GROUPS SIZED 1-50 Plan Overview
Why choose Providence? Collaboration We re consistently rated among the top 10 most integrated health systems in the country, with hospitals, health plans, clinics and providers all working together. Quality We re No. 1 in customer satisfaction in Portland, according to a recent survey. Network Our plans offer a variety of network options to fit your company whether or not the Providence name is on the door. Reputation Providence Health Plan has been named one of the Top 10 Most Admired Health Care Companies every year in the Portland Business Journal s annual survey of chief executives. Cost-control We are committed to providing top-quality care without skimping on benefits, while controlling costs through successful care management. Efficiency We deliver best-in-class claims processing, customer service and account management. If you have more than 20 employees, we ll also provide fullservice COBRA administration at no charge through Ceridian. Exclusive discounts Our tools for employees help them stay on top of their health, and their health care. Providence Health Plan members receive discounts on massage therapy, fitness classes, gym memberships, LASIK and other services to keep them happy, healthy and productive. Stability 2 Providence has been serving Oregon and southwest Washington for more than 160 years.
More flexibility. More choices. More value. We ve added some extras of our own to go the extra mile for your business and your employees. More plan choices Choose from traditional PPO products with strong benefits and extensive provider choices, or a health savings account (HSA) qualified plan that lets employees save tax-free dollars for future medical expenses. We also have two new plans centered on a medical home concept that let your employees choose a primary care clinic near them as their health care team. More plans with fourth-quarter deductible carryover All plans (except HSA) allow members to carry forward any deductible amounts paid for services received in the last three months of a calendar year and apply them toward the deductible for the following year. More bundled benefits, including vision and pharmacy Vision and pharmacy coverage are included in every plan. Broad selection of providers through the VSP Choice network Vision benefits for adults and children 90-day supply at preferred retail and mail-order pharmacies More value-added extras All members get discounts on healthenhancing extras, including: LifeBalance: exclusive discounts at the Oregon Zoo, Wildlife Safari, Disneyland, SeaWorld and other local and national family attractions, plus discounted tickets to local events, savings at hotels nationwide, and more Fitness: exclusive discounts at hundreds of fitness facilities across Oregon, such as 24 Hour Fitness, Curves and Gold s Gym TruVision: board-certified LASIK vision correction for $895 per eye, or custom LASIK for $1,295 per eye TruHearing: savings up to 60 percent on hearing aids More resources to help employees improve their health Our FitTogether programs and services include: ProvRN, our 24/7 registered nurse advice line to answer health questions Tobacco-cessation programs and support to help quit tobacco for good Award-winning care managers who provide support and encouragement to help your employees take control of asthma, diabetes and other chronic conditions Health and wellness classes to help employees learn to manage stress, achieve a healthy weight, begin a yoga practice and more An award-winning newsletter packed with health and wellness information and motivation More innovative tools to help employees manage their health With myprovidence, members can log on to our secure website to: Improve their health with personal health trackers and health assessments, a library of health articles and videos, and other great resources Make the most of their benefits by using our online directory to find in-network providers, reviewing their claims history online and seeing how much of their deductible they ve met Manage their health costs with our treatment cost estimator and online bill pay options 3
