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Town of Dracut

Town of Dracut. Health Plan Educational Information for Non-Medicare Retirees Spring 2013 Andrew Powell – PEC Chairperson. Agenda. Overview Group Insurance Commission (GIC) Plans Health Maintenance Organization (HMO) Plans Preferred Provider Organization (PPO) Plans Indemnity Plans

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Town of Dracut

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  1. Town of Dracut Health Plan Educational Information for Non-Medicare Retirees Spring 2013 Andrew Powell – PEC Chairperson

  2. Agenda • Overview • Group Insurance Commission (GIC) Plans • Health Maintenance Organization (HMO) Plans • Preferred Provider Organization (PPO) Plans • Indemnity Plans • Calendar Year Deductibles • Provider Tiering & Copays • Selecting a GIC Plan

  3. Overview • All Town employees and retirees will receive their health insurance through the Group Insurance Commission (GIC) starting on July 1, 2013 and continuing through June 30, 2016 • Current plans will be in effect until June 30, 2012 • Open enrollment will be held from Wednesday April 10ththrough Wednesday, May 8th • All employees and retirees MUST enroll in order to have coverage as of July 1, 2013 • Marriage licenses, Birth Certificates, Adoption and Guardianship records are required to enroll dependents

  4. What Is the GIC? The mission of the GIC is to deliver high quality care at reasonable costs GIC was established by the Legislature in 1955 GIC is a quasi-independent state agency governed by a 15-member Commission appointed by the Governor Commission members include representatives of labor and retirees GIC covers >212,000 subscribers and >375,000 lives

  5. GIC Premium Contributions • Employees will pay; • 15% of the cost of GIC HMO plans • 17% of the cost of GIC PPO plans • 20% of the cost of the GIC Indemnity Plans • Most plan participants will have lower premiums under the GIC

  6. GIC Plans • The GIC offers 12 plans to Non-Medicare Retirees • UniCare (4 Plans) • Harvard Pilgrim Health Care (2 Plans) • Tufts Health Plan (2 Plans) • Fallon Community Health Plan (2 Plans) • Neighborhood Health Plan (1 Plan) • Health New England (1 Plan)

  7. GIC Plans • Plans with the most Non-Medicare retiree subscribers • Tufts Navigator PPO • Harvard Pilgrim Independence PPO • UniCare Indemnity Plan Basic with CIC (Comprehensive) • 78% of current Non-Medicare retirees in these 3 plans • Enrollment restrictions • UniCare Indemnity Plan Basic has no restrictions, in or outside of the United States • Other plans are limited to Massachusetts and certain border states/counties; geographic area varies by plan • Consult the map on page 7 of your Benefit Decision Guide!

  8. GIC Health Maintenance Organization (HMO) Plans • Members must select a Primary Care Physician (PCP) • Referrals are required to see Specialists • No coverage for out-of-network providers • Except for emergency care • Lower premium cost than other plan types • “Limited” or “Select” network plans • Lowest premium costs • Limited physician and hospital access

  9. GIC Health Maintenance Organization (HMO) Plans • Broad Network HMO • Fallon Community Health Plan Select Care • Fallon Select Care members may need referrals to the following hospitals: • Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Children's Hospital, Dana-Farber Cancer Institute, Massachusetts General Hospital, Tufts Medical Center • Limited Network HMO • Fallon Community Health Plan Direct Care • Harvard Pilgrim Primary Choice • Health New England • NHP Care (Neighborhood Health Plan) • Tufts Health Plan Spirit

  10. GIC Preferred Provider Organization (PPO) Plans • In-network and out-of-network benefits • No requirement to select Primary Care Physician (PCP) • No referrals required for specialists • Can utilize any provider • In-network providers - lower out-of-pocket costs • Out-of-network providers - higher out-of-pocket costs • Average 25% higher premium cost than GIC’s limited network HMOs • Member must reside in network service area to enroll

  11. GIC Preferred Provider Organization (PPO) Plans Tufts Navigator PPO Harvard Pilgrim Independence PPO UniCare State Indemnity Plan/Plus 1 Unicare State Indemnity Plan Community Choice 2 1. All Massachusetts doctors and hospitals are “in-network” with UniCare Indemnity Plan /Plus but some out-of-state providers may be “out-of-network” 2. Many in-state hospitals are “out-of-network” with Community Choice

