Town of Dracut Health Plan Educational Information for Active Employees Spring 2013 Andrew Powell – PEC Chair

2 Agenda Overview Group Insurance Commission (GIC) Plans  Health Maintenance Organization (HMO) Plans  Preferred Provider Organization (PPO) Plans  Indemnity Plans Calendar Year Deductibles Provider Tiering & Copays Health Care Flexible Spending Account (FSA) Selecting a GIC Plan

3 Overview All Town employees and retirees will receive their health insurance through the Group Insurance Commission (GIC) starting on July 1, 2013 and continuing through June 30, 2016  Current plans will be in effect until June 30, 2013  Open enrollment will be held from Wednesday, April 10th through Wednesday, May 8th  All employees and retirees MUST enroll in order to have coverage as of July 1, 2013  Marriage licenses, Birth Certificates, Adoption and Guardianship records are required to enroll dependents Your other benefits will continue to be provided through the Town (dental & life insurance)

What Is the GIC? 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 15-member Commission appointed by the Governor Commission members include representatives of labor and retirees GIC covers >212,000 subscribers and >375,000 lives 4

5 GIC Premium Contributions  Employees will pay;  15% of the cost of GIC HMO plans  17% of the cost of GIC PPO plans  20% of the cost of the GIC Indemnity Plans  Most plan participants will have lower premiums under the GIC

6 GIC Plans The GIC offers 12 plans to Active Employees  UniCare (4 Plans)  Harvard Pilgrim Health Care (2 Plans)  Tufts Health Plan (2 Plans)  Fallon Community Health Plan (2 Plans)  Neighborhood Health Plan (1 Plan)  Health New England (1 Plan)

7 GIC Plans GIC Plans with the most Active employee subscribers  Tufts Navigator PPO  Harvard Pilgrim Independence PPO  UniCare Indemnity Plan Basic with CIC (Comprehensive)  60% of Active employee subscribers in these 3 plans Enrollment restrictions  UniCare Indemnity Plan Basic has no restrictions, in or outside of the United States  Other plans are limited to Massachusetts and certain border states/counties; geographic area varies by plan  Consult the map on page 7 of your Benefit Decision Guide!

8 GIC Health Maintenance Organization (HMO) Plans Members must select a Primary Care Physician (PCP) Referrals are required to see Specialists No coverage for out-of-network providers  Except for emergency care Lower premium cost than other plan types “Limited” or “Select” network plans  Lowest premium costs  Limited physician and hospital access

GIC Health Maintenance Organization (HMO) Plans 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 Limited Network HMO  Fallon Community Health Plan Direct Care  Harvard Pilgrim Primary Choice  Health New England  NHP Care (Neighborhood Health Plan)  Tufts Health Plan Spirit 9

10 GIC Preferred Provider Organization (PPO) Plans 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 Average 25% higher premium cost than GIC’s limited network HMOs Member must reside in network service area to enroll

GIC Preferred Provider Organization (PPO) Plans Tufts Navigator PPO Harvard Pilgrim Independence PPO UniCare State Indemnity Plan/Plus 1 Unicare State Indemnity Plan Community Choice 2 1. All Massachusetts doctors and hospitals are “in-network” with UniCare Indemnity Plan /Plus but some out-of-state providers may be “out-of-network” 2. Many in-state hospitals are “out-of-network” with Community Choice 11

12 UNICARE Indemnity Basic Plan 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 Without CIC rider, deductibles and copays are higher and coverage is only 80% for some services

13 Calendar Year Deductibles Fixed amount a member pays before the plan pays benefits Deductible generally does NOT apply to:  Prescription drug benefits  Outpatient mental health/substance abuse benefits  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)  Medically necessary child & adult immunizations  Hearing aids  Mammograms  Pap smears  EKGs  Colonoscopies

14 Calendar Year Deductibles Deductible DOES apply to:  Emergency room visits  Inpatient hospitalization  Surgery  Laboratory and blood tests  X-rays and radiology (including high-tech imaging, such as MRI, CT, and PET scans)  Durable medical equipment

15 Calendar Year Deductibles Calendar Year Deductible Amounts  $250 individual  $500 two-person  $750 family (no more than $250 per person)

Deductible/Copay Example First Visit to ER Total ER Visit$1,000 You Pay Deductible $250 You Pay ER Copay $ Your Total Cost $350 Plan Pays $650 Second Visit to ER Total ER Visit$1,000 You Pay Deductible N/A You Pay ER Copay $ Your Total Cost $100 Plan Pays $900 16

