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Preserving Our Health Benefits:
Changes to Sustain Comprehensive, Affordable andComprehensive, Affordable and
Dependable Coverage
AgendaAgendaWh h lth i ti• Why are our health insurance options changing?
• What’s being done?a s be g do e
• What’s my role in the new options?
• Questions and answersQuestions and answers
1
Fi i l Ch llFinancial Challenges
State of Tennessee Aggregate Health Care Costs (All Plans)
$1,400,000,000
$1,600,000,000
$1,000,000,000
$1,200,000,000
Total Expenses
,552
0,25
8
2,30
4
0,20
4
80,1
91
,653
,456
,869
,826
08,5
90
473
4,29
9
3,37
9
7,88
9
1,29
5
,890
,199
512,
331
755,
275
,416
,825
8,49
7,82
6
$400,000,000
$600,000,000
$800,000,000Total ExpensesPremium
$646
,334
,
$779
,950
$858
,482
$907
,430
$990
,28
$1,1
20,
$1,1
99
$1,3
28,8
0
$1,3
76,5
82,4
$578
,284
$748
,033
$893
,977
$962
,691
$1,0
68,
$1,1
03,5
$1,1
99,
$1,3
02,
$1,3
48
$-
$200,000,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 Proj.
2
Sources: State of Tennessee paid claim reports.
F di H lth B fitFunding Health BenefitsSt t i fi i ll ibl f l• State is financially responsible for plan expenses
• State Group Insurance Program bank S a e G oup su a ce og a baaccounts contain premiums collected each month
• Those premiums pay member claims• Those premiums pay member claims and plan administrative expenses
3
ParTNers for HealthParTNers for Health
P h i ff d bl• Preserve comprehensive, affordable, dependable benefits
• Members take a more active role in their e be s a e a o e ac e o e ehealth
• 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 OptionsOptions
Choose between Two Preferred Provider
Choose between Four Premium Levels
Choose an Insurance Carrier
Provider Organization (PPO) OptionsPartnership PPO
Levels• Employee
• Employee + child(ren)
• Employee + spouse
• BlueCross BlueShield of Tennessee
• CIGNA
Standard PPO• Employee + spouse
• 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 OptionsPPO Options
• Partnership PPO
• Standard PPO
• Limited PPO (Local Government only)
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How a PPO WorksHow a PPO Works
PPO P f d P id O i ti• 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 networkYou pay less when you use a network provider
7
Choosing An Insurance CarrierChoosing An Insurance Carrier
Bl C Bl Shi ld f T• BlueCross BlueShield of Tennessee
• CIGNA
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Finding Your Doctor and Other Health Care ProvidersHealth Care Providers
N t k f f d d t d• Network of preferred doctors and hospitals
• Provider directories available o de d ec o es a a ab e• Insurance Carriers• Agency Benefit Coordinators
P TN f H l h C ll C• ParTNers for Health Call Center• Research providers online
• OnlineOnline• Insurance carrier websites• Link through ParTNers for Health website
9
Choosing Your Premium Level (Tiers)(Tiers)
E l O l• 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 EmployerParticipating Employer
Ch P i L l t l• Choose your Premium Level separately
• Choose your PPO option and insurance carrier separatelyca e sepa a e y
11
Premiums for 2011: State PlanPremiums for 2011: State Plan
Premium Level Partnership PPO Standard PPO
Employee Share of Monthly Premiums
Employee Only $102.30 $127.30Employee + Child(ren) $153.45 $178.45Employee + Spouse $214.83 $264.83Employee + Spouse + Child(ren) $265.98 $315.98
The State pays 80% of the total premium cost for active employees.
12
Premiums for 2011: Local Education PlanEducation Plan
Premium Level Partnership PPO Standard PPO
Total Monthly Premiums
pEmployee Only $468.90 $493.90Employee + Child(ren) $773.69 $798.69Employee + Spouse $914 36 $964 36Employee + Spouse $914.36 $964.36Employee + 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.
13
Premiums for 2011: Local Government PlanGovernment Plan
Premium Level Partnership Standard Limited
Total Monthly Premiums
pPPO PPO PPO
Employee Only $526.55 $551.55 $337.18Employee + Child(ren) $816.15 $841.15 $522.63Employee + Spouse $1,132.07 $1,182.07 $724.94Employee + Spouse + Child(ren) $1,421.68 $1,471.68 $910.39
The State does not pay any premiums for Local Government Plan employees. However, some
Local Government employers may pay a portion.
14
Your Insurance Carrier Choice Affects Your Monthly Premium CostCost
C i t b d di i i• 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• CIGNA is the highest cost carrier in East and
Middle grand divisions
• If you select the highest cost carrier in d di i i hi hyour grand division, you pay a higher
monthly premium• Employee Only: $10 more
E l Child( ) $20• Employee + Child(ren): $20 more• Employee + Spouse: $20 more• Employee + Spouse + Child(ren): $20 more
15
Comparing Your PPO OptionsComparing Your PPO Options
Partnership PPORewards members for taking t t t t h lth
Standard PPONo incentives for healthy b h isteps to get or stay healthy
Commitment to Partnership Promise is required
behaviors
Members pay a greater share 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.
