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Home My WebLink AboutPEIP Benefit Summaries Step by Step Instructions for Enrollment in the Public Employees Insurance Program Advantage Plan ,ihic-su,a1 nolic Employees Insurance Prognni To help explain your options in the Public Employees Insurance Program,we have created the following guide. - • I—Choose YourPlan Level The Public Employees Insurance Program Advantage Plan has cost sharing features that will help you and your employer to better control health care costs while maintaining flexibility in access to doctors and clinics. The Public Employees Insurance Program offers three Plan choices: •Advantage (High) • Value(Medium) • HSA(Low) Choose the Benefit Level that best fits your needs. The premium and cost sharing will vary based on the Benefit Level you choose. You may change your Benefit Level each year during your group's annual open enrollment. ` - • 2—Choose YourPlan/Network The Public Employees Insurance Program offers three different Health Plans/Networks to choose from: • HealthPartners • Blue Cross Blue Shield • Preferred One Choose the network carrier that best fits your needs.Your network selection will not affect the cost of the plan; nor will it affect the premium rate. The benefits are similar under each network(HP includes a benefit for treatment of infertility).You may change your Health Plan/Network level each year during your group's annual renewal. - • 3—Choose Your Primary Care Clinics have been placed into one of four cost levels,depending on the care system in which the provider participates and that care system's total cost/quality of delivering health care. The amount of cost sharing that is paid for health care services varies depending upon the cost level of the Health Plan and Network that you choose. • Select a primary care clinic(PCC)for each family member Each family member must select a primary care clinic(PCC). Family members may choose different PCCs—even in a different cost level, but all family members must enroll with the same Plan Level and Network choice. Your enrollment form should include the primary care clinic#associated with your network carrier. All primary care clinics are broken into four tier levels that determine the benefits received by that family member. A list of participating clinics is available online to help you make your primary care clinic selection. This list includes your primary care clinic's clinic number that you will need in order to enroll. You can change clinics by calling the phone number on your ID card (changes are effective on the 1'day of the following month). Most medical care is coordinated through a Primary Care Clinic(PCC)and you will generally need a referral to see a specialist(referrals to a specialist's office will be covered at the same cost level as your PCC). You may self-refer to certain specialists including OBGYN,chiropractors,and mental health/chemical dependency practitioners, providing the practitioner is part of the carrier's self-referral network. No referrals needed for urgent care and emergencies. A statCwide primary care clinic listing and health plan documents, including the Summary Benefit Comparisons(SBC's) for all plan levels,are available online at www.innovomn.com/plan_information.html. IMPORTANT! Once enrolled,you will receive TWO ID cards. One card will be sent from your health plan (HP, BCBS, Pone)which is to be used for medical services. The second card from CVS is to be used for all pharmacy charges. If you have questions please call us at 952.746.3101 or 800.829.5601 or email us at shawn@innovomn.com. 8/17 Minnesota Public Employees Insurance Program (PEIP) Advanta e Health Plan 2017- 2018 Bene its Schedule Benefit Provision Cost Level 1—You Pa Cost Level 2—You Pa Cost Level 3—You Pa Cost Level 4—You Pa A.Preventive Care Services • Routine medical exams,cancer screening • Child health preventive services,routine Nothing Nothing Nothing Nothing immunizations • Prenatal and postnatal care and exams • Adult immunizations • Routine eye and hearing exams B.Annual First Dollar Deductible* $1501300 $250/500 $550/1,100 $1,250/2,500 sin lelfamily) C.Office visits for Illnesslinjury,for Outpatient Physical,Occupational or Speech Therapy, and Urgent Care • Outpatient visits in a physician's office $25 copay per visit $30 copay per visit $60 copay per visit $80 copay per visit • Chiropractic services annual deductible applies annual deductible applies annual deductible applies annual deductible applies • Outpatient mental health and chemical dependency • Urgent Care clinic visits in or out of network D.Convenience Clinics $10 copay $10 copay $10 copay $10 copay E.Emergency Care(in or out of network) $100 copay $100 copay $100 copay 25%coinsurance • Emergency care received in a hospital annual deductible applies annual deductible applies annual deductible applies annual deductible