Deep dive into vehi 2018 health plans

Deep dive into vehi 2018 health plans
Spring 2017

Claims scenarios These examples are for workshop purposes only and are not indicative of actual charges or discounts. Charges can vary greatly depending on the type of provider and services provided Unless otherwise noted, each scenario is the first claim(s) of the calendar year Actual employee responsibility will depend on employee premium share and OOP cost-share as determined by collective bargaining

Final Approved Rates January 1, 2018 – June 30, 2018
Monthly Rates FY 18 Single Parent/ Child(ren) Two-Person Family VEHI Platinum $657.55 $1,099.51 $1,315.10 $1,860.19 VEHI Gold $622.94 $1,042.53 $1,245.88 $1,763.38 VEHI Gold CDHP $523.29 $809.02 $982.75 $1,449.51 VEHI Silver CDHP $456.34 $769.27 $912.69 $1,298.60 Annual Rates FY 18 $7,890.60 $13,194.12 $15,781.20 $22,322.28 $7,475.28 $12,510.36 $14,950.56 $21,160.56 $6,279.48 $9,708.24 $11,793.00 $17,394.12 $5,476.08 $9,231.24 $10,952.28 $15,583.20

Sample claim charges* for our scenarios
Type of Service Cost of Service (not exact) Preventive Annual Exam $150 Outpatient Surgery $4,000 Office Visit Charge $85 Prenatal/Birth $22,000 Lab Work $45 Inpatient Surgery $50,000 Specialist Visit Generic Tier 1 Drug $15 Physical Therapy (outpatient) $125 Generic Tier 2 Drug $30 Chiropractic Visit (Spec) $75 Preferred Brand Name Drug $100 X-ray Non-preferred Brand Name Drug $1,000 *These examples are for workshop purposes only and are not indicative of actual charges or discounts. Charges can vary greatly depending on the type of provider and services provided.

Stacked vs aggregate cost shares
Does not apply to single policies Stacked deductible or out of pocket maximum means no one person has to meet more than the individual level, even when on a two- person, parent/child(ren) or family plan before receiving benefits, then when the family level is met, everyone receives the benefits Aggregate deductible or out of pocket maximum means the entire deductible must be met before anyone receives benefits, one person on a two-person, Parent/Child(ren) or family plan could potentially meet the entire family deductible or out of pocket maximum by themselves See videos for further explanation and examples

VEHI Platinum VEHI Gold VEHI Gold CDHP VEHI Silver CDHP
Health Plans VEHI Platinum Member Cost Share VEHI Gold VEHI Gold CDHP VEHI Silver CDHP HRA or HSA Compatible HRA HRA/HSA Medical Deductible $500/$1,000 (S) $1,200/$2,400 (S) $1,800/$3,600 (A) $3,000/$6,000 (S) Medical Out-of-pocket Maximum $1,500/$3,000 (S) $1,800/$3,600 (S) $2,500/$5,000 (A) $4,000/$8,000 (S) Prescription Deductible $0 Included in medical deductible Prescription Out-of-pocket Maximum $1,300/$2,600 (S) $1,300/$2,600 (A) (included in Medical OOPM) $1,300/$2,600 (A) (included in Medical OOPM) Total Out-of-pocket Exposure (Medical and Rx) $2,800/$5,600 (S) $3,100/$6,200 (S) Preventive PCP Visit (annual exam and associated screenings) Primary Care Physician / Mental Health or Substance Abuse Visit $25 Deductible, then 20% coinsurance Specialist Visit (Chiropractor, Urologist, Podiatrist, etc.) $35 Urgent Care Facility $75 Emergency Room $250 In/Out-patient, Radiology, Ambulance, DME, Physical Therapy, Lab Work, etc. Generic tier 1 / tier 2 / Brand / NP Brand $4 / $10 / $20 / 50% Wellness Prescriptions No member cost

Using the Sample Claims Charges sheet please identify the member expense for each scenario.
1. Jack goes to the doctor in January for a sick visit. How much is Jack’s out of pocket costs? Single plan Platinum Gold Gold CDHP Silver CDHP Copayment Deductible Coinsurance Total Member Cost-share Total Annual Premium Comparison ----- -$1,611 2. Jane has lab work done (not part of her annual exam). How much does Jane pay out of pocket? Two-Person plan -$4,829

