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City of Port Neches Laura Bloss, Benefit Services Specialist TML IEBP (512) 719-6500 2011-2012.

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Presentation on theme: "City of Port Neches Laura Bloss, Benefit Services Specialist TML IEBP (512) 719-6500 2011-2012."— Presentation transcript:

1 City of Port Neches Laura Bloss, Benefit Services Specialist TML IEBP (512)

2 TML IEBP Mission Statement To provide excellent service and administrative services to eligible municipalities in Texas by utilizing innovative, affordable alternatives while maintaining financial integrity. Not-for-Profit Member Equity Public & Private Sector Alliance Exclusive to Public Sector

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4 Benefit SummariesBenefit Summaries Provider SearchProvider Search Online Customer ServiceOnline Customer Service Account BalancesAccount Balances Consumer Driven Health GuidesConsumer Driven Health Guides Claim InformationClaim Information Flex FormsFlex Forms Dependent CareDependent Care Recurring ExpenseRecurring Expense Important NewsImportant News Find the Information You Need:

5 - TML IEBP continues to offer the Preferred Lab Benefit BUT QUEST is no longer in the network. TML IEBP will access United Healthcare ‘s Choice PLUS Network Not United Healthcare’s Options PPO Network TML IEBP will no longer have a Direct Network to supplement United’s Network TML IEBP has worked with United to add most direct providers into Choice PLUS What does that mean besides better discounts? TML IEBP’s STATEWIDE NETWORK IS IMPROVING! How is the Preferred Lab network affected?

6 The Provider Search Page will change after 1/1/2011. You may preview the Choice Plus network today.

7 NEW ID CARD: Please make certain to give providers a copy of your new ID Card and tell them that you have a different network

8 Benefit Assist Guide

9 Open Enrollment TML Intergovernmental Employee Benefits Pool

10 Open Enrollment is the month prior to the new plan year. Your group has an anniversary date of July 1, Open Enrollment would be during June, When is Open Enrollment?

11 They would have to wait until the following year’s open enrollment period unless there is a Qualifying Event: 1.Marriage, 2.Birth or adoption of a child, 3.Loss of eligibility under Medicaid or SCHIPTermination of a spouse’s employment, 4.Spouse changes from full-time to part-time or takes unpaid leave, 5.Significant change (10% or more) in the benefit coverage of your spouse’s plan. What if I do not add my dependents during the Open Enrollment period ? *Note: Dependents cannot be dropped during the plan year unless there is a qualifying event. SCHIPS eligibility is NOT a qualifying event

12 Healthcare Reform in Action TML Intergovernmental Employee Benefits Pool

13 External Appeal Language Ombudsmen Information » » Non English language declinations based on county specific 10% or more of the population residing in the claimant’s county who are literate only in the same non-English language as determined based on American Community Survey data published by the US Census Bureau. » »Diagnosis Code upon request » »Procedure Codes upon request » »Translation Request upon request in County Specific non-English Healthcare Reform (PPACA): Standardization of Communication   Compliance with standardization of the Explanation of Benefits (EOB’s)

14 Medical Plan TML Intergovernmental Employee Benefits Pool

15 Please refer to the Medical Benefits Booklet for complete details on your medical benefit program.

16 ServiceNotification Late Notification Penalty Notification Requirements Emergency AdmissionsOne (1) business day following an emergency or as soon as reasonably possible $400 Scheduled Admissions Includes Psychiatric / Chemical Dependency Intensive Outpatient Treatment Five (5) days prior to a non-emergency admission$400 Pregnancy Maternity Sonogram (in excess of three),Amnio, Home Health, Multiple Birth Diagnosis Within (48) hours Prior to Commencement for Outpatient and Home Health Procedures $200 Newborn/Pregnancy Maternity C-Section Within (48) Hours Within (96) hours $400 Transplant & Morbid Obesity(10) Working Days prior to initial evaluation$400 Outpatient Surgery(3) Working Days prior to procedure$200 MRI, PET, CAT, MRA, Chemotherapy, Radiation Therapy, Oral Oncology, Hyperbaric Oxygen Therapy, Cochlear Device/Implantation, Hospice, Home Health, Physician Home Visit, Convalescent Nursing Home for Rehab, Dialysis, Durable Medical Equipment for Charges in Excess of $1,000, Infusion Therapy, Dental Injury & Reconstructive Surgical Procedure, Testing for Genetic Markers Prior to Commencement$

