UMHS participation in health insurance plans on the Michigan Individual Marketplace and Small Business SHOP

Transcription

1 UMHS participation in health insurance plans on the Michigan Individual Marketplace and Small Business SHOP Detailed view Definitions for acronyms are at the end of the document As of 1/13/14 Alliance Health and Life Insurance (a subsidiary of Health Alliance Plan - HAP) *** See below for HAP plans *** HAP Personal Alliance (PA) 1500 PPO Gold Participating HAP Personal Alliance (PA) 1500 Direct PPO Gold Participating HAP Personal Alliance (PA) 2000 Direct PPO Silver Participating HAP Personal Alliance (PA) 2000 Direct PPO-HSA Gold Participating HAP Personal Alliance (PA) 3000 PPO Silver Participating HAP Personal Alliance (PA) 3000 Direct PPO Silver Participating HAP Personal Alliance (PA) 5000 PPO-HSA Bronze Participating HAP Personal Alliance (PA) 6350 PPO Catastrophic Participating HAP 500 PPO Platinum Participating HAP 1000 PPO Gold Participating HAP 2000 PPO Silver Participating HAP 3000 PPO Bronze Participating HAP 1500 HSA PPO-HSA Gold Participating HAP 2000 HSA PPO-HSA Bronze Participating Coverage area: Arenac, Bay, Clare, Genesee, Gladwin, Gratiot, Huron, Iosco, Isabella, Lapeer, Livingston, Macomb, Midland, Monroe, Oakland, Ogemaw, Roscommon, Saginaw, Sanilac, St. Clair, Tuscola, Washtenaw and Wayne counties. Contact Information: or Plan Highlights: All Alliance Health and Life plans are PPO plans. There are no referrals required to see specialists. Members may choose to receive care from participating and Not participating providers. Services by out-of-network (Not participating) providers will incur higher out-of-pocket costs.

2 Blue Cross Blue Shield of Michigan Blue Cross Gold, a Multi State Plan PPO Gold Participating Blue Cross Premier Bronze PPO Bronze Participating Blue Cross Premier Gold PPO Gold Participating Blue Cross Premier Silver PPO Silver Participating Blue Cross Premier Value PPO Catastrophic Participating Blue Cross Silver, a Multi State Plan PPO Silver Participating Simply Blue Gold $1500 PPO Gold Participating Simply Blue HSA Silver $2000 PPO-HSA Silver Participating Coverage Area: All of Michigan Contact Information: or Plan highlights: Blue Cross Multi-State, offered to Michigan residents only through the Marketplace website, has BCBSM s PPO network with nationwide coverage. Member cost-sharing is lower when services are obtained within the network. These are the only Blue s individual plans that provide medical, prescription, pediatric and adult dental and vision coverage all in one plan. Only available in the silver and gold options. Blue Cross Premier has BCBSM s PPO network with nationwide coverage. Member cost-sharing is lower when services are obtained within the network. Available in four options: value, bronze, silver and gold. Note: Some PPO plans include dental and vision plans; dental plans can also be purchased separately to pair with other insurance.

