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55.01 Health Care, Eligibility, Open Enrollment
A. General
The Employer shall provide comprehensive health care to all eligible
employees.
B. Open Enrollment
Every year the Employer shall conduct an open enrollment period, at which
time employees shall be able to enroll in a health plan, continue enrollment in
their current plan, switch to another plan, subject to plan availability in their area,
or waive coverage. The timing of the open enrollment period shall be established
by the Director of the Department of Administrative Services (DAS), in
consultation with the Joint Health Care Committee (JHCC).
Open enrollment fairs will be sponsored by the employer in those years when
a significant change in the benefits program has been implemented. Such a
change would include, but not be limited to, new insurance vendors, elimination
of existing insurance vendors, and significant changes to the insurance plan
design. The JHCC will evaluate the need for open enrollment fairs and will make
a recommendation to the Director of Administrative Services if it is determined
that open enrollment fairs are needed during a particular open enrollment period.
Whenever possible, the recommendation will be made at least six (6) months in
advance of the open enrollment period to allow for adequate time to plan for and
organize the open enrollment fairs. Fairs will be publicized among State
employees and employee attendance at the fairs will be allowed and encouraged
subject to the legitimate scheduling needs of the Employer.
If more than twelve (12) months pass without an open enrollment period, the
Employer shall provide an opportunity for State employees to add or drop
dependents, or add or drop health plan coverage. The JHCC and/or appropriate
sub-committee shall be consulted in the development of plans for such
opportunities.
C. Changes Outside of Open Enrollment
In order to maintain premium payment with pre-tax earnings, any changes
outside of open enrollment must be in compliance with the applicable rules of the
Internal Revenue Code Section 125 which may include but not be limited to the
following (see the DAS website for additional information):
Coverage changes may occur if requested within thirty-one (31) days of any
of the following events:
- 1. After marriage, death of a spouse, divorce, legal separation, or annulment, in which case coverage becomes effective the first day of the month following the month of the event.
- 2. Birth, adoption, placement for adoption, or death of a dependent, in which case coverage becomes effective with the birth, adoption, or placement of a child or date of death.
- 3. Termination or commencement of employment by the employee, spouse or dependent, in which case coverage becomes effective the first day of the month following the month of the event.
- 4. Reduction or increase in hours of employment by the employee (including layoff or reinstatement from layoff), spouse, or dependent, including a switch between part-time and full-time, strike, lockout, or commencement, return to work from an unpaid absence, or change in work site in which case coverage becomes effective the first day of the month following the month of the event.
- 5. Return to work through order of arbitration or settlement of a grievance, or any administrative body with authority to order the return to work of an employee.
- 6. The employee’s dependent satisfies or fails to satisfy the requirement of the definition of dependent due to attainment of age, student status or any similar circumstance as provided in the Health Plan under which the employee receives coverage.
- 7. If the plan receives a Qualified Medical Child Support Order (QMCSO) pertaining to an employee’s dependent, the Employer shall add or drop the child to the plan depending upon the requirement of the QMCSO.
- 8. If an employee, spouse, or dependent who is enrolled in a health plan becomes entitled to coverage (i.e. enrolled) under Part A or Part B of Title XVIII of the Social Security Act (Medicare) or Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928 of the Social Security Act (the program for distribution of pediatric vaccines).
- 9. If an employee, spouse, or dependent is no longer entitled to coverage (i.e. enrolled) under Part A or Part B of Title XVIII of the Social Security Act (Medicare) or Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928 of the Social Security Act (the program for distribution of pediatric vaccines). Requests for changes pursuant to sections (1) through (9) must be supported by proper documentation.
- 10. An employee may change third-party administrators if the employee no longer resides in the service area of the employee’s current third-party administrator.
D. Eligibility
All permanent full-time and part-time employees shall be eligible for health
benefits as well as for the benefits provided by the Union Benefits Trust. In
addition, employees to whom the Employer owes responsibility for providing
health benefits pursuant to the Patient Protection and Affordable Care Act
(PPACA) shall be eligible for health benefits. For new employees, coverage for
health care benefits as provided in this Article becomes effective on the first day
of the month following the month in which the employee begins employment with
the State. Changes made during open enrollment will become effective on the
first day of the new benefit period. The Employer reserves the right to perform
dependent eligibility audits after providing advanced notice and consulting with
the Joint Health Care Committee. Health care costs paid on behalf of ineligible
dependents will be subject to recovery.
The following dependents, and other dependents required by law, are eligible
for coverage (see the DAS website for more information):
- 1. The employee’s current legal spouse;
- 2a. Medical Benefits: the employee’s children until the end of the month in which they reach 26 (including legally adopted children, children for whom the employee has been appointed legal guardian, and dependent stepchildren and foster children);
- 2b. Vision and Dental Benefits: the employee’s unmarried children who are attending an accredited school and are primarily dependent upon the employee for maintenance and support until the end of the month in which they reach age 23.
- 3 Children of divorced or separated parents not residing with the employee but who are required by law to be supported by the employee.
- 4 Unmarried children of any age who are incapable of self- support due to mental or physical disability, whose disability began before age twentythree (23) and who are principally dependent on the employee. When there is an unsuccessful attempt at independent living, a child covered pursuant to this provision will be re-enrolled for coverage, provided application is made within five (5) years following the loss of coverage.
- 5 Dependent children placed for adoption in an employee’s home shall be eligible for coverage under the same conditions as children born to an employee or the spouse of the employee, whether or not the adoption has become final.
Employees that are called to active military service by the federal government
continue to be eligible for full health care benefits during their tour of duty. Their
dependents also continue to be eligible for health care benefits during their active
duty service.
An employee or dependent may only be covered once under the health plan,
except as required by the PPACA (e.g.: when both spouses in a family are
employed by the State, each may elect single coverage, or one may elect family
coverage provided that the spouse who elects single coverage may not be listed
as a dependent under the family coverage; a child who is eligible as an employee
of the State is not also eligible as the dependent of a parent who is also a State
employee; an individual who is the spouse of a State employee and the child of
another State employee may only be covered as a dependent under the family
coverage for one of the State employees.)
