abc_partners by fanzhongqing

VIEWS: 1 PAGES: 44

									Preserving Our Health Benefits:

    Changes to Sustain
Comprehensive, Affordable and
   Dependable Coverage
Agenda
• Why are our health insurance options
 changing?
• What’s being done?
• What’s my role in the new options?
• Questions and answers




                                         1
 Financial Challenges
                                                      State of Tennessee Aggregate Health Care Costs (All Plans)

 $1,600,000,000


 $1,400,000,000


 $1,200,000,000


 $1,000,000,000

                                                                                                                                                                                                                                                                                                                         Total Expenses
   $800,000,000
                                                                                                                                                                                                                                                                                                                         Premium

   $600,000,000




                                                                                                                                                                                                                                                                                                        $1,348,497,826
                                                                                                                                                                                                                  $1,199,869,826
                                                                                                                                                                                $1,120,653,456
                                                                                                                                                               $1,068,890,199




                                                                                                                                                                                                                                                                     $1,302,416,825
                                                                                                                                                                                                                                   $1,199,755,275
                                                                                                                                                                                                 $1,103,512,331




                                                                                                                                                                                                                                                    $1,328,808,590
                                                                                                                                                $990,280,191
                                                                                                                  $907,430,204
                                                                                                   $893,977,889
                                                                     $748,033,379




                                                                                                                                 $962,691,295
                                                                                    $858,482,304
                                       $578,284,299



                                                      $779,950,258
                        $646,334,552




   $400,000,000




                                                                                                                                                                                                                                                                                       $1,376,582,473
   $200,000,000


             $-
                          2001                            2002                        2003                          2004                            2005                         2006                               2007                              2008                            2009 Proj.

Sources: State of Tennessee paid claim reports.



                                                                                                                                                                                                                                                                                                                                          2
Funding Health Benefits
• State is financially responsible for plan
 expenses
• State Group Insurance Program bank
 accounts contain premiums collected
 each month
• Those premiums pay member claims
 and plan administrative expenses




                                              3
ParTNers for Health
• Preserve comprehensive, affordable,
 dependable benefits
• Members take a more active role in their
 health
• Reduce health care costs in the long term
• Members are rewarded with immediate
 savings

    Our approach is based on the idea that our members, the State and our
       plans can partner to improve member health and manage costs.
                  We all have a stake in this new approach.



                                                                            4
  New Health Insurance
  Options

 Choose between           Choose an                    Choose between
   Two Preferred               Insurance Carrier            Four Premium
   Provider                                                 Levels
                            • BlueCross BlueShield of
   Organization               Tennessee                   • Employee
   (PPO) Options
                            • CIGNA                       • Employee + child(ren)
  Partnership PPO
                                                          • Employee + spouse
  Standard PPO                                           • Employee + spouse +
                                                            children




        All members will have the same choices and will make their choices
              during the Annual Enrollment Transfer Period in the fall.



                                                                                    5
PPO Options
• Partnership PPO
• Standard PPO
• Limited PPO (Local Government only)




                                        6
How a PPO Works
• PPO – Preferred Provider Organization
• Visit any doctor or hospital you want
• A “preferred” network of providers
 agrees to lower fees
• You pay less when you use a network
 provider




                                          7
Choosing An Insurance Carrier
• BlueCross BlueShield of Tennessee
• CIGNA




                                      8
Finding Your Doctor and Other
Health Care Providers
• Network of preferred doctors and
 hospitals
• Provider directories available
 • Insurance Carriers
 • Agency Benefit Coordinators

• ParTNers for Health Call Center
 • Research providers online

• Online
 • Insurance carrier websites
 • Link through ParTNers for Health website


                                              9
Choosing Your Premium Level
(Tiers)
• Employee Only
• Employee + Child(ren)
• Employee + Spouse
• Employee + Spouse + Child(ren)




      Bottom line: The Partnership PPO premiums are lower than the
                     premiums for the Standard PPO.



