USD 259 Health

1
USD 259 Health Flex
PlansJanuary December 2010Town Hall
Meetings(For Complete Details Please Refer to
the Summary Plan Description on the Risk
Management website)
2
Program Format

• Introductions
• Enhanced Benefits Changes for 2010
• Frequently Asked Questions Presentation
• General Questions of Interest to All from
  Audience
• 1 on 1 Private Meetings for Individual Health
  Pharmacy Questions
• The slides will be available next week on the
  Risk Management website, http//www.usd259.com/emp
  loyees/riskmanagement

3
BENEFITS ENROLLMENT

• When is benefits open enrollment for the 2010
  Plan Year?
• November 2 -12, 2009.
• How will I enroll?
• Through the eBenefits online enrollment system.
  You must click submit twice in order for your
  election to go through. If go back and check,
  you must again click submit twice.
• Do I need to enroll online?
• Yes, online enrollment is mandatory even for
  those on cash option or you will be defaulted
  to No Coverage. Enrollment instructions are
  available in a handout. Enrollment assistance is
  available in the Risk Management offices, via
  e-mail at riskmanagement_at_usd259.net or by calling
  973-4581. (Retirees, COBRA and LOA are handled
  manually)

4
Health Plan Overview

• Self-funded health plan with monthly premium
  contributions from BOE, employee and spouse
  tobacco users, working spouses with access to
  health insurance and employees whose FTE is lt1.0.
• We have an aggregate health plan that includes
  major medical, pharmacy and dental.
• Administration of health plan by third party
  Coventry Healthcare of Kansas Dental Plan by
  Delta Dental of Kansas and Flex Plan by ASI.
• Third party administrator duties are payment of
  claims, pre-authorizations, network discount
  negotiations, management of pharmacy program,
  disease management.
• Health plan design and coverage decisions are
  determined by USD 259 with input from
  Labor/Management and the Employee Health Advisory
  Committee, not the third party administrator.

5
Your HealthYour Responsibility No one has
a greater stake in your health than you.

• Lifestyle Choices smoking, obesity, sleep
  deprivation and sedentary activity levels are
  linked to higher health care costs for cancer,
  heart disease, diabetes and stroke.
• Be an informed healthcare consumer learn to ask
  questions, learn which treatment options provide
  the best outcomes and develop an open, honest
  relationship with your healthcare provider.
• Play an active role in your healthcare get
  recommended free preventative annual checkups and
  immunizations.

6
Health Plan 2010

• Changes to the USD 259 Health Plan

7
Plan Enhancements starting January 2010

• Free generic blood pressure medications
• Free generic cholesterol medications
• Free colonoscopies for those 50 every ten years
• List of free prescription drugs handout or on
  the Risk Management Website for most up to date
  listing. www.usd259.com/riskmanagement/

8
Changes to Pharmacy in January 2010

• Changing from Caremark to Medco effective January
  1st .
• Medco will administer the pharmacy network.
• Accredo, a division of Medco, will administer the
  specialty pharmacy.
• If you still have mail order refills available
  after January 1st, they will be transferred.
• Mail order payment information must be updated
  after January 1st with Medco, as credit card
  information will not be transferred.
• New ID cards after December 7th, will include
  Medco information, but will not work until
  January 1.

9
Changes to Pharmacy in January 2010

• If your prescription is about to expire, please
  follow the process below
• Medco mail order process You will need to
  request a new 3 month prescription from your
  physician. Complete and mail the Medco Mail Order
  form along with your check. Please keep a copy.
  Allow three weeks for delivery of the first
  order. Subsequent orders will be delivered within
  5 to 10 days.

10
Mental Health Parity Act Changes 2010

• Mental Health Benefits in 2010 will mirror
  medical benefits under our plan.
• Office Visit co-pays - 40 or 30 depending on
  service.
• In-patient admissions for mental health related
  illnesses will have the same deductible and
  coinsurance as medical admissions.
• Pre-Authorization is required for all mental
  health services through MH Net 1-866-607-5970.

