2014 Commercial Group Plans

Transcription

1 2014 Commercial Group Plans For plans effective January 2014

2 Recommending HAP Exceptional Group Benefits in HMO, PPO, EPO, Self-funded or Shared-funded Plans In order to provide your customers with the best health plan options for their employees, you need a robust tool kit. HAP offers you a range of plans to choose from that cover any employee, no matter what age or stage he or she is in life. HAP s Portfolio of Commercial Group Plans Gives You Everything You Need to Know About HAP s Products and Services, Including: Value-added programs and services Benefits and advantages of each plan Health care reform information We have a lot of employees comment on how happy they are with HAP... It s a pretty easy decision for us to stay with HAP. Rob Farr, President, CEO, Bank of Birmingham 1

3 Table of Contents Value-added...3 Programs and Services Health Care Reform...8 Where to Buy Summary of Benefits and Coverage Essential Health Benefits Metal Tiers Product Overview...11 HAP Group Plan Designs Plan Type...13 Fully Insured HMO Plan Type...17 Fully Insured PPO/EPO Plan Type...23 Consumer-driven Health Plans (CDHPs) HSA and HRA Vision and Dental Benefits...29 Plan Type...33 Self-funding/Shared-funding A New Approach to Managing Health Costs...35 Fixed Group Health Care Expenses for Three Years Value-added Programs and Services We understand every business is unique. Our dedicated account representatives are experts at finding health plan solutions that best fit the specific needs of the commercial market. Along with our inspired customer service, we offer other value-added services listed below with our fully insured plans. Award-winning Customer Service Our client services specialists are in the business of helping. They are trained to provide a high level of customer service with every phone call and every and at every member touch point. Our materials and programs are also member and quality focused. No wonder, then, that our HMO has earned Excellent Accreditation from the National Committee for Quality Assurance (NCQA) every survey year since HAP was one of the first health plans in Michigan to receive accreditation for its HMO in An Excellent status confirms our commitment to clinical excellence and providing quality service. One of the ways we deliver this inspired service is by making sure every new HAP member gets a Personal Service Coordinator for his or her first two years. The Personal Service Coordinator is a health plan professional who is available to answer questions, provide assistance, explain plan details, and introduce members to special programs designed to help improve and maintain their health. HAP Direct for Employers and Producers Employer groups and producers receive fast, accurate customer service through the HAP Direct service line. Groups also get a dedicated account representative who works with agents or consultants to address the unique circumstances of their business. Member Satisfaction Matters J.D. Power Award J.D. Power health care ratings are your guide to finding which health plans rank highest in J.D. Power consumer studies. According to J.D. Power, HAP has the Highest Member Satisfaction among Commercial Health Plans in the Michigan Region, Six Years in a Row! * *Health Alliance Plan of Michigan received the highest numerical score among commercial health plans in the Michigan region in the proprietary J.D. Power U.S. Member Health Plan Study SM study based on 33,353 total member responses, measuring four plans in the Michigan region (excludes Medicare and Medicaid). Proprietary study results are based on experiences and perceptions of members surveyed December 2012 January Your experiences may vary. Visit jdpower.com. 2 3

4 Assist America Global Emergency Travel Services HAP members can travel worry-free knowing they can call upon Assist America for emergency travel services. These services span beyond their HAP emergency/urgent care coverage whenever members travel 100 miles or more away from home or to another country. Travelers with smartphones can download the Assist America mobile app for a one-touch connection to the call center, which is fully staffed 24/7. Assist America will completely arrange and pay for all the assistance services it provides without limits on the covered cost, including: Hospital admission guarantee Locate a health care provider Medical repatriation Emergency medical evacuation Lost prescription or luggage help Medical consultation, evaluation and referral Learn more about HAP s partnership with Assist America at Worksite Wellness HAP offers free and/or low-cost workshop wellness programs right at the worksite. We team up with local companies to deliver results-oriented programs for employees on topics such as physical activity and services such as health screenings and flu shots. HAP s Restore Programs Restore CareTrack Program Our award-winning Restore CareTrack Program is a free program for those members diagnosed with a chronic condition. This exclusive program is distinct from any other health plan and offers comprehensive services such as a: Nurse health coach who works with members one-on-one over the phone Behavioral health specialist who helps identify emotional or behavioral triggers that impact a member s ability to follow his/her doctor s treatment plan Medication review to ensure the right medication and dosage is being taken at the right time Restore Case Management This innovative program works to coordinate health services for members who have multiple or complex needs. In order to minimize return visits to the hospital or emergency room, the program helps these members understand the requirements of their health status. It also helps to coordinate their care and remove any barriers that might interfere with the services they need. Members requiring intensely focused coordination due to complex conditions or transitioning from one care setting to another qualify. A registered nurse from HAP will work closely with each member s health care provider to make sure the member is getting the right care when it s needed. Restore Comfort & Palliative Care The Restore Comfort & Palliative Care program focuses on helping HAP members manage end-stage terminal conditions while allowing for palliative and curative treatment options. HAP provides care 24/7, 365 days a year through this program and it s free to members. HAP members with the following end-stage conditions may be considered for this program: COPD CHF Metastatic cancer Other terminal conditions This program is different from hospice in that it allows the continuation of curative treatments while introducing a palliative care component to address the member s pain and comfort concerns. HAP Advantage Discounts Our members can access money-saving discounts and extras on a variety of health- and wellness-related activities in southeast Michigan, such as: Henry Ford OptimEyes Automobile Association of America (AAA) YMCA membership Edible Arrangements Also, members enjoy retail discounts from stores, museums and entertainment venues, and much more. The full list of discounts is available at hap.org/advantage. 4 5

