WELCOME TO A NEW ERA IN HEALTH CARE COVERAGE FOR TENNESSEE.

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1 WELCOME TO A NEW ERA IN HEALTH CARE COVERAGE FOR TENNESSEE. Quality Health Plans for Individuals and Families in Tennessee.

2 TABLE OF CONTENTS INTRODUCTION...1 Who are we?... 1 What is a CO-OP?...1 Our business model is unique...1 FINANCIAL ASSISTANCE...2 Am I eligible for premium credits?... 2 How much premium credit will I qualify for?.. 3 Why types of plans are available?... 3 How does the premium credit work?... 4 Who is eligible for cost sharing assistance?...4 How does cost-sharing assistance work?... 4 CHOOSING A PLAN...5 Understanding plan coverage...5 Our commitment to quality... 5 Privacy information...5 PRIMARY CARE PROVIDER...6 Partnering with you to keep you healthy...6 Provider network... 6 Go online to find an in-network provider... 6 Preventive care... 7 Specialty care... 7 Prior authorizations...7 Nurseline...7 PHARMACY BENEFITS...8 Understanding your pharmacy benefits... 8 Save Money!... 8 GLOSSARY... 9 With Community Health Alliance (CHA), you are part of a community dedicated to your best health. CHA is the only choice that gives you, the consumer, a true voice in your health care. We are mission-based and the needs of you and your family remain at the center of everything we do. INTRODUCTION TABLE OF CONTENTS WHY COMMUNITY HEALTH ALLIANCE? WHO ARE WE? Community Health Alliance is the only local, nonprofit, statewide, CO-OP option for Tennessee residents. We are member-governed. Members have the opportunity to serve on the board of directors. Finally, YOU have a voice. We are member-governed and memberfocused. Community Health Alliance is licensed by the Tennessee Department of Commerce and Insurance. We are subject to all state and federal regulations and guidelines set forth by the Centers for Medicare and Medicaid Services (CMS). We focus on prevention. You work with your doctor to create the best treatment plan. Our statewide network of accredited hospitals and providers provides a medical home option for our members, allowing the member and their primary care provider to create the best pathway to good health. We have individual and small group plans just right for you, your family or employees both on and off the Health Insurance Marketplace. WHAT IS A CO-OP? We are proud to be the only health insurance Consumer Operated and Oriented Plan (COOP) in the state. There are 23 CO-OPs in 26 states across the U.S. The purpose of a CO-OP is to offer individuals, families and businesses more high-quality, affordable health insurance options. CO-OPs also give members a voice in how their health care coverage is delivered. OUR BUSINESS MODEL IS UNIQUE We are nonprofit. Our savings go back into the health plan to keep it high quality and to lower premiums or increase benefits. 1

3 FINANCIAL ASSISTANCE MAKING HEALTH INSURANCE AFFORDABLE Gone are the days when only select groups of people had access to health insurance. You and your family can now get health insurance that s just right for your needs. Through the federal Health Insurance Marketplace, low to moderate income people may be eligible for tax credits and cost-sharing to help pay the cost of premiums and out-of-pocket expenses. AM I ELIGIBLE FOR PREMIUM CREDITS? HOW MUCH PREMIUM CREDIT WILL I QUALIFY FOR? Premium credits are based on household income. Larger credits go to those who earn less. The individual or family is expected to contribute a share of their income toward the cost of coverage. The amount a person or family contributes is based on a sliding scale. For example, an individual with an annual income of $23,000, which equals 200 percent of the poverty level, has an expected contribution of 6.3 percent of his income, or $121 a month. WHAT KINDS OF PLANS ARE AVAILABLE WITH THIS FINANCIAL ASSISTANCE? FINANCIAL ASSISTANCE BRONZE SILVER GOLD PLATINUM Monthly Cost $ $$ $$$ $$$$ Cost When You $$$$ $$$ $$ $ Get Care Good Option If You... Do not plan to need a lot of health care services. Need to balance monthly premium with out-of-pocket costs. Want to save on monthly costs and keep out-of-pocket costs low. Plan to use a lot of health care services. Individuals and families with incomes between 100 and 400 percent of the federal poverty level are eligible for premium tax credits. Some things to remember: You cannot get premium credits if you are eligible for Medicare or Medicaid. If your employer offers coverage, you may only qualify for premium credits if that coverage does not meet minimum essential value as a qualified health plan or if it costs more than the 9.5 percent of your annual income. Premium credits are also available to legal immigrants with incomes below 100 percent of the poverty line, but who are not eligible for Medicaid because they have lived in the United States for less than five years. There are four types of plans that can be offered on the Health Insurance Marketplace Platinum, Gold, Silver and Bronze. Community Health Alliance offers Gold, Silver and Bronze plans on the Marketplace. The level of benefits covered in each plan may vary, as well as the amount you pay for deductibles, coinsurance and/or copay amounts, and out-of-pocket maximums. Premium credits are based on the cost of the second lowest cost Silver plan available in the county or service area where the applicant lives. The credit can be applied to a lower cost plan at a reduced cost or a higher cost plan at an additional cost. While a Gold plan may cover more, you would have to pay the difference between the cost of the Gold plan selected and the second lowest cost Silver plan used to determine the subsidy. HOW DOES THE PREMIUM CREDIT WORK? Premium credits are actually tax credits that can be given in advance. The credits lower your monthly premium costs for health insurance. Depending on your household earnings you may also earn cost-sharing assistance, making your plan benefits better, too. Better plans for a better price! Again, this is based on your household income. The credits are paid directly to the insurer, with individuals responsible for the remaining premium amount. 2 3