                                                                     10
If Your Spouse Works for a
Participating Employer
• Choose your Premium Level separately
• Choose your PPO option and insurance
 carrier separately




                                         11
 Premiums for 2011: Local
 Education Plan

 Total Monthly Premiums

Premium Level                              Partnership PPO        Standard PPO
Employee Only                                  $468.90                $493.90
Employee + Child(ren)                          $773.69                $798.69
Employee + Spouse                              $914.36                $964.36
Employee + Spouse + Child(ren)                $1,219.14              $1,269.14


                 The State pays 45% of the total premium cost for
           certified instructional employees and may pay a portion for
                           non-instructional employees.



                                                                                 12
Your Insurance Carrier Choice
Affects Your Monthly Premium
Cost
• Carrier costs vary by grand division
 • BlueCross BlueShield of Tennessee is the
   highest cost carrier in the West grand division.
 • CIGNA is the highest cost carrier in East and
   Middle grand divisions

• If you select the highest cost carrier in
 your grand division, you pay a higher
 monthly premium
 •   Employee Only: $10 more
 •   Employee + Child(ren): $20 more
 •   Employee + Spouse: $20 more
 •   Employee + Spouse + Child(ren): $20 more


                                                      13
Comparing Your PPO Options

   Partnership PPO                         Standard PPO
  Rewards members for taking             No incentives for healthy
   steps to get or stay healthy            behaviors
  Commitment to Partnership              Members pay a greater share
   Promise is required                     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.



                                                                         14
How You Pay for Health Care
Services
• Co-pays
• Co-insurance
• Annual Deductible
• Annual Out-of-Pocket Maximum




                                 15
     Co-Pays
                                              Benefits Effective January 1, 2011
                                                 Partnership PPO                                         Standard PPO
                                       In-Network               Out-of-Network*                  In-Network     Out-of-Network*

 Preventive Care                 No charge                     $45 co-pay                   No charge           $50 co-pay
 Well Baby or Well               No charge                     $45 co-pay                   No charge           $50 co-pay
 Child Visits
 Primary Care                    $25 co-pay                    $45 co-pay                   $30 co-pay          $50 co-pay
 Specialty Care                  $40 co-pay                    $65 co-pay                   $45 co-pay          $70 co-pay
 Prescription Drugs              $5 co-pay                     Co-pay for                   $10 co-pay          Co-pay for
 (At Retail Pharmacy)            generic                       applicable tier              generic             applicable tier
                                                               plus amount over                                 plus amount over
                                 $30 co-pay                    maximum                      $40 co-pay          maximum
                                 preferred brand               allowable charge             preferred brand     allowable charge
                                 $80 co-pay                                                 $90 co-pay
                                 non-preferred                                              non-preferred
                                 brand                                                      brand
*Members are responsible for 100% of all out-of-network provider charges above the maximum allowable
charge (MAC).


                                                                                                                               16
Free Preventive Care
• Annual preventive care check-up
 offered to members at no cost
• Lab work covered at 100% after co-pay
• You need to visit an in-network provider
 for all preventive care services




        Regular preventive care is one of the most important things
                        you can do to stay healthy.




                                                                      17
     Co-Insurance
                                              Benefits Effective January 1, 2011
                                                 Partnership PPO                                             Standard PPO
                                       In-Network               Out-of-Network*                  In-Network          Out-of-Network*
 Inpatient Care                  You pay 10%                   You pay 40%                 You pay 20%               You pay 40%
 (Including Mental
 Health and
 Substance Abuse)
 Advanced X-ray,                 You pay 10%                   You pay 40%                 You pay 20%               You pay 40%
 Scans and Imaging
 Occupational                    You pay 10%                   You pay 40%                 You pay 20%               You pay 40%
 Therapy, Physical
 Therapy, Speech
 Therapy
*Members are responsible for 100% of all out-of-network provider charges above the maximum allowable charge (MAC).




                                                                                                                                   18
Maximum Allowable Charge
(MAC)
• All services have a maximum allowable
 charge (MAC)
• Your share of co-insurance is based
 on the MAC
• If a provider charges more than the
 MAC, you pay the additional amount
 due


     When you visit an in-network provider, you don’t have to worry about
    exceeding the MAC. In-network providers agree in advance to fees that
                          don’t exceed the maximum.



