State Employee Health Plan

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State Employee Health Plan

• Open Enrollment 2010

2
State of the Plan

• Reserves of the Plan have diminished
• Claim costs paid by the Plan continue to outpace
  premium revenue
• Governor and Legislature gave state agencies a 7
  pay period holiday from paying employer
  contribution
• Health Care Commission voted to
• Increase employee and employer rates
• Make some benefit adjustments to Plan A

3
Changes for 2010

• Medical Plans
• Plan changes for Plan A
• Quest Lab Card added
• Deductible increased to 150/300
• Coinsurance maximum increased to 1,200/2,400
• No plan changes for Plan B and Plan C
• Prescription Drug Plan
• Adding Performance Drug List
• Dental Plan
• Deductible increased to 50/150
• New value-based plan design

4
Medical Plan Options
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Medical Plan

• Standardized Plan designs
• All plans include preventive care
• Differences
• Provider networks
• All plans are Preferred Provider Organizations
  (PPO)
• Rates
• Services offered website, discounts, etc.
• Not all services are covered
• Review the benefit description
• Questions - contact plans customer service

6
Selecting a Medical Plan

• Pick a plan design (Plan A, B or C)
• Review the Provider Networks
• ? Each of the medical plans uses a
  different provider network
• Review the other services each medical plan
  offers
• 4. Review the premiums

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PPO Providers

• Claims paid based on the network status
• Network providers accept the plan allowance
• Non Network Providers can balance bill
• Non Network Providers may work at Network
  Facilities - examples
• Pathologists
• Emergency Room Providers
• Anesthesiologists
• Radiologists
• Laboratory Technicians

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Primary Care Providers
? Primary Care Providers (PCPs) are defined as

• General practice
• Family practice
• Geriatrics

• Internal medicine
• Physician extenders
• Pediatrics

• ? Use a network provider
• ? Referrals not required by the medical plan

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Preventive Care

• Physical Exams
• Well Woman
• Well Man
• Well Baby
• Well Child
• Immunizations
• Over age 60 shingles vaccine
• Flu shots

• Vision Exam
• Hearing Exam
• Bone Density Screening
• Mammogram
• Colonoscopy

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Plan A Network Providers

• Preventive Care Covered at 100
• Office Visit Copays
• 20 for Primary Care Office Visits
• 40 for Specialist Office Visits
• 150/300 Deductible
• 20 Coinsurance
• Coinsurance Max 1,200/2,400
• Quest LabCard Benefit

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Quest Lab Card

• Optional benefit
• You will need to request tests are sent to Quest
  or..
• Use a Quest collection site
• The decision is up to you and your provider
• 100 coverage of eligible outpatient lab tests
• Saves you and the plan money
• For non-emergency outpatient lab work only
• Testing must be performed and billed by Quest
• You will receive a Quest ID card
• Quest logo will also be on your medical card

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Quest Lab Card Savings
Charges on a typical lab claim for CBC, Lipid
Panel, TSH Basic Metabolic Panel

• Current Lab Fees
• Billed 194.83
• Allowed 155.86
• Coinsurance 80
• Plan pays 124.69
• Member pays 31.17

• LabCard Fees
• Total Charges 35.33
• Coinsurance 100
• Plan Pays 35.33
• Member Pays 0

Plan saves 89.36 and Employee saves 31.17
Source Quest Diagnostics, Inc.
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Plan B Network Providers

• Preventive Care Covered at 100
• Primary Care Office Visits
• 20 Adult Copay
• 10 Children age 18 and under Copay
• Specialist Office Visits
• 40 Adult Copay
• 25 Children age 18 and under Copay
• No Deductible
• 30 Coinsurance
• Coinsurance maximum 2,200/4,400
• Quest LabCard benefit

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Plans A B - Non Network Providers

• 500/1,500 Deductible
• 50 Coinsurance
• Coinsurance Max 3,650/7,300
• Preventive care not covered

