Union College Health Care Assistance Plan National Blue Card Network September 6, 2005 Ellen...

Union College

Health Care Assistance PlanNational Blue Card Network

September 6, 2005

Ellen EldridgeDirector, Health Care ServicesAdventist Risk Management

Health Care Assistance PlanPayment Limits

• Lifetime Plan Limit – Medical in total - $3,000,000– Infertility Treatment - $16,000– Refractive Eye Surgery - $2,400– Orthodontic Care - $2,300

• Plan Year Payment Limits– Hearing - $3,200– Durable Medical Equipment - $8,000– Vision - $560– Dental - $1,800 Individual; $3,680 Family

Health Care Assistance PlanMember Responsibility

• Co-pay each Office Visit - $15

• Deductible - $250 single / $500 family

• Out-of-Pocket (OOP)– Also known as Co-Insurance

– In-Network – 20%; $2000 single / $4000 family

– Out-of-Network – 35%; $4500 / $7000 family

Health Care Assistance PlanMember Responsibility

• Prescription Benefit– Retail

• 30-day supply

• $10 generic/$16 brand/$20 non-formulary

– Mail Order• 90-day supply

• $10 generic/$20 brand/$30 non-formulary

– Out-of-Pocket Maximum - $400 / $800

Health Care Assistance PlanMember Responsibility

• $15 Co-pay Office Visit

Urgent Care Centers

Mental Health Out-Patient Services– Professional Services Only (doctor’s fee)

– Plan pays 100% of office visit after co-pay

– Does not apply to deductible or OOP

– All other charges apply to deductible and OOP

– Plan pays 80% of these additional charges

Health Care Assistance PlanMember Responsibility

• Emergency Room– Applies to OOP– Does not apply to Deductible– Paid at 80%– $50 Co-pay/Deductible – waived if admitted

• Therapies PT, OT, Speech, Chiropractic, Acupuncture

– Plan year visit limits apply– Paid at 80%– Do not apply toward Deductible or OOP

Health Care Assistance PlanMember Responsibility

• Paid at 80%; Applies to Deductible and OOP– Out-Patient Services

– In-Patient / Out-Patient Hospital Stays• Medical• Mental Health• Substance Abuse

