For Individuals and Families

Transcription

1 For Individuals and Families Simple and Affordable. You re Covered Iowa, Nebraska, South Dakota Gold, Silver, Bronze, Catastrophic POS PPO HMO

2 a Simple and affordable. You re Covered care when you need it With Coventry Health Care, you know you re covered when you need care. Your Coventry plan includes these essential benefits: Ambulatory patient services Rehabilitative and habilitative services Emergency services and devices Hospitalization Laboratory services Maternity and newborn care Preventive and wellness services and Mental health and substance chronic disease management use disorder services, including Pediatric services, including oral* and behavioral health treatment vision care Prescription drugs Coventry Health Care, Inc., an Aetna company Local Health Plan Coventry Health Care has provided health insurance coverage to employers and individuals in Nebraska, Iowa and South Dakota for over twenty-five years. We serve over 267,000 members across the region with employer group, individual, Medicaid and Medicare coverage. We re proud of our relationships with the community and our members. We look forward to serving you for years to come. National Strength Aetna (NYSE: AET) is one of the nation s leading diversified health care benefits companies, serving an estimated 44 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities, Medicaid health care management services, workers compensation administrative services and health Programs to help you stay healthy Online tools for easy access Helping you maintain your health is important at Coventry Health Care. That s why we offer Coventry Complete Care health management and other healthy living programs: Coventry Compliments discount program on these services: Hearing aids Health clubs Massage therapy Day spa Skin care Acupuncture LASIK eye surgery Health and safety products Eye exams, eyewear and contact lenses For the most up-to-date listing of services and providers, go to Extra help from a Coventry nurse if you have a serious condition Help with Diabetes Free LifeScan OneTouch blood glucose meters Diabetic education classes Yearly dilated retinal eye exam screening for diabetic retinopathy Coventry WellBeing SM Program Health evaluation to help you understand your personal health Help with making healthy eating choices Help with setting and reaching exercise goals Help with keeping your kids healthy Get information about your benefits, claim history, health care options and more by phone, website or mobile phone app: Expert customer service Order prescription refills representatives, located in the Research costs for drugs or procedures United States, ready to answer your Compare quality results for providers questions Coventry Mobile App ID card Find a doctor, pharmacy or search Doctor and pharmacy search our drug list at Benefit information Surgery and procedure history MyOnline Services sm Check symptoms and learn about Check claim status common health conditions Request or print ID cards Current medications information technology services. 2 Simple and Affordable 3 *Off Exchange only

3 CoventryOne Provider Networks Select a network with doctors you trust Coventry contracts directly with hospitals, physicians and other medical providers so you can see the doctors you trust and save money too. Network Service Area Map Key Choose your network: Full POS Network HMO Alegent Creighton Health, HMO Methodist Health Partners or POS MIPPA Carelink Networks Full Network plans give you access to a broad network of trusted local doctors and hospitals with cost-saving discounts for services. Coventry built strong relationships with more than 18,000 providers and over hospitals to make up our regional network. Harding Perkins Corson Campbell Walworth McPherson Edmunds Brown Marshall Day Roberts Full POS Network or POS Patient Preferred Carelink Network Full POS Network or HMO Alegent Creighton Health, HMO Methodist Health Partners or POS MIPPA Carelink Networks Carelink High-performance Network (HPN) plans feature a select network formed primarily by the hospitals and doctors affiliated with a health system. Carelink plans are chosen for lower premiums, enhanced focus on health outcomes and access to trusted, local physicians and hospitals. Lawrence Butte Meade Ziebach Haakon Dewey Stanley Potter Sully Hughes Hyde Faulk Hand Spink Beadle Grant Codington Clark Deuel Hamlin Kingsbury Brookings