Advocating for Active and Retired State Employees and Educators
2016 SHBP–Provide Continuity and Stability in Plan Options
The Department of Community Health Commissioner, Clyde Reese III, stated on August 13, 2015 to the Board of Community Health that based upon the 2015 Medical Cost Benchmarking Study by AON the recommendations for CY 2016 State Health Benefit Plan options would provide continuity and stability. SHBP Division Director Jeff Rickman presented for approval the recommendations for CY 2016.
In summary, the recommendations and approvals are:
(1) The vendors are Blue Cross Blue Shield of Georgia (BCBSGa), UnitedHealthcare (UHC) and Kaiser Permanente (KP).
(2) Plan Options for retirees age 65+ are Standard and Premium Medicare Advantage.
(3) Plan Options for retirees under age 65 and for active members are:
(a) Gold, Silver, and Bronze Health Reimbursement Arrangements (HRAs) administered by BCBSGa;
(b) Statewide Health Maintenance Organization (HMO) administered by BCBSGa;
(c) Statewide HMO and statewide High Deductible Health Plan (HDHP) administered by UHC;
(d) Regional HMO in the Atlanta 27-county service area insured by KP;
(e) Express Scripts Inc. will continue to manage the pharmacy benefit for all BCBSGa and UHC
(f) Healthways Inc. will continue to manage the wellness benefits for all options administered by BCBSGa and UHC.
(4) Premium rates for the UHC Medicare Advantage options will not change in 2016.
(5) Premium rates for under age 65 retirees (and actives) will be reduced for some options and will increased for the HDHP.
(6) Telemedicine/Virtual visits are available for all options (page 23 and 24 of the Decision Gide).
Unused wellness credits will rollover to any Plan option (HRA, PPO, HDHP) and/or vendor (BCBSGa, Kaiser, or UHC) you choose (after six months for “run-out” claims), including Medicare Advantage. A balance of $100 or more in an HRA or other incentive account will be established in a Retiree Reimbursement Account (RRA) after being enrolled in the MA for six months. (See page 37 in the Decision Guide.)
SHBP Decision Guide and Educational Meetings
The Decision Guide and Educational Meetings schedule for retirees have been mailed to retirees. You are encouraged to study the Decision Guide and if you feel you need additional explanation, attend one of the educational meetings.
Standard and Premium Medicare Advantage Options (UHC)
The benefits offered under the Standard and Premium Medicare Advantage Options continue in CY 2016 at the same levels as in CY 2015. Each type service includes a dollar copay amount until the annual maximum out-of-pocket amount for medical expenses is met during the calendar year.
Benefits are outlined on pages 14-16 of the Decision Guide. You will note that there are differences in the copay amounts for most medical services for each option, but the major difference is the maximum out-of-pocket ($3,500 vs. $2,500).
There are no differences between the two options in the medical networks/providers. You can use any provider that will accept Medicare patients.
Health Reimbursement Arrangements
(HRAs - BCBSGa) (Gold, Silver, and Bronze)
The benefits offered under the HRA options (Gold, Silver, and Bronze) are the same in CY 2016 as in CY 2015.
Each level of the HRA offers benefits after the specified deductible amount – although a portion of the deductible may be offset by a HRA credit for that option.
Benefits for each option are outlined on pages 23, 25, 27, 29, and 31 of the Decision Guide. There are differences in the deductible amount, coinsurance percentage after the deductible, HRA credit, and maximum out-of-pocket amount for each of the HRA options.
The same provider network is used for the three HRA options offered by BCBSGa and can be found at www.bcbsga.con/shbp.
Health Maintenance Organization (HMO) BCBSGa and UHC
The benefits offered under the HMO options by BCBSGa and UHC are the same in CY 2016 as in CY 2015.
The benefits are the same for the BCBSGa and UHC HMO options; however, there are NO “out-of-network” benefits in either option.
Benefits are outlined on pages 24, 26, 28, 30 and 32 of the Decision Guide. Generally, hospital services require a coinsurance of 20% of allowed charges after a deductible is met and physician services in an office usually require a dollar copay at the visit.
Provider networks for BCBSGa and UHC are different. See www.bcbsga.com/shbp or www.welcometouhc.com/shbp for the networks for each insurance company.
Wellness credits are higher for UHC than BCBSGa.
High Deductible Health Plan (HDHP)
The benefit levels offered under the HDHP option by UHC are the same in CY 2016 as in CY 2015; however, the method of applying the deductible and maximum out-of-pocket will change. In CY 2015, if the member is enrolled in a coverage tier other than “YOU”, that coverage tier’s total deductible and maximum out-of-pocket is required to be met before benefits are paid under the option. Page 19 of your Decision Guide explains the change; however, in CY 2016 if any one of the family members meets the individual deductible, the HDHP option will provide benefits. The maximum out-of-pocket is also calculated per individual rather than the coverage tier maximum.
