2015 Broker Handbook. Your resource to plans, services and support for groups, individuals and family plans.

Transcription

1 2015 Broker Handbook Your resource to plans, services and support for groups, individuals and family plans. for broker use only April 2015

2 When it comes to healthcare, we re changing everything. Starting with building great working relationships with brokers like you. Coming together to improve healthcare for Arizona. Our goals are the same: to help Arizonans achieve better health through the kind of care they demand and deserve. Which is why we invite you to join us as we work together with brokers, healthcare professionals, organizations and our members to provide individuals, families and businesses with a wide array of affordable plans and benefits. We re dedicated to helping you serve your clients through responsive service, user-friendly technology and accessible information. This handbook is one of many tools you can expect from us. Use it as a resource to learn about us, the Marketplace, our plans, services, and more. Improving the health and wellbeing of Arizonans will take a team effort. Be a part of Meritus Together for better health. Meritus products and services are provided through Meritus Mutual Health Partners (a PPO) and Meritus Health Partners (an HMO). Questions? We re here for you. meritusaz.com Table of Contents About Meritus...2 Provider Networks...5 Understanding the Marketplace...15 Assistance: Making Healthcare Affordable for All...19 Meritus Rules Regarding Federal Marketplace...21 Step by Step Guide to Individual and Family Application Process...25 Meritus Small Groups...37 Meritus Health Plans and Rates...61 Meritus Pricing Sheets...94 Meritus Pharmacy Benefits Broker Resources and Support Updated April 2015 meritusaz.com Broker Use Only Meritus Broker Manual 1

3 Focused on maximizing consumer value, not shareholder value. Welcome to a whole new kind of healthcare. New to the market, but not to the healthcare world, we are a non-profit health insurance company and Arizona s first and only cooperative model. We started as a community coalition, and we ve been actively involved at the community level, working to create better access to affordable, quality healthcare choices for Arizonans. The Meritus team, comprised of experienced leaders in healthcare and the health insurance industry, bringing a broad range of expertise and innovation to our efforts. 2 Meritus Broker Manual

4 About Meritus How we re different We want our members to utilize their insurance coverage with confidence, helping them to be healthier than when they first joined us! Our cooperative (CO-OP) model is different from traditional health insurance companies. As a membergoverned organization, one in which members both serve and have the opportunity to vote on the Board of Directors, we answer to and focus on our members. We reinvest our excess revenue for the good of our members, helping to control premiums, improve benefits, promote wellness and encourage preventive care. Putting our members first means: Affordable healthcare that Arizonans can count on. What s New for 2015? MeMD 24/7 Telemedicine service at no charge to our members (see page 14) CVS Minute Clinics covered at a primary care copay (see page 14) New network options All new plans for both HMO, PPO & HSA Direct Enrollment to the Federal Marketplace no need to enroll using Healthcare.gov Focusing on maximizing consumer value not shareholder value. Innovative plans that include coverage for Naturopathy, Acupuncture, Massage Therapy and reward members for keeping healthy like reimbursement for gym members. Building strong broker partnerships. What s a CO-OP? CO-OPs (Consumer Operated and Oriented Plans) exist to serve their members. A CO-OP must use excess revenue to support members through premium control, expanded benefits and innovations in service models. Rather than focusing on money-saving short cuts, we focus on quality care and services for our members. As a non-profit organization, we are prohibited by law from ever being sold or re-organized as a for-profit corporation. Meritus is Arizona-owned and operated, with headquarters in Tempe. Meritus At a Glance Headquartered in Tempe Organized in 2012, physicianfounded local coalition Licensed by the Arizona Department of Insurance in 2013 Arizona s first and only health insurance cooperative Member-governed, nonprofit consumer operated and oriented plan (CO-OP) Certified by the Federal Government as a Qualified Health Plan meritusaz.com Broker Use Only Meritus Broker Manual 3

5 CO-OPs under the ACA The CO-OP program under the Patient Protection and Affordable Care Act (ACA) is intended to foster the creation of new consumer-governed, private, non-profit health insurance issuers, in every state. Arizona s insurance market is dominated by large commercial carriers; there is a need for competition and innovation. As a healthcare cooperative established under the ACA, Meritus is a new and different way of providing healthcare coverage. The success of other health plan CO-Ops such as Health Partners and Group Health have served as a model for the design and development of Meritus. Our predecessors have demonstrated that the healthcare CO-OP model can realign the financial goals of providers, insurers, brokers and patients. CO-OPs are subject to the same rules as all other insurance plans under healthcare reform. We re fully licensed by the Department of Insurance and certified by the Federal Government as a Qualified Health Plan (QHP). Meritus has all new plans for 2015 based on feedback from Brokers We designed HMO and PPO products structured around copays for most services, no hidden fees and predictable outof-pocket costs. We created a range of deductibles and copays. We designed plans with pharmacy benefits that provide generic maintenance medications without copays. We structured our plans with lower copays for primary care visits, sick visits or well visits, to help promote preventive care and wellness. We included complementary and alternative medicine benefits such as Acupuncture, Therapeutic Massage, Naturopathy and rewards for staying healthy, including up to $25 per month gym membership reimbursement. These benefits are included on all of our PPO plans and on Gold and Platinum HMO plans. Meritus Financial Information Meritus is a Qualified Health Plan licensed as Meritus Health Partners (HMO) and Meritus Mutual Health Partners (PPO) in Arizona. Meritus is subject to the same reserve requirements as all carriers in the state. Arizona Department of Insurance requires all carriers to maintain at least 300% risk based capital to ensure solvency CMS requires Meritus to maintain 500% risk based capital an even higher standard! Meritus is supported by a $90 million loan from CMS to ensure its capital position is strong. Meritus has reinsurance coverage from the federal government up to $250K per claim. Meritus also has commercial reinsurance coverage in excess of the federal limits. 4 Meritus Broker Manual

