Lou-Ann Milton Regional Relationship Specialist

Lou-Ann MiltonRegional Relationship Specialist

WelcomesThe Diocese of Virginia

to our Membership

The Episcopal Church Medical Trust

Agenda

• The Episcopal Church Medical Trust– Medical Plans– Additional Benefits

• Wellness• Resources• Questions


• Chartered by General Convention in 1978

• Report to Church Pension Fund Trustees

• Voluntary Employees’ Beneficiary Assn (VEBA)

• ERISA-exempt, free of most state benefit mandates

• Tax-favored not-for-profit church plan


Our Mission …

“Balancing compassionate

Christian benefits with financial stewardship”

Who Can Participate?

• Salaried (exempt) clergy and lay employees

• Hourly employees working a minimum of 20 hours/week (1,000 hours/year)

• Dependent children to age 30

• Employees on short-term or long-term disability

The Medical Trust – Serving You

We are here to support you with:

• Problem Resolution• Education and Awareness• Patient Advocacy

Our Client Engagement Team is availableMonday through Friday8:30 am to 8:00 pm ET

1-800-480-9967 / [email protected]

Your 2011 Medical Plan Choices

Network Only Plans• CIGNA HMO• Empire BCBS EPO 90• Empire BCBS EPO 80• Kaiser EPO 80• UnitedHealthcare Choice 80

Network & Out-of-Network Plans• Empire BCBS High Option PPO• Aetna Choice POS II• Empire BCBS PPO 80/60• Empire BCBS HDHP/HSA

All Plans – Preventive Care

Routine & Preventive Services

•$0 Copay Network

•Benefits include covered services received in a physician’s office such as:

– Routine Exams– Well-Woman and Well-Man exams– Routine Exam X-Rays & Lab Services– Well-Child Checkups– Immunizations– Other Routine Services

Network Only Plans – (HMO)

Health Maintenance Organization

Basic Elements

•Primary Care Physician (PCP) required

•Referrals required for specialty care

•Out-of-Network benefits are NOT available (except in emergency situations)

CIGNA HMO

administered by

CIGNA

Medical Trust Plan

$0 Preventive$20 (PCP or Specialist)

Office visit copay

0% Member coinsurance

$250Outpatient hospital copay

$350 per admissionInpatient hospital copay

$0 / $0Annual OOP max (single/family)

$0 / $0Annual deductible (single/family)

NetworkPlan Provision

CIGNA HMO – At a Glance

Kaiser EPO 80 (Kaiser HMO platform)

administered by

Kaiser

Medical Trust Plan

$0 Preventive$25 PCP, $35 Specialist

Office visit copay


20%Outpatient hospital coinsurance

20%Inpatient hospital coinsurance

$3,000 / $6,000Annual OOP max (single/family)

$500 / $1,000Annual deductible (single/family)


Kaiser EPO 80 – At a Glance

Network Only Plans – (EPO)

Exclusive Provider Organization

Basic Elements

•No Primary Care Physician (PCP) required

•No referrals required for specialty care

•Out-of-Network benefits are NOT available (except in emergency situations)

Empire BCBS EPO 80 Empire BCBS EPO 90

administered by

Empire BlueCross BlueShield

Medical Trust Plans


Office visit copay







Empire BCBS EPO 90 – At a Glance


Office visit copay







Empire BCBS EPO 80 – At a Glance

UHC Choice 80

administered by

UnitedHealthcare

Medical Trust Plan


Office visit copay





$1,000 / $2,000Annual deductible (single/family)


UHC Choice 80 – At a Glance

Network & Out-of-Network Plans – (PPO)

Preferred Provider Organization

Basic Elements



•Out-of-Network benefits are available, however you pay less when using a network provider

Empire BCBS High Option PPOEmpire BCBS PPO 80/60

administered by


Medical Trust Plans

Empire BCBS High Option PPO – At a Glance

30%$0 Preventive

$30 (PCP or Specialist)Office visit copay/coinsurance

$150 copay

$150 copay per admission

0%

$0 / $0

$200 / $500

Network

30%Member coinsurance

30%Outpatient hospital copay/coinsurance

30%Inpatient hospital copay/coinsurance



Out-of-NetworkPlan Provision

Empire BCBS PPO 80/60 – At a Glance

40%$0 Preventive


20%

$100 copay per day,$600 max per

admission; then 20%

20%

$1,500 / $3,000

$500 / $1,000

Network





$1,000 / $2,000Annual deductible (single/family)


