New Individual health insurance plans offered only in Connect for Health Colorado marketplace

Transcription

1 New Individual health insurance plans offered only in Connect for Health Colorado marketplace A Guide for Brokers

2 Introducing... Elevate by Denver Health Medical Plan Elevate is a new individual insurance product offered by the Denver Health Medical Plan, Inc. (DHMP). DHMP is licensed in Adams, Arapahoe, Denver and Jefferson counties. Denver Health Medical Plan, Inc. (DHMP), a nonprofit, is a wholly-owned subsidiary of Denver Health and Hospital Authority. DHMP is a separate entity from Denver Health and Hospital Authority. Currently we offer two Medicare Advantage plans, a Child Health Plan Plus program and four Large Group products. DHMP joins the individual market for the first time with the launch of Elevate. ffordable prices What s in a name? Why Elevate? DHMP wanted to create a health plan that is a step up from other plans. A plan that focuses on the member s needs and allows them to elevate their health plan. Now, more than ever, it is important for members to play a part in their own health care. Elevate staff is here to assist members in reaching the goals that are important to them. We are not a large health insurance company. We see this as a positive. Our size allows us to offer more personalized service to our members. We will work with them one-on-one, to make appointments, arrange for them to work with individual health coaches, and enroll in wellness classes. Elevate provides: Personal navigators Health coaches Wellness seminars Healthy cooking and shopping classes

3 Our Products Four affordable choices Elevate Gold Basic Expanded Elevate Silver Basic network choice Expanded Basic vs Expanded, what is the difference? The difference between the two is the choice of Network Basic is a closed-network plan that uses the Denver Health and Hospital Authority network and its facilities. This includes 8 family health centers scattered throughout Denver. These health centers offer one-stop care for members. Denver Health also has 15 school-based health clinics, where parents can give permission to have their child see a provider during the school day. This saves parents time and allows children to access care quickly and easily. There is no cost for any service at a school-based health center. Expanded also uses the Denver Health and Hospital Authority network and its facilities as listed above. In addition, members in the Expanded plans have the option to use all providers and facilities at University of Colorado Hospital and Children s Hospital Colorado. The Expanded network provides members with more choice at an affordable price

