2014-2015
Employee Benefits Annual Open Enrollment Presentation
Annual Enrollment
February 1, 2014 – January 31, 2015
Our insurance plans are designed to help you attain the health
and dental services you need on a regular basis as well as to
protect you against a catastrophic financial loss in the event of
a serious health condition, disability or death. They represent
a significant part of the total compensation package you have
with Lindley Habilitation Services. Please review the employee
benefits package carefully, and don’t hesitate to ask
questions.
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Overview
Introduction
Medical Plan
• Payroll Deductions
• Medical Benefits/Features
• Claims Examples
Other Benefits
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Dental
Vision
Health Advocate
Colonial
Things to Remember
What’s Next
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HR, Senn Dunn, & Health Advocate
Please contact Human Resources as your primary source of contact for
any benefit-related questions or concerns.
If for some reason, the Human Resources staff is not available, please
contact Health Advocate. These are clinical staff, mostly nurses, that
can help you with claims, benefits questions, ID cards, etc.
You may also contact Senn Dunn, our Employee Benefits Advisors.
Senn Dunn has dedicated Account Managers available to assist you
with you with any questions or concerns regarding your benefits.
Senn Dunn Insurance
Employee Benefits Services
855.313.1075
ebservices@senndunn.com
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866.695.8622
members.healthadvocate.com
Annual Open Enrollment
• Medical Benefits start over February 1, 2014
• Annual Open Enrollment each year is your only opportunity to
make changes, unless you experience a mid year qualifying
event
• Everyone enrolled in Medical or Dental will receive a new BCBS
and/or Ameritas ID card. Open ALL mail over the next few
weeks.
• If your enrollment, or any change, requires any additional
information, HR will let you know.
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2014-2015 Medical Payroll Deductions
Semi-Monthly
Rates
Monthly
Rates
Employee Only
$ 69.85
$ 139.70
Employee + Spouse
$ 221.03
$ 442.05
Employee/ Child(ren)
$ 205.12
$ 410.23
Family
$ 404.04
$ 808.08
Benefit Enhancements:
No increase in employee premiums
LHS will help employee with their deductible
Office copays now count towards out of pocket max
No more Pre-existing conditions
Better Provider Network, even on the Coast
We have no annual or lifetime maximum on our medical benefit
Health Advocate can help you keep costs down
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Healthcare Reimbursement Arrangement- HRA
If your Deductible related expenses exceeds
$2,000, you will submit your EOB from BCBS
to LHS HR and they will cut you a check to
reimburse you up to the remaining $1,000 of
Deductible
Examples:
1. If your deductible related expenses are $800,
you will receive no HRA reimbursement
2. If your deductible related expenses are
$2,700, then HR will reimburse you $700
Medical Plan Benefits
Benefit Overview
Medical
Individual Deductible
Family Deductible
Coinsurance
Individual Coinsurance Maximum
Family Coinsurance Maximum
Individual total Out-of-Pocket Maximum
Family total Out-of-Pocket Maximum
Lifetime Maximum
Physician Services
Primary Care Office Visits
Specialist Office Visits
Wellness & Preventive
Routine Physical Exams
Routine Eye Exams
Pap/ Mammograms/ PSA
Immunizations
Colonoscopies (Preventive Only)
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BCBS Plan
$3,000
$6,000
($2,000 after Lindley reimburses the last $1,000)
($5,000 after Lindley reimburses the last $1,000)
20% or 40%
$3,350
$6,700
$6,350
($5,350 after Lindley reimburses the last $1,000 of EE Ded)
$12,700
($11,700 after Lindley reimburses the last $1000 of EE
Ded)
Unlimited
$20 Copay
Deductible + 40%
100% Covered
100% Covered
100% Covered
100% Covered
100% Covered
Medical Plan Benefits
Benefit Overview
BCBS Plan
Lab and X-Ray
In Office
Out of Office
MRI, CAT & PET
$20 PCP, or Deductible + Coinsurance if SPC visit
Ded then 40% Coinsurance
Ded then 40% Coinsurance
Inpatient Services
Physician
Hospital
$250 admission Copay then Ded + 20% Coins
Ded then 20% Coinsurance
Outpatient Services
Physician
Hospital
Ded then 40% Coinsurance
Ded then 40% Coinsurance
Other Services
Emergency Room Services
Urgent Care Co-pay
Chiropractic Care
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Ded then 40% Coinsurance
Ded then 40% Coinsurance
Ded then 40% Coinsurance, up to 30 visits
Prescription Drug Benefits
Benefit Overview
BCBS Plan
Prescription Drugs (30-day supply)
Tier 1 (Generic)
$10 Copay
Tier 2 (Preferred Brand)
You pay 100% up to $100
Tier 3 (Brand)
You pay 100% up to $100
Tier 4 (Specialty Brand)
You pay 100% up to $100
Mail Order (90-day supply)
Tier 1 (Generic)
$30 Copay
Tier 2 (Preferred Brand)
You pay 100% up to $300
Tier 3 (Brand)
You pay 100% up to $300
Tier 4 (Specialty Brand)
You pay 100% up to $300
Don’t forget to Check Walmart, Walgreens, Target, Costco, Sam’s
Club etc. for their $4 generics list
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Claims Example: Preventive Exam
Employee Only
Coverage
• Fairly healthy individual
whose only medical care
for the year was a
preventive exam with a
primary care physician
$300 annual preventive
exam
TOTAL Cost = $300
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BCBS Plan
Preventive Exam
Spends out-of-pocket
Covered 100%
$0
Claims Example: Common Illness
Employee Only
Coverage
Overall healthy individual with a
couple sick care office visits and
prescriptions throughout
the year (e.g., sinus infection,
strep throat)
$160 annually in office visits
BCBS Plan
Preventive Exam
Covered 100%
Office Visits
$40 (2 copays)
Prescription Costs
$30 (3 copays)
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•
Estimated 2 office visits (not
preventive) at contracted rate
of $80 each
$300 annual preventive exam
$45 annually in Rx