The HDHP provides for out-of-network benefits, but reduces the percentage to be paid and limits the allowance for the acceptable charge for the OON provider.
Members can establish a Health Savings Account (HSA) under the conditions outlined on page 20 of the Decision Guide.
Health Maintenance Organization (HMO) KP
The benefit levels offered under the Kaiser HMO are the same in CY 2016 as in CY 2015.
The HMO does not have a deductible, although there is a maximum out-of-pocket for accumulation of copays for some services.
Benefits are outlined on pages 24, 26, 28, 30 and 32 of the Decision Guide.
Services must be provided by a network provider for coverage—there are no non-network benefits.
Members who live or work in the 27 counties of the Kaiser network are eligible to enroll in the Kaiser HMO option.
Turning age 65
Turning age 65 is a special time for health insurance coverage. As a RETIREE, You are required to change your SHBP coverage to one of the Medicare Advantage options or pay a very high premium ($1,300 or more) to remain in any of the SHBP options (Kaiser is different). You should start about 4 or 5 months before your 65th birthday obtaining the necessary Medicare cards for Part A and Part B. As soon as you have the information, contact the SHBP and provide the information so that your record can be updated. Although you may change up until 31 days following your 65th birthday, Medicare must approve all additions to MAP and if you do not notify Medicare before your 65th birthday, you will probably have to pay a late penalty fee to Medicare. Always verify that your coverage and premium have been changed.
Kaiser’s 27 Counties – CY 2016 Same as CY 2015
Barrow, Bartow, Butts, Carroll, Cherokee, Clayton, Cobb,
Coweta, Dawson, DeKalb, Douglas, Fayette, Forsyth,
Fulton, Gwinnett, Haralson, Heard, Henry, Lamar,
Meriwether, Newton, Paulding, Pickens, Pike, Rockdale,
Spalding and Walton/
Stable Premiums—CY 2016
Commissioner Reese stated that the recommendations to the Board were partially a result of the Medical Cost Benchmarking report by AON – specifically for the pre-65 retirees and active members:
(1) Employee out-of-pocket (OOP) costs is the highest of all Comparators and is 39% higher than the mean of all Comparators;
(2) The SHBP’s total cost (premiums and OOP) is the highest for the employee of all Comparators1 and is 29% higher than the mean with all Comparators, but drops to 23% higher than the mean when wellness credits and the tobacco surcharge are considered;
(3) SHBP employee deductions (premiums) are higher than all but two Comparators and are 18% higher than the mean of all Comparators, but drops to 15% higher than the mean after the tobacco surcharge is considered.
DCH, recognizing the high cost to members, recommended that the premiums be decreased for most options, but the premiums for the HDHP were increased because of the change in the method of calculating the deductible and OOPM. Also, the premiums for the Bronze HRA did not change for 2016. The following charts compare the premiums for CY 2015 and CY 2016.
Making a Coverage Decision for CY 2016 – Retirees Over Age 65
Making your decision for 2016 is a matter of finances. The benefit provisions and the provider network for the
Standard and Premium options are the same. See page 14-16 of the Decision Guide for a complete display of the benefit provisions. In addition to the provider network that is available, you have the option to use any provider that accepts Medicare. (Note: The provider can choose not to accept the MAP coverage.) As a general rule, providers request insurance information before treating you and will inform you if they will not accept the UHC MAP coverage. In addition, the copays for prescription drugs (not included in the medical OOPM) is the same under either option. Although there are some differences in medical copays, the bottom line is that the Out-of-Pocket Maximum for medical expenses under the Premium is $1,000 less ($3,500 less $2,500) than the Standard Option, BUT your deduction for the Premium Option is $754 (annually) more than the deduction for the Standard option. Your decision comes down to whether you want to pay the lower premium and hope that you will not have medical expenses with copays greater than the $2,500 or pay the higher premium so that you will not have medical expense risk for more than $2,500 out-of-pocket maximum
(copays) during the year.
Making a Decision – Under Age 65 SHBP Members
Making a decision for 2016 for an under age 65 SHBP member requires a substantial amount of study and analysis about provider networks and costs. The first thing that you need to determine is “Am I satisfied with the provider network offered by the option or am I willing to change providers” under the Option. Some points that you might consider are:
All options provide for emergency treatment from an out-of-network provider.