Selling Areas Employer s business must be located in the Providence Health Plan selling area for each plan type (counties highlighted in gray). Total, Value, Balance, HSA and Standard Selling area ZIP codes: All ZIP codes in Benton, Clackamas, Columbia, Crook, Deschutes, Douglas, Gilliam, Grant, Harney, Hood River, Jackson, Jefferson, Josephine, Linn, Marion, Multnomah, Polk, Sherman, Wasco, Washington, Wheeler and Yamhill counties. Lincoln Clatsop Tillamook Polk Benton Columbia Washington Yamhill Marion Multnomah Clackamas Linn Hood River Wasco Jefferson Sherman Umatilla Morrow Gilliam Wheeler Grant Wallowa Union Baker Selected ZIP codes in Lane County: 97401, 97402, 97403, 97404, 97405, 97408, 97409, 97412, 97413, 97419, 97424, 97426, 97427, 97431, 97434, 97437, 97438, 97440, 97448, 97451, 97452, 97454, 97455, 97461, 97463, 97472, 97477, 97478, 97482, 97487, 97488, 97489, 97490, 97492 Selected ZIP codes in Klamath County: 97425, 97733, 97737 Coos Curry Josephine Douglas Lane Jackson Deschutes Klamath Crook Lake Harney Malheur Choice Selling area ZIP codes: All ZIP codes in Benton, Clackamas, Columbia, Crook, Deschutes, Hood River, Jefferson, Josephine, Linn, Marion, Multnomah, Polk, Washington and Yamhill counties. Selected ZIP codes in Lane County: 97401, 97402, 97403, 97404, 97405, 97408, 97409, 97412, 97413, 97419, 97424, 97426, 97427, 97431, 97434, 97437, 97438, 97440, 97448, 97451, 97452, 97454, 97455, 97461, 97463, 97472, 97477, 97478, 97482, 97487, 97488, 97489, 97490, 97492 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 Umatilla Morrow Gilliam Wheeler Grant Crook Harney Lake Wallowa Union Baker Malheur Columbia Connect Washington Selling area ZIP codes: All ZIP codes in Clackamas, Multnomah and Washington counties. Multnomah Hood River 4 Yamhill Clackamas Polk Marion
Plan Comparison Plan Features Total Balance Value HSA Choice Connect Standard Provider network Broad PPO-style network Local medical home model No referrals required Benefits 4th-quarter deductible carryover Combined in-network and out-of-network deductibles and out-of-pocket maximums * Preventive care covered in full Deductible waived for PCP and specialist visits * Deductible waived for urgent care visits * Deductible waived for lab and X-ray Deductible waived for generic drugs * Deductible waived for preferred brand name drugs * Coverage for spinal manipulations and acupuncture Adult vision exams Adult vision hardware Higher cost shares for select services FitTogether population health management solution ProvRN 24/7 nurse line Disease management for chronic conditions LifeBalance recreational discount program Integrated HSA, HRA and FSA account administration Can be paired with an integrated HealthEquity HRA and/or FSA Can be paired with an integrated HealthEquity HSA *Applies to some plan options The plan information listed in this booklet provides an overview only. Please refer to a benefit summary for specific details. Some benefit limitations and exclusions apply to our plans Under the new health care reform law, pediatric dental coverage is required as an essential health benefit with all health plans. Since Providence Health Plan does not include pediatric dental coverage, employers will be required to purchase and offer that coverage separately. For a complete listing of benefits and exclusions, please see the plan contract documents. 5
Total Plans Our premier level of coverage, the Total plan offers your company best-inclass benefits with full access to the EPO network including non-participating providers for the ultimate flexibility. This plan does not skimp on benefits. Greatest cost predictability with low copays and many deductible-waived benefits Copays starting as low as $10, deductibles as low as $250, out-of-pocket maximums as low as $1,500 Deductible waived for doctor visits, specialist visits, urgent care, lab and X-ray, generic and preferred brand-name drugs Extra benefits included, such as spinal manipulations, acupuncture, routine vision exams and vision hardware Deductible amounts paid for services received in the last three months of the previous calendar year carry forward to the next year Strong variety of plan options, from platinum designs to bronze plans, and everything in-between Total freedom of provider selection, both within and outside of the Providence EPO Network Providence EPO Network: A national network with the broadest selection of nearly 1 million health care providers nationwide, both in Providence facilities and in other locations. 6 14 plans available Deductible Out-of-pocket maximum Total 250 copay10 $250 cd $1,500 Total 500 copay10 $500 cd $1,500 Total 1000 copay15 $1,000 cd $3,000 Total 1000 copay25 $1,000 cd $4,000 Total 1250 copay15 $1,250 cd $4,000 Total 1500 copay20 $1,500 cd $4,000 Total 1500 copay30 $1,500 cd $6,200 Total 1500 copay35 $1,500 cd $6,000 Total 2000 copay30 $2,000 cd $6,000 Total 2500 copay25 $2,500 cd $5,000 Total 3000 copay25 $3,000 cd $5,000 Total 3000 copay30 $3,000 cd $6,000 Total 2500 copay40 $2,500 cd $6,000 Total 6200 copay50 $6,200 cd $6,200 Plans in orange boxes require an employer HRA contribution. These unique plans allow for lower premiums.