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Drug Plan

• Generic Drugs
• 20 Coinsurance
• Preferred Brand
• 35 Coinsurance
• Special Case Medications
• 75 per 30-day supply
• Non Preferred Brand
• 60 Coinsurance
• Discount Tier
• 100 Member responsibility

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Drug Plan

• Print out the PDL and take it with you
• Preferred Drug List (PDL) available on website
• PDL is updated quarterly
• Talk to your doctor about prescription drug
  options
• Using Generics will save you money
• Specialty, Special Case and self-injectables
  lists
• drug list available on the website
• www.khpa.ks.gov
• www2.caremark.com/kse/

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Performance Drug List

• Three drug classes of Performance Drug List
• ACE/ARBs Blood pressure lowering
• HMGs Cholesterol lowering
• PPIs Stomach acid reducers
• Must try a Generic before using a Non Preferred
  Brand Name Drug
• Claim system will review members history
• Generic and Preferred Brands not effected
• Those using a Non Preferred drug will be notified
  by Caremark

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Performance Drug List
Blood Pressure Lowering

• Preferred ACE/ARBs

• Non Preferred ARBs

• Generic
• benazepril benazepril HCT
• captopril captopril HCT
• enlapril enlapril HCT
• fosinopril fosinopril HCT
• lisinopril lisinopril HCT
• moexipril moexipril HCT
• quinapril quinapril HCT
• ramipril
• trandolapril
• Preferred Brands
• Benicar Benicar HCT
• Micardis Micardis HCT

• Diovan Diovan HCT
• Teveten Teveten HCT
• Tekturna Tekturna HCT
• Angiotensin Converting Enzyme Inhibitors (ACEs)
• Angiotensin II Receptor Antagonists (ARBs)
• Direct Renin Inhibitors Combinations

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Performance Drug List
Cholesterol Lowering Agents
HMG-CoA Reductase Inhibitors (HMGs or
Statins)/Combinations

• Preferred HMGs

• Non Preferred HMGs

• Generic
• simvastatin
• pravastatin
• lovastatin
• Preferred Brands
• Lipitor
• Crestor

• Vytorin
• Lescol
• Lescol XL
• Altoprev
• Pravachol
• Zocor

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Performance Drug List
Stomach Acid Reducers
Proton Pump Inhibitors (PPIs)

• Preferred PPIs

• Non Preferred PPIs

• Generic
• omeprazole
• pantoprazole
• Preferred Brands
• Prevacid
• Nexium

• Aciphex
• Prilosec

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Home Delivery
Medical Plan

• Convenient and easy
• Timing of orders
• New orders process within 10-14 days
• Reorders process in 5-7 days
• Up to a 60-day supply available
• Same Coinsurance requirements
• Convenient re-orders
• Online _at_ Caremark.com
• Phone [phone]

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Projected Generic Launches

• 1st 2nd Qtr. 2010
• Arimidex
• Flomax 24 hour ER
• Hyzaar
• Effexor XR

• 3rd 4th Qtr. 2010
• Aricept
• Cozaar
• Namenda

• 4th Qtr. 2009
• Prevacid
• Pulmicort Inhalation Suspension
• Valtrex

http//www.khpa.ks.gov/sehp/2009_providers.html
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Specialty Biotech Drugs
Medical Plan

• Designed for conditions that are difficult to
  treat with traditional therapy
• Treatments for cancer, MS, hemophilia, hepatitis
  C, rheumatoid arthritis and growth hormone
• Self-administered drugs for home use
• Overnight shipping
• Available only at Caremark Specialty Pharmacy
• Call Caremark Connect 1.800.237.2767
• Coordinates patient care with provider
• List of Specialty Biotech drugs available

http//www.khpa.ks.gov/sehp/2009_providers.html
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Plan C QHDHP w/ HSA

• QHDHP is the medical drug plan
• HSA is the health savings account
• You are not eligible to enroll for an HSA if
• Anyone covered by Medicare
• Covered by another health plan that is not a
  QHDHP
• Covered by a health care flexible spending
  account
• Covered by TRICARE or TRICARE For Life
• Eligible to receive VA medical services

