Your 2015 Health Plan Renewal Kit

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1 Highlight indicates variable data [date] <<subscriber first>> <<last>> <<address>> <<city>> <<ST>> <<ZIP>> Your 2015 Health Plan Renewal Kit Thank you for choosing PacificSource! We look forward to helping you with your health insurance needs in There are a couple of important things to know as you renew your coverage: Your current medical coverage will end December 31, You ll need to choose a new plan for next year that meets the requirements of Affordable Care Act (ACA). This personalized Renewal Kit will make it easy to choose a new ACA-qualified health plan and maintain your PacificSource coverage without any disruption. Within this Kit you ll find: Steps for how to use this kit Information about healthcare reform and what s changing Your 2015 Best Match medical plan that most closely matches the coverage you have now Another plan or two with lower rates than your Best Match plan if available in your area Dental plan options If you like one of our Recommended Plans, simply complete and return the enclosed Enrollment Confirmation Form and we ll take care of the rest. Exploring options: With so many new coverage options, you may want to explore all our plans, and we ve made that easy, too. You can explore all of our individual and family medical and dental plans online at PacificSource.com/find-an-individual-plan, including those available through the exchange marketplace, which has transitioned from Cover Oregon to the federal website, HealthCare.gov. If you qualify for and would like to access financial assistance through HealthCare.gov, we can help you choose a PacificSource plan before you enroll. What happens if you do nothing: To make things easy for you and ensure your coverage continues without disruption, we will automatically move you to the Best Match plan quoted. In December you ll receive your first bill at your new premium. If you pay by EFT or autopay, we ll collect your payment as we normally would. If you wish to stop these services, or want to make any changes to your coverage, please return the Enrollment Confirmation Form, or call us.

2 [Your insurance agent is [name], [agency]. Your agent can help you explore your coverage options, provide premium rates for any of our 2015 plans, and let us know what plan you want. You re also welcome to call us direct if you prefer.] We re here to help. If you want a little help understanding the changes or finding the right plan for your needs, our Coverage Advisors are happy to help. Give us a call or send us an . Toll-free: (855) individual@pacificsource.com Hours: 7:00 a.m. to 6:00 p.m., Monday - Friday 2015 open enrollment will begin on November 15, 2014 and end on February 15, If you purchase a policy through the exchange Marketplace, HealthCare.gov, you may be eligible for a subsidy and/or tax credits based on your income. For more information, contact your insurance agent or HealthCare.gov at (TTY or 711).

3 How to Use this Renewal Kit Review Healthcare Reform: What s Changing? For a summary of the major changes impacting your coverage due to the Affordable Care Act, review the What s Changing section. Review Recommended Plans & Rates You ll find rates and benefit highlights for the closest available 2015 medical and dental plans ( Best Match plans). We ll also include another option or two with lower rates, when available. You ll also find more plan details at: PacificSource.com/Oregon-individual-plan-details We re here to help. If you could use a little help understanding the changes or finding the right plan, we re here for you. PacificSource Coverage Advisors Toll-free (855) individual@pacificsource.com 7 a.m. - 6 p.m., Mon. Fri. If you like the Best Match plan: If you like one of our other recommended plans: If you d like to explore all available plans: You ll find information about all plans available to you online at PacificSource.com/Oregonindividual-plan-details Your agent or one of our Coverage Advisors can help you with rates and choosing a plan to meet your needs. Let us know your plan choices. Complete and return the Enrollment Confirmation Form by December 15. You ll confirm your plan choices for each family member, primary care providers (if applicable), and payment method. If you aren t making any changes, or if we don t hear from you, we ll move you to your best match plan and continue billing you as we do now. Review the Timeline for information on what happens once we receive your Enrollment Confirmation Form.

4 Healthcare Reform: What s Changing? "Healthcare reform also known as the ACA or ObamaCare refers to two federal laws passed in These laws affect healthcare and health insurance. Most changes, including those that most impact you as you renew this year, are already in place: Your current coverage ends on December 31, This change is part of Oregon s transition to new plans that meet the requirements of the Affordable Care Act (ACA). In 2013, you were able to extend your existing plan through December 31, You ll need to select a new plan for coverage beginning January 1, New plans. New benefits. New premium rates. With all of the changes to health insurance, your current plan and premium rates may not look much like those available in Here are highlights of the differences that will affect you: Plans must fit into one of four new metal level benefit tiers (platinum, gold, silver, or bronze). As you might guess, metal levels increase in value with each metal level. Platinum and gold have the most generous benefits, followed by silver and bronze. Plans will cover essential health benefits, or EHBs, which will have no annual or lifetime dollar limitations. EHBs include pediatric dental and vision services. PacificSource medical plans include pediatric vision benefits; pediatric dental can be added to your medical plan through either a pediatric-only plan or a family dental plan. If you have enrolled family members under age 19, we ve quoted the required pediatric dental coverage for you. In some areas of Oregon we re offering new 2015 plans featuring a new provider network called [SmartHealth or SmartChoice]. Plans with the [SmartHealth or SmartChoice] network are designed to give you better access to select doctors who are engaged in helping you meet your health and wellness goals. [SmartHealth or SmartChoice] may be available to you at a lower premium than your Best Match 2015 plan. Essential Health Benefits (EHBs) include the following general categories: Ambulatory care, which includes doctor office visits and other same-day outpatient care Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including dental and vision care for anyone under 19 The way insurers determine premium rates for coverage has changed since you last renewed. ACA requirements have resulted in higher rates for some, and lower rates for others. Rates for each plan will be based only on your age, geographic location, and tobacco use. Financial assistance may be available. If there s a chance your 2015 household income might meet the federal poverty level requirements for financial assistance, you should check with HealthCare.gov to see if you qualify for help to pay for coverage. If you do, you ll need to enroll through HealthCare.gov. Our plans are available through this Marketplace.

