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Healthcare Purchasing Alliance April, 2009. Agenda What Is Self Funding? Why Self Funding? What is a Self-Insured Group? What is a TPA? This is your Plan.

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Presentation on theme: "Healthcare Purchasing Alliance April, 2009. Agenda What Is Self Funding? Why Self Funding? What is a Self-Insured Group? What is a TPA? This is your Plan."— Presentation transcript:

1 Healthcare Purchasing Alliance April, 2009

2 Agenda What Is Self Funding? Why Self Funding? What is a Self-Insured Group? What is a TPA? This is your Plan A few things to remember … Flexible Spending Pharmacy Benefit How to Enroll

3 What Is Self Funding? Self funding is a financing alternative that enables employers to manage rising healthcare costs Self funded provides flexibility in making key decisions on benefits, administration and funding, with the ability of providing limits to ones liability Self funding/self insurance with Stop Loss coverage for employer group health insurance is an attractive alternative to the fully insured market for cost- conscious employers

4 What Is Self Funding? In practical terms, self insured employers pay for each employee’s healthcare claims as they are incurred, instead of paying a fixed premium to an insurance carrier (e.g., a fully insured plan), which includes a margin of profit for the carrier

5 What is a Self-Insured Group? A self funded plan is one in which the employer assumes partial financial risk for providing healthcare benefits to its employees

6 Why Self Funding? Advantages Flexibility in plan design Network flexibility Redirects profit margins Eliminates premium taxes Improved cash flow

7 Why Self Funding? Advantages (continued) Minimizes state mandated benefits Controls reserves Savings from “better than expected” claims Manages risk through reinsurance/stop loss Lower administrative costs

8 Why Self Funding? Perceived Disadvantages High dollar claims experience means the plan will be costly Budgeting can be difficult Added fiduciary and legal responsibility

9 Self Funding vs. Fully Insured Self FundedFully Insured Payment of only administrative and stop loss expenses up front Pay ALL components of premium up front You hold reserve – you determine valueCarrier determines and holds reserves You hold margin until needed – you determine value Carrier determines value and holds margin You determine cost of administrative and stop loss expenses Carrier determines administrative and stop loss expenses Monthly and annual caps availableDeficit carry forward probable Complete flexibility in plan design – no need to insure expected claims Pay state premium taxes No need to insure claims for which you manage the cash flow Must comply with state mandated benefits Insure only the predictableLimited choice in plan design and networks Insure only the catastrophic Utilize fully pooled insurance

10 What is a TPA? A TPA’s responsibility includes maintaining eligibility, providing customer service, processing and paying eligible claims, coordination with Preferred Provider Organizations and Utilization Review Organizations, and billing and generating any special reports for the employer. A TPA is not an insurance company. Your healthcare plan is the focus of your self funded program.

11 This is your Plan The Plan is paid for and funded by: – Daytona State College or Radiology Associates – Your employee contributions Therefore it is in your best interest to use the Plan wisely Your Plan provides several wellness benefits at no cost to you – take advantage! Effective July 1st, FMH Benefit Services is your new claims administrator for medical, dental, vision and flexible spending plans – FMH may be reached from at (866) 550-5048 8:00-5:30 EST or

12 A few things to remember……. Your deductible starts over July 1 st and does not apply to your out of pocket maximum Mammograms routine or medically indicated are paid at 100% one time for members between the ages of 35-39 and one every year after the age of 40 Colonoscopy routine or medically indicated are paid at 100% for members at age of 50 – This benefit is limited one per member and one additional every 10 years thereafter

13 A few things to remember…… In-Network Benefits – You must use either the Volusia Health Network or the Florida Memorial Health Network to receive the highest benefit payment – For members that live outside the VHN and FMHN service area; the plan has contracted with PHCS Network. You must use the PHCS Network providers to receive the highest benefit payment Pre-certify is required for all inpatient care and certain medical procedures, as well as for specific medications, failure to Pre-cert could result in denial of charges or a penalty - check your SPD – The phone number to pre-certify will be located on your member ID card and is (888) 522-7742

