Get choice, value, and more with a Group Health plan

Transcription

1 INDIVIDUAL AND FAMILY Get choice, value, and more with a Group Health plan A guide to understanding the new health care market and choosing a Group Health plan that best meets your needs. Contents Intro letter Compare your plan options 2014 Adult Dental plan 2014 plan rates Getting the care you need: Core Alliant Plus Connect

2 Individual and Family Sales 320 Westlake Ave. N., Suite 100 Seattle, WA ghc.org Thank you for your interest in Group Health Cooperative or Group Health Options, Inc. health plans for individuals and families. We created this packet to give you everything you ll need to become familiar with our plans and choose a plan that best fits your needs. Compare Your Plan Options explains the basics about health care reform, helps you think through what you need in a health plan, and shows you the benefits and cost shares for each plan. Getting the Care You Need helps you understand how you can access care through a plan s network of providers and pharmacies Plan Rates provides the monthly premium rate (before tax credits or other financial assistance) for any plan you select. More choice than ever before. Whether your priority is having access to the broadest choice of doctors or reducing your out-of-pocket costs or something in between you ll find a Group Health plan that s right for you. You can choose from a broad selection of affordable, high quality plans for you and your family including our Connect3, Core3, and HealthPays HSA plans, which are available direct from Group Health. Or, if you qualify for financial assistance from the federal government or you re looking for one of our lower cost options, you can enroll in our Core or Core Basics Plus Catastrophic plans through Washington Healthplanfinder the new online exchange marketplace for purchasing health insurance. Perks to keep you healthy. Our plans offer you more than just health coverage. You get a suite of online health tools through MyGroupHealth for Members, access to a 24/7 Consulting Nurse Service, weight management and tobacco cessation programs, and much more. If you receive care at a Group Health Medical Centers location, you can also your doctor, schedule appointments, and check test results online. Plus you get the services you need exams, lab, pharmacy, and more all under one roof. Apply today. As of January 2014, most individuals will be required to maintain health coverage for themselves and dependents as part of health care reform. In addition, the law ensures that you cannot be denied coverage due to any pre-existing health conditions. Open enrollment is Oct. 1 through March 31 each year, and extended open enrollment for child-only policies is March 15 through April 30. You may enroll outside of these open enrollment periods under certain circumstances known as qualifying events. The quickest way to apply for coverage is online at ghc.org/if. Our online enrollment is secure and private. However, if you prefer to mail your application, be sure to complete all sections of the application form and enclose any supporting documentation so that we can process your application as soon as possible. If you qualify for financial assistance or want to sign up for our Core or Core Basics Plus Catastrophic plans, you can enroll online at wahealthplanfinder.org. Questions? Call us at (over)

3 When you apply outside of open enrollment, you will need to complete a qualifying event form and include it, along with supporting documentation, when you submit your application. This form is enclosed, titled Applying for a plan outside the standard open enrollment period. You can also indicate a qualifying event online when you apply through ghc.org/if, and then send us your supporting documentation separately by mail, , or fax. Your application must be received by the 23rd of the month prior to your desired effective date. For example, if you want your coverage to begin on July 1, your application must be received by June 23. More information In addition to the enclosed packet, you can also review the Summary of Benefits and Coverage (SBC), a federally required, standardized document for all health plans. You can view each plan s SBC online at ghc.org/if or call us at the number below to request a printed copy. If you have any questions or need additional assistance, please call our Individual and Family Sales team at or toll-free at If you are hearing- or speech-impaired, first call the Washington state TTY Relay number toll-free at or 711. Thank you again for considering Group Health for your health coverage. We look forward to caring for you and your family in the years to come. Group Health Individual and Family Sales 14-IF-1171_

4 INDIVIDUAL AND FAMILY Compare your plan options Effective Jan. 1, 2014, for individuals and families

5 Good news about your health care coverage Health care reform brings a whole new world of choices for That s great news for you. All health plans are now required to offer the 10 essential health benefits, so you get broad coverage no matter which plan, or whose plan, you choose. But that doesn t mean that all health plans are alike. Read on for some highlights of what sets Group Health plans apart, as well as 3 easy steps to understanding the different types of plans and choosing the plan that s right for you. Contents What sets Group Health apart? 1 3 easy steps to choosing a 2014 health plan Group Health plans 4 Details and definitions 12 Fast facts about health care reform 13 What sets Group Health apart? Our 2014 plans are all new, and they all offer the same full spectrum of covered benefits. No matter where you live and which plan you choose, you ll have access to a large network that includes primary care, specialty care, alternative care, and community hospitals in our service area. You choose how large of a network you want, and how you want costs to be shared between you and your health plan. Care is available whenever and wherever you need it. You can call our Consulting Nurse Service 24/7 from anywhere in the world for help with urgent medical questions. Our plans provide emergency coverage, worldwide. IMPORTANT DATES TO REMEMBER Online services make managing your health care easy. Go online to find a doctor, refill prescriptions, and get a personalized health status report. You can also check your health coverage and benefit usage, and view an extensive library of health topics. Wellness services help you stay as healthy as possible, and catch any problems early. Services include preventive screenings and immunizations, smoking cessation and weight management programs, discounts at fitness facilities, and more. Oct. 1, 2013 March 31, 2014 General open enrollment, when you can enroll in health plans.* Jan. 1, 2014 Coverage begins for plans purchased before Dec. 23, March 15, 2014 April 30, 2014 Extended open enrollment for individuals under age 19 (child-only plans) Counties where our plans are available: Benton, Columbia, Franklin, Island, King, Kitsap, Kittitas, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman, and Yakima. * Certain qualifying events such as if you lose your health coverage, or there is a birth or adoption in your family allow you to enroll in a health plan, or modify your coverage, at any time during the year, as long as it s no more than 60 days from the date of the qualifying event. COMPARE YOUR PLAN OPTIONS 1