3. Ed goes to a chiropractor, and has 3 chiropractic visits, how much does he owe his chiropractor? Parent/Child(ren) plan Platinum Gold Gold CDHP Silver CDHP Copayment Deductible Coinsurance Total Member Cost-share Total Annual Premium Comparison ----- 4. Cindy is on a single plan and has an outpatient surgery, what does she owe? Platinum Gold Gold CDHP Silver CDHP Copayment Deductible Coinsurance Total Member Cost-share Total Annual Premium Comparison ----- -$415 -$1,611 -$2,414

Using the Sample Claims Charges sheet please identify the member expense for the scenario.
5. Janet is on a family plan and has a baby, how much does she owe for her claim? Platinum Gold Gold CDHP Silver CDHP Copayment Deductible Coinsurance Total Member Cost-share Total Annual Premium Comparison -----

Using the Sample Claims Charges sheet please identify the member expense for the scenario.
6. Katie is on a family plan and has an inpatient surgery, what does she owe? Platinum Gold Gold CDHP Silver CDHP Copayment Deductible Coinsurance Total Member Cost-share Total Annual Premium Comparison --- -$1,162 -$4,928 -$6,739

7. Building off of #6, now Katie’s husband Justin hurt his back and went to see his PCP. He was referred for 10 sessions of physical therapy. How would his claims pay? Katie Platinum Gold Gold CDHP Silver CDHP Copayment $0 Deductible $500 $1,200 $3,600 $3000 Coinsurance $1,000 $600 $1,400 Total Cost-share for Katie $1,500 $1,800 $5,000 $4,000 Justin Total Cost-share for Justin Total Family Cost-share Total Annual Premium Comparison --- -$1,162 -$4,928 -$6,739

8. Mary, Ken and their children are on a Family Silver CDHP, follow the example to see how claims/deductibles/out of pocket maximums progress throughout the year ***Stacked Deductible Example*** (Silver CDHP - $3000/$6000 deductible, $4000/$8000 out of pocket maximum) SILVER Mary Ded Mary Coins Mary running OOP Ken Ded Ken Coins Ken running OOP Rachel Ded Rachel Coins Rachel running OOP Family Ded Family Coins Family running OOP Maximums $3,000 $1,000 $4,000 $6,000 $2,000 $8,000 Mary PCP sick visit $85 $0 Mary Lab work $45 $130 Ken Physical Therapy x 3 $375 $505 Rachel Annual Exam Ken Outpatient Surgery $2,625 $275 $3,275 $3,130 $3,405 Rachel ER visit $3,500 $2,870 $126 $2,996 $401 $6,401 Rachel Specialist Visit $30 $3,026 $431 $6,431 Rachel PT x 8 $200 $3,226 $631 $6,631 Mary Annual Exam Mary Outpatient Surgery $800 $930 $1,431 $7,431 Ken Chiro x 10 $150 $3,425 $1,581 $7,581 Individual totals $320 $356 Using a sheet of paper, or a ruler, follow the claims as they are calculated and accumulated toward the out of pocket maximums for this family.

(Gold CDHP - $3,600 deductible, $5,000 out of pocket maximum)
9. Mary, Ken and their children are on a Family Gold CDHP, follow the example to see how claims/deductibles/out of pocket maximums progress throughout the year ***Aggregate Deductible Example*** (Gold CDHP - $3,600 deductible, $5,000 out of pocket maximum) GOLD Mary Ded Mary Coins Mary OOP Ken Ded Ken Coins Ken OOP Rachel Ded Rachel Coins Rachel OOP Family Ded Family Coins Family OOP Maximums $3,600 $1,400 n/a n/a $5,000 Mary PCP sick visit $85 $0 Mary Lab work $45 $130 Ken Physical Therapy x 3 $375 $505 Rachel Annual Exam Ken Outpatient Surgery $3,095 $181 $3,781 Rachel ER visit $3,500 $700 $881 $4,481 Rachel Specialist Visit $30 $911 $4,511 Rachel PT x 8 $200 $1,111 $4,711 Mary Annual Exam Mary Outpatient Surgery $289 Ken Chiro x 10 Individual totals $3,470 $930 Using a sheet of paper, or a ruler, follow the claims as they are calculated and accumulated toward the out of pocket maximums for this family. See how the aggregate deductible and out of pocket come into play.

Premium compare CDHPs Single Parent Child/ren Two-person Family
Single Parent Child/ren Two-person Family Gold CDHP (monthly) $523 $809 $983 $1,450 Silver CDHP (monthly) $456 $769 $913 $1,299 Monthly Difference Between CDHPs -$67 -$40 -$70 -$151 Annual Difference Between CDHPs -$803 -$477 -$841 -$1,811 After reviewing claims examples on the two CDHP plans, see how the cost of the plans can impact total costs.

