Health Plan Comparison

Transcription

1 For Agent Use Only A healthier bottom line. Starmark Healthy Incentives Health Plan Comparison Self-Funded Health Plans Specifically for Businesses With Five or More Employees PPO Indemnity CDHP PPO CDHP Indemnity

2 Healthy Incentives means healthy savings. Starmark is the perfect choice for the healthcare benefit needs of small businesses: Easy paperless enrollment for employees online or via phone through Express Connect. Unparalleled personal service, including a personal welcome call for each new group. Plus, Starmark follows up to ensure customer satisfaction continues throughout the year and personally assists in plan renewal. Health and wellness management tools to help members get and stay healthy. Truly flexible plan designs your clients can customize to meet their needs and budget, including HSA-friendly plans. Starmark HRA features seamless integration of claims processing and HRA administration, and encourages the cost-effective use of healthcare services. Quick claims turnaround with one of the fastest, most efficient systems in the industry. Starmark Healthy Incentives Plans feature: Plan design flexibility to meet employer needs and budget Resources to simplify healthcare and promote employee health and wellness Freedom to choose any provider With self-funded plans, the employer finances the company s healthcare plan, funding claim expenses up to a predetermined amount. If actual expenses are less, the employer keeps the savings a healthy incentive. And for employees, these plans work like a fully insured plan. Starmark Choice of two traditional, self-funded plans offers a lower deductible and the same great benefits that employees would receive with a fully insured plan. Starmark Choice of two consumer-directed health plans (CDHPs) that encourage employees to become more engaged in the costs associated with their healthcare. Plus, plans can be paired with a health savings account (HSA) for tax advantages. All plans feature: Preventive care benefits Lab programs CareChampion 24/7 health advocacy program YourCare health and wellness outreach program 24-hour nurse line MaternaLink maternity wellness program Cost-saving prescription drug programs Alternative medicine benefit Discounts on vitamins, and vision and hearing services/supplies 1 1 The discount program, provided by New Benefits, Ltd., a discount medical plan organization, is not insurance and is not available to Vermont residents. Trustmark and Starmark are not affiliated with New Benefits, Ltd. 2

3 Mental Illness, Nervous Disorders, Substance Abuse and Alcohol Abuse Groups with up to 50 employees Outpatient expenses 40-visit limit per year; 120 visits per lifetime Covered charges are paid at 60 percent for an in-network provider; 50 percent for an out-of-network provider or for Healthy Incentives Indemnity Inpatient expenses 20 days per year; 40 days per lifetime. These limits do not apply to inpatient alcohol abuse treatment. Groups with 51 or more employees Outpatient and inpatient expenses Covered charges are paid the same as any other covered service. Groups with up to 50 employees Outpatient expenses 40-visit limit per calendar year; 120 visits per lifetime Covered charges are paid at 60 percent for an in-network provider (100 percent if the 100 in-network coinsurance is selected); 50 percent for an out-of-network provider or Healthy Incentives CDHP Indemnity. Inpatient expenses 20 days per calendar year; 40 days per lifetime. These limits do not apply to inpatient alcohol abuse treatment. Groups with 51 or more employees Outpatient and inpatient expenses Covered charges are paid the same as any other covered service. Therapies Speech, Occupational and Physical Therapies 60-visit limit per therapy per year Manipulative Therapy 20-visit limit per year Chronic Pain Treatment Programs Maximum 10 visits per year Alternative Medicine Acupuncture, Massage Therapy, Naturopathic Services 12-visit limit per therapy, per year Maximum of $250 per therapy, per visit Nutritional Counseling (Nutritional counseling may be covered under preventive care services.) 3-visit limit per lifetime, except for diabetic counseling Dual Plan Designs Resources to Help Members Get and Stay Healthy Dual plan designs offer flexibility for today s employers. Employers simply combine currently marketed plans using the established guidelines to create a plan to meet their business needs and budget. Employers should consult with their tax advisor to ensure that their multiple-plan offerings comply with applicable non-discrimination rules. Starmark offers resources to help simplify healthcare and maximize the health potential of plan members. CareChampion 24/7 is a health advocacy service that supports members as they navigate through the healthcare system. Advisors are available anytime, day or night, and can help members find a doctor or hospital in-network, understand healthcare benefits and claim payments, identify cost-saving opportunities, handle eldercare issues and more! Healthy Foundations provides a comprehensive suite of health and wellness management tools to help maximize the health potential of every plan member. Healthy Foundations includes the YourCare health and wellness outreach program, MyNurse 24/7, MaternaLink maternity wellness program, online support tools and the Healthy Foundations wellness e-newsletter. To learn more about CareChampion 24/7 and Healthy Foundations, visit Marketing Materials Healthy Incentives Brochure: MK83 Healthy Incentives Indemnity Flyer: MK115 Healthy Incentives CDHP Brochure: MK84 Healthy Incentives CDHP Indemnity Flyer: MK114 7

