Health Plans That Fit Your Life 2016

Transcription

1 Health Plans That Fit Your Life 2016 Maine Find the one that s right for you. Certified by the Health Insurance Marketplace

2 My husband and I both work for ourselves so Health Options has been a godsend! We pay less in monthly premiums and get more coverage with lower deductibles. You Have an Easy Choice to Make You don t have to choose between saving money and having access to quality healthcare providers. Health Options a nonprofit health insurer certified by the Health Insurance Marketplace offers a wide range of affordable health plans through its broad network of providers and hospitals. With our high-quality coverage and locally based Member support, answers you can trust are only a call or click away. We also make it easy to find out if you qualify for lower monthly costs through the Health Insurance Marketplace. Use our website, HealthOptions.org, to estimate your savings and find the plan that s right for you. Prefer to receive personal assistance? Call us directly, toll-free: (855) Selecting the Right Plan Selecting the right health insurance plan can be confusing. We want you to have a positive enrollment experience. Ask yourself these six questions before you enroll: 1 How much will I have to pay for medical or behavioral healthcare services? Familiarize yourself with a few important health insurance terms and how insurance works. Premium amount you pay for your health insurance plan amount you owe for healthcare services your plan covers before your health insurance begins to pay Co-Pay a fixed amount you pay for certain covered services when you receive care Coinsurance your share of the costs of a covered health service calculated as a percent of service cost after you meet your deductible Drug Formulary a list of drugs your insurance plan covers Covered Services goods/services that insurance companies will help pay as outlined in your health insurance plan Out-of-Pocket Maximum the most you pay during a policy period before your health insurance plan pays 100% of cost for covered services In-network/Out of network in-network providers have contracts with insurance companies to offer lower rates than out-of-network providers 2 (855) HealthOptions.org

3 At Health Options, your voice is our voice. 2 3 Are my prescription drugs in the Drug Formulary? Make sure the medications you take are in the Prescription Drug Formulary 5 6 Are there any special health care needs to consider? Learn more about our Chronic Illness Support Program 4 Do I qualify for an Advanced Premium Tax Credit to reduce my monthly Premiums? Use the Savings Calculator at HealthOptions.org/Individuals-Families/ Compare-Quote-Plans to get an estimate of any assistance you may be eligible to receive to save you money What will I need before I enroll? Gather the following information about yourself and others who will be covered on your plan: a. A copy of your income tax return or W-2 b. Your family s estimated household income c. Date of birth for everyone you are enrolling d. Social Security Number for everyone you are enrolling Will I be able to use my current doctor? We have a broad network of providers and hospitals. Check the Provider Directory to make sure your primary care provider (PCP) and specialists are in-network Use our website tools to quickly learn what your estimated advanced tax credit will be (855) HealthOptions.org 3

4 At HealthOptions.org, we make selecting the health plan that s best for you as easy as possible. Use Our Website to Find More Affordable Health Coverage Use the savings calculator. Provide some basic information for each family member to be covered. Answer a few simple questions to help determine plan availability and see an estimate of any assistance you may be eligible to receive under the Affordable Care Act. Choose your Health Options plan. View your Insurance Options or use the Help Me Choose selector to prioritize plans using your personal preferences. See the availability of plans with cost-sharing reductions. Once you choose the plan you prefer, you can see and save the details. It s that easy. If you qualify for and plan to use your tax credit, there are a few additional steps you have to take. You may be able to use the direct pathway on the Health Options website or you can go to the Marketplace to complete your enrollment. If your household income falls within the ranges shown below, you may qualify for lower monthly Premium costs through the Health Insurance Marketplace and other cost sharing through the Health Insurance Marketplace Savings Calculator Household Size Household Income* 1 $11,770 $47,080 2 $15,930 $63,720 3 $20,090 $80,360 4 $24,250 $97,000 5 $28,410 $113,640 6 $32,570 $130,280 * 2015 Federal Guidelines for 2016 Plans Plan Benefits that Give You Control All of our plans feature: Broad network of providers including all Maine and New Hampshire hospitals National network of providers Licensed network clinician locator 24/7 Nurse Line Medical management programs Comprehensive list of covered benefits Tobacco cessation services No-cost preventive services Integrated behavioral health services Laboratory services Lower Costs for Chronic Illness Support Our Chronic Illness Support Program (CISP) offers additional help to Members with certain medical conditions that are ongoing and can be managed for better health. With CISP, Members can save money through significantly lower Out-of- Pocket costs for Medically Necessary Services from a Plan Provider. Outof-Pocket costs are reduced through lower Co-Pays, s, and Coinsurance for disease management services. Disease management services include things such as office visits, prescription medications, lab services, and medical supplies. Covered Benefits include: Asthma Chronic Obstructive Pulmonary Disease (COPD)/Emphysema Diabetes Hypertension (high blood pressure) Coronary Artery Disease See pages 6 and 7 for more details. 4 (855) HealthOptions.org

