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Introduction to Benefits. Sapa Precision Tubing Rockledge. Agenda. Overview of How Insurance Works Common Definitions Covered Services In-Network vs. Out-of-Network Billing & Payments h ow to resolve questions Open Enrollment. $3,000 Deductible 10% Coinsurance
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Introduction to Benefits Sapa Precision Tubing Rockledge
Agenda Overview of How Insurance Works Common Definitions Covered Services In-Network vs. Out-of-Network Billing & Payments how to resolve questions Open Enrollment
$3,000 Deductible 10% Coinsurance $7,000 Out-of-Pocket Max $1,125 HRA Funds Imagine you have a $100,000 heart surgery…
$3,000 What is my deductible? Your deductible is $3,000. This is the amount you must pay each year before the insurance plan starts to pay. The only exception to this is Preventative Services. So with a $100,000 heart surgery bill, you are responsible for payiing the first $3,000.
$3,000 Deductible HRA 50% What about my HRA? You can use your HRA to cover part of the deductible. You can also choose to pay this out of pocket and continue saving the money in your HRA for future expenses. Each year your balance will roll over to the next year.
$3,000 90% 10% What Coinsurance? Coinsurance is a cost-sharing requirement. You are responsible to pay for 10% and the insurance company pays 90% after your deductible is met.
$7,000 $3,000 0% 100% The Out-of-Pocket limit is the maximum amount you will pay for covered medical expenses in a given year. After you pay $7,000, the plan pays 100% for everything.
Health Insurance Covered Services • Preventative Care • Immunizations • Primary Care Doctor & Specialist Visits • Diagnostic Tests • Prescription Drugs • Surgery • Emergency Treatment • Mental Health / Behavioral Health • Substance Abuse • Pregnancy • Rehabilitation • Medical Equipment • Routine Eye Care • Chiropractic Care
Health Insurance Services that are Not Covered • Acupuncture • Cosmetic Surgery • Dental Care • Hearing aids • Infertility Treatments • Long-Term Care
Dental Insurance Covered Services • Cleanings • X-Rays • Fillings / Crowns • Root Canals • Gum Disease • Extractions • Bridges / Dentures / Implants • Braces (Up to age 19)
In-Network vs. out-of-network In-network BCBS negotiates fees and sign agreements with health care providers and facilities that are then considered in network for members. This discount means you pay less for the same service at these in-network facilities. Out-of-network If BCBS do not have an agreement with an insurer, then they are considered out of network. Members who wish to visit an out-of-network provider or facility do not have the advantage of a negotiated lower rate. Because of this, services may be more expensive and may not be covered through the health plan.
Here’s an example In-Network Out-of-network Now let's say you go to a doctor that's out of network. No discount is applied to the total charge of $250. BCBS still pay $140 but you'll be responsible for the remainder, which is $110. Say you go to a doctor that's in network and the total charge is $250. A discount is applied to that amount for our negotiated rate with the doctor. The discount is $75. BCBS pays $140. You'll have to pay the remainder, which is $35. REMEMBER TO ASK Are you In-Network?
Exceptions • Major Procedures & Hospitalizations • Deductible is normally requested prior to the service being provided • Payment arrangements can typically be made • Prescription Drugs • You will always be asked to pay your portion up front.
Who really pays? SAPA IS SELF-INSURED • Sapa pays the full cost of our Medical and Dental expenses. • BCBS processes the claims and administration on our behalf. THESE COSTS DIRECTLY IMPACT OUR PROFITABILITY. • Be a smart consumer • Stay in-network • Utilize a Primary Care Doctor • Do your preventative Screenings • Live Healthy
EOB • Always verify medical bills to an EOB. • Online or Paper Available • Access to this information is is always online
Questions or Issues • Call BCBS or Delta • Let Lisa or I know if you are unable to resolve this issue.
Open Enrollment Open Enrollment is your opportunity to review your benefits and make changes. It happens once a year, typically in November and December Presents the benefits for the following year – effective January 1, 2014 • You can only make changes to your benefits if you experience a Qualified Life Event. This includes: • Marriage or divorce • Death • Birth or adoption • Spouse terminating or beginning employment • Changes must be made within 30 days of the event.
