Memorial Hermann Health Insurance Company Metal Select Plan Overview Houston, Texas

Transcription

1 Memorial Hermann Health Insurance Company Metal Select Plan Overview Houston, Texas

2 Who Will You Choose as Your Healthcare Partner? Small-business owners in Houston are discovering that Memorial Hermann Health Insurance Company s Metal Select Plans are affordable, easy to administer and local. Backed by the Memorial Hermann Health System, a trusted Houston healthcare resource for more than a century, our health plans have a track record of adding significant value for employers while reducing the business risk associated with rising health benefits costs. Quality: Award-winning Health Care in Houston When you choose Memorial Hermann Health Insurance Company as your healthcare partner, your employees have access to the high-quality, award-winning providers of the Memorial Hermann Health System. While some awards are based on reputation, others, like the Eisenberg Patient Safety Award, are based on clinical outcomes readily available from public data sources, including the Centers for Medicare & Medicaid Services through Hospital Compare, a consumer website that provides information on how well hospitals provide recommended care to their patients. Recognitions that rest on measures of a healthcare organization s overall performance patient outcomes and satisfaction, operational efficiency, physician performance, patient safety and financial stability are the true validations of quality. Leaders at Memorial Hermann Health System have created a culture of safety that begins in the executive suite and extends throughout the organization. The result is safer, more coordinated care that leads to better clinical outcomes and reduces costs for employers, consumers and society. These efforts have paid off in national, regional and state recognitions, making Memorial Hermann Health System the clear leader in Houston in quality and patient safety Eisenberg Patient Safety Award Truven Health Top 5 Large Health Systems NQF National Quality Healthcare Award National Health System Patient Safety Leadership Award America s 50 Best Hospitals by Healthgrades America s 100 Top Hospitals by Truven Health U.S. Best Hospitals by U.S.News & World Report American Hospital Association-McKesson Quest for Quality Prize Finalist Franklin Award of Distinction Affordability: Coordinated Health Care, Cost-efficient Health Insurance Employers partner with Memorial Hermann Health Insurance Company because they know that safer care leads to better clinical outcomes and lower costs for consumers and society. Their employees enjoy a more coordinated healthcare experience because relevant health information is shared electronically between hospitals and network physicians. Timely preventive care and screenings help physicians identify people at risk before they get sick. For your employees with chronic conditions, physicians and care managers work as a team to help manage their health and your healthcare costs. Our clinically integrated physician network unites physicians from every specialty in a common commitment to quality and accountability. These physicians practice evidence-based medicine proven to result in better clinical outcomes and shorter hospital stays as well as cost savings for employers and employees. Accessibility: We ve Got Houston Covered Our Metal Select Plans give your employees access to more than 5,000 providers affiliated with one of the largest not-for-profit health systems in the nation. They have 12 hospitals to choose from, including three in the Texas Medical Center a tertiary-care academic teaching hospital with physicians who are also faculty at UTHealth Medical School, a dedicated children s hospital offering very personalized care and the top-ranked rehabilitation hospital in the southern United States. Eight suburban hospitals provide specialty and subspecialty services in outlying neighborhoods, and Memorial Hermann Health System also operates three Heart & Vascular Institutes, a Center for Advanced Heart Failure, the Mischer Neuroscience Institute, the IRONMAN Sports Medicine Institute in three locations, Women s Memorial Hermann, and the Prevention and Recovery Center for chemical dependency treatment, as well as home health services, rehabilitation centers, outpatient imaging centers and laboratory services. Memorial Hermann Life Flight, the largest and busiest hospitalaffiliated air ambulance service in the United States, links community hospitals to Memorial Hermann s Level I Texas Trauma Institute and Level I Pediatric Trauma Center in the Texas Medical Center. The Memorial Hermann Convenient Care Center is a new healthcare delivery model that provides one-stop, highly coordinated access to a range of services in a single location. Our provider network also includes more than 80 urgent care facilities across our seven-county coverage area, as well as multiple networks for out-of-area coverage.

