Transcript NEW 2016 Joint Benefit Plans Conference Health Care Benefits Plan

Health Care Benefits Plan
2016 Joint Benefit Plans Conference
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Health Care Benefits Plan
Welcome, Introductions & Agenda
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Health Care Benefits Plan
Agenda
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Program Review
Health Care Program Structure
Health Care Eligibility
Health Maintenance Organizations (HMOs)
Hospital, Surgical and Medical Coverage
Mental Health & Substance Abuse Coverage
Prescription Drug Coverage
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Health Care Benefits Plan
Agenda
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Dental Coverage
Vision Coverage
Dependent Care Reimbursement Plan
Reimbursement for Third-Party Liability
Health Insurance Portability and Accountability Act (HIPAA)
The Patient Protection & Affordable Care Act (PPACA)
Questions & Answers
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Health Care Benefits Plan
Health Care Program Review
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Health Care Benefits Plan
UAW Active Health Care Program Costs
Coverage Category
2014 Costs
($ Millions)
Medical (TCN)
$409
Pharmacy (TCN)
$130
Mental Health & Substance Abuse
$13
Health Maintenance Organizations
$116
Dental
$44
Vision
$4
Administrative Expenses
$44
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Health Care Benefits Plan
Top Regions by Cost for UAW Health Care
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Health Care Benefits Plan
Top Hospitals by Cost Nationwide
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Health Care Benefits Plan
Office Visits & Emergency Room Utilization
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Health Care Benefits Plan
Top Clinical Episodes by Cost
Rank
Clinical Episode
Total 2014
Expense
# of Patients
1
Osteoarthritis
$36,900,000
6,300
2
Diabetes
$22,500,000
5,600
3
Preventive or Administrative Procedures
$19,900,000
44,200
4
Coronary Artery Disease
$16,200,000
1,800
5
Hypertension
$15,900,000
10,600
6
Spinal/Back Disorder, Low Back
$13,200,000
7,100
7
Condition Related to Treatment
$10,900,000
1,500
8
Arthropathies/Joint Disorders
$8,800,000
10,400
9
Breast Cancer
$8,600,000
500
10
Multiple Sclerosis
$8,500,000
200
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Health Care Benefits Plan
GM Heath Care Program for Hourly
Employees – Structure
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Health Care Benefits Plan
2015 UAW-GM Supplement Agreement
Exhibit C: Health Care Program
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Article I: Establishment, Financing & Administration
Article II: Health Care Coverages
Article III: Eligibility, Enrollment, Commencement, Contributions & Continuation
Article IV: Definitions
Health Plan Coverage:
– Appendix A: Hospital, Surgical, Medical, Prescription Drugs, Durable Medical
Equipment/Prosthetics & Orthotics, & Hearing Aid Coverages
– Appendix B: Mental Health & Substance Abuse
– Appendix C: Dental Plan Coverage
– Appendix D: Vision Plan Coverage
– Appendix F: Temporary Employee Health Care Plan
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Health Care Benefits Plan
Health Care Eligibility
(Article III)
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Health Care Benefits Plan
2015 Negotiations Update:
Eligibility & Effective Date of Coverage by Plan
NEW
Traditional Employees
In-Progression Employees
Temporary Employees
(Formerly Entry Level)
(Formerly Flex)
Traditional Health Care Plan
91st day of employment
91st day of employment
Not Eligible
Temporary Health Care Plan
Not Eligible
Not Eligible
91st day of employment
Health Maintenance Organizations (HMO)
91st day of employment
91st day of employment
Not Eligible
Dental Plan
91st day of employment
91st day of employment
Not Eligible
Vision Plan
91st day of employment
91st day of employment
Not Eligible
NEW
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Health Care Benefits Plan
Eligible Dependent of Eligible & Enrolled Employees
 Legal spouse
 Same-sex domestic partners (Important: Same-sex domestic partners will
become ineligible for coverage effective January 1, 2017 unless a legal
marriage is made between the partners by December 31, 2016)
 Dependent children by birth or legal adoption of primary enrollee or current
spouse of primary enrollee and are:
– Under age 26 (coverage ceases at the end of the month in which child turns age 26); or
– “Totally and Permanently Disabled” and meet the provisions outlined in Article III, Section
9(c)(1)(ii) and Section 9(c)(3)(iii)
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Health Care Benefits Plan
Eligible Dependent of Eligible & Enrolled Employees
 Dependent children by Legal Guardianship or of Eligible Same
Sex Domestic Partners, provided the child is:
– A full-time student beyond age 19, but not beyond the end of the calendar
year in which the child turns age 24
– Not married
– Resides with the primary enrollee, or the primary enrollee must be legally
responsible for health care coverage
 NOTE: Children of a Same Sex Domestic Partner will become
ineligible for coverage effective January 1, 2017 if a legal marriage
is not recognized between the Same Sex Domestic Partners
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Health Care Benefits Plan
Dependents: Documentation Requirements
 The primary enrollee is required to provide documentation
necessary to substantiate the eligibility of enrolled dependents
within sixty (60) days of enrollment
 Failure to provide documentation results in the cancellation of
coverage for the dependent
 If documentation is later provided, coverage in such cases will be
reinstated retroactively to the date the dependent was originally
enrolled (maximum 1 year)
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Health Care Benefits Plan
Legal Guardianship: Documentation Requirements
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Legal documents establishing guardianship must be provided, and
Evidence of blood relationship, and
Proof of residency; and
Proof of student status (if the child is between the ages of 19 and 24)
Proof to total & permanent disability (if applicable)
Health Care coverage is effective the date the guardianship becomes
final per court documents (retroactive effective date is limited to 12
months)
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Health Care Benefits Plan
Same-Sex Domestic Partners & Eligible Children:
Documentation Requirements
 Signed and notarized affidavit of a same-sex domestic partnership
(applicable to partner only); and
 Proof of joint ownership (applicable to partner only); and
 Proof of joint residency (applicable to partner and child); and
 Proof of full-time student status (if child is between Reminder: Same-sex
domestic partners &
the ages of 19 and 24) (applicable to child only)
their children are
eligible for coverage
 Health Care coverage is effective the first of the
through
December 31, 2016.