5 I recently became a Member and for the first time in eight years am celebrating that I have the security of health insurance. Thank you for making that financially possible! Healthy Options Services Healthy Options Team We want to support and encourage your efforts to protect your most important assets your health and the health of your family. As a Member of Health Options, you can take advantage of Healthy Options, our health and wellness program offering support in managing current health conditions, help for making healthy lifestyle changes, and 24/7 access to health coaches. Access to Health Advocates 24/7 The Healthy Options team consists of registered nurses and dieticians, licensed social workers, and certified health advocates who can answer questions, provide information, and help you make important healthcare decisions. A health advocate can help when: You have symptoms such as a sore throat, muscle strain, or other health concern; call any time of the day or night You have questions about your medications A Healthy Options Health Advocate may call you to talk about your condition. A Health Advocate can help you when: You are diagnosed with an ongoing health condition, such as Diabetes, Asthma, COPD, Hypertension, or Coronary Artery Disease You want to make a healthy change in your life, such as losing weight, quitting tobacco, or improving your eating habits You are preparing for upcoming tests or procedures You are thinking about treatment choices, including surgery You need support in preparing for conversations with your healthcare providers In addition to Healthy Options Health Advocates, you have access to: Shared Decision Making Online Tools: When you are thinking about treatment choices, including surgery When you need online support in preparing for conversations with your healthcare provider Healthy Options Online Health and Wellness portal, where you can: Get facts on over 6000 health topics Use tools and videos that can help you make more informed choices about treatment options Complete your health risk assessment Create your own personal goals and track your progress Care Management Our Care Management Team consists of registered nurses and dieticians, licensed social workers and certified health coaches who partner with your provider, local care managers, and other community resources to support you. Care Managers can help when: You have a general medical question or a more complex question You need support accessing behavioral health services You need support getting needed medical equipment or figuring out how to get specialty medications You need help when you experience a critical event or diagnosis that requires extensive use of resources We are there when you need it most and can help remove barriers so you can get the care you really need when and where you need it. (855) HealthOptions.org 5