Total Plans Network Referral required for in-network benefits 4th-quarter deductible carryover* Deductible is waived for these services TOTAL In-network Providence EPO Network *Deductible amounts paid for services received in the last three months of the previous calendar year carry forward to the next year No Yes Out-of-network Preventive Care Periodic health exams and well-baby care (from a personal physician/provider only) 30% to Maternity prenatal care 30% to 40% Gynecological exams; Pap tests 30% to 40% Mammograms 30% to 40% Colorectal cancer screenings (age 50 and over) 30% to 40% Office Visits for Medical Services Personal physician/provider $10 to $50 30% to Specialist $25 to $90 30% to Alternative care provider 10% to 20% 30% to 40% Hospital Services Inpatient hospital services and maternity delivery 10% to 20% 30% to 40% Emergency/Urgent Care Emergency services $250 then 10% to 20% $250 then 10% to 20% Urgent care visits $25 to $90 30% to Outpatient Diagnostic Services X-ray and lab services 10% to 30% to 40% High tech imaging services (such as PET, CT, MRI) 10% to 20% 30% to 40% Other Covered Services Outpatient surgery at an ambulatory surgery center $150 to $400 30% to 40% Outpatient surgery at a hospital-based facility 10% to 20% 30% to 40% Spinal manipulations and acupuncture (up to 10 visits/year) 10% to 20% 30% to 40% Prescription Drugs Generic drugs $7 to $25 Not covered Preferred brand name $30 to $95 Not covered Non-preferred and specialty 30% Not covered 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) $30 Vision hardware (frames, lenses, contact lenses) limits apply 7
Balance Plans This plan offers a balance of cost-saving features and coverage for the services your employees use the most. With excellent benefits at an affordable premium, this classic plan has many similarities to our previously offered plans. These plans are structured just like Total, with all the same deductibles waived for services, but with higher copays for select services like specialist visits and urgent care. We offer a variety of options for deductible and out-of-pocket maximums both separate, combined and 2x so you can select the plan and price point that fits within your budget. Extra benefits are included, such as spinal manipulations, acupuncture, routine vision exams and vision hardware. Deductible amounts paid for services received in the last three months of the previous calendar year carry forward to the next year. Employees have total freedom to select providers both within and outside of the Providence EPO Network. Providence EPO Network: A national network with the broadest selection of nearly 1 million health care providers nationwide, both in Providence facilities and in other locations. 8 plans available Deductible Out-of-pocket maximum Balance 500 copay35 $500/$1,000 $6,000/$12,000 Balance 725 copay25 $725/$1,450 $6,000/$12,000 Balance 1000 copay25 $1,000/$2,000 $6,000/$12,000 Balance 1500 copay25 $1,500 cd $6,200 Balance 2000 copay25 $2,000 cd $6,200 Balance 2900 copay20 $2,900 cd $6,000 8 Balance 3000 copay30 $3,000/$3,000 $5,000/$5,000 Balance 6200 copay50 $6,200/$6,200 $6,200/$6,200 Plans in orange boxes require an employer HRA contribution. These unique plans allow for lower premiums.
Balance Plans Network Referral required for in-network benefits 4th-quarter deductible carryover* Deductible is waived for these services BALANCE In-network Providence EPO Network *Deductible amounts paid for services received in the last three months of the previous calendar year carry forward to the next year No Yes Out-of-network Preventive Care Periodic health exams and well-baby care (from a personal physician/provider only) 40% to Maternity prenatal care 40% to Gynecological exams; Pap tests 40% to Mammograms 40% to Colorectal cancer screenings (age 50 and over) 40% to Office Visits for Medical Services Personal physician/provider $20 to $50 40% to Specialist $65 to $100 40% to Alternative care provider 20% to 40% to Hospital Services Inpatient hospital services and maternity delivery 20% to 40% to Emergency/Urgent Care Emergency services $250 then 20% to $250 then 20% to Urgent care visits $65 to $100 40% to Outpatient Diagnostic Services X-ray and lab services 20% to 40% to High tech imaging services (such as PET, CT, MRI) 20% to 40% to Other Covered Services Outpatient surgery at an ambulatory surgery center $200 to $400 40% to Outpatient surgery at a hospital-based facility 20% to 40% to Spinal manipulations and acupuncture (up to 10 visits/year) 20% to 40% to Prescription Drugs Generic drugs $15 to $25 Not covered Preferred brand name $60 to $100 Not covered Non-preferred and specialty Not covered 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) $30 Vision hardware (frames, lenses, contact lenses) limits apply 9
Value Plans With a lower premium and simplified benefits, this plan offers great value and strong financial protection in the event of a major medical problem. Most out-of-pocket costs count toward the deductible and coinsurance. Simple plan designs keep the premium low by covering most benefits at coinsurance after the deductible. Preventive care, generic drugs and routine vision services are covered before the deductible. Deductibles start at $500 and go as high as $6,200. Extra benefits are included, such as spinal manipulations, acupuncture, routine vision exams and vision hardware. Deductible amounts paid for services received in the last three months of the previous calendar year carry forward to the next year. These plans pair well with health reimbursement or flexible spending accounts to fund a portion of the deductible and keep out-of-pocket costs low for employees. Employees have total freedom to select providers both within and outside of the Providence EPO Network. Providence EPO Network: A national network with the broadest selection of nearly 1 million health care providers nationwide, both in Providence facilities and in other locations. 8 plans available Deductible Out-of-pocket maximum Value 500 $500/$500 $4,500/$4,500 Value 1500 $1,500/$1,500 $6,000/$6,000 Value 1750 $1,750/$1,750 $6,000/$6,000 Value 2000 $2,000/$2,000 $6,000/$6,000 Value 3500 $3,500/$3,500 $6,000/$6,000 Value 4000 $4,000/$4,000 $6,000/$6,000 10 Value 5000 $5,000/$5,000 $6,200/$6,200 Value 6200 $6,200/$6,200 $6,200/$6,200 Plans in orange boxes require an employer HRA contribution. These unique plans allow for lower premiums.