E. COBRA
The Employer shall provide COBRA coverage as required by applicable
laws. Specific information on COBRA shall be available on the DAS website.
55.02 Joint Health Care Committee (JHCC)
A. Membership and Purpose
The Employer agrees to retain the JHCC, which shall include the Labor cochair and five (5) representatives from OCSEA/AFSCME and one (1) each from
the four (4) remaining Unions which have the largest number of State employee
bargaining unit members and a like number of Management representatives.
Representatives from other Unions may be added as non-voting members by
mutual agreement of the Labor and Management co-chairs.
The committee shall meet quarterly unless otherwise agreed, to review and
act on subcommittee recommendations related to changes in any matters covered
in Article 55 of this Agreement or on other matters as mutually agreed to by the
co-chairs. The Management co-chair shall be designated by the Employer, and the
Labor co-chair shall be designated by the President, OCSEA, or designee.
Whenever possible meetings will be held during regular business hours and
employees will receive time off with pay at their regular rates, plus travel expenses
pursuant to Articles 25 and 65 to participate in committee and subcommittee
meetings.
The co-chairs of the JHCC shall advise the Director of DAS on the operation
of the health plans and will present recommendations from the JHCC or its
subcommittees to the Director in writing.
Within forty-five (45) days of receipt of a formal recommendation from the
JHCC, the Director will advise the co-chairs of any actions to be taken in response
to their recommendations.
The Director may request a meeting with the co-chairs at any time to explain
or discuss any recommendation.
The co-chairs may jointly request the Director of DAS to provide that the
costs of JHCC member attendance at conferences, seminars, or other educational
opportunities (including reasonable travel, hotel and meals) be paid for JHCC
members to attend events which the co-chairs mutually agree will assist in the
discharge of JHCC responsibilities under this Article. Such costs will be paid from
the education and communication account.
B. Subcommittee Functions
The JHCC shall have subcommittees for: planning, administration and
communications. JHCC subcommittees may be reconfigured by mutual
agreement of the Labor and Management co-chairs. These subcommittees shall
meet at least quarterly, unless otherwise agreed, with the co-chairs, or a designee,
as a member of each subcommittee.
Specific functions of the subcommittees shall include:
- 1. Planning
- (a) Make recommendations regarding the request for proposal, evaluation of bidders, and selection of all health plans and of the consultant(s) who will assist in the process of health plan evaluation and selection. The Labor co-chair of the JHCC, or designee, may at his/her discretion participate in any consultant or provider interview process. Upon agreement by the co-chairs, subcommittee members may participate in the interview process as well. The planning subcommittee will review the requests for proposals (RFPs) and the proposals of bidders, unless Labor agrees to waive this review in the interests of time, in which case the Labor co-chair will review the RFPs and the proposals of bidders.
- (b) Make recommendations regarding vendor contracts.
- (c) Facilitate research on new initiatives and review market analysis of health care issues and review the health care marketplace.
- 2. Administration
- (a) Monitor the operations, contract compliance and National Committee for Quality Assurance (NCQA) or other applicable accreditation status of health plans.
- (b) Review customer service issues and work with DAS Benefits Administration Services to resolve those issues.
- (c) Review the Health Plan Employer Data Information Set (HEDIS) reports and other data of the health plans, which shall be provided on a regular basis to the subcommittee.
- (d) Review any audits performed on the health plans.
- (e) Review benefit issues and changes proposed for health plans.
- (f) Monitor status of the State Employee Health Benefit fund.
- 3. Communications
- (a) Make recommendations regarding open enrollment.
- (b) Review communication materials prior to distribution to employees.
- (c) Explore use of alternative print and non-print methods of communication.
- (d) Assist in the implementation of 55.02(C) below.
C. Employee Education and Communication
A consultant shall be chosen in consultation with the communication
subcommittee to assist in the communication of benefits information to State
employees unless mutually agreed otherwise by the JHCC. The consultant will
have expertise in communicating benefits information to large and diverse
populations using multi-media approaches. Relevant public sector and/or Labor
Union experience shall be given consideration in the consultant selection process.
The Employer in conjunction with the consultant will work with the
communication subcommittee to update a strategic plan for communicating
benefits with State employees through both print and non-print means of
communications. The plan will include employee education as well as provisions
for employee input into and feedback concerning State employee health plans. It
will also include guidelines for health plan communications with State employees.
The strategic planning process will be ongoing and shall produce a plan covering
at least the period of the duration of this Agreement. A surcharge may be added
to the health plan premiums to maintain the employee education and
communication program. The surcharge shall be one dollar ($1.00) per month, per
employee, enrolled in a health plan, and may be adjusted based upon a review of
reports of revenue and expenditures of the account maintained for such purposes,
as recommended by the JHCC to the DAS Director. The surcharge shall be
equally split between the Employer’s and the employee’s premium share (e.g.
fifty cents ($.50) each). The funds shall be used to develop and implement
communication programs for all employee health plans, mental health and
substance use disorder programs, and other State health programs as identified by
the JHCC and to employ consultants as needed to assist the parties in health plan
selection, rate negotiations or any other function determined appropriate. Monies
unexpended or encumbered in one (1) fiscal year shall be carried forward and be
available in subsequent fiscal years. The JHCC shall receive quarterly fund
financial reports including revenue and expenditures.
D. Health Care Policy Analyst
The Employer will dedicate $150,000 annually in recognition of the
increased need for analysis in the administration of the State’s health management
programs. This amount may be adjusted upward by the DAS Director. Monies
unexpended or encumbered in one (1) fiscal year shall be carried forward and be
available in subsequent fiscal years. Additionally, due to monies carried forward
from one year to the next, the DAS Director may adjust the amount downward so
as not to exceed the $150,000 annual commitment.
