Your benefits questions answered

Thank you everyone who posted questions or shared personal stories on yesterday’s blog post.  It’s important that we have this dialog to ensure everyone has the most accurate information. 

This post will answer each of the questions posted on yesterday’s blog post.

What is self-insured plan? What does that mean to the subscriber over all?

Rather than paying the insurance company to pay out healthcare claims, we pay them ourselves. It doesn’t affect you as the subscriber; it’s simply the method we use to pay for claims.

How much of my insurance is being paid by Children's verses the amount that is the employee? Percentage wise?

We can only share the percentages for 2014, as the 2015 percentages have not yet been calculated. The hospital pays between 77% and 95% of the insurance. The percentage will vary depending on which tier you fall in and which plan you are subscribing to.

General question - Why do many companies like ours opt for self-insured plans vs. fully insured? What are the pros/cons for this decision?

Large employers use a self-insured plan when their premiums go up very high; they evaluate whether it is more beneficial to pay their claims directly and purchase stop loss insurance, or continue to pay the premium and allow the insurance carrier to pay the healthcare claims.

The pro is that by being self-insured, we manage our own risk. We don’t have to pay extra for the insurance company to pay our claims; in essence we are saving about 20% of the cost. The con is we can’t estimate the amount of claims we will be responsible for; however, we purchase insurance to protect us.

Is there a yearly benefit maximum for prescriptions?

On page 11 of the 2015 Benefits Guide you’ll see more details about our Express Scripts Prescription Drug Plan. This page states that there is an out-of-pocket maximum of $2,500 for individuals and $5,000 for families. Once a member/family has paid for scripts up to the out-of-pocket maximum associated with their plan within a calendar year, scripts will be covered 100% for the remainder of that calendar year.

Can the FSO maximum be raised? I exhausted my FSO account by June, having requested the maximum deduction ($2,500).

I think you meant to ask about the FSA maximum. The FSA maximum is set by the IRS, that’s not something Children’s Specialized or QualCare has a say in. Unfortunately it cannot be raised and the maximum deduction remains $2,500.

If the Core Plan does not cover vision, do you offer a separate vision plan that covers annual exams and glasses/contacts?

Vision coverage is included in the Plus plan. We offer Vision Service Plan (VSP) for all of our employees enrolled in the Core plan. For more details on the coverage offered with VSP, please see page 13 in the 2015 Benefits Guide. To see the payroll contributions, please see page 18 of the 2015 Benefits Guide.

As the above person asked I have a child with vision issues and we see the doctor a few times a year and she may need some procedures done. Are you telling me that VSP does not cover that so switching to the Core plan would not be in my best interest after all even if the doctor is listed on that QualCare website?

The VSP insurance must be purchased separate if you are enrolled in the Core plan. Eye exams are covered in both the Core and Plus plan. To see the payroll contributions, please see page 18 of the 2015 BenefitsGuide.

What would happen if you choose to leave your employment and want to purchase cobra. Would the costs of the 2 plans be significantly different?

COBRA insurance allows you to keep your health insurance for a certain amount of time after you resign from your position at Children’s Specialized Hospital. Since you’d no longer be considered an employee at Children’s Specialized, we are not required to subsidize your payments; therefore, you’d be responsible for the complete cost on your own. If you enroll in Cobra, you’d keep whichever plan you’re enrolled in (Core or Plus) and have an additional fee for COBRA.