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Southern Oregon University

PEBB plan changes effective January 1, 2012:

Surcharges:

       Tobacco surcharge - $25/month if employee uses tobacco + $25/month if spouse/DP uses tobacco

       Spouse/DP surcharge - $50/month if spouse/DP waives coverage in a non-state-agency employer’s group plan in favor of coverage through PEBB. 

       Health Engagement Model (HEM) surcharge if you and/or your spouse/domestic partner do not participate in the HEM.  The Board voted on and approved the annual surcharges at their August 26, 2011 meeting.  The surcharges were reduced from amounts published in the PEBB August newsletter.  The annual amount is based on your enrollment tier:

  • $420 annual surcharge for enrollment tiers
    • employee+spouse/domestic partner;   or
    • employee+spouse/domestic partner+children/DP’s children
  • $240 annual surcharge for enrollment tiers: 
    • employee only;  or 
    • employee+children/DP’s children

Health Engagement Model (HEM):
This is a summary of the PEBB Board Discussions.  Model design, activities, etc. are still being discussed at the Board level and are subject to change.

PEBB will ask if you and your spouse/domestic partner will participate in the HEM model.  If you do not participate, PEBB will require you to pay a monthly surcharge.  The monthly surcharge amount will depend on an employee’s enrollment tier and when the surcharge begins to be assessed/charged (January, April, or September based on required deadlines).

Currently, the proposed HEM model will require the employee and their spouse/DP to complete: 
1) a confidential health assessment and provide their waist circumference;
2) complete two e-learning lessons, and
3) “TRY” to change your health risks. 

Based on the information provided in the health assessment, the health plan will require the employee and the spouse/DP to complete certain activities (“TRY”).  This may include:  an exercise program; Weight Watchers; nutritional counseling; tobacco cessation program; additional online educational courses (online lesson about shared decision making for certain procedures, online lesson for maternity completed by end of second trimester);   stress, alcohol or substance abuse requirement; talking with a case manager regarding care management.  You are not required to be successful (i.e., lose weight, stop smoking), but you are required to participate.

PEBB will have two “check-in” periods to determine if the employee and their spouse/DP are completing the necessary tasks:  February 15, 2012 – for the healthcare assessment; and July 15, 2012 for the activities.  If the employee or the spouse/DP are not participating or have not begun and/or completed the activities at these check points, the employee will then be assessed a monthly surcharge for the balance of the year so that the total for the year would be the equivalent of the annual surcharge amount - $420 or $300 based on your enrollment tier.

Current Administrative Exceptions for the HEM model include:  Spouses in the military serving overseas between their plan year coverage effective date and their HEM action requirements; members enrolled in Hospice or extended hospital stays preventing them from completing their HEM action requirements; incarceration; members who are out of the country from their plan year coverage effective date and their HEM action requirements.

PEBB Q&A on the HEM model:  http://pebb.das.state.or.us/DAS/PEBB/news/QAHealthEngagementModel.shtml

PEBB HEM email address for members with questions or issues for PEBB response: pebb.hem@state.or.us

2012 Plan Changes - PEBB Statewide Plan (Full-time plans):

       $250 individual deductible/$750 family deductible (4 primary care visits per person not subject to deductible)

       $1500 individual out-of-pocket maximum, $4500 family
Out-of-pocket maximum does NOT include the $250 deductibles or the co-pay amounts ($100 or $500) for the "Additional-cost Tier"

       0% copay for Chronic Care Office Visit for Asthma, Diabetes, cardiovascular disease, and congestive heart failure

       $50 deductible for Prescriptions (no deductible for $0 value drugs)

       Prescription copays increased to $10 generic, $30 preferred brand, $100 specialty

       Prescriptions – NO TIER exceptions

       Additions to the “Additional-cost Tier” include:

  • Sinus surgery, $500
  • Resurfacing Knee/Hip, $500
  • Hip arthroplasty, $500
  • SPECT, nuclear imaging, $100
  • Upper endoscopy, copay reduced to $100 from $500

       Procedures no longer covered by insurance:

  • Wart Removal
  • Varicose Vein Surgery
  • Varicose Vein Stripping
  • TMJ Surgery
  • Ganglion Surgery
  • Corns, Neuromas and Hammertoe
  • Bunionectomy
  • Breast Reduction

       Weight Watchers – plans will now cover the cost of participation for the employee’s spouse or domestic partner

2012 Plan Changes – PEBB Statewide Plan (Part-time plan):
Part-time plans are available only to part-time classified employees.

       Weight Watchers – plans will now cover the cost of participation for the employee’s spouse or domestic partner

       $500 individual deductible/$1500 family deductible (4 visits primary care not subject to deductible)

       $2500 individual out-of-pocket maximum, $7500 family

       The $2500 out-of-pocket maximum does NOT include the amounts paid for the $500 deductible or the additional co-pay amounts ($100 & $500) for the “Additional-cost Tier”

       0% copay for Chronic Care Office Visit for asthma, diabetes, cardiovascular disease, and congestive heart failure

       $50 deductible for Prescriptions (no deductible for $0 value drugs)

       Prescription copays increased to $20 generic, $40 preferred brand, $100 specialty

       Prescriptions – NO TIER exceptions

“Additional-cost Tier” changes and Excluded Procedures are identical to the changes made in the “Full-time” plans, please refer to the Full-time plans for a listing of these changes