Such analysis will be conducted by an expert in the health care field or a
health care policy analyst or a combination of the two as determined by the
Director of DAS after recommendation from the JHCC. The functions performed
shall include but are not limited to:
- 1. Analyze health care claims data of State employees for trends and make recommendations to the JHCC on plan design and health management programs based on the trend analysis;
- 2. Monitor and analyze health care legislation for potential impact on the State health plans;
- 3. Analyze plans’ HEDIS data, issue logs and health plan contract compliance issues and make recommendations to the JHCC on actions it might take;
- 4. Monitor relevant health care issues and wellness initiatives and make recommendations to the JHCC for potential action.
The health care policy expert or analyst will at a minimum make quarterly
reports to the JHCC on its activities and will function as an ongoing resource to
the JHCC on health care policy and data analysis issues. The JHCC will develop
a list of key issues and outcomes to be addressed by the expert or analyst. The
JHCC labor co-chair will participate in the interview and selection process.
55.03 Health Plan Characteristics
Except as otherwise provided herein, health plans offered to State employees
must meet standards in the areas listed below. Prior to each subsequent rebidding
or re-evaluation of health plans offered to State employees, the Director of DAS
may revise the standards and add standards in additional areas if such revisions
and/or additions are recommended by the JHCC.
A. Networks
1. Health plan provider networks must have a full range of primary care
and specialist physicians with reasonable numbers of each in relationship
to eligible State employees.
2. Health plans newly offered to State employees shall ensure that no more
than a reasonable percent of network providers have closed practices,
and shall attempt to facilitate inclusion in their network primary care
physicians already serving State employees in their service area.
3. A designated percentage of primary care physicians and specialist
physicians shall be board certified.
4. Health plans shall adhere to reasonable standards of access for every
employee to primary care physicians and to hospitals in urban and rural
areas in time and distance as recommended by the administration
subcommittee of JHCC.
5. Health plans shall agree to refrain from dropping any hospital or health
care facility from the network during a benefit period, unless the health
plan has notified the Employer, and to the satisfaction of the Labor and
Management co-chairs, attempted to develop a method of delivering
continuity of care for those persons who may be adversely affected by
the change in the network.
6. Health plans shall include centers of excellence (COE) to perform highly
specialized, high cost procedures such as transplants. The JHCC or the
Director, in consultation with the JHCC may modify this provision to
best accommodate health plans while assuring quality services for
participants. Furthermore, after consultation with the JHCC, the Director
of DAS may provide financial or other incentives (including but not
limited to reduced copays or co-insurance) to participants to utilize
quality providers.
7. For any plan that offers out-of-network coverage, reimbursement to nonnetwork providers shall be at a level no greater than 60% of the
contracted allowable amount. Also, a member can be balance billed for
the difference between what is charged and what the plan allows.
8. Telehealth services with a reduced copay for physician services offered
via teleconferencing technology will be half of the office copays outlined
in Article 50.03(C) in the PPO plan.
9. No hospital, doctor, laboratory, or other health care provider can be
added to a plan network in violation of the vendor’s established selection
criteria, or in violation of the vendor’s established standards governing
the number of hospitals and other providers which will be part of the plan
network in any given geographic area.
10. Medical Necessity and Preventive Services
Health plans pay only for those covered services, supplies, and
hospital admissions which are medically necessary or are classified as
preventive services covered under the plan. Network providers and
facilities are responsible for ensuring that services, supplies, and
admissions are medically necessary or preventive as defined by a plan.
In plans with out-of-network benefits, the fact that a non-network
provider may prescribe, order, recommend, guarantee, or approve a
service, supply, or admission does not guarantee medical necessity or
make such charges an allowable expense, even though they are not
specifically listed as exclusions.
B. Cost Sharing
1. Except as modified by the Director of the Department of Administrative
Services (DAS), who may revise or add to the requirements in this
Section if such revisions and/or additions are recommended by the
JHCC, the following features will apply to this Section.
- a. Deductibles
- For the plan year beginning July 1, 2020, the in-network individual deductible is $400, and the family deductible is $800. The out-of-network individual deductible is $800, and the family deductible is $1,600. When any one family member has paid $250/$500, or in the plan year beginning July 1, 2020, $400/$800, for eligible expenses, that person’s deductible is met. The balance of the family deductible must be met by the combined expenses of other family members. Expenses which are applied towards meeting the individual or family deductible must be incurred during the benefit period.
- b. Reimbursement Levels and Coinsurance
- Network providers and hospitals shall be prohibited from balance billing, that is, from charging any participant any additional amount other than copays, coinsurance or deductibles for covered services. Network Providers shall submit bills and other required paperwork on behalf of the participant.
- With the exception of certain preventive services which are covered at one hundred percent (100%) and office visits which are covered in full after payment of an office visit copay or other specified service, the plan will pay eighty percent (80%) of those covered services performed by network providers. In those instances, the participant pays twenty percent (20%) of the plans’ reimbursement rate up to the medical/behavioral health out-ofpocket maximum. Except as provided for in Section 55.04 (A), employee co-insurance shall not exceed twenty percent (20%) of the paid charges for covered network services.
- In health plans which offer to employees the option of using a network or a non-network provider or facility, the plan will pay sixty percent (60%) of the contracted allowable amount for non-network providers for covered services. The participant pays forty percent (40%). The employee coinsurance when using a non-network provider or facility shall not exceed forty percent (40%) of the plan’s contracted allowable amount for non-network providers. Nonnetwork providers may or may not accept the plan’s payment as payment in full. The non-network provider may bill the participant the balance between what is charged and what the plan allows.