11
Other Changes in 2010

• Full time college students who have to drop hours
  because of a qualified serious illness, can still
  stay on health plan for up to 365 days.
• Full time college student verification letters
  will be mailed in January 2010.
• SSNs are required for employees and all
  dependents on the health plan. This is a
  federal/Medicare requirement.
• Members without SSNs can be terminated from
  coverage.
• Chemotherapy will be processed like any other IV
  infusion therapy with deductible/coinsurance
  instead of office visit co-pays.
• Member will receive new Coventry cards by January
  1st for 2010 Plan Year. The current Coventry
  cards will not work after December 31st.
• Avoid high ER charges at Walgreens Take Care
  clinics for 30 co-pay for non-life threatening
  illnesses.

12
Health Plan Premium Changes

• All employees pay 240 annual premium unless .
  . .
• Participate in 4 listed wellness activities
  between September 2008 and December 2009 and earn
  240 annual wellness credit for 2010. (Answers
  subject to audit 5 of all pay groups will be
  audited)
• 480 annual premium for those working less than
  1.0 FTE. This is a 120 annual reduction from
  last two years.

13
Health Plan Premiums

• Working Spouse (1,200 annual) and Tobacco (600
  annual per user) premiums will remain the same.
• Working Spouse Premium applies if spouse has
  access to employee only coverage through employer
  and the employer pays 50 of premium. (Example
  Premium is 300 and employer pays 150)
• Tobacco Premium for employees and spouses who use
  tobacco products. In order to avoid premium must
  be tobacco free for 12 consecutive months.
  (Example Quit March 2009, must pay until March
  2010)

14
Flex Spending

• Flex Spending Plan on IRS Calendar Year for
  easier calculation and participation. January
  December.
• Limits 5,000 per plan year for Flex Medical
  and 5,000 per plan year for Flex Dependent Day
  Care.
• Contributions are pre-tax, so save
• Optional district provided benefit in 2010 Flex
  Spending Card Can be swiped like credit card to
  pay out of pocket expenses, i.e. deductibles,
  co-pays. (Limitations if dont have enough to
  pay entire Out of Pocket Expense)
• Can still fax in receipts to ASI, the
  administrator.
• Covers many OTC purchases. (Handout)

15

• Frequently Asked Questions About Medical, Dental
  and Pharmacy Benefits

16
Questions About ELIGIBILITY

• Who is eligible for USD 259 health plan coverage?
• Full time employees, employees working at least
  20 hours per week in a benefitted position and
  eligible retirees.
• When does coverage begin?
• The first day of the month following date of
  hire.
• How long from my date of hire do I have to enroll
  online?
• Thirty-one days from date of hire.

17
Questions About ELIGIBILITY

• What dependents are eligible for coverage?
• Spouses, children for which the employee or
  spouse has been appointed legal guardian,
  unmarried disabled children if the disability
  occurred prior to age 19. Domestic partners are
  not currently eligible.
• What if I have other insurance and do not want
  health plan coverage?
• If you provide proof of other health insurance
  coverage, you are eligible to receive a 100
  monthly cash option payment. Interoffice mail to
  Employee Benefits/Risk Management or fax your
  proof to 973-4646.

18
Questions About
ELIGIBILITY

• If I am new to the health plan and have
  pre-existing conditions, how can I prevent denial
  of claims?
• If you provide a 12 month certificate of
  creditable insurance coverage for you and your
  dependents showing you had other health insurance
  within 63 days of coming to USD 259, there is no
  pre-existing condition exclusion.

19
Questions About DENTAL

• Who administers our dental plan?
• Delta Dental of Kansas. Customer service can be
  contacted at www.deltadentalks.com or
  1-800-234-3375. You will talk to a live person.
• How are dental services covered?
• Preventive and diagnostic services are covered at
  100 if dentist is Delta Preferred 70 if
  dentist is Delta Premier and 60 if dentist is
  non-participating.

20
Questions About DENTAL

• What other dental services are covered?
• Basic services such as extractions, regular
  restorative, endodontics and periodontics are
  covered (80/70/50) after deductible. Major
  services such as bridges, partial or complete
  dentures are covered (50/50/40) after deductible.
• What are the deductibles and limits on dental?
• We have a 16 month dental plan (through December
  2010) during the transition with a 62.50
  deductible (x3) and 2,000 maximum. We will
  return to the 50 deductible/1,500 maximum in
  2011.

