Employers with 1 50 employees Medical Plans Benefit Guide. Small Business Health Options Programs (SHOP) Alaska Plans

Transcription

1 Employers with 1 50 employees Medical Plans Benefit Guide Small Business Health Options Programs (SHOP) Alaska Plans

2 Provider network built for value and quality...2 Wellness rewards...3 Medical Travel Support and Air or Surface Transportation...4 Support for smart healthcare decisions...4 Easy-to-use online and mobile tools...5 Customer service experience...5 Premera health plans...6 The 10 essential benefits your plan covers...6 Plan summaries Optional benefits...10 Definitions General exclusions... back page b

3 Welcome to 2016 Premera Blue Cross Blue Shield of Alaska Along with the great service and rich network access you have come to expect from Premera, we are pleased to offer benefits tailored for the needs of groups based in Alaska. Robust provider network* Did you know that Premera boasts the largest provider network in Alaska? Remember that, depending on the Premera medical plan you purchase, your employees have access to over 3,000 providers and 20 hospitals all across Alaska. Together with the Blue Cross Blue Shield system, our extended network includes more than 6,900 hospitals and 1,014,000 physicians across the country the largest contracted nationwide network available in the United States delivering the broadest access and lowest total cost of care available in all markets. (See page 2.) Wellness rewards We spend most of our time at work. What better place to encourage people to make healthy lifestyle choices? By offering robust rewards to employers and employees for participating in wellness programs, we aim to help employers inspire employees to engage in a wellness program based on the latest research to make the greatest impact to their health and well-being Ask your Premera representative for more information about the embedded wellness rewards program. (See page 3.) Medical Travel Support Also known as medical tourism, our Medical Travel Support is a voluntary program that gives members broader access to quality care at lower cost for certain approved procedures outside of Alaska within the Blues national network. The benefit covers travel costs for the member and a companion, up to the IRS guidelines. Talk to your producer or your Premera sales professional for more information. (See page 4.) Cost transparency tools As soon as they choose a plan, your employees receive instant access to free, easy-to-use online and mobile tools that help them understand and track their medical spending and prescriptions, estimate costs, and review claim status. (See page 5.) Thank you for considering Premera for your employer-sponsored benefits. * Consortium Health Plans, Inc. Network Compare Key Findings as of June 5, Available at 1

4 Robust provider network Provider network built for value and quality The Premera network of doctors, hospitals, and other healthcare providers is designed to offer ready access to safe, effective, high-quality care at affordable prices. Our strong relationships with our provider partners help maximize healthcare dollars by: Focusing on quality and cost-effective care Helping control rising medical costs Providing resources for improved healthcare Premera also offers an excellent national network of preferred providers for members to access when outside Alaska. Members can use the Find a Doctor tool at premera.com to see if their favorite provider is in our network, or to find a new one. Balance Plus plans offer employees savings on health plan costs and give the highest benefit level to employees when they use preferred providers and hospitals. Nonpreferred and nonparticipating or out-of-network facilities and providers are also covered, but at a lower benefit level.* Healthcare coverage wherever you go National PPO access When outside of Alaska, employees can access doctors and hospitals in the BlueCard network around the world. In the U.S., the BlueCard Program gives them peace of mind that they ll be able to find the healthcare provider they need anywhere in the lower 48. Outside of the U.S., the BlueCard Worldwide Program gives them access to hospitals in nearly 200 countries and territories around the world. Blue Distinction Total Care A comprehensive solution for multi-state employers, this program integrates local valuebased care programs from Blue Plans across the country. Programs are custom designed to meet local market needs while also meeting national standards in four impact-driven categories: Value-based reimbursement Accountability across the care continuum Patient-centered quality care Provider empowerment Members who reside in geographic areas served by Blue Distinction Total Care are automatically assigned to these patient-centered, value-based programs. * Balance billing may still apply if a provider is not contracted with Premera Blue Cross Blue Shield of Alaska. For more information about providers, visit premera.com and use the Find a Doctor tool. 2