Value Plans Network Referral required for in-network benefits 4th-quarter deductible carryover* Deductible is waived for these services VALUE In-network Providence EPO Network *Deductible amounts paid for services received in the last three months of the previous calendar year carry forward to the next year No Yes Out-of-network Preventive Care Periodic health exams and well-baby care (from a personal physician/provider only) 40% Maternity prenatal care 40% Gynecological exams; Pap tests 40% Mammograms 40% Colorectal cancer screenings (age 50 and over) 40% Office Visits for Medical Services Personal physician/provider 10% to 30% 40% Specialist 10% to 30% 40% Alternative care provider 10% to 30% 40% Hospital Services Inpatient hospital services and maternity delivery 10% to 30% 40% Emergency/Urgent Care Emergency services $250 then 10% to 30% $250 then 10% to 30% Urgent care visits 10% to 30% 40% Outpatient Diagnostic Services X-ray and lab services 10% to 30% 40% High tech imaging services (such as PET, CT, MRI) 10% to 30% 40% Other Covered Services Outpatient surgery at an ambulatory surgery center $200 to $500 40% Outpatient surgery at a hospital-based facility 10% to 30% 40% Spinal manipulations and acupuncture (up to 10 visits/year) 10% to 30% 40% Prescription Drugs Generic drugs $15 to $20 Not covered Preferred brand name $45 to $60 Not covered Non-preferred and specialty Not covered 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) $30 Vision hardware (frames, lenses, contact lenses) limits apply 11
HSA Plans Paired with a tax-exempt savings account, HSAs combine health coverage with the ability to save pre-tax dollars to pay for future health care expenses. The Providence HSA is easy to set up and comes with unparalleled support. HSA-qualified plans keep premiums low through higher deductibles, with most services behind the deductible. Preventive care and routine vision services are covered before the deductible. Integrated Health Savings Account administration is available through HealthEquity to help simplify employee account set-up and contributions. A seamless member experience through integrated claims makes it simple for employees to track and pay for their HSA-qualified expenses. Employees have total freedom to select providers both within and outside of the Providence EPO Network. Providence EPO Network: A national network with the broadest selection of nearly 1 million health care providers nationwide, both in Providence facilities and in other locations. 9 plans available Deductible Out-of-pocket maximum HSA 1500 with 750 contribution $1,500 cd $5,000 HSA 1500 without contribution $1,500 cd $5,000 HSA 2400 with 1000 contribution $2,400 cd $4,500 HSA 2500 with 500 contribution $2,500 cd $6,200 HSA 2500 with 1000 contribution $2,500 cd $5,000 HSA 2500 without contribution $2,500 cd $6,200 HSA 3200 with 800 contribution $3,200 cd $6,200 12 HSA 5000 without contribution $5,000 cd $6,200 HSA 6200 without contribution $6,200 cd $6,200 Plans in orange boxes require an employer HSA contribution. These unique plans allow for lower premiums.
