Office of Group Benefits Annual Enrollment 2012 FOR RETIREES WITH MEDICARE PART A & PART B1 Welcome This presentation is a summary of information and does not purport to present complete details of all plan options offered by the Office of Group Benefits. For complete information on each plan option, individuals should read plan documents carefully and also consult other OGB and plan administrators’ publications. Welcome This presentation will cover: Ways to Save Eligibility Overview of Health Plans Life Insurance Office of Group Benefits OGB serves state agencies, universities and school boards Mental Health Benefits 1% Administrative Costs 3.5% Prescription Drug Benefits 21.9% Medical Benefits 71.4% Life Insurance 2.2% OGB’s administrative costs are only 3.5% of total costs (June 30, 2011) Annual Enrollment Timeline Annual Enrollment begins October 3 2012 plan year begins November 4 Annual Enrollment ends January 1 Ways to Save Your Health: Our Priority 6 Ways to Save Choose the right health plan for you 1 Out-of-state coverage differs by plan Out-of-state dependent? Job transfer? Travel? Are your providers in the plan’s network? All plans accessible through OGB website www.groupbenefits.org Stay in your health plan’s provider network Avoid balance-billing 3 Request generic drugs Same active ingredients and big savings 2 Your Health: Our Priority 6 Ways to Save 4 Get preventive (wellness) exams Prevention Early diagnosis After you fill your prescriptions for diabetes medication, use your prescription drug benefit on the same day to receive free diabetes testing supplies 6 5 Give providers complete, accurate information about your health Get correct diagnosis and treatment Ensure timely and correct payments Prescription Cost Comparison Brand-Name Drug insomnia $ 173.36 migraines 342.63 sumatriptan 66.85 231.48 gabapentin 21.54 prostate hyperplasia 143.47 tamsulosin 42.06 depression 198.93 venlafaxine XR 129.85 anti-viral 268.43 valacyclovir 149.43 pain 260.89 tramadol ER 138.33 258.79 bupriopion XL 61.16 seizures 404.79 lamotrigine 24.26 depression 320.23 fluoxetine 12.39 seizures 422.89 topiramate 31.06 147.35 simvastatin 9.59 147.95 pravastatin 12. 20 140.85 paroxetine 13.68 Ambien Imitrex seizures Neurontin Flomax Effexor XR Valtrex Ultram ER Wellbutrin XL Lamictal Prozac Topamax Zocor depression cholesterol Pravachol Paxil Average Cost per Approved Generic Average Cost per Prescription * Alternative Prescription * cholesterol depression zolpidem * Average costs as of 8-31-11 utilization; subject to change. $ 4.06 Source: Catalyst Rx Premium Cost-Saving Strategies Married Couples If both are state or school retirees... Both eligible? May save if split coverage Eligibility Eligibility – Same for All Plans Full-Time Employees and Dependents Legal spouse Louisiana does not recognize same-sex marriages regardless of other states’ laws Children up to age 26 – regardless of child’s student, marital or tax status No one can be enrolled simultaneously as both an employee and a dependent in OGB health plans or life insurance No dependent can be covered by more than one employee Dependent verification required Eligibility – Children • Natural child of you or your legal spouse • Legally adopted child • Child placed in home for adoption • Child in home under legal guardianship or custody • Grandchild dependent on you whose parent is your covered dependent Dependent Verification Plan member must provide proof of the legal relationship of each dependent within 30 days of date of application for coverage Proof: Official documents Marriage certificate Birth certificate Other court records or legal documents Over-Age Dependents Covered child under age 26 who is or becomes incapable of self-sustaining employment is eligible to continue coverage as an overage dependent OGB must receive required medical records before dependent reaches age 26 Definition of incapacity broadened – now includes both mental and physical incapacity Pre-Existing Condition Limitation for Late Applicants Must complete enrollment form (GB-01) within 30 days for new dependent … otherwise, pre-existing condition limitation (PEC) applies If diagnosed or treated within 6 months prior to enrollment date, condition is pre-existing ... no benefits are payable for that condition in first 12 months of coverage PEC limitation does not apply to anyone under age 19 May be exempt from pre-existing condition limitation if continuously covered without 63-day break in coverage prior to enrollment date What Happens If You Drop Coverage? If you drop coverage, you lose it FOREVER! UNLESS … You joined a non-OGB Medicare Advantage plan and it is no longer available or you withdraw You joined TriCare for Life and it is discontinued or had significant reduction in benefits You lost other creditable continuous coverage and you meet all requirements in PPO Plan Document Medicare Facts to Remember Medicare Part A and Part B OGB health plans