Transcript Back-Health Insurance 8-10 - Kings County Office of Education

Kings County Office of
Education
Judy Fussel, RHU
President/COO
Buckman-Mitchell Financial &
Insurance Services, Inc.
Health Care Reform
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Changes that must occur at renewal 2010
– No lifetime benefit maximums
– Dependent coverage up to age 26
– 100% coverage for preventive care
Mental Health Parity
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Effective October 1, 2010 new legislation requires
us to amend our benefits for Mental
Health/Substance Abuse
Coverage with PacifiCare Behavioral Health will be
eliminated
EAP Benefits provided through Anthem Blue Cross
Benefits for Mental Health/Substance Abuse will be
included under the medical plan
– Benefit structure still being evaluated by Anthem Blue
Cross to conform with the amended language
Emergency Room Co Pay
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2009 24,107 ER visits with $22,273,465 in
paid claims
Only 270 resulted in same day admits (1%)
totaling $6,936,079 in paid claims
Normal – 8% to 10% of ER visits would
result in same day admit.
– Translation – SISC 3,000 ER visits
– 21,000 ER visits unnecessary
Members could have utilized Urgent Care
Centers
Emergency Room Co Pay
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SISC Goal
– Increase Urgent Care utilization
– Increase member awareness
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How to get there
– Provide County Specific member mailings
– Provide County Specific Urgent Care listings
– Add ER Co Pays to all plans
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Effective October 1, 2010 all plans will have
a $100 ER co pay.
– Co pay will be waived if admitted
Centers of Excellence (COE)
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Focus on unique, high cost medical events that impact
members & families
– Transplants & Bariatric procedures
Select and credential providers and provide specialized case
management
Covered Transplants
– Heart, Lung, Liver, Kidney, Pancreas/Kidney, Bone Marrow
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Special programs to assure:
– Quality of care
– Comprehensive care for patient with nurse manager
– Cost effective management of care
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Intent to assure great outcomes for members
Centers of Excellence
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Two Parts – Network and Case Management
– Facilities chosen based on:
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Volume of procedures
Readmission rate
Post-operative complications & mortality rate
Accreditation
– Case management includes:
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Member education and coaching on the benefits, the
procedure and aftercare
Post surgical monitoring of care
Coordination of other plan benefits, such as wellness and
behavioral health
Centers of Excellence
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Benefit requirement includes:
– Members must use a COE hospital to receive benefits
– Members work with a nurse case manager
– Utilization approval is required
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Additional benefits include:
– Travel reimbursement if member lives 50 or more miles
from a COE facility
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Reimbursement of medically necessary trips based on IRS
mileage. Reimbursement for Air if member lives 300 miles
or more. Air requires pre-approval and is at coach level.
Hotel accommodations (actual charge or $174, lesser of)
Maximum total travel benefit: $5,000
90-Day Prescription Option
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Effective October 1, 2010
– Member will be able to receive a 90-day supply
of medications at a retail pharmacy
– Must have a prescription for a 90-day supply
– Co pay will be a 3 times the 30-day supply co
pay
– Can use all pharmacies except CVS for the 90day supply
Mail Order option with informedMail still
available with discounted co pays
RX Plans
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Effective October 1, 2010 Implementing Step Therapy for
ARB’s
– ACEI’s are considered first line agent for prevention,
detection, evaluation and treatment of High Blood
Pressure.