3 Blue Care Network of Michigan (a subsidiary of Blue Cross Blue Shield of Michigan) Blue Cross Partnered Bronze HMO Bronze Not participating Blue Cross Preferred Bronze HMO Bronze Participating Blue Cross Select Bronze HMO Bronze Participating Blue Cross Partnered Silver HMO Silver Not participating Blue Cross Preferred Silver HMO Silver Participating Blue Cross Select Silver HMO Silver Participating Blue Cross Partnered Gold HMO Gold Not participating Blue Cross Preferred Gold HMO Gold Participating Blue Cross Select Gold HMO Gold Participating Blue Cross Partnered Value HMO Catastrophic Not participating Blue Cross Preferred Value HMO Catastrophic Participating Blue Cross Select Value HMO Catastrophic Participating BCN Gold 1500 HMO Gold Participating BCN HSA PCP Focus Bronze $3000 HMO Bronze Participating BCN HSA PCP Focus Bronze $4000 HMO Bronze Participating BCN PCP Focus Gold $1500 HMO Gold Participating BCN PCP Focus Silver $3000 HMO Silver Participating BCN Silver $3000 HMO Silver Participating Coverage Area: All of Michigan s Lower Peninsula except Lenawee County; Houghton, Marquette and Mackinac counties in the Upper Peninsula Contact Information: or Plan Highlights: Blue Cross Preferred has BCN s statewide HMO network. Care must be coordinated by a primary care physician. Offered in four options: value, bronze, silver and gold. Blue Cross Select has BCN s PCP Focus HMO network. Care must be coordinated by a primary care physician. Available in four options: value, bronze, silver and gold. Blue Cross Partnered for residents of Kent, Muskegon and Oceana counties who agree to receive care within the Mercy Health network. Care within BCN s entire HMO network, but outside the Mercy Health network, requires plan authorization. Note: No-deductible, no-co-pay lab work in HMO plans. Plus, office visits, while they may be subject to a co-payment, will not count against deductibles. Health savings account in HMO plans.

4 Consumers Mutual Insurance of Michigan Consumers Mutual Generation Y PPO Catastrophic Participating Consumers Mutual Basic Medium Deductible PPO Bronze Participating Consumers Mutual Basic High Deductible (I) PPO Bronze Participating Consumers Mutual Basic High Deductible (II) PPO Bronze Participating Consumers Mutual Choice Low Deductible PPO Silver Participating Consumers Mutual Choice Health Savings PPO Silver Participating Account (HSA) Consumers Mutual Choice Medium Deductible PPO Silver Participating Consumers Mutual Premier Low Deductible PPO Gold Participating Consumers Mutual Premier No Deductible PPO Gold Participating Consumers Mutual Premier No Deductible PPO Gold Participating Consumers Mutual Premier Low Deductible PPO Gold Participating Consumers Mutual Choice Health Savings PPO-HSA Silver Participating Account (HSA) Consumers Mutual Choice Medium Deductible PPO Silver Participating Consumers Mutual Basic Medium Deductible PPO Bronze Participating Consumers Mutual Basic High Deductible (I) PPO Bronze Participating Consumers Mutual Basic High Deductible (II) PPO Bronze Participating Coverage Area: Alger, Baraga, Bay, Charlevoix, Cheboygan, Chippewa, Clinton, Crawford, Dickinson, Eaton, Emmet, Genesee, Gladwin, Gogebic, Hillsdale, Houghton, Ingham, Iosco, Iron, Isabella, Jackson, Kalamazoo, Kent, Keweenaw, Lapeer, Livingston, Luce, Mackinac, Macomb, Manistee, Marquette, Mason, Menominee, Monroe, Muskegon, Oakland, Oceana, Ontonagon, Otsego, Ottawa, Roscommon, Saginaw, Schoolcraft, Shiawassee, St. Clair, Washtenaw, Wayne and Wexford counties Contact Information: or Plan Highlights: Clients will have phone and Internet access to an emergency room doctor by phone 24 hours a day through a partnership with Arizona-based Stat Doctors. A phone app will allow clients to punch in their medications to find the closest, most inexpensive pharmacy or other provider of those drugs.

