MASC Regional Meeting Overview Employee Insurance Program 803-734-0498 (Products, Legal, and Policy)
Dec 24, 2015
Disclaimer
BENEFITS ADMINISTRATORS AND OTHERS CHOSEN BY YOUR EMPLOYER WHO MAY ASSIST WITH INSURANCE ENROLLMENT, CHANGES, RETIREMENT OR TERMINATION AND RELATED ACTIVITIES ARE NOT AGENTS OF THE EMPLOYEE INSURANCE PROGRAM AND ARE NOT AUTHORIZED TO BIND THE EMPLOYEE INSURANCE PROGRAM.
THIS PRESENTATION CONTAINS AN ABBREVIATED DESCRIPTION OF INSURANCE BENEFITS PROVIDED BY OR THROUGH THE EMPLOYEE INSURANCE PROGRAM. THE PLAN OF BENEFITS DOCUMENTS AND BENEFITS CONTRACTS CONTAIN COMPLETE DESCRIPTIONS OF THE HEALTH AND DENTAL PLANS AND ALL OTHER INSURANCE BENEFITS. THEIR TERMS AND CONDITIONS GOVERN ALL BENEFITS OFFERED BY OR THROUGH THE EMPLOYEE INSURANCE PROGRAM. IF YOU WOULD LIKE TO REVIEW THESE DOCUMENTS, CONTACT YOUR BENEFITS ADMINISTRATOR OR THE EMPLOYEE INSURANCE PROGRAM.
THE LANGUAGE USED IN THIS PRESENTATION DOES NOT CREATE AN EMPLOYMENT CONTRACT BETWEEN THE EMPLOYEE AND THE AGENCY. THIS PRESENTATION DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS. THE AGENCY RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS PRESENTATION, IN WHOLE OR IN PART. NO PROMISES OR ASSURANCES, WHETHER WRITTEN OR ORAL, WHICH ARE CONTRARY TO OR INCONSISTENT WITH THE TERMS OF THIS PARAGRAPH CREATE ANY CONTRACT OF EMPLOYMENT.
Review of Informational Materials
• Insurance Benefits Guide• Local Subdivision Handbook• List of participating counties and
municipalities• Plan comparison matrices• Cafeteria plan matrix
Local Subdivision Handbook and Application
Eligibility• Established by statute
Section 1-11-720 of the 1976 S.C. Code of Laws, as amended
Local Subdivision Handbook and Application
Participation Requirements• Minimum of four years
participation
• 90 days notice of intent to withdraw
• Minimum of four years before returning
• Must offer all EIP benefits to all eligible employees
Local Subdivision Handbook and Application
Participation Requirements• Designate a Benefits Administrator
• Verify eligibility of employees
• Make good-faith effort to notify eligible retirees, terminated employees, and surviving dependents of deceased employees/retirees
Local Subdivision Handbook and Application
Funding Requirements•Make same contribution as the state for employees and their dependents
•$3 administrative fee per employee
• Initial experience ratings <100 covered lives: 1.2% 100-500 covered lives : 2.2% >500 covered lives: 4.3%
Local Subdivision Handbook and Application
Submission Deadline and Fees• Submission of application to EIP by
February 15
• $500 non-refundable application fee
MASC Orientation
Support Resources• On-site orientation and training
• Continuing training programs
• Employee Benefits Services (EBS) online inquiry/enrollment system
• Multi-media education materials
• Other web-based resources
Frequently Asked Questions and Important Considerations
• Are HMO enrollees required to elect and disclose their PCP at time of enrollment? No
• How is the plan year determined? EIP’s plan year is always based upon the calendar year
• Does the State have an employee assistance program? No
• Does it cost extra for employers or employees to use the services of EIP’s Prevention Partners unit? There is no additional cost to the employer for Prevention Partners programs; however some workshops and programs may be offered at minimal fee to the employees and their dependents.
Frequently Asked Questions and Important Considerations
• What control does the employer have over which plans are offered? A participating employer must offer all EIP programs to employees and also must allow employees to elect any levels of coverage.
• Does the state administer its own COBRA? Employers are responsible for the day-to-day administration of COBRA continuation coverage. EIP offers many resources to support this function.
