individual products 2014 · heritage select plans • preferred gold 1000, 1500 • preferred...

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INDIVIDUAL PRODUCTS

2014

01……….…………………………………………….…..Our Story

02………….………………………………….….Medical Benefits

03…..……………………………………….……...Dental Benefits

04……..……………………………….……………………….Rates

05……….……………………………….………………….Network

06…………….……………………....Administrative Guidelines

07………..…………….……………………………Compensation

08………….………….……Current Member Communications

09……….…………….………………………………….Web Tools

10…………………….……………...Sales Materials & Contacts

AGENDA

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01 OUR STORY

PREMERA BLUE CROSS BLUE SHIELD OF ALASKA

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Go With The One You Know

04 RATES 02 MEDICAL BENEFITS

1. Ambulatory Patient Services

2. Emergency Services

3. Hospitalization

4. Maternity & Newborn Care

5. Mental Health & Substance Use Disorder Services, including

Behavioral Health Treatment

6. Prescription Drugs

7. Rehabilitative & Habilitative Services & Devices

8. Laboratory Services

9. Preventive/Wellness Services & Chronic Disease Management

10. Pediatric Services, including Oral & Vision Care

10 Essential Health Benefits

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Heritage Select Plans

• Preferred Gold 1000, 1500

• Preferred Silver 2000, 3000

• Preferred Bronze 5500, 6350

Heritage Select HSA Plans

• Preferred Silver HSA 2500

• Preferred Bronze HSA 5250

Medical Plans – Out of Exchange

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Heritage Plus Plans

• Preferred Gold 1000, 1500

• Preferred Silver 2000, 3000

• Preferred Bronze 5500, 6350

Heritage Plus HSA Plans

• Preferred Silver HSA 2500

• Preferred Bronze HSA 5250

Medical Plans – Out of Exchange

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BCBS MSP Select

• Preferred Gold 1000, 1500

• Preferred Silver 2000, 3000

• Preferred Bronze 5500, 6350

BCBS MSP Select HSA

• Preferred Silver HSA 2500

• Preferred Bronze HSA 5250

Medical Plans – Inside the Exchange

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BCBS MSP Plus

• Preferred Gold 1000, 1500

• Preferred Silver 2000, 3000

• Preferred Bronze 5500, 6350

BCBS MSP Plus HSA

• Preferred Silver HSA 2500

• Preferred Bronze HSA 5250

Cost Share Reduction Plans

Alaska Native / American Indian Plans

1 Tier Pharmacy Benefit

10 © LifeWise Health Plan of Oregon 2013

Pharmacy Benefit name: X1

Deductible + coinsurance

• Formulary generics

• Formulary brand

• Formulary specialty

Non-Formulary drugs

Non-formulary drugs may be covered with medical necessity approval or prior authorization

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4 Tier Pharmacy Benefit

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Pharmacy Benefit Name: X4

Tier 1 = generics

Tier 2 = preferred brand

Tier 3 = non-preferred brand

Tier 4 = specialty

Non-Formulary drugs

Non-formulary brands and specialty is covered when a medical

necessity approval or prior authorization is obtained

• Cost shares will match drug tier formulary

Section title

Pharmacy Administrative Rules

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• Rx copays and coinsurance count toward

medical out-of-pocket maximums

• HCR preventive drugs are still covered in full

• Specialty drugs

• Subject to medical deductible and cost shares

• Must use contracted pharmacies: Accredo and Walgreens

• Limited to 30-day supply

Section title 13

Select Package VH

•Gold 1500, Silver 3000 & Bronze 6350

Plus Package VH

•Gold 1500, Silver 3000 & Bronze 6350

Package VH includes:

•Vision Exam and Hardware

•Hearing Exam and Hardware

Adult Vision & Hearing

Heritage Select Plans

• Preferred Gold 1000, 1500

• Preferred Silver 2000, 3000

• Preferred Bronze 5500, 6350

Heritage Select HSA Plans

• Preferred Silver HSA 2500

• Preferred Bronze HSA 5250

Medical Plans – Out of Exchange

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Heritage Plus Plans

• Preferred Gold 1000, 1500

• Preferred Silver 2000, 3000

• Preferred Bronze 5500, 6350

Heritage Plus HSA Plans

• Preferred Silver HSA 2500

• Preferred Bronze HSA 5250

Medical Plans – Out of Exchange

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BCBS MSP Select

• Preferred Gold 1000, 1500

• Preferred Silver 2000, 3000

• Preferred Bronze 5500, 6350

BCBS MSP Select HSA

• Preferred Silver HSA 2500

• Preferred Bronze HSA 5250

Medical Plans – Inside the Exchange

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BCBS MSP Plus

• Preferred Gold 1000, 1500

• Preferred Silver 2000, 3000

• Preferred Bronze 5500, 6350

BCBS MSP Plus HSA

• Preferred Silver HSA 2500

• Preferred Bronze HSA 5250

MSP plans do not cover voluntary termination of pregnancy

Alaska Native / American Indian

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Alaska Natives and American Indians purchasing healthcare

benefits through the Exchange have no copays or other cost-

shares if their income is at or below 300% of the poverty level

Preferred Non-Preferred Participating Tribal Facilities

100% coverage*

40% member cost share

60% member cost share

100% coverage*

* Referrals from Preferred or Tribal providers to any other providers are

covered at 100%

Medical Travel Support

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Individual Plans • Available January 1, 2014 for new plans

• Certain procedures eligible when doctor says it safe

• Premera Blue Cross Heritage Signature Network in Washington or

BlueCard outside of Washington

• ACL Repair/Arthroscopy

• Breast Lumpectomy

• Cardiac Angioplasty (stent/no stent)

• Coronary Bypass (CBG)

• Hip Replacement

• Hysterectomy

• Knee Arthroscopy w/cartilage repair

• Knee Replacement

• Laminectomy

• Laparoscopic Gall Bladder Removal

• Left Heart Catheterization

• Lithotripsy – Fragmenting Kidney Stones

• Partial/Total Thyroid Gland Removal

• Prostate Gland & Surrounding Tissue

Removal

• Shoulder Arthroscopy

• Spinal Fusion

03 DENTAL BENEFITS

Embedded Pediatric Dental

20 © LifeWise Health Plan of Oregon 2013

• Embedded in all plans

• Benefit applies to dependents under age 19

• Medical deductible applies

• Benefits paid same in and out of network, no benefit limit

• No waiting periods, except orthodontia

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Class I Medical Deductible,

then 10%

Class II Medical Deductible,

then 20%

Class III Medical Deductible,

then 50%

Ortho Medical Deductible,

then 50%

• Routine Exams – 2 PCY

• Cleanings - 2 PCY

• Fluoride Treatment – 2

every 12 months

• Sealants – 1 every 3 CY

• Complete series or

panoramic – 1 every 5 CY

• Bitewings – 1 PCY

• Fillings

• Simple Extractions

• Stainless Steel Crowns –

every 60 months

• Periodontal Maintenance

– 4x per 12 months

• Periodontal Sealing &

Root Planning – once

every 24 months

• Endodontic – once per

tooth per lifetime

• Surgical Extractions

• Crowns – every 60

months

• Periodontal Surgery

• General Anesthesia

• Implants – once every 60

months

• Complex oral surgery

• Cleft Pallet or

Cleft Lip only

• Medically necessary with

prior authorization – 24

month benefit waiting

period

04 RATES

Geographic Rating Area

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Rates

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• Rates

• Area 1 – 995 (Anchorage)

• Area 2 – 996, 997

• Area 3 – 998, 999 (SE Alaska)

• Rate determined by the zip code where the

subscriber lives

• Single age bands

• Capped at first 3 dependents 20 years old & under

• Tobacco vs. Non-Tobacco

• Individuals and families eligible if income is between 100% and 400% of the Federal Poverty Level