6 Thank you for helping me and my family have good, affordable healthcare coverage for the first time in years! 60 never felt so good! Chronic Illness Support Programs Asthma & COPD Highlights All specific medications used to treat Asthma and COPD that are on our Formulary and are approved by the FDA are available at $0 cost-sharing for generics and 50% reduction in cost-sharing for preferred brands. Asthma/COPD-related services that are covered with $0 cost sharing when performed by a Plan Provider include: Office visits to primary care for routine management of Asthma/ COPD/Emphysema Pulmonologist consultation and management of Asthma/COPD/ Emphysema Pulmonary function test, one per year; home oxygen therapy assessment Laboratory services linked to an Asthma/COPD primary diagnosis code Immunotherapy to reduce impact and severity of allergic reaction Our Chronic Illness Support Program will help lower the cost of medications for Asthma/COPD, Diabetes, Hypertension, and Coronary Artery Disease. Inhaler adjuncts (e.g., spacer); Peak flow meter, one per year Asthma education: allergens/ triggers, Asthma action plan Pulmonary rehabilitation and ongoing exercise program for moderate to severe COPD (requires prior approval) Environmental (home) assessment - Asthma only: home assessment (e.g., through public health) is covered up to $75/year. Please note: COPD/Asthma/ Emphysema: if you have complications from Asthma or COPD, and use an Emergency Department, have a hospital stay, or get lung resection/transplant, services will be subject to standard Out-of-Pocket Costs as outlined in your Schedule of Benefits. Diabetes Highlights All specific medications used to treat Diabetes that are on our Formulary and are approved by the FDA are available at $0 cost-sharing for generics and 50% reduction in costsharing for preferred brands. Diabetes-related services that are covered with $0 cost share when performed by a Plan Provider include: Office visits to primary care for routine management of Diabetes Endocrinology consultation and management of Diabetes Podiatry consultation for routine diabetic foot care Nutritional counseling, Diabetes education, and behavioral modification counseling Once a year diabetic eye exam Glucose test strips listed on Formulary: up to 50 every 30 days or 150 every 90 days at $0 Out-of- Pocket Cost. Requests for additional strips will be considered based on Medical Necessity Laboratory services linked to a Diabetes primary diagnosis code Please note: Insulin pumps and supplies are considered Durable Medical Equipment (DME) and are covered according to the Schedule of Benefits. 6 (855) HealthOptions.org

7 At Health Options, we support our Members in taking an active role in their healthcare. Hypertension Highlights Coronary Artery Disease (CAD) Highlights All specific medications used to treat Hypertension and Hyperlipidemia that are on our Formulary and are approved by the FDA are available at $0 cost-sharing for generics and 50% reduction in cost-sharing for preferred brands. Hypertension-related services that are covered with $0 cost share when performed by a Plan Provider include: Office visits to primary care for routine management of Hypertension Cardiology or nephrology consultation and management of Hypertension Laboratory services linked to a Hypertension primary diagnosis code Please note: The plan specifically does not include waiver for other specialty services for complications of Hypertension, such as Emergency Department visits, inpatient hospitalization, or treatment for heart and kidney disease. The following services related to CAD are covered with $0 Out-of-Pocket Cost when performed by a Plan Provider (unless otherwise noted): Office visits to a Primary Care Provider for routine management of CAD Cardiology consultation and routine management of CAD Electrocardiogram (ECG) Cardiac rehabilitation ( is waived and the Coinsurance is reduced by half) Laboratory services linked to a Hyperlipidemia primary diagnosis code Cardiac Rehabilitation is covered at a 50% reduction in cost-sharing when performed by a Plan Provider. Expanded Pharmacy coverage is limited to $0 Out-of-Pocket Cost for generic medications and a reduction in Out-of-Pocket Cost for preferred brand medications as outlined below. If the Plan applies a and Coinsurance for preferred brand medications, the is waived and the Coinsurance is reduced by half. Medications that are on the Formulary and are approved by the FDA for treatment of CAD, Diabetes, Hypertension, and Hyperlipidemia are covered under this reduced Outof-Pocket Cost benefit. Please note: if you have complications from CAD and use an Emergency Department, have a hospital stay, or get a cardiac procedure not listed above (e.g., cardiac stress test, cardiac catheterization, echocardiogram, intravascular ultrasound, nuclear perfusion imaging, PET (positron emission tomography) imaging, angioplasty, coronary artery bypass graft), services will be subject to standard Out-of-Pocket Costs as outlined in your Schedule of Benefits. (855) HealthOptions.org 7

