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2015 Why Are There Changes With Healthcare? Copyright © 2014 Five Points ICT, Inc. All rights reserved.

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Presentation on theme: "2015 Why Are There Changes With Healthcare? Copyright © 2014 Five Points ICT, Inc. All rights reserved."— Presentation transcript:

1 2015 Why Are There Changes With Healthcare? Copyright © 2014 Five Points ICT, Inc. All rights reserved.

2 Health Care Reform Beginning Jan 1, 2015 HCR Requires: Large employers must offer a health plan: – To employees averaging 30+ hrs per week – That is considered HCR affordable – That provides min. essential benefits – Or, the employer must pay a penalty

3 Copyright © 2014 Five Points ICT, Inc. All rights reserved. Health Care Reform Beginning Jan 1, 2014 HCR Requires: All individuals including spouses and children to have qualified health insurance, or pay a penalty for not having coverage Our district will continue to offer coverage to employees averaging 30+ hours per week Non full time employees can apply for coverage through the Federal Marketplace – Based on your income the government may help pay for your coverage! – To learn more go to

4 The bottom line is Health Care Reform created new additional costs for our district and employees Like many other districts we will be offering a new health plan option in 2015: The new plan meets HCR requirements The benefits are comprehensive And, it will keep costs affordable for the district, employees, and their families 2015 Health Plan Cost Copyright © 2014 Five Points ICT, Inc. All rights reserved.

5 Your 2015 Health Insurance Options

6 2014 Health Insurance Options Provider Networks BlueCross BlueShield of Tennessee Cigna Premium Levels Employee only Employee + child(ren) Employee + spouse Employee + spouse + child(ren) Benefit Levels  Partnership Plan  Standard Plan  Limited Plan 

7 2015 Health Insurance Options Premium Levels Employee only Employee + child(ren) Employee + spouse Employee + spouse + child(ren) Benefit Levels Partnership Plan Standard Plan New Option Limited + Beazley Gap Plan Provider Networks BlueCross BlueShield of Tennessee Cigna 

8 What is the Limited PPO + Gap Plan? Copyright © 2014 Five Points ICT, Inc. All rights reserved.

9 The Limited PPO

10 The Limited PPO Overview Same covered and non-covered services as the Partnership / Standard options Same healthcare network providers (BCBST & Cigna networks) Premiums are lower, but Out-of-Pocket costs like deductibles and copays are higher There are no wellness requirements to qualify for the lower Limited PPO premiums IT IS NOT LIMITED COVERAGE…

11 Comparison of Copayments Copyright © 2014 Five Points ICT, Inc. All rights reserved. Services Copayments (deductible waived) Limited PPOPartnership PPO Standard PPO Primary Doctor Office (includes in office surgery) $35$25$30 Specialist Doctor Office (includes in office surgery) $55$45$50 Preventative Care/ScreeningsNo Charge Diagnostic Test(x-ray, blood)$35$25$30 ER Visit$165$125$145 Urgent Care$40$30$35 Max Copay Cost for Services (per person) Applies to OOP Max Prescription Copayments (deductible waived) Prescription separate deductible$100 per person$0 Generic RX$10$5$10 Preferred Brand RX$55$35$45 Non-Preferred Brand RX$105$85$95 Annual Maximum Prescription Copay Cost (Employee / Family) Applies to Annual Max OOP $2,500 / $5,000$3,000 / $6,000

12 Annual Out-of-Pocket Maximums Limited PPO Partnership PPOStandard PPO In-Network Annual Deductible Employee only$ 1,200$450$800 EE + Child(ren)$ 1,800$700$1,250 EE + Spouse$ 2,100$900$1,600 EE + Sp + Child(ren)$ 2,600$1,150$2,050 Annual Co-Insurance Max 70% / 30% 90% / 10% 80% / 20% Employee only$ 5,400 $1,850$1,800 EE + Child(ren)$ 11,400 $2,500$2,550 EE + Spouse$ 11,100 $2,800$2,900 EE + Sp + Child(ren)$ 10,600 $3,450$3,150 Annual Out-of-Pocket Max = Deductible + Co-insurance Max Employee only $6,600 Includes Copays$2,300 + Copays$2,600 + Copays EE + Child(ren) $13,200 Includes Copays$3,200 + Copays$3,800 + Copays EE + Spouse $13,200 Includes Copays$3,700 + Copays$4,500 + Copays EE + Sp + Child(ren) $13,200 Includes Copays$4,600 + Copays$5,200 + Copays Copyright © 2014 Five Points ICT, Inc. All rights reserved.

