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State of Tennessee Group Insurance Program New Employee Benefits Orientation Higher Education Employees - 2013.

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Presentation on theme: "State of Tennessee Group Insurance Program New Employee Benefits Orientation Higher Education Employees - 2013."— Presentation transcript:

1 State of Tennessee Group Insurance Program New Employee Benefits Orientation Higher Education Employees

2 1 Importance of Your Decisions The decisions you make now as a new employee will have lasting effects on your benefits Please note: some of your decisions can only be made during the new hire period Please make sure that you are aware of all the options available to you and that you make an informed decision Submit any questions to your Agency Benefits Coordinator (ABC) or Benefits Administration

3 2 Resource Materials You will also be provided with an Employee Checklist to confirm that you have been informed of important benefits information For more detailed information, refer to the Eligibility and Enrollment Guide provided by your ABC.

4 33 Resource Materials The Summary of Benefits Coverage (SBC) describes your health coverage options. You can print a copy on the Benefits Administration website, or ask your ABC for a copy.

5 4 About the Plan The State Group Insurance Program (also called the Plan) covers three different populations: State and Higher Education Employees Local Education Employees Local Government Employees We spend about $1.3 billion annually and cover nearly 300,000 members The health plan is self-insured, meaning that the State, not an insurance company, pays claims from premiums collected from members and their employers The Division of Benefits Administration manages the State Group Insurance Program and works with your Agency Benefits Coordinator (ABC) to serve our Plan members

6 5 Who is Eligible for Coverage? Generally, full time employees are eligible for health insurance coverage as well as their dependents, who may include: Legally married spouses Children up to age 26, including natural, adopted or step-children or children for whom the employee is the legal guardian There are special circumstances for employees with disabled dependents that may allow for coverage of these dependents after age 26 For more information about disabled dependents, refer to the Eligibility and Enrollment Guide or consult your ABC

7 6 Notice to TennCare Enrollees You must contact your caseworker at the Department of Human Services (DHS) within 10 days of your date of employment Report to DHS your new job, salary and that you have access to medical insurance with your new employer

8 7 Adding Coverage There are only three times you may add health coverage: 1. As a new employee 2. During the fall annual enrollment transfer period 3. If you experience a special qualifying event A specific life change, such as marriage, the birth of a baby or something that results in loss of other coverage Must submit paperwork within 60 days of the event or loss of other coverage A complete list is provided on page three of the enrollment application

9 8 Annual Enrollment Transfer Period During the Annual Enrollment Transfer Period (AETP), you may: Add health insurance coverage Change health insurance carriers Choose a different PPO Cancel health insurance coverage Changes are effective January 1 of the following year Add, cancel or make changes to optional benefits during AETP The Annual Enrollment Transfer Period occurs each year during the fall, usually around October.

10 9 Canceling Coverage You may only cancel health, dental or vision coverage for yourself or your dependents: 1.During the Annual Enrollment Transfer Period 2.If you become ineligible to continue coverage 3.If you experience a qualifying event listed on the Insurance Cancel Request Application You cannot cancel coverage during the plan year, outside of AETP, unless you have a qualifying event or lose eligibility under the plan

11 10 Definitions Premiums are the amount you pay each month for your coverage regardless of whether or not you receive health services A co-pay is a flat dollar amount you pay for services and products, like office visits and prescriptions A deductible is a set dollar amount that you pay out-of-pocket each year for services that require co-insurance Co-insurance is a form of payment where you pay a percentage of the cost for a service, after meeting your deductible

12 11 Definitions 11 The out-of-pocket co-insurance maximum is the limit on the amount of money you will have to pay each year in deductibles and co-insurance The out-of-pocket co-pay maximum limits how much you pay for certain in-network services that require co-pays A network is a group of doctors, hospitals and other health care providers contracted with a health insurance plan to provide services to members at pre-negotiated (and usually discounted) fees The maximum allowable charge (MAC) is the most a plan will pay for a service For a complete list of definitions, see the Eligibility and Enrollment Guide or visit our website.

