HomeMy WebLinkAboutRes.2788.11-04-2013BILL NO. 13-151
RESOLUTION NO. (3-M
A RESOLUTION AUTHORIZING THE CITY MANAGER TO
EXECUTE A CONTRACT WITH ANTHEM BLUE CROSS
FOR EMPLOYEE HEALTH INSURANCE SERVICES, IN
THE CITY OF CAPE GIRARDEAU, MISSOURI
BE IT RESOLVED BY THE COUNCIL OF THE CITY OF CAPE
GIRARDEAU, MISSOURI, AS FOLLOWS:
ARTICLE 1. The City Manager, for and on behalf of the City
of Cape Girardeau, Missouri, is hereby authorized to execute a
Contract with Anthem Blue Cross for employee health insurance
services, in the City of Cape Girardeau. Said Contract shall
contain the terms set out in the proposal from Anthem Blue
Cross. A copy of the proposal information is attached hereto
and made a part hereof.
PASSED AND ADOPTED THIS 1 DAY OF I CMKk' , 2013.
rry EJ R iger, Mayor
September 25, 2013
Ms. Lori Meyer
Human Resources and Risk Manager
City of Cape Girardeau, Missouri
401 Independence Street
P.O. Box 617
Cape Girardeau, MO 63702
Re: Medical Plan Renewal Effective January 1, 2014
Dear Lori:
CBIZ Benefits & Insurance Services, Inc.
11440 Tomahawk Creek Parkway
Leawood, KS 66211-9955. www.eblzkc.com
Tel: (913)234-1 D00 . Faz: (913) 2341100
The health insurance plan for the employees of the City of Cape Girardeau is due to renew effective January 1, 2014. The
following information is related to that renewal.
Plan History
CBIZ has formally reviewed the market for alternatives twice in the last seven years — once in 2007 and once in 2009.
Both times Anthem was clearly the best option versus the market.
After two years of reduced fixed costs, the City's claims increased dramatically in 2012. Effective with the plan renewal
for January 1, 2013, there were increases in all phases (administration, stop loss premium and claim maximums) of the
plan. "There were also increases in employee contributions, and two plan design changes.
Plan Financials
As you know, the City's medical plan is a fully insured plan. It is "unfunded", meaning that the City holds its own
reserves to pay for incurred but not recorded (IBNR) claims if the plan is cancelled. Also, the City pays for claims as they
are processed by Anthem. Thus, if claims are lower than projected, the City keeps these funds.
The current contract, which has been in place many years (prior to CBIZ's relationship with the City) does have a deficit
carry -forward provision. In other words, if the plan's expenses outweigh the claim liability limits in place, the City is
responsible for this deficit, but does not have to pay for this immediately. It is an eventual obligation, either in lower
claim years, or at cancellation. Thus, if the City terminates the plan to move to another vendor, they will be responsible
for the run off claims, (claims that have been incurred but not yet paid) as well as any accumulated deficit.
The contract does limit the deficit carry forward to 10% of the cumulative maximum claims liability for that year. In the
past, the City has been on both sides of this situation. You have carried a deficit in the past; as claims improved, that
deficit was paid off and positive balances were accumulated.
CBIZ Benefits & Insurance Services, Inc.
Current Financial Position
After two years of increasing claims, the last 12 months of claims have decreased. For 8/1/12 to 7/31/13, paid claims were
$2, 279,941, vs. $2,777,207 for 8/1/11 to 7/31/12, a decrease of approximately 18%. For the past 12 months, there was
S64,451 over your stop loss point of $150,000, while last year's number was $73,622.
More importantly, last year you had 15 claims over $50,000 with four over $100,000. While this year's largest claim is
over $200,000, you have three claims over $100,000, and only seven claims over $50,000, a dramatic decrease.
