INDIVIDUALS & FAMILIES Plan Overview

Transcription

1 INDIVIDUALS & FAMILIES 2015 Plan Overview

2 Your partner in health and wellness Choosing a health plan is a big decision. Sure, you want someone who ll cover your treatments when you re sick. But it s really about having a partner who encourages you to feel better and live well every day. Your pursuit of health and happiness is a unique journey. You deserve a partner who will go the distance with you. Why choose? You ll find a plan and options to fit your unique needs We offer a broad range of plan types and cost-sharing options (e.g., deductible, coinsurance and copayment). Our networks range from a local base of medical home providers to nearly 1 million providers nationwide. Everyone deserves better health. It s our Mission to take care of people in need, which is why we strive to improve the quality of life for those in the communities we serve by donating vital health care services. For the past eight years, we have been recognized by the Portland Business Journal as one of the most admired health care companies. We re a local, not-for-profit health plan that understands the specific issues and challenges of Oregonians. We re easy to work with. Our friendly, local customer service representatives process claims promptly. They answer your calls quickly and go the extra mile to resolve issues as fast as possible. You can get online claims and benefits information easily through my, a one-stop resource that can help you better understand and use your health plan benefits. You get more for your health and your health care dollar. You ll receive discounts on massage therapy, fitness classes, gym memberships, LASIK and other extras to keep you healthy, happy and engaged in life. With our online tools and classes, you can stay on target with your health and wellness goals. Exclusive wellness resources Our FitTogether wellness programs and services include: Access to ProvRN for free health advice, 24/7, from a registered nurse Tobacco cessation programs to help tobacco users quit for good Award-winning care managers who provide education and support for chronic conditions, such as asthma and diabetes Health and wellness classes to help you manage stress, achieve a healthy weight, begin a yoga practice and more An award-winning newsletter packed with health and wellness information from health experts Innovative tools to maintain and improve health With my, our secure member portal and complete source for health, wellness and benefits information, you can: Get a baseline of your overall health with a personal health assessment Search our online directory to find providers, review your claims history and calculate how much of your deductible you ve met Manage your health costs with our treatment cost estimator and online bill pay options Improve your health with Wellness Central, an integrated health and wellness hub that offers a personalized dashboard, health trackers and assessments, a library of health videos and articles, meal plans and medication information With MyChart, a secure website for Medical Group patients, you can: Schedule appointments online your PMG provider Pay bills online Access your lab and test results Health-enhancing extras for better fitness and more fun As a Health Plan member, you can enjoy savings on: Exclusive recreation discounts through LifeBalance for: Popular local and national family attractions, such as zoos and amusement parks Hundreds of fitness facilities throughout Oregon Discounted tickets to local events, savings at hotels nationwide and more Board-certified LASIK vision correction or custom LASIK through our partner, TruVision Hearing aids (up to 60 percent off) through our partner, TruHearing Experience and innovation mean better care for you. We re part of Health & Services, one of the nation s top 10 most-integrated health care providers, serving the Pacific Northwest for nearly 160 years. This booklet offers an overview of our individual and family plans and premiums, which are subject to change every year. For more information about plan benefits and enrollment requirements, limitations and exclusions, see the plan contract or contact our sales team or your insurance producer. To view a benefit summary, go to We re innovative. With telemedicine and close coordination between our hospitals and clinics, you get better care. 2 3

3 Your lifestyle, your plan Choose a 2015 health plan that best fits your life, and your health. You ll find robust benefits and extensive provider choices; an HSA-qualified plan that lets you save tax-free dollars for future medical expenses; and two plan types centered on a medical home model that lets you choose a primary care clinic near you with a health care team to coordinate your care. Alternative care options If you prefer to see a naturopath or other alternative care provider for covered benefits, including periodic exams and well-baby care, those services are covered at the same rate as they would be for a primary care physician, as long as the provider is licensed to perform the service provided. The Balance, Choice and Connect plans cover chiropractic manipulation and acupuncture with a $25 copay when you visit an provider. Flexibility to change plans We get it. Life throws curve balls that can change your financial situation. When you buy from, you can switch to a plan with a lower premium once during the contract year. If you buy your plan through the Federal Health Insurance Marketplace, any changes in plans throughout the year are subject to approval by the Marketplace. Pediatric dental coverage There s a plan for you and your family, no matter where you live in Oregon. Balance, HSA Qualified, Standard, Choice and Essential plans are available throughout Oregon. Your rate will be calculated according to your age, whether you use tobacco, and the county you live in. See the map on page 21 to find your rate area. Coos Lincoln Clatsop Tillamook Polk Benton Curry Josephine Columbia Washington Yamhill Douglas Marion Lane Jackson Multnomah Clackamas Linn Hood River Jefferson Deschutes Klamath Wasco Sherman Gilliam Wheeler Crook Lake Morrow Grant Umatilla Harney Union Baker Malheur Wallowa Where to buy plans Purchase the right plan for you at or ask a representative or your insurance producer for help. plans are also available through the Federal Health Insurance Marketplace at HealthCare.gov. Metal tier Plans available directly from or your producer Balance 2000 Silver Silver Balance 4000 Silver Silver HSA Qualified 2800 Bronze Bronze Plans available from the Federal Health Insurance Marketplace at HealthCare.gov Choice 2000 Silver Silver Choice 4000 Silver Silver Connect 2000 Silver Silver Connect 4000 Silver Silver Oregon Gold Oregon Silver Oregon Standard Bronze Plan Bronze Essential Catastrophic Pediatric dental care is an essential health benefit required by the ACA. It is included in all our medical plans, except the Essential and Standard plans. For your convenience and savings, dental benefits are subject to the medical deductible and out-of-pocket maximum. Connect plans are available only in Multnomah, Clackamas and Washington counties. Compare plans Check rates Apply and enroll online We can help you find the right plan. Apply and enroll: Columbia Online at Over the phone with a representative Washington Multnomah Hood River Portland metro area All other areas Yamhill Polk Marion Clackamas Monday through Friday, 8 a.m. to 8 p.m. With your insurance producer Apply during open enrollment from Nov. 15, 2014, through Feb. 15, After the open enrollment period ends, you must have a qualifying life event to enroll in a health insurance plan. Qualifying life events include losing employer 4 coverage, marriage and the birth of a child. See a list of qualifying life events at 5