5 Health Alliance Plan HAP Personal Alliance (PA) 1000 HMO Gold Participating HAP Personal Alliance (PA) 1000 Direct HMO Gold Participating HAP Personal Alliance (PA) 2500 HMO Silver Participating HAP Personal Alliance (PA) 2500 Direct HMO Silver Participating HAP Personal Alliance (PA) 500 HMO Platinum Participating HAP Personal Alliance (PA) 5000 HMO Bronze Participating HAP 500 HMO Platinum Participating HAP 1000 HMO Gold Participating HAP 2000 HMO Silver Participating HAP 3000 HMO Bronze Participating HAP 500 EPO Platinum Participating HAP 1000 EPO Gold Participating HAP 2000 EPO Silver Participating HAP 1500 HMO-HSA Gold Participating HAP 2000 HMO-HSA Silver Participating Coverage Area: Genesee, Lapeer, Livingston, Macomb, Monroe, Oakland, St. Clair, Washtenaw and Wayne counties. Contact Information: or Plan Highlights: All HAP plans are Health Maintenance Organization (HMO) or Exclusive Provider Organization (EPO) plans. There are no referrals required to see specialists. HMO members must have plan authorization to receive care from out-of-network (Not participating) providers. EPO members have no out-of-network benefits.

6 Humana Medical Plan of Michigan Humana Connect Basic 6350/6350 Plan HMO Catastrophic Not participating Humana Connect Bronze 6300/6300 Plan HMO Bronze Not participating Humana Connect Bronze 6300/6300 Plan HMO Bronze Not participating Humana Connect Gold 2500/3500 Plan HMO Gold Not participating Humana Connect Platinum 1000/1500 Plan HMO Platinum Not participating Humana Connect Silver 4600/6300 Plan HMO Silver Not participating None Coverage Area: Oakland, Wayne, Macomb. Contact Information: or Plan Highlights: All plans are an HMO which require PCP assignment and plan authorization for out-ofnetwork services by Not participating providers like UMHS. Humana will utilize a narrow focus network of providers instead of the Cofinity provider network which is used for other Humana PPO products in Michigan.

7 McLaren Health Plan McLaren Rewards Gold HMO Gold Participating 2/1/14 McLaren Rewards Gold Child Only HMO Gold Participating 2/1/14 McLaren Rewards Platinum HMO Platinum Participating 2/1/14 McLaren Rewards Platinum Child Only HMO Platinum Participating 2/1/14 McLaren Rewards Silver HMO Silver Participating 2/1/14 McLaren Rewards Silver Child Only HMO Silver Participating 2/1/14 McLaren Young Adult HMO Catastrophic Participating 2/1/14 McLaren Rewards Gold HMO Gold Participating 2/1/14 McLaren Rewards Platinum HMO Platinum Participating 2/1/14 McLaren Rewards Silver HMO Silver Participating 2/1/14 Coverage Area: Antrim, Arenac, Bay, Charlevoix, Cheboygan, Clinton, Eaton, Emmet, Genesee, Huron, Ingham, Ionia, Iosco, Isabella, Lapeer, Macomb, Montcalm, Oakland, Ogemaw, Oscoda, Otsego, Roscommon, Saginaw, Sanilac, Shiawassee, St. Clair, Tuscola and Wayne counties Contact Information: or Plan Highlights: All plans are an HMO, which require PCP assignment and plan authorization for out-ofnetwork services by non-participating providers. Members can go to any in-network provider in their service area (including UMHS) but all out-of-pocket costs will be waived completely if specialty care is provided selected Rewards providers about 1,500 in all. Specialty care requires a referral and services at non-participating providers requires a plan authorization.

8 Meridian Health Plan Meridian Choice: HMO Bronze Not participating Your Connection to Bronson Healthcare Meridian Choice: HMO Catastrophic Not participating Your Connection to Bronson Healthcare Meridian Choice: HMO Gold Not participating Your Connection to Bronson Healthcare Meridian Choice: HMO Silver Not participating Your Connection to Bronson Healthcare None Coverage Area: Kalamazoo area Contact Information: or Plan Highlights: All plans are an HMO which require PCP assignment and plan authorization for out-ofnetwork services by Not participating providers like UMHS. Meridian Choice only utilizes Bronson Healthcare providers at this time.