16
How You Pay for Health Care ServicesServices
C• Co-pays
• Co-insurance
• Annual Deductible
• Annual Out-of-Pocket Maximum
17
Co PaysCo-PaysBenefits Effective January 1, 2011Benefits Effective January 1, 2011
Partnership PPO Standard PPOIn-Network Out-of-Network* In-Network Out-of-Network*
Preventive Care No charge $45 co pay No charge $50 co payPreventive Care No charge $45 co-pay No charge $50 co-payWell Baby or Well Child Visits
No charge $45 co-pay No charge $50 co-pay
Primary Care $25 co-pay $45 co-pay $30 co-pay $50 co-paySpecialty Care $40 co-pay $65 co-pay $45 co-pay $70 co-payPrescription Drugs (At Retail Pharmacy)
$5 co-pay generic
$30 co-pay
Co-pay for applicable tier plus amount over maximum
$10 co-pay generic
$40 co-pay
Co-pay for applicable tier plus amount over maximump y
preferred brand
$80 co-pay non-preferred brand
maximum allowable charge
p ypreferred brand
$90 co-pay non-preferred brand
maximum allowable charge
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*Members are responsible for 100% of all out-of-network provider charges above the maximum allowable charge (MAC).
Free Preventive CareFree Preventive Care
A l ti h k• Annual preventive care check-up offered to members at no cost
• Lab work covered at 100% after co-payab o co e ed a 00% a e 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.
19
Co InsuranceCo-Insurance
Benefits Effective January 1, 2011Partnership PPO Standard PPO
In-Network Out-of-Network* In-Network Out-of-Network*Inpatient Care (Including Mental Health and Substance Abuse)
You pay 10% You pay 40% You pay 20% You pay 40%
Advanced X-ray You pay 10% You pay 40% You pay 20% You pay 40%Advanced X ray, Scans and Imaging
You pay 10% You pay 40% You pay 20% You pay 40%
Occupational Therapy, Physical Therapy, Speech Th
You pay 10% You pay 40% You pay 20% You pay 40%
Therapy *Members are responsible for 100% of all out-of-network provider charges above the maximum allowable charge (MAC).
20
Maximum Allowable Charge (MAC)(MAC)
All i h i ll bl• All services have a maximum allowable charge (MAC)
• Your share of co-insurance is based ou s a e o co su a ce s basedon the MAC
• If a provider charges more than the MAC you pay the additional amountMAC, 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.
21
Annual DeductiblesAnnual Deductibles
Benefits Effective January 1, 2011
Partnership PPO Standard PPO
Annual Deductible In-Network Out-of-Network* In-Network Out-of-Network*Annual Deductible In Network Out of Network In Network Out of NetworkEmployee only $350 $700 $700 $1,400Employee + Child(ren) $700 $1,400 $1,400 $2,800Employee + Spouse $700 $1,400 $1,400 $2,800Employee + Spouse + Child(ren)
$900 $1,800 $1,800 $3,600
*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.
22
Examples: Co-insurance and DeductiblesDeductibles
Scenario 1: $1 600 charge for in network inpatient hospital stay
You Pay PPO Pays
1 Your annual deductible $350 $0
Scenario 1: $1,600 charge for in-network inpatient hospital stay Charges do not exceed MAC
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 stayScenario 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 $0Total $1,160 $540
23
Out of Pocket MaximumsOut-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*Out of Pocket Maximum In Network Out of Network In Network Out of NetworkEmployee Only $1,350 $2,700 $1,700 $3,400Employee + Child(ren) $2,700 $5,400 $3,400 $6,800
Employee + Spouse $2,700 $5,400 $3,400 $6,800
Employee + Spouse + Child(ren)
$3,500 $7,000 $4,500 $9,000
*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.
24
Take Note!Take Note!D d tibl d t f k t• 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 maximumsmaximums
25
Seeking Care Through Your PPOSeeking Care Through Your PPO
Partnership PPO Standard PPOProvider Network ✔ ✔
Choose any doctor ✔ ✔
No PCP selection required
✔ ✔
N PCP f l ✔ ✔No PCP referrals ✔ ✔
26
Who’s Eligible for the Partnership PPO?Partnership PPO?
A• Anyone…
• …willing to make the Partnership Promise
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The Partnership PromiseThe Partnership Promise
K h lth hi t• 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.
28
What’s InvolvedWhat’s Involved
• Health Questionnaire – age, diet, exercise and tobacco and alcohol use
• Health Screening – height weight bloodHealth Screening height, weight, blood sugar, blood pressure and cholesterol
• Routine preventive care – most in-network services covered at no costservices 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.
29
Completing Your Health ScreeningScreening
• 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
30
Managing Your Health RisksManaging Your Health Risks
• APS Healthcare works with you
• Evaluates health and health risks
• Recommends actions to reduce risks
• Provides individual coaching
31
Keeping Your PromiseKeeping Your Promise
• Make the effort
• Follow recommendations of health and llwellness 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.
