Transcript WHAT IS AN EPO PLAN - Monmouth University

WELCOME TO
HEALTHCARE 2016
AGENDA ITEMS

What is an EPO?

Health Reimbursement Account

Plan Comparisons

Premiums and Cost Saving Factors

FAQ and examples.

Managing your HRA and FSA

Horizon Online Portal for Members
WHAT IS AN EPO PLAN

Exclusive Provider Organization (EPO) delivers in-network only benefits through the
Advantage EPO network and the National BlueCard PPO network
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Network comprises more than 600,000 physicians and 6,000 hospitals and is the
largest health care network in the nation (same network as the current plan)
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Portable benefits coverage in state, out-of-state, on business or vacation
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Once deductible is met, EPO operates like the traditional PPO

Vision and prescription coverage is under a freestanding plan; same as our current
coverage (no deductible applies)
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View provider network at Horizon Blue Cross Blue Shield of New Jersey and select
“Find a Doctor” along the top navigation bar using Plan name: “Horizon Advantage
EPO”
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Treatment of a severe or life threatening medical situation will be treated as an innetwork claim regardless of where you seek treatment
WHAT IS AN HEALTH REIMBURSEMENT
ACCOUNT

An HRA is an IRS approved, employer-funded, tax advantaged health benefit
connected to your health plan, that reimburses employees for out-of-pocket
expenses.
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Only employees enrolling in the Horizon EPO option are eligible

Subscribers can maintain an HRA as well as FSA, (Flexible Spending Account)

HRA funds will be available January 1st of each year. Unused HRA funds will roll over
year to year without limitation while actively employed
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Funding amounts : $750 for single and $1,500 for two person or family
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HRA accounts will include a spend down feature upon termination if fully vested
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Eligible claims can include medical, dental, prescription and vision costs to the
subscriber and verification of eligible expenses can be found at the IRS Publication
501 Section 213d
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Upon cessation of employment HRA funds can be used to pay for COBRA or Medicare
supplements (all Section 213d eligible expenses) but are not accessible in the Federal
or State Marketplace
COMPARISON OF PLANS
Benefit
Traditional Direct
Access
EPO
In Network
100% with no deductible
100% after meeting deductible
$1,500 individual
$3,000 family
Out-of-Network
$500/$1000 deductible
No benefit
Specialist
No referral needed for specialist
Preventive
Preventive and well care covered at 100%
CoPays
Prescription
Vision
Copays (no deductible):
Primary care:
$ 20
Specialist:
$ 40
Emergency Room: $ 100
Copays (after deductible
Primary care:
Specialist:
Emergency Room:
is met):
$ 20
$ 40
$ 100
Prescription Copays: $10 Generics; $25 Preferred Brand; $50 Non-Preferred
Brand; (No Deductible Applies)
Mail Order Option Available at no more than 2 copays for a 90 day supply
Vision: (No Deductible Applies)
$10 copay for exam every 12 months
$25 allowance toward spectacle lenses every 24 months
$0-$40 copay depending on frame collection
COMPARISON OF PLANS
Benefit
Traditional Direct
Access
EPO
Out-of-Pocket Maximum
$2,000 per individual
$4,000 per family
$4,000 per individual
$8,000 per family
In Patient Hospital
100% after $100 copay
100% after deductible plus
$250/day for max 5 days per
occurrence
Out Patient Hospital Facility
100% after $300 copay
Ambulatory Surgical Center
100%
Flexible Spending
Health Reimbursement
Account (HRA)
Pre-Authorization
100% after deductible and $200
copay
100% after deductible and $100
copay
Option available
Not an option
Employer funded $750 single
$1,500 two person/family
Procedure list remains same for both plans
Laboratory
100% in office setting or at
LabCorp
Chiropractic
100% with $20 copay (max 25
visits per benefit period)
100% after deductible in office
setting or at LabCorp
100% after deductible with $20
copay (max 25 visits per benefit
period)
PREMIUM COSTS
Traditional Plan 7/1/2015
Traditional Plan 1/1/2016
Employee
Employee Contribution Contribution
Monthly
Annual
$200
$260
$340
Individual
Individual +1
Family
$2400
$3120
$4080
EPO 1/1/2016
Employee
Employee Contribution Contribution
Monthly
Annual
Individual
Individual +1
Family
HRA 1/1/2016
Employee
Employee
Contributio Contribution
n Monthly
Annual
Individual
Individual +1
Family
Premium
Savings
$ 80
$130
$200
$ 960
$1,560
$2,400
University
Contribution
Annual
$ 750
$1,500
$1,500
Individual
Individual +1
Family
Monthly
Jan-Jun
Monthly
Jul-Dec
Annual
2016
$120
$130
$145
$175
$1,590
$1,830
Individual
Individual +1
Family
$140
$195
$2,010
Family
Individual
HRA
Individual +1
$225
$305
$395
$2700
$3660
$4740
Employee Annual Net
Cost 1/1/2016
Individual
Individual +1
Family
$210
$ 60
$900
University
Annual Premium
Contribution Savings Plus HRA
Annual
Funds
$750
$1,500
$1,500
$2,340
$3,330
$3,510
EXAMPLES of HRA BENEFITS

