Transcript Slide 1

Schreiner University
2011 Benefits
Information & Enrollment
Agenda
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Transition from Principal to Primary PhysicianCare (PPC)
Benefits & Plan design
Health Care Reform
Networks
PPC Information and Resources
Pre-certification
Quest/Lab One
ID cards
Pharmacy
2011 Enrollment
Questions
Benefits & Plan Design
• No change in benefit plan design (Health Care Reform only) under the
new TPA effective 6/1/11.
• Plans will remain the same:
– PPO 500
– PPO 3000
– HDHP 2000
• New unlimited lifetime maximum (Health Care Reform)
• Eligible dependents covered to age 26 (Health Care Reform)
• New Pharmacy Benefit Manager, Express Scripts
Preventive Care/Wellness
• The following services are covered at 100% for all plans (one per
calendar year)
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Routine physical exams
Routine gynecological exams
Routine colonoscopies
Routine mammograms
Hearing Exams
Well child care
Immunizations
X-ray and lab services provided during exam
Health Care Reform Changes
• Lifetime maximums no longer apply
• Calendar year maximum no longer applies to “essential benefits”
• Dependent children may be covered under parent’s policy to age 26
• Pre-existing conditions no longer apply to children under the age of 19
• Over the counter medications no longer reimbursable by flex spending
account without doctor’s prescription
Networks
• No network disruption
• Texas True Choice (TTC) will remain the primary network for
Schreiner University employees
– www.texastruechoice.com
• PHCS will remain the secondary/out-of-state network for
Schreiner University employees
– www.phcs.com
New Third Party Administrator (TPA)
• Principal is no longer in the health insurance administration
industry.
• PPC will begin handling administrative services such as claims
processing, customer service, etc, effective June 1, 2011.
• Primary is located in Charlotte, NC
Primary PhysicianCare
• What is a Third Party Administrator (TPA)?
– An organization that processes claims or certain aspects of
employee benefit plans for a separate entity. A TPA is NOT an
insurance company.
• What is a self-funded employee benefit plan?
– Rather than paying monthly premiums to an insurance company a
self-funded plan is paid by the employer.
• Who is Primary PhysicianCare, Inc. (PPC)?
– PPC manages health plans for self-funded employers.
– The sole responsibility of PPC is to manage the health plan per the
guidelines of the Summary Plan Description. PPC has aligned
interests with Schreiner University and their employees. We want to
provide members the tools and resources to make better choices
about their healthcare.
Primary PhysicianCare
• Dedicated Service Team:
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Account Representative
Customer Service Team Lead
Customer Service Specialists
Claims Processor
Eligibility Specialist
• Our customer service teams will be up to date with your plan
benefits and able to answer any questions you may have.
PPC Contact Information
• Hours:
– 8:00am – 7:00pm EST
– Please leave messages after hours
• By Phone:
– 800-446-5439
– Follow the prompts for customer service
• By Mail:
– Primary PhysicianCare, Inc.
P.O. Box 11088
Charlotte, NC 28220
• Important information to have ready:
– Your ID number (from ID card)
– Your Employer name
– Date of Service
Pre-certification
• Pre-certification
– Process by which PPC reviews prospective inpatient hospitalizations
and outpatient procedures to ensure that all patients receive
optimum-quality and cost-effective care
– 7 day advance notice (pre-authorization) is required for any elective
service
– Notice within 48 hours is required for any non-elective service
Pre-certification
• Services that require pre-certification:
– Emergency hospital admissions, non-emergency hospital admissions
(including observation), ambulatory surgery (outpatient surgery),
dialysis, inpatient care in substance treatment centers, inpatient
care in mental health treatment centers, inpatient care in extended
care facilities, inpatient care in skilled nursing facilities, hospice care,
inpatient rehabilitation services, chemotherapy/radiation therapy,
durable medical equipment (rental or purchase), prosthetics, pain
therapy (outpatient) and home health care.