For the current plan year, from January through August of 2013, your maximum liability was $2,255,318 and actual paid
claims were $1,590,304, or 71 % of your maximum. Your plan's maximum is set at 115% of expected paid claims, so your
plan is currently running at 81% of expected paid claims. (Last year at this time, the plan was at 83% of maximum, and
95% of expected paid)
Renewal Rating
Anthem has provided a renewal calculation for the 2013 plan year. The calculation uses the last three years of claims
history. In Anthem's original renewal, they had requested increases to all components of your plan, including + 4.7% to
your aggregate stop loss, + 19% to your specific stop loss costs, 3.1% to administration and 2.2% to your claim
maximums for an overall increase of 3.2%. However, after negotiations, we have secured the following offer. By
component, for both plans, Anthem has requested the following:
1) Aggregate stop loss costs would increase by 2.5%, or $.16 per employee per month (PEPM) on a composite basis.
2) Specific stop loss costs would increase by 16%, or $6.35 Per Employee Per Month (PEPM) on a composite basis.
3) There will be no increase to administrative costs.
4) Maximum claims will not increase.
5) Overall obligation would increase by about 1% for both plans.
These negotiations will result in an annual savings of over $90,000 to the city.
In addition, Anthem has requested an increase in your Terminal Liability rates of 3.6%, or $2.84 PEPM. This would only
impact the City if you were to terminate your medical plan with Anthem.
Affordable Care Act Mandated Benefit
Effective with your plan renewal, there will be an enhancement to your PPO plan design. Effective on January 1, 2014, all
out of pocket expenses paid by members, with the exception of prescription drugs copays will accumulate toward the out
of pocket limit. Today, those expenses (office visit copays, emergency room copays, etc.) are still payable after the out of
pocket limit is met.
.Anthem estimated this enhancement would cost the plan approximately 2%, but CBIZ was able to negotiate this impact on
the claim maximum to zero. It may, however, increase claim costs.
CBIZ Benefits & Insurance Services. Inc.
Affordable Care Act Taxes
Effective on January 1, 2014, the City will begin to be responsible for two of the three taxes imposed by the Affordable
Care Act; the Patient Centered Outcomes Research Fee (PCOR) and the Reinsurer Fee. The PCOR Fee is $2.00 per
member per year, and the Reinsurer Fee is $5.25 per member per month. The total cost of these two applicable taxes is
approximately $41,000 for 2014.
Conclusion
The good news with this renewal is that your overall cost obligations are just slightly higher than last year, even with the
additional ACA tax obligations.
Thank you for your continued confidence and support
Sincerely,
Davi hnson, CEBS
Senior Benefits Consultant
/ego
cc: John Richbourg, City of Cape Girardeau
C31Z Benefits & Insurance Services. Inc.
NI[N MUM PREMIUM RENEWAL RATES
ACCOUN7 NAME. City of Cepe Girard"„
GROUP NUMBER: W1276M
EFFECTIVE DATE: 1/12014
LINE OF BUSINESS: Mcd,.I/Dr ,
ACTIVE & Pre 65 - 8 0 7150 %; $2500 DED
Rd +65 - 80%/50%; 525M DED
EMP
EE/SP
EF/CH
FAM
COMP
E.pl.y"s
296
23
33
11
363
AGGREGATE S -L:
CURRENT RATES
55.33
510.55
$9.27
$14.48
56.30
RENEWAL RATES
55.46
510.81
59.50
514.84
56.46
% CHANGE
2.5%
2.5%
2.5%
2.5%
2.5%
SPECIFIC S -L @ 5150,000:
CURRENT RATES
$33.62
566.57
$58.33
S9I.29
$39.70
RENEWAL RATES
539.00
577.22
$67.66
$105.90
546.05
%CHANGE
16.0%
16.0%
16.0%
16.0%
16.0%
-kD%CHANGE
MINISTRATION:
CURRENTRATES
$30.69
560.82
$53.29
$83,381
$36.25
RENEWAL RATES
$30.69
560.82
$53.29
$83.38
536.25
%CHANGE
0.0%
0.0%
0.0%
0.0%
00%
COMMISSION:
CURRENTRATES
$0.00
$0.00
$o00
$0.00
$0.00
RENEWALRATES
$0.00
$0.00
$000
50.00
$0.00
%CHANGE
MAX. CLAIMS:
CURRENT RATES
$53585
$1061.40
$930.07
$1,336.46
5629.25
RENEWALRATES
$535.85
S1,061.40
S930.07
51,336.46
S629.25
-/.CHANGE
00%
0.0%
0.0%
0.0%
0.0%
TOTALCOST:
CURRENT RATES
$605.49
57,199.34
$1,050.96
$1,525.61
5711.50
RENEWALRATES
5611.00
$1,210.25
$1,060.52
51,540.58
5718.01
-/. CHANGE
0.9%
0.9%
0.9%
1.0%
0.9%
TERMINAL LIABILUY:
CURRENTRATES
$59.36
$118.17
$10340
$162.49
570.22
RENEWALRATES
561.50
$122.42$107.12
7.12
$168.34
572.75
%CHANGE
3.6%
.6 %
3.6./.!