Below is a synopsis of a claim history for a single person; comparing the out-of-pocket costs
between the traditional plan and the EPO/HRA plan. In this example, the participant hits the
annual deductible.:
Service Provider
Billable Amount
$653.00
$503.20
$135.00
$160.00
$200.00
$961.00
$500.00
$4,534.00
$595.00
$460.45
$160.00
$165.00
$879.23
$80.00
Amt Pd by
Horizon
$231.98
$279.06
$90.86
$145.78
$127.76
$357.65
$487.60
$2,777.
$405.99
$460.45
$150.16
$120.54
$404.26
$37.23
Subscriber Responsibility
Traditional
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Subscriber Responsibility in
EPO
$231.98
$279.16
$90.86
$145.78
$127.76
$357.65
$266.81
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Memorial Sloan .
Memorial Sloan .
Morris Elizabeth
Heerdt Alexandra
Regional Wome.
Memorial Sloan .
Traina Tiffany
Memorial Sloan .
Karimi Sasan
Memorial Sloan .
Heerdt Alexandra
Comstock Chris.
Memorial Sloan .
Hwang Sinchun
TOTALS
$9985.88
$6076.32
$0.00
$1500.00
Offset by HRA
Annual Premium
$0.00
$2,550.00
-$750.00
$960.00
Subscriber Outlay
$2,550.00
$1,710.00
EXAMPLES of HRA BENEFITS

