Why are we here today?. JUNE is OPEN ENROLLMENT for all benefits: HEALTH DENTAL VISION LONG TERM DISABILITY SHORT TERM DISABILITY OPTIONAL LIFE OPTIONAL LONG-TERM DISABILITY
April 1, 2014 or before and qualify for benefits.
You do not have to do anything. You will automatically be enrolled onto the benefits you currently have. You will receive a new card from HR after July 1st.
The only reason to act is to make changes to your current benefits. You can do this by visiting yourebl.com and clicking on “Get Application” to pull up your original application to make changes.
Your application and all health, dental, and vision information will be available on the Internet.
Simply search for yourebl.com –access your company on the right hand side of the page - and you will have everything you need.
WellVision Exam, Lenses, Frames, or Contacts
EVERY 12 MONTHS
Paid at R & C 90th percentile.
You may have more OOP
(12 month waiting period for those signing up at Open Enrollment, not new employees)
Individual $50 $75
Family $150 $225
$1,000 / Individual
Short-term disability insurance can help replace a portion of your income during the initial weeks of a disability to help you pay your bills and help maintain your current lifestyle.
Choose any weekly benefit amount in increments of $50 per week, subject to a minimum of $100. The maximum benefit amount is 60% of your gross weekly earnings or $1,000, whichever is less.
If you apply for : $100,000
Your Spouse can apply for: $50,000
Changes can be made on the online enrollment form at yourebl.com
$20 Brand no generic
$40 Brand with generic ava
50% Designer Drug
0% on any med covered in the OTC program
Some medications under this program are classified as “non-preferred”. This means there are alternative medications which are therapeutically equivalent. If your physician writes for a medication that is part of our “non-preferred” list you may want to discuss alternative medications which are just as effective.
THE NON-PREFERRED LIST IS AT YOUREBL.COM
If you are currently taking an anti-ulcer or allergy medication talk to your physician about using an OTC drug.
OTC drugs that are a $0 co-pay are:
Prevacid OTC Benadryl
Prilosec 20mg Claritin / Alavert
Zegerid OTC Zyrtec-D
If your physician writes a prescription, then you get these medications for free!
New this year, due to the new healthcare law, you will have a Maximum Out-of-Pocket (OOP) of $2,700 (single and family) for all drugs classified as “essential health benefits”.
This OOP will accumulate through your $10/$20/$40 co-pay amounts on specific drugs. The list is available at yourebl.com or by calling EHIM.
Having an OOP for pharmacy AND health ensures you will not have a total OOP that exceeds the lawful limit for covered services.
Each year you can have one of the following services at no cost to you.
Health maintenance exam including chest x-ray, EKG, cholesterol screening and other select lab procedures.
Routine Gynecological exam including lab and test fees.
Well-baby and child care exams and immunizations.
Fecal occult blood screening. Prostate exam. Colonoscopy.
Routine mammogram. Routine digital rectal exam.
Routine Immunizations (including flu shot). Women’s Services.
A PPO is a “network” of physicians and hospitals who contract with a vendor for a percentage off the providers billed price.
As a “self insured” employer, we can then contract with a network to have access to their doctors. We depend on the Network to negotiate with their physicians and hospitals for the best possible prices and are required to pay whatever the Networks contract with these providers. Your employer has no input or negotiating power with any providers.
Remember, the employer is required to pay whatever the network tells them to, in other words, the employer has no control over what the doctor bills or what the network tells them to pay. The contract the network has with providers is a percent off of billed price. The employer is never allowed to see the contract the network has with its providers nor are the providers required to be reasonable with what they bill.
How much do you think a hospital should bill for a MRI of one knee?
Last year, for the same exact test and code, our plans were billed a range of:
$115 - $10,600
This is the “billed” price over which there is no rule or regulation. Now, the doctor sends this bill to the network and they then “re-price” that bill according to their secret contract with that doctor. So, what did the network tell your employer plan to pay?
$72.19 - $5,019.48
Well, it just does not make sense for your employer to have NO CONTROL over the billed price or the price they have to pay.
What if – you needed a gallon of milk. Your local store has a deal where you can pick a coupon out of a box worth between 10% and 99% off the price of milk. Once at the store you find out they are charging $100.00 for the milk but you are going to try to pull that 99% off coupon out of the box. Only one catch, whatever you pull out of the box, you have to use toward the purchase of the milk, you cannot leave the store without purchasing the milk.
This means you are stuck paying anywhere from $90 to $1, you won’t know until you pull that coupon.