4 FINANCIAL ASSISTANCE WHO IS ELIGIBLE FOR COST-SHARING ASSISTANCE? People with incomes less than 250 percent of the poverty level ($29,175 for an individual, $59,625 for a family of four) will also receive additional assistance to help ensure that everyone can afford the care they need. HOW DOES COST-SHARING ASSISTANCE WORK? Premium credits allow individuals to buy a Silver plan which has a 70 percent actuarial value, meaning that the plan will cover approximately 70 percent of the costs for covered medical services with the covered individual paying the other 30 percent. Someone with an income below 250 percent of the poverty level will not have to pay the full 30 percent of the cost of covered services, ultimately giving them a plan with an actuarial value higher than 70 percent. Individuals with incomes below 150 percent of the poverty line ($17,505 for an individual, $35,775 for a family of four) will have plans that have an actuarial value of 94 percent. Plans for individuals with incomes between 150 percent and 200 percent of the poverty line ($17,505 - $23,340 for individuals, $35,775 - $47,700 for a family of four) will have an actuarial value of 87 percent. These higher actuarial values mean that low-income individuals and families will be able to enroll in plans with lower deductibles, copayments and/or total out-of-pocket costs thanks to cost-sharing assistance. CHOOSING A PLAN Choosing the right health plan is an important task. You want one that s right for you and offers the right benefits for your life and health. UNDERSTANDING PLAN COVERAGE Before choosing a health plan, please review the coverage details outlined in the Summary of Benefits and Coverage (SBC) provided for your consideration at the time of enrollment. You may access the SBC for any plan at, view them on the federal marketplace, request them from your agent or broker, or request help by calling. When you become a member of Community Health Alliance and after your first payment has been received, you will receive a new member packet with an ID card and additional plan documents. These are important documents that provide more detail about coverage, limitations, exclusions, notification requirements and other information to assist you in accessing your health insurance benefits. You may also call Customer Service to ask questions about your plan and benefits at. OUR COMMITMENT TO QUALITY Community Health Alliance is proud to have earned Interim Accreditation from the National Committee for Quality Assurance (NCQA),a private, nonprofit organization dedicated to improving health care quality. You can be assured that we are always working to improve the service we provide to you. PRIVACY INFORMATION Community Health Alliance complies with federal and state laws regarding the confidentiality of medical records and personal information about our members. Our policies and procedures help ensure that the collection, use and disclosure of information complies with the law. We give members access to their own information consistent with applicable laws and standards. Our policies and practices support appropriate and effective use of information, internally and externally, and enable us to serve and improve the health of our members, while being sensitive to privacy. For a copy of our Notice of Privacy Practices, please visit or call Customer Service at. CHOOSING A PLAN 4 5

