Transcript Slide 0

State of Tennessee Group Insurance Program
Annual Enrollment Transfer Period
October 1 – November 1, 2012
Agenda
• Annual Enrollment Transfer Period
• Using ESS in Edison
• What’s Changing for 2013?
• Health Benefits Overview
• 2013 Partnership Promise
• Dental Benefits Overview
www.partnersforhealthtn.gov
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Annual Enrollment Transfer Period
• Open Enrollment: October 1 – November 1, 2012

No increase to monthly late applicant fee
• Employees can make the following changes:

Switch PPOs (subject to eligibility)
 Change health insurance carriers
 Enroll in health insurance with a monthly late applicant fee
 Cancel health coverage
 Enroll in or cancel dental
www.partnersforhealthtn.gov
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Annual Enrollment Transfer Period
If you DO NOT want to make changes
• No action is required this year
• If you stay in the Partnership PPO, you (and your covered spouse)
are agreeing to fulfill the 2013 Partnership Promise
If you DO want to make changes
• You must use Employee Self Service (ESS) in Edison
• Benefits Administration will not accept paper forms
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Annual Enrollment Transfer Period
• Changes take effect on January 1, 2013
• Selections remain in effect through December 31, 2013
• A qualifying event or family status change is something that
results in a covered person losing coverage or becoming newly
eligible for other coverage
• Contact your agency benefits coordinator if you experience a
special qualifying event
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Using Edison ESS
•
To make changes to your coverage or add dental insurance, you must use
Employee Self Service (ESS) in Edison
•
To use ESS, log on to Edison at www.edison.tn.gov
» Local Education: your User ID and a temporary password will be mailed to your
home address
» If you did not receive this or are having trouble logging in, please call
Benefits Administration at 1-800-253-9981, option 3
• Instructions on how to use ESS are available in the Decision Guide or from
your Agency Benefits Coordinator
www.partnersforhealthtn.gov
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What’s Changing for 2013
 Member
cost sharing
 Pharmacy
coverage changes
www.partnersforhealthtn.gov
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What’s Changing for 2013
Member Cost Sharing: Health and Dental Premiums
•
Health insurance premiums will increase by the following percentages:

•
Local Education Plan = 9.2%
Dental insurance premiums will increase by 3% for both plans
Prepaid Plan
PDO Plan
Employee Only
$9.63
$20.46
Employee + Child(ren)
$20.00
$47.03
Employee + Spouse
$17.07
$38.69
Employee + Spouse + Child(ren)
$23.47
$75.71
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What’s Changing for 2013
Member Cost Sharing: Deductibles
• The deductibles for each PPO will increase in 2013
• The amount of the increase depends on your premium tier
Employee Only
$100 increase
Employee + Child(ren)
$150 increase
Employee + Spouse
$200 increase
Employee + Spouse + Child(ren)
$250 increase
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What’s Changing for 2013
Member Cost Sharing: Out-of-Pocket Maximums
• The out-of-pocket co-insurance maximums will also increase in 2013
• The amount of the increase depends on your premium tier
Employee Only
$200 increase
Employee + Child(ren)
$300 increase
Employee + Spouse
$400 increase
Employee + Spouse + Child(ren)
$500 increase
www.partnersforhealthtn.gov
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What’s Changing for 2013
Member Cost Sharing: Network Differential
• Depending on where you live, BlueCross BlueShield of Tennessee and
Cigna premiums vary because the networks have different costs in each
region
• If the State pays less, you will pay less too
• If you select the more expensive carrier in your region, the difference you
pay will be more in 2013:

Employee-only coverage will cost $20 more

Those with family coverage (all levels above employee-only) will pay $40 more
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What’s Changing for 2013
Member Cost Sharing: Specialist Office Visit Co-Pays
•
The co-pays for specialist office visits will increase by $5 in 2013
•
Specialist office visit co-pays for 2013 (including surgery in office setting):




•
Partnership PPO (in-network) = $45
Partnership PPO (out-of-network) = $70
Standard PPO (in-network) = $50
Standard PPO (out-of-network) = $75
Co-pays will not change for the following:




