Transcript 2013 Enrollment Presentation

SIM USA
Effective January 1, 2015
Shelia McAnally
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Agenda
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GuideStone’s Ministry
Medical plans: Traditional PPO plans
Resources for your family
How to enroll or make changes
Q&A
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GuideStone’s Ministry
is Serving You
• “Serving those that serve the Lord” for 96 years
• Not an insurance carrier or brokerage firm
◦ Self-insured church plan
◦ Serving over 80,000 ministry participants across
the globe
◦ Non-commissioned, not for profit
• GuideStone health plans do not include Biblically
objectionable services
◦ Contraceptive prescriptions and methods are
covered unless abortive in nature
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GuideStone Brings
Together Best-in-Class
Providers
Nationwide Medical Network
Prescription Drug Pharmacy
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Medical Plans
PPOs
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Health Choice 3500
Medical Benefits
In-network
Out-of-network
Covered at 100%
Not covered
Primary care visit copay
$25
50%
after deductible
Specialist visit copay
$35
50%
after deductible
Urgent Care/ER copay (followed by coinsurance)
$50
50%
after deductible
$3,500/$7,000
$8,000/$16,000
80%/20%
50%/50%
$6,350/$12,700
N/A
Wellness/preventive care
Annual deductible (individual/family) 1
Plan pays/you pay (after deductible)
Medical and prescription maximum out-of-pocket:
individual/family (in-network services only,
including deductible, co-pays and co-insurance)
1Includes
hospitalization, maternity, outpatient surgery & services.
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Embedded Deductible
PPO Plans
• When one person in a family reaches the individual
deductible level, that person moves to the
coinsurance benefit level.
• Other family members’ expenses accrue to meet the
remaining family deductible before they move to the
coinsurance benefit level.
• Deductible, co-insurance and copayments accrue to
meet the individual and family Maximum Out-ofPocket.
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Maximum Out-of-Pocket
PPO Plans - Individuals
• Out-of-pocket costs for all eligible, in-network
services — including deductible, co-pay
and co-insurance — count toward the
individual maximum.
Maximum
out-of-pocket
limits vary by plan.
Maximum limit
• Once you reach the MOOP limit, GuideStone
covers all eligible, in-network health care
expenses for the rest of the year!
Prescription drug
Emergency room
Urgent care
Note: Out-of-network expenses accumulate separately and do
not contribute to the maximum out-of-pocket limit.
Office visit
Co-insurance
Deductible
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Maximum Out-of-Pocket
PPO Plans - Family Coverage
The below applies to plans with an embedded deductible:
• Out-of-pocket costs for all eligible, in-network
services apply toward the deductible and also
count toward the family individual or aggregate
maximum out-of-pocket limit.
• Once one family member reaches the family
individual maximum out-of-pocket limit, all of that
member’s eligible, in-network expenses will be paid
at 100%.
• The remaining amount of the family maximum
out-of-pocket limit can be accumulated by one or
all of the family members.
• Once the family reaches the family maximum
out-of-pocket limit, everyone’s eligible, in-network
expenses will be paid at 100% for the rest of the
year.
Maximum
out-of-pocket
limits vary by plan.
Maximum limit
Prescription drug
Emergency room
Urgent care
Office visit
Co-insurance
Deductible
Note: Out-of-network and ineligible medical expenses do not accumulate
toward, or contribute to, the maximum out-of-pocket limit.
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Wellness Benefit
PPO Per Preventive Care Schedule
• Scheduled, in-network services are covered at
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100% including scheduled lab and x-ray.
Well-child and adult annual preventive care are
covered.
Immunizations covered for all ages according to
schedule and available at doctor’s office and
neighborhood pharmacy.
Recommendations are based on age and gender.
Services not listed on the Preventive Care
Schedule such as EKGs and lung X-rays are not
included in the 100% preventive exam.
◦ These services are included as diagnostic under deductible/
co-insurance benefits.
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Urgent Care
PPO Plans
• Standardized urgent care co-pay available for
eligible, in-network, urgent care services
• $50 co-pay on all plans in-network
• Out-of-network services are covered by the out-ofnetwork co-insurance amount after the deductible has
been met
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Lab and X-ray Benefits
PPO Plans
Diagnostic X-ray or lab work at a doctor’s office
• Office visit benefit applies when an in-network
doctor performs lab work or X-ray in his or her
office regardless of where the doctor has the lab
work or X-ray processed or read
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Lab and X-ray Benefits
PPO Plans
Free-standing diagnostic X-ray or lab facility
• You pay your deductible and co-insurance when
you receive a diagnostic X-ray or lab work at a
free-standing facility outside your physician's
office.
