Compare your plan options

Transcription

1 SMALL BUSINESS GROUP 2015 Compare your plan options Plans for businesses with 1 50 employees 1 SMALL BUSINESS GROUP

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3 Value, choice, and quality the Group Health difference Your job is running a business. Ours is providing the health plans that work for you and your employees. In response to the changing health care landscape, our 2015 plans are designed to help you keep costs down and satisfaction up, with a variety of choices to fit the needs of your employees. New options include two Bronze HSA-compatible plans and a Platinum plan. For many of our plans, we re offering expanded pre-deductible coverage to include specialty visits, and lower premium rates and deductibles. You can choose the level of coverage you want, looking at how plans share costs differently between the member and the plan. And you can choose between two networks. Each option gives employees access to a broad network that includes primary care physicians, specialists, alternative care practitioners, and community hospitals throughout our service area. Because we operate our own care system Group Health Medical Centers our health plan administrators and doctors work as a team to achieve the single objective of better health for all members, wherever they receive their care. Together, we build health plans and care systems that are more patientcentered and deliver care that keeps people healthier. Questions about our plans? We re always here to help at COMPARE YOUR PLAN OPTIONS 3

4 Your plan choices You ll want to familiarize yourself with the choices you have by reviewing the health plan grids on pages Once you ve reviewed them, get started with these 3 easy steps: 1 Determine whether you ll offer 1 or 2 plans To offer 2 plans, you must have between 10 and 50 employees. If you offer 2 plans, there are a few guidelines: You can offer any combination of Core plans and Connect plans Determine whether you ll offer 1 or 2 plans. Decide which provider network you want to offer Core or Connect for each plan. Choose the coverage level you want for each plan. Groups with employees must have at least 3 employees enrolled in each plan Groups with employees must have at least 5 employees enrolled in each plan 4 SMALL BUSINESS GROUP

5 2 Decide which provider networks you want to offer Core plans network (Also known as Group Health) Offered by Group Health Cooperative The network available with Core plans gives members access to: More than 1,000 Group Health Medical Centers doctors at 25 clinics More than 9,000 network providers Connect plans network (Also known as Alliant Plus) Offered by Group Health Options, Inc. The network available with Connect plans gives members access to: In network: More than 1,000 Group Health Medical Centers doctors at 25 clinics 450 Virginia Mason Medical Center doctors at 8 clinics Nearly 400 The Everett Clinic doctors at 16 clinics Why choose Core? Your highest priority is value. With Core, members have network access to physicians at Group Health Medical Centers our high-performing group practice an additional 9,000 network providers, and 45 hospitals in our service area. It s our most cost-effective option. More than 9,000 providers in our service area, plus thousands of additional practitioners Out of network: Providers with First Choice Health network in Oregon, Alaska, Montana, Idaho, and Washington. Discounted costs and no balance billing. Providers with First Health Network in all other states. Discounted costs and no balance billing. Any additional licensed provider in the U.S. Why choose Connect? Your highest priority is choice. Connect gives members access to any licensed physician and pharmacy. When members use in-network providers, they will save money with lower out-of-pocket costs. Source: OIC Provider Network Form A COMPARE YOUR PLAN OPTIONS 5