13 Everyone likes lower premiums, but how can the higher out-of-pocket exposure be reduced? The Bottom-Line:

14 Copyright © 2014 Five Points ICT, Inc. All rights reserved. Supplemental Gap Insurance Offered by Beazley Insurance

15 Copyright © 2014 Five Points ICT, Inc. All rights reserved. What is Gap Insurance? Medicare Gap supplement plans are a good example of Gap Insurance plans Medicare doesn’t pay for everything, so people buy a Medicare Gap plan that helps pay their out-of-pocket costs Like a Medicare Gap plan the Beazley Gap plan will help pay your out of pocket costs Employees who pick Limited PPO plan will eligible for our new Beazley Gap Plan The Gap plan will also cover family members who are covered on the Limited PPO

16 Great News! Beginning Jan 1, 2015 Copyright © 2014 Five Points ICT, Inc. All rights reserved. If you pick the Limited PPO plan the district will pay toward the cost of our Beazley Supplemental Gap plan Gap Coverage TypeDistrict PaysYou Pay Employee (EE) 100%0% EE + Child(ren) 100%0% EE + Spouse 100%0% EE + Spouse + Child(ren) 100%0%

17 Gap Plan Highlights The Beazley Gap plan is guaranteed issue with no health questions asked! There are no pre-existing conditions limitations other than what the state health plans requires (if any) The Gap plan pays qualified claims for both In and Out of Network providers The Gap plan reimburses qualified out of pocket expenses beginning first dollar! For example, you owe $500 in deductible expense the Gap plan will pays the $500 Claims must be qualified expenses Copyright © 2014 Five Points ICT, Inc. All rights reserved.

18 When do I Use the Gap Insurance? The Gap Plan will reimburse you for eligible expenses to reduce two key areas: 1.Deductibles 2.Co-insurance costs Gap insurance is typically used to reimburse out-of-pocket costs associated with: – Hospitalizations – Certain “Out-Patient” procedures – And, major medical tests like MRI’s Copyright © 2014 Five Points ICT, Inc. All rights reserved.

19 Presented By: Five Points Health Care Reform: Tools to Manage Required Tracking & Reporting Type Coverage In Patient Annual Maximum Out Patient Annual Maximum Employee only $6,000$4,000 EE + Child(ren) $6,000 per person $12,000 max $4,000 per person $8,000 max EE + Spouse $6,000 per person $12,000 max $4,000 per person $8,000 max EE + Sp + Child(ren) $6,000 per person $12,000 max $4,000 per person $8,000 max Annual Maximum Beazley Gap Benefits Copyright © 2014 Five Points ICT, Inc. All rights reserved.

20 Gap Inpatient Benefits Covered inpatient services included are: – Hospital room and board charges – Hospital ancillary charges – Surgery - surgeons fees, etc. – Chemotherapy, Radiation, Dialysis – Radiological Imaging (X-ray, CRT, MRI) – Drug or alcohol treatment is not covered See your Beazley policy for more details Copyright © 2014 Five Points ICT, Inc. All rights reserved.

21 Gap Out Patient Benefits Covered outpatient services included are: – Treatment in a Hospital Emergency Room, but not admitted to inpatient – Surgery in a Hospital Outpatient Facility or Freestanding Surgery Center – Radiological diagnostic testing in a Hospital Outpatient or MRI facility – Outpatient Radiation and Chemotherapy See your Beazley policy for more details Copyright © 2014 Five Points ICT, Inc. All rights reserved.

