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.  

Hot Topic - Benefits

It’s no secret; the employee deductions for our QualCare Plus plan will be increasing dramatically for 2015. We have developed this blog post to help you better understand the differences and similarities between both plans that we offer through Children’s Specialized Hospital. Below you will see some of the common questions regarding our benefits for 2015.

How come QualCare raised the rate?

This is a very popular question. We purchase access to the QualCare network each year. This means we are able to use their network of doctors and get the discounted rates that they are contracted with those doctors. However, we (Children’s Specialized Hospital) are self-insured and pay dollar for dollar for the cost of care for our employees. QualCare is not responsible for the increase in cost. The increase is beyond our control and driven by the overall increase in the cost of health care. We continue to work with QualCare to offer two great plans for you to choose from, to give you an option that best meets the needs of your family.

Why is only the Plus plan increasing?

The vast majority of the costs reside in the Plus plan, and therefore all of our increased costs have been pushed to the Plus plan in order to keep the Core plan – a very rich plan – at an affordable rate. The Plus plan is considered a “buy-up plan” – you pay a higher rate for the peace of mind that you are paying now in case you want to limit your out-of-pocket expenses at time of service. Regardless of if you need to use the benefits provided by the Plus plan, you are paying for them with each pay check.

Why are you suggesting we all chose the Core Plan?

We are not trying to “bully” anyone with this recent increase, as suggested in a recent question submitted through our Intranet forum. In fact, many organizations offer only one benefits plan to their employees. We are giving you the option of two plans that offer essentially the same coverage, and helping you make the best decision for you and your family. The only benefit covered in the Plus plan that is not covered in the Core plan is vision. All other benefits covered in the Plus plan are covered in the Core plan.

False: The doctors between the two plans are different.

One of the common misconceptions I’ve heard is that your doctor won’t be covered if you switch plans. That’s incorrect. You can visit the same doctors regardless of if you are in the Core or the Plus plan. As long as your doctor accepts QualCare POS insurance, your doctor is considered in-network.

If you choose to visit a doctor who is out-of-network, you have the same out-of-network benefits between the two plans and are responsible for the same out-of-pocket maximum. The only difference between the Core and Plus plan in regards to out-of-network doctors is you are required to pay 10% more of your coinsurance fees if you are in the Core plan than if you are in the Plus plan. Just 10% more! In the grand scheme of things, that difference is minor compared to your total expense throughout the year.

Let’s break it down

*This comparison compares both plans for an employee who makes less than $30,000 per year and is enrolled in an individual plan who only visits an in-network provider.

	QualCare Core Plan	QualCare Plus Plan
Deductions in each paycheck	$15.52	$125.70
Deductible	$500	None
Coinsurance	Plan pays 80%	Plan pays 100%
Out-of-pocket max	$2,000	$2,000
Copay	$15 PCP $15 Specialist	$15 PCP $15 Specialist

Some key terms you’ll need to know while we go over this chart are:

• Deductible: Amount a member pays for care before the plan begins to cover expenses
• Copay: Member cost for routine services
• Coinsurance: The percentage of costs a member must pay for care after the deductible has been met.
• Out-of-Pocket Maximum: The absolute maximum amount you’ll pay annually. Your medical copays, deductible and coinsurance responsibilities will accumulate toward the plan’s out-of-pocket maximum.

If you are in the core plan:

• You’re contributions to your benefits over the entire 2015 year will be: $403.50
• In order for your insurance to begin paying for 80% of the services you need (coinsurance), you are required to pay $500 yourself (deductible)
• In order for your insurance to pay 100% of the services you need, you must first pay $2,000 out of pocket (out-of-pocket max)
• This includes all copays, deductible, and coinsurance responsibilities
• The total amount that you’d have to pay throughout the year (your out-of-pocket max [including your copays] + your contributions) before every doctor’s visit and service is covered 100% would be $2,403.50

If you are in the Plus plan:

• You’re contributions to your benefits over the entire 2015 year will be: $3,268.20
• You do not need to meet a deductible for your insurance to begin paying 100% of the services you need (not inclusive of copays)
• In order for your insurance to pay 100% of your services (in this case, your copays only), you must first pay $2,000 out of pocket (out-of-pocket max)
• This means you are responsible for $2,000 in copays before they are paid for by your insurance
• The total amount that you’d have to pay throughout the year (your out-of-pocket max [in this plan, only your copays] + your contributions) before every doctors visit would be covered 100% would be $5,268.20

We refer to the Plus plan as our “buy-up” plan. It gives you the peace of mind knowing that you have a set fee that comes out of each paycheck, and the only thing you’ll be responsible for should you ever have any unexpected healthcare need is your copay (as long as you stay in network).

The Core plan is referred to our basic plan, but is still a very rich plan – it is more affordable, but still offers great coverage. The Core plan requires you to plan yourself, do some of the guess work on your own. You’ll have to reach a certain amount of expenses from your own pocket before you have the luxury of leaving the guesswork to the insurance company.

In fact, we offer a program called Flexible Spending Account that helps you to plan for those unplanned expenses.

If you look at the information I just shared with you and take advantage of the Benefits Calculator that was e-mailed to you, you’ll see that you can in fact save money versus having an increase in your costs.

The Children’s Specialized Hospital open enrollment period will run from November 9 through November 19. If you have any questions about your benefits, please call Victor Vena at x5497 or Dana Pettiford at x5560.

Amy B. Mansue President & CEO

Warren Moore Executive Vice President & COO