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Benefits Choices 2009 Open Enrollment

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  • Welcome to Open Enrollment Benefits Choices for 2009. Introduce yourself. Again, Sandia is offering you the option to change your medical plan anytime between October 20 th and November 10 th for effective coverage on 1/1/2009. Remember that if you are in the UHC HDHP or CIGNA Premier PPO, you need to make a new selection. The OE Change Form is on page 61 of your booklet Please hold your questions until the end of the presentation so that we can get all our vendor to come help answer your questions.
  • If you didn’t receive your packet, we may not have your correct address. Please stop by the Sandia table in the lobby to write down your address so we can update your records. We have extra supplies of these items at the Sandia table in the lobby. If after you leave here today, you realize that you didn’t pick up a copy of this information, you may call Benefits Customer Service at 844-4237. Of course, the Open Enrollment website is also available. Please call us anytime to make an address change when you move.
  • This is what we will be covering today…
  • We have eliminated two plan options for non-Medicare retirees: UHC High Deductible Health Plan with 8 subscribers CIGNA Premier PPO with 56 subscribers Read: We made some copay and coinsurance changes as described under each plan in your booklet Catalyst Rx is now the Pharmacy Benefit Manager under both UHC and CIGNA. Waiver of prescription drug coverage is not longer an option Dental Care Plan replaces the Dental Expense Plan Eligibility: We removed the financially dependent requirement for dependent children under age 24 – refer to the OE booklet for Tax Treatment under for “qualifying child” or “qualifying relative” to determine whether your dependents’ coverage is taxable. Contact your Tax Advisor to determine tax treatment and if you determine that you dependent’s benefits are taxable contact Sandia Benefits. New Class 2s will not be eligible for coverage (pg. 37), but current Class 2s will be allowed to continue coverage.
  • This will be a high-level overview since you can refer to your OE booklet and Chart for details. You can always call the plan’s Members Services if you think of any questions on coverage after you leave here today. The vendor Contact List is on page 49 of your OE booklet.
  • These are the two plan options available to non-Medicare retirees. Here is an example how the networks are different in NM under those two plans.
  • Deductible is the amount you need to meet before the plan will begin providing coverage for those services that are co-insurance based. Office visits and Rx drug copays do not go towards the deductible so you don’t need to meet the deductible to get coverage for OV copays. Out-of-pocket means that once you hit this amount the plan will pick up 100% of the eligible expenses for the remainder of the year Coinsurance – the percentage on the screen is the amount the member pays, the plan pays the other percentage. By definition, coinsurance will vary according to the price of the service – it is not a set amount like a copay Copay is a set amount – e.g., $20 for an office visit Other definitions are in the OE booklet on pages 43 through 46.
  • Here are the copay/coinsurance changes for the UHC plan. All the changes are listed under each plan in your OE booklet.
  • Here are the copay changes for the CIGNA In-Network Plan. All the changes listed under each plan in your OE booklet.
  • The following do not apply to the Out-of-Pocket Maximum: Charges for noncovered health services Reduction in benefit for non-compliance with pre-certification requirement Out-of-network behavioral health service Charge that exceed eligibile expenses Prescription Drug Program
  • This will be a high-level overview since you can refer to your OE booklet and Chart for detailed. The vendor Contact List is on page 49 of the OE booklet.
  • In-network Rx benefits review. This information is on pages 12 thru 14 of the OE booklet. Go over Rx drug retail copays Preferred brand means that it is listed on the plan’s formulary. Drugs are put on the formulary after being evaluated for cost, therapeutic merit, practice patterns, etc. Non-preferred brand drugs are not on the vendor’s formulary and will cost you more
  • The Specialty Drug Management Program drugs are listed on pages 57 thru 59 of the OE booklet. The Mandatory Specialty Program provides significant savings: those drugs are usually highly priced and limiting scripts to 30 days will help in reducing waste due to intolerance to a specific drug You will get personalized help by a certified technicians in specialty drug use and counseling
  • Read slide.
