5.1.2016 Open Enrollment
Meeting Agenda

2016 Field Employee Benefits

Health – KeySolution – New Plan Options
 Health

 RX
Preventive Services – Adults & Children
Management
 Know
 Key

Care 101
Where to Go, Before You Go…
Solutions Medical – 5M Program
MEC, MEC Plus, MEC Heavy, MEC Heavy Plus, MVP (ACA Compliant Plan)

Dental – Guardian – New Carrier/Plan

Contact Information
Potomac Companies, Inc.
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Healthcare 101
Insurance Definitions

Deductible
 Amount
 May

be different for certain benefits (i.e. Rx drugs)
Co-insurance
 Amount
pay

you pay before insurance starts to pay
of charges for a service that you are required to
Out-of-Pocket Limit
 Maximum amount
you pay for covered services in a year
 Often
(but not always) includes deductible, co-insurance
and co-payments
Potomac Companies, Inc.
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What is a preventive care service?

Preventive care services are provided during a
wellness exam. You and your doctor will
determine what tests and health screenings
are right for you. The screenings are based
on your:
 Age
 Gender
 Personal
 Current
Potomac Companies, Inc.
health history
health
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Preventive Services for Adults (18+)
Potomac Companies, Inc.
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Preventive Services for Women, Including Pregnant Women
Potomac Companies, Inc.
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Covered Services for Children
Potomac Companies, Inc.
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RX Management
Understanding Your RX Program
Simple ways to save on Prescriptions:


Know Your Prescription Plan Tiers – understanding the tier system can
help you choose high value, low cost medications

Generics – Usually the least expensive option (see next slide)

Mail-order – 90 day supply of maintenance medications for only 2
copays

Retail – Yes, you can get a 90 day supply at a local pharmacy for
maintenance medications for only 2 copays

Physician writes you a prescription for a 90-day supply (instead of 30
with 2 refills)
Pill Splitting