4 Balance Balance (continued) Balance plans are just that, a balance of cost-saving features and coverage for the services you use the most. The plans include: No deductible for primary care, generic drugs, and lab and X-ray services; your only out-ofpocket expense is your copay, where applicable A deductible you can apply to the out-of-pocket maximum Coverage for routine vision services, including glasses and contacts The freedom to choose any provider, in and out of the EPO Network Pediatric dental coverage Balance After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with EPO Network: A network of nearly 1 million health care providers nationwide, both in facilities and in other locations. Balance 2000 Silver Balance 4000 Silver out-of-network out-of-network Annual Deductible Individual/Family $2,000/$4,000 $4,000/$8,000 $4,000/$8,000 $8,000/$16,000 Annual Out-of-Pocket Maximum Individual/Family $5,900/$11,800 $11,800/$23,600 $5,900/$11,800 $11,800/$23,600 Accidental Injury Benefit PREVENTIVE CARE Periodic health exams and well-baby care (from any provider licensed to perform the service) The deductible is waived for all covered services required to treat an accidental injury within 90 days of injury. in in Maternity prenatal care in in Gynecological exams; Pap tests in in Mammograms in in Colorectal cancer screenings (age 50 and over) in in After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with OFFICE VISITS FOR MEDICAL SERVICES Balance 2000 Silver Balance 4000 Silver out-of-network out-of-network Personal Physician/Provider $25 $25 Specialist $50 $50 Alternative care provider (e.g., naturopath, chiropractor, acupuncturist) HOSPITAL SERVICES $25 $25 Inpatient hospital services and maternity care 30% 30% EMERGENCY/URGENT CARE Emergency services $250 then 30% $250 then 30% $250 then 30% $250 then 30% Urgent care services $75 $75 OUTPATIENT DIAGNOSTIC SERVICES X-ray and lab services 30% 30% High tech imaging services (such as PET, CT, MRI) 30% 30% MENTAL HEALTH AND SUBSTANCE ABUSE Inpatient and residential services 30% 30% Outpatient provider visits $25 $25 OTHER COVERED SERVICES Outpatient surgery at an ambulatory surgery center or hospital-based facility Chiropractic manipulation and acupuncture (limited to 3 visits combined per calendar year) PRESCRIPTION DRUGS 30% 30% $25 $25 Generic $15 $15 Preferred brand name $60 $60 Non-preferred brand name and specialty PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19) Routine eye exams (limited to one exam per calendar year) Vision hardware (frames, lenses, contact lenses) Limits apply ADULT VISION SERVICES Routine eye exams (limited to one exam per calendar year) Vision hardware (frames, lenses, contact lenses) Limits apply PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19) Preventive services (routine exams, cleanings, x-rays, topical fluoride, and sealants) in in in in $30 $30 6 in 30% in 30% 7 Basic services (includes restorative fillings - silver and composite, and space maintainers) Major services (includes oral surgery, crowns, bridges, periodontics, endodontics/root canals, dentures) 70% 70% 70% 70%

5 HSA Qualified These lower-premium, high-deductible health plans give you affordable coverage and the flexibility to choose any provider. With an HSA Qualified plan, paired with a tax-exempt savings account, you save pre-tax dollars to pay for future health care expenses. HSA Qualified plans offer: Care from specialists without a referral Lower premiums with most services subject to the deductible In-network preventive care and adult routine vision services that are covered before the deductible The freedom to choose any provider, in or out of the EPO Network A deductible that applies to the out-of-pocket maximum Pediatric dental coverage A preferred rate and easy set-up when you open a health savings account with HealthEquity, a partner of Health Plan HSA Qualified After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with EPO Network: A network of nearly 1 million health care providers nationwide, both in facilities and in other locations. HSA Qualified 2800 Bronze out-of-network Annual Deductible Individual/Family $2,800/$5,600 $5,600/$11,200 Annual Out-of-Pocket Maximum Individual/Family PREVENTIVE CARE Periodic health exams and well-baby care (from any provider licensed to perform the service) $6,200/$12,400 $12,400/$24,800 in Maternity prenatal care in Gynecological exams; Pap tests in Mammograms in Colorectal cancer screenings (age 50 and over) in HSA Qualified (continued) After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with OFFICE VISITS FOR MEDICAL SERVICES HSA Qualified 2800 Bronze 8 70% periodontics, endodontics/root canals, dentures) 9 out-of-network Personal Physician/Provider Specialist Alternative care provider (e.g., naturopath, chiropractor, acupuncturist) HOSPITAL SERVICES Inpatient hospital services and maternity care EMERGENCY/URGENT CARE Emergency services Urgent care services OUTPATIENT DIAGNOSTIC SERVICES X-ray and lab services High tech imaging services (such as PET, CT, MRI) MENTAL HEALTH AND SUBSTANCE ABUSE Inpatient and residential services Outpatient provider visits OTHER COVERED SERVICES Outpatient surgery at an ambulatory surgery center or hospital-based facility Chiropractic manipulation and acupuncture PRESCRIPTION DRUGS Generic Preferred brand name Non-preferred brand name and specialty PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19) Routine eye exams (limited to one exam per calendar year) in Vision hardware (frames, lenses, contact lenses) Limits apply in ADULT VISION SERVICES Routine eye exams (limited to one exam per calendar year) $25 Vision hardware (frames, lenses, contact lenses) Limits apply PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19) Preventive services (routine exams, cleanings, x-rays, topical fluoride, and sealants) Basic services (includes restorative fillings - silver and composite, and space maintainers) Major services (includes oral surgery, crowns, bridges, in 30% 70%

