Individual Member Guide

Transcription

1 Individual Member Guide IDAHO 2019 HEALTH IS BEAUTIFUL

2 Why SelectHealth Our mission is Helping People Live the Healthiest Lives Possible. For more than 30 years, we ve been committed to helping members like you stay healthy, offering personalized service, and providing access to high-quality care. Our mission is the foundation of everything we do. Get to know us a little better. LOCAL. We live, work, and play in the same communities you do. When you call us, you re talking to someone who lives in your community. We use the same providers and clinics you do. Isn t it nice to know that the person picking up the phone is a neighbor? ALLIANCE. Our alliance with St. Luke s Health System gives you access to your favorite doctors and facilities and allows us to work together for better healthcare at lower costs that s a win-win! A health plan that works means healthy and happy members. Let s make that happen. SUPERIOR SERVICE. We can help you find the right doctor, clinic, or mental health provider for your needs. We can even schedule an appointment no referral necessary. When you call us, a real person will pick up the phone in 20 seconds or less. EMPOWERING YOU. Through tools like My Health and Medical Cost Estimator to helping you get preventive services, treat chronic conditions, and take action to improve your health; we want to give you the resources to be your own health advocate. We are more than just an insurance company, we re your health plan. 2 selecthealth.org selecthealth.org 3

3 The Perfect Plan in Three Steps: CHECK FOR SUBSIDIES ADVANCED PREMIUM TAX CREDIT ESTIMATOR If you qualify for a subsidy, the federal government will pay a portion of your monthly premium. Visit yourhealthidaho.org and enter some simple information, including family size and household income, to see if you qualify and get an estimate. COST-SHARE REDUCTION In addition to a tax credit, you may be eligible for cost-sharing reduction plans that lower the amount you pay out of pocket for s, coinsurance, and copays. Members of a federally recognized American Indian tribe may also qualify for additional cost-sharing benefits. RESEARCH PLANS We know that finding the right plan can be confusing. That s why it s important to understand what the details mean before choosing a plan. Individual plans are organized by Metal Tier, Plan Type, and Network. Each one of these categories dictates which type of benefits and rates you can expect to see for each plan design. Metal Tiers Choose from four metal tiers Bronze, Expanded Bronze, Silver, and Gold. These are largely based on how the cost of healthcare is split between you and us. BRONZE We pay 60% on average. You pay about 40%. EXPANDED BRONZE We pay 65% on average. You pay about 35%. SILVER We pay 70% on average. You pay about 30%. GOLD We pay 80% on average. You pay about 20%. Plan Types Plan types are categorized by Traditional, HealthSave, Benchmark, and Catastrophic. Each type of plan offers different features depending on your needs, budget, and lifestyle. With a Traditional plan, you can expect to see a classic -style plan, including a waiver for Primary Care, Mental Health, and Specialty Care office visits. HealthSave plans give you the opportunity to pair your plan with a Health Savings Account (HSA). And a Catastrophic plan is developed for those who are under age 30 or qualify for a hardship exemption. Learn more about these plans on pages 8 and 9, at selecthealth.org, or by visiting healthcare.gov. Network The SelectHealth Network in Idaho gives you access to St. Luke s nationally recognized hospitals, facilities, and physicians as well as the St. Luke s Health Partners network. In Northern Idaho, you can also access First Choice Health providers and others in the MultiPlan networks of doctors and facilities. This network also provides access to many specialty hospitals in Utah, including Primary Children s Hospital and the Huntsman Cancer Institute MAKE YOUR FIRST PAYMENT Visit selecthealth.org/applyonline to use our convenient online application. The application must be completed and signed electronically. If you need help with your application, call Individual Sales at , or you can call your agent. You ll need to make your first month s payment before you receive an ID card. ALL YOUR INFO IN ONE PLACE Once enrolled, you ll have access to My Health. Here you ll have important health and benefit information. We also provide a number of health resources, including LiVe Well tools, to help you achieve your wellness goals. Learn more on page 11. Connect Care is now only $10* for Individual members! INTERMOUNTAIN CONNECT CARE Healthcare on your schedule no lines, no waiting room. Connect Care is a convenient way to talk to a provider about urgent medical issues, no appointment necessary. Only $10 for Individual members!* Download the app or visit intermountainconnectcare.org to get started. *Before. $49 before for those on a HealthSave plan. for cancer treatment. 4 selecthealth.org selecthealth.org 5

4 Choosing the Right Care Emergency Care Nurse Line Local Clinics PCP YOUR COMPLETE CARE Specialists Connect Care Hospitals Urgent Care PRIMARY CARE PROVIDERS A Primary Care Provider (PCP) is someone in family medicine, internal medicine, or another provider you see regularly. You can trust a PCP to know your health history, be your partner in preventive care, and help you find other doctors when you need them. CONNECT CARE Visit a provider 24/7 via live online video. At only $10 a visit for most plans, this is a great care option without even having to leave home. URGENT CARE What s open late and costs less than the ER? Our Urgent Care clinics. If you need urgent care, these are great options. HOSPITALS Our hospital network spans span the state of Idaho, offering a variety of care and services. Think heart care, cancer treatment, transplant services, women and newborns, and much more you name it, they can treat it. SPECIALISTS When you need more than your PCP, our network of specialists and surgeons can help and there are thousands to choose from. Get to Know Your Network Our expansive network, which includes St. Luke s Health Partners and BrightPath, gives you access to the best hospitals, clinics, and doctors throughout the state. You will have access to more than 5,000 providers and healthcare professionals, and 65 hospitals, surgery centers, and skilled nursing facilities throughout the state of Idaho. Our plans also provide members with out-of-network benefits in Idaho. LATAH BOUNDARY BONNER KOOTENAI BENEWAH NEZ PERCE LEWIS SHOSHONE CLEARWATER Gym Membership Program Staying healthy just got a little easier on your wallet. As a SelectHealth member, you can get reimbursed for gym memberships through our Healthy Living program. Hitting the gym never felt so good! Get Fitness Reimbursements > > Choose a club in the Virgin Pulse network or any gym you like best > > Get the guaranteed lowest gym membership rate through the Virgin Pulse network, with more than 12,000 clubs nationally > > Try a free one-week trial membership > > Submit your request for a fitness club and gym membership reimbursement Before scheduling an appointment, consider all of your care options. LOCAL CLINICS Community clinics and contracted clinics are in your area, so you never have to drive far to get the care you need. Plus, some clinics have extended hours! EMERGENCY CARE If you have an emergency, call 911 or go to the nearest hospital we ve got you covered anywhere you are. ST. LUKE S NURSE LINE Our free nurse line is available 24/7. Call about any medical condition and we ll help ease your mind. WASHINGTON PAYETTE CANYON ADAMS GEM ADA OWYHEE IDAHO VALLEY BOISE ELMORE CAMAS GOODING TWIN FALLS CUSTER LEMHI LINCOLN JEROME BLAINE MINIDOKA CASSIA BUTTE POWER CLARK JEFFERSON BINGHAM ONEIDA BANNOCK FREMONT MADISON FRANKLIN TETON BONNEVILLE CARIBOU BEAR LAKE > > Receive up to $240 per year, reimbursed quarterly Here s How It Works > > Be age 18 or older > > Create a My Health account > > Complete the Johnson & Johnson online health assessment > > Provide receipts for membership payments You may be eligible for other benefits too, such as discounts on home fitness equipment, streaming fitness videos, or race entry fees. To get started or learn more, log in to My Health at selecthealth.org. 6 selecthealth.org selecthealth.org 7

5 BRONZE We pay 60% on average. EXPANDED BRONZE We pay 65% on average. SILVER We pay 70% on average. GOLD We pay 80% on average. CATASTROPHIC We pay less than 60% on average. TRADITIONAL PLANS Traditional plans are a popular choice for those who d like a traditional or classic plan, including coverage for medical services, preventive care, and prescription drugs. Choose a and benefits that work for you. Some of these plans have a waiver for all Primary Care Providers, Secondary Care Providers, and urgent care visits, while others include a waiver for all Primary Care visits and one urgent care visit. SELECTHEALTH HEALTHSAVE Most HealthSave SM plans are designed to be paired with a Health Savings Account (HSA). With a HealthSave plan, you have more control over your healthcare dollars. Some HealthSave plans are cost-share reduction plans; however, not all cost-share reduction plans are eligible for an HSA. CATASTROPHIC PLAN If you are younger than age 30, or if you qualify for a hardship exemption, you may consider purchasing a catastrophic health plan. These plans have lower premiums, higher s, and higher out-of-pocket maximums, making them ideal for those who only want protection from very high medical costs. These plans are not eligible for a premium subsidy IDAHO PLAN Catastrophic SelectHealth HealthSave 2, 3 Standard Deductible No-Deductible Office Visits Limited Office Visit Waiver 1 Catastrophic 7900 Bronze 6750 Expanded Bronze 5000 Expanded Bronze 4000 Silver 3500 Expanded Bronze 3500 Silver 2750 Gold 2000 Silver Copay Expanded Bronze 7900 Bronze 7600 Expanded Bronze Copay Expanded Bronze 4500 Silver 3500 Deductible Single $7,900 $6,750 $5,000 $4,000 $3,500 $3,500 $2,750 $2,000 $4,000 $7,900 $7,600 $5,500 $4,500 $3,500 Family $15,800 $13,500 2 $10,000 2 $8,000 2 $7,000 2 $7,000 $5,500 $4,000 $8,000 $15,800 $15,200 $11,000 $9,000 $7,000 Out-of-Pocket Max Single $7,900 $6,750 $6,750 $6,750 $6,750 $7,900 $7,900 $6,000 $7,900 $7,900 $7,900 $7,900 $7,900 $7,900 Family $15,800 $13,500 3 $13,500 3 $13,500 3 $13,500 3 $15,800 $15,800 $12,000 $15,800 $15,800 $15,800 $15,800 $15,800 $15,800 Primary Care Provider (PCP) Secondary Care Provider (SCP) Preventive Care and Immunizations Minor Diagnostic Tests Inpatient Hospital Services Outpatient Services Emergency Room Rx Deductible Per Person Tier 1 Drugs Tier 2 Drugs Tier 3 Drugs Tier 4 Drugs Tier 5 Drugs $35 for first 3 in-network PCP and/or mental health office visits, then covered $40 after $40 after $40 after $35 after $60 after $35 after $60 after $25 $25 $40 $50 $35 $35 $30 $40 $50 $65 after $60 after Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% $400 after $400 after $400 after $500 after $500 after Covered 100% Covered 100% 20% after 20% after $350 after $650 per day after (up to 5 days) $600 after Medical and Rx Combined $1,500 $1,250 $500 $2,500 $15 after $15 after $15 after Medical and Rx Combined $600 after $650 per day after (up to 5 days) $600 after $60 after $600 after $50 after $350 after $1,500 $2,500 $1,750 $1,250 $15 $15 $15 $15 $10 $20 $25 $15 $15 $25 $25 $25 $25 $20 $30 $35 $25 $25 $45 after $55 after $45 after $55 after 1 The is waived for all in-network Primary Care Provider and Mental Health office visits. In addition, the first visit to an in-network urgent care clinic is not subject to the. This visit is subject to a copay only. Starting with the second visit to an in-network urgent care clinic, the and copay will apply. 2 When two or more are enrolled on a HealthSave plan, only the family applies. 3 When two or more are enrolled, no single person in a family will pay more than the single out-of-pocket maximum. Please note: The coverage and benefit details presented here do not include out-of-network cost-share details. Please refer to selecthealth.org for out-of-network cost-share information. 8 selecthealth.org selecthealth.org 9

6 Mobile App Everything at Your Fingertips My Health Take Charge of Your Health If you ve got a phone, we ve got you covered. With the SelectHealth mobile app, you have access to your health plan whenever and wherever you need it. My Health can be accessed from your mobile device or computer by visiting selecthealth.org. Once you log in, click the SelectHealth icon or link and enjoy being an informed healthcare consumer. SEARCH FOR DOCTORS AND FACILITIES Avoid searching all over for your next visit. View in-network hospitals, facilities, and urgent care clinics in your area on a responsive map. Quickly locate doctors by name, specialty rating, and more. ID CARD Forgot your ID card at home? Don t worry. The Mobile App has got you covered with the ability to view, , and even fax an image of your ID card. This is especially helpful when you need to reference your plan details or send a card to a provider. RX INFORMATION Look up prescription drug costs, which drug tier they fall into, and if they are considered a maintenance drug before heading to the. You ll also be able to learn about any potentially dangerous drug interactions prior to use. And when you re ready to pick up your Rx, use the handy Pharmacy Search to find a location closest to you. Select Med Map Instacare 5 min wait Satellite Urgent Care Instacare 5 min wait Instacare Kidscare 5 min wait Closed Instacare 5 min wait My Location Change Location List View MEDICAL COST ESTIMATOR Get an estimate for common healthcare services. For example, find out ahead of time how much to plan for when having a baby, including charges for the facility, provider, and anesthesiologist, if applicable. Bundling these numbers together, we ll estimate how much your plan will cover and what you will pay. YOUR HEALTH PLAN View claims, get a snapshot of year-to-date and out-of-pocket maximum totals, and search for a doctor. It s all here and updated to the minute. CHAT WITH US No time for a phone call? Use our secure chat feature to talk with Member Services online. Whether you need to know if your medication will be covered or how much a doctor s bill was, chat can help. 10 selecthealth.org selecthealth.org 11