6 Building better health in communities through our Provider Networks. We believe in developing long-term partnerships with providers by working together to improve health outcomes and better control healthcare costs for our members and the people of Arizona. It s this friendly approach to achieving real change that we believe creates a positive payer/provider dynamic - one we believe will change healthcare as we know it, for the good. meritusaz.com Broker Use Only Meritus Broker Manual 5

7 Meritus Provider Network Design Building better health in communities through our Provider Network. Meritus PPO Network 1 The Arizona Foundation for Medical Care Network is the backbone of the Meritus PPO Network. We contract directly with additional providers to make up our entire PPO network. We have a provider search tool on our website at meritusaz.com where you can find a complete list of doctors and facilities that are part of the Meritus PPO network. PPO 10,941 physicians and mid-level providers 45 Acute hospitals and 12 Behavioral Health hospitals HMO 4,148 physicians 30 Acute hospitals and 3 Behavioral Health hospitals PPO Network 1 Contracted Hospitals COUNTY CITY FACILITY NAME Apache Ganado Sage Memorial Hospital Springerville White Mountain Regional Medical Center Cochise Bisbee Copper Queen Community Hospital Douglas Southeast Arizona Medical Center Sierra Vista Sierra Vista Regional Health Center Willcox Northern Cochise Community Hospital Coconino Flagstaff Flagstaff Medical Center Page Page Hospital Tuba City Tuba City Regional Healthcare Gila Globe Cobre Valley Regional Medical Center Payson Payson Regional Medical Center Safford Mt Graham Regional Medical Center La Paz Bouse La Paz Regional Hospital Parker La Paz Regional Hospital Parker La Paz Regional Hospital Quartzsite La Paz Regional Hospital Salome La Paz Regional Hospital Maricopa Chandler Arizona Orthopedic & Surgical Specialty Chandler Regional Medical Center Gilbert Banner Gateway Medical Center Banner MD Anderson Cancer Center Mercy Gilbert Medical Center Glendale Arrowhead Hospital Banner Thunderbird Medical Center St. Joseph s Westgate Medical Center Goodyear West Valley Hospital Medical Center Mesa Arizona Spine & Joint Hospital Banner Baywood Medical Center Banner Desert Medical Center Banner Heart Hospital Cardon Children s Medical Center Phoenix Arizona Heart Hospital Banner Estrella Medical Center Banner Good Samaritan Medical Center John C. Lincoln Hospital - Deer Valley John C. Lincoln Hospital - North Mtn Maricopa Medical Center Maryvale Hospital Medical Center Oasis Hospital Paradise Valley Hospital Phoenix Baptist Hospital Phoenix Children s Hospital Select Specialty Hospital - Phoenix St. Joseph s Hospital & Medical Center 6 Meritus Broker Manual

8 PPO Network 1 Contracted Hospitals in Maricopa Maricopa County Scottsdale Lincoln Health Network Banner Health Abrazo Health Maricopa Medical Center Dignity Health Phoenix Children s Hospital COUNTY CITY FACILITY NAME Maricopa San Tan Valley Banner Ironwood Medical Center Scottsdale Scottsdale Healthcare Osborn Scottsdale Healthcare Shea Scottsdale Healthcare Thompson Peak Sun City Banner Boswell Medical Center Sun City West Banner Del E Webb Medical Center Mohave Bullhead City Western Arizona Regional Medical Center Kingman Kingman Regional Medical Center Lake Havasu City Havasu Regional Medical Center Navajo Show Low Summit Healthcare Regional Medical Center Winslow Little Colorado Medical Center Pima Tucson Carondelet St. Joseph s Hospital Carondelet St. Mary s Hospital Northwest Medical Center Tucson Medical Center Oro Valley Oro Valley Hospital Pinal Apache Junction Banner Goldfield Medical Center Casa Grande Casa Grande Medical Center Florence Florence Hospital at Anthem Sacaton Hu Hu Kam Memorial Hospital Santa Cruz Nogales Carondelet Holy Cross Hospital Yavapai Cottonwood Verde Valley Medical Center Prescott Yavapai Regional Medical Center Prescott Valley Mountain Valley Regional Rehab Hospital Yavapai Regional Medical Center-East Yuma Yuma Yuma Regional Medical Center See page 8 for the Pima and Santa Cruz Counties PPO Network 1 Contracted Hospital locations. meritusaz.com Broker Use Only Meritus Broker Manual 7

