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6.1. ERMUSR 11-09-2004 Elk River Municipal Utilities 13069 Orono Parkway phone: 763.441.2020 Elk River, MN 55330 Fax 763 441 8099 To: Elk River Municipal Utilities Commission Jerry Takle James Tralle John Dietz From: Bryan Adams Subject: Health Insurance As we are well aware, health care costs continue to rise. The Elk River Municipal Utilities currently carries a fully insured"Blue Cross Aware Gold"plan thru Resource Training& Solutions Pool. We have been informed that our health insurance costs will increase 15.9% effective 1-1-05 or approximately$40,000. In reviewing our options, we are still better off continuing in the Resource Training & Solutions Pool but possibly looking at other Blue Cross alternatives. Attached is the following plan benefit schedules: 1) Current Aware Gold with co-pay plan. 2) Comprehensive Major Medical CMM w/$15 co-pay (a) 3) Comprehensive Major Medical CMM w/$25 co-pay (b) The premiums are as follows: Monthly Annually %of Increase Single Family Aware Gold current $222.50 $839.50 $250,392 Aware Gold after 1-1-05 $258.00 $973.00 $290,222 15.91% CMM w/$15 co-pay (a) $242.50 $914.50 $272,772 8.94% CMM w/$25 co-pay (b) $238.00 $897.00 $267,564 6.86% As you recall, the employee pays 23%and Elk River Municipal Utilities pays 77%of the total monthly premium for single and family. The difference in the plans is that Aware Gold with a co-pay has NO major deductible. The CMM is a major medical in which the employee pays 20%of the cost for in and outpatient services,to a cap of$1,100 per person, $5,000 per family. Office visits are paid 100%after the co-pay. Prescription coverage would also change from a flat co-pay to 80%coverage, member responsible for a minimum of$10,and a maximum of$30 per prescription. The reason for reviewing the medical insurance is rising costs and Aware Gold plan is becoming the very best where the two alternate plans appear to be more in the mainstream. Staff solicits your comments on this issue. awareg `-' I Please note:Benefits are subject to regulatory i...„.,L ith copay plan p � v' '• *RR'i' Sr'sy'`xuodext P� r a IN-NETWORK EXTENDED/.OUT-OF-NETWORK• x -su`rc r k �S. e`IFiN ' f(fRkgp z+l'hYs L ival deductible none $300/person-$900/family $5,000/person Out-of-pocket maximum • $2,500/person A separate out-of-pocket maximum 1. of$500 per person applies to prescription drugs , $3 million tot•sen /Ices from all providers Lifetime maximum LOffice visits Behavioral health care(mental health, 00% after$15 copay 80% after deductible • B • Behavioral or Injury 100% after$15 copay* (see details below) 80% after deductible substance abuse, eating disorders and autism) • Chiropractic manipulation 100°/3 after $15 copay*(see details below) 80% after deductible, no benefits for _ ` P services from out-of-network providers • r Preventive surgery/allergy-related services 100% 80% after deductible LPreventive care 100% °/ after deductible • Well-child services and immunizations 100% 80 80% after deductible • Prenatal care - 80% after deductible • Routine physicals and eye exams 100% • Cancer screenings 100% 80% after deductible Lab and X-ray services 100% 80% after deductible �����In-and outpatient hospital services 100%+(see details below) 80°/o after deductible IIII • Facility services(includes behavioral health care) SO% after deductible • Professional services(includes behavioral 100%*(see details below) health care) emergency care 10C% after$6G copay Facility services 100% after$60 copay Professional services - 100% 803/0 after deductible Ambulance services 80% 80% Medical supplies 80 80% Therapy services + 80% after deductible, no benefits for • Chiropractic therapy 100% after$15 copay (see details below) services from out-of-network providers 100% after $15 copay 80% after deductible"".(see details below) • Occupational and physical therapy 100% after $15 copay 80% after deductible** (see details below) • Speech therapy Prescription drugs 80% coverage, member responsible for a • 31-day supply, 3-cycle supply of oral 80% coverage,member responsible for a of$10 and a maximum of $30 minimum of $10 and a maximum of$30:you contraceptives for 3 copays,formulary minimum cr.gsbnly Per prescription pay the pharmacy and file a claim In addition _ , . to copays, member will be responsible for amounts in excess of the allowed amount. • Mail-order drugs(90-day supply) 100% after $40 copay How cost sharing is calculated. Copays are flat fees you pay at the time you receive a service. Coinsurance is the percentage of charges you pay for a service. Its based on the allowed amount Deductible charges are subtracted from the allowed amount. Allowed amount is the negotiated amount that network providers have agreed to accept as full payment at the time your claim is processed. If you see a provider who doesn't participate with Blue Cross,the allowed amount is either the billed charge or a percentage of the network allowed amount, whicneve• is less. PI • For highest level of coverage,use Select Network providers for outpatient chiropractic and behavioral health services. For all other services use the Blue Cross Network. � '"Physical,occupational and speech therapy services limited to a$500 maximum