This edition of Pathways is dedicated to the benefits open enrollment period, scheduled this year from April 28 through May 16, 2003. Open enrollment is the time of year when you may make changes to your benefits coverage or enroll for benefits.

The benefits you select during this open enrollment will be in effect from July 1, 2003, through June 30, 2004. Your next opportunity to change your benefit elections after this period will be in the spring of 2004.

During the most recent collective bargaining talks between the state and OCSEA, much discussion centered around health care. A lot of hard work was done during negotiations to keep health care monthly premium increases to a minimum. To maintain the 90 percent/10 percent split for the first two years of the contract, the parties agreed to changes in plan design in the first year. The following illustrates the plan changes for the coming benefit year.

Effective July 1, many benefit levels for HMO covered services will be the same as those provided under the Ohio Med plan when using network providers. Many services that were covered by the HMOs at 100 percent or 90 percent will now be covered at 80 percent. Most services when using Ohio Med network physicians and providers are now covered at 80 percent. Some other important changes include:

• Office visits: $15 copay for HMOs and Ohio Med network office visit (Ohio Med non-network at $30). Other services conducted in the office may be subject to the deductible and/or coinsurance.
  
  
• Skilled nursing care is covered at 90 percent; the number of days covered varies by plan.

• Prescription drug coverage: Copays for retail and mail order have changed. All plans will now have a formulary. Please see the articles about prescription drugs on pages 6 and 7 for more information.
  
  
• Hospice services remain covered by all plans at 100 percent, and are not subject to a deductible.
  
  
• The ER copay will be $50 (This payment has not been raised for 14 years.)

Ohio Med remains the only plan that has an annual deductible, which you must pay out of your own pocket each year before the plan begins paying its share toward covered benefits.

Effective in July, the annual deductible will be $200 for an individual and $400 for a family when using in-network providers and, $300 individual and $600 family when using out-of-network providers.

Although annual out-of-pocket maximums (the total amount you must pay each year for covered services before the plan begins paying for covered services at 100 percent) have always applied to all plans, they often did not come into play when services were covered at 100 percent. The out-of-pocket maximum protects you and your family from on-going costs in the case of serious illness.

The annual out-of-pocket maximum effective July 1 will be $1,000 for each individual and $2,000 for a family for HMOs and Ohio Med in-network services. If you go outside the Ohio Med network, the annual out-of-pocket maximum will be $3,000 for each individual and $4,000 for a family. (Both the deductible and out-of-pocket-maximums have not been increased for nine years.)

Even if you are not planning to change plans it will be important for you to review the Benefits Comparison Chart and Guide and talk to your health care plan representative to assure that you understand how the changes impact your benefits.

If you wish to make changes during open enrollment, there are three methods you may use: the Web enrollment site, telephone enrollment system or enrollment form. Remember, you do not need to participate in open enrollment if your current benefits are as you want them and current information about your spouse and dependents is correct. Other articles in this Pathways will help you make some of those determinations.

• Web Enrollment Site. To use this site you must have the personal identification number (PIN) which is near the top of the open enrollment letter mailed to your home by the Department of Administrative Services (DAS). If you lose your PIN number, your agency’s payroll/personnel office can provide it to you.
  
  This site may be used to enroll in a health plan and to add or change information about your spouse and dependents. Exempt employees can also add or change their vision, dental and supplemental life insurance benefits using this site.
  
  To access the site, go to the DAS Benefits Administration Services homepage (www.ohio.gov/ employeebenefits) and click on the “Open Enrollment” button. You may visit the site as often as you like; the last change you make prior to midnight May 16 is the change which will become effective July 1.

• Telephone Enrollment System. This system, Ohio Benefits Direct, allows you to make changes to your benefits, but you cannot add or change information about your spouse and dependents. Union represented employees may use this system to change their health plan or to change from family to single coverage. Exempt employees additionally may change their dental, vision and supplemental life insurance benefits.
  
  You may call Ohio Benefits Direct as often as you like; the last change you make prior to midnight May 16 is the change which will become effective July 1. Call Ohio Benefits Direct toll-free at 1-877-4OHBENS (1-877-464-2367).
  
  
• Enrollment Form. By submitting an enrollment form, you may make changes to your benefits and add or change information about your spouse or dependents. You may download an enrollment form from the Benefits’ Web site. A form is also available from your agency and in the Comparison Chart and Guide which you will receive prior to open enrollment. 

National Employee Health and Fitness Week, May 19 through 23, will include events at many agency worksites as well as a free week of fitness for state employees at participating YMCAs, YWCAs and Jewish Community Centers throughout the state.

Contact your representative to the State Healthy Ohioans Committee for more information about events at your worksite and for more information about the organizations participating in the free fitness week. Visit the Benefits Web site at www.ohio.gov/employeebenefits for more information about National Employee Health and Fitness Week. 

The Governor’s Fitness Challenge events include a stationary bicycle race, a three-legged race, a soccer ball dribble obstacle course and a basketball shootout.

If you are interested in forming a team to represent your agency, please contact your agency’s State Healthy Ohioans committee member to obtain an event packet. Teams must be formed by April 25th.

If you do not know who your agency’s representative is, visit www.ohio.gov/employeebenefits on the Web for contact information. If you are not forming a team, please consider cheering on your agency’s team and taking advantage of the other opportunities available to you at this event.

There will be a variety of booths with health, wellness and exercise information and demonstrations by the Fairfield County Senior Volleyball Team and the Highway Patrol cadets who will demonstrate how fun fitness can be.

If you do not work in the downtown Columbus area and are unable to attend the day’s events, ask your agency’s State Healthy Ohioans committee member about activities scheduled at or near your worksite.