are secondary to Medicare Premium rates are reduced for retirees with Medicare Provider accepts Medicare assignment? Yes: Neither OGB nor patient is responsible for charges above Medicare-allowable amount No: OGB will consider remaining eligible charges Medicare and OGB Coverage If you reached age 65 on or after July 1, 2005, AND are retired AND are eligible for Medicare Part A premium-free, then… You MUST enroll in Medicare Part B to receive OGB health plan benefits for medical expenses covered by Medicare Part B You must submit Social Security verification to OGB: If eligible – submit copy of Medicare card If not eligible – submit letter from Social Security This also applies to your covered spouse If you are not yet retired, this will apply when you retire Overview of Health Plans OGB Health Plans for All Retirees PPO HMO (Statewide) (Nationwide) Administered by OGB Administered by Blue Cross Regional HMO (Regions 6, 7, 8 & 9) Fully insured by Vantage Health Plan Medical Home HMO (Statewide – must choose PCP in Region 9) Fully insured by Vantage Health Plan Key Points Can change health plans during Annual Enrollment Compare costs, benefits and restrictions when choosing a plan Retirees who choose to keep the same plan do not need to fill out an enrollment form Key Points Retirees who want to change plans must… Fill out an OGB enrollment form … or Write a letter to OGB that includes: Your plan choice Your name and address Your date of birth Your daytime phone number Sign form or letter and mail it to ... OGB Eligibility Division P.O. Box 66678 Baton Rouge, LA 70896 ... or visit any OGB Agency Services office Providers? Restrictions? For PPO plan members with Medicare Parts A and B: In-network and out-of-network benefits are the same, except … The inpatient deductible is waived for inpatient stays at network hospitals To access HMO in-network benefits, plan members must use network providers A provider directory for each OGB health plan is * available on the website…www.groupbenefits.org Plan Overview ... Plan Member Out-of-Pocket Expenses Administrator PPO HMO All regions OGB Medical Home HMO ** Regional HMO Nationwide Statewide – PCP must be in Region 9 Regions 6, 7, 8 & 9 Blue Cross Vantage Health Plan Vantage Health Plan Lifetime Maximum per Person Unlimited Deductible $300 retired 3-person maximum None None None Out-of-Pocket Maximum $2,000 per person $1,000 per person $3,000 per family No maximum $1,000 per person $3,000 per family Hospital In-Network 20% of Medicare co-insurance/ deductible * 0% of Medicare co-insurance *** 0% of Medicare co-insurance/deductible 0% of Medicare co-insurance *** Doctor Visits 20% of Medicare co-insurance/ deductible * 0% of Medicare co-insurance *** 0% of Medicare co-insurance/deductible Referrals waived for in-network providers 0% of Medicare co-insurance *** Network Providers No restrictions No restrictions Restrictions apply No restrictions * Subject to plan year deductible and/or applicable co-insurance ** Must use in-network providers *** May be subject to HMO co-payments/co-insurance based on amount paid by Medicare Plan Overview ... Plan Member Out-of-Pocket Expenses Services PPO HMO Medical Home HMO ** Regional HMO MRI/CAT Scans 20% of Medicare co-insurance/ deductible * 0% of Medicare co-insurance *** 0% of Medicare co-insurance 0% of Medicare co-insurance *** Sonograms 20% of Medicare co-insurance/ deductible * 0% of Medicare co-insurance *** 0% of Medicare co-insurance 0% of Medicare co-insurance *** Chemotherapy Radiation Therapy 20% of Medicare co-insurance/ deductible * 0% of Medicare co-insurance *** 0% of Medicare co-insurance 0% of Medicare co-insurance *** Routine PSAs 0% of Medicare co-insurance 0% of Medicare co-insurance 0% of Medicare co-insurance 0% of Medicare co-insurance *** Cardiac Rehabilitation 20% of Medicare co-insurance/ deductible * 0% of Medicare co-insurance *** Complete within 6 months Home Health Care Non-covered benefit when Medicare is primary 0% of Medicare co-insurance 0% of Medicare co-insurance *** 48 visits per plan year Up to 18 visits per 6-week period 48 visits per plan year Non-covered benefit when Medicare is primary 0% of Medicare co-insurance/ deductible Non-covered benefit when Medicare is primary * Subject to plan year deductible and/or co-insurance ** Must use in-network providers *** May be subject to HMO co-payments/co-insurance based on amount paid by Medicare Plan Overview … Plan Member Out-of-Pocket Expenses Out-of-Network Providers PPO HMO Louisiana resident Same as innetwork plus $50 per day deductible; maximum $250 per admission $1,000 deductible per person; $3,000 family maximum Out-of-state resident Same as in-network Same as Louisiana resident * 30% of reasonable and customary charge * Medical Home HMO Regional HMO Emergencies covered worldwide; all other services require prior plan approval 30% of Vantage allowable and $1,000 deductible * Same as Louisiana resident Same as