4 Basic Network Family Health Centers WELLINGTON WEBB CENTER FOR PRIMARY CARE 301 W. 6th Ave. ADULT MEDICINE CLINIC Burgundy Green Team KIDS CARE CLINIC GIPSON EASTSIDE th St. LA CASA/QUIGG NEWTON 4545 Navajo LOWRY 1001 Yosemite St. Suite 100 MONTBELLO Albrook Dr. PARK HILL th St. SANDOS WESTSIDE 1100 Federal Blvd WESTWOOD 4320 W. Alaska Ave. Hospital DENVER HEALTH MEDICAL CENTER 777 Bannock St. ADULT URGENT CARE WALK-IN CLINIC 777 Bannock St. PEDIATRIC URGENT CARE CLINIC 777 Bannock St. School-based Health Centers ABRAHAM LINCOLN 2285 S. Federal Blvd. ABRAHAM LINCOLN 2285 S. Federal Blvd. BRUCE RANDOLPH CAMPUS 3955 Steele Street EVIE DENNIS CAMPUs 4800 Telluride St. JOHN F. KENNEDY CAMPUS 2855 S. Lamar Street KEPNER CAMPUS 911 Hazel Court KUNSMILLER CREATIVE ARTS ACADEMY CAMPUS 2250 S. Quitman Way LAKE CAMPUS 1820 Lowell Blvd. MANUAL CAMPUS 1700 E. 28th Ave. MARTIN LUTHER KING, JR. EARLY COLLEGE CAMPUS E. 46th Avenue MONTBELLO CAMPUS 5000 Crown Blvd. NORTH CAMPUS 2960 N. Speer Blvd. PLACE BRIDGE ACADEMY 7125 Cherry Creek North Drive RACHEL B. NOEL CAMPUS 5290 Kittredge Street SOUTH CAMPUS 1700 E. Louisiana Ave. WEST CAMPUS 951 Elati Street Expanded Network Children s Hospital Colorado Main Campus East 16th Avenue Aurora, CO Network of Care NORTH CAMPUS 469 West State Highway W 168th Avenue Broomfield, CO CHILDREN S HOSPITAL COLORADO URGENT CARE AND OUTPATIENT SPECIALTY CARE, LITTLETON 151 W. County Line Road Littleton, CO OUTPATIENT SPECIALTY CARE, CENTENNIAL 7960 South University Boulevard, Suite 203 Centennial, CO University of Colorado Hospital Metro Area Clinics Anschutz Medical Campus ANSCHUTZ CANCER PAVILION 1665 Aurora Court Aurora, CO ANSCHUTZ INPATIENT PAVILION E. 16th Avenue Aurora, CO UNIVERSITY FAMILY MEDICINE BOULDER 350 Broadway, Suite 130 Boulder, CO UNIVERSITY FAMILY MEDICINE PARK MEADOWS 8080 E. Park Meadows Drive Lone Tree, CO THERAPY CARE, BROOMFIELD 8401 Arista Place, Suite 200 Broomfield, CO URGENT AND OUTPATIENT SPECIALTY CARE, WHEAT RIDGE 3455 Lutheran Parkway, Suite 230 Wheat Ridge, CO CHILDREN S HOSPITAL COLORADO AT ST. JOSEPH HOSPITAL 1830 Franklin Street Denver, CO CHILDREN S HOSPITAL COLORADO AT PARKER ADVENTIST HOSPITAL, PARKER 9395 Crown Crest Blvd Parker, CO OUTPATIENT SPECIALTY CARE, PARKER Sierra Medical Office Building 9399 Crown Crest Blvd, Suite 300 Parker, CO ANSCHUTZ OUTPATIENT PAVILION 1635 Aurora Court Aurora, CO Hospital Clinics SENIORS CLINIC 1665 Aurora Court, 5F UNIVERSITY MEDICINE 1635 Aurora Court Expanded network includes all Denver Health facilities and providers as well as Children s Hospital Colorado and University of Colorado Hospital facilities and providers UNIVERSITY FAMILY MEDICINE A.F. WILLIAMS AT STAPLETON 3055 Roslyn St, Suite 100 Denver, CO UNIVERSITY FAMILY MEDICINE WESTMINSTER 7403 Church Ranch Blvd., Suite 107 Westminster, CO UNIVERSITY INTERNAL MEDICINE AT LOWRY 8111 E. Lowry Boulevard, Suite 120 Denver, CO 80230

5 Expanded Network BOULDER LAFAYETTE LA CASA/QUIGG NEWTON GIPSON EASTSIDE MONTBELLO 70 N N 36 BROOMFIELD E470 SANDOS WESTSIDE HOSPITAL URGENT CARE CLINICS PARK HILL LOWRY W E W E WEBB CENTER FOR PRIMARY CARE Level One Physicians Clinic Adult Medicine Kids Care Clinic 76 WESTWOOD 225 S S WESTMINSTER 70 STAPLETON Denver Health Locations 70 GOLDEN WHEAT RIDGE LAKEWOOD DENVER LOWRY AURORA E470 LITTLETON C470 HIGHLANDS RANCH PARKER UNIVERSITY OF COLORADO HOSPITAL NETWORK CHILDREN S HOSPITAL COLORADO HOSPITAL NETWORK