5 Recommended Plans and Rates Your PacificSource policy currently covers the following family members: FAMILY ENROLLMENT Name Birth Date Dental required? [Name] 00/00/00 No Medical Plan Recommendations Below are highlights of your current medical coverage alongside our recommended 2015 plan options. You ll find more information on these and all our plans at PacificSource.com/Oregon-individual-plandetails MEDICAL PLAN RECOMMENDATIONS Plan Feature Current Plan Best Match Alternate Match #1 Alternate Match #2 Name [name] [name] [name] [name] Monthly premium $ $ $ $ Provider network PSN PSN SmartHealth SmartHealth Annual deductible $ $ $ $ Cost share for $ Covered in full Covered in full Covered in full routine preventive care Cost share for most inpatient services Notes about our medical plan recommendations: The premium rates quoted above are based on covering the same people currently enrolled under your policy, with everyone on the same plan. You can add or remove family members to your coverage if you wish; you may also choose different plans for each family member. We ll be happy to provide you with a rate quote if you d like to make those changes. [The rates quoted assume that there are no enrolled tobacco users age 21 or over. If there are tobacco users on your policy, you ll need to contact us for new rates. The premium for adult tobacco users is 20% higher than for non-users, but can be reduced by enrolling in a tobacco cessation program. Information about our programs can be found at PacificSource.com/members.] With [SmartHealth or SmartChoice], you ll choose a primary care provider (PCP) from the [SmartHealth or SmartChoice] network. Your PCP will work closely with you to help you meet your health and wellness goals. The benefit highlights shown above are based on using participating network providers. [For SmartHealth plans, they are based on accessing care from Tier 1 providers.] Benefits for nonparticipating [or Tier 2] providers may differ. Plan Features and Extras: All our 2015 medical plans include the essential health benefits, no-cost preventive care, and prescription drug coverage. Plus, you ll keep the award-winning service and many extras you ve come to expect with PacificSource. You ll also have access to our 24-Hour NurseLine service for medical advice any time, any place you need it, and our new mypacificsource app that enables you to access your ID card and other benefit information using your SmartPhone or mobile device.

6 Dental Plan Renewal If current dental: In 2014, you moved to qualified dental plan which meets the ACA requirement that everyone under age 19 to have dental coverage. We ll renew you on this same plan for Changes include a more simplified tier structure, coverage for cone beam X-rays, and reduction in participating provider out-ofpocket limits for pediatric services for members under age 18 to $350 per child/$700 per family. Your new rate and benefit highlights are shown below: Current Dental Plan 2015 Dental Plan Plan name <<Dental Plan Name>> <<Dental Plan Name>> Monthly premium $<<new plan rate>> $<<new plan rate>> Annual deductible $ $ Cost share for routine exams $ $ Cost share for Class II services $ $ The benefit highlights shown above are based on using participating network providers. Benefits for nonparticipating providers may differ. You ll find more information about the new dental plan online at PacificSource.com/Oregon-individualdental If not covered, with enrollees <19: The ACA requires everyone under age 19 to have dental coverage. If you don t have other dental coverage, you ll want to consider adding the following dental coverage to be sure you meet the law s requirements. DENTAL PLAN RECOMMENDATION Plan Features Kids Dental Advantage Monthly premium $<<rate >> Family members covered Only those under age 19; see Dental required? in the Family Enrollment table on the previous page. Annual deductible $ Cost share for routine exams $ Cost share for Class II services $ The benefit highlights shown above are based on using participating network providers. Benefits for nonparticipating providers may differ. You ll find more information about this coverage option at PacificSource.com/Oregon-individual-dental We also offer individual and family dental coverage. You re welcome to contact [your insurance agent or] us for a quote. If not covered, no enrollees <19: The ACA requires everyone under age 19 to have dental coverage; it s not required for those age 19 or older. If you re considering adding any children to your policy, or if you d like the added peace of mind

7 of dental coverage, consider a PacificSource dental plan. You ll find information about those options at PacificSource.com/Oregon-individual-dental You re also welcome to contact [your insurance agent or] us for a quote.