month following receipt of all appropriate
documentation by the GM Benefits & Services Center
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Health Care Benefits Plan
Dependent Enrollment Process
 Primary enrollee either calls the GM Benefits & Services Center or
goes online to initiate adding an eligible dependent
 The enrollee is mailed an Hourly Dependent Enrollment Document
Request Form:
– Advises the enrollee to complete the top portion
– Specifies required documents for each dependent type
– Mail documents with completed form to GM Benefits & Service Center
within sixty (60) days to avoid loss of coverage
– Provides mailing address (preferred method) and fax number
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Health Care Benefits Plan
Dependent Enrollment Process
 If documentation is not received in 30 days, a reminder letter is
mailed to the enrollee
 If documentation is not received after 60 days after initial
notification, the enrollee is mailed a letter indicating that the
dependent(s) have been dropped from coverage
 Dependent(s) are only reinstated the first of the month following
receipt of proper documentation, effective retroactively to the date
the dependent was originally enrolled (maximum 1 year) following
receipt of all required documentation
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Health Care Benefits Plan
Important Notes: Dependent Enrollment
 Primary enrollee must call the GM Benefits & Service Center when enrolling
the following dependents; enrollment cannot be completed online:
– Legal guardianship dependents
– Same-sex domestic partners
– Dependent child of a same-sex domestic partner
 Same-Sex Domestic Partner:
Reminder: Same-sex
domestic partners & their
children are eligible for
coverage through
December 31, 2016.
– The enrollee is mailed the “Domestic Partner Enrollment Document Request Form”,
which must be completed and returned with the appropriate documentation prior to
coverage commencing
– Legal Guardianships and children of same-sex dependents between the ages of 19 and
24 are audited each year beginning in February and have until end of August to provide
proof of full time student status, or are terminated from coverage. Coverage can be
reinstated the month following receipt of documentation
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Health Care Benefits Plan
Dependent Eligibility Audit
 April 13, 2016: Initial letters mailed to all participants announcing the audit and
the 30-day Amnesty Phase (ends May 31, 2016)
 June 3, 2016: Start of audit; Mailing letters to all employee’s with spouses on
file that documentation is due July 18, 2016
– June 29, 2016: Reminder letters mailed to all participants who have not provided proper
evidence of current marriage, documentation is due July 18, 2016
– July 18, 2016: Final letter announcing 20-day grace period, documentation is due
August 8, 2016
– August 8, 2016: Grace period ends
 September 1, 2016: Coverage dropped for all spouses of participants who did
not provide proof of dependent eligibility
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Health Care Benefits Plan
True or False:
Same-sex domestic partners and their
children will be eligible for health care
coverage during the 2017 Plan Year.
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Health Care Benefits Plan
Health Maintenance Organizations
(HMO) Overview
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Health Care Benefits Plan
2016 Changes
 On February 1, 2016, Health Alliance Plan and HealthPlus
announced the merger of their companies
– Now jointly operating under the name of “Health Alliance Plan”
– No impact to HealthPlus enrollees
– Rebranded ID cards and communications
 Effective March 1, 2016, In-Progression employees with 90 days of
service are eligible to enroll in HMO coverage if the employee lives
in an HMO service area (eligibility is based on zip code) NEW
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Health Care Benefits Plan
Health Maintenance Organizations Offered
HMO
Location
Total
Contracts*
Total Enrollees*
Blue Care Network (BCN)
Flint, Lansing & SE Michigan
3,413
9,914
Health Alliance Plan (HAP)
Southeast Michigan
1,074
2,882
HealthPlus
Flint & Saginaw
1,780
5,172
MercyCare
Wisconsin
124
382
*Enrollment as of March 1, 2016
 There are approximately 6,400 Traditional employees enrolled in HMOs
 Approximately 4,000 In-Progression employees became eligible on March 1, 2016
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Health Care Benefits Plan
Health Maintenance Organizations (HMO)
 General Motors is the Plan Sponsor of these Plans, however
 General Motors is not the Plan Administrator
 HMO plans are insured, which means the HMO (insurer):
– Assumes all risk
– Has control over plan design upon approval of the parties, case
management, prescription drug coverage and mental health & substance
abuse benefits
– Has control over appeals; all decisions by the insurer are final and binding
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Health Care Benefits Plan
What are the names of the current
HMO plans offered to Traditional &
In-Progression employees?
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Health Care Benefits Plan
Hospital, Surgical and Medical
Coverages
(Appendix A)
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Health Care Benefits Plan
Medical Plan Comparisons
Plan Element*
NEW
Traditional Health Care Plan
Temporary Health Care Plan
Traditional & In-Progression Employees
Temporary Employees
In-Network
Out-of-Network
In-Network
Out-of-Network
(Individual / Family)
(Individual / Family)
(Individual / Family)
(Individual / Family)
Deductible
$0 / $0
$0 / $0
$300 / $600
$1,200 / $2,100
Out-of-Pocket Maximum
$0 / $0
$250 / $500
$1,000 / $2,000
No Limit
0%
10%
10%D
35%D
$25*
Not Covered
100% of Allowed
Not Covered
$100**
$100**
Covered 100%D
Covered 100%D
$50*
$50*
Covered 100%D
Covered 100%D
Coinsurance
Office Visit Copay
ER Copay
Urgent Care Copay
* Not applied to out-of-pocket maximum
** Waived if admitted to hospital or under observation care
D Plan pays benefits after deductible is met; subject to out-of-pocket maximum
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Health Care Benefits Plan
Conditions of Benefit Payment
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Service must be prescribed by a physician
Service must be approved by the carrier
Enrollee must have benefit period days available, where applicable
Care must be medically necessary
Details in Appendix A, II. A.