21
Questions About DENTAL

• Are orthodontics covered?
• No, the FLEX spending program may be used.
• How are wisdom teeth extractions covered?
• Wisdom teeth extractions are covered jointly
  under major medical and dental.

22
Questions About DENTAL

• Is TMJ covered?
• YES, up to a 2500 lifetime maximum. Non-surgical
  treatments are covered under the dental plan.
  Surgical treatments are covered under the medical
  plan. Pre-authorization of services is required
  for both non-surgical and surgical treatments.
  Benefits will be coordinated between Delta Dental
  and Coventry.
• Are implants covered?
• Very limited only if you do not have any teeth
  and the cap is 2,000 for a lifetime.

23
Dental Tools through www.deltadentalks.com

• Check benefits and eligibility
• Locate a dentist
• Access customer service
• Check claims status
• Print ID cards
• Download forms and information
• Estimate flexible spending account
• Wellness Connection

24
Questions About MEDICAL

• How do I find whether my doctor/facility is in
  the Coventry network?
• Call the USD 259 dedicated customer service line
  at 1-866-765-7841, or a list of preferred
  providers may be found on Coventrys website at
  http//www.chckansas.com/ (Choose PPO product)
• If the provider is out of network, what costs
  will I have?
• There is no cap on your out-of pocket costs if
  you go out of network because the provider can
  balance bill.

25
Questions About MEDICAL

• What medical facilities are covered under the
  Coventry network?
• An example of some in-network area facilities
  Wesley Medical Center, Newton Medical Center,
  Susan B. Allen Memorial Hospital, Select
  Specialty Hospital-Wichita, Cypress Surgery
  Center, Surgery Center of Kansas, Surgicare of
  Wichita, Wichita Clinic Day Surgery and Wichita
  Clinic Surgery Center, West Wichita Surgery
  Center, Ridgewood Surgery and Endoscopy, Derby
  Ambulatory Surgery Center.

26
Questions About MEDICAL

• When do I need prior authorization for treatment?
• Prior authorization is needed for all scheduled
  inpatient surgeries, some outpatient procedures,
  high-tech radiology (except MRI) and
  non-emergency major medical procedures. Call
  1-866-765-7841. A full pre-certification list
  can be found online in the Summary Plan
  Description.
• If I fail to get pre-authorization, is there a
  penalty?
• YES, a 50 penalty up to a 2,000 cap will apply.
  There is no penalty if a true emergency
  exists.

27
Questions About MEDICAL

• What preventative care services will be covered?
• Well woman, well man and well child up to age 19.
  Well woman includes pap smear, mammogram and
  office visits. Well man includes PSA and office
  visit. Well child includes required immunizations
  and office visits.
• At what level are preventative services covered?
• 100 -- no deductible no coinsurance if a
  network provider is used. There is no
  preventative coverage for out-of-network
  providers.

28
Questions About MEDICAL

• What is the annual in-network deductible for
  the 12 month plan year?
• 850 (individual) for in-network services and
  1,700 (family) for in-network services.
• What is the coinsurance for the 12 month plan
  year?
• 70/30 coinsurance 2,750 (individual) for in-
  network and 5,500 (family) for in-network.
• What is the annual out of pocket maximum for
  in-network service?
• 3,600 (individual) and 7,200 (family)

29
Questions About MEDICAL

• What are the outof-network deductibles?
• 1,700 (individual) and 3,400 (family) but
  based on non-par fee schedule, not billed
  charges.
• What are the out-of-network coinsurance rates?
• 50/50 - There are no true out-of-network
  maximums because the provider can balance bill
  the difference to you.

30
Questions About MEDICAL

• Is routine lab work covered under preventative?
• NO, it is covered under the medical plan with
  deductible and co-insurance because we offer free
  blood work through the annual health fair.
• What are office visit co-pays and what do they
  cover?
• Office visit co-pays for in-network providers are
  30 for primary care and 40 for specialist
  visits. They cover all services for routine
  office visits, including most x-ray and lab work.
  There are exceptions if lab is sent outside, not
  routine or x-rays are read by a specialist.

