QHP Overview for Open Enrollment 2

Transcription

1 QHP Overview for Open Enrollment 2 KENTUCKY PRIMARY CARE ASSOCIATION NOVEMBER 13, 2014

2 Overview Brief KPCA Updates QHP Presentations Anthem CareSource WellCare Kentucky Health Co-Op Questions If time allows

3 KPCA Update kynect mobile app Social Media Case Notes Review the blog Quick Reference Guides Pre-screen on kynect shows new plans, rates, and plan information

4 Anthem

5 Anthem Update Amy M. Wertz KY ISG Account Executive 15

6 We re from here. And here is where we make a difference. Big company advantages with a local company approach: We live, work and raise our families in Kentucky Celebrating over 75 years of business in Kentucky We have more than 1,000 associates from Louisville, to Lexington, and everywhere in-between Local leadership with a legacy of giving 6

7 Strength in numbers And when you combine that with the power of Blue, we re virtually unstoppable 1.3 million Kentuckians are covered by Blue 92% of physicians 2x larger total membership than Blue s next largest competitor 1 in 3 Americans is covered by a Blue Cross Blue Shield plan 382 of Fortune 500 offer a Blue health plan 97% of hospitals 7

8 Last year, we committed over $1.5 million to improving health in Kentucky. Kentucky Homeplace Improving Diabetes Outcomes Disabled Sports USA Boys and Girls Clubs of America American Cancer Society American Lung Association And many more locally focused programs impacting health Plus countless volunteer hours from Kentucky associates giving back to their community. 8

9 We believe health care should be accessible 9

10 2015 Product Improvements Individual Closed Key Competitive Gaps Modified existing plans to improve pricing Introducing new HMO and PPO plans Added out of state coverage for MSP on exchange plans Improved Price Position Compliance Simplified The Portfolio Leverage OOP Max/Deductible limits to achieve lower price point Modification based on Mental Health Parity Modification based on AV calculator Modification based on state/federal legislative changes Increased number of plans Added pediatric dental to all medical plans More descriptive naming convention 10

11 New Naming Convention Individual On-exchange example American Indian and Subsidy plans will take on the name of their parent plan. This includes an indicator in the plan name that will distinguish between the plans (AI) for American Indian and an (S) for subsidy: Anthem Silver Pathway X HMO 3500/25% AI Anthem Gold Pathway X PPO 1500/10% AI Anthem Silver Pathway X PPO 10% for HSA S04 11

12 Portfolio Changes Individual 2014 BRONZE SILVER GOLD 2015 BRONZE SILVER GOLD 12

13 Portfolio Changes Individual Added BlueCard to the Multi-State on-exchange plans (MSP) Options to locate out of state BlueCard network providers for Multi-State Plans: Shopper Portal View and Select Plan page via messaging titled IMPORTANT NOTE FOR MULTI-STATE PLANS ONLY. ProviderFinder located on Anthem.com by selecting the state of Kentucky as well as select the plan as National PPO (BlueCard PPO Basic) network. Call the Coverage while traveling phone number on the back of their ID card. Effective January 2015, ability to access Find a Doctor and select their MSP plan name (i.e. Anthem Blue Cross and Blue Shield Gold DirectAccess,, a Multi-State Plan ). 13

14 New HMO Products Individual Offered in four regions: Louisville, Lexington, Paducah, Northern KY Counties include: (noted in blue on map) Anderson, Ballard, Boone, Bourbon, Bullitt, Campbell, Clark, Estill, Fayette, Franklin, Garrard, Hardin, Henry, Jackson, Jefferson, Jessamine, Kenton, LaRue, Madison, McCracken, Mercer, Montgomery, Nelson, Nicholas, Oldham, Rockcastle, Scott, Shelby, Spencer, Trimble, Washington, and Woodford 14

15 New HMO Products Individual Hospital network: Baptist (Louisville, Lexington, Paducah) KY One (Louisville, Lexington, Central KY) University of Kentucky Norton and Kosair Childrens Hardin Memorial Christ Hospital (Cincinnati/northern KY physician old Drawbridge Inn location) 15

16 New HMO Products Individual No gatekeeper, no referrals required Primary care selection required Locate a listing of providers within a network on Find A Doctor. Select Kentucky and select the applicable HMO product. 16

