Transcript EXPRESS - FMH | Home

Healthcare Purchasing Alliance
April, 2009
Agenda
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What Is Self Funding?
Why Self Funding?
What is a Self-Insured Group?
What is a TPA?
This is your Plan
A few things to remember …
Flexible Spending
Pharmacy Benefit
How to Enroll
What Is Self Funding?
• Self funding is a financing alternative that enables
employers to manage rising healthcare costs
• Self funded provides flexibility in making key
decisions on benefits, administration and funding,
with the ability of providing limits to ones liability
• Self funding/self insurance with Stop Loss coverage
for employer group health insurance is an attractive
alternative to the fully insured market for costconscious employers
What Is Self Funding?
• In practical terms, self insured employers pay
for each employee’s healthcare claims as they
are incurred, instead of paying a fixed
premium to an insurance carrier (e.g., a fully
insured plan), which includes a margin of
profit for the carrier
What is a Self-Insured Group?
• A self funded plan is one in which the
employer assumes partial financial risk for
providing healthcare benefits to its employees
Why Self Funding?
Advantages
• Flexibility in plan design
• Network flexibility
• Redirects profit margins
• Eliminates premium taxes
• Improved cash flow
Why Self Funding?
Advantages (continued)
• Minimizes state mandated benefits
• Controls reserves
• Savings from “better than expected” claims
• Manages risk through reinsurance/stop loss
• Lower administrative costs
Why Self Funding?
Perceived Disadvantages
• High dollar claims experience means the plan
will be costly
• Budgeting can be difficult
• Added fiduciary and legal responsibility
Self Funding vs. Fully Insured
Self Funded
Fully Insured
Payment of only administrative and stop loss
expenses up front
Pay ALL components of premium up front
You hold reserve – you determine value
Carrier determines and holds reserves
You hold margin until needed – you
determine value
Carrier determines value and holds margin
You determine cost of administrative and
stop loss expenses
Carrier determines administrative and stop
loss expenses
Monthly and annual caps available
Deficit carry forward probable
Complete flexibility in plan design – no need
to insure expected claims
Pay state premium taxes
No need to insure claims for which you
manage the cash flow
Must comply with state mandated benefits
Insure only the predictable
Limited choice in plan design and networks
Insure only the catastrophic
Utilize fully pooled insurance
What is a TPA?
• A TPA’s responsibility includes maintaining eligibility,
providing customer service, processing and paying
eligible claims, coordination with Preferred Provider
Organizations and Utilization Review Organizations,
and billing and generating any special reports for the
employer.
• A TPA is not an insurance company.
• Your healthcare plan is the focus of your self funded
program.
This is your Plan
• The Plan is paid for and funded by:
– Daytona State College or Radiology Associates
– Your employee contributions
• Therefore it is in your best interest to use the Plan wisely
• Your Plan provides several wellness benefits at no cost to you
– take advantage!
• Effective July 1st, FMH Benefit Services is your new claims
administrator for medical, dental, vision and flexible spending
plans
– FMH may be reached from
at (866) 550-5048 8:00-5:30 EST
or www.f-m-h.com/HPA
A few things to remember…….
• Your deductible starts over July 1st and does not
apply to your out of pocket maximum
• Mammograms routine or medically indicated are
paid at 100% one time for members between the
ages of 35-39 and one every year after the age of 40
• Colonoscopy routine or medically indicated are paid
at 100% for members at age of 50
– This benefit is limited one per member and one additional
every 10 years thereafter
A few things to remember……
• In-Network Benefits
– You must use either the Volusia Health Network or the Florida
Memorial Health Network to receive the highest benefit payment
– For members that live outside the VHN and FMHN service area; the
plan has contracted with PHCS Network. You must use the PHCS
Network providers to receive the highest benefit payment
• Pre-certify is required for all inpatient care and
certain medical procedures, as well as for specific
medications, failure to Pre-cert could result in denial
of charges or a penalty - check your SPD
– The phone number to pre-certify will be located on your
member ID card and is (888) 522-7742
A few things to remember……
• Adult well care (age 17 and over) is covered at 100%
up to $250 per plan year.
– Once the benefit has been exhausted, there is no benefit
until the following plan year
• Well Child Care is paid at 100% up to 18 visits for
members age sixteen and under
• Well Women Care benefits are covered at 100% and
do not apply to the Adult Well Care dollar maximum.