Co-pays for primary care
Mental health and substance abuse treatment
Allergy injections with a primary care office visit
Chiropractic visits (visits 1-20)
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What’s Changing for 2013
Member Cost Sharing: Emergency Room Co-Pays
•
Co-pays for emergency room visits will increase by $45 in 2013


Partnership PPO = $125
Standard PPO = $145
•
The emergency room co-pay will still be waived if the member is
admitted to the hospital
•
Members will continue to have access to urgent care clinics as an
alternative to the emergency room

Partnership PPO = $30

Standard PPO = $35

These rates will not change in 2013
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What’s Changing for 2013
Pharmacy: Women’s Contraceptives
• Generic contraceptives and brand name contraceptives without a generic
equivalent will be covered at $0 co-pay, including:

Oral contraceptives
 Emergency contraceptives
 Implantable devices/vaginal ring

Contraceptive transdermal patches
 Barrier methods
 Injectable contraceptives (limit four per year)
• Co-pays will still apply to brand contraceptives with generics available
• Once a brand drug in these categories has a generic equivalent on the
market, only the generic will be covered at $0 co-pay and the brand drug
will require the brand co-pay
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What’s Changing for 2013
Pharmacy: Co-pay changes
• Prescription drug co-pays will increase by $5 for:

Tier 2 (Preferred brand)
 Tier 3 (Non-preferred brand)
• The increase does not apply to:

Tier 1 (Generic)
 Drugs in the 90-day maintenance tier
•
Statins
•
Antihypertensives
•
Oral diabetic drugs, insulins and diabetic needles/test strips/lancets
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What’s Changing for 2013
Pharmacy: Dispense as Written Policy
• When a generic is available and your doctor indicates “may substitute” but
you request the brand name drug from the pharmacy, you will pay the
difference between the brand name drug and the generic drug plus the
brand co-pay.
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What’s Changing for 2013
Pharmacy: Preferred Specialty Drug Plan
• New users of the following must use a preferred specialty drug before the
plan will cover other non-preferred specialty drugs in the same drug class

Tumor necrosis factor (TNF) inhibitors (for inflammatory and autoimmune diseases)
 Multiple Sclerosis drugs
• This requirement is referred to as “step therapy”
Drug Class
Covered Medications
Preferred TNF inhibitors
Enbrel and Humira
Preferred Multiple Sclerosis drugs
Avonex, Copaxone and Betaseron
• This policy will not apply to current users of these drugs
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Health Benefits
Your Health Insurance Options
Subject to eligibility, you will continue to have the same health insurance options.
Provider
Two Insurance
 Preferred

Organization
Carriers
(PPO) Options
 Four Premium
Levels
• Employee
 Partnership PPO
• BlueCross BlueShield of
Tennessee
 Standard PPO
• Cigna
• Employee + spouse
• Employee + child(ren)
• Employee + spouse +
children
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Health Benefits
• Both PPOs cover services, treatments and products, such as:

In-network preventive care, x-ray, lab and diagnostics at no cost

Primary and specialist doctor office visits for a fixed co-pay without having to
meet a deductible

Prescription drugs for a fixed co-pay without having to meet a deductible
• Both PPOs offer:

