2020-07-07 Ex 08City of Okeechobee
Memo
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Date: for July 7 meeting
TO: Mayor and City Council
FR: Admin Marco Montes De Oca and India Riedel, Finance Dept
RE: PRM Group Health Insurance
The City’s current premium structure for plan 0727:
Employee Only $ 850.70 Empl & Spouse $2,123.81
Empl & child(ren) $1,698.25 Empl Family $2,708.95
The City’s’ claim experience has significantly improved from the prior 3 - 5 years. The
medical claims this year did not include any large claims (i.e. $150,000 or more) which can
severely impact an entity our size.
The PRM Group has an overall increase of 5.5%, with the application of city’s claims
experience rating the City’s increase in premium being presented is 4.5% increase. The fiscal
impact based on the number of employees equates to a $31,695.84 for the renewal.
The city is continuing to take a long term approach regarding the health of its employees by
continuing the current benefits including the Clinic. (Request on agenda for continuation for
the next 2 years).
Current plan, 0727
Affordable Care Act required option, 05901
Premium
City Cost
Per Employee
per Month
Deduction
per
Employee
Pay Check
Employee Only $888.98 $888.98 $0.00
Add’l for Spouse $1,294.88 $150.00 $528.41
Add’l for Child (ern) $861.96 $150.00 $328.60
Add’l for Family $1,941.87 $150.00 $827.02
Premium
City Cost
Per Employee
per Month
Deduction
per
Employee
Pay Check
Employee Only $699.52 $699.52 $0.00
Add’l for Spouse $1,046.83 $150.00 $413.93
Add’l for Child (ern) $696.85 $150.00 $252.40
Add’l for Family $1,527.96 $150.00 $635.99
Summary of Benefits for Covered Services BlueChoice BlueOptions
Per Benefit Period (BPM)0727 05901
Deductible (DED) (Per Person/Family Agg)
In-Network $500 / $1,500 $2,000 / Not Applicable
Out-of-Network Combined with In-Network $6,000 / Not Applicable
Coinsurance (Member Responsibility)
In-Network 20%50%
Out-of-Network 40%50%
Out of Pocket Maximum (Per Person/Family Agg)Includes DED, Coinsurance,
Copayments and Prescription
Drugs
Includes DED, Coinsurance,
Copayments and Prescription
Drugs
In-Network $1,500 / $4,500 $6,350 / $12,700
Out-of-Network Combined with In-Network $12,800 / $25,600
Physician Office Services
Primary Care Physician $15 $35
Specialist $15 $75
Convenient Care $15 $35
Teladoc $15 $35
Out-of-Network 40% after DED
Teladoc - N/A
50% after DED
Teladoc - N/A
Maternity (Cost Share for initial visit only)
Primary Care Physician $15 $35
Specialist $15 $75
Out-of-Network 40% after DED 50% aftter DED
Allergy Injections (per visit)
Primary Care Physician $5 $10
Specialist $5 $10
Out-of-Network 40% after DED 50% after DED
Advanced Imaging Services (AIS) (MRI,MRA,PET,CT,Nuclear Med)
In-Network $15 50% aftter DED
Out-of-Network 40% after DED 50% aftter DED
Routine Adult & Child Preventive Services, Wellness Services, and
Immunizations
In-Network $0 $0
Out-of-Network 40%50%
Mammograms
In-Network $0 $0
Out-of-Network $0 $0
Colonoscopy (Routine for age 50+ then frequency schedule applies)
In-Network $0 $0
Out-of-Network 40%$0
Urgent Care Centers (UCC)
In-Network $15 $75
Out-of-Network $15 $75
Emergency Room Facility Services (per visit)
In-Network 20% after DED 50% after DED
Out-of-Network 20% after DED 50% aftter DED
Ambulance Services
In-Network 20% after DED 50% after DED
Out-of-Network 20% after In-Network DED 50% after In-Ntwk DED
Financial Features
Public Risk Management of Florida
Medical Plan Designs
Effective 10/01/2020 - 09/30/2021
Emergency Medical Care
Office Services
Preventive Care
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Summary of Benefits for Covered Services BlueChoice BlueOptions
Per Benefit Period (BPM)0727 05901
Independent Diagnostic Testing Facility Services (per visit) (e.g. X-
rays)(Includes Provider Services)
In-Network -Diagnostic Services (except AIS)$15 $50
In-Network - Advanced Imaging Services (AIS)(MRI, MRA, PET, CT,
Nuclear Med.)$15 $200
Out-of-Network 40% after DED 50% after DED
Independent Clinical Lab (e.g. Blood Work)
In-Network 20%$0