– Please refer to your schedule of benefits for further details
A few things to remember……
• HPA sponsors flu shots, which are paid at
100% and do not apply to Well Care maximum
amounts
• Employee Assistance Program
– Counseling
– Pre-paid Legal
– Financial Services
– Online Work/Life Services
– EAP Webinars
What is a Flexible Spending Account?
• These accounts contains your pre-taxed
dollars, which you may use to pay for your
portion of eligible healthcare and dependent
care expenses for your eligible dependents
• These are IRS regulated accounts
• Calculate your withholdings wisely
• You must use your entire pledge amount
between July 1, 2009 and June 30, 2010
Flexible Spending Account
• Your plan offers two types of FSAs
– Medical Reimbursement Account
– Dependent Care Account
• “Deposit” pre-tax dollars, contributions made before
taxes are withheld, into an account through
automatic payroll deductions
• To pay for eligible expenses, you make
“withdrawals” from the account
• Disposable income may rise because FSA
participation reduces your taxable income
Eligible Healthcare Expenses
• Out of Pocket expenses, such as co-pays, coinsurance payments, and deductibles
• Over-the-Counter items used for the
diagnosis, treatment, or prevention of a
disease or to alleviate or prevent a physical
deficiency or illness
Flexible Spending Account Potential Savings
(Your savings may differ from those shown here on the example chart. Taxes were taken for a
single employee earning $25,000/yr.)
No FSA
$25,000
With FSA
Gross Earnings
$25,000
FSA Contribution
$2,500
$25,000
Net Taxable Income
$22,500
$3,333
Income Taxes*
$2,958
$1,500
Dependent Care
(Eligible Expense)
$0
$1,000
Unreimbursed Medical
(Eligible expense)
$0
$19,167
Take Home Pay
$0
$0
Tax Savings
*2009 Federal Tax Rate Schedule - Single
$19,542
$375
Healthcare Reimbursement Account
• Pay out-of-pocket or be reimbursed for healthcare expenses such as
prescriptions and dental or vision expenses, as well as medical deductibles
or co-insurance that are not covered by other healthcare benefits
• Deposits
– Contributions made by automatic payroll deductions
– Ask employer about the maximum amount you can contribute to this account
• 3 Options for Withdrawals & Reimbursement
– Check
– Direct Deposit – Auto-Flex
– Debit Card
• If you do not select either of these options, or if you incur allowable
expenses that do not appear on a claim, fill out a Request for
Reimbursement Form, attach a receipt and send the documents to FMH
to recoup your payment
Auto-Flex
• Here is how it works
– When claims are filed under your employer’s Health Care Plan,
benefits are calculated & payments sent to providers of service
– Depending on the service rendered & whether or not the providers
was a network or non-network provider, you could have some patient
responsibility
– Some examples of your responsibility
• Plan copays
• Prescription Drug copays
• Deductibles &/or Coinsurance
– These out of pocket expenses will be billed to you after your employer’s
Health Care Plan benefits are applied to the provider's bill
• To participate in Auto-Flex, select this option during open enrollment
– Please note—if you participate in Auto-Flex, you cannot participate in the
Debit Card feature
Debit Card
• Here is how it works
– Simply swipe the card to pay for eligible expenses
– Gives you first dollar access to your full Medical election amount &
provides you convenience of using your FSA dollars upfront without
waiting on a reimbursement check
– Works like MasterCard with your maximum election amount on it
– If asked to choose credit or debit, choose CREDIT
– Merchants who accept MasterCard prepaid cards AND who offer the
types are services are eligible for your Plan
• To participate in the Debit Card feature, select this option during
open enrollment
– Please note—if you participate in the Debit Card feature, you cannot
participate in Auto-Flex
IRS Claim Substantiation Rules
• Claims/expenses must be incurred between
July 1, 2009 and June 30, 2010
– Incurred is not when you pay the bill, but your
initial date of service
• Expenses must be from an eligible healthcare
provider
– You cannot pay for Dependent Care with your
Healthcare FSA dollars
• Itemized statements, not cancelled checks
Dependent Care Accounts
• Dependent Care Accounts allow you to pay for the care
for a dependent child or adult, while you and your
spouse are actively at work or searching for work
– Childcare costs are eligible for reimbursement if a child is
younger than 13 and you claim the child as a dependent on your
federal income tax return
– Costs of care for an adult dependent, including a spouse or a
parent, qualify if the adult is physically or mentally disabled
• Contributions to a Dependent Care Account are made
through automatic payroll deductions
Dependent Care
• Maximum contribution - $5,000 or $2,500 if
you are married and filing separate tax
returns
• Dollars must be in your account before you
can withdraw them, unlike your healthcare
account
• You cannot use your healthcare “Benny” card
to pay for Dependent care expenses
Withdrawals
• To be reimbursed for dependent care expenses, a claim must
be submitted to FMH Benefit Services, Inc.
