CARING FOR NEW YORK S SMALL BUSINESSES Off-Exchange 2016 Plans and Services for Downstate Groups With Up to 100 Employees

Transcription

1 CARING FOR NEW YORK S SMALL BUSINESSES Off-Exchange 2016 Plans and Services for Downstate Groups With Up to 100 Employees

2 SMALL GROUP PLANS AT A GLANCE With the needs and budgets of small businesses in mind, EmblemHealth offers four HMO plans for small groups. While all four plans offer identical, high-quality benefits, each plan has a different cost-sharing structure. EmblemHealth HMO 15/35 (Platinum) Our higher monthly premium plan with the lowest copays for members and no annual deductible. EmblemHealth HMO 40/60 (Gold) Our lower monthly premium plan with slightly higher copays and lowest annual deductible. EmblemHealth HMO 35/55 (Silver) Our moderately low premium, copay and annual deductible plan. EmblemHealth HMO HD6300 (Bronze) Our low-premium, high-deductible plan that covers most services in full after the annual deductible has been met. EmblemHealth on SHOP We also offer plans on the Small Business Marketplace (New York s SHOP). To see if your group qualifies for financial assistance through SHOP, visit emblemhealthreform.com FIND A DOCTOR To find a doctor in the Select Care network, use the Find a Doctor tool on emblemhealth.com. The indicates that the doctor is part of AdvantageCare Physicians. SELECT BETTER WITH THE SELECT CARE NETWORK EmblemHealth s small group plans provide in-network-only coverage from providers in our Select Care network. The EmblemHealth Select Care network features leading primary and specialty care doctors and hospitals in 28 New York counties including the five boroughs of New York City and its surrounding counties, plus upstate regions that stretch north of Albany. While part of a larger network, the Select Care network is not small; we have over 34,000 quality practitioners in our coverage area. The Select Care network also includes most of the hospitals in our coverage area. That means employers can be sure that their plan is competitively priced and features a competitive network. ADVANTAGECARE PHYSICIANS: THE CARE YOU NEED, ALL IN ONE PLACE The Select Care Network also includes AdvantageCare Physicians, New York metro s largest multispecialty physician-led practice, with 450 doctors and 36 locations most of which offer walk-in service and extended evening and weekend hours. AdvantageCare Physicians offers a full range of services, including primary care and 26 areas of specialty care, along with lab services, radiology (X-ray), cardiology screenings, pharmacies, and many other support services. Consider AdvantageCare Physicians your partner in wellness, holding your health to a higher standard by providing the convenient, connected and compassionate care you expect and deserve. For a closer look at the care and services available at AdvantageCare Physicians, visit acpny.com

3 HELPING MEMBERS STAY HEALTHY, GET WELL AND LIVE BETTER We ve invested in programs that help our members on their journey to better health. Our preventive care and wellness programs are industry recognized and focus on improving overall health in meaningful ways. OUR SMALL GROUP PLANS OFFER 1 : Discount programs on health-related products such as weight-loss programs and acupuncture Gym membership reimbursement Positive Actions Towards Health (PATH) programs for education and support in managing specific health conditions. 24/7 ACCESS TO DOCTORS WITH TELEHEALTH Telehealth is an exciting benefit included in these small group plans that offers members the convenience of seeing a doctor anytime through their computer, mobile device or phone for a $5 or $10 copay. Members can talk to primary care and family doctors, specialists and registered dietitians, to receive non-urgent medical care. They can even get prescriptions for certain medicines. 2 EMBLEMHEALTH NEIGHBORHOOD CARE A UNIQUE VALUE At our EmblemHealth Neighborhood Care locations, members can meet face-to-face with health care solutions specialists who will listen to their health challenges and help them use their insurance coverage and other community resources to lead healthier lives. Nurses, pharmacists and social workers are also available to discuss and respond to members needs at no cost. Learn more at ehnc.com. MYEMBLEMHEALTH MOBILE APP EmblemHealth members can download myemblemhealth on their Apple or Android devices for useful benefit and plan information, right at their fingertips. Complete Your Benefits Package with Dental Coverage You can choose to add the following dental programs to your group s medical plan. The plans feature different benefit designs, network size and cost-sharing responsibilities: Pediatric Dental: A low-cost pediatric dental care plan option underwritten by Dentcare and offered by EmblemHealth if you have not already purchased another stand-alone dental plan certified by the SHOP. EmblemHealth Preferred Dental: 100% coverage for all in-network preventive, basic and major services. EmblemHealth s Preferred PPO network includes over 8,000 dentists and specialists in New York and New Jersey, plus access to a nationwide network. EmblemHealth Dental Access Program: 100% coverage for all in-network preventive and diagnostic services performed by one of the 8,000 Dental Access Program dentists in New York and New Jersey. The Dental Access Program also provides discounted fees on many complex and costly dental services. To learn more about the big value in our small group plans, call to speak with a sales representative, or visit emblemhealth.com/smallgroupplans. 1 Certain conditions and limitations may apply. 2 Only applicable in US states where Telehealth prescriptions are allowed. New York State permits Telehealth prescriptions, but others may not.