6 3 easy steps to choosing a 2014 health plan Follow these steps and you ll be ready to make an informed decision about the health coverage that s right for you and your family. 2 Consider how often you use health care services. This will help you determine what level of coverage you need. The Affordable Care Act (ACA) allows health plan carriers to offer different levels of coverage called the metal tiers that define how costs are shared between you and your health plan. Group Health offers Gold, Silver, and Bronze plans. Find out if you re 1 You may be able to save eligible for financial on premiums and other costs (deductibles, copays, assistance. coinsurance) if: Depending on your family size and income, you may qualify for assistance on your monthly health plan premiums and even on deductibles, coinsurance, and copayments. To find out if you qualify, go to ghc.org/if and click on Estimate your savings. If you qualify, you ll need to purchase your coverage through Washington Healthplanfinder the online exchange marketplace for purchasing health insurance to get that savings. You are under age 65 and are not eli gible for Medicare, Medicaid, Children s Health Insurance Program (CHIP), an employer-sponsored plan, a grandfathered plan, or other coverage recognized by Health and Human Services (HHS). You are a lawful U.S. resident. Your income is 139 percent to 400 percent of the federal poverty level. Many middleincome house holds fall within this range. Your employer s coverage is unafford able (your share of the plan premium for employee coverage would be greater than 9.5 percent of your household income) or inade quate (the plan pays less than 60 percent of the cost of covered benefits). gold SILVER BRONZE Monthly premium $$$ $$ $ Cost to you when you get care (copays, de ductible, coinsurance) Good choice if you $ $$ $$$ Expect to use a lot of health care services Want a balance between monthly premium costs and out-of-pocket costs when you get care 3 Choose a plan that matches your needs. Don t expect to use a lot of health care services All our plans offer the same broad set of benefits. So how are they different? Plans vary in the amount of choice you have in doctors, your monthly premiums, and your cost shares (deductibles, copays, coinsurance, and out-of-pocket limits). Go to our Core plans (p. 4) if you re eligible for financial assistance through Washington Healthplanfinder or you re looking for one of our lower cost options. Go to our Core3 plans (p. 8) if you want a balance between value, choice, and cost, and don t qualify for financial assistance. (These plans are only available direct from Group Health, not through Washington Healthplanfinder.) Go to our Connect3 plans (p. 10) if you want maximum choice in providers and don t qualify for financial assistance. (These plans are only available direct from Group Health, not through Washington Healthplanfinder.) Go to our HealthPays HSA Bronze plans (p. 9, 11) if you want a lower cost, high-deductible plan or an HSA-compatible plan. (These plans are only available direct from Group Health, not through Washington Healthplanfinder.) 2 INDIVIDUAL AND FAMILY COMPARE YOUR PLAN OPTIONS 3

7 2014 Group Health plans on Washington Healthplanfinder Group Health Cooperative Core plans Our Core plans offer quality, value, and a broad range of benefits. Core plans give you access to: Nearly 1,100 Group Health doctors at 25 Group Health Medical Centers locations.* More than 9,000 in-network providers in our service area.* To learn more about the doctors in our Core plans network (also known as Group Health ), go to ghc.org/provider. These plans are a great choice if you qualify for financial assistance on premiums or other cost shares and want to purchase a plan through Washington Healthplanfinder. Coordinated care at Group Health Medical Centers At our 25 clinics, your care is coordinated between doctors, nurses, specialists, and phar ma cists. Electronic medical records give your entire health care team access to your health information, so decisions can be made quickly and safely. Other advantages include: Online services such as ing your doctor, scheduling appoint ments, viewing your medical record, and checking test results. All the services you need under one roof: doctors, lab, pharmacy, and radiology at most locations. Access to more than 90 specialties and sub specialties with self-referral to many of them. COVERAGE Annual deductible Deductible does not apply to services noted with Member coinsurance Out-of-pocket limit BENEFITS Office visits Preventive care services Maternity care Routine outpatient prenatal and postpartum visits Labor and delivery Chiropractic/manipulative therapy 10 visits per calendar year Acupuncture 12 visits per calendar year Lab/X-ray services Devices, equipment, and supplies (including prosthetics) Outpatient surgery Emergency care Ambulance Hospital stays inpatient Skilled nursing 60 days per calendar year Pediatric vision 1 routine exam per year; Hardware 1 pair of lenses and frames or contacts per year Prescription drugs Cost per 30-day supply CORE GOLD CORE SILVER CORE BRONZE $750 per member or $1,500 per family $1,500 per member or $3,000 per family $5,000 per member or $10,000 per family 10% 20% 40% $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family After deductible is met, you pay: After deductible is met, you pay: After deductible is met, you pay: Primary: $10 copay per visit Specialty: $15 copay per visit Primary: $20 copay per visit Specialty: $30 copay per visit Primary: $40 copay per visit Specialty: $60 copay per visit 10% coinsurance 20% coinsurance 40% coinsurance $10 primary/$15 specialty copay per visit $20 primary/$30 specialty copay per visit $40 primary/$60 specialty copay per visit $10 primary/$15 specialty copay per visit $20 primary/$30 specialty copay per visit $40 primary/$60 specialty copay per visit 10% coinsurance 20% coinsurance 40% coinsurance 10% coinsurance 20% coinsurance 40% coinsurance 10% coinsurance 20% coinsurance 40% coinsurance $100 copay + 10% coinsurance $150 copay + 20% coinsurance $200 copay + 40% coinsurance 10% coinsurance 20% coinsurance 40% coinsurance 10% coinsurance 20% coinsurance 40% coinsurance 10% coinsurance 20% coinsurance 40% coinsurance Filled at pharmacy: $10 preferred generic 20% preferred brand, Filled by mail order: $5 preferred generic 15% preferred brand, Filled at pharmacy: $10 preferred generic 40% preferred brand, Filled by mail order: $5 preferred generic 35% preferred brand, Filled at pharmacy: 40% preferred generic, preferred brand, Filled by mail order: 35% preferred generic, preferred brand, To enroll in one of these plans, go to wahealthplanfinder.org. *Source: OIC Provider Network Form A NOTE: This is a summary of benefits. The contents are not to be accepted or construed as a substitute for the provisions of the medical coverage agreement. Other terms and conditions may apply. A list of excluded services and other limitations can be found in each plan s Summary of Benefits and Coverage document. Primary care COPAYS APPLY TO: Acupuncture Audiology Chemical Dependency/Substance Abuse Chiropractic/Manipulative Therapy Emergency Medicine (where ER copay doesn t apply) Enterostomal Therapy Family Planning Family Medicine Health Education Internal Medicine Massage Therapy Mental Health Midwifery Naturopathy Nutrition Obstetrics/Gynecology Occupational Medicine Occupational Therapy Optometry Osteopathy Pediatrics Physical Therapy Respiratory Therapy Speech Therapy Specialty care COPAYS APPLY TO: Allergy and Immunology Anesthesiology Cardiology (pediatric and cardio vascular disease) Critical Care Medicine Dentistry Dermatology Endocrinology Gastroenterology Genetics Hematology Hepatology Infectious Disease Neonatal-Perinatal Medicine Nephrology Neurology Oncology Ophthalmology Orthopedics Otolaryngology (ear, nose, and throat) Pathology Physiatry (Physical Medicine) Podiatry Pulmonary Medicine/Disease Radiology (nuclear medicine, radiation therapy) Rheumatology Sports Medicine General Surgery (all surgical specialties) Urology 4 INDIVIDUAL AND FAMILY COMPARE YOUR PLAN OPTIONS 5