17 Medical Plan Benefit Changes / Choice Plus Network

18 Major Medical Medical Plan Changes Medical Plan Changes Benefit   2012 Calendar Year preventive/routine benefit expands $500   Speech Therapy No notification required: 12 visits   Occupational Therapy No notification required: Combined 18 visits Physical Therapy   Ambulance Ground $1,500   Ambulance Air $9,000   Obesity- follow up treatment is eligible benefit if surgery received prior to being covered under this plan

19 Evidence Based Medicine is a process of external expert medical evaluation to ensure clinically appropriate healthcare. It seeks to assess the quality of evidence of the risks and benefits of treatments (including lack of treatment). TML IEBP contracts with a multitude of Specialty Review Medical Consultants to work with your attending physician to achieve the most effective treatment outcome using evidence based medicine approaches for benefit plan coverage. Healthcare Reform (PPACA): Evidence Based Medicine

20 Please refer to Medical Book, Schedule of Benefits and Summary of Benefit Changes for specific plan details. To comply with national Standards, TML IEBP is changing ages to for Fecal Occult Test & Mammograms Healthy Initiatives Incentive

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22 Medical Plan Benefit Changes Population Health Management will replace Outreach. A Professional Health Coach is available to all eligible enrollees. You can reach a health coach by calling: or by calling the number on your ID Card to reach your coach directly. BeWellat TML IEBP Contact a Professional Health Coach Discuss your health concerns, understand medications, develop healthy habits and more

23 Prescription Benefits TML Intergovernmental Employee Benefits Pool

24 Medication Therapy Management Program (MTMP) $ $$ $$$ Lowest Cost Highest Cost Mac A Retail Copay Mail Order Copay Over the Counter Equivalence: Non-Sedating Antihistamines (Claritin, Alavert) Stomach and Ulcer (Prilosec) Allergy Medication (Zyrtec) Smoking Cessation (Nicorette Gum) Limit - 3 boxes Allegra and Allegra-D $0.00N/A Value Tiered 34 day generic dispensement$0.00N/A Value Tiered day generic dispensement$9.00N/A Generic$10.00$25.00 Best Brand Price List$38.00$95.00 Non-Best Brand Price List$60.00$ Cost Share$120.00$ Specialty/Biotech Prescriptions$ for 34 day dispensement 8 ways to Purchase Prescription Drugs CVS Caremark will continue to administer mail order / Biotech

25 Align Pharmacy Network New Pharmacies are being added each month

26 Cost Share Drugs Evidence Based Drug Formulary Generic Cost Share Drugs

27 Cost Share Drugs Evidence Based Drug Formulary

28 Clinical Prior Authorization

29 Step Therapy

30 Member Login Restat Website

31 RESTAT Website Drug Pricing Lookup Drug Name Medical Condition Dosage

32 Drug Form/ Quantity Zipcode

33 Shop & Compare

34 RESTAT Website Drug Pricing Lookup

35 RESTAT Website Drug Pricing Lookup

36 Is based on Evidence Based Medicine. Converts Patients from costly drugs to therapeutically equivalent, cost effective alternatives. Ask your Dr. to contact Rx Results, ( the number is on your ID Card) Look up drug prices at Medication Therapy Mangement Program:

37 TML Intergovernmental Employee Benefits Pool Medical Plans

38 Plan Copay Individual Deductible (2 x Family) Individual Out of Pocket (2 x Family) P HRA Eligible $30.00 $200.00$2, P HRA Eligible 30% $0.00$3, P HRA Eligible 20% $500.00$2, P HRA Eligible 20% $500.00$3, P HRA Eligible 20% $750.00$3, P HRA Eligible 20% $1,000.00$3, P * HSA Eligible $1, (IRS: High Deductible Health Plan) $4, (IRS: High Deductible Health Plan) P * HSA Eligible $2, (IRS: High Deductible Health Plan) $3, (IRS: High Deductible Health Plan) Medical Plan Options – Port Neches

