What is the Consumer Driven PPO High Deductible Health Plan (CD PPO HDHP)?
The PPO HDHP is a high deductible health plan that works in conjunction with a Health Savings Account or Health Reimbursement Arrangement and a wellness program. The plan has a $1,900 individual deductible (participant only tier) and a $3,800 family deductible (any tier with two or more members; family deductible includes a $2,400 individual family member deductible). To maximize benefits under the PPO HDHP, PEBP will continue to offer the preferred provider organization (PPO) network. The medical and pharmacy benefits are both subject to the annual deductible amounts and copayments do not apply. Generally, after meeting the annual combined medical and prescription drug deductible amount, the plan will pay 75% coinsurance when using contracted PPO providers.

What is the annual maximum out-of-pocket for the CD PPO HDHP?
The annual out-of-pocket maximum is $3,900 for an individual with no covered dependents and $7,800 for a family (all other tiers). Once the annual maximum out-of-pocket has been met, the plan will pay 100% of covered medical and pharmacy expenses when using contracted providers.

What expenses apply to the annual maximum out-of-pocket?
Both the deductible and coinsurance amounts accumulate toward the annual out-of-pocket maximum.

Would the family maximum out-of-pocket have to be met by more than one person?
The $7,800 family out-of-pocket maximum may be met by one individual or through a combination of claims incurred by all family members. The family out-of-pocket maximum does not include an "individual" out-of-pocket maximum.

What is a Health Savings Account (HSA)?
HSAs are tax-exempt accounts that are coupled with high deductible health plans. They are employee-owned interest bearing/investment accounts that allow an individual to pay for qualified health care expenses on a pre-tax basis. HSA funds carryover from year-to-year and belong to the employee even if the employee terminates employment, retires or ceases to participate in the CD PPO HDHP. HSA contributions will be reported by your employer to you and the IRS on form W-2 in box 12 using code W. You will be required to report contributions to and distributions from your HSA on your annual tax return using form 8889 (see IRS Publication 969).

All participants who open an HSA are subject to federal identification verification procedures. Some participants will be required to provide additional identifying information. Participants who fail to provide the requested documentation within six months of the effective date of coverage will forfeit the HSA contribution provided by PEBP and it will be converted to an HRA contribution. Participants will receive a postcard warning of the forfeiture approximately two months prior to conversion. Participants who receive the postcard should contact HealthSCOPE at 1-888-763-8232.

What is a Health Reimbursement Arrangement?
HRAs are accounts established for individual participants but owned by PEBP. The funds in an individual’s HRA can be used to pay for qualified health care expenses. HRA funds carryover from year-to-year subject to maximum carryover limitations that may be set by the Board in the future. If you terminate your coverage or choose a different plan, the funds in your HRA revert back to PEBP. HRA contributions and distributions are not reported to the IRS.

What are qualified medical expenses?
Qualified medical expenses are amounts paid for medical care as defined by the IRS provided that reimbursements for such paid amounts are not received from any other source, including insurance. Qualified medical expenses include payment of deductibles, coinsurance, dental or vision costs incurred by you, your spouse or any other dependent claimed on your annual tax return (see IRS Publication 502). Participants on the CD PPO HDHP may not use HSA/HRA funds to pay premiums. Retirees on the Medicare Exchange may use Exchange HRA funds to pay premiums.

Who is eligible to contribute to the HSA?
You may not establish or contribute to a Health Savings Account if any of the following apply:

•  You are covered under other medical insurance coverage unless that medical insurance coverage: (1) is also a High Deductible Health Plan as defined by the IRS; (2) covers a specific disease state (such as cancer insurance); or (3) only reimburses for expenses after you have met the deductible

•  You are enrolled in Medicare, Tricare, Tribal or similar coverage

•  You can be claimed as a dependent on someone else’s tax return unless you are married filing jointly

•  You or your spouse has a Medical Flexible Spending Account (excludes Dependent Care or Limited Use Flexible Spending Accounts)

•  Your spouse has an HRA that can be used to pay for your medical expenses

•  You are on COBRA

•  You are retired

  Who is eligible to have an PPO-HRA?
  Employees who select CD PPO HDHP and who are not eligible to have a HSA will get a PPO HRA. Retirees and surviving spouses of retiree who select CD PPO HDHP coverage will receive a PPO HRA.
  
