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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

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Why are we here today

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

  • This is your opportunity to change your current benefits, add additional benefits or join for the first time if you have been employed since

    April 1, 2014 or before and qualify for benefits.

  • Benefits will be effective July1st

  • Your employer may offer some benefits (such as LTD and life) to you at no cost. Please see your HR representative to be sure what benefits you may or may not be eligible for.


  • What if i have benefits now and i do not want to make any changes

    What if I have benefits now and I do not want to make any changes?

    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.


    What if i want to join for the first time

    What if I want to join for the first time?

    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.


    Vision

    Vision

    WellVision Exam, Lenses, Frames, or Contacts

    EVERY 12 MONTHS


    Metlife dental

    MetLife Dental

    In-NetworkOut-of-Network

    Paid at R & C 90th percentile.

    You may have more OOP

    • Type A – Preventative 100% 100%

    • Type B – Basic 80% 80%

    • Type C – Major 50% 50%

      (12 month waiting period for those signing up at Open Enrollment, not new employees)

    • Calendar Year Deductible

      Individual $50 $75

      Family $150 $225

    • Maximum benefit

      $1,000 / Individual


    Metlife s hort t erm d isability

    MetLifeShort-Term Disability

    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.


    Metlife optional life

    MetLife OPTIONAL Life

    • This benefit is above and beyond what the employer provides for all full-time staff as a life benefit. You may also enroll your spouse and dependents in your Optional Life benefits.

    • To find out what you are receiving as a full-time staff member please see your HR representative.

    • In order to receive this benefit you must fill out BOTH the Application and Statement of Health.


    Metlife optional life benefits

    MetLife Optional Life Benefits

    • This is Life Insurance that is above and beyond what your employer provides for you, and enables you to enroll your family in optional life benefits.

    • Employees are eligible for benefits in $10,000 increments up to $500,000 (not to exceed 5x your salary, whichever is less). So someone making $15/hr would be eligible for $150,000.

    • $15/hr x 2080 (full time hours in a year) x 5 = $156,000

    • This benefit is not guaranteed. Therefore, you must qualify for this benefit by completing a Statement of Health.

    • Spouses are eligible for amounts that do not exceed 50% of the your Optional life amount. Spouses MUST fill out a SEPARATE Statement of Health Form to be submitted with your application.

      If you apply for : $100,000

      Your Spouse can apply for: $50,000

    • Dependents are eligible for 10% of your Optional life amount, with a MAX of $10,000 per dependent.

      Changes can be made on the online enrollment form at yourebl.com


    Pharmacy

    Pharmacy


    Rx a benefit only with health coverage

    Rxa benefit only with health coverage

    Low co-pay

    $10 Generic

    $20 Brand no generic

    $40 Brand with generic ava

    or DAW

    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


    Rx 0 co pay on otc

    Rx $0 Co-pay on OTC

    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:

    Axid Allegra

    Pepcid Allegra-D

    Prevacid OTC Benadryl

    Prilosec 20mg Claritin / Alavert

    Tagamet Claritin-D/Alavert-D

    Zantac Zyrtec

    Zegerid OTC Zyrtec-D

    If your physician writes a prescription, then you get these medications for free!


    Pharmacy out of pocket max

    Pharmacy Out-Of-Pocket Max

    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.


    Preventative care

    Preventative care

    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.


    How does a ppo network work

    How does aPPO “network” work?

    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.


    So how does a ppo network work in real life

    So, how does a PPO network work in real life?

    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?


    Mri of one knee

    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


    Why are we here today

    So?

    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. . . . . . . .


    There is another way

    There is 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.


    Medicare referenced based pricing

    Medicare Referenced-Based pricing

    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.


    Do all services have a medicare rate

    Do all services have a Medicare rate?

    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.


    So what is my plan called

    So what is my plan called?

    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.


    Why are we here today

    Can the provider bill me for the difference between what they ask for and what the employer pays them?

    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.


    Your new card

    Your new card

    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.


    So what happens if i get a bill at home

    So, what happens if I get a bill at home?

    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.


    Please remember

    Please remember. . .

    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.


    What will your out of pocket amounts be this year

    What will your out-of-pocket amounts be this year?

    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.


    What will my total out of pocket amount be for the plan year until june 30 2015

    What will my total Out-Of-Pocket amount be for the plan year (until June 30, 2015)?

    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:

    Employee $2,000

    Spouse $3,000

    Child $2,000

    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


    Exclusions and special issues

    Exclusions and special issues

    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.


    Why are we here today

    DME

    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.


    How will i know what was paid on my behalf and if i owe anything

    How will I know what was paid on my behalf and if I owe anything?

    • You will receive an EOB (explanation of benefits) from the plan at your home. It will state how much the plan has paid and how much, if any, you owe the provider.

    • Keep all of these documents for your records.

    • The provider will receive the same EOB and expect payment from you for any expense you may owe.


    Alert

    ALERT

    • It is of the utmost importance that you keep your address current with Employee Benefit Logistics so that you receive your information on time


    When does your new benefit year begin

    When does your new benefit year begin?

    July 1, 2014


    It s up to you

    IT’S UP TO YOU!

    • If you want benefit coverage or coverage changes you must complete the on-line application, or update your previous on-line application. Visit:

      yourebl.com

    • After you complete the on-line application you must go to your human resource office where the application will be printed out and you will go over all the benefits you have chosen and sign the application. Only after you have signed your application is it considered a valid submission and request for benefits.


    Important

    IMPORTANT!

    • You must enroll online at yourebl.com and sign for all benefits with your HR representative BEFORE

      June 30th

      In order to begin benefits on July 1st

    • Any applications that are incomplete or received AFTER June 30th will NOT be accepted.

    • Please be sure each application is filled out completely, legibly, and signed & datedbefore submission.


    Change your mind after july 1

    Change your mind after July 1?

    • You will not be able to make any plan changes to your benefits until the next open enrollment period which is

      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.


    Questions

    ?Questions?

    • I will not be taking questions here.

    • Questions regarding specific Plan coverage or benefits should be directed to the Plan at 877-480-7442.

    • Questions regarding specific payroll deductions or coverage should be directed to HR.

    • The details of the plans are on yourebl.com. Please refer to the website.


    It is time to act

    IT IS TIME TO ACT

    • If you wish to sign up or make changes to your benefits please visit

      yourebl.com today.

    • Your HR rep has the amount each of the benefits cost per pay.


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