6 Choice Choice plans utilize a medical home model which provides a team of health professionals dedicated to each member s overall well-being. Members select a medical home at time of enrollment from the Choice Network. The medical home team then works collaboratively to support all aspects of a member s health, from wellness and prevention to active management of chronic conditions. Choice plans offer: More than 200 medical home clinics in Oregon and southwest Washington that provide a patient-focused, coordinated care experience Access a broad network of specialists and facilities via referral from the medical home in order to receive coverage at the level Deductibles waived for doctor and specialist visits, urgent care, lab and X-ray services, chiropractic manipulation and acupuncture, and generic and preferred brand-name drugs Higher cost shares for select services such as knee and hip replacement, sleep studies, and sinus surgery Separate deductibles and out-of-pocket maximums in and out of the network Pediatric dental coverage Adult vision coverage (exams and hardware) Choice After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with Choice Network: A network of over 200 primary care clinics located throughout Oregon and southwest Washington designated as medical homes Coos Wahkiakum Lincoln Clatsop Tillamook Polk Benton Curry Josephine Columbia Washington Yamhill Douglas Cowlitz Marion Hood Multnomah River Lane Jackson Clark Clackamas Linn Skamania Deschutes Klamath Wasco Jefferson Klickitat Sherman Gilliam Wheeler Crook Lake Morrow Grant Umatilla Harney Union Baker Malheur Wallowa For a complete list of medical homes and providers by location, visit Choice 2000 Silver Choice 4000 Silver Annual Deductible Individual/Family $2,000/$4,000 $4,000/$8,000 $4,000/$8,000 $8,000/$16,000 Annual Out-of-Pocket Maximum Individual/Family $5,900/$11,800 $11,800/$23,600 $5,900/$11,800 $11,800/$23,600 Accidental Injury Benefit PREVENTIVE CARE Periodic health exams and well-baby care (from any provider licensed to perform the service) The deductible is waived for all covered services required to treat an accidental injury within 90 days of injury. in in Maternity prenatal care in in After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with OFFICE VISITS FOR MEDICAL SERVICES Choice 2000 Silver Choice 4000 Silver Gynecological exams; Pap tests in in in 30% in 30% 10 x-rays, topical fluoride, and sealants) 11 Mammograms in in Colorectal cancer screenings (age 50 and over) in in Choice (continued) Personal Physician/Provider $25 $25 Specialist $50 $50 Alternative care provider (e.g., naturopath, chiropractor, acupuncturist) HOSPITAL SERVICES $25 $25 Inpatient hospital services and maternity care 30% 30% EMERGENCY/URGENT CARE Emergency services $250 then 30% $250 then 30% $250 then 30% $250 then 30% Urgent care services $75 $75 OUTPATIENT DIAGNOSTIC SERVICES X-ray and lab services 30% 30% High tech imaging services (such as PET, CT, MRI) 30% 30% MENTAL HEALTH AND SUBSTANCE ABUSE Inpatient and residential services 30% 30% Outpatient provider visits $25 $25 OTHER COVERED SERVICES Outpatient surgery at an ambulatory surgery center or hospital-based facility Chiropractic manipulation and acupuncture (limited to 3 visits combined per calendar year) PRESCRIPTION DRUGS 30% 30% $25 $25 Generic $15 $15 Preferred brand name $60 $60 Non-preferred brand name and specialty PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19) Routine eye exams (limited to one exam per calendar year) Vision hardware (frames, lenses, contact lenses) Limits apply ADULT VISION SERVICES Routine eye exams (limited to one exam per calendar year) Vision hardware (frames, lenses, contact lenses) Limits apply PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19) Preventive services (routine exams, cleanings, Basic services (includes restorative fillings - silver and composite, and space maintainers) Major services (includes oral surgery, crowns, bridges, periodontics, endodontics/root canals, dentures) in in in in $30 $30 70% 70% 70% 70%