5 Built-in rewards for wellness activities The built-in wellness rewards program is a simple way to encourage your workforce to engage in wellness activities. Your employees get access to tools designed to help them maintain and improve their health. Our wellness rewards program rewards both employers and employees. All program participation data sharing and reports are HIPAA-compliant. Wellness tools The wellness reward program offers: Biometric screenings by using physician fax forms, home test kits, retail options, or at employer-sponsored on-site events Health assessments when members log in to use the Premera online wellness tools Rewards for employers Employers can earn a premium discount based on employee participation. Ask your Premera representative how to get your group involved in a wellness rewards program. Rewards for employees Employees earn a generous reward card if they participate in a biometric screening and take a health assessment within a designated time frame. 3

6 Support for smart network decisions Medical Travel Support Premera s Medical Travel Support benefit reimburses members for approved travel expenses when they travel for qualified medical procedures at pre-approved medical facilities in and outside of Alaska. Approved travel expenses are covered up to IRS guidelines for both the member and a travel companion. Because the price of medical care may be lower outside Alaska, the member s share of the medical costs may also be lower. Customer Service can also assist in medical records transfers if needed. Air or Surface Transportation Beginning in 2016, all group plans will include a standard Air or Surface Transportation benefit of three round trips. Transportation to the nearest in-network location equipped to provide treatment is available for: A life-endangering illness or injury A required surgery that cannot be performed locally An existing condition that cannot be treated locally When transportation is for a child under the age of 18, the benefit also covers a parent or guardian to accompany the child. Premera health support programs help your employees maintain good health and change unhealthy behavior. Health support programs included in all plans: Virtual care gives covered members immediate and convenient access to care from a physician via phone call, online video, or other online media to treat certain ailments such as cold and flu symptoms, ear infections, and bronchitis. 24-Hour NurseLine offers free, confidential health advice from a registered nurse by phone any time day or night. CareCompass360 is a whole-person approach to health support that meets members needs wherever they land on the care continuum whether they re healthy or navigating complex conditions. Members receive easily accessible, appropriate health support services tailored to their health needs. Maternity and newborn support program promotes healthier mothers and babies and reduces costs associated with high-risk pregnancies and newborns that end up in neonatal intensive care units. Exclusive member discounts on fitness club memberships, weight loss programs, and many other health products and services not covered by their health plan. 4

7 Easy-to-use online and mobile tools These tools make it simple for administrators and your employees to manage money, care, and wellness. Tools for plan administrators We streamlined the experience of administering group plans with easy-to-use online tools. You can view helpful information such as: Administrator s Quick Reference Guide Employer contract and member benefit booklet Medical and dental invoices You can add and make changes to employee enrollment information, including ordering identification cards. Online tools for members Members register and log in at premera.com to use tools securely: Find and compare providers, including qualifications and user reviews with Find a Doctor. Enter different coverage options to see how choices affect costs before deciding on a health plan with the Treatment Cost Estimator. Review status of medical, prescription drug, and dental claims. Manage and monitor consumerdriven health plans spending and saving amounts, including reviewing account balances. Access pharmacy information and order prescriptions Award-winning mobile apps Premera app Find nearby doctors and clinics, look up benefits, and check claims. ExpressScripts pharmacy app Track medications, order prescriptions, and find a pharmacy. ConnectYourCare app Check spending and account balances on health savings accounts (HSA). Wellness apps Track activities, participate in fun fitness challenges, and get healthier. Customer service experience All Premera customer service representatives are fully trained to provide excellent service to members. Our representatives are especially knowledgeable about the unique needs of Alaska, such as: Alaska s logistical challenges Alaskan culture Our customer service standard is first call resolution. 5

8 Premera health plans Premera offers a wide range of Bronze, Silver, and Gold plans. Each plan covers the 10 essential benefits as required by the Affordable Care Act (ACA) These essential benefits focus on prevention and primary care to help people stay healthy. They also aim to manage chronic medical conditions before these conditions become more complex. INSURANCE PLANS MONTHLY PREMIUM IN-NETWORK DEDUCTIBLE INSURANCE PAYS Bronze Plans $ $$$ $ Silver Plans $$ $$ $$ Gold Plans $$$ $ $$$ The 10 essential benefits your plan covers: 1 1 Ambulatory patient services such as office visits to your in-network primary care doctor or specialists. 2 2 Emergency services for issues that could lead to death or disability if you do not treat them. 3 3 Hospitalization covers room and board, tests, drugs, and care from doctors and nurses while admitted; includes organ and tissue transplants, and hospice and respite care. 4 4 Maternity and newborn care covers prenatal and postnatal care, delivery and inpatient maternity services, plus newborn child care. 5 5 Mental health and substance use disorder services, including behavioral health treatment covers inpatient hospital and outpatient mental and behavioral health. 6 6 Prescription drugs covers retail, mail order, and specialty drugs. 7 7 Rehabilitative and habilitative services and devices to help gain or regain mental and physical skills in case of injury, disability, or chronic condition. Includes inpatient rehabilitation; physical, speech, and occupational therapy; durable medical equipment; or skilled nursing. 8 8 Laboratory services covers lab tests, X-ray services, and pathology, and imaging and diagnostics such as MRI, CT scan, and PET scan. 9 9 Preventive/Wellness services and chronic disease management includes mammograms, colonoscopies, vaccines, and more. if you use in-network providers for care such as routine physicals, screening, and immunizations. Care management programs and services seek to coordinate care for a variety of chronic conditions, 10 such as diabetes and asthma. 10 Pediatric services Kids are covered for vision care (eye exam, lenses, and eyewear). 6

9 1 Blue Cross Blue Shield Plus 6350, a Multi-State Plan Alaska plans for groups 1-50 Beginning January 1, 2016 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PCY = per calendar year Individual Deductible Coinsurance Out-of-Pocket Maximum Office Visits Network 10 Essential Benefits Covered Services Ambulatory Patient Services Office visits PCY Family = 2x individual Amount you pay after your deductible is met Includes deductible, coinsurance, and copays Family = 2x individual Designated PCP office visit Non-designated PCP or specialist office visit Outpatient services Spinal manipulation (12 visits PCY); Acupuncture (12 visits PCY) Preferred (In-network) $6,350 Non-participating 30% 40% 60% $6,850 First 6 visits PCY $30/deductible waived, otherwise deductible, then coinsurance Heritage Plus $30 PLUS 6350 Non-preferred Deductible, then 40% Deductible, then 40% 2x individual deductible Unlimited Out-of-network Deductible, then 60% Deductible, then 60% 2 3 Emergency Services Hospitalization Emergency Care Copay waived if directly admitted to inpatient facility Ambulance transportation (air & ground) Inpatient Hospice 10 days inpatient Respite care: 240 hours lifetime Organ and tissue transplants, inpatient unlimited, except $75,000 donor and $7,500 travel and lodging per transplant $200 copay, then deductible, then in-network coinsurance $25 copay, then deductible, then in-network coinsurance Emergent: Same as in-network Non-emergent: Air Ded, then 40% / Ded, then 60%; Ground Same as in-network Deductible, then 40% Not covered Deductible, then 60% Maternity & Newborn Care Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment Rehabilitative & Habilitative Services & Devices Therapy Rehabilitative and habilitative benefits have the same number of visits, but are counted separately Prenatal, delivery, postnatal care Office visit Inpatient hospital: mental/behavioral health Outpatient services Inpatient rehabilitation: 30 days PCY Physical, speech, occupational, massage therapy: 45 visits PCY Durable medical equipment Skilled nursing facility: 60 days PCY 7 Laboratory Services Includes x-ray, pathology, imaging/diagnostic, CT, PET, MRI (Prior Authorization required for certain services) 8 9 Preventive/Wellness Services & Chronic Disease Management Pediatric Services, including Vision & Oral Care Under 19 years of age Screenings Exams and immunizations Eye exam: 1 PCY Eyewear: 1 set of frames PCY; 1 set of lenses or 12- month supply contact lenses PCY Dental: preventive/basic/major Orthodontia (medically necessary only) 10 Prescription Drugs 4-Tier: Generic/Brand/ Retail up to 90-day supply (copay x 3) Mail Order 90-day supply (copay x 3) Non-Preferred Brand/Specialty Specialty Rx 30-day supply Drug Formulary X4 Additional benefits / / $35 / / / Deductible, then 50% Deductible waived, 10% / Deductible, then 40% / Retail: Same as in-network; Mail order & specialty: not covered Adult vision Hearing A full list of services is available on premera.com/ak/member Vision exam: 1 PCY Eyewear: 1 pair lenses PCY; 1 pair frames every 2 calendar years ($90 retail max); contacts $170 retail max; $350 annual max shared with vision exam. Hearing exam: 1 per 2 calendar years Hearing aids and hardware: $1,000/3 calendar years Deductible waived, 10% Deductible waived, 20% 7

