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Public Employees' Benefit Board

Q&A on Plan Design Changes
Additional-cost Tier for Medical Services

 
Q
What assistance will people have in deciding about procedures on the Additional-cost Tier?
A
Providence Health Plans, which administers the Statewide and Choice plans, offers a variety of decision-support tools on its website that help members in learning about and discussing the range of treatment options with their primary care providers and specialty physicians. Members in Providence Choice also can rely on guidance from their medical home care team to help them understand and make treatment choices that are right for them
Q
Will the $500 copay for procedures on the Additional-cost Tier apply to the out-of-pocket maximum?
A
No, the copay for procedures on the Additional-cost Tier will not apply to the annual out-of-pocket maximum.
Q
If I make an appointment in March for a procedure on the Additional-cost Tier to take place in April, will I have to pay the additional cost?
A
Yes, the additional cost applies to services provided on or after April 1.
Q
Are there exceptions to paying the additional cost for any of the services on the Additional-cost Tier?
A
Exceptions may apply for procedures related to ongoing treatment for certain cancers.
QWith these changes in member cost share, can I enroll in or increase a contribution to a health-care FSA ?
ANo, IRS code, which governs operation of health-care FSAs, specifically disallows such changes midyear.
Q
If I have already discussed treatment alternatives with my provider and choose to have a procedure on the Additional-cost Tier, will I still have to pay the additional cost?
A
Yes, you will be required to pay the additional cost for the procedure.
Q
If I have already tried an alternative but it didn’t resolve the problem, will I still have to pay the additional cost for a procedure on the Additional-cost Tier?
A
Yes, you will be required to pay the additional cost for the procedure.
Q
If I have arthroscopic surgery to repair a knee injury, will I have to pay the additional member cost?
A
Yes, you will be required to pay the additional cost for the procedure.
Q
If I have arthroscopic shoulder surgery (not for cancer or traumatic injury), will I have to pay the additional member cost?
A
Yes, you will be required to pay the additional cost for the procedure.
Q
If I have plan approval for bariatric surgery in the Statewide or Providence Choice plan, will I have to pay the additional cost?
A
Yes, you will be required to pay the additional cost for the surgical procedure, not for processes required prior to accessing the surgical benefit.
Q
Does the additional member cost in the Additional-cost Tier apply to the deductible in the part-time employee version of the Statewide plan?
A
Yes, the additional member cost in this tier applies to the deductible in the Statewide part-time plan.
Q
Does the additional member cost in the Additional-cost Tier apply for services from providers who are not in the network?
A
Yes, the additional member cost in this tier applies to services from any provider.
Q
Does the additional member cost for procedures on the Additional-cost Tier apply to facility costs or only physician costs?
A
The additional member cost applies to physician costs, not facility costs.
Q
Will the $100 copay for using the emergency department apply to the out-of-pocket maximum?
A
No, the copay for emergency department use won’t apply to the out-of-pocket maximum.
Q
Will I have the $100 copay if I am admitted to the hospital from the emergency room?
A
No, the $100 copay along with your other emergency department costs will be waived if you are admitted to the hospital for diagnosis or treatment (not observation).

Limit on Alternative Care Visits
(Chiropractic, Acupuncture, Naturopathic)
 

Q
Since my plan – Providence Choice – already limits alternative care services to a maximum annual benefit of $1,000, am I limited to 60 covered visits?
A
In Providence Choice, the alternative care limit is the lesser of 60 covered visits a year or $1,000.
Q
If I have 20 visits with my chiropractor this year, 20 with my acupuncturist and 20 with my naturopath, have I met the limit in the Statewide plan?
A
Yes, the limit applies to the total of all provider visits in this category of care.
Q
Does the limit on number of covered visits apply only to visits on or after April 1, or does it apply to all visits in 2011?
A
The limit applies to visits from April 1 through the end of 2011.

Member Share for Dental Crowns in ODS Plans
 

Q
If I’m now in the process of having a tooth prepared for a crown, will I have to pay the 50 percent coinsurance if the crown is placed in April?
A
Yes, you will be required to pay the 50 percent coinsurance if the crown is placed (seated) on the tooth on or after April 1.
Q
Does the member cost share for crowns apply to abutments on implants?
A
Yes, the 50 percent cost share applies to a crown or abutment on an implant as well as a crown on one’s own tooth.
Q
Does the 50 percent coinsurance for a crown apply toward the annual maximum benefit?
A
Yes, all member and plan payments in these ODS plans apply to the annual maximum benefit.
Q
Does the 50 percent coinsurance for a crown apply toward the plan deductible?
A
Yes, coinsurance and copayments in these ODS plans apply to any plan deductible.
Q
If my provider submits a care plan for a crown in March with the work planned in April, will ODS confirm plan coverage for the crown at 75 percent or 50 percent?
A
ODS’ automated process will show coverage at 75 percent until April 1; however, your coinsurance for a crown placed on or after April 1 will be 50 percent of the cost.
QAs a part-time employee, can I switch to a part-time dental plan since the full-time plan will have the same coinsurance (50 percent) for crowns?
ANo, the Board determined the level of changes to plan designs are not significant enough to allow for midyear enrollment in other plans.

End of Rural Subsidy in 18 Counties
 

Q
If I live in one of the 18 counties and am receiving care from an out-of-network provider on April 1, will I have to pay out-of-network coinsurance?
A
Yes, you will be required to pay the out-of-network coinsurance for any services you receive from an out-of-network provider on or after April 1.
Q
Will I have to pay the out-of-network share if I’m in the hospital on April 1?
A
No, the coverage in effect when you were admitted to the hospital prior to April 1 will apply until you are discharged.
Q
Will the plan provide transition-of-care services before April 1 if I’m undergoing a plan of treatment with an out-of-network provider?
A
Contact the plan’s customer service to inquire. You may also want to ask the provider for a referral to an in-network provider and for assistance in transitioning your care.
Q
How does the rural subsidy affect the supply of primary or specialty providers in rural areas?
A
There is no evidence that PEBB’s rural subsidy affects the number or geographic location of health care providers anywhere in the state.

Board Decisions on Midyear Plan Changes in 2011
 

Q
How big is the projected shortfall in funds for payment of health care claims in 2011?
A
Right now, it looks like PEBB will need $10.9 million more than projected to pay member health care claims.
Q
Why will 2011 claims costs be higher than projected?
A
More new members than projected brought more health care needs into the plan in 2011. Also, more members moved from a tier with fewer dependents to a tier that covers more dependents, which increases costs to the plan. The economy is also playing a part; eligible dependents of state employees who lose a job may be seeking PEBB coverage.
Q
Why is the Board making these changes now?
A
Adjusting plan design as soon as possible can avoid later, more radical changes, which would have greater impact on members. It also helps to frame current discussions with plans on contract renewals for 2012 and requests for proposals for the 2013 plan year.
Q
What other options did the Board consider for making up the shortfall?
A
The Board considered
  • Asking agencies to budget more for benefits: Agency budgets for 2011 are already set and are strained to the point of layoffs and reduction of services.
  • Using self-insurance reserves: The Board must maintain self-insurance reserves at a level that can sustain health benefits into the future.
  • Paying providers less: Negotiating new provider contracts could disrupt established patient-provider relationships and care plans for many members.
  • Directly shifting costs to employees: Pure cost shifts such as deductibles or higher out-of-pocket maximums have the potential to act as barriers to needed care.
  • Requiring an employee contribution: PEBB plays no role in negotiating employer and employee contribution to benefits.
Q
Why isn’t the Board opening up enrollment so members can move to another plan?
A
 The Board determined the changes are not significant enough to allow for midyear enrollment in other plans.