  • You can begin to register in the Mail Service Program beginning January 1, 2008, after your eligibility data has been loaded. You can register by mail by completing the form included in your Catalyst Welcome packet, or you may call Catalyst to register, or you can register online with Catalyst: The instructions for their website will be included in the “Welcome” packet. You must register first to obtain refills. The following will require new prescriptions from your doctor: Compound medications Controlled substances Expired prescriptions Prescriptions without remaining refills and future fill prescriptions. For those CIGNA members that have mail order prescriptions, you may want to order your refills (TelDrug for CIGNA members) no later than mid-December if you’re going to run out of pills in early January. I believe you can get refills 25 days before your prescription runs out. Check your prescription bottle to make sure.
  • This table is identical to the OE Change Form. It lists the medical plan combination options (during OE) for families that have members that are Medicare eligible as well as members that are not Medicare eligible. You’ll see that the Presbyterian MediCare PPO has no corresponding plan for non-Medicare eligibles.
  • Provider networks – Do you use Lovelace or Pres doctors; Do you use facilities outside of NM? Benefit coverage – Does the plan cover a particular service you may need (e.g., acupuncture and behavioral health), Does it have any limitation on coverage? In/out-of-network coverage – Do you want flexibility to go outside the network or does this matter? Copays vs. coinsurance – Are payments for service through a fixed copay or through coinsurance which varies depending on the cost of service Coverage while on travel – How does the plan provide coverage while you are on travel such as for emergency, urgent care, or follow-up care – you might need both internationally and within the US depending on where you travel? Dependent coverage – What plan is my spouse eligible for? Remember, all members of your family must be Medicare-eligible to enroll in the Presbyterian Medicare. Check out the premiums for all the plans in the booklet starting on page26 of the OE booklet.
  • Screen shot of how it looks on the web.
  • The plan will automatically include the number of service you will need according to your health requirements. You can change any number you’d like. Screen shot also.
  • Calculation of your costs for medical care needs according to plans.
  • The Dental Care Plan is coinsurance based instead of a fixed coverage amount. More information on the Dental Care Plan is on pages 24 and 25 of your OE booklet.
  • Delta Dental has two networks: a PPO network and a Premier network.
  • So, how can I get the most from my benefits under the medical plans..
  • Stay in the network because network providers charge you a discounted rate while the out-of-network can charge you their full rate.
  • Most likely your provider will do this if in-network...but you want to make sure they do as the onus is on the member
  • This list changes from time to time…your physician may access the latest list by calling 1-800-244-6224
  • IMPORTANT TO NOTE: if you waived medical coverage and as a retiree you die, your surviving spouse will not be allowed to enroll in any Sandia medical plan. The surviving spouse must have coverage with Sandia at the time of the retiree death to be eligible for continued coverage through Sandia
  • ID cards – Make sure that your providers have the new # on your ID card to process claims otherwise you may have claims problems.
  • Screenshot of OE website. Sandia’s open enrollment website on the external web for retirees…here you can access the retiree booklet, the change form,
  • Complete the OE change form especially those on the UHC High Deductible Health Plan and the CIGNA Premier PPO.
  • No changes, no action.
  • Vendor contacts list is on pages 49 and 50 of the OE booklet.
  • Other items that are in the OE booklet are: Option to waive coverage if you don’t want Sandia health plans coverage on pages 47 and 48 (when you waive coverage for yourself, you are also waiving for all your dependents. Preventive health reference guide to use when you go for you annual physical (make sure you tell each office you visit for those service that it’s your preventive care service that is covered at 100%. Medicare Part D Creditable Coverage Notice (keep in case you are waiving Sandia’s coverage and are getting coverage somewhere else or with a separate Medicare plan). That way you won’t have to pay a late enrollment fee for the rest of your life.
  • Transcript

    • 1. Non-Medicare Retirees October 20 - November 10, 2008 Benefits Choices 2009 Open Enrollment
    • 2. What Should I Have Received in the Mail?