10 Blue Cross Blue Shield Plus 2000, a Multi-State Plan Alaska plans for groups 1-50 Beginning January 1, 2016 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PLUS 2000 PCY = per calendar year Preferred (In-network) Non-preferred Non-participating Individual Deductible PCY Family = 2x individual $2,000 2x individual deductible Coinsurance Amount you pay after your deductible is met 30% 40% 60% Out-of-Pocket Maximum Includes deductible, coinsurance, and copays Family = 2x individual $6,850 Unlimited Office Visits Designated PCP office visit Non-designated PCP or specialist office visit $25 copay, first 2 PCP visits covered in full $45 40% 60% Network Heritage Plus Out-of-network 10 Essential Benefits Covered Services 1 Ambulatory Patient Services Office visits Outpatient services Spinal manipulation (12 visits PCY); Acupuncture (12 visits PCY) $25 Deductible, then 40% Deductible, then 60% 2 Emergency Services Emergency Care Copay waived if directly admitted to inpatient facility $200 Copay, then in-network deductible & coinsurance Ambulance transportation (air & ground) $25 copay, then deductible & in-network coinsurance Emergent: Same as in-network Non-emergent: Air 40% / 60%; Ground Same as in-network 3 Hospitalization Inpatient Hospice 10 days inpatient Respite care: 240 hours lifetime Organ and tissue transplants, inpatient unlimited, except $75,000 donor and $7,500 travel and lodging per transplant Deductible, then 40% Not covered Deductible, then 60% 4 Maternity & Newborn Care Prenatal, delivery, postnatal care Deductible, then 40% Deductible, then 60% 5 Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment Office visit $45 Inpatient hospital: mental/behavioral health Outpatient services Rehabilitative & Habilitative Services & Devices Therapy Rehabilitative and habilitative benefits have the same number of visits, but are counted separately Laboratory Services Preventive/Wellness Services & Chronic Disease Management Pediatric Services, including Vision & Oral Care Under 19 years of age Inpatient rehabilitation: 30 days PCY Physical, speech, occupational, massage therapy: 45 visits PCY Durable medical equipment Skilled nursing facility: 60 days PCY Includes x-ray, pathology, imaging/diagnostic, CT, PET, MRI (Prior Authorization required for certain services) Eye exam: 1 PCY Dental: preventive/basic/major 10 Prescription Drugs 4-Tier: Generic/Brand/ Retail up to 90-day supply (copay x 3) Mail Order 90-day supply (copay x 3) Non-Preferred Brand/Specialty Specialty Rx 30-day supply Additional benefits Screenings Exams and immunizations Eyewear: One pair of glasses PCY (frames & lenses); or 12-month supply of contacts PCY, in lieu of glasses (frames & lenses) Orthodontia (medically necessary only) Drug Formulary X4 Deductible, then $45 / Deductible, then 20% / $15 / $50 / $150 / $45 / Deductible, then 40% / Retail: Same as in-network; Mail order & specialty: not covered 8 Adult vision Hearing A full list of services is available on premera.com/ak/member Vision exam: 1 PCY Eyewear: 1 pair lenses PCY; 1 pair frames every 2 calendar years ($90 retail max); contacts $170 retail max; $350 annual max shared with vision exam. Hearing exam: 1 per 2 calendar years Hearing aids and hardware: $1,000/3 calendar years $45 $45 Covered in Full

