Town of Hingham Health Plan Educational Information for

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Town of Hingham Health Plan Educational Information for Active Employees and Non-Medicare Retirees April

Town of Hingham Health Plan Educational Information for Active Employees and Non-Medicare Retirees April 2017

Agenda n n Overview Group Insurance Commission (GIC) Plans Health Maintenance Organization (HMO) Plan

Agenda n n Overview Group Insurance Commission (GIC) Plans Health Maintenance Organization (HMO) Plan ¨ Preferred Provider Organization (PPO) Plan ¨ Point of Service (POS) Plan ¨ Indemnity Plan ¨ n n Fiscal Year Deductibles Provider Tiering & Copays Mitigation Plan Selecting a GIC Plan 2

Overview n Town employees and retirees will receive their health insurance through the plans

Overview n Town employees and retirees will receive their health insurance through the plans offered by the Group Insurance Commission (GIC) starting on July 1, 2017 Current Town plans will be in effect until June 30, 2017 Open enrollment will be held from Wednesday, April 5 th through Wednesday, May 3 rd ¨ ALL employees and retirees MUST enroll if you want coverage as of July 1, 2017 ¨ Marriage licenses, Birth Certificates, Adoption and Guardianship records are required to enroll dependents ¨ ¨ n n Life Insurance & Dental Insurance will still be administered through the Town with a separate Open Enrollment period Health Care Flexible Spending Account (FSA) for active employees will still be offered through the Town 3

What Is the GIC? n n n The mission of the GIC is to

What Is the GIC? n n n The mission of the GIC is to deliver high quality care at reasonable costs GIC was established by the Legislature in 1955 GIC is a quasi-independent state agency governed by a 17 -member Commission appointed by the Governor Commission members include representatives of labor, municipalities, and retirees GIC's FY 17 appropriation is $2. 1 billion. GIC covers 250, 000 subscribers and 436, 000 lives 4

GIC Plans n The GIC Offers 12 plans to Active Employees ¨ Uni. Care

GIC Plans n The GIC Offers 12 plans to Active Employees ¨ Uni. Care (4 Plans) ¨ Harvard Pilgrim Health Care (2 Plans) ¨ Tufts (2 Plans) ¨ Fallon Community Health Plan (2 Plans) ¨ Neighborhood Health Plan (1 Plan) ¨ Health New England (1 Plan) 5

GIC Plans n Plans with the most subscribers ¨ n Active and Non-Medicare Retiree

GIC Plans n Plans with the most subscribers ¨ n Active and Non-Medicare Retiree Plans n Tufts Navigator POS n Harvard Pilgrim Independence POS n Uni. Care Indemnity Plan Basic with CIC [Comprehensive] Enrollment restrictions (residence) Uni. Care Indemnity Plan Basic throughout the United States and outside the United States ¨ Other plans limited to Massachusetts and certain border states/counties by plan ¨ Consult the map in your Benefit Decision Guide! ¨ 6

GIC Health Maintenance Organization (HMO) Plans n n n Members must select a Primary

GIC Health Maintenance Organization (HMO) Plans n n n Members must select a Primary Care Physician (PCP) Referrals are required to see Specialists No coverage for out of network [non-contracted] providers ¨ Except for emergency care and Students living out of service area [emergencies] n n Lower premium cost than other plan types “Limited” or “Select” network plans ¨ Lowest premium costs ¨ Limited physician and hospital access 7

GIC Health Maintenance Organization (HMO) Plans n Broad Network HMO Fallon Community Health Plan

GIC Health Maintenance Organization (HMO) Plans n Broad Network HMO Fallon Community Health Plan Select Care ¨ Fallon Select Care members may need referrals to the following hospitals: Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Children’s Hospital, Dana-Farber Cancer Institute, Massachusetts General Hospital, Tufts Medical Center ¨ Neighborhood Health Care (NHP Prime) ¨ n Limited Network HMOs Fallon Community Health Plan Direct Care ¨ Harvard Pilgrim Primary Choice ¨ Health New England ¨ Tufts Health Plan Spirit ¨ 8

GIC Preferred Provider Organization (PPO) Plans n n n In-Network and Out of Network

GIC Preferred Provider Organization (PPO) Plans n n n In-Network and Out of Network Benefits No requirement to select Primary Care Physician (PCP) No referrals required for specialists Can utilize any provider ¨ In-network providers - lower out of pocket costs ¨ Out of network providers - higher out of pocket costs Higher premium cost than HMOs Member must reside in network service area to enroll 9

GIC Preferred Provider Organization (PPO) Plans Uni. Care State Indemnity Plan/Plus 1 n Uni.

