individual products 2014 · heritage select plans • preferred gold 1000, 1500 • preferred...
TRANSCRIPT
1
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
2
01 OUR STORY
PREMERA BLUE CROSS BLUE SHIELD OF ALASKA
4
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
6
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
7
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
8
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
9
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
10
4 Tier Pharmacy Benefit
11
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
12
• 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
14
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
15
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
16
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
17
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
18
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
20
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
22
Rates
23
• 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
24
Cost Share Reduction Subsidy
Federal Poverty Level Maximum Actuarial Value
100% – 150% 94%
150% – 200% 87%
200% – 250% 73%
25
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)
27
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
29
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.
30
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/
31
32
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
33
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
34
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
35
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
36
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
37
(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
38
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
39
• 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
40
41
•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
43
08 CURRENT MEMBERS COMMUNICATIONS
45
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
46
GRANDFATHERED
• Member communications
• November 1 – Options letter
• Renewal is May 1, 2014
• Plan change tool
Current Member Communications
09 WEB RESOURCES
Website
48
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
50
Individual Sales & Service Team
Sales Leadership Sales and Account
Management Producer Support
John Mychalishyn
Director of Sales
425-918-4780
Kelly Jones
Regional Sales Manager
Work:425-918-5851
Cell: 206-214-8774
John Reynolds
Team Lead, Producer Support
425-918-6270
Nancy Valdez
Sales Executive
907-677-2406
Producer Support Team
Laura Binder
Lucy French
Nicole Goodspeed
877-205-9725, option 1, then 1
Fax: 425-918-3378
51
QUESTIONS?
THANK YOU FOR JOINING US TODAY
029618 (10-2013)