9 Molina Healthcare of Michigan Molina Marketplace Bronze Plan HMO Bronze Not participating Molina Marketplace Gold Plan HMO Gold Not participating Molina Marketplace Silver 100 Plan HMO Silver Not participating Molina Marketplace Silver 150 Plan HMO Silver Not participating Molina Marketplace Silver 200 Plan HMO Silver Not participating Molina Marketplace Silver 250 Plan HMO Silver Not participating None Coverage Area: Wayne, Oakland and Macomb counties Contact Information: or call Plan Highlights: All plans are an HMO which require PCP assignment and plan authorization for out-ofnetwork services by Not participating providers like UMHS. There are no referrals required for specialty care within the network of participating providers.

10 Priority Health HMO MyPriority HSA Bronze 6000 HMO Bronze Participating MyPriority HSA Gold 1250 HMO Gold Participating MyPriority HSA Silver 2000 HMO Silver Participating MyPriority MyHealth Bronze 5000 HMO Bronze Participating MyPriority MyHealth Gold 1000 HMO Gold Participating MyPriority MyHealth Gold 1500 HMO Gold Participating MyPriority MyHealth Silver 1500 HMO Silver Participating MyPriority MyHealth Silver 2000 HMO Silver Participating MyPriority MyHealth Silver 2500 HMO Silver Participating MyPriority Vida HMO Catastrophic Participating Priority Health HMO Platinum 250 HMO Platinum Participating Priority Health HMO - 90 Platinum 250 HMO Platinum Participating Priority Health HMO Gold 1000 HMO Gold Participating Priority Health HMO Gold tier Rx HMO Gold Participating Priority Health HMO HSA Silver 1500 HMO-HSA Silver Participating Priority Health HMO HSA Bronze 3000 HMO-HSA Bronze Participating Priority Health HMO HSA Gold tier Rx HMO-HSA Gold Participating Priority Health HMO VP Silver 1500 HMO Silver Participating Priority Health HMO VP Silver 2000 HMO Silver Participating Priority Health POS Platinum 250 POS Platinum Participating Priority Health POS - 90 Platinum 250 POS Platinum Participating Priority Health POS Gold tier Rx POS Gold Participating Priority Health POS HSA Gold tier Rx POS-HSA Gold Participating Coverage Area: Coverage Area: Alcona, Allegan, Alpena, Antrim, Arenac, Barry, Bay, Benzie, Berrien, Branch, Calhoun, Cass, Charlevoix, Cheboygan, Clare, Clinton, Crawford, Eaton, Emmet, Genesee, Gladwin, Grand Traverse, Gratiot, Hillsdale, Huron, Ingham, Ionia, Iosco, Isabella, Jackson, Kalamazoo, Kalkaska, Kent, Lake, Lapeer, Leelanau, Lenawee, Livingston, Mackinac, Macomb, Manistee, Mason, Mecosta, Midland, Missaukee, Monroe, Montcalm, Montmorency, Muskegon, Newaygo, Oakland, Oceana, Ogemaw, Osceola, Oscoda, Otsego, Ottawa, Presque Isle, Roscommon, Saginaw, Sanilac, Shiawassee, St. Clair, St. Joseph, Tuscola, Van Buren, Washtenaw, Wayne and Wexford counties Contact Information: or Plan highlights: HMO and POS plans and plan authorization for out-of-network services by Not participating providers like UMHS. There are no referrals required for specialty care within the network of participating providers. Discounts are available at fitness centers and retailers that sell fitness equipment.