Pre-certification
• In order to receive full benefits for services that require precertification, the covered person must complete the process prior to
receiving the services or treatment at least seven days in advance.
• Pre-certification is the responsibility of the member. If the member is
unsure whether pre-certification has been made, he or she should call
to verify.
• For pre-certification call:
1-800-472-5001
8:30am – 5:00pm EST
Monday through Friday
Quest/Lab One
• Use is voluntary by the provider/member
• If the provider uses Quest/Lab One, expenses are paid at 100%
• If the provider does not use Quest/Lab One, regular benefits apply
ID Cards
• You will be receiving new ID Cards prior to 6/1/11
• One card per employee, and each dependent over 16
• Please make sure that you have provided your (and your dependents, if
applicable) new PPC ID card(s) to your doctors and pharmacies to
ensure accurate and timely processing of claims
• Do not assume that your provider’s office has updated your
information, please verify with your provider
ID Cards
• This is a SAMPLE, your benefits have not changed
PPC Resources
• Create your PPC account to:
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Access claims activity
View deductibles
View out-of-pocket limits
View prescriptions
Request replacement or additional cards
Print EOB’s (Explanation of Benefit’s)
Print claim forms
Much more!
Go to www.primarypc.com and click
on the “Member Login” link
Register as a New User
New users
register
here…
Step 1 – Member Registration
Step 2 – Verify Information
Step 3 – Registration Complete
PPC Help Desk
If you have any questions or need technical
support, please email
[email protected]
Express Scripts
• Express Scripts will be the new Pharmacy Benefit Manager
• No benefit/copay changes
• Out of pocket expenses met prior to 6/1/11 will be transferred from
Principal to Primary PhysicianCare and Express Scripts
• Mail order program available for maintenance medications (i.e. blood
pressure, cholesterol, etc)
• Anyone currently using mail order will need to obtain a new
prescription and submit with a mail order profile to Express Scripts
Express Scripts
• Generic and Brand Name Medications: What to know and what to
ask.
– Ask your doctor about starting a generic medication at the
beginning of treatment
– Doctors do not have generic samples in their offices, skip brand
name samples unless your doctor confirms you can safely switch to
a generic after using a brand name drug
– Ask your doctor to explore generics in the same class if your brand
name drug dose does not have a chemical equivalent
Express Scripts
• Express Scripts Contact Information:
– Phone: 800-889-0350
– Website: www.express-scripts.com
Tips on How to Get Your Claim
Processed Quickly And Correctly
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Most Claims are filed electronically: However, you retain some responsibilities just
as before
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For students over age 19: Proof of full time student status is no longer required.
Eligible dependents are covered under your plan to age 26, unless they have access
to other Employer coverage
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Accident Information: For each claim that is an accident, please include how, when
and where the accident occurred.
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When you have other coverage: For children or spouse’s claims, the process can
be expedited with other coverage information attached or sent in separately on a
claim form. Without this information, we will hold claims and request information,
which will slow down the processing
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Medical Supplies: Please ask doctor to include a letter of medical necessity when
prescribing medical equipment and supplies
Consuming Healthcare
• Only use the Emergency Room for true emergencies.
• Use generic drugs whenever possible; ask your doctor to prescribe a
generic first!
• Seek comparable care in lower cost settings (i.e. colonoscopies in an office
vs. hospital)
• Call PPC and we can assist and direct you!
– All contact phone numbers are on the back of your ID card
2011 Enrollment
• If you currently participate in Schreiner University’s health plan you will be
automatically enrolled with your current coverage for the remainder of
2011. You do not need to complete a new enrollment form.
• If you currently participate in Schreiner University’s health plan and need
to make changes (i.e. drop/add dependent, drop plan) pick up a change
form today. This form will need to be returned to HR no later than April 30,
2011.
• If you are not currently participating in Schreiner University’s health plan
but would like to join please fill out a blank enrollment form.
Questions?