17 New HMO Products Individual 17

18 Marketing Materials 18

19 2015 Product Improvements Small Group Closed Key Competitive Gaps Added one Platinum plan off-exchange (Anthem Platinum Pathway PPO $15/10%/3500 Plus) Added pediatric dental to all medical plans Ability to quote and bill for two-tier composite rating Improved Price Position Optimized Plan Options Leveraged OPM/Deductible limits to achieve price point Analyzed plans/price curve and made adjustments to ensure adequate plan choices Removed separate RX out of pocket maximum All member cost shares must accumulate to and not exceed out of pock maximum Compliance Modified based on AV calculator 19

20 New Naming Convention Small Group On-exchange example Anthem Gold Pathway X PPO $1000/20%/5000 Plus Anthem Gold Pathway X PPO $1300/10%/6000 Plus w/hsa Off-exchange example Anthem Gold Blue Access PPO $2000/40%/4000 Anthem Bronze Pathway PPO $6300/0%/6300 Plus w/ Dental w/ HSA 20

21 Marketing Materials 21

22 Introducing LiveHealth Online Health care where you need it, when you need it. 22

23 What is LiveHealth Online? LiveHealth Online is a convenient way for our members to interact with a doctor via live, two-way video on their computer or mobile device. Easier and less expensive than urgent care. LiveHealth Online: Is available anywhere you have an internet connection (at home, in the office or on the go) Is available 24 hours a day/7 days a week/365 days a year Provides access to in-network, U.S. board-certified doctors Offers help at the same price as (or less than) a regular doctor visit Doctors can eprescribe to local pharmacies (where applicable) Takes member payments via Visa, MasterCard and Discover Is secure, convenient and easy-to-use LiveHealth Online is the trade name of Health Management Corporation, a separate company providing telehealth services on behalf of Anthem Blue Cross and Blue Shield. 23

24 Thank You. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 24

25 CareSource

26 CareSource Just4Me Benefits and Market Overview Health insurance you can afford, understand and use Information Confidential and Proprietary 1

27 Health Care with Heart 27 Information Confidential and Proprietary

28 What Makes CareSource Different? Understand the challenges consumers face navigating the health care system Committed to putting health care within reach for over 1 million members Low administrative rates - 92% of revenue spent on member care A forerunner in innovative programs and member satisfaction Dedication to our mission is at the core of our company s success People over profits 28 Information Confidential and Proprietary

29 Our Mission To make a lasting difference in our members lives by improving their health and well-being. 4 Information Confidential and Proprietary

30 Market Insights 5 Information Confidential and Proprietary

31 Tradeoff Between Health and Cost 61% of Uninsured in Kentucky market don t have insurance due to cost 40% of uninsured shoulder all of their medical costs 56% of uninsured do not have a personal doctor Sources: AMSA.org an Uninsured Primer retrieved at: acainternational.org Health Care Collection Statistics retrieved at: Information Confidential and Proprietary 6

32 Medicaid Gap An Unmet Need CareSource Focus 250% FPL ( $58,750 for family of 4, $28,725 for an individual) Information Confidential and Proprietary Source: KFF How will the Uninsured in Kentucky fare Under Affordable Care Act retrieved at: uninsured-under-aca-kentucky/ 7

33 Why is Kentucky Uninsured? About 1 out of 10 respondents report that they do not have insurance. Of those, 61% say they can t afford it; 10% say they re looking for a job that offers health insurance. Have Insurance 33 Information Confidential and Proprietary

34 REASONS FOR SELECTING CARESOURCE JUST4ME Reasons for Selecting CareSource Just4Me in Ohio 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% Pre-existing condition 10% Most affordable option 68% Doctor in network Best Reputation 7% 18% Member Choice Friend or Family Recommendation 5% N=402 Broker Recommendation 5% 9 Information Confidential and Proprietary

35 CareSource Just4Me Plan Details 10 Information Confidential and Proprietary

36 CareSource Just4Me Targeted for those who have never had coverage or don t have enough coverage Quality health care across a robust network of providers Comprehensive individual or family health insurance plans 36 Information Confidential and Proprietary