So, there must be another way. . . . . . . .
Many employers have dropped their PPO Network for something called
Medicare Referenced-Based pricing
This concept is easy. Almost all services you receive have a Medicare amount (or price) assigned to them by the Government.
The Government sets the Medicare rate based on what services actually cost.
Your employers new plan will pay your doctors and hospitals their Medicare rate plus 40 percent.
So, if the Medicare rate for an MRI of the knee is $240, your employer would pay your doctor $336.
While MOST services do - not all services have a Medicare rate. For instance, services at a Children’s hospital do not have Medicare rates.
But, ALL services DO have a Medicare equivalent/related rate which is what we will use in this instance.
You have a self-insured employer plan that utilizes:
“Medicare reference-based pricing”
You do not have Medicare or a Medicare plan.
Your plan simply uses Medicare published rates as a starting point to make payment to the providers.
Yes they can, but. . . .
All providers will know ahead of time how your plan works because. . .
You will present all of your providers with your new card which clearly states what and how they will be reimbursed.
This information will also be on each Explanation of Benefits and the check they receive for their services.
The information on your new card will tell the provider,
“This Plan does not utilize a PPO Network. As such all medical service providers are reimbursed per the terms of the Plan Document, up to the Maximum Payable Amount. Payment is based on Medicare PLUS 40%. Prior to treatment, confirm the provider accepts this as payment in full.”
You must present your card to your provider so there is no misrepresentation regarding how your plan will pay for your services.
A bill at home is called “balance billing”. Meaning your provider wants to be reimbursed over the reasonable/agreed upon amount your employer has paid on your behalf.
Your employer has contracted with a Patient Advocate for YOU for just this instance. You will have a toll-free number directly to a person who will contact the provider on your behalf. Anytime the Patient Advocate communicates with your provider you will receive a copy of the communication so you are completely aware of the entire process.
I will be handing out a Member Packet from the Patient Advocate here today for you to keep. I would suggest that EVERYONE here contact them as soon as possible because one of their responsibilities is to contact your provider for you before July 1st to ensure they will accept your new plan. But they need to hear from you first.
This information will also always be available on yourebl.com under your employer name.
If you get a bill at home it is your responsibility to call your Advocate and let them work for you.
You are the ONLY one who will get the bill from your provider and you are the ONLY one who can ask for the Advocate help.
You will have a co-pay only if you need services at specific locations.
Any covered service in your physician office (including lab and x-ray) $0
Urgent Care $50
Outpatient Hospital (surgery, MRI, CT Scan) $250
Ambulatory Surgical Center $250
Birthing Center $250
Emergency Room $300
Home Health Care $250
Hospice $250 OP/$1,000 IP
Inpatient Rehabilitation Facility (Ortho, Cardiac) $1,000
Outpatient Rehabilitation (Speech, Occupational, Physical) $250
Inpatient Hospital $1,000
Ambulance (ground only) $500
*These co-pays are per occurrence so each time you go to Urgent Care you will be responsible for $50. If you are admitted to the hospital as an inpatient you will be responsible for $1,000 for that entire stay.
*services must be covered benefits.
Part of the Affordable Care Act law dictates what limits you can be charged as out-of-pocket expenses. Your employer has chosen to keep these out-of-pocket amounts well below what the law allows.
The out-of-pocket is as follows:
The TOTAL out-of-pocket for a family is $10,000. But remember, because each person accumulates individually an employee who insures themselves, their spouse and two children will max out at $9,000. If it is just you and your spouse, you max out at $5,000.
You accumulate this TOTAL through the co-pays only if you need special services – from previous slide.
Each person will accumulate their own out-of-pocket up to this amount
Mental health is EXCLUDED from your plan.
Your employer plan is secondary to your auto insurance. Meaning, you need to call your auto carrier and tell them they are primary for your health care in case of injury in an auto accident.
It is against the law to operate a vehicle without insurance. If you are injured in an auto accident and are not carrying auto insurance you will have no coverage.
All DME including diabetic supplies:
Syringes, needles, alcohol swabs, gauze, test strips, lancets, tubing and pumps will be covered at 100% up to a plan maximum of $2,000 per year.
July 1, 2014
In order to begin benefits on July 1st
June 2015 for the effective date of
July 1, 2015
There are a few exceptions to this rule. If you have what you think is a qualifying event such as divorce, birth or adoption of a child, marriage – please see your HR rep. These changes must be made within 30 days of the event.