HSA Plans Network Referral required for in-network benefits Deductible is waived for these services HSA In-network Providence EPO Network No Out-of-network Preventive Care Periodic health exams and well-baby care (from a personal physician/provider only) 40% to Maternity prenatal care 40% to Gynecological exams; Pap tests 40% to Mammograms 40% to Colorectal cancer screenings (age 50 and over) 40% to Office Visits for Medical Services Personal physician/provider 20% to 40% to Specialist 20% to 40% to Alternative care provider 20% to 40% to Hospital Services Inpatient hospital services and maternity delivery 20% to 40% to Emergency/Urgent Care Emergency services 20% to 20% to Urgent care visits 20% to 40% to Outpatient Diagnostic Services X-ray and lab services 20% to 40% to High tech imaging services (such as PET, CT, MRI) 20% to 40% to Other Covered Services Outpatient surgery at an ambulatory surgery center 20% to 40% to Outpatient surgery at a hospital-based facility 20% to 40% to Spinal manipulations and acupuncture (up to 10 visits/year) Not covered Not covered Prescription Drugs Generic drugs Not covered Preferred brand name Not covered Non-preferred and specialty Not covered 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) $25 Vision hardware (frames, lenses, contact lenses) limits apply Not covered Not covered 13
Choice Plans With the Choice plan, your employees select a medical home from the Providence Choice Network. From then on, their health will be supported by a team of health professionals within their medical home. Team members work collaboratively to support all aspects of an employee s health, from wellness and prevention to active management of chronic conditions. Employees can choose from more than 180 medical home clinics in Oregon and southwest Washington that provide a patient-focused, coordinated experience. Employees have access to a broad network of specialists and facilities via referral from the medical home in order to receive coverage at the in-network level. The deductible is waived for doctor visits, specialist visits, urgent care, lab and X-ray, generic and preferred brand-name drugs. Member cost shares are higher for going out-ofnetwork, seeing a specialist without a referral, Wahkiakum and for select services including spinal surgery, Cowlitz hip and knee replacements, and sleep studies. Extra benefits are included in the plan, such as spinal manipulations, acupuncture, routine vision exams and vision hardware. Deductible amounts paid for services received in the last three months of the previous calendar year carry forward to the next year. Lincoln Clatsop Tillamook Polk Benton Columbia Washington Yamhill Marion Clark Multnomah Clackamas Linn Skamania Hood River Wasco Jefferson Klickitat Sherman Gilliam Wheeler Crook Morrow Grant Umatilla Union Baker Wallowa Lane Deschutes Providence Choice Network: This statewide network allows your employees to choose a primary care clinic from more than 180 clinics as their medical home. Coos Douglas Curry Josephine Jackson Klamath Lake Harney Malheur 9 plans available Deductible Out-of-pocket maximum Choice 500 copay20 $500/$500 $4,000/$4,000 Choice 500 copay25 $500/$500 $4,000/$4,000 Choice 1000 copay15 $1,000/$1,000 $4,000/$4,000 Choice 1000 copay45 $1,000/$1,000 $6,000/$6,000 Choice 1200 copay15 $1,200/$1,200 $4,000/$4,000 Choice 1500 copay30 $1,500/$1,500 $6,000/$6,000 14 Choice 1750 copay30 $1,750/$1,750 $6,000/$6,000 Choice 2000 copay50 $2,000/$2,000 $6,000/$6,000 Choice 6200 copay50 $6,200/$6,200 $6,200/$6,200
Choice Plans Network Referral required for in-network benefits 4th-quarter deductible carryover* Deductible is waived for these services CHOICE In-network Providence Choice Network *Deductible amounts paid for services received in the last three months of the previous calendar year carry forward to the next year Yes Yes Out-of-network Preventive Care Periodic health exams and well-baby care (from a personal physician/provider only) 40% to Maternity prenatal care 40% to Gynecological exams; Pap tests 40% to Mammograms 40% to Colorectal cancer screenings (age 50 and over) 40% to Office Visits for Medical Services Personal physician/provider $15 to $50 40% to Specialist $60 to $90 40% to Alternative care provider 10% to 40% to Hospital Services Inpatient hospital services and maternity delivery 10% to 40% to Emergency/Urgent Care Emergency services $250 then 10% to $250 then 10% to Urgent care visits $60 to $90 40% to Outpatient Diagnostic Services X-ray and lab services 10% to 40% to High tech imaging services (such as PET, CT, MRI) 10% to 40% to Other Covered Services Outpatient surgery at an ambulatory surgery center $200 to $500 40% to Outpatient surgery at a hospital-based facility 10% to 40% to Spinal manipulations and acupuncture (up to 10 visits/year) 10% to 40% to Prescription Drugs Generic drugs $10 to $25 Not covered Preferred brand name $45 to $95 Not covered Non-preferred and specialty Not covered 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) $30 Vision hardware (frames, lenses, contact lenses) limits apply 15