31
Questions About MEDICAL

• If I have a chronic illness and am new to the
  health plan, or if I am pregnant with delivery
  date, how can I insure that I will not have
  disruption in my medical coverage?
• Please complete a Coventry Transition of Care
  form so that your information can be reviewed and
  your provider can be contacted, if necessary.
• How do I get a Transition of Care form?
• Forms will be available after the meeting, in the
  Risk Management office or on the Risk Management
  website or come see us after the meeting.

32
Questions About MEDICAL

• How do I know if I need to complete a Transition
  of Care form?
• Health plan members new to the health plan with
  the following conditions or needs should complete
  a Transition of Care form.
• Pregnant with delivery date
• Currently undergoing chemotherapy
• Scheduled surgeries or planned procedures at a
  non-participating provider
• Diabetes
• Congestive Heart Failure
• Asthma
• Dialysis
• Durable Medical Equipment such as CPAP or oxygen.
  
• Ostomy Supplies
• Injectibles

33
Questions About MEDICAL

• How often are new services considered?
• For the last several years, Labor/Management and
  the Employee Health Advisory Committee review
  requests for coverage, claims costs and look at
  plan changes that will provide enhancements and
  encourage employees to be healthier.

• What hearing services are covered?
• Routine hearing exams by in-network providers are
  covered. HEARING AIDS are not covered, but a FLEX
  spending program may be used.

34
Questions About MEDICAL

• How and where do I get my durable medical
  equipment and supplies?
• Coventry has a network of durable medical
  equipment providers and any can be used. (Apria
  Healthcare, First Care, Hart Home Medical, Home
  Medical Services, Knoll Patient Supply, National
  Seating and Mobility, Peeples Orthotics, Personal
  Image, Therapeutic Medical Supply). This list can
  be found on Coventrys website.
• Are there caps on durable medical equipment?
• 5,000 annually.

35
Questions About MEDICAL

• What are the limitations on physical therapy,
  occupational therapy and speech therapy?
• 40 visits combined are covered for PT, OT and
  Speech Therapy. Physical and occupational therapy
  do not require prior authorization.
• Will chiropractic treatment be covered?
• Yes, up to a maximum of 1,000 per member per
  year. To maximize this benefit, a network
  provider is recommended.

36
Questions About MEDICAL

• Are there co-pays for ER visits and Immediate
  Care?
• Yes, 100 for ER (unless admitted) and 30 for
  Immediate Care. The co-pays are in addition to
  the deductible and coinsurance.
• Are there co-pays for high tech radiology?
• Yes, there is a 100 co-pay for MRI, Pet Scan,
  and others
• Where are organ transplants authorized?
• At Coventry Centers for Excellence, depending on
  the organ involved. (Kidney KU Med Center, St.
  Lukes and Research Hospital, Barnes Hospital in
  St. Louis)(Heart St. Lukes)(Liver KU Med
  Center Barnes Hospital in St. Louis) A 10,000
  travel allowance is available.

37
Questions About MEDICAL

• How will mental health benefits be covered?
• Through MH Net. The MH Net telephone number will
  be on the back of your Coventry ID card.
• Will we still have an Employee Assistance
  program?
• Yes, EMPAC will continue to provide up to 12 free
  visits for any employee and their families. If
  additional care is needed, health plan members
  will be referred to an MH Net provider.

38
Questions About MEDICAL

• Are eye exams covered?
• Annual routine eye exams are covered up to 80
  with an in-network provider, pre-deductible.
• Are eyeglasses and contact lenses covered?
• No, the FLEX spending program can be used.

39
Questions About MEDICAL

• What is the lifetime cap on health plan benefits?
• 1 Million is the lifetime cap.
• Will the lifetime cap be increased due to rising
  medical costs?
• Lifetime caps are reviewed periodically by the
  Employee Health Advisory Committee, but there has
  been no recommendation to increase them.