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Health Care Benefits Plan
2015 Negotiations Update: Networks
NEW
 Effective April 1, 2016 certain enrollees residing in applicable
service areas were placed in alternative networks which provide a
discount advantage
 Effected enrollees received a new member ID card early in the
year:
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New Jersey: Horizon Managed Care Network
District of Columbia/Maryland: BlueChoice Advantage Open Access
Florida: Network Blue
Georgia: Blue OpenAccess POS
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Health Care Benefits Plan
2015 Negotiations Update: New Coverages
NEW
 Preventive Services: The provision, as set forth under ACA, will
remain in-force even if the law is amended or repealed; details
outlined in Appendix A, III. E. and in a miscellaneous letter titled
“Preventive Services and Medications in Compliance with the
Patient Protection and Affordable Care Act”
 Office Visit Services: Injections are now a covered service in an
office visit setting
 Speech & Language Therapy (SLT): Limits to the number of visits
for children under the age of six are removed (Appendix A, III. C.)
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Health Care Benefits Plan
2015 Negotiations Update: New Coverages
NEW
 Air Ambulance: Enrollees are protected from balance billing in the event that
they receive medically necessary air and boat ambulance services from a nonparticipating provider that otherwise meets Program standards
 Durable Medical Equipment (DME): The following are now covered:
– Continual Glucose Monitors
– OmniPod Insulin pumps
– Orthopedic shoe inserts limited to one pair per calendar year
 Hearing Aids: Digital hearing aids allowance increased to $2,200 which
currently equates to carrier mid-high level standard aids covered in full;
upgrades available at additional costs
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Health Care Benefits Plan
Outpatient Hospital Coverage
 Emergency Room (ER)
– ER services are covered for the initial examination and treatment of
conditions resulting from accidental injury or medical emergencies
– In-Progression employees now have a $100 copayment
– Copayment is waived if patient is admitted or placed in observation care
NEW
 Urgent Care Centers
– $50 copayment per visits
– Facility charges are covered by the Plan in this setting
NEW
 Details in Appendix A, III. A. 3.
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NEW
Health Care Benefits Plan
Physical Therapy (PT):
Out-of-Network Reminder
 Services that are obtained from providers who are NOT in the
TheraMatrix network are NOT covered
 If there are no TheraMatrix network providers within 25 miles of an
enrollee’s home, TheraMatrix will attempt to locate a provider and
reimburse expenses
 TheraMatrix MUST be contacted prior to services being rendered
by a non-network provider in order to be eligible for reimbursement
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Health Care Benefits Plan
Hearing Aid Coverage
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AudioNet America/SVS provides hearing coverage nationwide
Audiometric Examination: Covered in full, once every 36 months
Hearing Aid Evaluation Test: Covered in full, once every 36 months
Conformity Evaluation: Covered in full, once every 36 months
Digital Hearing Aids: $2,200 allowance which currently provides mid-high
level standard aids; upgrades available at additional cost NEW
 In-Network Services:
– Eligible for up to two hearing aids every 36 months
– Preauthorization is required for all services
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Health Care Benefits Plan
Integrated Health Management (IHM)
 BlueHealthConnection (BCBSM) & ConditionCare (Anthem) are
Programs that offer support and resources to TCN enrollees that
have complex care needs, or multiple chronic conditions including:
– Asthma
– Diabetes
– Obstructive pulmonary disease
– Congestive heart failure
– Coronary artery disease
 If a nurse calls, say “YES!”
– If selected for the program, the enrollee receives an introduction letter,
followed by a telephone call from a registered nurse-case manager
– Enrollees are welcome to call to participate
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Health Care Benefits Plan
Integrated Health Management
 24-hour nurse line available seven days a week
 Registered nurse health coaches are ready to answer health care
questions about:
– Symptom Management: Help assessing symptoms to determine the level
of care and medical follow-up needed
– Health Information: Answers to health care questions or concerns
– Health Decision Support: Help making decisions about treatment options
for a condition or disease
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Health Care Benefits Plan
Mental Health & Substance Abuse
(MHSA)
(Appendix B)
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Health Care Benefits Plan
Beacon Health Options
 Administered through a managed care program called CareLine
 Merger of ValueOptions and Beacon Health Strategies in
May, 2014
 Serves 45 million people nationwide
 Appendix B of the Health Care Program
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Health Care Benefits Plan
2016 Changes and Helpful Tips
 Vivitrol injection now covered in the medical setting
NEW
– Prior Authorization is required through BCBSM to ensure appropriate
treatment prior to receiving the drug-assisted therapy
 Outpatient treatment for substance abuse
– First 35 visits are covered at 100%
– Note that only 30 of the 172 enrollees who had inpatient or residential
treatment center admission for substance abuse took advantage of the
recommended outpatient treatment available
 www.achievesolutions.net/gmc
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Health Care Benefits Plan
MHSA Network Providers
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Psychiatrists (Board Certified and Licensed)
Psychologists (Ph.D, Ed.D, DMH, PsyD. , and Licensure)
Social Workers (MSW, MSSW, DSW, and Licensure)
Clinical Nurse Specialist (MA, MS, MSN, and Licensure)
Hospitals
Detoxification, Residential Care, and Outpatient Facilities
Halfway Houses
Appendix B, II.
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Health Care Benefits Plan
MHSA: Responsibilities of Beacon Health Options
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UBR inquiries
Authorize/approve treatment
Coordinate mental health and outpatient substance abuse care
Authorize psychological testing
Provide face-to-face assessments for the development of
substance abuse continuing care treatment plans
 Make referrals to panel providers & after-care
 Appendix B, II. 4-12
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Health Care Benefits Plan
MHSA: Outpatient Care Coverage
Traditional / In-Progression Enrollees
Temporary Enrollees
Visits 1-20
Covered 100%
Covered 100%
Visits 21-35
Covered 75% (max. $25 enrollee cost)
Covered 75% (no maximum)
Covered 100% after $25 office visit copayment
100% coinsurance
Mental Health (In-Network)
Visits 36 and more
Substance Abuse (In-Network)
Visits 1–35
Visits 36 and more
Covered 100%
Covered 100%
Covered 100% after $25 office visit copayment
Not Covered
If outpatient mental health services are rendered by a out-of-network physician, the first visit will be covered. Any additional visits must be authorized
by the Central Review Organization (CRO). Unauthorized visits to an out-of-network physician will be paid at 50 of the Allowed Amount, directly to
the enrollee, not the provider. The enrollee is responsible for paying out-of-network providers. Mental health services rendered by out-of-network, nonphysician providers, (psychologists, social workers, etc.) are not covered under the Program.
