Union College Health Care Assistance Plan National Blue Card Network September 6, 2005 - PowerPoint PPT Presentation

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Union College Health Care Assistance Plan National Blue Card Network September 6, 2005 PowerPoint Presentation
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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

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  1. Union College Health Care Assistance PlanNational Blue Card NetworkSeptember 6, 2005 Ellen Eldridge Director, Health Care Services Adventist Risk Management

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. Claims PaymentExplanation of Benefits Accumulators Deductible $150 Co-Insurance $ 0

  9. Claims PaymentExplanation of Benefits Accumulators Deductible $150 100 Co-Insurance $ 0 25

  10. Claims PaymentExplanation of Benefits Accumulators Deductible $150 100 0 Co-Insurance $ 0 25 300

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. Union College Health Care CostsBenefit Year 2004-2005

  22. North American Division Health Care CostsBenefit Year 2004-2005

  23. 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%

  24. Union CollegeBlue Cross Discounts Blue Cross Discounts in Nebraska In-Patient 34-49% Out-Patient 21-26% Professional 29-34%

  25. 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%

  26. 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

  27. References • Provider look-up • www.ibx.com • Provider search • ARM’s Customer Care Service • (888) 276-4732 • (888) ARM-4SDA

  28. Questions – Concerns for Ellen

  29. Questions – Concerns for Ellen

  30. Questions – Concerns for Ellen