BENEFITS DECISION SUPPORT BOOKLET
Which plan is the right fit for me and my family? Employee benefit plan decisions are very personal. Everyone has unique needs and circumstances, which is why we offer a variety of plans and options. In making benefit plan decisions you should consider the following: •
Who do I need to cover?
•
How much will it cost in payroll deductions?
•
What will be my out-of-pocket costs when I need care?
•
Are there any big events in my life happening next year that may affect my benefit plan needs?
Take a look at the following examples of fictional RWJBarnabas employees to learn about how they decided which benefits fit their needs.
MEDICAL CLAIM BENEFITS: EXAMPLES: PLAN CHOICES SAM To learn more about Premier or Inner Circle doctors and facilities, and explanations on medical benefit terms, click here.
Horizon Medical Plans: What You Need To Know
CONTRIBUTIONS
OMNIA
Direct Access**
HDHP
$ (Lowest)
$$$ (Highest)
$$
NETWORK TIERS WITHIN EACH PLAN
Premier: This tier includes RWJBH facilities and employed physicians, such as Medical Group providers and our joint venture partners. There may be some types of providers that are unavailable in this tier.
No charge
$$ Inner Circle: This tier includes providers affiliated with RWJBH, and providers who have admitting privileges in our facilities. In-Network Horizon/BlueCard: This tier includes all facilities and physicians in Horizon’s Direct Access Network in NJ (including all providers in all OMNIA plan tiers). Outside of NJ, it includes providers in the national BlueCard network. Out-of-Network NOTE: The OMNIA plan has NO out-of-network coverage. * **
2
$$ (Tier 1) OR
B E N E F I T S
D E C I S I O N
S U P P O R T
No coverage
B O O K L E T
$$$
$$$ (Tier 2)
Copay will apply for Emergency Room visits Employees who reside outside of the RWJBarnabas Health service area will be offered an Out of Area plan in place of Direct Access.
|
$$$
$
$$$$
$$$$
MEET SAM! Sam is a respiratory therapist who lives in Bridgewater, NJ. What is Sam’s family like? •
He’s married, with 3 children; a 19 year old daughter and 9 year old twin boys
•
His daughter is a Type 1 diabetic; it’s generally under control but she’s been hospitalized once in the past
•
One of his sons has asthma
•
His wife is self-employed and expecting baby #4 this Spring
How often does his family expect to use care? •
Everyone gets an annual physical and his wife will need prenatal care
•
They see some specialists to keep on top of the his daughter’s diabetes
Which medical plan is right for Sam? Because Sam and his family live close to RWJBarnabas Health facilities and stay in-network, it makes the most sense for him to choose the Omnia plan. He saves money on his contributions, and is also able to access free care for his family. The claim examples shown on the following page illustrate how Sam can save money by going to Premier/Preferred providers as much as possible.
Sam also wants to make sure all of his other benefits are in order: DENTAL All of his family members see the dentist twice a year. He enrolls the family in the Dental PPO Buy-Up plan so that they can choose to see any dentist.
LIFE Sam also elects additional employee life insurance, as well as coverage for his wife and children. He wants to make sure all of the children are taken care of if anything unexpected should happen.
and his son’s asthma •
They’ll have some prescriptions related to their conditions
B E N E F I T S
D E C I S I O N
S U P P O R T
B O O K L E T
|
3
MEDICAL COST OF CARE CLAIMEXAMPLES EXAMPLES: IN SAM THE OMNIA PLAN Claim Example: Maternity (Normal Delivery) Sample Health Care Services & Expenses
Total Cost of Service
Benefit Type
Premier Member Cost
Inner Circle Member Cost
Tier 1 Member Cost
Prenatal Office Visits
$4,000.00
Specialist Copay*
$0.00
$40.00
$80.00
Routine Ultrasounds + Testing
$1,500.00
Specialist Copay*
$0.00
$0.00
$0.00
Physician Delivery Charges
$2,000.00
Inpatient Hospital Stay
$0.00
$0.00
$2,000.00
Facility Delivery Charges
$4,000.00
Inpatient Hospital Stay
$0.00
$0.00
$2,500.00
TOTAL OUT-OF-POCKET COST
$11,500.00
$0.00
$40.00
$4,580.00
* Initial visit only
Claim Example: Doctor Visits Sample Health Care Services & Expenses
Total Cost of Service
Benefit Type
Premier Member Cost
Inner Circle Member Cost
Tier 1 Member Cost
Preventive Care Visit including blood work
$150.00
Covered at 100%
$0.00
$0.00
$0.00
Sick visit to Primary Care Provider
$90.00
PCP Copay
$0.00
$20.00
$40.00
Ear ache visit to Primary Care Provider
$135.00
PCP Copay
$0.00
$20.00
$40.00
Visit to Specialist
$200.00
Specialist Copay
$0.00
$40.00
$80.00
TOTAL OUT-OF-POCKET COST
$575.00
$0.00
$80.00
$160.00
Claim Example: Inpatient Stay Sample Health Care Services & Expenses
Total Cost of Service
Benefit Type
Premier Member Cost
Inner Circle Member Cost
Tier 1 Member Cost
Emergency Room Visit
$2,000.00
ER Copay
$125.00
$125.00
$125.00
Inpatient Stay
$20,000.00
Inpatient Hospital Copay
$0.00
$0.00
$8,975.00
Specialist Follow-up + Testing
$400.00
Specialist Copay
$0.00
$40.00
$0.00*
Specialist Follow-up + Testing
$400.00
Specialist Copay
$0.00
$40.00
$0.00*
TOTAL OUT-OF-POCKET COST
$22,800.00
$125.00
$205.00
$9,100.00
* $0 copay because the maximum out-of-pocket was reached Note: For illustrative purposes, the out-of-pocket costs are limited by specific out-of-pocket maximums associated with each service line item's benefit tier.
