Compare your plan options

Transcription

1 SMALL BUSINESS GROUP Compare your plan options 2014 plans for businesses with 1 50 employees I SMALL BUSINESS GROUP

2 Group Health plans offer value, choice, and more A well-run business takes a lot of time, focus, and energy. We know that s your priority. Ours? It s helping you find a health care plan that s right for you and your employees. Our 2014 plans are all new and designed to meet your needs. All of our plans for small businesses include the 10 essential health benefits required by health care reform. But since they re from Group Health, our plans offer something more. You can choose the level of coverage you want, with different plans offering options for how costs are shared between the plan member and the health plan. You also have a clear choice in the size of provider network. Whatever choice you make, and wherever your employees live, they will have access to a large network that includes primary care, specialty care, allied health and alternative care practitioners, and community hospitals in 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 systems that are more patient centered and deliver care that keeps people healthier. We know there s a lot that s new for We re ready to help you. Please call us with your questions at COMPARE YOUR PLAN OPTIONS 1

3 Your plan choices You ll want to familiarize yourself with the choices you have by reviewing the health plan grids on pages 6 9. Once you ve reviewed them, get started with these 3 easy steps: Determine whether you ll offer 1 or 2 plans. Decide which provider network you want to offer. Choose the coverage level you want. 1 2 Decide which provider networks you want to offer. 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. 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. Core plans network (Also known as Group Health) Offered by Group Health Cooperative The network available with Core plans gives members access to: 1,100 Group Health Medical Centers doctors at 25 clinics* More than 9,000 network providers* Why choose Core? Your highest priority is value. With Core, members have in-network access to physicians at Group Health Medical Centers, our high-performing group practice, an additional 9,000 network providers, and 50 hospitals in our service area. It s our most cost-effective option. 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: 1,100 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 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 you access to many additional providers, both in network and out of network. This is the largest physician network available to small group employers. When members use in-network providers, they ll enjoy lower out-of-pocket costs. *Source: OIC Provider Network Form A 2 SMALL BUSINESS GROUP COMPARE YOUR PLAN OPTIONS 3

4 3 Choose the coverage level you want The 10 essential health benefits All small group plans include the 10 essential health benefits. They are: Health insurers offer different levels of coverage under health care reform. They re called metal tiers and offer options for how costs are shared between the health plan member and the health plan. We re offering Gold, Silver, and Bronze plans to small group employers. All of our small group plans include the same benefits. What s different are the monthly premiums versus the member s cost shares (deductibles, copays, coinsurance, and out-of-pocket limits). Compare the coverage levels Bronze plans have lower premium costs and higher out-of-pocket costs. Gold plans have higher premium costs and lower out-of-pocket costs. Silver plans land between these two. Core3 and Connect3 plans include three primary care office visits before the deductible applies. GOLD SILVER BRONZE Monthly premium $$$ $$ $ Cost to enrollees when they get care (copays, deductible, coinsurance) $ $$ $$$ 1. Ambulatory patient services. The care you receive without being admitted to a hospital. For example, at a clinic, a physician s office, or a same-day surgery center. 2. Emergency care. Care for conditions which, if not immediately treated, could lead to serious disability or death. 3. Hospitalization. The care and services you receive as a patient in a hospital, such as care from doctors and nurses, tests and drugs administered during your stay, and room and board. 4. Maternity and newborn care. The care provided to women during pregnancy, during and after labor and delivery, and care for newborn children. 5. Mental health and substance abuse disorder services, including behavioral health treatment. This is care to evaluate, diagnose, and treat mental health and substance abuse issues. 6. Prescription drugs. These are drugs prescribed by a doctor to treat an acute illness like an infection, or to treat an ongoing condition like high blood pressure. 7. Rehabilitative and habilitative services and devices. The former refers to relearning skills lost due to disease or injury, and the latter to keeping and learning age-appropriate skills and functioning. 8. Laboratory services. The testing of a patient s blood, tissues, etc., to help a doctor diagnose a medical condition or monitor the effectiveness of a treatment. 9. Preventive and wellness services, including chronic disease management. This includes routine physicals, screening, and immunization. Chronic disease management is an integrated approach to manage an ongoing condition like asthma or diabetes. 10. Pediatric services for children under age 19 including the nine benefits already listed, and dental services such as preventive and restorative care, and vision care such as eye exams and prescription glasses. Good choice for enrollees who... Expect to use a lot of health care services Want a balance between premium costs and out-of-pocket costs Don t expect to use a lot of health care services Benefit definitions Below are definitions of some of the terms you ll find on pages 6 9. 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. Outpatient surgery Surgery in an office, outpatient surgery center, or hospital setting that does not require an overnight stay. Pediatric dental For children up to and including age 18. Pediatric vision For children up to and including age 18. Prescription drugs Outpatient: Formulary drugs and medicines that require prescriptions, including self-administered injectables, mental health drugs, and diabetic pharmacy supplies. Preventive care services For children and adults. Includes wellness visits and immunizations, as established in Group Health s well-care schedule, formulary contraceptive drugs including counseling, contraceptive devices, and female sterilization. Devices and supplies related to contraception are covered as preventive as required by federal law and covered in full. Also includes drugs and medicines such as aspirin, fluoride, and folic acid. 4 SMALL BUSINESS GROUP COMPARE YOUR PLAN OPTIONS 5