37 Member Centric Plan Design Our Consumers Want Just4Me Offers Cost Low premium Low deductible Low cost medications Easy & Simple Education: Health Insurance 101; What is a deductible, what is co-insurance and how is it different than a co-pay? Value: What do I get for my money? We help you enroll Network Clarity on who they can see Are willing to switch providers to save money Affordable plans Offer the lowest or second lowest premiums for Silver plans Low copays & deductibles Attractive pharmacy offering No deductible $0 generics for Silver & Ultra Gold Accessibility $0 - $20 PCP visits $0 - $50 Specialist visits Care management support Customized per region Robust network of hospitals and providers Retail locations for convenience (i.e. Minute Clinics) Ease of Payment Convenient options for timely payments Online & mail premium payment options Retail partnerships for payments - planned Pay by phone payment option - planned 37 Information Confidential and Proprietary

38 Health Partners Information Confidential and Proprietary

39 2015 Kentucky Market 16 Counties 39 Information Confidential and Proprietary

40 Plan Features Low premiums, low deductible and low copays Low or No Copays for prescriptions with Silver* plans Low copays for doctor (primary care) visits Free generic medications with Silver and Gold plans Robust network of doctors and providers CareSource24, 24/7/365 nurse advice line Healthy living programs (to help you deal with conditions such as diabetes and asthma) *Some exclusions may apply. 40 Information Confidential and Proprietary

41 Plan Offerings Ultra Gold Higher premiums than Silver and Bronze plans Lower out-of-pocket costs than Silver and Bronze plans Coverage for those who want the most comprehensive benefits and greatest protection for health care 41 Information Confidential and Proprietary

42 Plan Offerings - Silver Highest potential for cost savings Low premiums, but higher annual deductible, copays, coinsurance and outof-pocket costs Coverage for those who want the health insurance company to pay more and want additional coverage for the unexpected 42 Information Confidential and Proprietary

43 Plan Offerings - Bronze Lowest premiums with highest out-ofpocket costs Coverage for those who rarely go to the doctor but want coverage for the unexpected 43 Information Confidential and Proprietary

44 Plan Offerings - Catastrophic Minimum coverage at the lowest premiums Include 3 primary care visits per year High out-of-pocket costs Only available to those under 30 years old 44 Information Confidential and Proprietary

45 Individual Plan Comparison Chart Individual Plans Annual Deductible Out-of- Pocket Limit Gold $1,000 $1,750 (Medical) $1500 Coinsurance Primary Care Visit Copay Specialist Visit Copay Emergency Copay 10% $20* $50* $250 after deductible** (Pharmacy) Silver $3,500 $6,500 30% $20* $50* $500 after deductible** Silver 1 $3,500 $4,850 30% $10* $50* $300 after deductible** Silver 2 $1,000 $2,000 10% $0* $0* $300 after deductible** Silver 3 $200 $650 0% $0* $0* $300 after deductible** Bronze $6,500 $6,600 10% $40* $80* $100 after deductible** Catastrophic $6,600 $6,600 0% 3 visits per No charge No charge after year before after deductible*** deductible*** deductible*** Information Confidential and Proprietary *You do not have to meet the annual deductible before seeing a primary care doctor or specialist doctor. **You do need to meet the annual deductible and pay a copayment for emergency room visits. ***You must meet the annual deductible to see a specialist doctor, visit the emergency room and if you exceed three primary care doctor visits per year. 45

46 Family Plan Comparison Chart Family Plans Annual Deductible Information Confidential and Proprietary Out-of- Pocket Limit Gold $2,000 $3,500 (Medical) $3000 (Pharmacy) Coinsurance Primary Care Visit Copay Specialist Visit Copay Emergency Copay 10% $20* $50* $250 after deductible** Silver $7,000 $13,000 30% $20* $50* $500 after deductible** Silver 1 $7,000 $9,700 30% $10* $50* $300 after deductible** Silver 2 $2,000 $4,000 10% $0* $0* $300 after deductible** Silver 3 $400 $1,300 0% $0* $0* $300 after deductible** Bronze $13,000 $13,200 10% $40* $80* $200 after deductible** Catastrophic $13,200 $13,200 0% 3 visits per year before deductible*** No charge after deductible*** No charge after deductible*** *You do not have to meet the annual deductible before seeing a primary care doctor or specialist doctor. **You do need to meet the annual deductible and pay a copayment for emergency room visits. ***You must meet the annual deductible to see a specialist doctor, visit the emergency room and if you exceed three primary care doctor visits per year. 46