GIC Preferred Provider Organization (PPO) Plans Uni. Care State Indemnity Plan/Plus 1 n Uni. Care State Indemnity Plan Community Choice 2 n 1. All Massachusetts doctors and hospitals are “in-network” with Uni. Care Indemnity Plan /Plus but some out of state providers and mental health/substance abuse providers may be “out of network”. 2. Many in-state hospitals are “out of network” with Community Choice. 10

GIC Point of Service (POS) Plans n n n In-Network and Out of Network

GIC Point of Service (POS) Plans n n n In-Network and Out of Network Benefits Members must select a Primary Care Physician (PCP) Referrals required for specialists Can utilize any provider ¨ In-network providers - lower out of pocket costs ¨ Out of network providers - higher out of pocket costs Higher premium cost than HMOs Member must reside in network service area to enroll 11

GIC Point of Service (POS) Plans Tufts Navigator POS n Harvard Pilgrim Independence POS

GIC Point of Service (POS) Plans Tufts Navigator POS n Harvard Pilgrim Independence POS n 12

GIC Indemnity Plans n n n Members not required to select a Primary Care

GIC Indemnity Plans n n n Members not required to select a Primary Care Physician (PCP) No referrals required for specialists Can utilize any provider Highest premium cost plan No geographical restrictions on enrollment ¨ Member can live anywhere in the United States n Without CIC, deductibles and copays are higher and coverage is only 80% for some services 13

Open Enrollment for FY 18 Only n n Harvard Independence POS, Tufts Navigator POS

Open Enrollment for FY 18 Only n n Harvard Independence POS, Tufts Navigator POS and the Fallon Select HMO are “frozen”, meaning no new subscribers can enroll in these plans A one time only exception for the Town of Hingham ¨ ¨ n Eligible active employees and Non-Medicare retirees can enroll in these plans during the open enrollment period for a July 1, 2017 effective date Once enrolled in one of these plans, you can move from single to family [same plan] and vice versa, within 60 days of a qualifying event New hires eligible after May 3, 2017 and those eligible who don’t enroll in these plans during open enrollment 14 can not enroll in these plans during FY 18

Fiscal Year Deductibles ¨ Amount a member pays before the plan pays benefits; ¨

Fiscal Year Deductibles ¨ Amount a member pays before the plan pays benefits; ¨ Deductible generally does NOT apply to: n Mental health/substance abuse benefits n Office visits (primary care physician, specialist, retail clinics, preventive care, maternity & well baby care, routine eye exam, occupational therapy, physical therapy, chiropractic care & speech therapy) n Medically necessary child & adult immunizations n Wigs (medically necessary) n Hearing aids n Routine Mammograms n Pap smears n Routine EKGs n Routine Colonoscopies 15

Fiscal Year Deductibles Deductible DOES apply to: n Emergency room visits n Inpatient hospitalization

Fiscal Year Deductibles Deductible DOES apply to: n Emergency room visits n Inpatient hospitalization n Surgery n Laboratory and blood tests [non-preventive] n Bone density screenings n X-rays and radiology (including high-tech imaging, such as MRI, PET and CT scans) n Durable medical equipment 16

Fiscal Year Deductibles n Fiscal Year Deductible Amounts ¨$500 individual ¨$1, 000 family n

Fiscal Year Deductibles n Fiscal Year Deductible Amounts ¨$500 individual ¨$1, 000 family n (no more than $500 person) n Fallon Health Direct and Select Health Plans Only ¨$550 individual ¨$1, 100 family n (no more than $550 person) 17

Fiscal Year Deductibles - Drug n n Separate, and in addition to medical deductible

Fiscal Year Deductibles - Drug n n Separate, and in addition to medical deductible Fiscal Year Deductible Amounts ¨$100 individual ¨$200 family n (no more than $100 person) n No separate drug deductible on the Fallon Health Direct and Select Plans 18

Deductible/Copay Example First Visit to ER in FY Second Visit to ER in FY

Deductible/Copay Example First Visit to ER in FY Second Visit to ER in FY Total ER Visit $1, 000 You Pay Deductible $500 You Pay ER Copay $100 ------------------ Total ER Visit $1, 000 You Pay Deductible N/A You Pay ER Copay $100 ------------------- Your Total Cost $600 Plan Pays $400 Your Total Cost $100 Plan Pays $900 19

Tiered Provider Copays ¨ Providers are grouped into “tiers” based on cost, quality, and

Tiered Provider Copays ¨ Providers are grouped into “tiers” based on cost, quality, and outcomes measures from third parties ¨ GIC Plans use tiering to set office visit copays [primary care and specialists] and inpatient admission copays ¨ Different tiering for different health plans…a primary care doctor, specialist or hospital can be on one tier with one GIC health plan and on another tier with another GIC health plan ¨ Tier 1 Providers have lowest member cost & Tier 3 Providers have the highest member cost ¨ Tier copay is in addition to the deductible, if not already satisfied by the member 20