• This facility may be adjacent to or within the
same suite as your doctor’s office.
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Vision Exam Benefit
PPO Plans
• One annual eye health examination for each
participant, including:
◦ Dilation
◦ Refraction for eyeglasses or contact lens
prescription
• Available at the Primary Care office visit level.
• No coverage for glasses, contacts or other eyewear.
• Must use a BCBS in-network optical provider
(optometrist or ophthalmologist) to receive benefit.
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Prescription Benefits
PPO Plans
Retail:
30-day supply2
Mail Order:
90-day supply2
Generic drug co-pay
80%
80%
Preferred drug co-pay1
80%
80%
Non-preferred drug co-pay1
80%
80%
Specialty drug co-pay
80%
80%
Prescription Benefits
1If
a preferred or non-preferred drug is purchased when a generic is available, the participant must pay the generic copayment and the cost between the preferred/non-preferred drug and its generic equivalent. The cost difference does not
apply to the Maximum-Out-Of-Pocket cost.
2The
copay is the maximum you pay for a medication unless receiving brand over a generic. If the medication costs less, you
only pay the true cost of the medication.
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Prescription Benefits
PPO Plans
• Brand Rx over Generic Rx
◦ If a preferred or non-preferred drug is purchased
when a generic drug is available, the participant
must pay the generic copay and the cost
difference between the preferred/non-preferred
drug and its generic drug equivalent.
◦ The cost difference will not apply toward the
participant’s maximum out-of-pocket limit.
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Important Rx Protection
Practices
Clinical rules and coverage management
• Step therapy for certain medications
• Pre-authorization for some medications
• Drug therapy helping patients take mediation
correctly and consistently for chronic conditions
• Quantity limits to maintain safe limits
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Questions?
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Tools and Resources
for Your Family
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MyGuideStone.org
1. Establish log-in on vendor websites
◦ www.HighmarkBCBS.com
◦ www.Express-Scripts.com
2. Go to www.GuideStone.org and establish log-in
3. Then sign in once at GuideStone and you’re done!
Single point of access to everything you need:
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Review your insurance product details
Download detailed plan booklets
Find a provider
Access wellness support and information
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www.GuideStone.org
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Download forms and resources for your plan
Get wellness support and inspiration
Learn more about health care reform
Find education about a range of personal finance,
insurance, wellness and retirement topics
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Save Money When You
Use In-network Providers
In-network Provider
Out-of-network Provider
Receive highest level of benefits
You share more of the cost
Benefit from provider discounts
No provider discounts
Provider files claims
You file claims
Lowest out-of-pocket costs
Greater out-of-pocket costs
Maximum out-of-pocket cost
accumulation
Separate out-of-pocket maximum
Compare your provider bills to your Explanation of Benefits (EOBs)
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Blue365®
Highmark Blue Cross Blue Shield
• Discounts on services and products plus
valuable information you can use all year long
• To access these discounts:
◦ Visit www.HighmarkBCBS.com
◦ Choose the Members tab and log in, or
select “Register Now”
◦ Select the Your Coverage tab and go to
“Member Discounts”
• Highlight of available discounts :
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Questions?
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How to Enroll
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Key Date
• All employees must complete enrollment within 31
days of employment.
• If you have any questions regarding enrollment
changes or your employee benefits, please notify
your benefits administrator.
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Before You Receive
Your ID Cards
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After the effective date of coverage, if you need to see
a doctor or fill a prescription and you haven’t received
your ID cards, information found on the “Important
Reminders” page of your enrollment packet will help
you access care
Watch the mail for TWO ID cards
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One for medical – each covered participant
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One for pharmacy – two cards per household
Can order additional or misplaced cards online
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Questions?
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This information only highlights the depth of coverage and benefits you can
receive when you protect yourself with GuideStone Financial Resources.
Limitations and exclusions apply. This material is a general summary of the
plans. The official plan documents and contracts set forth the eligibility
rules, limitations, exclusions and benefits. These alone govern and control
the actual operation of the plan. In the event of a conflict with the
description in this material, the terms of the official plan documents and
contracts will control its operation.
GuideStone Financial Resources of the Southern Baptist Convention
reserves the right to change or cancel these programs at any time. This
material does not imply an employment contract or guarantee of benefits.
Medical underwriting could be required.