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How to Use Your CVUSD Health Benefits Effectively - PowerPoint PPT Presentation

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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
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


  • 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
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
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
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.
    • 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
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
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
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
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?
    • Who is the best person to do it?
  • 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
additional programs to help
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
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
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
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


if you do have an emergency
If you do have an emergency
  • If you get checked into a non-network hospital
    • Anthem will pay as if you are in-network


  • Once you are stabilized, you begin to pay out-of-network rates
  • Get to an in-network hospital ASAP
top 5 chronic conditions hmo
Top 5 chronic conditions HMO
  • Cancer
  • Depression
  • Asthma
  • CAD
  • Hyperlipidemia
kaiser changes last year to this year
Kaiser Changes last year to this year
  • Inpatient Costs- UP 250%
  • Outpatient Costs- DOWN 29%
  • Pharmacy- DOWN 15%
  • “Other”- UP 62%
kaiser inpatient analysis
Kaiser Inpatient Analysis
  • Medical- UP 625%
  • Surgical- DOWN 50%
  • Maternity- UP 132%
  • Mental Health- UP 801%
    • PPO is up 21% total
    • HMO is up 32% total
parting thoughts
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.