• Are elected members of participating county and city councils eligible to participate? Those elected members who contribute to the South Carolina Retirement Systems are considered full-time employees and are eligible
Overview
EIP Benefit Programs• Health Plans• Dental Plans• Vision Plan• Life Insurance• Long Term Disability• Long Term Care• MoneyPlu$ (Pre-tax programs)
Eligibility
Active Employee• Must be employed in permanent,
full-time position
• Work at least 30 hours per week unless Employed as a part-time teacher (only
eligible for health, dental, vision and MoneyPlu$)
Employed by employer who allows coverage for 20-hour employees
Retired Employee• Must meet certain
requirements to continue coverage in retirement
• EIP will accept Benefits Administrator certification of eligibility
Eligibility
Eligible Spouse• Spouse or former spouse* if
coverage is court-ordered
• Cannot cover spouse who is eligible for benefits through EIP as active employee or funded retiree
Eligibility
* Documentation required to cover a former spouse
Eligibility
Eligible Children• Under age 26*• No access to insurance
through employer of child or child’s spouse
• Approved for incapacitation*
* To be eligible for Dependent Life-Child, a child age 19-24 must be a full-time student or certified incapacitated
Enrollment
October Enrollment Periods• Annual Enrollment (Every year)
Change health plans Enroll in or drop State Vision Plan Enroll or re-enroll in MoneyPlu$
programs• Open Enrollment (Odd-numbered years, i.e., 2011, 2013)
Enroll in or drop health, dental or Dental Plus
Add or drop eligible dependents
Overview
Health Plan Options• State Health Plan
Standard Plan
Savings Plan
• HMO BlueChoice HealthPlan HMO
CIGNA HMO
Common to Both• Worldwide coverage
• In- and out-of-network benefits
• Pharmacy network
• Online access available www.SouthCarolinaBlues.com
State Health Plan Standard Plan and Savings Plan
Limited Preventive Benefits*
• Routine mammogram
• Pap test
• Well child care
• Routine colonoscopy
State Health Plan Standard Plan and Savings Plan
* Refer to the 2011 Insurance Benefits Guide for plan guidelines
Preauthorization• Medi-Call
Required for specific services, including maternity care
If pre-authorization is not obtained, penalties apply
$200 per inpatient admission Related charges do not satisfy any
portion of the annual coinsurance maximum
State Health Plan Standard Plan and Savings Plan
Standard Plan
Annual Deductible $350 individual $700 family
Out-of-network Coinsurance Plan pays
60%
Subscriber pays 40%
Coinsurance Maximum $4,000 individual
$8,000 family
In-network Coinsurance Plan pays 80%
Subscriber pays 20%
Coinsurance Maximum $2,000 individual
$4,000 family
Deductibles and Coinsurance
Standard Plan
Per-occurrence Deductibles $10 Office visit
$75 Outpatient facility service
$125 Emergency room visit
Network Retail
Pharmacy*
(up to 31-day supply)
$ 9 Tier 1 $ 30 Tier 2 $ 50 Tier 3
MedcoMail Order*
(up to 90-day supply)
$ 22 Tier 1 $ 75 Tier 2 $125 Tier 3
Retail Maintenance Network
Prescription Drug Benefits
$2,500 maximum copayment per person
Standard Plan
*”Pay the Difference” applies
Annual Deductible
$3,000 individual
$6,000 family
Out-of-network Coinsurance Plan pays
60%
Subscriber pays 40%
Coinsurance Maximum $4,000 individual
$8,000 family
In-network Coinsurance Plan pays 80%
Subscriber pays 20%
Coinsurance Maximum $2,000 individual
$4,000 family
Deductibles and Coinsurance
Savings Plan
Savings Plan
Rules• Subscriber pays 100% of
Allowable charges in-network
Actual charges out-of-network
Allowable charges at network pharmacies
• After deductible is met, Plan will reimburse subscriber 80% of allowable charges
Savings Plan
Added benefits• Annual flu shot
• Annual physical that includes specific services
• Eligibility to contribute to Health Savings Account (HSA)
HMOs
Requirements• Must live or work in HMO
service area
• Must choose Primary Care Physician (PCP) in network and receive referrals before seeing specialist
• Only out-of-network benefit is emergency care
BlueChoice HealthPlan (Available in all South Carolina counties)