4
|
B E N E F I T S
D E C I S I O N
S U P P O R T
B O O K L E T
MEET ALEXA! Alexa is a nurse who lives in Jersey City, NJ. What is Alexa’s family like? •
Her sons play sports, so there are sometimes injuries
•
Her older son has been struggling with depression
How often does her family expect to use care? •
Although the OMNIA contributions would be less money coming out of her paycheck, Alexa decided to choose the Direct Access plan. She can still take advantage of low-cost Premier/Inner Circle care, and the plan also offers the outof-network coverage she needs.
She has a husband and teenage sons
•
Which medical plan is right for Alexa?
She sees her PCP throughout the year for an annual physical
Alexa also wants to make sure all of her other benefits are in order: DENTAL All of her family members see the dentist twice a year, and one of her sons is in the middle of orthodontic treatment. Alexa chooses the DHMO since their dentist is in the network and they can maximize the orthodontic coverage.
VISION Her husband wears glasses, and so do both children, so Alexa enrolls in vision coverage so they can get annual screenings as well as new glasses when they need them.
and to manage her asthma •
Her sons sometimes need to visit urgent care for the occasional sports injury
•
Her older son has been seeing
LIFE Alexa also elects additional employee life insurance, as well as coverage for her husband and children. With two children approaching college, she wants to make sure her family has the right amount of protection.
a therapist that has been very helpful, but she is out-ofnetwork. She does not want to interrupt his care
OTHER BENEFITS Worrying about a child dealing with a mental illness issue can take its toll on a parent; Alexa can also take advantage of the EAP and/or AbleTo, if she needs a little extra help for herself.
B E N E F I T S
D E C I S I O N
S U P P O R T
B O O K L E T
|
5
MEET JUSTIN!
Which medical plan is right for Justin?
Justin is an anesthesiologist who lives in Hoboken, NJ. What is Justin’s family like? •
Justin is single; he has a circle of friends with whom he likes to
His preventive care will be covered at 100% regardless of which plan he chooses, but he likes the idea of the HDHP so he can also save money to cover any qualified expenses by opening up an HSA. If he doesn’t end up having many claims throughout the year, his money will roll over to the next year. There are tax advantages with an HSA, and he can also choose to invest the money as his balance grows.
train and run marathons •
He is focused on saving money now so he’s prepared in case he expands his family in the future
•
Justin plans to get his annual
VISION
physical and preventive screenings
Justin also enrolls in the vision plan so that he can get his annual vision screening and coverage for his contacts.
Once in a while he gets a sinus
LIMITED PURPOSE FSA
infection or a running injury, so
Since he wears daily contacts, he usually has to pay extra out of pocket to supplement the vision allowance. He puts some money on a pre-tax basis aside in a Limited Purpose FSA to save for this expense.
he may need to see a doctor occasionally
6
DENTAL Justin enrolls in the Dental PPO Base plan, since he sees a dentist twice a year. He has the freedom to choose any dentist in his area with this plan.
How often does Justin expect to use care? •
Justin also wants to make sure all of his other benefits are in order:
|
B E N E F I T S
D E C I S I O N
S U P P O R T
B O O K L E T
MEET LUCY! Lucy is a medical coder who lives in Tarrytown, NY. What is Lucy’s home life like? •
She is able to work remotely most of the time but will commute to New Jersey when
Which medical plan is right for Lucy? Since Lucy lives in New York, she is eligible for and chooses the Out of Area plan. She sees a RWJBH cardiologist in the Premier network since she usually has pre-planned visits only twice a year. She can coordinate those for when she will be commuting into New Jersey; this will save her money on her own medical costs. She is also able to take advantage of rich in-network benefits that will help limit her out of pocket costs for her daughter’s care.
she has meetings. •
She has one daughter who
Lucy also wants to make sure all of her other benefits are in order:
is 9 years old
DENTAL How often does Lucy expect to use care? •
Lucy and her daughter see the dentist twice a year. She enrolls them in the dental PPO plan so that they can choose to see any dentist.
Lucy gets her annual preventive visits every year, eats healthy,
VISION
and exercises, but was born with
Lucy also elects additional employee life insurance, as well as coverage for her daughter. She wants to make she has enough coverage so that if anything happened to her, her daughter would be taken care of.
a heart condition that she needs to monitor for the rest of her life, so she sees a cardiologist every six months. •
Lucy’s daughter has cystic fibrosis and often requires
DEPENDENT CARE FSA Lucy’s daughter goes to summer camp, so she also plans on putting some pre-tax money into a Dependent Care FSA to save up for it.
medical treatment
B E N E F I T S
D E C I S I O N
S U P P O R T
B O O K L E T
|
7