Shopping for Catamount Health Insurance Vermont Consumer Handbook - January 2011

Transcription

1 VERMONT DEPARTMENT OF BANKING, INSURANCE, SECURITIES AND HEALTH CARE ADMINISTRATION Shopping for Catamount Health Insurance Vermont Consumer Handbook - January 2011

2 OTHER FORMATS FOR THIS PUBLICATION This publication is also available on the Department s website at using the Division of Health Care Administration s Consumer Publications link. To speak with a health insurance consumer specialist call Persons with hearing impairments may contact the Vermont Relay Service at (TTY), or (voice). Persons with reading or visual impairments may contact the Vermont Association for the Blind and Visually Impaired (VABVI) at: Brattleboro Montpelier Rutland South Burlington

3 TABLE OF CONTENTS Introduction to Catamount Health 1 Common Characteristics of Catamount Health Insurance Plans 3 Who May Purchase Catamount Health Insurance 4 Before You Choose a Catamount Insurance Plan 6 What is it Going to Cost? 7 Introduction to Premium Assistance 8 Important Health Insurance Terms 10

4 Introduction to Catamount Health CATAMOUNT HEALTH Catamount Health is a health insurance plan within the Green Mountain Care family of plans. It is an individual health insurance product created for uninsured Vermonters who do not have access to employer (group) insurance or other Green Mountain Care plans, such as the Vermont Health Access Program (VHAP) or Dr. Dynasaur. 1 Catamount Health is offered, in cooperation with the State of Vermont, by Blue Cross Blue Shield of Vermont and MVP Health Care. Catamount Health provides a comprehensive benefits package that covers primary care, chronic care, acute care and hospital services. Prescription drugs are also covered. HEALTH INSURANCE COMPANIES SELLING CATAMOUNT HEALTH INSURANCE: Blue Cross Blue Shield of Vermont (BCBSVT) Catamount Blue Individual Products/Catamount P.O. Box 186 Montpelier, VT (888) TTY: (800) TTY: (800) (Premium Assistance) 1 You may be able to purchase Catamount Health Insurance even if you have access to Employer Sponsored Insurance (ESI) under some circumstances. For further information on the guidelines and exceptions, visit ( or contact Health Access Member Services for Green Mountain Care at 1 (800) , TDD: 1 (888) on business days between 7:45 a.m. and 4:30 p.m. Page 1

5 HEALTH INSURANCE COMPANIES SELLING CATAMOUNT HEALTH INSURANCE (CONTINUED): MVP Health Insurance Company MVP Catamount Choice EAS-Catamount 625 State Street P.O. Box 2207 Schenectady, New York (888) TTY: (802) (Voice) TTY/HCO: (800) SPECIAL PROTECTIONS FOR PARTICIPATING IN CHRONIC CARE MANAGEMENT PROGRAMS Catamount Health emphasizes improved care for people with chronic conditions. If you have a chronic condition, check to see if the Catamount Health plans offer a chronic care management program for your condition. In addition to providing valuable health benefits, Catamount Health provides financial incentives for you if you participate in a chronic care management program. For example, you may not be subject to preexisting condition limitations for chronic care and may not have to pay certain deductibles, co-insurance or co-payments if you are enrolled and actively participating in a chronic care management program. Please note that chronic care management programs are not currently available for every chronic condition. Page 2

6 Common Characteristics of Catamount Health Insurance Plans The services covered by Catamount Health insurance will depend on which insurance company you choose. Some services may not be covered. It might cost more for you to go to certain providers who are not in your insurer s network. The table below shows those characteristics that are the same in the two Catamount Health plans. Always check with the insurance company to get details about coverage. In-network Out-of-network Annual Deductibles $500/individual $1,000/family $1,000/individual $2,000/family Co-Insurance 20% 20% Co-Payment Prescription Drugs Co-payments $10/office visit per individual No deductible $10 for generic; $35 for Preferred Brandname; $55 for Nonpreferred Brand-name per 30-day supply. $10/office visit per individual Not covered Preventive Care $0 Not subject to deductible, coinsurance, co-payments Out-of-Pocket Maximum* $1,050/ individual $2,100 /family Not covered $ 2,000/individual $ 4,000/family * Includes deductibles, co-insurance, and co-payments. Premium payments and prescription drug payments are not included in the out-of-pocket maximums. Page 3