8 2014 Group Health plans on Washington Healthplanfinder Group Health Cooperative Core plans COVERAGE Annual deductible Deductible does not apply to services noted with CORE SILVER 94 CORE SILVER 87 CORE SILVER 73 $50 per member or $100 per family $200 per member or $400 per family $1,200 per member or $2,400 per family CORE BASICS PLUS CATASTROPHIC $6,350 per member or $12,700 per family Our Core Silver 94, Core Silver 87, and Core Silver 73 plans are only available to individuals and families who qualify for financial assistance based on family size and income. Our Core Basics Plus Catastrophic plan is available to adults under age 30, adults experiencing some type of hardship (determined on a case-by-case basis), and adults who were enrolled in a 2013 health plan that was cancelled. We also offer a Core Bronze AIAN plan that s available to American Indians and Alaska Natives who qualify. For details about this plan, go to wahealthplanfinder.org. Core plans are only available online through Washington Healthplanfinder. These plans are only available to those who qualify. Member coinsurance Out-of-pocket limit BENEFITS Office visits Preventive care services Maternity care Routine outpatient prenatal and postpartum visits Labor and delivery Chiropractic/manipulative therapy 10 visits per calendar year Acupuncture 12 visits per calendar year Lab/X-ray services Devices, equipment, and supplies (including prosthetics) Outpatient surgery Emergency care Ambulance Hospital stays inpatient Skilled nursing 60 days per calendar year Pediatric vision 1 routine exam per year; Hardware 1 pair of lenses and frames or contacts per year 5% 10% 20% None $2,250 per member or $4,500 per family $2,250 per member or $4,500 per family $5,200 per member or $10,400 per family $6,350 per member or $12,700 per family After deductible is met, you pay: After deductible is met, you pay: After deductible is met, you pay: After deductible is met, you pay: Primary: No charge Primary: $10 copay per visit Primary: $20 copay per visit First 3 primary care visits covered in full Primary: No charge Specialty: No charge Specialty: $15 copay per visit Specialty: $30 copay per visit Specialty: No charge 5% coinsurance 10% coinsurance 20% coinsurance No charge No charge $10 primary / $15 specialty copay per visit $20 primary / $30 specialty copay per visit No charge No charge $10 primary / $15 specialty copay per visit $20 primary / $30 specialty copay per visit No charge 5% coinsurance 10% coinsurance 20% coinsurance No charge 5% coinsurance 10% coinsurance 20% coinsurance No charge 5% coinsurance 10% coinsurance 20% coinsurance No charge $150 copay + 5% coinsurance $150 copay + 10% coinsurance $150 copay + 20% coinsurance No charge 5% coinsurance 10% coinsurance 20% coinsurance No charge 5% coinsurance 10% coinsurance 20% coinsurance No charge 5% coinsurance 10% coinsurance 20% coinsurance No charge Prescription drugs Cost per 30-day supply Filled at pharmacy: $7 preferred generic 10% preferred brand, Filled by mail order: $2 preferred generic 5% preferred brand, Filled at pharmacy: $10 preferred generic 30% preferred brand, Filled by mail order: $5 preferred generic 25% preferred brand, Filled at pharmacy: $10 preferred generic 30% preferred brand, Filled by mail order: $5 preferred generic 25% preferred brand, Filled at pharmacy No charge for preferred generic No charge for preferred brand, Filled by mail order No charge for preferred generic No charge for preferred brand, To enroll in one of these plans, go to wahealthplanfinder.org. NOTE: This is a summary of benefits. The contents are not to be accepted or construed as a substitute for the provisions of the medical coverage agreement. Other terms and conditions may apply. A list of excluded services and other limitations can be found in each plan s Summary of Benefits and Coverage document. Primary care COPAYS APPLY TO: Acupuncture Audiology Chemical Dependency/Substance Abuse Chiropractic/Manipulative Therapy Emergency Medicine (where ER copay doesn t apply) Enterostomal Therapy Family Planning Family Medicine Health Education Internal Medicine Massage Therapy Mental Health Midwifery Naturopathy Nutrition Obstetrics/Gynecology Occupational Medicine Occupational Therapy Optometry Osteopathy Pediatrics Physical Therapy Respiratory Therapy Speech Therapy Specialty care COPAYS APPLY TO: Allergy and Immunology Anesthesiology Cardiology (pediatric and cardio vascular disease) Critical Care Medicine Dentistry Dermatology Endocrinology Gastroenterology Genetics Hematology Hepatology Infectious Disease Neonatal-Perinatal Medicine Nephrology Neurology Oncology Ophthalmology Orthopedics Otolaryngology (ear, nose, and throat) Pathology Physiatry (Physical Medicine) Podiatry Pulmonary Medicine/Disease Radiology (nuclear medicine, radiation therapy) Rheumatology Sports Medicine General Surgery (all surgical specialties) Urology 6 INDIVIDUAL AND FAMILY COMPARE YOUR PLAN OPTIONS 7