• Receive credit toward premium cost

• Premium credit is $____________

Premium Assistance Credit Available only in the Exchange

Individual 100% FPL = $14,350 400% FPL = $57,400

Family of 4 100% FPL = $29,440 400% FPL = $117,760

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Cost Share Reduction Subsidy

Federal Poverty Level Maximum Actuarial Value

100% – 150% 94%

150% – 200% 87%

200% – 250% 73%

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Available only through the Exchange

• Must purchase a “Silver Plan” to access Cost Share Subsidy

• Reduces eligible participant’s out-of-pocket expenses by

increasing the actuarial value of the plan they qualify for:

• Qualified individuals and families can access both the Premium

Assistance Credit and Cost-Sharing Subsidy

05 NETWORK

Medical Network

• HeritageSelect – hospitals only

• HeritagePlus– hospitals and providers

• Washington : Heritage Signature (hospitals & providers)

• National Network: BlueCard (outside of Alaska and

Washington)

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06 ADMINISTRATIVE GUIDELINES

– General Physician – Naturopath

– Pediatrician – Family Physicians

– Internist – Geriatrics

– Nurse Practitioner – ARNP/Physician Assistant

– Gynecologist – Obstetrician

Primary Care Provider

• Office Visit Copays

• Incentive-based

• Selecting a PCP

• Changing a PCP

• PCP provider types

Encouraging deeper relationships between our members and their physicians

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Prior Authorization Effective 2014 for Individual

• No surprises. Prior authorization guarantees coverage to eligible

members before certain services are provided

• Highest quality care. Members know that medical services are reviewed

for quality and cost-effectiveness appropriate for their medical needs

• Cost control. Prior authorization helps contain costs for members and

providers and ensures fast claim payment

• Protection. Prior authorization protects members from risk and harm by

avoiding services that do not show benefit

If a member does not receive prior authorization for certain services, they

may be liable for up to $1,500 of the allowed charges.

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Prior Authorization

Examples of services that require prior authorization

• Planned hospitalizations

• Elective outpatient surgeries

• Admission to a skilled nursing facility or rehabilitation facility

• Non-emergency and elective air ambulance services

• Some outpatient services

• Some organ transplants

• Supplies, appliances, durable medical equipment (DME), and

prosthetic devices over $500 (purchase)

• Provider-administered drugs

A more complete list is available online at: https://www.premera.com/ak/provider/utilization-review/prospective-review/

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Health Savings Account (HSA)

Annual Enrollment Period

First year: October 1, 2013 – March 31, 2014

Second year: October 15, 2014 – December 7, 2014

All members on non-grandfathered plans must select a

new plan with a January 1 effective date

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Applying For Coverage OUTSIDE THE EXCHANGE

Applications

Online

– Online Enrollment Tool

– Your personal link

– How to register

Paper

Effective Dates – 1st and 15th of the month

– Apply up to last day before effective date

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Inside the Exchange

Applications

• Online

• Paper

Effective Dates

• 1st of the month only

• Driven by enrollment date

Enroll by Effective Date Oct 1 to Dec 15 January 1st

Dec 16 to Jan 15 February 1st

Jan 16 to Feb 15 March 1st

Feb 16 to Mar 15 April 1st

Mar 16 to Mar 31 May 1st

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Applying For Coverage

Eligibility Requirements

Individuals eligible to apply for a plan

• A resident of and have a principal residence

in the state of Alaska

• Not entitled to Medicare at the time of enrollment

Eligible dependents

• A spouse or domestic partner

• Natural or legally adopted children under

the age of 26

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Qualifying Events

(1) A qualified individual or dependent loses minimum essential coverage;

(2) A qualified individual gains a dependent or becomes a dependent through

marriage, birth, adoption or placement for adoption;

(3) An individual, who was not previously a citizen, national, or lawfully present

individual who gains such status;