11 Blue Cross Blue Shield Plus 1000, a Multi-State Plan Alaska plans for groups 1-50 Beginning January 1, 2016 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. PCY = per calendar year Individual Deductible PCY Family = 2x individual Preferred (In-network) PLUS 1000 Non-preferred $1,000 2x individual deductible Non-participating Coinsurance Amount you pay after your deductible is met 20% 40% 60% Out-of-Pocket Maximum Includes deductible, coinsurance, and copays Family = 2x individual $5,000 Unlimited Office Visits Designated PCP office visit Non-designated PCP or specialist office visit $10 copay, first 2 PCP visits covered in full $40 40% 60% Network Heritage Plus Out-of-network 10 Essential Benefits Covered Services 1 Ambulatory Patient Services Office visits Outpatient services Spinal manipulation (12 visits PCY); Acupuncture (12 visits PCY) $10 Deductible, then 40% Deductible, then 60% 2 Emergency Services Emergency Care Copay waived if directly admitted to inpatient facility $200 Copay, then in-network deductible & coinsurance Ambulance transportation (air & ground) $25 copay, then deductible & in-network coinsurance Emergent: Same as in-network Non-emergent: Air 40% / 60%; Ground Same as in-network 3 Hospitalization Inpatient Hospice 10 days inpatient Respite care: 240 hours lifetime Organ and tissue transplants, inpatient unlimited, except $75,000 donor and $7,500 travel and lodging per transplant Not covered Maternity & Newborn Care Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment Rehabilitative & Habilitative Services & Devices Therapy Rehabilitative and habilitative benefits have the same number of visits, but are counted separately Laboratory Services Prenatal, delivery, postnatal care Office visit $40 Inpatient hospital: mental/behavioral health Outpatient services Inpatient rehabilitation: 30 days PCY Physical, speech, occupational, massage therapy: 45 visits PCY Durable medical equipment Skilled nursing facility: 60 days PCY Includes x-ray, pathology, imaging/diagnostic, CT, PET, MRI (Prior Authorization required for certain services) Deductible, then $40 8 Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations 9 Pediatric Services, including Vision & Oral Care Under 19 years of age Eye exam: 1 PCY Eyewear: 1 set of frames PCY; 1 set of lenses or 12- month supply contact lenses PCY Dental: preventive/basic/major /Deductible, then 20% / $40 /Deductible, then 40% / Deductible, then 50% Orthodontia (medically necessary only) 10 Prescription Drugs 4-Tier: Generic/Brand/ Retail up to 90-day supply (copay x 3) Mail Order 90-day supply (copay x 3) Non-Preferred Brand/Specialty Specialty Rx 30-day supply Drug Formulary X4 Additional benefits $10 / $40 / Deductible waived, then 50% / Deductible waived, then 20% Retail: Same as in-network; Mail order & specialty: not covered Adult vision Hearing Vision exam: 1 PCY Eyewear: 1 pair lenses PCY; 1 pair frames every 2 calendar years ($90 retail max); contacts $170 retail max; $350 annual max shared with vision exam. Hearing exam: 1 per 2 calendar years Hearing aids and hardware: $1,000/3 calendar years $40 $40 A full list of services is available on premera.com/ak/member 9