8 Timeline What to Expect Here s a look at what happens once you complete and return your Enrollment Confirmation Form. If you have questions along the way, just give us a call at (855) Your steps: Select your plan. Complete, sign, and return your Enrollment Confirmation Form by December 15, Note: If we don t hear from you or you don t return your enrollment form, we ll automatically move you to the Best Match plan and continue your current method of payment at the new premium rate with your January bill (due in December). Our steps: We ll enroll you. Once we receive your renewal form, we ll activate your new benefits on January 1, We ll mail your ID cards. Your new ID cards will be mailed to you within 7 to 10 days after we receive your Enrollment Confirmation Form. Pay your premium. If you pay by EFT or credit card now, we ll continue these services, billing you at the new premium amount effective with your January premium. Otherwise, please make your payment by check by the due date. Review your information. Once you receive your packet, review the materials, then store the packet with your other important documents. We ll mail your bill or collect your EFT payment. Your bill will include your new premium amount and due date. A copy of your bill will also be posted to your InTouch account. We ll mail your plan information and post your policy to your InTouch account. Your plan information includes your policy and other materials to help you get the most out of your new plan. And with InTouch, you ll have 24/7 access to your benefit information online.

9 Enrollment Confirmation Form <<subscriber first>> <<last>> <<address>> <<city>> <<ST>> <<ZIP>> Step 1: Choose Your Plan Best Match Check your selections: Alternate #1 Alternate #2 Dental Plan Name [name] [name] [name] [name] Monthly premium [$] [$] [$] [$] Provider network PSN SmartHealth SmartHealth Dental Advantage If enrolling in health insurance through HealthCare.gov or elsewhere: Please discontinue my PacificSource policy as of January 1. I am enrolling in other health insurance coverage at that time. (Skip ahead to Step 4.) Step 2: Review and Update Your Information Birth Name Date [subscriber] [00/00/00 ] [member 1] [00/00/00 ] [member 2] [00/00/00 ] [member 3] [00/00/00 ] Include in 2015 medical coverage? FAMILY ENROLLMENT Dental coverage required? Include in 2015 dental coverage? Tobacco user?** Yes No [No] Yes No Yes No Yes No [No] Yes No Yes No Yes No [Yes] Yes No Yes No Yes No [No] Yes No Yes No If enrolling in a SmartHealth or SmartChoice plan: Provide first and last names of your chosen PCP* PLEASE ADD THE FOLLOWING FAMILY MEMBERS Note, adding or deleting family members will impact your premium. We will contact you to complete your enrollment process and provide you with your new premium. Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No *If enrolling in a [SmartHealth or SmartChoice] plan, you ll need to choose a PCP (primary care provider) who participates in the [SmartHealth or SmartChoice] network. To find eligible [SmartHealth or SmartChoice] PCPs in your area visit PacificSource.com/FindaProvider. **You are considered a tobacco user if you have used any tobacco products an average of four or more times a week within the last six months. Premium rates for tobacco users are 20% higher than those quoted; please contact us for an adjusted rate if any tobacco users are enrolling. By checking No to this question you certify that you are not a tobacco user.

10 Enrollment Confirmation Form (continued) Step 3: Choose Your Payment Option If we receive your Enrollment Confirmation Form by December 1, your payment preferences will be in place for your January premium payment. If we receive this information after December 1, we ll mail your January premium bill in December and your account changes will be in place for your February payment. You can set up automatic monthly payment by credit card by logging into InTouch and selecting the Payment Center tab. I currently pay by EFT or credit card and I want to continue that process. Go to Step 4. I currently pay by check and want to continue that process. Go to Step 4. I would like to enroll in EFT, or change my current EFT account information. Please complete the following: Electronic Funds Transfer (EFT) Authorization: I authorize and direct PacificSource Health Plans to withdraw funds each month to pay for my individual insurance policy premium. I understand that funds will be withdrawn on the 5 th of each month (or the first business day after the 5 th in the case of weekends or holidays). I understand that if my premium is past due when EFT begins, the first withdrawal will include my current premium and the outstanding amount. Bank name: Account number: Account Type: Checking attach a voided check Savings attach a voided savings withdrawal slip This authorization will remain in effect until termination by either party. If the individual policy premium changes due to a rate increase, alternate plan selection, or age migration of a member, this authorization will automatically be amended to authorize withdrawal of an amount equal to the new premium. Step 4: Review, Sign, Date, and Return this Form by December 15, Please review your choices and information, sign and date below, and return this form to us: By fax: By individual@pacificsource.com By mail: Use enclosed postage paid envelope, or mail it to: Individual Sales and Service, PacificSource Health Plans, 110 International Way, Springfield, OR Your new plan(s) will be effective January 1, Signature Date address (please print) Phone We re here to help. Our Coverage Advisors are available 7 a.m. to 6 p.m., Monday Friday. Toll-free (855) individual@pacificsource.com