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New health plan to help low-income OSU employees

Posted on | October 21, 2009 | 277 views |

By Adam King

Some of the university’s lowest-earning employees will be getting a break on their health care costs with the introduction of Prime Care Connect to Ohio State’s medical plan offerings for 2010.

Targeted to help between 1 percent and 3 percent of OSU employees with the lowest household earnings, the new plan will help reduce out-of-pocket costs, with an estimated savings of more than $350 annually per enrolled member. Only full-time employees with a continuous year of service who are at or below 175 percent of the 2009 federal poverty level guidelines qualify.

Premiums for the plan will be at the same level as Prime Care Advantage (PCA), which 90 percent of OSU employees use. But co-payments for primary care and specialist office visits, for pharmaceuticals or for going to an urgent care or an emergency room have been significantly reduced.

“We are often told that health plan premiums are something our population budgets for, but it’s the unexpected cost of care when it comes to filling prescriptions or needing a diagnostic test or procedure where they’re having difficulty coming up with the money,” said Pam Doseck, Office of Human Resources director of benefits. “So we were concerned that some were avoiding necessary care because of budgetary issues and we wanted to come up with a way to make the actual care and the services that go with it more affordable.”

Prime Care Connect members will not have to pay for a primary care physician office visit ($20 for PCA members) or for any lab or x-ray work. A visit with a specialist or to urgent care will require a $10 co-pay ($35 each for PCA members), emergency room visits are $50 (regularly $150), outpatient procedures have a $35 co-pay (regularly $100) and inpatient hospitalization is $100 (regularly $350).

“If there was necessary care this population was avoiding, we hope to increase utilization in those areas so people with chronic conditions are seeing appropriate specialists and those who need specific services to follow their physician’s care plan can better afford it,” Doseck said.

Removing any barriers for lower-income employees to develop a relationship with a primary care physician was the lynchpin for zeroing out the cost of those office visits.

“We think a relationship with a primary care physician is key to helping patients maintain good health, identifying and effectively treating routine health problems and referring patients if a more serious problem is identified,” Doseck said. “They might eventually need to see a specialist, but that initial relationship and discovery should be with their primary care physician.”

In determining what income level to target for Prime Care Connect, the Office of Human Resources did not have access to employees’ household income, so it had to use salary as a gauge.

“We don’t know if the co-pay levels we established are going to be where a person on the plan says, ‘Now I can afford to get the care my family and I need,’” Doseck said.

“We had to start somewhere and we’re going to have to closely monitor the use. We came up with projections and the plan design was finalized with input from the Health Plan Oversight Committee. We have to see how many people hear about and apply for the plan and then watch to see if utilization of care increases and make assumptions going forward based on the first year’s experience.”

Initially, the review of applications and determination of eligibility for Prime Care Connect will be outsourced to a third party, Hewitt Associates Advocacy Service, which has experience providing one-on-one support for individuals needing assistance with health care issues. Employees who wish to apply will be directed to contact Hewitt on behalf of Ohio State University Health Plan for the first year this plan is available. The application and eligibility process will eventually be taken on by OSU Health Plan.

Once an employee has been approved for Prime Care Connect, Hewitt will notify Human Resources to enroll the individual in that plan. To ensure medical coverage, individuals are encouraged to enroll in another plan while their application for Prime Care Connect is being evaluated.

Virtually status quo for health plans

Other than the introduction of the new Prime Care Connect plan for low-income Ohio State employees, there aren’t many other changes in the works for OSU’s health plans, which hold Open Enrollment Oct. 26-Nov. 6 (visit hr.osu.edu/oe).

Premiums in 2010 for full-time employees who take the Personal Health Assessment (PHA) will remain at 2009 levels to account for the tough economic climate; and to be consistent with the university’s directive on premiums, the Office of Human Resources, in concert with the Health Plan Oversight Committee, proposed only minor changes to plan design as well, said Director of Benefits Pam Doseck.

“We believe we can continue to rely on the strategies implemented through Your Plan for Health to help control costs and minimize having to pass on a portion of any plan cost increase to members in 2010 to keep with the message,” Doseck said.

One important thing to note is that premiums only stay flat for those full-time employees who take the Personal Health Assessment. Those who do not take it will see a $5 monthly increase in 2010. Overall, PHA participants will have their premiums reduced by $20 per month over those who elect not to take it.

Some lightly used prescription drug benefits are changing in 2010. Generally, once drugs advance to over-the-counter availability, they will no longer be covered under the prescription plan. An exception to this is Prilosec OTC, which will increase to a $5 co-pay from $1. Also, the generic form of a specialty medication for the treatment of specific chronic and complex illnesses, defined as a specialized biological therapy, will now have a 20 percent coinsurance, up to a maximum of $30 per retail prescription.

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