5 Weight Management Program Our comprehensive weight management program empowers members to eat smart, keep moving and stay healthy for a lifetime. To date, more than 50,000 HAP members have lost almost 400,000 pounds. HAP s partnership with Weight Watchers allows eligible members to enroll in up to four 12-week sessions per lifetime for just $25 per session. istrive for Better Health is a free digital health coaching program, in partnership with HealthMedia, to help members understand their health risks, manage their goals and guide decisions. Online Tools and OnTheGo Mobile App HAP offers personalized and secure online tools and a mobile app. Health Reminders an online tool that reminds members when important preventive services are due Health Library a reliable link to thousands of health topics, treatments, tests and interactive decision aids to help members make informed decisions Find a Doctor/Facility an online search tool that enables members to locate a doctor or facility either by name, by proximity to their home or business, or by health condition Employer Tools a way to enable employers to securely add, delete and modify enrollment HAP OnTheGo Mobile App a smartphone app that makes it easy to find a doctor or a nearby facility, download an ID card, check symptoms and manage health conditions 6 7

6 Health Care Reform Through HAP In order to give your customers the widest possible choices, HAP will offer a variety of small group plans. Your customers can rest assured that all HAP plans will meet the same high standards for coverage, quality and customer service. For more information, visit choosehap.org, or call us toll-free at (855) WITH-HAP. Health Care Is In for Big Changes It s called many names, but the official law, signed in 2010, is called the Patient Protection and Affordable Care Act (PPACA or just ACA). It was designed to improve access to health care for everyone. While some parts of the law are already in place, most of the major provisions of ACA become effective in These changes are aimed at making health coverage more accessible and affordable for many more people. They include the creation of Health Insurance Marketplace websites (also called exchanges), coverage of Essential Health Benefits (EHBs) and individual tax credits. There will be even more changes coming over the next several years. With ACA, no one can be denied coverage, or pay a higher rate, based on a pre-existing condition. If a person does not have coverage through an employer plan, Medicare or Medicaid, he or she will have to buy it on his or her own. Some ACA benefits are already available. Health plans already have broader coverage because of the ACA. Here are some of the new benefits available now: Young adults can remain on a parent s health plan until the age of 26, even if they live away from home, attend school or are married Preventive care and women s health care services with no s, coinsurance or s Children with pre-existing conditions can t be denied coverage No set lifetime dollar limits on coverage Plus, health plans can t cancel coverage if you get sick. The only reason coverage can be canceled now is if someone committed fraud when applying for health insurance. Through the Health Insurance Marketplace The Health Insurance Marketplace for small group business is the Small Business Health Options Program referred to as the SHOP or the SHOP Marketplace. This is where your customers can compare and select qualified health plans. Through HAP s Private Exchange Partnership with iselect HAP s partnership with iselect, a new, locally based private health care exchange, offers another option to purchase health care plans and ancillary products. It brings affordable, predictable pricing through defined contributions and overall savings to employers and employees alike. HAP offers 10 competitive and qualified health plans through iselect, including six PPO products and four HMO products. All 10 HAP plans offered on iselect meet the Accountable Care Act Essential Health Benefits (EHBs) requirements effective Summary of Benefits and Coverage All health plans must also use the same standard form to compare plans. The Summary of Benefits and Coverage (SBC) is a short, plain-language overview of what is covered, along with s, coinsurance and s. The SBC also includes coverage examples that show how much a member would typically pay in two common medical situations: Type 2 diabetes care and childbirth. In addition, health insurance companies are now expected to spend at least 80 percent of premiums on medical care and related quality improvements for members in individual and small group plans (85 percent for large group plans). If they re not met, members would receive the difference in the form of rebates or reduced premiums. Where can your customers buy health insurance? Your customers can buy a qualified health care plan through a variety of channels directly from HAP, through the Health Insurance Marketplace website, s private exchange iselect and through producers using any one of these options. 8 9