  Who is eligible for the Exchange-HRA?
  Retirees who are covered through the Medicare Exchange will receive an Exchange HRA. Surviving spouses enrolled in the Medicare Exchange will not receive an Exchange-HRA. To learn more, read the Exchange-HRA Summary Plan Description FAQs.

  What qualifying medical expenses can I be reimbursed for?
  You may use the funds in your HSA, PPO HRA or Exchange HRA to pay for the qualified medical expenses of your spouse or dependent child as defined by the IRS, regardless of whether the spouse or dependent is covered by PEBP. HSA, PPO HRA and Exchange HRA funds may not be used for a person who does not meet the IRS definition of “dependent,” including many domestic partners, children of domestic partners and older children who cannot be claimed on your tax return, regardless of whether PEBP provides coverage for the child. See  IRS Publication 502  for more details regarding qualified children.
  
  

  How much will PEBP contribute to my HSA/HRA?
  

• PPO Participants: For Plan Year 2013, PEBP will provide annual contributions of $700 for each participant and $200 for each covered dependent (regardless of whether the dependent is defined as a dependent by the IRS) up to a maximum of $1,300 in your HSA or PPO HRA. Funds will be available in the HSA or PPO HRA on the first business day in July 2012. Participants who join the CD PPO HDHP or add dependents mid-year due to a qualifying event will receive a prorated amount based on the number of months remaining in the plan year. These funds will be available on the first business day of the month after the month in which the qualifying event is processed, but no earlier than the effective date of the qualifying event.

  Exchange Retirees: For Plan Year 2013, retiree enrolled through the Medicare  Exchange  will receive a HRA contribution of $10 per month, for each year of service (excluding purchased service) up to a maximum of $200. Retirees who retired on or before December 31, 1993 will receive a flat $150 per month contribution. Retirees who were hired by their last public employer on or after January 1, 2010 and who have less than 15 years of service are not eligible for an Medicare Exchange HRA. Dependents and survivors are not eligible for the Medicare Exchange HRA.
  

How much can I contribute to my PPO HSA?
For Calendar Year 2012, you can contribute funds to your HSA up to the IRS maximum allowable HSA contribution of $3,100 for individuals and $6,250 for families (subject to the last month rule and the testing period discussed below – see IRS Publication 969), less any amount provided by PEBP or your employer. Additionally, employees  aged 55 or older may contribute an additional $1,000 to their HSA account. In order to contribute more than the IRS individual HSA maximum amount (up to the family maximum), you must have at least one dependent who is:



• Not covered under other medical insurance coverage unless that medical insurance coverage: (1) is also a High Deductible Health Plan as defined by the IRS; (2) covers a specific disease state (such as cancer insurance); or (3) only reimburses expenses after the dependent has met the deductible





• Not enrolled in Medicare, Tricare, Tribal or similar coverage





• Not a dependent on someone else’s tax return

 



• Not covered under a Medical FSA or HRA



How Do I change my HSA contribution?
You may change your HSA contributions by using one of the following options:

1.    Log on the HSA section of the HealthSCOPE Benefits website and select "Change an Election."

2.    Call HealthSCOPE Benefits at 888-763-8232 to request a form to change the election.

3.    Contact HealthSCOPE Benefits via email at pebphsahra@healthscopebenefits.com and request a form to change the election.

What is the HSA last-month rule and how does it impact the maximum calendar year contributions?
If an employee is eligible to contribute to an HSA on December 1, 2012, the employee may contribute up to the 2012 maximum, subject to the testing period explained below. If the employee is not eligible on December 1, 2012, the maximum contribution is based on the months the employee qualifies as an eligible individual (see IRS Publication 969). For example, if an employee is eligible to contribute to their HSA on July 1, 2012 as a single individual and their coverage continues through October 31, 2012, the employee may contribute 4/12ths of the calendar year 2012 maximum contribution amount ($3,100 x 4 / 12 = $1,033.33). This example assumes the employee is under age 55 and thus not eligible for the $1,000 catch-up provision.

