SIM USA Effective January 1, 2015 Shelia McAnally 1 Agenda • • • • • GuideStone’s Ministry Medical plans: Traditional PPO plans Resources for your family How to enroll or make changes Q&A 2 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 3 GuideStone Brings Together Best-in-Class Providers Nationwide Medical Network Prescription Drug Pharmacy 4 Medical Plans PPOs 5 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. 6 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. 7 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 8 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. 9 Wellness Benefit PPO Per Preventive Care Schedule • Scheduled, in-network services are covered at • • • • 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. 10 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 11 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 12 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. 13 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. 14 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. 15 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. 16 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 17 Questions? 18 Tools and Resources for Your Family 19 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: ◦ ◦ ◦ ◦ Review your insurance product details Download detailed plan booklets Find a provider Access wellness support and information 20 www.GuideStone.org • • • • 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 21 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) 22 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 : 23 Questions? 24 How to Enroll 25 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. 26 Before You Receive Your ID Cards • • • 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 o One for medical – each covered participant o One for pharmacy – two cards per household Can order additional or misplaced cards online 27 Questions? 28 29 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.