5 PRIMARY CARE PROVIDER 6 PRIMARY CARE PROVIDERS Every great team is made up of different players and you need a team to help keep you in the best health possible. By partnering with Community Health Alliance and your primary care provider, you can stay in the game, and keep your health the # 1 goal! PARTNERING WITH YOU TO KEEP YOU HEALTHY While it s not required, CHA encourages our members to select a Primary Care Provider or PCP. A PCP is your main health care provider in non-emergency situations. Your PCP s role is to: Provide preventive care and teach healthy lifestyle choices. Identify and treat common medical conditions. Assess the urgency of your medical problems and direct you to the best place for that care. Coordinate your care with medical specialists when necessary. Learn more about primary care at or by calling Customer Service at. PROVIDER NETWORK The Community Health Alliance provider network is an open access network, meaning you may choose to see any doctor in our network without a referral. We ask that you choose a PCP from our network when you enroll. If you do not choose a PCP, we will choose one for you. Your PCP will coordinate your care. Out-of- network services are processed at a separate deductible and higher co-insurance except in the event of a medical emergency. Note that benefits received for an out-of-network provider could result in you being billed for the excess of the contractually allowed amount. Only providers in your CHA network (Choice or Select) have agreed not to bill you for this additional amount. GO ONLINE TO FIND AN IN-NETWORK PROVIDER It s easy to find a provider in the Community Health Alliance network. Go to and select your provider network. Choose Find and select a doctor in your area. You ll be able to search for providers that participate in the Community Health Alliance provider network in which you are enrolled, using a variety of search options. PREVENTIVE CARE A little bit of prevention goes a long way to keeping you and your family healthy. Community Health Alliance plans cover the following preventive services without charging you a copayment or coinsurance, even if you haven t met your yearly deductible. That means it s affordable to see your in-network PCP to keep you at your healthiest. Immunizations Screenings recommended for women and children Wellness visits for children and adults Preventive prostate screening Preventive mammography Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women Identified contraception devices or services SPECIALTY CARE You do not need a referral to receive specialty care. It s always a good idea to discuss treatment options with your PCP first. He or she may recommend that you see a specialist for certain conditions. PRIOR-AUTHORIZATIONS It is important that you get the care you need in the right setting. Preauthorization is the process we use to decide if certain services are medically necessary. Some covered benefits or services must be preauthorized. Some of these are: In-patient hospital stays Skilled nursing center care Home health services Advanced testing such as MRIs (magnetic resonance imaging) NURSELINE The Community Health Alliance Nurseline is one-on-one health support, at no additional cost to you. Your Community Health Alliance Health Coach will support you and your family as you work with your doctor to make the best health choices. There is no question too big or too small for your Health Coach and the call is free. Call a Health Coach today at Call a Health Coach to: Get information on a variety of health topics. Learn about resources to help you make healthy changes from losing weight to sleeping well. If you think you may have a medical emergency, call your doctor or 911 immediately. Health Coaches DO NOT provide clinical services and should not be used in emergency situations. PRIMARY CARE PROVIDER 7

6 PHARMACY BENEFITS PHARMACY BENEFITS UNDERSTANDING YOUR PHARMACY BENEFITS Your pharmacy benefits are one of the keys to keeping you healthy. The Community Health Alliance drug plan has a five-tier closed formulary structure. The amount you pay for your prescription depends on the tier or category in which your medication is listed, and what plan you are enrolled in at the time. These five tiers are generic, preferred brand, non-preferred brand, specialty and preventive. Choosing a generic or preferred drug when appropriate can help reduce your health care costs. Non-preferred and specialty drugs generally have higher out-of-pocket expenses. Coverage for preventive drugs on the formulary is mandated by law and covered at 100 percent. Our website has information about pharmacy benefits, including the drug formulary and quarterly updates. A formulary is a listing TIER 1 TIER 2 TIER 3 TIER 4 GENERIC PREFERRED NON-PREFERRED SPECIALTY DRUGS of the drugs covered by Community Health Alliance. You can also visit Catamaran online, our Pharmacy Benefit Manager: On their site, members can search for an in-network pharmacy, review information on drugs such as interactions and side effects, calculate prices on their prescription medications, view their own pharmacy history, order mail-order prescriptions, and much more. Through the Catamaran network, we have over 65,000 pharmacies nationwide in our pharmacy network. The only way to receive covered benefits for your prescriptions is to use an in-network pharmacy. Members can receive up to a 30 day supply of all medications at retail or up to a 90 day supply of maintenance medications at retail. A 90 day supply at retail is 2 times the 30-day copay. SAVE MONEY! Use generic drugs any time they re available. Generic drugs are safe and save you money. The next time you get a prescription for a brand-name medication, ask if a generic equivalent option is available and if it might be right for you. Generic medications are covered under your pharmacy benefits, while some of their brand-name versions are not. GLOSSARY Here are a few definitions that may make understanding your benefits a little easier. COINSURANCE Coinsurance is a fixed percentage of the allowed amount. Typically, the plan pays a portion and the member pays a portion. COPAYMENT Your copayment, sometimes called a copay, is a set dollar amount you pay each time you receive a health service. For example, your plan might have a $30 copay for a visit to your doctor. You pay this amount directly to the doctor s office during your visit. DEDUCTIBLE The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won t pay anything until you ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. OUT-OF-POCKET COSTS Out-of-pocket costs are costs that your health plan doesn t pay for, and are expenses paid by the member. Plans vary, but would include your deductible, coinsurance and copayments for covered services. PRIMARY CARE PROVIDER A Primary Care Provider (PCP) is your main health care provider in non-emergency situations. With Community Health Alliance, you can choose a PCP from the following practice types: Family Medicine Internal Medicine Pediatrics GLOSSARY TIER 5 PREVENTIVE FIVE TIER DRUG PLAN The five tiers dictate what you will pay for your prescription drugs. OB/GYN SPECIALIST A Specialist is a health care provider who focuses on treating certain conditions. 8 9

7 Community Health Alliance Mutual Insurance Company