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Public Employees' Benefit Board

PEBB August 2011 Newsletter
Download and print a copy
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Download a copy and print it to share with your family.
 
 

Health care is changing
smiling doctor
Unsustainable cost increases are driving change in the world of health care. Your Benefit Board continues to push these changes in the right direction by staying solid in its commitment to providing quality plans at affordable cost.
 
While regular inflation has increased only about 2 percent per year over the last decade, annual medical inflation rates have skyrocketed 10 percent and more. At the same time, your Benefit Board has kept premium increases below 7 percent through innovations in plan design and by leveraging the power of PEBB’s size.
 
Change can appear frightening – especially when it touches something as personal as health care. From the Board’s strategic perspective, change presents opportunities to continue demanding better value from the health care system by:
  • Requiring the system to measure and report on quality of care
  • Selecting plans organized around coordinated, patient-focused care
  • Designing plans based on the best evidence from medical research
  • Self-insuring rather than adding money to insurance company margins
  • Negotiating with plans and administrators for the lowest possible rates
No matter what changes PEBB faces, your Benefit Board holds firm to this priority: member health comes first.
 
PEBB’s vision for health care keeps the Board focused on better care for you and your family,, and better value for your money. You can be confident that PEBB will offer comprehensive coverage at the best available cost.
 

Your role in controlling costs
group with hands together
PEBB members have a vital role in controlling the group’s costs by:
  • Recognizing that finite resources must cover the whole group
  • Carefully choosing care supported by evidence of its value
You play an even more powerful role in holding down costs when you try to reduce your risks for chronic disease.
 
Medical science shows that, as much or more than genetics or environment, everyday behaviors are the fundamental cause of most chronic diseases, including type-2 diabetes and heart disease. For the most part, medical care can’t prevent or cure these diseases – just treat their symptoms and complications.
 
Chronic conditions are becoming much more common in the PEBB group, just as they are in the whole population. The incidence of chronic diseases and their complications is one reason PEBB claims and costs continue to climb and one reason for member contributions to managing these costs.
 

Three steps to success in HEM
apple and barbell
The health engagement model (HEM) in 2012 plans is an engine for positive change, and it’s easy to get onboard. Members who enroll in a HEM plan commit to taking just three steps:
  1. Completing a confidential, online assessment to identify health risks
  2. Taking two short e-lessons related to their risks; click here and here for examples
  3. TRYING to change health risks they can control
"Trying" is the key word. Nobody is held accountable for a specific measure of success, either in dealing with a health condition or in reducing their health risks. Success – and the personal pride that goes with it – comes just from taking the steps and trying.
 
The model is built around studies showing that when people become aware of their health risks and learn ways to reduce them, they’re motivated to try new behaviors.
 
Through HEM, everyone benefits from better quality of life and lower health care costs and premiums.
 

2012 plan design changes
pharmacist
To meet the state’s ongoing financial crisis and ensure quality care for PEBB members, your Benefit Board has introduced changes to plan designs for 2012. This is a high-level summary only. The Board will meet Aug. 26 and 30 to finalize plan designs and premium rates.
 
HEM Plan
Members can choose to enroll in a HEM plan as their contribution to managing the group’s costs in 2012. Or they can enroll in the same basic plan design but without HEM and pay $30 per month ($45 for employee and spouse or partner) as their contribution to controlling costs. Note: The Board changed these amounts to $20 and $35 during its meeting on Aug. 26, 2011.
 
Weight Watchers coverage
The plans will cover the cost of participation in Weight Watchers for covered spouses and domestic partners as well as the principal subscriber.
 
Member-share reductions
The first four visits with a primary care provider will have reduced member share, as will office visits for certain chronic conditions.
 
Deductibles
Members will pay out of pocket for covered services until they reach the plan deductible. The individual deductible is $250 when using in-network providers and $500 when using out-of-network providers. Corrected 09/13/11: The family deductible (three or more people) is $750 in-network and $1,500 out-of-network. Amounts accumulate separately for use of in- and out-of-network providers.
 
Out-of-pocket maximums
After a member has paid the out-of-pocket maximum, the plan fully covers eligible
claims. The maximum will be $1,500 per individual, $4,500 per family (more than
one person).
 
Prescription drug coverage
Prescription coverage will have a $50-per-person deductible. Plan formularies will have four copay tiers:
  • Value drugs $0
  • Generic drugs $10
  • Brand formulary drugs $30
  • Specialty drugs $100
Existing exceptions to copays for non-formulary drugs will no longer be valid beginning Jan. 1, 2012.
 
Waiving other coverage
Members who cover a spouse or domestic partner will pay a $50 monthly surcharge when the spouse or domestic partner waives coverage in a non-state-agency employer’s group plan in favor of coverage through PEBB.
 
Tobacco use
Members and spouses or domestic partners who currently use tobacco will pay a $25-per-user monthly surcharge. Note: Beginning 2013, premiums for optional life insurance will be tobacco-rated based on member use of tobacco in the prior 12 months (from November 2011 forward).
 
Coverage exclusions
Plans will no longer cover surgical procedures for the following: removal of common warts; TMJ syndrome; varicose veins; breast-reduction; and ganglion cysts, bunions, corns, hammer toe and non-cancerous neuroma.
 
Additional cost tier
Plans will require an additional copay for partial hip and knee replacement, SPECT imaging and sinus surgery. Copays on this tier don’t apply to the annual out-of-pocket maximum or the annual deductible.
 

Confidentiality and privacy
confidential
All PEBB plans assure patients that their personal health information (PHI) is secure. All plans meet state and federal requirements on privacy and confidentiality of PHI.
 
PEBB itself does not get access to confidential patient or member information related to their health or health care. Only those people who already have access to PHI through claims information (doctors’ offices, insurers, plan administrators, care management personnel, etc.) continue to be the ones who have that access.