9 2014 plans direct from Group Health Cooperative Group Health Core3 and HealthPays HSA plans Our Core3 and HealthPays HSA plans from Group Health Cooperative combine high-quality care and great value. Our Core3 plans give you three primary care visits per year at just your office visit copay without having to pay your deductible first. And the network of providers includes: Nearly 1,100 Group Health doctors at 25 Group Health Medical Centers locations.* More than 9,000 in-network providers.* To learn more about the doctors in our Core plans network (also known as Group Health ), go to ghc.org/provider. Coordinated care at Group Health Medical Centers At our 25 clinics, your care is coordinated between doctors, nurses, specialists, and phar ma cists. Electronic medical records give your entire health care team access to your health information, so decisions can be made quickly and safely. Other advantages include: Online services such as ing your doctor, scheduling appoint ments, viewing your medical record, and checking test results. All the services you need under one roof: doctors, lab, pharmacy, and radiology at most locations. Access to more than 90 specialties and sub specialties with self-referral to many of them. COVERAGE Annual deductible Deductible does not apply to services noted with Member coinsurance Out-of-pocket limit BENEFITS Office visits Preventive care services Maternity care Routine outpatient prenatal and postpartum visits Labor and delivery Chiropractic/manipulative therapy 10 visits per calendar year Acupuncture 12 visits per calendar year Lab/X-ray services Devices, equipment, and supplies (including prosthetics) Outpatient surgery Emergency care Ambulance Hospital stays inpatient Skilled nursing 60 days per calendar year Adult vision 1 routine exam per year Pediatric vision 1 routine exam per year; Hardware 1 pair of lenses and frames or contacts per year Pediatric dental See separate pediatric dental benefit summary available online at ghc.org/if CORE3 gold CORE3 silver HEALTHPAYS HSA BRONZE $500 per member or $1,000 per family $1,250 per member or $2,500 per family $4,000 per member or $8,000 per family 20% 30% 20% $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family After deductible is met, you pay: After deductible is met, you pay: After deductible is met, you pay: Primary: $10 copay per visit Deductible does not apply to first 3 primary care visits per year Specialty: $15 copay per visit Primary: $20 copay per visit Deductible does not apply to first 3 primary care visits per year Specialty: $30 copay per visit Primary: 20% coinsurance per visit Specialty: 20% coinsurance per visit 20% coinsurance $10 Primary/$15 Specialty copay per visit $10 Primary/$15 Specialty copay per visit 30% coinsurance $20 Primary/$30 Specialty copay per visit $20 Primary/$30 Specialty copay per visit 20% coinsurance Primary & Specialty: 20% coinsurance per visit Primary & Specialty: 20% coinsurance per visit 20% coinsurance 30% coinsurance 20% coinsurance 20% coinsurance 30% coinsurance 20% coinsurance 20% coinsurance 30% coinsurance 20% coinsurance $100 copay + 20% coinsurance $150 copay + 30% coinsurance 20% coinsurance 20% coinsurance 30% coinsurance 20% coinsurance 20% coinsurance 30% coinsurance 20% coinsurance 20% coinsurance 30% coinsurance 20% coinsurance $10 Primary/$15 Specialty copay per visit $20 Primary/$30 Specialty copay per visit Primary & Specialty: 20% coinsurance per visit Preventive services covered in full Major services subject to dental deductible and 50% coinsurance Preventive services covered in full Major services subject to dental deductible and 50% coinsurance Preventive services covered in full Major services subject to medical deductible and 50% coinsurance What s an HSA (health savings account) and is it right for you? See Details and definitions on page 12. Prescription drugs Cost per 30-day supply Filled at pharmacy: $10 preferred generic 20% preferred brand, Filled by mail order: $5 preferred generic 15% preferred brand, Filled at pharmacy: $10 preferred generic 40% preferred brand, Filled by mail order: $5 preferred generic 35% preferred brand, Filled at pharmacy: 20% preferred generic 40% preferred brand, Filled by mail order: 15% preferred generic 35% preferred brand, To enroll in one of these plans, go to ghc.org/if. *Source: OIC Provider Network Form A NOTE: This is a summary of benefits. The contents are not to be accepted or construed as a substitute for the provisions of the medical coverage agreement. Other terms and conditions may apply. A list of excluded services and other limitations can be found in each plan s Summary of Benefits and Coverage document. Primary care COPAYS APPLY TO: Acupuncture Audiology Chemical Dependency/Substance Abuse Chiropractic/Manipulative Therapy Emergency Medicine (where ER copay doesn t apply) Enterostomal Therapy Family Planning Family Medicine Health Education Internal Medicine Massage Therapy Mental Health Midwifery Naturopathy Nutrition Obstetrics/Gynecology Occupational Medicine Occupational Therapy Optometry Osteopathy Pediatrics Physical Therapy Respiratory Therapy Speech Therapy Specialty care COPAYS APPLY TO: Allergy and Immunology Anesthesiology Cardiology (pediatric and cardio vascular disease) Critical Care Medicine Dentistry Dermatology Endocrinology Gastroenterology Genetics Hematology Hepatology Infectious Disease Neonatal-Perinatal Medicine Nephrology Neurology Oncology Ophthalmology Orthopedics Otolaryngology (ear, nose, and throat) Pathology Physiatry (Physical Medicine) Podiatry Pulmonary Medicine/Disease Radiology (nuclear medicine, radiation therapy) Rheumatology Sports Medicine General Surgery (all surgical specialties) Urology 8 INDIVIDUAL AND FAMILY COMPARE YOUR PLAN OPTIONS 9