6 Personal Service Member Services Member Services is available to answer all of your questions from 7 a.m. - 8 p.m., Monday Saturday; 8 a.m. - 5 p.m., Sunday/holidays. Our representatives are specially trained to: Answer questions about health network Provide additional information about how to receive services Answer questions about benefits Provide access to a wide variety of information, such as handbooks and provider directories, in both electronic and printed formats Care Support Team Within Care Support Services, health care navigators are available Monday Friday, 8 a.m. 5 p.m. to assist members with all aspects of receiving care in the Denver Health network. Having a medical home has been shown to have a positive effect on a person s health and well-being; Care Support Services strives to assist members in navigating within their medical home. Care Support Services staff can also assist members with appointments, both primary care and specialty, as well as many other member needs. Health Coaches Health coaches are trained professionals who partner with members to identify goals and action plans to achieve those goals. These coaches also provide complimentary Health and Wellness classes as well as an array of classes for chronic disease management. One-on-one health coaching for members who want to reach specific health and lifestyle goals Cooking Matters classes to help members learn to cook the personal service foods they love in a healthier ways Shopping Matters: Our health coaches take members to grocery stores to learn how to choose healthy foods on a budget

7 Special Programs for your Clients Preventive care is very important, especially during pregnancy and the first year of life. Elevate understands the pressures and financial responsibilities that exist during this time as well. Elevate offers these programs to ensure our members receive the necessary care to keep themselves and their families healthy. Our Mom s-to-be and Baby s First Year programs offer incentives to members who receive their preventive care. A few examples are... Mom s-to-be Babys First Year Pregnancy Calendar First Prenatal Visit After your baby s two week visit, receive a Diaper Bag Denver Health Onesie Clinic Visit between weeks of pregnancy After your baby s two month visit,receive a Baby Monitor Umbrella Stroller After Denver Health hospital tour Car Seat After Delivery at Denver Health After your baby s four month visit, receive a Healthy Baby Kit Two-month Diaper Supply After Delivery at Denver Health After your baby s six month visit, receive a Activity Gym Healthy Heroes for Kids Elevate offers the Healthy Heroes program as a fun way to encourage healthy habits in kids. Children receive special promotions such as quarterly kids newsletters, activity sheets and Health Tip postcards in the mail. The program is for children ages 3-12 and is split into three groups so that each group receives age-friendly materials. The three groups are: Explorers for children 3-5, Rangers for children 6-9, and X-Kidz for pre-teens

8 Silver Deductible Individual Family Out of Pocket Maximum Individual Family $150 $2,500 $300 $5,000 In Network All coinsurance and copays will apply to the deductible. All individual deductible amounts will count toward the family deductible; an individual will not have to pay more than the individual deductible amount $675 $6,250 $1,350 $12,500 Out of Network Not applicable. Not applicable. The out of pocket maximum includes the annual deductible, coinsurance and all copays. Lifetime maximum Covered Providers Medical Office Visits Personal providers (Family Medicine, Internal Medicine and Pediatrics) Specialist Preventive Services All individual out of pocket amounts will count toward the family out of pocket maximum; an individual will not have to pay more than the individual out of pocket maximum No lifetime maximum Not applicable. Basic Expanded Not applicable. Denver Health and Hospital Authority, providers and includes all facilities associated with these entities. See provider directory for a complete list of current providers Providers at Denver Health and Hospital Authority, University of Colorado Hospital and Children s Hospital Colorado and University Physicians Inc. Also includes all facilities associated with these entities. See provider directory for a complete list of current providers $5 $40 (Deductible and coinsurance do not apply.) $15 $65 (Deductible and coinsurance do not apply.) No Copayment (100% covered) Children Adults Maternity Prenatal Care Delivery, Inpatient and Well Baby Care This applies to all preventive services with an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF) Annual well visit, well woman exams, prenatal visits; colonoscopy, mammogram. See USPSTF list on our web site at $0 copay per visit

