Select Us. We re local, we re nonprofit, and we re integrated with Intermountain Healthcare. Utah Small Employer 2014

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1 Select Us We re local, we re nonprofit, and we re integrated with Intermountain Healthcare. Small employers know that for nearly 30 years, we have been committed to providing access to high-quality healthcare, helping members stay healthy, and offering superior service. Our integration with Intermountain Healthcare allows small business owners to have more financial control, stable insurance premiums, and continued access to a trusted healthcare network. Utah Small Employer 2014 AWARDS AND REOGNITION Intermountain Healthcare s nonprofit system is one of the nation s top-ranked integrated health systems (Modern Healthcare magazine, January 2012). The system includes physicians, clinics, and 22 hospitals, as well as insurance plans from SelectHealth. SelectHealth is consistently rated as Utah s top HMO plan by state and national organizations, receiving top scores in both member satisfaction and clinical performance. SelectHealth is also accredited by the National ommittee for Quality Assurance (NQA). Results show that NQA-accredited plans outperform nonaccredited plans in all measures of clinical care and member satisfaction. For more awards and details, visit selecthealth.org/awards and NQA.org. BUILD A UNIQUE PLAN FOR YOUR SMALL BUSINESS Follow these five steps to create your customized plan: STEP 1: Learn about the extra resources that SelectHealth provides (pages 2 3) STEP 2: ompare plan elements using our benefit charts (pages 4 7) STEP 3: hoose the network of hospitals and providers covered by your plan (pages 8 9) STEP 4: onsider optional benefits like dental, eyewear, group life, and disability insurance (pages 10 11) STEP 5: Become familiar with our medical and coverage guidelines (page 12)

2 ONLINE RESOURES AND MEMBER SERVIES Our member service representatives are available with extended hours. In addition, My Health, our secure member website, provides important health and benefit information 24 hours a day, seven days a week. BENEFITS AND DISOUNTS We want your employees to live well, so we provide a number of resources to supplement our plan benefits. From care management to discounts on wellness-related services, our wellness program is designed to help employees maintain and enjoy a healthy lifestyle. EXEPTIONAL SERVIE Member Services and SelectHealth Member Advocates Representatives are available during extended hours to answer questions over the phone and help resolve concerns. To contact Member Services, call weekdays, from 7:00 a.m. to 8:00 p.m., and Saturdays, from 9:00 a.m. to 2:00 p.m. Members can also ask coverage questions through our secure online messaging system. On business days, we respond to messages within 24 hours. Our Member Advocates help members find the right doctor for their needs. They can assist with the following: Appointment scheduling, including urgent conditions Finding the closest facility or doctor with the nearest available appointment To contact Member Advocates, call weekdays, from 7:00 a.m. to 8:00 p.m. and Saturdays, from 9:00 a.m. to 2:00 p.m. MY HEALTH ONLINE TOOLS overage, laims, and Medical Records Our integration with Intermountain Healthcare gives members access to their medical records* through My Health. They can view lab results, imaging reports, doctor appointments, and can questions to participating Intermountain providers. Members can also view their personalized plan information, claim details, and Explanation of Benefits (EOBs), and sign up for paperless communications. *Records are only available for Intermountain doctors and hospitals and may not be available at all facilities. Pharmacy Tools Members can access their pharmacy benefit information, claims, prescription history, and lowercost drug alternatives. See page 7 for details. LiVeWell Online Members can print healthy recipes, access the nutrition blog, learn how to recognize stress, use our online symptom checker, view information about sports training programs, and watch videos that encourage an active lifestyle. PREVENTIVE ARE Regular preventive care exams can help maintain optimal health by detecting and treating concerns early. All of our small employer health plans cover preventive care 100 percent that means no copays, coinsurance, or deductibles. Physical exams, pediatric eye exams, colonoscopies (generally for members over 50), immunizations, and many laboratory screening tests are included