Frequently Asked Questions
Here is a list of frequently asked questions and the corresponding answer. Select from the category tabs and click-on the question to see the answer. For a simple search within a category, select control-F or command-F and enter a keyword.
- General Questions
- HRA Questions
- Doctor By Phone Questions
Q. If I was to call my doctor to see if she accepted our plans (both PPO and Advantage Plan), who would I say the carrier is?
A. Physicians and facilities recognize that Omnicare is a self- funded benefit plan, with the exception of the HMO plans. A large percentage of employee benefit plans are self- funded and work with third party claims administrators; therefore providers are fully aware of this type of arrangement. If a provider has any questions regarding eligibility, benefits or the PPO networks associated with the Omnicare plan, they should contact ARM Grp at 1-800-968-7222. Omnicare engaged ARM Grp to replace the administrative/adjudication process of Anthem, Cigna and several HMO administrators as their claims administrator. Each employee will receive a customized member ID card that will include logos of networks their providers will recognize and accept. The new Omnicare medical benefit plans have access to over 200 national, regional and local PPO networks that include both your current providers as well as many additional. The members’ current providers will be receiving notifications informing them of the new administrator and information about the new Omnicare benefit plans.
Q. For the PPO plan, the summary refers to network providers, yet the newsletter says “…no out-of network charges, giving you access to any doctor…”. With this plan can providers can charge above what is reasonable, usual and customary?
A. Both the PPO and Advantage plans provide Omnicare and their members with discounts through network arrangements with physicians and facilities. With this extensive access to network providers, in the rare occurrence your provider does not participate in network arrangements, our administrator will work directly with the provider to arrive at a reasonable rate on behalf of Omnicare and the member. The member will not be responsible for the difference in the cost between the billed charge and the discounted rate, except for normal copayment, deductibles and coinsurance. Should an Omnicare member ever receive a balance bill for charges in excess of the discount, we ask that the member immediately contact our new administrator, ARM Grp at 1-800-968-7222 for review.
Q. Will I receive a more detailed summary of our benefits?
A. Yes, members will receive a Summary Plan Description which will provide complete details of the plans covered expenses and excluded services. The Summary Plan Description will also be posted to this website.
Q. What if I have pre-approved for a procedure by my current administrator that will take place on or after January 1, 2012?
A. If your current administrator has pre-approved a medically necessary procedure, we will grandfather the approval under the new plan as long as the patient remains an eligible participant under the Omnicare medical plan. However, we will require your physician to submit the same paperwork supplied to your current administrator for the pre-approval process along with a copy of the letter of approval. Please fax your paperwork to our secure fax at (630) 759-5219 or you can mail it to ARM Grp at 340 Quadrangle Drive, Bolingbrook, IL 60440.
Q. If I am scheduled for a procedure that will take place in 2011, who should I call for pre-certification?
A. You will continue to pre-certify your procedure with your current administrator until December 31, 2011.
Q. Will I receive a new Identification Card?
A. Yes, you will receive a new Identification Card (ID) by the last week of December, 2011. Please be sure to show your new ID card to your providers when obtaining services on or after January 1, 2012. Should your providers have any questions concerning your new benefits, please direct them to call ARM Grp at 1-800-968-7222. You will receive a separate ID card for your prescription drug plan. If you require additional ID cards for your dependents, please contact ARM Grp. After January 1, 2012, you can also click on the “member” tab of this website to request additional ID cards via our member support services.
Q. Will I be subject to a pre-existing condition limitation under the new medical plans?
A. You will not be subject to a NEW pre-existing condition limitation under the new medical plans as long as you have been continuously enrolled in the current Omnicare medical plan and you satisfied your pre-existing condition limitation. If you had not satisfied your pre-existing condition limitation under the current plan, you will be given credit for the period of time previously credited toward satisfaction of your pre-existing condition limitation under the new plan. The pre-existing condition limitation does not apply to enrollees under the age of 19.
Q. Who do I call if I have questions concerning my eligibility under the new medical plans?
A. If you have questions concerning your or your dependents eligibility, please contact the Omnicare Solution Center at 1-800-422-1554. The Solution Center hours are Monday through Friday, 10:00 a.m. – 8:00 p.m. EST.
Q. Does the PPO Plan or the Advantage Plan require a Primary Care Physician (PCP) for referrals or hospital admissions?
A. No, the PPO Plan or the Advantage Plan do not require you to select a PCP for referrals or hospital admissions.
Q. Are preventive care services offered under the new medical plans?
A. Yes, both the PPO Plan and the Advantage Plan provide first dollar coverage for preventive care services at 100% without the requirement of a copayment or satisfaction of a deductible. Please refer to your Summary Plan Description for a description of the preventive care services that are covered under the medical plans.