3.6%
3.6%
3.6%
Rd +65 - 80%/50%; 525M DED
EMP
EESP
EE/CH
FAM
COMP
Employees
2
1
0
0
3
AGGREGATE S -L:
CURRENT RATES
$3.20
$6.41
S5b1
S8.77
54.27
RENEWALRATES
5318
$6.57
55.75
58.99
54.38
%CHANGE
2.5%
2.5%
2.5%
2.5%
2.5%
SPECIFIC S -L @ $150,000:
CURRENT RATES
$20.32
$40.28
$39.52.
$55.25
526.97
RENEWALRATES
S23.57
546.72
$45.84
564.09
531.29
%CHANGE
160%
16.0%
16.0%
16.0%
16.0%
MINISTRATION:
CURRENT RATES
$18.57
$36.76
$32.20
$50.43
$24.63
RENEWALRATES
518.57
536.76
$32.20
$50.43
524.63
%CHANGE
00%
0.0%
0.0%
00%
0.0%
COMMISSION:
CURRENT RATES
50.00
$0.00
$0.0D
$0.00
So DO
RENEWAL RATES
$0.00
50.00
50.00
50.00
50.00
%CHANGE
CLAIMS:
CURRENTRATES
5535.85
51,061.40
$93007
$1,336.46
$711.03
RENEWALRATES
5535.85
51,061.40
$930.07
$1,336.46
5711.03
%CHANGE
0.0%
0.0%
0.0%
0.0%
0.0%
OTALCOST:
CURRENTRATES
5577.94
$1,144.65
$1,007.40
$1,450.91
5766.90
RENEWAL RATES
558117
51,151.46
51,013.86
51,459.97
577132
%CHANGE
06%
06%
0+6%
0.6%
0.65
TERMINAL LIABILITY:
CURRENT RATES
$59.36
5118.17
$103.40
516249
578.96
RENEWALRATES
S61.50
5122.4251
7.12
576834
S81.80
%CHANGE
3.6%
3.6 %
3.6%
3.6%
3.6%
HSA - 80%/60%; S2000 D ED
NOTES:
Please nate, at this time, we do not know if additional guidance and clarification from the U.S.
• IRS has Jurisdiction over the Insurer Fee and HHS over Reinsurance Fee
• Rates and benefits for most large groups ore likely to change -further communication will be
Section 1341 afthe Affordable Care Ad (ACA or health care reform lour) provides that a transitional
EMP
EE/SP
EE/CH
FAM
cow
Em 1 ccs
70
3
10
7
90
AGGREGATE S -L:
CURRENT RATES
$533
- $10.55
$9.27
$14.48
56.65
RENEWALRATES
S5.46
510.81
59.50
S14.84
$6.82
%CHANGE
2.5%
2.5%
2.5%
2.5%
2.5%
SPECIFIC 5-L @ $150,000:
CURRENTRATES
$33.62
566.57
$58.33
591.29
$41.95
RENEWALRATES
539.00
577.22
567.66
$105.90
548.66
%CHANGE
16.0%
16.0%
16.0%
16.0%
16.0%
MINISTRATION:
CURRENT RATES
532.73
562.85
$55.32
$85A31
Y70.34
RENEWAL RATES
532.73
562.85
S55.32
585.43
$40.34
% CHANGE
0.0%
0.0%
0.0%
0.0%
0.0%
OMMISSION'
CURRENT RATES
50.00
$0.00
50.00
50.00
50.00
RENEWALRATES
$0.00
$0.00
$0.00
50.00
$0.00
%CHANGE
CLAIMS.