All of Blue Cross Blue Shield options use the same network, the UnitedHealthcare HMO and HDHP
options use the same network, and the Kaiser HMO provides care through a network of facilities.
BCBSGA’s Bronze, Silver, and Gold options and the UHC High Deductible Health Plan option have “out-of-network” benefits (if desired), although all of the costs for out-of-network services are treated separately for the purpose of deductibles, copays, and OOPM.
BCBSGA and UHC options for HMO do not have an out-of-network benefit; therefore, if you are not satisfied with the network and are not willing to use another choice in the network, the entire cost for that service (except for emergency) is out-of-pocket and not covered by the plan.
The Kaiser option does not have an “out-of-network” benefit; therefore, any services (unless emergency) is not a covered medical service.
The Kaiser option requires you to live or work in one of the 27 counties listed. The Retiree Decision Guide (pages 9-10) or page 8 of the Active Decision Guide provides Decision Support Tools to help you compare each benefit option. When analyzing your cost for each option, the bottom line is that you will pay about the same amount in premiums and out of-pocket expense in any option you choose if you have extensive medical needs. If you pay a lower premium, you will pay higher out-of-pocket amounts when you receive medical services or if you pay a higher premium, you will pay lower out-of-pocket when you receive medical services. The question comes down to what medical expenses do you expect and would you rather pay a higher premium on a regular basis, or pay lower premiums that may require a higher out-of-pocket amount when you receive medical services. Some points that you may want to consider are:
When analyzing the HRA options, don’t forget to subtract the HRA credits (1st page of the comparison) that reduce the deductible and the OOPM. The HRA credits can be used for first dollar medical expense.
All BCBSGA and UHC options (including the Medicare Advantage) provide for well-being (by different names) incentive credits when you comply with the requirements of the wellness programs. The amount of credits vary by type of incentive. Calculate your medical expenses for each year during the last two to three years and your expected or at-risk cost for the upcoming year. Determine how best to meet those needs based on the premiums, deductibles, copayments, and coinsurance, and process your change (if any) in option according to instructions provided by SHBP. At minimum, each person should verify that the coverage information on the SHBP website (www.mySHBPga.adp.com) is correct. Verification may require creating an account, or at minimum it may require a new password for the account. Enrolling in Pension Deductions If you are a retiree with a retirement benefit from the Employees Retirement System, consider having your GSRA dues deducted from your benefit. It is easy. Go to www.mygsra.com (Select Join US, Benefits, and Pension Deduction form.) Complete the Authorization, complete your “pension ID number” and mail as instructed on the form. Caution: Medicare Advantage Members YOU will, as an enrollee of a Medicare Advantage option, negatively affect YOUR coverage if YOU:
Discontinue paying the Medicare Part B premium;
Enroll in a Medicare Supplement Plan
Enroll in a non-SHBP MA plan
Enroll in a Medicare Part D pharmacy plan.
Should you take any of the above actions, the MA coverage with SHBP will be terminated by Medicare and the SHBP will transfer you to the BCBSGa Bronze HRA plan. The premium with BCBSGa Bronze option will not be subsidized by the SHBP.
State Health Benefit Plan (SHBP)-February 18, 2014
2014 Plan Design Changes-Frequently Asked Questions
SHBP January Changes Q&A
A question and answer article for the State Health Benefit Plan has been released by the Department of Community Health. The paper may answer some of your questions about how the changes that were approved on January 27th may be applied to the SHBP decision you made during the Open Enrollment/Retiree Option Change period. You can view the Q&A by clicking here.
SHBP Running On "Empty"
The State Health Benefit Plan is BROKE. As noted in previous GSRA Newsletters, funding for the SHBP since FY 2008 has been reduced to such an extent that all reserves have been used to pay current claims and the SHBP has been placed on a “cash” rather than an accrual payment basis. The Plan is technically insolvent. As shown in the chart below it does not have sufficient funds in reserve to pay claims for medical care already provided to members and for which claims have not yet been filed for payment—referred to as “IBNR” (Incurred But Not Reported) reserves. Commissioner Clyde Reese reported to the Board of Community Health that the Department of Community Health is preparing a grant request under the Affordable Healthcare Act to pay a portion of the health care costs for early retirees—between the ages 55-64. DCH staff presented to and the Board approved a resolution to “front-load” employer receipts to help restore SHBP reserves.
GSRA asked for financial information from the Department of Community Health. The specific information requested was a “Balance Sheet”, a “Revenue and Expense Statement”, and the cost for providing each of the options. The most telling financial information is the Balance Sheet which can be compared to DCH website Balance Sheet information for FY 2008 and FY 2009.