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Health Care Benefits Plan
MHSA: Inpatient Care Coverage
Traditional / In-Progression Enrollees
Temporary Enrollees
365 continuous inpatient days (renewable after 60
days of non-treatment)
365 continuous inpatient days (renewable after 60
days of non-treatment)
Deductible
No deductible
$300 / $600 (in coordination with medical services)
Coinsurance
Covered 100% (no enrollee coinsurance)
10% coinsurance (of Allowed Amount)
Out-of-Pocket Maximum
Not Applicable
$1,000 / $2,000 (in coordination with medical services)
Benefit Period
In-Network (Single/Family)
Out-of-Network (Single/Family)
Deductible
No deductible
$600 / $2,100 (in coordination with medical services)
Coinsurance
10% coinsurance (of Allowed Amount)
35% coinsurance (of Allowed Amount)
Out-of-Pocket Maximum
$250 / $500 (in coordination with medical services)
No out-of-pocket maximum
• Balance Billing applied: Charges above in-network allowed
amount are the responsibility of the enrollee
• Balance Billing liabilities are not applied toward the out-ofpocket maximum
• Balance Billing applied: Charges above in-network
allowed amount are the responsibility of the enrollee
• Balance Billing liabilities are not applied toward the nonnetwork deductible
Out-of- Network
Provisions
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Health Care Benefits Plan
How many in-network outpatient mental
health visits are covered at 100% with no
copay or coinsurance?
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Health Care Benefits Plan
How many in-network outpatient
substance abuse visits are covered at
100% with no copay or coinsurance?
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Health Care Benefits Plan
Prescription Drug Coverage
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Health Care Benefits Plan
Prescription Drug Coverage: Helpful Tips
 Generic Drug Substitution: A drug
product that is equivalent to a brand
listed drug in dosage form, strength,
quality and performance; but less
expensive
 Mail-Order Pharmacy Service:
Medications filled through ESI mailorder service fell 5% in 2015
 Site of Service (infused/injected
medications)
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Health Care Benefits Plan
Prescription Drug Copayments
Retail
(34-day supply)
Traditional & In-Progression
Employees
Temporary Employees
Generic
$6
$7.50
Brand
$12
$15
Erectile Dysfunction
$17
No Coverage
Traditional & In-Progression
Employees
Temporary Employees
Generic
$12
$7.50
Brand
$17
$15
Erectile Dysfunction
$21
No Coverage
Mail-Order
(90-day supply)
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Health Care Benefits Plan
Preventive Medication without Cost-Sharing
Medication*
Coverage
Notes
Aspirin
Ages 45-79 for protection of cardiovascular disease
Fluoride
Children thru age 5 for prevention of cavities
Folic Acid
Women thru age 50 who are, or who are planning to become, pregnant
Iron Supplements
Ferrous Sulfate drops for children thru age 12 months old
Tobacco Cessation
Age 18 and older
Contraceptives
Generic oral & non-oral (e.g. diaphragms, NuvaRing) contraceptives (brand name
drugs will be covered if no generic equivalent available)
Vitamin D Supplements
OTC product for community-dwelling adults aged 65 years or older. Vitamin D2 or D3
1,000 IU or less
Effective
01/01/2014
Breast Cancer Prevention
(Tomaxafen/Raloxifene)
For women who have NOT been diagnosed with breast cancer, but are at increased
risk and at low risk for adverse medication effects.
Effective
01/01/2015
*Requires physician’s prescription & must be dispensed by a participating retail pharmacy or ESI mail-order service.
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Health Care Benefits Plan
Benefits of Mail-Order Pharmacy Service
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Exceptional dispensing accuracy
Greater compliance with utilization and safety rules
Specialized pharmacy care for chronic conditions
24-hour, toll-free access to customer service or a pharmacist
Sophisticated drug utilization review that alerts the pharmacist to the member’s
total medication profile
 Automatic refills
 Tamper-evident packaging
 Delivery to the address of choice with no cost for standard shipping
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Health Care Benefits Plan
Express Scripts Mail-Order Pharmacy
 To fill a prescription with Express Scripts Mail-Order Pharmacy:
– Enrollees can send a new prescription with a completed mail-order form to
Express Scripts via U.S. Mail
– Providers may fax, telephone or ePrescribe new prescriptions
 Providers can call Express Scripts to receive instructions for
submitting prescriptions
 FOR REFILLS ONLY: Enrollees can call the Express Scripts
automated refill system or visit www.express-scripts.com (hover
over Manage Prescriptions and select Order Prescriptions to
initiate a refill request)
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Health Care Benefits Plan
Mandatory Mail-Order for Maintenance Medications
 “Maintenance medications” are medications prescribed for chronic, long-term
conditions and are taken on a regular, ongoing basis
 New prescriptions can be filled at a retail pharmacy three times at the
applicable copayment
 Thereafter, these drugs are only covered if filled through the ESI mail-order
pharmacy service; Appendix A, Section III (G)(5)(b)
– 90-day supply
– Delivered to the address of choice, no cost for standard shipping & handling
 To find out if a medication is subject to these Plan provisions
– Call Express Scripts at 800-464-4679
– Visit their website www.express-scripts.com
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Health Care Benefits Plan
www.express-scripts.com
First time users:
Following
instructions by
clicking on
“Register Now”
Established users
enter User Name
& Password
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Health Care Benefits Plan
Price a Medication
Hover over “Manage Prescriptions” on the main
toolbar and click on “Price a Medication”
Enter the medication you wish to have priced
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Health Care Benefits Plan
Price a Medication
Select the drug
strength you have
been prescribed
Determine if a generic
equivalent is available
Provide the quantity
you have been
prescribed
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Health Care Benefits Plan
Price a Medication
Prices for
Home Delivery
& Retail
purchase will
display here
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Health Care Benefits Plan
Accredo: Specialty Drug Retail Network
 Accredo Health Group, Inc. (Express Scripts Specialty Pharmacy)
– Provides specialty pharmacy and related services for patients with certain complex and
chronic conditions through their unique Therapeutic Resource Centers
 Specialty Drugs
– Drugs generally prescribed for patients with complex diseases, which require specialized
training for self-administration and physician coordination prior to initiation of therapy
– Patient compliance and monitoring protocols
– Drugs tend to be high cost; significant potential for waste
– Special coverage procedures include use of identified providers, coverage review and
dispensing controls
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Health Care Benefits Plan
Utilization Management / Rx Tools
 Prior Authorization (PA)
– A prior approval process that allows prescriptions to be filled only when specific and
predefined conditions, consistent with clinical practice guidelines, are met
– Generally approved for one year and require annual review with physician
 Dose Optimization: Process in which Express Scripts contacts the prescriber
about dosing opportunity for higher strength at same total daily dose
 Step-Therapy (ST): Requires certain medical conditions, practice begins by
prescribing a medication with the most cost-effective drug therapy and
progressing to other more costly or risky therapies only if necessary
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Health Care Benefits Plan
How much is the generic drug
copayment for Temporary Employees at
both mail-order and retail pharmacy?