Louisiana resident * * Plan member may owe deductible, co-payment, co-insurance and balance of billed charges Mental Health & Substance Abuse Treatment Benefit Out-of-Network Providers PPO HMO Medical Home HMO Regional HMO ValueOptions ValueOptions Vantage Health Plan Vantage Health Plan 2 Member pays 20% of contracted rate 1 $100 co-payment; $300 maximum per admission Member pays 0% of Medicare co-insurance/ deductible $100 co-payment; $300 maximum per admission Outpatient Member pays 20% of contracted rate 1 $15 office visit co-payment Member pays 0% of Medicare co-insurance/ deductible 2 $15 office visit co-payment 2 Inpatient 1 2 Subject to plan year deductible and/or co-insurance Pre-authorization required Prescription Drug Benefit PPO and HMO (Administered by Medco and Catalyst Rx) Prescription Drug Benefit In-Network Plan Member Out-ofPocket Expense Generic and brand-name drugs: Plan member pays 50% of cost Maximum $50 per 31-day fill After $1,200 per person per plan year, plan member pays co-pay of $15 for brand-name drug, $0 for generic drug Plan member will be automatically enrolled in OGB Medicare Part D prescription drug plan with wrap-around coverage at no additional cost Formulary Open * Mail Order Same as above Program * OGB’s open formulary means all FDA-approved prescription drugs that are currently covered will continue to be covered in 2012 Prescription Drug Benefit Regional HMO (Administered by VHP’s Catalyst Rx) Prescription Drug Benefit In-Network Plan Member Out-ofPocket Expense Generic drug and brand-name drug with no generic available: Plan member pays 50% of cost Maximum $50 per 30-day fill After $1,200 per person per plan year, plan member pays co-pay of $15 for brand-name drug, $0 for generic drug Brand-name drug with FDA-approved generic available: Plan member pays cost difference between brand-name drug and generic, plus 50% of brand-name drug cost Cost not applied to $1,200 out-of-pocket maximum Formulary Closed with exceptions * 30-day supply – 1 co-pay Mail Order Program 60-day supply – 2 co-pays 90-day supply – 3 co-pays * Prescription drugs not on Vantage’s formulary list may be available at higher out-of-pocket cost Prescription Drug Benefit Medical Home HMO (Administered by VHP’s Catalyst Rx) Prescription Drug Benefit In-Network Per 30-day fill Plan Member Generic drug – $5 co-pay Out-of-Pocket Preferred brand drug – $30 co-pay Expense Non-preferred brand drug – $50 co-pay Specialty drug – 20% co-insurance Formulary Closed with exceptions * Mail Order Program 30-day supply – 1 co-pay 60-day supply – 2 co-pays 90-day supply – 3 co-pays * Prescription drugs not on Vantage’s formulary list may be available at higher out-of-pocket cost Prescription Drug Benefit PPO and HMO Plan Members with Medicare Only Effective January 1, 2012 … OGB will transition to an Employer Group Waiver Plan (EGWP) Medicare Part D prescription drug plan – plus wrap-around coverage for medications not included in the Medicare D plan FDA-approved prescription drugs that are now covered will continue to be covered in 2012 Applies to retirees (and covered spouses) who … Have Medicare Part A and/or Part B coverage; and Are enrolled in OGB’s standard PPO or HMO health plans Prescription Drug Benefit PPO and HMO Plan Members with Medicare Only Effective January 1, 2012 … OGB will enroll you in new Medicare Part D prescription drug plan and wrap-around drug coverage automatically – at no additional cost to you The current retiree drug subsidy (RDS) is being phased out The transition will enable OGB to receive new federal EGWP subsidy for providing Medicare Part D prescription drug coverage to retired OGB plan members with Medicare The EGWP subsidy will help OGB offset rising health care costs … this helps OGB keep premiums as low as possible Prescription Drug Benefit PPO and HMO Plan Members with Medicare Only Before December 1, 2011 … You will receive letters and information by mail (from OGB, Medco and Catalyst Rx) about the effects of the transition – if any – on your OGB prescription drug benefits Be sure to read – and save – this information! Prescription Drug Benefit PPO and HMO Plan Members with Medicare Only Effective January 1, 2012 … No change in plan member prescription co-payment (50% of drug cost to $50 maximum) – for 31-day supply Same $1,200 plan member out-of-pocket maximum; after maximum, co-pay still $15 brand-name drug, $0 generic No change in retail pharmacy network Drug formulary remains open Continued coverage for FDA-approved prescription drugs now covered by Catalyst Rx Coverage for some drugs previously not covered Prescription Drug Benefit PPO and HMO Plan Members with Medicare Only Effective January 1, 2012 … Fill limits increased to 31/62/93 days (now 30/60/90 days) Can buy 93-day fill at retail pharmacy – no 31-day wait Quantity limits may vary Prescriptions that now require prior authorization may require re-authorization – no transfers (required