How to Use Your CVUSD Health Benefits Effectively Why the presentation? • Education – A better understanding of our system – A better understanding of the funding – Empower you to be a better health care consumer • We are in NO WAY are telling to avoid the doctor • Trying to be smarter about usage of benefits Funding • CVUSD collects contributions from members and pays out of the general fund into the health benefits fund – This year it is $14,273 per employee in PPO. 963 employees enrolled in PPO. – Anthem Blue Cross HMO for singles $5,871; $12,045 for double; $17,908 for families. 231 HMO employees enrolled. • CVUSD pays Kaiser an amount per employee for their coverage. – We negotiate each year with Kaiser for the amount charged. – Singles- $5,346; $10,692 double; $15,129 for families – 315 employees enrolled • CVUSD pays Blue Cross to “rent” their insurance pool. – The money in the CVUSD health benefits fund pays for PPO claims that are processed through Anthem Blue Cross. – EACH time you go to the doc or have something done, CVUSD gets a bill from Blue Cross for the agreed-upon amount. • It is paid out of CVUSD’s Health Fund – If any claims go above $260,000 we have an insurance plan called “Stop/Loss” that covers all medical costs in excess of that amount. • Approximately $78K per month Total Cost of Health Benefits $18,800,000 $18,688,407 Premium payments added this year $18,600,000 $18,400,000 $18,304,501 $18,234,425 $18,200,000 $18,155,377 $18,083,634 $17,969,115 $18,000,000 $17,800,000 $17,600,000 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 est Health benefits as % of budget 11.4 11.28 11.18 11.2 11.27 11.2 11.25 11 10.8 10.65 10.6 10.4 10.2 10 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 est Employees and retirees enrolled in insurance 1900 1856 1850 1840 1837 1800 1761 1750 1700 1636 1650 1600 1550 1509 1500 1450 1400 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 est Employees enrolled in insurance 1900 1856 1850 1840 1837 1800 1761 1750 1700 1636 1650 1600 1509 1550 1500 1450 1400 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 est In short • Total costs dropped, but on the rise – Employee contributions helped flatten the trend out – Fewer employees – As the budget decreases health care becomes a larger share. • Costs per employee up and costs TO employee up – Premium increases – More usage – Doc fee increases – Plan modifications How to read your plan description • In-Network – These are doctors/facilities that have negotiated with Anthem and have agreed to accept their reimbursement rate. – Anthem pays for 80% of the bill (after the deductible) and you pay 20% -Once you reach $2,000 per person or $4,000 for a family, Anthem (the district’s health fund) pays the rest. DO NOT ASK “Do you take Anthem?” ASK “Are you In-Network for Anthem?” • Out-of-Network – These doctors HAVE NOT agreed to be in Anthem’s system. – Anthem only pays for 40% of the bill (after the deductible) - – YOU PAY 60% up to $8,000 What is a deductible? • • • This is the amount of money you pay before Anthem starts paying the bill. There is an individual amount AND a family amount. – Individual amount is $500 • Each person covered in your plan has to pay up to this amount • UNLESS you hit the family maximum of $1,250 • After you paid the entire amount of the deductible Anthem starts to pay 80% of the medical bills you incur. • You pay 20% of everything up to $2,000 per individual; $4,000 for a family. Once you have paid the amount, the coverage is 100%. These are ANNUAL maximum out-of-pocket costs, starts back to ZERO on January 1. VERY IMPORTANT – The out-of-network deductible is HIGHER and NOT part of the in-network deductible- they are separate – Individual is $1,000 – Family $3,000 – MAX OOP $8,000 Preventative Care • Affordable Care Act (aka “Health Care Reform” or “Obamacare”) – Should not cost you anything out-of-pocket (IN-NETWORK ONLY) – No more co-pays for preventive check ups – Cost of appointment to plan not applied to deductible • The key is to set the appointment the correct way. – When you set the appointment make sure you ask for a “preventive care” screening. – Once in the appointment, do not ask for a diagnosis of another issue or ask for a prescription, or Rx renewal. – Adding a diagnosis and/or prescription makes it a diagnostic appointment and then no longer qualifies as preventive screening. – The doctor may make a diagnosis or give a prescription as a result of the screening, but that should be his/her decision, not your request. – Remind your