47 Individual + Family Plans Pharmacy Comparison Chart Plans (Individual + Family) Preventive Medicines Information Confidential and Proprietary Generic Medicines Preferred Brand Medicines Non- Preferred Brand Medicines Specialty Medications Gold $0 $0 $120 $160 40% Coinsurance (up to $300) Silver $0 $0 $50 $125 40% Coinsurance (up to $300) Silver 1 $0 $0 $50 $125 40% Coinsurance (up to $300) Silver 2 $0 $0 $30 $70 40% Coinsurance (up to $150) Silver 3 $0 $0 $5 $20 25% Coinsurance (up to $150) Bronze $0 $20 $75 $125 40% Coinsurance (up to $300) Catastrophic No charge after deductible* No charge after deductible* No charge after deductible* No charge after deductible* No charge after deductible* *You do need to meet the annual deductible for medications. 47

48 Member ID Card (based on 2014 design) FRONT SUFFIX KEY Suffix 04 = FV 73% Silver 1 Suffix 05 = FV 87% Silver 2 Suffix 06 = FV 94% Silver 3 Suffix 03 = Silver and Gold (limited cost share plans) Suffix 01 = Exchange Standard Silver and Gold BACK 48 Information Confidential and Proprietary

49 Tools Window shop plans Subsidy calculator /7 CMS Consumer Call Center: Prescription info, covered services and physician info Spanish assistance: CuidadoDeSalud.gov CMS Marketplace Overview player_embedded Information Confidential and Proprietary 49

50 CareSource Just4Me Health insurance you can afford, understand and use Information Confidential and Proprietary 27

51 Appendix 28 Information Confidential and Proprietary

52

53 Types of Plans Catastrophic Coverage Plans 3 primary care visits per year Low premiums, high out of pocket costs and deductibles Provide only for emergency care HMO (Health Maintenance Organization) Use closed-network benefit model Referrals required for specialist care Benefits not available if care given out of network unless it is emergency POS (Point of Sale) Uses a network benefit model similar to HMO Higher out of pocket costs if care given out of network May require referrals for specialist care HSA (Health Savings Accounts) tied to high deductible plan which features lower premiums higher out of pocket costs Savings account that allows tax advantage dollars to be put away to pay for qualified medical expenses PPO (Preferred Provider Organizations) Use open network benefit model that allows for out of network services at a higher out of pocket cost Referrals not needed to see specialists Premiums are typically higher than HMO s 53 Information Confidential and Proprietary

54 Two Ways to Reduce Cost 1. Advanced Premium Tax Credit 2. Cost Sharing Reductions 54 Information Confidential and Proprietary

55 Health Insurance Marketplace Income Ratio to Federal Poverty Level 2014

56 This is a solicitation for health insurance. *Some exclusions and limitations may apply. Benefits and costs vary by plan. See the CareSource Just4Me Evidence of Coverage or Schedule of Benefits document for details at CareSourceJust4Me.com. CareSource Just4Me does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. CareSource Just4Me is a Qualified Health Plan issuer in the Kentucky Health Benefit Exchange. 56 Information Confidential and Proprietary KY-EXCM-118

57 WellCare

58 WellCare Health Plans, Inc Exchange Product

59 About WellCare WellCare Health Plans, Inc. provides managed care services targeted to government-sponsored health care programs, focusing on Medicaid and Medicare. Headquartered in Tampa, FL., WellCare offers a variety of health plans for families, children, and the aged, blind, and disabled, as well as prescription drug plans. Local offices are available in Hazard, Owensboro, Lexington, Louisville, Bowling Green and Ashland KY. The company serves approximately 4 million members nationwide as of Sept. 30, For 2015, WellCare has been certified as a Qualified Health Plan to offer plans on Kynect. Page 2

60 Our Mission and Vision Mission o Enhance our members health and quality of life; o Partner with providers and governments to provide quality, cost-effective health care solutions; and o Create a rewarding and enriching environment for our associates. Vision o To be the leader in government-sponsored health care programs in partnership with the members, providers, governments and communities we serve. Page 3

61 Service Area Medicaid Plans and Medicare Prescription Drug Plans are available statewide. Medicare Advantage Plans are available in Boone, Bourbon, Bullitt, Campbell, Carroll, Clark, Fayette, Gallatin, Grant, Jefferson, Kenton, Owen, Pendleton, and Scott counties. Individual Exchange Plans are available in 12 counties including: o Warren o Jefferson o Bullitt o Boone o Kenton o Campbell o Fayette o Jessamine o Clay o Leslie o Harlan o Laurel Page 4