39 ► Employee & Dependents must enroll on same plan ► Employee can change plans at open enrollment or with qualifying event   Should an employee select a plan that is more expensive than the amount pledged, an optional pretax payroll deduction would allow them to “buy-up” to a more expensive plan.   Should an employee select a plan that is less expensive than the amount pledged, they can “buy-down”. The balance of remaining dollars can be used to offset the monthly cost of dependent coverage or if not applied to coverage, can be deposited in a pre-tax account Health Reimbursement Account (HRA)- Employees that “buy-down” to a less expensive PPO plan (not one of the two IRS High Deductible Plans) are able to have the excess money deposited into a Health Reimbursement Account. High Deductible Health Savings Account (HSA) - Employees that “buy-down” to one of the two IRS High Deductible Plans are able to have the excess money deposited into a Health Savings Account. PRE-TAX Medical Plan Options – Port Neches

40   As you receive non-preventive medical care, you must meet the plan deductible before the health plan pays benefits.   Enrollees must pay all diagnosis related expenses (non-preventive) until the deductible is met. This include preferred lab charges and prescription drug charges.   Preventive prescription drugs can be purchased with a copay (or at no cost for certain generic drugs). However, non-preventive prescriptions are not eligible for a copay (or no cost) until the deductible is met (A list of preventive drugs is available).   Both healthcare and prescription drug expenses can accumulate to the deductible and out of pocket max.   Once the deductible & out-of-pocket max is met, eligible, in-network services and eligible prescriptions will be paid at 100%. HIGH DEDUCTIBLE HEALTH PLANS The High Deductible Health Plans (HDHP) are IRS designed plans that have a number of features that make them very different from a traditional PPO:

41 HDHP Preventive Drug List

42   Flex money cannot be used until the HDHP deductible is satisfied. (H.S.A. money in your H.S.A bank account can!)   Flex money can be used for dental or vision expenses. HIGH DEDUCTIBLE HEALTH PLANS How does this work with Section 125 (FLEX) plan? It becomes a Limited Post Deductible Section 125 Plan

43   HRA money cannot be used until the deductible is satisfied. (HSA money can!)   HRA money can be used for dental or vision expenses.   HRA money can be used once the HDHP deductible is satisfied. Current Flex/Debit card de-activated 09/30/2011. Paper receipts must be filed for reimbursement. HIGH DEDUCTIBLE HEALTH PLANS What if I have money in my HRA today? What if I have satisfied some or all of my yearly deductible? Do I get credit for monies spent?   Per IRS, deductible credit cannot be given if you used HRA money.   You will get credit for any portion of the deductible that was satisfied without using HRA monies.

44 Health Reimbursement Account (HRA) TML Intergovernmental Employee Benefits Pool

45 HRA All Over-the-Counter medicines or drugs must be prescribed by a physician. The following are examples of some of the OTC items that will remain available without a doctor's prescription: Band Aids Birth Control Braces & Supports Catheters Contact Lens Supplies & Solutions Denture Adhesives Diagnostic Tests & Monitors Elastic Bandages & Wraps First Aid Supplies Insulin & Diabetic Supplies Ostomy Products Reading Glasses Wheelchairs, Walkers, Canes Healthcare Reform in Action FAQ: If I get a doctor’s prescription for an OTC medication, can I still use my Benefits Debit Card? No. The Benefits Debit Card cannot be used to pay for any OTC medications after December 31, However, you may use another form of payment and submit a FSA/HRA/HSA Claim Form with a doctor’s prescription for reimbursement

46 Availability of Funds HRA funds are only available as they are deposited by the employer. When using the debit card only the amount available will be approved. Example: Claim totals $250, but only $ is available; debit card transaction will be denied. A claim of $ would be approved and the remaining $0.01 should be paid through alternate means (cash or personal credit card)

47 HRA Funds are NOT Use it or Lose It HRA Funds can be used to: 1.Purchase eligible medical expenses per the IRS guidelines and Plan Document 2.Offset cost of Dependent Coverage 3.Purchase Voluntary Products (i.e, vision/dental) or 4.Can accumulate year to year and later be converted to a Retiree Reimbursement Account

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49 Debit Card Guidelines In many cases, the software will substantiate procedures for Debit Card Claims Receipts should always be maintained by participant (keep a folder with all the receipts and documentation!) Even though it’s called a “Debit” card, there is no PIN# so you must select “Credit” when swiping the card