10 2014 plans direct from Group Health Options, Inc. Group Health Connect3 and HealthPays HSA plans If having a lot of choice is most important to you, you may want to select one of our Connect3 plans, or our Group Health Options, Inc. HealthPays plan that s compatible with health savings accounts (HSAs). These plans give you access to many additional providers, both in-network and out-ofnetwork. (The Connect plans network is also known as Alliant Plus.) And our Connect3 plans give you three primary care visits at just your office visit copay without meeting the deductible first. Providers include: In Network Nearly 1,100 Group Health doctors at 25 Group Health Medical Centers locations.* 450 doctors at 8 Virginia Mason Medical Centers locations. Nearly 400 doctors at 16 The Everett Clinic locations. More than 9,000 in-network providers.* Out of Network More than 5,000 regional doctors in Washington, Oregon, Idaho, Alaska, and Montana with First Choice Health. More than 590,000 doctors in all other states with First Health Network. Any licensed provider in the U.S. To learn more about the doctors in our Connect plans network, go to ghc.org/provider. COVERAGE Annual deductible Deductible does not apply to services noted with Member coinsurance Out-of-pocket limit BENEFITS Office visits Preventive care services Maternity care Routine outpatient prenatal and postpartum visits Labor and delivery Chiropractic/manipulative therapy 10 visits per calendar year Acupuncture 12 visits per calendar year Lab/X-ray services Devices, equipment, and supplies (including prosthetics) Outpatient surgery Emergency care Ambulance Hospital stays inpatient Skilled nursing 60 days per calendar year Adult vision 1 routine exam per year Pediatric vision 1 routine exam per year; Hardware 1 pair of lenses and frames or contacts per year Pediatric dental See separate pediatric dental benefit summary available online at ghc.org/if COnnect3 gold COnnect3 silver HEALTHPAYS HSA BRONZE In Network Out of Network In Network Out of Network In Network Out of Network $500 per member or $1,000 per family $1,250 per member or $2,500 per family $4,000 per member or $8,000 per family 20% 40% 30% 50% 20% 50% $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family After deductible is met, you pay: After deductible is met, you pay: After deductible is met, you pay: Deductible does not apply to first 3 primary care visits per year Primary: $10 copay per visit Specialty: $15 copay per visit Primary: 40% coinsurance per visit Specialty: 40% coinsurance per visit Deductible does not apply to first 3 primary care visits per year Primary: $20 copay per visit Specialty: $30 copay per visit Primary: 50% coinsurance per visit Specialty: 50% coinsurance per visit Primary: 20% coinsurance per visit Specialty: 20% coinsurance per visit Primary: 50% coinsurance per visit Specialty: 50% coinsurance per visit 20% coinsurance $10 Primary/$15 Specialty copay per visit $10 Primary/$15 Specialty copay per visit 40% coinsurance Primary & Specialty: 40% coinsurance per visit Primary & Specialty: 40% coinsurance per visit 30% coinsurance $20 Primary/$30 Specialty copay per visit $20 Primary/$30 Specialty copay per visit 50% coinsurance Primary & Specialty: 50% coinsurance per visit Primary & Specialty: 50% coinsurance per visit 20% coinsurance Primary & Specialty: 20% coinsurance per visit Primary & Specialty: 20% coinsurance per visit 50% coinsurance Primary & Specialty: 50% coinsurance per visit Primary & Specialty: 50% coinsurance per visit 20% coinsurance 40% coinsurance 30% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 20% coinsurance 40% coinsurance 30% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 20% coinsurance 40% coinsurance 30% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance $100 copay + 20% coinsurance $100 copay + 20% coinsurance $150 copay + 30% coinsurance $150 copay + 30% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 40% coinsurance 30% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 20% coinsurance 40% coinsurance 30% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 20% coinsurance 40% coinsurance 30% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance Primary: $10 copay per visit Specialty: $15 copay per visit Preventive services covered in full Major services subject to dental deductible and 50% coinsurance Primary & Specialty: 40% coinsurance per visit 40% coinsurance for routine exam; Covered in full for hardware Preventive services covered in full Major services subject to dental deductible and 50% coinsurance Primary: $20 copay per visit Specialty: $30 copay per visit Preventive services covered in full Major services subject to dental deductible and 50% coinsurance Primary & Specialty: 50% coinsurance per visit 50% coinsurance for routine exam; Covered in full for hardware Preventive services covered in full Major services subject to dental deductible and 50% coinsurance Primary & Specialty: 20% coinsurance per visit Preventive services covered in full Major services subject to medical deductible and 50% coinsurance Primary & Specialty: 50% coinsurance per visit 50% coinsurance for routine exam; Hardware not covered Preventive services covered in full Major services subject to medical deductible and 50% coinsurance What s an HSA (health savings account) and is it right for you? See Details and definitions on page 12. To enroll in one of these plans, go to ghc.org/if. Prescription drugs Cost per 30-day supply Filled at pharmacy: $10 preferred generic 20% preferred brand, Filled by mail order: $5 preferred generic 15% preferred brand, Filled at pharmacy: 40% preferred generic 50% preferred brand, Filled by mail order: 35% preferred generic 45% preferred brand, Filled at pharmacy: $10 preferred generic 40% preferred brand, Filled by mail order: $5 preferred generic 35% preferred brand, Available only when filled through a Group Health designated mail order service. Primary care COPAYS APPLY TO: Acupuncture Audiology Chemical Dependency/Substance Abuse Chiropractic/Manipulative Therapy Emergency Medicine (where ER copay doesn t apply) Enterostomal Therapy Family Planning Family Medicine Health Education Internal Medicine Massage Therapy Mental Health Midwifery Naturopathy Nutrition Obstetrics/Gynecology Occupational Medicine Occupational Therapy Optometry Osteopathy Pediatrics Physical Therapy Respiratory Therapy Filled at pharmacy: 50% preferred generic 50% preferred brand, Filled by mail order: 45% preferred generic 45% preferred brand, Filled at pharmacy: 20% preferred generic 40% preferred brand, Filled by mail order: 15% preferred generic 35% preferred brand, Filled at pharmacy: 50% preferred generic 50% preferred brand, Filled by mail order: 45% preferred generic 45% preferred brand, *Source: OIC Provider Network Form A NOTE: This is a summary of benefits. The contents are not to be Specialty care COPAYS APPLY TO: Allergy and Immunology Anesthesiology Cardiology (pediatric and cardio vascular disease) accepted or construed as a substitute for the provisions of the Critical Care Medicine Dentistry Dermatology Endocrinology Gastroenterology Genetics Hematology Hepatology Infectious medical coverage agreement. Other terms and conditions may Disease Neonatal-Perinatal Medicine Nephrology Neurology Oncology Ophthalmology Orthopedics Otolaryngology (ear, nose, apply. A list of excluded services and other limitations can be found and throat) Pathology Physiatry (Physical Medicine) Podiatry Pulmonary Medicine/Disease Radiology (nuclear medicine, radiation in each plan s Summary of Benefits and Coverage document. therapy) Rheumatology Sports Medicine General Surgery (all surgical specialties) Urology Speech Therapy 10 INDIVIDUAL AND FAMILY COMPARE YOUR PLAN OPTIONS 11