40
Questions About PHARMACY

• What pharmacies are covered in the Coventry
  network?
• Preferred pharmacies may be found on Coventrys
  website at http//www.chckansas.com/
• How can I find out if my drugs are on the
  Coventry formulary?
• Coventrys drug formulary may be found on their
  website at http//www.chckansas.com/
• If the formulary changes, how will I know?
• If your drug is no longer available, you will be
  notified and given the alternatives.

41
Questions About PHARMACY

• How will the pharmacy plan work?
• There will be four tiers Tier 1 Generic, 10
  co-pay per script Tier 2 Formulary brand, 30
  co-pay per script Tier 3 Non-formulary, 55
  co-pay per script and Tier 4 Self-adminstered
  injectibles, 100 co-pay per script.
• Are smoking cessation drug therapies covered?
• Yes, under the third tier of the pharmacy plan.

42
Questions About PHARMACY

• In what tier do diabetic medications fall?
• Formulary insulin and formulary glucose meter and
  supplies will be free through any network
  pharmacy. Need to register with diabetic
  coordinator. Non-formulary insulin and
  non-formulary supplies will fall in the third
  tier.
• Are there other restrictions with pharmacy
  benefits?
• Certain drugs have quantity limits, some require
  prior authorization and some require step
  therapy. A list of the drugs in these categories
  can be found at www.chckansas.com

43
Questions About PHARMACY

• Are there categories of drugs that are or are not
  available through mail order?
• Controlled substances, such as narcotics for pain
  or stimulants for ADHD are not available through
  the mail. There may be others that are not
  available through the mail, so please contact USD
  259 Customer Service at 1-866-765-7841 for more
  information.

44
Questions About PHARMACY

• Are there any prescriptions that I can get a
  three month supply at my local pharmacy?
• Oral contraceptives, formulary insulin and
  formulary diabetic monitoring supplies may be
  obtained in three month quantities at retail
  pharmacies. (3 co-pays for oral contraceptives
  formulary insulin supplies are free.)
• If I use a retail pharmacy, how do I fill
  prescriptions in January 2010?
• Employees filling prescriptions after January 1,
  2010 will need to give their new Coventry ID card
  information to the pharmacy. Customer service
  can help if you dont have your card.

45
Questions About PHARMACY

• Will I need to get prior-authorization for
  certain drug therapies?
• Some drugs require prior-authorization by
  Coventry Health Care before the prescription will
  be filled at the pharmacy. Your doctor will
  coordinate this approval for you. If the
  prescription is approved, you will be responsible
  for the copayment. If the request is not
  approved, it does not mean your doctor cannot
  prescribe the medicine for you. It means that you
  are responsible for paying the full retail price
  for the prescription.

46
Questions About PHARMACY

• If I have been through step drug therapy with
  another plan, am I required to start over with
  Coventry?
• Your situation will be reviewed to determine
  whether you can be grandfathered.
• If I have not been through step therapy, will I
  be required to do step therapy?
• Yes, for drugs that require step therapy, it will
  be required if not already completed.

47
Questions About PHARMACY

• Are there quantity limits for any drugs?
• Review is required for drugs that exceed the FDA
  recommended dose or Coventry clinical
  recommendations. Your physician can request this
  review by calling 1-877-215-4098

48
Questions About PHARMACY

• What about over-the-counter drugs?
• Over the counter (OTC) medications available
  January 2010 Loratadine OTC (generic Claritin
  or Claritin D) Zyrtec OTC (generic - cetirizine
  hydrocholoride) Prilosec-OTC (PPI) Prevacid
  24HR are available with written prescription at
  1st tier copay.

49
Questions About Customer Service

• When will we get our 2010 Coventry health plan
  cards?
• New health plan cards will be mailed to you
  before January 1st. Your old card will not work
  after December 31st.
• How long does it take Coventry to resolve an
  issue?
• Most issues can be resolved within 48 hours. More
  complex issues will be resolved within 30 days.

50
Questions About Customer Service

• How can I reach Coventry to resolve an issue or
  get information?
• Call the USD 259 dedicated customer service line
  at 1-866-765-7841. The Coventry customer
  service telephone will be answered by a live
  person. This person will have authority to answer
  questions and resolve issues when possible.
• If I disagree with the decision, what can I do?
• You can file an appeal with Coventry and then
  with EHAC and Administrative Review.

