Benefit changes: POS plan deductible

The new benefit year went into effect July 1, and employees who have medical coverage through Rice are reminded about three significant changes to previous years’ plans:

• A requirement to have maintenance medication filled in 90-day supplies.
• A “dispense-as-written” provision.
• Changes to out of pocket costs, including a deductible for the point-of-service plan.

Susan Prochazka

Rice News already focused on the first two changes, and in this final column, Susan Prochazka, Rice’s new director of benefits, explains a change to the point-of-service plan, which for the first time has a deductible on the in-network side.

How does the new in-network deductible work on the POS plan?
Most point-of-service plans have both in- and out-of-network deductibles, and 2016-2017 is the first year the Rice POS plan has an in-network deductible. Employees and their dependents enrolled in the POS plan need to satisfy the in-network deductible of $250 for an individual and/or $500 for a family before the plan will pay covered expenses.

The deductible applies to most plan expenses except primary-care physician office visits, specialist physician office visits and prescription drug copays. In these cases, you can purchase prescription drugs for the specified copay and visit your physicians for the applicable copay of $35 or $45, even if you have not fulfilled the deductible.

If you use other plan services, you will pay the first $250 for an individual and another $250 among all the other members of a family for a total not to exceed $500 before your other eligible medical expenses will be covered by the plan.

The copays you incur for prescription drugs and primary care physician and specialist office visits do not count toward the $250/$500 deductibles. In the case of the family plan, as soon as one member meets their individual deductible of $250, the rest of that person’s plan services will be covered at the applicable copay level without having to reach the $500 family deductible. If several individuals incur $500 of deductible expenses, the deductible will be met for the whole family without the need for each member to meet the $250 individual deductible.

The Aetna design statement has been revised to specify when the deductible is and is not applied and is posted on the benefits open enrollment website at http://openenrollment.rice.edu/health-insurance/pos-ii/.

Can you give an example of how this applies to in-network providers?
Jane and her family are on the POS plan. Jane has a heart attack and has to be admitted to the hospital. The total cost for the hospital stay was $45,000. Jane will pay a $250 deductible and the $400 per hospitalization copay. Jane will have met her individual deductible, and she will pay only copays for the remainder of the plan year, which runs from July 1 to June 30.

Her husband, Joe, hurts his knee and requires a specialist office visit and an MRI at an outpatient facility (not in his doctor’s office). It costs $1,000. Joe will pay the specialist office visit copay, which not subject to the deductible for the office visit. For the MRI, Joe will pay the deductible of $250 and the $45 copay for the MRI for a total of $295. After that, the $500 family deductible will have been met, and no further deductible will be owed.

Benefits-eligible employees who have questions about Rice’s health and welfare plans can contact the benefits team at benefits@rice.edu or 713-348-2363.