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Estimated 3 generic medications
at $15 each
TOTAL Cost= $505
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Spends Out-of-pocket
$70
Claims Example: Common Illness
Family Coverage
• Overall healthy family with a
few sick care office visits and
prescriptions throughout the year
(e.g., sinus infection, strep throat)
$480 annually in office visits
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Estimated 6 office visits
(not preventive) at contracted rate
of $80 each
$1,200: 4 Annual Preventive
Exams
$270 annually for Rx
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Estimated 6 generic medications
at $15 each
Estimated 3 preferred brand name
medications at $60 each
TOTAL
Cost = $1,950
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$270 towards
BCBS Plan
Preventive Exams
Covered 100%
Office Visits
$120 (6 copays)
Prescription Costs
Spends Out-of-pocket
$240 (6 generic copays and
$60 each for the 3 Brand
medications)
$360
Claims Example: Chronic Condition
Employee Only
Coverage
• Chronic condition such as high
blood pressure or diabetes that
requires several office visits and
medications throughout the year
$1,360 annually for office visits
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Estimated 8 office visits (2 PCP
average $80 each & 6 specialist
average $200 each
$300 Annual Preventive Exam
$1,440 annually for Rx
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Estimated 4 monthly generics
average $15 each & 1 monthly
preferred brand average $60
TOTAL Cost = $3,100
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BCBS Plan
Preventive Exam
Covered 100%
Office Visits
$1,240 (2 PCP copays and $200
each for the 6 SPC visits)
Prescription Costs
$1,200 (4 generic copays per
month and $60 per mo for the
one brand medication
Spends out-of-pocket
$2,440
Claims Example:
Chronic Condition, ER, and IP stay
Family Coverage
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Chronic condition such as high blood
pressure or diabetes that requires
several office visits and medications
throughout the year
BCBS Plan
Preventive Exams
Office Visits
$2,720 annually for office visits
•
Estimated 16 office visits (4 PCP,
average $80 each & 12 SPC average
$200 each
$1,200 4 Annual Prev Exams
$1,300 ER visit
$19,000 Inpatient Stay
$3,840 annually for Rx
•
Estimated 8 monthly generics average
$15 each & 2 monthly Non-preferred
brand average $100 each
TOTAL Cost = $28,060
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Prescription Costs
Covered 100%
$3,280 (4 PCP copays… $3,200
towards Deductible- 16 SPC visits)
$3,680 (8 generic copays per month
and $100 per mo for the two brand
medications
Emergency Room Visit
$1,300 towards Deductible
Inpatient Hospital Stay
$5,250: ($250 admission copay,
then $1,500 remaining Deductible,
then $3,500 Coinsurance --20% of
the remaining $17,500)
Lindley HRA Deductible
Reimbursement
- $1,000
Spends Out-of-pocket
$12,510
Dental Plan Benefits: Ameritas
Benefit Overview
Benefit Maximum Per Year
Preventive Care
Routine Exam, 2 Cleanings per Year, Flouride Treatments and
Emergency Pain Relief
Deductible
Basic Services
Diagnostic X-Rays, Fillings, Some Oral Surgery, and Extractions
Major Services 12 month wait
Endodontics, Periodontics, Crown, Bridges, Dentures, Implants
Benefit Carryover ** New Benefit
Orthodontia 12 month wait
$1,250 per Member
Covered 100% of Usual & Customary
$50 annual per member
$150 annual family maximum
Benefits are paid at 80% of Usual &
Customary Pricing
Benefits are paid at 50% of Usual &
Customary
As long as you receive at least one dental
service during the year… you may be able to
carryover up to $250 of any remaining unused
benefit, into the following year.
Covered at 50% up to a lifetime Maximum
coverage of $1,250
Please always Keep UCR (Usual, Customary, and Reasonable) pricing in mind.
If your charges will be more than $250, it is always wise to obtain a benefit estimate.
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Voluntary Vision Coverage: Community EyeCare
In Network
Copays
Comprehensive Exam
Contact Lenses
Contact Lens Fitting
Lenses (single/bifocal/trifocal/lenticular)
Frames
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Exam:$10 – Glasses:$25
Covered in full, once per year
Up to $130, once per year
$25 Copay
Covered in full, once per year
Up to $130, once per year
Voluntary Worksite Benefits: Colonial
Accident Plan
• This provides a lump sum benefit based on the type of injury (or covered
incident) you sustain or the type of treatment you need. Examples of covered
injuries include: broken bones, torn ligament, concussion, etc.
Short Term Disability Plan
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This will pay when a disability occurs, depending on the amount of the policy
that you purchase. This can ease the burden of additional medical expenses
as well as lowered income while out of work.
Critical Illness Plan
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This can help fill the gaps in major medical coverage, and pays directly to
you, a lump sum benefit upon the diagnosis of a covered critical illness.
Cancer Policy
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This can help fill the gaps in major medical coverage, and pays directly to
you, a lump sum benefit upon the diagnosis of cancer.
Things to remember:
• Please turn in your election form to HR, no later than Friday January
31st. You need to turn in your form even if you are declining all
voluntary benefits, or making no changes
• Colonial packets have been sent to each location, Speak to Colonial if
you wish to make any changes or enroll.
• This has been a summary overview of employee benefits
provided/offered by Lindley Habilitation Services – See Plan Documents
for details
• The updated 2014 Benefit Summary booklet and your election form,
both of which were emailed to you, and have both been posted to the
LHS website.
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