per calendar year c . (�'� This is only an outline of plan benefits Tne contract and certificate induce complete details or what is and isn t covered nts Sere c s not c are edsmeude eyeglasses,hearing aids,items primarily used for a non-medical purpose,over the-counter drugs/nutit onai supp Bluecross Blueshield experimental,not medically necessary.or covered by workers'compensation or no-fedi:auto insurance.Pre-existing nS ndoptns rea diet be covered for of Minnesota a limited period of time.This limit is reduced by prior continuous coverage and doesn't apply pregnancy dependents.We feature a large network of neeith care providers.Each provider is an independent contractor and is not our agent Nonparticipating lyreSRls i9/04i providers do not have contracts with Blue Cross and Blue Shield of Minnesota Blue cross and Blue Shield of Minnesota is an independent licensee Sian numye n'. of the Blue Cross and Blue Shield Association.Benefits are effective Ian 2005 y'i �.1 1-� (1 (11 ` f 1 r k" f 1 f I ) (. w I t h C O p n 1' p 1 a 11 Please note e eOrs are cub ngirramry pproval N R r "Or( 'I.�tV Ott trr-"#3iRS Annual deductible none 5200/person—$600/family Out-of-pocket maximum Q $1,100/person—$5,000/family 0 52,500/person A separate out-of-pocket maximum Q $1,300/person—$5,000/family 0 $2,500/person of$500 per person or 51,000 per family applies to prescription drugs. Lifetime maximum $3 million for services from all providers Office visits • Illness or Injury 100%after 08/5 copay or 0525 copay * 60% after deductible • Behavioral health care(mental heath, 100% after Q$15 copay or 0$25 copay * 60% after deductible substance abuse,eating disorders (rev scrods ddo+d and autism) • Chirop'actic manipulation 100%after Q $15 copay or 0825 copay * 60% after deductible, no benefits for treederaih ceiow/ services from out-of-network providers • In-office surgery/allergy-related services 80% 60% after deducible Preventive care • Well-child services and immu n lzat ions 100% 60% after deductible • Prenatal care 100% 60% after deductible • Routine physicals and eye exams 100% 60% after deductible • Cancer screenings 100% 60% after deductible Lab and X-ray services ,00%; 80% for inpatient services 60% after deductible In-and outpatient hospital services • Facility services(Includes behavioral 80%* :see details below) 60% after deductible health care) • Professional services(includes behavioral 80%* (see derails below) 60% after deductible health care) •mergency care Facility services 100%after $60 copay 1C0% after $60 copay • Professional services 80% 60% after deductible Ambulance services 803' 80% Medical supplies 80% 60%after deductible Therapy services • Chiropractic therapy 80%* (see detaJs below) 60% after deductible no benefits for services from out-of-network providers • Occupational and physical therapy 80% 608% after deductible** (see details below) • Speech therapy 80% 60% after deductible** (see details be/ow) Prescription drugs • 31-day supply,3-cycle supply of oral 80% coverage, member responsible for a 8O% coverage, member responsible for a contraceptives for 3 copays, formulary minim.lrn of $10 and a.maximum of $30 minimum of$10 and a maximum of$30; you drugs only per prescript-on pay the pharmacy and file a claim. In addition to copays,member will be responsible for amounts in excess of the allowed amount. • Ma border drugs(50-day supply) 100%after 540 copay How cost sharing is calculated Copays are flat fees you pay at the time you receive a service. Coinsurance is the percentage of charges you pay for a service its based on the allowed amount. Deductible charges are subtracted from the allowed amount Allowed amount is the negotiated amount that network providers have agreed to accept as full payment at the time your claim s processed if you see a provider who doesn't participate with Blue Cross, the allowed amount is either the billed charge or a percentage of the network allowed amount, whichever is less For highest level of coverage,use Select Network providers for outpatient chiropractic and behavioral health services. For all other services use the Blue Cross Network. .. .'� **Physical,occupational and speech therapy services limited to a 5500 maximum per calendar year j ' his is only an outline of plan ben of's The contract anti ce. f c re nciude complete derails ot vvhat a d!sr,t co'e -u services not covered inciude eyeglasses,hearing aids lens primarily used for a con-medical psir pose,over-she-counter drugsnu. t anal sunolemerts,services rat are cosmetic. 81ueCross BIue$hleld experimental not med-ca.ry necessar,.or co vereo he v:crkers cdmpensabor or no foot auto insurance.Pre-er;Mg condi:ors may nol he covered nor of Minnesota a limited period of lime 'F us nit S reduced by pi or continuous coverage ana doesn't apply to pregnancy newborns adopted children or handicapped dependents See'mature a large network or health care providers.Each provider Is an ndependent contractor ana is not our agent Norpart coating F5906520 19/04) providers do not hate contractswim v Bt„e C'tss ana Biue Shed or Minnesota Blue Cross and Ste Shield or Minnesota is a^i^deciencem licensee ;clan wmbersa tr3 brrci of rite Blun C'oss and Bve Shield Association Benefits ate efeuve Jan 1,2026