applies emergency room F.Inpatient Hospital Copay $100 copay $200 copay $500 copay 25%coinsurance annual deductible applies annual deductible applies annual deductible applies annual deductible applies G.Outpatient Surgery Copay $60 copay $120 copay $250 copay 25%coinsurance annual deductible applies annual deductible applies annual deductible applies annual deductible applies H. Hospice and Skilled Nursing Facility Nothing Nothing Nothing Nothing I. Prosthetics and Durable Medical 20%coinsurance 20%coinsurance 20%coinsurance 25%coinsurance Equipment annual deductible applies J.Lab(including allergy shots),Pathology, and X-ray(not included as part of preventive 5%coinsurance 5%coinsurance 20%coinsurance 25%coinsurance care and not subject to office visit or facility annual deductible applies annual deductible applies annual deductible applies annual deductible applies co a ments K.MRIICT Scans 5%coinsurance 10%coinsurance 20%coinsurance 25%coinsurance annual deductible applies annual deductible applies annual deductible applies annual deductible applies L.Other expenses not covered in A—K above,including but not limited to: • Ambulance • Home Health Care • Outpatient Hospital Services(non-surgical) 5%coinsurance 5%coinsurance 20%coinsurance 25%coinsurance • Radiation/chemotherapy annual deductible applies annual deductible applies annual deductible applies annual deductible applies • Dialysis • Day treatment for mental health and chemical dependency • Other diagnostic or treatment related outpatient services M.Prescription Drugs $14 tier one $14 tier one $14 tier one $14 tier one 30-day supply of Tier 1,Tier 2,or Tier 3 $25 tier two $25 tier two $25 tier two $25 tier two prescription drugs,including insulin;or a $50 tier three $50 tier three $50 tier three $50 tier three 3-cycle supply of oral contraceptives. N.Plan Maximum Out-of-pocket Expense for Prescription Drugs(excludes infertility) $800/1,600 $80011,600 $80011,600 $80011,600 sin lelfamil 0.Plan Maximum Out-of•Pocket Expense 11.90012.400 $1,20012,400 $1,600/3,200 $2,60015,200 (excludin prescription dru s sin illy) Emergency care or urgent care at a hospital emergency room or urgent care center out of the plan's service area or out of network is covered as described in sections C and E above. This chart applies only to in-network coverage.Point of Service coverage is available only for members whose permanent residence is outside the State of Minnesota and outside the service areas of the health laps participating in Advantage.This category includes employees temporarily residing outside Minnesota on temporary assignment or paid leave (ncluding sabbatical leaves]a;d college students.It is also available to all dependent children and spouses permanently esiding outside the service area.These members pay a $350 single or$700 family deductible(separate and distinct from the deductibles listed in section B above)and 30%coinsurance:to the out-of-pocket maximums described in section 0 above.Members pay the drug copayment described at section M above to the out-of-pocket maximum described at section N. A standard set of benefits is offered in all PEIP Advantage Plans.There are still some differences from plan to plan in the way that benefits,including the transplant benefits,are administered,in the referral and diagnosis coding pattems of primary care clinics,and in the definition of Allowed Amount. *This Plan uses an embedded deductible:If any family member reaches the individual deductible then the deductible is satisfied for that family member.If any combination of family members reaches the family deductible,then the deductible is satisfied for the entire family. 10/2017 Minnesota Public Employees Insurance Program (PEIP) Advantage Health Plan 2017- 2018 Benefits Schedule Value D tion Benefit Provision Cost Level 1—You Pay Cost Level 2—You Pay Cost Level 3—You Pay Cost Level 4—You Pa A.Preventive Care Services • Routine medical exams,cancer screening • Child health preventive services,routine Nothing Nothing Nothing Nothing immunizations • Prenatal and postnatal care and exams • Adult immunizations • Routine eye and hearing exams B.Annual First Dollar Deductible* $500/1,000 $70011,400 $1,10012,200 $1,800/3,600 (single/family) C.Office visits for Illness/Injury,for Outpatient Physical,Occupational or Speech Therapy, and Urgent Care • Outpatient visits in a physician's office $30 copay per visit $35 copay per visit $95 copay per visit $120 copay per visit • Chiropractic services annual deductible applies annual deductible applies annual deductible applies annual deductible applies • Outpatient mental health and chemical dependency • Urgent Care clinic visits in or out of network D.Convenience Clinics $15 copay $15 copay $15 copay $15 copay E.Emergency Care(in or out of network) $125 copay $125 copay $125 copay 30%coinsurance • Emergency care received in a hospital emer enc room annual