Open Enrollment 2012Non State Employer Groups

Health Care Commission (HCC) Health Care Commission (HCC)

Approved employee & employer rates◦NSG’s & Agency rates increased

12.5% on 7/1/10 15% on 7/1/11

◦NSG’s & Agency rates will increase 7.5% on 7/1/12

◦Return to the 95/55 employer contribution Coverage cost for employee-only will increase

◦Actual increase depends upon plan, tier and coverage level

Continue to provide a 55% contribution toward dependent coverage

Other HCC ActionOther HCC Action

No plan design changes for Plans A and BPlan design changes for Plan C pharmacy

benefitAdded Stormont-Vail HealthCare as a

regional preferred lab vendor Quest will continue to offer a statewide

preferred lab optionAdded the HealthQuest Rewards Program

Legislative ChangesLegislative Changes

Autism Spectrum Disorder Pilot◦Benefit will be continued for 2012

Limits placed on SEHP coverage for abortions◦Only covered to protect life of the mother

2012 SEHP Medical Plans2012 SEHP Medical PlansAll plans are

Preferred Provider Organizations (PPOs)

◦Claims paid based on the network status

◦Network providers accept the plan allowance as

payment in full

◦Non Network Providers can balance bill

◦All plans include preventive care

Vendor OptionsVendor Options

Plans A B C

Blue Cross and Blue Shield of Kansas

√ √ √

Coventry/PHS √ √ √

UnitedHealthcare Company √ √ √

General practiceFamily practiceGeriatrics

Internal medicinePhysician extendersPediatrics

• Plans A & B only• PCPs have lower office visit copays • Member may have more than one

PCP• No referrals required

Selecting a Medical PlanSelecting a Medical Plan

1. Pick a plan design (A, B or C)◦ Which plan design provides the coverage

you and your family need?

2. Review the Provider Networks ◦ Each of the medical plans uses a different

provider network

3. Review the other services each medical plan offers

4. Review the premiums

Network Benefit* Plan A Plan B Plan C

Deductible$300 Single$600 Family

$150 Single$300 Family

$1,500 Single$3,000 Family

Coinsurance 20% 35% 20%

Coinsurance Maximum$1,400 Single$2,800 Family

$3000 Single $6000 Family

None

Out-of-Pocket Maximum None None $3,000 Single$6,000 Family

Office Visit – Primary Care Providers

$25 Copay $20 Copay – Adult$10 Copay -

Children < age 19

Deductible & Coinsurance

Office Visit - Specialist $45 Copay $40 Copay - Adult $25 Copay -

Children < age 19

Deductible & Coinsurance

Preferred Lab Benefit Yes Yes No

*Use of Non Network providers will increase your out-of-pocket cost.

Covered Preventive CareCovered Preventive Care

Services Services

Well Baby Exams - includes newborn screenings and age-appropriate office visits.

Well Child Exam – includes office visit and age-appropriate screenings and counseling.

Well Woman Exam - includes office visit and age-appropriate screenings and counseling.

Well Man Exam - includes office visit and age-appropriate screenings and counseling.

Prenatal Screening & Counseling - Limited screening services. See benefit description for details.

Ultrasonography for Aortic Aneurysm - Limited to one for men ages 65-75 with history of tobacco use.

Age-Appropriate Bone Density Screening

Mammography – not limited to one.

Immunizations Routine Hearing Exam

Colonoscopy – not limited to one.

Vision Exam – one covered per person per year

Quest DiagnosticsQuest Diagnostics

www.questdiagnostics.com

Stormont-Vail HealthCareStormont-Vail HealthCare

Stormont-Vail HealthCare is a new regional preferred lab vendor in NE Kansas.

All Plan A and B members may use the Stormont-Vail draw site locations.

Labs drawn at other Cotton-O’Neil locations may be included if by network providers.

Covered lab procedures are covered at 100%.◦Show your medical ID card to access benefit.