11 Priority Health Insurance MyPriority Access HSA Bronze 6000 PPO Bronze Participating MyPriority Access HSA Gold 1250 PPO Gold Participating MyPriority Access HSA Silver 2000 PPO Silver Participating MyPriority MyHealth Access Bronze 5000 PPO Bronze Participating MyPriority MyHealth Access Gold 1000 PPO Gold Participating MyPriority MyHealth Access Gold 1500 PPO Gold Participating MyPriority MyHealth Access Silver 1500 PPO Silver Participating MyPriority MyHealth Access Silver 2000 PPO Silver Participating MyPriority MyHealth Access Silver 2500 PPO Silver Participating Priority Health PPO Platinum 250 PPO Platinum Participating Priority Health PPO - 90 Platinum 250 PPO Platinum Participating Priority Health PPO Gold 1000 PPO Gold Participating Priority Health PPO Gold tier Rx PPO Gold Participating Priority Health PPO HSA Silver 1500 PPO-HSA Silver Participating Priority Health PPO HSA Gold tier Rx PPO-HSA Gold Participating Priority Health PPO VP Silver 1500 PPO Silver Participating Priority Health PPO VP Silver 2000 PPO Silver Participating Coverage Area: Alcona, Allegan, Alpena, Antrim, Arenac, Barry, Bay, Benzie, Berrien, Branch, Calhoun, Cass, Charlevoix, Cheboygan, Clare, Clinton, Crawford, Eaton, Emmet, Genesee, Gladwin, Grand Traverse, Gratiot, Hillsdale, Huron, Ingham, Ionia, Iosco, Isabella, Jackson, Kalamazoo, Kalkaska, Kent, Lake, Lapeer, Leelanau, Lenawee, Livingston, Mackinac, Macomb, Manistee, Mason, Mecosta, Midland, Missaukee, Monroe, Montcalm, Montmorency, Muskegon, Newaygo, Oakland, Oceana, Ogemaw, Osceola, Oscoda, Otsego, Ottawa, Presque Isle, Roscommon, Saginaw, Sanilac, Shiawassee, St. Clair, St. Joseph, Tuscola, Van Buren, Washtenaw, Wayne and Wexford counties Contact Information: or Plan highlights: Cost comparison tool available compare different providers costs for common medical procedures such as knee surgery or kidney stone treatments. Discounts are available at fitness centers and retailers that sell fitness equipment.

12 Total Health Care USA Totally You HMO Silver Not participating Totally You 73 HMO Silver Not participating Totally You 87 HMO Silver Not participating Totally You 94 HMO Silver Not participating Total HMO Standard HMO Gold Not participating Total Gold Complete HMO Gold Not participating Total Gold Premier HMO Gold Not participating Total Gold Signature HMO Gold Not participating Total Platinum Complete HMO Platinum Not participating Total Platinum Premier HMO Platinum Not participating Total Platinum Signature HMO Platinum Not participating Total Platinum Ultimate HMO Platinum Not participating Total Saver Complete HMO Bronze Not participating Total Saver Plus HMO Bronze Not participating Total Value Complete HMO Silver Not participating Total Value Plus HMO Silver Not participating Coverage Area: Wayne, Oakland, Macomb and Genesee Contact Information: or Plan Highlights: All plans are an HMO. Members must select a Primary Care Physician (PCP) and referral is required for specialty care within the network of participating providers. Services by out-of-network (Not participating) providers require plan authorization.

13 UnitedHealthCare None UnitedHealthcare Bronze Choice PPO HSA POS Bronze Participating UnitedHealthcare Gold Navigate PPO POS Gold Not Participating UnitedHealthcare Silver Navigate PPO POS Silver Not Participating Coverage area: Alcona, Allegan, Alpena, Antrim, Arenac, Berry, Bay, Berrien, Branch, Calhoun, Cass, Charlevoix, Cheboygan, Claire, Clinton, Crawford, Eaton, Genesee, Gladwin, Grand Traverse, Gratiot, Hillsdale, Huron, Ingham, Ionia, Iosco, Isabella, Jackson, Kalamazoo, Kalkaska, Kent, Lake, Lapeer, Lenawee, Livingston, Macomb, Manistee, Mason, Mecosta, Midland, Missaukee, Monroe, Montcalm, Montmorency, Muskegon, Newaygo, Oakland, Oceana, Ogemaw, Osceola, Oscoda, Otsego, Ottawa, Presque Isle, Roscommon, Saginaw, Sanilac, Shiawassee, St. Clair, St. Joseph, Tuscola, Van Buren, Washtenaw, Wayne, and Wexford counties. Contact Information: or Plan Highlights: These Point-of-Service plans require members to select a PCP. Members of Navigate plans are required to have a referral for specialty care services in-network at the lowest out-of-pocket cost. Navigate members may choose to have services rendered by Not participating providers, but will have higher out-of-pocket costs. Health4Me mobile app will provide instant access to members critical health information. Clients can compare costs for common treatments in their area.