Full POS Network or POS UnityPoint Health Carelink Networks Full PPO Network Carelink High-performance Networks: Alegent Creighton Health (HMO) Methodist Health Partners (HMO) MIPPA (POS) Patient Preferred (POS) UnityPoint Health Cedar Rapids (POS) UnityPoint Health Des Moines (POS) UnityPoint Health Quad Cities (POS) UnityPoint Health Waterloo (POS) What do POS, PPO and HMO mean? POS (Point-of-Service) plans cover both in-network and out-ofnetwork care, but you get the highest level of coverage when getting care in-network. PPO (Preferred Provider Organization) plans offer local and out-of-area coverage for both non-urgent and urgent care. PPO members have full access to the Coventry regional network and the Coventry National Network. Pennington Custer Shannon Fall River Dawes Sioux Sheridan Box Butte Scotts Bluff Morrill Garden Banner Kimball Cheyenne Deuel Jackson Bennett Grant Arthur Chase Dundy Keith Perkins Cherry Hooker McPherson Jones Mellette Todd Thomas Logan Lincoln Hayes Frontier Hitchcock Red Willow Lyman Tripp Brown Blaine Custer Dawson Gosper Furnas Keya Paha Rock Loup Phelps Buffalo Brule Gregory Harlan Garfield Valley Sherman Buffalo Kearney Franklin Jerauld Boyd Aurora Douglas Charles Mix Holt Wheeler Greeley Howard Hall Adams Webster Sanborn Davison Hanson McCook Bon Homme Yankton Antelope Boone Hamilton Clay Hutchinson Knox Nance Merrick Nuckolls Miner Pierce Madison Platte Polk York Fillmore Thayer Lake Turner Cedar Wayne Stanton Butler Clay Union Colfax Seward Saline Jefferson Minnehaha Lincoln Dixon Moody Cuming Dakota Thurston Burt Harrison Dodge Washington Saunders Lancaster Gage Lyon Sioux Plymouth Woodbury Douglas Cass Johnson Monona Sarpy Otoe Pawnee Clay Humboldt Cherokee Buena VistaPocahontas Nemaha Osceola O'Brien Mills Ida Fremont Crawford Pottawattamie Richardson Dickinson Sac Carroll Cass Emmet Calhoun Montgomery Adams Greene Shelby Audubon Guthrie Page Palo Alto Taylor Adair Kossuth Webster Union Ringgold Boone Dallas Madison Winnebago Hancock Cerro Gordo Floyd Wright Hamilton Clarke Decatur Story Polk Warren Worth Franklin Hardin Lucas Wayne Marshall Jasper Marion Mitchell Butler Appanoose Howard Chickasaw Bremer Davis Winneshiek Allamakee Benton Fayette Clayton Black Hawk Buchanan Delaware Dubuque Grundy Monroe Tama Poweshiek Mahaska Wapello Iowa Keokuk Jefferson Van Buren Linn Johnson Washington Jones Cedar Henry Des Moines Lee Muscatine Louisa Jackson Clinton Scott HMO (Health Maintenance Organization) plans provide coverage for care received in-network and emergency care received outside of the network. 1 Approximate Iowa, South Dakota, and Nebraska providers and hospitals in POS network, as of September CoventryOne Provider Networks 5

4 CoventryOne Benefit Plans for Iowa (POS and HMO), Nebraska (POS and HMO) & South Dakota (PPO) PLAN BENEFITS Gold 5 Copay Plan Silver 10 Copay Plan Bronze 10 Copay Plan Bronze uctible Only HSA Eligible Plan Catastrophic Plan 4 In-Network You Pay In-Network You Pay In-Network You Pay In-Network You Pay In-Network You Pay Annual uctible () - calendar year 1,750 Individual/3,500 Family 3,750 Individual/7,500 Family 5,600 Individual/11,200 Family 6,300 Individual/ 12,600 Family 6,350 Individual³/12,700 Family³ Coinsurance (Coins) 20% 30% 30% 0% 0% Out-of-Pocket Maximum - calendar year 5,000 Individual/10,000 Family 6,350 Individual/12,700 Family 6,350 Individual/12,700 Family 6,300 Individual/12,600 Family 6,350 Individual³/12,700 Family³ Includes s, Coins and Copays Primary Physician Office Visit (PCP) 5 Copay 10 Copay 10 Copay First 3 visits: 20 Copay; 4+ visits: Specialist Office Visit First 5 visits: 50 Copay; First visit: 75 Copay; 75 Copay+ 6+ visits: 50 Copay+ 2+ visits: 75 Copay+ Preventive / Wellness Services Lab / Radiology¹ Advanced Imaging / High Tech Radiology Included in PCP office visit; Other: +Coins Free-standing Facility: 250 Copay; Other: +Coins Included in PCP office visit; Other: +Coins Free-standing Facility: 250 Copay+ Other: 250 Copay++Coins Included in PCP office visit; Other: +Coins Free-standing Facility: 250 Copay+ Other: 250 Copay++Coins Convenience Care 25 Copay 25 Copay 25 Copay Urgent Care 75 Copay 75 Copay 75 Copay+ Emergency Room First 3 visits: 250 Copay First visit: 500 Copay 500 Copay+ 4+ visits: 250 Copay+ 2+ visits: 500 Copay+ Inpatient Hospitalization +Coins 500 Copay++Coins 500 Copay++Coins Outpatient Facility/Physician Services; Home Health +Coins +Coins +Coins Care; Skilled