9 Prescription Drugs Denver Health pharmacy (30 day supply) Discount: $4 copay Generic: $5 $20 copay Preferred Brand: $30 $45 copay Non preferred Brand: $80 copay Denver Health pharmacy (90 day supply) Discount: $8 copay Generic: $10 $40 copay Preferred Brand: $60 $90 copay Non preferred Brand: $160 copay Non Denver Health pharmacy (30 day supply) Discount: $8 copay Generic: $10 $40 copay Preferred Brand: $60 $90 copay Non preferred Brand: $160 copay Non Denver Health pharmacy (90 day supply) Discount: $16 copay Generic: $20 $80 copay Preferred Brand: $120 $180 copay Non preferred Brand: $320 copay Inpatient Hospital Outpatient/Ambulatory Surgery Diagnostics Laboratory and Radiology (including CT scans, MRI and PET scans) Emergency Care Urgent Care Ambulance For drugs on our approved list, call Member Services at (303) or visit our web site at $100 $250 Copay (deductible and coinsurance do not apply) $50 $125 Copay (deductible and coinsurance do not apply) Behavioral Health and other Mental Health Care Outpatient: Inpatient: Therapies Rehabilitative: Physical, Occupational, and Speech Therapy Habilitative: Physical, Occupational, and Speech Therapy Pulmonary Rehabilitation Cardiac Rehabilitation $5 $40 (Deductible and coinsurance do not apply.) 20 visits of each therapy per calendar year 20 visits of each therapy per calendar year $100 $250 Copay (deductible and coinsurance do not apply) $50 $125 Copay (deductible and coinsurance do not apply) Deductible and 5% 25% coinsurance apply

10 Durable Medical Equipment Hearing Aids Adults Children 18 and under Prosthetics Orthotics Oxygen/Oxygen Equipment Oxygen Equipment Organ Transplants Home Health Care Hospice Care Skilled Nursing Facility Dental Care Vision Care Adults and Children over age 6 Children under age 6 No cost for items less than $100 4 items below $1000 or 1 item above $1000 Covered at 100% 100% Covered Limitation: 28 hours per week Benefit maximum: 100 days per calendar year Not Covered $15 $70 Covered at 100%

11 Gold Deductible Individual Family $1,600 $3,200 In Network Not applicable. Out of Network Copays do not apply to deductible. Out of Pocket Maximum Individual Family All individual deductible amounts will count toward the family deductible; an individual will not have to pay more than the individual deductible amount $5,000 $10,000 Not applicable. The out-of-pocket maximum includes the annual deductible, coinsurance and all copays. Lifetime maximum Covered Providers Medical Office Visits Personal providers (Family Medicine, Internal Medicine and Pediatrics) Specialist Preventive Services Children Adults All individual out-of-pocket amounts will count toward the family out-of-pocket maximum; an individual will not have to pay more than the individual out-of-pocket maximum No lifetime maximum Not applicable. Basic Expanded Not applicable. Denver Health and Hospital Authority providers and Denver Health Medical Center. See provider directory for a complete list of current providers Providers at Denver Health and Hospital Authority, University of Colorado Hospital and Children s Hospital Colorado and University Physicians Inc. Also includes all facilities associated with these entities. See provider directory for a complete list of current providers $15 Deductible and coinsurance do not apply. $25 Deductible and coinsurance do not apply. No Copayment (100% covered) This applies to all preventive services with an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF) Annual well visit, well woman exams, prenatal visits; colonoscopy, mammogram. See USPSTF list on our website at

