Presentation on theme: "Harrisonburg City Public Schools Open Enrollment 2014 Harrisonburg City Public Schools Open Enrollment 2014."— Presentation transcript:
Harrisonburg City Public Schools Open Enrollment 2014 Harrisonburg City Public Schools Open Enrollment 2014
Today’s Agenda Welcome Review Anthem Plan Effective 07/01/14 –What’s Staying the Same –Why & What’s Changing –Claim Examples Q&A
WHAT’S STAYING THE SAME: KeyCare - Preferred Provider Organization (PPO) Plan PCP not required No referrals needed No claim forms needed when using network providers Very large network of providers available both in Virginia and throughout the U.S. Out-of-network benefits available but at lower coverage levels Dependents covered until the end of the month in which they reach age 26. Annual eye exam - $15 copay (provided through Blue View Vision) Out of pocket maximum (in-network)-$3,000/$6,000 Plan Overview
WHY & WHAT’S CHANGING: WHY CHANGE: Health care costs are affected by: Price inflation, utilization, legislation changes, new treatments, therapies and technologies 8% is the national average rate increase… If HCPS made NO changes, our rate increase would be: 22.3%... this is not sustainable Solution: Change to a plan that is: Considered a quality program in the market Cost effective and sustainable Plan Overview
WHY & WHAT’S CHANGING: WHAT’s CHANGING Benefits – plan is changing to KeyCare 25 Preventive services have been added as a result of the Affordable Care Act Plan Overview
Preventive Care Preventive Care Services covered at 100% in-network with no member copay. *Preventive care services are those services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits, and include such services as: Well Baby Visit with associated immunizations and screenings Well Woman Visit with associated gyn exam, pap smear, and mammogram. Medical and Pharmacy contraceptives, 1 breast pump purchase or rental per pregnancy when purchased from a participating Durable Medical Equipment provider. Routine Physical with associated immunizations and screenings Select OTC drugs with prescription from doctor (ex - iron supplements for children 0-12 months, aspirin for men age and women age 55-79) Screening related to tobacco use including tobacco cessation products with prescription from doctor * During the course of a routine screening procedure, abnormalities or problems may be identified that require immediate intervention or additional diagnosis. If this occurs, and your provider performs additional necessary procedures, the service will be considered diagnostic and/or surgical, rather than screening, depending on the claim for the services submitted by your provider, which will result in a member cost share.
Benefits Overview-KeyCare 25 In-network ServicesCurrent PlanKeyCare 25 Plan Preventive Care Services No charge Doctor Visits – includes: Office visits Urgent care visits $20 PCP $40 Specialist $25 PCP $50 Specialist Spinal Manipulation (Chiropractic) visits- 30 visits $20 PCP $40 Specialist $25/visit Deductible (applies to all services with coinsurance) None$500/person $1,000/family You will pay the costs associated with your care until you have paid $500 in one calendar year. This is known as your deductible. If two people are covered, each will pay $500 ($1,000 total) If three or more people are covered, together you will pay the first $1,000. The most one family member will pay is $500.
Benefits Overview-KeyCare 25 In-network ServicesCurrent PlanKeyCare 25 Plan Diagnostic Labs & X-rays (provided in physician’s office, emergency room or facility) Lab: no charge X-rays-$40 copay Advanced Diagnostic-$150 20%* after deductible Emergency Room Facility $150 copay/visit, then 20%* 20%* after deductible Outpatient Surgery $150 copay/visit, then 20%* 20%* after deductible Inpatient Stays in a Network Hospital $400/stay, then 20%*20%* after deductible *Anthem bases claim payment on the amount the health care providers in our network agree to accept for their services. This is called “allowable charge”. Network providers cannot balance bill for the difference in what we pay and what they charge.