      • Packet including:
      • Annual Open Enrollment Booklet (2009)
        • Open Enrollment Change Form
      • Medical Plans Comparison Chart
      • Self-addressed envelope
    • 3. Presentation Topics
      • What’s New for 2009
      • 2009 Medical Plans Overview
      • 2009 Prescription Drugs Overview
      • Choosing a Medical Plan
      • 2009 Dental Care Plan Overview
      • How to Get the Most from Your Benefits
      • Open Enrollment Information
      • Questions
    • 4.
      • Plans eliminated: UHC High Deductible Health Plan, and CIGNA Premier PPO
      • Plan design changes (e.g., copays and coinsurance as described under each plan)
      • Prescription drug coverage for CIGNA members change to Catalyst Rx
      • Waiver of prescription drug coverage no longer an option
      • New Dental Care Plan replaces Dental Expense Plan
      • Class I eligibility rules modified (OE Booklet, pg. 36-38)
      • New Class IIs no longer eligible
      What’s New for 2009?
    • 5. 2009 Medical Plans Overview
    • 6. Medical Plan Options for 2009 For details, review your 2009 OE Booklet and Medical Plan Comparison Chart UnitedHealthcare Premier PPO Plan CIGNA In-Network Plan Presbyterian Hospital/Doctors UNMH Independent Providers Lovelace Health System ABQ Health Partners UNMH Independent Providers
    • 7. Summarized Comparison * Does not include prescription drug coverage. Catalyst Rx Catalyst Rx Prescription drug coverage administrator Yes Yes National network coverage Primarily copay Primarily coinsurance Payment via No No Referrals to specialist required In-network only Both In- and out-of-network coverage $1500 per person/ $3000 family $1750 per person/ $3500 family Annual CY out-of-pocket (in-network) * None $250 per person/ $750 family Annual CY deductible (in-network) * CIGNA In-Network Plan UHC Premier PPO Plan
    • 8. UHC Premier PPO Plan Changes *Subject to deductible 15% * $25 copay Allergy Treatment Not covered $25 copay Hypnotherapy/biofeedback $1000 each maximum/CY $1500 combined maximum/CY ChiropracticAcupuncture (combined with out-of-network) $35 copay $25 copay Specialist Office Visit $20 copay $15 copay PCP Office Visit 2009 2008 In-Network
    • 9. CIGNA In-Network Plan Changes *Combined maximum of 60 visits per calendar year $30 copay $25 copay Allergy Testing $125 copay $100 copay Emergency Room Visit $75 copay $50 copay Ambulance $125 coopay $100 copay Outpatient Surgery Not covered $25 copay Hypnotherapy/biofeedback $20 copay $15 copay Speech, Physical, and Occupational Therapy * $20 copay $15 copay ChiropracticAcupuncture * $400 copay $200/day up to $500 Inpatient Admit $30 copay $25 copay Specialist Office Visit $20 copay $15 copay PCP Office Visit 2009 2008 In-Network CIGNA In-Network Plan
    • 10. What is Applied to Deductibles and Out-of-Pocket Maximums
      • CIGNA In-Network Plan
        • Copays (e.g., $20/PCP visit, $30/specialist visit) DO apply to the out-of-pocket maximum (except for Rx drug copays)
      • UHC Premier PPO Plan
        • Copays for PCP or specialist office visits (including Rx copays/coinsurance) are NOT applied to out-of-pocket maximum or to the deductible
        • Deductibles and coinsurance amounts ( e.g., 15%, 20%, 30%) DO apply to out-of-pocket maximums (with some exceptions)
        • Deductibles and out-of-pocket maximums are NOT cross applied between in-network and out-of-network benefits
    • 11. Emergencies, Urgent Care, Follow-up Care
        • Call 911 if you require immediate medical or surgical care or go to the nearest hospital!
          • If admitted, call member services within 48 hours or as soon as reasonably possible.
        • Emergencies are covered at the in-network benefit level worldwide under all plans as determined by the claims administrator.
