Harrisonburg City Public Schools Open Enrollment 2014 Harrisonburg City Public Schools Open Enrollment 2014

Harrisonburg City Harrisonburg City Public SchoolsPublic Schools

Open Enrollment Open Enrollment 20142014

Harrisonburg City Harrisonburg City Public SchoolsPublic Schools

Open Enrollment Open Enrollment 20142014

Today’s AgendaToday’s Agenda

• Welcome

• Review Anthem Plan Effective 07/01/14– What’s Staying the Same– Why & What’s Changing– Claim Examples

• Q&A

WHAT’S STAYING THE SAME:KeyCare - Preferred Provider Organization (PPO) Plan

• PCP not required• No referrals needed• No claim forms needed when using network providers• Very large network of providers available both in Virginia and

throughout the U.S.• Out-of-network benefits available but at lower coverage

levels• Dependents covered until the end of the month in which they

reach age 26.• Annual eye exam - $15 copay (provided through Blue View

Vision)• Out of pocket maximum (in-network)-$3,000/$6,000

Plan OverviewPlan Overview

WHY & WHAT’S CHANGING:• WHY CHANGE:

• Health care costs are affected by:• Price inflation, utilization, legislation changes, new treatments, therapies

and technologies

• 8% is the national average rate increase…

• If HCPS made NO changes, our rate increase would be: 22.3%...this is not sustainable

• Solution: Change to a plan that is:• Considered a quality program in the market

• Cost effective and sustainable


WHY & WHAT’S CHANGING:

• WHAT’s CHANGING

• Benefits – plan is changing to KeyCare 25• Preventive services have been added as a result

of the Affordable Care Act


Preventive CarePreventive Care• Preventive Care Services covered at 100% in-network with

no member copay.• *Preventive care services are those services that meet the requirements of federal and

state law, including certain screenings, immunizations and physician visits, and include such services as:

Well Baby Visit with associated immunizations and screenings Well Woman Visit with associated gyn exam, pap smear, and mammogram. Medical

and Pharmacy contraceptives, 1 breast pump purchase or rental per pregnancy when purchased from a participating Durable Medical Equipment provider.

Routine Physical with associated immunizations and screenings Select OTC drugs with prescription from doctor (ex - iron supplements for children 0-12

months, aspirin for men age 45-79 and women age 55-79) Screening related to tobacco use including tobacco cessation products with

prescription from doctor

• *During the course of a routine screening procedure, abnormalities or problems may be identified that require immediate intervention or additional diagnosis. If this occurs, and your provider performs additional necessary procedures, the service will be considered diagnostic and/or surgical, rather than screening, depending on the claim for the services submitted by your provider, which will result in a member cost share.

Benefits Overview-KeyCare Benefits Overview-KeyCare 2525

In-network Services Current Plan KeyCare 25 Plan

Preventive Care Services No charge No charge

Doctor Visits – includes:•Office visits•Urgent care visits

$20 PCP$40 Specialist


•Spinal Manipulation (Chiropractic) visits-30 visits


$25/visit

Deductible(applies to all services with coinsurance)

None $500/person$1,000/family

You will pay the costs associated with your care until you have paid $500 in one calendar year. This is known as your deductible.

•If two people are covered, each will pay $500 ($1,000 total)•If three or more people are covered, together you will pay the first $1,000. The most one family member will pay is $500.



Diagnostic Labs & X-rays(provided in physician’s office, emergency room or facility)

Lab: no chargeX-rays-$40 copay

Advanced Diagnostic-$150

20%* after deductible

Emergency Room Facility $150 copay/visit, then 20%*


Outpatient Surgery $150 copay/visit, then 20%*


Inpatient Stays in a Network Hospital

$400/stay, then 20%* 20%* after deductible

*Anthem bases claim payment on the amount the health care providers in our network agree to accept for their services. This is called “allowable charge”. Network providers cannot balance bill for the difference in what we pay and what they charge.