Nursing Facility (IA and SD: 90 days/yr; NE: 60 days/yr) Rehabilitation Services (Physical/Speech/Occupational (NE: 45 visits comb/yr)/ Cardiac/Pulmonary (NE: 36 visits comb/yr)/spinal (NE: 20 visits comb/yr)) +Coins +Coins +Coins Maternity and Newborn Care Mental Health / Substance Abuse MHNet network must be used for In-Network benefits Pediatric Vision EyeMed network must be used for In- Network benefits² Pediatric Dental Coventry Dental network must be used for In-Network benefits² Off Exchange Only Prescription Drugs Tier 1A: Lower Cost Preferred Generic Drugs Mail order = 2x Preferred Pharmacy copay Tier 1: Preferred Generic Drugs Mail order = 2x Preferred Pharmacy copay Tier 2: Preferred Brand Drugs Mail order = 2.5x Preferred Pharmacy copay Tier 3: NonPreferred Brand / Generic Drugs Mail order = 3x Preferred Pharmacy copay Physician: One-time 250 Copay Inpatient: +Coins Physician: One-time 250 Copay Inpatient: 500 Copay++Coins Physician: One-time 500 Copay Inpatient: 500 Copay++Coins Same benefits as medical Same benefits as medical Same benefits as medical Same benefits as medical Same benefits as medical Basic/Major/Orthodontia: +50% Coins Separate 250 Rx Per Individual on Tiers 2-5 Preferred Pharmacy: 3 Copay NonPreferred Pharmacy: 10 Copay Preferred Pharmacy: 5 Copay NonPreferred Pharmacy: 10 Copay Preferred Pharmacy: Rx +30 Copay NonPreferred Pharmacy: Rx +40 Copay Preferred Pharmacy: Rx +60 Copay NonPreferred Pharmacy: Rx +75 Copay Basic/Major/Orthodontia: +50% Coins Separate 1,000 Rx Per Individual on Tiers 2-5 Preferred Pharmacy: 5 Copay NonPreferred Pharmacy: 20 Copay Preferred Pharmacy: 15 Copay NonPreferred Pharmacy: 20 Copay Preferred Pharmacy: Rx +45 Copay NonPreferred Pharmacy: Rx +55 Copay Preferred Pharmacy: Rx +75 Copay NonPreferred Pharmacy: Rx +85 Copay Basic/Major/Orthodontia: +50% Coins Basic/Major/Orthodontia: +50% Coins Basic/Major/Orthodontia: +50% Coins Integrated Medical+Rx Integrated Medical+Rx Integrated Medical+Rx N/A N/A N/A Preferred Pharmacy: 15 Copay NonPreferred Pharmacy: 20 Copay Preferred Pharmacy: +45 Copay NonPreferred Pharmacy: +55 Copay Preferred Pharmacy: +75 Copay NonPreferred Pharmacy: +85 Copay Tier 4: Preferred Specialty Drugs Preferred Pharmacy: Rx +20% Coins Preferred Pharmacy: Rx +30% Coins Preferred Pharmacy: +30% Coins Tier 5: NonPreferred Specialty Drugs Preferred Pharmacy: Rx +30% Coins Preferred Pharmacy: Rx +40% Coins Preferred Pharmacy: +40% Coins Choosing Your Plan Plans are grouped into four metal levels. Coventry offers the Gold, Silver and Bronze. The metal level does not reflect the quality of the plan. The metal level tells you how much you pay in premiums relative to how much you ll pay on your own, also known as outof-pocket costs. Let s look at an example. If you choose a Gold plan, you are choosing to pay more in premium so you can have a lower out-of-pocket cost when visiting your doctor. You pay * Plan Premium Out-of-pocket Coventry Category costs Pays * Gold 80% 20% Silver 70% 30% Bronze 60% 40% Catastrophic Plans People under the age of 30 and some people with limited incomes may buy what is called a catastrophic health plan. It protects you from very high medical costs. Catastrophic plans offer lower premiums. However, the out-of-pocket costs for deductibles, copayments, and coinsurance are generally higher. To qualify for a catastrophic plan, you must be under 30 years old OR get a hardship exemption because the Marketplace determined that you re unable to afford health coverage. Native American and Alaskan Natives If you re an American Indian or an Alaska Native, you may qualify for low-cost or no-cost health insurance coverage. Coventry s American Indian plans are available on the exchange. Visit to see if your re eligible and enroll. Health Savings Account with Bronze uctible Only Plan If you choose the Bronze uctible Only plan, you have the option of selecting a Health Savings Account (HSA) administered through our partner, HealthEquity. Displaying select in-network benefits only. Out-of-network benefits are available for POS and PPO plans. Out-of-network benefits are not available for HMO plans, except for emergency care coverage. See Schedule of Benefits for details. Note: ¹ Lab work drawn at PCP but processed by outside vendor, will not be included in Copay. ² This benefit is only available to children who are under the age of 19. ³ When more than one person is applying for coverage, the Family and out-of-pocket maximum must be met before any benefits are paid that are subject to the or out-of-pocket maximum. 