600
•Preventive Care 100%
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Preventive Care 70%
•Basic Care 40%
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Basic Care 30%
•Major Care 40%
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Major Care 30%
•Annual Benefit Max
$1,500
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Annual Benefit Max
$500
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Life & Disability
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Life Insurance
Basic Life & AD&D
100% Employer Paid
•Employee
1 x annual earnings (maximum $200,000)
• AD&D
Equal to Basic Life
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Optional Life & AD&D
Optional Life
•Employee
Increments of $10,000 to a maximum of lesser of 5x
earnings or $500,000
• Spouse
Increments of $5,000; to a maximum of $250,000 (not to
exceed 100% of employee’s basic and optional amount)
• Children
Age 14 days to age 26; Increments of $2,000; to a
maximum of $10,000 (Not to exceed 100% of employee’s
basic and optional amount)
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Optional Life
Evidence of Insurability Rules
• Employee and Spouse:
If not already covered and not elected within 31 days of eligibility, this would
be a late enrollment and EOI is needed for any amount.
If already covered, you can go up one increment (within the guarantee issue
amount) without EOI. EOI is needed if the increase is more than one
increment or over the guarantee issue.
• Children
EOI is not required.
Evidence of Insurability is not required for Supplemental AD&D coverage.
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Optional Life & AD&D
Optional AD&D
•Employee
Increments of $10,000 to a maximum of $250,000 (Cannot
exceed 10 times BAE)
• Spouse
$5,000; to a maximum of $250,000 (Not to exceed 50% of
employee’s basic and optional amount or 40% if child
coverage is elected
• Children
Age 14 days to age 26; Increments of $2,000; to a maximum of
$10,000 (Not to exceed 15% of employee’s basic and optional
amount or 10% if spouse and child coverage is elected.
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Long Term Disability (LTD)
•Eligibility: All regular full-time and part-time employees
working 30 or more hours per week with one or more years of
service
•100% employer paid
•Elimination Period: 180 days of continuous disability due to
occupational or non-occupational injury or illness
•Monthly Benefit: Replace up to 60% of pre-disability
monthly earnings
•Maximum Monthly Benefit: $8,000
•Benefit Duration: Normal retirement age as defined by Social
Security
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Aetna Life Essentials
Financial
Legal
While You’re Living
(Caring for Yourself)
At the End of Life
(Caring Support and
Resources)
After You’re Gone
(Caring for Loved Ones)
Financial advice services
Accelerated Death Benefit
Financial counseling
Legal access
Access to legal advice – estate
planning
Access to legal
advice – estate planning*
Access to end-of-life Info –
Compassionate Care website
Bereavement
counseling
Emotional
Physical
Discount programs
Medical case management
Services for members with Supplemental Life
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Service for members with ADB
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Everest Funeral Planning
•24/7 Advisor Planning Assistance
–Funeral planning issues
–Creating a personal funeral plan for the family/client
•PriceFinder Research Reports
–Detailed local funeral home price comparisons available on demand via Everest’s
website
•Online Funeral Planning Tools
–Personal Profile, 10 Key Decisions Planner, Reference Guide, “My Wishes”
Planning Guide and more
–Information stored and maintained in a secure data warehouse
•At-Need Family Support, 24/7
–Family assistance and plan implementation
–Communicate the client’s Personal Funeral Plan to the funeral home; removing
the family from a sales-focused environment
•Negotiation Assistance
– Gather pricing information and present to family in an easy-to-read format
– Negotiate funeral service pricing with local funeral homes
– Help the family compare prices of caskets and other products
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Employee Assistance Program (EAP)
• Eligibility: All employees, household
members and dependent children not living
in household
• Unlimited telephonic or
• Five face to-face consultations
• Referrals to community services
• Internet access to EAP website 24 hours/7
days a week
• Work/life services
• Child/elder care, legal and financial services
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Employee Assistance Program (EAP)
•Confidentially discuss:
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Mental health and well-being
Personal and professional relationships
Substance abuse
Family life
Daily stress
•Contact the Aetna EAP anytime toll-free or
visit via the web 24/7
1-888-AETNA-EAP (1-888-238-6232)
www.mylifevalues.com (Aetna EAP/CHSFLEAP)
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Thank you
Health insurance and health benefits plans are offered, underwritten and/or administered by Aetna Health Inc., Aetna Health
Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by
Aetna Health Inc. and/or Aetna Life Insurance Company. The in-network and out-of-network referred benefits are underwritten by:
Aetna Health Inc. and Aetna Life Insurance Company; and in Arizona and Texas by Aetna Health Inc. Self-referred benefits are
underwritten by: Aetna Health Insurance Company of New York and Aetna Health Insurance Company; and in Arizona and Texas by
Aetna Health Insurance Company (Aetna). In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each
insurer has sole financial responsibility for its own products.
This material is for information only and is not an offer or invitation to contract. Health insurance and health benefits plans contain
exclusions and limitations. Not all health services are covered. See plan documents for a complete description of benefits, exclusions,
limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are
independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or
guarantee access to health services. Aetna Consumer Financial Solutions products, administered by PayFlex®, are provided by Aetna Life
Insurance Company. Note: There may be fees associated with an HSA. The types of fees may be similar to those you may pay for bank
checking account transactions. Please see the HSA fee schedule in your HSA enrollment materials for more information. Discount
programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the
discounted services. Health information programs provide general health information and are not a substitute for diagnosis or treatment
by a physician or other health care professional. Information is believed to be accurate as of the production date; however, it is subject
to change. For more information about Aetna plans, refer to www.aetna.com.
Policy forms issued in Oklahoma include: HMO OK COC-5 09/07, HMO/OK GA-3 11/01, HMO OK POS RIDER 08/07, GR-23 and/or
GR-29/GR-29N.
©2012 Aetna Inc.
69.25.301.1 (10/12)
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