Roswell Independent School District 1. (a)NMPSIA doesn’t care about its members (b) NMPSIA...
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Transcript of Roswell Independent School District 1. (a)NMPSIA doesn’t care about its members (b) NMPSIA...
NEW MEXICO PUBLIC SCHOOLS INSURANCE AUTHORITY
Roswell Independent School District
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(a) NMPSIA doesn’t care about its members
(b) NMPSIA loathes 89% member satisfaction
(c) NMPSIA staff pocketed the extra millions
(d) Bernie Madoff made us do it
(e) NMPSIA’s reserves are depleted & claim costs are up
Why the Plan Changes?
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Self – Insured Coverage
Excess Fund Balance went from $25 million on April 30, 2008 to negative $2 million on March 30, 2009
No Premium Increases allowed in FY10 legislative budget process
Why the Plan Changes?
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Why the Plan Changes?
$(1,500,000)$500,000
$2,500,000 $4,500,000 $6,500,000 $8,500,000
$10,500,000 $12,500,000 $14,500,000 $16,500,000 $18,500,000 $20,500,000 $22,500,000 $24,500,000 $26,500,000 $28,500,000
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
Revenues
Expenditures
Fund Balance
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Blue Cross Medical: No ChangePresbyterian Medical: No ChangeUCCI Dental: No Change
Davis Vision: No ChangeThe Standard Life: No ChangeThe Standard Disability: No Change
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Premiums October 2009
No Choice But To Downsize
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JULY 1ST PLANCURRENT PLAN
New Introduction (Executive Director’s Letter)
New Employer Plan Matrix
Expanded Rules and Regulations Summary
New Summary of Benefits High & Low Options
New Prescription Drug Summary
New Davis Vision Summary 7
July 1, 2009 Program Guide
Copay - The predictable fixed dollar amounts you pay for certain services.
Deductible - The amount you pay for health care before the PPO begins to pay
Coinsurance - The percentage of covered charges you pay after you meet the deductible
Out-of-Pocket Maximum – The maximum amount you pay for covered services in a calendar year. (Charges above the maximum allowable fees do not apply to the out-of-pocket maximum.)
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July 1, 2009 Program Guide
Worst Case Scenario to meet Out of Pocket
$300 Deductible
Plan pays 80% of next $12,500*(Member pays 20% or $2,500)
$2,800 Out of Pocket met ($300 + $2,500)Plan pays 100% for rest of calendar year
*This amount may be less if copays were also paid
BenefitsWhat You Pay
Preferred Provider Nonpreferred Provider
High Option Low Option High Option Low Option
PPP Office Visit(Deductible waived) $20 $25 30%
(after deductible)50%
(after deductible)
Specialist Visit(Deductible waived) $30 $35 30%
(after deductible)50%
(after deductible)
Preventive Services(PAP test, cholesterol test, immunizations, etc.)(Deductible waived)
$0 $0 30% 50%
Lab, X-Ray, and Pathology 20% 25% 30% 50%
High-Tech Radiology(MRIs, PET Scans, CT Scans) 20% 25% 30% 50%
Surgery, Outpatient $150 copay per occurrence + 20%
25% 30% 50%
Inpatient Hospital/Facility Services
$500 copay per admission + 20%
25% 30% 50%
Ambulance – emergency(Copay per trip) $30 25% $30 25%
Emergency Room 20% 25% 20% 25%
Urgent Care Facility(Deductible waived) $50 $50 30% 25%
Brief summary of benefits
The Bucket List
Copays DON’T go in the deductible bucketNeither do non-allowed charges
Deductible, coinsurance, and copays go in the out-of-pocket bucket
Deductible Bucket Out of Pocket Bucket
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Non-Allowed Charges
Charges which are:
Not Covered, or
In Excess of Plan’s Allowable Amount when going out of network (balance billing)
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Balance BillingApplies to Out of
Network Charges
Charge $1,000Allowed $ 800Balance $ 200
$200 does not go to deductible. Member is 100% responsible for this amount
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High Option benefit example*An example of what the member’s responsibility could be for a medical office visit including lab and radiological services once the deductible has been met.
Billed Allowable Plan Pays
You Pay(In-Network) Notes
Office Visit $300.00 $73.00 $53.00 $20.00 Copayment (Deductible waived and not applied to deductible).
Venipuncture
$3.00 $2.40 .60
Coinsurance after deductible is met.
Urinalysis $4.00 $3.20 .80
Complete Blood Count $70.00 $56.00 $14.00
Radiologic Exam/Chest X-ray
$39.00 $31.20 $7.80
Grand Totals $300.00 $189.00 $145.80 $43.20 Note: Your OOP includes co-pays, deductibles and coinsurance .
*Please note that this is set up as an example and actual payments will vary.
High Option benefit example*A member obtains a routine physical and associated testing. Later in the year, the member suffers an injury requiring an emergency room visit. The member also sees their PPP, which includes associated lab test and a high-tech radiology test (MRI). These tests show a need for surgery, a brief hospitalization, and short-term physical therapy.
Billed Allowable Plan PaysYou Pay
(In-Network) Notes
Wellness Visit $300.00 $200.00 $200.00 $0.00 The plan pays 100% of preventive care.
ER Visit $7,000.00 $1,700.00 $300.00 Deductible
$280.00 Coinsurance
$1,120.00 $580.00 Total you pay for the ER facility.
PPP Visit $190.00 $90.00 $70.00 $20.00 Copayment. Follow up from ER service.
Lab/X-Ray $250.00 $175.00 $140.00 $35.00 Coinsurance
MRI $2,300.00 $1,500.00 $1,200.00 $300.00 Total you pay for MRI.
Out of Pocket So Far $935.00
Hospitalization $40,000.00 $28,000.00 $26,135.00$1,865.0
0$500 Copay plus Coinsurance
Physical Therapy (x5) $2,000.00 $500.00 $500.00 $0.00 You have satisfied your out-of-pocket max.
The plan now picks you up at 100%.
Grand Totals $52,040.00 $32,165.00 $29,365.00$2,800.0
0Note: Your OOPM includes the deductible, copayments and coinsurance amounts.
*Please note that this is set up as an example and actual payments will vary.
Drug Firms' Spending on Consumer Ads Fell 8% in '08, a Rare Marketing Pullback - - spending on such ads reached a high of $4.8 billion in 2007, compared with less than $1 billion in 1997
Third tier (non-formulary) still covered, but member will pay 70% of discounted price
Formulary at nmpsia.com or catalystrx.com
Prescription Plan Changes
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Prescription Plan ChangeLunesta or Ambien CR for
insomnia
70% of Discounted Price is $54. Member pays $54.
Generic for Ambien (zolpidem tartrate) another sleep aid,
would cost member $2.
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Other Non-Formulary Examples
Celebrex $48naproxen $2
Vytorin $70Zetia + simvastatin $35
Cozaar $35Diovan $17
Aciphex$116
omeprazole $218
Davis Vision Changes Occupational Eyeware
option (safety or VDT glasses)
Contact lens discount of 15% for amounts over allowable
Lens 123 offers 50% savings on replacement contact lenses
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In Closing . . .
Any More Questions?
Comments?
Thanks!
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