Deductibles and co-insurance for certain services

Out-of-pocket maximums to limit your co-insurance and physician visit co-pay
costs
Both carriers also offer discounts for services
not covered. Refer to the carrier’s member
handbooks or websites for more information.
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Health Benefits
• Free preventive health services include, but are not limited to:
• Flu vaccination and pneumococcal vaccinations
• Annual preventive visit (i.e., physical exam)
• Annual well-woman visit
• Cholesterol test
• Osteoporosis screening for women
• Screenings for colon, breast or cervical cancer or prostate cancer
• If other services or related treatments are received during the same visit, an
office visit co-pay may apply
You need to visit an in-network provider to receive
preventive care services at no cost.
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Health Benefits
• Each carrier has its own network
• Both BlueCross and Cigna have made significant changes to their networks
for 2013
• Be sure to check the networks carefully when making your decision
• Provider directories are available on the ParTNers for Health website, by
calling the carrier or from your ABC
• BlueCross BlueShield offers Network S
• CIGNA offers Open Access Plus, OA Plus, Choice Fund OA Plus
www.partnersforhealthtn.gov
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Health Benefits
• Carrier costs vary by grand division
STEWART
• In East and Middle Tennessee,
LAKE
OBION
ROBE RTSON
JACKSON
WILSON
PUTNAM
RUTHERFORD
CIGNA costs $20 more per month for
employee only coverage and $40 more
per month for all other premium levels
ROANE
CANNON
VAN BURE N
BLEDSOE
MAURY
LEWIS
BEDFORD
CHESTER
HARDEMAN
MCNAI RY
HARDIN
WAYNE
LAWRENC E
GILES
LINCOLN
MCMINN
BLOUNT
MONROE
SEQUATCHIE
MOORE
FAYETT E
LOUDON
MEIGS
GRUNDY
SEVIER
RHEA
COFFEE
MARSHALL
SHELBY
COCKE
WARRE N
PERRY
DECATUR
GREENE
JEFFERSON
CUMBERLAND
WHITE
WILLIAMSON
HENDERSON
HAMBLEN
UNICOI
ANDERSON
KNOX
DEKALB
HICKMAN
MADISON
MORGAN
CARTER
GRAINGER
SMITH
DAVIDSO N
DICKSON
LAUDERDALE
HAYWOO D
WASHINGTON
UNION
JOHNSON
HAWKIN S
CAMPBELL
FENTRESS
HUMPHREYS
CARROLL
CROCKETT
TIPTON
OVERTON
SULLI VAN
HANCOCK
CLAIBORNE
SCOTT
TROUSDALE
BENTON
PICKETT
CLAY
MACON
SUMNER
CHEATHAM
HOUS TON
DYER
GIBSON
MONTGOME RY
HENRY
WEAKLEY
FRANKLIN
MARION
HAMILTON
BRADLEY
POLK
• In West Tennessee, BlueCross BlueShield costs $20 more per month for
employee only coverage and $40 more per month for all other premium
levels
www.partnersforhealthtn.gov
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Covered Services
Services that Require Co-Pays
• The following are some of the services that require co-pays:
• Primary Care Office Visit *
• Pharmacy
• Specialist Office Visit*
• Emergency Room Visit
• Urgent Care
• Urgent Care
• Allergy Injection (with office visit*)
• Mental Health and Substance Abuse*
• Chiropractors
* Subject to Out-of-Pocket Co-pay Maximum
www.partnersforhealthtn.gov
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Covered Services
Services that Require Co-Insurance
• The following are some of the services that require co-insurance:
• Hospital/Facility Services
• Maternity
• Home Care
• Equipment and Supplies
• Ambulance
• Hospice Care
• Rehabilitation and Therapy Services
• Dental
• Advanced X-Ray, Scans and Imaging
• Out-of-Country Charges
www.partnersforhealthtn.gov
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2013 Deductibles and Out-ofPocket Co-insurance Maximums
Partnership PPO
Standard PPO
In-Network
Out-of-Network
In-Network
Out-of-Network
Employee only
$450
$800
$800
$1,500
Employee + Child(ren)
$700
$1,250
$1,250
$2,350
Employee + Spouse
$900
$1,600
$1,600
$3,000
$1,150
$2,050
$2,050
$3,850
Employee only
$1,550
$2,900
$1,900
$3,600
Employee + Child(ren)
$2,450
$4,600
$3,100
$5,900
Employee + Spouse
$3,100
$5,800
$3,800
$7,200
Employee + Spouse + Child(ren)
$4,000
$7,500
$4,000
$9,500
Annual Deductible
Employee + Spouse + Child(ren)
Out-of-Pocket Co-Insurance Maximum
www.partnersforhealthtn.gov
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Premiums for 2013:
Local Education
Total Monthly Premiums
Premium Level
Partnership PPO
Standard PPO
Employee Only
$512.04
$537.04
Employee + Child(ren)
$844.87
$869.87
Employee + Spouse
$998.48
$1,048.48
$1,331.30
$1,381.30
Employee + Spouse + Child(ren)
• Premiums shown are for the least expensive carrier in the region. A complete chart is available in
the Decision Guide and on the ParTNers for Health website.
The State pays 45% of the total premium cost for
certified instructional employees
www.partnersforhealthtn.gov
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Partnership Promise
In 2013, members and covered spouses must:
• Complete the online Healthways Well-Being Assessment™
(health questionnaire) by March 15
• Engage in ONE ParTNers for Health wellness activity by July 15
• Keep your contact information current with your employer
• Engage in tobacco cessation program if you are a tobacco user
A health screening for all members is not required in 2013.
www.partnersforhealthtn.gov
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Partnership Promise
At-risk members and covered spouses must also:
• Complete a biometric screening at your health care provider’s
office between July 15 2012, and July 15 2013
• Participate in health coaching and/or case management, if
identified
Healthways will manage the Partnership Promise in 2013.
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Partnership Promise
Online Well-Being Assessment (WBA)
• Summarizes your overall health and offers steps you can take to improve
• By completing the confidential assessment, you will learn more about your
physical, emotional and social health and how your lifestyle habits affect
your overall well-being
• Beginning January 1, 2013, visit www.partnersforhealthtn.gov and create a
new, online well-being account to access the assessment
The Well-Being Assessment must be completed
between January 1 and March 15, 2013.
www.partnersforhealthtn.gov
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Partnership Promise
Wellness Activities
Wellness activities are easy actions you can take to work towards better health.
You must engage in only ONE of the following wellness activities.
Receive an ageappropriate
preventive service




