Caring for Small Business in New YorkEmblemHealth’s 2014 PortfolioNovember 2013

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Today’s Discussion

• Overview

• 2014 SG Off Exchange Product Portfolio

• Select Care Network

• SA Commissions

• Portal Renewal Functionality

• Manual Transactions for EH Conversions

“Not Business as Usual”

EmblemHealth is transforming to compete in the commercial market

“NY Marketplace” on and off-exchange products

Neighborhood Care – Care Café SelectCare - AdvantageCare Physician Groups – tailored

high performance network

Focused on distribution channel and business relationships

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“We are committed to the small group market and you our valued partners”

“We are committed to the small group market and you our valued partners”

Small Group Product Summary

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Service HMO 40/60 (Gold) HMO 35/55 (Silver) HMO HD6300 (Bronze) In Network Only (except for emergency care)

Select Care network Select Care network Select Care network

Coinsurance (member responsibility)

10% 30% 0%

Annual deductible (individual/family)

No deductible $2,000/$4,000 $6,300/$12,600

Annual out-of-pocket maximum (individual/family)

$4,000/$8,000 $6,000 /$12,000 $6,300/$12,600

Annual/lifetime maximum benefit

Unlimited Unlimited Unlimited

Preventive services (e.g., well-child care including immunizations; annual physical; mammography; prostate exam; bone density screening; colonoscopy and more)

Covered in full Covered in full Covered in full

Office visit copay (primary care/ specialist)

$40/$60 copay $35/$55 copay Covered in full after deductible

Diagnostic lab and radiology $60 copay $55 copay Covered in full after deductible Inpatient hospital admission

$1,500 copay per admission 30% coinsurance after deductible

Covered in full after deductible

Emergency room facility $200 copay $200 copay Covered in full after deductible Emergency ambulance $100 copay $150 copay Covered in full after deductible Urgent care facility $60 copay $60 copay Covered in full after deductible Ambulatory surgery facility $150 copay 30% coinsurance after

deductible Covered in full after deductible

Pediatric vision exams $40 copay $35 copay Covered in full after deductible Pediatric vision lenses and frames

10% coinsurance 30% coinsurance Covered in full after deductible

Durable medical equipment (DME)

10% coinsurance 30% coinsurance Covered in full after deductible

Gym Reimbursement Subscriber reimbursed up to $200 per six-month period and 50 exercise facility visits. Covered spouse reimbursed up to $100 per six-month period and 50 exercise facility visits.

Prescription Drugs — Retail (30 Day Supply)

$100 deductible per person must be met by either Retail or Mail Order, before the following copay applies (Tier 1/Tier 2/Tier 3)*: $15 / $35 / $75

Covered in full after deductible

Prescription Drugs — Mail Order (90 Day Supply)

$100 deductible per person must be met by either Retail or Mail Order, before the following copay applies (Tier 1/Tier 2/Tier 3)*: $38 / $88 / $188

Covered in full after deductible

Small Group Rates

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 Rating Region Rate Tier HMO 40/60 (Gold)

HMO 35/55 (Silver)

HMO HD6300 (Bronze)

Bronx, Kings, New York, Queens, Richmond, Westchester, Rockland and Orange counties.

Employee $460.08 $392.54 $342.74

Employee/spouse

$920.16 $785.08 $685.48

Employee/children

$782.14 $667.32 $582.66

Family $1,311.23 $1,118.74 $976.81

 

Nassau and Suffolk counties.

Employee $522.86 $446.10 $389.51 Employee/spouse

$1,045.72 $892.20 $779.02

Employee/children

$888.86 $758.37 $662.17

Family $1,490.15 $1,271.39 $1,110.10

Small Group Underwriting Guidelines - Highlights

• No Participation Requirement

• Submission Deadline – 23rd of the prior month

• Husband/Wife – Must go to the Exchange

• Requalification will begin 2Q of 2014

• Multiple Plan Offerings

- Up to 4 enrolled = 1 plan

- 5 to 20 enrolled = up to 3 plans

- Groups of 21+ enrolled = up to 4 plans

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2014 Commission Schedule

Commissions for Groups covering up to 50 eligible employeesSelling Agent

General Agent

Competitive Commissions for all New Small Group Plans

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2014 Incentive Opportunity

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Small Group Individual

Select Care Network

COUNTYNon-Physician

Specialist PCP Specialist Grand TotalBronx 698 810 1113 2621Kings 187 349 495 1031Nassau 371 439 1072 1882New York 268 594 1378 2240Orange 24 24 230 278Queens 299 572 747 1618Richmond 64 86 295 445Rockland 13 21 61 95Suffolk 149 160 339 648Westchester 105 269 530 904Grand Total 2178 3324 6260 11762