4 Lifetime Maximum Benefit Unlimited for essential health benefits (as defined by federal regulation) Individual Deductible CHOICES: Calendar Year Plan Year PPO $ 0/$2,000 $ 250/$750 $ 500/$1,500 $ 750/$1,500 $ 1,000/$2,000 $ 1,500/$3,000 $ 2,000/$4,000 $ 2,500/$5,000 $ 3,000/$6,000 $ 4,000/$8,000 $ 5,000/$10,000 $10,000/$20,000 Indemnity $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,000 $ 2,500 $ 3,000 $ 4,000 $ 5,000 $ 10,000 CDHP PPO $ 1,200/$2,400 $ 1,500/$3,000 $ 2,000/$4,000 $ 2,500/$5,000 $ 3,000/$6,000 $ 4,000/$8,000 $ 5,000/$10,000 In- and out-of-network deductibles accrue separately. CDHP Indemnity $ 1,200 $ 1,500 $ 2,000 $ 2,500 $ 3,000 $4,000 $ 5,000 In- and out-of-network deductibles accrue separately. Deductible Type Embedded: Benefits are payable for a member once either the individual deductible is met, or for the entire family once the family deductible is met. Employers choose one. Aggregate: Benefits are payable once the entire family deductible is met. Embedded: Benefits are payable for a member once either the individual deductible is met, or for the entire family once the family deductible is met. For the plan to be qualified for use with an HSA, the embedded deductible must be selected only with individual deductibles of $2,500 ($5,000 for families) or higher. Coinsurance PPO Indemnity CDHP PPO CDHP Indemnity 100/70 90/70 80/60 70/50 50/ /70 90/70 80/60 70/

5 Benefit Options (continued) (available on all plans) Supplemental Accident Option Supplemental accident coverage helps prepare members for an unexpected accident or injury by providing first-dollar coverage. The first $500 of covered charges per accident is paid at 100 percent. Additional covered charges are subject to the plan deductible and coinsurance. Coverage includes medical charges resulting from accidental injury incurred within 90 days of the accident. Maternity Option The maternity option provides members with peace of mind when planning for pregnancy and delivery. Normal maternity and nursery care covered charges are subject to the plan deductible and coinsurance. Outpatient Diagnostic X-Ray and Lab 100% up to $250 per person, per year 100% up to $500 per person, per year 100% up to $1,000 per person, per year Coinsurance only (deductible waived)* Deductible and coinsurance Covered charges are subject to the plan deductible and coinsurance. Coverage includes in-network x-ray, lab, pathology and radiology services. Covered charges exceeding the maximum or services received out-of network, are subject to the plan deductible and coinsurance. *The coinsurance only option is not available when the 100/70 coinsurance is selected. Outpatient Laboratory Testing Lab Card Program This voluntary program offers 100 percent coverage for covered outpatient laboratory testing when testing is directed to a participating Quest Diagnostics laboratory as part of the Lab Card Program. Provider collection and handling fees may apply and are subject to health benefit plan provisions. For more information, visit Note: Quest Diagnostics Incorporated is a provider of laboratory testing, information and services, and is not affiliated with the Trustmark Companies. Covered charges are subject to the plan deductible and coinsurance. Lab Card Select Program This voluntary discount program offers outpatient laboratory testing at significant savings compared with other labs when testing is directed to a participating Quest Diagnostics laboratory as part of the Lab Card Select Program. For more information, visit Note: Quest Diagnostics Incorporated is a provider of laboratory testing, information and services, and is not affiliated with the Trustmark Companies. Preventive Care Services Preventive care services, as defined by federal regulation, are paid at 100 percent when received in-network. Age and frequency schedules apply. Covered preventive care services include, but are not limited to: physician office visits for preventive care services (adult physicals, routine ob/gyn visits, well-child visits), routine mammograms, PSA (prostate-specific antigen), colonoscopy, and adult and child immunizations (including flu and pneumonia shots). 6