3 Conroe GEORGE BUSH INTERCONTINENTAL AIRPORT A HOBBY AIRPORT ELLINGTON FIELD 6 45 LBJ SPACE CENTER 146 Hospitals Specialty Care Memorial Hermann Urgent Care Other Urgent Care 6

4 Memorial Hermann Health Insurance Company Metal Plans Overview Platinum Gold Silver Bronze PLAN NAME H.S.A H.S.A. Deductible In Network $500 $250 $1,500 $750 $2,000 $2,000 $2,000 $2,000 $2,500 $3,000 Medical Annual Out of Pocket Maximum $1,000 1 $1,250 1 $3,000 1 $3,500 1 $2,500 1 $5,000 1 $6,350 1 $6,300 1 $6,350 2 $6,350 2 Pharmacy Annual Out of Pocket Maximum $1,000 1 $1,250 1 $3,000 1 $3,500 1 $2,500 1 $5,000 1 $6,350 1 $6,300 1 pharmacy out of pocket maximum No separate Health Savings Account Compatible No No No No No No No No Yes Yes PCP Office Visit $25 $35 Specialist Office Visit $30 $50 $30 $70 $80 Emergency Room % % Urgent Care $30 $50 $75 $75 $75 $75 Inpatient Facility 85% 90% 90% 70% 100% 60% 70% 80% Outpatient Medical Services 85% 90% 90% 70% 100% 60% 70% 80% Diagnostic Lab & X-Ray 85% 90% 90% 70% 100% 60% 70% 80% CAT/PET Scan, MRI/MRA 85% 90% 90% 70% 100% 60% 70% 80% Professional Services 85% 90% 90% 70% 100% 60% 70% 80% Physical/Occupational Therapy/Medicine 85% 90% 90% 70% 100% 60% 70% 80% Ambulance 85% 90% 90% 70% 100% 60% 70% 80% Home Health Care 85% 90% 90% 70% 100% 60% 70% 80% Skilled Nursing Facility 85% 90% 90% 70% 100% 60% 70% 80% Durable Medial Equipment 85% 90% 90% 70% 100% 60% 70% 80% Hospice 85% 90% 90% 70% 100% 60% 70% 80% Rehabilitation Services 85% 90% 90% 70% 100% 60% 70% 80% Habilitation Services 85% 90% 90% 70% 100% 60% 70% 80% Mental/Behavioral Health Inpatient Facility 85% 90% 90% 70% 100% 60% 70% 80% Mental/Behavioral Health Outpatient Professional Services $25 $35 Substance Use Disorder Inpatient Facility 85% 90% 90% 70% 100% 60% 70% 80% Substance Use Disorder Outpatient Professional Services $25 $35 Preventive 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Prescription Drugs - Retail - 30 day Supply Generic $5 80% $5 60% Preferred Brand Name $30 $50 $10 $50 $50 80% $10 60% Non-Preferred Brand Name Specialty Drugs $80 Eye Exam: Covered at PCP or Specialist depending on provider type Glasses: age 18 and under - covered at co-insurance amount Pediatric Dental: Class A No Charge; Class B, C and D 50% Coinsurance. 1 Separate Annual Medical and Pharmacy Out of Pocket Maximum 2 Annual Out of Pocket Maximum Medical and Pharmacy Combined on HSA Plans $80 $60 $80 80% 60% 50% 50% 50% 80% 50% 60%

5 Integrated: Houston s Largest Integrated Health Plan and Care Delivery System During a life-threatening emergency or routine treatment, delivering the best possible care begins with access to up-to-date patient information and clinical data. Clinically integrated providers share patient information with each other, allowing them to deliver more coordinated care while giving each provider a more complete picture of the patients they treat. Local: We re Your Neighbors Memorial Hermann Health Insurance Company offers you and your employees a local health insurance solution. Our client list includes more than 400 Houston employers, and we re right here in Houston when you need us, combining local expertise and national recognition. Four Levels of Coverage: Platinum, Gold, Silver and Bronze Memorial Hermann Health Insurance Company offers plans at the Platinum, Gold, Silver and Bronze levels to give you the flexibility you need to balance employee benefits and cost while meeting the Patient Protection and Affordable Care Act coverage requirements. Each of the plans covers different amounts of the actuarial costs of your employees healthcare benefits, ranging from 90 percent for Platinum to 60 percent for Bronze. We re Here to Help Questions? We re committed to providing exceptional service to small companies who choose Memorial Hermann Health Insurance Company. Please call us at

