The legislature has decided to fund 1/2 of the employer’s portion of the increase for FY 2011. The other half of the increase will be funded through benefit plan changes. The premium split percentage between the State and employees on each plan will be the same as FY 2010; however, employees will see a slight increase in the dollar amount of the premium, as they must fund their own portion of the increased premium.
The proposed changes in benefit plan design are:
- Increase the out-of-pocket maximum from the current $2000 individual/$4000 family, to $2500 single coverage/$5000 double coverage/$7500 family coverage
- Add an out-of-pocket maximum to the pharmacy benefit of $3000 per individual
What is an out-of-pocket maximum?
PEHP has set limits for maximum out-of-pocket expense for members. After the member’s share of eligible expenses exceeds specified amounts, PEHP will pay further eligible benefits incurred during the remaining plan year at 100% of Maximum Allowable Fee. (Please see the PEHP Master Policy for further detail.)
Other Changes:
- Employees who are double-covered under 2 PEHP administered plans will see changes beginning July 1, 2010.
- All employees who are double-covered under any 2 plans (regardless of being a PEHP plan or not) will have all claims processed under industry standard coordination of benefits rules. Each claim will be evaluated for payment individually. Deductibles, co-insurance, and co-payment amounts may or may not be waived, depending on the specific claim filed, the cost of the service, and if deductibles have already been met by the member, etc.
Secondary coverage will never pay more than what it would have paid had it been the primary coverage.
- Pharmacy claims will also be handled differently. Members covered under 2 PEHP plans must now run their prescriptions through their primary plan and then submit receipts to PEHP to be reimbursed by the secondary plan. This is the same policy that all other double-covered members follow.
- Life insurance maximums will increase from the current $300,000 to $450,000. More details on this change will be coming shortly.
These, and any other benefit plan changes, are proposed changes and must be approved by the PEHP Board before they are official.
Additionally, please plan to attend one of the upcoming benefits fairs all across the state beginning in April, 2010, for further information on all of your benefits and to speak directly to benefit vendors with your specific questions.