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Select Care Hospital Network

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Bronx Jacobi Medical Center Lincoln Medical and Mental Health Center Montefiore Medical Center - Henry and Lucy Moses Division Montefiore Medical Center - Jack D. Weiler Hospital of Albert Einstein College Division

Montefiore Medical Center - North Division New York Westchester Square Medical Center - (OP Site) North Central Bronx Hospital St Barnabas HospitalKings Beth Israel Medical Center - Kings Highway Division Brookdale University Hospital Medical Center Coney Island Hospital Kings County Hospital Center Lutheran Medical Center Woodhull Medical and Mental Health CenterNew York City Bellevue Hospital Center Beth Israel Medical Center - Petrie Campus Coler-Goldwater Specialty Hospital and Nursing Facility Harlem Hospital Center Hospital for Special Surgery Lenox Hill Hospital Metropolitan Hospital Center Mount Sinai Hospital Mount Sinai Hospital - Queens New York Eye and Ear Infirmary New York Presbyterian Hospital St Luke's Roosevelt Hospital Center - Roosevelt Division St Luke's Roosevelt Hospital Center - St. Luke's Division

Orange Bon Secours Community Hospital St Anthony's Community HospitalWestchester Lawrence Hospital Center Northern Westchester Hospital Phelps Memorial Hospital Center St Joseph's Hospital Medical Center – Yonkers White Plains HospitalQueens Elmhurst Hospital Flushing Hospital Medical Center Forest Hills Hospital Jamaica Hospital Medical Center Queens Hospital CenterRichmond Staten Island University Hospital – North Staten Island University Hospital – South Good Samaritan Hospital of SuffernNassau Franklin Hospital Glen Cove Hospital Long Island Jewish Medical Center North Shore University Hospital – Manhasset North Shore University Hospital – Syosset Plainview HospitalSuffolk Eastern Long Island Hospital Huntington Hospital Peconic Bay Medical Center Southampton Hospital Southside Hospital

AdvantageCare Physician brings together four legacy medical groups:

By joining forces, we are better able to cohesively:

•Improve clinical quality outcomes through a model that enables team-based and coordinated care

•Improve the patient experience – helping them better navigate the healthcare system to meet their health care needs

•Make health care more affordable – creating a sustainable future for our physicians and staff, our patients and our communities

Introducing AdvantageCare Physicians

• Manhattan’s Physician Group

• Preferred Health Partners

• Queens-Long Island Medical Group

• Staten Island Physician Practice

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New Product Features

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• Select Care network

• PCP's/Referral required

• RX Deductible (retail/mail): $100 per member; Retail: $15/$35/$75; Mail: $38.00/$88.00/$188 with Value Plus Formulary –Gold/Silver

• Individual deductible can apply towards family deductible

• Stand Alone PED Dental - DentCare (Dentcare Junior)

• Pediatric Vision - GVS (exams & material), comprehensive professional Systems (materials only), EyeCare Advantage (materials only)

• Optional Age 29 Rider

New Business Cases

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Submission process remains the same.

HIP/HIPIC/Comprehealth Conversions

• Performed under Renewal Functionality within EH portal

• Model Plans (compare all three plans)

• Make Roster Changes when available

• Allocate Subs for Multiple Plan Options – Must meet Underwriting guidelines

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NOTE: Brokers/GA’s obtain letter of instruction, signed rates, and roster changes from the group

NOTE: Brokers/GA’s obtain letter of instruction, signed rates, and roster changes from the group

Small Group Renewal Process

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HIP/HIPIC/CH Renewals:

1.Renewal Plan pre-populated:

Silver

Except Select EPO/PPO - Gold

2.Model up to 3 Plans – Make Selection – subject to previous rules at this time

3.Submit to EH

4.View/change PCP’s

Groups without Member/Roster listing

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HIP/HIPIC/CH Renewals:

1.Groups without roster/member listings will be unable to make any roster changes and only select one plan

2.Submit paperwork for all other transactions

Subgroups – different LOB & Rider options

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Groups with more than one benefit set, must each be processed individually.

EH Product Conversions

• Manual Process

• Requirements:

1. New Master App

2. Latest NYS 45

3. New Transaction forms (if needed)

4. No Binder Checks

• Email/mail documents to your dedicated EH representative

• Enter as new business on the portal

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Questions?

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