12 Maternity Prenatal Care Delivery, Inpatient and Well Baby Care Prescription Drugs $0 copay per visit Denver Health pharmacy (30-day supply) Discount: $4 copay Generic: $10 copay Preferred Brand: $35 copay Non-preferred Brand: $60 copay Denver Health pharmacy (90-day supply) Discount: $8 copay Generic: $20 copay Preferred Brand: $70 copay Non-preferred Brand: $120 copay Non-Denver Health pharmacy (30-day supply) Discount: $8 copay Generic: $20 copay Preferred Brand: $70 copay Non-preferred Brand: $120 copay* Denver Health pharmacy (90-day supply) Discount: $16 copay Generic: $40 copay Preferred Brand: $140 copay Non-preferred Brand: $280 copay* *Prior authorization required. Inpatient Hospital Outpatient/Ambulatory Surgery For drugs on our approved list, call Member Services at or visit our web site at www. elevatehealthplans.org Diagnostics Laboratory and Radiology (including CT scans, MRI and PET scans) Emergency Care Urgent Care Ambulance $150 Copay (deductible and coinsurance do not apply) $75 Copay (deductible and coinsurance do not apply) Behavioral Health and other Mental Health Care Outpatient: Inpatient: $15 Deductible and coinsurance do not apply. $150 Copay (deductible and coinsurance do not apply) $75 Copay (deductible and coinsurance do not apply)

13 Therapies Rehabilitative: Physical, Occupational, and Speech Therapy Habilitative: Physical, Occupational, and Speech Therapy Pulmonary Rehabilitation Cardiac Rehabilitation Durable Medical Equipment Hearing Aids Adults Children under 18 Prosthetics Orthotics Oxygen/Oxygen Equipment Oxygen Equipment Organ Transplants Home Health Care Hospice Care Skilled Nursing Facility Dental Care Vision Care Adults Children under of each therapy per calendar year 20 of each therapy per calendar year No cost for items less than $100 4 items below $1000 or 1 item above $1000 Covered at 100%;. Not Covered 100% Covered; Limitation: 28 hours per week Benefit maximum: 100 days per calendar year Not Covered $25 Covered at 100% Not covered Not covered

14 Silver Cost Sharing Levels Deductible/ Coinsurance Copays Pharmacy Copays If you have no subsidy, your cost sharing will be: If you have 73% subsidy, your cost sharing will be: If you have 87% subsidy, your cost sharing will be: If you have 94% subsidy, your cost sharing will be: Deductible: $2,500 Coinsurance: 25% Maximum Out of Pocket: $6,250 Deductible: $2,250 Coinsurance: 25% Maximum Out of Pocket: $5,200 Deductible: $900 Coinsurance: 5% Maximum Out of Pocket: $1,000 Deductible: $150 Coinsurance: 5% Maximum Out of Pocket: $675 ER: $250 Urgent Care: $125 PCP: $40 Specialist: $65 Mental Health Outpatient: $40 Copays: ER: $250 Urgent Care: $125 PCP: $30 Specialist: $50 Mental Health Outpatient: $30 Copays: ER: $125 Urgent Care: $60 PCP: $10 Specialist: $25 Mental Health Outpatient: $10 Copays: ER: $100 Urgent Care: $50 PCP: $5 Specialist: $15 Mental Health Outpatient: $5 Denver Health Pharmacy (30-day supply) Discount: $4 copay Generic: $20 copay Preferred Brand: $45 copay Non-preferred Brand: $80 copay (90-day supply) Discount: $8 copay Generic: $40 copay Preferred Brand: $90 copay Non-preferred Brand: $160 copay Denver Health Pharmacy (30-day supply) Discount: $4 copay Generic: $10 copay Preferred Brand: $35 copay Non-preferred Brand: $80 copay (90-day supply) Discount: $8 copay Generic: $20 copay Preferred Brand: $70 copay Non-preferred Brand: $160 copay Denver Health Pharmacy (30-day supply) Discount: $4 copay Generic: $10 copay Preferred Brand: $35 copay Non-preferred Brand: $80 copay (90-day supply) Discount: $8 copay Generic: $20 copay Preferred Brand: $70 copay Non-preferred Brand: $160 copay Denver Health Pharmacy (30-day supply) Discount: $4 copay Generic: $5 copay Preferred Brand: $30 copay Non-preferred Brand: $80 copay (90-day supply) Discount: $8 copay Generic: $10 copay Preferred Brand: $60 copay Non-preferred Brand: $160 copay

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16 Broker Contacts Laurie Goss Heather Bollig