6 3 Choose the coverage level you want Under the Affordable Care Act (ACA), health plan carriers can offer different levels of coverage that define how costs are shared between the plan member and the health plan. We re offering all four of those levels: Bronze, Silver, Gold, and new for 2015 Platinum. All of our small group plans include the same benefits. What is different are the monthly premiums versus the member s cost shares (deductibles, copays, coinsurance, and out-of-pocket limits). Compare the coverage levels As premium costs go up for different metal levels, cost shares go down, so it s important to consider how much your employees tend to use health care services in deciding what plan or plans to offer. (See chart below.) In addition to overall plan differences between metal levels, we are offering Core Plus plans at the Silver, Gold, and Platinum levels in which the deductible does not apply to the first three office visits per calendar year either primary care or specialty care. Similarly, the deductible does not apply to the first three in-network primary care office visits per calendar year in the Connect3 Silver and Connect3 Gold plans. (See grids for details.) Advantages of a Bronze HSA plan Our Core Bronze HSA and Connect Bronze HSA plans offer a lower-cost HSA-compatible, high-deductible plan that can be combined with a tax-favored savings account. The savings account used to pay for eligible medical expenses is owned and controlled by the employee. Employers are increasingly turning to account-based plans to lower their costs and to help employees have more personal control over their health care expenses. Any unused funds in the account are carried over from year to year, which further encourages thoughtful choices in spending. Employees can open an HSA with their own financial institution. BRONZE SILVER GOLD PLATINUM Monthly premium $ $$ $$$ $$$$ Cost to enrollees when they get care Copays, deductible, coinsurance $$$$ $$$ $$ $ Good choice for enrollees who... Don t expect to use a lot of health care services. Need to balance monthly premium with out-of-pocket costs. Want to save on monthly premiums while keeping out-of-pocket costs low. Expect to use a lot of health care services. 6 SMALL BUSINESS GROUP

7 The 10 essential health benefits In accordance with the Affordable Care Act (ACA), all small group plans must include the 10 essential health benefits: ambulatory patient services, emergency care, hospitalization, maternity and newborn care, mental health and substance abuse disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services, and pediatric services. Definitions Coinsurance The percentage amount you pay for the cost of the care you receive. You ll notice that the coinsurance levels differ among all of the plans. Copayment, copay The set dollar amount you pay when you receive certain covered services. Deductible What you ll pay each calendar year before your full coverage kicks in. All our Small Business Group plans have traditional deductibles (also called embedded deductibles). Once a family member meets their individual deductible, services are covered for that person without the entire family deductible being met. Other family members continue to pay toward the family deductible amount. For certain services, the deductible does not apply. Drug formulary The list of generic and brand-name prescription drugs that are usually covered by our health plans. The drugs are selected by a committee of Group Health physicians and pharmacists based on safety, effectiveness, and cost. Hospital stays inpatient Hospital room and board; inpatient surgery; anesthesia; intensive and coronary care; laboratory tests; radiology services; drugs while in hospital. Includes mental health inpatient treatment. Office visits Primary and specialty care, including naturopathy and outpatient mental health and substance abuse visits. Out-of-pocket maximum The most you ll be required to pay for covered services in a calendar year. Deductible, coinsurance, and copays count toward limit. Outpatient surgery Surgery in an office, outpatient surgery center, or hospital setting that does not require an overnight stay. Pediatric dental and pediatric vision For children up to and including age 18. Prescription drugs, outpatient Formulary drugs that require prescriptions, including self-administered injectables, mental health drugs, and diabetic pharmacy supplies. Preventive care services For children and adults. Includes wellness visits, screenings, supplies, and immunizations as established in Group Health s well-care schedule and the U.S. Health Resources and Services Administration women s preventive and wellness services guidelines. COMPARE YOUR PLAN OPTIONS 7