12 Optional benefits Life and disability Employers can offer an integrated benefits program to help reduce disability and healthcare costs, improve health, and increase workforce productivity. Through our partner, USAble Life, groups will find flexible products, high-quality customer service, and fast, reliable claims service. Several package options are available for employers with 1 50 employees. Employers with 10 or more enrolled employees can choose from the following products: Group life insurance Group term life Provides benefits to a beneficiary in the event of an employee s death Accidental death and dismemberment (AD&D) Provides benefits in the event that a death or dismemberment is caused by an accident Dependent life Provides benefits to the employee in the event of a dependent s death Supplemental life and AD&D Provides additional coverage options for your employees Disability coverage Short-term disability coverage: Protects a portion of employees income in the event of a disability Long-term disability coverage: Provides employees and their families the income needed to help meet financial commitments and give them financial stability Dental coverage It s no secret good dental health affects your employees overall health. Premera s dental plans help both kids and adults maintain healthy teeth. Plus, they have access to a nationwide network of more than 120,000 dentists for dental care. See our DentalBlue benefit guide for information about our full line of dental plans. NOTE: The Balance Kids Dental plan meets the federal requirements for providing pediatric dental plans. 10

13 Definitions Allowed amount* The negotiated amount for which a contracted provider agrees to provide services or supplies. Coinsurance Your employee s share of the cost for a service. If the plan s coinsurance is 20%, the employee pays 20% of the allowed amount and the plan benefit pays the other 80% of the allowed amount. Copay Deductible Formulary In-network Out-of-pocket maximum Primary care provider (PCP) A flat fee your employee pays for a specific service, such as an office visit, at the time they receive service. Services the plan pays for in full. Benefits provided at 100 percent of the allowed amount; not subject to deductible or coinsurance. The amount of money your employee pays every year before the plan pays for certain services. A list of drugs the plan covers for specific uses. Not all generic, name-brand, and specialty drugs are included in the formulary. To find the formulary for your employee s plan, go to premera.com and select Pharmacy. A group of doctors, dentists, hospitals, and other healthcare providers that contract with Premera to provide services and supplies at negotiated amounts called allowed amounts. A preset limit after which the plan pays 100 percent of the allowed amount for services received in-network. All in-network essential benefits apply to the out-of-pocket maximum. The provider who helps coordinate your employee s care. They can choose a different primary care provider for each family member from: physicians and internists, physician assistants, and nurse practitioners; ob/gyns and women s health specialists, pediatricians, and geriatric specialists; or naturopaths. To get a reduced office visit copay with the PCP plans, your employee must choose a provider contracted as part of the Premera network and inform us this is your designated PCP. This is not a contract. Please see premera.com/sbc for the Summary of Benefits and Coverage and Glossary. On our website, you can also find a Supplemental Guide with information about privacy policies, provider organization, key utilization management procedures, and pharmaceutical management procedures. * Note that if they see a non-contracted provider, your employee will be responsible for the difference between the allowed amount and the provider s billed charges, in addition to the coinsurance and any applicable copay. The allowed amount for a non-contracted provider is determined by Premera as described in your forthcoming benefit book. 11

14 General exclusions Benefits are not provided for treatment, surgery, services, drugs, or supplies for any of the following: Cosmetic surgery Experimental or investigative services Infertility Obesity/morbid obesity, related surgery, drugs, and supplements obesity surgery, drugs, and supplements for weight loss or weight control Orthognathic surgery Services in excess of specified benefit maximums Services payable by other types of insurance coverage Services received when you are not covered by this program Sexual dysfunction Sterilization reversal For a complete list of exclusions and limitations, visit premera.com and click the Member Services tab, then click Benefit Exclusions. Prior authorization Certain medical services and prescriptions require prior authorization (approval from the health plan). See your Premera representative for more information. This is only a summary of the major benefits provided by our plans. This is not a contract. Please see premera.com/sbc for the Summary of Benefits and Coverage and Glossary. On our website, you can also find a Supplemental Guide with information about privacy policies, provider organization, key utilization management procedures, and pharmaceutical management procedures. Contact information Premera Blue Cross Blue Shield of Alaska 2550 Denali St., Suite 1404 Anchorage, AK ( )