4 Eligibility restrictions. This information is a partial description of the benefits and in no way details all of the benefits, limitations, or exclusions of the plan. Please refer to the Individual Policy, Schedule of Benefits, and applicable Riders to determine exact terms, conditions and scope of coverage, including all exclusions and limitations and defined terms. Family Premium Pricing Family premiums are calculated by adding the premium of each parent, plus the premium of each dependent over the age of 21, plus the premium of the three oldest dependents under the age of 21. Premium will not be added for each additional covered dependent. 6 CoventryOne Benefit Plans 7 *On average

5 Using Your Benefits Important information about your CoventryOne plan Most CoventryOne plans will pay your benefits at different levels for in- and out-of-network providers. You ll want to use an in-network provider to get the most benefits from your plan. Provider Network Find an in-network provider Doctors, hospitals and other medical providers: then Find a Doctor Pharmacies: then Find a Pharmacy ; Preferred pharmacies say Preferred for up to one month supply only Mental health or substance abuse providers: then Find a Provider and Commercial Vision care providers: then Find a Provider and network Insight Pediatric dental providers: then Search for a Provider and Pediatric Dental Use your preventive care benefits to help you stay healthy. Visits to your PCP are affordable. Check the benefit details to see the low copay options. Your personal PCP is a valuable resource. If you need to see a specialist, your PCP can help coordinate your care with the specialist. No referrals are needed to see a specialist. When you are traveling and not close to our network providers, you still have coverage for emergency care. There are some treatments, services, drugs and other health care that are not covered by our plans. We want you to have all of the information about what is covered when you make your benefit plan choice. Please call us at (On Exchange plans) or (Off Exchange plans) if you want to confirm covered services. Our customer service reps can also tell you how much of the cost is covered. Your doctor may need to contact us to confirm if the plan will pay for certain drugs, tests or procedures. This is known as prior authorization. Why should I choose a Primary Care Physician? A Primary Care Physician (PCP) can help improve your family s health. For example, if you or one of your covered dependents has a condition, like asthma, your PCP will make sure he/she gets consistent care. Also, your PCP will help make sure your children get the shots they need for school. Your PCP can help keep your health care costs low. The PCPs know how our plans work and they will help you get the most from your benefits. For example, your PCP may prescribe generic drugs to save you money. Using a PCP can help save you time. Your PCP will know you and your health history. He/she can assist any specialists you may need to see because the PCP has a complete picture of your health. 8 Your Coventry plan uses a provider network. This is a list of doctors, hospitals and other providers contracted by Coventry to provide you with health care. The contracted providers are participating or in-network for your Coventry plan. You will always receive the highest level of benefits when seeing a Coventry participating provider for your care. It s important to know which doctors and hospitals are part of the network. Go to and choose Find a Doctor to learn more about your network. If your plan includes out-of-network benefits: When you receive services from a nonparticipating provider (a health care provider who is not part of Coventry s network), payment for covered services is limited to the out-of-network rate. The amount of the bill above the out-of-network rate is your responsibility, in addition to your copayment, deductible and/or coinsurance amounts. If your plan does not include out-ofnetwork benefits: Non-emergency services received from out-of-network providers are not covered. It is important to use a participating provider in order to receive benefits. Emergency Coverage If you have a medical emergency, get the treatment you need right away. Emergency services outside the service area will be covered at the in-network level. If