Out of Pocket Maximum(once you meet your OOP Max, the plans pays 100% for the remainder of the calendar year)

$3,000/person$6,000/family


What counts toward this maximum:•medical copays (example - $25 PCP visit)

•deductible under KeyCare 25•your coinsurance amounts (20% of allowable charge)

What doesn’t count toward this maximum:•prescription drug copays

•vision plan copay•cost of care when benefit limits are reached


Out of Network Services (services provided by providers who are not part of the Anthem

KeyCare network)

Current Plan KeyCare 25 Plan

Deductible* $500/person$1,000/family

$750/person$1,500/family

Coinsurance Plan Pays: 70%You Pay: 30%

Plan pays: 60%You Pay: 40%

Out of Pocket Maximum* $4,500/person$9,000/family


*Deductibles and out-of-pocket maximums do not cross accumulate between in-network and out of network. Anthem bases claim payment on the amount the health care providers in our network agree to accept for their services. This is called “allowable charge”. Non-Network providers can balance bill for the difference in what we pay and what they charge.

Benefits OverviewBenefits Overview

Prescription Drug Benefits Current Plan KeyCare 25 Plan

Express Scripts, Inc (ESI) is the Pharmacy Company that Anthem uses

Up to a 30 day medication supply at participating Retail pharmacies

Tier 1 - $10 Tier 2 - $30Tier 3 - $50

Tier 1 - $10 Tier 2 - $40Tier 3 - $75

Up to a 90 day medication supply through ESI home delivery pharmacy

Tier 1 - $20 Tier 2 - $60Tier 3 - $100

Tier 1 - $20 Tier 2 - $80Tier 3 - $150

Meet Carol Lewis | Employee Only Meet Carol Lewis | Employee Only CoverageCoverageClaim Examples/Starting July 1, 2014Claim Examples/Starting July 1, 2014

Carol’s Services Date of Service

Anthem’s Allowable

Charge

Anthem Claim Payment

Carol’s Payment to Providers

Amount toward OOP

that Carol has met

Preventive Ob/GYN visit & lab tests

7/10/14 $300-visit$150-lab

$300-visit$150-lab

$0 $0

Diagnostic visit to PCP & lab work for strep throat

9/30/14 $350-visit$100-lab

$325-visit($350-$25 copay)

$0-lab(deductible not

met)

$25 copay-visit$100- lab

($100 toward deductible)

$125

MRI for knee injury

10/1/14 $1,000 $480($1,000-$400

(deductible owed=$600 x 80%)

$520($400 remainder of deductible + $120 which is 20% of $600)

$645($125 + $520)

Meet Carol Lewis | Employee Only Meet Carol Lewis | Employee Only CoverageCoverage

Claim Examples (continuedClaim Examples (continued))Carol’s Services Date of

ServiceAnthem’s Allowable

Charge



Amount toward OOP

that Carol has met

Outpatient Surgery for knee injury

10/15/14 $12,000 $9,600($12,000 x 80%)

$2,355(20% of $12K

would be $2400, but OOP would

be met)

$3,000($645 + $2355)

Follow-up visit with Specialist who did knee surgery

11/1/14 $150 $150 $0 OOP has been met for

2014*

*For the remainder of 2014, Anthem pays 100% of any remaining medical charges.Carol continues to pay for any prescriptions and/or routine vision exam.

Meet Carol Lewis | Employee Only Meet Carol Lewis | Employee Only CoverageCoverageClaim Examples/Starting January 1, 2015Claim Examples/Starting January 1, 2015

Carol’s Services Date of Service

Anthem’s Allowable

Charge



Amount toward OOP

that Carol has met

Confirmation of pregnancy at OB/GYN’s office

01/01/15 $200-visit$100-lab

$150-visit($200-$50 copay)

$0-lab(deductible not

met)

$50/visit$100 lab

($100 toward deductible)

$150

Pregnancy Related Ultrasound at GYN’s office

03/01/15 $400 $0(deductible not

met)

$400(remainder of deductible)

$550($150 + $400)

Pregnancy Related Ultrasound at GYN’s office

06/01/15 $400 $320($400 x 80%)

$80($400 x 20%)

$630($550 + $80)

Maternity-Delivery and Global Bill from GYN

09/01/15 $7600 $6,080($7600 x 80%)

$1,520($7600 x 20%)

$2,150($550 + $1520)

Questions

Documents

Harrisonburg City Public Schools Open Enrollment 2014 Harrisonburg City Public Schools Open Enrollment 2014