11 Details and definitions Coinsurance The percentage amount you pay for the cost of the care you receive. You ll notice that the coinsurance levels differ among all of the plans. Copayment, copay The set dollar amount you pay when you receive certain covered services. Deductible What you ll pay each year before your full coverage kicks in. All our individual and family plans have traditional deductibles (also called embedded deductibles). Once a family member meets their individual deductible, services are covered for that person without the entire family deductible being met. Other family members continue to pay toward the family deductible amount. For certain services, the deductible does not apply. Drug formulary The list of generic and brand-name prescription drugs that are usually covered by our health plans. The drugs are selected by a committee of Group Health physicians and pharmacists based on safety, effectiveness, and cost. Hospital stays inpatient Hospital room and board; inpatient surgery; anesthesia; intensive and coronary care; laboratory tests; radiology services; drugs while in hospital. Includes mental health inpatient treatment. What s an HSA and is it right for you? A health savings ac count (HSA) is a per sonal sav ings account that s used to pay for eligible medi cal expenses. The money you deposit in the account is not taxed, and you own and control that money. You re eligible for an HSA if you choose a high-deductible, HSA-compatible health plan and aren t covered under another plan or enrolled in Medicare. Group Health s HealthPays HSA Bronze plans (see pages 9 and 11) are HSA-compatible plans. An HSA may be a good choice if you re healthy and want to save for future health care expenses. It s probably not a great idea if you think you may need Office visits Primary and specialty care, including naturopathy and outpatient mental health and substance abuse visits. Out-of-pocket limit The most you ll be required to pay for covered services in a calendar year. Deductible, coinsurance, and copays count toward limit. Outpatient surgery Surgery in an office, outpatient surgery center, or hospital setting that does not require an overnight stay. Pediatric dental For children up to and including age 18. Pediatric vision For children up to and including age 18. Prescription drugs Outpatient: Formulary drugs and medicines that require prescriptions, including self-administered injectables, mental health drugs, and diabetic supplies. Preventive care services For children and adults. Includes wellness visits and immunizations, as established in Group Health s well-care schedule, formulary contraceptive drugs including counseling, contraceptive devices, and female sterilization. Devices and supplies related to contraception are covered as preventive as required by federal law and covered in full. Also includes drugs and medicines such as aspirin, fluoride, and folic acid. expensive medical care in the next year and would have trouble meeting the high deductible. You can open an HSA with your own financial institution, or with our HSA partner, HealthEquity. To learn more about HealthEquity, visit or call us toll-free at Fast facts about health care reform What s new in 2014? The Affordable Care Act (ACA) was created to provide better health coverage to all Americans. Effective Jan. 1, 2014: Health plans for individuals and small businesses are now required to offer the 10 essential health benefits (see details below). Insurers can offer four levels of coverage Platinum, Gold, Silver, and Bronze plus a Catastrophic plan. If you have a pre-existing health condition you can t be denied coverage by an insurance company. Health plans cannot place a yearly or lifetime dollar limit on essential health benefits. If you re under age 65 and are not covered by your employer, Medicare, or Medicaid, you may be able to save on monthly premiums and costs at time of service such as copays. What are the 10 essential health benefits? As of Jan. 1, 2014, all health plans are required to cover: 1. Ambulatory patient services. Includes care you receive without being admitted to a hospital, such as services at a clinic, physician s office, or outpatient surgery center. 2. Emergency care. Includes care for conditions which, if not immediately treated, could lead to serious disability or death. 3. hospitalization. Includes room and board, medical care, tests, and prescription drugs administered during your stay. 4. Maternity and newborn care. Includes care provided during pregnancy, during and after labor, and care to newborn children. 5. Mental health and substance abuse disorder services, including behavioral health treatment. Covers evaluation, diagnosis, and treatment services. Washington state residents can buy health cover age through Washington Healthplanfinder, the state s online exchange marketplace, as of Oct. 1, In fact, if you qualify for financial assistance, you must buy through the exchange to get the savings. On the Washington Healthplanfinder website, you ll be able to make side-by-side comparisons between health plans in the exchange marketplace. Medicaid will be expanded in Washington state to cover more people who have low incomes. 6. Prescription drugs. Includes drugs for treating urgent health issues and chronic conditions like high blood pressure. 7. Rehabilitative and habilitative services and devices. Helps people with injuries, disabilities, or chronic health conditions. 8. laboratory services. Includes tests to diagnose conditions and monitor treatments. 9. Preventive and wellness services. Includes routine physicals, screenings, immunizations, and chronic disease management. 10. Pediatric services. Includes dental and vision care. 12 INDIVIDUAL AND FAMILY COMPARE YOUR PLAN OPTIONS 13