14 A few things to remember…… Adult well care (age 17 and over) is covered at 100% up to $250 per plan year. – Once the benefit has been exhausted, there is no benefit until the following plan year Well Child Care is paid at 100% up to 18 visits for members age sixteen and under Well Women Care benefits are covered at 100% and do not apply to the Adult Well Care dollar maximum. – Please refer to your schedule of benefits for further details

15 A few things to remember…… HPA sponsors flu shots, which are paid at 100% and do not apply to Well Care maximum amounts Employee Assistance Program – Counseling – Pre-paid Legal – Financial Services – Online Work/Life Services – EAP Webinars

16 What is a Flexible Spending Account? These accounts contains your pre-taxed dollars, which you may use to pay for your portion of eligible healthcare and dependent care expenses for your eligible dependents These are IRS regulated accounts Calculate your withholdings wisely You must use your entire pledge amount between July 1, 2009 and June 30, 2010

17 Flexible Spending Account Your plan offers two types of FSAs – Medical Reimbursement Account – Dependent Care Account “Deposit” pre-tax dollars, contributions made before taxes are withheld, into an account through automatic payroll deductions To pay for eligible expenses, you make “withdrawals” from the account Disposable income may rise because FSA participation reduces your taxable income

18 Eligible Healthcare Expenses Out of Pocket expenses, such as co-pays, co- insurance payments, and deductibles Over-the-Counter items used for the diagnosis, treatment, or prevention of a disease or to alleviate or prevent a physical deficiency or illness

19 Flexible Spending Account Potential Savings (Your savings may differ from those shown here on the example chart. Taxes were taken for a single employee earning $25,000/yr.) No FSAWith FSA $25,000 Gross Earnings $25,000 $0 FSA Contribution $2,500 $25,000 Net Taxable Income $22,500 $3,333 Income Taxes* $2,958 $1,500 Dependent Care (Eligible Expense) $0 $1,000 Unreimbursed Medical (Eligible expense) $0 $19,167 Take Home Pay $19,542 $0Tax Savings$375 *2009 Federal Tax Rate Schedule - Single

20 Healthcare Reimbursement Account Pay out-of-pocket or be reimbursed for healthcare expenses such as prescriptions and dental or vision expenses, as well as medical deductibles or co-insurance that are not covered by other healthcare benefits Deposits – Contributions made by automatic payroll deductions – Ask employer about the maximum amount you can contribute to this account 3 Options for Withdrawals & Reimbursement – Check – Direct Deposit – Auto-Flex – Debit Card If you do not select either of these options, or if you incur allowable expenses that do not appear on a claim, fill out a Request for Reimbursement Form, attach a receipt and send the documents to FMH to recoup your payment

21 Auto-Flex Here is how it works – When claims are filed under your employer’s Health Care Plan, benefits are calculated & payments sent to providers of service – Depending on the service rendered & whether or not the providers was a network or non-network provider, you could have some patient responsibility – Some examples of your responsibility Plan copays Prescription Drug copays Deductibles &/or Coinsurance – These out of pocket expenses will be billed to you after your employer’s Health Care Plan benefits are applied to the provider's bill To participate in Auto-Flex, select this option during open enrollment – Please note—if you participate in Auto-Flex, you cannot participate in the Debit Card feature

22 Debit Card Here is how it works – Simply swipe the card to pay for eligible expenses – Gives you first dollar access to your full Medical election amount & provides you convenience of using your FSA dollars upfront without waiting on a reimbursement check – Works like MasterCard with your maximum election amount on it – If asked to choose credit or debit, choose CREDIT – Merchants who accept MasterCard prepaid cards AND who offer the types are services are eligible for your Plan To participate in the Debit Card feature, select this option during open enrollment – Please note—if you participate in the Debit Card feature, you cannot participate in Auto-Flex

23 IRS Claim Substantiation Rules Claims/expenses must be incurred between July 1, 2009 and June 30, 2010 – Incurred is not when you pay the bill, but your initial date of service Expenses must be from an eligible healthcare provider – You cannot pay for Dependent Care with your Healthcare FSA dollars Itemized statements, not cancelled checks