32
If You Cover Your SpouseIf You Cover Your Spouse
• Same PPO Option
• Your spouse must also sign a P t hi P iPartnership Promise
• Exception: If you and your spouse both work for a Participating Employerp g p y
• No Partnership Promise is required for covered children
33
Your PrivacyYour Privacy
• Members’ personal health information is strictly confidential
• Written permission required in order• Written permission required in order for the State or employers to see any individual’s:
Health risk q estionnaire responses» 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.”
34
Pharmacy BenefitsPharmacy Benefits
• Caremark is now our Pharmacy Benefits Manager
C t S i 1 877 522 TNRX• Customer Service: 1-877-522-TNRX (8679)
• Web: www.caremark.com
35
Optional DentalOptional Dental
Prepaid Plan• Fixed co-pays
PDO Plan• Any dentistp y
• Participating dentists only
y
• Pay less with network providers
Local Education Plan and Local Government Plan members should check with their agency benefits coordinator to see if
dental insurance is offered.
36
Accident and Life InsuranceAccident and Life Insurance
• State provides $20,000 of term life and $40,000 of special accident insurance
Additi l ti l b• Additional optional coverage may be available for you and your family
Local Education Plan and Local Government Plan members should check with their agency benefits coordinator to see if
accident and life insurance is offered.
37
Flexible BenefitsFlexible Benefits
• Lowers your income taxes
• Use pre-tax earnings to pay for health d t l i ior dental insurance premiums
• Set aside pre-tax earnings to pay for eligible health and dependent care g pexpenses
• You must sign up each year
If you are not a State employee, check with your employer to see if you are eligible for flexible benefits.
38
Flexible Benefits Reimbursement AccountsReimbursement Accounts
Medical Expense Reimbursement Account
• Use the account to reimburse
Dependent Day Care Reimbursement Account
• Use the account to reimburse• Use the account to reimburse yourself for eligible medical, dental and vision care expenses
• Contribute up to $7,500 per year
• Use the account to reimburse yourself for eligible dependent day care expenses
• Contribute from $2,500 to $5,000, p p ydepending on your tax filing status
Refer to the Department of Treasury website for more information about the program, including eligible expenses.
39
Enrolling for BenefitsEnrolling for Benefits
• It’s an “Open Enrollment” this year
• All benefits-eligible employees can ll th l d th i d d tenroll 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.
40
Special Considerations for DependentsDependents
• Cover dependent child(ren) up to age 26
• Enroll eligible dependents for 2011 during th O E ll t i dthe Open Enrollment period
• Dependents turning age 24 between July 1 and December 31, 2010, will not y , ,be disenrolled; current coverage continues through year-end
41
Verifying Your DependentsVerifying Your Dependents
• Information about verifying documentation will be in the Enrollment Kit.
42
12-Month Pre-Existing Condition ExclusionCondition Exclusion
• May apply for anyone age 19 or older who enrolls for the first time during Open Enrollment
A i ti diti i h lth bl th t• 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• 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
43
exclusion period
Making Your ChoicesMaking Your Choices 1 H lth i ti 3 O ti l id t d lif1. Health insurance option
• Partnership OR Standard PPO• Insurance carrier
3. Optional accident and life insurance• Purchase optional coverage for
yourself your spouse or your• Premium Level• Enroll eligible dependents under
age 26
yourself, your spouse or your eligible dependent child(ren)
4. Flexible Benefits Reimbursement Accounts2. Dental coverage
• Prepaid Dental OR PDO• Premium Level
Reimbursement Accounts• Elect contribution(s) for Medical
Expense Reimbursement Account and/or Dependent Day
• Enroll eligible dependents under age 26
ccou a d/o epe de ayCare Reimbursement Account
44
Completing Your EnrollmentCompleting 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• ParTNers for Health Call Center 1-866-741-6464 – available 24 hours, 7 days a week to answer questions
45
Online Enrollment through ESSESS
• Available to State employees
• Elect your health, insurance and flexible b fit tibenefits options
• Log on to Edison» Navigate to Employee Self Service > Benefits >» Navigate to Employee Self Service > Benefits >
Benefits Enrollment» Click the SELECT button» Follow the prompts to enrollp p
If you are covering dependents, you need to submit a paper enrollment form and applicable dependent eligibility verification.
46
Take Note!Take Note!
• Employees must meet the enrollment deadline: October 15, 2010
N h til th t A l• No changes until the next Annual Enrollment Transfer Period
Current members who do not complete enrollment will be enrolled in the Standard PPO.
47
Communications GoalsCommunications Goals
• All members need to understand:» Change is coming and they need to make a choice» What’s changing and whya s c a g g a d y» What choices they have» When they need to make their choices» How to use and get the most out of theHow 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.
48
Member CommunicationsMember Communications
Agency Benefits Coordinators, will receive ongoing communication
throughout October 2010
49
Questions?Questions?
• Contact – [email protected]
• Call ParTNers for Health Call Center • ABCs: 1-877-741-2363• Members: 1-866-741-6464
• Go online to www partnersforhealthtn govGo online to www.partnersforhealthtn.gov
50