7 Connect Connect plans combine a medical home model of care with a narrow provider network to achieve substantial premium savings. Members choose a medical home at time of enrollment from our Portland metro-area Connect Network. The medical home model provides a team of health professionals dedicated to your overall wellbeing. The medical home team members work collaboratively to support all aspects of your health, from wellness and prevention to active management of chronic conditions. Connect plans offer: More than 65 medical home clinics in the Portland metro area Access to specialists and facilities via referral from the medical home in order to receive coverage at the level A deductible that applies to the out-of-pocket maximum No deductible for doctor and specialist visits, lab and X-ray services, and generic drugs Pediatric dental coverage Higher cost shares for select services such as knee and hip replacement, sleep studies, and sinus surgery Connect After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with Connect Network: A Portlandarea network of over 65 primary care clinics in Multnomah, Washington and Clackamas counties designated as medical homes. Yamhill Polk Columbia Washington Marion Multnomah Clackamas Hood River For a complete list of medical homes and providers by location, visit Connect 2000 Silver Connect 4000 Silver Annual Deductible Individual/Family $2,000/$4,000 $4,000/$8,000 $4,000/$8,000 $8,000/$16,000 Annual Out-of-Pocket Maximum Individual/Family $5,900/$11,800 $11,800/$23,600 $5,900/$11,800 $11,800/$23,600 Accidental Injury Benefit PREVENTIVE CARE Periodic health exams and well-baby care (from any provider licensed to perform the service) The deductible is waived for all covered services required to treat an accidental injury within 90 days of injury. in in Maternity prenatal care in in in 30% in 30% 12 Gynecological exams; Pap tests in in x-rays, topical fluoride, and sealants) 13 Mammograms in in Colorectal cancer screenings (age 50 and over) in in Connect (continued) After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with OFFICE VISITS FOR MEDICAL SERVICES Connect 2000 Silver Connect 4000 Silver Personal Physician/Provider $25 $25 Specialist $50 $50 Alternative care provider (e.g., naturopath, chiropractor, acupuncturist) HOSPITAL SERVICES $25 $25 Inpatient hospital services and maternity care 30% 30% EMERGENCY/URGENT CARE Emergency services $250 then 30% $250 then 30% $250 then 30% $250 then 30% Urgent care services $75 $75 OUTPATIENT DIAGNOSTIC SERVICES X-ray and lab services 30% 30% High tech imaging services (such as PET, CT, MRI) 30% 30% MENTAL HEALTH AND SUBSTANCE ABUSE Inpatient and residential services 30% 30% Outpatient provider visits $25 $25 OTHER COVERED SERVICES Outpatient surgery at an ambulatory surgery center or hospital-based facility Chiropractic manipulation and acupuncture (limited to 3 visits combined per calendar year) PRESCRIPTION DRUGS 30% 30% $25 $25 Generic $15 $15 Preferred brand name $60 $60 Non-preferred brand name and specialty PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19) Routine eye exams (limited to one exam per calendar year) Vision hardware (frames, lenses, contact lenses) Limits apply ADULT VISION SERVICES Routine eye exams (limited to one exam per calendar year) Vision hardware (frames, lenses, contact lenses) Limits apply PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19) Preventive services (routine exams, cleanings, Basic services (includes restorative fillings - silver and composite, and space maintainers) Major services (includes oral surgery, crowns, bridges, periodontics, endodontics/root canals, dentures) in in in in $25 $25 70% 70% 70% 70%

8 Standard Benefits for Standard plans are defined by the state of Oregon. Choose a Gold, Silver or Bronze plan with deductibles ranging from $1,300 to $5,000. Standard plans offer: Copays starting as low as $20 and deductibles as low as $1,300 A deductible that applies to the out-of-pocket maximum The freedom to choose any provider in and out of the EPO Network The Oregon Standard Bronze Plan is HSA qualified To note: Standard plans do not cover chiropractic manipulation, acupuncture, adult routine vision exams and vision hardware, or pediatric dental services. Standard After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with Annual Deductible Individual/Family Annual Out-of-Pocket Maximum Individual/Family PREVENTIVE CARE Periodic health exams and well-baby care (from any provider licensed to perform the service) Maternity prenatal care Gynecological exams; Pap tests Mammograms Colorectal cancer screenings (age 50 and over) OFFICE VISITS FOR MEDICAL SERVICES Oregon Standard Gold $1,300/ $2,600 $6,350/ $12,700 in in in in in $2,600/ $5,200 $12,700/ $25,400 EPO Network: A network of nearly 1 million health care providers nationwide, both in facilities and in other locations. Oregon Standard Silver $2,500/ $5,000 $6,350/ $12,700 in in in in in $5,000/ $10,000 $12,700/ $25,400 Oregon Standard Bronze $5,000/ $10,000 $6,350/ $12,700 in in in in in $10,000/ $20,000 $12,700/ $25, Personal Physician/Provider $20 $35 $60 Basic services (includes restorative 15 Specialist $40 $70 $100 Alternative care provider (e.g.,naturopath, chiropractor, acupuncturist) $40 $70 $100 Standard (continued) After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with HOSPITAL SERVICES Inpatient hospital services and maternity care EMERGENCY/URGENT CARE Oregon Standard Gold Oregon Standard Silver Oregon Standard Bronze innetwork innetwork innetwork innetwork innetwork innetwork 10% 30% Emergency services 10% 10% 30% 30% Urgent care services $60 $90 $120 OUTPATIENT DIAGNOSTIC SERVICES X-ray and lab services 10% 30% High tech imaging services (such as PET, CT, MRI) MENTAL HEALTH AND SUBSTANCE ABUSE 10% 30% Inpatient and residential services 10% 30% Outpatient provider visits $20 $35 $60 OTHER COVERED SERVICES Outpatient surgery at an ambulatory surgery center or hospital-based facility Chiropractic manipulation and acupuncture PRESCRIPTION DRUGS Generic Preferred brand name Non-preferred brand name and specialty 10% 30% $10 $30 PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19) Routine eye exams (limited to one exam per calendar year) Vision hardware (frames, lenses, contact lenses) Limits apply ADULT VISION SERVICES Routine eye exams (limited to one exam per calendar year) Vision hardware (frames, lenses, contact lenses) Limits apply in in PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19) Preventive services (routine exams, cleanings, x-rays, topical fluoride, and sealants) fillings - silver and composite, and space maintainers) Major services (includes oral surgery, crowns, bridges, periodontics, endodontics/root canals, dentures) $15 $50 in in $20 $80 in in