24 Dependent Care Accounts Dependent Care Accounts allow you to pay for the care for a dependent child or adult, while you and your spouse are actively at work or searching for work – Childcare costs are eligible for reimbursement if a child is younger than 13 and you claim the child as a dependent on your federal income tax return – Costs of care for an adult dependent, including a spouse or a parent, qualify if the adult is physically or mentally disabled Contributions to a Dependent Care Account are made through automatic payroll deductions

25 Dependent Care Maximum contribution - $5,000 or $2,500 if you are married and filing separate tax returns Dollars must be in your account before you can withdraw them, unlike your healthcare account You cannot use your healthcare “Benny” card to pay for Dependent care expenses

26 Withdrawals To be reimbursed for dependent care expenses, a claim must be submitted to FMH Benefit Services, Inc. Complete an FSA Reimbursement Form & include the following information: – Name of the dependent child(ren) or adult(s) – Amount paid – Dates of service – Provider’s name – Provider’s Tax Identification Number or Social Security Number If the provider is a daycare center, a printout of your charges can be submitted with the Reimbursement Form If your provider is an individual with no tax identification number, a receipt signed by the provider must be provided

27 Additional Information for Reimbursement To obtain a claim Reimbursement Form: – Print out the form from our website at – Email your request to – Call 866.500.5048 ext 2086 To submit a claim: – Email your paperwork to – Fax your paperwork to 866.514.8287 – Mail your paperwork to: FMH Benefit Services, Inc. A Division of CoreSource Attn: Flexible Spending Department P.O. Box 25946 Overland Park, KS 66225

28 Pharmacy Services MedTrak is HPA’s new prescription provider effective July 1st, 2009 You will receive a new FMH health insurance card Show this card to your pharmacist when you get a prescription filled on or after July 1, 2009 MedTrak Customer Service Number: 800-771-4648 MedTrak web-site:

29 Where to fill a prescription on or after July 1st Retail Pharmacies – MedTrak is contracted with all of the big chains like Walgreens, CVS, Publix, Wal-Mart, Sam’s Club, Target – To find a specific pharmacy in your area log onto our website and click on Pharmacy locator, or call MedTrak Services MedTrak 90 Pharmacies – These pharmacies are able to fill 90-day supplies of maintenance medications – Again, these include the big chains listed above – To find a specific pharmacy log onto our website and click on Pharmacy locator and look for the MT90 icon, or call MedTrak Services Walgreens Mail Pharmacy – Mail order can be used to fill 90-day supplies of maintenance medications – Complete the Walgreens Registration and Prescription Order Form and mail it in with new written prescriptions from your doctor written for a 90 day supply and 3 refills – Allow two weeks from receipt for delivery MedTrak Customer Service Number: 800-771-4648 MedTrak web-site:

30 HPA Plan Design Member Copays (unchanged): Participating Pharmacy: RetailMedTrak 90Mail Service Maximum Day Supply Allowed: 30 day supply90 day supply Generic Copay:$10$20 Preferred Formulary Copay: $30$60 Non-Formulary Copay:$60$120 MedTrak Customer Service Number: 800-771-4648 MedTrak web-site:

31 What do I do if I already use Walgreens Mail Order Pharmacy? If you have refills on your prescription(s) as of 7/1, then continue as before – The Rx number will remain the same, call in your refill or go online to and place your If your prescription has run out of refills, have your doctor fax a new prescription to 800-332-9581 or mail it to Walgreens Mail Pharmacy MedTrak Customer Service Number: 800-771-4648 MedTrak web-site:

32 How to Enroll 1.Go to: 2.Click on Register 3.Type in your Social Security Number, Company Key and Date of Birth. Your Company Key is ‘HPA’. The company key is case sensitive. 4.Read through the Electronic Signature notification and click ‘Accept’ to move forward. 5.Create your User Name and Password. Confirm your password (at least 7 characters). Select your security phrase and answer. Click ‘Continue’. Please make a note of your ID and password for future use. 6.Click ‘Continue’ to proceed to Login Page. 7.Login with your new User Name and Password that you just created in step 5 above.

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