Connect Plans Our Connect plan combines the medical home model with additional cost-effective care options. Your employees may choose a medical home from our Portland metro-area Providence Neighborhood Network. Their health will be supported by a team of expert health professionals who collaborate with them to address all aspects of their health, from preventive care to health management. With this plan, employees can connect with their team in both traditional and innovative ways, including e-visits and phone visits for better time management and smaller copays. This is our lowest premium plan. Employees can select from more than 25 medical homes in the Portland metro area that work with an aligned network of select specialists to provide highly coordinated care. The deductible is waived for doctor visits, specialist visits, X-ray and lab, and generic drugs. Member cost shares are higher for going out of network, seeing a specialist without a referral Yamhill and for select services, including spinal surgery, hip and knee replacements, and sleep studies. Polk Extra benefits are included in the plan, such as spinal manipulations, acupuncture, routine vision exams and vision hardware. Deductible amounts paid for services received in the last three months of the previous calendar year carry forward to the next year. Columbia Washington Marion Multnomah Clackamas Hood River Providence Neighborhood Network: This Portland-area network lets your employees choose a medical home from more than 25 primary care clinics in Multnomah, Washington and Clackamas counties. 10 plans available Deductible Out-of-pocket maximum Connect 500 copay35 $500/$1,000 $5,000/$10,000 Connect 750 copay25 $750/$1,500 $5,000/$10,000 Connect 750 copay30 $750/$1,500 $5,000/$10,000 Connect 1250 copay40 $1,250/$2,500 $6,000/$12,000 Connect 1500 copay35 $1,500/$3,000 $5,000/$10,000 Connect 1750 copay30 $1,750/$3,500 $6,000/$12,000 16 Connect 1750 copay35 $1,750/$3,500 $6,000/$12,000 Connect 2000 copay35 $2,000/$4,000 $5,000/$10,000 Connect 2000 copay40 $2,000/$4,000 $6,000/$12,000 Connect 6200 copay50 $6,200/$12,400 $6,200/$12,400
Connect Plans Network Referral required for in-network benefits 4th-quarter deductible carryover* Deductible is waived for these services CONNECT Providence Neighborhood Network In-network *Deductible amounts paid for services received in the last three months of the previous calendar year carry forward to the next year Yes Yes Out-of-network Preventive Care Periodic health exams and well-baby care (from a personal physician/provider only) 40% to Maternity prenatal care 40% to Gynecological exams; Pap tests 40% to Mammograms 40% to Colorectal cancer screenings (age 50 and over) 40% to Office Visits for Medical Services Personal physician/provider $25 to $50 40% to Specialist $65 to $90 40% to Alternative care provider 10% to 40% to Hospital Services Inpatient hospital services and maternity delivery 10% to 40% to Emergency/Urgent Care Emergency services $250 then 10% to $250 then 10% to Urgent care visits $65 to $90 40% to Outpatient Diagnostic Services X-ray and lab services 10% to 40% to High tech imaging services (such as PET, CT, MRI) 10% to 40% to Other Covered Services Outpatient surgery at an ambulatory surgery center $300 to $500 40% to Outpatient surgery at a hospital-based facility 10% to 40% to Spinal manipulations and acupuncture (up to 10 visits/year) Not covered Not covered Prescription Drugs Generic drugs $15 to $25 Not covered Preferred brand name $45 to $90 Not covered Non-preferred and specialty Not covered 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) $25 Vision hardware (frames, lenses, contact lenses) limits apply Not covered Not covered 17
Standard Plans Defined by the state of Oregon, the Standard plans offer a choice between coverage levels and premiums. They use the Providence EPO Network. Standard plans are the same both inside Cover Oregon and in the private market (Gold Plan sold only in Cover Oregon). Total freedom of provider selection, both within and outside of the Providence EPO Network No coverage for spinal manipulations, acupuncture, and adult routine vision exams and vision hardware Deductible amounts paid for services received in the last three months of the previous calendar year carry forward to the next year Providence EPO Network: A national network with the broadest selection of nearly 1 million health care providers nationwide, both in Providence facilities and in other locations. 3 plans available Deductible Out-of-pocket maximum Providence Oregon* Standard Gold Plan Providence Oregon Standard Silver Plan Providence Oregon Standard Bronze Plan $1,300/$2,600 $6,350/$12,700 $2,500/$5,000 $6,350/$12,700 $5,000/$10,000 $6,350/$12,700 *This plan sold in Cover Oregon only. 18