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Health Care Benefits Plan
What is the name of Express Scripts’
Specialty Drug Pharmacy?
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Health Care Benefits Plan
Dental Coverage
(Appendix C)
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Health Care Benefits Plan
2016 Changes
 Effective March 1, 2016, In-Progression employees with 90 days
of service are eligible for dental coverage
NEW
– The previous 3 year seniority requirement no longer applies
 Routine cleaning and oral examinations
 Cost saving opportunity through PPO network
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Health Care Benefits Plan
Dental Coverage
 Coverage offered to Traditional and In-Progression employees
 Temporary employees not eligible
 Delta Dental offers two nationwide networks
– Delta Dental PPO and Delta Dental Premier
– 2015 total network utilization = 95.5%
 2015 Plan utilization
– 74% of employees, 75% of spouses and 67% of enrolled children received services
– Plan paid $37.5 million for 425,000 services received
– Enrollee out-of-pocket expenses totaled $11.8 million
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Health Care Benefits Plan
Dental Plan: Summary of Covered Services
Diagnostic and Preventive Services
PPO Dentist
Plan Pays
Diagnostic & Preventive
100%
Premier Dentist
Plan Pays
Non-Participating Dentist
Plan Pays
100%
100%*
90%
90%
90%
90%
90%
90%
90%
90%*
90%*
90%*
90%*
90%*
90%*
90%*
50%
50%
50%
50%*
50%*
50%*
50%
50%*
Basic Services
Radiographs
Minor Restorative Services (i.e. fillings)
Endodontic Services (i.e. root canals)
Periodontic Services
Extractions
Oral Surgery
Major Restorative Services – crowns
100%
100%
100%
100%
100%
90%
90%
Major Services
Adjustments to Dentures; partial or complete
Prosthodontic Services – bridges and denture
Implants – endosteal implants
70%
70%
50%
Orthodontic Services
Orthodontic Services – braces (must begin prior to 19 years of age)
60%
* Of carrier allowed amount
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Health Care Benefits Plan
Dental Plan Maximum Benefits
 Annual Maximum:
– $1,850 per eligible enrollee
 Lifetime Orthodontia Maximum:
– $2,200 per eligible enrollee under the age of 19
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Health Care Benefits Plan
Dental: Covered Diagnostic & Preventive Services
 Payable at 100% (of maximum allowed cost)
 General population
– Routine oral examinations and prophylaxes
– Emergency palliative treatment
 Defined population (limitations apply)
–
–
–
–
Topical fluoride application for enrollees under age 15
Fluoride trays
One Brush Biopsy per calendar year
Space maintainers
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Health Care Benefits Plan
Dental: Covered Basic Services










Payable at 90% (limitations apply)
Dental x-rays
Extractions
Oral Surgery, including general anesthetics and intravenous sedation
Minor Restorations, including fillings
Major Restorations
Cosmetic Bonding
One Occlusal Guard
Endodontic Treatment
Periodontic Treatment
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Health Care Benefits Plan
Dental: Covered Major Services
 Payable 70% for PPO providers; payable at 50% for Premier
providers (limitations apply)
– Initial installation of fixed bridgework
– Initial installation, replacement or adjustments of partial or full removable
dentures
 Endosteal single tooth implants are payable at 50% for services
received by a PPO or Premier provider
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Health Care Benefits Plan
Predetermination of Services
 When a course of treatment that is expected to be greater than
$200 in cost:
– Request an estimate from Delta Dental prior to the commencement of
treatment
– Delta Dental will notify the enrollee and provider of the Plan payable
amount, and provide alternative treatment options, if appropriate
 Predetermination is not applicable to emergency treatment, routine
oral exams and cleanings, fluoride treatments and x-rays
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Health Care Benefits Plan
Accidental Dental Injury
 Involves repair of sound natural teeth as a result of sudden,
unexpected impact to the outside of the mouth
– Services provided under this provision are exempt from the annual benefit
maximum and the lifetime orthodontic maximum
– Regular copayments apply
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Health Care Benefits Plan
Delta PPO Network: Savings Advantage
Comprehensive
Orthodontics
Delta Premier
Delta PPO
Charge
$5,250
$5,250
Allowed Amount
$5,250
$4,635
Coinsurance %
50%
60%
GM Pays
$2,200*
$2,200*
Patient Pays
$3,050
$2,435
Employee Savings
$615
*Benefits limited to lifetime $2,200 orthodontia maximum for course of treatment
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Health Care Benefits Plan
What are some examples of diagnostic
and preventive dental services?
