Benefits Orientation - Video 2 - Health and Vision Insurance - YouTube

Welcome to the next video in the New  Employee Benefits Orientation series.  

In this video, we will cover the  health and vision insurance options.

As an employee, you are offered several  health insurance coverage options.  

We will cover each one in more  detail during this presentation.  

The health plan options include several HMO  choices, three Open Access Plans, the Quality Care  

Health Plan, and the Consumer Driven  health plan. Employees who wish to decline  

coverage may do so but must still complete  their enrollment in the MyBenefits portal.

The first of several options are the  Health Maintenance Organizations or HMOs.  

Available to you are the Health Alliance  HMO, the Aetna HMO, the Blue Cross Blue Shield  

HMO Illinois, and the Blue Cross Blue  Shield Blue Advantage HMO. The primary  

difference between the four HMOs will be  the network of providers and facilities.  

If you decide to enroll with an HMO,  we encourage you to review each plan  

and its providers to determine which one is the  best option for you. Currently, there are very few  

Blue Cross Blue Shield providers in McLean County  for our plans. We recommend thoroughly researching  

in-network providers and facilities before  selecting HMO Illinois or Blue Advantage HMO.

Members who elect an HMO plan will need to select  a primary care physician, or PCP, from a network of  

participating providers. A PCP can be a family  practice, general practice, internal medicine,  

pediatric, or OB/GYN physician. The PCP will direct  all healthcare services and will make referrals  

for specialists and hospitalizations. When care  and services are coordinated through the PCP,  

only a copayment will apply. Copay amounts  for in-network primary care office visits  

and specialist office visits are shown at the  bottom of the slide and are also found in the  

Benefit Choice book on the Orientation site  included in your Benefit Orientation email. 

There are no plan year deductibles for medical  services obtained through an HMO. Preventive  

care is paid at 100% when services  are received through a network provider.  

If you are someone who travels outside of the  area regularly or has a dependent who lives out  

of the area, we encourage you to review each plan  to determine whether it will suit your needs as  

HMOs require the use of in-network providers  with the exception of emergency situations.  

Each of the HMOs offers coverage for  mental health and substance abuse services.

When electing an HMO on the MyBenefits portal,  you will need to identify a PCP for yourself  

and any dependent covered by the plan. Health  Alliance and Aetna require you to provide the  

NPI number for the provider you select. This is  a 10-digit number that can be found by reviewing  

in-network providers on the plan's website. The  two Blue Cross Blue Shield plans require you to  

enter the 3-digit facility code associated  with your selected provider. This number can also  

be found by reviewing in-network providers on the  plan's website. You can find the websites and phone  

numbers for each of the health plans by reviewing  the "Plan Administrator Contact Information"  

link on the Benefit Orientation page. Further  information on specific benefits can be  

found by reviewing the Benefit Choice  book on the Benefit Orientation page.

Each HMO offers prescription coverage. You  will not receive a separate insurance card  

to use for prescription benefits. Instead you  will just provide your health insurance card  

when picking up a prescription. Prescriptions have  an annual deductible per enrollee, which resets  

on the plan year each July 1st. The current year  deductible is shown at the bottom of the screen  

and is also found in the Benefit Choice book on  the Orientation site included in your Benefit  

Orientation email. After the deductible has been  met, prescriptions are available for copays based  

on the tier that the drug falls into. Each HMO will  have its own qualifying list of drugs to determine  

the tier and cost of the prescription. Preventive  prescriptions are available with no copay.  

There is also a reduced tier 1 pharmacy benefit  for HMO members. Certain medications are available  

for a reduced copay when obtained in either a 30  or 90-day supply. Please contact your health plan  

administrator to learn more about this benefit  and which medicines apply to the reduced copay.

The next type of plan we'll discuss  are the Open Access Plans or OAPs.  

There are three choices for OAPs. You can  select either Healthlink OAP, Aetna OAP,  

or Blue Cross Blue Shield of Illinois OAP. Just  like the HMOs, we encourage you to review each OAP  

and its provider network to determine  which one is the best option for you.  

The primary difference between the three OAPs  will be the network of providers and facilities.

Open access plans combine  similar benefits of an HMO  

with the coverage offered under a  traditional health insurance plan.  

Members who elect an OAP may choose from three  tiers of providers when obtaining services.  