you re outside of the United States, only emergency services are covered. Getting the Care You Need Prior Authorization Some medical services and prescription drugs require prior authorization. Prior authorization is Coventry Health Care approval that is required before you receive certain medical services. Prior authorization helps you and your family receive the right care in the right place at the right time. Participating providers will generally take care of prior authorizations for you. You are responsible for verifying that prior authorization has been obtained. Case management If you have a serious medical condition, you may take part in Coventry case management. A Coventry case management nurse will work with you and your doctor. Your Coventry nurse will help coordinate resources to meet your health care needs. Disease management If you have asthma or diabetes, you can get extra help from Coventry. We will send you information to help you manage your condition. You may also receive reminders if you are past due for an important test or service. Prescription Drug Program Your Coventry plan covers prescription drugs. Your costs can vary based on the prescription drug and the pharmacy you use. It s important to check Coventry s Prescription Drug List, or formulary, to find out how a prescription drug is covered. Your copay could be lower if you use a preferred pharmacy. A preferred pharmacy is a retail pharmacy, or pharmacy chain, that Coventry has contracted with to provide you with lower prices on your prescription medications. Go to and choose Find a Pharmacy to find a preferred pharmacy. Some prescription drugs require prior authorization. Your doctor can contact Coventry if prior authorization is required. Exclusions and Limitations by your health plan. Below is a partial list of exclusions that may apply to your Coventry health plan. Please refer to the Evidence of Coverage for a complete listing. Any service or supply that is not medically necessary Any service or supply that is not covered or that is directly or indirectly a result of receiving a non-covered service Any service or supply for which you have no financial liability or that was provided at no charge Procedures and treatments that are experimental or investigational Court-ordered services or services that are a condition of probation or parole Cosmetic services and surgery, and the complications incurred as a result of those services and surgeries Adult dental care, appliances, dentures, implants or X-rays, including any provider services or X-ray examinations involving one or more teeth, the tissue or structure around them, the alveolar process or the gums Immunizations for travel or employment, or unexpected mass immunizations directed or ordered by public health officials for general population groups Work-related injuries or illnesses covered by worker compensation laws Any service for which a prior authorization is required and is not obtained Infertility services and supplies - Any medical service, office visit, lab, diagnostic test, prescription drug, equipment, medicine, supply, or procedure directly or indirectly related to promoting conception by artificial means Maintenance treatment or therapy that is not part of an active treatment plan intended to or reasonably expected to improve the member s medical condition or functional ability Certain services and supplies are not covered Using Your CoventryOne Benefits 9

6 HOw do I apply for a coventryone plan? Applying is easy. Just follow these steps: Glossary 1. Choose your plan. CoventryOne has different insurance plans to fit your budget and meet your needs. You can select a product at or with the help of your agent or a navigator. You can also shop on the Health Insurance Marketplace at Open enrollment is October 1, 2013 through March 31, In future years, open enrollment will run from October 15 through December Go to to apply for you and your family members who will be covered by the health insurance plan. You will not be denied due to a pre-existing health condition. Pre-existing conditions are covered without waiting periods. You and your lawful spouse are eligible to apply if you are under the age of 64½, not eligible for Medicare, reside in the service area, and have been a United States resident for at least 6 months. Eligible dependent children under the age of 26 may apply. 