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Health Care Benefits Plan
Vision Coverage
(Appendix D)
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Health Care Benefits Plan
2016 Changes
NEW
 Effective March 1, 2016, In-Progression employees with 90 days of
service are eligible for Vision coverage; the 3 and 5 year seniority
requirements no longer applies
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Health Care Benefits Plan
Vision Plan Review

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
Coverage offered to Traditional & In-Progression employees
Temporary employees are not eligible
Davis Vision is the nationwide network & Plan administrator
2015 Plan utilization: 36% enrollees received services
2015 Total Plan spend was $6 million
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Health Care Benefits Plan
Vision Plan: Summary of Covered Services
Service
Vision Exam
(Including
refractions)
Eyeglass
Frames
Eyeglass
Lenses
Contact
Lenses
Corrective
Eye Surgery
*
**
***
****
Frequency
In-Network
Out-of-Network
Out-of-Area
(No network provider within 25 miles of residence)
Optometrist:
100% Covered Optometrist:
$7 copay, then reimbursed
up to $39
Optometrist:
Reimbursed based
on R&C*
Ophthalmologist:
100% Covered Ophthalmologist:
$7 copay, then reimbursed
based on R&C*
Ophthalmologist:
Reimbursed based
on R&C*
One exam annually
(Between Jan. 1–Dec. 31)
Once every other
calendar year
100% Covered for frames with
retail value of up to $80**
Once annually
(Basic lenses and tints #1 & #2, additional lens
options are covered and subject to specific
copays)
100% Covered
(Between Jan. 1–Dec. 31)
Note: Enrollee may not have eyeglass lenses
and contact lenses covered in the same year
Reimbursed up to $80
Following date of service, the enrollee
is ineligible for material benefits in
that year & 3 subsequent years
$10 copay***, the reimbursed up to $24
Reimbursed up to $24
$10 copay***, then reimbursed based on fee
schedule
Reimbursed based on R&C*
$10 copay, then reimbursed $170 if medically
necessary, $65 if elective
Reimbursed R&C* if medically
necessary, otherwise $80
Reimbursed up to $295****
(Corrective eye surgery claim form is necessary for reimbursement)
R&C = Reasonable and customary charges
Plan will pay up to $24 for frames exceed the $80 allowance
Combined annual copayment of $10 for lenses and frames
Enrollee receiving benefits for corrective eye surgery will be ineligible for material benefits (frames, lenses and contact lenses) for 36 subsequent months
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Health Care Benefits Plan
For eligible enrollees, how frequently are
frames covered under the Vision Plan?
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Health Care Benefits Plan
Dependent Care Reimbursement Plan
(FSA)
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Health Care Benefits Plan
Dependent Care Reimbursement Plan
 Purpose: Lets you use pretax dollars to pay for eligible expenses
related to care for a qualified dependent so you and your spouse (if
applicable) can work, look for work or attend school full-time.
 Benefit: Employees participating in the Plan can:
– Save an average of 30% on eligible dependent care expenses
– Reduce the overall tax burden - funds are deducted from pay for deposit
into account before taxes are withheld
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Health Care Benefits Plan
The Tax Savings Advantage
Rob is married and has two children, ages 7 and 4. Rob’s wife also works full-time. Together Rob
and his wife have a household income of $82,000 with a tax filing status of “Married (joint)”. The 7
year old goes to school and the after-school childcare program at her elementary school. During
the summer months, she attends a summer day-camp. The younger child goes to a licensed
daycare center all-year.
Type of Expenses
Licensed daycare center
Annual
Projected Cost
$10,200
Type of Expenses
Annual
Projected Cost
Suggested FSA Contribution
$5,000
After-school care
$1,440
Potential FICA tax savings
$750
Summer day camp
$2,220
Potential FICA tax savings
$383
Total Projected Eligible Expenses
$13,860
Total Tax Savings*
$1,133
*Depending on where you live/work, you may also have state
and city tax savings.
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Health Care Benefits Plan
Who is an eligible dependent?
 Participant’s child or step-child under the age of 13
 “Qualifying child or relative” such as a spouse, adult relative or adult child who is physically or
cognitively incapable of self-care
– Provide more than 50% of the person's support for the calendar year; and
– Has the same principal place of residence; and
– Is not a qualifying child or relative of any other person, an eligible dependent may be a:
•
•
•
•
•
•
•
Spouse
Child, grandchild, stepchild, foster child, or adopted child
Brother, half-brother or stepbrother; sister, half-sister, or stepsister; nephew or niece
Child or grandchild of any of the relatives listed above
Father, grandfather, stepfather, mother, grandmother, or stepmother
Uncle or aunt
Son-, daughter-, father-, mother-, brother- or sister-in-law, or any other person who will reside with you for
the entire year (while not in violation of local law)
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Health Care Benefits Plan
Examples of Eligible Dependent Care Expenses
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

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Adult daycare center
Au Pair
Before and After-school program
Custodial elder care (workrelated)
 Daycare
 Elder care (while you work)
 Nanny
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 Nursery school
 Preschool
 Registration fees (for eligible
care)
 Senior daycare
 Sick child care
 Summer day camp
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Health Care Benefits Plan
Examples of Ineligible Dependent Care Expenses
 Babysitting (not work-related)
 Babysitting (by a tax
dependent)
 Dance lessons
 Field trips
 Housekeeper
 Late payment fees
 Meals, food or snacks
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

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
Medical care
Residential nursing home care
Piano lessons
Private school tuition
School tuition
Sleep-away camp
Tutoring
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Health Care Benefits Plan
Dependent Care Reimbursement Plan
 Eligibility: Employees may participate in the Plan on the first day
of the first pay period following the attainment of seniority
 Enrollment: Eligible employees may enroll as a Participant in the
Plan during the annual election period, held each November, or
when a qualifying life event occurs
– Participants may elect an annual pledge via pre-tax payroll contributions
– Minimum annual pledge = $48; Maximum annual pledge = $5,000
– IRS establishes the maximum benefit; currently $5,000 annually ($2,500 in
the case of a married participant that files a separate tax return)
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Health Care Benefits Plan
Dependent Care Reimbursement Plan
 Eligible expenses that are incurred during the Plan year* may be
submitted to Acclaris at any time before April 30th of the following
Plan year
 Reimbursements for eligible dependent care expenses are not
considered taxable income
 Payable benefits may not exceed the account balance
 “Use It or Lose It” Rule: Funds that the employee contributed for
the Plan Year* that are not used are forfeited
* Plan Year = January 1 – December 31, including a “Grace Period” of January 1st – March 15th of the following year
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Health Care Benefits Plan
Reimbursement Requests
 Participants submit reimbursement requests to Acclaris
– Claim forms available by calling Acclaris or from the website
– One reimbursement claim submission permitted per week
– Minimum claim submission is $25; the final claim submission at the end of the Plan Year
may be less than $25
– Copy of receipts for services must be submitted with the claim form
 If an employee has any questions concerning their Dependent Care
Reimbursement Account, the first point of contact should be Acclaris
 Eligibility questions should be directed to the GM Benefits & Services Center
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Health Care Benefits Plan
What is the annual maximum pre-tax
payroll deduction for the Dependent Care
Reimbursement Plan (assuming joint tax
filing if married)?
