Terminology 4 60-Day Waiting Period - The State of Kansas has a 60- day waiting period before health insurance begins. Since coverage is monthly, an employees health insurance will start on the first day of the month following the end of the 60-day waiting period. 4 Pre-Existing Conditions - a condition for which medical diagnosis or treatment is recommended or received before the date your coverage begins. Since there is a waiting period, the State of Kansas does not have any exclusions or waiting periods for coverage of pre-existing conditions.
Terminology 4 Premium - the amount charged for coverage of your health insurance package. 4 Certificate of Coverage or Benefit Description – document that outlines which is covered, under what circumstances and what is excluded from coverage. –Fully Insured Plans have Certificates of Coverage –Self-Insured Plans have Benefit Descriptions
Terminology 4 Network – a group of providers that contract with an insurance company that agree to provide services to members of a health plan for a discounted fee. 4 Exclusions- items for which the plan does not provide coverage 4 Limitations – services which have limits on coverage. Limitations may be subjective, such as medically necessary and appropriate.
Terminology 4 Preventative Care Services – Care designed to prevent, detect and treat conditions early and/or to manage its treatment effectively. These include well- baby care, regular OB-GYN visits, mammograms, routine physical exams and routine eye exams. 4 Prior Authorization or Pre-Authorization – services that must be approved by the insurance company before treatment is started.
Terminology 4 Copayment- a flat dollar amount you pay for a specific covered service. Copayments are not applied to coinsurance maximums. 4 Deductible – the amount the participant must pay each plan year for covered services before the plan will begin to pay. 4 Coinsurance - a type of cost sharing in which the participate and the plan share payment (usually a specific percentage) of covered services once the deductible is met.
Terminology 4 Coinsurance Maximum – the maximum amount of coinsurance you pay in a plan year 4 Lifetime Maximum- the maximum amount the insurance company will pay toward your covered expenses during your lifetime.
Terminology 4 Allowable Charges or Plan Allowance or Usual, Customary & Reasonable (UCR) Charges – the maximum amount a plan will pay for a covered service. 4 Provider Write Off – the amount a provider will not require you to pay over the plan allowance, usually because of an agreement with the insurance company
Medical Coverage Options 4 The Kansas Health Policy Authority (KHPA) negotiates all health care contracts and sets employee and employer premium rates for all State of Kansas employees. 4 Detailed information about all the health plans offered is located on their web site - –Benefit Descriptions –Links to Provider Directories
Medical Coverage Options 4 All of our medical plans are Preferred Provider Organizations or PPOs. –The level of reimbursement is based upon the network status of the provider of the service. –Network services are provided at a higher plan payment and lower out of pocket costs –Non Network services are paid at lower plan payment percentage and higher out of pocket costs.
Medical Coverage Options 4 Finding Network Providers –Links to web-based provider directories are located on the KHPA web site. –It is often helpful to search provider by location rather than by name to avoid spelling and abbreviation discrepancies (i.e., Saint or St) –All plans have local and nationwide provider networks. It is recommended to search all provider networks, such as Kansas, Out of Kansas and Kansas City Area to find a provider.
Medical Coverage Options There are three Medical Plan Designs and each Plan Design has 3 or 4 Plan Providers to choose from to administer the plan. Plan A Blue Cross/Blue Shield Coventry Health Care Preferred Health Systems UMR United Healthcare Plan B Blue Cross/Blue Shield Coventry Health Care Preferred Health Systems UMR United Healthcare Plan C Coventry Health Care Preferred Health Systems UMR United Healthcare
Medical Coverage Options 4 Plan A – Network Benefits –Copayments $20 Primary Care Providers $40 Specialists –Deductible $50 single/$100 family –Coinsurance – 20% –Coinsurance Maximum $1,100 single/$2,200 family
Medical Coverage Options 4 Plan B – Network Benefits –Copayments Adults - $20 Primary Care Providers Under 18 - $10 Primary Care Providers Adults - $40 Specialists Under 18 - $25 Specialists –Deductible - $0 –Coinsurance – 30% –Coinsurance Maximum $2,200 single/$4,400 family –Voluntary Quest Diagnostics Lab Card Program
Medical Coverage Options 4 Plan C – Network Benefits Qualified High Deductible Plan with Health Savings Account –Deductible $1,500 single/$3,000 family –Coinsurance – 20% –Coinsurance Maximum $3,000 single/$6,000 family –Health Savings Account with Employer Contribution Single $900 per year Family $1,350 per year
Dental Coverage 4 Administered by Delta Dental 4 Two networks of dentists employees have access to use –Delta Premier - large nationwide network with lower plan payments and higher out of pocket costs –Delta Preferred – small PPO network with higher plan payments and lower out of pocket costs
Dental Coverage 4 Covers 100% for diagnostic and preventative services 4 Deductible - $45 per person per plan year for some services 4 Coinsurance –50% to 60% - Delta Premier Dentist –50% to 80% - Delta Preferred Dentist
Prescription Drug Coverage 4 The benefits that follow are only available to employees enrolled in Plan A or Plan B. 4 Employees enrolled in Plan C have a separate prescription benefit that is subject to the deductibles and coinsurance amounts of Plan C. 4 Administered by Caremark 4 Preferred Name Brand medications can be found on the Formulary List on the KHPA website.
Prescription Drug Coverage 4 Tiered Coinsurance –Generics – 20% Diabetes & Asthma Medications –10% to a maximum of $10 –Preferred Name Brands – 35% Diabetes & Asthmas Medications –20% to a maximum of $20 –Non Preferred Name Brands – 60% 4 Specialty Medications – $75 copayment
Optional Benefits 4 Vision Service Plan – no employer contribution –Administered by Superior Vision Services –Must use a Network Provider to get the best benefit from this plan –Two levels of coverage elect to participate in – Basic or Enhanced
Optional Benefits 4 Basic Vision Plan –$50 copayment for eye exam –$25 copayment for 1 pair of eyeglasses or up to $150 of contacts in a plan year –Pays for up to $100 for frames –Pays for basic lenses –Any extra costs for frames or special lenses or coating are not covered by plan
Optional Benefits 4 Enhanced Plan –$50 copayment for eye exam –$25 copayment for 1 pair of eyeglasses or up to $150 of contacts in a plan year –Pays for up to $100 for frames –Pays for basic lenses plus UV coat, scratch coat, progressive lenses and either high index lenses or polycarbonate lenses.
Optional Benefits 4 KanElect Program has two components: –Pre-Tax Premium Option –Flexible Spending Accounts Administered by ASI (www.asiflex.com) Health Care Accounts – pay for out of pocket medical expenses with pre-tax dollars Dependent Care Accounts – pay for child care expenses with pre-tax dollars
Participant Opportunities 4 Open Enrollment – occurs every year in October. This is your opportunity to review the benefit options available to you and make changes for the next plan year (changes effective January 1) 4 Mid Year Changes – life changing events that happen during the plan year which will allow you to make changes to your health coverage. These changes become effective on the first of the month following the event. Written notification must be received by HRS within 31 days of the event.
Participant Responsibilities 4 Consider these items when selecting health insurance options –Premiums –Out of Pocket Costs –How do YOU use health care –What providers are in the plan network
Participant Responsibilities 4 Be familiar with the plan you select 4 Respond to the Questionnaires sent by the Health Plan –Coordination of Benefits (COB) –Work Related or Auto Accident 4 Notify HRS of any changes –family members –addresses
4 For more information, contact Human Resource Services