9 PPO Network 1 Contracted Hospitals in Pima and Santa Cruz Counties Pima and Santa Cruz Counties Carondelet Health Network Tucson Medical Center Northwest Medical Center/ Oro Valley Nogales Holy Cross Hospital Let us help you find the right doctor. It is very important for us to help our members find doctors that are in their network. We want to help them avoid unnecessary medical bills and any confusion that could result from using doctors that are not contracted in their Meritus plan. When someone signs up for a Meritus plan, it is very important that the member understands where they are able to receive care and the importance of using doctors in their network. Steps to View Providers Please visit meritusaz.com for a complete listing of doctors and facilities by plan. 1. Visit meritusaz.com 2. Click on the Providers tab on the top of the Meritus homepage 3. Click the Find a Provider link 8 Meritus Broker Manual

10 Meritus Complete HMO Network 2 Meritus built our Complete HMO network of doctors with the help from our primary care physicians. Working in partnership with these PCPs, we reached out to other physicians, specialists and hospitals to create a broad and complimentary HMO network for our members. Meritus Community Networks In order to offer low premiums and quality benefits to our members, Meritus also created community HMO network options in partnership with some of the best hospital based healthcare systems in Arizona. Meritus HMO MIHS Network - Maricopa Integrated Healthcare Systems Meritus HMO Banner Network - Banner Health System Meritus HMO Pima Network - Carondelet Health Network Meritus HMO Abrazo Network - Abrazo Health System Meritus HMO Mohave Network - Western Arizona Regional Medical Center A complete listing of the participating Meritus HMO community networks of doctors can be found on our website at meritusazcom. Due to the popularity of our three community network plans from 2014, we will continue to offer these plans in 2015 under new plan names: Meritus Neighborhood Network Maricopa is a plan in partnership with Maricopa Integrated Health System 2015 PLAN NAME Meritus Neighborhood Network Silver HMO MIHS Meritus Community Network Phoenix is a plan in partnership with Banner Health 2015 PLAN NAME Meritus Community Network Silver HMO Banner Meritus Community network Pima is a plan in partnership with Carondelet Health Network 2015 PLAN NAME Meritus Community Network Silver HMO Pima These are the only three plans which include Pediatric Dental. Complementary and Alternative Medicine Network 3 At Meritus, we know that health isn t something that you only fix when it s broken. Acupuncture Naturopathy Therapeutic massage Gym membership reimbursement 4 These benefits are available to members in a number of individual and group plans and are designed to support overall health and well-being. meritusaz.com Broker Use Only Meritus Broker Manual 9

11 Meritus Complete HMO Network 2 Contracted Hospitals in Maricopa County Maricopa County Scottsdale/ Lincoln Health Network Banner Health Abrazo Health Maricopa Medical Center Meritus Complete HMO Network 2 Contracted Hospitals in Pima and Santa Cruz Counties Pima and Santa Cruz Counties Carondelet Health Network Tucson Medical Center Nogales Holy Cross Hospital 10 Meritus Broker Manual

12 Meritus HMO MIHS Network 2 Maricopa County Maricopa Medical Center Phoenix Cancer Center Arizona Burn Center McDowell Health Care Center 11 MIHS Family Health and Community Centers Meritus HMO Banner Network 2 Maricopa County All of the Banner hospitals MD Anderson Cancer Center Cardon Children s Medical Center Banner Heart Hospital meritusaz.com Broker Use Only Meritus Broker Manual 11

13 Meritus HMO Abrazo Network 2 Maricopa County Arizona Heart Hospital Arizona Heart Institute Arrowhead Hospital Maryvale Hospital Paradise Valley Hospital Phoenix Baptist Hospital West Valley Hospital Meritus HMO Pima and Santa Cruz Network 2 Pima and Santa Cruz Counties St. Mary s Hosptial St. Joseph s Hospital - Tucson Carondelet Heart & Vascular Institute Carondelet Neurological Institute Holy Cross Hospital Nogales Holy Cross Hospital 12 Meritus Broker Manual

14 Colorado City Meritus HMO Mohave Network 2 Western Arizona Regional Medical Center Valley Health System, Las Vegas - Centennial Hills Hospital Medical Center - Desert Springs Hospital Medical Center - Spring Valley Hospital Medical Center - Summerlin Hospital Medical Center - Valley Hospital Medical Center Dolan Springs Kingman Bullhead City Mohave Valley Lake Havasu City Peach Springs If you have any questions about Meritus provider networks or need additional information, please call us at or toll free at Hearing Impaired? Call the Arizona Relay Service at 711. Please have the Meritus phone number available for the relay operator Meritus. Meritus products and services are provided through Meritus Mutual Health Partners PPO and Meritus Health Partners HMO. 1 PPO Networks ONLY: You are not required to go to a Preferred Provider. At the time of services, you may obtain Treatment from a Preferred Provider or a Non-Preferred Provider. However, to maximize the benefit reimbursement level under a policy, a preferred Provider must be used. The insured will incur higher out-of-pocket costs if you choose to receive services from an out-of-network provider, and will be responsible for the difference between billed charges and the amount paid by Meritus, other than copayments, co-insurance, or any amounts that my remain on your annual deductible. If you plan to use a non-network provider, you should inquire about the fees you can expect to be charged before you receive services. 2 HMO Networks ONLY: There are no out of network benefits for an HMO. The only out of network services are for emergencies or for services that are arranged for the member due to provider network coverage. 3 Complimentary and Alternative Therapies (CAM) are not a covered benefit in all plans. CAM therapies include therapeutic Massage Therapy, Acupuncture and Naturopathy. CAM Therapies are limited to 12 visits per year. 4 The $25/Month Gym Reimbursement is only available for certain plan options. In order to obtain a gym membership reimbursement, you must submit a claim. Meritus will pay up to $25 per month for each covered person, age 18 and above, who has a gym membership. Gym means a business licensed by the state or +local government to conduct business as: (1) a gym; (2) fitness center; or (3) health club. The gym must have exercise/fitness equipment and have personnel to assist gym members. For a complete listing of benefits available for all plans as well as limitations and exclusions, please contact Meritus. This is an advertisement/informational flyer. A licensed insurance producer may contact you to discuss enrollment in a Meritus health plan. Meritus Mutual Health Partners PPO and Meritus Health Partners HMO are licensed only in Arizona and are Qualified Health Plan issuers in the Health Insurance Marketplace. meritusaz.com Broker Use Only Meritus Broker Manual 13