as preventive care. We even provide education, schedules, and reminder calls and mailings to help your employees seek the appropriate preventive care. MEMBER DISOUNTS As SelectHealth members, your employees will receive discounts on the following services and products: Fitness enters Personal Training LASIK Alternative Medicine Spas and osmetic Services Nutritional Supplements Eyewear ARE MANAGEMENT Whether your employees have an urgent or ongoing condition, our registered nurse care managers offer one-on-one support. They provide educational materials, referrals to online and community resources, and follow-up phone calls to help employees manage their conditions. SELETHEALTH HEALTHY BEGINNINGS Our prenatal care program provides emotional support and coaching for expectant mothers from a team of nurse care managers. In addition to pregnancy planning education materials and an overthe-phone screening, the program includes high-risk care management when needed. SMOKING ESSATION One of the most significant things a person can do to improve overall health is to quit smoking. We offer a program that can help. Quit for Life allows participants to progress at their own pace from home. SelectHealth members have 100 percent coverage with no copay or coinsurance. Hearing Aids Medical Supplies FOR MORE INFORMATION ABOUT OUR HEALTHARE OPTIONS, ONTAT YOUR SELETHEALTH-APPOINTED INSURANE AGENT OR ALL

3 ONSIDER YOUR PLAN OPTIONS We offer several plans to fit your needs and budget. Use these tables to compare your options for both traditional plans and those that can be paired with a Health Savings Account (HSA). METAL TIERS Beginning in 2014, the government will give each plan a designated metal tier Platinum, Gold, Silver, or Bronze that represents the plan s coverage levels for a specific group of health benefits. onsumers will be able to see these metal tier values when shopping for plans through online health insurance Marketplaces. The charts below help show some of the benefit differences between our Gold, Silver, and Bronze plans for small employers. SELETHEALTH SIGNATURE SM These traditional plans offer comprehensive coverage with a variety of deductible options and flexible benefit features. Most Signature plans cover office visits prior to the deductible being met and all pay for a wide-range of preventive services at 100 percent, which means there is no out-of-pocket cost for members. Several of these plans also offer a buy-up option to cover prescription drugs prior to meeting the deductible. SELETHEALTH HEALTHSAVE SM These plans conform to the U.S. Treasury Department guidelines for a high deductible health plan and are designed to be paired with a taxadvantaged HSA. While HealthSave plans often have lower premiums, they typically require greater out-of-pocket spending for healthcare costs. WHAT IS AN HSA? An HSA is similar to a personal savings account but with a few differences. For HSA-eligible individuals money contributed to an HSA can be used for certain medical expenses (as defined by the IRS) like deductibles, copays, and coinsurance. Our preferred HSA vendor is HealthEquity. Please visit healthequity.com for more information about an HSA. GENERALLY HIGHER PREMIUMS GENERALLY LOWER OUT-OF-POKET OST GENERALLY LOWER PREMIUMS GENERALLY HIGHER OUT-OF-POKET OST Signature Gold Signature Silver HealthSave SM Silver HealthSave Bronze Deductible (individual/family) Out-of-Pocket Maximum (individual/ family) Primary are Provider (PP) $250/$750 $500/$1,500 $500/$1,500 $1,000/$2,500 $2,000/$4,000 $1,000/$2,500 $2,000/$4,000 $1,500/$3,000 $3,500/$7,000 $2,000/$4,000 $3,500/$7,000 $5,000/$10,000 $4,000/$8,000 $5,000/$10,000 $4,000/$8,000 $4,400/$8,800 $5,000/$10,000 $6,350/$12,700 $5,000/$10,000 $3,500/$7,000 $5,000/$10,000 $6,350/$12,700 $25 copay $25 copay $25 copay $25 copay $10 copay $25 copay* $25 copay* $25 copay* $0 copay* $25 copay* $25 copay* Secondary are Provider (SP) $40 copay $40 copay $40 copay $40 copay $15 copay $50 copay* $40 copay* $40 copay* $0 copay* $40 copay* $40 copay* Preventive are/ Immunizations Inpatient/Outpatient Services, Maternity, and Mental Health/hemical Dependency 1 No out-of-pocket cost No out-of-pocket cost No out-of-pocket cost No out-of-pocket cost No out-of-pocket cost No out-of-pocket cost No out-of-pocket cost No out-of-pocket cost No out-of-pocket cost No out-of-pocket cost No out-of-pocket cost 20% 20% 20% 20% 10% 50% 30% 20% 0% 20% 30% Emergency Room $250 copay* $250 copay* $250 copay* $250 copay* $150 copay* $500 copay* $250 copay* $250 copay* $0 copay* $250 copay* $550 copay* Prescription Drug overage 1 (see page 7 for more prescription drug coverage information) $100/$300 (individual/ family) deductible** $250/$750 (individual/ family) deductible $0 deductible coinsurance $600/$1,500 (individual/family) deductible** $0 deductible covered at 10% coinsurance $600/$1,500 (individual/family) covered at 50% $0 deductible covered at 30% coinsurance overage begins after overage begins after covered at 0% overage begins after overage begins after covered at 30% *After deductible **This plan has a buy-up option to cover prescription drugs before the Rx deductible is met (e.g., $0 deductible). 