8 At Health Options, we want to help you find the highest quality healthcare and health services locally. Honoring the Partnership with Your Provider We want you to have access to the best doctors and hospitals so you and your healthcare provider can make the best choices to maintain and improve your health. Our providers are focused on providing services to match community needs. We believe providers and patients know how best to improve health and wellbeing. We are flexible in our approach and responsive to providers ideas. Our online Provider Directory is constantly being updated. If you do not see your provider listed, please contact Health Options Member Services at (855) or nominate your provider by going to HealthOptions.org/ SearchProviders. Health Insurance Coverage and Access A CO-OP is a Consumer Oriented and Operated Plan. Consumers in this case, its Members play an integral role in the direction of the organization. We have a Member majority on our Board of Directors so that Members have a strong voice in the operation of the organization. Health Options wants to make it easy to find health coverage that works for you. We also want to make it easier to understand how health insurance works. Here are some of the ways our Member-directed approach benefits you and your family. Transparent and nonprofit We use excess funds to lower costs and/or increase coverage value for you and your family. Preventive care and disease management From annual exams and other preventive services to the management of chronic diseases, our benefit designs allow you and your healthcare provider to make the best choices to maintain and improve your health. Open and broad provider network We place value on the patient-provider relationship and believe it is central to delivering quality healthcare. For more detailed information about our health plans or to review our Member Services Agreement and Benefit Schedule, Provider Directory, Prescription Formulary or Privacy Notice, please visit our website at HealthOptions.org. If you do not have access to a computer or internet services, please call (855) and a Member Services Associate will be happy to provide you with a print version and answer any questions you may have. 8 (855) HealthOptions.org

9 For years we could not afford quality health insurance after my husband lost his job now we have it. We want you to use prescription medicines that are proven effective. In many cases these medications are available at low or no cost. This list of medicines or Formulary is covered under all of our plans. We aim to keep all of your drug costs reasonable and give you the information you need to make smart decisions for your pharmacy needs. You will have four Tier options with hundreds of drugs on the Formulary. Drugs include generics and brand names. If you choose a generic drug instead of a brand-name drug, you can save money. Ask your doctor or pharmacist if a generic drug would work for you in place of a brandname drug you may be using now. Mail order service, generic Co-Pay waiver, and tablet-splitting programs are all available. We will also make it easy to find a pharmacy that fits your needs. To help prevent certain chronic conditions and illnesses, we also offer a Preventive Drug Benefit. This is to reduce high costs associated with treating long-term chronic conditions. We make selected preventive drugs available to eligible Members without first having to meet plan deductibles for prescriptions. Good health requires good oral health. Health Options is pleased to partner with Northeast Delta Dental a leader in dental benefits to increase access to pediatric dental coverage directly within our plan offerings and also make it easier for everyone to purchase complimentary dental plans. We offer plans with a pediatric dental benefit embedded in the design: Advance, Complete, and Align. This coverage is for individuals who are 18 years of age or younger unless otherwise provided in the contract. The dental benefit will be administered by Northeast Delta Dental. Please go to pages 10 and 11 for more details. People and businesses can continue to purchase stand alone Northeast Delta Dental plans for themselves and/or their families. Pediatric Dental Benefit (855) HealthOptions.org 9