The benefit level is determined by the tier in  which the healthcare provider is contracted.  

Members enrolled in an OAP can  mix and match providers and tiers.  

Preventive care is paid at 100% without having to meet the annual  

deductible when services are obtained  through a Tier 1 or Tier 2 provider.  

Each OAP offers coverage for mental  health and substance abuse services.

Tier 1 offers a managed care network,  which provides enhanced benefits.  

Tier 1 benefits require copayments that  mirror typical HMO plan copayments,  

but do not require a plan year deductible. The  current copayments for Tier 1 primary care and  

specialist office visits are shown on the screen  and are also found in the Benefit Choice book  

on the Orientation site included  in your Benefit Orientation email.

Tier 2 offers another managed care network  which provides enhanced benefits in addition  

to the managed care network offered in Tier  1. Tier 2 requires copayments, coinsurance,  

and is subject to a plan year deductible which  resets on July 1st each year. The current plan  

year deductible is shown on the screen and  is also found in the Benefit Choice book  

on the Orientation site included  in your Benefit Orientation email.

Tier 3 covers all providers outside of the managed  care networks of Tiers 1 and 2. Using Tier 3 can  

offer members flexibility in selecting healthcare  providers but involves higher out-of-pocket costs.  

Tier 3 has a higher plan year deductible and has  a higher coinsurance amount than Tier 2 services.  

The current plan year deductible is shown  on the screen and is also found in the  

Benefit Choice book on the Orientation site  included in your Benefit Orientation email.  

In addition, certain services, such  as preventive and wellness care,  

are not covered under Tier 3. Furthermore,  members who use out-of-network providers will  

be responsible for any amount that is over and  above the charges allowed by the plan for services  

(called allowable charges), which could result  in much higher out-of-pocket costs. When  

using out-of-network providers, a member should  obtain preauthorization of benefits to ensure  

that medical services meet medical necessity  criteria and are eligible for benefit coverage.  

Members who use providers in Tiers 2 and 3 will  be responsible for the plan year deductible. In  

accordance with the Affordable Care Act, Tier  2 and 3 deductibles will not 'cross accumulate,' 

which means that the amounts paid toward the  deductible in one tier will not apply toward the  

deductible in the other tier. It is also important  to note that there is not an out-of-pocket  

maximum for Tier 3 services. However, there is a  combined out-of-pocket maximum for Tiers 1 and 2.  

The current plan year out-of-pocket combined  maximum for individual and family is shown on  

the screen and is also found in the Benefit  Choice book on the site included in your  

Benefit Orientation email. Further information  on specific benefits for the current plan year  

can be found by reviewing the Benefit Choice  book found on the Benefit Orientation website.

Each OAP offers prescription coverage.  

You will receive a separate prescription  card to use when filling a prescription.  

Regardless of the tier used, an annual prescription  deductible applies for each member and dependent,  

in addition to applicable copayments, coinsurance,  and medical deductibles. The current plan year  

deductible per enrollee for prescriptions is  shown on the screen and is also found in the  

Benefit Choice book on the Orientation site  included in your Benefit Orientation email.

Each plan will have its own qualifying list of  drugs to determine the cost of the prescription  

copay after the deductible has been met. Preventive  prescriptions are available with no copay.  

Prescriptions may be filled at an in-network  pharmacy or through the plan's mail order program.  

OAPs require a mandatory maintenance medication  program. If you have a prescription that has  

been determined a mandatory maintenance  medication, you are required to fill that  

prescription at an in-network pharmacy or  through the CVS Caremark mail order program.  

Prescriptions filled through this program as a  90-day supply can be received at a reduced copay.

The Quality Care Health Plan is the  third option available to employees.  

The plan is administered by Aetna and offers  access to a nationwide network of providers. Under  

the Quality Care Health Plan, members can choose  any physician or hospital for medical services;  

however, they receive enhanced benefits, resulting  in lower out-of-pocket costs, when receiving  

services from a Quality Care network provider. An  annual deductible per participant, which resets  

on July 1st each year, applies to this plan and  varies based upon the member's annual salary.  

After the deductible has been met, most  services are paid at 85 % up to an  

out-of-pocket maximum. When using out-of-network  providers, a separate deductible applies,  

and services are usually paid at 60% of allowable  charges. The current plan year deductible range and  

out-of-pocket maximums are shown on the screen for  in-network and out-of-network and are also found  

in the Benefit Choice book on the Orientation  site included in your Benefit Orientation email.  