CURRENTRATES
$47639
$943.58
5826.84.
$1,188.13
$586.26
RENEWAL RATES
$476J9
5943.58
5826.84
51,188.13
5586.26
% CHANGE
0.0%
0.0%
0.0%
0.0%
0.0%
TOTALCOST:
CURRENT RATES
5548.07
$1,083.55
$949.76
$1,379.33
5675.20
RENEWALRATES
555358
57,094.46
5959.32
S1J9430
5682.08
%CHANGE
1.0%
1.0%
1.0%
1.1%
1:0%
TERMINAL LIABILITY:
CURRENTRATES
$59.36
5118.17
$103.40
SI62A9
$74.23
RENEWALRATES
$61.50
SI22.42
$107.12
5168.34
576.90
%CHANGE
3.6%
3.6%
3.6%
3.6%
3.6%
NOTES:
Please nate, at this time, we do not know if additional guidance and clarification from the U.S.
• IRS has Jurisdiction over the Insurer Fee and HHS over Reinsurance Fee
• Rates and benefits for most large groups ore likely to change -further communication will be
Section 1341 afthe Affordable Care Ad (ACA or health care reform lour) provides that a transitional
Your Summary of Benefits
City of Cape Girardeau
Blue Access® PPO
Effective January 1, 2014
Anthem,
B1ueCross B1ueShield
City of Cape Grt amai PPO -20194
Made, Blue Cents and Blue Shield a t a babe name for RigdCHOIGE0. Managed Cam, Inc. (Ren. Hea y,
Atianaatd Insuramm Company MIC), and HMO Mamoun, Inc. RIT and rein afi4aWs atlmimaler iwn-IMO
defaft untlawiOaA by HALIC and HMO beneft uWem a by HMO M¢smvl, Inc. RR antl certain al 1b
only dwarf, ad.daddrative services for se&funded plant and ad nm undemia bereftIndependent T"mm, d
the Blue Cross and Blue Shield Aawd bon QAMHEM m a ` Vddred rademak The Blue Cmss and Blue S*W
nares antl symbols are mg,s dd maks dra Thom C.. and Blue Stmeld Astoc*on.
Deductible (Single/Family)
$2,500/$7,500
$2,500/$7,500
Out -of -Pocket Limit (Single/Family)
$5,000/$10,000 <select>
$10,000/$20,000
Physician Home and Office Services (PCPISCP)
$30/$60
50%
Primary Care Physician (PCP)/
Specialty Care Physician (SCP)
Including Office Surgeries and allergy serum:
o allergy injections (PCP and SCP)
$5
50%
o allergy testing
20%
50%
o MRAs, MRIs, PETS, C -Scans, Nuclear
20%
50%
Cardiology Imaging Studies, non -maternity
related Ultrasounds, and pharmaceutical products
Preventive Care Services
Services included but not limited to:
o Routine medical exams, Mammograms, Pelvic
50%
Exams, Pap testing, PSA tests, Immunizations,
No copayment/coinsurance
Annual diabetic eye exam, Hearing screenings
and Vision screenings which are limited to
Screening tests (i.e. Snellen eye chart) and
Ocular Photo screening
o Immunizations through age 5
NCS
NCS
Emergency and Urgent Care
Emergency Room Services
$150/20%<select>
$150/20%
o facilitylother covered services
(copayment waived if admitted)
Urgent Care Center Services
$50
50%
o MRAs, MRIs, PETS, C -Scans, Nuclear
20%
<select>
Cardiology Imaging Studies,
non -maternity related Ultrasounds, and
pharmaceutical products
o Allergy injections
$5
50%
o Allergy testing
20%
50%
Inpatient and Outpatient Professional Services
20%
50%
Include but are not limited to:
o Medical Care visits (1 per day), Intensive
Medical Care, Concurrent Care, Consultations,
Surgery and administration of general
anesthesia and Newborn exams
Blue 7.0 500 Series
City of Cape Grt amai PPO -20194
Made, Blue Cents and Blue Shield a t a babe name for RigdCHOIGE0. Managed Cam, Inc. (Ren. Hea y,
Atianaatd Insuramm Company MIC), and HMO Mamoun, Inc. RIT and rein afi4aWs atlmimaler iwn-IMO
defaft untlawiOaA by HALIC and HMO beneft uWem a by HMO M¢smvl, Inc. RR antl certain al 1b
only dwarf, ad.daddrative services for se&funded plant and ad nm undemia bereftIndependent T"mm, d
the Blue Cross and Blue Shield Aawd bon QAMHEM m a ` Vddred rademak The Blue Cmss and Blue S*W
nares antl symbols are mg,s dd maks dra Thom C.. and Blue Stmeld Astoc*on.