17 Tiered Provider Copays Providers are grouped into “tiers” based on cost, quality, and outcomes measures from third parties 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 GIC Plans use tiering to set office visit copays (primary care and specialists) and inpatient admission copays Tiered hospital copay is in addition to the deductible, if not already satisfied by the member

Tiered Provider Copays Vary by Plan Primary Care Office Visit Copays Tier 1 $15 or $20 Tier 2 $25 or $30 Tier 3 $30 or $35 Hospital Copays Tier 1 $200 to $300 Tier 2 $500 to $700 Tier 3 $700 to $750 18

19 Prescription Drug Tiering Drug formularies vary by plan Pharmacy tiering  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 - $25  Tier 3 - $50  Mail Order 90-day supply  Tier 1 - $20  Tier 2 - $50  Tier 3 - $110

20 Plan Design Example Plan FeatureHPHC Independence PPO In-NetworkOut-of-Network PCP Office Visit$20 copay20% after deductible Specialist Office Visit$20 Tier 1 $35 Tier 2 $45 Tier 3 20% after deductible Calendar Year Deductible$250 Ind/$500 2-Person/$750 Family$400 Ind/$800 2-Person/$800 Family Emergency Room$100 Inpatient Hospital CareTier 1 $250 per admission Tier 2 $500 per admission Tier 3 $750 per admission Maximum of 1 inpatient copay per calendar quarter 20% after deductible Outpatient Surgery$150 per occurrence Maximum of 4 per calendar year 20% after deductible Prescription Drugs Retail Mail-Order (90-day supply) $10/$25/$50 $20/$50/$110

21 HPHC Independence PPO Hospital Tiering FacilityTier 1 - $250 1 per quarter Tier 2 - $500 1 per quarter Tier 3 - $750 1 per quarter Lowell General HospitalX Saints Memorial Med. CtrX Holy FamilyX Lawrence General HospitalX Southern N.H. Med. CtrX Dana FarberX Children’s HospitalX Lahey ClinicX Mass General HospitalX Brigham & Women’s Hospital X

22 HPHC Primary Choice HMO Hospital Tiering FacilityTier 1 - $250 1 per quarter Tier 2 - $500 1 per quarter Lowell General HospitalX Saints Memorial Med. Ctr.X Holy Family HospitalX Lawrence General HospitalX Southern N.H. Medical Ctr.X Dana FarberX Children’s HospitalX Lahey ClinicX Mass General Hospital Not a Covered Hospital Brigham & Women’s Hospital Not a Covered Hospital

23 Health Care Flexible Spending Account (FSA) Employees can set aside money from their paychecks on a “pre- tax” basis to pay for qualified medical expenses  Money must be used within the plan year (or any grace period extensions) or it is forfeited (“use it or lose it”)  Money can be used for any non-reimbursed qualified medical expense for any family member, examples:  Dental  Orthodontics  Copayments and deductibles  Prescription eye glasses and contact lenses  Certain over-the-counter medications with a prescription  Entire annual amount pledged is available for use on the first day of the plan year

24 Mitigation Plan Public Employee Committee (PEC) and Town negotiated mitigation plan for specific subscribers  Any person enrolled in the Blue Care Elect PPO as of June 30, 2013 And who are;  Required to enroll in the GIC’s Indemnity Plan because of GIC enrollment rules will be entitled to;  The premium difference of their current contribution and the GIC Indemnity Plan  Premium subsidy ends on 6/30/2017 or upon exit from the GIC (whichever comes first)

Dracut GIC Health Fair 25 April 25 th Thursday 11:00 AM - 4:30 PM Lakeview Junior High School 1570 Lakeview Avenue

Tips for Selecting a GIC Plan Carefully review the GIC Benefit Decision Guide Complete a questionnaire and estimate your utilization of medical services Discuss the GIC plans with family, friends and your physician(s) 26

Tips for Selecting a GIC Plan 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 Attend a GIC Health Fair 27

Tips for Selecting a GIC Plan Contact Information: Group Insurance Commission: (617) www.mass.gov/gic Harvard Pilgrim Health Plan: (800) www.harvardpilgrim.org/gic Tufts Health Plan: (888) www.tuftshealthplan.com/gic Fallon Community Health Plan: (866) www.fchp.org UniCare: (800) www.unicarestateplan.com Caremark Pharmacy (877) www.caremark.com/gic Health New England: (800) www.hne.com 28

Questions and Answers 29