8 2015 Core plans CORE BRONZE HSA CORE SILVER COVERAGE Annual deductible Deductible does not apply to services noted with u $2,850 per member or $5,700 per family $1,500 per member or $3,000 per family Member coinsurance 40% 20% Out-of-pocket maximum $6,450 per member or $12,900 per family $6,350 per member or $12,700 per family BENEFITS After deductible is met, you pay: After deductible is met, you pay: Office visits $20 primary / $30 specialty Preventive care services Maternity care Routine outpatient prenatal and postpartum visits Labor and delivery inpatient 20% coinsurance Chiropractic/manipulative therapy 10 visits per calendar year $20 primary / $30 specialty Acupuncture 12 visits per calendar year $20 primary / $30 specialty Lab/radiology services 20% coinsurance Devices, equipment, and supplies Including prosthetics 20% coinsurance Outpatient surgery 20% coinsurance Emergency care $200 + $ % coinsurance Urgent care At network urgent care center $20 primary / $30 specialty Ambulance 20% coinsurance Hospital stays inpatient 20% coinsurance Skilled nursing 60 days per calendar year 20% coinsurance Adult vision 1 routine exam per year; annual hardware allowance toward glasses or contact lenses Pediatric vision 1 routine eye exam per year; hardware 1 pair of lenses and frames per year or annual supply of contacts Pediatric dental Prescription drugs Cost per 30-day supply Deductible notes $100 hardware allowance u Deductible shared with annual medical deductible Class I preventive services covered in full u Class I diagnostic services subject to 50% coinsurance u 40% preferred generic, 40% preferred brand, including specialty brand 35% preferred generic, 35% preferred brand, including specialty brand Does not apply to preventive care, Class I pediatric dental, pediatric eye exam & glasses, or adult vision hardware allowance $20 primary / $30 specialty $100 hardware allowance u $50 deductible per member per year (separate from medical) Class I preventive services covered in full u Class I diagnostic services subject to 50% coinsurance u $10 preferred generic u, 50% preferred $5 preferred generic u, 45% preferred Does not apply to preventive care, prescription drugs, Class I pediatric dental, pediatric eye exam & glasses, or adult vision hardware allowance This is an overview of benefits. The contents are not to be accepted or construed as a substitute for the provisions of the medical coverage agreement. Other terms and conditions may apply. A list of excluded services and other limitations can be found in each plan s Summary of Benefits and Coverage document. PRIMARY CARE COPAYS APPLY TO: Acupuncture Audiology Chemical Dependency/Substance Abuse Chiropractic/Manipulative Therapy Emergency Medicine (where ER copay doesn t apply) Enterostomal Therapy Family Planning Family Medicine Health Education Internal Medicine Massage Therapy Mental Health Midwifery Naturopathy Nutrition Obstetrics/Gynecology Occupational Medicine Occupational Therapy Optometry Osteopathy Pediatrics Physical Therapy Respiratory Therapy Speech Therapy NOTE: The specialty care copay will apply if a service is provided by a specialty care provider. 8 SMALL BUSINESS GROUP

