2019 Health Benefits - PDF document

12019 Health BenefitsOpen Enrollment B
12019 Health BenefitsOpen Enrollment Benefits Over-view2Health InsurancePowered by:3The Cost Containment You Need,The Compassionate Service You Want.44We are excited to partner with Graff Financial, LLC in providing cutting edge healthcare benefits administration with a human touch. We look forward to working with you and for

you. Welcome to Prairie States55Sea
you. Welcome to Prairie States55Seamless IntegrationBy keeping your health management and administration services in-house, we provide seamless care and integration throughout every step of your personal health experience.About UsWe provide benefits administration for customers across the nationfrom our offices in

Chicago, IL and Sheboygan, WI.Your Se
Chicago, IL and Sheboygan, WI.Your ServicesPrairie States, working with Self-Funding Partners, will administer the back end of your Medical, COBRA, FSA and Health Management, services effective July 1, 2019. 6One Call for All the Answers•Self-Funding PartnersandPrairie States work together to simplify communica

tion, answer healthcare questions, a
tion, answer healthcare questions, and ensure you get the most out of your benefits plan. •Whenever you have a question or concern, simply call. We are able to help you with:•Reviewing medical claims•Understanding eligibility•Medical coverage and benefits•Basic prescription coverage•Pre-certification requireme

nts•Website assistance•Taking ad
nts•Website assistance•Taking advantage of preventive services•Topics to discuss with your physician•Referral to in-house nurses•Choosing the right healthcare providerSelf-Funding Partners(248) 566-60638:00 AM –5:00 PMMonday -Friday7Your Prairie States TeamServiceContactMedical ClaimsLori Copeland

ID Cards / Eligibility / COBRAJess Vos
ID Cards / Eligibility / COBRAJess VoskuilFlexibleSpending Account (FSA)AmyMullensPre-CertificationBarb Laehn, LPNUtilization ManagementTami Stoffregen,BSN RNCase ManagementLisa Schmidt, BSN RNWebsite AssistanceSteve GodlewskiPrairie States Contact InformationPhone Number(800) 615-7020Fax Number(920) 451-7023 M

y Prairie Onlinewww.prairieontheweb.com
y Prairie Onlinewww.prairieontheweb.comBusiness Hours8:30 AM to 4:30 PM CST, Monday through FridayOffice Address615 Pennsylvania Avenue, Sheboygan, WI 53081-4642Mailing AddressP.O. Box 23, Sheboygan, WI 53082-0023Prairie States dedicated team of in-house professionals works closely with Self-Funding Partners to get you

the answers you need.8Claims Adminis
the answers you need.8Claims AdministrationOnlineToolsCaseManagementTransitions of CareUtilizationManagementWe Keep Youat the CenterPrairie States and the Continuum of Care9Case ManagementCase Management helps members with severe, complex, and catastrophic illnesses.Our nurses guide you through the healthcare syste

m, answer questions, and offer support
m, answer questions, and offer support.Transitions of CareTransitions of care helps members after a hospital stay, surgery or maternity stay. We walk you through discharge instructions, and help you coordinate care.UtilizationManagementUtilization Management and Pre-Certification clinicians work closely with you and your prov

iders to ensure you receive appropriate
iders to ensure you receive appropriate care and coverage in the most appropriate and cost-effective setting.Health ManagementOur clinicians have an average 23years of experience.10•All Hospitalization Services (over 23 hours)

•Chemotherapy and Radiation Therap
•Chemotherapy and Radiation Therapy (notification of oral agents)•Clinical Trials•Diagnostics (outpatient) -MRI, PET•Dialysis•Durable Medical Equipment (DME) -All rentals. Purchases over $500.•Genetic Testing•Home Health / Home Infusion•Hospice Services•Pain Management Injections -Epidural Steroid

and Facet•Specialty Medications cov
and Facet•Specialty Medications covered under the Medical Plan•Surgical Procedures -Inpatient and Outpatient•Transplant ServicesPre-CertificationPenalty of $250 for Non-CertificationPre-certification is required 7 days in advance for scheduled services, or 48 hours after emergency procedures/admissions11Gra

ff Financial, LLC -Plan OptionsHSAHR
ff Financial, LLC -Plan OptionsHSAHRAMECBenefit Plan Type:HDHP/HSAHDHP/HRAMECNon-EmbeddedEmbeddedDeductible: PlanIndividual \FamilyIndividual \FamilyIndividual \Family$2,000 \$4,000$5,000 \$10,000$0 $5,000 \$10,000$5,000 \$10,000$0 Deductible: Employee's AmountIndividual \FamilyIndividual \FamilyInd

ividual \FamilyIn-Network:$2,000
ividual \FamilyIn-Network:$2,000 \$4,000$500 \1,000$0 Out-Of-Network:$5,000 \$10,000$500 \$1,000$0 Deductible: Employer HRAIndividual\FamilyIn-Network:$0 $4,500 \$9,000$0 Out-Of-Network:$0 $4,500 \$9,000$0 Co-InsuranceIn-Network:100%90% up to $1,000\Individual and $2,000\Family100%Ou

t-Of-Network:70%70% up to $2,000\
t-Of-Network:70%70% up to $2,000\Individual and $4,000\FamilyNot coveredOut of Pocket Max (Includes Ded.)Individual \FamilyIndividual \FamilyIndividual\FamilyIn-Network:$4,000 \$8,000$7,350 \$14,700N/AOut-Of-Network:UnlimitedUnlimitedN/AEmployee Max In-Network$4,800 / $8,000$2,850 / $5,700N/ALife

time Max:UnlimitedUnlimitedUnlimited
time Max:UnlimitedUnlimitedUnlimitedOffice Visit:*PCP (In-Network):Subj. to Ded. & Coins.$25 copay/office visit then 0%N/ASpecialist (In-Network):Subj. to Ded. & Coins.$25 copay/office visit then 0%N/AOut of Network:Subj. to Ded. & Coins.Subj. to Ded. & Coins.N/ATeladoc$45 Consult Fee$0 N/AUrgent Care (Stand Alone Cl

inic ):*Subj. to Ded. & Coins.$50 copa
inic ):*Subj. to Ded. & Coins.$50 copay, Ded. WaivedN/AER (In and Out of Network): Subj. to Ded. & Coins.$150 copay, Ded. WaivedN/ARoutine Care:In-Network:Covered at 100%Covered at 100%Covered at 100%Out-Of-Network:70% after Ded.70% after Ded.Not CoveredPrescription Drugs:*Retail Mail Order (In Network)Retail/Mail Or

der (In Network)Retail/Mail OrderGener
der (In Network)Retail/Mail OrderGeneric:Retail: $10 copay after deductibleMail Order: $20 copay after deductibleRetail: $20 copay Mail Order: $40 copay100%: Drugs required by the ACA for preventive servicesPreferred Brand:Retail: $25 copay after deductibleMail Order: $50 copay after deductibleRetail: $50 copayMail Order:

$100 copay100%: Drugs required by the
$100 copay100%: Drugs required by the ACA for preventive servicesNon PreferredBrand:Retail: $40 copay after deductibleMail Order: $80 copay after deductibleRetail: $80 copayMail Order: $160 copay100%: Drugs required by the ACA for preventive servicesPreferred Specialty:Retail: $50 copay after deductibleMail Order: Not Cov

eredSee applicable tier above100%: Dr
eredSee applicable tier above100%: Drugs required by the ACA for preventive servicesNon-Preferred Specialty$75 / $150Hospital In Patient/Out Patient:In-Network:Subj. to Ded. & Coins.Subj. to Ded. & Coins.N/AOut-Of-Network:Subj. to Ded. & Coins.Subj. to Ded. & Coins.N/AThis benefit comparison will not replace the ben

efit summary furnished (SBC). Please s
efit summary furnished (SBC). Please see Summary for complete details. * Office Visit Copays and Prescription Drug Copays apply to Out of Pocket Maximums but not Deductibles. 12What is an HSA, Benefits of an HSA, ContributionLimits•A health savings account (HSA) is an account that you can use to pay qualified medical expenses, p

er the IRS.•Must be in conjunction
er the IRS.•Must be in conjunction with a high-deductible health plan (HDHP).•Funds rollover each year, so you can use your HSA to save tax-free money for medical expenses after retirement.•You own the account, even if you leave the company.•HSAs can only be offered with a high-deductible health plan with the below mi

nimum deductibles and out of pocket max
nimum deductibles and out of pocket maximums:•Minimum deductible for network providers: •$1,350 single, $2,700 family (2019 limits established by the IRS)•Maximum annual out-of-pocket for network providers: •$6,750 single, $13,500 family (2019 limits established by the IRS)•HSA Contribution Limits:•2019•$3,50