6 Exclusions and Limitations: What the Plan Does Not Pay For Excluded Services The Participating Provider Plan does not provide benefits for: A. Any amounts in excess of maximum amounts of Covered Expenses stated in this Plan. B. Services not specifically listed in this Plan as Covered Services. C. Services or supplies that are not Medically Necessary as defined by Memorial Hermann Health Insurance Company (MHHIC). D. Services or supplies that MHHIC considers to be Experimental or Investigative. E. Services received before the Effective Date of Coverage. F. Services received after coverage ends. G. Services for which the insured ( You ) have no legal obligation to pay or for which no charge would be made if You did not have a health plan or insurance coverage, except to the extent that the availability of insurance or health plan coverage may be considered by a tax supported institution of the State of Texas providing treatment of Mental Illness or mental retardation to determine if a patient is non-indigent, as provided in Article 3196a of Vernon s Texas Civil Statutes. H. Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers compensation, employer s liability law or occupational disease law, even if You do not claim those benefits. I. Conditions caused by or contributed by (a) an act of war; (b) The inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) An Insured Person participating in the military service of any country; (d) An Insured Person participating in an insurrection, rebellion, or riot; (e) Services received for any condition caused by an Insured Person s commission of, or attempt to commit a felony; (f) An Insured Person, age 19 or older, being under the influence of alcohol, illegal narcotics or non-prescribed controlled substances unless administered on the advice of a Physician. J. Any intentionally self-inflicted Injury or Illness. K. Any services provided by a local, state or federal government agency except (a) when payment under this Plan is expressly required by federal or state law; or (b) services provided for the treatment of Mental or Nervous Disorders by a tax supported institution of the State of Texas. L. Professional services received or supplies purchased from Yourself, a person who lives in the Insured Person s home or who is related to the Insured Person by blood, marriage or adoption, or the Insured Person s employer, unless the employer is a Hospital or a Doctor of Medicine. M. Inpatient or outpatient services of a private duty nurse. N. Inpatient room and board charges in connection with a Hospital stay primarily for environmental change, Physical Therapy or treatment of chronic pain; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service. O. Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. P. Dental services, dentures, bridges, crowns, caps or other Dental Prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically stated under Dental Care and Pediatric Dental Benefits in the Comprehensive Benefits section of this Plan, including dental services for Temporomandibular Joint Dysfunction (TMJ). Q. Orthodontic Services, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction, except as specifically stated under Pediatric Dental Benefits in the Comprehensive Benefits section of this Plan. R. Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants, except as specifically stated under Pediatric Dental Benefits in the Comprehensive Benefits section of this Plan. S. Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this Plan. T. An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia). U. Any Drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this Plan. This includes, but is not limited to, items dispensed by a Physician. V. Cosmetic surgery or other services for beautification, including any medical complications that are generally predictable and associated with such services by the organized medical community. This exclusion does not apply to Medically Necessary Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a Newborn child, or to breast reconstruction performed to restore or achieve breast symmetry incident to a mastectomy, or abnormal craniofacial structure caused by congenital defects. W. Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change. X. Treatment of sexual dysfunction, impotence and/or inadequacy. Y. Charges for pregnancy and maternity care including but not limited to normal delivery, cesarean sections, and elective abortions, except as specifically stated in the Plan under Comprehensive Benefits, pregnancy and maternity care or Complications of Pregnancy as defined in Your Certificate of Coverage. Z. All services related to the evaluation or treatment of fertility and/or Infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization, except as specifically stated under Comprehensive Benefits, What the Plan Pays For Sterilization or if the In-Vitro Rider is elected. AA. Cryopreservation of sperm or eggs. AB. All non-prescription contraceptive devices and supplies including but not limited to all consultations, examinations, evaluations, medications, medical, laboratory, devices, Prescription Drugs or surgical procedures except as specifically stated in this Plan. Oral contraceptives and Prescription contraceptive devices available through a pharmacy are covered under the Prescription Drug benefit of this Policy.

