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1 2014 Benefit Options Presentation Plan Year January 1 through December 31, 2014 This publication is issued by the Office of Management and Enterprise.

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Presentation on theme: "1 2014 Benefit Options Presentation Plan Year January 1 through December 31, 2014 This publication is issued by the Office of Management and Enterprise."— Presentation transcript:

1 Benefit Options Presentation Plan Year January 1 through December 31, 2014 This publication is issued by the Office of Management and Enterprise Services as authorized by Title 62, Section 34. Copies have not been printed but are available through the agency website. This work is licensed under a Creative Attribution-NonCommercial-NoDerivs 3.0 Unported License. 2949

2 The Employee Benefit Options Guide 2 How to access the Guide: View the Guide on the EGID website at or Complete the online request to get one by mail Contact your Insurance Coordinator Contact EGID Member Services

3 2014 Plan Changes Health Plans Dental Plans Vision Plans HealthChoice Life Insurance Plan Eligibility 3 Topics

4 For More Information 2014 Employee Benefit Options Guide Frequently Asked Questions at or Plan websites and customer service representatives Your Insurance Coordinator EGID Member Services 4

5 5 Click the links below to access a particular section of this presentation Plan Changes HealthChoice Health Plans HMO Health Plans Dental Plans Vision Plans HealthChoice Life Insurance Plan Eligibility Index

6 2014 PLAN CHANGES 6

7 7 Eligibility Changes Enrolling a newborn: HealthChoice and HMO plan members must enroll the newborn for the month of birth if dependent coverage is desired Premium for month of birth must be paid

8 HealthChoice High and USA Plans Calendar year out-of-pocket maximum is being increased to $3,300 for an individual/Network and $3,800 for an individual/non-Network HealthChoice High Alternative Plan Calendar year out-of-pocket maximum is being increased to $3,550 for an individual/Network and $4,050 for an individual/non-Network Calendar year out-of-pocket maximum is being decreased to $8,400 for a family 8 HealthChoice Plan Changes

9 HealthChoice S-Account Plan Copays for physician office visits for general practitioners, etc., and VA, Military and Indian Clinics is being reduced to $30 Copay for specialist office visit will remain $50 9 HealthChoice Plan Changes

10 CommunityCare HMO Calendar year out-of-pocket is being increased to $4,000 for an individual and $8,000 for a family Copay for hospital inpatient admission increased to $750 Copay for hospital outpatient visit increased to $500 Copay for mental health or substance abuse inpatient admission increased to $750 No referral needed for most specialist visits Visit state.ccok.com to view benefits, claims, EOBs, and more 10 HMO Plan Changes

11 GlobalHealth HMO Copay for specialty scans will be $750 Copay for outpatient visits in free-standing facility will be $250 and $750 in a hospital facility Copay for emergency health care facility visit increased to $300 Durable medical equipment – 20% coinsurance Occupational or speech therapy and physical therapy/physical medicine limit: 60 combined inpatient and outpatient visits per acute illness or injury 11 HMO Plan Changes

12 HealthChoice Dental 12-month waiting period will apply to all members, including those who had previous group dental coverage 12 Dental Plan Changes

13 CIGNA Dental Cost for sealant increased to $17 per tooth Cost for amalgam, one surface increased to $23 Cost for a root canal, anterior, increased to $375 Cost for periodontal/scaling/root planing, 1-3 teeth, increased to $75 Out-of-pocket for children through 18 increased to $2,472 Out-of-pocket for adults increased to $3, Dental Plan Changes

14 Delta Dental Delta Dental Premier is now Delta Dental PPO Plus Premier 14 Dental Plan Changes

15 Primary Vision Care Services (PVCS) Discounts offered through nJoy Vision, previously TLC, call PVCS for details Vision Services Plan $25 copay on contact lenses 15 Vision Plan Changes

16 16 Return to Index HealthChoice Life Insurance Plan Changes Dependent Life Insurance Dependent life benefit for birth to 6 months of age is being eliminated Dependent children eligible for Low, Standard, or Premier Option from live birth to age 26

17 HEALTHCHOICE HEALTH PLANS 17

18 Available Plans HealthChoice High HealthChoice High Alternative HealthChoice Basic HealthChoice Basic Alternative HealthChoice S-Account HealthChoice USA Using a HealthChoice Network Provider will lower your out-of-pocket costs. 18 Click here to view HealthChoice plan changes

19 Tobacco-free Attestation To remain enrolled in the HealthChoice High or Basic Plan, you must attest that you and your covered dependents are tobacco-free Due to HealthChoice by Nov. 15, 2013 The Attestation is available: On the EGID website Through a mobile app, or By calling HealthChoice Member Services 19 HealthChoice Plan Changes