                                                                            19
     Annual Deductibles
                                                 Benefits Effective January 1, 2011
                                                      Partnership PPO                                          Standard PPO
 Annual Deductible                          In-Network              Out-of-Network*                In-Network         Out-of-Network*
 Employee only                                   $350                        $700                       $700              $1,400
 Employee + Child(ren)                           $700                      $1,400                     $1,400              $2,800
 Employee + Spouse                               $700                      $1,400                     $1,400              $2,800
 Employee + Spouse +                             $900                      $1,800                     $1,800              $3,600
 Child(ren)
*Members are responsible for 100% of all out-of-network provider charges above the maximum allowable charge (MAC).




                You pay the annual deductible before co-insurance benefits kick in.



                                                                                                                                   20
 Examples: Co-insurance and
 Deductibles
Scenario 1: $1,600 charge for in-network inpatient hospital stay
Charges do not exceed MAC
                               You Pay                       PPO Pays
1. Your annual deductible      $350                          $0
2. Co-insurance                $125 (10% of $1,250)          $1,125 (90% of $1,250)
Total                          $475                          $1,125

Scenario 2: $1,700 charge for out-of-network inpatient hospital stay
Charges exceed MAC by $100
                               You Pay                       PPO Pays
1. Your annual deductible      $700                          $0
2. Co-insurance                $360 (40% of $900)            $540 (60% of $900)
3. Amount that exceeds MAC     $100                          $0
Total                          $1,160                        $540



                                                                                      21
     Out-of-Pocket Maximums
                                                 Benefits Effective January 1, 2011
                                                      Partnership PPO                                          Standard PPO
 Out-of-Pocket Maximum                      In-Network              Out-of-Network*                In-Network         Out-of-Network*
 Employee Only                                  $1,350                     $2,700                     $1,700              $3,400
 Employee + Child(ren)                          $2,700                     $5,400                     $3,400              $6,800
 Employee + Spouse                              $2,700                     $5,400                     $3,400              $6,800
 Employee + Spouse +                            $3,500                     $7,000                     $4,500              $9,000
 Child(ren)
*Members are responsible for 100% of all out-of-network provider charges above the maximum allowable charge (MAC).




            The maximums limit how much co-insurance you’ll pay in any given year
               if you or a covered family member have a serious illness or injury.



                                                                                                                                   22
Take Note!
• Deductibles and out-of-pocket
 maximums for in-network and out-of-
 network services add up separately
• Expenses over the MAC don’t count
 toward deductibles and out-of-pocket
 maximums
• Co-pays don’t count toward
 deductibles and out-of-pocket
 maximums




                                        23
Seeking Care Through Your PPO
                    Partnership PPO   Standard PPO
Provider Network           ✔               ✔


Choose any doctor         ✔                ✔


No PCP selection          ✔                ✔
required

No PCP referrals          ✔                ✔




                                                     24
Who’s Eligible for the
Partnership PPO?
• Anyone…
• …willing to make the Partnership Promise




                                             25
The Partnership Promise
• Know your health history
• Know your health risks
• Take steps to get and stay healthy
• Sign the State’s Partnership Promise




              In return for making the Partnership Promise,
                your health insurance costs will be lower.



                                                              26
What’s Involved
• Health Questionnaire – age, diet,
  exercise and tobacco and alcohol use
• Health Screening – height, weight, blood
  sugar, blood pressure and cholesterol
• Routine preventive care – most in-network
  services covered at no cost
• Next steps depend on results – health
  coaching and programs to manage health risks


   APS Healthcare will serve as the State’s health and wellness manager.



                                                                           27
Completing Your Health
Screening
• Based on any tests or screenings
  (e.g., through your regular annual
  physical) conducted after July 1, 2010
• You have until June 2011 to complete
  your health screening




                                           28
Managing Your Health Risks
• APS Healthcare works with you
• Evaluates health and health risks
• Recommends actions to reduce risks
• Provides individual coaching




                                       29
Keeping Your Promise
• Make the effort
• Follow recommendations of health and
  wellness manager
• Complete prescribed program




      We encourage you to think about how your commitment to the
  Partnership Promise can improve your health. The ParTNers for Health
                  program is designed to support you.