7 Essential Health Benefits The Essential Health Benefits are the minimum categories of health insurance coverage that every qualified health plan must have starting January 1, Employers save money by giving employees control over their health care with the freedom to choose their own benefits plan. The ACA defines 10 categories of Essential Health Benefits: Product Overview Ambulatory patient services Emergency services The 2014 qualified health plan designs below are for groups with two or more eligible employees, with the exception of the iselect suite of large group plans. Customization of plans is available to groups of 51 or more eligible employees. Hospitalization Out-of-Pocket Max (InNetwork) (Individual/ Family) Primary Care Physician/ Specialist Office Visit Emergency Room/Urgent Care Rx Generic/ Preferred Brand/ Nonpreferred Brand/Specialty $1,000/$2,000 $20/$40/5/5 $0/$0 $1,000/$2,000 $20/$40/5/5 HAP 500 HMO $500/$1,000 $1,000/$2,000 $10/$30/5/5 Laboratory services HAP 500 PPO $500/$1,000 $1,000/$2,000 $10/$30/5/5 Preventive and wellness services and chronic disease management HAP 500 EPO $500/$1,000 $1,000/$2,000 $10/$30/5/5 Pediatric services, including oral and vision care HAP 1000 HMO $1,000/$2,000 $3,000/$6,000 $15/$40/5/5 HAP 1000 PPO $1,000/$2,000 $3,000/$6,000 $15/$40/5/5 HAP 1000 EPO $1,000/$2,000 $3,000/$6,000 $15/$40/5/5 HAP 1500 HSA HMO $1,500/$3,000 2 $2,000/$4,000 2 after 2 after 2 after HAP 1500 HSA PPO $1,500/$3,000 2 $2,000/$4,000 2 after 2 after 2 after HAP 2000 HMO $2,000/$4,000 2 $6,000/$12,000 $20/$60/5/5 HAP 2000 PPO $2,000/$4,000 2 $6,000/$12,000 $20/$60/5/5 HAP 2000 EPO $2,000/$4,000 2 $6,000/$12,000 $20/$60/5/5 HAP 2000 HSA HMO $2,000/$4,000 $4,000/$8,000 Covered after Covered after $20/$40/5/5 after HAP 2000 HSA PPO $2,000/$4,000 $4,000/$8,000 Covered after Covered after $20/$40/5/5 after HAP 3000 HMO $3,000/$6,000 $6,350/$12,700 $45/$60 after $25/$100/5/5 after $6,350/$12,700 $45 ; limit 2, then covered after /$60 after $20/$60/5/5 after Deductible (In-network) (Individual/ Family) Coinsurance (In-network) Hap 0 Direct HMO $0/$0 Hap 0 Direct PPO Rehabilitative and habilitative services and devices Maternity and newborn care Metal Tier Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Platinum Gold Metal Tiers: Bronze, Silver, Gold, Platinum Starting in 2014, health plans will be ranked using metal tiers: Bronze, Silver, Gold and Platinum. The idea behind metal level plans, or metal tiers, is to allow your customers to compare health plans with similar coverage value (the technical term is actuarial value). What this means is that health plans offered or the Small Business Health Options Program (SHOP) will be grouped in different metal tiers based on the percentage of health care costs the health plan covers. Silver Bronze health plans usually will have the lowest premiums and highest out-of-pocket costs s, s and coinsurance while Platinum health plans usually have the highest premiums and the lowest member cost-sharing. Bronze Plan Name HAP 3000 PPO $3,000/$6,000 HAP health plans available 10 HAP health plans available through the Health Insurance Marketplace HAP plans available through iselect private exchange NOTE: The above comparisons are to be used for general reference only. Please refer to individual benefit summaries for benefit levels for each service. 11

8 Plan Type: Fully Insured HMO How It Works In a health maintenance organization (HMO), members must choose a personal care physician (PCP) who coordinates all of their health care needs. When members need to see a specialist, it s easy with paperless referrals. Most of our networks offer the option to see specialists from any network. In addition, members are covered for emergency and urgent care, no matter where they go. Plans range from traditional coverage to plans with annual out-of-pocket maximums and a wide range of s and coinsurance options with lower premiums. Service Area The service area, where HAP is licensed to sell the HMO product, consists of the following nine counties: Genesee, Lapeer, Livingston, Macomb, Monroe, Oakland, St. Clair, Wayne and Washtenaw. Network HAP HMO members can access the HMO network within the nine-county service area