- c. Out-of-Pocket Maximum (OPM)
- Except as provided for in Section 55.04 (A), employee out-ofpocket maximums for a benefit period shall not exceed $2,500 for single coverage and $5,000 for family coverage when using covered network services. In health plans which offer to employees the option of using a network or non-network provider or facility, employee out-of-pocket maximums for a benefit period shall not exceed a combined total of $5,000 for single coverage and $10,000 for family coverage for covered services in any instance.
- Employee out-of-pocket maximums for prescription drug copays for a benefit period shall not exceed a combined total of $3,500 for single coverage and $7,000 for family coverage. As soon as any individual in the family meets the individual coverage medical/behavioral health OPM, further eligible expenses on behalf of that individual shall be covered in full except as indicated below. All participants’ eligible expenses shall count toward satisfying the individual and/or family medical/behavioral health OPM, except that any penalties paid and/or prescription drug copays shall not count toward satisfying the medical/behavioral health OPM. After participant eligible expenses have reached the OPM, eligible services are covered in full except where nonnetwork providers engage in balance billing.
2. Employees will pay fifteen percent (15%) of the health care premium
and the Employer will pay eighty-five percent (85%) of the health care
premium; however, for any alternative plans offered pursuant to Section
55.04 (A), the employees’ premium share will be determined by the
Director of DAS, but will not exceed fifteen (15%) of the premium.
Employees who include a spouse as a dependent for healthcare coverage
shall pay a surcharge of twenty dollars ($20.00) per month in addition to
the family premium.
The State will deduct the employee’s monthly share of the health
care premium twice a month or biweekly as determined by the Employer
3. The Employer’s premium share of eighty-five (85%) shall be paid only
on behalf of the following employees:
- 1. Full-time employees.
- 2. Part-time employees who are in active pay status an average of thirty (30) or more hours a week averaged over a 12-month measurement period or otherwise in accordance with the employer responsibility provisions of the Patient Protection and Affordable Care Act (PPACA); according to the schedule in 55.03 (B) (4), provided that all part-time employees who are grandfathered under the provisions of the previous Agreements shall continue to have premiums paid pursuant to those provisions as long as the employee remains in the same appointment category.
4. The Employer’s premium share for all other eligible part-time employees
shall be paid as follows:
- 1. The Employer shall pay no share of the premium for part-time employees who are in active pay status an average of less than twenty (20) hours a week. However, such employees shall have the option of self-paying the entire health plan premium.
- 2. The Employer shall pay fifty percent (50%) of the premium for part-time employees who are in active pay status an average of twenty (20) hours or more a week but less than thirty (30) hours a week averaged over a 12-month measurement period.
Average hours in active pay status shall be calculated on a 12-month
measurement period. Pursuant to the PPACA, the measurement period
and hours required to qualify for full-time health insurance shall be
adjusted for employees who work on a school-year calendar. For newly
hired part-time employees, estimated scheduled hours shall determine
the Employer contribution toward the premium cost for the first twelve
(12) months of coverage.
Employees subject to the pro-rated Employer health plan premium
share under this subsection shall be advised in writing regarding the
amount of the Employer’s share which applies to them.
Employer payments for premium costs under this Article shall
continue during unpaid family leaves granted pursuant to Section 49,
provided the employee continues to contribute his/her share of the
premium.
The parties reserve the right to amend this Section mid-term if the
thirty (30) hour threshold under the PPACA is amended.
5. Health Care Spending Account – The Employer will continue to offer a
Health Care Spending Account to employees. Only employees who have
completed one (1) year of continuous state service are eligible to enroll
in the health care spending account. The purpose of this account is for
employees to use pre-tax earnings to pay for eligible health care costs as
allowed by IRS Code 125 incurred within a calendar year. Such health
care costs may include but are not limited to, annual deductibles, copays,
co-insurance, and medical procedures not covered by the medical,
dental, and vision plans like acupuncture, Lasik eye surgery, etc. The
Health Care Spending Account Third Party Administrator’s fee will be
paid for by the State. Upon recommendation of the JHCC the Director
of DAS may determine the annual caps, implement the IRS permitted
grace period, and/or implement a debit card to be used by employees to
purchase IRS approved medical expenses with their account dollars.
C. Benefits and Exclusions
Only medically necessary and/or eligible services are covered. The State,
after consultation with the JHCC, may carve-out procedures and services,
including but not limited to, durable medical equipment, laboratory services, and
prosthetics so that carved-out procedures and services may be provided by a
vendor other than the participant’s health plan. After consultation with the JHCC,
the Director of DAS may require participants to use centers of excellence for
designated procedures or services. Additionally, upon the recommendation of the
JHCC, the Director of DAS may place limits on certain benefits.
1. In-Patient Hospital Benefits:
Health plans will offer at least the following hospital services:
- a. Unlimited duration of eligible medically necessary services except as provided herein.
- b. Semi-private room.
- c. Hospital ancillary services.
- d. Emergency room services.
- There is a one-hundred and fifty dollar ($150) charge for the use of the emergency room which does not result in an admission. If there is a penalty charge established by the Department of Administrative Services for the non-emergency use of a non-network hospital, it shall be no greater than $350.
- e. Diagnostic imaging and laboratory tests.
- f. All other eligible medically necessary treatments and procedures.
2. Other Than In-Patient-Hospital Benefits
Benefits for all health plans offered to State employees shall
minimally include:
- a. Physician services. Routine office visits, house calls and consultations. Office visits provided by a network physician and billed by that office shall be covered at one hundred percent (100%) with no co-insurance or deductibles after a thirty-dollar ($30.00) co-payment. If such visit, house call, or consultation is covered on an out-of-network basis, the participant shall pay a fifty-dollar ($50.00) co-payment with no coinsurance or deductible.
- b. Outpatient medical services.
- c. Emergency medical services.
- d. Diagnostic laboratory and diagnostic and therapeutic radiological services.
- e. Infertility services to include diagnostic services to establish cause or reason for infertility. In Vitro fertilization and embryo transplantation, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and any costs associated with the collection, preparation or storage of sperm for artificial insemination (including donor fees) coverage applicable to the cost sharing as referenced in Section 55.03 B, Cost Sharing, not to exceed a twenty thousand dollar ($20,000) lifetime benefit.