62 Network Extensive network of 8162 providers including Hospitals, Ancillaries, FQHC s and RHC s, Dental, Vision, Behavioral Health and Pharmacy providers including: o 2899 PCP s o 2365 Specialists o 221 FQHC s and RHC s o 142 Behavioral Health Specialists o 21 Hospitals Major Physician group networks: o o o o o o o o Kentucky Primary Care Association The Physician Network The Association of Primary Care Physicians Kentucky Medical Services Foundation Saint Elizabeth Physicians and the Summit Medical Group Baptist Physician Group Norton Physician group CHC Network Hospital Network Includes: o The Medical Center of Bowling Green o Kosair Childrens Hospital o Norton Health System o Baptist Health o University of Kentucky Health System o Saint Elizabeth Health System o Pineville Community Hospital o Knox County Hospital Page 5

63 Plan Features General Features o o o o o o HMO plan offerings (Catastrophic, Silver, Gold). $0 copay for the first three PCP visits, Mental Health and Substance Abuse visits, and PT/OT/ST visits. Waiver of deductible on PCP visits, Mental Health and Substance Abuse visits, and PT/OT/ST visits. Waiver of deductible on Specialist visits. Waiver of deductibles for preferred generic drugs. Integrated medical/pharmacy deductibles and MOOPs. Wellness Discounts o Through our partnership with Healthways, members can enjoy the following: Online education tools. Up to 30% discount on CAM providers like acupuncture, chiro, diet/supplement advisors, exercise/movement, massage and relaxation. Additional discounts for Jenny Craig, eyeglasses, hearing screening and hearing aids, dental insurance and more. Page 6

64 Plan Offerings Metal Level Catastrophic Silver Silver Level C Silver Level B Silver Level A Individual/Family Deductible $6,600/$13,200 $3,000/$6,000 $3,000/$6,000 $500/$1,000 $0/$0 $1,000/$2,000 Deductible Note: Individual/Family Maximum Out Of Pocket (MOOP) MOOP Note: PCP Office Visits Medical and Rx Combined Medical and Rx Combined Medical and Rx Combined Medical and Rx Combined Medical and Rx Combined Gold Medical and Rx Combined $6,600/$13,200 $5,000/$10,000 $3,850/$7,700 $1,500/$3,000 $950/$1,900 $3,250/$6,500 Medical and Rx Combined Visits 1-3: $0 (Ded Waived) Visits 4+: $0 after Ded Medical and Rx Combined Visits 1-3: $0 (Ded Waived) Visits 4+: 30% (Ded Waived) Medical and Rx Combined MEDICAL Visits 1-3: $0 (Ded Waived) Visits 4+: $25 (Ded Waived) Medical and Rx Combined Visits 1-3: $0 (Ded Waived) Visits 4+: $15 (Ded Waived) Medical and Rx Combined Visits 1-3: $0 Visits 4+: $15 Medical and Rx Combined Visits 1-3: $0 (Ded Waived) Visits 4+: 20% (Ded Waived) Specialist Office Visits $0 after Ded 30% (Ded Waived) $35 (Ded Waived) $30 (Ded Waived) $30 20% (Ded Waived) Inpatient Hospital Care (Incl. MH/SA) $0 after Ded 30% after Ded 30% after Ded $250 after Ded $150 20% after Ded Emergency Care $0 after Ded 30% after Ded 30% after Ded $100 after Ded $100 20% after Ded Urgent Care $0 after Ded 30% after Ded $35 after Ded $30 after Ded $30 20% after Ded Outpatient Hospital Services $0 after Ded 30% after Ded 30% after Ded $150 after Ded $75 20% after Ded Ambulatory Surgical Center $0 after Ded 30% after Ded 30% after Ded $100 after Ded $50 20% after Ded Outpatient MH/SA $0 after Ded Visits 1-3: $0 (Ded Waived) Visits 4+: 30% (Ded Waived) Visits 1-3: $0 (Ded Waived) Visits 4+: $25 (Ded Waived) Visits 1-3: $0 (Ded Waived) Visits 4+: $15 (Ded Waived) Visits 1-3: $0 Visits 4+: $15 Visits 1-3: $0 (Ded Waived) Visits 4+: 20% (Ded Waived) Outpatient PT/OT/ST $0 after Ded Visits 1-3: $0 (Ded Waived) Visits 4+: 30% (Ded Waived) Visits 1-3: $0 (Ded Waived) Visits 4+: $25 (Ded Waived) Visits 1-3: $0 (Ded Waived) Visits 4+: $15 (Ded Waived) Visits 1-3: $0 Visits 4+: $15 Visits 1-3: $0 (Ded Waived) Visits 4+: 20% (Ded Waived) OP Lab and Prof Services $0 after Ded 30% after Ded 30% after Ded $25 after Ded $10 20% after Ded X-Rays and Diagnostic Imaging $0 after Ded 30% after Ded 30% after Ded $25 after Ded $15 20% after Ded Advanced Imaging (CAT/PET scans, MRI) $0 after Ded 30% after Ded 30% after Ded $50 after Ded $30 20% after Ded OTHER Pediatric Dental and Vision Yes Yes Yes Yes Yes Yes Healthways Discount Yes Yes Yes Yes Yes Yes PHARMACY Generics $0 after Ded 30% (Ded Waived) $10 (Ded Waived) $4 (Ded Waived) $4 $0 (Ded Waived) Preferred Brand Drugs $0 after Ded 30% after Ded $35 after Ded $25 after Ded $15 20% after Ded Non-Preferred Brand Drugs $0 after Ded 30% after Ded 30% after Ded $45 after Ded $35 20% after Ded Specialty Drugs $0 after Ded 30% after Ded 30% after Ded $65 after Ded $55 20% after Ded Page 7