BlueChoice HealthPlan HMOAvailable in all South Carolina Counties
Coinsurance Maximum
$2,000 individual
$4,000 family
Annual Deductible
$250 individual
$500 family
Network Coinsurance Plan pays 85%
Subscriber pays 15%
Deductibles and Coinsurance
BlueChoice HealthPlan(Available in all South Carolina counties)
Annual Benefits Maximum $2,000,000
BlueChoice HealthPlan(Available in all South Carolina counties)
Provider:
$15 PCP $15 OB-GYN $40 specialist $35 urgent care
Plan pays 100% after copay
Facility:
$100 outpatient $125 ER $200 inpatient
Plan pays 85% after copay
Copays
Network Retail Pharmacy
(up to 31-day supply)
$ 8 Lower-cost generic
$ 15 Higher-cost generic
$ 35 Preferred brand
$ 55 Non-preferred brand
$ 80 Preferred brand specialty
pharmaceuticals
$125 Specialty pharmaceuticals
Mail Order (up to 90-day supply)
$ 20.00 Lower-cost generic
$ 37.50 Higher-cost generic
$ 87.50 Preferred brand
$137.50 Non-preferred brand
BlueChoice HealthPlan (Available in all South Carolina counties)
CIGNA HMO
CIGNA HMOAvailable in all South Carolina counties except Abbeville,
Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda
Coinsurance Maximum $2,000 individual $4,000 family
Annual Deductible
None
In-network Coinsurance Plan pays
80% Subscriber pays 20%
Deductibles and Coinsurance
CIGNA HMOAvailable in all South Carolina counties except Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda
Copays
Provider
$15 PCP $15 OB-GYN $30 specialist $100 ER
Plan pays 100%after copay
Hospital
$250 outpatient $500 inpatient
Plan pays 80%after copay
CIGNA HMOAvailable in all South Carolina counties except Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda
Mail-Order (up to 90-day supply)
$ 14 generic $ 50 preferred brand $100 non-preferred brand
Network Retail Pharmacy (up to 30-day supply)
$ 7 generic $25 preferred brand $50 non-preferred brand
CIGNA HMOAvailable in all South Carolina counties except Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda
Tobacco Surcharge• $40 per month for subscribers• $60 per month for subscribers who
cover at least one dependent
• Automatically charged unless certify no one uses tobacco
• May certify by completing paper Certification Regarding Tobacco Use form
Tobacco Surcharge
State Dental Plan
Features• Free to choose dentist
• No pre-existing condition exclusions
• Two year plan – may not drop or change until next open enrollment
• $1,000 maximum benefit per year
* $25 Combined Deductible for Classes II and III
Classes of Services Class I Preventive
services 100% of fee
schedule
Class III*
Prosthodontics 50% of fee schedule
Class IV Orthodontics (only
children younger than 19; $1,000 lifetime maximum)
Class II*
Basic services 80% of fee
schedule
State Dental Plan
Dental Plus
Features• Supplement to Basic Dental
• Higher allowance for Class I, II and III services
• Combined maximum benefit of $2,000
• May enroll in or cancel coverage during open enrollment
State Vision Plan
Vision Care Services• Eye exams
• Frames
• Lenses
• Contact lens services and materials
• Discounts on LASIK and PRK vision correction
State Vision Plan
Providers• In-network
No claims to file Pay copayment and charges above the
plan’s allowance
• Out-of-network Pay provider for service EyeMed will reimburse you for a
portion of expenses for certain services* Locate a provider on EIP’s web site or by calling EyeMed at 877-735-9314
State Vision Plan
Eye Exams• $10 copayment
• Standard contact lens fitting No copayment
• Premium contact lens fitting 10% discount and
$55 allowance toward discounted price
State Vision Plan
Eyeglasses• Frames every 2 years
$140 allowance*
20% discount off balance
• Lenses every year $10 copayment for single vision,
bifocal, trifocal and lenticular plastic lenses
$45 copayment for standard progressive lenses
*Cannot be combined with any other promotion or discount
State Vision Plan
Contact Lenses*
• Every 12 months
• Conventional lenses $130 allowance 15% discount off balance
• Disposable lenses $130 allowance
• Declining balance* Subscriber may choose either eyeglass lenses or contact lenses, but not both in the same plan year.