The following facts can be gleaned from the above chart:
· In less than 2 years, the SHBP cash basis trust funds have gone from a well-funded $884,846,177 (including partial funding for OPEB) to a negative $(195,986,701) (without any OPEB funding);
· The SHBP accrual basis trust funds (considering IBNR claims) reserves have decreased from $661,957,177 in 2008 to a negative $(1,095,54,878) in April 2010;
· The cash basis trust fund declined $93,110,924 ($-102,875,777 to $-195,986,701) in one month (March to April, 2010);
· $1.1 billion has been cut from the SHBP funding during FY 2008, FY 2009 and 10 months of FY 1010 while member premiums have increased 10% and benefits reduced by increasing deductibles, coinsurance (copays) and out-of-pocket maxims.
The bottom line: The SHBP is insolvent and if the Plan continues to decline at a monthly rate close to $93 million—as it did in April—the plan will have a negative cash net worth of approximately $382 to $400 million at the close of FY 2010. In addition to the cash net worth, IBNR liabilities increase the negative accrual net work to $619 to $637 million. At the Board of Community Health Meeting on June 10, 2010, the Chief Financial Officer, Scott Frederking, stated that the FY 2011 projected cost of the SHBP was $200 million more than the FY 2011 funds appropriated. He further stated that the DCH was working through the issues to present the member rates required for medical options with reduced benefits beginning January 2011.
DCH Commissioner Clyde Reese stated that the department was preparing a $100 million—about one-half of the currently projected shortage for FY 2011—grant request to the federal government to reimburse the SHBP for a portion of the cost for retirees age 55-64. In the national Affordable Health Care Act, Congress appropriated $5 billion to help employers until 2014 pay for retirees from age 55-64. Under the act, health plans can be reimbursed at 80% of the claim costs between $15,000 and $90,000 for a retiree age 55-64.
Commissioner Reese stated that there was no assurance that the grant request would be approved, but that it would be very helpful to “fill-in” the shortage. Recent news articles have reported on the race by big employers to request retiree funds. Companies are concerned that the early-retiree fund will be exhausted quickly. General Electric Company, the state of California and retired union auto workers are among those preparing to apply.
In addition to the grant request, the Board approved resolutions to “front-load” the employer contributions to meet the funding needs during the FY 2011 1st quarter. The Appropriation Act provided for a state department rate of 22.165% of salaries, the teacher rate of 18.534% of state-based salaries, and $30,261,983 for school service employees. However, by “front loading” receipt of employer contributions, the Board approved the state employees’ rate at 25.586% and the teachers’ rate at 21.55% for the first calendar quarter of FY 2011. The resolution also included transmittal during the first calendar quarter of the entire $30,261,983 that was appropriated for school service employees’ health insurance during FY 2011.
SHBP Questions & Answers - October 2009
GSRA developed two sets of questions from members' questions about the State Health Benefit Plan. Some of the questions were general "in nature" and could be answered by GSRA officials and other questions were submitted to the Department of Community Health (DCH) for response. Two documents have been prepared for your information. The Q&As developed by GSRA were distributed to all attendees at the Annual Meeting of October 21st and can be reviewed by clicking on this link (GSRA Q&As). Other questions were asked and responses verbally given by DCH staff at the Annual Meeting. However, DCH also provided written responses to those verbally asked and others that could not be asked because of time. You can view these Q&As by clicking on this link (DCH Q&As).
New Retiree Policies Announced for July 2009 and January 2010
In October 2008, the Department of Community Health announced major changes for retirees age 65+ to become effective in July 2009 and January 2010. Briefly stated the policies (1) require retirees age 65+ to enroll for Medicare Part B or pay an additional $300 per month as of July 1, 2009
(2) require retirees age 65+ to transfer to the Medicare Advantage Plan (MAP) on January 1, 2010 in order to receive any State employer subsidy to the premium.
GSRA has addressed the retiree issues in several newsletters. Specific GSRA newsletters having articles related to the policies are dated March 18, 2009, February 28, 2009, February 11, 2009, December 2008, and October 2008 newsletters. A recent presentation providing a simplified view of the policies, Medicare Part B Premium for 2010 and limited information on Healthcare Reform may be of interest.
New Vendors for January 2009
The Department of Community Health announces the selection of two vendors to administer SHBP options beginning 2009. The two vendors are United Healthcare and CIGNA.
Transition, Premiums, and Other Updates
The Department of Community Health announces several updates to the State Health Benefit Plan (SHBP) that will take effect in late 2008 and early 2009. See the May 2008 Update for: