Frequently Asked Questions
Health Care Reform and PEBP
H.R. 3590, The Patient Protection and Affordable Care Act was signed by President Obama (enacted) on March 23, 2010. Section 1001 of the act requires that, if a plan covers children, that coverage must be available to children up to their 26th birthday. Section 1004 says that section 1001 is effective on the plan year beginning on or after the date of enactment of the Act (September 23, 2010). For PEBP, the first plan year after this date begins July 1, 2011.
Many private insurers have elected to begin coverage for adult children immediately for marketing purposes. However, PEBP rates for the plan year beginning July 1, 2010 were set on March 11, 2010, prior to enactment of the Affordable Care Act. It is estimated that the annual cost to cover adult children up to age 26 is approximately $2.8 million to $4.2 million for the self funded PPO plan. Therefore, early coverage of adult children through age 26 would cause a deficit that would be paid for by participants in the next plan year. To date, the Board has not taken any action to begin coverage earlier than required by the Affordable Care Act.
While the cost to cover children under PEBP, in general, will likely go up in the coming plan year, the cost to participants to enroll children through age 26 will be the same as the cost to enroll any other child. Furthermore, IRS Notice 2010-38 (released April 27, 2010) allows premiums for children covered through age 26 to be deducted from employees paychecks on a pre-tax basis as is allowed for children currently covered by PEBP.
During the Plan Year 2012 open enrollment, currently scheduled for May 1- 31, 2011, participants will have the opportunity to add any dependent child under the age of 26 effective July 1, 2011. Participants will receive notice of this eligibility with their open enrollment letter in April 2011.
PEBP may deny coverage to children up to their 26th birthday if the adult child is eligible to enroll in an eligible employer-sponsored health plan. However, this exclusion provision will be eliminated on June 30, 2014. The PEBP Board has not yet decided whether it will allow this exclusion. The Board is expected to review this matter in the fall.
Otherwise, effective July 1, 2011, PEBP will be required to cover all dependent adult children regardless of their status of financial dependency, residency, student status, marital status, employment or eligibility of coverage under the participant’s spouse or domestic partner.
The original language of the Affordable Care Act (H.R. 3590) allowed plans to exclude married children. However Section 2201(b) of H.R. 4872, The Health Care and Education Reconciliation Act of 2010 (signed by President Obama on March 30, 2010) eliminated this exclusion.
PEBP has not yet altered its Master Plan Document to conform to this new law. These changes are expected to appear in the 2012 Master Plan Document scheduled for publication in May 2011. However, you can review the Federal Acts and Regulations at the following websites:
H.R. 3590, The Patient Protection and Affordable Care Act: http://www.govtrack.us/congress/bill.xpd?bill=h111-3590
H.R. 4872, The Health Care and Education Reconciliation Act of 2010: http://www.govtrack.us/congress/bill.xpd?bill=h111-4872
Interim Final Regulations:
IRS Notice 2010-38: http://www.irs.gov/newsroom/article/0,,id=222193,00.html
PY 2011 Rates
As approved by the Board in March 2008, a supplemental subsidy is provided to any tier with:
Under the new PPO Plan, there are two deductibles, depending on coverage selected. Deductibles, for individual or family coverage, accumulate separately for in-network provider expenses and out-of-network provider expenses. If both in-network and out-of-network providers are used, the deductible will have to be met twice-- once for in-network and once for out-of-network.
For single coverage individuals, this plan has a $800 individual deductible.
For coverage of two or more persons, this plan has a $1,600 family deductible. The family deductible could be met by any combination of eligible medical expenses from two or more members of the same family coverage tier. No one single family member would be required to contribute more than the equivalent of the individual deductible toward the family deductible.
In the fall of 2008, the Board approved a measure that indexes the self funded PPO deductibles to plan medical inflation. This measure was approved in order to meet the budget cut requirements due to subsidy reductions caused by the dire financial conditions of the State.
PEBP offers a general wellness benefit in the form of an annual maximum benefit of $2,500 per covered individual. The wellness benefit covers routine wellcare services such as physicals, screening laboratory and radiology tests, immunizations, colonoscopies, hearing test and skin cancer screenings.. Participants should consult with their physicians to determine what their individual screening needs might be. This benefit is only available when participating PPO providers are used. Preventive screening benefits are only for wellcare. Any test or procedure done that is related to a known or present condition will be considered as a regular medical claim and processed accordingly. Once the annual wellness benefit is exhausted, the participant will be responsible for subsequent charges.
How much does the plan pay on the wellness benefit?
Wellness services are payable up to a maximum annual benefit of $2500 per covered participant and each covered dependent.Is the wellness benefit available to all my covered family members?
The Wellness benefit is provided by PEBP and is administered by UMR (formulary Fiserv Health).
Wellness services described in PEBP Master Plan Document are not subject to the annual deductible.
It is the patient’s responsibility to inform their physician and their physician’s billing staff of their wellness benefits. The physician however, makes the determination regarding the purpose of the visit, i.e. was the visit for screening purposes only or a follow up visit for a known medical condition.
If I obtain an eligible wellness benefit from a non-contracted provider because there are no PPO contracted providers within 50 miles of my residence, would my wellness benefit apply?
Yes. You will however, be responsible for any billed amounts that exceed the Plan’s usual and customary allowance. Information regarding the usual and customary allowance can be obtained from UMR.
What is the difference between the Wellness Program and the Cardiac Wellness Program?
The Cardiac Wellness Program (CWP) is a pilot program and is available to participants of the self-funded PPO plan and their covered dependents. Participation in the CWP is by invitation only while the effectiveness of the pilot program is being evaluated. The CWP provides additional coverage for some medical services that may not be covered under the current wellness benefit. The CWP also applies wellness benefits to medical services rendered for a known cardiac related issue.
How do I know when I have reached my maximum wellness benefit?
You can contact UMR to inquire about the amount remaining on your annual wellness maximum benefit. Individual wellness benefits remaining can also be found on the most current medical Explanation of Benefits (EOB) that you have received from UMR or by accessing your claim records on the UMR website.
Certain wellness services have been identified in Nevada statute as mandated. This means that even if you have exceeded your annual maximum wellness benefit, certain wellness services will be covered. If you have exhausted your annual wellness benefits, these services will be covered but are subject to the annual deductible, copayments and coinsurance requirements.
Mandated wellness benefits are identified in the following statutes:
NRS 287.027 – colon cancer screening
NRS 287.0272 – HPV vaccination for cervical cancer
NRS 287.029 – PSA screening blood test
NRS Annual pap smears and mammograms for females
If I have a pre-existing condition am I excluded from the wellness benefit?
Medical conditions previously diagnosed and/or treated are not eligible for wellness benefits but are eligible for consideration under standard medical benefits subject to the annual deductible, copayments, coinsurance and other plan requirements as described in the PEBP Master Plan Document.
I’ve been told that services for a condition that I have a previous diagnosis are not covered under the wellness benefit. What does that mean? Does it matter how long ago the previous diagnosis was made?
Office visits and other medical services such as laboratory and radiology done in conjunction with a known medical condition are subject to the annual deductible, copayments, coinsurance and other plan requirements as described in the PEBP Master Plan Document. For the majority of individuals with chronic conditions such as diabetes, hypertension, high cholesterol, etc., their office visits and related ancillary services, are not eligible to receive wellness benefits. Generally, there are no time indicators. Once you have been diagnosed with a chronic medical condition, your medical treatment plan continues during your lifetime.
Are colonoscopies covered under the wellness benefit?
Colonoscopies performed for screening purposes are covered under the wellness benefit. However, unless determined to be medically necessary by UMR and PEBP’s Utilization Management Company (APS Healthcare), virtual colonoscopies are not covered under any circumstances under the PEBP PPO plan.
Under what condition(s) is a colonoscopy not covered under the wellness benefit?
Colonoscopies are not covered under the wellness benefit when you have been previously diagnosed and treated for a medical condition, e.g. colon cancer, colon polyps and the purpose of the colonoscopy is to follow up on that previously diagnosed and treated condition.
What should I tell my doctor’s office when I’m scheduling my colonoscopy about my wellness benefit?
If your colonoscopy is for screening purposes, you should tell your doctor’s office that you are scheduling a routine screening colonoscopy. If you are scheduling a follow up colonoscopy because of a previously diagnosed and treated medical condition, your claim will be billed with a medical diagnosis and considered under the standard medical benefits subject to the annual deductible, copayments, coinsurance and plan requirements.
What should I do if my colonoscopy has not been paid under the wellness benefit when I think it should have been?
UMR cannot disclose to you, the diagnosis submitted by your physician. UMR can inform you if the bill submitted by your physician did not indicate a routine screening colonoscopy. If you disagree with the outcome of your claim and would like more information regarding the information submitted by your physician, you should contact your physician’s office.
If I have a family history of colon cancer, is a colonoscopy still covered under my wellness benefit?
If I go in for a colonoscopy and they find a polyp and remove it, is the cost of the removal paid under wellness?
Skin cancer screenings
Are skin cancer screenings covered under the wellness benefit?
Under what condition(s) is a skin cancer screening not covered under the wellness benefit?
Skin cancer screenings are not covered under the wellness benefit if you have been previously diagnosed and treated for any type of skin cancer.
What should I tell my dermatologist’s office when I’m scheduling my skin cancer screening about my wellness benefit?
You should tell your doctor’s office that you are scheduling a routine skin cancer screening. If you have been previously diagnosed and treated for any type of skin cancer, wellness benefits will not apply.
What should I do if my skin cancer screening has not been paid under wellness when I think it should have been?
UMR cannot disclose to you, the diagnosis submitted by your physician. UMR can inform you if the bill submitted by your physician indicated a routine office visit (not related to a known medical condition) or if the bill indicated the purpose of the office visit was treatment of a known medical condition. If you disagree with the outcome of your claim and would like more information regarding the information submitted by your physician, you should contact your physician’s office.
If I go in for a skin cancer screening and they find a spot and remove it, is the cost of the removal paid under wellness?
Does it matter if they do it at the same time or if they do it in a follow-up visit?
The removal of spot or lesion at the same time of the skin cancer screening will be paid under the wellness benefit. Follow up visits are usually billed with a medical diagnosis and paid at regular plan benefits.
I am a breast cancer survivor. It has been four years since my surgery
and my subsequent mammograms have been clear. At what point
would I be eligible to obtain future mammograms under my wellness
Generally after the fifth year, a breast cancer survivor will be eligible to obtain a mammogram under the wellness benefit. You should discuss the purpose of your mammogram with your physician.
I want to get my mammogram in Carson City. Where can I go and have the cost covered by my wellness benefit? Does it matter what kind of mammogram is performed?
Participating providers in Carson City are: Great Basin Imaging and Sierra Surgery Hospital. The wellness benefit applies to standard and digital mammograms.
Is the cost of the H1N1, flu, or pneumonia immunizations paid by the wellness benefit?
Does it matter where I go to get the immunization?
The H1N1, flu, or pneumonia immunizations should be administered by a PPO provider to assure that you receive the maximum benefit available. As an alternative, standard flu and pneumonia vaccines are available at the Wellness Fairs which are offered during the flu season. At times, the quantity of flu and pneumonia vaccines is limited and you might not be able to obtain them at a Wellness Fair. The H1N1 vaccine has been recommended by the Centers for Disease Control (CDC) to certain targeted groups such as pregnant women and persons age 6 months to 24 years. Please contact your primary care physician to find out if they have any of these vaccinations available. For information regarding the wellness fairs, please consult the PEBP website.
Children are supposed to get more than one shot for the H1N1 virus. Does the wellness benefit pay for both shots?
I’m going overseas and need several vaccinations. Are they covered under wellness?
Yes. However, most of the vaccines required for overseas travel are not available through your primary care physician. Contact your local health department for information about the various vaccines available through them. Since your local health department is not a PPO provider, you will be required need to pay for the cost of the vaccines. PEBP does allow exceptions for reimbursement of the vaccines under the wellness benefit. You will need to submit a copy of itemized receipt that indicates the name and location of the entity who administered the vaccines, the vaccine type, dose and cost for each immunization and proof of your payment. The itemized receipt should be attached to a medical claim form (available on the PEBP website) and submitted to UMR for consideration.
Other questions about the wellness benefit
Would the wellness benefit pay for weight loss programs and gym memberships?
Benefits are payable for medically supervised weight loss treatment programs and are subject to the plan year maximum benefit. The weight loss benefit does not include programs such as Weight Watchers, Jenny Craig or Slim fast products. Expenses for memberships in or visits to health clubs, exercise programs, gymnasiums, and/or other facility for physical fitness programs, including exercise equipment are not covered.
Mobile biometric screenings are offered annually in my community. The company sponsoring this service is not a contracted provider. If I obtain my screenings from this mobile unit, would they be covered under my wellness benefit?
No. Biometric laboratory screening tests should be provided by a PPO provider to assure that you receive the maximum benefit available.
Can I get help to quit smoking under the wellness program? If so, how much will it cost me?
Yes. Tobacco/Smoking cessation treatment is covered under the annual wellness benefit. Smoking cessation products available by prescription only such as Chantix and over the counter smoking cessation products such as nicotine gum and nicotine patches are covered under the prescription drug program and must be accompanied by a prescription written by your physician and presented to pharmacy that is a participating pharmacy with Catalyst Rx. The PPO Plan waives the annual deductible and copayment for prescription and over-the-counter smoking cessation products. For more information about this benefit, please contact UMR or Catalyst Rx.
Does it matter where I go to get blood lab tests?
Lab screening tests such as pap smears, cholesterol, glucose, etc., are covered under the wellness benefit and should be provided by a PPO provider to assure that you receive the maximum benefit available. Lab tests ordered for diagnostic purposes or as part of an ongoing treatment plan should be provided by a PPO provider to assure that you receive the maximum benefit available. Please refer to the PEBP website for names and locations of participating laboratories.
I’ve heard that the price varies a lot between different providers (e.g. hospital lab vs. a stand-alone lab), why is that?
Prices do vary between a hospital laboratory and a stand-alone laboratory. Typically, hospitals will charge more for their services, while a stand-alone laboratory will charge substantially less. If your physician refers you to a hospital rather than a stand-alone laboratory, please ask your doctor to refer you to a stand-alone laboratory since the costs will be less.
I’m on the HMO. Can I participate in the Cardiac Wellness Program?
No. This is a pilot project and was “By Invitation Only” for participants enrolled in the self funded PPO Plan.
Medicare is the federal health insurance program that covers individuals age 65 and older. In some cases, Medicare can also cover individuals under age 65 with certain disabilities and individuals with End-State Renal Disease (ESRD).
Part A is hospital insurance that helps pay for inpatient hospital stays and skilled nursing facilities, hospice care, and some home health care. Individuals age 65 are entitled to premium-free Part A coverage if they worked for at least 10 years (40 quarters) in Social Security and/or Medicare-covered employment. Generally, Part A coverage does not have a monthly premium. Those who do not qualify for premium-free Part A may qualify through a current, former, or deceased spouse.