9 Essential The Essential plan covers you in case of unforeseen major medical expenses. This catastrophic plan is available only to individuals aged 29 years and younger. The Essential plan offers: Affordable coverage with lower monthly premiums Coverage for up to three personal physician/provider office visits per calendar year before the deductible is met Prescription drug coverage The freedom to choose any provider, in and out of the EPO Network Essential After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with EPO Network: A network of nearly 1 million health care providers nationwide, both in facilities and in other locations. Essential out-of-network Annual Deductible Individual/Family $6,600/$13,200 $13,200/$26,400 Annual Out-of-Pocket Maximum Individual/Family $6,600/$13,200 $13,200/$26,400 PREVENTIVE CARE Periodic health exams and well-baby care (from any provider licensed to perform the service) in in full Maternity prenatal care in in full Gynecological exams; Pap tests in in full Mammograms in in full Colorectal cancer screenings (age 50 and over) in in full OFFICE VISITS FOR MEDICAL SERVICES Personal Physician/Provider first 3 visits in full Specialist in full in full Alternative care provider (e.g., naturopath, chiropractor, acupuncturist) Essential (continued) After meeting your deductible, you pay the following amounts for covered services. The deductible is waived for some covered services. These are marked with HOSPITAL SERVICES Essential 16 in full in full 17 out-of-network Inpatient hospital services and maternity care in full in full EMERGENCY/URGENT CARE Emergency services in full in full Urgent care services in full in full OUTPATIENT DIAGNOSTIC SERVICES X-ray and lab services in full in full High tech imaging services (such as PET, CT, MRI) in full in full MENTAL HEALTH AND SUBSTANCE ABUSE Inpatient and residential services in full in full Outpatient provider visits in full in full OTHER COVERED SERVICES Outpatient surgery at an ambulatory surgery center or hospitalbased facility in full in full Chiropractic manipulation and acupuncture PRESCRIPTION DRUGS Generic in full Preferred brand name in full Non-preferred brand name and specialty in full PEDIATRIC VISION SERVICES (CHILDREN UP TO AGE 19) Routine eye exams (limited to one exam per calendar year) in Vision hardware (frames, lenses, contact lenses) Limits apply in ADULT VISION SERVICES Routine eye exams (limited to one exam per calendar year) Vision hardware (frames, lenses, contact lenses) Limits apply PEDIATRIC DENTAL SERVICES (CHILDREN UP TO AGE 19) Preventive services (routine exams, cleanings, x-rays, topical fluoride, and sealants) Basic services (includes restorative fillings - silver and composite, and space maintainers) Major services (includes oral surgery, crowns, bridges, periodontics, endodontics/root canals, dentures)