Benefits Overview-KeyCare 25 In-network ServicesCurrent PlanKeyCare 25 Plan Out of Pocket Maximum (once you meet your OOP Max, the plans pays 100% for the remainder of the calendar year) $3,000/person $6,000/family $3,000/person $6,000/family What counts toward this maximum: medical copays (example - $25 PCP visit) deductible under KeyCare 25 your coinsurance amounts (20% of allowable charge) What doesn’t count toward this maximum: prescription drug copays vision plan copay cost of care when benefit limits are reached
Benefits Overview-KeyCare 25 Out of Network Services (services provided by providers who are not part of the Anthem KeyCare network) Current PlanKeyCare 25 Plan Deductible*$500/person $1,000/family $750/person $1,500/family CoinsurancePlan Pays: 70% You Pay: 30% Plan pays: 60% You Pay: 40% Out of Pocket Maximum* $4,500/person $9,000/family $4,500/person $9,000/family *Deductibles and out-of-pocket maximums do not cross accumulate between in-network and out of network. Anthem bases claim payment on the amount the health care providers in our network agree to accept for their services. This is called “allowable charge”. Non-Network providers can balance bill for the difference in what we pay and what they charge.
Benefits Overview Prescription Drug BenefitsCurrent PlanKeyCare 25 Plan Express Scripts, Inc (ESI) is the Pharmacy Company that Anthem uses Up to a 30 day medication supply at participating Retail pharmacies Tier 1 - $10 Tier 2 - $30 Tier 3 - $50 Tier 1 - $10 Tier 2 - $40 Tier 3 - $75 Up to a 90 day medication supply through ESI home delivery pharmacy Tier 1 - $20 Tier 2 - $60 Tier 3 - $100 Tier 1 - $20 Tier 2 - $80 Tier 3 - $150
Meet Carol Lewis | Employee Only Coverage Claim Examples/Starting July 1, 2014 Carol’s ServicesDate of Service Anthem’s Allowable Charge Anthem Claim Payment Carol’s Payment to Providers Amount toward OOP that Carol has met Preventive Ob/GYN visit & lab tests 7/10/14$300-visit $150-lab $300-visit $150-lab $0 Diagnostic visit to PCP & lab work for strep throat 9/30/14$350-visit $100-lab $325-visit ($350-$25 copay) $0-lab (deductible not met) $25 copay-visit $100- lab ($100 toward deductible) $125 MRI for knee injury 10/1/14$1,000$480 ($1,000-$400 (deductible owed= $600 x 80%) $520 ($400 remainder of deductible + $120 which is 20% of $600) $645 ($125 + $520)
Meet Carol Lewis | Employee Only Coverage Claim Examples (continued ) Carol’s ServicesDate of Service Anthem’s Allowable Charge Anthem Claim Payment Carol’s Payment to Providers Amount toward OOP that Carol has met Outpatient Surgery for knee injury 10/15/14$12,000$9,600 ($12,000 x 80%) $2,355 (20% of $12K would be $2400, but OOP would be met) $3,000 ($645 + $2355) Follow-up visit with Specialist who did knee surgery 11/1/14$150 $0OOP has been met for 2014* *For the remainder of 2014, Anthem pays 100% of any remaining medical charges. Carol continues to pay for any prescriptions and/or routine vision exam.
Meet Carol Lewis | Employee Only Coverage Claim Examples/Starting January 1, 2015 Carol’s ServicesDate of Service Anthem’s Allowable Charge Anthem Claim Payment Carol’s Payment to Providers Amount toward OOP that Carol has met Confirmation of pregnancy at OB/GYN’s office 01/01/15$200-visit $100-lab $150-visit ($200-$50 copay) $0-lab (deductible not met) $50/visit $100 lab ($100 toward deductible) $150 Pregnancy Related Ultrasound at GYN’s office 03/01/15$400$0 (deductible not met) $400 (remainder of deductible) $550 ($150 + $400) Pregnancy Related Ultrasound at GYN’s office 06/01/15$400$320 ($400 x 80%) $80 ($400 x 20%) $630 ($550 + $80) Maternity-Delivery and Global Bill from GYN 09/01/15$7600$6,080 ($7600 x 80%) $1,520 ($7600 x 20%) $2,150 ($550 + $1520)