1 Preauthorization is required for the following services: (a) all inpatient services; (b) certain injectable drugs and specialty medications; (c) certain prescription drugs; (d) certain DME items; (e) certain mental health and chemical dependency services; (f) home health nursing and; (g) pain management services; (h) cochlear implants, organ transplants, and all services obtained outside of the United States unless a routine, urgent or emergency condition. Benefits may be reduced or denied if you do not preauthorize certain services. Refer to your contract or call Member Services for more information. 4 5

4 DUAL OPTION: EMPLOYEE HOIE We realize that each of your employees are unique and may have different coverage needs. If you have five employees living in the state of Utah at all times, you qualify for Dual Option. This flexibility allows your employees to choose between a SelectHealth Signature plan and a HealthSave plan. All of our Dual Option Signature plans cover office visits prior to the deductible being met. Option Plan A Plan B Select Med Plus Signature $1,000/$2,500 deductible, 20% coinsurance, $25/$40 copay $500/$1,500 deductible, 20% coinsurance, $25/$40 copay, $250 Rx deductible $500/$1,500 deductible, 20% coinsurance, $25/$40 copay, $250 Rx deductible Select Value Signature Select Value Signature Select are Plus Signature Select are Plus Signature $2,000/$4,000 deductible, 10% coinsurance, $10/$15 copay, $2,000/$4,000 deductible, 10% coinsurance, $10/$15 copay, $2,000/$4,000 deductible, 10% coinsurance, $10/$15 copay, Select Med Plus HealthSave Select Value HealthSave Select Value HealthSave $3,500/$7,000 deductible, 0% coinsurance, $0 copay Select Value HealthSave Select Value HealthSave PRESRIPTION DRUG OVERAGE SelectHealth Prescriptions uses many unique initiatives that keep your drug costs low. Because we are a local company, we work closely with area doctors and pharmacists to develop evidence-based prescription drug coverage options. Pharmacy benefits are included with all of our small employer plans. Our RxSelect formulary (a list of prescription drugs covered by your plan) includes a wide range of medications, placing minimal restrictions on product selection. RxSelect pharmacy benefits are included with all small employer plans. Benefits have four tiers (levels) of coverage. Drugs on lower tiers will cost members less without compromising quality. Use the chart at the bottom of this page to determine how your plan will cover prescription drugs. Remember, many of our plans include the option to have prescription drugs covered prior to the deducible being met. Please consider this valueadded benefit for your employees. RETAIL90 Maintenance medications are drugs that members have been using for at least one month and expect to continue using for the next year. With Retail90, members can purchase a 90-day supply of maintenance medications at their convenience using a local pharmacy. MAIL ORDER Our members have the option to fill prescriptions through the mail using Express Scripts. This service allows members to order and pay for refills online with a credit card. Express Scripts can also send reminders when it is time to refill a prescription. Tier 1 Tier 2 Tier 3 GENERISAMPLE GenericSample is a great way to try a generic drug at no cost to you. This program eliminates your copay/ coinsurance for the first 30-day fill of select generic prescriptions. GenericSample is only available through participating retail pharmacies. GenericSample is not available on HealthSave plans or under the 90-day maintenance drug benefit. ONLINE PHARMAY TOOLS Our online tools, available via My Health, allow members to access the following information: Pharmacy claims history The tier statuses of prescription drugs opay and benefit information Drug prices and lower-cost alternatives Potential drug interactions Pharmacy lookup Tier 4 (certain injectable drugs and speciality medications) RxSelect Tiers $10 copay 25% coinsurance 50% coinsurance overage varies by plan. See the medical benefit charts on pages four and five to view coverage levels for these drugs. 6 7