Vision CareDiscount Program
Features
• No enrollment or premium
• Discount program
• Participating providers only $60 for routine eye exam – excludes
contact lens exam
20% discount on eyewear except disposable contact lenses
Basic Life
Basic Life
• $3,000 term life insurance to all eligible employees under age 70
• Premium paid by employer
• Employees enrolled in any health plan are covered
• Accidental death and dismemberment benefits
Optional Life
Optional Life• Premium based on amount of
coverage and employee’s age• Coverage up to three times salary if
enrolled within 31 days of employment
• Medical evidence required for additional coverage
• Maximum coverage level of $500,000
Dependent Life
Child coverage• $15,000 per child
• Premiums ─ $1.24 per month, regardless of number of children covered
• Can enroll eligible children throughout the year without medical evidence of good health
Dependent Life
Spouse coverage• New hire can enroll spouse for
$10,000 or $20,000 without medical evidence of good health
• Premiums based on employee’s age and amount of coverage
• Employee is beneficiary • May enroll in up to 50% of
employee’s Optional Life coverage with medical evidence
Basic Long TermDisability Insurance
Basic Long Term Disability (BLTD)
• Premiums paid by employer
• Employee automatically enrolled with selection of a health plan
• 62.5 percent benefit, up to $800 per month
• 90-day waiting period
Supplemental Long TermDisability Insurance
Supplemental Long TermDisability (SLTD)
• Provides protection for employee if annual salary exceeds $15,360
• Benefit – 65% of monthly salary up to $8,000 per month
• Choice of two plans 90-day waiting period
180-day waiting period
Supplemental Long TermDisability Insurance
Enrollment in SLTD• New hire may enroll without
providing medical evidence of good health
• Late entrant must provide medical evidence of good health to enroll
• Employee pays premium – based on monthly salary, plan chosen and age
Long Term Care
Features
• Benefits paid when subscriber, for at least 90 days: Is unable to perform at least two
activities of daily living (ADL) or
Has severe cognitive impairment requiring ongoing help or supervision
Long Term Care
Eligible Participants• Active full-time permanent
employees and their Spouse, parents, parents-in-law,
grandparents, grandparents-in-law, siblings, adult children (and their spouses)
• Retirees and their spouse
• Surviving spouses
Long Term Care
Premiums• Based on
Age at time of purchase Selected plan
• Paid directly to Prudential -- subscriber may continue coverage upon retirement or leaving employment
MoneyPlu$
Features• Pretax premiums
• Medical Spending Account (MSA)
• Dependent Care Spending Account (DCSA)
• Health Savings Account (HSA)
MoneyPlu$Pre-tax Premium
Pretax Premiums• Health• Dental and Dental Plus• State Vision Plan• First $50,000 of Optional Life • Tobacco Surcharge• $0.28 monthly administrative fee
MoneyPlu$Medical Spending Account
Medical Spending Account (MSA)
• Employed for one year before participating
• $5,000 maximum annual contribution
• $3.50 monthly administrative fee
• “Use it or lose it” account
MoneyPlu$Medical Spending Account
Eligible expenses include• Deductibles, coinsurance
and copayments
• Medically necessary expenses
• Prescribed medications, approved OTC medications with prescription, approved OTC items
MoneyPlu$Dependent Care Spending Account
Dependent Care Spending
Account (DCSA)
• $5,000 maximum contribution
• $3.50 monthly administrative fee
MoneyPlu$Dependent Care Spending Account
Eligible expenses• Day care fees
• Care for qualified individuals in your home or someone else’s home
• Summer day camps
MoneyPlu$Health Savings Account
Health Savings Account (HSA)• Employee must be enrolled in the
SHP Savings Plan
• Money deposited into account carries forward from year to year
• Account is portable
• Fees $1 per month to FBMC $1 per month ($10/year) to NBSC
Health Savings AccountLimited-Use Medical Spending Account (MSA)
Limited-Use MSA• Must be employed for one year
• Only used for dental and vision care expenses
• $5,000 maximum contribution
• $3.50 monthly administrative fee
• “Use it or Lose it” account