OHSU Benefits
2015 Updates – effective January 1, 2015
Key Points to Remember
• Open Enrollment moving – starting October 27 –
November 21
• New system still access via Employee Self Service
– Changes will be visible on 10/10 paycheck
• 250 PPO Plan is being replaced in 2015
• Significant changes from 2014 in employee costs
if you receive services at Providence in 2015
• Tobacco usage surcharge will start in 2015
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Factors influencing decisions for 2015
• Philosophy to offer one of best employee benefit
programs in area
• Employee feedback
• Costs of the 250 PPO and pharmacy benefits
have been operating at a loss in 2013 and 2014
• Tobacco use is a major contributor to high claims
costs
• Continued modifications to remain compliant with
ACA and avoid Cadillac tax
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Open Enrollment – Moved to late October
Oct. 27 – Nov. 21
• New benefits enrollment system: easier to enroll,
can view more detailed data online
• All enrollments done online, no paper forms
• New open enrollment dates: Oct. 27-Nov. 21
– All changes will be effective January 1, 2015
• System went live 9/15 for new hires
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How the networks work in 2014
OHSU PPO
250 Plan
Non-Contracted*
Non-Contracted**
ODS Plus
PHCS
OHSU
PPO
ODS Plus
Non-Contracted*
Rural 250 Plan
* Member will be balance billed for charges above
Moda / PHCS’ reimbursement determination
National
Network
(PHCS)
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(available to employees living out of
Oregon and in mostly rural areas)
How the networks will work in 2015
Regional Medical Home:
“formerly known as 250 PPO”
OHSU PPO
Non-Contracted*
Non-Contracted**
Community
Care Network (CCN)
ODS
Plus/Connexus
Synergy/
Summit Network
OHSU
PPO
Synergy/
Summit
Medical Home
Non-Contracted*
* Member will be balance billed for charges above
Moda / PHCS’ reimbursement determination
National
Network (ODS
Plus/Connexus
in OR/SW WA
and PHCS
elsewhere)
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National PPO Plan
(participants outside of the State of Oregon
and SW-WA, eligibility determined based
on zip codes at time of enrollment)
Significant changes to medical plan networks
• OHSU PPO
– Core providers (OHSU and affiliates) who are
currently reimbursed at the highest level have
not changed
– The wrap around network currently MODA’s
ODS Plus/Connexus will change to the MODA
Community Care Network (CCN) in 2015
• CCN excludes Providence( and Kaiser) but otherwise
has the same major Oregon and SW Washington
health systems and provider groups. Please refer to
MyModa.com for CCN providers.
• Services provided by non- OHSU PPO or CCN
facilities or providers will be balanced billed
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Significant changes to medical plan networks
• 250 plan is being replaced with the Regional
Medical Home plan
– The Synergy network (I-5 Corridor) and Summit
network (Eastern Oregon) will be core network and
provide the highest level of reimbursement for this
plan
• The Synergy network contains most of the major health
systems and provider groups in Oregon and SW Washington,
except for Providence and Kaiser. Please refer to
MyModa.com for in-network providers.
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Regional Medical Home Plan
– Individuals and all covered dependents must choose
a medical home clinic
• Each dependent may select a different medical home
– This medical home will coordinate care, including
helping to refer you to specialists and hospitals.
Medical Home providers do not need to contact Moda
directly to report a referral and members can see any
in-network specialist.
• Referrals are not mandatory but existing prior authorization
and medical necessity requirements will remain
– If you have non-specialty services at Medical Home
provider who is not part of your preselected Medical
Home, you will receive a lower benefit level.