Stormont-Vail Draw Sites Stormont-Vail Draw Sites Facility Address City/State

Stormont-Vail HealthCare Laboratory

1500 SW 10th Ave Topeka, KS

Cotton-O’Neil 901 Laboratory 901 SW Garfield Topeka, KS

Cotton-O’Neil 823 Laboratory 823 SW Mulvane Topeka, KS

Cotton-O’Neil Croco Laboratory 2909 SE Walnut Drive Topeka, KS

Cotton-O’Neil Urish Laboratory 6725 SW 29th Street Topeka, KS

Cotton-O’Neil Carbondale Laboratory

211 East Main Carbondale, KS

Emporia Medical Arts Clinic 1301 W 12th Avenue, Suite 401

Emporia, KS

Cotton-O’Neil Wamego Laboratory 1704 Commercial Circle Wamego, KS

CaremarkCaremarkPlans A & B Prescription Drug BenefitPlans A & B Prescription Drug Benefit

Generic Drugs◦20% Coinsurance

Preferred Brand◦35% Coinsurance

Special Case Medications ◦25% to a max of $75 per 30-day supply

Non Preferred Brand◦60% Coinsurance

www2.caremark.com/kse

Up to a sixty (60) day supply of most drugs available

2011Nasacort 3rd

QtrLevaquin 3rd

QtrTegretol XR 3rd QtrCaduet 4th

QtrLipitor 4th

QtrZyprexa 4th

Qtr

2012• Avalide 1st Qtr• Avandia 1st Qtr• Lexapro 1st Qtr• Lescol 2nd Qtr• Provigil 2nd Qtr• Plavix2nd Qtr• Actos 3rd Qtr• Diovan 3rd Qtr• Maxalt 4th Qtr• Singular 4th Qtr• Tricor4th Qtr

www2.caremark.com/kse

Full-Time EmployeeEmployee

Only*Employee +

Dependents*Employer Contribution

$75.00 mo.($900 a yr)

$112.50 mo.($1,350 a yr)

EmployeeContribution

$25 to $91.66 $25 to $204.16

Maximum Annual HSA Contribution

$3,100 $6,250

*All columns represent 24 semi-monthly deductions •Each health plan uses a different HSA vendor•HSA vendor info – www.kdheks.gov/hcf/sehp/HSA.htm•Employees must open their HSA account by 1/1/12•HSA account and funds belong to the employee•Minimum contribution to HSA of $25 semi-monthly by the employee is required•See the Health Plan Comparison Chart for part-time information.

CaremarkCaremarkPlan C Drug PlanPlan C Drug Plan

Plan C now has a Coinsurance Drug PlanDrugs are subject to the Deductible, then:

◦Generic 20% Coinsurance◦Preferred Brand 35% Coinsurance◦Non Preferred Brand 60% Coinsurance◦Special Case Drugs 25% Coinsurance to a

max of $75Generic Incentive ProvisionNot creditable coverage

Plan C Chronic Care BenefitPlan C Chronic Care Benefit

Prescription Drugs for:

Prescription Drug Product

Member ResponsibilityPer 30-Day Supply

Diabetes

Generic Drug Deductible and then 10%to a maximum of $10

Preferred Brand Drug

Deductible and then 20% to a maximum of $20

Asthma

Generic Drug Deductible and then 10% to a maximum of $10

Preferred Brand Drug

Deductible and then 20% to a maximum of $20

Deltal DentalDeltal DentalDental CoverageDental Coverage

Plan pays in full for two exams & cleanings per person per year

Plan Deductible◦Applies to Basic & Major Restorative Care◦$50 per person, maximum of 3 per family

Orthodontic benefit ◦$1,000 per person per lifetime

Annual benefit maximum◦$1,700 per person per year

Dental BenefitDental Benefit

Benefit Level PPO PremierNon

Network

Preventive Services

Covered in full

Covered in full

Allowed amount

covered in full

Basic Benefit

Basic Restorative

Services50% 50% 50%

Enhanced BenefitBasic

Restorative Services

20% 40% 40%

Superior Vision/Vision PlanSuperior Vision/Vision PlanBasic Plan includes

$25 Materials Copay then: 100% single vision, standard bifocal, trifocal

lenticular lenses Up to $100 allowance for frames

Elective Contact lens allowance $150 Office visit subject to $50 Copay

Enhanced Vision Plan includes Basic, plus… Contact Lens Fitting Fee subject to $35 Copay High index lenses or Poly-carbonate lenses up to $116 Progressive lenses up to $165 Scratch and UV coating

Open EnrollmentOpen Enrollment

New Enrollment portal for NSE Group Members - http://employee.hrissuite.com

Here you can complete your enrollment◦Make health plan selections◦Add/drop dependents◦Declare tobacco status ◦Coverage effective January 1, 2012

Required DocumentationRequired Documentation

If you are adding a dependent, documentation of eligibility is required. Provide copies of:◦Birth certificates ◦Marriage licenses◦Affidavit of common law marriage◦Social Security numbers required

Documents due by 10/31/11 to your HR office

DefaultsDefaults

Members currently enrolled in UMR who do not make an enrollment election will have United HealthCare for 2012.