7 AC. Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment, except as provided under the Child and Adult Preventive Care Services provision. AD. Routine physical exams or tests that do not directly treat an actual Illness, Injury or condition, including those required by employment or government authority except as specifically stated under the Professional and Other Services, Child and Adult Preventive Care Services and Routine Care Services sections of this Plan. AE. Charges by a provider for telephone consultations and for Telemedicine or Telehealth Services. (Note: a Telemedicine Medical Service or Telehealth Service will not be excluded solely because the service is not provided through a face to face consultation). AF. Items which are furnished primarily for Your personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification including wigs, etc.). AG. Educational services except as specifically provided for Diabetes Self- Management Training or as provided or arranged by MHHIC. AH. Nutritional counseling or food supplements, except for formulas necessary for the treatment of phenylketonuria and as provided under the Child and Adult Preventive Care Services provision. AI. Durable medical equipment except as specifically stated in this Plan. Excluded durable medical equipment includes, but is not limited to: air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; and supplies for comfort, hygiene or beautification. AJ. Physical and/or Occupational Therapy/Medicine, except when provided during an inpatient Hospital confinement or as specifically provided under the benefits for Physical and/or Occupational Therapy/Medicine. AK. All Infusion Therapy together with any associated supplies, Drugs or professional services are excluded except as specifically provided under the benefit for Infusion Therapy described in this Plan. AL. All Foreign Country Provider charges are excluded under this Plan except as specifically stated under Treatment received from Foreign Country Providers under the Benefits section of this Plan. AM. Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized Illness, Injury or symptoms involving the feet, diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency. AN. Charges for which We are unable to determine Our liability because You or an Insured Person failed, within 60 days, or as soon as reasonably possible to (a) authorize Us to receive all the medical records and information We requested or, (b) provide Us with information We requested regarding the circumstances of the claim or other insurance coverage. AO. Charges for the services of a standby Physician. AP. Charges for animal to human organ transplants. AQ. Self-administered injectable Drugs and syringes, except as stated in the Prescription Drug Benefits section of this Plan. AR. Claims received more than 12 months after the date service was rendered. Prescription Drug Exclusions and Limitations Prescription Drug reimbursement is subject to and treated as part of any benefit maximums or any other exclusions or limitations contained in this entire Plan. In addition, reimbursement will not be provided for: Drugs and medications not requiring a Prescription, except insulin. Non-medical substances or items, with the exception that pharmaceuticals to aid smoking cessation are covered. Drugs and medications used to induce non-spontaneous abortions. Dietary supplements, cosmetics, health or beauty aids. Any vitamin, mineral, herb or botanical product which is thought to have health benefits, but does not have a Food an Drug Administration (FDA) approved indication to treat, diagnose or cure a medical condition, even if it is thought to have health benefits. Drugs taken while You are in a Hospital, Skilled Nursing Facility, rest home, sanitarium, convalescent Hospital or similar facility. Any Drug labeled Caution, limited by federal law to investigational use or Non-FDA approved Investigational Drugs. Any drug or medication prescribed for experimental indications (such as progesterone suppositories). Syringes and/or needles, except those dispensed for use with insulin or selfadministered injectable drugs. Durable medical equipment, devices, appliances and supplies except as specifically stated under the Professional and Other Services section of this Plan. Immunizing agents, biological sera, blood, blood products or blood plasma. Oxygen. Professional charges in connection with administering, injecting or dispensing of Drugs. Drugs and medications dispensed or administered in an outpatient setting, including but not limited to outpatient Hospital facilities and doctor s offices. Such drugs and medications are covered under the Professional and Other Services benefit. Drugs used for cosmetic purposes. Drugs used for the primary purpose of treating Infertility or promoting fertility, except in association with an approved Course of Treatment for In vitro Fertilization. Anorexiants or drugs associated with weight loss, except as provided under Child and Adult Preventative Care Services. Drugs obtained outside the United States. Allergy desensitization products, allergy serum. All Infusion Therapy is excluded under this Plan except as specifically stated in the Covered Services section. Drugs for treatment of a condition, Illness, or Injury for which benefits are excluded or limited by a contract limitation. Growth Hormone Treatment. Select classes of Drugs where non-preferred medications, which have therapeutic alternatives, have shown no benefit regarding efficacy or side effects over Preferred Drugs. However, this will not apply if the Prescriber denotes, dispense as written or do not substitute. Prescription Drugs with a non-prescription (over the counter) chemical and dose equivalent, except insulin. Replacement of lost or stolen Prescription Drugs. Services or prescription drugs may be subject to prior authorization requirements set forth in the Certificate of Coverage. If you do not obtain required prior authorization, you will be subject to a 50% reduction in benefits.

8 Insurance coverage is underwritten by Memorial Hermann Health Insurance Company. Memorial Hermann Health Insurance Company and the Memorial Hermann Health Insurance Company logo are registered trademarks of Memorial Hermann Health System. Copyright 2013 Memorial Hermann Health System. All rights reserved.