Part B helps pay for outpatient health care expenses, including doctor visits. Individuals elect this medical coverage and pay a monthly premium. The Social Security Administration adjusts the premium annually. In addition, the Social Security Administration bases your Part B premium on your annual income (referred to as Income Related Monthly Adjustment Amount (IRMMA)). This means individuals who earn higher incomes may pay higher Part B premiums. The Social Security Administration will notify you annually of your new Part B premium.
Medicare Part C is a Medicare Advantage health plan that is approved by the Centers for Medicare and Medicaid Services. PEBP offers two Medicare Advantage plans: Senior Dimensions Retiree Choice Plus Plan for individuals residing in Clark, Esmeralda and Nye counties and Senior Care Plus Plan for individuals residing in Washoe county. To enroll in a Medicare Advantage plan, you must be retired and have both Medicare Parts A and B.
Medicare Part D (Medicare Prescription Drug Coverage)
Medicare Part D is the federal voluntary outpatient prescription drug benefit that was added to the Medicare program in 2006. PEBP health plans provide prescription drug coverage that is as good as, or better than the standard benefits of Medicare Part D. For information about how Medicare Part D enrollment will affect your PEBP coverage, refer tothe Medicare Part D questions below.
How do I qualify for Medicare?
You may qualify for premium-free Medicare Part A at age 65 if you:
· Receive or are eligible to receive Social Security benefits; or
· Receive or are eligible to receive railroad retirement benefits; or
· You or your spouse (living or deceased, including divorced spouses) worked 10 years (40 quarters) in Social Security or Medicare covered employment; or
· You are the dependent parent of someone who worked long enough in a job where Medicare taxes were paid and you meet the requirements of the Social Security Disability Program;
· Other conditions may also allow you to qualify for premium-free Medicare Part A. To learn more contact Social Security at 1-800-772-1213.
I do not qualify for Part A; may I still purchase Part B?
If you are not eligible for premium-free Medicare Part A, you can still buy Medicare Part B at age 65.
When should I apply for Medicare?
If you are already receiving Social Security retirement, disability benefits or railroad retirement benefits you will automatically be enrolled in Medicare Parts A and B. If you are not receiving Social Security benefits, you should contact Social Security three months before your 65th birthday to sign up for Medicare.
You can sign up for Medicare Part A even if you do not plan to retire at age 65. If you are still working at age 65, you may wait to enroll in Medicare Part B until you leave your active employment. For information on Medicare enrollment dates and benefits, contact the CMS at 800-633-4227 or visit their web site atwww.medicare.gov.
Medicare Part B - Initial enrollment
When you first become eligible for hospital insurance (Part A), you will have a seven-month period (your initial enrollment period) in which to sign up for medical insurance (Part B). A delay on your part will cause a delay in coverage and result in higher premiums. If you are eligible at age 65, your initial enrollment period begins three months before your 65th birthday, includes the month you turn age 65 and ends three months after that birthday. If you are still working at age 65, please refer to the Special enrollment period for working individuals.
Special enrollment period for working individuals
At age 65 if you are still working and have coverage under an employer group health plan, (i.e., PEBP), you may qualify for a special enrollment period in which to sign up for Medicare Part B. This means that you may delay your enrollment in Medicare Part B (until you stop working) without having to wait for the general enrollment period and pay the 10 percent premium surcharge for late enrollment. For information on Medicare enrollment dates and benefits, contact the CMS at 800-633-4227 or visit their web site at www.medicare.gov.
What is the Cost of Medicare Part B?
You will pay a premium each month for Part B. Most people pay the standard premium amount which is $96.40 in 2009. However, your monthly premium will be higher if you meet certain income levels. Contact Social Security at
1-800-772-1213 to determine your monthly premium cost.
If am still working; do I enroll in Medicare Part B when I turn age 65?
PEBP would not require you to enroll in Part B until you retire--regardless of your age. However, you will want to contact CMS at 800-633-4227, or visit their website atwww.medicare.gov to obtain information on Medicare’s enrollment requirements.