13 12 Choosing Your Health Insurance Options Choose between Two Preferred Provider Organization (PPO) Options Partnership PPO Standard PPO Choose between Four Premium Levels Employee Employee + child(ren) Employee + spouse Employee + spouse + children All members have the same choices. After the initial new hire period, changes can only be made if you experience a special qualifying event or during AETP in the fall. Choose an Insurance Carrier BlueCross BlueShield of Tennessee Cigna

14 13 PPO Options There are two health insurance options available to you: Partnership PPO Standard PPO Both of these options are Preferred Provider Organizations (PPOs) How a PPO Works: Visit any doctor or hospital you want However, the PPO has a list of in-network doctors, hospitals and other providers that you are encouraged to use These in-network providers have agreed to take lower fees so you pay less for services You will pay more for services from out-of-network providers

15 14 Comparing Your PPO Options Partnership PPO Rewards members for taking an active role in their health Commitment to Partnership Promise is required Standard PPO No incentives for healthy behaviors Members pay a greater share of costs Both options cover the same services, treatments and products. However, under the Partnership PPO, when you take an active role in your health, you will pay less.

16 15 Partnership PPO The Partnership PPO option allows you to pay less for your coverage by taking an active role in your health and fulfilling the Partnership Promise The Partnership Promise is an annual commitment In order to remain in the Partnership PPO, you must meet your commitment each year by the deadline The Partnership Promise requirements may change from one year to the next

17 16 Partnership Promise New members and their covered spouses must: Complete the online Well-Being Assessment Get a biometric health screening * Both requirements must be completed within 120 days of your insurance coverage effective date.

18 17 Partnership Promise You will have 120 days to complete the Well-Being Assessment. Online Well-Being Assessment (WBA) Summarizes your overall health and offers steps you can take to improve By completing the confidential assessment online, you will learn more about your physical, emotional and social health and how your lifestyle habits affect your overall well-being You must visit and create an online well- being account to access the assessment

19 18 Partnership Promise Biometric Health Screening You must get a health screening from your health care provider This includes height, weight, blood sugar, blood pressure and cholesterol level You may use screening results from a doctors visit within the last 12 months Simply ask your doctor to complete the Physician Screening Form, which is available online at Send the completed form to Healthways by the 120-day deadline

20 19 If You Cover Your Spouse Same PPO Option Your spouse must also commit to the Partnership Promise Exception: If you and your spouse both work for a Participating Employer you can choose different options Partnership Promise is not required for covered children

21 20 Standard PPO The Standard PPO offers the same services as the Partnership PPO, but you will pay more for monthly premiums, annual deductibles, pharmacy co-pays, medical care co-insurance and out-of-pocket maximums Members enrolled in the Standard PPO are not required to fulfill the Partnership Promise

22 21 Choosing an Insurance Carrier Once you choose your PPO, you have a choice of two carriers: BlueCross BlueShield of Tennessee (Network S) Cigna (Open Access Plus) You may choose between these two carriers, regardless of the PPO option you select

23 22 Choosing an Insurance Carrier Each carrier has its own network of preferred doctors, hospitals and other health care providers Check the networks for each carrier carefully when making your decision Provider directories are available Online By calling the carriers customer service phone line From your ABC

24 23 Choosing an Insurance Carrier There are three regions (grand divisions): East, Middle and West Carrier costs vary by grand division CIGNA is more expensive in the East and Middle grand divisions BlueCross BlueShield of Tennessee is more expensive in the West grand division If you live and work in different regions, you can choose between the two Before selecting a carrier, review the premium rate and provider network to help you decide Each carrier offers statewide and national networks, regardless of the region where you live

25 24 Choosing Your Premium Level The amount you pay in premiums depends on the PPO you choose and the number of people you cover under the plan There are four premium levels (tiers) available: Employee Only Employee + Child(ren) Employee + Spouse Employee + Spouse + Child(ren) Remember: The Partnership PPO premiums are lower than the premiums for the Standard PPO.