- f. Preventive health care services, as recommended by the United States preventive services task force (USPSTF) guidelines shall be covered with no copay, co-insurance or deductible if provided by a network physician and shall include at least the following:
- (1) Screening colonoscopy beginning at age 45.
- (2) Routine physical examinations including routine lab profiles (including but not limited to cholesterol and other lab screenings). For non-network physicians, benefits shall be paid after the fifty dollar ($50.00) copay, with no deductible or co-insurance: one (1) every two (2) years for ages 40-59; one (1) each year for ages 60 and over.
- (3) Cervical cancer screening, which at a minimum shall include annual gynecological physical examinations, including screenings and rescreenings for cervical cancer for women age 18 and over, and for women younger than 18 who are sexually active. Adjunctive technologies approved by the U.S. Food and Drug Administration in addition to traditional Papanicolaou smears shall be covered. Additional testing for cervical cancer is covered when medically necessary.
- (4) Mammographies to detect the presence of breast cancer shall be covered as follows: Routine or screening mammography (age 35-39) one in five (5) years, one (1) screening or diagnostic mammography during that five (5) year period; age 40 and older, annually covered; high risk individuals as needed, regardless of age. Mammography coverage will include both males and females; any additional mammogram(s) shall be covered subject to deductibles or co-payments.
- (5) Pre-natal obstetrical care and pre-natal care outreach. A pre-natal outreach program to encourage pre-natal care beginning in the first trimester.
- (6) Well child care. This includes the initial inpatient examination of a newborn infant. The plans cover annual physical exams including hearing examinations, developmental assessments, anticipatory guidance, immunizations (including, but not limited to meningococcal) and laboratory tests in accordance with the recommendations of the preventive care task force guidelines (or other recommending body as determined to be appropriate by the JHCC).
- (7) Immunizations as recommended by the Centers for Disease Control and Prevention guidelines.
- (8) Prostate Specific Antigen (PSA) Testing PSA screening. One (1) screening test per 12 months for men age 40 and over.
- (9) Skin Cancer Screening. One (1) screening test per twelve (12) months.
- g. Skilled Nursing Facility, including Extended Care is covered at eighty percent (80%) for up to one hundred eighty (180) days for each confinement provided that the benefit must immediately follow a hospital confinement, or provided that the confinement will avoid a hospitalization which would otherwise be necessary. Coverage is at eighty percent (80%) of the contracted allowable amount and not subject to deductibles and copays. Additional days of coverage for medically necessary care at sixty percent (60%) of the contracted allowable amount and are not subject to deductibles.
- h. Allergy injections.
- i. Home Health Care Services: Home Health Care (noncustodial) services prescribed by a physician to treat a medical condition for which the patient was or would otherwise have been hospitalized shall be covered at eighty percent (80%) if provided by a network provider, and at sixty percent (60%) of contracted allowable if provided by a non-network provider in plans that permit use of non-network providers. Such benefit shall not exceed one hundred eighty (180) days.
- j. Registered dietitian services for up to six (6) visits per member per year.
- k. Physical therapy.
- l. Occupational therapy.
- m. Speech therapy.
- n. Chiropractic services.
- o. Initial internal or external prosthetic devices and medically necessary replacements.
- p. Non-experimental organ transplants. Participants are required to utilize a center of excellence for transplants.
- q. Liaison services with the State Employee Assistance Program.
- r. No fewer than three disease management programs unless otherwise provided by the State through contracts with disease management vendors. The disease management programs shall not be subject to deductibles or co-payments. Two of the disease management programs must address diabetes and asthma.
- s. Diabetes supplies, insulin and durable medical equipment (including insulin pumps where medically necessary) covered at one hundred (100%) with no deductibles, co-payments or coinsurance upon participation in a diabetes disease management program.
- t. Ambulance service.
- u. Tubal Ligation covered at 100%.
- v. Vasectomy covered at 100%.
- w. Hemodialysis.
- x. Hospice services, with one hundred percent (100%) coverage of medically appropriate care (with no deductibles, copays or arbitrary day or visit limits).
- y. Durable medical equipment.
- Effective July 1, 2022, one (1) cold cap with a maximum cost of one hundred and fifty dollars ($150) and one (1) wig with a maximum cost of six hundred dollars ($600) per benefit period to prevent and/or address hair loss due to chemotherapy.
- Effective July 1, 2022, one wig with a maximum cost of six hundred dollars ($600) per benefit period for hair loss due to treatment for cancer, radiation, alopecia, thyroid disease, anemia, pregnancy, medical burns, or ongoing drug treatment plans.
- Cold caps and wigs shall be covered as referenced in Section 55.03 B, Cost Sharing.
- Effective July 1, 2023, one (1) pair of foot orthotics shall be covered as referenced is Section 55.03 B, Cost Sharing, with a limit of new/replacement orthotics every three (3) years. For dependents under 18, allow for one (1) pair every plan year.
- z. Mental health services are provided as described in Section 55.03 (C)(5).
- aa. Birth control, including oral contraceptives, patches, IUDS, injectables, implantable contraceptives and diaphragms.
- bb. Clinical Trials
- Participation in sponsored clinical trials is covered on a limited basis. This is an exception from the coverage exclusions for experimental procedures. Coverage includes Phase I, Phase II, Phase III, and Phase IV clinical trials as required by the PPACA. All care and testing required to determine eligibility for a clinical trial and all medical care that is required as a result of participation in a clinical trial will be eligible for coverage. Pre-authorization is required. A participant should contact the health plan Administrator for more information.
- cc. Voluntary Family Planning Services.
- dd. Hearing aids are covered as referenced in Section 55.03 B, Cost Sharing, with a limit of new/replacement every three (3) years. This does not include over-the-counter devices.
