State Health Benefit Plan copay changes
Tier 1: $20
Tier 2: $50
Tier 3: $80
Primary care (family practice, general practice, internal medicine, pediatrics, ob-gyn): $35
Rehab services: $25
Emergency room: $150
Urgent care: $35
Source: Georgia Department of Community Health
Less than one month after the new state health benefits plan went into effect, the Department of Community Health has approved changes designed to ease financial burdens for state employees on it.
The biggest change is the replacement of coinsurance with copays for both medical and pharmacy costs.
“While the original plan design approved in August of 2013 focused on quality and affordable care, we could not ignore the financial distress created by the institution of cost sharing with our members,” said Clyde Reese, the commissioner of the department, in a prepared statement.
BlueCross BlueShield of Georgia took over the plan Jan. 1, while Express Scripts now oversees prescription drug benefits. There are approximately 650,000 state employees, dependents and retirees on the plan. Around 30 percent of those are active teachers; 16 percent are retired teachers.
Reaction against the plan was swift, with the Facebook group Teachers Rally Against Georgia Insurance Changes growing to more than 11,000 members since Jan. 2. There are many complaints, one of the main ones being that there was no copay option, causing out-of-pocket costs for doctor visits and medications to increase.
The Department of Community Health’s board met Monday, giving unanimous approval to the changes aimed at reducing those costs.
The pharmacy coinsurance is now a copay of either $20, $50 or $80, depending on the level of the drug, with generic drugs being the least expensive and specialty drugs having a higher cost.
Copays across all plans have changed to $35 per primary care visit, $45 for a specialist visit, $25 for rehabilitation services, $150 for an emergency room visit and $35 for an urgent care visit.
“We are hopeful that this decision will not only help to offset the associated costs of health care, but that it will be a noticeable difference,” Brad Brown, human resources executive director for the Hall County School District, said about the changes. “It will be interesting to see how much of a direct impact this will have on our employees with regards to their out-of-pocket expenses.”
Under the 2013 plan, via UnitedHealthcare, state employees had a choice between an HMO or HRA. Now there’s only the HRA, or health reimbursement arrangement, option. Traditionally with an HRA, there is no copay.
“In an HRA, you go and there’s a certain amount of money put into an account based on the plan you have,” Brown had previously told The Times. “So you go to a physician and it’s charged and it comes out of that account. First, nothing’s out of pocket. Once you run out, then it kicks into a different bracket.”
The cost of Monday’s announced changes is being absorbed by fund reserves and shouldn’t be passed on to members. The total estimated claims cost is around $116 million for 12 months.
Gainesville Superintendent Merrianne Dyer said it’s good to know concerns have been heard.
“Our employees will appreciate the consideration that has been given to making changes,” she said. “It is gratifying to know that these concerns were taken into consideration.”
The copays become effective March 14 and are retroactive to Jan. 1. Premiums, deductibles and HRA contributions are not affected.
“We heard our state employees and teachers and we listened,” Gov. Nathan Deal said in a news release. “I appreciate the board and the commissioner’s willingness to work with me on a timely solution.”
Deal’s office has said all along the changes are driven by mandates in the Affordable Care Act. The insurance changes come through the Department of Community Health’s board. Members are appointed by Deal, but the governor’s office doesn’t have a direct vote on the insurance.
“The Department of Community Health board faced very tough decisions last year as it sought cost savings in light of large new costs brought on by the federal health care law,” Deal said. “These are the same pressures affecting private sector employers across the country, many of whom are tightening eligibility or dropping coverage altogether.
“In the next budget year for the state, the mandates in the Affordable Care Act will cost the State Health Benefit Plan an additional $225 million.”
Since the Jan. 1 insurance switchover, Deal’s office has received more than 1,000 calls and emails regarding the matter.
A news release from the Georgia Senate Democratic Caucus said the changes don’t go far enough, reading in part “the new state health plan still costs more and provides less coverage than previous plans.”
Democrats have asked for the passage of Senate Bill 328, which would require at least two provider choices in the selection of state health plans.
Founder of the TRAGIC Facebook group Ashley Cline said she is reserving judgment until she can learn more about the changes.
“It does not address all of the shortcomings in the current plan, and we will have to examine the plan closely to see how it affects our members,” she said. “However, we feel it is a step in the right direction.”