15 More Healthcare Options Available to Members! Introducing MeMD, one of our benefits! Meritus has teamed up with MeMD to deliver online telehealth services to you. It s simple! Visit login using your Meritus ID. You will be connected to a medical provider over the phone or by webcam to discuss minor conditions, medication refills, or even a second opinion. MeMD is the fastest, most convenient way to see a medical provider online or by phone for common conditions like: Sinus Infections Seasonal Allergies Sprains & Strains Medication Refills Cold & Flu Symptoms Pink Eye Urinary Tract Infections Sore Throats Skin Infections And more! Receive treatment from home, the office or even when you re on vacation! Adding the benefit of the Minute Clinic, brings care to your client s neighborhood Your clients want to make the best choice for their family. You may already know how convenient Minute Clinics are: Open 7 days a week, including evenings and weekends No appointment necessary Located in select CVS/pharmacy stores nationwide Adding new clinics and services all the time Plus, the Minute Clinics accept Meritus plans You might not know that CVS Minute Clinics offer a broad range of services. In addition to diagnosing and treating illnesses, injuries and skin conditions, they also provide all kinds of wellness services, including vaccinations, physicals, screenings and monitoring for chronic conditions. The Minute Clinics family of nurse practitioners and physician assistants provide services for both adults and children, 18 months and older. And they can send a summary of your visit to your primary care provider, with your permission. We hope you choose Minute Clinic to help with your family s health care needs. MeMD.me/meritus cvs.com/minuteclinic/clinics/arizona 14 Meritus Broker Manual

16 The health insurance market as we know it has changed. Understanding the Marketplace. The ACA includes several provisions geared to create greater access to health insurance benefits to more people. Beginning in 2014, most Americans must purchase a minimum amount of health insurance or be taxed by the government. This tax is paid through Federal Income Tax reporting in April each year. For more details about the ACA, visit Healthcare.gov. meritusaz.com Broker Use Only Meritus Broker Manual 15

17 Understanding the Marketplace Under the ACA, each state is required to operate a Health Insurance Marketplace, or in Arizona s case, the Federally Facilitated Marketplace (FFM) also known as an Exchange. People can purchase coverage from private companies like Meritus that have been approved as Qualified Health Plans (QHPs). All QHPs must offer the same core set of benefits called essential health benefits. The difference between plans will be in what and how they offer nonessential health benefits, their deductibles, copayments and coinsurance, and value added benefits. Essential health benefits package must include services and items for the following categories of care:* 1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care *Healthcare.gov: Essential health benefits (accessed October 2012) Marketplace Benefit to Consumers Advanced Premium Tax Credit (APTC) and Cost-Sharing Reductions (CSR) will provide many Arizonans with access to affordable health insurance. Consumers can get lower costs on coverage Our online quoting tool allows you and your clients to find out if they are eligible for subsidies or tax credits to help lower the cost of their monthly premiums or out-of-pocket costs for private insurance. You ll also learn if they qualify for free or low-cost coverage through AHCCCS. Pre-existing conditions are covered Plans are not able to deny consumers coverage or charge them more due to pre-existing health conditions, including a pregnancy or disability. Eligibility for Tax Credits & Cost-Sharing Reductions Individuals or families who purchase coverage in the Marketplace are eligible for a tax credit as long as their household income is up to 400 percent of federal poverty level guidelines; that equals $11,670 to $46,680 per year for an individual and $23,850 to $95,400 per year for a family of four (see income table on page 20). The assistance amount that a person can receive varies with income. The tax credit may be applied to any plan level (Catastrophic, Bronze, Silver, Gold or Platinum). Cost-Sharing Reductions Those who earn up to 250 percent of federal poverty guidelines and enroll at the Silver level only may also be eligible for cost-sharing reductions (CSR). The subsidy amount will vary according to income. Examples of cost-sharing that may be reduced include deductibles, co-insurance, copayments or similar charges and do not include balance billing for non-network providers or spending on non-covered services. (See table on page 20). Penalties for Uninsured Individuals In 2014, legal U.S. citizens who do not carry a minimum amount of health coverage will receive a penalty. Each year through 2016, penalties will increase. 16 Meritus Broker Manual