deductible applies annual deductible applies annual deductible applies annual deductible applies F.Inpatient Hospital Copay $150 copay $325 copay $750 copay 30%coinsurance annual deductible applies annual deductible applies annual deductible applies annual deductible applies G.Outpatient Surgery Copay $100 copay $175 copay $350 copay 35%coinsurance annual deductible applies annual deductible applies annual deductible applies annual deductible applies H. Hospice and Skilled Nursing Facility Nothing Nothing Nothing Nothing I. Prosthetics and Durable Medical 20%coinsurance 20%coinsurance 25%coinsurance 35%coinsurance Equipment annual deductible applies J.Lab(including allergy shots),Pathology, and X-ray(not included as part of preventive 10%coinsurance 10%coinsurance 20%coinsurance 35%coinsurance care and not subject to office visit or facility annual deductible applies annual deductible applies annual deductible applies annual deductible applies co a ments K.MRI/CT Scans 10%coinsurance 10%coinsurance 20%coinsurance 351f6 coinsurance annual deductible applies annual deductible applies annual deductible applies annual deductible applies L.Other expenses not covered in A—K above,including but not limited to: • Ambulance • Home Health Care • Outpatient Hospital Services(non-surgical) 10%coinsurance 10%coinsurance 20%coinsurance 35%coinsurance • Radiation/chemotherapy • Dialysis annual deductible applies annual deductible applies annual deductible applies annual deductible applies • Day treatment for mental health and chemical dependency • Other diagnostic or treatment related outpatient services M.Prescription Drugs 30-day supply of Tier 1,Tier 2,or Tier 3 $20 tier one $20 tier one $20 tier one $20 tier one prescription drugs,including insulin;or a $40 tier two $40 tier two $40 tier two $40 tier two 3-cycleri prescription supplyof oral ladingcontra in idle; $65 tier three $65 tier three $65 tier three $65 tier three N.Plan Maximum Out-of-Pocket Expense for Prescription Drugs(excludes Infertility) $1,00012,000 $1,000/2,000 $1,00012,000 $1,000/2,000 (single/family) 0.Plan Maximum Out-of-Pocket Expense $2,20014.400 $2,200/4,400 $3,200/6,400 $4,200/8,400 excluding prescription drugs (sin lelfamily Emergency care or urgent care at a hospital emergency room or urgent care center out of the plan's service area or out of network is covered as described in sections C and E above. This chart applies only to in-network coverage.Point of Service coverage is available only for members whose permanent residence is outside the State of Minnesota and outside the service areas of the health f Ians participating in Advantage.This category includes employees temporarily residing outside Minnesota on temporary assignment or paid leave[including sabbatical leaves]and collect a students.It is also available to all dependent children and spouses permanently residing outs a the service area.These members pay a$350 single or$700 family deductible(separate and distinct from the deductibles listed in section B above)and 30%coinsurance to the out-of-pocket maximums described in section 0 above.Members pay the drug copayment described at section M above to the out-of-pocket maximum described at section N. A standard set of benefits is offered in all PEIP Advantage Plans.There are still some differences from plan to plan in the way that benefits,including the transplant benefits,are administered,in the referral and diagnosis coding patterns of primary care clinics,and in the defrnftion of Allowed Amount. 'This Plan uses an embedded deductible:if any family member reaches the individual deductible then the deductible is satisfied for that family member it any combination of family members reaches the family deductible,then the deductible is satisfied for the entire family. 7/16 Minnesota Public Employees Insurance Program (PEIP) Advanta e Health Plan 2017-2018 Benefits Schedule-HSA Compatible Benefit Provision Cost Level 1—You Pa Cost Level 2—You Pay Cost Level 3—You Pay Cost Level 4—You Pa A.Preventive Care Services • Routine medical exams,cancer screening • Child health preventive services,routine immunizations Nothing Nothing Nothing Nothing • Prenatal and postnatal care and exams • Adult immunizations • Routine eye and hearing exams B.Annual First Dollar Deductible* $1,500 $2,000 $3,000 $4,000 Combined Medical/Pharmacy(single coverage) Combined Medical/Pharmacy(family coverage) S2,600 per family member $3,200 per family member $4.800 per family member $6,400 per family member $3,000 per family $4,000 per family $6,000 per family $8,000 per family C.Office visits for lllnessflnjury,for Outpatient Physical,Occupational or Speech Therapy, and Urgent Care • Outpatient visits in a physician's office $40 cepay per visit $50 copay per visit $100 copay per visit $120 copay per visit • Chiropractic services annual deductible applies annual deductible applies annual deductible