26 25 Choosing Your Premium Level If your spouse works for a participating employer, you have another option: Choose premium level separately (employee only) Choose your PPO option and insurance carrier separately If you and your spouse are both State and Higher Education employees: You may each want to consider enrolling in employee only coverage or employee + children, if you have children, to ensure that you receive the maximum life insurance benefit.

27 26 Premiums: Higher Education Plan Employee Share of Monthly Premiums* The State pays 80% of the total premium cost for active employees. *This chart shows the premiums for the less expensive carrier in your region Premium LevelPartnership PPOStandard PPO Employee Only$108.52$ Employee + Child(ren)$162.78$ Employee + Spouse$227.89$ Employee + Spouse + Child(ren)$282.15$332.15

28 27 Covered Services The Partnership PPO and the Standard PPO both cover the same services, treatments and products, including the following: Preventive care Primary care Specialty care Hospitalization and surgery Laboratory and x-rays A comparison chart that lists covered services and their costs is available in the Eligibility and Enrollment guide and on the ParTNers for Health websiteParTNers for Health website A pre-existing condition exclusion period of 12 months may apply unless you can provide proof of prior creditable coverage

29 28 Co-Pays Partnership PPOStandard PPO In-NetworkOut-of-Network*In-NetworkOut-of-Network* Preventive CareNo charge$45 co-payNo charge$50 co-pay Well-baby or Well-child Visits No charge$45 co-payNo charge$50 co-pay Primary Care$25 co-pay$45 co-pay$30 co-pay$50 co-pay Specialty Care$45 co-pay$70 co-pay$50 co-pay$75 co-pay Prescription Drugs (30-day supply at Retail Pharmacy) $5 co-pay generic $35 co-pay preferred brand $85 co-pay non-preferred brand Co-pay for applicable tier plus amount over MAC $10 co-pay generic $45 co-pay preferred brand $95 co-pay non-preferred brand Co-pay for applicable tier plus amount over MAC

30 29 Free In-Network Preventive Care Annual preventive care check-up offered to members at no cost Lab work related to the preventive care visit covered at 100% You need to visit an in-network provider to receive preventive care services at no cost Regular preventive care is one of the most important things you can do to stay healthy.

31 30 Co-Insurance Note: Prior authorization is required for inpatient care, advanced x-ray, scans and imaging, inpatient therapy and certain medical equipment. Partnership PPOStandard PPO In-NetworkOut-of-Network*In-NetworkOut-of-Network* Inpatient Care (Including Mental Health and Substance Abuse) You pay 10%You pay 40%You pay 20%You pay 40% Advanced X-ray, Scans and Imaging You pay 10%You pay 40%You pay 20%You pay 40% Occupational Therapy, Physical Therapy, Speech Therapy You pay 10%You pay 40%You pay 20%You pay 40% Durable Medical Equipment You pay 10%You pay 40%You pay 20%You pay 40%

32 31 Annual Deductibles You pay the annual deductible before co-insurance benefits kick in. Partnership PPOStandard PPO Annual DeductibleIn-NetworkOut-of-NetworkIn-NetworkOut-of-Network Employee only$450$800 $1,500 Employee + Child(ren)$700$1,250 $2,350 Employee + Spouse$900$1,600 $3,000 Employee + Spouse + Child(ren)$1,150$2,050 $3,850

33 32 Out-of-Pocket Maximums *Members are responsible for 100% of non-emergency out-of-network provider charges above the maximum allowable charge (MAC). Partnership PPOStandard PPO Out-of-Pocket Co-pay MaximumIn-NetworkOut-of-Network*In-NetworkOut-of-Network* Per Individual$900N/A$1,100N/A *Out-of-Pocket Co-Pay maximum does not apply to out-of-network providers. Partnership PPOStandard PPO Out-of-Pocket Co-insurance Maximum In-NetworkOut-of-Network*In-NetworkOut-of-Network* Employee Only$1,550$2,900$1,900$3,600 Employee + Child(ren)$2,450$4,600$3,100$5,900 Employee + Spouse$3,100$5,800$3,800$7,200 Employee + Spouse + Child(ren)$4,000$7,500$5,000$9,500

