FY 2015 Changes• Changes (listed on page 4 of the Benefits Choice book and

page 2 of the flyer):

– Deductibles and plan year deductible caps– Coinsurance– OAP out-of-pocket maximum– Vision lens benefit frequency – Retiree premiums

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FY 2015 Changes• Remaining the same:– Employee premiums – Employee premium annual salary bands – QCHP deductible salary bands– Life insurance rates– Dental rates

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Out-of-Pocket Maximum• The following do not count toward the out-of-pocket

maximum:– Amounts over allowable charges for the plan – Non-covered services– Charges for services deemed to be not medically necessary– Penalties for failing to pre-certify/provide notification– Prescription deductibles and copayments (see Coventry

HMO exception)

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Out-of-Pocket Maximum• Effective 7/1/14, Coventry HMO will count

prescription deductibles and copayments towards the out-of-pocket maximum. Therefore, once the out-of-pocket maximum has been met, prescription charges will be covered at 100% for the rest of the plan year.

• In FY 2016, prescriptions will apply to all health plan out-of-pocket maximums.

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Out-of-Pocket MaximumOut-of-Pocket Max Limits

Annual Plan Year Deductible

Additional Deductibles (QCHP)/ Copayments

Coinsurance Amounts over Allowed Charges

QCHP In-NetworkIndividual - $1,500Family - $3,750Out-of-NetworkIndividual - $6,000Family - $12,000

X X X QCHP out-of-network providers and OAP Tier III providers: Amounts over the plan’s allowable charges are the member’s responsibility and do not go toward the out-of-pocket maximum.

HMO Individual - $3,000Family - $6,000

N/A X X

OAP Tier I Individual - $6,250Family - $12,700

N/A X X

OAP Tier II Individual - $6,250Family - $12,700

X X X

• Eligible charges from Tiers I and II will be added together when calculating the out-of-pocket maximum.• Tier III will no longer have an out-of-pocket maximum.

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FY 2015 Benefit ChangesQuality Care Health Plan (QCHP)

Individual Family Cap

Annual Deductibles * FY 2014 FY 2015 FY 2014 FY 2015

Employee $60,700 or less $350 $375 $875 $937.50

$60,701-$75,900 $450 $475 $1,125 $1,187.50

$75,901 and above $500 $525 $1,250 $1,312.50

Retiree/Annuitant/Survivor $350 $375 $875 $937.50

Dependents $350 $375 N/A N/A

* Salary bands for QCHP deductibles did not change this year.

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QCHP Deductibles

Deductibles FY 2014 FY 2015

Inpatient Hospitalization (In-Network) $75 $100

Inpatient Hospitalization (Out-of-Network) $400 $500

Emergency Care – Hospital $425 $450

Individual Out-of-Pocket Maximum (In-Network) $1,500 $1,500

Individual Out-of-Pocket Maximum (Out-of-Network) $6,000 $6,000

Family Out-of-Pocket Maximum (In-Network) $3,750 $3,750

Family Out-of-Pocket Maximum (Out-of-Network) $12,000 $12,000

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QCHP Benefit Levels

FY 2014 FY 2015

After all applicable deductibles are met (in-network) 90% 85%

After all applicable deductibles are met (out-of-network) 60% 60%

After the out-of-pocket maximums are met 100% 100%

Note: Percentages are based on the allowable charge for covered services.

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QCHP PrescriptionsFY 2014 FY 2015

Deductibles $100 $125

Copayments

Generic (30-day supply) $10 $10

Preferred brand (30-day supply) $30 $30

Non-preferred brand (30-day supply) $60 $60

Mail order generic (90-day supply) $25 $25

Mail order preferred brand (90-day supply) $75 $75

Mail order non-preferred brand (90-day supply) $150 $150

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HMO Health Plans

Copayments FY 2014 FY 2015

Office Visit (PCP) $18 $20

Office Visit (Specialist) $25 $30

Home Health Visit $25 $30

Inpatient $325 $350

Outpatient $225 $250

Emergency Room $225 $250

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Open Access Plans – Tier I

Copayments FY 2014 FY 2015

Physician Office Visit $18 $20

Specialist Office Visit $25 $30

Home Health Visit $25 $30

Inpatient $325 $350

Outpatient $225 $250

Emergency Room $225 $250

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Open Access Plans – Tier IICopayments FY 2014 FY 2015

Annual Plan Deductible $250 $250

Inpatient 90% after $375 copay 90% after $400 copay

Outpatient 90% after $225 copay 90% after $250 copay

Emergency Room 100% after $225 copay 100% after $250 copay

Out-of-Pocket Maximum *IndividualFamily

$900$1,500

$6,250$12,700

Note: Percentages are based on network charges for covered services.* FY 2015 out-of-pocket maximum includes eligible charges from Tiers I and II combined.

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Open Access Plans – Tier IIIFY 2014 FY 2015

Annual Plan Deductible $350 $350

Physician Office Visit 60% 60%

Specialist Office Visit 60% 60%

Inpatient 60% after $475 copay 60% after $500 copay

Outpatient 60% after $225 copay 60% after $250 copay

Emergency Room 100% after $225 copay 100% after $250 copay

Out-of-Pocket Maximum IndividualFamily

$1,800$3,800

Unlimited

Note: Percentages are based on the allowable charge for covered services.

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HMO and OAP PrescriptionsFY 2014 FY 2015

Deductibles $75 $100

Copayments

Generic (30-day supply) $8 $8

Preferred brand (30-day supply) $26 $26

Non-preferred brand (30-day supply) $50 $50

Mail order generic (90-day supply) $20 $20

Mail order preferred brand (90-day supply) $65 $65

Mail order non-preferred brand (90-day supply) $125 $125

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Vision

FY 2014 FY 2015

Eye exam $20 $25

Lenses $20 $25

Standard frames (available every 24 months) $20 $25

Replacement lenses, including contacts 24 months 12 months

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Dental

FY 2014 FY 2015

Annual Deductible $150 $175

Annual Max (In-Network) $2,500 $2,500

Annual Max (Out-of-Network) $2,000 $2,000

Ortho Max (In-Network) $2,000 $2,000

Ortho Max (Out-of-Network) $1,500 $1,500

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If you have questions…

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If you have questions, please contact Benefits staff by calling 650-2190.

Or review the Benefits Choice Options booklet on the CMS website at:http://www2.illinois.gov/cms/Employees/benefits/StateEmployee/Pages/BenefitsBooks.aspx.

Thank you!