2. Get financial help. Financial help may be available based on how much money you make. Be sure to complete the questions on the Health Insurance Marketplace to see if you qualify. You may have to pay a penalty on your federal income tax if you don t have health insurance in The penalty is 95 per adult and per child (up to 285 for a family). Or, the penalty is 1.0% of your family income. You could be charged whichever is greater if you don t have coverage. These penalties will increase each year. The penalty does not apply to everyone. Visit to learn more. 4. Submit your first month s premium. After you enroll, you will receive instructions on how to make your premium payment. Your enrollment will be complete when we receive your first month s premium payment. Then you will get a member welcome letter. This letter will tell you how to get your plan documents Benefit: A service, medical supply or drug that health insurance helps pay for. Some examples are doctor visits, tests and X-rays. Premium: The set amount you pay for health insurance. Premium is usually paid on the same day of each month. Out-of-pocket: The total costs you pay for covered services including copays, deductibles and coinsurance. Copay (copayment): A set cost you pay when you receive a covered service. Most plans have a copay for doctor visits. uctible: The amount you pay each year before your health insurance starts paying toward your covered services. Coinsurance: The part of the medical bill you pay after meeting your annual deductible. For example, if you have an X-ray after you have paid your deductible for the year, your health insurance company will pay most of the allowed amount, and you will pay a certain percentage of it. The percentage you pay is the coinsurance. 5. Read your plan documents. These documents explain how your insurance coverage works. Read them carefully to get the most of your benefits. 6. Put your member ID card in your purse or wallet. You will need to show your member ID card when you get health care services or prescription drugs. Cost Sharing: The shared costs you and Coventy pay throughout your benefit plan year. You pay your share of the costs though your deductibles, coinsurance and copays. This does not include your premium payments. The percentage you pay is based on the plan level you choose. Enrollment Dates 1 Member Enrolls Effective Date Member Enrolls Effective Date January 1-15 February 1, 2014 January March 1, 2014 February 1-15 March 1, 2014 February April 1, 2014 March 1-15 April 1, 2014 March May 1, If you have a qualifying life event after open enrollment, you are eligible for a special open enrollment. Qualifying life events include marriage, divorce and pregnancy. See a full list of qualifying events at Subsidy Chart 2 Family size Qualifying yearly income levels for Premium subsidies Qualifying yearly income levels for Out-of-Pocket subsidies Individual 45,960 or lower 28,725 or lower Family of 2 62,040 or lower 38,775 or lower Family of 3 78,120 or lower 48,825 or lower Family of 4 94,200 or lower 58,875 or lower Family of 5 110,280 or lower 68,925 or lower Family of 6 126,360 or lower 78,975 or lower Family of 7 142,440 or lower 89,025 or lower Family of 8 158,520 or lower 99,075 or lower 2Data obtained from Provider Network: A group of health care providers contracted with Coventry to offer services to Coventry members at a discounted price. Utilization Management: Health insurance services that help you get the right care from the right doctor at the right time. Health Insurance Exchange: The health insurance exchange (or marketplace) is a new way to shop for health insurance. Online stores help you find, compare and choose a health insurance plan that fits your needs Applying for a CoventryOne Plan is Easy 11

7 Enroll Today! Toll Free: Simple and affordable. You re covered The policy has exclusions, limitations, reductions and terms under which the policy may be continued in force or discontinued. For costs and complete details of coverage, contact Coventry. CoventryOne is offered in Iowa through Coventry Health Care of Iowa, Inc., in Nebraska through Coventry Health Care of Nebraska, Inc., and in South Dakota through Coventry Health and Life Insurance Company. Coventry Health Care of Iowa, Inc. is a Qualified Health Plan issuer in the Health Insurance Marketplace. Coventry Health Care of Nebraska, Inc. is a Qualified Health Plan issuer in the Health Insurance Marketplace and Small Business Health Option Program. III-M-AD-C1-C1 11/13