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Changes to the state health benefit plan
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Monday, the board of the Department of Community Health made changes to the present State Health Benefit Plan, which are retroactive to Jan. 1.

These changes basically add HMO features to the plan and apply to all three plans proposed by SHBP: Bronze, Silver and Gold.

Note: Member premiums, deductibles, plan contributions and out-of-pocket limits in the current plan and fiscal year 2015 budget remain the same.

Changes are in two major categories:
1. Pharmacy co-pays
2. Office co-pays and emergency room co-pays

1. Pharmacy co-pays
New changes will replace pharmacy co-insurance with co-pays. These will be at the same level as the 2013 plan under the wellness option.

Pharmacy co-pays:
• Tier 1 drugs (generic) - $20
• Tier 2 drugs (preferred) - $50
• Tier 3 drugs (non-preferred) - $80 (was $90 in 2013)

Like the 2013 HMO plan, co-pays for pharmacy will not count toward deductible or out-of-pocket limits. Health reimbursement account (HRA) funds can be used.

2. Office and emergency room co-pays
For doctor’s office, rehabilitation or ER visits, the change will replace out-of-pocket costs and co-insurance for office/ER visits with co-pays. These co-pays are identical to those in the 2013 HMO wellness option.

Note: Preventive care office visits continue to be covered 100 percent.

• Primary care (general practice, pediatrics, OB/GYN) - $35
• Specialist - $45
• Rehabilitation services - $25
• Emergency room - $150
• Urgent care - $35

Co-pay will end when out-of-pocket maximum is satisfied. After that the plan will pay 100 percent.

HRA funds can be used for co-payments. For different ER visits, members’ co-pays will count towards deductible and out-of-pocket limits.

The total estimated cost over 12 months for changes will be $114 million, which will be taken from the plan reserves.

As mentioned previously, member premiums will not be impacted. For Plan Year 2014, members will have access to HMO cost-sharing features at HRA prices. Unlike traditional HMO plans, members will also have access to a reimbursement account which may be used to satisfy co-pays and other out-of-pocket expenses.

For additional information regarding the changes in the 2014 SHBP go to:

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