18 Individual Shared Responsibility Payment Amounts for 2014 and 2015 Tax Years The amount of the individual shared responsibility payment increases between 2014 and It is important that you communicate this policy and the increase in payment amounts to your clients. 2014: The annual individual shared responsibility payment is the greater of - 1% of the taxpayer s household income that is above the tax return filing threshold for the taxpayer s filing status, or - The taxpayer s flat dollar amount, which is $95 per adult and $47.50 per child, limited to a family maximum of $285. However the total payment amount is capped at the cost of the national average premium for a Bronze level health plan available through the Marketplaces in : The annual individual responsibility payment is the greater of - 2% of the taxpayer s household income that is above the tax return filing threshold for the taxpayer s filing status, or - The taxpayer s flat dollar amount, which is $325 per adult and $ per child, limited to a family maximum of $975. However the total payment amount is capped at the cost of the national average premium for a Bronze level health plan available through the Marketplaces in The calculations above represent the amount of the payment for not having health insurance coverage for the entire year. Individuals will owe 1/12th of the annual payment for each month they (or their dependents) do not have coverage and are not exempt. Individuals without coverage for less than three consecutive months during the year may qualify for the short coverage gap exemption and will not have to make a payment for those months. The short coverage gap exemption only applies to the first coverage gap during a year. The same method of calculation is used in 2016 and later years. In 2016, the payment is the greater of 2.5% of income over the filing threshold, or $695 per person ($ per child under 18). After 2016, the payment is adjusted for inflation. Key Information for Consumers: Purchasing insurance using the Marketplace provides guaranteed coverage All pre-existing conditions are covered and companies can t charge more for a policy because of past or present health conditions To be eligible for health coverage through the Marketplace, consumers must: - Live in the United States - Be a U.S. citizen or national (or be lawfully present) -Not be currently incarcerated You might be eligible for tax subsidies (see chart on page 20) meritusaz.com Broker Use Only Meritus Broker Manual 17

19 Purchasing Health Insurance: On & Off the Marketplace The Marketplace is the Federally Facilitated Marketplace at Healthcare.gov. Using the Meritus online enrollment tool, you can accurately determine if an Individual or Family will qualify for Advance Premium Tax Credit (APTC). Meritus now features a Direct Enrollment tool allowing applicants to apply for On Marketplace purchases with the ability to receive APTC avoiding applying through Healthcare.gov. With you as their guide, individuals and small businesses can compare health plans, get answers to questions and find out if they are eligible for tax credits. Standard benefits packages There are five levels of plans, four represented by metal values and one catastrophic, and are defined by the percentage each plan will pay toward healthcare expenses for an average person, known as the actuarial value (AV). Health insurers offering QHPs must offer at least one plan at the Silver level and one plan at the Gold level on the Marketplace. Under each metal level there can be several plans available, which will vary according to the deductibles, co-insurance and copays offered. Some plans offer lower monthly premiums that may charge more out-of-pocket fees for care, while others have higherpremium plans that cover more costs when you need care; other plans will fall in between. Catastrophic Bronze Less Than 60% Coverage 60% Coverage Silver Gold Platinum 70% Coverage 80% Coverage 90% Coverage In addition to the metal level plans, issuers can offer catastrophic plans. Eligibility for catastrophic plans is limited to: Individuals under age 30 Individuals who otherwise do not have an affordable coverage option, or who may qualify for a hardship exemption to the minimum essential coverage requirement If an individual qualifies for enrollment in a catastrophic plan, the catastrophic plan counts as minimum essential coverage. There is no set AV for catastrophic plans. Instead, enrollees in catastrophic plans have a higher deductible limit than enrollees in Bronze, Silver, Gold, or Platinum plans. 18 Meritus Broker Manual

20 How to determine your income for 2015? When your client applies for premium tax credits and other savings in the Marketplace, they ll need to estimate their income for Your client can start by adding up the following items: Your client and spouses income, if they re married and filing joint tax return Any dependents who make enough to file a tax return Which income sources to include For each of the following sources, estimate what your client s income will be in If they re not sure what their income will be, have them make their best estimate. Assistance: Making Healthcare Affordable for All To address the needs of those who fall in certain income levels and cannot afford insurance, the law includes provisions for federal subsidies to reduce the cost of premiums. Wages Salaries Tips Net income from any self-employment or business (generally the amount of money taken in from a business minus business expenses) Unemployment compensation Social Security payments, including disability payments - but not Supplemental Security Income (SSI) Alimony Eligibility for Tax Credits & Cost-Sharing Reductions Individuals or families who purchase coverage in the Marketplace are eligible for a tax credit as long as their household income is up to 400 percent of federal poverty level guidelines; that equals $11,670 to $46,680 per year for an individual and $23,850 to $95,400 per year for a family of four (see income table on page 20). The assistance amount that a person can receive varies with income. The tax credit may be applied to any plan level (Catastrophic, Bronze, Silver, Gold or Platinum). Other items to include when estimating your client s 2015 income are: retirement income, investment income, pension income, rental income, and other taxable income such as prizes, awards, and gambling winnings. Don t include the following kinds of income: Child support Gifts Supplemental Security Income (SSI) Veterans disability payments Workers compensation Proceeds from loans (like student loans, home equity loans, or bank loans) meritusaz.com Broker Use Only Meritus Broker Manual 19