50 Prompt Pay TML Intergovernmental Employee Benefits Pool

51 SB 418 ~ Prompt Pay Governor Perry signed into law SB 418 to support prompt payments for network providers. Claim MethodologyPayment Timeline Paper Claim (5 days after claim is mailed)45 days Electronic Claim or overnight receipt30 days Affirmative adjudicated Pharmacy Claim21 days * Claims that are not paid within the timeline will revert back to the billed amount and may lose the discounts of the contracted amount. Requesting Additional Information and Impact on Claim Payment Timeline Many network provider contracts, including Baylor Medical System, stipulate that payors requesting additional information from someone other than the Prompt Pay Provider will not stop the claim payment timeline. Thus, getting the requested information from the covered individual, in a timely manner, is critical to ensure that penalties are avoided. Below are examples of information that a claim could be pended/denied for while awaiting information from the covered individual: 1. 1.Other Insurance, 2. 2.Pre-existing Condition Inquiry, 3. 3.Verification of dependent eligibility 4. 4.Right of Recovery Investigation, 5. 5.Coordination of Benefits. If the information is not received, the covered individual may be balance billed. Healthcare Reform in Action

52 Accident / Injury Questionnaire Do I have to submit the Accident/Injury Questionnaire even if I was not in an accident? Yes! The information requested can affect the way your claims are processed. Because of this, all claims related to this accident or injury will be put on hold until TML IEBP receives your completed Accident/Injury Questionnaire. If TML IEBP does not receive your completed Accident/Injury Questionnaire, you may be balanced billed by your medical care provider(s). Once the questionnaire is received, claims will be released for processing

53 Other Coverage Inquiry

54 Understanding Your Explanation of Benefits 1.Date of Service - Date the service was incurred. 2.Total Charge - The amount your provider is charging for services. 3.Ineligible - Any amounts listed in this column may not be covered under the terms of your benefit plan and may be your responsibility to pay. 4.Remark Code - The code used regarding payment. The code is defined under Remark Code description. 5.Type of Service - The numeric code for type of service rendered. The code is defined under Type of Service rendered. 6.Cost Management Savings - You are not responsible for this amount because you received services from an In Network provider or from a provider that was willing to negotiate his or her fee. The discount was negotiated with the provider of service on your behalf. The affiliation, if shown, indicates the provider organization through which the discounts were negotiated

55 7.Copay - The amount shown represents either the copay you paid at the time of service or the copay amount that you will be responsible to pay. This amount usually does not apply towards the satisfaction of your deductible or out of pocket maximum. Copays are described in your Benefit Book and on your Schedule of Medical Expense Benefits. 8.Deductible Amount - The amount shown is the amount applied to toward the patient’s deductible. The deductible is your responsibility to pay. Deductibles are described in your Benefit Book and on your Schedule of Medical Expense Benefits. 9.Covered Expenses - The amount shown is the amount that is considered for payment by your benefit plan. 10.Balance - The amount shown is the amount charged minus the ineligible, cost management savings, copay and deductible amount. 11.Pay % - The amount shown is the benefit percentage that was paid by your benefit plan. 12.Amount Payable - The amount shown is the benefit amount paid by your benefit plan

56 13.Out of Pocket - This is the portion of the Covered Expenses that is the patient’s responsibility. Non Network amounts may not apply to the cumulative out of pocket depending on plan design. 14.Patient’s Total Responsibility - If there is no Other Payment Adjustment amount, the Patient’s Total Responsibility equals the Total Charge less Cost Management Savings less Other less Total Benefit. Note: The Patient’s Total Responsibility will not be shown if there is an Other Payment Adjustment amount or if this EOB is for an adjusted claim. 15.Other - This is the total of any charges listed in the Ineligible column for which we are awaiting documentation or for which we have determined the provide may have inappropriately coded this service or for which we determined the amount was a duplicate. Upon receipt of the requested information, a decision will be made to determine which, if any, of these charges are eligible expenses. If the provider believes that the charges were appropriately coded and billed, supporting documentation must be submitted for further review to determine if any additional allowance is warranted. If the amount is for a duplicate, no action is necessary

57 SUPERIOR VALUE Preferred labs pay at 100% for eligible laboratory tests… remember Quest labs are not a network provider! No Cost for many Generic Drugs at Align Pharmacies $150 Incentive for completing Annual Tests – –No cost (network) + $300 for wellness (2011) increases to $500 (201 - Calendar Year). Professional Health Coaches – –You can reach a health coach by calling:


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