5 PROVIDER NETWORK OPTIONS PARTIIPATING HOSPITALS AND LINIS hoosing the right network is important. SelectHealth offers three provider and facility networks that range in size and coverage area Select Value, Select Med, and Select are. Smaller networks generally have lower premiums. Primary hildren s Hospital is participating in all our networks and we have options that include University of Utah facilities and doctors. You can search for participating doctors, hospitals and clinics at selecthealth.org/providers and selecthealth.org/facilities, where you will also find patient satisfaction and quality ratings for many providers and clinics. SelectHealth members have access to Intermountain Healthcare s nationally recognized facilities and contracted hospitals and clinics. aribou Memorial Hospital Portneuf Med. enter HIGHER OST LOWER OST LESS PROVIDER AESS assia Regional Med. enter* Alta View Hospital* LDS Hospital* Franklin ounty Med. enter Logan Regional Hospital* Bear River Valley Hospital* 34 PARTIIPATING HOSPITALS 3,900+ PARTIIPATING PHYSIIANS & PROVIDERS Davis Hospital & Med. enter Riverton Hospital* University of Utah Hospital Select are only University of Utah Orthopaedic enter V Select are only overage Mountain West Med. enter American Fork Hospital* V Orem ommunity Hospital* V Heber Valley Med. enter* Uintah Basin Med. enter Sanpete Valley Hospital* Delta ommunity Med. enter* M Select Med Emergency are For an emergency, members should call 911 or go to the nearest hospital. Though copays are the same at all emergency rooms, members will save money by visiting participating hospitals. Gunnison Valley Hospital Select are Fillmore ommunity Med. enter* V Select Value V entral Valley Med. enter Networks overage is provided through participating providers for daily hospital room and board, miscellaneous hospital services, anesthesia services, in-hospital medical services, and out-ofhospital care. overage is subject to deductibles, copay provisions, or other limitations that may be set forth in the ontract. Ashley Valley Med. enter Utah Valley Regional Med. enter* Urgent are *Intermountain-owned Facility Sevier Valley Med. enter* 8 Select are is our largest provider network and includes the University of Utah Hospital. It extends into rural areas of Utah where Select Med and Select Value are not available. Plus network options provide benefits (50 percent coverage after deductible) at nonparticipating hospitals or providers. Beaver Valley Hospital Outside the State of Utah Garfield Memorial Hospital* San Juan Hospital Blue Mountain Hospital Valley View Med. enter* Dixie Regional Med. enter* (400 E. & River Rd. ampuses) For an illness or injury that is not life threatening but needs medical attention within 24 hours, members should call a participating provider. Moab Regional Hospital Milford Valley Memorial Hospital Select Med is both affordable and comprehensive, including three times more hospitals and providers than Select Value. As our most popular provider network, Select Med reaches northern and southern Utah. For cancer treatment, the Huntsman ancer Hospital is participating. Plus network options provide benefits (50 percent coverage after deductible) at nonparticipating hospitals or providers. HV V TOSH The Orthopedic Specialty Hospital * V Park ity Med. enter* Select Value is highly integrated with Intermountain Healthcare and serves members along the Wasatch Front. Although it is smaller, products with this network are considered among the best value available in Utah. Select Value includes access to great hospitals like Primary hildren s Hospital, LDS Hospital, Intermountain Medical enter, Alta View Hospital, McKay-Dee Hospital enter, Riverton Hospital and Utah Valley Regional Medical enter. V V Primary hildren s Medical enter* McKay-Dee Hospital enter* 43 PARTIIPATING HOSPITALS 5,000+ PARTIIPATING PHYSIIANS & PROVIDERS (M-ancer treatment only) Intermountain Medical enter* Bear Lake Memorial Hospital 10 PARTIIPATING HOSPITALS 1,300+ PARTIIPATING PHYSIIANS & PROVIDERS V Huntsman ancer Hospital Oneida ounty Hospital MORE PROVIDER AESS Salt Lake Area Kane ounty Hospital H If members have an emergency or need urgent care outside of Utah, participating benefits apply to services received in a doctor s office, urgent care facility, or emergency room. Members can save money on out-of area services by using Multiplan or PHS providers and facilities. To find one, call or visit multiplan.com. 9