0 for individual coverage•$7,000 for
0 for individual coverage•$7,000 for family coverage•$1,000 Catch-up (For individuals ages 55-plus, IRS allows additional $1,00013Who is Eligible for an HSA & HSA Distribution Rules•Anyone who is:•Covered by a HDHP•Not enrolled in Medicare•Not covered under other health insurance*•Not another person’s depend

ent*Other health insurance does not inc
ent*Other health insurance does not include: specific disease or illness insurance, accident, disability, dental care, vision care and long-term care insurance.•HSA distributions can be taken for qualified medical expenses for the following people:•The account holder (person covered by the HDHP)•Spouse of that individual â€

¢Even if not covered by the HDHP•I
¢Even if not covered by the HDHP•IRS eligible Dependents of that individual •Even if not covered by the HDHP•Distributions from your HSA are tax-free if they are taken for “qualified medical expenses.”•The IRS defines expenses that are considered “qualified medical expenses” for HSA distributions. Expenses mus

t be primarily to treat or prevent a phy
t be primarily to treat or prevent a physical or mental defect or illness.•Your HSA can only be used for expenses that are incurred on or after the date the HSA was established. However, HSA funds can be used for expenses from a prior year, as long as the expenses incurred on or after the date the HSA was established.14A welcome le

tter is being mailed to your home with i
tter is being mailed to your home with instructions for setting up your Teladoc® account, completing your medical history and requesting a consult. Once you're set up, a Teladoc doctor is just a call or click away.15Teladoc gives you access 24 hours, 7 days a week to a U.S. board-certified doctor through the convenience of phone, vide

o or mobile app visits. Set up your acc
o or mobile app visits. Set up your account today so when you need care now,a Teladoc doctor is just a call or click away.Go to Teladoc.com and click “set up account”.Download the app and click “Activate account”. Visit teladoc.com/mobile app to download the app.Teladoc can help you register your account over the phone.

16TeladocTeladoc is a convenient and
16TeladocTeladoc is a convenient and affordable option for quality care when you need care now, if you’re considering the ER or urgent care for non-emergency issues, or if you’re away from home. Call 1-800-Teladoc for on-demand access, day or night, to board-certified doctors.How Do I Choose?By knowing where to get car

e, you can make smarter
e, you can make smarter decisions for your health and healthcare expenses.Primary Care PhysicianWhether you are looking for preventive or wellness services, or guidance and care in managing a condition or other health issue, your Primary Care Physician is in the best position to provide a co

mprehensive plan and coordination of ca
mprehensive plan and coordination of care for your needs. Urgent CareUrgent Care facilities are typically stand-alone clinics that do not carry the expensive costs of an ER. If you can’t get into your own doctor and the health issue can’t wait, have a need outside of regular office hours, or are traveling outside of your

hometown, Urgent Care is a great altern
hometown, Urgent Care is a great alternative to fill this patient need. Emergency CareEmergency Room departments are located within hospitals and are prepared to care for patients suffering true emergencies such as heart attacks, serious motor vehicle accidents, strokes, and other life threateningconditions. 17PPO Networks and Rx

ProgramPreferred Provider Organization
ProgramPreferred Provider Organization (PPO)Prescription Benefit Manager(PBM)Rx ProgramOutside of Michigan18•You will receive new Member ID Cards from Prairie States. •The ID cards will be mailed to your home.•Please destroy your old ID cards when you receive the new version. •To ensure proper handling of your cl

aims, beginning July 1, 2019 present
aims, beginning July 1, 2019 present your Prairie States Member ID card. •If you do not yet have your ID card as of July 1, 2019, simply call (248) 566-6063, and we will give you and/or your physicians the information needed at the time of your appointment.ID Cards19This section provides a brief overview of

how claims were paid for a specified p
how claims were paid for a specified period of time, as well as the portion providers may bill you after your health plan benefits are paid. The Prairie States EOB is not a bill.This section shows payment details for each claim.How to Read Your EOB20Claims are also shown individually including service code, p

rocedure description, applicable co-
rocedure description, applicable co-pay, payment amount, etc.The Accumulator Description Section lists year to date amounts paid toward Individual and/or Family Deductibles and Out-of-Pocket amounts.Details on how to file an appeal are provided at the bottom of your EOB.This section provides service code descriptions for c