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Plan C - QHDHP

• Network Provider Coverage
• 1,500/3,000 Deductible
• 20 Coinsurance
• 3,000/6,000 Out-of-Pocket Maximum
• Preventive Care Services paid at 100
• Non Network Provider Coverage
• 2,000/4,000 Deductible
• 50 Coinsurance
• 3,650/7,300 Out-of-Pocket Maximum
• Preventive Care is not covered

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Plan C QHDHP Drug Plan

• Drugs are subject to the Deductible then
• Generic 10 Copayment
• Preferred Brand 30 Copayment
• Non Preferred Brand 55 Copayment
• Copayment is per 31-day supply
• Generic Incentive Provision
• Uses Caremark Preferred Drug List, Performance
  Drug list and Specialty Pharmacy
• Not creditable drug coverage for Medicare

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Plan C Health Savings Account (HSA)

• Employer contribution to your HSA
• 37.50 per pay period for single
• 56.25 per pay period for family
• Member contribution to HSA
• Require contribution of 25 per pay period
• HSA bank depends on medical plan vendor selected
• http//www.khpa.ks.gov/SEHBP/benlink.htm
• HSA funds can be used to pay
• Deductible, Coinsurance, Copayments

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Dental Coverage

• You have access to two PPO provider networks
• Delta Dental PPO
• Delta Dental Premier
• Plan Deductible
• Applies to Basic Major Restorative Care
• 50 per person, maximum of 3 per family
• Orthodontic benefit
• 1,000 per person per lifetime
• Annual benefit maximum
• 1,700 per person per year

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Dental Preventive Care

• Covered in full
• Prophylaxis/cleanings twice per year.
• Oral examinations twice per year.
• Bitewing x-rays
• adults 1 x a year
• children under 18 - 2 x a year
• Full mouth x-rays once each five (5) years.
• Limited coverage for children only
• Sealants
• Space maintainers
• Topical fluoride
• Ancillary emergency relief of pain.

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Dental Restorative Services

• Basic Restorative
• Regular restorative dentistry fillings
• Oral surgery
• Endodontics root canals
• Periodontics treatment of gum bone disease
• Additional Diagnostic X-Rays
• Major Restorative
• Special restorative dentistry crowns
• Prosthodontics bridges, implants, dentures
• TMJ Treatment Requires prior authorization
• Restorative care is subject to a 50 deductible

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Basic Benefit

• If You have NOT had one preventive or office
  visit for cleaning or exam of the teeth in the
  preceding 12-month period

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Enhanced Benefit

• If You have had at least one preventive or office
  visit for cleaning or exam of the teeth in the
  preceding 12-month period

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Basic Vision Plan

• Exams subject to 50 Copay
• 25 Materials Copay then
• 100 single-vision, standard bifocal, trifocal
  lenticular lenses
• Up to 100 allowance for frames
• Elective Contact lens allowance 150
• Home delivery SVcontacts.com

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Enhanced Vision Plan

• Includes Basic Plan Coverage PLUS
• Progressive lenses up to 165
• High index lenses or Poly-carbonate lenses up to
  116
• Scratch and UV coating
• Contact Lens Fitting Fee
• Subject to 35 Copay
• Limited Coverage
• Enhanced benefits not available from Non Network
  Providers

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HealthyKIDS Program

• Premium assistance for childrens health
  insurance coverage
• Families at 250 of poverty level
• State pays 90 of childrens premium
• Same coverage
• Must enroll every year
• Enroll Online
• Use the Employee Self Service Center

http//www.kansas.gov/employee/
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Flexible Spending Accounts

• Health Care Flexible Spending Account
• Deductibles, Copays Coinsurance
• Eyeglasses, contacts, orthodontics hearing aids
• Over-the-counter medications
• Dependent Care Flexible Spending Account
• Day care services Pre-school
• Babysitters
• Pre-tax contributions
• Up to 5,000 per account per year
• Extended grace period for Health Care FSA
• Details on eligible expenses available at

www.asiflex.com
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Claiming your Flex Funds