5 2014 Core plans PLAN NAME COVERAGE Annual deductible Deductible does not apply to services noted with u CORE3 GOLD CORE3 SILVER CORE GOLD CORE SILVER CORE BRONZE $500 per member or $1,000 per family $1,250 per member or $2,500 per family $750 per member or $1,500 per family $1,500 per member or $3,000 per family $2,650 per member or $5,300 per family Member coinsurance 20% 30% 10% 20% 40% Out-of-pocket limit $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family BENEFITS After deductible is met, you pay: After deductible is met, you pay: After deductible is met, you pay: After deductible is met, you pay: After deductible is met, you pay: Deductible does not apply to first 3 primary care visits per year Office visits Primary: $10 Primary: $20 Primary: $10 Primary: $20 Primary: per visit Specialty: $15 Specialty: $30 Specialty: $15 Specialty: $30 Specialty: per visit Preventive care services Maternity care Routine outpatient prenatal and postpartum visits Labor and delivery 20% coinsurance 10% coinsurance 20% coinsurance Chiropractic/Manipulative therapy 10 visits per calendar year Acupuncture 12 visits per calendar year Lab/X-ray services 20% coinsurance 10% coinsurance 20% coinsurance Devices, equipment, and supplies (including prosthetics) 20% coinsurance 10% coinsurance 20% coinsurance Outpatient surgery 20% coinsurance 10% coinsurance 20% coinsurance Emergency care $100 copay + 20% coinsurance $150 copay + $100 copay + 10% coinsurance $150 copay + 20% coinsurance Ambulance 20% coinsurance 10% coinsurance 20% coinsurance Hospital stays inpatient 20% coinsurance 10% coinsurance 20% coinsurance Skilled nursing 60 days per calendar year 20% coinsurance 10% coinsurance 20% coinsurance Adult vision 1 routine exam per year; annual hardware allowance $10 primary / $10 specialty contact lenses u $20 primary / $20 specialty contact lenses u $10 primary / $10 specialty contact lenses u $20 primary / $20 specialty contact lenses u contact lenses u Pediatric vision 1 routine exam per year; Hardware 1 pair of lenses and frames or contacts per year Pediatric dental Preventive and restorative services (See separate pediatric dental benefit summary available online at ghc.org/sbg) deductible deductible deductible deductible deductible Prescription drugs Cost per 30-day supply (Note lower cost through mail order) $10 preferred generic u; 20% preferred brand u, $5 preferred generic u; 15% preferred brand u, $10 preferred generic u; 50% preferred brand u, $5 preferred generic u; 45% preferred brand u, $10 preferred generic u; 20% preferred brand u, $5 preferred generic u; 15% preferred brand u, $10 preferred generic u; 50% preferred brand u, $5 preferred generic u; 45% preferred brand u, Prescription drug coverage begins after plan deductible is met 40% preferred generic; 40% preferred brand, 35% preferred generic; 35% preferred brand, This is a summary 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 6 SMALL BUSINESS GROUP Core plans offered by Group Health Cooperative. NOTE: There is a 90-day benefit wait period for transplants. This wait period may be fully or partially based on current or prior coverage. SPECIALTY CARE COPAYS APPLY TO: Allergy and Immunology Anesthesiology Cardiology (pediatric and cardio vascular disease) 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 7

