FY 2015 Changes
• Changes (listed on page 4 of the Benefits Choice book and
page 2 of the flyer):
– Deductibles and plan year deductible caps
– Coinsurance
– OAP out-of-pocket maximum
– Vision lens benefit frequency
– Retiree premiums
2
FY 2015 Changes
• Remaining the same:
– Employee premiums
– Employee premium annual salary bands
– QCHP deductible salary bands
– Life insurance rates
– Dental rates
3
Out-of-Pocket Maximum
• The following do not count toward the out-of-pocket
maximum:
–
–
–
–
–
Amounts over allowable charges for the plan
Non-covered services
Charges for services deemed to be not medically necessary
Penalties for failing to pre-certify/provide notification
Prescription deductibles and copayments (see Coventry
HMO exception)
4
Out-of-Pocket Maximum
• Effective 7/1/14, Coventry HMO will count
prescription deductibles and copayments towards
the out-of-pocket maximum. Therefore, once the
out-of-pocket maximum has been met, prescription
charges will be covered at 100% for the rest of the
plan year.
• In FY 2016, prescriptions will apply to all health plan
out-of-pocket maximums.
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Out-of-Pocket Maximum
Out-of-Pocket Max
Limits
Annual Plan
Year Deductible
QCHP
In-Network
Individual - $1,500
Family - $3,750
Out-of-Network
Individual - $6,000
Family - $12,000
X
X
X
HMO
Individual - $3,000
Family - $6,000
N/A
X
X
OAP Tier I
Individual - $6,250
Family - $12,700
N/A
X
X
OAP Tier II
Individual - $6,250
Family - $12,700
X
X
X
•
•
Additional
Deductibles
(QCHP)/
Copayments
Coinsurance
Amounts over
Allowed
Charges
QCHP out-ofnetwork
providers and
OAP Tier III
providers:
Amounts over
the plan’s
allowable
charges are the
member’s
responsibility
and do not go
toward the outof-pocket
maximum.
Eligible charges from Tiers I and II will be added together when calculating the out-of-pocket maximum.
Tier III will no longer have an out-of-pocket maximum.
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FY 2015 Benefit Changes
Quality Care Health Plan (QCHP)
Individual
Annual Deductibles *
Family Cap
FY 2014
FY 2015
FY 2014
FY 2015
Employee $60,700 or less
$350
$375
$875
$937.50
$60,701-$75,900
$450
$475
$1,125
$1,187.50
$75,901 and above
$500
$525
$1,250
$1,312.50
Retiree/Annuitant/Survivor
$350
$375
$875
$937.50
Dependents
$350
$375
N/A
N/A
* Salary bands for QCHP deductibles did not change this year.
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QCHP Deductibles
Deductibles
FY 2014
FY 2015
Inpatient Hospitalization (In-Network)
$75
$100
Inpatient Hospitalization (Out-of-Network)
$400
$500
Emergency Care – Hospital
$425
$450
Individual Out-of-Pocket Maximum (In-Network)
$1,500
$1,500
Individual Out-of-Pocket Maximum (Out-of-Network)
$6,000
$6,000
Family Out-of-Pocket Maximum (In-Network)
$3,750
$3,750
Family Out-of-Pocket Maximum (Out-of-Network)
$12,000
$12,000
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QCHP Benefit Levels
FY 2014
FY 2015
After all applicable deductibles are met (in-network)
90%
85%
After all applicable deductibles are met (out-of-network)
60%
60%
After the out-of-pocket maximums are met
100%
100%
Note: Percentages are based on the allowable charge for covered services.
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QCHP Prescriptions
FY 2014
FY 2015
$100
$125
Generic (30-day supply)
$10
$10
Preferred brand (30-day supply)
$30
$30
Non-preferred brand (30-day supply)
$60
$60
Mail order generic (90-day supply)
$25
$25
Mail order preferred brand (90-day supply)
$75
$75
Mail order non-preferred brand (90-day supply)
$150
$150
Deductibles
Copayments
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HMO Health Plans
Copayments
FY 2014
FY 2015
Office Visit (PCP)
$18
$20
Office Visit (Specialist)
$25
$30
Home Health Visit
$25
$30
Inpatient
$325
$350
Outpatient
$225
$250
Emergency Room
$225
$250
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Open Access Plans – Tier I
Copayments
FY 2014
FY 2015
Physician Office Visit
$18
$20
Specialist Office Visit
$25
$30
Home Health Visit
$25
$30
Inpatient
$325
$350
Outpatient
$225
$250
Emergency Room
$225
$250
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Open Access Plans – Tier II
Copayments
Annual Plan Deductible
FY 2014
FY 2015
$250
$250
Inpatient
90% after $375 copay
90% after $400 copay
Outpatient
90% after $225 copay
90% after $250 copay
Emergency Room
100% after $225 copay
100% after $250 copay
$900
$1,500
$6,250
$12,700
Out-of-Pocket Maximum *
Individual
Family
Note: Percentages are based on network charges for covered services.
* FY 2015 out-of-pocket maximum includes eligible charges from Tiers I and II combined.
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Open Access Plans – Tier III
FY 2014
FY 2015
Annual Plan Deductible
$350
$350
Physician Office Visit
60%
60%
Specialist Office Visit
60%
60%
Inpatient
60% after $475 copay
60% after $500 copay
Outpatient
60% after $225 copay
60% after $250 copay
Emergency Room
100% after $225 copay 100% after $250 copay
Out-of-Pocket Maximum
Individual
Family
$1,800
$3,800
Unlimited
Note: Percentages are based on the allowable charge for covered services.
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HMO and OAP Prescriptions
FY 2014
FY 2015
$75
$100
Generic (30-day supply)
$8
$8
Preferred brand (30-day supply)
$26
$26
Non-preferred brand (30-day supply)
$50
$50
Mail order generic (90-day supply)
$20
$20
Mail order preferred brand (90-day supply)
$65
$65
Mail order non-preferred brand (90-day supply)
$125
$125
Deductibles
Copayments
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Vision
FY 2014
FY 2015
Eye exam
$20
$25
Lenses
$20
$25
Standard frames (available every 24 months)
$20
$25
24 months
12 months
Replacement lenses, including contacts
16
Dental
FY 2014
FY 2015
$150
$175
Annual Max (In-Network)
$2,500
$2,500
Annual Max (Out-of-Network)
$2,000
$2,000
Ortho Max (In-Network)
$2,000
$2,000
Ortho Max (Out-of-Network)
$1,500
$1,500
Annual Deductible
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If you have questions…
If you have questions, please contact Benefits staff by calling
650-2190.
Or review the Benefits Choice Options booklet on the CMS
website at:
http://www2.illinois.gov/cms/Employees/benefits/StateEmploye
e/Pages/BenefitsBooks.aspx.
Thank you!
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