Preventive care is paid at 100% without  having to meet the annual deductible  

per participant when services are  obtained through a network provider.  

Notification to Aetna is required for certain  medical services in order to avoid penalties.  

The Quality Care Health plan also offers coverage  for mental health and substance abuse services.

The Quality Care Health Plan offers prescription  coverage. You will receive a separate prescription  

card to use when filling a prescription. An annual  prescription deductible applies for each member  

and dependent, in addition to applicable  copayments, coinsurance, and medical deductibles.  

The current plan year deductible per enrollee  is shown on the screen and is also found in the  

Benefit Choice book on the Orientation site  included in your Benefit Orientation email.

The plan has a qualifying list of drugs to  determine the cost of the prescription copay  

after the deductible has been met. Preventive  prescriptions are available with no copay.  

Prescriptions may be filled at an in-network  pharmacy or through the plan's mail order program.  

The Quality Care Health Plan requires a mandatory  maintenance medication program. If you have a  

prescription that has been deemed a mandatory  maintenance medication, you are required to fill  

that prescription at an in-network pharmacy  or through the CVS Caremark mail order program.  

Prescriptions filled through this program as a  90-day supply can be received at a reduced copay.

The final health plan available to choose from  is the Consumer Driven Health Plan. This plan is a  

high deductible health plan as defined by the IRS.  The Consumer Driven Health Plan is administered  

through Aetna and has the same network of  providers as the Quality Care Health Plan.  

Under the Consumer Driven Health Plan, members  can choose any physician or hospital for  

medical services; however, they receive enhanced  benefits, resulting in lower out-of-pocket costs,  

when receiving services from a network provider.  

An annual deductible per participant, which  resets on July 1st each year, applies to this plan.  

After the deductible has been met, most services  are paid at 90% up to an out of pocket maximum.  

When using out-of-network providers,  a separate deductible applies,  

and services are typically paid at 65% of allowable  charges. The current plan year deductibles for  

in-network and out-of-network are shown  on the screen and are also found in the  

Benefit Choice book on the Orientation site  included in your Benefit Orientation email.

Preventive care is paid at 100% without having  to meet the annual deductible per participant  

when services are obtained  through a network provider.  

Notification to Aetna is required for certain  medical services in order to avoid penalties. The  

Consumer Driven Health Plan also offers coverage  for mental health and substance abuse services.

The Consumer Driven Health Plan  offers prescription coverage.  

You will receive a separate prescription card  to use when filling a prescription in this plan.  

The plan has a qualifying list of drugs to  determine the cost of the prescription. Preventive  

prescriptions are available with no copay and are  not subject to the plan year medical deductible.  

In addition, other certain prescriptions or  supplies that are considered preventive per  

IRS guidelines are covered at 90% and  do not require the medical deductible to be met.  

Other types of prescriptions are  typically covered at 90%  

after the plan year medical  deductible has been met.  

Prescriptions may be filled at an in-network  pharmacy or through the plan's mail order program.  

The Consumer Driven Health Plan requires  a mandatory maintenance medication program.  

If you have a prescription that has been  deemed a mandatory maintenance medication,  

you are required to fill that  prescription at an in-network pharmacy  

or through the CVS Caremark mail order program.  

Prescriptions filled through this program as a  90-day supply can be received at a reduced rate.

A benefit is available every 24 months for  hearing instruments and related services  

through all health plans when a hearing care  professional prescribes a hearing instrument.  

Members should contact their insurance plan  provider for additional details on this benefit.

Vision coverage is provided at no additional cost  to members enrolled in any of the health plans.  

All members have the same vision coverage  regardless of the health plan selected. Eye exams  

and replacement lenses are covered once every  12 months from the last date the exam benefit  

was used. Standard frames are available once every  24 months from the date last used. Copayments are  

required for in-network services, and allowances  are provided for out-of-network services. The plan  

administrator for the vision benefit is EyeMed. You  may visit in or out of network providers with EyeMed  

but will usually have lower out-of-pocket  costs when visiting an in-network provider.

This completes the health and vision video in  the New Employee Benefit Orientation series.  

Please continue to the next video to learn  more about the benefits available to you.