Aetna Choice POS II(Functions as a PPO plan)

administered by

Aetna

Medical Trust Plan

Aetna POS II – At a Glance

30%$0 Preventive


10%

$100 copay per day,$600 max per

admission; then 10%

10%

$1,000 / $2,000

$250 / $500

Network







High Deductible Health Plan partnered withHealth Savings Account

Basic Elements

•Traditional PPO Plan



•Out-of-Network benefits are available, however you pay less when using a network provider

•Designed to be partnered with Health Savings Account

Consumer Directed Health Plans

•Thinking like consumers when it comes to health care and taking on more responsibility for:

– Improving health– Managing costs – Making health care

decisions when choosing coverage during enrollment and using coverage throughout the year

Visible Cost of Health Care

Real Health Care Costs

Employees can begin…

Empire BCBS HDHP/HSA

administered by


Medical Trust Plan

Empire BCBS HDHP/HSA – At a Glance

$4,000 / $7,000$1,500 / $3,000Annual coinsurance max – single/family(combined with Rx & MH/SA)

45%0% Preventive

20%Office visit coinsurance

20%

20%

20%

$4,200 / $8,450

$2,700 / $5,450

Network




$7,000 / $13,000Annual OOP max – single/family(combined with Rx & MH/SA)

$3,000 / $6,000Annual deductible – single/family(combined with Rx & MH/SA)


What are Health Savings Accounts?

• Tax-advantaged savings account for qualified healthcare expenses

• Employee sets up the account and owns it

• Balances accumulate and roll over year after year

• Portable from employer to employer

• Act like an IRA or 401(k) for healthcare expenses

• May be invested

• Account must be held by a qualified trustee

• Anyone can make a contribution to employee’s HSA on an annual basis:– Employer, employee, others

What are Health Savings Accounts?

• IRS sets annual limits on contributions:– $3,050 single / $6,150 family for 2011– Employee is responsible to ensure the maximum is not

exceeded

• May be set up by individuals who:– Are covered by a qualifying HDHP– Are not covered by other health insurance (with few

specific exceptions)– Cannot be claimed as a dependent on someone else’s

tax return– Are not eligible for Medicare

How to create an HSA

• Empire BCBS – Medical Trust has relationship with Mellon Bank

• Enrollment information received from Empire– Complete enrollment card and return to Mellon Bank– Complete enrollment online

• Contributions to HSA cannot be made until enrollment is complete– Contributions take time to process

• May use a qualified banking institution of your choice

• Distributions are tax free if made for qualified healthcare expenses

• Other distributions are subject to federal income tax and an additional 20% penalty

• Distributions do not have to be made in any year

• Distributions can be made for the qualifying healthcare expenses of dependents

• Distributions can be made even after the employee is no longer eligible to contribute to an HSA

Health Savings Account Distributions

How are Distributions Made?

• At point of service:– Use the HSA debit card– Write a check from the HSA account– Use own funds and reimburse from HSA (or not)

• Caution:– You must keep records to prove the distributions from

the HSA were used for qualifying medical expenses– You are responsible for any overdraft fees on the HSA

Pharmacy Benefits by Medco

Medco Pharmacy Tiers

What are the three tiers?

Generic: Same active ingredients as the brand-name it replaces. Binder may differ.

Formulary: A list of brand-name drugs preferred by a plan based on clinical effectiveness and cost. (Also called “Preferred Brand Name”)

Non-Formulary: Brand-name drugs not on your plan’s formulary. (Also called “Non-Preferred Brand Name”)

Up to a 30-day supply (retail)Up to a 90-day supply (mail order)

Up to a 90-day supply


Dispensing Limits Per Copayment

You pay 50% after deductibleUp to $120Up to $50Copays Tier 3: Non-Formulary

You pay 25% after deductibleUp to $70Up to $30Copays Tier 2: Formulary

You pay 15% after deductibleUp to $25Up to $10Copays Tier 1: Generic

$2,700 per person$5,450 per family(combined with Medical & MH/SA)

none$50 per person

Annual Prescription Deductible

Retail & Mail OrderMail OrderRetail

HDHP/HSAStandard Plan

Medco Pharmacy – At a Glance

Mail Order for Maintenance Medications

• Mail Order required for maintenance medications– 3 fills covered at retail pharmacy– After 3rd fill mail order required

• Mail Order is easy, convenient, accurate– Member can mail, or doctor can fax– Refills by phone or online– Email reminder for refills

• Up to triple the supply for less than triple copay– Controls costs for both member and plan

• Example:– Brand name costs $90– Generic costs $30– Generic copayment is $10– $90 (brand name) - $30 (generic) = $60– $10 copay + $60 difference = $70– Member pays $70

“Generic or Pay the Difference”

If you cannot use a generic medication for a medical reason, call us to discuss

Be Proactive!