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Health Care Benefits Plan
Reimbursement for Third Party Liability
(Article I, Section 8)
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Health Care Benefits Plan
Reimbursement for Third-Party Liability
(Subrogation)
 Definition: A legal process whereby financial reimbursement is
sought for payment of health care claims that were caused
because of another party’s action or inaction
 Examples:
– If GM paid health care benefits on your behalf for injuries that were
sustained in an automobile accident, and you received a financial
settlement from someone else’s insurance company, GM is entitled to be
reimbursed for health care expenses paid.
– Award from medical malpractice litigation and product liability cases
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Health Care Benefits Plan
How are third-party liabilities collected?
 Trover Solutions, Inc. identifies cases with the use of proprietary software
combined with monthly claim data provided by Blue Cross Blue Shield of
Michigan (BCBSM)
 Trover only seeks recovery on medical & prescription drug claims associated
with traumatic injuries, with a minimum cost exposure of $750
 BCBSM alerts Trover when medical malpractice cases arise against providers
or particular facilities that involve GM enrollees
 Trover does not conduct subrogation with Delta
Dental or the HMOs; these carriers
conduct their own
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Health Care Benefits Plan
Third-Party Reimbursement: The Process
 When a case is identified as potentially recoverable, Trover sends the enrollee
up to four investigative letters (at 60-day intervals); enrollees are asked to
contact Trover (via phone or web) to respond to questions relative to the
identified medical claim
– Letters are co-branded and contain both GM and the Trover logos
– If the employee responds to the first letter, no additional letters are sent; based on the
response, Trover may determine that the claim payment is not reimbursable
– Each letter is “stronger” in content urging the enrollee to contact Trover
– A fourth (final) letter is mailed on “Gibson and Sharps” letterhead indicating the enrollee
has an obligation under the GM Health Care Program provisions to respond
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Health Care Benefits Plan
Third-Party Reimbursement: The Process (continued)
 Once the enrollee has responded to Trover and the case is
confirmed as recoverable:
– Trover will interact into ongoing legal cases and take action to receive a
portion of the proceeds of that litigation
– GM Health Care Administrator oversees, reviews and approves all
settlement authorizations
– Process is subject to HIPAA Privacy regulations
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Health Care Benefits Plan
Questions you can expect?
 I received this letter with a GM and Trover logo, is this legitimate?
Yes. The letter is legitimate and you should follow the instructions in the letter
as soon as possible. Trover Solutions, Inc. administers GM’s the
Reimbursement for Third-Party Liability policy on behalf of the Health Care
Program.
 If I receive a letter from Trover, am I required to respond?
Yes. As an employee enrolled in the GM Health Care Program for Hourly
Employees, you are obligated to respond if you receive a letter from Trover.
 Where can I find more information about the reimbursement process?
