On the agenda for Sept. 16 Association Council meeting: Does the Faculty Want a Second Health Insurance Option?

In July, President Dunn announced a second health insurance option that may be offered to WMU employees during open enrollment this fall, BCBSM’s Healthy Blue Living HMO.

We provide below an analysis of the Healthy Blue Living HMO to help faculty members make an informed decision about whether to allow the plan to be offered to the faculty along with our existing health insurance plan. (See also our summary comparison table of overall benefits here and our pharmacy benefit comparison table, linked here.)

On September 16, the WMU-AAUP Association Council will discuss whether the new plan should be offered to our members. We encourage all WMU-AAUP bargaining-unit faculty to attend this meeting.

WMU-AAUP Association Council meeting Friday, September 16, 2016
1:30 p.m. in 157 Bernhard

Special guests to help answer your questions about healthcare:

  • Lisa Marshall, Director of Sindecuse Health Center, Western Michigan University
  • ŸWil Arbogast, Director of the WMU Sports Medicine Clinic
  • ŸJim Middleton, Director of Pharmacy, Sindecuse Health Center

This meeting is open to all members of the WMU-AAUP bargaining unit.

 Quick overview: The Healthy Blue Living HMO might work for you if:

  • Getting your premium amount down is your highest priority.
  • You are confident that you and your family will not need services that are subject to the HMO’s out-of-pocket deductible payments, which could offset premium savings.
  • You like working toward wellness goals and don’t mind the HMO’s wellness plan requirements.
  • You and your family are healthy and you’re confident that you’re likely to remain so.
  • You have no dependents on your insurance and who live out of state or overseas.
  • You rarely or never travel out of state or internationally.
  • You don’t mind getting a referral from a primary care provider if you need to see a specialist.
  • No one on your insurance needs to take any nongeneric prescription drugs.
  • You don’t mind giving up access to no-copay, no-deductible providers and clinicians at the Sindecuse Health Center on campus.

Quick overview: The Healthy Blue Living HMO might NOT work for you if:

  • You and/or members of your family need nongeneric prescription medications. The copays under the HMO and loss of access to Sindecuse pharmacy discount could offset your premium savings.
  • You expect that you and/or members of your family will need to visit providers. The HMO deductible requirements could offset your premium savings.
  • You have a spouse or child on your insurance who lives out of state or overseas.
  • You travel out of state and need non-emergency care or prescription drugs while you are away.
  • You travel internationally and need non-emergency care or prescription drugs while you are away.
  • You don’t want to have to get a referral from a primary-care physician to go to a specialist.
  • You use services at Sindecuse, such as physical therapy, lab and x-ray, and other medical and clinical services and providers and want to continue to do so.

More details: Some important facts about The Healthy Blue Living HMO

  • The main advantage of the HMO: Lower premium equivalents. (See Table 1.)
  • Lower copays for office visits but only after deductible is met. The HMO offers $20 copays for Enhanced Plan, $30 for the Standard Plan, compared to $35 for our current plan. However, your deductible must be met before you’ll be eligible for these copays. (See Table 1.)
  • That means you’ll pay 100% of the bill for non-preventive medical services until your deductible is met, potentially negating any savings from lower premiums. Our current plan includes many services to which the deductible does not apply and does not require that the deductible be met before covering most office visits.
  • If you are on the employee-only plan, you’ll pay out-of-pocket for office visits and/or other care up to $400 (Enhanced Plan) or $1000 (Standard Plan) before you will be eligible for copay-only office visits. (See Table 1.)
  • If you are on the two-person or family plan, you’ll pay out-of-pocket for office visits and/or other care up to $800 (Enhanced Plan) or $2000 (Standard Plan) before you will be eligible for copay-only for office visits. (See Table 1.)
  • If you or members of your family need any nonpreventive healthcare services at all, there is a good chance that these deductible requirements will offset savings of the reduced premium.
  • The HMO provides no coverage for medical or clinical services at Sindecuse Health Center. On our current plan, we enjoy at Sindecuse with zero out-of-pocket costs. Enrollees in the HMO will be responsible for all charges for services at Sindecuse. (See Table 1.)
  • The HMO does not include a prescription drug discount at Sindecuse. HMO enrollees may use the pharmacy at Sindecuse, but prescription drug prices under that plan will not be discounted. (See Table 2.)
  • With the HMO, 90-day prescriptions will be available by mail-order only. (See Table 2.)
  • The HMO has a 5-tier prescription drug plan with high copays for for tiers 4 and 5. On our current plan, copays for tier 4 and tier 5 drugs are equivalent to those for tiers 2 and 3, respectively. On the HMO, tiers 4 and 5 are very expensive. (See Table 2.)
  • It’s an HMO. That means there is no out-of-network option and that your providers must all be part of the Michigan BCBSM network.
  • Kids live out of state? With the HMO, if you have kids up to age 26 who don’t live in Michigan but are on your insurance, they would not be covered except for emergency treatment.
  • If you travel outside Michigan: With the HMO, according to information on BCBSM’s website, “there are limits to the type of care you get that’s covered when you travel outside your plan’s network and around the U.S.” You’ll need a referral from your primary care provider and approval from BCBSM to get care except in case of emergency. Approval is required but not guaranteed, and there may still be out-of-pocket costs to you even if approved. The HMO plan “covers only a limited amount of health care services when you’re outside of your plan’s network area or outside of Michigan.”
  • If you travel internationally: BCBSM’s “How to get care while you’re traveling” page notes that with the HMO, “You’re only covered for emergency care and accidental injuries when traveling abroad.”
  • Some might find the wellness program requirements invasive or burdensome. Enrollees are “graded” on six measures: weight, blood sugar, cholesterol, blood pressure, tobacco use, and depression.

According to the BCBSM website, a grade of A means you meet the health target; B means you have a health condition that may not be controlled but you are actively participating in treatment to improve the condition; and C means you’re not meeting the wellness target and haven’t committed to treatment to improve your condition.

If you get any grades of C, you’ll be required to commit to a plan of action and follow through in order to remain eligible for the Enhanced Plan. You don’t actually have to lose the weight, reduce cholesterol, quit smoking, kick that depression once and for all, etc., but you do have to participate in the action plan until you achieve the desired goal.

In cases where the goal might not actually be achievable for some enrollees, you will apparently be required to follow the action plan in perpetuity to remain eligible for the lower-cost Enhanced Plan.

  • If you don’t follow your wellness plan or you don’t complete other requirements within 90 days of enrollment or re-enrollment (meaning annually), you will be switched from the Enhanced Plan to the Standard Plan, which has substantially higher out-of-pocket costs. (See Table 1.)

For more information:

What else you can do:

  • Come to the Association Council meeting on Friday, September 16, at 1:30 pm in 157 Bernhard, to participate in the conversation about whether this plan should be offered to WMU-AAUP faculty in addition to our existing plan.
  • Talk to colleagues and help keep other faculty members informed.
  • Got expertise? Share it with the faculty by speaking at the Association Council meeting or write an article for the blog.