Members currently enrolled in Preferred Health Systems who do not make an enrollment election will have Coventry/PHS for 2012.

If you fail to make a tobacco use election you will be defaulted to paying the base rates in 2012.

Identification CardsIdentification Cards

All medical plans are issuing new ID cards.Delta Dental is issuing new ID cards.

ResourcesResources

Review the Open Enrollment (OE) booklet

?’s: Call the health plan customer service◦Phone numbers in the front of the OE booklet

Visit the website: www.kdheks.gov/hcf/sehp.htm◦Benefit descriptions available◦Provider directory listings◦Preferred drug list

Email ?’s to SEHP: benefits@kdheks.gov

Thank You for Attending Thank You for Attending

Questions?Questions?

Option SlidesOption Slides

General practiceFamily practiceGeriatrics

Internal medicinePhysician extendersPediatrics

• Plans A & B only• PCPs have lower office visit copays • Member may have more than one PCP• No referrals required

Network vs. Non NetworkNetwork vs. Non Network

Plan A - Non Network Provider 

Service on 1/2/2011 Plan Pays Member PaysProvider Write-

Off

Billed Charge $1,500      

Allowed Charge $1,400   $100 $0

$500 Deductible ($500)   $500  

50% Coinsurance $900 $ 450 $450  

Total   $450 $1,050 $0

Plan A - Network Provider 

Service on 1/2/2011 Plan Pays Member PaysProvider Write-

Off

Billed Charge $1,500      

Allowed Charge $1,400     $100

$300 Deductible ($300)   $300  

20% Coinsurance $1,100 $880 $220  

Total   $880 $520 $100

Plan A – Network ProvidersPlan A – Network Providers

Office Visit Copays◦$25 for Primary Care Office Visits◦$45 for Specialist Office Visits

$300/$600 Deductible 20% CoinsuranceCoinsurance Max $1,400/$2,800• Preventive Care Services paid at 100%

Lab Card Benefit

Plan B – Network ProvidersPlan B – Network Providers

Primary Care Office Visits◦$20 Copay for Adults ◦$10 Copay for Children <age 18

Specialist Office Visits◦$40 Copay for Adults◦$25 Copay for Children <age 18

$150/$300 Deductible35% CoinsuranceCoinsurance max $3,000/$6,000• Preventive Care Services paid at 100%

Lab Card benefit

Plans A & B Non Network ProvidersPlans A & B Non Network Providers$500/$1,500 Deductible50% CoinsuranceCoinsurance Max $3,650/$7,300Non Network Providers can balance billPreventive care not covered

Plan C w/ Health Savings AccountPlan C w/ Health Savings AccountNetwork Provider Coverage

◦$1,500/$3,000 Deductible◦20% Coinsurance◦$3,000/$6,000 Out-of-Pocket Maximum◦Preventive Care Services paid at 100%

Non Network Provider Coverage◦$2,000/$4,000 Deductible ◦50% Coinsurance◦$3,650/$7,300 OOP Maximum ◦Preventive Care is not covered

Dental Preventive CareDental Preventive CareCovered in full:

◦Prophylaxis/cleanings – twice per year.◦Oral examinations – twice per year.◦Bitewing x-rays –

adults – 1 x a year children under 18 - 2 x a year

◦Full mouth x-rays – once each five (5) years.

◦Limited coverage for children only: Sealants Space maintainers Topical fluoride

◦Ancillary – emergency relief of pain.

Dental Restorative ServicesDental Restorative ServicesBasic Restorative

◦Regular restorative dentistry – fillings◦Oral surgery◦Endodontics – root canals ◦Periodontics – treatment of gum & bone disease◦Additional diagnostic X-Rays

Major Restorative◦Special restorative dentistry – crowns◦Prosthodontics – bridges, implants, dentures◦TMJ Treatment – Requires prior authorization

Restorative care is subject to a $50 deductible

Dependent Eligibility ChangeDependent Eligibility Change

Effective 1/1/11, dependents are eligible to be covered on the plan to age 26 even if:◦they do not live with you◦they are not a student◦they are not dependent on you for support, or◦are married

Spouses of dependents are not eligible. Grandchildren are only eligible under limited

circumstances. You can add coverage for your eligible

dependents during this Open Enrollment.