22 When Does Gap Not Pay? These are some services that are not covered by Gap and are not reimbursed: – Doctor office visits, urgent care centers, preventative exams, chiropractic visits – Prescription drugs – Ambulance – Durable medical equipment (DME) – Out Patient kidney dialysis – Out Patient Therapy (speech, occupational, rehab) – Dental and Vision, unless injury or congenital anomaly of newborn See your Beazley policy for more details Copyright © 2014 Five Points ICT, Inc. All rights reserved.

23 Let’s Review… * Review the state health plan and Gap plan benefit summaries for complete details, exclusions, and limitations. The above information is a brief summary and is for illustrative purposes only. Type of ServiceLimited PPO BenefitsGap Benefits In-Patient Hospital CareSubject to Ded / CoinsurGap Pays Surgery In HospitalSubject to Ded / CoinsurGap Pays Out-Patient Surgery in Hospital or ClinicSubject to Ded / CoinsurGap Pays Diagnostic Tests in Hospital & Out-patient CenterSubject to Ded / CoinsurGap Pays In and / or Out-Patient Radiation & ChemotherapySubject to Ded / CoinsurGap Pays In and/ or Out-Patient Drug & Alcohol TreatmentSubject to Ded / CoinsurNot Reimbursed Ambulance ServicesSubject to Ded / CoinsurNot Reimbursed Doctors Office, Specialist, & Urgent Care CenterSubject to CopayNot Reimbursed PrescriptionsSubject to CopayNot Reimbursed Out-Patient Physical, Speech, Rehab TherapySubject to Copay or Ded / CoinsurNot Reimbursed Durable Medical Equipment (DME)Subject to Ded / CoinsurNot Reimbursed Out-Patient Kidney DialysisSubject to Ded / CoinsurNot Reimbursed

24 Copyright © 2014 Five Points ICT, Inc. All rights reserved. Exclusions and Limitations Like all insurance plans the Beazley Gap plan has exclusions and limitations Examples of exclusions would be: – Out of pocket expenses incurred as a result of the insured committing a crime, or as a result of being legally intoxicated – Acts of war – Dental and vision services other than for accidents or birth defects – Injuries as a result of hazardous activities like hang gliding, etc.

25 Copyright © 2014 Five Points ICT, Inc. All rights reserved. Exclusions and Limitations The Partnership, Standard, and Limited PPO plans also have exclusions and limitations Review the benefit summaries to learn more about what’s covered and non-covered, exclusions, and limitations

26 Copyright © 2014 Five Points ICT, Inc. All rights reserved. How Does the Limited PPO and Gap Plan Work Together?

27 How Gap Plans Save You Money Employees who pick the Limited PPO + Gap plan can save money: – Per paycheck with lower premiums – Can have significantly lower OOP costs because the Gap plan can pay all or most of OOP’s The combined savings of lower OOP’s and lower premiums can be significant Copyright © 2014 Five Points ICT, Inc. All rights reserved.

28 2015 Employee Monthly Cost 1. BCBST Limited PPO + Gap Plan Partnership PPOStandard PPO Employee (EE)$0.00$27.04$52.04 EE + Child(ren)$142.75$267.65$ EE + Spouse$168.70$316.32$ EE + Sp. + Child(ren)$224.94$421.75$ Cigna Open Access Employee (EE)$0.00$47.04$72.04 EE + Child(ren)$152.75$307.65$ EE + Spouse$178.70$356.32$ EE + Sp + Child(ren)$234.94$461.75$511.75

29 Copyright © 2014 Five Points ICT, Inc. All rights reserved Employee Savings BCBST 2014 Partnership $ Your 2015 Limited + Gap $ Limited + Gap Mo. Savings Limited + Gap Annual Savings Employee (EE)$27.04$0.00$27.04$ EE + Child(ren)$267.65$142.75$124.90$1, EE + Spouse$316.32$168.70$147.62$1, EE + Sp. + Child(ren)$421.75$224.94$196.81$2,361.72

30 What is your Total Cost of Healthcare? Your Insurance Premium Cost + Your Out-of-Pocket Expenses = Your Total Cost Copyright © 2014 Five Points ICT, Inc. All rights reserved.