Q. What is the difference between an HRA (Health Reimbursement Account) and HSA (Health Savings Account)?
A. First, Omnicare only offers an HRA, not an HSA, with the Omnicare Advantage Plan. Many people are familiar with an HSA. The HRA is similar to an HSA in concept but has some key differences that you need to understand.
An HSA is portable, meaning it moves with the employee from job to job and the employee and employer may contribute funds to it. The HRA is funded only by Omnicare and will not go with the employee should they leave their job at Omnicare. An employee can not contribute funds to the HRA, but you may contribute your own money pre-tax to a Healthcare FSA which can be used in conjunction with the HRA.
The HRA is used to pay for medical expenses associated with your Advantage plan such as office visits, medical tests and surgeries. Whereas an HSA may be used toward not only medical expenses but also items such as prescriptions, dental visits and other approved expenses by the IRS (www.irs.gov/pub/irs-pdf/p503.pdf). But an Omnicare employee that enrolls in the Advantage plan with HRA may also contribute their own money pre-tax to a Healthcare FSA. The Healthcare FSA can be used toward the eligible expenses approved by the IRS (see above website) and may be used toward medical expenses once an employee’s HRA account has been spent.
Q. What are the Advantage plan’s out-of-pocket maximum expenses?
A. Including the deductible it is $4,800 for Employee Only and $9,600 for Employee & Child(ren), Employee & Spouse, and Family. After this is met, everything is paid at 100%. This is the maximum total out-of-pocket expenses that you may incur within a year (this is accumulated by your deductible and the 20% coinsurance that is your responsibility). Continue reading to understand the breakdown of these costs and what benefits are available to you to help pay these out-of-pocket costs.
The annual deductible is $1,800 for the Employee Only level of coverage; and $3,600 for the Employee & Child(ren), Employee & Spouse, and Family levels of coverage. Once you reach your deductible, other benefits are paid at 80%, with the exception of Preventive Care services which are paid at 100% and do not require you to meet your deductible.
The out-of-pocket maximum after the deductible is met is $3,000 for Employee Only coverage and $6,000 for Employee & Child(ren), Employee & Spouse, and Family coverage. You must add your deductible and out-of-pocket maximum to get the complete total you may pay within a year. This total is the $4,800 for employee only and $9,600 for Employee & Child(ren), Employee & Spouse and Family.
Your HRA will cover part of your medical expenses that apply toward your deductible: $750 for Employee Only coverage; $1,200 Employee & Child(ren); $1,500 Employee & Spouse coverage; and $1,875 for Family coverage. After your HRA has been spent you may pay for additional expenses with a Healthcare FSA. An employee will contribute funds to a FSA pre-tax.
Q. If I don’t use all my HRA money, can I carryover it over into the next year?
A. Yes, if you don’t use all or a portion of your money in the HRA and you remain in the Advantage Plan, you may carryover the unused portion of the HRA, up to a maximum of 3 years. Therefore, the maximum amount you may carryover is $2,250 Single, $3,600 Employee & Child(ren), $4,500 Employee & Spouse and $5,625 Family.
Q. After three years, does your HRA reach a maximum limit?
A. Yes, after three years of not using any money, or a portion of the money, from the HRA, the amount may reach a potential maximum of $2,250 Single, $3,600 Employee & Child(ren), $4,500 Employee & Spouse and $5,625 Family. The HRA will reach these maximums if the HRA is not used at all over the course of three years.
Q. If you have family coverage and the maximum in the HRA after three years is $5,625 and you then switch to the Employee and Spouse coverage do you keep the maximum $5,625 in your HRA?
A. No, if you switch levels of coverage and your HRA amount is more than what is allowed in your new level of coverage the HRA will be adjusted. For example if you had family coverage and had $5,625 (the maximum) in your account and then switch to Employee and Spouse coverage the maximum HRA amount cannot be greater than $4,500 so your HRA will be adjusted down to that amount.
Q. Do the HRA funds begin on January 1, 2012 or does a certain dollar amount have to be met first?
A. The benefits are effective January 1, 2012 and the entire amount of the HRA will be available on that date.
Q. How is the HRA reimbursed?
A. The HRA reimbursement process is a simple five step process.
1. The employee visits a provider and receives service. You do not pay at this time.
2. The provider sends an itemized bill including cost and information about the service to ARM Grp. Your claim will be re-priced, processed and applied to your deductible.
3. After the claim has been processed, ARM Grp will send the employee and Kereon an Explanation of Benefits (EOB). (Kereon is the company that pays the HRA.) The EOB will indicate total charges, discounts, deductible, co-insurance and patient responsibility amounts.
4. When Kereon receives the EOB, a claims analyst will review the employee’s HRA account; access the amount needed and the amount actually available to cover the member’s deductible. Kereon will then mail a check directly to the employee enrolled in the plan.