• Talk to your doctor about your Rx plan– Discuss the Medco Formulary– Ask for generic drugs when available

• Review your prescriptions– Are Mail Order prescriptions for 90 days?– Did your doctor indicate “DAW” (Dispense as

Written)?

Prescription Benefits Managed by Medco

Behind-the-Scenes

• Coverage Management Program– Majority of medications are filled immediately– Some medications fall under this program

• Coverage Review Process ensures:– Reasonable Cost – Safety– Medical Efficacy– Ongoing monitoring for drug interactions

Prescription Benefits Managed by Medco

• Step therapy required for certain medications– Utilizes evidence based medicine– Certain medications will be dispensed only after

others have been tried and failed

• Prior authorization required for certain medications– Based on need– Based on quantity

• If there is a question, a pharmacist will contact your doctor

• The process is more seamless if your doctor is willing to work with Medco

Kaiser Pharmacy Benefits

Kaiser Pharmacy Tiers

Generic: Same active ingredients as the brand-name it replaces. Binder may differ.

Formulary: A list of brand-name drugs preferred by a plan based on clinical effectiveness and cost. (Also called “Preferred Brand Name”)

Kaiser EPO 80 Pharmacy – At a Glance

Up to a 30-day supply (retail)Up to a 90-day supply (mail order)


Dispensing Limits Per Copayment

$30/Up to 30 days$60/Up to 90 days

$30CopaysTier 2: Formulary

$10/Up to 30 days$20/Up to 90 days

$10 CopaysTier 1: Generic

nonenoneAnnual Prescription Deductible

Mail OrderRetail

KaiserPlan Provision

Mail order recommended but not required for maintenance medications

Additional Benefits

• Mental Health / Substance Abuse

• Employee Assistance Program

• Health Advocate

• EyeMed Vision

• MEDEX

• HearPO

• Plan Partner – CIGNA Behavioral Health*

• Thirty years experience

• Extensive mental Health Provider Network

• Out-of-Network MH/SA benefits in MT Plans*

• Employee Assistance Program (EAP)

Mental Health / Substance Abuse Benefits

*Kaiser and Empire BCBS HDHP have only EAP through CIGNA Behavioral Health; MH/SA benefits are embedded in their plan designs

Changes for 2011

• Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 extends the Mental Health Parity Act of 1996

• Pre-certification mirrors medical

• Pre-authorization is required after 20 visits in the calendar year to any provider for a medical necessity check

• Shares out-of-pocket maximums with medical

• Annual deductibles do not apply to MH/SA benefits*

Mental Health / Substance Abuse Benefits

*Kaiser and Empire BCBS HDHP have only EAP through CIGNA Behavioral Health; MH/SA benefits are embedded in their plan designs

• 10 in-person sessions per issue with no copay

• Unlimited telephonic sessions

• Multiple episodes of treatment per year

• Extensive geographic availability of services

• Household benefit

Employee Assistance Program (EAP)

Employee Assistance Program (EAP)

Assistance with Family Care Services

– Child care– Parenting programs– Adoption information– Long-distance care-

giving– Assistance in

researching nursing homes

– Pet insurance programs

Online Services– Emotional Well-Being and Life

Events– Family and Care Giving Resources– Health and Wellness Resources– Daily Living Resources– Email assisted search

Personal Services– 30-minute free legal consultation– Stress management– Debt management– Identity Theft Assistance

Health Advocate

•Personal Health Advocate, typically RNs, who work with a team of medical directors and administrative experts

•Facilitate member interactions with healthcare providers, insurance plans and other community resources

•Assist members with: – finding doctors, hospitals and other healthcare

providers– resolving claims, billing and administrative problems

with providers– issues encountered while accessing the healthcare

system

•Household benefit and available to parents and parents-in-law

Vision

• Administered by EyeMed

• Annual eye exam – $0 network copay

• Annual benefit for:–Frames–Lenses or–Contact lenses

• Broad-based PPO network–Retail chains– Independent provider locations

EyeMed Vision – At a Glance

Plan pays up to$100

$130 allowance,then you pay

balance over $130

Contact LensesDisposable

Plan pays up to$100

$130 allowance,15% off balance

over $130

Contact LensesConventional

Plan pays up to$47

$130 allowance,20% off balance

over $130Frames

Plan pays up to$32$46$57

You pay$10

Lensessingle visionbifocaltrifocal

Plan pays up to$30

You pay $0Eye Exam

Out-of-NetworkNetworkPlan Provision

MEDEX and HearPO

MEDEX• Access to Medex Assistance Corporation• Provides 24/7 Emergency Medical AdvocacyNote: MEDEX is not responsible for medical costs while you are traveling.