Your Summary of Benefits
Inpatient Facility Services
20%
50%
Unlimited days except for:
0 60 days Network/Non-Network combined
for physical medicinelrehab (limit includes
Day Rehabilitation Therapy Services on an
outpatient basis)
0 90 days Network/Non-Network combined
for skilled nursing facility
Outpatient Surgery Hospital/Alternative Care Facility
20%
50%
o Surgery and administration of general anesthesia
Other Outpatient Services
20%
50%
(including but not limited to):
o Non Surgical Outpatient Services
For example: MRIs, C -Scans,
Chemotherapy, Ultrasounds, and
other diagnostic outpatient services.
o Home Care Services 100 visits
(excludes IV Therapy)
(Network/Non-Network combined)
o Durable Medical Equipment, Orthotics
and Prosthetics
o Physical Medicine Therapy Day
Rehabilitation programs
o Hospice Care
20%
50%
o Ambulance Services
20%
20%
Outpatient Therapy Services
$30/$60
(Combined Network & Non -Network limits apply)
o Physician Home and Office Visits (PCP/SCP)
50%
o Other Outpatient Services @ Hospital/Alternative
50%
Care Facility
Limits apply to:
o Physical/Manipulation therapy excluding
Chiropractic Services: 20 visits
o Occupational therapy: 20 visits
o Chiropractic Services: 26 visits(Network only)
o Speech therapy: Unlimited visits
o Cardiac Rehabilitation: 36 visits
o Pulmonary Rehabilitation: 20 visits
Accidental Dental Services $3,000 per accident
Copayments/Coinsurance
50%
(Network and Non -network combined)
based on setting where
covered services are
received
Your Summary of Benefits
Behavioral Health ServlCeS2:
Mental Health and Substance Abuse
(Network and Non -Network)
o Inpatient Facility Services
o Physician Home and Office Visits (PCP/SCP)
o Other Outpatient Services, Outpatient Facility
@ Hospital/Alternative Care Facility,
Outpatient Professional
mEMENEM
Benefits provided in
accordance with Federal
Mental Health Parity
50%
Human Organ and Tissue Transplants;
NCS
30%
o . Acquisition and transplant procedures, harvest
and storage.
Prescription Drugs
Network Tier structure equals 11213
(and 4, if applicable)
o Network Retail Pharmacies:
$101$35/$75125%
50% (min $75)
(30 -day supply)
cost share brands
Includes diabetic test strip
o Anthem Rx Home Delivery Service:
$20/$90/$190/25%
Not covered
(90 -day supply)
Includes diabetic test strip
Out of Pocket Limit
$2,500 - 4th tier
Member may be responsible for additional cost when
not selecting the available generic drug.
Medicare Rx - Wrap
Specialty Medications must be obtained via our
Specialty Pharmacy network in order to receive
network level benefits.
Specialty medications are limited to 30 day supply
regardless of whether they are retail or mail order.
