| Updated May 2014
Self-Insured High Deductible Health Plan with Health Savings Account (HDHP/HSA) and Open Access Plan / Preferred Provider Organization (OAP/PPO)
Employees may choose
between two medical plans. Under either plan,
employees may choose a preferred provider from the Cigna Open Access Plus (OAP) network in order to receive the highest level of benefits. If
the provider you choose is a network provider, the provider agrees to
accept the allowable charge as payment in full. Participants are responsible
only for applicable copays (OAP/PPO only), deductibles, coinsurance, amounts in excess
of stated benefit maximums, and charges for non-covered services and
not required to select a primary care physician (PCP) or to process a referral
through a PCP prior to seeking care from a specialist. However, participants must
select an OAP provider (in-network) in order to receive the highest
level of benefits.
If the provider
chosen is a non-network provider (or a participating or non-contracting provider), benefits are provided at the lowest
level and participants will also be responsible for amounts above the
allowable charge - referred to as "balance billing - in addition to applicable copays, deductibles, coinsurance,
amounts in excess of stated benefit maximums, and charges for non-covered
services and supplies. Amounts in excess of the allowable charge do
not count toward the deductible, if any, or as coinsurance.
Access to benefits, services provided, and provider
networks are the same for both medical plan options. The HDHP/HSA has reduced monthly premiums along with a higher annual deductible. The OAP/PPO has higher monthly premiums with a lower annual deductible.
Coverage Comparison: 7/1/2014 - 6/302015
See Comparison Chart for main differences.
Which option is best for you and your family? Run the Numbers to Find the Plan for You!
Some things to consider:
- HDHP/HSA employees with dependent coverage will significantly reduce their monthly premiums.
- HDHP/HSA savings in premiums could easily be offset by the much higher deductible - particularly as both medical and pharmacy costs are paid in full by the employee until the deductible is met. For example, a charge by a provider of $125, marked down to $100 by the discount the provider accepts due to their Cigna contract, means that the employee will pay the full $100 for the service and continue to pay those full costs for this and other medical expenses until the deductible is met. The coiinsurance rate does not apply until the deductible has been met. Medications are also part of this deductible. Full cost of meds (after adjustment for any Cigna discount) must be paid by the employee until the combined medical + prescription deductible has been met.
- The HSA is an account where SPU provides some contribution to you on a monthly basis. In some cases, a bonus/incentive or match might also be available. These amounts can be used to pay for expenses counting toward the deductible and out-of-pocket maximums. They can also be used to reimburse for other IRS Qualified Medical Expenses (which include dental and vision). Finally, they can be used to reimburse for those qualified expenses that IRS dependents (spouse and claimed children) experience regardless of whether they themselves are enrolled on SPU's medical, dental or vision plans.
- Contributions by SPU and any contributions made by the employee are all pre-tax (as is any interest) as long as funds are distributed from the HSA for qualified expenses only.
- The HSA bank account belongs to the employee. When/if the employee leaves employment, they take the account and any balance with them to use in the future for qualified expenses. Once more than $2,000 in funds are in the HSA, the employee can choose to invest the "excess" in various funds.
- Because the HSA has preferential IRS treatment, there are tax documents and a filing that need to be made annually by the employee.
- As the HSA is the employee's money there is some incentive to "shop around" for the best cost and quality.
- Contributions into the HSA are limited by the IRS and can only be made while an employee is participating in an underlying qualified HDHP plan. Distributions out of the account can occur without such enrollment.
- Depending on your prescription and medical claims costs, this could mean large expenses in the first few months on the plan. An individual or family may want to spread out the impact of their medical and pharmacy claims over the plan year but the HDHP/HSA pushes those expenses into the beginning of the plan year. Chronic conditions and/or conditions that may have high prescription drug costs may be reason enough to choose the OAP/PPO plan.
Identification Cards and Claim Filing
SPU has contracted
with Cigna to process claims and provide customer service
for employees and health care providers. Employees who choose either plan will receive a Cigna identification (ID) card for each covered participant to present to the health care provider
when receiving services. Those participating in the HSA program will aslo receive one or more debit cards to easily access their account. When utilizing an in-network (OAP) health
care provider, the provider will bill charges directly to Cigna on behalf of the patient. When using out-of-network or out of
area services, the participant will submit payment directly
to the provider and subsequently submit a claim to Cigna for reimbursement. Additionally, that out-of-network provider will "balance bill" to the participant the difference between the provider's billed rate and the rate that Cigna considers allowable for the service. Balance billing does not count toward deductible. Claim form(s) may be found here.
of Medical Plan
pays the full premium for regular full-time employees' HDHP/HSA coverage(subject to change each year, based on renewal of program contracts). Regular full-time employees participating in the OAP/PPO, will pay a monthly premium for their own coverage.
For regular part-time
employees (.5 FTE through .79 FTE for Staff and .5 FTE through .74 for Faculty), the University pays a prorated portion
of the premium for employee coverage, based on the employee's FTE. Employees
pay the remainder of the employee premium via payroll deduction. The employee-rate is noted below.
Employees who elect
spouse and/or children coverage pay for the entire cost of their dependents' premiums
by payroll deduction.
All medical insurance
premiums deducted from employee earnings are taken on a pretax basis.
MONTHLY PREMIUM COSTS: 7/1/14 - 6/30/15
HDHP / HSA
OAP / PPO
(SPU pays 100% of $576/mo for full-time employees)
(SPU pays $576 for full-time employees. Part-time employees pay $110 + pro-rated %)