          • UHC Premier PPO Plan
            • Urgent care and follow-up care benefit level (within USA) is according to the provider of service (in-network versus out-of-network provider)
            • Urgent care and follow-up care (outside USA) will be covered at the out-of-network benefit level
          • CIGNA In-Network Plan
            • Urgent care is covered worldwide
            • Follow-up care (within USA) is covered only if received from an in-network providers
            • Follow up care (outside USA) is NOT covered
    • 12. Eligibility Changes
        • Refer to IRS Code Section 152 or Publication 502, or consult your tax advisor for “qualifying child or qualifying relative” for health care coverage.
          • “ Financially dependent on you” has been eliminated and changed to “unmarried child under age 24”
          • Although dependent may be eligible for our plans, you are required to report to Sandia any dependents who do not meet the tax requirements as we will need to impute income on the premiums
            • Imputed income means that the full premium rate for your dependent shall be reported as taxable
          • Stepchildren of the primary covered member who lives with the primary covered member at least 50% of the calendar year, or if ages 19 through 23, is a full-time student.
    • 13. Ineligible Dependents
        • You must disenroll ineligible dependents within 31 calendar day of the event causing ineligibility
          • Consequence of failing to disenroll ineligible dependents:
            • Ineligible dependent’s coverage retroactively terminated
            • You will be held liable to refund to Sandia the health care plan claims or monthly premiums
            • Your dependent could lose any rights to temporary continued health care coverage (COBRA)
            • Sandia shall not be required to refund any premiums to the subscriber
    • 14. 2009 Prescription Drug Overview
    • 15. Summarized Rx Changes Mail Order (up to 90 day maximum supply) 30% with $25 min. and $40 max. $30 copay No change 30% with $25 min. and $40 max. Preferred Brand 40% with $40 min. and $60 max. N/A No change 40% with $40 min. and $60 max. Non-preferred Brand 20% with $12 min. and $24 max $20 copay 20% with $12 min. and $24 max $18 copay Generic 40% with $80 min. and $120 max. N/A 40% with $80 min. and $120 max. $100 copay Non-preferred Brand 30% with $50 min. and $80 max. $60 copay 30% with $50 min. and $80 max. $65 copay Preferred Brand 20% with $6 min. and $12 max. $10 copay No change 20% with $6 min. and $12 max. Generic Retail (up to 30 day maximum supply) 2009 2008 2009 2008 In-Network CIGNA In-Network Plan UHC Premier PPO
    • 16. Specialty Drug Program – New!
      • Specialty drug coverage through Walgreens/MedMark
      • Limited to 30 day supply at the preferred brand drug rate (30% with a $25 minimum and $40 maximum)
      • Drugs delivered via mail order through Walgreens/MedMark
      • Specialty Care Team
        • Making contact by December 15
        • Available Monday to Friday (6 a.m. to 5 p.m MST) at 866-823-2712
      • Specialty Drugs
        • Treatment for cancer, multiple sclerosis, HIV, hemophilia, etc.
        • Tend to be very expensive and require special monitoring
    • 17. Catalyst Rx Coverage – New Members
      • Catalyst has different preferred drug list so the status of your drug may change (e.g., from preferred to non-preferred)
      • Mail Service is provided by Walgreens Mail Service
        • Most prescriptions with open refills will be transferred to Catalyst/Walgreens
        • Certain prescriptions such as controlled substances cannot be transferred and will require a new prescription from your provider
        • Register with Walgreens Mail Service first before ordering refills through mail order
    • 18.
        • Welcome Kit mailed in mid-December
          • Letter with general info
          • ID cards (1/single; 2/family)
          • Preferred brand name listing (condensed version)
          • Pharmacies (major) listing (include Lovelace pharmacies)
          • Registration and prescription form
        • Present your new Catalyst ID card when getting a new prescription beginning January 1, 2009
        • Pharmacy Help Desk 1-866-854-8851 (available 24/7)
        • Website www.catalystrx.com – Username: SNL Password: SNL
        • Sandia external website at www.sandia.gov , Resources for…, Employees and Retirees, Retiree Open Enrollment
        • Catalyst reps will be available in the lobby
      Catalyst Rx Coverage – New Members
    • 19. Choosing a Medical Plan
    • 20. Open Enrollment Coverage Options Lovelace Senior Plan CIGNA In-Network Plan Presbyterian MediCare PPO No corresponding plan UHC Senior Premier PPO UHC Premier PPO Medicare-Member Plans Non-Medicare Member Plans
    • 21. What to Consider When Choosing a Medical Plan
        • Provider Networks (e.g., doctors, hospitals)
        • Benefits coverage
        • In-network and out-of-network coverage
        • Copays vs. coinsurance payment for services
        • Coverage while on travel
        • Dependent coverage
        • Premiums, if applicable
    • 22. How do I know which medical plan is best for me?