Notes:
o All medical deductibles, copayments and coinsurance apply toward the out-of-pocket maximum (excluding Prescription Drug cost share options
and Non -Network Human Organ and Tissue Transplant (HOTT) Services)
o Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance, including 0%. However, the deductible does not apply
to Emergency Room Services where a copayment and a percentage (%) coinsurance applies and may not apply to some Behavioral Health services
where coinsurance applies.
o Network and Non -network deductibles, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward
each other.
o Dependent age: to end of the month which the child attains age 26
o Specialist copayment is applicable to all Specialists excluding General Physicians, Internist, Pediatricians, OB/GYNs and Geriatrics or any other
Network Provider as allowed by the plan.
o When allergy injections are rendered with a Physicians Home and Office Visit, only the Office Visit cost share applies.
o No copaymenl.coinsurance means no deductible/copayment/coinsurance up to the maximum allowable amount. 0% means no coinsurance up
to the maximum allowable amount. However, when choosing a Non -network provider, the member is responsible for any balance due after the
plan payment.
o PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics,
obstetrics/gynecology, geriatrics or any other Network provider as allowed by the plan.
o SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice.
o Certain diabetic and asthmatic supplies have no deductible/copayment/coinsurance up to the maximum allowable amount at network pharmacies,
except diabetic test strips.
o Benefit period = calendar year
o Elective abortions are not covered.
Your Summary of Benefits
o Mammograms (Diagnostic) are no copayment/coinsurance in Network office and outpatient facility settings.
o Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity.
o Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits
are covered.
o Private Duty Nursing — limited to 82 visits/Calendar Year and 164 visits/lifetime
1. These covered services for age 6 and above are not subject to the deductible/copayment it you have a flat dollar copayment and fl rendered without an office visit
2. We encourage you to review the Schedule of Benefits for limitations. .
q. Kidney and comea are treated the same as any other illness and subject to the medical benefits.
If applicable, all prescription drug expenses except ger 1, (Network RetailfMail-service combined) apply to the per individual RX deductible. Once the RX
deductible is met, the appropriate copayment applies. Also if applicable, the Prescription Drug out of pocket maximum applies to Network Retail and Mail -Service
combined. Once the RX deductible is met, the appropriate copayment applies. Also if applicable, the Prescription Drug out of pocket maximum applies to
Network/Non-network Retail and Home Delivery -Service combined.
5. Rx non -network diabeticlasthmatic supplies not covered except diabetic test strips.
Rx Option K: Generic Premium uses a condensed preferred drug list Non -preferred drugs are not covered. Requires Home Delivery service after 3rd fill at retail
Precertification:
Members are encouraged to always obtain prior approval when using non -network providers. Precertifficaflon will help the member know if the services are considered not
medically necessary.
Pre-existing Exclusion Period: NONE
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform
laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor
and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.
This benefit overview is for illustrative purposes and some content may be pending Missouri Department of Insurance approval
This summary of benefits is intended to be a brief outline of coverage. The entire previsions of benefits and exclusions are contained in the Group Contract, Certificate and
Schedule of Benefits. In the evefa conflict between the Group Contract and this description, the terms of the Group Contract will prevail.
By signing this Sum ry of Benefits;I agree to the benefit for the product selected as of the effective date indicated.
t
onzed up signatulicable)
Date
n OVAting signatu (if ap cab)
Date
Your Summary of Benefits
City of Cape Girardeau
Lumenos Health Savings Accounts Option 7
Effective January 1, 2014
Rx Option Z
Anthema
B1ueCross B1ueShield ®R.
a
,
Deductible
Single: $2,000
Single: $2,000
Family coverage requires the family deductible to be met
Family: $4,000
Family: $4,000
before coinsurance applies. The single deductible
does not apply to family coverage.