5. Your provider will mail you a bill that lists your services, costs and where to pay. The employee will then use the HRA funds sent to them to pay the provider.
Q. Is there a complete list of what the HRA funds can be used for?
A. No, there is not a list. Employees do not facilitate how their HRA funds are spent. A third party company determines what the HRA is spent on. In general, the HRA is used to pay for medical expenses including office visits, surgeries, specialist visits, emergency room visits, and medical tests.
Q. Do office visit co-pays come out of an employee’s HRA?
A. With the new Advantage plan, there are no co-pays. Unless it is a preventative visit, the employee will receive a statement of charges from their doctor after the visit and will be expected to pay it. This payment will come from the HRA first as long as funds remain in the HRA. After the HRA is used the office visit will be paid out of the employee’s pocket or they can use funds from their Healthcare FSA.
Remember that once the employee’s deductible is met, the plan will pay 80% and the employee is responsible for the remaining 20%, with the exception of preventive care services which are paid at 100%.
Q. Can the HRA funds be used to pay for premiums?
A. No, premiums can not be paid with the HRA.
Q. Will the HRA cover orthodontia?
A. No, the HRA will not cover dental. It can only be used toward medical costs. However, the employee’s FSA can be used toward dental and orthodontia.
Q. Are prescriptions covered by the HRA?
A. No, prescriptions are not covered by an HRA. However, an employee can use their FSA to cover prescription costs. The HRA can only be used for medical; it can not be used toward dental, vision or prescriptions.
Q. If an employee goes to the doctor and wants to use their HRA and FSA together, how does this work?
A. Funds from the HRA will be used first. Once the HRA funds have been depleted, you are free to use the FSA to pay remaining out-of-pocket costs.
Q. If an employee has money remaining in their HRA through the Advantage plan at the end of the year, but they switch to the PPO the following year, what happens to the HRA money?
A. If the employee switches to the PPO plan they will lose that money and will not be able to use it or carry it with them to the PPO plan as it does not have an HRA. The HRA only works with the Advantage plan.
Q. If an employee has a life status change mid-year, how will this affect their HRA?
A. If an employee has a life status change in the middle of the year, the HRA amount will also change at that time. It will be prorated based on the month of the year. For example, if an employee has a baby in July and adds the baby to their medical insurance plan, they will receive additional funds in their HRA account. This is because the employee will move from the Employee & Spouse level of coverage to the Family level of coverage. They would not receive the full Family HRA amount ($1,875) but it would be prorated based on the month they move to the Family level of coverage and how much they have already received in their HRA for the year.
Q. Is there a debit card associated with the HRA like there is with the FSA?
A. No, there is no debit card for the HRA. Payments will be handled through an automated claims payment process between ARM Grp and Kereon.
Q. How can the HRA money be transferred into an FSA?
A. The HRA can not be transferred to a FSA.
Q. Can an employee choose to use their FSA before the HRA since the FSA is a “use it or lose it” plan?
A. No, the HRA must be used first with the Advantage plan. Keep in mind that the HRA can only be used for medical expenses and an FSA can be used for items such as dental, vision and prescription (which an HRA can not be used for).
Q. As the employee pays for medical premiums throughout the year, are the premiums adding to and building upon the initial Omnicare contribution to the HRA? Does its value increase throughout the year?
A. No, the premiums are the same as the bi-weekly or monthly premiums that you would pay if you participate in the HMO or PPO. They are not added to the HRA. The value of the HRA does not increase throughout the year. The HRA is only funded by the company, not the employee, so after the initial amount is added at the beginning of the year, the amount will not increase after that.
Q. If an employee is hospitalized, does the single coverage employee pay for entire cost of the visit up to the $1,800 deductible?
A. No, the funds will be taken from the HRA account first, then the employee will have to meet the rest of the deductible.
Q. What is Doctor By Phone?
A. An on-demand service known as MDLiveCare. This service allows you to speak with board-certified doctors and registered nurses 24 hours a day, 7 days a week. Doctors can recommend treatment and prescribe medication over the phone.
Q. When should I use Doctor By Phone service?
A. For non-emergency medical issues and questions. To request prescriptions or get refills. When traveling and in need of medical care. During or after normal business hours, nights, weekends and even holidays.
Q. What can be treated?
A. Many non-emergency illnesses such as; Acne, Allergies, Asthma, Bronchitis, Cellulitis, Cold & Flu, Constipation, Diarrhea, Ear Infection, Fever, Gout, Headache, Infections, Insect Bites, Joint Aches, Nausea, Pink Eye and Rashes.
Q. Can I use it for my children?
A. Yes. Children ages 2 and older can be treated. A legal parent or guardian must be identified during
the initial registration, and must be available to participate during the call involving minors.