Medical

 

CHOOSING A HEALTH PLAN THAT IS RIGHT FOR YOU

The more you know about health insurance, the easier it will be to choose a plan that is right for you and your family and also fits your budget. Understanding these common terms may help you feel more confident in your selection:
  • Premium - the monthly amount you pay to purchase health plan coverage through one of the district’s health plan options. You pay the same monthly premium regardless of whether you use your coverage or not.
  • Deductible - the amount you pay for covered health services before your insurance plan starts to share in the costs. If you have a $2,000 calendar-year deductible, you’ll pay 100 percent of your medical bills until the amount you’ve paid reaches $2,000.
  • Coinsurance - the percentage of the cost you pay for each office visit, test, hospital visit, etc. (20%, for example) after you’ve met your deductible.
  • Out-of-Pocket Maximum (OOP Maximum) – The maximum amount you pay during a calendar year for covered medical services under your health plan. After you reach the OOP Maximum, your health plan pays 100% of covered services for the rest of the year.
When comparing different plans, think about your family’s medical needs and the amount and type of treatment you’ve received in the past. If you have a preferred doctor or hospital and want to keep using them, make sure they’re part of the network for the plan(s) you are considering. If you take a medication on a regular basis, check what it will cost under the health plan’s preferred drug list.
St. Vrain offers three health plan options to benefits-eligible employees and their eligible family members-the UMR Choice Plus plan, the UMR DIrect Care plan and the Kaiser Permanente DHMO plan. Review the coverage chart on pages 8-9 and the premium chart on page 20 to help you decide which plan option is right for you.

UMR CHOICE PLUS PLAN

The self-insured UMR Choice Plus Plan is a Preferred Provider Organization (PPO) plan that offers a large network of contracted doctors, hospitals and other providers to choose from whenever care is needed. The plan is administered through UMR.
 
In-network care is provided, nation-wide, through the United Health Care Choice Plus PPO network. After you meet your annual deductible, you are responsible for paying 10% of remaining eligible expenses (your coinsurance) until you reach your out-of-pocket maximum of $4,000 as an individual or $8,000 as a family. To locate in-network providers go to umr.com or contact UMR at 800.826.9781.
 
You always have the option to receive care outside the Choice Plus PPO network. However, your costs will be higher because you have a higher deductible and benefits are paid at a lower level once you meet your deductible.
 
When you enroll in the UMR Choice Plus Plan, your pharmacy coverage is provided through National Pharmaceutical Services (NPS). You must use an in-network pharmacy to receive a benefit under the NPS pharmacy plan. Most national pharmacy chains and local pharmacies participate in the NPS Network.
 
(Please visit the NPS website at pti-nps.com to view the most up-to-date listing of pharmacy providers near you.)
 
Refer to the coverage chart below for additional coverage details.

UMR PPO (2017)

UMR Choice Plus PPO (2018)

UMR Direct Care PPO (2018)

Health Reimbursement Account (HRA)

The district contributes to a Health Reimbursement Account (HRA) for each employee who enrolls in the UMR Choice Plus Plan to assist in paying a portion of your deductible. An HRA is a type of health care account, funded entirely by the district, from which you can withdraw money, tax-free, to pay for eligible medical expenses. The district-funded HRA can only be used to pay expenses that are applied towards your UMR Choice Plus Plan deductible. It cannot be used to pay for prescriptions, dental or vision claims or coinsurance amounts.

UMR administers the HRA account and will automatically pay your provider for HRA-eligible expenses if money is available in your HRA account. Unused funds carry over, up to the maximum of your health plan deductible, and can be used in future years to pay for eligible medical expenses. The funds are only accessible while you are actively employed at St. Vrain and participating in the UMR Choice Plus plan or if you continue your participation via COBRA.
 
For calendar year 2018, the district will contribute up to $750 into your HRA if you have “Employee Only” coverage and $1,500 if you cover yourself and your dependent(s) under the UMR Choice Plus Plan. The district does not contribute to the HRA if you participate in any of the district’s other health plan options. The money will be deposited into your HRA at the beginning of the calendar plan year and if you do not spend the money in 2018, you may carry it over to 2018 and beyond, up to the maximum allowed. (New hires qualify only for a prorated HRA contribution based on their benefits eligibility date).
 

UMR DIRECT CARE PLAN

The district’s newest health plan option features an innovative new Direct Primary Care partnership with Nextera Healthcare and UMR. Similar to the Choice Plus Plan, in-network care is provided, nation-wide, through the United Healthcare Choice Plus PPO network but the Direct Care Plan also offers unlimited, no-cost primary care access to insured employees and dependents through Nextera Healthcare. If you are enrolled in a government healthcare program such as Medicare, Medicaid, Tricare, VA or Indian Health Service coverage, you cannot utilize direct primary care services through Nextera Healthcare.
 