Out -of -Pocket Limit
Single: $5,000
Single: $10,000
Family: $10,000
Family: $20,000
Physician Home and Office Services
20%
40%
o Including Office Surgeries, allergy serum,
allergy injections and allergy testing
Preventive Care Services
NCS
40%
Services included but not limited to:
o Routine medical exams, Mammograms, Pelvic
Exams, Pap testing, PSA tests, Immunizations,
Annual diabetic eye exam, Hearing screenings
and Vision screenings which are limited to
Screening tests (Le, Snellen eye chart) and
Ocular Photo screening
o Immunizations through age 5
NCS
NCS
Emergency and Urgent Care
o Emergency Room Services
20%
20%
(facilitylother covered services)
(copayment waived if admitted)
o Urgent Care Center Services
20%
40%
Inpatient and Outpatient Professional Services
20%
40%
Include but are not limited to:
o Medical Care visits (1 per day), Intensive
Medical Care, Concurrent Care, Consultations,
Surgery and administration of general
anesthesia and Newborn exams
Inpatient Facility Services (Network/Non-network
20%
40%
combined) Unlimited days except for:
0 60 days for physical medicine/rehab (limit
includes Day Rehabilitation Therapy Services
on an outpatient basis)
0 100 days for skilled nursing facility
Blue 7.0 500 Series
City of Cape G drdeau- HSA- 2014 SDR4
Antam Blue Cmss and Blue Shield u the tante name for Rign CHOICE® Managed Car, I= (Rm. Hearty
Alliance® life Insurance Dompan IHAMC) and Mo Mssoud. Inc. RR and oeradn elfidales adminis0'i unn-
HMDbdneWsuideiwntlenby yIC and MD benefits untlenvdlkn by HMD W.A, Inc. RR and ceRan
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Your Summary of Benefits
,-
Outpatient Surgery Hospital/Alternative Care Facility
20%
40%
o Surgery and administration of
general anesthesia
Other Outpatient Services
20%
40%
including but not limited to:
o Non Surgical Outpatient Services
For example: MRIs, C -Scans,
Chemotherapy, Ultrasounds and
other diagnostic outpatient services.
o Home Care Services 100 visits
(excludes IV Therapy)(Network/Non-network
combined)
o Durable Medical Equipment, Orthotics and
Prosthetics
o Physical Medicine Therapy Day
Rehabilitation programs
o Hospice Care
NCS
NCS
o Ambulance Services
20%
20%
Accidental Dental Services $3,000 limit per accident
Copayments/Coinsurance
40%
(Network and Non -network combined)
based on setting where
covered services
are received
Outpatient Therapy Services
(Combined Network & Non -Network limits apply)
o Physician Home and Office Visits
20%
40%
o Other Outpatient Services @
20%
40%
Hospital/Alternative Care Facility
Limits apply to:
o Cardiac Rehabilitation 36 visits
o Pulmonary Rehabilitation 20 visits
o Physical/Manipulation therapy excludes
Chiropractic Services:: 20 visits
o Occupational Therapy: 20 visits
o Chiropractic Services: 26 visits (Network)
o Speech therapy: Unlimited
Behavioral Health Services:
Benefits provided in
30%
Mental Illness and Substance Abuse'
accordance with Federal
o Inpatient Facility Services
Mental Health Parity
o Physician Home and Office Visits
o Other Outpatient Services @
Hospital/Alternative Care Facility
Human Organ and Tissue Transplants
20%
40%
o Acquisition and transplant procedures,
harvest and storage.
Your Summary of Benefits
Notes:
o All medical and drug cost shares, deductibles and percentage (%) coinsurance apply toward the out-of-pocket maximum (excluding Non -
Network Human Organ and Tissue Transplant (HOTT) Services.
o Deductible(s) apply to covered services listed with a percentage (%) coinsurance, including 0%.
o Deductible applies to all prescription drug expenses for Rx plans except HRA with copay plans. Once the deductible is met the appropriate
copayment/ coinsurance applies. Copayments/coinsurance accumulate to the Medical OOP max. Once the Medical OOP max is met, no
additional costshare applies.
o Once the family deductible is satisfied by either one member or all members collectively, then the additional percentage coinsurance will be
required before the family out-of-pocket is satisfied. Does not apply to embedded deductible plans.
o Network and Non -network Deductible, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward
each other.