HearPO• Access to HearPO network discount

Online Open Enrollment

Tips for Selecting Your Plan

• Enrollment Guide

• Historical Usage

• Current Needs

• Covered Benefits

• Provider Choice & Availability

• Premiums vs. Out-of-Pocket Costs


Please printfor your records

Complete survey at the end!

WellnessMaking a Case for Healthy Lifestyles

Episcopal Church Medical Trust Wellness Definition:

• Wellness is an active, lifelong process of becoming aware of choices and making decisions that will enable a person to achieve the best possible level of physical, mental and spiritual well-being.

• It is an approach to healthcare that emphasizes preventing illness and prolonging one’s quality of life, as opposed to emphasizing treating diseases.

Wellness Definition continued…

• Wellness is not the absence of illness, but an individual’s active process of managing or achieving their full potential. This quality of life definition can be applied to anyone regardless of any physical or mental limitations.

• A more extensive definition of wellness must acknowledge that family, workplace, church, community and the world in which one lives, have the potential to both positively and negatively influence or impact ones level of well-being.

75% of healthcare costs are attributable to chronic conditions caused by

modifiable risk factors – primarily obesity, sedentary lifestyles, and

smoking.

Centers for Disease Control

The Impact

Taking Control of Our Health

Living a healthy lifestyle is not just a good idea it, has become a national imperative

The New ‘Fountain of Youth’

• Physical activity is one of the greatest bargains this world has ever known

• Exercise is as close to a magic bullet as anything we have ever seen

• If physical activity were a pill it would be the single most effective medicine

• By walking 30-45 minutes on most or all days you can delay disability by 10-12 years

• Physical activity affects: learning, stress, anxiety, depression, attention deficit and addiction

Taking Control of Our Health

Benefits of Exercise:

• Regular exercise improves levels of quality sleep

• Reduces stress

• Increases resistance to fatigue

• Gives you more energy

• How long does it take for the body to begin experiencing the benefits of exercise? About 30 seconds!

Can we improve our overall health?

Medical Trust Promotes Healthy Changes

• The biggest impact we can make as a nation to our healthcare dilemma is by making lifestyle changes.

• Small Changes, Big Difference– 16 month campaign to raise awareness and encourage healthy lifestyle

changes

• Recent studies show small changes can have significant impact on one’s overall health.

• Being aware of your health status is the first step – know your numbers! – Blood pressure– Glucose– Cholesterol

What is one thing you can do in the next 24 hours…

…..that will start you on the path to better health?

Health & WellnessA Lifelong Journey not a Destination

Resources

Your ID Cards

Our Vendors’ Websites

Getting Help: Contacts

• Aetna – (877) 235-4005– www.aetna.com

• CIGNA– (800) 244-6224– www.cigna.com

• Empire BlueCross BlueShield– (800) 352-3152– www.empireblue.com/medicaltrust

• UnitedHealthcare– (866) 204-8533– www.myuhc.com

• Kaiser Permanente – Mid-Atlantic States: (877) 740-4117– http://my.kp.org/ecmt

Getting Help: Contacts

• Medco – (800) 841-3361– www.medco.com

• CIGNA Behavioral Health (& EAP)– (866) 395-7794– www.cignabehavioral.com

• EyeMed– (866) 723-0596– www.eyemedvisioncare.com

• Health Advocate– (866) 695-8622– www.healthadvocate.com

• MEDEX– (800) 527-0218– www.medexassist.com

• HearPO– (888) 432-7464– www.hearpo.com

The Medical Trust Website

www.cpg.org

Forms & Publications /

Publications /

Health Plans

Client Engagement

We are here to serve our membersMonday through Friday:

8:30am to 8:00pm Eastern

Telephone Direct Toll Free1-800-480-9967

Email: [email protected]

Best problem resolution sequence for help:

• 1st: Call Vendor for most benefit related issues• 2nd: Call Health Advocate • 3rd: Call Medical Trust

Warning signs of good health….. ☺

1. Increased awareness & appreciation of yourself

2. Tendency to set aside time each day to relax or meditate

3. Persistent ability to maintain close relationships

4. Chronic appetite for physical activity and healthy food

5. Acute and chronic attacks of laughter

6. Repeated bouts of hope and optimism

7. Recurrent rejection of worry

8. Chronic condition of caring for your bodySource: McDermott & O’Conner, South Portland, Maine

Thank You ~Questions?

78

This presentation is provided for your informational purposes only. In the event of a conflict between the information contained in this presentation and the official plan documents, the official plan documents will govern. The Church Pension Fund and its affiliates retain the right to amend, terminate or modify the terms of any benefit plans described in this presentation, consistent with applicable law.

Lou-Ann Milton Regional Relationship Specialist

Documents

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