20 If you cannot complete the Attestation, you must either: Enroll in the quit tobacco program AND complete three coaching calls, or Provide a letter from your doctor indicating it is not medically advisable for you or your dependent to quit tobacco. If you do not complete the Attestation or complete one of the reasonable alternatives as defined previously, you will be enrolled in the HealthChoice High Alternative or Basic Alternative Plan with a higher deductible and out-of-pocket maximum. 20 HealthChoice Plan Changes

21 When using a Network Provider: $30 copay for primary care office visits $50 copay for specialist office visits Annual deductible $500 for an individual or $1,500 for a family Plan pays 80% and member pays 20% of Allowed Charges up to the out-of- pocket maximum of $3,300 for an individual or $8,400 for a family High 21

22 22 High Alternative When using a Network Provider: Benefits the same as High Plan except deductible and out-of-pocket maximum Annual deductible $750 for an individual or $2,250 for a family Plan pays 80% and member pays 20% of Allowed Charges up to the out-of- pocket maximum of $3,550 for an individual or $8,400 for a family

23 When using a Network Provider: Office visit copays do not apply Plan pays first $500 then member pays next $500 as deductible; $1,000 deductible for a family of two or more Plan then pays 50% until the out-of- pocket maximum is met; $5,500 for an individual or $11,000 for a family Plan then pays 100% of Allowed Charges Basic 23

24 24 When using a Network Provider: Office visit copays do not apply Plan pays first $250 then member pays next $750 as deductible; $1,500 deductible for a family of two or more Plan then pays 50% until the out-of- pocket maximum is met; $5,750 for an individual or $11,500 for a family Plan then pays 100% of Allowed Charges Basic Alternative

25 Plan designed for members with a Health Savings Account (HSA) When using a Network Provider: Combined $1,500 deductible for an individual and $3,000 for a family* Entire deductible must be met before benefits are paid (including prescriptions) $30/$50 copay for office visits The calendar year out-of-pocket maximum is $3,000 for an individual or $6,000 for a family *Individual deductible does not apply if two or more family members are covered. S-Account 25

26 For members who live and work outside of Oklahoma and Arkansas for more than 90 consecutive days Benefits are the same as the HealthChoice High Plan Members have access to the USA Plan’s nationwide provider network USA 26

27 Network Pharmacy Benefits 27 Prescriptions can be filled at HealthChoice Network Pharmacies Benefits are the same for all plans; S- Account members must meet the Plan deductible before benefits are paid You are responsible for the cost difference when choosing a brand- name if a generic is available

28 Network Pharmacy Benefits 28 When purchasing up to a 30-day supply: Generic – Up to $10 Preferred brand-name – Up to $45 Non-Preferred brand-name – Up to $75

29 Network Pharmacy Benefits 29 When purchasing up to a 90-day supply: Generic – Up to $25 Preferred brand-name – Up to $90 Non-Preferred brand-name – Up to $ day fill does not apply to medications with quantity or dosage limits

30 Network Pharmacy Benefits 30 Certain prescription tobacco cessation medications for a $0 copay A calendar year pharmacy out-of-pocket maximum of $2,500/individual, $4,000/ family (does not apply to S-Account Plan) Specialty medications must be purchased through Accredo Health, the HealthChoice specialty care, delivery service pharmacy Return to Index

31 HMO PLANS 31

32 32 You must live or work within the ZIP Code service area of the HMO Copay system for services and supplies Primary Care Physician (PCP) is required Select your providers from the network designated by your plan for the State of Oklahoma You must select another provider within your HMO’s network in the event your provider leaves the network. Click here to view HMO Plan Changes HMO Plans

33 33 $35 office visit copay for PCP $50 office visit copay for specialist $750 copay for hospital and mental health or substance use disorder admission $200 copay each emergency room visit $50 copay for after-hours urgent care Out-of-pocket maximum of $4,000 for an individual or $8,000 for a family

34 34 30-day supply per copay $0 copay for select generics Up to a $10 copay for formulary generic medications Up to a $40 copay for formulary brand- name medications Up to a $65 copay for all other medications Some medications have quantity limits Pharmacy Benefits

35 35 $25/$50 office visit copay for PCP/specialist $300 copay each emergency room visit $25 copay for after-hours urgent care PCP; $50 copay for all others $250 copay for free-standing outpatient facility or $750 for a hospital facility No copay for x-ray and lab services MRI, PET, CAT, or nuclear scan – copay of $250 for free-standing facility or $750 for hospital facility Out-of-pocket maximum of $3,000 for an individual or $5,000 for a family

36 36 30-day supply per copay $4 copay for select generics Up to a $10 copay for formulary generic medications Up to a $50 copay for formulary brand- name medications Up to a $75 copay for all other medications Some medications have quantity limits Pharmacy Benefits Return to Index