10 Compare our 2015 plans side-by-side Plan name Oregon Standard Gold Plan Oregon Standard Silver Plan Balance 2000 Silver Balance 4000 Silver Choice 2000 Silver Choice 4000 Silver Connect 2000 Silver Connect 4000 Silver HSA Qualified 2800 Bronze Metal level Gold Silver Silver Silver Silver Silver Silver Silver Bronze Bronze Catastrophic Where to buy Health Plan/nt and/or Marketplace Health Plan/nt and/or Marketplace Health Plan/nt Health Plan/nt Health Plan/ nt and/or Marketplace Health Plan/ nt Health Plan/ nt and/or Marketplace Health Plan/ nt Health Plan/ nt Oregon Standard Bronze Plan Health Plan/ nt and/or Marketplace Essential Health Plan/nt and/or Marketplace Annual Deductible Individual/Family $1,300/$2,600 $2,500/$5,000 $2,000/$4,000 $4,000/$8,000 $2,000/$4,000 $4,000/$8,000 $2,000/$4,000 $4,000/$8,000 $2,800/$5,600 $5,000/$10,000 $6,600/$13,200 Annual Out-of-Pocket Maximum Individual/Family $6,350/$12,700 $6,350/$12,700 $5,900/$11,800 $5,900/$11,800 $5,900/$11,800 $5,900/$11,800 $5,900/$11,800 $5,900/$11,800 $6,200/$12,400 $6,350/$12,700 $13,200/$26,400 Accidental Injury Benefit covered covered The deductible is waived for all covered services required to treat an accidental injury within 90 days of injury covered covered covered PPP office visit $20 3 $35 3 $25 3 $25 3 $25 3 $25 3 $25 3 $25 3 $60 first 3 visits 3 Specialist office visit $40 3 $70 3 $50 3 $50 3 $50 3 $50 3 $50 3 $50 3 $100 in full Chiropractic manipulation & Acupuncture $25 3 $25 3 $25 3 $25 3 $25 3 $25 3 Prescription Drugs (generic) $10 3 $15 3 $15 3 $15 3 $15 3 $15 3 $15 3 $15 3 $20 in full Preferred brand name drugs $30 3 $50 3 $60 3 $60 3 $60 3 $60 3 $60 3 $60 3 $80 in full Inpatient Hospital 10% 30% 30% 30% 30% 30% 30% 30% in full Emergency services 10% 30% $250 then 30% $250 then 30% $250 then 30% $250 then 30% $250 then 30% $250 then 30% in full Urgent care visits $60 3 $90 3 $75 3 $75 3 $75 3 $75 3 $75 3 $75 3 $120 in full Mental health - Outpatient visits $20 3 $35 3 $25 3 $25 3 $25 3 $25 3 $25 3 $25 3 $60 in full Outpatient diagnostic lab & x-ray 10% 30% 30% 3 30% 3 30% 3 30% 3 30% 3 30% 3 in full Adult vision exams covered covered $30 3 $30 3 $30 3 $30 3 $25 3 $25 3 $25 3 covered covered Pediatric vision (exams & hardware) in full 3 in full 3 in full 3 in full 3 in full 3 in full 3 in full 3 in full 3 in full 3 in full 3 in full 3 Pediatric Dental covered covered Premium examples for non-tobacco users for rating Region A (Clackamas, Multnomah, Washington and Yamhill* counties) Single, 26 years old $219 $187 $199 $186 $185 $173 $170 $159 $165 $158 $152 Single, 55 years old $477 $408 $433 $406 $404 $377 $370 $346 $359 $343 N/A Family: parents aged 38 & 40, children aged 7 & 10 $812 $694 $736 $692 $687 $641 $629 $587 $611 $585 N/A Networks EPO Network Choice Network Connect Network EPO Network *Connect plans are not available for purchase in Yamhill county. 3 Deductible waived for these services PLEASE NOTE: Benefit examples shown above for coverage only. For the full listing of in- and out-of-network benefits, visit A network of nearly 1 million health care providers nationwide, both in providence facilities and in other locations A network of over 200 primary care clinics located throughout Oregon and southwest Washington designated as medical homes A Portland-area network of over 65 primary care clinics in Multnomah, Washington and Clackamas counties designated as medical homes A network of nearly 1 million health care providers nationwide, both in providence facilities and in other locations Lane Deschutes 18 Yamhill Clackamas 19 Coos Wahkiakum Lincoln Clatsop Tillamook Polk Benton Columbia Washington Yamhill Douglas Cowlitz Marion Clark Multnomah Clackamas Linn Skamania Hood River Wasco Jefferson Klickitat Sherman Gilliam Wheeler Crook Morrow Grant Umatilla Harney Union Baker Malheur Wallowa Columbia Washington Multnomah Hood River Curry Josephine Jackson Klamath Lake Polk Marion

11 Glossary of Terms Accidental injury An injury that is due directly to an unintentional act, independent of all other causes. Calendar year The period from January 1 through December 31 each year. Coinsurance A percentage of the amount you are responsible to pay a health care provider for a covered service. For example, if a health care service is covered at a 20 percent coinsurance, you would pay 20 percent of the covered costs and the plan would pay 80 percent. Copay A fixed dollar amount that you are responsible for paying to a health care provider at the time you receive the service. For example, if an office visit is covered at a $20 copay, you would pay $20 and the plan would pay the remaining balance. Deductible A deductible is the amount you must pay for services that are that are covered by the health plan before your plan will begin to pay for these services. A new deductible must be met each calendar year. Dependent A person who is supported by the policyholder or the policyholder s spouse. Effective date of coverage Effective date of coverage means the date upon which coverage starts for a newly-enrolled health plan member. Exclusion A service or supply not covered by the health plan. Exclusion period A period of time during which all specified treatments or procedures are excluded from coverage. If treatment was covered under a previous plan, then the exclusion period is reduced by each day of continuous prior creditable coverage. Limitations Certain covered services have a plan maximum for coverage for a set period of time, usually a calendar year. Marketplace Also called an exchange, a health insurance marketplace is an online place where you can buy health coverage. If you qualify for a tax credit or subsidy to help pay for your coverage, you must buy your health plan through the Federal Health Insurance Marketplace, located at HealthCare.gov. Member A policyholder or eligible spouse or dependent who is properly enrolled in the plan. Non-participating provider A health care provider or facility with no agreement to participate with Health Plan. When you use non-participating providers, you receive out-of-network benefits and pay a higher coinsurance for your share of the costs. Out-of-pocket maximum The total amount you will pay in the deductible, copays and coinsurance for covered services in a calendar year. After you meet your plan s out-of-pocket maximum, the plan will pay for 100 percent of covered serviced for the remainder of the year. Participating provider A health care provider or facility with an agreement to participate with providence Health Plan. When you use participating providers you receive benefits and have lower costs. Personal physician/provider A participating provider who has agreed to provide or coordinate medical care and is listed in the personal physician/provider section of the Provider Directory. Premium The monthly rate you pay for health plan coverage. Provider network A provider network is a collection of physicians, hospitals, and facilities that have agreed to set reimbursement rates for health care services delivered to members of a health insurance plan. Health Plan has three networks that are matched to our various plans. Service area The geographic area in Oregon where the policyholder, spouse of the policyholder or child-only member must physically reside in order to qualify for coverage. Plan availability may vary by county. Individual and Family plan rates for 2015 Several factors make up your monthly premium rate: Your age Whether or not you use tobacco The county where you live has combined Oregon counties into three rate groups: Group A: Clackamas, Multnomah, Washington, Yamhill Group B: Benton, Douglas, Jackson, Josephine, Lane, Linn, Marion, Polk Group C: Baker, Clatsop, Columbia, Coos, Crook, Curry, Deschutes, Gilliam, Grant, Harney, Hood River, Jefferson, Klamath, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, Wasco, Wheeler To determine the premium for yourself as an individual, go to the rate sheet for the county in which you live, use your age and choose the plan that fits your needs. To determine the premium for you and your family, go to the rate sheet for the county in which you live, choose the plan that fits your needs, then use the ages for each person to be covered. Add the premium amounts for each family member to determine your total. If you re covering more than three children 20 years of age and younger, add only the premiums for your first three children. PLEASE NOTE: Tobacco use is defined as the use of tobacco products in any form an average of four or more times per week within the past six months.

