Union college health care assistance plan national blue card network september 6 2005
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Union College Health Care Assistance Plan National Blue Card Network September 6, 2005 Ellen Eldridge Director, Health Care Services Adventist Risk Management Health Care Assistance Plan Payment Limits Lifetime Plan Limit Medical in total - $3,000,000 Infertility Treatment - $16,000

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Union College Health Care Assistance PlanNational Blue Card NetworkSeptember 6, 2005

Ellen Eldridge

Director, Health Care Services

Adventist Risk Management


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Health Care Assistance PlanPayment Limits

  • Lifetime Plan Limit

    • Medical in total - $3,000,000

    • Infertility Treatment - $16,000

    • Refractive Eye Surgery - $2,400

    • Orthodontic Care - $2,300

  • Plan Year Payment Limits

    • Hearing - $3,200

    • Durable Medical Equipment - $8,000

    • Vision - $560

    • Dental - $1,800 Individual; $3,680 Family


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Health Care Assistance PlanMember Responsibility

  • Co-pay each Office Visit - $15

  • Deductible - $250 single / $500 family

  • Out-of-Pocket (OOP)

    • Also known as Co-Insurance

    • In-Network – 20%; $2000 single / $4000 family

    • Out-of-Network – 35%; $4500 / $7000 family


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Health Care Assistance PlanMember Responsibility

  • Prescription Benefit

    • Retail

      • 30-day supply

      • $10 generic/$16 brand/$20 non-formulary

    • Mail Order

      • 90-day supply

      • $10 generic/$20 brand/$30 non-formulary

    • Out-of-Pocket Maximum - $400 / $800


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Health Care Assistance PlanMember Responsibility

  • $15 Co-pay Office Visit

    Urgent Care Centers

    Mental Health Out-Patient Services

    • Professional Services Only (doctor’s fee)

    • Plan pays 100% of office visit after co-pay

    • Does not apply to deductible or OOP

    • All other charges apply to deductible and OOP

    • Plan pays 80% of these additional charges


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Health Care Assistance PlanMember Responsibility

  • Emergency Room

    • Applies to OOP

    • Does not apply to Deductible

    • Paid at 80%

    • $50 Co-pay/Deductible – waived if admitted

  • Therapies PT, OT, Speech,

    Chiropractic, Acupuncture

    • Plan year visit limits apply

    • Paid at 80%

    • Do not apply toward Deductible or OOP


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Health Care Assistance PlanMember Responsibility

  • Paid at 80%; Applies to Deductible and OOP

    • Out-Patient Services

    • In-Patient / Out-Patient Hospital Stays

      • Medical

      • Mental Health

      • Substance Abuse

    • Office / Ambulatory Surgical Procedures

    • Ambulance Services


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Claims PaymentExplanation of Benefits

Accumulators

Deductible

$150

Co-Insurance

$ 0


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Claims PaymentExplanation of Benefits

Accumulators

Deductible

$150

100

Co-Insurance

$ 0

25


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Claims PaymentExplanation of Benefits

Accumulators

Deductible

$150

100

0

Co-Insurance

$ 0

25

300


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Blue Card PPO Network

  • More than 650,000 providers nationwide

  • More than 5,500 hospitals nationwide

  • Medical claims processed by IBC

    • 99.5 % Claim adjudication accuracy

    • 93.0% Home plan claims – 10-day TAT

    • 98.0% Host plan claims – 30-day TAT


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Negotiation Process

  • Contract is between ARM and Independence Blue Cross in Philadelphia

    • Downstream contract between ARM and Client

  • ARM negotiatied the PEPM Fee for all NAD participating employers

    • Continues to use our large group advantages


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Negotiation Process

  • ARM remains Customer Service

    • Access to Blue Cross system for customer service

    • Single point of contact

    • Continuation of historical knowledge

  • NAD Health Care Plan design stays intact

  • Medco Health remains our Prescription Benefits Manager


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Blue Card PPO Network

  • Home Plan

    • Independence Blue Cross

      Philadelphia, Pennsylvania

  • Host or Local Plan

    • Any Blue Cross Network outside Home Plan where services are rendered


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Blue Cross Claims Flow

OOA Provider►Local Plan►Home Plan

►Local Plan►OOA Provider

  • Includes the following services

    • Transplant network

    • Utilization and case management coordinated in 50 states

    • Out of the country coverage based on medical necessity

    • Wellness Incentive Program


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Overview

  • NAD Plan - medical benefits remain intact

  • ARM continues to manage the Plan

    • Consults with and recommends to NAD

    • no changes in organizational management

  • Access to Blue Cross providers nation-wide

  • Single network / Single payor

  • Simplifies PPO management

  • Reduces claims payment staffing needs

  • Potential savings to NAD-wide medical expenses by $15M - $18M

  • Wellness Incentive program at no cost


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Benefits at a Glance

  • No benefit changes as a result of Blue Card

    • All benefits remain the same

    • Medical claims are paperless, nationwide when in-network

  • ARM continues to pay dental and vision

  • ARM continues to manage prescription plan

  • No change in coordination or management

  • ARM remains Customer Care service


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Benefits at a Glance

Medical Services carved out of Blue Card NOT excluded benefits

WILL BE reimbursed by ARM

  • Massage Therapy

    Access BC therapist for significant discount

  • Adult Immunizations - for travel or work

    NAD Plan policy limits apply

    Mail claims to PO Box 4759 Silver Spring MD


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Value Added Benefits

  • Childhood Immunizations

    • $15 office visit co-pay

    • Balance paid at 100%

    • Does not go to Deductible or OOP

  • Mammography, pap screening

    • $15 office visit co-pay

    • Balance paid at 100%

    • Does not go to Deductible or OOP

  • Therapies i.e. PT, OT, Speech

    • Apply to Deductible and to OOP


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Value Added Benefits

  • Healthy Lifestyles Incentive Programs

    • Fitness Program – Up to $150 reimbursement

    • Weight Management - Up to $200 reimbursement for cost of Weight Watchers

    • Safety Program - Up to $25 reimbursement of certificate for CPR or first aid course

    • Adds no costs to employee or conference


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Union College Health Care CostsBenefit Year 2004-2005


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North American Division Health Care CostsBenefit Year 2004-2005


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Union College2004-2005 Medical Expenses

  • Benefit Year 2004-2005

    • Allowable Charges $1,290,671

    • PPO Discounts 288,019

    • Member Responsibility 156,378

    • Net Paid by Employer 846,274

    • Effective PPO Discount 22.3%


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Union CollegeBlue Cross Discounts

Blue Cross Discounts in Nebraska

In-Patient 34-49%

Out-Patient 21-26%

Professional 29-34%


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Union CollegeMedical Expense Retrospect

  • Benefit Year 2004-2005

    -- If it had been under Blue Card

    • Allowable Charges $1,290,671

    • PPO Discounts 393,655

    • Member Responsibility 134,552

    • Net Paid by Employer 762,464

    • Effective PPO Discount 30.5%


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Union College Medical Expense Net Affect

  • Benefit Year 2004-2005

    -- Summary Net Affect

    • Additional Savings $105,636

    • Net Employer Savings 83,810

    • Net Member Savings 8,062


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References

  • Provider look-up

    • www.ibx.com

      • Provider search

  • ARM’s Customer Care Service

    • (888) 276-4732

    • (888) ARM-4SDA





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