At age 65, do retirees need to enroll in Medicare Part B?
At age 65, retirees enrolled in the Self-funded PPO Plan are encouraged to purchase Medicare Part B.
What happens if I do not purchase Medicare Part B?
If you do not enroll in Medicare Part B when eligible (retiree or retiree’s covered spouse, aged 65), PEBP will assume that you have Medicare Part B. That assumption would mean that PEBP would be the secondary payer to eligible medical expenses ordinarily covered by Medicare Part B. You would be the primary payer for medical services provided on your behalf that would ordinarily be covered by Medicare Part B. In other words, you would pay 80% as the primary and PEBP would pay 20% as the secondary payer.
What happens to my retiree coverage at age 65?
At age 65, if you are enrolled in the Self-funded PPO Plan will need to enroll in Medicare Part A if you qualify for the premium-free Part A coverage. You will also need to purchase Medicare Part B. Your Medicare coverage (Parts A and B) would then become your primary insurance and PEBP would become the secondary payer.
What if I do not qualify for Medicare Part A?
PEBP would remain as the primary payer for eligible hospital expenses ordinarily covered by Medicare Part A.
Am I required to enroll in Medicare Part D?
In accordance with Plan provisions, retirees are encouraged not to enroll in Medicare Part D. Enrollment in Medicare Part D will result in the automatic disenrollment of PEBP’s prescription drug coverage (all plans) for the remainder of that plan year or the plan year in which disenrollment from Medicare Part D occurs. Furthermore, PEBP will not reduce the retiree premium as a result of the discontinuance of its prescription drug coverage.
When I get Medicare do I need to re-enroll in PEBP coverage?
Once you become entitled to Medicare, you will need to submit a copy of your Medicare card to the PEBP office. No other action is necessary. That is, unless you wish to change your health plan from the regular HMO plan to that carrier’s Medicare Advantage plan. In that case, you would be required to complete the Retiree Benefit Enrollment and Change Form and the applicable Medicare Advantage plan’s enrollment application.
Will my retiree premium decrease if I enroll in Medicare Part A and/or B?
If PEBP receives a copy of your Medicare enrollment (medical card) within 60 days of your initial Medicare coverage effective date, PEBP will reduce your premium based on your plan option, Medicare status and coverage tier in the month that you become Medicare eligible. If PEBP receives a copy of your Medicare card after the initial 60 day notification period, your premium will be reduced on the first of the month concurrent with or following receipt of the copy of your Medicare card.
How Can I Learn More About Medicare?
For more information about Medicare, refer to the Centers for Medicare and Medicaid Services’ (CMS) handbook, Medicare & You, contact the Social Security Administration at 800-772-1213 or visit: www.ssa.gov. For Medicare enrollment dates and benefits, call CMS at 800-633-4227.
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Yes, the Program is fully solvent. The Program can pay all of its liabilities and has a fully funded reserve. The current proposed decreases in benefits and subsidization rates are due to the Governor’s request to keep subsidy levels flat over the next two years despite medical inflation rates. The proposed changes will maintain required reserve levels and plan solvency. For further details regarding the financial status of the Program see the Financial Information page or select the Staying Informed link in the menu at the top of the page.
Domestic Partners and their children will be covered by PEBP effective July 1, 2010. Domestic Partners and their children will have the same coverage and benefits as a spouse and step-children except:
1. 1. Due to funding limitations Domestic Partners and their children will not be subsidized by the state.
2. 2. Due to IRS regulations, the portion of the premiums paid to cover Domestic Partners and their children will be deducted on a post-tax basis.
3. 3. Due to IRS regulations, any reimbursements under the Flexible Spending Account (FSA) will not be allowed for the Domestic Partner or their children, unless the individual qualifies as a dependent of the primary insured under 26 U.S.C. § 152.
Employees can waive their PEBP benefit if they so choose during open enrollment. Such a waiver would be for all benefits provided by PEBP.
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