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Union College Health Care Assistance Plan National Blue Card Network September 6, 2005 Ellen Eldridge Director, Health Care Services Adventist Risk Management.

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Presentation on theme: "Union College Health Care Assistance Plan National Blue Card Network September 6, 2005 Ellen Eldridge Director, Health Care Services Adventist Risk Management."— Presentation transcript:

1 Union College Health Care Assistance Plan National Blue Card Network September 6, 2005 Ellen Eldridge Director, Health Care Services Adventist Risk Management

2 Health Care Assistance Plan Payment Limits Lifetime Plan Limit –Medical in total - $3,000,000 –Infertility Treatment - $16,000 –Refractive Eye Surgery - $2,400 –Orthodontic Care - $2,300 Plan Year Payment Limits –Hearing - $3,200 –D urable Medical Equipment - $8,000 –Vision - $560 –Dental - $1,800 Individual; $3,680 Family

3 Health Care Assistance Plan Member Responsibility Co-pay each Office Visit - $15 Deductible - $250 single / $500 family Out-of-Pocket (OOP) –Also known as Co-Insurance –In-Network – 20%; $2000 single / $4000 family –Out-of-Network – 35%; $4500 / $7000 family

4 Health Care Assistance Plan Member Responsibility Prescription Benefit –Retail 30-day supply $10 generic/$16 brand/$20 non-formulary –Mail Order 90-day supply $10 generic/$20 brand/$30 non-formulary –Out-of-Pocket Maximum - $400 / $800

5 Health Care Assistance Plan Member Responsibility $15 Co-pay Office Visit Urgent Care Centers Mental Health Out-Patient Services –Professional Services Only (doctors fee) –Plan pays 100% of office visit after co-pay –Does not apply to deductible or OOP –All other charges apply to deductible and OOP –Plan pays 80% of these additional charges

6 Health Care Assistance Plan Member Responsibility Emergency Room –Applies to OOP –Does not apply to Deductible –Paid at 80% –$50 Co-pay/Deductible – waived if admitted TherapiesPT, OT, Speech, Chiropractic, Acupuncture –Plan year visit limits apply –Paid at 80% –Do not apply toward Deductible or OOP

7 Health Care Assistance Plan Member Responsibility Paid at 80%; Applies to Deductible and OOP –Out-Patient Services –In-Patient / Out-Patient Hospital Stays Medical Mental Health Substance Abuse –Office / Ambulatory Surgical Procedures –Ambulance Services

8 Claims Payment Explanation of Benefits Accumulators Deductible $150 Co-Insurance $ 0 ChargesPayment Office Visit200 Co-pay15 Plan Pays185 Lab Work150 Deductible150 20% Co-Insurance0 Plan Pays 0 350

9 Claims Payment Explanation of Benefits Accumulators Deductible $150 100 Co-Insurance $ 0 25 ChargesPayment Office Visit150 Co-pay15 Plan Pays135 X-Rays225 Deductible100 20% Co-Insurance25 Plan Pays100 375

10 Claims Payment Explanation of Benefits Accumulators Deductible $150 100 0 Co-Insurance $ 0 25 300 ChargesPayment Out-Pt Surg$1,500 Co-pay $ 0 Deductible0 20% Co-Insurance300 Plan Pays1,200 $1,500

11 Blue Card PPO Network More than 650,000 providers nationwide More than 5,500 hospitals nationwide Medical claims processed by IBC –99.5 % Claim adjudication accuracy –93.0% Home plan claims – 10-day TAT –98.0% Host plan claims – 30-day TAT

12 Negotiation Process Contract is between ARM and Independence Blue Cross in Philadelphia –Downstream contract between ARM and Client ARM negotiatied the PEPM Fee for all NAD participating employers –Continues to use our large group advantages

13 Negotiation Process ARM remains Customer Service –Access to Blue Cross system for customer service –Single point of contact –Continuation of historical knowledge NAD Health Care Plan design stays intact Medco Health remains our Prescription Benefits Manager

