City of Peabody Health Plan Educational Information for Active Employees October 2012 Boston Benefit Partners: Lenna Bablouzian, Carol Chandor, Robyn Olson. - презентация

1 City of Peabody Health Plan Educational Information for Active Employees October 2012 Boston Benefit Partners: Lenna Bablouzian, Carol Chandor, Robyn Olson AFT-MA: Andrew Powell

2 2 Agenda Overview Group Insurance Commission (GIC) Plans Health Maintenance Organization (HMO) Plans Preferred Provider Organization (PPO) Plans Indemnity Plans Calendar Year Deductibles Provider Tiering & Copays Health Care Flexible Spending Account (FSA) Health Reimbursement Arrangement (HRA) Selecting a GIC Plan

3 3 Overview All City employees will receive their health insurance through the Group Insurance Commission (GIC) starting on January 1, 2013 and continuing through June 30, 2016 Current plans will be in effect until December 31, 2012 Open enrollment will be held from Tuesday, October 9 th through Wednesday, October 24 th All employees and retirees MUST enroll in order to have coverage as of January 1, 2013 Marriage licenses, Birth Certificates, Adoption and Guardianship records are required to enroll dependents The City of Peabody will continue to provide your dental & life insurance benefits

4 What Is the GIC? The mission of the GIC is to deliver high quality care at reasonable costs GIC was established by the Legislature in 1955 GIC is a quasi-independent state agency governed by a 15-member Commission appointed by the Governor Commission members include representatives of labor and retirees GIC covers >212,000 subscribers and >375,000 lives 4

5 5 GIC Premium Contributions Employees will continue to pay 15% of the cost of their GIC HMO, PPO or Indemnity plan premiums Most plan participants will have lower premiums under the GIC

6 6 GIC Plans The GIC offers 12 plans to Active Employees UniCare (4 Plans) Harvard Pilgrim Health Care (2 Plans) Tufts Health Plan (2 Plans) Fallon Community Health Plan (2 Plans) Neighborhood Health Plan (1 Plan) Health New England (1 Plan)

7 7 GIC Plans GIC Plans with the most Active employee subscribers Tufts Navigator PPO Harvard Pilgrim Independence PPO UniCare Indemnity Plan Basic with CIC (Comprehensive) 60% of Active employee subscribers in these 3 plans Enrollment restrictions UniCare Indemnity Plan Basic has no restrictions, in or outside of the United States Other plans are limited to Massachusetts and certain border states/counties; geographic area varies by plan Consult the map on page 7 of your Benefit Decision Guide!

8 8 GIC Health Maintenance Organization (HMO) Plans Members must select a Primary Care Physician (PCP) Referrals are required to see Specialists No coverage for out-of-network providers Except for emergency care Lower premium cost than other plan types Limited or Select network plans Lowest premium costs Limited physician and hospital access

9 GIC Health Maintenance Organization (HMO) Plans Broad Network HMO Fallon Community Health Plan Select Care Fallon Select Care members may need referrals to the following hospitals: Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Children's Hospital, Dana-Farber Cancer Institute, Massachusetts General Hospital, Tufts Medical Center Limited Network HMO Fallon Community Health Plan Direct Care Harvard Pilgrim Primary Choice Health New England NHP Care (Neighborhood Health Plan) Tufts Health Plan Spirit 9

10 10 GIC Preferred Provider Organization (PPO) Plans In-network and out-of-network benefits No requirement to select Primary Care Physician (PCP) No referrals required for specialists Can utilize any provider In-network providers - lower out-of-pocket costs Out-of-network providers - higher out-of-pocket costs Average 25% higher premium cost than GICs limited network HMOs Member must reside in network service area to enroll

11 GIC Preferred Provider Organization (PPO) Plans Tufts Navigator PPO Harvard Pilgrim Independence PPO UniCare State Indemnity Plan/Plus 1 Unicare State Indemnity Plan Community Choice 2 1. All Massachusetts doctors and hospitals are in-network with UniCare Indemnity Plan /Plus but some out-of-state providers may be out-of-network 2. Many in-state hospitals are out-of-network with Community Choice 11

12 12 UNICARE Indemnity Basic Plan Members not required to select a Primary Care Physician (PCP) No referrals required for specialists Can utilize any provider Highest premium cost plan No geographical restrictions on enrollment Without CIC rider, deductibles and copays are higher and coverage is only 80% for some services

13 13 Calendar Year Deductibles Fixed amount a member pays before the plan pays benefits Deductible generally does NOT apply to: Prescription drug benefits Outpatient mental health/substance abuse benefits Office visits (primary care physician, specialist, retail clinics, preventive care, maternity & well baby care, routine eye exam, occupational therapy, physical therapy, chiropractic care & speech therapy) Medically necessary child & adult immunizations Hearing aids Mammograms Pap smears EKGs Colonoscopies

14 14 Calendar Year Deductibles Deductible DOES apply to: Emergency room visits Inpatient hospitalization Surgery Laboratory and blood tests X-rays and radiology (including high-tech imaging, such as MRI, CT, and PET scans) Durable medical equipment

15 15 Calendar Year Deductibles Calendar Year Deductible Amounts $250 individual $500 two-person $750 family (no more than $250 per person)

16 Deductible/Copay Example First Visit to ER Total ER Visit$1,000 You Pay Deductible $250 You Pay ER Copay $ Your Total Cost $350 Plan Pays $650 Second Visit to ER Total ER Visit$1,000 You Pay Deductible N/A You Pay ER Copay $ Your Total Cost $100 Plan Pays $900 16

