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Missouri Department of Transportation & Missouri State Highway Patrol Employee Benefits Meeting for 2007. What is New for the MoDOT/MSHP Medical Plan for 2007?. Employees will have one plan design effective January 01, 2007.
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Missouri Department of Transportation & Missouri State Highway Patrol Employee Benefits Meeting for 2007
What is New for the MoDOT/MSHP Medical Plan for 2007? • Employees will have one plan design effective January 01, 2007. • The plan will be called Open Access III (OAIII) Plan, but benefits will change • All active employees will have the same out-of-pocket premium structure.
Why is MoDOT/MSHP Not Offering the 100% Coverage Plan under OAIII • The current OAIII plan is not self-supporting and would require large increases in the monthly out-of-pocket premium for our members. • As of June 30, 2006, this plan has a deficit of $1,000,000+. • That means the claims paid is $1 million greater than the premiums collected for this plan.
Rates Required to Maintain Current 100% Coverage Plan OUT-OF-POCKET RATES CURRENT2007 • Sub only $51 $216 • Sub/spouse $234 $564 • Sub/family $308 $811 • Sub/child $173 $503 • Sub/2 children $256 $632
COMPARING SPOUSE CONTRIBUTION PLAN RATES • Spouse contribution plans are plan categories where both the subscriber and spouse work for MoDOT or MSHP. • They receive additional state share contributions. • Comparison of current 2006 out-of-pocket monthly premium costs to 2007 as follows: CURRENT 2007 Sub/spouse $0 $252 Sub/family $2 $499
In-Network Benefits Deductible -$300/individual/CY, $900 maximum per family). Coinsurance – 10% coinsurance after deductible is met Office Visit - $15 co-payment for office visit only. Other services applied to deductible and coinsurance Out-of-Pocket Maximums Individual coverage $750 Family coverage $2,000. Other co-pays which may apply $75 ER $15 urgent care (office visit only) Out-of-Network Benefits Deductible -$300/individual/CY, $900 maximum per family). Coinsurance – 20% coinsurance after deductible is met Office Visit – 20% coinsurance of allowed amount after deductible .Out-of-Pocket Maximum – Individual coverage $1,500 Family coverage $4,500. UCR – For out-of-network services you may be billed by the provider for any charges above usual, reasonable & customary. MoDOT/MSHP’s Plan for 2007 is HealthLink Open Access III Plan with Freedom Network Select
OUT-OF-POCKET COST COMPARISON Total Out-of-Pocket Costs for Covered Medical Services for 2007 Plan Utilizing in-network providers • Deductibles/CY - $300 Medical & $75 RX • 10% Coinsurance – $750 max • Potential CY out-of-pocket costs (excluding co-pays for office visit, urgent care or ER, which you currently pay) are: • $1,125/individual • $3,125/family of 3 or sub/2child • $2,250/sub/spouse or sub/1child • Does not include increase from 20% to 30% for prescription drugs Out-of-Pocket Premium Costs to Maintain Current 100% Coverage Plan for 2007 • Sub Only - $216 x 12 = $2,592 • Sub/family - $811 x 12 = $9,732 • Sub/spouse - $564 x 12 = $6,768 • Sub/child - $503 x 12 = $6,036 • Sub/2child - $632 x 12 = $7,584 Spouse Contribution Categories • Sub/family - $499 x 12 = $5,988 • Sub/spouse - $252 x 12 = $3,024
Pharmacy Benefit Changes • $75 Deductible per participant per CY • After the deductible is met, the participant pays a 30% coinsurance or a minimum $5 co-pay (not both).
Pharmacy Benefits That Will Not Change From Your Current Coverage • 30-day starter quantity if the drug is a new medication, has not been purchased in the past 6 months or the strength of the drug has changed. • Mandatory generic policy that requires generic drugs be used, unless a generic is not available or the individual has a Prior Authorization (PA) to use the brand over the generic. • There are some drugs that are not covered. • Examples include: Drugs for weight loss, hair loss, fertility and impotence
Pharmacy Benefits That Will Not Change From Your Current Coverage • Participants can fill a 90 day prescription at both retail or mail order participating pharmacies. • Some drugs are paid at a $50 maximum co-payment. • Some drugs require a prior authorization (PA) • Most PA’s must be renewed on an annual basis. • examples include: Cox inhibitors, hypertensive agents, anti-migraine agents and some asthma drugs
Pharmacy Benefits • The PBM has their own network of pharmacies that participants of the plan must use when purchasing their prescriptions. • A retail or mail order pharmacy may be used when purchasing maintenance drugs.
Pharmacy Benefits • The Medical Board is currently in the process of finalizing the bid process for the 2007 pharmacy benefits manager (PBM). • Once the PBM is selected you can access their website to verify if your pharmacy is participating. • Plan participants will receive a new prescription card that must be presented each time they have a prescription filled at a local retail pharmacy.
PREVENTIVE BENEFITS FOR 2007 • Preventive Benefits will remain the same except for your dependent children for 2007: • Non-Medicare Subscriber $350 • Non-Medicare Spouse $350 • Non-Medicare Child $200
MoDOT/MSHP’s Plan for 2007 is HealthLink Open Access III Plan with Freedom Network Select The Network Scenario is as follows: • In-Network Benefits – When you seek services from a provider that participates with HealthLink HMO and/or PPO Network, Freedom Network Select (western MO), AHI-HealthLink (Texas only) & Quincy Tri-State Coalition Network. • Out-of-Network Benefits – When you seek services from a provider that falls outside the service area of the networks mentioned above including those providers that participate with Freedom Network only.
Advantages of one Consolidated Health Plan for the MODOT/MSHP Employees • Precertification requirements have been simplified to only include inpatient precertification. • Employees currently in the Open Access – HMO Plan will have premium reductions effective January 01, 2007. • Exception may be spouse contribution plan members • Out of Network Benefits have improved in the 2007 MODOT/MSHP Plan as it compares to the current Open Access – HMO Plan.
DO I NEED TO DO ANYTHING TO ENROLL IN THE NEW MEDICAL PLAN? • NO • You and any participants currently enrolled in the 2006 OAIII medical plan will be automatically enrolled in the new OAIII medical plan for 2007 • New ID cards will be issued • Only requires action if you are making a plan change such as terminating coverage, etc. or have a qualifying event to add dependents, etc.
Benefits of one Consolidated Health Plan for MoDOT/MSHP Employees • Additional provider network savings to the MODOT/MSHP plan. • All employees will have access to the MedCall – 24 hour nurse & the Maternicall Program.
GOOD NEWS • The eligibility of a dependent is changing for 2007 • Unmarried dependents can now be covered up to age 23 without full time student verification • They must meet the definition of a dependent.
How to Find a HealthLink Open Access III or Freedom Network Select provider? • HealthLink’s website is www.healthlink.com. • Freedom Network Select’s website is www.phpkc.com. (For Western MO) • HealthLink’s Customer Service (CS) number is (888) 724-9395. • When calling the CS number, specifically ask for Freedom Select if you live in their network area.
Meritain Health • The third party claims administrator for the MoDOT/MSHP Medical Plan. • Meritain continues to be your main contact for information regarding benefits, claims and eligibility questions.
Meritain Health • Meritain’s toll-free number is (888) 306-6681. • Meritain’s Customer Service Representatives are available Monday through Friday from 8:00 am – 5:00 pm.
CONTACT INFORMATION • Employee Benefit’s toll free # is 877-863-9406 • Look under “Benefits” on the MoDOT intranet site. • www.modot.mo.gov/newsandinfo/benefits.htm • Contact your local insurance representative in your district, division or troop