34 33 Take Note! Deductibles and out-of-pocket maximums for in-network and out-of-network services add up separately Services received in network count toward your in-network deductible and out-of-pocket maximum Services received out of network count toward your out-of-network deductible and out-of-pocket maximum Ineligible expenses, including non-covered services and expenses over the MAC dont count toward deductibles and out-of-pocket maximums. DeductibleOut-of-Pocket Max In-Network$450$1,550 DeductibleOut-of-Pocket Max Out-of-Network$800$2,900

35 34 Pharmacy Benefits Your health plan also includes pharmacy benefits The covered drug list is the same for both the Partnership PPO and Standard PPO, although co-pays differ between the two Pharmacy benefits are administered by CVS Caremark, one of the largest pharmacy benefits managers in the country with over 1,600 in-network pharmacies statewide

36 35 Co-pay amounts are based on three different factors: the type of pharmacy you use, your PPO option and the drug level (tier) of the medication There are three drug levels: Generic Drug (tier one) is a generic medicine that is FDA-approved and equal to the brand-name product in safety, effectiveness, quality and performance –Least expensive option Preferred Brand (tier two) is a brand-name drug included on the drug list –More expensive option Non-preferred Brand (tier three) is a brand-name drug not on the drug list –Most expensive option Pharmacy Benefits

37 36 Prescription Drug Co-pays Partnership PPOStandard PPO In-NetworkOut-of-NetworkIn-NetworkOut-of-Network 30-Day Supply (only from pharmacies in the 30-day network) $5 co-pay generic $35 co-pay preferred brand $85 co-pay non- preferred brand Co-pay, plus any amount exceeding MAC $10 co-pay for generic $45 co-pay for preferred brand $95 co-pay for non- preferred brand Co-pay, plus any amount exceeding MAC 90-Day Supply (90-day network pharmacy or mail order) $10 co-pay generic $65 co-pay preferred brand $165 co-pay non- preferred brand Co-pay, plus any amount exceeding MAC $20 co-pay for generic $85 co-pay for preferred brand $185 co-pay for non-preferred brand Co-pay, plus any amount exceeding MAC 90-Day Supply (certain maintenance medications from 90-day pharmacy or mail order) $5 co-pay generic $30 co-pay preferred brand $160 co-pay non- preferred brand Co-pay, plus any amount exceeding MAC $10 co-pay generic $40 co-pay preferred brand $180 co-pay non- preferred brand Co-pay, plus any amount exceeding MAC

38 37 Mental Health and Substance Abuse Treatment Employees and dependents who are enrolled in health coverage are also eligible for mental health and substance abuse services Mental Health and Substance Abuse services generally include: Individual and group treatment Hospitalization Aftercare Costs are based on your health plan Prior authorization is required for some services

39 38 Eligible employees can choose between two dental options Each year during the Annual Enrollment Transfer Period, eligible employees can enroll in or transfer between dental options Unlike health insurance where a portion of the premium is paid by the employer, dental insurance is paid 100% by the member Optional Dental Benefits Prepaid Plan Participating dentists only Fixed co-pays PDO Plan Any dentist Pay less with network providers

40 39 Prepaid Plan The Prepaid plan is administered by Assurant Employee Benefits The Prepaid Plan provides dental services at predetermined co-pay amounts from a limited network of participating dentists and specialists This means you must select a provider from a limited network of dentists and submit your selection to Assurant before any services will be covered The are no deductibles, no claims to file, no waiting periods, no annual dollar maximum, pre-existing conditions are covered and referrals are not required To find a dentist in Assurants network, visit the dental section of the ParTNers for Health website or call the Assurant number listed in the Eligibility and Enrollment Guide