9 Health Engagement Program Our Health Engagement program is a two-tier HMO plan design. HAP s Health Engagement program is designed for employers who have committed to providing a healthier workplace and will support their employees (and covered spouses) in reaching their health goals. To meet your organization s unique needs, HAP offers two tiers with our Health Engagement program, Aspire and Achieve. Members in either plan must visit their PCP to get a deeper understanding and assessment of their health risks, enabling them to set healthy goals. HMO Standard Plan Designs The plan designs below are for groups with two or more eligible employees. Groups of 51 or more eligible employees can also customize a plan. PLATINUM HMO 0 DIRECT PLATINUM HMO 500 GOLD HMO 1000 SILVER HMO 2000 BRONZE HMO 3000 Aspire is participation-based and rewards employees who attempt to improve their health with out-of-pocket savings. Achieve is outcomes-based and rewards employees for achieving their health goals with out-of-pocket savings. Member Liability Annual Deductibles (Individual/Family) None $500/$1,000 $1,000/$2,000 $2,000/$4,000 $3,000/$6,000 Member Coinsurance 2 Out-of-Pocket Maximum(*) (Individual/Family) $1,000/$2,000 $1,000/$2,000 $3,000/$6,000 $6,000/$12,000 $6,350/$12,700 Both programs measure key health factors that can be controlled through lifestyle choice and positively impact employee health and performance. The key measures are: Preventive services Tobacco use Blood pressure Cholesterol Preventive Office Visit (Preventive) Periodic Physical Exams, Well Baby/Child Exams, Immunizations, Routine Eye and Hearing Exams Immunizations, Related Lab Tests and X-rays, Pap Smears and Mammograms Outpatient Services Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Weight Blood sugar Alcohol use Office Visit PCP/Specialist $45/$60 after Outpatient Surgery and Related Services Covered Covered after Covered after 2 after Covered after Inpatient Services Inpatient, Labor/Delivery, Mental Health, Chemical Dependency Covered Covered after Covered after 2 after Covered after Emergency Services Emergency Care $200 $200 $200 $200 $200 Urgent Care $65 $65 $65 $65 $65 Additional Benefits Vision Hardware Adult/Pediatric Eyeglasses every 12 months Eyeglasses every 12 months Eyeglasses every 12 months Eyeglasses every 12 months Eyeglasses every 12 months Dental Benefits Adult/Pediatric Prescription Drugs Rx Copay Generic/Preferred Brand/Nonpreferred Brand/Specialty $20/$40/5/5 $10/$30/5/5 $15/$40/5/5 $20/$60/5/5 $25/$100/5/5 after NOTE: The above comparisons are to be used for general reference only. Please refer to individual benefit summaries for benefit levels for each service. *Out-of-Pocket Maximum includes, coinsurance and s

10 Plan Type: Fully Insured PPO/EPO How It Works The preferred provider organization (PPO) lets members seek care from providers either within or outside of the network, without referrals. The plan offers a wide range of benefit designs that includes incentives to seek care from preferred providers. The exclusive provider organization (EPO) offers the freedom of our PPO, without the out-of-network benefits. Members can see any doctor within the EPO network, without a referral and without choosing a personal care physician. The network for both the PPO and EPO is the same. Service Area The PPO and EPO products* are licensed to be sold in a 23-county service area that includes: Arenac Huron Midland Sanilac Bay Iosco Monroe St. Clair Clare Isabella Oakland Tuscola Genesee Lapeer Ogemaw Washtenaw Gladwin Livingston Roscommon Wayne Gratiot Macomb Saginaw *PPO/EPO products are offered by Alliance Health and Life Insurance Company, a wholly owned subsidiary of Health Alliance Plan.

11 PPO/EPO Standard Plan Designs The plan designs below are for groups with two or more eligible employees. Groups of 51 or more eligible employees can also customize a plan. PLATINUM PPO HAP 0 DIRECT PLATINUM PPO/EPO 500 GOLD PPO/EPO 1000 SILVER PPO/EPO 2000 BRONZE PPO 3000 IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK Member Liability Annual Deductibles (Individual/Family) $0/$0 $500/$1,000 $500/$1,000 $1,000/$2,000 $1,000/$2,000 $2,000/$4,000 $2,000/$4,000 $4,000/$8,000 $3,000/$6,000 $6,000/$12,000 Member Coinsurance Out-of-Pocket Maximum(*) (Individual/Family) $1,000/$2,000 $2,000/$4,000 $1,000/$2,000 $2,000/$4,000 $3,000/$6,000 $6,000/$12,000 $6,000/$12,000 Preventive Office Visit (Preventive) Periodic Physical Exams, Well Baby/Child Exams, Immunizations, Routine Eye and Hearing Exams Immunizations, Related Lab Tests and X-rays, Pap Smears and Mammograms Outpatient Services $12,000/ $24,000 $6,350/$12,700 $15,000/$30,000 Covered Not covered Covered Not covered Covered Not covered Covered Not covered Covered Not covered Covered Not covered Covered Not covered Covered Not covered Covered Not covered Covered Not covered Office Visit PCP/Specialist 5 after 5 after 5 after 5 after $45 limit 2, then covered after /$60 after 5 after Outpatient Surgery and Related Services Covered 5 after Covered after 5 after Covered after 5 after 2 after 5 after Covered after 5 after Inpatient Services Inpatient, Labor/Delivery, Mental Health, Chemical Dependency Covered 5 after Covered after 5 after Covered after 5 after 2 after 5 after Covered after 5 after Emergency Services Emergency Care $200 $200 $200 $200 $200 $200 $200 $200 $200 $200 Urgent Care $65 $65 $65 $65 $65 $65 $65 $65 $65 $65 Additional Benefits Vision Hardware Adult/Pediatric Eyeglasses every 12 months Not covered Eyeglasses every 12 months Not covered Eyeglasses every 12 months Not covered Eyeglasses every 12 months Not covered Eyeglasses every 12 months Not covered Dental Benefits Adult/Pediatric Prescription Drugs Rx Copay Generic/Preferred Brand/Nonpreferred Brand/Specialty $20/$40/5/5 $20/$40/5/5 $10/$30/5/5 $10/$30/5/5 $15/$40/5/5 $15/$40/5/5 $20/$60/5/5 $20/$60/5/5 $20/$60/5/5 $20/$60/5/5 after in-network NOTE: The above comparisons are to be used for general reference only. Please refer to individual benefit summaries for benefit levels for each service. * Out-of-Pocket Maximum includes, coinsurance and s

12 Network PPO and EPO members can access the statewide network throughout the entire state of Michigan. Outside of the state of Michigan, members can access CIGNA or other affiliated national networks. Statewide Network National Network CIGNA 20 21

13 Plan Type: Consumer-driven Health Plans (CDHPs) HSA and HRA How It Works Consumer-driven Health Plans (CDHPs) consist of a tax-advantaged funding structure paired with a health plan. These plans encourage members to use their health care benefits judiciously, while giving them the freedom to decide where their allocated dollars go. Premiums are generally lower, and cost-sharing with employees helps make coverage affordable for everyone. HAP s CDHPs can be offered using our HMO, PPO or EPO products and can be paired with either a Health Savings Account (HSA) or health reimbursement arrangement (HRA) qualified plan. Health Savings Account A health savings account (HSA) is an individually owned bank account that can be used to pay for qualified medical expenses such as s, coinsurance, s, vision and dental services, and much more. An HSA is a good choice for employers who are looking for ways to reduce health care premiums, while still providing a tax-free way for their employees to save money on their out-of-pocket health care expenses. HAP offers a variety of federally qualified high- HMO, PPO and EPO plans to pair with an HSA, giving employees the opportunity to save for future health care expenditures. Our HSA plans offer: Lower premiums with HSA-qualified plans Valuable federal and state tax savings on employee contributions Significant tax savings on employer contributions Simple online funding No minimum deposit Dedicated employer/producer customer support

14 Health Reimbursement Arrangement (HRA) HAP s health reimbursement arrangement (HRA) helps employers control costs by putting employees in charge of their health care spending. Once a HAP or Alliance Health and Life Insurance Company (Alliance) plan design is selected, HAP and our HRA partner can establish a reimbursement account of any dollar amount to help share the cost of health care between employers and employees. This provides a financial incentive to employees to adopt healthy lifestyles and make informed health care choices. Advantages of an HRA include: Employer can deposit pretax dollars in an HRA Choice and flexibility to determine reimbursement approach Lower premiums with high- HRA plans Timely HRA reimbursement and electronic eligibility verification Three HRA options offer greater flexibility in plan design: 1. An employee submits all receipts to our HRA partner for reimbursement, which goes directly to the employee. 2. HAP automatically directs HRA-eligible claims for reimbursement, which goes directly to the employee. 3. HAP automatically directs HRA-eligible claims to our HRA partner for reimbursement, which goes directly to the provider. 24

15 HSA vs. HRA CDHP Standard Plan Designs Health Savings Account (HSA) Health Reimbursement Account (HRA) The plan designs below are for groups with two or more eligible employees. Groups of 51 or more eligible employees can also customize a plan. Account Overview Tax-exempt account created to pay for the qualified medical expenses of the account holder and his/her spouse/dependents An employer-funded account used to reimburse employees for qualified medical expenses GOLD HMO 1500 HSA SILVER HMO 2000 HSA GOLD PPO 1500 HSA SILVER PPO 2000 HSA Eligibility A person enrolled in a qualified high- Health Plan A person whose employer offers an HRA IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK Covered Expenses All qualified medical expenses defined in Section 213(d) of the Internal Revenue Code Defined by employer Member Liabilities Annual Deductibles (Individual/Family) $1,500 Individual $3,000 Family $2,000 Individual $4,000 Family $1,500 Individual $3,000 Family $3,000 Individual $6,000 Family $2,000 Individual $4,000 Family $4,000 Individual $8,000 Family Account Owner The employee The employer Contributions Portability The employee, employer or both can make contributions up to the maximum amount set each year by the IRS. Fully portable Only the employer can make contributions. There is no limit. Portability allowed but not required; defined by employer Rollover of Unused Balance Yes, automatic yearly rollover Defined by employer Member Coinsurance Out-of-Pocket Maximum(*) (Individual/Family) $2,000/$4,000 $4,000/$8,000 Preventive Office Visit (Preventive) Periodic Physical Exams, Well Baby/Child Exams, Immunizations, Routine Eye and Hearing Exams Immunizations, Related Lab Tests and X-rays, Pap Smears and Mammograms Outpatient Services $2,000 Individual $4,000 Family $4,000 Individual $8,000 Family $4,000 Individual $8,000 Family $8,000 Individual $16,000 Family Covered Covered Covered Not covered Covered Not covered Covered Covered Covered Not covered Covered Not covered Office Visit PCP/Specialist 2 after Covered after 2 after 5 after Covered after 5 after Outpatient Surgery and Related Services 2 after Covered after 2 after 5 after Covered after 5 after Tax Advantages Employer contributions are tax ; may be excluded from gross income. Employee contributions are tax. Employer contributions are tax ; may be excluded from gross income. Inpatient Services Inpatient, Labor/Delivery, Mental Health, Chemical Dependency Emergency Services 2 after Covered after 2 after 5 after Covered after 5 after Minimum Deductible for 2014 $1,250 single; $2,500 family No minimum Out-of-pocket Maximum for 2014 $6,350 single; $12,700 family Not applicable Emergency Care 2 after Covered after 2 after 2 after in-network Covered after Covered after in-network Urgent Care 2 after Covered after 2 after 2 after in-network Covered after Covered after in-network Additional Benefits Vision Hardware Adult/Pediatric Eyeglasses every 12 months Eyeglasses every 12 months Eyeglasses every 12 months Not covered Eyeglasses every 12 months Not covered Maximum Contributions for 2014 $3,300 single; $6,550 family Defined by employer Dental Benefits Adult/Pediatric Prescription Drugs Rx Copay Generic/Preferred Brand/Nonpreferred Brand/Specialty 2 after $20/$40/5/5 after 2 covered after 2 covered after in-network $20/$40/5/5 after $20/$40/5/5 after in-network NOTE: The above comparisons are to be used for general reference only. Please refer to individual benefit summaries for benefit levels for each service. *Out-of-pocket maximum includes and coinsurance, and s

16 Vision and Dental Benefits Vision Benefits HAP has vision benefits covered! One of the 10 Essential Health Benefits is pediatric vision, and pediatric is defined as those members under 19 years of age. All HAP qualified health plans include vision coverage. All members, both adult and pediatric, will receive the following benefits. Included vision benefits: Annual routine eye exam One pair of eyeglasses every calendar year One pair of lenses every calendar year, including your choice of single vision, conventional (lined bifocal or trifocal) and lenticular Lenses including choice of glass, plastic or polycarbonate, fashion and gradient tinting, oversized scratch resistant coating, and glass-grey #3 prescription sunglass lenses are covered without cost-sharing Contact lenses once every calendar year in lieu of eyeglasses Wide selection of designated collection frames and contact lenses Routine teeth cleanings can help people with diabetes better manage their condition Delta Dental When considering a health plan, don t forget about smiles! Dental care is so very important. Minor oral health problems, left untreated, can lead to more serious health problems which can affect overall health. Dental care can also be very expensive without insurance. A quality dental plan from Delta Dental can help your customers get the care they need. They can find additional benefits and coverage information and search for an affiliated dentist at deltadentalmi.com. Did you know? Many productive school and work hours are lost each year to dental-related illness During a dental checkup, a dentist can detect oral cancer in its earliest stages or even when cells in your mouth are precancerous

17 Dental Benefits One of the 10 Essential Health Benefits is pediatric dental and pediatric is defined as those members under 19 years of age. If you purchase a health plan, and have not purchased dental benefits from a Health Insurance Marketplace-certified stand-alone dental carrier, you must choose from one of the following Delta Dental options: Pediatric dental coverage Pediatric and adult dental coverage Delta Dental Pediatric Benefits Pediatric dental is an EHB and includes members under the age of 19. Pediatric dental coverage is required with a health plan purchased directly. For the pediatric-only dental plans, the children s coverage terminates at the end of the year they turn 19. The children s benefit automatically converts to adult coverage the next January 1 after they turn 19. Coverage will continue at the same rate until the children reach the maximum age of 26. Diagnostic and Preventive Pediatric Dental PPO Dentist In-Network Premier Dentist Out-of-Network Nonparticipating Dentist Plan Pays Plan Pays Plan Pays Diagnostic and Preventive Services exams, cleanings, fluoride and space maintainers Brush Biopsy to detect oral cancer Emergency Palliative Treatment to temporarily relieve pain Radiographs X-rays Sealants to prevent decay of permanent teeth Basic services Minor Restorative Services fillings and crown repair Oral Surgery Services extractions and dental surgery Endodontic Services root canals Periodontic Services to treat gum disease Relines and Repairs to bridges and dentures Other Basic Services misc. services Major services Prosthodontic Services bridges and dentures Major Restorative Services crowns In-Network Out-of-Pocket Maximum for EHB Covered Services - An Out-of-Pocket Maximum is the maximum amount that you or an Eligible Dependent will pay for Covered Services throughout a Benefit Year. For all In-Network EHB Covered Services provided to individuals under the age of 19, your maximum out-of-pocket payments under this Policy shall be $700 per Benefit Year if this Policy covers one individual under the age of 19, or $1400 per Benefit Year if this Policy covers two or more individuals under the age of 19. Any Coinsurance, Copayments or Deductibles paid by you for In-Network EHB Covered Services provided to individuals under the age of 19 shall count toward that In-Network Out-of-Pocket Maximum. The In-Network Out-of-Pocket Maximum will not include any amounts paid for the following: (i) premiums; (ii) payments made by you for Non-covered services; (iii) payments made by you to Out-of-Network Dentists; (iv) Coinsurance, Copayments, or Deductibles paid by you for services other than EHB Covered Services; or (v) Coinsurance, Copayments, or Deductibles paid by you for EHB Covered Services provided to individuals 19 years of age and older. Once your applicable In-Network Out-of-Pocket Maximum is reached for the Benefit Year, all In-Network EHB Covered Services provided to individuals under the age of 19 will be covered at 10 of the Maximum Approved Fee. Out-of-Network Out-of-Pocket Maximum for EHB Covered Services - There is no annual Out-of-Pocket Maximum for Out-of-Network EHB Covered Services. You will be responsible for all Coinsurance, Copayments, Deductibles and Balanced Billing Amounts associated with all Out-of-Network EHB Covered Services provided to you or your Eligible Dependent throughout the Benefit Year. Annual and Lifetime Maximum Payments for EHB Covered Services - For all EHB Covered Services provided to individuals under the age of 19, there are no annual or lifetime Maximum Payments. Deductibles for EHB Covered Services - None. Waiting Period for EHB Covered Services - There are no waiting periods for individuals under the age of 19 seeking EHB Covered Services. If you have any questions about this Policy, please call Delta Dental s Customer Service department, toll-free, at (800) You may also write to Delta Dental s Customer Service department at P.O. Box 1596, Indianapolis, Indiana This document is intended as a supplement to your Dental Care Certificate and Summary of Dental Plan Benefits. Please refer to your certificate and summary for costs and complete details of coverage, including policy exclusions and limitations, or call us toll-free at (800) This Policy is underwritten by Delta Dental Plan of Michigan, Inc., a nonprofit dental care corporation.

18 Delta Dental PPO Adult Benefits For families that want adult dental coverage, all adults have to elect coverage. If members indicate they have EHB-certified pediatric coverage, HAP will not offer adult-only dental coverage. Adults without children will be charged a $0 pediatric plan premium and will be provided with evidence of compliance for the EHB pediatric coverage from Delta Dental. All adults (over the age of 19 upon effective date) will be included if adult coverage is selected. Only the three oldest children under 19 are charged the pediatric rate. Plan Type: Self-funding/Shared-funding Adult Dental Diagnostic and Preventive Delta Dental PPO Dentist In-Network Delta Dental Premier Dentist Out-of-Network Nonparticipating Dentist Plan Pays Plan Pays Plan Pays Diagnostic and Preventive Services exams, cleanings, fluoride and space maintainers Brush Biopsy to detect oral cancer Emergency Palliative Treatment to temporarily relieve pain Radiographs X-rays Sealants to prevent decay of permanent teeth Basic services Minor Restorative Services fillings and crown repair Oral Surgery Services extractions and dental surgery Endodontic Services root canals Periodontic Services to treat gum disease Relines and Repairs to bridges and dentures Other Basic Services misc. services Major services Major Restorative Services crowns Prosthodontic Services bridges, implants and dentures Annual and Lifetime Maximum Payments for Non-EHB Covered Services - For individuals 19 years of age or older, or individuals under the age of 19 seeking Non- EHB Covered Services, the Maximum Payment is $1,000 per individual total per Benefit Year on all services. Out-of Pocket Maximum Payment for Non-EHB Covered Services - An Out-of-Pocket Maximum is the maximum amount that you or your Eligible Dependent will pay for Covered Services throughout a Benefit Year. There is no Annual Out-of-Pocket Maximum Payment for Non-EHB Covered Services. You will be responsible for all Coinsurance, Copayments, Deductibles and Balanced Billing Amounts associated with all Non-EHB Covered Services provided to you or your Eligible Dependent throughout the Benefit Year. Deductibles for Non-EHB Covered Services - None. Waiting Period for Non-EHB Covered Services - There are no waiting periods for Covered Services under this Plan. Eligibility - In addition to you, the following persons are eligible under this Policy: Your Legal Spouse and your Children under age 26, including your Children who are married, who no longer live with you, who are not your dependents for Federal income tax purposes, and/or who are not permanently disabled. You and your Eligible Dependents must enroll for a minimum of 12 months. If Coverage is terminated prior to completing 12 months, you may not re-enroll for at least 12 months from the date of termination. Self-funding HAP can help groups with self-funding plan administration by offering guidance with risk management, claims management and compliance. We work with groups to design a plan that meets their needs and we regularly review the plan and provide guidance. Every claims payment is made known to the employer group and is available online 24/7. We provide detailed reports daily, monthly or annually. Because HAP manages the plan and administers all claims, the data we collect can be used to provide comprehensive benefit and utilization reports. Shared-funding Shared-funding is a type of self-funding designed to allow groups with as few as 51 employees to consider this unique approach. With shared-funding, a monthly funding level is established that can be budgeted much like a premium. This approach makes it possible for smaller groups to take advantage of the economics of self-funding, just as many larger groups have done for years. For example, set premium taxes are not assessed on claim payments, and if claims do not reach the funding limit, the group retains those funds rather than HAP. Often, the fixed costs of a separate self-funded plan are lower than the fixed costs included in a group health insurance premium. Network Clients can access HAP s statewide network, which offers access to providers throughout the state of Michigan. Arrangements with national and regional networks provide access to care for employees outside of Michigan. Together, we will identify the best national partner for your client. Benefits will cease on the last day of the month in which you have paid premium. If you have any questions about this Policy, please call Delta Dental s Customer Service department, toll-free, at (800) You may also write to Delta Dental s Customer Service department at P.O. Box 1596, Indianapolis, Indiana This document is intended as a supplement to your Dental Care Certificate and Summary of Dental Plan Benefits. Please refer to your certificate and summary for costs and complete details of coverage, including policy exclusions and limitations, or call us toll-free at (800) This Policy is underwritten by Delta Dental Plan of Michigan, Inc., a nonprofit dental care corporation