Running Total Out of Pocket Running Total Rx Out of Pocket
10. Robin is on a single Gold CDHP and has been prescribed an expensive non-preferred brand name prescriptions. Review how the claims play out throughout the year. Gold CDHP Pharmacy Example Deductible Coinsurance Running Deductible Running Total Out of Pocket Running Total Rx Out of Pocket Annual Exam PCP sick visit Lab work Specialist Pharmacy NPB ER Visit ($1500) Specialist visit Individual totals

11. How do prescriptions pay on a single plan
11. How do prescriptions pay on a single plan? Includes Non-Preferred Brand Prescriptions Platinum Gold Gold CDHP Silver CDHP January: Generic tier 1 $4 $15 Generic tier 2 $10 $30 Wellness (Brand) $20 $0 Brand Name $100 Non-preferred Brand Name $500 $1,000 Diabetic Medication (any) February: March: $138 Total Rx Spend $1,300 Medical additional potential exposure $1,500 $1,800 $1,200 $2,700

12. How do prescriptions pay for one member of a TP/PC/Fam plan
12. How do prescriptions pay for one member of a TP/PC/Fam plan? Includes Non-Preferred Brand Prescriptions Platinum Gold Gold CDHP Silver CDHP January: Generic tier 1 $4 $15 Generic tier 2 $10 $30 Wellness (Brand) $20 $0 Brand Name $100 Non-preferred Brand Name $500 $1,000 Diabetic Medication (any) February: March: $138 $165 Rx total spend $1,300 $2,600 Additional Family Rx? Yes No Medical potential OOP for this member? $1,500 $1,800 $2,400* $1,400 *Shared by all members on policy

13. How do prescriptions pay on a single plan
13. How do prescriptions pay on a single plan? No Non-Preferred Brand Prescriptions Platinum Gold Gold CDHP Silver CDHP January: Generic tier 1 $4 $15 Generic tier 2 $10 $30 Wellness (Brand) $20 $0 Brand Name $100 Diabetic Medication (any) February: March: Total Rx Spend $222 $735

Final thoughts Aren’t you glad you don’t process claims everyday??
All plans cover all services with different cost-sharing options Preventive services have no oOP costs Employees need to know c.b.a. terms for employer contributions toward premium and cost-sharing Employee needs to consider premium and OOP costs when making a decision All plans have maximum oop caps in calendar year Aggregate plan costs can be lower overall if member has high cost services Each employee will have unique circumstances and make different decisions on what works best for them Employees can change plans once per year upon open enrollment or if they have a qualifying event

Answer section

Answer: Review the claim examples to see how different services pay under different plans.
1. Jack goes to the doctor in January for a sick visit. How much is Jack’s out of pocket costs? Single plan Platinum Gold Gold CDHP Silver CDHP Copayment $25 $0 Deductible $85 Coinsurance Total Member Cost-share Total Annual Premium Comparison --- -$415 -$1,611 -$2,414 2. Jane has lab work done (not part of her annual exam). How much does Jane pay out of pocket? Two-Person plan $45 -$831 -$3,988 -$4,829 Using the platinum rate, calculate the annual difference between the platinum plans and the others. (Subtract the annual cost of the Gold from the Platinum to see the annual savings. Then subtract the annual cost of the Gold CDHP from the Platinum to do the same, and so on)

3. Ed goes to a chiropractor, and has 3 chiropractic visits, how much does he owe his chiropractor? Parent Child Platinum Gold Gold CDHP Silver CDHP Copayment $105 ($35x3) $105 (3x$35) $0 Deductible $225 ($75x3) Coinsurance Total Member Cost-share $105 $225 Total Annual Premium Comparison --- -$684 -$3,486 -$3,963 Using the platinum rate, calculate the annual difference between the platinum plans and the others. (Subtract the annual cost of the Gold from the Platinum to see the annual savings. Then subtract the annual cost of the Gold CDHP from the Platinum to do the same, and so on)

4. Cindy is on a single plan and has an outpatient surgery, what does she owe? (assume this is her first claim of the calendar year) Platinum Gold Gold CDHP Silver CDHP Copayment $0 Deductible $500 $1200 $1800 $3000 Coinsurance $700 $560 $440 $200 Total Member Cost-share $1,200 $1,760 $2,240 $3,200 Total Annual Premium Comparison --- -$415 -$1,611 -$2,414 Platinum: $4,000 - $500 = $3,500 x 20% (or .20) = $700 Gold: $4,000 – $1,200 = $2,800 x 20% (or .20) = $560 Gold CDHP: $4,000 – $1,800 = $2,200 x 20% (or .20) = $440 Silver CDHP: $4,000 – $3,000 = $1,000 x 20% (or .20) = $200