31 Having a Baby OOP’sHaving a Baby OOP’s Hospital and Doctor Bills$7,540 Employee Pay These OOP Expenses Limited PPO + GapPartnership PPOStandard PPO Deductible$1,200$450$800 Co-Insurance$1,902$709$1,348 Primary Care Office Visit Copays$105$75$90 Specialist Copays$330$270$300 Gap Reimbursement for OOP Costs($3,102)$0 Net OOP Cost$435$1,504$2,538 Total Cost = OOP’s + Annual PremiumsTotal Cost = OOP’s + Annual Premiums BCBST Limited PPO + GapPartnership PPOStandard PPO Employee (EE)$435$1,828$3,162 EE + Child(ren)$2,148$4,716$6,050 EE + Spouse$2,459$5,300$6,934 EE + Spouse + Child(ren)$3,134$6,565$8,199

32 Copyright © 2014 Five Points ICT, Inc. All rights reserved. Having a Baby (complications)Having a Baby (complications) Hospital and Doctor Bills$89,125 Employee Pay These OOP Expenses Limited PPO + GapPartnership PPOStandard PPO Deductible (EE + Child)$1,800$700$1,250 Co-Insurance (EE + Child)$11,400$2,500$2,550 Primary Care Office Visit Copays$0 Specialist Copays$0 Generic Drugs$0$180$360 Non-Preferred Drugs$0$3,060$3,420 Gap Reimbursement for OOP Costs($12,000)$0 Net OOP Cost$1,200$6,440$7,580 Total Cost = OOP’s + Annual PremiumsTotal Cost = OOP’s + Annual Premiums BCBSTLimited PPO + GapPartnership PPOStandard PPO Employee (EE)$1,200$6,764$8,204 EE + Child(ren)$2,913$9,652$11,092 EE + Spouse$3,224$10,236$11,976 EE + Spouse + Child(ren)$3,899$11,501$13,241

33 Copyright © 2014 Five Points ICT, Inc. All rights reserved. Outpatient Knee SurgeryOutpatient Knee Surgery Hospital and Doctor Bills$6,340 Employee Pay These OOP Expenses Limited PPO + GapPartnership PPOStandard PPO Deductible$1,200$450$800 Co-Insurance$1,902$634$1,268 Emergency Room Copay$165$125$145 Primary Care Copays$105$75$90 Specialist Care Copays$330$270$300 Generic Drug Copays$100$45$90 Gap Reimbursement for OOP Costs($3,267)$0 Net OOP Cost$535$1,599$2,693 Total Cost = OOP’s + Annual PremiumsTotal Cost = OOP’s + Annual Premiums BCBSTLimited PPO + GapPartnership PPOStandard PPO Employee (EE)$535$1,923$3,317 EE + Child(ren)$2,248$4,811$6,205 EE + Spouse$2,559$5,395$7,089 EE + Spouse + Child(ren)$3,234$6,660$8,354

34 Copyright © 2014 Five Points ICT, Inc. All rights reserved. Managing DiabetesManaging Diabetes Hospital and Doctor Bills$1,300 Employee Pay These OOP Expenses Limited PPO + GapPartnership PPOStandard PPO Deductible$1,200$450$800 Co-Insurance$30$85$100 Emergency Room Copay$165$125$145 Primary Care Office Visit Copays$420$300$360 Specialist Copays$165$135$150 Generic Drugs Copays$90$45$90 Non-Preferred Drugs$1,980$1,620$1,800 Gap Reimbursement for OOP Costs($165)$0 Net OOP Cost$3,885$2,760$3,445 Total Cost = OOP’s + Annual PremiumsTotal Cost = OOP’s + Annual Premiums BCBSTLimited PPO + GapPartnership PPOStandard PPO Employee (EE)$3,885$3,084$4,069 EE + Child(ren)$5,598$5,972$6,957 EE + Spouse$5,909$6,556$7,841 EE + Spouse + Child(ren)$6,584$7,821$9,106