- ee. Tobacco cessation supplies and services.
- ff. Otoplasty to address disproportionate, asymmetrical, or misshapen ears resulting from accident, illness, or birth defect.
3. Pharmacy Benefits
a. Pharmacy benefits are available to all State of Ohio employees and
their dependents enrolled in a health plan.
b. The JHCC will review the procedure for obtaining biotech drugs and
upon recommendation of the JHCC, the Director of DAS may
require that such biotech drugs be obtained from specialty
pharmacies. Furthermore, upon recommendation from the JHCC,
the Director of DAS may establish a separate cost-sharing structure
for biotech or lifestyle drugs.
c. After consultation with the JHCC, the Director of DAS may review
the following:
- (1) Alternative pharmacy cost-sharing plan options such as coinsurance.
- (2) Coverage of certain Over-the-Counter (OTC) drugs.
- (3) Alternative pharmacy procurement and distribution channels.
- (4) A special retail generic program.
d. The pharmacy benefit manager may not remove from its formulary
or require preauthorization for any prescription drug that is among
its ten (10) most frequently prescribed drugs unless the pharmacy
vendor has notified the Employer and consulted with the JHCC,
including in that consultation a review of the health plan research
recommending that the drug be excluded or put on preauthorization
status.
e. Retail pharmacy program. There will be a retail pharmacy program
with easy access to pharmacies throughout the state. Copays for a
thirty-day supply of prescription drugs including coverage of
prescriptions from a licensed dentist are: ten dollar ($10.00) copayment for generic, forty dollar ($40.00) copay for a formulary
brand name drug and a seventy five ($75.00) copay for a nonformulary brand name drug. Where a generic equivalent is available,
the copay for a non-formulary brand name drug shall be seventyfive dollars ($75.00) and the difference in cost between the generic
equivalent and the non-formulary brand name drug. Generic
medication classifications will be determined by the PBM based on
industry standards in which the PBM utilizes an independent third
party data service for new and existing drug product pricing, coding,
and classification information. Preventive medication may be
provided at no cost as required by the Patient Protection and
Affordable Care Act. Specialty medications are filled and mailed by
a specialty pharmacy and limited to a thirty (30) day supply; the
copays shall be the same as a thirty (30) day supply at retail. For a
ninety (90) day supply obtained at a retail pharmacy, the copays
shall be three (3) times the copay amounts for a thirty (30) day
supply. Oral oncology medications have a maximum copay of one
hundred dollars ($100) for a thirty (30) day supply.
f. Mail Order Drug Program
In addition to the retail pharmacy program, the state shall
maintain a mail order drug program for long-term or maintenance
medications lasting more than thirty (30) days.
The following copays for mail order prescriptions of ninety (90)
days shall apply. For a generic drug, the copay is twenty-five dollars
($25.00). For a formulary brand name drug, the copay will be one
hundred dollars ($100.00).
For a non-formulary brand name drug, the copay is one hundred
and eighty seven dollars and fifty cents ($187.50). Where a generic
equivalent is available, the copay for a non-formulary brand name
drug shall be one hundred and eighty seven dollars and fifty cents
($187.50) and the difference in cost between the generic equivalent
and the non-formulary brand name drug. Generic medication
classifications will be determined by the PBM based on industry
standards in which the PBM utilizes an independent third party data
service for new and existing drug product pricing, coding, and
classification information.
g. Prior Authorizations and Exclusions for Prescription Drug Programs
(1) Prior Authorization. A number of prescription drugs require
prior authorization, all approvals for such prescriptions will be
handled by the Pharmacy Benefit Manager (PBM). During the
life of this contract other drugs may be added to the list of prior
authorization after consultation with the JHCC, if required.
(2) It is recognized that certain drugs may not be covered by the
plans.
4. Health Plan Exclusions and Limitations
Exclusions and limitations shall be as follows:
- a. Services which would be provided free of charge in the absence of insurance.
- b. Local anesthesia when billed separately, and hypnotism used for anesthetic purposes.
- c. Elective cosmetic surgery performed only for the purpose of changing or improving appearance.
- d. Custodial care, care in a sanitarium, rest home, nursing home, rehabilitation facility, health resort, health spa, institution for chronic care, personal care, residential or domiciliary care, home for the aged, camp or school.
- e. Personal comfort services such as telephones, radio, television, barber and beauty services, or in connection with air conditioners, air purification units, humidifiers, allergy-free pillows, blanket or mattress covers, electric heating units, swimming pools, orthopedic mattresses, vibratory equipment, elevator or stair lifts, blood pressure instruments, stethoscopes, clinical thermometers, scales, elastic bandages, or compression stockings; unless otherwise provided for by a specific benefit.
- f. Devices for simulating natural body contours unless prescribed in connection with a mastectomy.
- g. In network charges which exceed the contracted allowable amount maximums.
- h. Chest x-rays and eye examinations not necessary to the treatment of an illness, injury, or disease.
- i. Services which are not medically necessary or are not classified as preventive services.
- j. Services received before the effective date of the contract, or services not specifically covered by the contract.
- k. Expenses of injury or illness paid for or furnished by an Employer, whether under Workers’ Compensation or otherwise, and services provided and paid by any governmental program or hospital.
- l. Vitamins, dietary or food supplements or non-prescription drugs, except where prescribed by a physician.
- m. Routine foot care for other than diabetics.
- n. Treatments or diagnosis for obesity, including diet control, prescription drugs, exercise and weight reductions, except for morbid obesity. This exclusion does not apply to any obesity or disease management program agreed to by the parties.
- o. Illness or injury related to war (declared or undeclared) or by participation in civil disturbance.
- p. Devices used for contraceptive purposes, except birth control pills, IUD, patches, injectables, implantable contraceptives, diaphragms which are covered by the plan.
- q. Reverse sterilization.
- r. Dental care, including osseous surgery. If no dental insurance exists or does not cover osseous surgery, such surgery shall be covered as any other surgery.