  12. UNICARE Indemnity Basic Plan • Members not required to select a Primary Care Physician (PCP) • No referrals required for specialists • Can utilize any provider • Highest premium cost plan • No geographical restrictions on enrollment • Without CIC rider, deductibles and copays are higher and coverage is only 80% for some services

  13. Calendar Year Deductibles • Fixed amount a member pays before the plan pays benefits • Deductible generally does NOT apply to: • Prescription drug benefits • Outpatient mental health/substance abuse benefits • Office visits (primary care physician, specialist, retail clinics, preventive care, maternity & well baby care, routine eye exam, occupational therapy, physical therapy, chiropractic care & speech therapy) • Medically necessary child & adult immunizations • Hearing aids • Mammograms • Pap smears • EKGs • Colonoscopies

  14. Calendar Year Deductibles • Deductible DOES apply to: • Emergency room visits • Inpatient hospitalization • Surgery • Laboratory and blood tests • X-rays and radiology (including high-tech imaging, such as MRI, PET and CT scans) • Durable medical equipment

  15. Calendar Year Deductibles • Calendar Year Deductible Amounts • $250 individual • $500 two-person • $750 family (no more than $250 per person)

  16. Deductible/Copay Example First Visit to ER Second Visit to ER Total ER Visit $1,000 You Pay Deductible N/A You Pay ER Copay $100 ------------------------------------- Your Total Cost $100 Plan Pays $900 Total ER Visit $1,000 You Pay Deductible $250 You Pay ER Copay $100 ------------------------------------ Your Total Cost $350 Plan Pays $650

  17. Tiered Provider Copays • Providers are grouped into “tiers” based on cost, quality, and outcomes measures from third parties • Different tiering for different health plans; a primary care doctor, specialist or hospital can be on one tier with one GIC health plan and on another tier with another GIC health plan • Tier 1 Providers have lowest member cost & Tier 3 Providers have the highest member cost • GIC Plans use tiering to set office visit copays (primary care and specialists) and inpatient admission copays • Tiered hospital copay is in addition to the deductible, if not already satisfied by the member

  18. Tiered Provider Copays Vary by Plan

  19. Prescription Drug Tiering • Drug formularies vary by plan • Pharmacy tiering • Tier 1 – Generic and low cost brand drugs • Tier 2 – Brand name and high cost generic drugs • Tier 3 – Brand name non-preferred drugs • Copayments • Retail 30-day supply • Tier 1 - $10 • Tier 2 - $25 • Tier 3 - $50 • Mail Order 90-day supply • Tier 1 - $20 • Tier 2 - $50 • Tier 3 - $110

  20. Plan Design Example

  21. HPHC Independence PPOHospital Tiering

  22. HPHC Primary Choice HMOHospital Tiering

  23. Mitigation Plan • Public Employee Committee (PEC) and Town negotiated mitigation plan for specific subscribers • Any person enrolled in the Blue Care Elect PPO as of June 30, 2013 And who are; • Required to enroll in the GIC’s Indemnity Plan because of GIC enrollment rules will be entitled to; • The premium difference of their current contribution and the GIC Indemnity Plan • Premium subsidy ends on 6/30/2017 or upon exit from the GIC (whichever comes first)

  24. Dracut GIC Health Fair April 25th Thursday  11:00 AM - 4:30 PM Lakeview Junior High School 1570 Lakeview Avenue

  25. Tips for Selecting a GIC Plan Carefully review the GIC Benefit Decision Guide Complete a questionnaire and estimate your utilization of medical services Discuss the GIC plans with family, friends and your physician(s)

  26. Tips for Selecting a GIC Plan • Contact the carriers on the telephone or using the Internet. Ask the carriers about: • The physicians who treat you • The hospitals where you get care • The prescription drugs that you take • Any durable medical equipment or device that you regularly use • Attend a GIC Health Fair

  27. Tips for Selecting a GIC Plan Contact Information: Group Insurance Commission: www.mass.gov/gic (617) 727-2310 Harvard Pilgrim Health Plan: www.harvardpilgrim.org/gic (800) 542-1499 Tufts Health Plan: www.tuftshealthplan.com/gic (888) 333-0880 Fallon Community Health Plan: www.fchp.org (866) 344-4442 UniCare: www.unicarestateplan.com (800) 442-9300 Caremark Pharmacy www.caremark.com/gic (877) 876-7214 Health New England: www.hne.com (800) 842-4464

  28. Questions and Answers

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