4 HIGHLIGHTS OF BENEFITS AND SERVICES Service Limitations HMO 15/35 (Platinum) HMO 40/60 (Gold) HMO 35/55 (Silver) HMO HD6300 (Bronze) Annual deductible (individual/family) No deductible $200/$400 (includes hospital and medical services) $3,000/$6,000 (includes hospital and medical services) $6,300/$12,600 (includes hospital, medical and pharmacy services) Annual out-of-pocket maximum (individual/ family) Includes deductible, copays and coinsurance $2,000/$4,000 medical and hospital $5,500/$11,000 $6,000 /$12,000 $6,300/$12,600 Preventive services (e.g., well-child care including immunizations; annual physical; and more) Office visit copay (primary care/specialist) Diagnostic lab and radiology Telehealth consultation fee (physician/ registered dietitian) Referral needed from member s PCP for specialist care Outpatient facility only Available 365 days per year via computer, mobile device or phone $15/$35 copay $40/$60 copay $35/$55 copay $35 copay $60 copay $55 copay $10/$5 $10/$5 $10/$5 $10/$5 Inpatient hospital admission 365 days per calendar year $500 copay per admission $1,500 copay per admission 30% coinsurance Emergency room facility Copay waived if admitted; covered in and out of network $100 copay $200 copay $200 copay Emergency ambulance $100 copay $100 copay $150 copay Urgent care facility In-network only $55 copay $60 copay $60 copay Ambulatory surgery facility $100 copay $150 copay 30% coinsurance Pediatric vision exams, lenses and frames One exam per 12-month period; one set of lenses and frames or contacts per 12-month period; coverage up to age 19 (end of month). $15 copay per exam; 10% coinsurance for lenses/frames/ contacts $40 copay per exam; 10% coinsurance for lenses/frames/ contacts $35 copay per exam; 30% coinsurance for lenses/frames/ contacts Durable medical equipment (DME) Gym reimbursement Standard equipment only; excludes orthotics Only available to subscriber and subscriber s covered spouse. Not applied to out-of-pocket maximum or deductible. 10% coinsurance 10% coinsurance 30% coinsurance Subscriber reimbursed at the lesser of $200 or actual cost of membership per six-month period and 50 visits. Subscriber s covered spouse reimbursed at the lesser of $100 or actual cost of membership per six-month period and 50 visits. Prescription drugs Retail (generic/brand/nonformulary) 30-day supply $10 / $30 / $60 copays $15/$35/$75 copays ($100 indiv/$200 family deductible for combined retail and mail order must be met before copays apply) Prescription drugs Mail Order (generic/brand/nonformulary) 90-day supply $25 / $75 / $150 copays $38/$88/$188 copays ($100 indiv/$200 family deductible for combined retail and mail order must be met before copays apply) Small groups may obtain pediatric dental coverage through a stand-alone dental plan offered either on or off the Small Business Marketplace. An extended dependent coverage rider is available for purchase, extending the age limit to 29 for all eligible dependents. All prescription drug program options include voluntary home delivery, clinical prior authorization and specialty pharmacy programs. Certain services must be approved in advance by EmblemHealth. The benefits described here are only brief highlights of the covered services and benefits available. Some covered services and/or benefits may have ANNUAL DAY OR VISIT limits and/or maximums. The terms, limitations, conditions and exclusions of the insurance contract and certificate will govern.

5 CARING FOR NEW YORK S SMALL BUSINESSES As a New York-based company serving local businesses for more than 75 years, EmblemHealth respects our community s demand for affordable, high-quality health coverage. Our commitment to providing value to New York s small business customers is stronger than ever, with new plan offerings that are among the most competitively priced in the market. We are creating a customer service and health care experience that is uniquely New York and uniquely EmblemHealth. That is why EmblemHealth is more than just a health insurer we are New York s health and wellness company.

6 55 Water Street, New York, New York LOCATIONS Corporate Headquarters 55 Water Street New York, NY Melville 39 North Service Road Suite 110 Melville, NY Buffalo 374 Delaware Avenue Buffalo, NY New York City 441 Ninth Avenue New York, NY Albany 80 Wolf Road Albany, NY Syracuse Pioneer Business Park 5015 Campuswood Drive East Syracuse NY EMBLEMHEALTH NEIGHBORHOOD CARE LOCATIONS Cambria Heights Linden Boulevard Cambria Heights, NY Harlem 215 W 125th Street New York, NY Chinatown 87 Bowery New York, NY The EmblemHealth HMO 15/35 Plan, HMO 40/60 Plan, HMO 35/55 Plan and HMO HD3600 Plan are underwritten by HIP Health Plan of New York and provide in-network benefits only. Except for emergency hospital care, no out-of-network services are covered. Coverage is subject to all terms, conditions, limitations, and exclusions set forth in the contract. Refer to HIP policy form number SGOFFHIXCONTRACT(04/14), et al. The EmblemHealth Preferred Dental plan and the EmblemHealth Dental Access Program are underwritten by Group Health Incorporated (GHI). Refer to policy forms PLD-1104-C and PLD-1103-C. Discounted fees available under the EmblemHealth Dental Access Program are not underwritten or insured. Small employer groups may purchase pediatric dental coverage through Dentcare or any other stand-alone dental plan offered either on or off the NY State of Health marketplace. If the group application indicates that the small employer group has not obtained such coverage, this dental coverage will be provided by EmblemHealth and will be underwritten by Dentcare. Dentcare is not an EmblemHealth company. Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies /15