POS Individual Health Plans

Transcription

1 Louisiana Health cooperative POS Individual Health Plans Available in all parishes statewide LOUISIANA HEALTH COOPERATIVE 2014 Benefits at a Glance POS-I V.1

2 POS Individual Health Plans Louisiana Health Cooperative, Inc. (LAHC) is a non-profit, member-governed health insurance company with a mission to promote community health and well-being by engaging members and providers in the valued delivery of high quality, integrated health care services. LAHC offers a wide range of insurance options to fit the needs of individuals, families and employers. This Benefits at a Glance details important information about each plan offered. Coverage options are divided into POS (broad provider network) and HMO (narrow provider network) plans. Plans are categorized as Platinum, Gold, Silver, Bronze or Catastrophic. Platinum plans have higher premium, but lower outof-pocket costs for co-pays and s. Catastrophic plans offer lower cost insurance premiums, with higher co-pays and s. In between these two plan options, are the Gold, Silver and Bronze medal plans. POS Provider Network HMO Provider Network 12,000+ Health Care Providers 8,000+ Health Care Providers 200 Hospitals (approximately) 115 Hospitals (approximately) 3,000+ Primary Care Physicians 1,700+ Primary Care Physicians 5,000+ Specialists 3,000+ Specialists LAHC s POS network covers the entire state. Members enrolled in an HMO insurance plan may utilize services of providers in any HMO service region in the state. Urgent care for HMO members is covered in the New Orleans, Baton Rouge, Shreveport, and Lafayette service areas. * Emergency Care is covered worldwide. ** Louisiana Health Cooperative provides Essential Health Benefits within each plan: Ambulatory patient services Emergency care Maternity and newborn care Mental health & substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative & restorative services and devices Laboratory services Preventative & wellness services Pediatric services (including vision care) The LAHC Difference The development of health cooperatives are a direct result of the Affordable Care Act (ACA). Consumer Operated and Oriented Plans (CO-OPs) are non-profit, member-governed health insurance companies with a focus on developing programs intended to improve the quality of health care delivered to members. All surplus remaining in the cooperative after paying the cost of operations helps to lower premiums, improve benefits, expand enrollment and improve the quality of health care services delivered to the Members. * Urgent care for HMO members is not in the Lake Charles, Alexandria, Monroe service areas, or outside of Louisiana. ** Urgent Care facilities are generally used when the illness or injury is something you d normally see a doctor for, but you can t get an appointment right away or it s after hours. Emergency care is needed when the absence of immediate medical attention would result in a threat to life, limb, or eyesight, or when the person has painful symptoms requiring immediate attention to relieve suffering. Emergency care is usually offered 24/7 and includes emergency room and ambulance services.

3 The Benefits at a Glance below helps with choosing the right health insurance plan for individuals. This is only a summary. For more details about LAHC benefits and coverage, go to mylahc.org Individual Benefits Platinum Plus Gold Plus Silver Plus Bronze Plus Catastrophic Plus Participating Provider Non-Participating Provider Participating Provider Non-Participating Provider Participating Provider Non-Participating Provider Participating Provider Non-Participating Provider Participating Provider Non-Participating Provider Preventive/Wellness Care 50% After Deductible 60% After Deductible 70% After Deductible 80% After Deductible Preventive Screenings 50% After Deductible 60% After Deductible 70% After Deductible 80% After Deductible Immunizations* 50% After Deductible 60% After Deductible 70% After Deductible 80% After Deductible Doctor s Office Visit $10 Co- Pay 50% After Deductible $20 Co-Pay 60% After Deductible $40 Co-Pay 70% After Deductible $60 Co-Pay 80% After Deductible - Up to 3 primary care visits covered at no charge before Specialist/Other Practitioner $20 Co-Pay 50% After Deductible $40 Co-Pay 60% After Deductible $60 Co-Pay 70% After Deductible $100 Co-Pay 80% After Deductible Lab 50% After Deductible 60% After Deductible 70% After Deductible 80% After Deductible Imaging (CT/PET scans, MRIs) $375 Co-Pay 50% After Deductible $375 Co-Pay 60% After Deductible $375 Co-Pay 70% After Deductible $375 Co-Pay 80% After Deductible $375 Co-Pay Outpatient Ambulatory Surgery up at 50% co-insurance after then then maximum, then Urgent Care $200 Co-Pay $200 Co-Pay and 50% after $200 Co-Pay $200 Co-Pay and 60% after $200 Co-Pay $200 Co-Pay and 70% after $100 Co-Pay $200 Co-Pay and 80% after Emergency Care** (includes Emergency Room and Emergency Medical Transport) $375 Co-Pay + 20% Co-insurance, waived if admitted $375 Co-Pay + 20% Co-insurance, waived if admitted $375 Co-Pay + 20% Co-insurance, waived if admitted $375 Co-pay + 40% Co-insurance, waived if admitted $375 Co-Pay/day for first 3 days + 20% coinsurance after 50% coinsurance after maximum, then $375 Co-Pay/day for first 3 days + 20% coinsurance after $700 Co-Pay/day for first 3 days + 60% coinsurance after maximum, then $375 Co-Pay/day for first 3 days + 20% coinsurance after maximum, then 70% coinsurance after $375 Co-Pay/day for first 3 days + 40% coinsurance after maximum, then 80% coinsurance after up Maternity Pre and Postnatal Care Delivery and All Inpatient up at 50% co-insurance after 50% co-insurance after then then then maximum, then Mental/Behavioral Health & Substance Abuse Outpatient Inpatient $20 Co-Pay up at 50% co-insurance after $40 Co-Pay then $60 Co-Pay then $100 Co-Pay maximum, then Prescription Drugs Co-Pay (In or Out-of-Network) (Preferred Generic/ Non-Preferred Generic) Prescription Drugs Co-Pay (In or Out of Network) (Preferred Brand/Non-Preferred Brand/Specialty) Pediatric (vision care only) Covers 1 eye exam and up to 50% of a single pair of eyeglasses per benefit period, except Catastrophic, for ages 17 and younger. Deductible Up to $5/ Up to $20 Up to $10/ Up to $30 Up to $15/ Up to $40 Up to $25/ Up to $60 $0 per Prescription After Deductible Up to $30/ Up to $60/ 25% Speciality Up to $40/ Up to $70/ 25% Speciality Up to $50/ Up to $80/ 25% Speciality Up to $75/ Up to $120/ 40% Speciality $0 per Prescription After Deductible $20 Co-Pay 50% After Deductible $40 Co-Pay 60% After Deductible $60 Co-Pay 70% After Deductible $100 Co-Pay 80% After Deductible Overall Deductible (person/family) $500/$1,000 $1,500/$3,000 $1,500/$3,000 $3,500/$7,000 $2,000/$4,000 $4,500/$9,000 $4,750/$9,500 $7,500/$15,000 $6,350/$12,700 $10,000/$20,000 Out-of-Pocket Limit (person/family) $1,400/$2,800 $6,000/$12,000 $3,000/$6,000 $8,500/$17,000 $6,000/$12,000 $10,000/$20,000 $6,350/$12,700 $20,000/$40,000 $6,350/$12,700 $25,000/$45,000 * Many immunizations are covered at no additional charge and no. Immunizations required prior to traveling abroad are not covered. **Emergency are covered worldwide. For up to a 30-day supply. All co-pays, co-insurance, s and out-of-pocket expenses shown are member responsibilities. Please refer to the LAHC Summary of Benefits on our website, mylahc.org for more detailed plan descriptions.

4 Subsidy Variations Individuals who meet certain income requirements may qualify for cost-sharing subsidies to help offset out of pocket costs which are only available through the Federal Health Insurance Marketplace. The percentage of costs subsidized are based on the premium for Louisiana Health Cooperative s Silver plan, which are displayed on the front & back of this page. Silver Plus 2014 Individual Benefits Silver Plus This is only a summary. For more details about LAHC benefits and coverage, go to mylahc.org. Base 73% 87% 94% Participating Provider Non-Participating Provider Participating Provider Non-Participating Provider Participating Provider Non-Participating Provider Participating Provider Non-Participating Provider Preventive/Wellness Care 70% After Deductible 70% After Deductible 70% After Deductible 70% After Deductible Preventive Screenings 70% After Deductible 70% After Deductible 70% After Deductible 70% After Deductible Immunizations* 70% After Deductible 70% After Deductible 70% After Deductible 70% After Deductible Doctor s Office Visit $40 Co-Pay 70% After Deductible $25 Co-Pay 70% After Deductible $15 Co-Pay 70% After Deductible $5 Co-Pay 70% After Deductible Specialist/Other Practitioner $60 Co-Pay 70% After Deductible $50 Co-Pay 70% After Deductible $30 Co-Pay 70% After Deductible $15 Co-Pay 70% After Deductible Lab 70% After Deductible 70% After Deductible 70% After Deductible 70% After Deductible Imaging (CT/PET scans, MRIs) $375 Co-Pay 70% After Deductible $250 Co-Pay 70% After Deductible $125 Co-Pay 70% After Deductible $50 Co-Pay 70% After Deductible Outpatient Ambulatory Surgery maximum, then 15% co-insurance after 10% co-insurance after up Urgent Care $200 Co-Pay $200 Co-Pay and 70% after $150 Co-Pay $200 Co-Pay and 70% after $100 Co-Pay $200 Co-Pay and 70% after $50 Co-Pay $200 Co-Pay and 70% after Emergency Care** (includes Emergency Room and Emergency Medical Transport) $375 Co-Pay + 20% Co-insurance up to out of pocket maximum, then, waived if admitted $250 Co-Pay + 20% Co-insurance up to out of pocket maximum, then, waived if admitted $125 Co-Pay + 15% Co-insurance up at, waived if admitted $50 Co-Pay + 10% Co-insurance up at, waived if admitted $375 Co-Pay/day for first 3 days + 20% coinsurance after up to out of pocket maximum, then paid at $700 Co-Pay/day for first 3 days + 70% coinsurance after maximum, then $250 Co-Pay/day for first 3 days + 20% coinsurance after up to out of pocket maximum, then paid at $700 Co-Pay/day for first 3 days + 70% coinsurance after up to out of pocket maximum, then $125 Co-Pay/day for first 3 days + 15% coinsurance after 70% coinsurance after $50 Co-Pay/day for first 3 days + 10% coinsurance after up 70% coinsurance after up Maternity Pre and Postnatal Care Delivery and All Inpatient maximum, then 15% co-insurance after 10% co-insurance after up Mental/Behavioral Health & Substance Abuse Outpatient Inpatient $60 Co-Pay maximum, then $50 Co-Pay $30 Co-Pay 15% co-insurance after $15 Co-Pay 10% co-insurance after up Prescription Drugs Co-Pay (In or Out-of-Network) (Preferred Generic/ Non-Preferred Generic) Prescription Drugs Co-Pay (In or Out of Network) (Preferred Brand/Non-Preferred Brand/Specialty) Pediatric (vision care only) Covers 1 eye exam and up to 50% of a single pair of eyeglasses per benefit period, except Catastrophic, for ages 17 and younger. Up to $15/ Up to $40 Up to $10/ Up to $30 Up to $10/ Up to $30 Up to $5/ Up to $5 Up to $50/ Up to $80/ 25% Speciality Up to $50/ Up to $80/ 25% Speciality Up to $40/ Up to $60/ 25% Speciality Up to $20/ Up to $40/ 25% Speciality $60 Co-Pay 70% After Deductible $50 Co-Pay 70% After Deductible $30 Co-Pay 70% After Deductible $15 Co-Pay 70% After Deductible Deductible Overall Deductible (person/family) $2,000/$4,000 $4,500/$9,000 $1,750/$3,500 $4,500/$9,000 $500/$1,000 $4,500/$9,000 $150/$300 $4,500/$9,000 Out-of-Pocket Limit (person/family) $6,000/$12,000 $10,000/$20,000 $5,200/$10,400 $10,000/$20,000 $1,500/$3,000 $10,000/$20,000 $700/$1,400 $10,000/$20,000 * Many immunizations are covered at no additional charge and no. Immunizations required prior to traveling abroad are not covered. **Emergency are covered worldwide. For up to a 30-day supply. All co-pays, co-insurance, s and out-of-pocket expenses shown are member responsibilities. Please refer to the LAHC Summary of Benefits on our website, mylahc.org for more detailed plan descriptions.

5 You may be able to receive subsidies to help offset monthly premiums that are only available through the Federal Health Insurance Marketplace. Eligibility of low and moderate income individuals is determined by the Marketplace. To learn if you qualify for subsidies, call: Louisiana Health Cooperative Monday Friday, 8:00 a.m. 8:00 p.m. Small Business Resources Have questions about the SHOP Marketplace for businesses with 50 or fewer employees? Call: TTY users should call Monday Friday, 8:00 a.m. 4:00 p.m. CST Agents and brokers may also use this number. Federal Health Insurance Marketplace TTY users should call Lines open 24 hours a day LAHC is sponsored by a coalition of health care providers, business leaders and community leaders, who believe that providing better access to high quality care will improve patients outcomes. Exchange POS/HMO Commercial POS/HMO For More Information Consult your insurance agent, visit or call toll-free: Louisiana Health Cooperative, Inc N. Causeway Blvd, Suite 800 Metairie, LA