Physician writes you a prescription for 2 times the strength and then
you split the tablet – you get your usual dosage for half the cost
Over The Counter (OTC) Substitutions – Some prescriptions have OTC
alternatives – check with your doctor or pharmacy
Potomac Companies, Inc.
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Know Where to Go
Know Where to Go
Know where to go
when you need medical
care and receive the best
treatment with the lowest
out-of-pocket costs.
Potomac Companies, Inc.
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KeySoltution’s
KeySolution 5M Program™
MVP
MEC
&
MEC PLUS
MEC
HEAVY
&
MEC
HEAVY
PLUS
MEC & MEC PLUS PLAN DESIGNS
The next few slides is only a brief overview. See detailed Summary of
Benefits or Evidence of Coverage for more specifics.
5M MEC Benefit Description
Covered Benefits
Deductible (single/family)
MEC
In-Network
MEC Plus
In-Network
$0/$0
$0/$0
Coinsurance
100%
100%
Out-of-Pocket Maximum
(single/family)
$0/$0
$0/$0
Multiplan
Network
Multiplan
Network
100% covered
100% covered
PPO Network
ACA Required Preventive Care/
Screening/Immunization Benefits
(MEC)
Potomac Companies, Inc.
Description
Minimum Essential Coverage covers
100% of the government’s listed
Preventive and Wellness Benefits
when you visit a network provider
(40% out-of-network). Self-Insured
by employers, this coverage is
required to satisfy the individual
mandate under the new healthcare
law.
15
MEC & MEC Plus Plan Designs (Cont.)
Covered Benefits
MEC
In-Network
MEC Plus
In-Network
Description
Fully Insured Indemnity Benefits*
Inpatient Hospital
Daily Indemnity
Benefit
N/A
Inpatient Surgery &
Anesthesia Daily
Indemnity Benefit
N/A
Outpatient Surgery &
Anesthesia Daily
Indemnity Benefit
N/A
Outpatient Physician
Office Visit Daily
Indemnity Benefit
N/A
Outpatient
Diagnostic X Ray and
Lab Daily indemnity
Benefit
N/A
Daily Prescription
Drug Benefit
N/A
Potomac Companies, Inc.
If a Covered Person, while insured, is Confined in a Hospital
$200 daily benefit, 180 as a result of Accident or Sickness, the plan will pay the
maximum days
Daily In-Hospital Indemnity Benefit amount up to 180 days
per benefit period.
$1,000 per day/$200
If a Covered Person has a covered in-patient surgery
Anesthesia, 1 day
performed, the plan will pay the daily In-Patient Surgical
maximum per benefit
Indemnity Benefit up to the maximum per benefit period.
period
$500 per day/$100
If a Covered Person has a covered out-patient surgery
Anesthesia, 1 day
performed, the plan will pay the daily In-Patient Surgical
maximum per benefit
Indemnity Benefit up to the maximum per benefit period.
period
The plan will pay the Outpatient Physician Office Visit
$60 per day, 6 day
Indemnity Benefit for each day the Covered Person visits a
maximum per benefit
Physician’s office as a result of Sickness or Accident up to
period
the maximum number of days per benefit period.
The plan will pay the Outpatient Diagnostic X-Ray and
$50 per day with a 3 Laboratory Indemnity Benefit when a Covered Person has
day maximum per
diagnostic x-ray and laboratory tests performed. This
benefit period
benefit is limited to once per day of testing up to the
maximum days per benefit period.
$15 per day, 20 day
maximum per benefit
period
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MEC & MEC Plus Plan Designs (Cont.)
Covered Benefits
MEC
In-Network
MEC Plus
In-Network
Description
Fully Insured Indemnity Benefits*
Inpatient Hospital
Daily Indemnity
Benefit
N/A
Inpatient Surgery &
Anesthesia Daily
Indemnity Benefit
N/A
Outpatient Surgery &
Anesthesia Daily
Indemnity Benefit
N/A
Outpatient Physician
Office Visit Daily
Indemnity Benefit
N/A
Outpatient
Diagnostic X Ray and
Lab Daily indemnity
Benefit
N/A
Daily Prescription
Drug Benefit
N/A
If a Covered Person, while insured, is Confined in a Hospital
$200 daily benefit, 180 as a result of Accident or Sickness, the plan will pay the
maximum days
Daily In-Hospital Indemnity Benefit amount up to 180 days
per benefit period.
$1,000 per day/$200
If a Covered Person has a covered in-patient surgery
Anesthesia, 1 day
performed, the plan will pay the daily In-Patient Surgical
maximum per benefit
Indemnity Benefit up to the maximum per benefit period.
period
$500 per day/$100
If a Covered Person has a covered out-patient surgery
Anesthesia, 1 day
performed, the plan will pay the daily In-Patient Surgical
maximum per benefit
Indemnity Benefit up to the maximum per benefit period.
period
The plan will pay the Outpatient Physician Office Visit
$60 per day, 6 day
Indemnity Benefit for each day the Covered Person visits a
maximum per benefit
Physician’s office as a result of Sickness or Accident up to
period
the maximum number of days per benefit period.
The plan will pay the Outpatient Diagnostic X-Ray and
$50 per day with a 3 Laboratory Indemnity Benefit when a Covered Person has
day maximum per
diagnostic x-ray and laboratory tests performed. This
benefit period
benefit is limited to once per day of testing up to the
maximum days per benefit period.
$15 per day, 20 day
maximum per benefit
period
MEC & MEC Plus Plan Designs (Cont.)
Covered Benefits
MEC
In-Network
MEC Plus
In-Network
If a Covered Person, while insured, is Confined in a Hospital as
a result of Accident or Sickness, the plan will pay a one time
N/A
admission benefit with a maximum of one admission per
benefit period.
The Critical Illness Benefit will be paid only if a covered
condition first occurs and is diagnosed after the effective date
Critical Illness Benefit
N/A
$5,000 per Employee
of coverage, except for the covered condition Diagnosis of
Invasive and In Situ Cancer, as stated in the Policy Schedule.
The plan will pay an Emergency Room Indemnity Benefit for
Emergency Room Visit
$100 daily benefit with a each day of emergency room services that result from a/an
Daily Indemnity Benefit
N/A
max of 3 days per
Accident or Sickness and is/are provided on an Emergency
*covers illness and
benefit period
basis that do not result in Hospital Confinement up to the
accidents
maximum number of days per benefit period.
If a Covered Person requires the use of Ground Ambulance
Service for transportation to or from a Hospital as a result of
$100 per day, 3 day Accident or Sickness, the plan will pay the daily Ground
Ambulance Service Daily
N/A
maximum per benefit Ambulance Service Indemnity Benefit up to the maximum
Indemnity Benefit
period
number of days per benefit period. Air ambulance
transportation will be payable to the nearest facility equipped
to handle the Covered Person’s Accident or Sickness.
Employee Group Term
The group term life benefit is a flat Life AD&D benefit for the
N/A
$5,000 per Employee
Life
enrolled employee only.
Cobra
Included
Included
* Fully insured indemnity benefits will vary slightly by carrier and state.
Initial Hospital
Admission Daily
Indemnity Benefit
$1,000 per day,1 day
maximum with 1
Admission per benefit
period
Description
MEC HEAVY & MEC HEAVY Plus Plan Designs
MEC Heavy™ In-Network
MEC Heavy™ Plus
In-Network
Deductible (single/family)
$0/$0
$0/$0
Coinsurance
100%
100%
$2,500/$13,200
$2,500/$13,200
Multiplan Network
Multiplan Network
Emergency Room Services
$400 copay then plan pays 100%
$400 copay then plan pays 100%
Inpatient Hospital Services
NOT COVERED
NOT COVERED
Primary Care Visit to Treat an Injury or Illness
$15 copay then plan pays 100%
$15 copay then plan pays 100%
Specialist Visit
$25 copay then plan pays 100%
$25 copay then plan pays 100%
NOT COVERED
NOT COVERED
$400 copay then plan pays 100%
$400 copay then plan pays 100%
Covered Benefits
Out-of-Pocket Maximum (single/family)
PPO Network
Mental/Behavioral Health and Substance Abuse Disorder
Outpatient Services
Imaging (CT, PET Scans, MRIs)
MEC HEAVY & MEC HEAVY Plus Plan Designs
MEC Heavy™ In-Network
MEC Heavy™ Plus
In-Network
Rehabilitative Speech Therapy
NOT COVERED
NOT COVERED
Rehabilitative Occupational and Rehabilitative Physical
Therapy
NOT COVERED
NOT COVERED
Preventive Care/ Screening/Immunization (MEC)
100% covered
100% covered
Laboratory Outpatient and Professional Services
$50 copay then plan pays 100%
$50 copay then plan pays 100%
X-rays and Diagnostic Imaging
$50 copay then plan pays 100%
$50 copay then plan pays 100%
Skilled Nursing Facility
NOT COVERED
NOT COVERED
Outpatient Facility Fee (e.g., Ambulatory Surgery
Center)
NOT COVERED
NOT COVERED
Outpatient Surgery Physician/Surgical Services
NOT COVERED
NOT COVERED
Chronic Disease Management (CDM) Benefit
100% covered
100% covered
$10,000
$10,000
Covered Benefits
Life AD&D Benefit
MEC HEAVY & MEC HEAVY Plus Plan Designs (Cont.)
MEC Heavy™
In-Network
MEC Heavy™ Plus
In-Network
Certain Generics
$15 copay then plan pays 100%
$15 copay then plan pays 100%
Certain Preferred Brand Drugs
$25 copay then plan pays 100%
$25 copay then plan pays 100%
Certain Non-Preferred Brand
Drugs
$75 copay then plan pays 100%
$75 copay then plan pays 100%
Specialty Drugs & Compounds
NOT COVERED
NOT COVERED
Inpatient Hospital Daily
Indemnity Benefit
N/A
$400 per day with 180 day benefit period maximum.
Initial Hospital Admission Daily
Indemnity Benefit
N/A
$500 1 day benefit with a maximum of 1 admission per
benefit period.
Inpatient Surgery & Anesthesia
Daily Indemnity Benefit
N/A
$500 daily benefit with a maximum of 1 day per benefit
period. Includes a 20% Daily Anesthesia Benefit.
Outpatient Surgery & Anesthesia
Daily Indemnity Benefit
N/A
$250 daily benefit with a maximum of 1 day per benefit
period.
Intensive Care Daily Indemnity
Benefit
N/A
$500 daily benefit with a maximum of 30 days per benefit
period.
N/A
Included
$5,000 Benefit
Included
Covered Benefits
Prescription Drugs
Fully Insured Indemnity Benefits
Critical Illness Benefit
Cobra
MVP Plan Design
MVP Benefit Description
Covered Benefits
Deductible (single/family)
Coinsurance
Out-of-Pocket Maximum (single/family)
In-Network
$6,500/$13,200
60%
$6,500/$13,200
PPO Network (There are NO out of network benefits)
Multiplan Limited Network
Emergency Room Services
Inpatient Hospital Services
$6,500 deductible
You pay $6,500 deductible
Primary Care Visit to Treat an Injury or Illness
$50 copay and 60% coinsurance
Specialist Visit
$70 copay and 60% coinsurance
Mental/Behavioral Health and Substance Abuse Disorder
Outpatient Services
Imaging (CT, PET Scans, MRIs)
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical
Therapy
Preventive Care/ Screening/Immunization (MEC)
NOT COVERED
$6,500 deductible
NOT COVERED
NOT COVERED
100% covered
MVP Plan Design (Cont.)
MVP Benefit Description
Covered Benefits
In-Network
Laboratory Outpatient and Professional Services
$6,500 deductible
X-rays and Diagnostic Imaging
$6,500 deductible
Skilled Nursing Facility
NOT COVERED
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
NOT COVERED
Outpatient Surgery Physician/Surgical Services
NOT COVERED
Chronic Disease Management (CDM) Benefit
100% covered
Life AD&D Benefit
Not Available
Prescription Drugs
Certain Generics
$6,500 deductible
Certain Preferred Brand Drugs
$6,500 deductible
Certain Non-Preferred Brand Drugs
NOT COVERED
Specialty Drugs & Compounds
NOT COVERED
Cobra
Included
Example of Benefits and Cost for Services
Covered
Benefits
MEC
MEC+
MEC HEAVY
MEC HEAVY+
MVP
Deductible
(single/family)
$0/$0
$0/$0
$0/$0
$0/$0
$6,500/$13,200
Coinsurance
100%
100%
100%
100%
60%
Out-of-Pocket
Maximum
(single/family)
$0/$0
$0/$0
N/A
$60 per day, 6
day maximum
per benefit
period
$15 copay then
plan pays 100%
$15 copay then
plan pays 100%
$50 copay and
60%
coinsurance
N/A
$50 per day
with a 3 day
maximum per
benefit period
$50 copay then
plan pays 100%
$50 copay then
plan pays 100%
$6,500
deductible
Out Patient
Physician
Office Visit
Out Patient
Lab & X-ray
$2,500/$13,200 $2,500/$13,200 $6,500/$13,200
Guardian Dental
Guardian Dental
Type of
Service
Examples
In-Network
Out of Network
Deductible
$50
$50
Calendar Year
Maximum
$1,500
$1,000
Preventive
Cleaning, evaluations,
Bitewings , X-rays,
Space Maintainers
100% of Fee Schedule
Basic
Amalgam/ composite
filling, anesthesia
80% of Fee Schedule
60% of UCR 90th
Major
Bridge work, Crown
work, Dentures
80% of Fee Schedule
60% of UCR 90th
Potomac Companies, Inc.
100% of UCR 90th
26
Guardian Dental 2016

Benefits include:

No waiting periods

Full Mouth Composite Fillings

Max Rollover

Implants

2 Periodontal Maintenance Visits

Dependents are covered up to age 26 regardless of student
status
Potomac Companies, Inc.
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Dental Contributions 2016
Employee Pretax Premium Contributions Per Pay (52 Pay Periods)
Coverage Level
Contribution Per Pay
(52 Pay Periods)
Employee Only
$8.19
EE + Spouse
$16.62
EE + Child
$18.60
EE + Family
$28.63
Potomac Companies, Inc.
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Guardian Online
 Guardian Anytime – Online Access
 Note: Guardian issues ID cards, therefore it is important for
all members to verify a dental provider’s network
participation prior to a dental appointment – the easiest
way to do this is online at GuardianAnytime
 Network dentists are easy to locate. Simply use the On-Line
DentalGuard Provider Directory at
www.guardiananytime.com or call the number on the back
of your ID card
 Other services GuardianAnytime provides quick access to:




Find a Dentist
Your Plan Coverage
Check a Claim
Common Questions & Answers
Potomac Companies, Inc.
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Potomac Contacts
[email protected]
Milton Foster III – Senior Vice President
1.800.230.0770 x133
301.840.0770 x133
[email protected]
THANK YOU!
Joseph Appelbaum - President
301.840.0770 x111
[email protected]
Potomac Companies, Inc.
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