6 Coinsurance Limit PPO Indemnity CDHP PPO CDHP Indemnity $ 5,000/$10,000 $ 10,000/$15,000 $ 15,000/$20,000 $ 20,000/$25,000 $ 5,000 $ 10,000 $ 15,000 $ 20,000 $ 5,000/$10,000 $ 10,000/$20,000 $ 15,000/$30,000 $ 5,000 $ 10,000 $ 15,000 Family Deductible Family Deductible and Out-of-Pocket Limit Multiplier: Out-of-Pocket Limits A multiple of the individual deductible and out-of-pocket limit. One time Two times Three times In- and out-of-network deductibles accrue separately on Healthy Incentives PPO. The percentage of covered charges the member must pay each year. The family out-of-pocket limit is one, two or three times the individual out-of-pocket limit, depending on the family deductible and out-of-pocket limit multiplier selected. The out-of-pocket limit does not include the deductible. Refer to the proposal for the out-of-pocket limits applicable to the plan. In- and out-of-network out-of-pocket limits accrue separately on Healthy Incentives PPO. Two times the individual deductible and out-of-pocket limit. In- and out-of-network deductibles accrue separately on Health Incentives CDHP PPO. The percentage of covered charges the member must pay each year. The family out-of-pocket limit is two times the individual out-of-pocket limit. The annual out-of-pocket limit does not include the deductible. Refer to the proposal for the out-of-pocket limits applicable to the plan. In- and out-of-network out-of-pocket limits accrue separately on Healthy Incentives CDHP PPO. Prescription Drug Benefit OPTION 1 Prescription Drug Card Prescription Deductible Choices: $0 per person $250 per person $500 per person Retail Copay (up to a 30-day supply) Mail Service Copay (up to a 90-day supply) Generic Preferred Brand Nonpreferred Brand Generic Preferred Brand Nonpreferred Brand $ 0 $ 30 $ 50 $ 0 $ 75 $150 $ 0 $ 45 $ 75 $ 0 $110 $225 $10 $ 30 $ 50 $20 $ 75 $150 $15 $ 45 $ 75 $30 $110 $225 $20 $60 $100 $40 $150 $300 Prescription deductible must be met in full every year by each member; does not apply to generics. The $0 generic prescription drug copays can be selected only with the $0 prescription deductible. The Prescription Drug Card option is not available. 4

7 Prescription Drug Benefit (continued) OPTION 2 Price Assurance Program This program provides prescription drug savings at thousands of participating pharmacies nationwide. Covered prescription drugs are subject to the in-network plan deductible and coinsurance. When members present their medical ID card at a participating pharmacy, they receive: The lowest price available in that store, on that day Generic drug savings Drug utilization review The Price Assurance Program includes most drugs that, by federal law, require a prescription. If a prescription drug is excluded from coverage under the health plan, members may still receive a discount on their prescription through this program. OPTION 3 No Outpatient Prescription Drug Coverage Benefit Options Members do not receive a discount and pay the full price for prescriptions filled at a retail, mail service or specialty pharmacy. Prescription drugs received inpatient or administered in a physician s office are covered under the health plan, subject to the plan deductible and coinsurance. Select a physician office visit copay and receive the corresponding urgent care copay. An emergency room copay can also be selected. The option to waive outpatient prescription drug coverage is not available. Physician office visit, urgent care, emergency room, therapy and alternative medicine copays are not available. Covered charges are subject to the plan deductible and coinsurance. Physician Office Visit $20 copay $30 copay $40 copay Deductible and coinsurance Urgent Care $40 copay $60 copay $80 copay Deductible and coinsurance Emergency Room (optional) $150 copay $200 copay $250 copay $200 access fee (per occurrence, waived if admitted as inpatient) If desired, therapy and alternative medicine copays can be selected. Therapies (optional): If selected, the copay amount is equal to the physician office visit copay selected. Alternative Medicine (optional): If selected, the copay amount is equal to the physician office visit copay selected. 5

8 Why Starmark Small business is our only business. For more than 25 years, Starmark s sole focus has been serving small businesses. This expertise enables us to help you work with your clients to achieve their needs. Robust benefits, tailored to fit. Starmark offers a wide range of benefit plans employers can customize to their needs and budget, including HSA- and HRA-friendly plans and dual plan designs. Greater provider choice. Strong network access nationwide allows clients freedom of choice in provider care, exceptional negotiated arrangements when using in-network providers and PHCS-negotiated discounts when outside the primary PPO service area through PHCS Healthy Directions. Financial strength. Trustmark Life Insurance Company provides stop-loss insurance for the self-funded plans in the Starmark portfolio. Trustmark Life is rated A- (Excellent) by A.M. Best. The information contained in this brochure is a general summary of plan highlights only. Limitations, exclusions, renewability and pre-existing condition limitations apply and are described in the product brochures. For detailed product information, please refer to the applicable product brochure and plan document. The plan document is the prevailing document and the basis for benefit payment. Federal IRS restrictions and state mandates may apply. Self-funded plans are administered by Starmark, and stop-loss insurance is provided by Trustmark Life Insurance Company. Plan benefits are subject to change to comply with federal healthcare reform, as necessary. Plan availability and/or coverage may vary by state. For more details, refer to the separate state insert page (MK85) or ask your Starmark distribution partner. Coverage is not effective without written notification from Trustmark Life Insurance Company or Star Marketing and Administration, Inc. 400 Field Drive Lake Forest, Illinois Starmark is a distinguished leader in small group healthcare benefits. By offering flexible health plans, unparalleled personal service, innovative, paperless employee enrollment, comprehensive health and wellness management tools, nationwide network access, and seamless HRA administration, Starmark is the choice to meet the diverse needs of small businesses today Star Marketing and Administration, Inc. MK99 (2-11)