9 CORE GOLD CORE PLUS SILVER CORE PLUS GOLD CORE PLUS PLATINUM $750 per member or $1,500 per family $1,250 per member or $2,500 per family $600 per member or $1,200 per family $250 per member or $500 per family 10% 30% 20% 10% $4,500 per member or $9,000 per family $6,350 per member or $12,700 per family $4,500 per member or $9,000 per family $2,000 per member or $4,000 per family After deductible is met, you pay: After deductible is met, you pay: After deductible is met, you pay: After deductible is met, you pay: $10 primary / $15 specialty Deductible does not apply to first 3 office visits per year $20 primary / $45 specialty Deductible does not apply to first 3 office visits per year $10 primary / $30 specialty Deductible does not apply to first 3 office visits per year $10 primary / $25 specialty 10% coinsurance 20% coinsurance 10% coinsurance $10 primary / $15 specialty $20 primary / $45 specialty $10 primary / $30 specialty $10 primary / $25 specialty $10 primary / $15 specialty $20 primary / $45 specialty $10 primary / $30 specialty $10 primary / $25 specialty 10% coinsurance 20% coinsurance 10% coinsurance 10% coinsurance 20% coinsurance 10% coinsurance 10% coinsurance 20% coinsurance 10% coinsurance $ % coinsurance $200 + $ % coinsurance $ % coinsurance $10 primary / $15 specialty $20 primary / $45 specialty $10 primary / $30 specialty $10 primary / $25 specialty 10% coinsurance 20% coinsurance 10% coinsurance 10% coinsurance 20% coinsurance 10% coinsurance 10% coinsurance 20% coinsurance 10% coinsurance $10 primary / $15 specialty $100 hardware allowance u $20 primary / $45 specialty $100 hardware allowance u $10 primary / $30 specialty $100 hardware allowance u $10 primary / $25 specialty $100 hardware allowance u $50 deductible per member per year (separate from medical) Class I preventive services covered in full u Class I diagnostic services subject to 50% coinsurance u $50 deductible per member per year (separate from medical) Class I preventive services covered in full u Class I diagnostic services subject to 50% coinsurance u $50 deductible per member per year (separate from medical) Class I preventive services covered in full u Class I diagnostic services subject to 50% coinsurance u $50 deductible per member per year (separate from medical) Class I preventive services covered in full u Class I diagnostic services subject to 50% coinsurance u $10 preferred generic u, 20% preferred $5 preferred generic u, 15% preferred $10 preferred generic u, 50% preferred $5 preferred generic u, 45% preferred $10 preferred generic u, 20% preferred $5 preferred generic u, 15% preferred $7 preferred generic u, $25 preferred $2 preferred generic u, $20 preferred Does not apply to preventive care, prescription drugs, Class I pediatric dental, pediatric eye exam & glasses, or adult vision hardware allowance Does not apply to preventive care, prescription drugs, Class I pediatric dental, pediatric eye exam & glasses, or adult vision hardware allowance Does not apply to preventive care, prescription drugs, Class I pediatric dental, pediatric eye exam & glasses, or adult vision hardware allowance Does not apply to preventive care, prescription drugs, Class I pediatric dental, pediatric eye exam & glasses, or adult vision hardware allowance Core plans offered by Group Health Cooperative. SPECIALTY CARE COPAYS APPLY TO: Acupuncture Allergy and Immunology Anesthesiology Cardiology (pediatric and cardio vascular disease) Chiropractic/Manipulative Therapy Critical Care Medicine Dentistry Dermatology Endocrinology Gastroenterology Genetics Hematology Hepatology Infectious Disease Neonatal-Perinatal Medicine Nephrology Neurology Oncology Ophthalmology Orthopedics Otolaryngology (ear, nose, and throat) Pathology Physiatry (Physical Medicine) Podiatry Pulmonary Medicine/ Disease Radiology (nuclear medicine, radiation therapy) Rheumatology Sports Medicine General Surgery (all surgical specialties) Urology COMPARE YOUR PLAN OPTIONS 9

10 2015 Connect plans CONNECT BRONZE HSA COVERAGE Annual deductible Deductible does not apply to services noted with u In network $2,800 per member or $5,600 per family Out of network Member coinsurance 40% 50% Out-of-pocket maximum BENEFITS $6,450 per member or $12,900 per family After deductible is met, you pay: Office visits 50% coinsurance Preventive care services Maternity care Routine outpatient prenatal and postpartum visits Labor and delivery inpatient 50% coinsurance Chiropractic/manipulative therapy 10 visits per calendar year 50% coinsurance Acupuncture 12 visits per calendar year 50% coinsurance Lab/radiology services 50% coinsurance Devices, equipment, and supplies (including prosthetics) 50% coinsurance Outpatient surgery 50% coinsurance Emergency care $200 copay + Urgent care At urgent care center 50% coinsurance Ambulance 50% coinsurance Hospital stays inpatient 50% coinsurance Skilled nursing 60 days per calendar year 50% coinsurance Adult vision 1 routine exam per year; shared annual hardware allowance toward glasses or contact lenses Pediatric vision 1 routine eye exam per year; hardware 1 pair of lenses and frames per year or annual supply of contacts $100 hardware allowance 50% coinsurance $100 hardware allowance 50% coinsurance for routine exam; for hardware Pediatric dental Deductible: Shared with annual medical deductible Class I preventive services covered in full Class I diagnostic services subject to 50% coinsurance Prescription drugs Cost per 30-day supply 40% preferred generic, 40% preferred brand, including specialty brand 35% preferred generic, 35% preferred brand, including specialty brand 50% preferred generic, 50% preferred brand, including specialty brand Available only when filled through a Group Health designated mail order service. Deductible notes Does not apply to preventive care, Class I pediatric dental, pediatric eye exam & glasses, or adult vision hardware allowance This is an overview of benefits. The contents are not to be accepted or construed as a substitute for the provisions of the medical coverage agreement. Other terms and conditions may apply. A list of excluded services and other limitations can be found in each plan s Summary of Benefits and Coverage document. PRIMARY CARE COPAYS APPLY TO: Acupuncture Audiology Chemical Dependency/Substance Abuse Chiropractic/Manipulative Therapy Emergency Medicine (where ER copay doesn t apply) Enterostomal Therapy Family Planning Family Medicine Health Education Internal Medicine Massage Therapy Mental Health Midwifery Naturopathy Nutrition Obstetrics/Gynecology Occupational Medicine Occupational Therapy Optometry Osteopathy Pediatrics Physical Therapy Respiratory Therapy Speech Therapy NOTE: The specialty care copay will apply if a service is provided by a specialty care provider. 10 SMALL BUSINESS GROUP