Some Provider Copays Vary by Tier* Specialist Care Office Visit Copays Hospital Copays Tier

Some Provider Copays Vary by Tier* Specialist Care Office Visit Copays Hospital Copays Tier 1 $275 Tier 1 $30 Tier 2 $500 Tier 2 $60 Tier 3 $1500 Tier 3 $90 21

Prescription Drug Tiering n n Drug Formularies Vary by Plan Pharmacy Tiering (typically) n

Prescription Drug Tiering n n Drug Formularies Vary by Plan Pharmacy Tiering (typically) n n Tier 1 – Generic and Low Cost Brand Drugs Tier 2 – Brand Name and High Cost Generic Drugs Tier 3 – Brand Name Non-Preferred Drugs Copayments ¨ Retail 30 day supply ¨ Tier 1 - $10 ¨ Tier 2 - $30 ¨ Tier 3 - $65 ¨ Mail Order 90 day supply ¨ Tier 1 - $25 ¨ Tier 2 - $75 ¨ Tier 3 - $165 22

Plan Design Example (sample) Plan Feature Tufts Navigator POS Plan In-Network Out-of-Network $10/$20/$40 copay

Plan Design Example (sample) Plan Feature Tufts Navigator POS Plan In-Network Out-of-Network $10/$20/$40 copay 20% after deductible Specialist Office Visit $30 Tier 1 $60 Tier 2 $90 Tier 3 20% after deductible Fiscal Year Deductible $500/$1, 000 $450/$900 $100 Tier 1 $275 per admission Tier 2 $500 per admission Tier 3 $1, 500 per admission Maximum of 1 inpatient copay per calendar quarter 20% after deductible $250 per occurrence Maximum of 4 per calendar year 20% after deductible $100 per scan/Maximum 1/day 20% after deductible PCP Office Visit Emergency Room Inpatient Hospital Care Outpatient Surgery Hi Tech Imaging Drugs Retail Mail Order (90 day) $10/$30/$65 $25/$75/$165 23

Mitigation Plan n Public Employee Committee [PEC] and Town Negotiated a Mitigation Program ¨

Mitigation Plan n Public Employee Committee [PEC] and Town Negotiated a Mitigation Program ¨ Health Reimbursement Arrangement [HRA] will reimburse the following n n n Outpatient Surgery Copays 100% Inpatient Admission Copays 100% Hi-Tech Imaging Copays 100% Claim forms available and processed by the Town Accountant’s office One time premium credit of $75/$150 in November 24

Local GIC Health Fair April 13 th THURSDAY 11: 00 AM - 4: 00

Local GIC Health Fair April 13 th THURSDAY 11: 00 AM - 4: 00 PM Hingham Middle School GYM 1103 Main Street Hingham 25

TIPS FOR SELECTING A GIC PLAN n Carefully review the GIC Benefit Decision Guide.

TIPS FOR SELECTING A GIC PLAN n Carefully review the GIC Benefit Decision Guide. n Complete a questionnaire and estimate your utilization of medical services. ¨ Doctors ¨ Hospitals ¨ Prescriptions n Discuss the GIC plans with family, friends and your physician(s). 26

TIPS FOR SELECTING A GIC PLAN n Contact the carriers on the telephone or

TIPS FOR SELECTING A GIC PLAN n Contact the carriers on the telephone or using the internet. Ask the carriers about: ¨ The physicians who treat you ¨ The hospitals where you get care ¨ The prescription drugs that you take ¨ Any Durable Medical Equipment or Device that you regularly use n Attend a GIC Health Fair n Review Rate Sheets for Monthly Premiums 27

TIPS FOR SELECTING A GIC PLAN Contact Information Group Insurance Commission: www. mass. gov/gic

TIPS FOR SELECTING A GIC PLAN Contact Information Group Insurance Commission: www. mass. gov/gic (617) 727 -2310 Harvard Pilgrim Health Plan: www. harvardpilgrim. org/gic (800) 542 -1499 Tufts Health Plan: www. tuftshealthplan. com/gic (800) 870 -9488 Fallon Community Health Plan: www. fallonhealth. org/gic (866) 344 -4442 Uni. Care: www. unicarestateplan. com (800) 442 -9300 Caremark Pharmacy www. caremark. com/gic (877) 876 -7214 Health New England: www. hne. com/gic (800) 842 -4464 Neighborhood Health Plan: www. nhp. org/gic (866)-567 -9715 28

Questions and Answers 29

Questions and Answers 29