21 How your clients can get coverage. Connecting Individuals and Families to coverage, benefits and services. Medicaid coverage Private Marketplace health plans You may qualify for lower premiums on a Marketplace Insurance plan if your yearly income is between... See next row if your income is at the lower end of this range. You may qualify for lower premiums AND lower out-of-pocket costs for Marketplace insurance if your yearly income is between... If your state is expanding Medicaid in 2014: You may qualify for Medicaid coverage if your yearly income is between... If your state isn t expanding Medicaid in 2014: You may not qualify for any Marketplace savings programs if your yearly income is between... Number of people in your household $11,670 - $46,680 $11,670 - $29,175 $15,730 - $62,920 $15,730 - $39,325 $19,790 - $79,160 $19,790 - $49,475 $23,850 - $95,400 $23,850 - $59,625 $27,910 - $111,640 $27,910 - $69,775 $31,970 - $127,880 $31,970 - $79,925 $16,105 $21,707 $27,310 $32,913 $38,516 $44,119 $11,670 $15,730 $19,790 $23,850 $27,910 $31,970 Cost-Sharing Reductions Those who earn up to 250 percent of federal poverty guidelines and enroll at the Silver level only may also be eligible for cost-sharing reductions (CSR). The subsidy amount will vary according to income. Examples of cost-sharing that may be reduced include deductibles, co-insurance, copayments or similar charges and do not include balance billing for non-network providers or spending on non-covered services. Example Meritus Healthy Silver $4,000 Network benefits including CSR benefit levels Standard Silver No CSR CSR Plan for up to 150% FPL (up to $17,505) CSR Plan for % FPL ($17,505 to $23,340) CSR Plan for % FPL ($23,340 to $29,175) Actuarial Value 70% AV 94% AV 87% AV 73% AV Deductible (Individual) $4,000 $150 $500 $2,000 Coinsurance 30% 0% 0% 30% Office Visit PCP/ $30 copay/ $0 copay/ $0 copay/ $20 copay/ Non-PCP $60 copay $10 copay $30 copay $60 copay Max Out-of-Pocket $6,600 $1,000 $2,250 $5, Meritus Broker Manual

22 Meritus Rules Regarding Federal Marketplace Enrollments Enrollment, Termination, Special Enrollment Periods and Plan Changes meritusaz.com Broker Use Only Meritus Broker Manual 21

23 Rules for Special Enrollment Period changes (SEP) If a client applies on the FFM, and they qualify for a SEP to change plans or enroll for the first time, they will have 60 days from the life event to enroll. After reporting life changes to the Marketplace, they will get a new eligibility notice that will explain if they qualify for a Special Enrollment Period and if this will lower costs. If your client qualifies for a SEP, you can assist them by phone with the FFM or through your Meritus direct link. When the application is finished and they get to the To-do list page, you ll see a statement that they can enroll only if they have a SEP. You can then continue the process and enroll in a plan. Type of SEP Termination Date of Existing Enrollment, if currently Enrolled Plan Selection Date Effective Date Not eligible for an SEP or eligible for the following SEPs: 1. Move to a new exchange service area 2. Release from incarceration 3. Becoming lawfully present 4. Gain status as an Indian Day before effective date. Between the 1st and 15th day of the month (1/1/15 and 3/15/15) Between the 16th and last day of the month (1/16/15 and 3/31/15) First day of the following month First day of the second following month Loss of MEC* and gaining a dependent through marriage SEP Day before effective date Any day of the month First day of the following month Future loss of MEC* (loss up to 60 days in the future) Day before effective date Any day of the month First day of the month following the date of the loss of MEC Birth, adoption, or placement for adoption or foster care SEP Day before effective date Any day of the month Day the child was born, adopted, or placed for adoption or foster care *Minimum Essential Coverage ** Advanced Premium Tax Credit 22 Meritus Broker Manual

24 Meritus makes it easier than ever to help you sell and retain clients on Individual and Small Group Affordable Care Act (ACA) health plans. On Market Enrollee-Initiated Terminations Enrollees have the right to terminate their coverage in a QHP. On Market members must either go online through their FFM account or contact Healthcare.gov to terminate their coverage. Upon termination, individuals will be unable to enroll in a new QHP unless they qualify for a SEP. NOTE: Consumers who are notified that their enrollment has been canceled by the issuer for non-payment of premiums will need to create a new account, complete an application and make a new plan selection. The effective date of coverage will be based on the date of the new plan selection under the regular effective date schedule. Flexibility to Change Plans at the Same Metal Level CMS allows enrollees to change plans during the Initial Open Enrollment Period after the effective date of their enrollment under certain conditions. This process can be used for individuals who have paid their first month s premium and whose coverage is already effective. Plan changes may be made provided the change meets ALL of the following criteria: Change is to another plan offered by the same issuer. Change is to another plan offered at the same metal level and Cost-Sharing Reduction (CSR) level, if applicable (i.e. Silver to Silver, CSR87 to CSR87, etc). Change is made in order to move to a plan with a more extensive provider network or for other isolated circumstances determined by CMS. Change is being requested within the Initial Open Enrollment Period. The individual who makes a change that meets the criteria above must notify Meritus who will initiate the plan change. Meritus will determine the effective date for the plan change. meritusaz.com Broker Use Only Meritus Broker Manual 23

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26 Here is a step-by-step guide to help you through Individual and Family enrollment. The following pages contain instructions on how to process a quote or application using a Meritus populated link, or the Meritus Broker Sales Portal at meritusaz.com for Individuals and Families. meritusaz.com Broker Use Only Meritus Broker Manual 25