12 Individual and Family Plan Rates, Group A: Non-Tobacco User Purchase any of these plans directly from at or your insurance producer. Plans marked * may also be purchased through the Federal Marketplace at HealthCare.gov. Effective Jan. 1, 2015 Dec. 31, 2015 Group A counties: Clackamas, Multnomah, Washington, Yamhill* *Connect plans are not available for purchase in Yamhill county. Metal Level 0 to Balance 2000 Silver Silver $ Balance 4000 Silver Silver $ HSA Qualified 2800 Bronze Bronze $ Choice 2000 Silver* Silver $ Choice 4000 Silver Silver $ Connect 2000 Silver* Silver $ Connect 4000 Silver Silver $ Standard Bronze Plan Gold $ Silver $ Bronze $ Essential* Catastrophic $ available to people age 30 and older Metal Level and Over Balance 2000 Silver Silver Balance 4000 Silver Silver HSA Qualified 2800 Bronze Bronze Choice 2000 Silver* Silver Choice 4000 Silver Silver Connect 2000 Silver* Silver Connect 4000 Silver Silver Gold Silver Bronze Standard Bronze Plan 23 Essential* Catastrophic available to people age 30 and older

13 Individual and Family Plan Rates, Group A: Tobacco User Purchase any of these plans directly from at or your insurance producer. Plans marked * may also be purchased through the Federal Marketplace at HealthCare.gov. Effective Jan. 1, 2015 Dec. 31, 2015 Group A counties: Clackamas, Multnomah, Washington, Yamhill* *Connect plans are not available for purchase in Yamhill county. Metal Level 0 to Balance 2000 Silver Silver $ Balance 4000 Silver Silver $ HSA Qualified 2800 Bronze Bronze $ Choice 2000 Silver* Silver $ Choice 4000 Silver Silver $ Connect 2000 Silver* Silver $ Connect 4000 Silver Silver $ Standard Bronze Plan Gold $ Silver $ Bronze $ Essential* Catastrophic $ available to people age 30 and older Metal Level and Over Balance 2000 Silver Silver Balance 4000 Silver Silver HSA Qualified 2800 Bronze Bronze Choice 2000 Silver* Silver Choice 4000 Silver Silver Connect 2000 Silver* Silver Connect 4000 Silver Silver Gold Silver Bronze Standard Bronze Plan 25 Essential* Catastrophic available to people age 30 and older Tobacco use is defined as the use of tobacco products in any form an average of four or more times per week within the past six months.

14 Individual and Family Plan Rates, Group B: Non-Tobacco User Purchase any of these plans directly from at or your insurance producer. Plans marked * may also be purchased through the Federal Marketplace at HealthCare.gov. Effective Jan. 1, 2015 Dec. 31, 2015 Group B counties: Benton, Douglas, Jackson, Josephine, Lane, Linn, Marion, Polk Metal Level 0 to Balance 2000 Silver Silver $ Balance 4000 Silver Silver $ HSA Qualified 2800 Bronze Bronze $ Choice 2000 Silver* Silver $ Choice 4000 Silver Silver $ Connect 2000 Silver* Silver available in these counties Connect 4000 Silver Silver available in these counties Standard Bronze Plan Gold $ Silver $ Bronze $ Essential* Catastrophic $ available to people age 30 and older Metal Level and Over Balance 2000 Silver Silver Balance 4000 Silver Silver HSA Qualified 2800 Bronze Bronze Choice 2000 Silver* Silver Choice 4000 Silver Silver Connect 2000 Silver* Silver available in these counties Connect 4000 Silver Silver available in these counties Gold Silver Bronze Standard Bronze Plan 27 Essential* Catastrophic available to people age 30 and older

15 Individual and Family Plan Rates, Group B: Tobacco User Purchase any of these plans directly from at or your insurance producer. Plans marked * may also be purchased through the Federal Marketplace at HealthCare.gov. Effective Jan. 1, 2015 Dec. 31, 2015 Group B counties: Benton, Douglas, Jackson, Josephine, Lane, Linn, Marion, Polk Metal Level 0 to Balance 2000 Silver Silver $ Balance 4000 Silver Silver $ HSA Qualified 2800 Bronze Bronze $ Choice 2000 Silver* Silver $ Choice 4000 Silver Silver $ Connect 2000 Silver* Silver available in these counties Connect 4000 Silver Silver available in these counties Standard Bronze Plan Gold $ Silver $ Bronze $ Essential* Catastrophic $ available to people age 30 and older Metal Level and Over Balance 2000 Silver Silver Balance 4000 Silver Silver HSA Qualified 2800 Bronze Bronze Choice 2000 Silver* Silver Choice 4000 Silver Silver Connect 2000 Silver* Silver available in these counties Connect 4000 Silver Silver available in these counties Gold Silver Bronze Standard Bronze Plan 29 Essential* Catastrophic available to people age 30 and older Tobacco use is defined as the use of tobacco products in any form an average of four or more times per week within the past six months.