Answer: Review the claim examples to see how different services pay under different plans, paying particular attention to the Gold CDHP. 5. Janet is on a family plan and has a baby ($22,000), how much does she owe for her claim? Platinum Gold Gold CDHP Silver CDHP Copayment $0 Deductible $500 $1,200 $3,600 $3,000 Coinsurance $1,000 $600 $1,400 Total Member Cost-share $1,500 $1,800 $5,000 $4,000 Total Annual Premium Comparison -$1,162 -$4,928 $6,739 Platinum: $22,000 - $500 = $21,500 x 20% (or .20) = $4,300 capped at $1,000 Gold: $22,000 – $1,200 = $20,800 x 20% (or .20) = $4,160 capped at $600 Gold CDHP: $22,000 – $3,600 = $18,400 x 20% (or .20) = $3,680 capped at $1,400 Silver CDHP: $22,000 – $3,000 = $47,000 x 20% (or .20) = $4,400 capped at $1,000 Using the platinum rate, calculate the annual difference between the platinum plans and the others. (Subtract the annual cost of the Gold from the Platinum to see the annual savings. Then subtract the annual cost of the Gold CDHP from the Platinum to do the same, and so on)

6. Katie is on a family plan and has an inpatient surgery, what does she owe? (assume this is her first claim of the calendar year) Platinum Gold Gold CDHP Silver CDHP Copayment $0 Deductible $500 $1,200 $3,600 $3000 Coinsurance $1,000 $600 $1,400 Total Member Cost-share $1,500 $1,800 $5,000 $4,000 Total Annual Premium Comparison --- -$1,162 -$4,928 -$6,739 Platinum: $50,000 - $500 = $49,500 x 20% (or .20) = $9,900 capped at $1,000 Gold: $50,000 – $1,200 = $48,800 x 20% (or .20) = $9,760 capped at $600 Gold CDHP: $50,000 – $3,600 = $46,400 x 20% (or .20) = $9,280 capped at $1,400 Silver CDHP: $50,000 – $3,000 = $47,000 x 20% (or .20) = $9,400 capped at $1,000 Review the claim examples to see how different services pay under different plans, and the impact of premium savings on a family plan. Using the platinum rate, calculate the annual difference between the platinum plans and the others. (Subtract the annual cost of the Gold from the Platinum to see the annual savings. Then subtract the annual cost of the Gold CDHP from the Platinum to do the same, and so on)

Answer: Review the claim examples to see how different services pay under different plans, and how stacked vs aggregate can impact the amount owed. 7. Building off of #6, now Katie’s husband Justin hurt his back and went to see his PCP and was referred for 10 sessions of physical therapy. How would his claims pay? Katie Platinum Gold Gold CDHP Silver CDHP Copayment $0 Deductible $500 $1,200 $3,600 $3000 Coinsurance $1,000 $600 $1,400 Total Cost-share for Katie $1,500 $1,800 $5,000 $4,000 Justin $25 $1,335 $150 $10 Total Cost-share for Justin $675 $1,235 Total Family Cost-share $2,175 $3,035 $5,335 Total Annual Premium Comparison --- -$1,162 -$4,928 -$6,739 10 x $125 = $ $85 ov Platinum: $ $500 = $750 x 20% (or .20) = $150 Gold: $1250 – $1,200 = $50 x 20% (or .20) = $10 Gold CDHP $1335 – $0 = $0 x 20% (or .20) = $0 Silver CDHP $1335 – $1,335 = $0 x 20% (or .20) = $0

Running Total Out of Pocket Running Total Rx Out of Pocket
Answers: Don’t forget that this is a Single Plan, and CDHP, and prescriptions are included in the overall total out of pocket, but pharmacy is also tracked separately. 10. Robin is on a single Gold CDHP and has been prescribed an expensive non-preferred brand name prescriptions. Review how the claims play out throughout the year. Gold CDHP Pharmacy Example Deductible Coinsurance Running Deductible Running Total Out of Pocket Running Total Rx Out of Pocket Annual Exam $0 PCP sick visit $85 Lab work $45 $130 Specialist $150 $280 Pharmacy NPB $1000 $1,280 $300 $1,580 $1,300 ER Visit ($1,500) $220 $256 $1,800 $2,056 $17 $2,073 Specialist visit $30 $2,103 Individual totals $303

Deep dive into vehi 2018 health plans

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