Reimbursement for Third-Party Liability (Subrogation) is found in Article I,
Section 8 of the GM Health Care Program for Hourly Employees
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Health Care Benefits Plan
Health Insurance Portability and
Accountability Act (HIPAA) and Protected
Health Information (PHI)
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Health Care Benefits Plan
Health Insurance Portability & Accountability Act
(HIPAA)
 Federal law passed in 1996 that provides data privacy and security provision
for safeguarding medical information
 Covered Entities and Business Associates must:
– Safeguard individuals’ Protected Health Information (PHI)
– Request, use or disclose PHI only as permitted by HIPAA
– Provide individuals certain rights with respect to their PHI
– Provide a Privacy Notice that explains certain rights under HIPAA
– Ensure group health documents comply with HIPAA
– Create HIPAA Privacy & Security policies and procedures
– Appoint a Privacy Office and Security Officer
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Health Care Benefits Plan
Protected Health Information (PHI)
 Protected Health Information (PHI) is all information held or
transmitted by a Covered Entity or Business Associate, in any form
or media, that relates to:
– An individual’s past, present or future physical or mental health,
– The provision of health care to the individual, and
– The past, present or future payment for the provisions of health care to the
individual where the information identifies the individual or gives a
reasonable basis for identifying the individual
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Health Care Benefits Plan
Examples of PHI






Name
Social Security Number
Email address
A personal description
Telephone number
Birth date
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

License plate number
Health plan number
Photographs
Zip code
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Health Care Benefits Plan
Organizations that Must Comply
 Covered Entity
– Health care providers
– Health plans
– Health care clearing houses
 Business Associates (companies that perform services for Covered Entities
& have access to PHI)
– Claims processing vendor
– Administrative services
– Pharmacy benefit manager
– Actuarial services
– Management consulting
– Legal services
– Accounting services
– Billing
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Health Care Benefits Plan
Breach of Privacy
 Covered Entities must notify affected individuals of any breach of
privacy
 If PHI has been impermissibly accessed, it must be reported to the
Privacy Officer; GM is required to conduct and document an
analysis of the use or disclosure to determine if it is a breach
 A Covered Entity that has a breach affecting more than 500 people
must notify HHS immediately and provide prominent media outlets
following the discovery of a breach
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Health Care Benefits Plan
How GM Protects PHI




Encryption of data when transmitting and storing PHI electronically
Avoid sending PHI via fax
Lock up hardcopy files
Properly dispose of PHI that is no longer needed, by shredding and
electronically “wiping”
 Talk behind closed doors
 Securing laptops
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Health Care Benefits Plan
Privacy Release Authorization
 Union Benefit Representatives are not covered entities
– Plan administrators and carriers cannot share PHI with a UBR without the
employee’s signed authorization
 Examples of when the Health Care Program must get an
individual’s written/signed authorization before PHI may be
released:
– When assisting an enrollee with a denied benefit claim
– When verifying the need for FMLA leave
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Health Care Benefits Plan
Privacy Release Authorization
 A valid authorization must include:
– Who may release PHI and what PHI permitted to be disclosed
– Who may receive or use PHI
– Statement of the individual’s right to revoke the authorization & a description of how to do
so
– A statement of the individual’s right to refuse to sign the authorization
– A statement that the PHI might be further disclosed by the recipient and may not be
protected by HIPAA thereafter
– The individual’s signature or his/her personal representative
– The purpose of the use or disclosure
 A sample HIPAA Privacy Authorization Form is in the binder materials
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Health Care Benefits Plan
Minimum Necessary Rule
 HIPAA Privacy Rule requires that we limit the use and/or disclosure
of PHI to the minimum necessary to accomplish the intended
purpose
 Representatives of the Covered Entity have the responsibility to
limit the PHI disclosed to the minimum necessary, even if a person
or representative requests more
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Health Care Benefits Plan
Patient Protection and Affordable
Care Act (PPACA)
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Health Care Benefits Plan
Summary
 Signed into law on March 23, 2010
 Since that date, many regulatory guidance provisions have been
issued
 Most provisions have required implementation prior to
January 1, 2016
 Provisions for 2016 and beyond:
– Form-1095 provision was implemented during first quarter, 2016
– Excise Tax (delayed to 2020)
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Health Care Benefits Plan
What is Form 1095?
 PPACA requires all Americans to have qualifying health coverage or potentially
face a fine
 Provides proof to the IRS that an individual had or was offered coverage
– Form 1095-A is provided by the U.S. government if an individual purchased 2015 health
coverage from the marketplace (healthcare.gov)
– Form 1095-B is provided by an insurer (such as an HMO) if insured coverage was
purchased directly from the insurer (either individually or through a fully-insured employer
sponsored plan)
– Form 1095-C is provided by employers offering self-funded group health coverage
 2015 Form 1095s must be mailed on or before March 31, 2016
 2016 Form 1095s must be mailed on or before January 31, 2017
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Health Care Benefits Plan
What is Form 1095-C
 Employee and Employer Information
(Part 1) reports information about the
individual and the employer
 Employee Offer and Coverage (Part 2)
reports information about:
–
Employer coverage offered to the individual
–
Affordability of the coverage offered
–
Reason the individual was or was not
offered coverage by the employer
 Covered Individuals (Part 3) reports
information about the individuals (including
spouses and child dependents) enrolled in
coverage
 Copy of the Form 1095 is not needed when
filing a tax return, however individuals
should keep the form with tax records
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Health Care Benefits Plan
Who received Form 1095?
 Employees waiving coverage
– Full-time employees working an average of 30+ hours/week
 All employees enrolled in GM health coverage at any time during 2015
 BCBSM TCN Coverage: Form 1095-C
 HMO Coverage:
– Form 1095-B from the HMO
– Form 1095-C from GM
 Employees who worked at more than one company may receive a Form 1095C from each company
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Health Care Benefits Plan
Who will not receive Form 1095?
 Employees who worked less than an average of 30 or more
hours/week in any month during 2015; AND
 Were not enrolled in health care coverage at any time during 2015
 Individuals who were not the primary contract holder (e.g. spouse
or dependent children)
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Health Care Benefits Plan
Excise Tax
 Designed to slow the rising cost of healthcare and raise revenue to
pay for other components of PPACA
 40% tax on employers who offer premium health insurance plans
that exceed specified high-cost limits
 40% tax applies to the amount above the cost threshold (currently
$10,200 for individuals and $27,000 for families)
 Originally scheduled to take effect on January 1, 2018
 December 18, 2015, President Obama signed a large spending
and tax bill that pushed back the start of the Excise Tax from 2018
to 2020
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Health Care Benefits Plan
What does this mean for GM?
 Provides GM a two-year delay to properly assess how our health
care plans stand under the Excise Tax cost limits
 Allows for time to identify cost savings opportunities in anticipation
of the 2020 effective date, if necessary
 Any amounts employers or plan sponsors pay toward the Excise
Tax will be a tax-deductible expense
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Health Care Benefits Plan
December’s Spending & Tax Bill
 Calls for a study to determine whether PPACA uses “suitable” age
and gender benchmarks to determine the tax thresholds
 The bill suspended the 2.3% excise tax on all medical devices for 2
years, delaying it to January 1, 2018
 Imposed a moratorium for one year on the collection of PPACA’s
annual health insurance provider fee for fully insured plans, which
took effect in 2014; the fee will kick back in January 1, 2017
 The Excise Tax will now be deductible
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Health Care Benefits Plan
Thank You
Questions?
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Health Care Benefits Plan
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