51
Questions About Customer Service

• How do I verify my college student is full-time?
• Coventry will mail a questionnaire in January.
  You will have 30 days to submit required
  documentation.
• What documents will I need to prove full-time
  student status?
• Class schedule or tuition bill payment or letter
  from registrar verifying at least 12 credit
  hours. Document must contain the students name
  and institutions name.

52
Questions About Customer Service

• How long can full-time students stay on the
  health plan?
• Through the last day of the month the student
  turns 23.
• What if my student lives out-of-state?
• Please provide Risk Management with your
  students name and their schools name and
  address so your student can be added to
  Coventrys national network.
• What if I need care while traveling out of state?
• In an emergency you can go anywhere, but in a
  non-emergency, call the number on your Coventry
  card for a national network provider.

53
Questions About Plan Administration

• How does COBRA work?
• Under COBRA, coverage may be purchased for the
  full monthly premium plus a 2 administrative
  fee. The COBRA application must be made within 60
  days of termination from the plan. Ex-spouses,
  full-time students that turn 23, dependents that
  turn 19 and are not full-time students, etc. are
  eligible.

54
Questions About Plan
Administration

• If I have additional health care coverage, how
  will coordination of benefits be handled?
• Throughout the plan year, Coventry will mail a
  questionnaire to all employees on the plan
  requesting information on other coverage so they
  can coordinate benefits with any other insurance.
  All new employees will receive a letter asking
  about other insurance coverage.

55
Questions About Plan Administration

• How long do I have to add a dependent?
• 31 days from the date of marriage, birth,
  adoption. Use the eBenefits online Life Event
  process to add a dependent. Contact Risk
  Management at 973-4581 if assistance is needed.
• How long do I have to remove a dependent?
• 31 days from the life event (such as divorce or
  other health plan coverage)

56
Questions About Retiree
Medical

• How long can eligible retirees stay on the health
  plan?
• Until the first day of the month in which the
  retiree turns 65.
• Do retirees need Medicare Part D coverage?
• Not while covered under the USD 259 health plan.

57
Questions About Retiree
Medical

• If I am an active employee who is 65 or over,
  what coverage do I have?
• If you are an active working employee of USD 259,
  you must apply for Medicare Part A (Hospital) at
  age 65, but our health plan provides primary
  coverage to you and your dependents, and Medicare
  provides secondary coverage.

58
Questions About Retiree
Medical

• I am an active employee who is 65 or over, and
  have Medicare Part A only, plus I have a younger
  spouse under 65 with no other coverage, what plan
  is primary?
• The USD 259 health plan is primary and Medicare
  is secondary as long as you continue to be an
  active employee.
• I am retired from the district but not yet 65 and
  have a spouse who is over 65, what coverage
  should I have?
• When your spouse becomes 65, they must have
  Medicare Part A B. Our plan would be secondary
  for your spouse. Our plan would provide primary
  coverage for the retiree who is not yet 65.

59
Questions About Retiree
Medical

• If I am retired from the district and am age 65
  (single or with older spouse), what coverage do I
  have?
• You are no longer covered by our plan. Primary
  and secondary coverage under our plan is
  terminated. Medicare (Part A B) is the only
  option for both, but a supplemental policy may be
  purchased from an insurance carrier, not the
  district.

60
Questions About Retiree
Medical

• If I am retired and 65 with a younger spouse,
  what coverage do I have?
• Medicare Part AB would be primary for the
  retired employee and our health plan is
  secondary. Medicare Part D is not required for
  the retiree because our plan includes pharmacy
  benefits. Currently our plan would provide
  primary coverage for the younger spouse until age
  65.
• Please contact SCHICK (Senior Health Insurance
  Counseling for Kansas to explore the best health
  plan options. (Sarah Taylor -722-7721 x 117)

61

• General Questions of Interest to All
  from Audience

62

• 1 on 1 Private Meetings for Individual Health
  Pharmacy Questions