11 CONNECT3 SILVER CONNECT3 GOLD In network Out of network In network Out of network $1,300 per member or $2,600 per family $600 per member or $1,200 per family 20% 40% 10% 30% $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family After deductible is met, you pay: After deductible is met, you pay: Deductible does not apply to first 3 PRIMARY CARE visits per year $20 primary / $30 specialty Deductible does not apply to first 3 PRIMARY CARE visits per year $10 primary / $15 specialty 20% coinsurance 10% coinsurance $20 primary / $30 specialty $10 primary / $15 specialty $20 primary / $30 specialty $10 primary / $15 specialty 20% coinsurance 10% coinsurance 20% coinsurance 10% coinsurance 20% coinsurance 10% coinsurance $200 copay + 20% coinsurance $200 copay + 10% coinsurance $20 primary / $30 specialty $10 primary / $15 specialty 20% coinsurance 10% coinsurance 20% coinsurance 10% coinsurance 20% coinsurance 10% coinsurance $20 primary / $30 specialty $100 hardware allowance $100 hardware allowance $10 primary / $15 specialty $100 hardware allowance $100 hardware allowance for routine exam; for hardware for routine exam; for hardware $50 deductible per member per year (separate from medical) Class I preventive services covered in full Class I diagnostic services subject to 50% coinsurance $50 deductible per member per year (separate from medical) Class I preventive services covered in full Class I diagnostic services subject to 50% coinsurance $10 preferred generic, 50% preferred brand, including specialty brand $5 preferred generic, 45% preferred brand, including specialty brand 40% preferred generic, 50% preferred brand, including specialty brand Available only when filled through a Group Health designated mail order service. $10 preferred generic, 20% preferred brand, including specialty brand $5 preferred generic, 15% preferred brand, including specialty brand 30% preferred generic, 50% preferred brand, including specialty brand Available only when filled through a Group Health designated mail order service. Does not apply to preventive care, in-network prescription drugs, Class I pediatric dental, pediatric eye exam & glasses, or adult vision hardware allowance Does not apply to preventive care, in-network prescription drugs, Class I pediatric dental, pediatric eye exam & glasses, or adult vision hardware allowance Connect plans offered by Group Health Options, Inc. (same network as Alliant Plus). SPECIALTY CARE COPAYS APPLY TO: Acupuncture Allergy and Immunology Anesthesiology Cardiology (pediatric and cardio vascular disease) Chiropractic/Manipulative Therapy Critical Care Medicine Dentistry Dermatology Endocrinology Gastroenterology Genetics Hematology Hepatology Infectious Disease Neonatal-Perinatal Medicine Nephrology Neurology Oncology Ophthalmology Orthopedics Otolaryngology (ear, nose, and throat) Pathology Physiatry (Physical Medicine) Podiatry Pulmonary Medicine/Disease Radiology (nuclear medicine, radiation therapy) Rheumatology Sports Medicine General Surgery (all surgical specialties) Urology COMPARE YOUR PLAN OPTIONS 11

12 FOR MORE INFORMATION Contact your producer (agent/broker) Contact your Group Health sales representative directly or call Visit ghc.org/sbg 14-SBG