(4) A qualified individual’s enrollment or non-enrollment in a QHP is unintentional,

inadvertent, or erroneous and is the result of the error, misrepresentation, or

inaction of an officer, employee, or agent of the Exchange or HHS, or its

instrumentalities as evaluated and determined by the Exchange. In such cases,

the Exchange may take such action as may be necessary to correct or eliminate

the effects of such error, misrepresentation, or inaction;

(5) An enrollee adequately demonstrates to the Exchange that the QHP in which he or

she is enrolled substantially violated a material provision of its contract in relation

to the individual;

Applying outside of Open Enrollment

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(6) An individual is determined newly eligible or newly ineligible for advance payments

of the premium tax credit or has a change in eligibility for cost-sharing reductions,

regardless of whether such individual is already enrolled in a QHP. The Exchange

must permit an individual whose existing coverage through an eligible employers

sponsored plan will no longer be affordable or provide minimum value for his or

her employer’s upcoming plan year to access this special enrollment period prior

to the end of his or her coverage through such eligible employer-sponsored plan;

(7) A qualified individual or enrollee gains access to new QHPs as a result of a

permanent move;

(8) Alaska Native or American Indian, as defined by section 4 of the Indian Health

Care Improvement Act, may enroll in a QHP or change from one QHP to another 1

time per month

(9) A qualified individual or enrollee meets other exceptional circumstances as the

Exchange or HHS may provide.

(10) A loss of Medicaid or other public program providing health benefits

(11) Coverage is discontinued in a QHP by the health benefit exchange

Qualifying Events

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Billing Payment Options

• Automatic withdrawal from bank

• Credit & Debit Card

– One-Time

– Recurring

• Monthly Bill - pay by check

Payment grace periods

• Outside Exchange:

– 30-day grace period

• Inside Exchange

– Subsidized: 3-month grace period

– Not subsidized: 30-day grace period

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• Current rating structure (age band)

• Current network

• Renewal date – May 1, 2014

• Can purchase Qualified Health Plan during AEP

Grandfathered Plans Members get to keep what they have

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•Re-Named

•Re-Tooled

•In-Depth

•Coming in October

Administrative Guide

07 COMPENSATION

• $25 per member per month

• In and out of exchange

• Grandfathered and non-grandfathered members

• Effective dates beginning January 1, 2014

Commission paid by Premera for business

placed both in and out of exchange

Medical Plan Commission

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08 CURRENT MEMBERS COMMUNICATIONS

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NON-GRANDFATHERED

• Member communications

• August 28 – Educational Mailing

• September 23 – Discontinuation/Change Over Packet

• December 3 – Reminder Letter

• Plan change tool

• Plan change matrix

Current Member Communications

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GRANDFATHERED

• Member communications

• November 1 – Options letter

• Renewal is May 1, 2014

• Plan change tool

Current Member Communications

09 WEB RESOURCES

Website

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10 SALES MATERIALS & CONTACTS

Sales Kits available:

October 2, 2013 (date may be delayed)

Process to order supplies:

Supply order form posted on website

www.premera.com/ak/producer/forms

Ordering Supplies

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Individual Sales & Service Team

Sales Leadership Sales and Account

Management Producer Support

John Mychalishyn

Director of Sales

425-918-4780

john.mychalishyn@premera.com

Kelly Jones

Regional Sales Manager

Work:425-918-5851

Cell: 206-214-8774

kelly.jones@premera.com

John Reynolds

Team Lead, Producer Support

425-918-6270

john.reynolds@premera.com

Nancy Valdez

Sales Executive

907-677-2406

nancy.valdez@premera.com

Producer Support Team

Laura Binder

Lucy French

Nicole Goodspeed

877-205-9725, option 1, then 1

Fax: 425-918-3378

producer.support@premera.com

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QUESTIONS?

THANK YOU FOR JOINING US TODAY

029618 (10-2013)