12 FOR MORE INFORMATION Go to ghc.org/if to compare plans and enroll Call us toll-free at or call your producer (agent/broker) 14-IF-1213_

13 INDIVIDUAL AND FAMILY 2014 Adult Dental Plan As a Group Health member, you can choose to enroll in the Individual and Family Adult Dental Plan offered by Group Health Options, Inc. The plan is available to members and their dependents 19 and older, and is administered by United Concordia Dental (UCD). It utilizes UCD s Advantage Plus network. When you receive your dental care from a UCD Advantage Plus dentist, you ll receive a higher level of coverage and will have lower out-of-pocket costs than if you see a non-network dentist. This is a brief summary of benefits. Please see reverse for a list of general exclusions, and refer to your dental coverage agreement for full benefit details. BENEFITS AND COVERAGE Class I: Diagnostic and preventive Exams, prophys, fluoride, X-rays, sealants When you see a United Concordia Advantage Plus dentist When you see a non-network dentist 100% covered; No deductible 100% covered; No deductible Class II: Restorative Fillings, oral surgery, endodontics, periodontics Class III: Major Crowns, dentures, partials, bridges, implants Deductible Per calendar year (Does not apply to Class I services) 50% covered You pay 50% 30% covered You pay 70% No deductible 50% covered You pay 50%, after deductible 30% covered You pay 70%, after deductible $50/person or $150/family Annual benefit maximum Per person, per calendar year $1,000 (UCD Advantage Plus and non-network combined) MONTHLY RATES Subscriber only $51.50 Subscriber and spouse $99.29 Subscriber and child(ren), age 19 up to 26 $89.82 Subscriber and spouse and child(ren), age 19 up to 26 $ Dental Customer Service for Group Health members: (toll-free) Find UCD Advantage Plus dental providers online at ghc.ourdentalcoverage.com/find-a-dentist. Rates and plans are subject to Office of the Insurance Commissioner (OIC) approval.

14 GENERAL EXCLUSIONS The following is a summary of services and supplies that are not covered under the Individual and Family Adult Dental Plan. Please refer to your dental coverage agreement for full benefit details. Dentistry for cosmetic reasons. Restorations or appliances necessary to correct vertical dimension or to restore the occlusion. Such procedures include restoration of tooth structure lost from attrition, abrasion, or erosion, and restorations for malalignment of teeth. Application of desensitizing agents. Experimental services or supplies. General anesthesia/intravenous (deep) sedation, except as specified for certain oral, periodontal, or endodontic surgical procedures. Analgesics such as nitrous oxide, conscious sedation, euphoric drugs, injections, or prescription drugs. Hospitalization charges and any additional fees charged by the dentist for hospital treatment. Orthodontic services, appliances, or supplies. TMJ (temporomandibular joint dysfunction) services, appliances, prosthetics, or supplies. Benefits are not covered for charges related to: broken appointments, patient management problems, or improperly completed insurance forms. Group Health shall have the discretionary authority to determine whether services are covered benefits in accordance with the general limitations and exclusions shown in this contract, but it shall not exercise this authority arbitrarily or capriciously or in violation of the provisions of the contract. This plan does not provide benefits for services or supplies to the extent that benefits are payable for them under any motor vehicle medical, motor vehicle no-fault, uninsured motorist, underinsured motorist, personal injury protection (PIP), commercial liability, homeowner s policy, or other similar type of coverage. This plan does not provide benefits for services not specifically included in the coverage agreement as Covered Dental Benefits. This is a brief summary of benefits and does not constitute a contract. For complete plan information, please refer to your dental coverage agreement. Group Health refers to Group Health Cooperative or Group Health Options, Inc. Group Health Options, Inc. 14-IF-1178_

15 Individual and family 2014 plan rates Effective Jan. 1, 2014, for individuals and families What to know before looking up rates Monthly premium rates page Areas where Group Health plans are offered: King County, Area 1 Western WA, Area 2 Island, Kitsap, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties Spokane County, Area 4 South Central and Southeastern WA, Area 5 Benton, Columbia, Franklin, Kittitas, Walla Walla, Whitman, and Yakima counties Rates for dependents If you have dependents, you ll need to find the rates for their ages and add them to your rate to get your family s total monthly premium. Your first 3 children ages 0 20 each will be charged the age 0 20 rate. There s no charge for additional children ages 0 20, unless they are on child-only policies*. Each child older than age 20 will be charged the rate applicable to his or her individual age. Smoker rates These apply to individuals who have used tobacco or nicotine products regularly within the last 6 months. Regular tobacco use is defined as 4 or more times per week, excluding religious or ceremonial use. Plans through Washington Healthplanfinder Plans direct from Group Health Core Gold 2 Core Silver 3 Core Bronze 4 Core Basics Plus Catastrophic Core3 Gold 6 Core3 Silver 7 Group Health Cooperative HealthPays HSA Bronze Connect3 Gold 9 Connect3 Silver 10 Group Health Options, Inc. HealthPays HSA Bronze * For child-only policies, when enrolling more than one child, each child must be enrolled in his or her own plan and each child will be charged the age 0 20 rate. Rates and plans are subject to Office of the Insurance Commissioner (OIC) approval.