6 INREASING EMPLOYEE HEALTH: SELETHEALTH DENTAL Our expanded SelectHealth Dental products offer more flexible plan designs. We can help you create the right plan at the right price. FLEXIBLE OPTIONS From plans with no deductibles to other value-based designs, our products can meet your budget and your employees needs. We offer the following advantages: ompetitive rates Flexible plan designs Buy up options like orthodontia and implants Top-ranked customer service* Simplified administration when combined with SelectHealth medical coverage For contributory plans, the employer contribution must be equal to at least 50 percent of the single coverage monthly premium. Employers with up to four eligible employees must have 100 percent participation after valid waivers. Employers with five or more eligible employees much have 75 percent participation after valid waivers. For voluntary plans, employers with two to 50 enrolling employees need at least 30 percent participation. BENEFITS FOR TRADITIONAL PLANS AN EXPANSIVE NETWORK All of our small employer dental plans include our lassic network. This is our largest network and allows members to choose from more than 1,400 dental providers. Employers can choose options like deductible amounts, annual maximum plan payments, and access to nonparticipating providers. HEALTHARE REFORM AND DENTAL The Affordable are Act requires small employer medical plans to cover certain Essential Health Benefits. One of these benefits is a pediatric dental benefit. We offer a pediatric-only dental plan to help employers meet this requirement.** Additionally, we bundle our regular SelectHealth Dental with this pediatric benefit. For more information about SelectHealth Dental, speak with your SelectHealth-appointed insurance agent or contact us. OVERAGE Deductible (Individual/Family) $0 $500/$0 $1,500 Annual Maximum Plan Payment (Individual) $0 $2,000 PREVENTIVE AND DIAGNOSTI (No waiting period) Oral exams, cleanings, fluoride, X-rays BASI (Three month waiting period without prior coverage) Fillings, oral surgery, anesthesia for basic services MAJOR (12-month waiting period without prior coverage) rowns, bridges, dentures, anesthesia for major services, endodontics, and periodontics Plan Pays % Plan pays 60 80% after deductible Plan pays 40 60% after deductible Implants (Buy-up option) Plans pays 40 60% Orthodontics (Buy-up option) Plan pays 40 60% Orthodontic Lifetime Maximum Plan Payment (Individual) $1,000 $5,000 Nonparticipating benefits are covered the same as participating benefits; however, they are not subject to SelectHealth-negotiated rates for dental services so members are responsible for the difference between our negotiated rate and the billed amount. Limitations apply to the following services: oral examinations, cleanings, x-rays, sealants, space maintainers, fluoride, fillings, endodontics, periodontal surgery, periodontal debridement, periodontal scaling/root planing, periodontal maintenance, prosthodontic devices, and dentures. INREASING EMPLOYEE HEALTH: EYEWEAR, GROUP LIFE, AND DISABILITY OVERAGE onsider adding value to your employees coverage through these three additional benefits. Remember, some of these benefits can be added as options at no cost to employers. SELETHEALTH EYEWEAR SM Good vision is an important part of overall health. In addition to the routine eye exams covered by our medical plans, SelectHealth offers coverage for vision hardware through EyeMed Vision are. Benefits include contacts, frames, lenses, and lens options. Here are just a few reasons to add SelectHealth Eyewear to your current medical plan: Affordability and Simplicity Low monthly premiums Enrollment is optional at the employee level, and there is no minimum enrollment percentage for participation. However, a minimum of five employees must be enrolled at all times. Voluntary plans are available at no cost to the employer. If the employer choose a contributory plan, the employer contribution must be equal to at least 75 percent of the single coverage monthly premium. Access and Service 200 Utah locations, nearly 23,000 locations nationwide, including private practitioners and leading retailers such as Lensrafters, Target Optical, Sears Optical SM, and Pearle Vision EyeMed provides exceptional customer service, available seven days a week. For more information, speak with your SelectHealthappointed insurance agent and remember to request