65 Quality Improvement Our quality improvement programs includes implementation of quality improvement activities that include: o Quality reporting. o Effective case management. o Care coordination. o Chronic disease management. o Medication and care compliance initiatives. Examples of a few of our strategies include: o Improving health outcomes. o Preventing hospital readmissions. o Improving patient safety. o Wellness and health promotion activities. o Reducing health and health care disparities. o Behavioral health services. Page 8

66 Customer Service and Access to Information WellCare has a team of highly trained Customer Service professionals strictly dedicated to service members who have enrolled in WellCare products through Kynect. Customer Service representatives are also available to service members who have a primary language other than English. Dedicated Phone Number for KY. Representatives are available Monday Friday from 8AM 6PM. Information can also be access through the WellCare web at Members can request materials, see claims and payments, access information, change PCP. Page 9

67 New Member On Boarding New member kits will be sent out 5 days after receiving a completed enrollment. Members will receive their first bill within several days of enrollment. After the first payment is received, a payment book will be mailed to subscriber on the account. Members will need to select a Primary Care Physician (PCP), if not selected it will be assigned. Members can change their PCP at any time. ID Cards will be mailed when a PCP is selected or 10 days prior to enrollment. Health Risk Assessment initiated to new members after effective date (telephonic). Page 10

68 QUESTIONS Page 11

69 Kentucky Health Cooperative

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72 Overview for 2015 a. Certificate of Coverage & Schedule of Benefits Certificate completely rewritten to enhance readability and comprehension and minimize ambiguity. Schedule of Benefits rewritten to enhance readability and comprehension. b. Benefit Changes i. Platinum Deductible increased, PCP and SCP copays decreased. ii. Gold No changes. iii. Silver Deductible and PCP copay increased. iv. Silver, Bronze and Catastrophic MOOP increased to $6,600. c. Pharmacy Elimination of prior authorizations for many of the pharmaceuticals that required them in Loosening of Quantity Level Limit restrictions. d. All products are offered in all eight of Kentucky s rating regions.

73 Overview for 2015 continued 2. Rates a. Filed & approved 20% increase to base rates. 3. Network and Network Service Area a. Network Composition 97% of KY hospitals and 89% of KY physicians are innetwork. b. Network Service Area Redefined to include all of Kentucky and bordering counties in all contiguous states. 4. First stage of member-governed board effective in January. 47 nominations for board positions were received from current members.