doc that lab coding must be for preventative care – not with a diagnosis code. Who pays for preventative care? • You don’t pay anything, intent is to encourage you to go to the doc for the check-up • Intent to save money over the long-term because issues will be caught early • District (health plan) DOES pay the full amount. Preventative Services (PPO) 1,600 1,502 1,400 1,204 1,200 1,000 922 869 800 708 600 402 293 400 200 655 487 454 323 364 202 145 572 338 343 165123 12096 Colorectal Cancer Breast Cancer Cervical Cancer Eligible Prostate Cancer Receiving Cholesterol Adult Well Adolecent Visit Well Visit BC Avg Prescriptionssame for in and out-of-network • Going to the pharmacy – 30 Day Supply • $15 for generic • $30 for brand name • Mail Order – 90 Day Supply • $30 generic • $60 brand Monthly Premium Payments - CVUSD What would be the best plan for me to do a surgery? • You need to do the research: – Where is the best place to do it? • IS IT IN-NETWORK? – Who is the best person to do it? • IS HE/SHE IN-NETWORK? • Be sure both doctor and facility are in-network – Would a HMO cover the surgery? – How much is the deductible? • Do your research on Anthem webpage – www.anthem.com Additional programs to help • Anthem 360 – – • Future Moms (Anthem) – – • • Must call in Nurse help Nurseline (Anthem) – • Not a scam Disease management for high risk issues • Diabetes, coronary artery disease, asthma, etc. 800-337-4770 Kaiser: Kaiser after-hours advice: 1-888-576-6225 Conejo Cares (everybody) – – – Mix It Up Thrive Across America Waverly Wellness • Know Your Numbers – Costs $20 – if you have it done at Los Robles it can be as high as $600 • Health Risk Assessments • Classes District Website- Under Departments/Employee Benefits Emergency Room Visits • • • • 213 total last year $429,714 in total claims $1,471 per visit average Of the 213 visits, only 2 were admitted to the hospital What’s the difference?! • Approximate emergency room costs (national avg. ER visit $1,349): – To YOU: • $100 Co-Pay • 20%- $249.80 – To the PLAN (the district) • 80% of remaining- $997 • Approximate cost of urgent care visit ($100 national avg.) – To YOU: • Co-pay- $20 • 20%- $16 – To the PLAN: • 80% of remaining- $64 Emergency Room Visits # of Visits 40 35 30 25 20 15 10 5 0 # of Visits Anthem ER Alt If you are having an emergencygo to the ER • Urgent care is for ear infections, sometimes stitches, tummy aches, sore throats, etc. If you’re having chest pain GO TO THE ER! If you do have an emergency • If you get checked into a non-network hospital – Anthem will pay as if you are in-network UNTIL YOU ARE STABILIZED • Once you are stabilized, you begin to pay out-of-network rates • Get to an in-network hospital ASAP How do our top 5 CHRONIC conditions compare (PPO) per member per month? $25.00 $20.00 $23.22 $19.11 $18.62 $15.00 $10.00 $6.70 $6.24 $5.99 $5.00 $2.07 $2.35 $2.22 $1.00 $Cancer Low Back Pain BC Avg CAD CVUSD Depression Asthma Top 5 chronic conditions HMO 1. 2. 3. 4. 5. Cancer Depression Asthma CAD Hyperlipidemia Top 5 conditions by cost (PPO) PMPM $80 $74.77 Last Year $70 BC AVG $60 $50 $45.92 $40 $30 $33.73 $30.06 $29.55 $24.36 $27.32 $22.77 $20 $21.66 $18.25 $10 $0 Musculoskeleton Digestive Ill-defined conditions Circulatory Injury/Poison Top 5 HMO Conditions PMPM Current Year 42.69 16.59 Suppl Class Digestive 11.26 10.43 Infectious Neoplasms 8.72 Mental Disorders Kaiser Changes last year to this year • Inpatient Costs- UP 250% • Outpatient Costs- DOWN 29% • Pharmacy- DOWN 15% • “Other”- UP 62% Kaiser Inpatient Analysis • Medical- UP 625% • Surgical- DOWN 50% • Maternity- UP 132% • Mental Health- UP 801% –PPO is up 21% total –HMO is up 32% total Top Kaiser Prescriptions Paid Claims Respiratory Therapy 4% Vaginal Products 6% Multiple Sclerosis 5% Dermatological 5% Endocrine 17% Central Nervous System 63% Top Prescriptions PPO $350,000.00 $300,000.00 $250,000.00 $200,000.00 $304,949.00 $217,388.00 $171,001.00 $165,702.00 $157,157.00 $150,000.00 $100,000.00 $50,000.00 $0.00 CVUSD Total Nationwide trend of usage 100% 3 90% 19 80% 70% 50 25 60% 50% 40% 30% 35 53 20% 10% 0% 10 5 % of employees % of claims Parting thoughts • • • • • • • • • Eat right Exercise REST Do preventive appointments – Better to catch things early – “I save the plan money because I never go to the doctor”- DOESN’T SAVE MONEY Go to the dentist Get an annual eye exam Encourage each other for better health Participate in the programs that have been created like Conejo Cares Wellness Plan. 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