37 DENTAL PLANS 37

38 38 Assurant Freedom Preferred Assurant Heritage Plus with SBA (Prepaid) Assurant Heritage Secure (Prepaid) CIGNA Dental Care Plan (Prepaid) Delta Dental PPO Delta Dental PPO Plus Premier Delta Dental PPO – Choice HealthChoice Dental Dental Plans Available

39 39 All the dental plans have the same core benefits which are divided into four different classes: Preventive Care includes cleanings, bitewing x-rays, and routine oral exams Basic Care includes fillings, extractions, root canals, endodontics, and periodontics Dental Benefits

40 *Assurant Freedom Preferred has a 12-month waiting period for orthodontic care; waived if proof of continuous dental insurance is provided. HealthChoice has a 12-month waiting period for orthodontic care. Major Care includes dentures, bridgework, crowns, and implants Orthodontic Care* is covered for members under age 19 and members age 19 or older with temporomandibular joint dysfunction (unless otherwise noted) 40 Dental Benefits

41 Preventive Care is covered at 100% A $25 deductible applies to Basic and Major Care After the deductible: Basic Care is covered at 85% Major Care is covered at 60% Orthodontic Care under age 19 is covered at 60%; lifetime maximum benefit $2,000 All other services have a combined $2,000 maximum annual benefit Freedom Preferred Dental Plan 41

42 No deductible or annual maximum for general dentist You must select a Primary Care Dentist for each covered person Preventive Care is covered at 100% Copay schedule applies to other services Orthodontic Care for children and adults The Special Benefit Amendment provides an additional discount for network specialists Heritage Plus with SBA Dental Plan 42

43 No deductible or annual maximum with general dentist You must select a Primary Care Dentist for each covered person Preventive Care is covered at 100% Copay schedule applies to other services Orthodontic Care for children and adults Heritage Secure Dental Plan 43

44 No deductible or maximum annual benefit You must select a Primary Care Dentist for each covered person After a $5 copay, routine cleanings, x-rays, and evaluations are covered at 100% A copay schedule applies to other services, including specialist care Orthodontic Care for children and adults Dental Care Plan 44

45 Preventive Care is covered at 100% $25 annual deductible for Basic and Major Care Basic Care is covered at 85% Major Care is covered at 60% Orthodontic Care for children and adults is covered at 60% with a $2,000 lifetime maximum benefit $2,500 maximum annual benefit for other services Delta Dental PPO 45

46 A $50 combined deductible applies to Diagnostic, Preventive, Basic, and Major Care Preventive Care is covered at 100% Basic Care is covered at 70% Major Care is covered at 50% Orthodontic Care for children and adults is covered at 60% with a lifetime maximum of $2,000 $3,000 maximum annual benefit Delta Dental PPO Plus Premier 46

47 You must select a Primary Care Dentist for each covered person No deductible for Preventive or Basic Care $100 deductible for Major Care Copay schedule for all other services Orthodontic Care for children and adults has a maximum lifetime benefit of $1,800 $2,000 maximum annual benefit for Preventive, Basic, and Major Care Delta Dental PPO – Choice 47

48 When using a Network Provider: Preventive Care is covered at 100% A $25 deductible applies to Basic and Major Care Basic Care is covered at 85% Major Care is covered at 60% Orthodontic Care is covered at 50% —no lifetime maximum, 12-month waiting period applies A $2,500 calendar year maximum applies to all other services Dental 48 Return to Index

49 VISION PLANS 49

50 50 Humana CompBenefits VisionCare Plan Primary Vision Care Services (PVCS) Superior Vision Plan UnitedHealthcare Vision Vision Service Plan (VSP) Vision Plans Available

51 Each vision plan has its own provider network A copay schedule for services and materials The toll-free number and website address of each plan is listed in the Employee Benefit Options Guide Contact each vision plan for specific benefit questions 51 Vision Plans Overview

52 When using an in-network provider: $10 copay for an annual eye exam $25 copay for lenses and frames; one pair per year Discounts are available for other vision services and lens options Contact lenses are available instead of glasses; $130 allowance Discount through TLC for laser surgery Humana/CompBenefits 52

53 When using an in-network provider: There is no copay or limit on the number of eye exams Lenses and frames are sold at wholesale cost There is no limit on the number of pairs of glasses Benefits available for contact lenses Discount through nJoy for laser surgery Primary Vision Care Services 53

54 When using an in-network provider: $10 copay for eye exams; one per year $25 copay for lenses and frames; one pair per year Contact lenses – available instead of glasses; $25 copay/standard fitting then plan pays 100% or $50 copay/specialty fitting then plan pays up to $50 Discounts available for other vision services and lens options, including laser vision correction Superior Vision 54

55 When using an in-network provider: $10 copay for eye exams; one per year $25 copay for lenses and frames; one pair per year Lens UV coating and tints are covered in full Contact lenses are available instead of glasses Discounts available for other vision services and lens options including laser vision correction UnitedHealthcare Vision 55