19 Why Choose HAP for Self-funding? Complete customer service. HAP gives every self-funded client a dedicated account team, including an account executive, an account coordinator, a claims supervisor, a claims analyst and a plan administration representative. Statewide and national networks. Employers and organized labor markets can access HAP s statewide network, which offers providers throughout the state of Michigan. Arrangements with national and regional networks provide access to care for employees outside of Michigan. Together, we will identify the best national partner for you and your employees. Your customers determine their benefits. We work with you to design a plan that meets your customers needs. We build the benefit plan on our system and provide the summary plan descriptions for your customers employees. We also regularly review their plans and provide guidance. We work with you, but your customers have control. Your customers will know where every dollar is spent. We re committed to full transparency. Every claims payment is made known to your customer and is available online 24/7. We provide detailed reports daily, monthly or annually. We even allow audits. We manage risk. Because HAP manages the plan and administers all claims, the data we collect can be used to provide comprehensive benefit and utilization reports. These reports provide a road map to help continually improve the benefit plan and control future costs. That is truly what managing health benefits is all about. A New Approach to Managing Health Care Costs Fixed Group Health Care Expenses for Three Years HAP is the exclusive Michigan health plan partner for Trendline Health. Trendline Health is an organization that offers risk management and funding options via its proprietary Trendline Health Model. This program has been used successfully for more than 16 years to help groups better budget and set overall limits on their health care costs. Groups that qualify* for this program will realize the following benefits: Predictable Health Care Expenses Level health insurance costs at a fixed rate for the next three years. Insulate and protect customers from unpredictable trend increases in health care costs and excessive risks from claim expense anomalies or variations. An Improved Balance Sheet Let expenses that normally vary widely from year to year play a more productive role on customers balance sheet. Protect clients credit and bond ratings. Groups will enhance their financial position by prepaying against their existing and future liabilities. Employers will be able to move their current health care liabilities to contingent liabilities, effectively removing these significant obligations from their balance sheet. Build Cash Reserves Groups can build plan capital by setting aside health care funds in a tax-free reserve that will accrue interest. These investment gains will be used to buy down your customers future health care costs. *Groups must be reviewed and approved by HAP s Risk Assessment, Revenue Management & Client Reporting (R3) department in advance. Groups must provide complete claims and enrollment data; must exhibit consistency in enrollment, employer commitment, employee participation and minimum size requirements; and have a sound employer contribution structure

20 How It Works The Trendline Model is a proprietary mathematical and statistical system that captures and analyzes detailed claim, retention and demographic data to determine future health plan benefit costs in conjunction with HAP. This program quantifies the upper limit of health care liability exposure and integrates it into a powerful financial risk management tool. There are two models: one for self-funded plans and one for fully insured plans. Self-funded groups: A trust is formed, and then Trendline goes to the capital markets to fund the net present value of the group s expected health care exposure (over three years using a short-term note offering or loan transaction). The new trust is fully funded up front and holds this debt as opposed to the employer group or labor organization. This future health care liability is now a contingent liability on the customers balance sheet. The group s employees are designated as the beneficiaries of this trust. Fully insured groups: HAP will form the trust and will hold the funds. Interest accrued will be applied to offset the group s health care costs for the three-year term. Payment transactions: The trust holds the cash proceeds from the loan or short-term note, employee contributions, and investment income. Any residual investment income is used to service the principal and interest on the loan. This fund is used to pay the health plan for variable claims, fixed costs, and the principal and interest on the loan. The group simply pays the trust a fixed, predetermined monthly remittance over a three-year term. For fully insured groups, HAP will hold the trust proceeds, and the group will remit payments to HAP. This model develops significant cash-flow savings, whether the group is self-funded or fully insured. Payment flexibility: The program can be tailored over the three-year period to meet the needs of the group s employees based on its current situation. During the quoting process, HAP can make adjustments for this anticipated up-front revenue and credit the customer s lower administrative costs (no plan marketing, renewals or negotiations) and accrued interest

21 Health Alliance Plan Subsidiaries: Alliance Health and Life Insurance Company HAP Preferred Inc. hap.org 2013 Health Alliance Plan of Michigan A Nonprofit Company /13 1M 335