Below is a synopsis of a claim history for two people; comparing the out-of-pocket costs between the
traditional plan and the EPO/HRA plan. In this example, neither participant hits the annual deductible:
Service Provider
Participant #1
New Jersey Imaging
Network Llc
New Jersey Imaging
Network Llc
Shoremark Healthcare Llc
Professional Associates Of
Jac
TOTALS #1
Participant #2
Samir Jain Md Pc
Samir Jain Md Pc
Samir Jain Md Pc
Professional Associates Of
Jac
Professional Associates Of
Jac
Samir Jain Md Pc
TOTALS #2
TOTALS Combined
Offset by HRA
Annual Premium
Subscriber Outlay
HRA Remaining Balance
Billable
Amount
Amt Allowed By
Horizon
Horizon Pd.
Subscriber Responsbility
Traditional
Subscriber Responsbility
EPO
$88.00
$33.93
$33.93
$0.00
$276.00
$126.39
$126.39
$0.00
$85.00
$27.58
$27.58
$0.00
$125.00
$82.68
$82.68
$0.00
$574.00
$270.58
$270.58
$0.00
$270.58
$1,200.00
$675.00
$500.00
$89.94
$91.50
$72.45
$89.94
$51.50
$32.45
$0.00
$40.00
$40.00
$89.94
$91.50
$72.45
$22.10
$22.10
$22.10
$0.00
$64.99
$62.94
$62.94
$0.00
$150.00
$72.45
$32.45
$40.00
$62.94
$72.45
$2,612.09
$411.38
$291.38
$120.00
$411.38
$3,186.09
$681.96
$561.96
$120.00
$0.00
$3,390.00
$681.96
-$681.96
$2,040.00
$3,510.00
$2,040.00
$818.04
$33.93
$126.39
$27.58
$82.68
$22.10
EXAMPLES of HRA BENEFITS
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Below is a synopsis of a claim history for a family; comparing the out-of-pocket costs between the traditional
plan and the EPO/HRA plan. In this example, the family meets the annual deductible:
Service Provider
Billable
Amount
Amt Allowed By
Horizon Pd.
Horizon
Subscriber
Responsbility
Traditional
Subscriber Responsbility EPO
Participant #1
TOTALS #1
$574.00
$270.58
$270.58
$0.00
$270.58
TOTALS #2
Participant #3
$2,612.09
$411.38
$291.38
$120.00
$411.38
TOTALS #3
$9,985.88
$6,076.32
$6,076.32
$0.00
$1,500.00
$13,171.97
$6,758.28
$6,638.28
$120.00
$2,181.96
$0.00
($1,500.00)
Annual Premium
$4,410.00
$2,400.00
Subscriber Outlay
$4,530.00
$3,081.96
Participant #2
TOTALS Combined
Offset by HRA
HRA Remaining Balance
$0.00
Use your FSA Visa
debit card to pay for
eligible copays,
coinsurance or
deductibles incurred
by subscriber.
Use of funds is
limited to your
annual election for
healthcare or your
account balance for
dependent care.
HRA
Claim for services
rendered is
submitted by
provider of services
on behalf of
subscriber. Claim
processes and an
explanation of
benefits is received.
FSA
HORIZON
PAYING FOR HEALTH CARE EXPENSE WITH
YOUR HRA AND FSA
Use your HRA Visa
debit card to pay for
eligible copays,
coinsurance or
deductibles incurred
by subscriber.
Use of funds is
limited to the
amount funded by
the employer.
FAQ for the EPO Plan
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
Q1. Do Prescription copays count toward the deductible?
A1. No, your prescription copays do not count toward deductibles but they do count toward the
out-of-pocket maximum.
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Q2. Do Vision copays or other out of pocket expenses count toward the deductible?
A2. No, your vision copays do not count toward deductibles or the out-of-pocket maximum.
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
Q3 Will dependent children be able to stay on the plan until 26?
A3. Yes, adult children age out of the plan on the last day of the month in which they turn 26
years of age. At that time they will have the option to continue their coverage under the
COBRA provision, through the NJ Dependent Under 31 provision if eligible, or through
the marketplace exchange at healthcare.gov.
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
Q4. Will I need to choose a primary care physician?
A4. No, as with the traditional plan no designation of a primary care physician is required.
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Q5. How are the individual and family deductibles met if I have 2 Person or Family coverage?
A5. Once an individual meet the individual $1,500 deductible, claims for that individual will be
paid at 100% after any applicable copay. When the family deductible of $3,000 is met then
claims for all members of the family are paid at 100% after the applicable copays.
FAQ for the EPO Plan


Q6. Will I have access to doctors and hospitals outside of NJ?
A6. Yes, the EPO plan includes the BlueCard PPO network which includes 6,000 hospitals and
600,000 physicians, including 23,500 specialists. Hospital such as Memorial Sloan Kettering
Children Hospital of Philadelphia, NY Presbyterian, the Mayo Clinic and the Hospital of the
University of Pennsylvania are among those in network facilities.


Q7. Am I able to have a flexible spending account if I elect the EPO with the HRA Plan?
A7. Yes, you can maintain a FSA while a subscriber in the EPO Plan. The Plan Documents will
allow participants to utilize the funds in their FSA account first and then the HRA account.
Keep in mind that the FSA is a use-it-or-lose-it account, however we provide a 2 ½ month
grade period wherein you can have an extended amount of time to incur and submit
claims. Maximum annual contribution is $2,550 for healthcare and $5,000 for dependent
care.


Q8. How can I find physicians outside of the state of NJ?
A8. There is a Blue Card Access line that can be reached at 1-800-810-2583 or your can check
the Blue Card Physician Finder to confirm.
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Q9. What is the subscriber responsibility for inpatient admission services?
A9. For any inpatient admission there is a $250 per day copay, with a maximum of 5 copays
per stay ($1,250), after the deductible has been met. Then the claim pays at 100%.
FAQ for the HRA Plan


Q1. Can employees contribute to the HRA plan?
A1. No, per IRS regulations, participants are not permitted to contribute to an HRA plan.


