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1 2011 Health Care Update Devon Hooper OPERS Jason Davis OPERS.

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Presentation on theme: "1 2011 Health Care Update Devon Hooper OPERS Jason Davis OPERS."— Presentation transcript:

1 Health Care Update Devon Hooper OPERS Jason Davis OPERS

2 2 Health Care Challenges & Opportunities Baby Boomers’ Retiring Retirees Living Longer Benefits Perception (a.k.a. “Pension Envy”) Economy and Budget Increasing Cost of Health Care Solvency of Medicare and Social Security National Health Care Reform

3 3 Present & Future of OPERS Health Care Although Ohio law does not mandate health care coverage, OPERS understands the importance of health care coverage to our benefit recipients As of 12/31/09, HCPP 1.0 & 2.0 have had an impact of $1.8 billion on the health care fund $11.4 billion in health care fund as of 12/31/09 OPERS spent $1.5 billion in 2009 on health care claims for our retirees & dependents OPERS is currently planning for future changes aiming to improve solvency of health care fund

4 4 Eligible Dependent Guidelines in 2011 Your Legal Spouse - Spouses under age 55 will pay full premium cost - Once covered spouse reaches age 55 OPERS will again subsidize portion of premium cost Your biological and/or legally adopted children: - Under age 26 with no other qualifications Grandchildren, only if legally adopted or with a court order pursuant to the Ohio Revised Code See page 14 of 2011 Health Care Coverage Guide

5 5 Dependent Coverage You may add coverage for a dependent during Open Enrollment or within 60 days of a qualifying event such as: - Involuntary loss of health insurance - Marriage - Birth of a child You may drop coverage for a dependent at any time See page 14 of 2011 Health Care Coverage Guide

6 Medical Mutual Plan Medical Mutual administers plan for all Non- Medicare participants (under 65) & Medicare retirees or spouses in a “split family” Non-Medicare participants have lower out of pocket costs by using network providers (PPO) Medical Mutual has largest provider network of any insurer in Ohio Enhanced plan level Intermediate plan level Basic plan level See pages of 2011 Health Care Coverage Guide

7 Non-Medicare Medical Mutual Plan Highlights 2011 Non-Medicare Medical Mutual Enhanced Plan Item Deductible (In Network)$700 Out-of-Pocket Max (In Network)$1,500 Emergency Room Co-Pay (Non-Emergent Issue) $200 Physician Office Visit Co-Pay$20 PCP/$35 Specialist 2011

8 Non-Medicare Prescription Coverage Administered by Express Scripts See page 7 of 2011 Health Care Coverage Guide 30-day supply at retail pharmacy 90-day supply through Express Scripts mail order Our formulary is a preferred list of medications Formulary brands & generics have lowest copays Cost savings through mail order

9 Non-Medicare Prescription Enhanced Plan Comparison Chart Item2011 Generic Co-Pay (30-day Retail/ 90-day Mail) $4 retail /$10 mail Formulary Co-Pay (30-day Retail/ 90-day Mail) 30% ($30 min $60 max) retail/ $75 mail Non-Formulary Co-Pay (30-day Retail/ 90-day Mail) 40% ($75 min $150 max) retail/ $ mail Deductible (Brand Name Only) $50 retail or mail PPI medications Cover only generic & OTC PPI medications OTC $5/$12.50 Generics $25/$62.50 Diabetic Medications & Supplies Cover all diabetes medications and testing supplies for Disease Management participants at 100%

10 10 Medicare & Your Health Coverage Medicare A is hospitalization coverage - 40 credits required by Social Security but you may qualify through a spouse Medicare B is medical coverage - Everyone is eligible, usually at age 65 - Enrollment is required when first eligible - Medicare proof must be submitted to OPERS OPERS will reimburse a retiree’s Medicare B premium up to $96.40 See pages of 2011 Health Care Guide

11 11 Medicare & Your Health Coverage Medicare C is Medicare Advantage Plans that administer Medicare through insurance companies - OPERS has enrolled our Medicare eligible participants in Humana Medicare Advantage Plan Medicare D is prescription coverage through Medicare & administered by insurance companies - OPERS has enrolled our Medicare eligible participants in Medicare D Plan through Express Scripts

12 Humana Medicare Advantage Plan Retirees and covered spouses with Medicare A & B or Medicare B only who live in the U.S. and not covering children are enrolled Claims are sent directly to Humana for processing & are not sent to Medicare Member must meet annual deductible of $250 before most services are paid at 96% or higher Provider must accept Medicare & Humana card Diabetic testing supplies covered at 100% See pages 1 & 2 of 2011 Health Care Guide

13 Humana Medical Plan Item 2011 Deductible$250 Out-of-Pocket$850 Emergency Room$50 Physician Office Visit Co-Insurance 96% PCP / 92% Specialist 2011 Humana Medicare Advantage Plan Highlights

14 OPERS Medicare Part D Drug Plan Administered by Express Scripts See page 3 of 2011 Health Care Coverage Guide 90-day supply at Medicare approved pharmacy 90-day supply through Express Scripts mail order Zostavax vaccine for Shingles covered 100% coverage for all diabetic medications Copays for Medicare retirees will remain the same

15 OPERS Medicare Part D Drug Plan GenericFormulary BrandNon-Formulary Brand Day supply 30 days 90 days 30 days 90 days 30 days 90 days Retail$4 $12 $20 $60 $50 $150 MailN/A $10 N/A $50 N/A $125 Diabetic Meds & Supplies $0 co-pay

16 Optional Coverage MetLife Dental –High Option –Low Option Aetna Vision –High Option –Low Option Prudential Long Term Care –Coverage includes custodial nursing home care & home health care –Coverage is subject medical underwriting See pages 9 – 12 of 2011 Health Care Guide See page 17 of 2011 Health Care Guide

17 Preventive Coverage One routine physical exam covered at 100% Preventive services include PAP, PSA, EKG, Colonoscopy, Mammogram, Bone Density Test Most preventive services covered once per calendar year at 100% of UCR including associated lab work Preventive services must have a routine diagnosis to be paid at 100% of UCR Preventive services will not be subject to coinsurance or deductible

18 18 OPERS Wellness Programs $50 deposit in RMA for each of the following with a maximum of $100 per year: Complete a Health Assessment questionnaire Have an annual physical exam Complete a Lifestyle Coaching Program Participate in a Disease Management Program for those with certain chronic conditions See page 18 of 2011 Health Care Coverage Guide

19 19 Retiree Medical Account The incentive earned will be placed into the retiree’s RMA –An RMA will automatically be created by OPERS The RMA can be used for additional/future health care expenditures –It is not taxable –Can be rolled over from year to year –Currently earns interest –Administered by Aetna See page 19 of 2011 Health Care Coverage Guide

20 20 What Can You Do? Stay Informed: OPERS website OPERS newsletters Ongoing OPERS & vendor communications Educate your physician about your coverage: Provide physician with Express Scripts formulary Inform physician about 100% preventive coverage

21 21 Important Phone Numbers Humana Prudential LTC Medical Mutual MetLife Dental Express Scripts Aetna Vision Aetna RMA OPERS


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