56 When using an in-network provider: $10 copay for eye exams; one per year $25 copay for lenses and frames; one pair per year No copay for contact lens exam with network provider Contact lenses are available instead of glasses Discounts are available for glasses and other vision benefits, including laser vision correction VSP 56 Return to Index

57 LIFE INSURANCE PLAN 57

58 Basic and Supplemental Life for You First $20,000 of life coverage (Basic Life) All additional coverage is known as Supplemental Life $500,000 of Supplemental Life coverage is available with an approved Life Insurance Application Basic Life and the first $20,000 of Supplemental Life include Accidental Death and Dismemberment (AD&D) benefits 58 Employee Life

59 During initial enrollment: You can enroll in Guaranteed Issue (two times your annual salary rounded up to the next $20,000) without a Life Insurance Application You can apply for amounts above Guaranteed Issue; a Life Insurance Application is required 59 Employee Life

60 During Option Period: You can enroll in Basic Life You can enroll in Supplemental Life You can enroll in up to $500,000 of Supplemental Life insurance coverage An approved Life Insurance Application is required 60 Employee Life

61 Keep your beneficiary designation up-to- date Beneficiaries can be changed at any time Review your beneficiaries if you have a change, such as a marriage, divorce, death of a family member, or birth of a child Beneficiary Designation Forms are available online, from your Insurance Coordinator, or by calling EGID Member Services 61 Beneficiary Designation

62 Premier Option Spouse$20,000 Child$10,000 Premier Option Spouse$20,000 Child$10,000 Standard Option Spouse$10,000 Child $5,000 Standard Option Spouse$10,000 Child $5,000 Low Option Spouse$6,000 Child$3,000 Low Option Spouse$6,000 Child$3, You must be enrolled in Basic Life coverage to enroll your eligible dependents in Dependent Life. Dependent Life Return to Index No coverage for a stillbirth.

63 ELIGIBILITY 63

64 An education employee must be: Currently employed, eligible for TRS, and working at least four hours a day or 20 hours a week A local government employee must be: Currently employed, regularly scheduled to work 1,000 hours or more per year, and cannot be listed as a temporary or seasonal employee 64 Eligible Employees

65 Eligible dependents include: Your legal spouse (including common- law) Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child, or child legally placed with you for adoption up to age 26, whether married or unmarried Disabled dependents over age 26 with approved documentation 65 Eligible Dependents

66 If you insure one dependent, all eligible dependents must be insured You can exclude dependents who do not reside with you, are married, are not financially dependent on you for support, have other group insurance, or are eligible for Indian or military benefits A spouse can be excluded by signing the Spouse Exclusion Certification statement on the back of the form 66 Eligible Dependents

67 67 Other unmarried dependent children up to age 26, upon completion of an Application for Coverage for Other Dependent Children Guardianship papers or a tax return showing dependency can be provided in lieu of the application Dependents cannot include your parents or grandparents Other Dependent Children

68 Certain qualifying events allow you to make a midyear change, examples include: Marriage Divorce Adoption Death Childbirth* Gain or loss of other group insurance *Must be added the first of the month of birth. Notify your Insurance Coordinator within 30 days of the event or wait until the next annual Option Period. 68 Midyear Qualifying Events

69 Option Period Enrollment/Change Form: Your Insurance Coordinator will provide the deadline Insurance Enrollment Form: Return your form to your Insurance Coordinator within 30 days Insurance Change Form: Return your form to your Insurance Coordinator within 30 days of a qualifying event 69 Deadlines for Forms

70 Tobacco-free Attestation: Must be completed as part of the Option Period enrollment process The Attestation can be completed online or returned to your Insurance Coordinator Deadline is November 15, Deadlines for Forms

71 EGID mails you a Confirmation Statement when you enroll or make changes to coverage If your Confirmation Statement is incorrect, contact your Insurance Coordinator immediately 71 Confirmation Statements

72 If you do not make changes during the annual Option Period and are not automatically enrolled in a HealthChoice alternative plan, no Confirmation Statement will be sent; keep your enrollment form as verification of coverage 72 Confirmation Statements

73 Option Period is the only time you can make changes to coverage with a qualifying event HealthChoice High and Basic require a completed tobacco-free Attestation To enroll in dental or life coverage, you must have group health insurance If excluding your spouse, your spouse must sign the Spouse Exclusion Certification Return signed and dated forms to your Insurance Coordinator by the set deadline Notify your Insurance Coordinator if you have a change of address 73 Reminders

74 The 2014 Employee Benefit Options Guide Plan websites and toll-free numbers available in your Option Period packet The FAQ section of the EGID website EGID Member Services at or toll-free ; TDD users call or toll-free Your Insurance Coordinator 74 Questions Return to Index


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