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Significant changes to medical plan networks
• National PPO plan
– Eligibility based upon the employee’s or a covered
dependent's zip code
• For coverage outside Oregon and SW Washington
• Replaces the rarely used “Rural 250” plan
– MODA’s PHCS "Healthy Directions" is the national
network
– The ODS Plus/Connexus is the network used in
Oregon and SW Washington
– Email benefits@ohsu.edu if you or a covered
dependent reside outside Oregon or SW Washington
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OHSU PPO Plan Design
Current Design
Feature
Tier 1: OHSU
and Affiliates
Deductible
Tier 2:
ODS Plus**
2015 Design
Tier 1: OHSU
and Affiliates
$250 / $750
Tier 2:
CCN
$250 / $750
Tier 3: OON /
NonContracted**
$500 / $1,500
Coinsurance*
20%
40%
20%
30%
40%
Office Visit
$25
Deductible +
Coinsurance
$25
$40
Deductible +
Coinsurance
Select Services***
 Office Visit
N/A
 Services subject to
deductible +
coinsurance
N/A
OOP Max (Med)
OOP Max (Rx)
$1,600 /
$3,250
$25
Deductible + 20% Coinsurance
$4,250 /
$8,750
$1,500 / $2,500
$1,600 /
$3,250
Deductible +
Coinsurance
$3,500 /
$7,000
$4,250 /
$8,750
$1,500 / $2,500
* Member coinsurance
** Member will be balance billed for charges above Moda’s reimbursement determination
*** Select services may include: mental health, chemical dependency,, and podiatry
Note: Deductibles and OOP’s will apply up and down the network tiers
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Regional Medical Home PPO Plan Design
Current Design
Feature
Deductible
Tier 1:
ODS Plus
2015 Design
Tier 1:
Synergy
/Summit
Tier 2:
All Other**
$500 / $1,500
Tier 3: OON /
NonContracted**
Tier 2:
ODS Plus
$400 / $1,200
$500 / $1,500
Coinsurance*
20%
40%
20%
40%
Office Visit
$25
Deductible +
Coinsurance
$25
$40
$3,500 /
$7,000
$4,250 /
$8,750
$3,500 /
$7,000
$4,250 / $8,750
OOP Max (Med)
OOP Max (Rx)
$1,500 / $2,500
$1,500 / $2,500
* Member coinsurance
** Member will be balance billed for charges above Moda’s reimbursement determination
Note: Deductibles and OOP’s will apply up and down the network tiers
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National PPO Plan Design
2015 Design
Tier 1 : ODS/Plus
Connexus or PHCS
Tier 2: OON /
Non-Contracted**
$500 / $1,500
$500 / $1,500
Coinsurance*
20%
40%
Office Visit
$25
$40
OOP Max (Med)
$3,500 / $7,000
$4,250 / $8,750
OOP Max (Rx)
$1,500 / $2,500
$1,500 / $2,500
Feature
Deductible
* Member coinsurance
** Member will be balance billed for charges above ODS Plus/Connexus PHCS’ reimbursement determination
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2015 Pharmacy Changes
Retail
(30 day supply)
Mail-Order
(90 day supply)
Specialty
(30 day supply)
$6
15%, $200 max from 10%, $100
max
25%, $200 max from 20%, $100
max
50%, $300 max from 33%, $100
max
N/A
OHSU pharmacies
Value
$2
Select Generic (Tier 1)
20%, $100 max
Preferred (Tier 2)
30%, $100 max
Non-Preferred (Tier 3)
50%, $150 max from $100 max
25%, $100 max
25%, $100 max
50%, $100 max from $150 max
OPDP pharmacies
Value
$4
N/A
N/A
Select Generic (Tier 1)
25%, $10 min & $100 max
N/A
25%, $100 max
Preferred (Tier 2)
35%, $10 min & $100 max
N/A
25%, $100 max
50%, $10 min & $150 max from $100 max
N/A
50%, $150 max from $100 max
Non-Preferred (Tier 3)
Plan Year Out-of-Pocket Maximum
$1,500 individual max/$2,500 family max
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What about costs for 2015?
• Monthly medical premiums for 2015 will increase:
– Kaiser Permanente rates will be about 5 percent
higher; OHSU PPO, Regional Medical Home and
National plan rates will increase between 2 and 9
percent depending on coverage level.
• OHSU’s monthly benefit contribution:
– Benefit contributions from OHSU (“benefit dollars”) will
increase for the majority of employees, and have been
adjusted to be equitable across all employee
classification groups (AFSCME, ONA, Unclassified).