41 40 Preferred Dental Organization The PDO is administered by Delta Dental of Tennessee Under the Preferred Dental Organization (PDO), you may use any dentist Referrals are not necessary with the PDO and you or your dentist file claims for covered services There is a one-year waiting period for some services, such as orthodontia Calendar year maximum of $1,500 per person Lifetime orthodontics maximum of $1,250 per person To find a dentist in Delta Dentals network, visit the dental section of the ParTNers for Health website or call the number listed on the inside cover of the Eligibility and Enrollment Guide

42 41 Optional Dental Benefits Dental services for both the Prepaid Plan and the Dental PDO include: Periodic oral evaluations Routine Cleanings Amalgam fillings Endodontic X-rays Extractions Major restorations Orthodontics Dentures PremiumsPrepaid PlanPDO Plan Employee Only$9.63$20.46 Employee + Child(ren)$20.00$47.03 Employee + Spouse$17.07$38.69 Employee + Spouse + Child(ren)$23.47$75.71

43 42 Optional Vision Insurance 42 Eligible employees can choose between two vision plans Full list of vision benefits is available in the Eligibility and Enrollment Guide and on the ParTNers for Health website Administered by EyeMed Vision Care Members have access to EyeMeds Select Network Basic Plan Discounted rates Allowances Expanded Plan Co-pays Allowances Discounted rates

44 43 Optional Vision Insurance PremiumsBasic PlanExpanded Plan Employee Only $3.27$5.73 Employee + Child(ren) $6.54$11.46 Employee + Spouse $6.21$10.89 Employee + Spouse + Child(ren) $9.61$16.84 Both plans offer the same services: Annual routine eye exam Eyeglass lenses Frames Contact lenses Discount on Lasik/refractive surgery Each year during AETP, eligible employees can enroll in or transfer between vision options.

45 44 Additional Benefits Higher Education employees are also eligible for: ParTNers Employee Assistance Program ParTNers for Health Wellness Program Life Insurance Long-Term Care Insurance Your ABC will provide you with information about additional benefits your employer may offer, such as a flexible benefits or deferred compensation Did You Know? Services provided by ParTNers EAP are FREE regardless of whether you enroll in health insurance! Learn more about these valuable services on the following slides.

46 45 ParTNers EAP ParTNers Employee Assistance Program (EAP) helps you and your family members deal with problems we all experience during our daily lives Your EAP can handle issues related to: Stress, depression and anxiety Family, relationship or marital issues Child and elder care Grief and loss You receive up to 5 free counseling sessions per separate incident Your EAP also offers free financial and legal consultations

47 46 ParTNers EAP There is no cost to you for services provided by ParTNers EAP, and your confidentiality is always a top priority ParTNers EAP is administered by Magellan Health Services Services are available 24/7 at or by calling Magellan at the number listed on the inside cover of your Eligibility and Enrollment

48 47 ParTNers for Health Wellness Program The Wellness Program is designed to provide opportunities to manage and improve your health Services are free to all members enrolled in health coverage and their covered spouses and dependents The Nurse Advice Line gives you medical information and support 24/7 Health coaching offers professional support to create and meet goals to improve your health Well-Being Connect, the ParTNers for Health Web Portal, links you to powerful online tools and health information at your fingertips (look for My Wellness Login)

49 48 ParTNers for Health Wellness Program An online Well-Being Assessment is available to help you learn more about your health and identify any potential risks Sign up for weekly health tips by to receive a short with each weeks healthy living tip Fitness center discounts are available to plan members for fitness centers across the state To access any of the services listed here, visit the wellness webpage on the ParTNers for Health websitewellness webpage

50 49 Basic Term Life and Accidental Death and Dismemberment The State provides, at no cost to every full-time employee: $20,000 of basic term life insurance $40,000 of basic accidental death and dismemberment (AD&D) If you are enrolled in health insurance, your coverage increases with your salary up to: $50,000 for term life insurance $100,000 for AD&D insurance If you enroll in health insurance, your eligible dependents are also covered for $3,000 of basic dependent term life coverage and an amount for basic AD&D based on your salary and family composition

