Union College

Health Care Assistance PlanNational Blue Card Network

September 6, 2005

Ellen EldridgeDirector, Health Care ServicesAdventist Risk Management

Health Care Assistance PlanPayment Limits

• Lifetime Plan Limit – Medical in total - $3,000,000– Infertility Treatment - $16,000– Refractive Eye Surgery - $2,400– Orthodontic Care - $2,300

• Plan Year Payment Limits– Hearing - $3,200– Durable Medical Equipment - $8,000– Vision - $560– Dental - $1,800 Individual; $3,680 Family

Health Care Assistance PlanMember Responsibility

• Co-pay each Office Visit - $15

• Deductible - $250 single / $500 family

• Out-of-Pocket (OOP)– Also known as Co-Insurance

– In-Network – 20%; $2000 single / $4000 family

– Out-of-Network – 35%; $4500 / $7000 family

Health Care Assistance PlanMember Responsibility

• Prescription Benefit– Retail

• 30-day supply

• $10 generic/$16 brand/$20 non-formulary

– Mail Order• 90-day supply

• $10 generic/$20 brand/$30 non-formulary

– Out-of-Pocket Maximum - $400 / $800

Health Care Assistance PlanMember Responsibility

• $15 Co-pay Office Visit

Urgent Care Centers

Mental Health Out-Patient Services– Professional Services Only (doctor’s fee)

– Plan pays 100% of office visit after co-pay

– Does not apply to deductible or OOP

– All other charges apply to deductible and OOP

– Plan pays 80% of these additional charges

Health Care Assistance PlanMember Responsibility

• Emergency Room– Applies to OOP– Does not apply to Deductible– Paid at 80%– $50 Co-pay/Deductible – waived if admitted

• Therapies PT, OT, Speech, Chiropractic, Acupuncture

– Plan year visit limits apply– Paid at 80%– Do not apply toward Deductible or OOP

Health Care Assistance PlanMember Responsibility

• Paid at 80%; Applies to Deductible and OOP– Out-Patient Services

– In-Patient / Out-Patient Hospital Stays• Medical• Mental Health• Substance Abuse