• Complete an FSA Reimbursement Form & include the
following information:
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Name of the dependent child(ren) or adult(s)
Amount paid
Dates of service
Provider’s name
Provider’s Tax Identification Number or Social Security Number
• If the provider is a daycare center, a printout of your charges
can be submitted with the Reimbursement Form
• If your provider is an individual with no tax identification
number, a receipt signed by the provider must be provided
Additional Information for Reimbursement
• To obtain a claim Reimbursement Form:
– Print out the form from our website at
www.f-m-h.com/hpa
– Email your request to [email protected]
– Call 866.500.5048 ext 2086
• To submit a claim:
– Email your paperwork to [email protected]
– Fax your paperwork to 866.514.8287
– Mail your paperwork to:
FMH Benefit Services, Inc.
A Division of CoreSource
Attn: Flexible Spending Department
P.O. Box 25946
Overland Park, KS 66225
Pharmacy Services
• MedTrak is HPA’s new prescription provider effective
July 1st, 2009
• You will receive a new FMH health insurance card
• Show this card to your pharmacist when you get a
prescription filled on or after July 1, 2009
MedTrak Customer Service Number: 800-771-4648
MedTrak web-site: www.medtrakrx.com
Where to fill a prescription
on or after July 1st
• Retail Pharmacies
– MedTrak is contracted with all of the big chains like Walgreens, CVS, Publix,
Wal-Mart, Sam’s Club, Target
– To find a specific pharmacy in your area log onto our website and click on
Pharmacy locator, or call MedTrak Services
• MedTrak 90 Pharmacies
– These pharmacies are able to fill 90-day supplies of maintenance medications
– Again, these include the big chains listed above
– To find a specific pharmacy log onto our website and click on Pharmacy
locator and look for the MT90 icon, or call MedTrak Services
• Walgreens Mail Pharmacy
– Mail order can be used to fill 90-day supplies of maintenance
medications
– Complete the Walgreens Registration and Prescription Order Form
and mail it in with new written prescriptions from your doctor written
for a 90 day supply and 3 refills
– Allow two weeks from receipt for delivery
MedTrak Customer Service Number: 800-771-4648
MedTrak web-site: www.medtrakrx.com
HPA Plan Design
Member Copays (unchanged):
Participating
Pharmacy:
Retail
MedTrak 90
Mail Service
30 day supply
90 day supply
90 day supply
Generic Copay:
$10
$20
$20
Preferred Formulary
Copay:
$30
$60
$60
Non-Formulary Copay:
$60
$120
$120
Maximum Day Supply
Allowed:
MedTrak Customer Service Number: 800-771-4648
MedTrak web-site: www.medtrakrx.com
What do I do if I already use Walgreens Mail
Order Pharmacy?
• If you have refills on your prescription(s) as of 7/1,
then continue as before
– The Rx number will remain the same, call in your refill or
go online to www.walgreensmail.com and place your
order
• If your prescription has run out of refills, have your
doctor fax a new prescription to 800-332-9581 or
mail it to Walgreens Mail Pharmacy
MedTrak Customer Service Number: 800-771-4648
MedTrak web-site: www.medtrakrx.com
How to Enroll
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Go to: www.f-m-h.com/HPA
Click on Register
Type in your Social Security Number, Company Key and Date of
Birth. Your Company Key is ‘HPA’. The company key is case
sensitive.
Read through the Electronic Signature notification and click
‘Accept’ to move forward.
Create your User Name and Password. Confirm your password
(at least 7 characters). Select your security phrase and answer.
Click ‘Continue’. Please make a note of your ID and password for
future use.
Click ‘Continue’ to proceed to Login Page.
Login with your new User Name and Password that you just
created in step 5 above.