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28 Individual and Family Enrollment Guide 1 Proposal Enter demographic information, select plan and create proposal. 2 Application Fill out the enrollment application and sign form. 3 Sent to Membership Applications is sent to membership for processing. 4 Member Individual is now an active member. meritusaz.com Broker Use Only Meritus Broker Manual 27

29 1 Proposal The Quote and Enrollment Process To quote and enroll Individual and Family plans, go to the meritusaz.com website, click on the Broker tab, select Broker Sales Portal Login, or use your Meritus populated broker link. After you access the Broker Portal, you will see the online Meritus Dashboard where you can select the Individual or Tools tabs. Individual and Family Applications for both On and Off the Marketplace You can sell both On or Off Market plans with Meritus. Your Meritus Broker Sales Portal can be used for Off Market enrollment and/or help determine whether your client may qualify for assistance from the FFM. The Meritus Direct Enrollment tool can be utilized for quick and efficient placement for On Market business. The Direct Enrollment tool will assist in determining APTC information for clients, verify eligibility with Healthcare.gov and to complete the enrollment. Determining Marketplace Eligibility Primary Subscriber and ACA Eligibility From the main Meritus Dashboard, select Tools and then click on ACA Individual Calculator to initiate the Individual quote process. The ACA Calculator will determine whether your client is eligible for premium assistance credits or cost-sharing reductions and it will calculate their shared-responsibility penalty. 28 Meritus Broker Manual

30 Individual & Family Application Due Dates: Using the ACA Calculator, you can determine if affordable employer coverage is available or there is a certificate of exemption from the Marketplace. On Market Due on or before the 15th of the month to be live on the 1st of the following month Off Market Due on or before the 15th of the month to be live on the 1st of the following month. NOTE: If your client appears to be eligible for an On Market plan, please proceed to the instructions of how to assist clients with the Broker Direct Enrollment Tool. See page 30. The ACA Individual Calculator will present estimates and show results for Individual and Family profiles, shared responsibility (tax penalty) and coverage and assistance eligibility. For those who do not qualify, continue with Off Market, on page 33. For those qualified for On Market, go to Direct Enrollment link on page 30. meritusaz.com Broker Use Only Meritus Broker Manual 29

31 2 Direct Enrollment - On Market Application On Market Direct Enrollment Tool The Direct Enrollment tool will allow you to assist your clients to apply with the FFM and qualify for a tax credit and/or to determine whether they may qualify for plans with costsharing reductions. This online process will help you to streamline the FFM/CMS qualification process and connect you directly back to Meritus for an online application. How to Access The Direct Enrollment Tool Once you have set up your Broker Sales Portal you will be able to access the Direct Enrollment tool to assist your clients who wish to apply On the Market. Set Up Log onto your Broker Sales Portal by going to meritusaz.com and then click on My Account. It is recommended to use Google Chrome when utilizing the Direct Enrollment tool. After clicking on My Account, fill in the fields including your National Producer Number (NPN) and your Federal Marketplace User ID (this is the ID you used to access portal.cms.gov). Now save the information and you are ready to assist your client on the FFM for assistance and apply for a Meritus plan. Step 1: Direct Enrollment Application Enter your client s first and last name and then click the Marketplace button. 30 Meritus Broker Manual

32 The Next Steps page will describe what happens next and what you ll need to complete the application. Click Next. Step 2: Redirection to FFM Site You will now be taken to HealthCare.gov where your User Name will be autopopulated. Now enter in your Marketplace password, which is the password you used to access portal.cms.gov. Now click on LOG IN. Step 3: Start the FFM Eligibility Application on HealthCare.gov. NOTE: It is recommended to bypass all optional questions as this may hinder your client s application. meritusaz.com Broker Use Only Meritus Broker Manual 31

33 Step 4: View Eligibility. Once you reach the Eligibility Results, click on View Eligibility Results. This will display, showing you your client s Premium Tax Credits and whether they also qualify for a Cost-Sharing Reduction plan. These amounts will match the Eligibility Results which were displayed on the Healthcare.gov page. Step 5: Now click the Return to Enrollment Website button to return to your Broker Sales Portal. Now proceed to picking a plan. Step 6: Selecting the Plan Click on Browse Plans to continue the enrollment, and you will be redirected to Meritus. You will be able to assist your client as noted on page 33 and help them choose the plan and complete the Meritus application. 32 Meritus Broker Manual

34 2 Off Market Application Plan Choices You will be presented with a list of eligible plans for the Individual subscriber and household. You may further Filter Results to customize plan selection views for your clients based on: Benefit (metal) level Premium range Deductible Out-of-pocket (OOP) Office visit copays Select and Compare Plans Compare plans (see above) by checking the small Compare box next to each plan that you would like to compare, and then click on one of the large Compare buttons to display your results. Note, that you can only compare up to four plans at any one time. Lifestyle benefits HSA compatibility Provider network type Then select the desired plan(s) for quoting by clicking on Select or for initiating an or enrollment of a final plan with an application. Proposal and Application The Proposal screen will allow you to: Make any necessary edits prior to sending the quote. Save the proposal for work at a later date. Be sure to SAVE your proposal so you can refer back to the quote at a later time. the proposal to your client. Save and send the proposal as a pdf. Start the application. meritusaz.com Broker Use Only Meritus Broker Manual 33