• Monthly dental premiums
– No change
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2015 Costs, continued
• Some changes to deductibles and co-insurance
depending on plan, including prescription
• New tobacco surcharge
– $50 per month for any employee who uses tobacco or
covers a dependent who uses tobacco
• Wellness surcharge
– Same cost difference as 2014 but will show as a
surcharge rather than a different medical plan for
employees not meeting wellness requirements
• 5% of the medical premium
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Other changes
• Vision will be “unbundled” from medical
(except for Kaiser)
– Allows for dropping vision, keeping your
current vision coverage, or “buying up” to an
enhanced coverage
• The Hartford Insurance will provide all life
insurance and AD&D coverage
– One-time opportunity to increase coverage
without evidence of insurability
• New short-term disability option: 1/15
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Appendix
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What is a medical home?
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Standards for Care for a Medical Home
– Accessible: Care is available when patients need it.
– Accountable: Clinics take responsibility for their community and
provide quality care.
– Comprehensive: Patients get the care, information and services
they need to stay healthy.
– Continuous: Providers know their patients and work with them to
improve their health over time.
– Coordinated: Clinics help patients navigate the health care
system to get the care they need in a safe and timely way.
– Patient & Family Centered: Patients and families are the most
important part of health care. Care should draw on a patient’s
strengths to set goals, and communication should be culturally
competent and understandable for all.
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Current Synergy Providers – Examples
not exhaustive
Current Hospitals
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Oregon Health & Science University in
Portland Metro
PeaceHealth in SW Washington and
Lane County
Adventist Health in Portland Metro
Salem Health in Marion/Polk Counties
Legacy Health in Portland Metro and
SW Washington
Samaritan Health Services in
Linn/Benton Counties
Asante in Jackson and Josephine
Counties
Columbia Memorial Hospital (Astoria)
Mid-Columbia Hospital (The Dalles)
Tillamook General Hospital (Tillamook)
Current Clinics
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OHSU Clinics
Legacy Clinics
Portland Adventist Medical Center
The Portland Clinic
The Oregon Clinic
NW Primary Care Group
Pacific Medical Group
Tuality Clinics
Sellwood Medical Clinic
The Vancouver Clinic
Cascade Physicians PC
Womens’ Healthcare Associates LLC
Current Synergy Providers - Pediatrics
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Bernard Bueffel MD
Broadway Medical Clinic
Calcagno Pediatrics
Charlotte Ott MD
Childrens Medical Clinic of Newberg
Clackamas Pediatric Clinic
Dr Anandhi Mandi LLC
East Portland Pediatric Clinic
Evergreen Pediatric Clinic
GreenField Health System
Hillsboro Clinic LLC
Horizon Pediatrics PC
Integrative Pediatrics LLC
Jack Rosenberg MD
James Lubischer MD
James Resk MD PC
Jo Anne Nielsen MD PC
Joel Amundson MD
Kartini Clinic
Kathryn Todd MD
Kids First Pediatric Clinic
Legacy Clinics
Legacy Emanuel Hospital
Legacy Salmon Creek Hospital
Metropolitan Pediatrics
Northwest Acute Care Specialists
NW Newborn Specialists
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OHSU Hospitals and Clinics
Olson Pediatric Clinic LLC
Oregon City Pediatrics
Oregon Pediatrics - Happy Valley
Oregon Pediatrics - NE Portland
Oregon Pediatrics Meridian Park LLC
Pediatric Associates Of Gresham PC
Pediatric Associates of the NW
Pediatric Urgent Care
Physicians Medical Center
Ronald L Clarke MD LLC
Rose City Pediatrics LLC
Sandra Vilhauer MD
Scholls Pediatric Clinic, LLC
Sellwood Medical Clinic
Shannon Brigman MD
Sunset Pediatric LLC
SW Washington Medical Center
Tanasbourne Pediatrics LLC
The Childrens Clinic
The Doctors Luce Pediatrics LLC
The Portland Clinic
The Vancouver Clinic
Tuality Community Hospital
Virginia Garcia Memorial Health Center
West Linn Pediatrics
Westside Pediatric Clinic
Willamette Falls Pediatric Group PC
Zoom Care