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75 3 Things 1. Keep your health insurance information in a safe spot where you can always find it. 2. Know what defines an emergency. 3. Know where to find the closest pharmacy. 75

76 Property and Casualty Insurance you never hope to use.

77 Health Insurance Insurance you might want to use.

78 Source: Google Images Why the ACA is a Big Deal

79 79 Consumer Welcome Page

80 The Right Plan for You Bronze Silver Gold Platinum Plan pays 60% covered expenses Plan pays 70% covered expenses Plan pays 80% covered expenses Plan pays 90% covered expenses You pay 40% You pay 30% You pay 20% You pay 10% As plans share of expenses increase, so do premiums. As plans share of expenses decrease, so do premiums. 80

81 Essential Health Benefits: All ACA- Qualified Health Plans 1. Hospitalization 6. Preventive, wellness, chronic disease management 2. Emergency services 7. Pediatric services 3. Prescription drugs 8. Rehabilitative & habilitative services 4. Laboratory services 9. Maternity & newborn care 5. Ambulatory patient services 10. Mental health & substance abuse services

82 What Happens (Or, how you may have gotten here) You submitted an application or someone helped you. Payment of first premium required. Allow 5 days for processing. Your policy arrived. Your right, as a consumer: 10-day free look.

83 What Happens (cont d) Insurer sends: ID card Welcome kit Special notices Certificate of Coverage Covers your benefits. You should: Read what you re sent. Get more familiar with drug list. Know who is in-network. Get to know insurance terms. Keep information in a safe spot.

84 Assignment Locate on membership card: Member number Group number Cost of a specialist copayment Cost of ER visit Cost of urgent care visit Cost of pharmacy copayments

85 Another Assignment Look at Summary of Benefits. Are chiropractic visits covered? How about mental/behavioral health? What is deductible for Primary Care visit? What is deductible for seeing a specialist?

86 Yet Another Assignment Look at the Explanation of Benefits (EOB). Is this document a bill/statement? How much money has John Doe spent on in-network deductibles? How much did the plan pay for John Doe s Crestor? Does John Doe have generic drug options? 86

87 Scenario #1. We never get sick. We are invincible. You have coverage. Should you use it?

88 Scenario #2. Deon has poison ivy. He is probably going to need a prescription. What do these options cost, and which should he do? 1. Go to the emergency room. 2. Go to an urgent treatment center. 3. Visit his innetwork primary care doctor. 4. Go to an outof-network primary care doctor.

89 Or. What about talking with your pharmacist? Cost: Free, and from a trusted community health professional. Could require cost of medication. What everyone should know: Location of nearest pharmacy or pharmacist. 89

90 Think About Your Choices Emergency Rooms Sudden and life-threatening injuries/illnesses. Call 911. Fainting Chest pain/pressure Uncontrolled bleeding Coughing/vomiting blood Sudden severe pain Poisoning Major injuries (broken bones) Sudden facial drooping or weakness in arm/leg Urgent Treatment Center Not emergencies, but medical problems Cold/flu Earache Sore throat/cough Minor accidents/falls Minor sprains Minor cuts not bleeding a lot but requiring stitches Fever Mild vomiting/diarrhea Mild-to-moderate asthma Source: Jefferson County Department of Public Health.

91 Prescription Drugs Most frequently-used benefit

92 Drug Lists Open formulary: may group drugs into categories such as generic, preferred brand-name, nonpreferred brandname.

93 How They Work Prescription drug benefits may have a deductible. After deductible is satisfied, copayments are charged according to tier of the prescription. Some health plans limit what you spend out of your own pocket during a 12-month period (annual out-of-pocket maximum).

94 Penalty Income-based penalty 1% of income above filing threshold 2% of income above filing threshold 2.5% of income above filing threshold 2.5% of income above filing threshold Minimum penalty amount $95 $325 $695 $695 + inflation adjustment * Be sure to consult a financial or tax professional for specific guidance.

95 Important Dates 95 March 31, 2014/ April 15, 2014* Sign-up deadline for coverage to avoid a penalty *Some enrollees qualified for extended enrollment due to technical difficulties. April 1, 2014 Special enrollment opens. Triggered by qualifying events* * Examples: Birth, relocation, death, change in job status November 15, 2014 Open enrollment for 2015 plans begins. Lasts through February 15, 2015.

96 For those eligible to apply now: Kynect customer service kynect ( ) Agents, kynectors

97 Kentucky Health Cooperative Contacts Not a member? Already a member? Agent or broker? Health care provider?

98 Other Resources Medicaid Medicare DCBS Nurse Line on back of insurance card 98

99 Questions? 99

100 Questions? Lindsay Nelson Coordinator of Community Development and Outreach