Employee Benefit Guide GD
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The document provides an overview and summary of the employee benefit plans for an organization's open enrollment period. It includes information about the new medical and prescription drug plan administrator, wellness incentives that reduce premium costs, and an overview of the dental, vision, life, disability, and voluntary accident and critical illness plans. Employees can obtain ID cards, check claims status, and find plan forms on the new administrator's website. The summary also reviews dependent eligibility, premium costs for each plan, and details about coverage and provider networks.
Employee Benefit Guide GD
- 1. Employee Benefit Guide Open Enrollment Presentation November 2014
- 2. 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.
- 3. 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
- 4. 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.
- 5. 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.com o Plan information o Claims information o Plan forms o Wellness tools • Patient Advocacy Services o 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
- 6. 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
- 8. Medical Details 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 services No Cost Share Urgent Care $25 Emergency Room $250-30% coinsurance Inpatient / Outpatient Services @ Hospital 70% after deductible 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.
- 9. Prescription Drug Retail (up to 31-day supply) Tier 1 / Tier 2 / Tier 3 Mail Order (90-day supply) Tier 1 / Tier 2 / Tier 3 *Mandatory Generic DAW2* **Required mail services after 3rd fill at retail** $5 copay / $80 copay / 50% $10 copay / $160 copay / 50% …. Up to out of pocket maximum
- 10. Prescription Drug • Pharmacy Benefit o 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 in obtaining the full advantages of the best specialty pharmacy benefit options in the marketplace today.
- 11. 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**
- 12. 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.
- 13. 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. July 2011. Accessed at http://theirf.org/direct/user/site/0/files/IRF%20Wellness%20Phase%20One%20Final%20June%2 017%202011%20(1).pdf
- 14. 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
- 15. Medical/Rx: Employee Bi-Weekly 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
- 16. Contribution Savings **Rates Assume Wellness Incentive Taken**
- 17. 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
- 18. Anthem - Dental 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. Basic Enhanced Deductible Single / 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
- 19. 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
- 20. VSP – Vision Vision 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 Lenses OR… 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
- 21. Vision: Employee Bi-Weekly Contributions Coverage Level Bi-Weekly Weekly Employee Only $3.86 $1.93 Employee + 1 $5.89 $2.94 Family $10.56 $5.28
- 22. 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&D Employee: • $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 ** If you currently have coverage and elect additional coverage during annual enrollment: you may increase your coverage by one $10,000 increment not to exceed $100,000. Amounts greater will require evidence of good health. You may increase your spouse coverage one $10,000 increment not to exceed $50,000.**
- 23. Short Term & Long Term Disability • Short-Term Disability o 50% of your average weekly salary o Maximum Weekly benefit: $450 o Waiting Period: 15th Day Accident / 15th Day Sickness o Benefit Duration: 24 weeks • Long-Term Disability o 50% of your earnings up to $2,000 o Elimination Period: 180 days o Benefit Duration: Social Security normal retirement age o Pre-Existing Condition Limitation: 3 months prior / 12 months after **These are a packaged benefits. You can not purchase them separately**
- 24. 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.
- 25. 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
- 26. 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
- 29. 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
- 30. 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.
- 32. Allstate Benefits Website https://www.allstateatwork.com/mybenefits/
- 33. 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 Voluntarybenefits@brittongallagher.com
- 34. 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.
- 35. ID Cards o Watch your mail for new ID Cards • J.P. Farley – Medical • Anthem – Dental (All Employees will receive new ID cards)
- 36. 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
- 37. QUESTIONS??
Editor's Notes
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