        • Want to choose the plan that gives you the most “bang for your buck”? Use the Medical Plan Estimator Tool!
          • Estimates your costs for both premiums and out-of-pocket expenses (deductibles, copays)
        • Located on Sandia external website: www.sandia.gov under Resources for…
          • Employees and Retirees
            • Retiree Open Enrollment
    • 23. Medical Plan Estimator Tool
    • 24. Medical Plan Estimator Calculation
    • 25. Dental Care Plan Overview
    • 26. 2009 Dental Care Plan Overview
      • Delta Dental remains the Administrator
      • Dental Care Plan (one plan)
        • Coinsurance coverage based on a percentage of the maximum approved fee:
          • 100% preventive care
          • 80% basic and restorative
          • 50% major and orthodontic
        • Deductible Maximum $50 individual/$150 family
        • Annual Maximum $1500 per person
        • Lifetime Maximum $1800 orthodontia
      • Premium-sharing if retirement after 12/31/2008
        • $8.00 for retiree only
        • $15.00 for retiree + 1
        • $20.00 for retiree + 2
    • 27. 2009 Dental Overview
      • The Dental Care Plan includes coverage enhancements:
      • Sealants covered for all dependent children under age 14
      • Benefits for specified (Endosteal) implant services
      • You can see any dentist in the Delta Dental PPO or the Delta Dental Premier or an out-of network dentist.
      • Your out-of-pocket costs will be lower if you see a Delta Dental PPO network dentist because those dentists have agreed to a lower maximum approved fee thus making your percentage portion lower.
      • If you see an out-of-network dentist, those dentists can balance bill you for any amount above the maximum approved fee for the Delta Dental Premier network.
      • Maximum approved fee is contracted fee between Delta Dental and the network providers.
    • 28. How to Get the Most from your Benefits
    • 29. Maximizing Your Benefits
        • Preventive Care – covered 100% by your plan
          • Annual Physical including CBC, urinalysis, metabolic profile, diabetes screening, thyroid screening
          • Pap Test, PSA Test, Mammography, Colonoscopy, Bone Density Testing at certain intervals
          • Immunizations, including flu shots
        • Prescription Drugs
          • Use Generics – much lower copays and costs for therapeutically equivalent medicines
          • Mail Order for maintenance medications – can save up to the cost of one 30 day prescription at retail and convenient delivery
        • Stay in the network!
        • Get any necessary pre-authorizations from the claims administrator) ahead of time
    • 30. UnitedHealthcare Pre-certification Requirements
      • UHC Plans – must call prior to certain services
        • Congenital heart disease services
        • Dental services stemming from an accident/injury/sickness
        • Durable medical equipment (DME) with a purchase/cumulative rental value of $1,000 or more (includes oxygen)
        • Home health care
        • Hospice care
        • Hospital inpatient stays
        • Reconstructive procedures
        • Air ambulance services
        • Skilled nursing facility/inpatient rehab
        • Transplant services
        • Certain behavioral health benefits
        • Failure to pre-notify will result in reduction of benefits by $300.
    • 31. CIGNA Pre-certification Requirements
      • CIGNA In-Network Plan
        • Ask your provider to handle this for in-network care
        • Services that need pre-certification include:
          • Hospital stay
          • Surgical procedures (inpatient or outpatient)
          • Acupuncture
          • Biofeedback
          • Dental service stemming from an accident or illness
          • Durable medical equipment (DME) including oxygen
          • External prosthetic appliances
          • Home health care
          • Hospice care
          • MRI, CT and PET scans
          • Varicose veins treatment, etc.