our Eyewear brochure, which includes rates, benefit summaries and underwriting guidelines. GROUP LIFE AND DISABILITY SelectHealth has teamed up with MetLife to offer customized group term life insurance and group disability programs. In addition, special Premium- Per-Employee (PPE) plan designs were developed with SelectHealth small employers in mind. These plans offer the convenience of fixed rates no need to submit occupations and salaries just to receive a quote. This means that the rates are the same for each of your employees. In Utah, MetLife makes this option available only through SelectHealth. Our small employers will also enjoy the advantage of pooled risk by participating in the MetLife Multiple Employer Trust. Review our plan designs and learn how easily you can add value to your employee benefit packages at a competitive rate. If you have questions speak with your SelectHealthappointed agent and remember to request our Group Life and Disability brochure, which includes rates, benefit summaries, and underwriting guidelines. *According to NQA s Health Insurance Plan Rankings ** These plans cover two yearly exams, cleanings (including fluoride treatment), and bitewing X-rays for those under 19. That is the totality of their coverage. Employees can choose between two copay options. One is a $15 office visit copay, the other is a $32 office visit copay

7 ENROLLMENT, STATUS, ONTRIBUTION, AND LIMITATIONS Our small business plans include participation and contribution requirements as well as certain limitations on coverage. ONTRIBUTION AND PARTIIPATION Employer Monthly ontribution Small employers must contribute an amount equivalent to at least 50 percent of the lowest individual monthly premium of the group s plan. The employer s contribution must be consistent for all employee classes. Required Minimum Employee Enrollment For employers with four or less enrolling employees, 100 percent of their employees must participate. For employers with five or more enrolling employees, 75 percent of employees must participate. Employees waiving coverage due to a valid waiver will not be counted toward participation. Valid waivers include having coverage through another carrier, coverage through Medicare or another government program or coverage through a spouse or parent. Also, groups enrolling between November 15 and December 15 for a January effective date are not subject to participation or contribution requirements. SMALL GROUP STATUS It is important to determine whether a group meets the definition of a small employer or a large employer, as outlined by the Utah Insurance Department. To make this determination, employers should calculate the average number of eligible employees they had on each business day during the previous calendar year (e.g., groups renewing Dec. 1, 2013 should use the 2012 calendar year). If the average number of eligible employees is greater than 50, the group will be considered a large employer. If the average number of eligible employees is 50 or fewer, the group will be considered a small employer. If the group s plan covers out-of-state employees, all eligible out-of-state employees should be included in the count. GENERAL LIMITATIONS AND EXLUSIONS Eligibility Employees and their dependents may apply for coverage if they are a full-time resident of Utah. Eligible dependents include the insured s legal spouse, children younger than age 26, eligible disabled children older than age 26 and children who are under court-ordered legal guardianship until legal guardianship ends. overage and Termination overage for members and any dependents listed on the application will be effective upon approval by SelectHealth. overage will not terminate for health reasons; however, coverage will terminate for any of the following: Nonpayment of premiums Fraud or intentional misrepresentation of material fact An employee no longer resides, lives, or works in the service area Your group is on a plan we terminate If we do not receive a premium or we are unable to collect a premium, employers and their SelectHealth appointed agents will be notified. Excess harges These are charges from providers and facilities that exceed the SelectHealth allowed amount for covered services. Members are responsible to pay for excess charges from nonparticipating providers and facilities. These charges do not apply to out-ofpocket maximums. Excluded Services ertain services are not covered. For a list of excluded services, visit selecthealth.org/exclusions SelectHealth. All rights reserved. 2169R 1/14