16 Plans on washington healthplanfinder If you qualify for financial assistance, your premium rate may be lower than what is shown. Find out more at ghc.org/if. Plans on washington healthplanfinder If you qualify for financial assistance, your premium rate for the Core Silver plan may be lower than what is shown. Find out more at ghc.org/if. Depending on the level of financial assistance you qualify for, you may also be eligible for a Core Silver 94, Core Silver 87, or Core Silver 73 plan. Find out more about these three plans and their premiums at wahealthplanfinder.org. Core Gold from Group Health Cooperative King County Area 1 Western WA* Area 2 Spokane County Area 4 South Central and Southeastern WA Area 5 Core Silver from Group Health Cooperative King County Area 1 Western WA* Area 2 Spokane County Area 4 South Central and Southeastern WA Area 5 Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker AGE * Western Washington includes Island, Kitsap, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties. South Central and Southeastern Washington includes Benton, Columbia, Franklin, Kittitas, Walla Walla, Whitman, and Yakima counties. First 3 children ages 0 20 each will be charged the age 0 20 rate. There s no charge for additional children ages 0 20, unless they are on child-only policies. Each child older than age 20 will be charged the rate applicable to his or her individual age. 2 Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker AGE * Western Washington includes Island, Kitsap, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties. South Central and Southeastern Washington includes Benton, Columbia, Franklin, Kittitas, Walla Walla, Whitman, and Yakima counties. First 3 children ages 0 20 each will be charged the age 0 20 rate. There s no charge for additional children ages 0 20, unless they are on child-only policies. Each child older than age 20 will be charged the rate applicable to his or her individual age. 3

17 Plans on washington healthplanfinder If you qualify for financial assistance, your premium rate may be lower than what is shown. Find out more at ghc.org/if. Plans on washington healthplanfinder This plan is available only to adults under 30 or adults experiencing financial hardship. To find out more, go to ghc.org/if. Core Bronze from Group Health Cooperative King County Area 1 Western WA* Area 2 Spokane County Area 4 South Central and Southeastern WA Area 5 Core Basics Plus Catastrophic from Group Health Cooperative King County Area 1 Western WA* Area 2 Spokane County Area 4 South Central and Southeastern WA Area 5 Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker AGE * Western Washington includes Island, Kitsap, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties. South Central and Southeastern Washington includes Benton, Columbia, Franklin, Kittitas, Walla Walla, Whitman, and Yakima counties. First 3 children ages 0 20 each will be charged the age 0 20 rate. There s no charge for additional children ages 0 20, unless they are on child-only policies. Each child older than age 20 will be charged the rate applicable to his or her individual age. Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker AGE * Western Washington includes Island, Kitsap, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties. South Central and Southeastern Washington includes Benton, Columbia, Franklin, Kittitas, Walla Walla, Whitman, and Yakima counties. First 3 children ages 0 20 each will be charged the age 0 20 rate. There s no charge for additional children ages 0 20, unless they are on child-only policies. Each child older than age 20 will be charged the rate applicable to his or her individual age. 4 5

18 Plans Direct from Group Health Plans Direct from Group Health Core3 Gold from Group Health Cooperative Core3 Silver from Group Health Cooperative King County Area 1 Western WA* Area 2 Spokane County Area 4 South Central and Southeastern WA Area 5 King County Area 1 Western WA* Area 2 Spokane County Area 4 South Central and Southeastern WA Area 5 Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker AGE * Western Washington includes Island, Kitsap, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties. South Central and Southeastern Washington includes Benton, Columbia, Franklin, Kittitas, Walla Walla, Whitman, and Yakima counties. First 3 children ages 0 20 each will be charged the age 0 20 rate. There s no charge for additional children ages 0 20, unless they are on child-only policies. Each child older than age 20 will be charged the rate applicable to his or her individual age. Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker AGE * Western Washington includes Island, Kitsap, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties. South Central and Southeastern Washington includes Benton, Columbia, Franklin, Kittitas, Walla Walla, Whitman, and Yakima counties. First 3 children ages 0 20 each will be charged the age 0 20 rate. There s no charge for additional children ages 0 20, unless they are on child-only policies. Each child older than age 20 will be charged the rate applicable to his or her individual age. 6 7

19 Plans Direct from Group Health Plans Direct from Group Health HealthPays HSA Bronze from Group Health Cooperative King County Area 1 Western WA* Area 2 Spokane County Area 4 South Central and Southeastern WA Area 5 Connect3 Gold from Group Health Options, Inc. King County Area 1 Western WA* Area 2 Spokane County Area 4 South Central and Southeastern WA Area 5 Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker AGE * Western Washington includes Island, Kitsap, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties. South Central and Southeastern Washington includes Benton, Columbia, Franklin, Kittitas, Walla Walla, Whitman, and Yakima counties. First 3 children ages 0 20 each will be charged the age 0 20 rate. There s no charge for additional children ages 0 20, unless they are on child-only policies. Each child older than age 20 will be charged the rate applicable to his or her individual age. 8 Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker AGE * Western Washington includes Island, Kitsap, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties. South Central and Southeastern Washington includes Benton, Columbia, Franklin, Kittitas, Walla Walla, Whitman, and Yakima counties. First 3 children ages 0 20 each will be charged the age 0 20 rate. There s no charge for additional children ages 0 20, unless they are on child-only policies. Each child older than age 20 will be charged the rate applicable to his or her individual age. 9

20 Plans Direct from Group Health Plans Direct from Group Health Connect3 Silver from Group Health Options, Inc. King County Area 1 Western WA* Area 2 Spokane County Area 4 South Central and Southeastern WA Area 5 HealthPays HSA Bronze from Group Health Options, Inc. King County Area 1 Western WA* Area 2 Spokane County Area 4 South Central and Southeastern WA Area 5 Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker AGE * Western Washington includes Island, Kitsap, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties. South Central and Southeastern Washington includes Benton, Columbia, Franklin, Kittitas, Walla Walla, Whitman, and Yakima counties. First 3 children ages 0 20 each will be charged the age 0 20 rate. There s no charge for additional children ages 0 20, unless they are on child-only policies. Each child older than age 20 will be charged the rate applicable to his or her individual age. Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker AGE * Western Washington includes Island, Kitsap, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom counties. South Central and Southeastern Washington includes Benton, Columbia, Franklin, Kittitas, Walla Walla, Whitman, and Yakima counties. First 3 children ages 0 20 each will be charged the age 0 20 rate. There s no charge for additional children ages 0 20, unless they are on child-only policies. Each child older than age 20 will be charged the rate applicable to his or her individual age