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Potomac Pediatrics OE - 3.1.2018

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Katie Trinh

on 1 February 2018

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Transcript of Potomac Pediatrics OE - 3.1.2018

Open Enrollment
Presented by:

Healthcare 101
Insurance Definitions
Preventive Services
CareFirst -
New Carrier

BlueChoice Advantage HSA $1,500 -
New Plan
CareFirst Resources
HSA: What is it? How does it work?
Rx Management
Know Where to Go
Meeting Agenda
Insurance Definitions
Amount you pay before insurance starts to pay
May be different for certain benefits (i.e. Rx drugs)

Amount of charges for a service that you are required to pay

Out-of-Pocket Limit
Maximum amount you pay for covered services in a year
Often (but not always) includes deductible, co-insurance and co-payments

Health Savings Account (HSA)
Only available to those enrolled in a high deductible health plan
Tax free dollars can be used for qualified medical expenses
Funds roll over year to year
Know Where to Go
Know where to go
when you need medical
care and receive the best
treatment with the lowest
out-of-pocket costs.
CareFirst Online
On-Line Access for CareFirst Members through “

Once Registered with your own ID and password, you will be able to:
View the status of your claims
View your benefits
Determine you out-of-pocket costs
Provides quick access to:
Prescription Drug Information
Health & Wellness Information
The link to your Benefit Wallet Account
Resource for Medical news, CareFirst news and a whole lot more
Find a DOC at www.carefirst.com
CareFirst Resources
Preventive care services are provided during a wellness exam. You and your doctor will determine what tests and health screenings are right for you. The screenings are based on your:

Personal health history
Current health

Examples of Preventive Care:

Wellness visits and standard immunizations
Screenings for blood pressure, cancer, cholesterol, depression, obesity and diabetes
Pediatric screenings for hearing, vision, autism and developmental disorders, depression and obesity

Your provider may invoice for the non-preventive part of your annual preventive exam for treatment of a diagnosis (high blood pressure, diabetes, skin rash, headache, etc.)

Example of non-preventive care during a preventive care visit:
During the preventive visit, member complains of pain/swelling in the knee. The provider codes for both examinations and a cost share will apply to the non-preventive examination of the knee.
Understanding Your Rx Program
Simple ways to save on Prescriptions:
Know Your Prescription Plan Tiers – understanding the tier system can help you choose high value, low cost medications
Generics – Usually the least expensive option
Mail-order – 90-day supply of maintenance medications for only 2 copays
Pill splitting:

Physician writes you a prescription for 2 times the strength and then you split the tablet - you get your usual dosage for half the cost! (not suitable for all medications)

Over-the-Counter (OTC) Substitutions: Some prescriptions have OTC alternatives - check with your doctor or pharmacy

Synthroid (100 mcg - $34.33) $34.33

Zoloft (50mg - $265.72): $65
Xanax (.5mg - $373.79): $45
Crestor (10mg - $260.60): $65

Generic Equivalent
Levothyroxine Sodium –($12.84) $10

Sertraline HCL – ($2.04) $2.04
Alprazolam – ($2.57) $2.57
Simvastatin – ($32.58) $10
Generic prescriptions fall under Tier 1 of Potomac Pediatrics' Rx plan, resulting in the lowest cost.
Members will pay up to a $10 copay for generic prescriptions after the deductible has been met.
Brand/Non-Preferred Brand Name vs. Generic Prescriptions
BlueRewards Incentive Process - Participation
All steps must be completed within 120 days of your effective date.
Note: Members outside the service area can select any PCP-like specialty
Register or log in to "
My Account"

Click on the "
Start Earning Now"

Select a Patient-Centered Medical Home PCP
BlueRewards Card Guidelines
Results-Based Reward
You have until the end of your benefit period to achieve this additional reward
The results from your Health and Wellness Evaluation will be measured against the following results-based goals. As long as your results fall within all of the recommended ranges, you will earn an additional reward.
If you do not meet these health measures during the initial visit with your PCP, you will need to work with your doctor to develop a goal and a plan of action. You should schedule a re-screening visit with your PCP to check your progress
the end of the benefit period. If your re-screening results are within the range the doctor established, you will earn the results-based reward.
Should your provider feel it is not medically advisable for you to be measured on a specific health factor based on clinical circumstances, they are allowed to “WAIVE” that requirement.
How Blue Rewards works

Blue Rewards is CareFirst's exclusive incentive program that rewards you for taking steps to get and stay healthy.