What is the HSA testing period and how does it impact the calendar year 2012 maximum calendar year contributions?
If an employee is eligible to contribute to an HSA on the first day of the last month of the tax year (generally December 1), the employee may contribute up to the annual maximum if the employee is eligible to contribute to an HSA through the end of the following year (the testing period). If the employee is not eligible for the entirety of the testing period, any amount contributed to the HSA in excess of the prorated maximum annual amount will be treated as taxable income in the following tax year and will be subject to an additional penalty (see IRS Publication 969). For example, assume an employee under age 55 is eligible to contribute to an HSA beginning July 1, 2012 and gets a new job with another employer with non-high deductible coverage effective November 1, 2012. Because the employee is not eligible to contribute to an HSA for the entirety of the testing period (December 1, 2011 through December 31, 2012), the maximum contribution for Calendar Year 2012 is reduced to 4/12ths (July 2012 through October 2012) of the maximum annual amount ($3,100 x 4 /12 = $1,033.33). Any amount contributed in excess of $1,033.33 would be treated as taxable income in tax year 2012 and would be subject to an additional penalty.

Are HMO participants eligible to have an HSA or HRA?
No, HMO participants are not eligible to have an HSA or HRA.

Who is eligible to have a Medical Flexible Spending Account (FSA)?
Generally, employees on the HMO or employees on the PPO who have an HRA are eligible to contribute to a Medical FSA.

Employees who contribute to an HSA cannot contribute to a Medical FSA, but may be eligible to contribute to a Limited Use or Limited Scope FSA. A Limited Use FSA can only be used to pay for dental or vision expenses.

Retirees cannot have an FSA.

If you are employed by a state agency and receive your paycheck through Central Payroll (generally, if you have access to NEATS), see the PEBP Flexible Spending Account Summary Plan Description for more details. Otherwise, contact your employer’s human resources department.

Who is eligible to have a Dependent Care FSA?
Generally, all employees are eligible to contribute to a Dependent Care FSA. If you are employed by a state agency and receive your paycheck through Central Payroll (generally, if you have access to NEATS), see the PEBP Flexible Spending Account Summary Plan Description for more details. Otherwise, contact your employer’s human resources department.

Do retirees receive a years of service subsidy to offset premium costs like they have received in the past?
Retirees who are covered under the PPO HDHP or HMO plans will continue to receive the premium years of service subsidy for Plan Year 2012. However, retirees who are covered through the Individual Market Medicare Exchange will not receive a premium years of service subsidy and will instead receive an Exchange HRA contribution that can be used to pay for their premiums or other out-of-pocket medical expenses.

Does the PPO HDHP cover wellness/preventive care?
Yes, eligible wellness/preventive care benefits are covered 100% when using in-network providers.

Is there an annual maximum on wellness/preventive care benefits?
No, effective July 1, 2011, there is not an annual maximum dollar amount the plan will pay for wellness and preventive services. However, for CD PPO HDHP participants and dependents, PEBP will only pay for wellness or preventive care benefits based on the recommended guidelines published by the Centers for Disease Control and Prevention (CDC). For HMO participants, contact your plan for the associated wellness guidelines.

Are my covered dependents also eligible for wellness/preventive care benefits?
Yes, covered dependents on the CD PPO HDHP are eligible for wellness/preventive care benefits as recommended by the Centers for Disease Control and Prevention (CDC). For HMO participants, contact your plan for the associated wellness guidelines and programs.

Whose responsibility is it to ensure their doctor bills the wellness benefit correctly?
The physician makes the determination regarding the purpose of the visit (e.g., was the visit for screening purposes only or was the visit a follow up for a known medical condition?). However, it is the patient’s responsibility to inform their physician and the physician’s billing staff about the wellness benefits.

If wellness services are received from an out-of-network provider because there are no in-network providers within 50 miles of my residence, would wellness services be covered?
The 50 mile rule would apply to eligible wellness services. The participant would be responsible for any billed amounts that exceed the Plan’s usual and customary allowance. Information regarding the 50 mile rule and the usual and customary allowance can be obtained by calling the PPO HDHP third-party administrator.

What wellness services are mandated by Nevada statute?
NRS 287.04335 (695G.171) – Human Papilloma Virus vaccination for cervical cancer
NRS 287.04335 (695G.177) – Prostate cancer screening test

I’ve been told that services relating to a condition for which I have a previous diagnosis are not covered under the wellness benefit. Does it matter how long ago the previous diagnosis was made?
Office visits and other medical services such as laboratory and radiology done in conjunction with a known medical condition are subject to the annual deductible, coinsurance and other plan requirements as described in the PEBP Master Plan Document. For the majority of individuals with chronic conditions such as diabetes, hypertension, high cholesterol, etc., office visits and related ancillary services will not be covered under the PPO HDHP wellness benefit and will be subject to deductible and coinsurance. Generally, there are no time limits and once you have been diagnosed with a chronic medical condition, your medical treatment plan continues during your lifetime and is no longer considered preventive or wellness. For HMO participants, contact your plan for the associated wellness guidelines.