35 Fill out all required fields as indicated and then click on the Complete this Section button on the lower right side of the screen. Electronic Signature After reviewing sections and completing the Electronic Signature, the client s name needs to be typed into the box under E-Sign section. Now you are ready to proceed to the Payment page. Payment The next step in the Individual Application process is to select the method for the Initial Premium Payment. This is the final step of submitting the application. 34 Meritus Broker Manual

36 3 Sent to Membership Off Market Click on Continue on the lower right side of the Collect Payment screen. The application has now been submitted to Meritus and can be seen in your Broker Sales Portal. To see this, click on Individual and then click on Applications. NOTE: The application will be approved within 5 7 business days, at which time, you can look in your Broker Sales Portal under Individual and then click on Members. On Market Click on Continue on the lower right side of the Collect Payment screen. The application has now been submitted to Meritus through the FFM. NOTE: You will not be able to see FFM submissions on your Broker Sales Portal. Direct Enrollment Tool Updates For the latest updates, on the Direct Enrollment Tool, go to meritusaz.com, click on Broker, click on Resources and click on Direct Enrollment Tool. meritusaz.com Broker Use Only Meritus Broker Manual 35

37 4 Member Off Market Once the application is approved, the Member will be assigned a Member number by our Customer Care system. The Membership Packet will then be mailed out to them in 7 10 business days. NOTE: If a Member does not receive their Meritus card and packet prior to their live date, the Member may call Meritus Customer Care ( ) for instructions on how to proceed until their card is received. Please also note that the Member will only be effectuated by Meritus once their binder payment has been received. On Market Once the application is sent through the FFM, the Member will be assigned a Member number by our Customer Care system within 2 3 business days. The Membership Packet will then be mailed out to them in 5 10 business days. NOTE: If a Member does not receive their Meritus card and packet prior to their live date, the Member may call Meritus Customer Care ( ) for instructions on how to proceed until their card is received. Please also note that the Member will only be effectuated by Meritus once their binder payment has been received. 36 Meritus Broker Manual

38 Meritus Small Group 2-50 Employees Underwriting Guidelines And a step-by-step guide to help you through the group process. The following pages contain instructions on how to process a small group quote, complete an online Employer Group application, begin/close employee Open Enrollment and submit a completed group for enrollment into Meritus utilizing the Meritus Broker Sales Portal at meritusaz.com for Small Group Employees. meritusaz.com Broker Use Only Meritus Broker Manual 37

39 Small Group Underwriting Requirements Minimum of 2 eligible enrolling employees Minimum of 70% participation excluding valid waivers - Valid waivers include Medicare, TriCare, AHCCCS, Indian Health Services and Spousal Coverage - Individual coverage is not a valid waiver Out-of-Area Employees 75% or more of eligible employees must reside in the Meritus Arizona service area (Maricopa, Pima or Santa Cruz, or Mohave County). A PPO plan would be the only option for Out-of-Area employees (less than 25% of the eligible employees). Employer may choose to offer up to three (3) Plans Employer Contribution Minimum 50% of the employee-only premium cost across all plans offered First of the Month effective dates only and new hire waiting periods cannot exceed 90 days. Waiting period options are: - FOMF Date of Hire - FOMF 30 Days - FOMF 60 Days Group Application must be submitted by the 23rd of the month prior to the effective date. Enrollment must be completed by the 30th of the month. Small Group Eligibility Full-Time Employee Definition Employer determines definition of full-time status; no full-time status defined as less than 20 hours per week Employees - Sole contract with Group must have Employer/Employee relationship - Work hour requirement equal to that of eligible W-2 employees - Employer must provide working environment Domestic Partners allowed Current Quarterly Wage & Tax Report (Form UC018) Required For new employees not listed on the report, indicate names and dates of hire on the W&T report or separate sheet. Newly Formed Group Will accept a newly formed group provided two weeks of payroll is submitted. Owners & Partners Applies when owners are not on the quarterly wage & tax report. Must submit legal ownership documents that show affiliation with the group and Articles of Incorporation. If LLC, all owners must be listed. Workers Compensation All employees, except those not required by law, must be covered by workers compensation. 38 Meritus Broker Manual

40 Meritus Rules for Small Business Health Options Program (SHOP) plans on the Marketplace In 2015, small businesses that offer coverage through the Federally-Facilitated SHOP (FF-SHOP) will be able to choose a Qualified Health Plan (QHP) to offer their employees. Eligibility Requirements for SHOP Employer s business must: Be located in a SHOP s service area. Have at least one eligible employee on payroll (generally excludes owners, including sole proprietors, and owners spouses and dependents on payroll). Have no more than 50 full-time equivalent (FTE) employees on payroll. 1 Offer coverage to all full-time employees (full-time status is defined as working more than 30 hours per week). Eligibility Requirements for the Small Business Tax Credit The small business must: Have an average of fewer than 25 FTE employees (based on a 40-hour work week and excluding owners, owner s family members and seasonal employees). Have average annual employee wages below $50,000. Pay a uniform percentage (at least 50%) of the cost of each employee s health insurance. Offer coverage to all full-time employees (full-time status is defined as working more than 30 hours per week). 1 Part-time workers must be counted as fractions of an FTE when determining employer size, even if part-time workers are not offered coverage, but does not include seasonal employees who work fewer than 120 days per year. meritusaz.com Broker Use Only Meritus Broker Manual 39