Q2. What happens to any unused portion of my HRA funds at the end of the year?
A2. Unused HRA balances at the end of the Plan Year will be carried over into the next year while
in active employment.


Q3.
A3.


Q4. How do I receive reimbursement from my HRA account?
A4. You may use your HRA debit card to cover the cost of copays and eligible expenses. You may
also fax, mail or submit a claim for reimbursement. Or you may use the “pay my provider’
feature available with through the Wage Works (the HRA administrator) website.


Q5. Do I pay taxes on the funds contributed to my HRA account by the University?
A5. No, the HRA account has no tax obligation for the employee.
What happens to my HRA when I leave employment?
There will be a spend down feature upon termination if fully vested. You are fully vested if
you have 5 years of full time service with the University. The spend down feature is
available if your account balance remains above $250 and will be available up to 10 years.
FAQ for the HRA Plan

Q6. Is there a cap on the amount I may roll over year to year in the HRA?
– No, you may continue to rollover any unused portion of your HRA account year to year without
any caps.

Q7. When are funds in the HRA made available?
– The employer contribution to the HRA account is made on January 1st each year. You will have
full access to the full HRA contribution on January 1st each year, plus any unused portion from
the prior year that has rolled over.

Q8. If I don’t use all of my HRA funds each year, what else am I eligible to use those funds for?
– You may use your HRA funds for any IRS Code 213(d) eligible healthcare expense. This
includes expenses that go towards your deductible, your prescription copays, and even out of
pocket vision or dental expenses.
EXAMPLES of HRA BENEFITS


Single, Young, and Healthy
Other than the occasional cold, your annual checkup, and an eye exam, you really don’t spend
much on your health care. However, your new contact lenses and dental treatment added up over
the course of the year. Here’s how an HRA will keep more money in your pocket.

Plan Year 1: You visit your doctor for an annual exam, and since it’s covered at 100 percent, there’s
no money deducted from your account. Throughout the year, you use your HRA funds to pay for an
eye exam, a year’s worth of contacts, solution, and eye drops and had a filling at your dental office
— totaling $450. Deduct this amount from your $750 beginning balance that your employer
provides, and you’re left with $300 that you can carry over to the next plan year. You haven’t spent
a single dime all year!

Plan Year 2: On January 1st Monmouth contributes another $750 to your HRA account which has a
balance carried over of $300. You now have $1,050 in your HRA to use toward eligible health care
expenses. That’s more than enough money for your vision expenses and a cushion of savings if you
get sick. Year two was a good year and you have only $75 in expenses for some prescription
medications. At the end of year two your HRA account is at $975.
EXAMPLES of HRA BENEFITS


Single Parent
At times we are all stretched to the limits and so is our bank accounts. You never know when you’ll
be heading to your child’s doctor because of an ear infection or an unexpected injury. Your medical
expenses can take a toll on your budget. Find out why an HRA is the plan for you.

Plan Year 1: Your employer gives you $1,500 to start off your HRA. Preventive checkups for both
you and your child are covered at 100 percent — no cost out of your pocket or HRA for annual
exams. However, your child comes down with an ear infection in March and then the flu in
November. Unfortunately, you get the flu as well. So you use $400 of your HRA funds to pay for
three visits to the doctor and three prescriptions. At the end of the year, you’ve used $400 of your
HRA funds. That leaves a remainder of $1,100 that rolls over to the next plan year.

Plan Year 2: Add $1,500 to your $1,100 balance from the previous year, and you begin the second
plan year with $2,600 in your HRA. That’s plenty of money to cover your family’s health care
incidentals throughout the year.
HOW TO ACCESS ONLINE TOOLS
1. Go to the Horizon Member Online Tools Site and register yourself for an online account
2. You will need to create a username and password with these three simple steps
3. Online Services include:
• Browse benefit details
• Pharmacy tools to help with drug interactions or identifying specific medications
• Print duplicate identifications cards
• Review recent claim activity for all members under your plan
• Search for claims by claim number, date of service and status
4. Video Library available to assist with finding a provider, understanding claims or updating information on
your member profile by visiting the Horizon Video Learning Library
5. There is even a mobile app!!