      • Failure to pre-certify will result in reduction of benefits by $300.
    • 32. Continuation of Coverage for Surviving Spouse
      • Medical Coverage
      • Coverage for surviving spouse and enrolled dependents is provided for six months, after retiree’s death, at the same premium-share rate that retiree paid
      • To continue coverage after six months, surviving spouse/dependents must elect continuation of coverage prior to the end of this six-months period
      • Continued coverage (7th month and beyond) cost is 50% of the full medical premium for the applicable medical plan (see pg 34 of OE booklet).
      • Continued coverage is available until surviving spouse remarries, dependent children become ineligible and/or coverage is terminated with Sandia
      • Premiums for 2009 can be located in the Open Enrollment Booklet
    • 33. Continuation of Coverage for Surviving Spouse
      • Dental Coverage
      • Dental coverage for surviving spouse and eligible dependents is discontinued at the end of the month of retiree’s death
      • Coverage may be temporarily continued (COBRA process), for up to thirty-six months, by paying the monthly COBRA surviving spouse/dependent group rate (2009 single rate – $38.00/month + 2% administrative fee)
    • 34. What Do I Do When I Turn 65?
        • Within a few months before reaching age 65…
          • Enroll in Medicare Parts A and B
            • Approximately 2-3 months before you turn 65, you should receive information from Sandia Benefits and Medicare
          • Once you reach age 65, the Retiree Medical Plan Option is available for transition as follows:
            • UHC Senior Premier PPO for aging-in UHC Premier PPO members
            • Lovelace Senior Plan for aging in CIGNA In-Network members, (must complete Lovelace enrollment paperwork to assign Medicare)
            • Lovelace Senior Plan for retirees whose spouse is already in this Plan (must complete Lovelace enrollment paperwork to assign Medicare)
            • Presbyterian MediCare PPO Plan for retirees whose spouse is already in this Plan (must complete Presbyterian enrollment paperwork to assign Medicare)
          • Coverage takes effect the first day of the month in which you reach age 65
          • Contact Medicare or your local Social Security office for Medicare Parts A and B information
    • 35. Open Enrollment Information
    • 36. Open Enrollment Process Tips
      • Review “Medical Plans Comparison Chart”
      • Review “Annual Open Enrollment” booklet for more information
      • Use the “Medical Plan Estimator Tool”
      • Complete “Open Enrollment Change Form 2009” (especially important for current members in the UnitedHealthcare High Deductible Health Plan or the CIGNA Premier PPO Plan)
        • Submit to Benefits by deadline of Nov. 10 th
      • Confirmations will be sent to only those who make changes
    • 37. OE website…
    • 38. To make a change…
    • 39. Do I Need to Take Action?
      • To continue under the Dental Care Plan
      • If you waived dental coverage previously and wish to remain in this status
      • To enroll if not currently enrolled
      • To add or disenroll a dependent
      Dental Coverage
      • To continue current medical plan coverage ( except UHC High Deductible Health Plan or CIGNA Premier PPO Plan )
      • If you waived medical coverage previously and wish to remain in this status
      • To elect new coverage if currently under the UHC High Deductible Health Plan or CIGNA Premier PPO Plan
      • To enroll if not currently enrolled
      • To change your current medical plan
      • To add or disenroll a dependent
      Medical Coverage No Action Action  
    • 40. Sandia Benefits Contacts
      • Sandia Open Enrollment website at www.sandia.gov Resources for…
        • Employees and Retirees
          • Retiree Open Enrollment
      • Benefits Customer Service Center
      • (505) 844-HBES (4237) or
      • (800) 417-2634, ext. 844-HBES (4237)
      • Fax # (505) 844-7535
      • If you have questions you can…
      • Send an email to [email_address] OR
      • Go to http://www.sandia.gov
        • click on Employees & Retirees
        • click on HBE Weekly Update
        • click on ? Get answers
    • 41. Open Enrollment Period October 20 – November 10, 2008 No changes to any of your open enrollment elections will be allowed after November 10th
    • 42. Questions ?