Blue Rewards gives you the opportunity to be rewarded twice! First, you can earn a participation-based reward for completing four important steps. Then, you can also earn a results-based reward by meeting certain health measures.
CareFirst Blue Rewards Visa Incentive Card
Once you complete the (4) four participation-based steps, you will receive an incentive card in the mail. Only one card is issued to the policyholder however, it can be used by everyone covered under your policy

Incentive cards should be retained as long as you remain a CareFirst member. Incentive cards will be replenished with funds once you earn another Blue Reward
To receive the incentive card immediately, you can choose to certify either:

No contributions will be made (by you or your employer) to the HSA for the current benefit period; or

The card will only be used for CareFirst dental and vision expenses until meeting the IRS minimum deductible

You have until the
end of your benefit period
to use your incentive card toward annual deductibles and out-of-pocket costs like copays or coinsurance related to eligible expenses (medical, prescription drug, dental and vision) under your CareFirst health plan

You should always save your receipts as proof of your expense. As long as the card is used correctly there are no tax reporting obligations

For members enrolled under the Health Savings Account (HSA) plan, typically you will receive the incentive card

once you have met the Internal Revenue Service (IRS) minimum deductible for an HSA plan - $1,350 for an individual and $2,700 for a family
Blue Rewards Incentive Amounts
With Blue Rewards you have the opportunity to earn financial incentives for taking an active role in your health. By completing (4) four important steps and achieving certain health measures, you and your covered spouse/domestic partner can each earn up to $300.
For more information, visit
Let's take
a closer look...
Logging into CareFirst
Treatment Estimator Tool
Prescription Pricing Tool
View Claims
Explanation of Benefits (EOB)
Mobile App for Members
Members can:
Verify eligibility
View benefits
View claims status
View your Balance in Benefit Wallet
Go Green - Review and Print EOBs
Track out-of-pocket expenses (deductible balance)
Compare drug prices, check generic availability
Update Coordination of Benefits information (COB)
Find A Provider
Urgent Care
FirstHelp® Nurse Hotline
CareFirst Video Visit
What is CareFirst Video Visit?

CareFirst Video Visit allows members to securely connect with a board-certified doctor 24/7 from their desktop, tablet or smart phone
Effective January 15, 2018, the allowed amount for CareFirst Video Visit has been reduced to $49 (from $60)
Just like any other PCP office sick visit, the member will need to satisfy their deductible
Visit charges are in-network and based on real time claims information taking into consideration the amount of deductible the insured has already met
How to set up a Video Visit
On-Line Access for CareFirst Members through

or download the CareFirst Video Visit app (iTunes and Android) for smartphone or tablet use
Once Registered members will receive a welcome email with instructions to schedule a visit
For more information, or to register, visit:

Wrap Up
During Open Enrollment you can:
Add or drop coverage
Add or remove dependents
Update information and beneficiaries

All enrollment/change forms must be signed and submitted by February 6, 2018

The new plan year will begin March 1, 2018 and extends through February 28, 2019

Your new coverage will be effective on March 1, 2018
Complete 4 steps to earn the Participation-based Reward
Consent to electronic communications
Complete the health assessment
Complete the health assessment
2018 HMO
Reviewing the Health Savings Account
What you should know about an HSA
What is a Health Savings Account?
HSA eligibility requirements
Annual HSA contribution limits
How you can use the HSA
How the HSA plan works
Administered by Benefit Wallet
What you should know about the HSA
How you can use the HSA
Other qualified expenses
What is a Health Savings Account?
You can open and fund the HSA to pay the plan deductible and other qualified health care costs - or you can let your account grow.
Annual HSA Contribution Limits
Annual contribution limits are set by the IRS. The amounts shown below reflect both employee and employer contributions.
Contributions above the annual limit are subject to income tax and tax penalty
How you can use the HSA
HSA Eligibility Requirements
You may be eligible to open an HSA if:
You are covered by a qualified high deductible health plan.
You are

covered by any other non-high deductible health plan, such as a spouse’s plan
You are


enrolled in Medicare
You do


receive health benefits under TRICARE unless for disability
You have


received Veterans Administration (VA) benefits within the past three months


be claimed as a dependent on another person’s tax return


be covered by a health care FSA or HRA (dependent care FSA is allowed and available)
After the deductible has been met
Up $50 from 2017 / Up $150 from 2017
Participation-based reward:
You must complete these steps within 120 days of your effective date.
Select a PCMH PCP
Agree to receive wellness-related communications electronically
Complete an online health assessment
Visit your selected PCMH PCP and complete the Health and Wellness Evaluation Form
BlueChoice Advantage HSA $1,500 Silver
Below is a brief overview
See detailed Summary of Benefits or Evidence of Coverage for more specifics
Potomac Contacts
Dedicated Team:
Sara Martinez – Account Manager | Jon Lee – Account Manager
Stephanie Williams - Director, Account Management
Joseph Appelbaum
Milton Foster
Executive Vice President
Potomac Pediatrics will contribute $600 towards the HSA distributed monthly ($50 per month on 1st pay period of the month)
BlueChoice Advantage Network
Open Access / no referrals
PCP selection NOT required
CareFirst Service Area: MD, DC, Northern VA
BlueChoice network in the service area
BlueCard PPO network outside service area
CareFirst PPO (no balance billing) network and non-participating providers (subject to balance billing) in the service area
BlueCard participating providers (no balance billing) and non-participating providers (subject to balance billing) outside service area
CareFirst BlueDental Plus
CareFirst Vision
CareFirst BlueVision Plus
Complete the health assessment
Full transcript