16 Individual and Family Plan Rates, Group C: Non-Tobacco User Purchase any of these plans directly from at or your insurance producer. Plans marked * may also be purchased through the Federal Marketplace at HealthCare.gov. Effective Jan. 1, 2015 Dec. 31, 2015 Group C counties: Baker, Clatsop, Columbia, Coos, Crook, Curry, Deschutes, Gilliam, Grant, Harney, Hood River, Jefferson, Klamath, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, Wasco, Wheeler Metal Level 0 to Balance 2000 Silver Silver $ Balance 4000 Silver Silver $ HSA Qualified 2800 Bronze Bronze $ Choice 2000 Silver* Silver $ Choice 4000 Silver Silver $ Connect 2000 Silver* Silver available in these counties Connect 4000 Silver Silver available in these counties Standard Bronze Plan Gold $ Silver $ Bronze $ Essential * Catastrophic $ available to people age 30 and older Metal Level and Over Balance 2000 Silver Silver Balance 4000 Silver Silver HSA Qualified 2800 Bronze Bronze Choice 2000 Silver* Silver Choice 4000 Silver Silver Connect 2000 Silver* Silver available in these counties Connect 4000 Silver Silver available in these counties Gold Silver Bronze Standard Bronze Plan 31 Essential* Catastrophic available to people age 30 and older

17 Individual and Family Plan Rates, Group C: Tobacco User Purchase any of these plans directly from at or your insurance producer. Plans marked * may also be purchased through the Federal Marketplace at HealthCare.gov. Effective Jan. 1, 2015 Dec. 31, 2015 Group C counties: Baker, Clatsop, Columbia, Coos, Crook, Curry, Deschutes, Gilliam, Grant, Harney, Hood River, Jefferson, Klamath, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, Wasco, Wheeler Metal Level 0 to Balance 2000 Silver Silver $ Balance 4000 Silver Silver $ HSA Qualified 2800 Bronze Bronze $ Choice 2000 Silver* Silver $ Choice 4000 Silver Silver $ Connect 2000 Silver* Silver available in these counties Connect 4000 Silver Silver available in these counties Standard Bronze Plan Gold $ Silver $ Bronze $ Essential * Catastrophic $ available to people age 30 and older Metal Level and Over Balance 2000 Silver Silver Balance 4000 Silver Silver HSA Qualified 2800 Bronze Bronze Choice 2000 Silver* Silver Choice 4000 Silver Silver Connect 2000 Silver* Silver available in these counties Connect 4000 Silver Silver available in these counties Standard Bronze Plan Gold Silver Bronze Essential* Catastrophic available to people age 30 and older Tobacco use is defined as the use of tobacco products in any form an average of four or more times per week within the past six months.

18 Decision-Making Guide With all of the options you have, choosing a new health plan could be challenging, to say the least. Here is a step-by-step guide to help you make the right decision for yourself and your family. Step 1: Review your current plan. What do you like about it? What aspects of your current plan do you definitely want to keep in your new plan? Make a list to refer to as you review your new plan options. Step 2: Think about your health care needs for How many doctor visits, aside from preventive care, do you anticipate needing? Do you want to keep your current providers? Are you planning any surgeries? Do you need new eyeglasses? Step 3: Decide what type of provider network you prefer. Do you want the freedom to choose from nearly 1 million providers nationwide? If so, consider a Balance, HSA, Standard or Essential plan. (Essential plan is available only to people age 29 and younger) Would you prefer to work closely with a care team from one medical home, with the flexibility for specialist referrals? If so, consider a Choice plan. Would you rather have a care team from one medical home in the Portland metro area to support every aspect of your health and wellness? If so, consider a Connect plan. Decision worksheet Use this worksheet to compare plans and determine your monthly premium. There is no additional cost for more than three children ages Plan name Plan name Plan name Pros Pros Pros Cons Cons Cons Step 4: Determine your budget. What can your budget handle for monthly premiums and out-ofpocket costs? Review the benefit summary and rate charts to compare benefits and premiums. Shop now at to review side-by-side comparisons of benefits, rates and networks. Step 5: Find out if you are eligible for financial assistance. Use the calculator at to determine the exact amount of any tax credit or cost-sharing subsidy you may be eligible for. If you are eligible, you must complete the steps on the Marketplace website at to receive your tax credit or subsidy. Step 6: Choose your new plan. Be sure to specify which plan you ve chosen if you shop on the Marketplace website. Questions? Call a representative at or TTY: 711, Monday through Friday, 8 a.m. to 8 p.m. es: Monthly premium Monthly premium Subscriber Subscriber Subscriber Spouse Spouse Spouse Child #1 Child #1 Child #1 Monthly premium Child #2 Child #2 Child #2 Child #3 Child #3 Child #3 Total premium Total premium Total premium 34 35

19 Our Mission As people of, we reveal God s love for all, especially the poor and vulnerable, through our compassionate service. Our Core Values Respect, Compassion, Justice, Excellence, Stewardship Portland Metro Area All other areas Monday Friday, 8 a.m. to 8 p.m. Health & Services, a not-for-profit health system, is an equal-opportunity organization in the provision of health care services and employment opportunities Health Plan. All rights reserved. IND-016N (11/14)_OR