Out-of-Network 40%50% aftter DED
Outpatient Hospital Facility Services (per visit) (e.g. Blood Work and X-
rays)
In-Network 20% after DED Option 1 - $300
Option 2 - $400
Out-of-Network 40% after DED 50% after DED
Ambulatory Surgical Center Facility (ASC)
In-Network 20% after DED 50% after DED
Out-of-Network 40% after DED 50% after DED
Outpatient Hospital Facility Services (per visit)
Therapy Services
In-Network 20% after DED Option 1 - $80
Option 2 - $90
Out-of-Network 40% after DED 50% after DED
All other Services
In-Network 20% after DED Option 1 - $300
Option 2 - $400
Out-of-Network 40% after DED 50% after DED
Inpatient Hospital Facility and Rehabilitation Services (per admit)
In-Network 20% after DED Option 1 - $2,000
Option 2 - $3,000
Out-of-Network $300 PAD, then 40% after DED 50% after DED
Inpatient Hospitalization Facility Services (per admit)
In-Network 20% after DED Option 1 - $2,000
Option 2 - $3,000
Out-of-Network $300 PAD, then 40% after DED 50% after DED
Outpatient Hospitalization Facility Service (per visit)
In-Network 20% after DED Option 1 - $300
Option 2 - $400
Out-of-Network 40% after DED 50% after DED
Emergency Room Facility Services (per visit)
In-Network 20% after DED 50% after DED
Out-of-Network 20% after DED 50% after DED
Provider Services at Hospital
Primary Care Physician / Specialist 20% after DED $0
Out-of-Network 40% after DED 50% after In-Ntwk DED
Provider Services at ER
Primary Care Physician / Specialist 20% after DED $0
Out-of-Network 20% after DED 50% after In-Ntwk DED
Provider Services at Locations other than Hospital and ER
Primary Care Physician / Specialist $0 50% after DED
Out-of-Network 40% after DED 50% after DED
Outpatient Office Visit
Primary Care Physician/Specialist $15 $35 /$75
Out-of-Network Provider 40% after DED 50% after DED
Hospital/Surgical
Mental Health/Substance Dependency
Outpatient Diagnostic Services
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Summary of Benefits for Covered Services BlueChoice BlueOptions
Per Benefit Period (BPM)0727 05901
Provider Services at Hospital
In-Network 20% after DED 50% after DED
Out-of-Network 20% after DED 50% after DED
Provider Services at ER
In-Network 20% after DED 50% after DED
Out-of-Network 20% after DED 50% after In-ntwk DED
Radiology, Pathology and Anesthesiology Provider Services at an
Ambulatory Surgical Center (ASC)
In-Network 20% after DED 50% after DED
Out-of-Network 40% after DED 50% after DED
Provider Services at Locations other than Office, Hospital and ER
Primary Care Physician / Specialist 20% after DED 50% after DED
Out-of-Network 40% after DED 50% after DED
Combined Outpatient Cardiac Rehabilitation and Occupational,
Physical, Speech and Massage Therapies and Spinal Manipulations
Outpatient Rehabilitation Therapy Center 20% after DED $75
Out-of-Network 40% after DED 50% after DED
Outpatient Hospital Facility Services (per visit)20% after DED Option 1 - $80
Option 2 - $90
Out-of-Network 40% after DED 50% after DED
Durable Medical Equipment, Prosthetics, Orthotics
In-Network 20% after DED 20% after DED
Out-of-Network 40% after DED 50% after DED
Home Health Care 20 Visits 20 Visits
In-Network 20% after DED 50% after DED
Out-of-Network 40% after DED 50% after DED
Hospice LTM
In-Network 20% after DED 50% after DED
Out-of-Network 40% after DED 50% after DED
Outpatient Therapy and Spinal Manipulations BPM 54 Visits (Includes up to 26
Spinal Manipulations)
35 Visits (Includes up to 26
Spinal Manipulations)
Skilled Nursing Facility BPM 60 Days 60 Days
In-Network 20% after DED 50% after DED
Out-of-Network 40% after DED 50% after DED
Retail (30 Days)
Generic/Preferred Brand/Non-Preferred Brand
In-Network $5/ $35 /$35 $10 / $60 / $100
Out-of-Network 50% of Allowance 50% of allowance
Mail Order (90 Days)
Generic/Preferred Brand/Non-Preferred Brand
In-Network $10/ $70 /$70 $30 / $180 / $300
Out-of-Network 50% of Allowance 50% of allowance
Prescription Drug Coverage
Other Special Services
Other Provider Servicers
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