• Optional Debit Card for health care FSA
• Information will be sent to you to elect debit
  card
• You pay 12 service fee per year
• You may still need to send documentation to ASI
• Reimbursements by check or direct deposit
  available
• Fill out a claim form, attach receipts, and mail
  or fax to ASI.
• Fill out form electronically, attach electronic
  copies of receipts, and email to
• claims_at_asiflex.com

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Non Tobacco Users Discount

• You must enroll online and complete the tobacco
  certification to get the discount!
• 20 discount per 24 pay periods
• Must be a non tobacco user
• - or -
• Tobacco users agreeing to enroll in the
  HealthQuest tobacco control program beginning
  1/1/10
• The program will be through a new vendor Free and
  Clear for 2010
• Members will receive a letter from the vendor
• You need to enroll in January 2010
• Must complete the program to keep the discount

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Tobacco Control Program

• Enroll in the tobacco control program between
  1/1/2010 1/31/2010 
• Complete an assessment with a Quit Coach by
  1/31/2010 
• Complete a minimum of four remaining telephone
  discussions with a Quit Coach by 5/31/2010
• call the toll free number from 7 AM 2 AM any
  time you need to speak with a Quit Coach.
• Quit for Life will notify the SEHP once you have
  completed and you will receive a congratulatory
  letter from the SEHP. Additionally, employees
  will be requested to complete a survey to give
  their feedback on the program.

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Paying the Base Rate in 2010

• The following will NOT be receiving the discount
• Elects not to disclose Tobacco status
• Tobacco users not enrolled in the tobacco control
  program
• Failed to enroll online and declare tobacco
  status
• Members who enroll but fail to complete the
  tobacco control course within the required
  timeline will be notified of the loss of the non
  tobacco discount
• Every 6.5 seconds someone around the world dies
  from tobacco use. In fact, it is the only legal
  consumer product that kills when used as
  intended. Tobacco use is the second leading cause
  of death around the globe it causes more death
  globally than AIDS, illegal drugs, motor vehicle
  accidents, murder, and suicide combined.
• Source National Business Group on Health
  Tobacco the Business of Quitting

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Resources

• Review the Open Enrollment (OE) booklet
• Call the health plan customer service
• Phone number in the front of the OE booklet
• Visit the KHPA website http//www.khpa.ks.gov/SEH
  P/Active.htm
• Benefit descriptions available
• Caremark PDL
• Provider listings
• Information on HSA accounts
• Email ?s to SEHP benefits_at_khpa.ks.gov

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HealthQuest

• Health Screenings Online Health Assessment
• 50 gift card for completion
• Health Coaching
• Online Wellness Newsletter
• HealthQuest Website and Blog
• Wellness Presentations
• LIFELINE Employee Assistance Program
• 1-800-284-7575
• 24/7 support
• Confidential, personal counseling referrals
• http//www.khpa.ks.gov/healthquest/default.htm

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Annual Open Enrollment

• October 1 October 31, 2009
• Enroll online
• Declare tobacco status
• Make changes
• Add/drop dependents
• Enroll in Flexible Spending Accounts
• HealthyKIDS
• Paper enrollment forms required
• New employees hired after September 10, 2009
• Coverage effective January 1, 2010

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Required Documentation

• If you are adding a dependent, documentation of
  eligibility is required
• Birth certificates
• Marriage licenses
• Affidavit of common law marriage
• Social Security numbers for all covered members
• Document due by 11/1/09
• If documentation is not received dependents will
  not be added to your plan for 2010

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Identification Cards

• Make sure your address is up-to-date
• Plan A members will get new health plan id card
• All Plan A members will get a LabCard id card
• Delta will be issuing everyone new id cards
• New cards for new/changed memberships only
• Superior Vision
• Caremark
• Plans B and C
• If you lose your card, call the health plan

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Open Enrollment Checklist

• Enrollment Online
• Must declare tobacco status
• Review health plan selections
• Enroll in HealthyKIDS
• Enroll in flexible spending accounts
• Confirmation statements
• Available online 12/1/09

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Questions?