Standard Plans STANDARD Providence Oregon Standard Gold Plan Providence Oregon Standard Silver Plan Deductible is waived for these services *Deductible amounts paid for services received in the last three months of the previous year carry forward to the next year Providence Oregon Standard Bronze Plan Network Providence EPO Network Providence EPO Network Providence EPO Network Referral required for innetwork benefits No No No 4th-quarter deductible carryover* Yes Yes Yes In-network Out-of-network In-network Out-of-network In-network Out-of-network Preventive Care Periodic health exams and well-baby care (from a personal physician/provider only) Maternity prenatal care Gynecological exams; Pap tests Mammograms Colorectal cancer screenings (age 50 and over) Office Visits for Medical Services Personal physician/provider $20 $35 $60 Specialist $40 $70 $100 Alternative care provider $40 $70 $100 Hospital Services Inpatient hospital services and maternity delivery 10% 30% Emergency/Urgent Care Emergency services 10% 10% 30% 30% Urgent care visits $60 $90 $120 Outpatient Diagnostic Services X-ray and lab services 10% 30% High tech imaging services (such as PET, CT, MRI) 10% 30% Other Covered Services Outpatient surgery at an ambulatory surgery center 10% 30% Outpatient surgery at a hospital-based facility 10% 30% Spinal manipulations and acupuncture (up to 10 visits/year) Not covered Not covered Not covered Not covered Not covered Not covered Prescription Drugs Generic drugs $10 Not covered $15 Not covered $20 Not covered Preferred brand name $30 Not covered $50 Not covered $80 Not covered Non-preferred and specialty Not covered Not covered Not covered 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) Not covered Not covered Not covered Not covered Not covered Not covered Vision hardware (frames, lenses, contact lenses) limits apply Not covered Not covered Not covered Not covered Not covered Not covered 19
Integrated HSA, HRA and FSA Providence Health Plan partners with HealthEquity to bring you best-in-class, consumer-directed health plans. They lower costs, support choice and flexibility, and provide tax advantages. They also encourage employees to be more judicious with their health care dollars and make better health care decisions. Teaming up with HealthEquity, the nation s oldest and largest dedicated health savings trustee, makes it easy on you. 24/7 customer service View claims and payment information all in one place, anytime, anywhere Pay providers online Integrated plan setup, enrollment and billing: set up your health plan and employee health care accounts in one place. Fully equipped employer portal: manage contributions, view reporting and upload contribution information. Account type Employee account activation and set-up Monthly administration Employer plan set-up and annual plan maintenance fee (paid directly to HealthEquity) Health Savings Account (HSA) HSAs are employee-owned bank accounts where money earned can be used for employees current and future health care expenses. HSAs can be paired with any HSA-qualified plan. Free $2.70 per account (paid as part of Providence bill) Free Health Reimbursement Arrangement (HRA) HRAs are employer-owned accounts that are set up to reimburse employees for their qualified medical expenses and can be paired with any non-hsa plan. Employers have flexibility in designing a plan to meet their unique needs. Free $3.45 per account (paid as part of Providence bill) 1-100 accounts: $250 Flexible Spending Account (FSA) FSAs allow employees to set aside pre-tax dollars from their paycheck to help pay for their eligible health care costs throughout the year. FSAs can be paired with any non-hsa plan. Free $3.45 per account (paid directly to HealthEquity) 1-100 accounts: $250 Limited Purpose Flexible Spending Account (LPFSA) LPFSAs can be paired with an HSA and can be used to reimburse employees for dental and vision care. Free $1.95 per account (paid directly to HealthEquity) Free 20
The defined-contribution option Which plan works best for your employees? Offering a defined contribution lets them choose. Defined contribution is an insurance purchasing option that allows your company to give each employee a fixed dollar amount a defined contribution that they can use to buy or help pay for a health plan that they choose themselves. Each employee chooses the plan that best fits his or her needs from a group of options that your company has chosen to offer. This approach offers cost savings and predictability for employers while giving employees a stronger voice in their health coverage choices. Employees may share in the cost of coverage depending on which plan they choose and the amount of the company s contribution. Advantages to the company: Eliminates the burden of having to choose one plan that will satisfy all employees Makes it easier to predict and control insurance costs, regardless of fluctuations in insurance rates and employee census Allows you to set a fixed budget for insurance Increases employee satisfaction with benefit choices Advantages to employees: Greater control, involvement and choice in benefit selection Ability to stretch benefit dollars by choosing lower-priced options Increased satisfaction with coverage that they have determined themselves to best fit their needs Defined contribution with Providence Health Plan When you choose defined contribution with Providence Health Plan, you can offer employees a choice of two or three plans instead of one. The group of plans that you choose must meet these guidelines: The difference in cost between the lowest-cost and highest-cost plans must be no more than 20 percent, based on the monthly premium. The employer contribution must be at least 50 percent of the lowest-cost plan. If you offer Connect or Choice, you also must offer at least one plan that includes our full EPO Network (Total, Balance, Value or HSA). Here s an example of how this might look: Plans chosen: Plan A = $360 monthly premium Plan B = $330 monthly premium Plan C = $300 monthly premium Employer contribution: This amount is up to the employer, but would need to be a minimum of $150 (50 percent of the lowest premium) in this example. 21
