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How to Use Your CVUSD Health Benefits Effectively. Why the presentation?. Education A better understanding of our system A better understanding of the funding Empower you to be a better health care consumer We are in NO WAY are telling to avoid the doctor
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Why the presentation? • Education • A better understanding of our system • A better understanding of the funding • Empower you to be a better health care consumer • We are in NO WAY are telling to avoid the doctor • Trying to be smarter about usage of benefits
Funding • CVUSD collects contributions from members and pays out of the general fund into the health benefits fund • This year it is $14,273 per employee in PPO. 963 employees enrolled in PPO. • Anthem Blue Cross HMO for singles $5,871; $12,045 for double; $17,908 for families. 231 HMO employees enrolled. • CVUSD pays Kaiser an amount per employee for their coverage. • We negotiate each year with Kaiser for the amount charged. • Singles- $5,346; $10,692 double; $15,129 for families • 315 employees enrolled • CVUSD pays Blue Cross to “rent” their insurance pool. • The money in the CVUSD health benefits fund pays for PPO claims that are processed through Anthem Blue Cross. • EACH time you go to the doc or have something done, CVUSD gets a bill from Blue Cross for the agreed-upon amount. • It is paid out of CVUSD’s Health Fund • If any claims go above $260,000 we have an insurance plan called “Stop/Loss” that covers all medical costs in excess of that amount. • Approximately $78K per month
In short • Total costs dropped, but on the rise • Employee contributions helped flatten the trend out • Fewer employees • As the budget decreases health care becomes a larger share. • Costs per employee up and costs TO employee up • Premium increases • More usage • Doc fee increases • Plan modifications
How to read your plan description • In-Network • These are doctors/facilities that have negotiated with Anthem and have agreed to accept their reimbursement rate. • Anthem pays for 80% of the bill (after the deductible) and you pay 20% -Once you reach $2,000 per person or $4,000 for a family, Anthem (the district’s health fund) pays the rest. DO NOT ASK “Do you take Anthem?” ASK “Are you In-Network for Anthem?” • Out-of-Network • These doctors HAVE NOT agreed to be in Anthem’s system. • Anthem only pays for 40% of the bill (after the deductible) - • YOU PAY 60% up to $8,000
What is a deductible? • This is the amount of money you pay before Anthem starts paying the bill. • There is an individual amount AND a family amount. • Individual amount is $500 • Each person covered in your plan has to pay up to this amount • UNLESS you hit the family maximum of $1,250 • After you paid the entire amount of the deductible Anthem starts to pay 80% of the medical bills you incur. • You pay 20% of everything up to $2,000 per individual; $4,000 for a family. Once you have paid the amount, the coverage is 100%. These are ANNUAL maximum out-of-pocket costs, starts back to ZERO on January 1. • VERY IMPORTANT • The out-of-network deductible is HIGHER and NOT part of the in-network deductible- they are separate • Individual is $1,000 • Family $3,000 • MAX OOP $8,000
Preventative Care • Affordable Care Act (aka “Health Care Reform” or “Obamacare”) • Should not cost you anything out-of-pocket (IN-NETWORK ONLY) • No more co-pays for preventive check ups • Cost of appointment to plan not applied to deductible • The key is to set the appointment the correct way. • When you set the appointment make sure you ask for a “preventive care” screening. • Once in the appointment, do not ask for a diagnosis of another issue or ask for a prescription, or Rx renewal. • Adding a diagnosis and/or prescription makes it a diagnostic appointment and then no longer qualifies as preventive screening. • The doctor may make a diagnosis or give a prescription as a result of the screening, but that should be his/her decision, not your request. • Remind your doc that lab coding must be for preventative care – not with a diagnosis code.
Who pays for preventative care? • You don’t pay anything, intent is to encourage you to go to the doc for the check-up • Intent to save money over the long-term because issues will be caught early • District (health plan) DOES pay the full amount.
Prescriptions- same for in and out-of-network • Going to the pharmacy • 30 Day Supply • $15 for generic • $30 for brand name • Mail Order • 90 Day Supply • $30 generic • $60 brand
What would be the best plan for me to do a surgery? • You need to do the research: • Where is the best place to do it? • IS IT IN-NETWORK? • Who is the best person to do it? • IS HE/SHE IN-NETWORK? • Be sure both doctor and facility are in-network • Would a HMO cover the surgery? • How much is the deductible? • Do your research on Anthem webpage • www.anthem.com
Additional programs to help • Anthem 360 • Not a scam • Disease management for high risk issues • Diabetes, coronary artery disease, asthma, etc. • Future Moms (Anthem) • Must call in • Nurse help • Nurseline (Anthem) • 800-337-4770 • Kaiser: Kaiser after-hours advice: 1-888-576-6225 • Conejo Cares (everybody) • Mix It Up • Thrive Across America • Waverly Wellness • Know Your Numbers • Costs $20 • if you have it done at Los Robles it can be as high as $600 • Health Risk Assessments • Classes
Emergency Room Visits • 213 total last year • $429,714 in total claims • $1,471 per visit average • Of the 213 visits, only 2 were admitted to the hospital
What’s the difference?! • Approximate emergency room costs (national avg. ER visit $1,349): • To YOU: • $100 Co-Pay • 20%- $249.80 • To the PLAN (the district) • 80% of remaining- $997 • Approximate cost of urgent care visit ($100 national avg.) • To YOU: • Co-pay- $20 • 20%- $16 • To the PLAN: • 80% of remaining- $64
If you are having an emergency- go to the ER • Urgent care is for ear infections, sometimes stitches, tummy aches, sore throats, etc. If you’re having chest pain GO TO THE ER!
If you do have an emergency • If you get checked into a non-network hospital • Anthem will pay as if you are in-network UNTIL YOU ARE STABILIZED • Once you are stabilized, you begin to pay out-of-network rates • Get to an in-network hospital ASAP
Parting thoughts • Eat right • Exercise • REST • Do preventive appointments • Better to catch things early • “I save the plan money because I never go to the doctor”- DOESN’T SAVE MONEY • Go to the dentist • Get an annual eye exam • Encourage each other for better health • Participate in the programs that have been created like Conejo Cares Wellness Plan. • ASK QUESTIONS