- s. Eyeglasses, contact lenses, or examinations for the fitting of such devices or for the prescription of such devices, unless necessitated as a result of an injury, illness or disease.
- t. Ordinary bandages and dressings.
- u. Expenses which are covered under any other group insurance program.
- v. Expenses incurred in a Skilled Nursing Facility for:
- (1) Services rendered or supplies furnished principally for custodial care, which includes, but is not limited to, nonmedical, day-to-day patient care such as assisting the patient to get dressed and use bathroom facilities;
- (2) Services rendered for care of mental decline, mental deficiency, or mental disability.
- w. Examinations and procedures performed for screening-testing done without necessity, except as specifically provided by Article 55, when not indicated by symptoms or performed for treatment, including pre-marital testing surveys, research, and any procedure performed in connection with a physical examination ordered or required by an Employer as a condition of employment or the continuance of employment.
- x. Charges for mileage costs or for completion of claims forms or for preparation of medical reports.
- y. Services rendered beyond the period of time generally considered necessary for diagnosis of mental disability or mental deficiency.
- z. Services rendered for a psychiatric condition usually considered to be irremediable, except for the purpose of diagnosis of the condition as being irremediable.
- aa. Any services rendered primarily for training or educational purposes; self-administered services; services directed toward self-enhancement.
- bb. Treatment programs and services which are not of proven value or whose value is under investigation; research-oriented treatment; developmental or perceptual therapy; primal therapy; biofeedback; marriage counseling; orthomolecular testing and therapy; cathectathon therapy; marathon therapy; collaborative therapy. A drug or treatment is considered experimental or investigational if it cannot be legally marketed in the U.S.; it is a subject of Phase I, II or III clinical trials or under study to determine dosage, toxicity, safety, efficacy or efficacy compared with standard means of treatment; or reliable evidence shows that the consensus of experts is that further studies are necessary to determine maximum dosage, toxicity, safety, efficacy or efficacy compared with standard means of treatment. Treatment in approved cancer clinical trials pursuant to the DAS cancer clinical or other DAS approved trial program(s) are covered.
- cc. Clinic charges which are services billed by a resident, intern or other employee of a hospital or skilled nursing facility.
- dd. Services for emergency first aid which are rendered in the office, place of business, or other facility maintained by the Employer.
- ee. Services for which no claim was submitted within fifteen (15) months of the date of the service.
- ff. Any service considered to be in the category of mental health and substance use disorder which is provided to covered persons under a separate plan as described in Section 55.03 (C)(5).
- gg. Hepatitis B vaccinations provided for employees pursuant to other terms of a collective bargaining agreement.
- hh. Any service for which a benefit is not specifically provided by the plans.
5. Mental Health/Substance Use Disorder Plan Characteristics
A mental health and substance use disorder program is provided to all
participants enrolled in any Employer-sponsored health plan. Premiums for
the mental health and substance use disorder program shall be calculated and
shall be added to the health plan premiums. The Employer shall contract for
mental health and substance use disorder benefits consistent with mental
health parity provisions.
In addition, habilitative services are available to members with a medical
diagnosis of Autism Spectrum Disorder. Clinical Therapeutic Intervention
must be administered by or under the supervisor of a qualified/approved
provider, in accordance with an approved applied behavioral analysis (ABA)
treatment plan. Mental/behavioral health outpatient services shall be
performed by a psychologist, psychiatrist, physician or board-certified
behavior analyst who is a licensed, qualified, or approved provider for
consultation, assessment, development, or oversight of treatment plans.
The care vendor shall provide quarterly reports to DAS, which shall
share the reports with the JHCC, on utilization and treatment outcomes, and
on the composition of its provider network (including contracted facilities).
The vendor will also provide information about its programs for use in the
participant education program.
Programs must include the following features:
- a. A full range of culturally diverse service providers, including psychiatrists, psychologists, social workers, and licensed and certified alcohol and drug counselors;
- b. A full range of facilities, including inpatient facilities and facilities for residential treatment (halfway houses, transitional programs, etc.);
- c. A full range of programs at various treatment levels, including inpatient treatment, a variety of intensive outpatient programs, and a variety of outpatient programs;
- d. A range of service providers and facilities within a reasonable distance in all parts of the state;
- e. Group programs on smoking cessation, stress management, weight control, family discord, and other life stress management issues;
- f. Timely responses to emergency calls;
- g. Protocols and programs for integrating mental health/substance use disorder and other physical health programs;
- h. Coordination with the State Employee Assistance Program;
- i. No preset caps on participant visits or treatment;
- j. A provision that the program will pay the costs of treatment by a provider not included in the care network for those persons for whom an appropriate provider is not available as follows: an individual practitioner within twenty (20) miles, facility within thirty (30) miles (Urban/Suburban); individual practitioner within forty-five (45) miles, facility within sixty (60) miles (Rural);
- k. Use of the proper placement criteria;
- l. Separate, appropriate diagnostic capacity for discrete categories of illness (e.g. Mental health, substance use disorder, eating disorders);
- m. Internal financial arrangements which will not encourage under- treatment, placement at inappropriately low levels of treatment, or withholding of treatment;
- n. Capacity to provide appropriate critical incident stress management in conjunction with the State Employee Assistance Program; and
- o. ABA services for Autism.
D. Quality Standards
1. All licensed health plans offered to State employees shall be accredited
by the National Committee for Quality Assurance (NCQA) unless the
health plan is of a type not accredited by NCQA. The NCQA
accreditation requirement may be waived by the Director of DAS after
consultation with the JHCC to evaluate whether the quality measures can
be met without the NCQA certification. The JHCC may require that any
other health plans offered to State employees be accredited by an
appropriate accreditation body.
- a. Any health plan must be properly accredited prior to submitting a bid or otherwise seeking to provide services to State employees. Such accreditation shall be in accordance with (D)(1).
