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Employee Benefit GuideOpen Enrollment Presentation
November 2014
Introduction• New plan administrator-J.P. Farley for the medical and prescription drug
coverage.
• No action needed if not making any changes. Current plan election will transfer to new administrator.
• ID cards are mailed directly to your home address, watch your mail.
• Should you choose to waive coverage at this time, you must wait until next open enrollment if you choose to reapply.
Today’s Discussion• JP Farley: Medical/Prescription
o Referenced Based Pricing
• Wellness Incentives
• Anthem: Dental
• VSP: Vision
• Aetna:
o Life and Voluntary Life
o Short Term Disability (STD)
o Long Term Disability (LTD)
• Allstate:
o Voluntary Accident & Critical Illness
• Next Steps for Enrollment
• Questions
Plan Features
• Your plan does not utilize a network.
o The plan covers all legal and appropriate providers of covered
services.
o Your health plan will reimburse your claims on a set fee schedule
• You will have an ID card
o This card will have all the information providers need:
• To submit a claim to your health plan for payment.
• More information about the specific benefits your plan covers.
Plan Features• Connected Care Management Services
o Nurse Care Manager provides a customized, coordinated treatment plan and education
that compliments your health care providers’ on-going care.
• 24/7 Website Access : JPFarley.como Plan information
o Claims information
o Plan forms
o Wellness tools
• Patient Advocacy Serviceso Billing and out-of-pocket collections assistance:
• Help with favorable payment arrangements
• Protect against aggressive medical bill collectors
• Provide support to advocate for the participant’s patient rights
Patient Advocacy Q & A
• What if my provider bills me differently than my plan states? o Should you receive a bill from your provider asking you to pay more for a service than indicated on
Explanation of Benefits (EOB) statement, call J.P. Farley and speak with a Patient Advocate.
• Balanced Billed?
1. Contact Patient Advocate Services
2. Patient Advocate will engage you and forward appropriate documentation to
provider and credit bureaus
3. Patient Advocate will maintain follow up and communication
4. Standard process usually only entails the need for two dispute letters
5. If collection notifications or aggressive bill collection attempts continue,
Patient Advocate will provide direction to legal resources to assist
How to Read Your Explanation(EOB) of Benefits Statement
Medical Details
Precertification will be required if you have any of the following: Inpatient hospitalization, Inpatient surgery, Outpatient surgery, Diagnostic testing and
imaging studies, Mental health and chemical dependency services.
In-Network
Deductible (Embedded/Per Person) $750 / $2,250
Coinsurance 70%
Out-of-Pocket Limit
Plan pays 100% after annual out-of-pocket maximum (includes deductible and coinsurance)
$5,000 / $10,000
Preventive
Nationally recommended servicesNo Cost Share
Urgent Care $25
Emergency Room $250-30% coinsurance
Inpatient / Outpatient Services @ Hospital 70% after deductible
Prescription Drug Details
Prescription Drug
• Pharmacy Benefito Prescription Benefit Coverage is designed to provide coverage for retail and mail order
prescriptions. Your medical plan enrollment provides you access to this benefit. Options
include home delivery and 90-day retail supplies.
• Prescription Precertification o Required for all medications that cost $750+ per month or per dose. We can assist
you with additional care and assistance in obtaining the full advantages of the
best specialty pharmacy benefit options in the marketplace today.
Practical Prescription Tips
$4 Generic Programs
o Walgreens, CVS, Wal-Mart, K Mart, Marcs, Giant Eagle, Sam’s Club
o Fill your 30 day generic Rx for $4
– Only applicable for select generic Rx’s
Free Medications
o Giant Eagle
o Blood Pressure, Antibiotics
– Only applicable on select medications
**Utilizing these programs to purchase your prescription will not
cause a claim through your insurance**
Prevention is Key• Some of the recommended services you’ll have full coverage for include:
o Immunizations and wellness visits for children
o Routine preventive exams for adults
o Adult immunizations
o Adult screenings (e.g. mammogram, prostate, diabetes)
o Colorectal cancer screenings
• PLEASE NOTE:
o You won’t have to pay anything for these services when the purpose of your visit is to
get preventive care
o The services listed above are not preventive if you get them as part of a visit to diagnose,
monitor or treat an illness or injury. Then copays, coinsurance and deductibles apply.
o Let your doctor know that these preventive services are covered at 100% when they are
billed as part of your preventive care.