                                                                         30
If You Cover Your Spouse
• Same PPO Option
• Your spouse must also sign a
  Partnership Promise
• Exception: If you and your spouse
  both work for a Participating Employer
• No Partnership Promise is required for
  covered children




                                           31
Your Privacy
• Members’ personal health information is
  strictly confidential
• Written permission required in order
  for the State or employers to see any
  individual’s:
   » Health risk questionnaire responses
   » Health screening results
   » Participation in health and lifestyle management programs

            Your health privacy rights are protected through a
                       federal law called “HIPAA.”



                                                                 32
Pharmacy Benefits
• Caremark is now our Pharmacy
  Benefits Manager
• Customer Service: 1-877-522-TNRX
  (8679)
• Web: www.caremark.com




                                     33
Enrolling for Benefits
• It’s an “Open Enrollment” this year
• All benefits-eligible employees can
  enroll themselves and their dependents
  to age 26




                The Open Enrollment period runs from
               September 15 through October 15, 2010.
        The choices you make go into effect on January 1, 2011.



                                                                  34
Special Considerations for
Dependents
• Cover dependent child(ren) up to age 26
• Enroll eligible dependents for 2011 during
  the Open Enrollment period
• Dependents turning age 24 between
  July 1 and December 31, 2010, will not
  be disenrolled; current coverage
  continues through year-end




                                               35
Verifying Your Dependents
• Information about verifying documentation
  will be in the Enrollment Kit.




                                              36
12-Month Pre-Existing
Condition Exclusion
• May apply for any employee or employee spouse
  who enrolls for the first time during Open Enrollment
• A pre-existing condition is a health problem that
  existed before your enrollment in a State-sponsored
  health insurance option
   • Applies to conditions you sought treatment for in the past six
     months
   • Coverage is not provided for services related to these
     conditions

• “Creditable coverage” from another health insurance
  plan can offset the length of the exclusion period


                                                                      37
 Making Your Choices
1. Health insurance option                3. Optional accident and life
   •   Partnership OR Standard PPO           insurance --- DOES NOT
   •   Insurance carrier                     APPLY TO DEKALB
   •   Premium Level                         COUNTY BOE
   •   Enroll eligible dependents under   4. Flexible Benefits
       age 26
                                             Reimbursement Accounts
2. Dental coverage                           DOES NOT APPLY TO DEKALB
   DOES NOT APPLY TO DEKALB                    COUNTY BOE
     COUNTY BOE




                                                                          38
Completing Your Enrollment
• Your Enrollment Kit – includes Decision
  Guide, information DVD, premium sheet
  and enrollment forms
   • Mailed to current members in late August
   • Available to all eligible employees on request

• ParTNers for Health Call Center
  1-866-741-6464 – available 24 hours, 7
  days a week to answer questions




                                                      39
Take Note!
• Employees must meet the enrollment
  deadline: October 15, 2010
  DeKalb County Employees must turn the
  enrollment form into Central Office
  (Teresa) BEFORE they go home for FALL
  Break -- Please do NOT wait until the last
  minute.
• No changes until the next Annual
  Enrollment Transfer Period
       Current members who do not complete enrollment will be
                   enrolled in the Standard PPO.



                                                                40
Communications Goals
• All members need to understand:
 » Change is coming and they need to make a choice
 » What’s changing and why
 » What choices they have
 » When they need to make their choices
 » How to use and get the most out of the
   ParTNers for Health program
 » Whom to contact with questions


     You play a critical role in supporting and communicating change.
  Be visible. Answer questions. Direct members to the ParTNers for Health
   website for more information and to the Call Center if they need help.



                                                                            41
Member Communications




            Agency Benefits Coordinators, will
             receive ongoing communication
                throughout October 2010




                                                 42
Questions?
• Contact – benefits.info@tn.gov
• Call ParTNers for Health Call Center
 • ABCs: 1-877-741-2363
 • Members: 1-866-741-6464

• Go online to www.partnersforhealthtn.gov




                                             43

								
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