Under the Nextera Healthcare partnership, the following services are covered at no cost to you or your covered family members when obtained through a Nextera Healthcare physician (not subject to an upfront deductible, coinsurance or copayments);
 
  • Treatment of most sprains, cuts, broken bones and other non-life threatening, urgent care needs
  • Extended office visits (average visit 20-30 minutes vs. 5-7 minutes under traditional health plans)
  • Physicals for work, school and sports
  • Pediatric care
  • Allergy testing
  • EKG’s and many other labs including pregnancy tests, strep test, urinalysis, etc.
  • Men’s care including initial testosterone shots, etc.
  • Women’s health services including gynecological care, etc.
  • Specialty consultations via RubiconMD
  • Convenient onsite pharmacy offering many commonly-used prescriptions at discounted prices
  • Child, adolescent and adult mental health consultations
Not all in-office services are provided at no cost through Nextera. The following services are available in-office, at reduced fees:
  • Labwork and immunizations (billed to UMR or provided at reduced cost)
  • Onsite pharmacy access (Nextera offices stock many commonly-used medicines in their in-house pharmacy including antibiotics, diabetic medicines, anti-depressants, cholesterol medicines, etc.) available to you and your family at cost
  • Durable medical equipment including walking boots, wrist braces, finger splints and more

Nextera Healthcare Direct Primary Care network providers are located in:

LongmontBoulderDenverDurangoFrasier
FrederickLafayetteFt. CollinsBuena VistaColorado Springs

For a complete list of Nextera providers and locations, log onto the Nextera website at: nexterahealthcare.com/svvsd.

In addition to being able to access the Nextera Healthcare Network, when you enroll in the Direct Care Plan, you also have access to the United Healthcare Choice Plus PPO network. After you meet your annual deductible, you are responsible for paying 20% of remaining eligible expenses (your coinsurance) up to your out-of-pocket maximum of $4,000 for an individual, $8,000 for a family. To locate in-network PPO providers, go to umr.com or contact UMR at 800.826.9781.
 
You always have the option to receive care outside the Nextera Healthcare or Choice Plus PPO networks. However your costs will be higher because you have a higher deductible and, once you’ve met your deductible, benefits are paid at a lower level.
 
When you enroll in the UMR Direct Care Plan, your pharmacy coverage is provided through National Pharmaceutical Services (NPS). You must use an in-network pharmacy to receive a benefit under the NPS pharmacy plan. Most national pharmacy chains and local pharmacies participate in the NPS Network.
 
(Please visit the NPS website at pti-nps.com to view the most up-to-date listing of pharmacy providers near you.) Refer to the coverage chart on pages 8-9 for additional coverage details.
The following programs are included in both UMR health plan options at no additional premium cost:
 

ZERO CARD

Say goodbye to deductibles, copays and coinsurance when you use the Zero Card to obtain dozens of covered non-emergency surgical procedures and medical services. If you opt to use a participating Zero Card provider for the procedure, you will pay zero dollars—no copays, deductibles or coinsurance—for covered procedures including knee replacements, hysterectomies, gall bladder removals, MRI’s, colonoscopies and more.
 

VIVIO HEALTH

VIVIO Health is a specialty drug management company that helps UMR health plan participants taking specialty drugs to save money and get better care. With VIVIO Health, your pharmacy copay is waived and you pay nothing for covered specialty medications prescribed by your physician. (Specialty drugs are used to treat complex or rare chronic conditions such as cancer, rheumatoid arthritis, hemophilia, multiple sclerosis, etc.) VIVIO Health is not affiliated with any pharmaceutical manufacturer.

KAISER PERMANENTE (DHMO) PLAN

The district offers a Deductible Health Maintenance Organization (DHMO) plan through Kaiser Permanente that offers a low upfront deductible and copays when care is received through Kaiser Permanente doctors, partner hospitals and other health care facilities. (Out-of-network coverage is only available in urgent care and emergency situations where you become injured or unexpectedly ill while outside the service area.)
 
Each time you visit a Kaiser Permanente pharmacy or other provider for care, you pay a copay or an amount based on your deductible and coinsurance responsibility. Your out-of-pocket costs for eligible expenses are capped annually at $4,000 for an individual or $8,000 for a family.
 
Refer to the coverage chart below for additional coverage details.

Kaiser Permanente DHMO