What is a Wellness Program?
• “Workplace Wellness refers to programs designed to improve the health
and well-being of employees in order to enhance organizational
performance and reduce costs. Wellness programs typically address
specific behaviors and health risk factors, such as poor nutrition, physical
inactivity, stress, obesity, and tobacco use. Wellness programs can also
focus on chronic disease management programs for asthma, diabetes,
insomnia and heart disease.” 1
1 Schweyer A. Energizing Workplace Wellness Programs: The Role of Incentives, Rewards & Recognition. Incentive Research Foundation. July2011.
Accessed at http://theirf.org/direct/user/site/0/files/IRF%20Wellness%20Phase%20One%20Final%20June%2017%202011%20(1).pdf
Wellness Program• Preventive Care Form
o Form is completed by Physician which states that participant is up to date with their
preventive care services for their age and gender.
You receive a reduction in your contribution of $25.00 a month for completing
Preventive Care Form
Medical/Rx: Employee Contributions
Coverage Level W/out Wellness Incentive W/ Wellness Incentive
Bi-Weekly Weekly Bi-Weekly Weekly
Employee Only $50.65 $25.33 $39.11 $19.56
Employee + 1 $82.07 $41.03 $70.53 $35.26
Family $122.46 $61.23 $110.92 $55.46
Contribution Savings
Coverage2014 Monthly
RatesAnnual $ Saving vs.
2014Annual % Savings
vs. 2014
Employee Only 117.61 $394.42 27.9%
Employee + 1 241.48 $1063.92 36.7%
Family 315.10 $897.26 23.7%
**Rates Assume Wellness Incentive Taken**
Dependent Eligibility
• In order to enroll a spouse in the company sponsored health plan you must:
o Provide proof of marriage
o Your spouse must not be eligible for benefits through their own employer
o You must provide a signed affidavit from their employer stating they are not eligible
for health insurance through their company.
• Children who submit proof of eligibility are eligible for all benefits until age 26
• Proof of eligibility documents include:
o Most recent federal tax filing form with financial information blacked-off.
o Birth certificate if child covered as tax dependent by another parent
o Marriage certificate dated within the last 12 months
Anthem - Dental
Basic Enhanced
DeductibleSingle / Family
$50 / $150 $50 / $150
Waived for Preventive Yes Yes
Preventive Services 100% 100%
Basic Services 80% 80%
Major Services N/A 50%
Annual Maximum $1,000 $1,000
Orthodontia Not Covered 50%
Out of Network Reimbursement
90th percentile 90th percentile
Search For Dental Providers at: www.anthem.com
Select Find a Doctor - Dental - Search Criteria - State - Plan Type = Dental - Plan Name = Dental Blue 100/200/300.
Dental: Employee Contributions
Coverage Level Basic Enhanced
Bi-Weekly Weekly Bi-Weekly Weekly
Employee Only $6.23 $3.12 $9.73 $4.87
Employee + 1 $12.15 $6.07 $18.87 $9.44
Family $23.03 $11.52 $33.98 $16.99
VSP – VisionVision Services Member Cost Out of Network Allowance
Exam w/ Dilation(1x every 12 months)
$10 copay $45
Frames (1x every 12 months)
$25 copay$130 Allowance
$70
Standard LensesOR…Elective Contact Lenses(1x every 12 months)
$25 Copay
Up to $60 copay$130 Allowance
Varies $30 to $65
$105
Medically Necessary Contact Lenses(1x every 12 months)
No Copay $105
Search vision providers at: www.VSP.com> select Find a VSP Doctor >Enter Search Criteria
Vision: Employee Contributions
Coverage Level Bi-Weekly Weekly
Employee Only $3.86 $1.93
Employee + 1 $5.89 $2.94
Family $10.56 $5.28
Aetna-Life and Voluntary Life
• Basic Life/AD&D • Employer paid benefit• $20,000 employee coverage • 1x base salary up to $150,000 (qualifying employees)
• Voluntary Life/AD&DEmployee:
• $10,000 increments, minimum $20,000 up to $100,000• $100,000 guaranteed issue amount
Spouse:Employee must elect coverage in order for spouse or child to be eligible for coverage.