7 Who May Purchase Catamount Health Insurance YOU CAN QUALIFY FOR CATAMOUNT HEALTH IF YOU: Are a Vermont resident who is 18 years or older. Are currently not eligible for other Green Mountain Care plans such as Medicaid, VHAP or Dr. Dynasaur. Have been living without health insurance for 12 months or more. You do not have to be without insurance for 12 months or more if you meet any of the following exceptions: o You have insurance that only covers hospital care or doctor visits (but not both) or your insurance is not considered creditable coverage (ask your insurer if you do not know). o You had another Green Mountain Care plan but circumstances such as household income or size changed, making you eligible for Catamount instead. o Within the last 12 months, you had insurance but lost it because: Your job ended for any reason (quit, fired, laid off, or retired) or your work hours were reduced. You got divorced or your civil union dissolved. You had insurance through someone who passed away. You had your college enrollment reduced below a threshold for continuation of coverage (either parental or school sponsored insurance). You are no longer a dependent on your parent's or caretaker's health insurance. You were getting your insurance through college and can no longer do so because you graduated, took a leave of absence, reduced your credits or stopped going to college. Page 4

8 You have been enrolled for at least six months in a nongroup insurance plan (i.e., a policy that is not sponsored by an employer or association) with an annual deductible of $7,500 or more for single coverage or $15,000 or more for two-person or family coverage. (Please note that you will not be eligible for Premium Assistance until you have been on Catamount Health for 12 months). You lost insurance due to domestic violence or abuse. Are over income for Catamount Health with Premium Assistance. Do not have access to employer-sponsored insurance unless you meet any of the following conditions: o You have access but it is not comprehensive, meaning it covers hospital care or doctor visits (but not both). o You are waiting to enroll in your employer's plan. o You lost insurance due to a business closure (you may be eligible for coverage without a waiting period). For further information on the guidelines and exceptions, please contact Health Access Member Services for Green Mountain Care at on business days between 7:45 a.m. and 4:30 p.m. YOU DO NOT QUALIFY FOR CATAMOUNT HEALTH IF YOU: Are 18 or older and are claimed on a tax return as a dependent of a resident of another state. Page 5

9 Before You Choose a Catamount Health Insurance Plan CHOOSING THE RIGHT HEALTH INSURANCE CAN BE DIFFICULT. THE FOLLOWING IS A LIST OF THINGS YOU MAY WANT TO CONSIDER: Know your rights. In Vermont you cannot be turned down on the basis of your age, health, gender or medical history. The only reason you can be turned down for Catamount Health is if you do not meet the eligibility requirements. If you are denied Catamount Health insurance and you believe you are eligible, contact Health Access Member Services for Green Mountain Care at 1 (800) , TDD: 1 (888) on business days between 7:45 a.m. and 4:30 p.m. Comparison shop. Both Blue Cross Blue Shield of Vermont (BCBSVT) and MVP Health Care offer a Catamount Health plan. Contact the two companies to compare the products and decide which will best meet your needs. Although all Catamount Health plans must cover certain mandated benefits, there are some differences between the MVP and BCBSVT products. Make sure you know what the different products cover and what services are excluded. For example, some services may be covered only if you use certain providers. It might cost more for you to go to certain providers who are not in the insurer s network. Check with the insurance company to see if the health care providers you prefer are in the network. Remember that the product you select may also affect your Catamount Health insurance premium costs. Understand your policy. Before you apply, check to see if coverage is limited for preexisting conditions that you may have. Once you purchase health insurance, read the policy carefully to make certain that you understand its terms. Refer to it before you seek care to make sure you do what is required to get coverage. Keep good files. Keep your insurance policy and all your insurance records in a safe place where you can easily refer to them. Page 6

10 What is it Going to Cost? The cost of health insurance is usually paid monthly. The monthly charge is called a premium. The premiums and rates listed within this publication are effective from January 1, 2011 to March 31, 2011, unless otherwise noted. Before choosing an insurer, please contact the company to make sure the rates are still current. Note that Catamount Health premium rates may increase each quarter for new policies, but your monthly premium rate is locked in for 12 months after coverage begins. Plan Single Person Premium Per Month Two Person Premium Per Month One Parent & Child(ren) Family Premium Per Month Blue Cross Blue Shield of VT $ $ NA $1, MVP Health Insurance Company $ $1, $1, $1, Note: There are differences in coverage between the two plans, including dependent coverage. Please check with BCBSVT or MVP and review each plan s policy to determine which policy best meets your needs. Page 7