– Office / Ambulatory Surgical Procedures

– Ambulance Services

Claims PaymentExplanation of Benefits

Accumulators

Deductible

$150

Co-Insurance

$ 0

Charges Payment

Office Visit 200

Co-pay 15

Plan Pays 185

Lab Work 150

Deductible 150

20% Co-Insurance 0

Plan Pays   0

350 350

Claims PaymentExplanation of Benefits

Accumulators Deductible

$150

100

Co-Insurance

$ 0

25

Charges Payment

Office Visit 150

Co-pay 15

Plan Pays 135

X-Rays 225

Deductible 100

20% Co-Insurance 25

Plan Pays 100

375 375

Claims PaymentExplanation of Benefits

Accumulators

Deductible

$150

100

0

Co-Insurance

$ 0

25

300

Charges Payment

Out-Pt Surg $1,500

Co-pay $ 0

Deductible 0

20% Co-Insurance 300

Plan Pays 1,200

$1,500 $1,500

Blue Card PPO Network

• More than 650,000 providers nationwide

• More than 5,500 hospitals nationwide

• Medical claims processed by IBC

– 99.5 % Claim adjudication accuracy

– 93.0% Home plan claims – 10-day TAT

– 98.0% Host plan claims – 30-day TAT

Negotiation Process

• Contract is between ARM and Independence Blue Cross in Philadelphia

– Downstream contract between ARM and Client

• ARM negotiatied the PEPM Fee for all NAD participating employers

– Continues to use our large group advantages

Negotiation Process

• ARM remains Customer Service

– Access to Blue Cross system for customer service

– Single point of contact

– Continuation of historical knowledge

• NAD Health Care Plan design stays intact

• Medco Health remains our Prescription Benefits Manager

Blue Card PPO Network

• Home Plan– Independence Blue Cross

Philadelphia, Pennsylvania

• Host or Local Plan– Any Blue Cross Network outside Home Plan

where services are rendered

Blue Cross Claims Flow

OOA Provider►Local Plan►Home Plan►Local Plan►OOA Provider

• Includes the following services

– Transplant network– Utilization and case management coordinated

in 50 states– Out of the country coverage based on medical

necessity– Wellness Incentive Program

Overview

• NAD Plan - medical benefits remain intact• ARM continues to manage the Plan

– Consults with and recommends to NAD– no changes in organizational management

• Access to Blue Cross providers nation-wide• Single network / Single payor• Simplifies PPO management• Reduces claims payment staffing needs• Potential savings to NAD-wide medical

expenses by $15M - $18M• Wellness Incentive program at no cost

Benefits at a Glance

• No benefit changes as a result of Blue Card– All benefits remain the same– Medical claims are paperless, nationwide when

in-network

• ARM continues to pay dental and vision

• ARM continues to manage prescription plan

• No change in coordination or management

• ARM remains Customer Care service

Benefits at a Glance

Medical Services carved out of Blue Card NOT excluded benefits

WILL BE reimbursed by ARM

• Massage Therapy

Access BC therapist for significant discount

• Adult Immunizations - for travel or work

NAD Plan policy limits apply

Mail claims to PO Box 4759 Silver Spring MD

Value Added Benefits

• Childhood Immunizations– $15 office visit co-pay– Balance paid at 100%– Does not go to Deductible or OOP

• Mammography, pap screening– $15 office visit co-pay– Balance paid at 100%– Does not go to Deductible or OOP

• Therapies i.e. PT, OT, Speech– Apply to Deductible and to OOP

Value Added Benefits

• Healthy Lifestyles Incentive Programs– Fitness Program – Up to $150 reimbursement

– Weight Management - Up to $200 reimbursement for cost of Weight Watchers

– Safety Program - Up to $25 reimbursement of certificate for CPR or first aid course

– Adds no costs to employee or conference

Union College Health Care Costs

Benefit Year 2004-2005

Prd Allowable Discount Mbr Resp NetPaid

MM 1,290,671

288,019 156,378 846,274

DE 98,320

5 14,756 83,560

VI 50,436

121 10,056 40,259

RX 209,101 0 29,082

180,019

GT 1,595,186

288,145 210,272 1,150,112

North American Division Health Care Costs

Benefit Year 2004-2005

Prd Allowable Discount Mbr Resp NetPaid

MM 101,595,238 24,518,614 12,223,418 64,853,208

DE 11,867,432 12,873 2,177,796 9,676,761

VI 3,042,012 67,527 602,577 2,371,909

RX 14,574,371 - 1,950,649 12,623,723

GT 131,079,053 24,599,014 16,954,439 89,525,601

Union College2004-2005 Medical Expenses

• Benefit Year 2004-2005

– Allowable Charges $1,290,671– PPO Discounts 288,019– Member Responsibility 156,378– Net Paid by Employer 846,274– Effective PPO Discount 22.3%

Union CollegeBlue Cross Discounts

Blue Cross Discounts in Nebraska

In-Patient 34-49%

Out-Patient 21-26%

Professional 29-34%

Union CollegeMedical Expense Retrospect

• Benefit Year 2004-2005 -- If it had been under Blue Card

– Allowable Charges $1,290,671

– PPO Discounts 393,655

– Member Responsibility 134,552

– Net Paid by Employer 762,464

– Effective PPO Discount 30.5%

Union College Medical Expense Net Affect

• Benefit Year 2004-2005 -- Summary Net Affect

– Additional Savings $105,636– Net Employer Savings 83,810– Net Member Savings 8,062

References

• Provider look-up– www.ibx.com

• Provider search

• ARM’s Customer Care Service– (888) 276-4732– (888) ARM-4SDA

Questions – Concerns for Ellen

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Questions – Concerns for Ellen

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