• $10,000 benefit up to $50,000 (not to exceed 50% of Employee amount)• $50,000 guaranteed issue amount
Child(ren): • $5,000 benefit Guaranteed Issue
** Elect additional coverage during annual enrollment- increase your coverage by one $10,000 increment not to exceed $100,000. Increase your spouse coverage one $10,000 increment not to exceed $50,000.**
Short Term & Long Term Disability
• Short-Term Disability
o 60% of your earnings up to $1,500 / week
o Waiting Period: 15th Day Accident / 15th Day Sickness
o Benefit Duration: 24 weeks
• Long-Term Disability
o 60% of your earnings up to $10,000 / month
o Elimination Period: 180 days
o Benefit Duration: Up to Age 65
o Pre-Existing Condition Limitation: 3 months prior / 12 months after
**These are a packaged benefits. You can not purchase them separately**
Allstate Voluntary Benefits
• Type of Coverage Available:
o Voluntary Off-the-Job Accident Plan
o Voluntary Critical Illness Plan (includes cancer coverage)
• Key Features:
o Coverage is available to employee, spouse and/or children.
o These plans are LIFETIME plans, coverage is portable.
o Money is paid directly to you.
Allstate Accident Plan
• Benefit payments for off-the-job accidental injuries including: x-rays, stitches, broken
bones, dislocations, burns, hospital confinement, life insurance and more…
• Guaranteed issue for all ages.
• Outpatient Physician Treatment Benefit (OPR)
o Pays you $100 per physician visit for any reason. Does not have to be
related to an accident (i.e. dental cleaning, eye doctor, sore throat,
physical…).
o 2 visits per person per calendar year
o 4 visits per family $200 per person or $400 per family
Allstate Accident Plan
• Example of Injury Payout from a Car Accident:
o Fractured Arm: $3,300
o X-Ray: $300
o Emergency Room: $300
o Physician Treatment: $150
o Physical Therapy 6 visits: $540
o Ambulance Ride: $300
o 2 follow up visits to doctor: $300
• Accident Plan Payout: $5,190
Allstate Accident Plan
Allstate Accident Plan
Allstate Critical Illness
• Benefit Amount Available
o $10,000 (Low) or $15,000 (High)
o High Plan includes Cancer Benefit
• Payments for Illnesses such as:
Cancer
Heart Attack
Stroke
Coronary Artery By-Pass Surgery and more…
• Wellness Benefit
o $75 - includes screenings for cancer or heart screening tests, cholesterol tests, Colonoscopy,
Mammogram, Pap Smear, PSA Test, Stress Test, etc.
o 1 test per covered person, per calendar year
o Visit https://www.allstatebenefits.com/mybenefits/ to file this claim online without a receipt
Allstate Critical Illness
• Premiums are based on employee age and employee/spouse tobacco usage
• Free coverage for children
• Premiums are locked in by age class for the lifetime of the plan.
Example: EE age 36-50 / high plan / non-smoker
Cost of plan = $6.02 per week
When the employee turns 51 they will remain in the 36-50 age bracket and avoid a doubling of rates by moving up into the next age bracket.
Allstate Critical Illness
Allstate Benefits Websitehttps://www.allstateatwork.com/mybenefits/
Allstate Voluntary Benefits
For more information the Allstate Voluntary Benefits please contact your
broker, Britton Gallagher at:
Voluntary Benefits
216-658-8577 or 216-658-7806
1-866-230-9184
Next Steps for Enrollment • Enrollment Steps
o If electing coverage for the first time, or changing your current
benefits election complete a Benefit Plan Enrollment Form.
o Return completed forms to Rhonda Petruzzi by November 21st
o After electing coverage, ID cards are mailed directly to the
address listed on application, watch your mail.
ID Cards
o Watch your mail for new ID Cards
• J.P. Farley – Medical
• Anthem – Dental (All Employees will receive new ID cards)
Qualifying Events
• During the year, the only time you are permitted to make
election changes is:
o Birth of a child
o Marriage
o Divorce/Legal Separation
o Loss of coverage
o Adoption
• HR Must Be Notified within 31 Days of the Qualifying (Life
Changing) Event
QUESTIONS??