10 We are pleased to present our 2016 health insurance plans. Find the health plan that works for you and your family gold 1 Advantage Lowest Out-of-Pocket costs with a higher Premium. Chronic Illness Support Program Provides the lowest Out-of-Pocket costs but with a higher monthly Premium. This is a plan for Members who prefer low deductibles, Co-Pays, and Coinsurance. 2 Advance 3 Preferred Balanced Premium with lower Out-of-Pocket costs. Chronic Illness Support Program Balances higher Premiums and lower Out-of-Pocket costs. This plan is for Members who are looking for low Co-Pays, low Coinsurance, and reduced/lower Out-of-Pocket limits. Includes pediatric dental. Balanced Premium with lower Out-of-Pocket costs. Chronic Illness Support Program Balances higher Premiums and lower Out-of-Pocket costs. This plan is for Members who are looking for low Co-Pays, low Coinsurance, and reduced/lower Out-of-Pocket limits. silver 4 Choice Low monthly Premium with low Coinsurance percentage. Chronic Illness Support Program Balances low Premiums with low Coinsurance and a moderate. This plan is for Members who prefer lower Coinsurance. 5 Complete 6 Value 7 Align Low monthly Premium with low office visit Co-Pay. Chronic Illness Support Program Balances low Premiums with low Co-Pays for common services and a moderate. This plan is for Members who prefer lower Co-Pays. Includes pediatric dental. Low monthly Premium with low office visit Co-Pay. Chronic Illness Support Program Balances low Premiums with low Co-Pays for common services and a moderate. This plan is for Members who prefer lower Co-Pays. Low monthly Premium. Chronic Illness Support Program Combines lower Premiums with a high and some pre-defined Co-Pay amounts for common services such as your primary care provider (PCP) or specialist visits. Includes pediatric dental. bronze 8 Option Low monthly Premium. Chronic Illness Support Program Combines lower Premiums with a high and some pre-defined Co-Pay amounts for common services such as your primary care provider (PCP) or specialist visits. 9 Option HSA Low monthly Premium; HSA compatible Offers one of our lower Premiums combined with a high. This plan is compatible with a Health Savings Account (HSA) for more flexibility and potential tax advantages. catastrophic 10 Safe Harbor Low monthly Premium with the highest allowable ; no Coinsurance Balances our lowest monthly Premium with the highest. This plan is meant to provide a financial backstop against the burden associated with major medical expenses. The plan offers the first three visits to your primary care provider (PCP) and preventive services with no cost sharing. Certain eligibility requirements must be met to enroll in this plan. 10 For more detailed information about our health plans or to review our Member Benefit Agreement and Schedule of Benefits, Provider Directory, Prescription Formulary or Privacy Notice, please visit our website at HealthOptions.org. If you do not have access to a computer or internet services please call (855) A Member Services Associate will be happy to provide you with printed copies and answer any questions you may have.

11 In-Network { Cost-Sharing These 10 plans offer a variety of options to fit your health insurance needs. Max Outof-Pocket PCP/Mental Health Visit Generic Tier 1 Prescription Drugs Emergency Care Inpatient Hospital Individual $750 $4,250 Family $1,500 $8,500 $25 Co-Pay $10 Co-Pay $500 Co-Pay 20% Coinsurance after Individual $2,450 $6,000 Family $4,900 $12,000 $25 Co-Pay $10 Co-Pay 30% Coinsurance after 30% Coinsurance after Individual $2,450 $6,000 Family $4,900 $12,000 $25 Co-Pay $10 Co-Pay 30% Coinsurance after 30% Coinsurance after Individual $2,500 $6,850 Family $5,000 $13,700 $30 Co-Pay $15 Co-Pay 30% Coinsurance after 30% Coinsurance after Individual $2,500 $6,850 Family $5,000 $13,700 $20 Co-Pay $15 Co-Pay after after Individual $2,500 $6,850 Family $5,000 $13,700 $20 Co-Pay $15 Co-Pay after after Individual $5,500 $6,850 Family $11,000 $13,700 $45 Co-Pay after after after Individual $5,500 $6,850 Family $11,000 $13,700 $45 Co-Pay after after after Individual $5,000 $6,550 Family $10,000 $13,100 10% Coinsurance after 10% Coinsurance after after after Individual $6,850 $6,850 Family $13,700 $13,700 Subject to Subject to Subject to Subject to These plans feature our Chronic Illness Support Program (CISP). CISP offers reduced cost-sharing, including $0 cost-sharing for specific Tier 1 generic medications and certain medical supplies, as well as lab services and office visits when performed by a Health Options in-network provider for the following conditions: Diabetes, Asthma/Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease, Hypertension Advanced premium tax credits may help pay for your coverage. (855) HealthOptions.org 11 Visit our website or call us to see if you qualify.

12 Call us. A Member Service Associate will be happy to answer your questions or visit our website for our user-friendly online enrollment tools. A leading, nonprofit health plan providing individuals and businesses with affordable, high quality health insurance. (855) HealthOptions.org