applies annual deductible applies • Outpatient mental health and chemical dependency • Urgent Care Clinic visits in or out of network D.Convenience Clinics $20 copay $20 copay $20 copay $20 copay annual deductible applies annual deductible applies annual deductible applies annual deductible applies E.Emergency Care(in or out of network)Emergency care received in a hospital $150 copay $150 copay $150 copay 50%coinsurance • emergency room annual deductible applies annual deductible applies annual deductible applies annual deductible applies F.Inpatient Hospital Copay $400 copay $650 copay $1,500 copay 50%coinsurance annual deductible applies annual deductible applies annual deductible applies annual deductible applies G.Outpatient Surgery Copay $250 copay $400 copay $800 copay 50%coinsurance annual deductible applies annual deductible applies annual deductible applies annual deductible applies H. Hospice and Skilled Nursing Facility Nothing after Nothing after Nothing after Nothing after annual deductible annual deductible annual deductible annual deductible I. Prosthetics and Durable Medical 20%coinsurance 25%coinsurance 30%coinsurance 50%coinsurance Equipment annual deductible applies annual deductible applies annual deductible applies annual deductible a plies J.Lab(including allergy shots),Pathology, and X-ray(not included as part of preventive 20%coinsurance 25%coinsurance 30%coinsurance 50%coinsurance care and not subject to office visit or facility annual deductible applies annual deductible applies annual deductible applies annual deductible applies co a ments K.MRIICT Scans 20%coinsurance 25%coinsurance 30%coinsurance 50%coinsurance annual deductible applies annual deductible applies annual deductible applies annual deductible applies L.Other expenses not covered in A—K above,including but not limited to: • Ambulance • Home Health Care • Outpatient Hospital Services(non-surgical)• Radiation/chemotherapy 20%coinsurance 25%coinsurance 30%coinsurance 50%coinsurance • Dialysis annual deductible applies annual deductible applies annual deductible applies annual deductible applies • Day treatment for mental health and chemical dependency • Other diagnostic or treatment related outpatient services M.Prescription Drugs $25 tier one $25 tier one $25 tier one $25 tier one 30-day supply of Tier 1,Tier 2,or Tier 3 $40 tier two $40 tier two $40 tier two $40 tier two prescription drugs,including insulin;or a $65 tier three $65 tier three $65 tier three $65 tier three 3-cycle supply of oral contraceptives. annual deductible applies annual deductible applies annual deductible applies annual deductible applies N.Plan Maximum Out-of-pocket Expense- (including $3,C00 $4,000 $5,000 (including prescription drugs) Single Coverage Family Coverage $5,000 per family member $5,000 per family member $6,850 per family member $6,850 per family member $6,000 per family $6,000 per family $8,000 per family $10,000 per family Emergency care or urgent care at a hospital emergency room or urgent care center out of the plan's service area or out of network is covered as described in sections C and E above. This chart applies only to in-nehvork coverage.Point of Service coverage is available only for members whose permanent residence Is outside the State ofMinnesota and outside the service areas of the health plans participating in Advantage.This category includes employees temporarily residing outside Minnesota on temporary assignment or paid leave[including sabbatical leaves]and college students.It is also available to all dependent children and spouses permanently residing outside the service area.These members pay a$1,500 single or$3,000 family deductible(separate and distinct from the deductibles listed in section B above) and 30%coinsurance to the out-of-pocket maximums described in section N above.Members pay the drug copayment described at section M above to the out-of-pocket maximum described at section N. A standard set otlbenefits is offered in all PEIP Advantage Plans.There are still some differences from plan to plan in the way that benlefits are administered,and in the referral and diagnosis coding patterns of primary care clinics, 'The family Deductible is the maximum amount that a family has to pay In deductible expenses in any one calendar year.The family Deductible is not the amount of expenses a family must incur before any family member can receive benefits.Individual family members only need to satisfy their individual deductible once to be eligible for benefits.Once the family Deductible has been met,deductible expenses for the family are waived for the balance of the year. "The family Out-of-Pocket Maximum is the maximum amount that a family has to pay in any one calendar year.The per-family member embedded Gut-of-Pocket Maximum is the maximum amount that a family has to pay In any one calendar year on behalf of any indwidual family member. 7/16