o Dependent Age: to end of the month which the child attains age 26
0 0% means no coinsurance up to the maximum allowable amount. However, when choosing a Non -network provider, the member is
responsible for any balance due after the plan payment.
o Benefit period = calendar year
o Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity,
O Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician
visits.
o No Cost Share (NCS): No deductible/copaymenUcoinsurance up to the maximum allowable amount
o Private Duty Nursing — limited to 82 visits/Calendar Year and 164 visits/lifetime.
o Wigs limited to 1 per benefit period
'4th Tier per script 30 day supply
1 We encourage you to review the Schedule of Benefits for limitations. .
2 Rx non -network diabe6dasthmabc supplies not covered except diabetic test strips.
Precertification:
Members are encouraged to always obtain prior approval when using non -network providers. Precerffication will help the member know if the services are considered
not medically necessary.
Pre-existing Exclusion Period: NONE
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care
reform laws. As we receive additional guidance and daycation on the new health care reform taws from the U.S. Department of Health and Human Services,
Department of tabor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.
This benefit overview is for illustrative purposes and some content may be pending Missouri Department of Insurance approval
This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate
and Schedule of Benefits. In nl of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.
ky igninq this Su ary cf Bea fns, I agree to the benefit for the product selected as of the effective date indicated.
uthodzed gro sgna if applicable)
Date
Prescription Drugs
Medical deductible applies before
o Network Retail Pharmacies:
$10/$30/$50 25% $150 max50% min $75 2
(30 -day supply)
Includes diabetic test strip
$101$751$15025%$150 max'
o Anthem Rx Home Delivery Service:
Not covered
(90 -day supply)
Accumulates to overall medical
Includes diabetic test strip
- Specialty medications are limited up to a 30 day supply
regardless of whether they are retail or mail service
- Member may be responsible for additional cost when
not selecting the available generic drug.
Medicare Rx - Wrap
Notes:
o All medical and drug cost shares, deductibles and percentage (%) coinsurance apply toward the out-of-pocket maximum (excluding Non -
Network Human Organ and Tissue Transplant (HOTT) Services.
o Deductible(s) apply to covered services listed with a percentage (%) coinsurance, including 0%.
o Deductible applies to all prescription drug expenses for Rx plans except HRA with copay plans. Once the deductible is met the appropriate
copayment/ coinsurance applies. Copayments/coinsurance accumulate to the Medical OOP max. Once the Medical OOP max is met, no
additional costshare applies.
o Once the family deductible is satisfied by either one member or all members collectively, then the additional percentage coinsurance will be
required before the family out-of-pocket is satisfied. Does not apply to embedded deductible plans.
o Network and Non -network Deductible, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward
each other.
o Dependent Age: to end of the month which the child attains age 26
0 0% means no coinsurance up to the maximum allowable amount. However, when choosing a Non -network provider, the member is
responsible for any balance due after the plan payment.
o Benefit period = calendar year
o Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity,
O Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician
visits.
o No Cost Share (NCS): No deductible/copaymenUcoinsurance up to the maximum allowable amount
o Private Duty Nursing — limited to 82 visits/Calendar Year and 164 visits/lifetime.
o Wigs limited to 1 per benefit period
'4th Tier per script 30 day supply
1 We encourage you to review the Schedule of Benefits for limitations. .
2 Rx non -network diabe6dasthmabc supplies not covered except diabetic test strips.
Precertification:
Members are encouraged to always obtain prior approval when using non -network providers. Precerffication will help the member know if the services are considered
not medically necessary.
Pre-existing Exclusion Period: NONE
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care
reform laws. As we receive additional guidance and daycation on the new health care reform taws from the U.S. Department of Health and Human Services,
Department of tabor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.
This benefit overview is for illustrative purposes and some content may be pending Missouri Department of Insurance approval
This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate
and Schedule of Benefits. In nl of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.
ky igninq this Su ary cf Bea fns, I agree to the benefit for the product selected as of the effective date indicated.
uthodzed gro sgna if applicable)
Date
U signature ( appli ble)
Date