by CMS) Can continue to get free testing supplies by mail or at any network pharmacy when you fill diabetes prescription (insulin or oral medication) Prescription Drug Benefit PPO and HMO Plan Members with Medicare Only Effective January 1, 2012 … If your annual income is less than … $16,335 as an individual, or $22,065 for a family of 2 … you may qualify for a Medicare subsidy that reduces your co-payment This means your out-of-pocket expenses for prescription drugs may be lower Prescription Drug Benefit PPO and HMO Plan Members with Medicare Only Effective January 1, 2012 … You will have 2 separate ID cards … You will receive a new ID card from Medco for each plan member with Medicare – for prescription benefits for that person only Medco (in partnership with Catalyst Rx) will administer your Medicare Part D prescription drug coverage and wrap-around coverage You will continue to use your health plan ID card – for all other medical benefits for all plan members with Medicare If you change health plans during Annual Enrollment, you will receive a new OGB health plan ID card If you do not change health plans during Annual Enrollment, you will continue to use your current OGB health plan ID card IMPORTANT Reminder # 1 PPO and HMO Plan Members with Medicare Only The information you receive by mail (from OGB, Medco and Catalyst Rx) before December 1 will … Include more details about OGB’s EGWP Medicare Part D prescription drug plan and wrap-around coverage Offer you a chance to “opt out” of OGB’s Medicare Part D drug coverage – as required by CMS (the federal Centers for Medicare and Medicaid Services) – but OGB strongly recommends that you DO NOT OPT OUT! If you opt out of OGB’s Medicare Part D coverage, you also opt out of ALL of your OGB health and prescription drug coverage -- FOREVER! IMPORTANT Reminder # 2 PPO and HMO Plan Members with Medicare Only After you are automatically enrolled in OGB’s Medicare Part D prescription plan, DO NOT purchase or enroll in … An individual Medicare Advantage plan A group Medicare Advantage plan not sponsored by OGB Another Medicare Part D plan for drug coverage only because … IMPORTANT Reminder # 2 (continued) PPO and HMO Plan Members with Medicare Only Each person can be enrolled in only ONE Medicare-type plan Signing up for ANY individual Medicare-type plan cancels your current OGB coverage – and could leave you without OGB health and prescription coverage! If a husband and wife currently have dual coverage, each must now choose ONE plan based on his or her own health situation Retiree 100 – PPO Plan Members Optional coverage available to retired plan members who have Medicare Part A and Part B as primary health coverage May provide higher reimbursements for eligible medical expenses after deductibles are met Considers total charges billed by eligible provider, not just balance due after Medicare has paid Additional premium – $39 per person per month Sources of Information OGB Website – www.groupbenefits.org Plan Comparison & Premium Rates Annual Enrollment Materials Agency Human Resources Office OGB Agency Services Offices Your Health: Our Priority The OGB website… www.groupbenefits.org ….offers links to a current provider directory for each health plan — accessible any time Go to the OGB home page Click on the Health Plans link to access a searchable list of network providers (and other information) for each OGB health plan Life Insurance Life Insurance Prudential Insurance Co. of America Group term life insurance plan State pays half of premium for employees and retirees Employee pays full premium for dependent life insurance 25% reduction in coverage and appropriate reduction in premiums on July 1 after plan member reaches age 65 and age 70 Life Insurance Basic Plan Option I Option II Employee $5,000 $5,000 Spouse $1,000 $2,000 Each Child $ 500 $1,000 Employee Schedule in Premiums Helpful Information Book Premiums for Dependent Life Employee Pays $0.88/mo $1.76/mo Life Insurance Basic Plus Supplemental Plan Option I Option II Employee Schedule to maximum of $50,000 (amount based on employee’s annual salary) Same Same Spouse $2,000 $4,000 Each Child $1,000 $2,000 Employee Premiums Schedule in Helpful Information Book Premiums for Dependent Life Employee Pays $1.76/mo $3.52/mo Life Insurance Accidental Death and Dismemberment (AD&D) benefits available to all active and retired employee covered under Basic or Basic Plus plan Retirees over age 70 not eligible for AD&D ALL inquiries and changes in life insurance must be made through your agency’s HR department Sources of Information OGB website with links to all OGB health plans….. www.groupbenefits.org OGB (PPO)…..1-800-272-8451 Blue Cross and Blue Shield of LA (HMO)…..1-800-392-4089 Vantage Health Plan (Medical Home & Regional HMO)…..1-888-823-1910 Medco…..1-866-808-5271 (or 1-800-716-3231 TTY/TDD) * effective 12-1-11 * Catalyst Rx…..1-866-358-9530 ValueOptions…..1-866-492-7143 Questions?