– Office / Ambulatory Surgical Procedures

– Ambulance Services

Claims PaymentExplanation of Benefits

Accumulators

Deductible

$150

Co-Insurance

$ 0

Charges Payment

Office Visit 200

Co-pay 15

Plan Pays 185

Lab Work 150

Deductible 150

20% Co-Insurance 0

Plan Pays   0

350 350

Claims PaymentExplanation of Benefits

Accumulators Deductible

$150

100

Co-Insurance

$ 0

25

Charges Payment

Office Visit 150

Co-pay 15

Plan Pays 135

X-Rays 225

Deductible 100

20% Co-Insurance 25

Plan Pays 100

375 375

Claims PaymentExplanation of Benefits

Accumulators

Deductible

$150

100

0

Co-Insurance

$ 0

25

300

Charges Payment

Out-Pt Surg $1,500

Co-pay $ 0

Deductible 0

20% Co-Insurance 300

Plan Pays 1,200

$1,500 $1,500

Blue Card PPO Network

• More than 650,000 providers nationwide

• More than 5,500 hospitals nationwide

• Medical claims processed by IBC

– 99.5 % Claim adjudication accuracy

– 93.0% Home plan claims – 10-day TAT

– 98.0% Host plan claims – 30-day TAT

Negotiation Process

• Contract is between ARM and Independence Blue Cross in Philadelphia

– Downstream contract between ARM and Client

• ARM negotiatied the PEPM Fee for all NAD participating employers

– Continues to use our large group advantages

Negotiation Process

• ARM remains Customer Service

– Access to Blue Cross system for customer service

– Single point of contact

– Continuation of historical knowledge

• NAD Health Care Plan design stays intact

• Medco Health remains our Prescription Benefits Manager

Blue Card PPO Network

• Home Plan– Independence Blue Cross

Philadelphia, Pennsylvania

• Host or Local Plan– Any Blue Cross Network outside Home Plan

where services are rendered

Blue Cross Claims Flow

OOA Provider►Local Plan►Home Plan►Local Plan►OOA Provider

• Includes the following services

– Transplant network– Utilization and case management coordinated

in 50 states– Out of the country coverage based on medical

necessity– Wellness Incentive Program

Overview

• NAD Plan - medical benefits remain intact• ARM continues to manage the Plan

– Consults with and recommends to NAD– no changes in organizational management

• Access to Blue Cross providers nation-wide• Single network / Single payor• Simplifies PPO management• Reduces claims payment staffing needs• Potential savings to NAD-wide medical

expenses by $15M - $18M• Wellness Incentive program at no cost

Benefits at a Glance

• No benefit changes as a result of Blue Card– All benefits remain the same– Medical claims are paperless, nationwide when

in-network

• ARM continues to pay dental and vision

• ARM continues to manage prescription plan

• No change in coordination or management

• ARM remains Customer Care service

Benefits at a Glance

Medical Services carved out of Blue Card NOT excluded benefits

WILL BE reimbursed by ARM

• Massage Therapy

Access BC therapist for significant discount

• Adult Immunizations - for travel or work

NAD Plan policy limits apply

Mail claims to PO Box 4759 Silver Spring MD

Value Added Benefits

• Childhood Immunizations– $15 office visit co-pay– Balance paid at 100%– Does not go to Deductible or OOP

• Mammography, pap screening– $15 office visit co-pay– Balance paid at 100%– Does not go to Deductible or OOP

• Therapies i.e. PT, OT, Speech– Apply to Deductible and to OOP

Value Added Benefits

• Healthy Lifestyles Incentive Programs– Fitness Program – Up to $150 reimbursement

– Weight Management - Up to $200 reimbursement for cost of Weight Watchers

– Safety Program - Up to $25 reimbursement of certificate for CPR or first aid course

– Adds no costs to employee or conference

Union College Health Care Costs

Benefit Year 2004-2005

Prd Allowable Discount Mbr Resp NetPaid

MM 1,290,671

288,019 156,378 846,274

DE 98,320

5 14,756 83,560

VI 50,436

121 10,056 40,259

RX 209,101 0 29,082

180,019

GT 1,595,186

288,145 210,272 1,150,112

North American Division Health Care Costs

Benefit Year 2004-2005

Prd Allowable Discount Mbr Resp NetPaid

MM 101,595,238 24,518,614 12,223,418 64,853,208

DE 11,867,432 12,873 2,177,796 9,676,761

VI 3,042,012 67,527 602,577 2,371,909

RX 14,574,371 - 1,950,649 12,623,723

GT 131,079,053 24,599,014 16,954,439 89,525,601

Union College2004-2005 Medical Expenses

• Benefit Year 2004-2005

– Allowable Charges $1,290,671– PPO Discounts 288,019– Member Responsibility 156,378– Net Paid by Employer 846,274– Effective PPO Discount 22.3%

Union CollegeBlue Cross Discounts

Blue Cross Discounts in Nebraska

In-Patient 34-49%

Out-Patient 21-26%

Professional 29-34%

Union CollegeMedical Expense Retrospect

• Benefit Year 2004-2005 -- If it had been under Blue Card

– Allowable Charges $1,290,671

– PPO Discounts 393,655

– Member Responsibility 134,552

– Net Paid by Employer 762,464

– Effective PPO Discount 30.5%

Union College Medical Expense Net Affect

• Benefit Year 2004-2005 -- Summary Net Affect

– Additional Savings $105,636– Net Employer Savings 83,810– Net Member Savings 8,062

References

• Provider look-up– www.ibx.com

• Provider search

• ARM’s Customer Care Service– (888) 276-4732– (888) ARM-4SDA

Questions – Concerns for Ellen

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Questions – Concerns for Ellen

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Questions – Concerns for Ellen

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