14 Definitions Exclusive Provider Organization (EPO) A type of managed care healthcare insurance with no out-ofnetwork benefits. Some EPO plans require PCP assignment and referrals for specialty care. Individual Health Insurance Marketplace (HIM) A place for individuals and families to compare health insurance plan costs, benefits and features. These Marketplaces also provide information regarding ways to save on premiums and out-of-pocket costs available through the Affordable Care Act as well as other health programs like Medicaid and the Children s Health Insurance Program (CHIP). In Michigan the Marketplace is run by the federal government. Health Maintenance Organization (HMO) A type of managed care healthcare insurance that focuses on preventative care. Members are required to select a participating Primary Care Physician to coordinate their healthcare. Many HMO plans require a PCP referral for specialty care. Out-of-network services are only covered with a plan authorization. Health Savings Account (HSA) A type of savings account where pre-tax funds may be deposited and used for qualified medical expenses. Unlike other types of medical savings accounts, the funds belong to the individual and can be carried to the next year if not used. Participating Provider (Par) An in-network provider (e.g. physician, hospital, durable medical equipment supplier), who is contracted with a member s health plan to render care. Plan Authorization (PA) A requirement of the health plan that certain types of services must be reviewed to verify that they are a covered benefit and/or medically necessary in order to be paid. HMO and EPO plans require that all Not emergent services by Not participating providers receive prior plan authorization. Point of Service (POS) A type of managed care healthcare insurance that encourages members to select and utilize an in-network Primary Care Physician in return for lower out-of-pocket costs. Preferred Provider Organization (PPO) - A type of managed care healthcare insurance that does not require the selection of a Primary Care Physician. There are no referrals required for specialty care. Members may choose to receive care from participating and Not participating providers. Care from Not participating providers will incur higher out-of-pocket costs. Referral A request from a Primary Care Physician for a member to receive care from a specialist. Referrals are often required by HMO plans for services from anyone other than the assigned PCP to be covered. Small Business Health Insurance Options Program (SHOP) A Marketplace allowing small businesses to compare health insurance plan costs, benefits and features in one place. Usual Customary and Reasonable (UCR) This is an amount allowed for medical services that a healthcare insurance plan will base its payment on for services by Not participating providers. UCR rates vary by geographic area and plan. Patients may be billed the difference between the provider s charges and the plan s UCR addition to their normal cost share (co-insurance, co-payment and/or deductible). Metal Levels: Health insurance plans sold on the HIM are assigned a metal (Bronze, Silver, Gold and Platinum)) based on the average expected insurance expenses to be paid by the plan.

15 Platinum A plan designed to pay at least 90% of covered healthcare expenses with the remaining 10% to be paid by the member. Gold A plan designed to pay 80% of covered healthcare expenses with the remaining 20% to be paid by the member. Silver A plan designed to pay 70% of covered healthcare expenses with the remaining 30% to be paid by the member. Bronze A plan designed to pay 60% of covered healthcare expenses with the remaining 40% to be paid by the member. Catastrophic A plan available to people under thirty and some people with limited incomes that requires members to pay all healthcare expenses up to a certain dollar amount (usually several thousand) before coverage begins. While these plans cover certain free preventative services, they are designed to protect members only from extreme medical expenses in return for lower monthly premiums.