Annual physical
Well-woman visit
Flu and pneumonia shots
Screenings for colon,
breast and prostate
cancers
www.partnersforhealthtn.gov
OR
Join a ParTNers for
Health Wellness
Challenge
OR
• Fun way to develop
healthier lifestyle with
group support
• Choose one of the first
two quarterly challenges
• Offered online
Complete Your WellBeing Plan and
Three Action Items
• Create plan with
recommended focus
areas from WBA
• Complete 3 simple action
items
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Partnership Promise
Updating Contact Information
• You must make sure that your phone number, mailing address and email
address, if you have one, are current with your employer.
• If your information changes during the year, you must notify your employer to
update your record.
 Local Education employees: Change your contact information yourself in Edison, by
contacting your agency benefits coordinator, Tiffany Latta or by calling the Benefits
Administration Service Center at 1-800-253-9981 and selecting option 6.
www.partnersforhealthtn.gov
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Partnership Promise
Tobacco Cessation
• Partnership PPO members must be tobacco free or agree to participate
in the tobacco cessation program and work toward becoming tobacco
free
• Members who use tobacco must answer “Yes” to the question “are you a
tobacco user” on the required WBA
• Healthways will reach out to enroll you in a tobacco cessation program
• You will not be required to stop using tobacco by the end of 2013, but you
must complete the tobacco cessation program and make an effort to quit
• This requirement applies to both you and your covered spouse
www.partnersforhealthtn.gov
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Partnership Promise
At-Risk Members
• Members who are identified as at risk will be required to take extra steps to
manage their current conditions and prevent new health risks from
developing

Complete a biometric screening with your health care provider

Participate in health coaching or case management during 2013
• Healthways will determine who is at risk based on medical conditions and
behaviors that may cause current or future health issues
Your health risks are determined using information from health insurance claims, your
Well-Being Assessment results and past health screening results.
www.partnersforhealthtn.gov
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Partnership Promise
Biometric Health Screening
• If identified, you must get a health screening from your health care provider
by July 15, 2013
• You may use screening results from a doctor’s visit between July 15, 2012,
and July 15, 2013
• Worksite screenings will not be available in 2013
• Simply ask your doctor to complete the Physician Screening Form, which
will be available online on January 1, 2013, and send the completed form to
Healthways by the July 15 deadline
www.partnersforhealthtn.gov
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Partnership Promise
Health Coaching
• Lifestyle management helps you form better health habits. Coaches help with:

High blood pressure

Weight management

High cholesterol

Tobacco use
• Disease management is for those with chronic conditions such as:



Diabetes
Asthma
Coronary artery disease


Congestive heart failure
Chronic obstructive pulmonary disease
(COPD)
• Case management is administered by BlueCross, Cigna and Magellan

Promotes quality and cost-effective coordination of care for those with complicated
medical needs, chronic conditions and/or catastrophic illnesses or injuries
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Partnership Promise
Health Coaching
• A health coach works with you and your provider to help you with selfmanagement skills to make sure that you are taking medicines and
getting the right care
• Health coaches are trained health care professionals
• All conversations with your health coach are confidential
• When you participate in coaching, your frequency of calls will be tailored
to your individual plan of care
• Your health coach will communicate with you using telephone calls,
mailings and the web
Healthways’ hours of operation:
Monday – Friday 7:30 a.m. – 9:30 p.m.
Saturday 8:00 a.m. – 6:30 p.m. (Central Time)
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Dental Benefits
Eligible employees can choose between two dental options
Prepaid Plan
PDO Plan
• Fixed co-pays
• Any dentist
• Participating dentists only
• Pay less with network providers
• During the enrollment period, eligible employees can enroll in or transfer
between the two options.
• If you don’t ask to change your current dental carrier or cancel
coverage, you will keep your current coverage.
HENRY COUNTY SCHOOL SYSTEM EMPLOYEES SHOULD
NOT CHOOSE THIS PLAN. THERE ARE NO DENTIST IN
WEST TN THAT ACCEPT THIS TYPE OF INSURANCE
www.partnersforhealthtn.gov
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Dental Benefits
Preferred Dental Organization (PDO)
• Administered by Delta Dental
• Use any dentist
• Members have access to Delta Dental’s PPO network
• You pay co-insurance for covered services
• A deductible applies for out-of-network dental care
• You or your dentist will file claims for covered services
• Some services require waiting periods and limitations/exclusions apply
• Premiums will increase by 3% in 2013 for the PDO
www.partnersforhealthtn.gov
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Dental Benefits
2013 Premiums
Assurant Prepaid
Delta Dental PDO
Employee Only
$9.63
$20.46
Employee + Child(ren)
$20.00
$47.03
Employee + Spouse
$17.07
$38.69
Employee + Spouse + Child(ren)
$23.47
$75.71
Dental services for both the Prepaid Plan and the Dental PDO include:
• Periodic oral evaluations
• Routine Cleanings
• Amalgam fillings
• Endodontic
• X-rays
• Extractions
• Major restorations
• Orthodontics
• Dentures
www.partnersforhealthtn.gov
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Additional Benefits
Employee Assistance Program (EAP)
• Provides support tools that help you and your family deal with personal
issues and situations
• All services are confidential and available at no cost to members
• Services can be easily accessed by calling Magellan, 24/7
• You and your eligible dependents may get up to five free counseling
sessions per problem episode
• Contact ParTNers EAP:

1.855.HERE4TN (1.855.437.3486)

www.Here4TN.com
www.partnersforhealthtn.gov
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Take Note!
• If you do not want to make changes,
no action is required
• If you do want to make changes or add coverage,
you must use ESS and meet the enrollment deadline of
November 1, 2012
 You
must click “submit” in ESS to finalize your selections by
11:59 p.m. on November 1, 2012
• No changes until the next Annual Enrollment Transfer Period
www.partnersforhealthtn.gov
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Member Communications
Current members will receive
a copy of the 2013 Decision
Guide at their homes in midSeptember.
www.partnersforhealthtn.gov
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Who to Contact
• Primary point of contact – Tiffany Latta, agency benefits
coordinator (ABC)
• Questions about a provider or claim – contact your insurance
carrier
• Questions about eligibility and enrollment – call Benefits
Administration service center at 1-800-253-9981
• Our ParTNers for Health website –
www.partnersforhealthtn.gov
• Enrollment forms and handbooks – www.tn.gov/finance/ins
www.partnersforhealthtn.gov
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Agency Benefits Coordinator
Contact Information
Tiffany Latta
Henry County School System
Secretary to the Director/Agency Benefits Coordinator
642-9733 Office
642-8073 Fax
[email protected]
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Questions?
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