6 2014 Connect plans PLAN NAME CONNECT3 GOLD CONNECT3 SILVER CONNECT GOLD CONNECT SILVER In network Out of network In network Out of network In network Out of network In network Out of network COVERAGE Annual deductible Deductible does not apply to services noted with u $400 per member or $800 per family $1,250 per member or $2,500 per family $600 per member or $1,200 per family $1,300 per member or $2,600 per family Member coinsurance 20% 40% 30% 50% 10% 30% 20% 40% Out-of-pocket limit $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family $6,350 per member or $12,700 per family BENEFITS After deductible is met, you pay: After deductible is met, you pay: After deductible is met, you pay: After deductible is met, you pay: Office visits Deductible does not apply to first 3 primary care visits per year Primary: $10 Specialty: $15 Primary: Specialty: Deductible does not apply to first 3 primary care visits per year Primary: $20 Specialty: $30 Primary: 50% coinsurance Specialty: 50% coinsurance Primary: $10 Specialty: $15 Primary: Specialty: Primary: $20 Specialty: $30 Primary: Specialty: Preventive care services Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Maternity care Routine outpatient prenatal and postpartum visits Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Labor and delivery 20% coinsurance 50% coinsurance 10% coinsurance 20% coinsurance Chiropractic/Manipulative therapy 10 visits per calendar year 50% coinsurance Acupuncture 12 visits per calendar year 50% coinsurance Lab/X-ray services 20% coinsurance 50% coinsurance 10% coinsurance 20% coinsurance Devices, equipment, and supplies (including prosthetics) 20% coinsurance 50% coinsurance 10% coinsurance 20% coinsurance Outpatient surgery 20% coinsurance 50% coinsurance 10% coinsurance 20% coinsurance Emergency care $100 copay + 20% coinsurance $100 copay + 20% coinsurance $150 copay + $150 copay + $100 copay + 10% coinsurance $100 copay + 10% coinsurance $150 copay + 20% coinsurance $150 copay + 20% coinsurance Ambulance 20% coinsurance 50% coinsurance 10% coinsurance 20% coinsurance Hospital stays inpatient 20% coinsurance 50% coinsurance 10% coinsurance 20% coinsurance Skilled nursing 60 days per calendar year 20% coinsurance 50% coinsurance 10% coinsurance 20% coinsurance Adult vision 1 routine exam per year; shared annual hardware allowance 50% coinsurance Pediatric vision 1 routine exam per year; Hardware 1 pair of lenses and frames or contacts per year Covered in full Covered in full 50% coinsurance Covered in full Covered in full Pediatric dental Preventive and restorative services (See separate pediatric dental benefit summary available online at ghc.org/sbg) Prescription drugs Cost per 30-day supply (Note lower cost through mail order) 20% preferred brand, 15% preferred brand, Prescription drug coverage begins after plan deductible is met 40% preferred generic; 50% preferred brand, 45% preferred brand, Prescription drug coverage begins after plan deductible is met 50% preferred generic; 20% preferred brand, 15% preferred brand, Prescription drug coverage begins after plan deductible is met 30% preferred generic; 50% preferred brand, 45% preferred brand, Prescription drug coverage begins after plan deductible is met 40% preferred generic; This is a summary 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 8 SMALL BUSINESS GROUP Connect plans offered by Group Health Options, Inc., (same network as Alliant Plus). NOTE: There is a 90-day benefit wait period for transplants. This wait period may be fully or partially waived depending on current or prior coverage. SPECIALTY CARE COPAYS APPLY TO: Allergy and Immunology Anesthesiology Cardiology (pediatric and cardio vascular disease) 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

7 FOR MORE INFORMATION Contact your producer (agent/broker) Contact your Group Health sales representative directly or call toll-free at Visit ghc.org/sbg 14-SBG-1094_