NEW MEXICO PUBLIC SCHOOLS INSURANCE AUTHORITY

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NEW MEXICO PUBLIC SCHOOLS INSURANCE AUTHORITY

• Roswell Independent School District

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Why the Plan Changes?

• (a) NMPSIA doesnt care about its members
• (b) NMPSIA loathes 89 member satisfaction
• (c) NMPSIA staff pocketed the extra millions
• (d) Bernie Madoff made us do it
• (e) NMPSIAs reserves are depleted claim
  costs are up

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Why the Plan Changes?

• Self Insured Coverage
• Excess Fund Balance went from 25 million on
  April 30, 2008 to negative 2 million on March
  30, 2009
• No Premium Increases allowed in FY10 legislative
  budget process

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Why the Plan Changes?
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Premiums October 2009

• Blue Cross Medical No Change
• Presbyterian Medical No Change
• UCCI Dental No Change
• Davis Vision No Change
• The Standard Life No Change
• The Standard Disability No Change

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No Choice But To Downsize

• JULY 1ST PLAN

• CURRENT PLAN

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July 1, 2009 Program Guide

• New Introduction (Executive Directors Letter)
• New Employer Plan Matrix
• Expanded Rules and Regulations Summary
• New Summary of Benefits High Low Options
• New Prescription Drug Summary
• New Davis Vision Summary

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July 1, 2009 Program Guide

• Copay - The predictable fixed dollar amounts you
  pay for certain services.
• Deductible - The amount you pay for health care
  before the PPO begins to pay
• Coinsurance - The percentage of covered charges
  you pay after you meet the deductible
• Out-of-Pocket Maximum The maximum amount you
  pay for covered services in a calendar year.
  (Charges above the maximum allowable fees do not
  apply to the out-of-pocket maximum.)

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Worst Case Scenario to meet Out of Pocket
This amount may be less if copays were also
paid
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Brief summary of benefits
Benefits What You Pay What You Pay What You Pay What You Pay
Benefits Preferred Provider Preferred Provider Nonpreferred Provider Nonpreferred Provider
Benefits High Option Low Option High Option Low Option
PPP Office Visit (Deductible waived) 20 25 30 (after deductible) 50 (after deductible)
Specialist Visit (Deductible waived) 30 35 30 (after deductible) 50 (after deductible)
Preventive Services (PAP test, cholesterol test, immunizations, etc.) (Deductible waived) 0 0 30 50
Lab, X-Ray, and Pathology 20 25 30 50
High-Tech Radiology (MRIs, PET Scans, CT Scans) 20 25 30 50
Surgery, Outpatient 150 copay per occurrence 20 25 30 50
Inpatient Hospital/ Facility Services 500 copay per admission 20 25 30 50
Ambulance emergency (Copay per trip) 30 25 30 25
Emergency Room 20 25 20 25
Urgent Care Facility (Deductible waived) 50 50 30 25
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The Bucket List

• Deductible Bucket

• Out of Pocket Bucket

• Copays DONT go in the deductible bucket
• Neither do non-allowed charges

• Deductible, coinsurance, and copays go in the
  out-of-pocket bucket

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Non-Allowed Charges

• Charges which are
• Not Covered, or
• In Excess of Plans Allowable Amount when going
  out of network (balance billing)

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Balance Billing

• Applies to Out of Network Charges
• Charge 1,000
• Allowed 800
• Balance 200
• 200 does not go to deductible. Member is 100
  responsible for this amount

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High Option benefit example

• An example of what the members responsibility
  could be for a medical office visit including
  lab and radiological services once the deductible
  has been met.

Billed Allowable Plan Pays You Pay (In-Network) Notes
Office Visit 300.00 73.00 53.00 20.00 Copayment (Deductible waived and not applied to deductible).
Venipuncture     3.00 2.40 .60 Coinsurance after deductible is met.
Urinalysis     4.00 3.20 .80 Coinsurance after deductible is met.
Complete Blood Count      70.00  56.00 14.00 Coinsurance after deductible is met.
Radiologic Exam/Chest X-ray       39.00 31.20  7.80 Coinsurance after deductible is met.
Grand Totals 300.00 189.00 145.80 43.20  Note Your OOP includes co-pays, deductibles and coinsurance .
Please note that this is set up as an example and actual payments will vary. Please note that this is set up as an example and actual payments will vary. Please note that this is set up as an example and actual payments will vary. Please note that this is set up as an example and actual payments will vary. Please note that this is set up as an example and actual payments will vary. Please note that this is set up as an example and actual payments will vary.
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High Option benefit example

• A member obtains a routine physical and
  associated testing. Later in the year, the
  member suffers an injury requiring an emergency
  room visit. The member also sees their PPP,
  which includes associated lab test and a
  high-tech radiology test (MRI). These tests show
  a need for surgery, a brief hospitalization, and
  short-term physical therapy.

Billed Allowable Plan Pays You Pay (In-Network) Notes
Wellness Visit 300.00 200.00 200.00 0.00 The plan pays 100 of preventive care.
ER Visit 7,000.00 1,700.00 300.00 Deductible
  280.00 Coinsurance
1,120.00 580.00 Total you pay for the ER facility.
PPP Visit 190.00 90.00 70.00 20.00 Copayment. Follow up from ER service.
Lab/X-Ray 250.00 175.00 140.00 35.00 Coinsurance
MRI 2,300.00 1,500.00 1,200.00 300.00 Total you pay for MRI.
Out of Pocket So Far 935.00 Out of Pocket So Far 935.00 Out of Pocket So Far 935.00 Out of Pocket So Far 935.00 Out of Pocket So Far 935.00 Out of Pocket So Far 935.00
Hospitalization 40,000.00 28,000.00 26,135.00 1,865.00 500 Copay plus Coinsurance
Physical Therapy (x5) 2,000.00 500.00 500.00 0.00 You have satisfied your out-of-pocket max. The plan now picks you up at 100.
Grand Totals 52,040.00 32,165.00 29,365.00 2,800.00 Note Your OOPM includes the deductible, copayments and coinsurance amounts.
Please note that this is set up as an example and actual payments will vary. Please note that this is set up as an example and actual payments will vary. Please note that this is set up as an example and actual payments will vary. Please note that this is set up as an example and actual payments will vary. Please note that this is set up as an example and actual payments will vary. Please note that this is set up as an example and actual payments will vary.
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Prescription Plan Changes

• Drug Firms' Spending on Consumer Ads Fell 8 in
  '08, a Rare Marketing Pullback - - spending on
  such ads reached a high of 4.8 billion in 2007,
  compared with less than 1 billion in 1997
• Third tier (non-formulary) still covered, but
  member will pay 70 of discounted price
• Formulary at nmpsia.com or catalystrx.com

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Prescription Plan Change

• Lunesta or Ambien CR for insomnia
• 70 of Discounted Price is 54. Member pays 54.
• Generic for Ambien (zolpidem tartrate) another
  sleep aid,
• would cost member 2.

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Other Non-Formulary Examples

• Celebrex 48
• naproxen 2
• Vytorin 70
• Zetia simvastatin 35
• Cozaar 35
• Diovan 17
• Aciphex 116
• omeprazole 2

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Davis Vision Changes

• Occupational Eyeware option (safety or VDT
  glasses)
• Contact lens discount of 15 for amounts over
• allowable
• Lens 123 offers 50 savings on replacement
  contact lenses

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In Closing . . .

• Any More Questions?
• Comments?
• Thanks!