- b. Any health plan providing services to State employees which loses its accreditation with NCQA or other accrediting body as described in (D)(1) above shall, from the time of such loss of accreditation, no longer be offered to newly eligible State employees, and shall not be offered to employees at the time of the next open enrollment period unless the DAS Director, upon the JHCC’s recommendations, determines that the plan continue to be offered.
2. Customer Service
All health plans offered to State employees shall have in place a toll
free customer service telephone line.
3. Reporting Requirements
Following the NCQA data definitions and specifications, all health
plans shall annually submit to DAS and NCQA both Health Plan
Employer Data Information Set (HEDIS) data and customer service
performance data for its commercial membership, and to DAS both
HEDIS data and customer service performance data for its State
employee membership. Such data shall be presented to the JHCC
administrative subcommittee.
4. Administrative
a. Health plans must be able to demonstrate to the DAS Benefits
Administration that they can successfully provide services for their
anticipated enrollment.
b. Health plans must ensure that all participants are held harmless from
any charges beyond established fees or copays for any benefit
provided consistent with the health plan, regardless of the
contracting or non-contracting status of the provider.
c. All licensed health plans will carry reinsurance coverage holding
participants harmless from any charges resulting from out-ofnetwork claims in the event that the health plan becomes insolvent.
E. Coordination of Benefits
If a health plan which is self-insured or otherwise unregulated is the
secondary payer, the amount which the plan will pay shall be limited to an amount
that will yield a benefit no greater than what would have been paid if the plan
were the primary payer. The primary plan’s benefit is subtracted from the amount
the plan normally pays.
When a plan is determined to be secondary, it acts to provide benefits in
excess of those provided by the primary plan. If a health plan is the secondary
payer, the secondary plan shall not be required to make payment in an amount
which exceeds the amount it would have paid if it were the primary plan. But, in
no event, when combined with the amount paid by the primary plan, shall
payments by the secondary plan exceed one hundred percent (100%) of expenses
allowable under the provisions of the applicable policies and contracts.
F. Wellness and Health Management
1. The State and the Union are jointly committed to promoting healthy
lifestyles for State of Ohio employees. To that end the Labor co-chair of
the JHCC will serve on the State Healthy Ohioans Committee.
Furthermore, those agencies that wish to develop Joint Labor
Management Wellness Committees to further promote wellness
initiatives within their agency may do so. The activities of the wellness
committees may include but are not limited to the following:
- a. Identify areas where employees can exercise on state property on breaks, lunch or off hours;
- b. Identify ways to acquire exercise equipment for State employees to use;
- c. Disseminate wellness information to State employees in a variety of ways including but not limited to newsletters, wellness fairs, lunch seminars, internet information;
- d. Secure discounts for fitness clubs/gyms for State employees; and/or
- e. Work with management to eliminate barriers to employees attending wellness events or accessing wellness information.
2. Such wellness initiative shall not be construed to represent a fitness for
duty requirement nor shall this Section be tied to any State fitness for
duty requirements. The JHCC will review the progress of agency
wellness programs. The JHCC will also explore incentives and
disincentives for employee participation and make recommendations for
implementation of statewide wellness initiatives to the Director of DAS.
3. Health Management Programs shall be available to all participants
enrolled in a health plan regardless of which plan they are enrolled in.
The State, in consultation with the JHCC, may carve-out health
management services from any or all health plans.
4. The State shall offer to employees a wellness track option which may
offer employees a monthly premium reduction or other monetary
incentive for those employees who participate in the wellness track. The
JHCC will be consulted on the type and amount of premium reduction
or monetary incentive.
55.04 Health Plan Selection and Contracting
A. The Director of DAS upon recommendation by the JHCC will determine the
number of health plans offered to employees in each county or other
appropriate geographic grouping. In addition, a statewide plan will be
available in every county. Upon recommendation of the JHCC the Director
of DAS may offer alternative health plans including but not limited to
multiple plan designs and networks and delivery models for medical and drug
benefits.
B. During the evaluation and selection process, cost will be weighted at no more
than 50 percent (50%) of the total. The financial part of the evaluation tool
can be increased beyond fifty percent (50%) by the Director of DAS after
consultation with the JHCC to evaluate if quality is not compromised.
C. At any time during this Agreement, the Employer may also conduct rate
negotiations with health plans. Negotiations shall only be concerning rates,
and once begun, the Employer shall not accept new health plan proposals to
amend their schedule of benefits, co-payments, deductibles, or out-of-pocket
maximum. The Employer shall consult with the JHCC about the rate
negotiations and inform the JHCC on the progress and results of said rate
negotiations. If negotiations with a particular health plan do not result in rates
which are satisfactory to the Employer, the Employer may, after providing
notice to the JHCC refuse to permit any new enrollment in said health plan
or cancel the health plan contract.
D. A consultant with expertise in large group purchasing strategies and quality
measurement will be retained to assist in the development and
implementation of the health plan selection process and may be retained to
assist with rate negotiations. Experience in the public sector and with
employee unions will be a factor in the consultant selection process.
E. Where it is advantageous to the Employer and its employees, DAS may
execute multi-year contracts or contract extensions with health plans.
F. If other political subdivisions or Employers are permitted to enroll in the State
employee health plans the State will take measures as are necessary to protect
such health plans from adverse experience and/or penalties under the Patient
Protection and Affordability Care Act (PPACA) of such admitted
subdivisions or Employers.
G. The Director of DAS, after consultation with the JHCC, may at his/her
discretion offer an additional high deductible health care plan (HDHP) in
compliance with IRS guidelines. It is not covered by Article 55 but: (i) is in
addition to (and not in lieu of) the health plan(s) required to be offered under
this Article 55, (ii) is a statewide plan whose terms apply the same to
bargaining unit employees and non-bargaining unit employees equally, and
(iii) is offered to bargaining unit employees on a voluntary basis.[2]
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