14 Blue Card PPO Network Home Plan –Independence Blue Cross Philadelphia, Pennsylvania Host or Local Plan –Any Blue Cross Network outside Home Plan where services are rendered

15 Blue Cross Claims Flow OOA ProviderLocal PlanHome Plan Local PlanOOA Provider Includes the following services –Transplant network –Utilization and case management coordinated in 50 states –Out of the country coverage based on medical necessity –Wellness Incentive Program

16 Overview NAD Plan - medical benefits remain intact ARM continues to manage the Plan –Consults with and recommends to NAD –no changes in organizational management Access to Blue Cross providers nation-wide Single network / Single payor Simplifies PPO management Reduces claims payment staffing needs Potential savings to NAD-wide medical expenses by $15M - $18M Wellness Incentive program at no cost

17 Benefits at a Glance No benefit changes as a result of Blue Card –All benefits remain the same –Medical claims are paperless, nationwide when in-network ARM continues to pay dental and vision ARM continues to manage prescription plan No change in coordination or management ARM remains Customer Care service

18 Benefits at a Glance Medical Services carved out of Blue Card NOT excluded benefits WILL BE reimbursed by ARM Massage Therapy Access BC therapist for significant discount Adult Immunizations - for travel or work NAD Plan policy limits apply Mail claims to PO Box 4759 Silver Spring MD

19 Value Added Benefits Childhood Immunizations –$15 office visit co-pay –Balance paid at 100% –Does not go to Deductible or OOP Mammography, pap screening –$15 office visit co-pay –Balance paid at 100% –Does not go to Deductible or OOP Therapies i.e. PT, OT, Speech –Apply to Deductible and to OOP

20 Value Added Benefits Healthy Lifestyles Incentive Programs –Fitness Program – Up to $150 reimbursement –Weight Management - Up to $200 reimbursement for cost of Weight Watchers –Safety Program - Up to $25 reimbursement of certificate for CPR or first aid course –Adds no costs to employee or conference

21 Union College Health Care Costs Benefit Year 2004-2005 Prd Allowable Discount Mbr RespNetPaid MM 1,290,671 288,019 156,378 846,274 DE 98,320 5 14,756 83,560 VI 50,436 121 10,056 40,259 RX 209,101 0 29,082 180,019 GT 1,595,186 288,145 210,272 1,150,112

22 North American Division Health Care Costs Benefit Year 2004-2005 Prd Allowable Discount Mbr Resp NetPaid MM 101,595,238 24,518,614 12,223,418 64,853,208 DE 11,867,432 12,873 2,177,796 9,676,761 VI 3,042,012 67,527 602,577 2,371,909 RX 14,574,371 - 1,950,649 12,623,723 GT 131,079,053 24,599,014 16,954,439 89,525,601

23 Union College 2004-2005 Medical Expenses Benefit Year 2004-2005 –Allowable Charges $1,290,671 –PPO Discounts 288,019 –Member Responsibility 156,378 –Net Paid by Employer846,274 –Effective PPO Discount 22.3%

24 Union College Blue Cross Discounts Blue Cross Discounts in Nebraska In-Patient34-49% Out-Patient21-26% Professional29-34%

25 Union College Medical Expense Retrospect Benefit Year 2004-2005 -- If it had been under Blue Card –Allowable Charges $1,290,671 –PPO Discounts 393,655 –Member Responsibility 134,552 –Net Paid by Employer 762,464 –Effective PPO Discount30.5%

26 Union College Medical Expense Net Affect Benefit Year 2004-2005 -- Summary Net Affect –Additional Savings $105,636 –Net Employer Savings 83,810 –Net Member Savings8,062

27 References Provider look-up –www.ibx.comwww.ibx.com Provider search ARMs Customer Care Service –(888) 276-4732 –(888) ARM-4SDA

28 Questions – Concerns for Ellen

29 Questions – Concerns for Ellen

30 Questions – Concerns for Ellen


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