laims processed.21Flexible Spending A
laims processed.21Flexible Spending Account Review•Flexible Spending Accounts allows employees to put money away on a pre-tax basis, through payroll deductions to pay for:•Un-reimbursed Medical, Dental and Vision eligible expenses:•Health Plan Deductible, Co-insurance•Dental and Vision eligible expenses•Over the

counter medications are only eligible wi
counter medications are only eligible with a prescription from your physicians•Dependent Care eligible expenses:•The day care provider must file taxes and be willing to write you a receipt for services•Dependents must be less than 13 years of age and claimed on your taxes•Dependent Care may also apply to physically or mentally

challenged spouse or family member for
challenged spouse or family member for whom you are legally responsible and claim as an exemption on your taxes. •Tax Advantage:•25% -30% of the contributions based on employee tax bracket•No Federal, State or FICA taxes taken on deduction amount•Enrollment in June of every year for July 1 effective date.•Determine a

n annual amount to cover your potential
n annual amount to cover your potential out-of-pocket eligible expenses for the new year.22Flexible Spending Account Review•Maximum election amount allowed per Calendar Year for Medical FSA has been increased to $2,700and it is available to you on July 1.•Maximum election amount allowed per Calendar Year for Dependen

t FSA is $5,000 ($2,500 if you and your
t FSA is $5,000 ($2,500 if you and your spouse both have a DCSA).•Dependent FSA –Member can only request reimbursement for the amount that has accumulated in Dependent FSA account.23Flexible Spending Account ReviewLimited Scope•If you participate in the High Deductible Health Plan and have an HSA (Health Savings Account),

you may participate in a Limited Scop
you may participate in a Limited Scope FSA:•Dental and Vision eligible expenses ONLY•Different from the regular FSA, in that medical expenses are not eligible as you would have the HSA for those amounts for deductible and out-of-pocket eligible expenses. 24FSAReminders•Be conservative –under the IRS Regulations th

e Health FSA, Dependent FSA and Limited
e Health FSA, Dependent FSA and Limited Scope FSA are a Use it or Lose it account. Any unused funds at the end of the year are forfeited.•Claims must be incurred between July 1 and June 30.•Claims must be filed for reimbursement within 90 days following the end of the plan year or prior to September 30.•You cannot change

the Annual Election unless you have a qu
the Annual Election unless you have a qualifying event per the IRS regulations.25FSAClaim Submissions•Direct Deposit Option:•Complete the Direct Deposit form on Self-Funding Partners Portal•Include a voided check or savings deposit ticket•EFT’s are released on Wednesdays.•Manual Claim submission:•Submit a Rei

mbursement Form, found self-Funding P
mbursement Form, found self-Funding Partners Portal, along with copy of bill, receipt or statement from the provider of service, prescription stub or print out from pharmacy. A paper form is also available on Self-Funding Partner’s portal with mail, fax, email instructions.•Physical checks are mailed on Fridays. 26My Prairie

Online Portal•Medical and Rx Claims
Online Portal•Medical and Rx Claims•Eligibility Information•PPO and PBM Links•Explanation of Benefits (EOB) View•Single-sign-on access: •Wellness Portal•Cost Transparency Tools•Request an ID card•Pre-Authorizations•Out-of-area student action plan•At-a-glance dashboard for current de

ductible and out-of-pocket totalsâ
ductible and out-of-pocket totals•Mobile-enabled –full functionality 2727Health Insurance Questions?28Voluntary BenefitsDental,Vision,Life,STD, LTDPowered by:2930Guardian Life3132Guardian Life3334Guardian Life3536Guardian Life3738Guardian Life3940Guardian Life414243Guardian Life44Guardian Life

4546Guardian Life4747Voluntary Bene
4546Guardian Life4747Voluntary Benefits Questions?48Graff Group’s Team4950ServiceContactMedical ClaimsSelf-Funding PartnersGraff Group Advocate TeamElizabeth (Liz) Wivo, Regional Advocateewivo@self-fundingpartners.comPoint of Service Issue ResolutionID Cards / Eligibility / COBRAEnrollment changesFlexibleSpendin

g Account (FSA)Health Savings Account (
g Account (FSA)Health Savings Account (HSA)Guardian Benefits (Dental, Vision, Life, ST-D / LT-D)Website AssistanceSelf-Funding PartnersPhone Number(248) 566-6063Self-Funding Portalwww.self-fundingpartners.com/graffBusiness Hours8:00 AM to 5:00 PM, Monday through FridayOffice Address4150 Grange Hall Rd, Holly, MI 48