51 50 Optional AD&D Insurance In addition to basic coverage, you and your dependents may also enroll in optional accidental death and dismemberment insurance For a premium, this coverage pays an additional amount in the case of accidental death or dismemberment You may enroll as a new employee or during AETP Coverage is available at low group rates, no questions asked Basic Term Life, Basic AD&D and Optional AD&D are administered by Dearborn National

52 51 Optional Term Life Insurance Premiums are based on age and the amount of coverage requested Coverage is also available for spouses and dependent children Spouses: maximum level of coverage is $30,000 Children: $5,000 or $10,000 term rider Must enroll in first 30 days of employment for guaranteed issue coverage and coverage is effective after 3 months of employment You can apply later during AETP by answering health questions Select up to 5 times your annual base salary when first eligible Minimum coverage level: $5,000 Maximum coverage level: $500,000 Optional Term Life Insurance is administered by Minnesota Life

53 52 Long-Term Care Insurance Covers services for qualified members who are unable to care for themselves without the assistance of others Nursing home care Assisted living Home health care You have 90 days to enroll with guaranteed-issue coverage Your spouse, dependent children, parents and parents-in-law may also apply through medical underwriting Premiums are based on the age of the insured at the time of enrollment Plan administered by MedAmerica Home care Adult day care

54 53 Enrolling in Benefits Two ways to enroll: Enrollment Change Application Edison Employee Self Service (ESS) Enrollment must be completed within 31 days of your hire date Any required dependent verification must also be submitted during this timeframe See page 2 of the enrollment application or the forms and publications section of our website for information about dependent verification To enroll in optional benefit products such as life insurance, use the separate enrollment forms provided by your ABC.

55 54 Online Enrollment through ESS Select your health insurance and other benefit options online Log on to Edison » »Use username and temporary password provided by your ABC »Navigate to Employee Self Service > Benefits > Benefits Enrollment »Click the SELECT button »Follow the prompts to enroll If you are covering dependents, you can submit dependent verification by: »Uploading electronic documentation »Faxing documentation to Benefits Administration service center

56 55 When Will Coverage Begin? Health, dental and vision coverage begin on the first day of the month following your hire date For example, if you are hired on September 15 th, your coverage would begin on October 1 st Ask your ABC if you have questions about when your coverage begins

57 56 When Are Premiums Paid? Your ABC will tell you when your premiums will be deducted from your paycheck To avoid a large deduction from your first paycheck, submit your benefit selections in ESS or your enrollment forms to your ABC as soon as possible

58 57 When Will My ID Cards Arrive? Within three weeks of the date your application is processed CVS Caremark will send separate ID cards for your pharmacy benefits (Note: each family members card may arrive in a separate envelope) If you enroll in dental or vision benefits, you will also receive your ID cards within three weeks BlueCross BlueShield Will send up to two ID cards automatically, both with the members name These may be used by any covered dependent Cigna Will send separate ID cards for each insured family member with each participants name There may be up to four ID cards in each envelope

59 58 Your Privacy Your personal health information is strictly confidential Your health privacy rights are protected through a federal law called HIPAA Benefits Administration can only discuss benefits information with the head of contract (HOC) The Authorization for Release of Protected Health Information form must be completed before Benefits Administration can discuss benefits information with your spouse or other authorized representative To print and complete a release form, Visit the forms section of

60 59 Insurance Carrier Websites BlueCross BlueShield, Cigna and CVS Caremark each offer member websites that allow you to: View detailed information about your claims Print temporary ID cards Access other helpful member services BlueCross BlueShield Cigna CVS Caremark

61 60 Who to Contact Your primary point of contact is your agency benefits coordinator (ABC) If you have questions about a provider or insurance claim, contact your insurance carrier directly at the number listed on the inside cover of the Eligibility and Enrollment Guide, visit your carriers member website or use the number on the back of your ID card If you have questions about eligibility and enrollment, call the Benefits Administration service center at Benefits Administration ParTNers for Health

62 61 Thank you for your attention during this presentation. More information is available at If you have questions, please ask your Agency Benefits Coordinator at this time.

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