17 17 Tiered Provider Copays Providers are grouped into tiers based on cost, quality, and outcomes measures from third parties Different tiering for different health plans; a primary care doctor, specialist or hospital can be on one tier with one GIC health plan and on another tier with another GIC health plan Tier 1 Providers have lowest member cost & Tier 3 Providers have the highest member cost GIC Plans use tiering to set office visit copays (primary care and specialists) and inpatient admission copays Tiered hospital copay is in addition to the deductible, if not already satisfied by the member

18 Tiered Provider Copays Vary by Plan Primary Care Office Visit Copays Tier 1 $15 or $20 Tier 2 $25 or $30 Tier 3 $30 or $35 Hospital Copays Tier 1 $200 to $300 Tier 2 $500 to $700 Tier 3 $700 to $750 18

19 19 Prescription Drug Tiering Drug formularies vary by plan Pharmacy tiering Tier 1 – Generic and low cost brand drugs Tier 2 – Brand name and high cost generic drugs Tier 3 – Brand name non-preferred drugs Copayments Retail 30-day supply Tier 1 - $10 Tier 2 - $25 Tier 3 - $50 Mail Order 90-day supply Tier 1 - $20 Tier 2 - $50 Tier 3 - $110

20 20 Plan Design Example Plan FeatureHPHC Independence PPO In-NetworkOut-of-Network PCP Office Visit$20 copay20% after deductible Specialist Office Visit$20 Tier 1 $35 Tier 2 $45 Tier 3 20% after deductible Calendar Year Deductible$250 Ind/$500 2-Person/$750 Family$400 Ind/$800 2-Person/$800 Family Emergency Room$100 Inpatient Hospital CareTier 1 $250 per admission Tier 2 $500 per admission Tier 3 $750 per admission Maximum of 1 inpatient copay per calendar quarter 20% after deductible Outpatient Surgery$150 per occurrence Maximum of 4 per calendar year 20% after deductible MRI, CT Scans, Pet Scans$100 Per occurrence$100 per occurrence Prescription Drugs Retail Mail-Order (90-day supply) $10/$25/$50 $20/$50/$110

21 21 HPHC Independence PPO Hospital Tiering FacilityTier 1 - $250 1 per quarter Tier 2 - $500 1 per quarter Tier 3 - $750 1 per quarter Beverly HospitalX Melrose-Wakefield HospitalX North Shore Medical CenterX Winchester HospitalX Dana FarberX Mount Auburn HospitalX Childrens HospitalX Lahey ClinicX Mass General HospitalX Brigham & Womens Hospital X

22 22 HPHC Primary Choice HMO Hospital Tiering FacilityTier 1 - $250 1 per quarter Tier 2 - $500 1 per quarter Beverly HospitalX Melrose-Wakefield HospitalX North Shore Medical Center Not a Covered Hospital Winchester HospitalX Dana FarberX Mount Auburn HospitalX Childrens HospitalX Lahey ClinicX Mass General Hospital Not a Covered Hospital Brigham & Womens Hospital Not a Covered Hospital

23 23 Health Care Flexible Spending Account (FSA) Employees can set aside money from their paychecks on a pre- tax basis to pay for qualified medical expenses Money must be used within the plan year (or any grace period extensions) or it is forfeited (use it or lose it) Money can be used for any non-reimbursed qualified medical expense for any family member, examples: Dental Orthodontics Copayments and deductibles Prescription eye glasses and contact lenses Certain over-the-counter medications with a prescription Entire annual amount pledged is available for use on the first day of the plan year

24 24 Mitigation Plan Public Employee Committee (PEC) and City Negotiated a Mitigation Program: PEC Agreement creates 3½ -Year, City-funded Employee Health Mitigation Fund [EHMF] Some current Blue Care Elect PPO subscribers will receive a subsidy of the GIC Indemnity plan premium Employees have access to two separate health reimbursement account (HRA) programs: 1. HRA Part 1 – Reimbursement of new GIC copays 2. HRA Part 2 – Reimbursement of high out-of-pocket costs

25 25 Mitigation Plan HRA Part 1 – Reimbursement of new GIC copays Outpatient surgery copays Inpatient hospital admission copays High-tech imaging copays (such as MRI, CT, and PET scans) HRA Part 2 – Reimbursement of high out-of-pocket costs HRA Part 2 covers out-of-pocket expenses greater than: $2,000/member or $4,000/family to maximum of $5,000/member or $10,000/family Additional information about the mitigation plans will be distributed to all participants

26 GIC Health Fair 26 October 18 th Thursday 11:00 AM - 4:00 PM Kiley School Administration Building 21 Johnson Street

27 Tips for Selecting a GIC Plan Carefully review the GIC Benefit Decision Guide Complete a questionnaire and estimate your utilization of medical services Discuss the GIC plans with family, friends and your physician(s) 27

28 Tips for Selecting a GIC Plan Contact the carriers on the telephone or using the Internet. Ask the carriers about: The physicians who treat you The hospitals where you get care The prescription drugs that you take Any durable medical equipment or device that you regularly use Attend a GIC Health Fair 28

29 Tips for Selecting a GIC Plan Contact Information: Group Insurance Commission: (617) www.mass.gov/gic Harvard Pilgrim Health Plan: (800) www.harvardpilgrim.org/gic Tufts Health Plan: (888) www.tuftshealthplan.com/gic Fallon Community Health Plan: (866) www.fchp.org UniCare: (800) www.unicarestateplan.com Caremark Pharmacy (877) www.caremark.com/gic Health New England: (800) www.hne.com ADDITIONAL RESOURCES; or 29

30 Questions and Answers 30