35 Copyright © 2014 Five Points ICT, Inc. All rights reserved. Outpatient Dialysis OOP'sOutpatient Dialysis OOP's Outpatient Bills$32,356 Employee Pays These OOP ExpensesLimited PPO + GapPartnership PPOStandard PPO Deductible$1,200$450$800 Co-Insurance$5,400$1,850$1,800 Emergency Room Copay$0 Primary Care Office Visit Copays$0 Specialist Copays$0 Generic Drugs Copays$0 Non-Preferred Drugs$0$2,500$3,000 Gap Reimbursement for OOP Costs$0 Net OOP Cost$6,435$4,800$5,600 Total Cost = OOP’s + Annual PremiumsTotal Cost = OOP’s + Annual Premiums BCBSTLimited PPO + GapPartnership PPOStandard PPO Employee (EE)$6,435$5,124$6,224 EE + Child(ren)$8,148$8,012$9,112 EE + Spouse$8,459$8,596$9,996 EE + Spouse + Child(ren)$9,134$9,861$11,261

36 Copyright © 2014 Five Points ICT, Inc. All rights reserved. Comparison of Deductibles and Co-Insurance Maximums With Gap * Assumes claim qualifies for first dollar reimbursement from Gap insurance In-Network Annual Deductible *Limited PPO + Beazley Gap Partnership PPOStandard PPO Employee only$0 - $1,200$450$800 EE + Child(ren)$0 - $1,800$700$1,250 EE + Spouse$0 - $2,100$900$1,600 EE + Sp + Child(ren)$0 - $2,600$1,150$2,050 Out-of-Pocket Co-Insurance Maximum Employee only$0 - $5,400$1,850$1,800 EE + Child(ren)$0 - $11,400$2,500$2,550 EE + Spouse$0 - $11,100$2,800$2,900 EE + Sp + Child(ren)$0 - $10,600$3,450$3,150 * After Gap $

37 How the Limited + Gap Plan Works

38 How to File Gap Claims There are 2 ways to file claims: 1.Have the Gap plan pay benefits directly to your healthcare provider 2.Or, have the Gap plan benefits paid directly to you Copyright © 2014 Five Points ICT, Inc. All rights reserved.

39 Paid to Providers 1.Present your Limited PPO and Beazley Gap ID cards to your provider 2.Ask them to file your claims 3.You will get an EOB from the Limited PPO showing your OOP expenses 4.File a Gap claim with Beazley: – Either mail or fax the Limited PPO plan EOB directly to Beazley insurance 5.No claim forms to complete! Copyright © 2014 Five Points ICT, Inc. All rights reserved.

40 Paid to You 1.Present your Limited PPO ID card 2.Ask them to file your medical claim 3.Ask for a copy of the itemized bill 4.You will get an EOB from the Limited PPO showing your OOP expenses 5.File a Gap claim with Beazley: – Either mail or fax the Limited PPO plan EOB and a copy of the itemized bill directly to Beazley insurance 6.No claim forms to complete! Copyright © 2014 Five Points ICT, Inc. All rights reserved.

41 Want the Limited PPO + Gap Plan? You must pick the Limited PPO during your open enrollment Annual open enrollment is Oct 1 – Oct 31 It’s as easy as 1,2,3: 1.Go to the state health plans website 2.Log in & pick the Limited PPO you want 3.Enroll family members to be covered You and covered family members on the Limited PPO will be auto enrolled for Gap Your benefits department can help if needed

42 Special Notice Copyright © 2014 Five Points ICT, Inc. All rights reserved. The content of this communication is for informational purposes only and is not intended as any form of professional advice. This communication is not intended to outline every benefit, limitation, or exclusion of the State-sponsored benefit plans For questions or advice about your benefits, please contact your human resources representative or the Tennessee Benefits Administration Division website at partnerforhealthtn.gov Five Points ICT, Inc. and its affiliate companies are not responsible for errors or omissions in this communication This communication is copyright by Five Points ICT, Incorporated. All rights are reserved

43 Presented By: Five Points Health Care Reform: Tools to Manage Required Tracking & Reporting Understanding your benefits is important. Thank you! Five Points Benefits


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