Are colonoscopies covered under the wellness benefit?
Colonoscopies performed for screening purposes, and in accordance with CDC guidelines, are covered under the PPO HDHP wellness benefit. However, virtual colonoscopies are not covered unless deemed medically necessary by PEBP’s third-party administrator and utilization management company. For HMO participants, contact your plan for the associated wellness guidelines.

Is the cost of the H1N1, flu, or pneumonia immunizations paid by the wellness benefit?
Yes, H1N1, flu and pneumonia immunizations are paid through the wellness benefit as longs as they are received in the frequency and age groups as recommended by the CDC. For HMO participants, contact your plan for the associated wellness guidelines.

Does it matter where I go to get the immunization?
The H1N1, flu, or pneumonia immunizations should be administered by a PPO provider to assure that the immunizations you receive are necessary, within CDC guidelines and covered under the wellness benefit. Standard flu and pneumonia vaccines received at certain out-of-network providers, such as local and state health departments, or Catalyst Rx contracted pharmacies may be reimbursed as part of the annual PPO HDHP wellness benefit. For HMO participants, contact your plan for the associated wellness guidelines.

Children are supposed to get more than one shot for the H1N1 virus. Does the wellness benefit pay for both shots?
Yes, all vaccinations recommended by the CDC are covered under the wellness benefit. For HMO participants, contact your plan for the associated wellness guidelines.

I’m going overseas and need several vaccinations. Are they covered under wellness?
Generally, vaccinations required for overseas travel are covered under the PPO HDHP wellness benefit. However, most of the vaccines required for overseas travel are not available through a primary care physician. Contact your local health department for information about the various vaccines they offer. Local health departments will not bill the third-party administrator (TPA). Therefore, a claim must be submitted to the TPA and accompanied by an itemized receipt indicating the name and location of the entity who administered the vaccines, the vaccine type, dose and cost for each immunization and proof of your payment. For HMO participants, contact your plan for the associated wellness guidelines.

Will the wellness benefit cover programs to help quit smoking?
Yes, tobacco/smoking cessation treatment is generally covered under the CD PPO HDHP wellness benefit, including prescription medication and some over-the-counter products. For more information about this benefit, contact the TPA or pharmacy benefit manager. For HMO participants, contact your plan for the associated wellness guidelines.

Are routine laboratory tests covered under the CD PPO HDHP?
Generally, routine lab tests associated with wellness services as defined by the CDC will be covered under the CD PPO HDHP wellness benefit if the test is conducted at a free-standing laboratory facility. Generally, lab tests that are not associated with wellness services are subject to deductible and coinsurance if the lab is conducted at a free-standing laboratory facility. However, effective July 1, 2011, labs provided in a hospital will not be covered unless the lab is for pre-admission testing, inpatient admissions, urgent or emergency care. PEBP will allow exceptions for participants residing in rural areas where no free-standing laboratory exists within 50 miles and services must be provided in a hospital setting. For HMO participants, contact your plan for the associated guidelines.

Is it more expensive to use an outpatient hospital lab than a free-standing lab such as Lab Corp or Quest?
Generally, hospitals charge substantially more for these services than a stand-alone laboratory does. If your physician refers you to a hospital rather than a stand-alone laboratory, ask your doctor to refer you to a stand-alone laboratory to reduce your costs.

Will the Live Well, Be Well Prevention Plan still be offered next year?
Yes, the Live Well, Be Well Prevention Plan will continue to be administered by US Preventive Medicine.

Will the premium incentives I earned during Plan Year 2012 (through February 29, 2012) by participating in the Live Well, Be Well Prevention Plan be honored in Plan Year 2013?
The Live Well, Be Well Prevention Plan and its associated premium incentives are currently only available to primary insured employees and retirees on the PPO HDHP. s and  Yes, as long as you are continuously enrolled in the CD PPO HDHP for Plan Year 2013, any premium credit you earned for participating in the Live Well, Be Well Prevention Plan in Plan Year 2012 will be applied to your monthly premium.





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