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i.e. lisinopril
– Following medications require use or trial of ACEI before
being approved under the plan
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Atacand, Teveten, Avapro, Micardis, Diovan, Cozaar, Benicar
RX Plans
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Generics are free at Costco
OTC products for PPI’s and Allergy meds are
free with doctor’s prescription and must be tried
first
Step Therapy in effect for:
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Allergy Meds
Migraine
Osteoporosis
Non-Sedating Antihistamines
Depression Med
Sleep Aides
Proton Pump Inhibitors
RX Plans
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Allergy Medications
– $0 Co Pay for Zyrtec OTC, Claritin OTC, ZyrtecD OTC & Claritin-D OTC
– Includes the generic OTC equivalents
– Requires prescription from your physician
– No other allergy medications are covered
Migraine Medications
– Must try sumatriptan (generic Imitrex) or
Relpax First
– If not effective, Physician can work with AHC
for authorization of another medication
RX Plans
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Osteoporosis Medications
– Must try alendronate (generic Fosamax)
first
– If not effective, Physician can work with
AHC for authorization of another medication
Non-sedating Antihistamine Medications
– Must try Fluticasone (generic) or Nasonex
first
– If not effective, Physician can work with
AHC for authorization of another medication
RxPortal
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www.americanhealthcare.com
– Follow the RxPortal link under the Members tab
to reach the RxPortal homepage
– You will need to register. Do not use the first 3
letters of your ID card
 Can check your prescription history
 Covered drugs
 Mail Order Refills
 And do a trial claim on your medication
Renewal
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Medical Plans – 9.5% Overall
– Range 8.4% to 12.2%
RX Plans – 5.6% Overall
– Range 2.8% to 14.8%
Dental –
– Incentive Plan No Increase
– PPO Plan 10.8%
Vision – 5.8%
Medical Options
CSEA Members
Option #1
Option #2
Option # 3
Deductible
$200/$500
$500/$1,000
$500/$1,000
Coinsurance
90%
80%
80%
$300 Ind/$900
Fam
$1,000 Ind/$3000
Fam
$1,000 Ind/$3000
Fam
$10
$20
$30
Retail $3 G - $15 B
Mail $3 G - $35 B
Consumer Share
Retail $5 – $15 - $35
Mail $10 - $35 - $80
Consumer Share
Retail $5 – $15 - $35
Mail $10 - $35 - $80
OOP Max
Office Visit
RX
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Open enrollment October 1, 2010
Medical Options
Unrepresented Members
Option #1
Option #2
Option # 3 *
Deductible
$200/$500
$500/$1,000
$500/$1,000
Coinsurance
90%
80%
80%
$300 Ind/$900
Fam
$1,000 Ind/$3000
Fam
$1,000 Ind/$3000 Fam
$10
$20
$30
Retail $3 G - $15 B
Mail $3 G - $35 B
Consumer Share
Retail $5 – $15 - $35
Mail $10 - $35 - $80
$200 Ind/$500 Fam Ded
Retail $10 G - $35 B
Mail $25 G -$90 B
OOP Max
Office Visit
RX
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Option 3 – Power Select Network
Open enrollment October 1, 2009
Medical Options
KTA Members
Option #1
Deductible
$200/$500
Coinsurance
90%
OOP Max
Office Visit
RX
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$300 Ind/$900
Fam
$10
Retail $3 G - $15 B
Mail $3 G - $35 B
Open enrollment October 1, 2009
Dental Options
Incentive Plan
InNetwork
Out of
Network
Deductible
Diagnostic,
Preventive,
Basic, Crowns
Prosthodontics
None
None
$25/$75
100%
50% UCR
50%
50% UCR
50%
50% UCR
$2,000
$1,000
Orthodontics
50% to $1,000 Lifetime
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Out of
Network
70%-80%90% 100%
UCR
$1,500
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In-Network
70%-80%90% 100%
Annual Max
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Delta Preferred Option
100% to $2,000 Lifetime
If using a PPO dentist under the Incentive Option, benefits increased by $200 per year
Open Enrollment October 1, 2010
Moving from Incentive Plan to DPO & Back again, start at 70%
Vision Plan
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Vision Service Plan
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Exam & Lenses Every 12 months
Frames Every 24 month
$5 Co Pay Exam
$25 Co Pay Materials
Kings County Office of
Education
Judy Fussel, RHU
President/COO
Buckman-Mitchell Financial &
Insurance Services, Inc.