11 Introduction to Premium Assistance WHAT IS PREMIUM ASSISTANCE? You may be eligible for help to pay for Catamount Health premiums. This is called premium assistance. You may be eligible for premium assistance if you meet the qualifications above and your income is found on the chart on page 9. The amount of assistance available is based on your household size and income. You may still qualify if your monthly income is higher, if you have earned income and/or child care expenses. For larger households call Member Services for Green Mountain Care at 1(800) HOW DOES IT WORK? The cost of health insurance is usually paid monthly. The monthly charge is called a premium. Premium assistance lowers your monthly premiums for the least expensive Catamount Health plan. You will still get premium assistance if you choose the more expensive plan, but you will also be responsible for paying the difference between the two plans. Each month you will pay the reduced monthly premium to the insurance company. For questions about eligibility for premium assistance, call Green Mountain Care at 1(800) , TDD: 1(888) The member services representatives can help you understand Catamount Health Insurance eligibility and the Premium Assistance Program. You may also visit Page 8

12 TABLE 1: HOUSEHOLD INCOME AND LIKELY MONTHLY PREMIUM The information in this table is effective from January 1, 2011 to March 31, It is also updated each quarter at Number of People in Household 1 : If your total monthly/yearly household income is less than: If your total monthly/yearly household income is more than: Your likely Individual Monthly Premium Using BCBSVT: $1,842/ $22,100 $2,072/ $24,860 $2,303/ $27,625 $2,533/ $30,388 $2,763/ $33,150 Over $2,763/ $33,150 $2,475/ $29,700 $2,785/ $33,413 $3,094/ $37,125 $3,404/ $40,838 $3,713/ $44,550 Over $3,713/ $44,550 $3,109/ $37,300 $3,497/ $41,963 $3,886/ $46,625 $4,274/ $51,288 $4,663/ $55,950 Over $4,663/ $55,950 $3,742/ $44,900 $4,210/ $50,513 $4,678/ $56,125 $5,145/ $61,738 $5,613/ $67,350 Over $5,613/ $67,350 $60/mo $124/mo $152/mo $180/mo $208/mo $413.84/mo Your Likely Individual Monthly Premium Using MVP: $173/mo $237/mo $265/mo $293/mo $321/mo $526.92/mo 1 Number of People in Household: A household is defined as the number of related people living in the same house. Page 9

13 Important Health Insurance Terms In dealing with health insurance, you may come across a number of unfamiliar terms. This section can help you understand the general terms. You must also read your policy definitions to understand what these and the other terms mean in your particular Catamount Health Insurance policy. Appeal A request for your health insurer or plan to review a decision or grievance again. Balance Billing When a health care provider bills you for the difference between the health care provider s charge and the allowed amount. For example, if the health care provider s charge is $100 and the allowed amount is $70, the health care provider may bill you for the remaining $30. In many situations, this practice is prohibited. In-Network Providers The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services that are part of a health insurer's network of providers, and with which the health insurer has negotiated a discount. Out-of-Network Providers Providers who do not contract with your health insurer or plan. Depending on your health insurance plan, expenses for services provided by out-ofnetwork providers may not be covered, or may be covered only in part by your health insurer. Page 10

14 Out-of-Pocket Costs Most health insurance policies require that you pay some portion of your health care costs, known as out-of-pocket costs. Three types of out-ofpocket costs are typically used in health insurance policies: Co-insurance Your share of the cost of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan s allowed amount for an office visit is $100 and you ve met your deductible, your co-insurance or plan pays the rest of the allowed amount. Co-Payment A fixed amount (for example, $15) you pay for a covered health care service. The amount can vary by the type of covered health care service. Deductible The amount you pay 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 paid $1,000 for covered health care services that are subject to the deductible. The deductible may not apply to all services. Page 11

15 Pre-authorization A decision by your health insurer or plan before you receive care that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurer or plan may require pre-authorization for certain services before you receive them, except in an emergency. Pre-authorization isn t a promise your health insurance or plan will cover the cost. Pre-existing Condition Exclusion A pre-existing medical condition is defined as any illness or health condition (whether physical or mental), regardless of the cause of the condition, for which you received medical advice, treatment, diagnosis, or care during the months prior to the start of your new health insurance coverage. With some restrictions, health insurers may exclude coverage for that condition for a limited period of time. Genetic information cannot be treated as a condition. Exclusions are not applicable to pregnancy and certain newborns. Typically, if you have had insurance for a specific time period (for example, 12 months) without a significant gap in coverage, you will not be subject to a pre-existing condition exclusion. Your child can get coverage regardless of pre-existing medical conditions. The rules about pre-existing conditions can be complicated. If you have any questions about pre-existing conditions, waiting periods or chronic care programs, you can contact Catamount Blue at (888) , or MVP Catamount Choice at (888) Page 12

16 DEPARTMENT OF BANKING, INSURANCE, SECURITIES & HEALTH CARE ADMINISTRATION 89 MAIN STREET, MONTPELIER, VERMONT TOLL FREE: (800) TEL: (802) FAX: (802) CONSUMER WEBSITE: Page 13