Benefit changes for 2014 Vision Vision coverage is embedded in all of our 2014 plans through our partner, Vision Service Plan, or VSP, the largest nonprofit vision benefits and services company in the U.S. The VSP Choice Network gives members access to 50,000 providers in more than 48,000 locations nationwide. All plans except Standard plans include both pediatric and adult vision coverage In-network pediatric exams and hardware are covered in full for all plans The deductible is waived for eye exams (one per calendar year) both in and out of the network Copays apply for adult exams The adult hardware benefit varies by plan Pharmacy Prescription drug coverage, which is embedded in all of our plans, includes four tiers of benefits: generic, preferred brand name, non-preferred brand name and specialty. Members can use one of our 25,000 participating pharmacies nationwide or choose a mail-order option. Maintenance medications for chronic conditions may be purchased (up to a 90-day supply at one time) through a preferred retail or a mail-order pharmacy. Local preferred pharmacies include, but are not limited to: Albertsons/Sav-on Costco Fred Meyer/Kroger/QFC Safeway Walgreens Mail-order pharmacies: Postal Prescriptions Services Walgreens Mail Service Wellpartner New formulary for small groups; visit www.providencehealthplan.com/pharmacy for the complete list Cost shares accumulate to the out-of-pocket maximum Some cost shares are subject to the deductible New member 90-day pharmacy transition period for prescriptions that normally require prior authorization During the first 90 days of coverage, members must ask their provider to request a prior authorization to continue using the prescription after the 90-day transition period Alternative care providers Under the health care reform law, an important change has been made to how services by alternative care providers are covered. The law requires that any benefit covered by a health plan may not exclude any specific provider type, as long as the provider is licensed to perform the service. This means that medical services received from an alternative care provider, like a naturopath or chiropractor, are now covered, which includes services such as office visits, labs and X-rays. Conversely, if a plan excludes a service such as acupuncture, it must be excluded for all provider types. American Specialty Health (ASH) is our alternative care provider network and all of our plans offer both in- and out-of-network benefits. Spinal Manipulation and Acupuncture 22 Many of our plans include coverage for spinal manipulation and acupuncture, covered for any provider type who is licensed to perform the service. Coverage is up to a combined 5 or 10 visits per calendar year, depending on the medical plan chosen Member cost share is at the plan coinsurance level, subject to the deductible Massage therapy is excluded from coverage ASH is our provider network and there are both in- and out-of-network benefits
Providence plans sold through Cover Oregon In addition to the 60 plans we sell in the private market, Providence Health Plan offers nine medical plans in the Cover Oregon marketplace. Product highlights for plans sold in Cover Oregon: Same networks and plan design structure Standard plans are the same both in Cover Oregon and in the private market Same value-added benefits included for all plans such as LifeBalance and ProvRN 9 plans available Deductible Out-of-pocket maximum Providence Oregon Standard Gold Plan $1,300/$2,600 $6,350/$12,700 Providence Oregon Standard Silver Plan $2,500/$5,000 $6,350/$12,700 Providence Oregon Standard Bronze Plan $5,000/$10,000 $6,350/$12,700 Total 1250 Gold Small Group $1,250 cd $4,000 Balance 1500 Silver Small Group $1,500/$3,000 $6,200/$12,400 Balance 2000 Silver Small Group $2,000/$2,000 $4,000/$4,000 Balance 6200 Bronze Small Group $6,200/$6,200 $6,200/$6,200 Value 5500 Bronze Small Group $5,500/$5,500 $6,200/$6,200 Choice 1750 Silver Small Group $1,750/$1,750 $6,000/$6,000 Contact Cover Oregon directly for questions regarding: Cover Oregon Portal Quoting Eligibility Enrollment Tax credits/subsidies Commission www.coveroregon.com 1-855-CoverOR (855-268-3767) 23
Our Mission As people of Providence, we reveal God s love for all, especially the poor and vulnerable, through our compassionate service. Our Core Values Respect, Compassion, Justice, Excellence, Stewardship Dedicated customer service resources 503-574-7500 or 800-878-4445, TTY: 711 Monday Friday, 8 a.m. to 5 p.m. Sales 503-574-6300 or 877-245-4077 www.providencehealthplan.com Providence Health & Services, a not-for-profit health system, is an equal-opportunity organization in the provision of health care services and employment opportunities. 2013 Providence Health Plan. All rights reserved. SGP-002_13-07010