Exempt Supplemental Life Insurance
New Lower Rates and Portability

The premiums will be 5 percent less for employees and spouses, both current and new enrollees. The lower rates are automatic.

You need not re-enroll to receive the lower premiums. The lower rates also apply if you decide to increase your coverage during open enrollment.

Effective July 1, 2003, only current stepchildren who live in the employee’s home over half the time will be eligible for coverage. Stepchildren who live elsewhere most of the time will not be covered by a state employee’s health plan. Former stepchildren will no longer be eligible for coverage. If this new coverage change applies to any of your current dependents, please take these steps as necessary:

1. During open enrollment, remove from your coverage any stepchildren who live elsewhere most of the time or are former stepchildren. Use a paper enrollment form or Web enrollment.

2. If you have been covering stepchildren because your spouse is obligated under his/her medical insurance support obligation pursuant to a divorce or dissolution agreement or other court or administrative order, please be advised that your spouse should contact the local child support enforcement agency to report this change.

3. If you want to continue covering stepchildren who are no longer eligible for coverage, see your payroll/personnel officer about paying for COBRA continuation coverage. COBRA coverage allows you to continue coverage for your dependents for up to 36 months by paying the entire premium amount plus a 2 percent administrative fee.

Effective July 1, 2003, dependents age 19 up to age 23 must be attending an accredited school to be covered under your state health care plan, unless they are handicapped or severely mentally ill.

If you are currently covering a dependent age 19 up to 23 who is not listed as a student on the state’s payroll system, coverage in all plans will be automatically dropped effective July 1.

If you previously checked the “primarily dependent” box on form ADM 4729 Annual Affidavit of Dependent Status, but your dependent is now a student at an accredited school, you must submit a new form ADM 4729 attesting to student status during this year’s open enrollment period.

Effective this enrollment period, exempt employees have two vision plans from which to select: VSP and Cole Managed Vision. Cole Managed Vision plan is a new option for exempt employees. Cole’s network includes such familiar names as Sears Optical, JCPenney Optical, Target Optical, and participating Pearle Vision Centers. The network also offers many independent private practice providers.

The benefits are similar to the exempt Vision Service Plan (VSP) benefits, but with lower member copays. The eye exam copay is $5, and there is no copay for lenses and frames up to the plan limits. Like VSP, the Cole plan has a $115 retail frame allowance and covers progressive bifocal lenses in full. Cole also has an out-of-network benefit. VSP’s network consists of independent private practice providers.

For a list of providers in your area, visit each plan’s Web site at www.vsp.com or www.colemanagedvision.com. When visiting the Cole Managed Vision site, the plan number needed to search for providers is 40830. On the VSP site, click the “Guest & Future Members” button or the “Member Sign-on” button.

You now have a choice at open enrollment: Cole Managed Vision or Vision Service Plan. (The phone number listed in this newsletter is for open enrollment only. Once the new benefit year starts, the number will be (800) 334-7591). If you are a new enrollee or you want to switch to the Cole Managed Vision Plan, just enroll by phone at Ohio Benefits Direct, via the Web enrollment site, or use a dental and vision change form.

• As in the past, if you work an average of less than 40 hours in an 80-hour bi-weekly pay period averaged over a six-month period, you will not be eligible for any state contribution toward the premium. You will have the option of self-paying the entire premium.
  
  
• If you work an average of 40 hours but less than 60 hours in a bi-weekly pay period averaged over a six-month period, the state will pay 50 percent of your health care premium.

• If you work an average of 60 hours but less than 80 hours in a bi-weekly pay period averaged over a six-month period, the state will pay 75 percent of your health care premium.
  
  
• The state will pay 90 percent of your premium if you work an average of 80 hours or more in a bi-weekly pay period, averaged over a six-month period.

While most HMOs had a formulary, this is new for Ohio Med, Paramount, and SummaCare. It will also be new to those HMOs that have had closed formularies. Here are the answers to some general questions about how a formulary works.

What does generic mean?
By definition, generic means “chemical name.” The brand name is copyrighted and is used by the manufacturer to help build recognition. That’s why brand names are shorter and easier to remember.

Why are generic drugs less expensive?
Generic manufacturers do not have to bear the initial cost of research, development and advertising. Also, more than one company can produce the generic, which results in competitive pricing.

New drug copays take effect this July 1. Below is a chart that explains what you will be responsible for when you fill a prescription.

For more information on formularies, please see the article above. 

For example, over the past nine years state employees enrolled in the Ohio Med PPO with family coverage have seen their share of the premium increase by less than $4 a month. The total increase has been only $30 more a month since 1993. During that time, the scope of the benefits also improved. The JHCC is proud of this track record.

Unfortunately, with the rapidly rising cost of health care, it is very difficult for employers and unions to provide high levels of benefit coverage and achieve low premium increases.

During most of the 1990’s as employer health plans moved to managed care, health care costs increased at about the rate of inflation—some years even less than general inflation.

• Both the medical care system and our own lifestyles usually emphasize using costly medical services over prevention.

• New medical technologies and drugs often produce better results but at substantially higher cost. As the new generation of very expensive biotech drugs reaches the market, the costs will only increase more.
  
  
• A barrage of direct-to-consumer advertising, including many for drugs that offer little or even no improvement over existing medicines, prompts consumers to ask for the advertised medications.
  
  
• Finally, managed care has achieved most of the more easily identified savings from the health care system. Physicians and hospitals continue to aggressively identify methods to recover higher payments from managed care insurers.

For example, if your share of health care is $100, it will be deducted $50 at a time over two paychecks rather than deducting the entire $100 from one paycheck.

The first half will be deducted from the first paycheck you receive in a month, and the remaining amount will be deducted from your second check.