7 Your Prescription Benefits Prescription drug benefits for everyone, plus access to more than 45,000 pharmacies nationwide. PRESCRIPTION DRUGS Coverage is divided into five tiers (levels). Each drug is covered under a specific tier that corresponds to a copay or coinsurance amount this is the amount you pay. Drugs on lower tiers may provide the treatment you need at the best value. Tier 1 Lowest cost (mostly generic drugs) Tier 2 Medium cost (non-preferred generic and some brand-name drugs) Tier 3 Higher cost (generic and brand-name drugs) Tier 4 Highest cost (mostly brand-name drugs) Tier 5 Highest cost (injectable drugs and specialty medications) PRESCRIPTION DRUG LIST (PDL) Individual plans use our RxCore PDL. Search for your drug on our website (see Pharmacy) to find the tier and any special requirements. SPECIAL REQUIREMENTS Some drugs require step therapy or preauthorization before they will be covered by your plan. Step Therapy If your drug requires step therapy, your doctor must first prescribe an alternative drug. These are generally more cost effective and do not compromise clinical quality. Step therapy may be waived for medical necessity. Preauthorization This means that your doctor must contact us for approval before your drug will be covered. 90-DAY MAINTENANCE DRUG BENEFIT The 90-day maintenance drug benefit allows you to obtain a 90-day supply of certain generic medications. It applies to drugs that you have been using for at least one month and expect to continue using for the next year. Your member responsibility (e.g., copay or coinsurance amounts) may be lower when you fill prescriptions using the 90-day benefit. There are two ways to fill a 90-day prescription: A local that participates in our Retail90 program (search for Retail90 pharmacies online) or the Intermountain Home Delivery Pharmacy (intermountainrx.org). ONLINE TOOLS It s easy to view your family s prescription history or find out how much a drug will cost. Log in to My Health at selecthealth.org to access these useful tools: > > Review drug coverage > > View Rx claims > > Compare drug prices > > Find in-network pharmacies > > Check for drug interactions 12 selecthealth.org selecthealth.org 13

8 We Can Help Health insurance doesn t have to be complicated. We can help you with everything from understanding your benefits to finding the right doctor. Our customer service General Medical Information teams are dedicated to providing exceptional service. MY HEALTH CUSTOMER SERVICES No time to call? Log in to My Health and chat with us or request a call back at a time that s more convenient for you. selecthealth.org MEMBER SERVICES We want to help you understand your insurance plan so, when you have a question, give us a call. And we realize that life doesn t always happen between nine and five, so we re here late. 7 a.m. to 8 p.m., weekdays 9 a.m. to 2 p.m., Saturdays MEMBER ADVOCATES SM We can help you find the right doctor for your needs. We ll find the closest facility or doctor with the nearest available appointment, schedule appointments for you, and help you make the most of your benefits OUR PLANS Our plans are designed to provide coverage for hospital, medical, preventive care, and surgical expenses incurred as a result of a covered accident or illness. Coverage is provided through in-network providers for daily hospital room and board, miscellaneous hospital services, anesthesia services, in-hospital medical services, and out-of-hospital care. Coverage is subject to any, copay provisions, or other limitations that may be set forth in your Contract. ELIGIBILITY You and your dependents may apply for coverage if you are a resident of Idaho and not eligible for Medicare. Eligible dependents include the subscriber s legal spouse, children younger than age 26, eligible disabled children older than age 26, and children who are under courtordered legal guardianship until legal guardianship ends. See your Contract for more details on guardianship. TERMINATION Your coverage will not terminate (end) for health reasons. However, your coverage may end according to the terms of your Contract, including any of these reasons: > > Nonpayment of premiums > > Fraud or intentional misrepresentation of material fact > > You no longer reside, live, or work in the service area If we do not receive a premium or we are unable to collect a premium, you will be notified. EXCLUDED SERVICES Certain services are not covered by your plan. For a list of excluded services, see your member materials or visit selecthealth.org/exclusions. EXCESS CHARGES These are charges from providers and facilities that exceed the SelectHealth allowed amount for covered services. When you use an out-of-network provider or facility, you will be responsible for any incurred excess charges. These charges do not apply to your out-of-pocket maximum. APPEALS/ UTILIZATION MANAGEMENT (UM) For information about what requires preauthorization, our care management programs, or how to file an appeal, see your member materials or visit our Member Resources page selecthealth.org/policy. SelectHealth complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a SelectHealth: (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 SelectHealth: (TTY: 711). 14 selecthealth.org selecthealth.org 15

9 We re committed to helping you stay healthy by providing access to high-quality healthcare at an affordable cost, giving superior service, and offering the tools you need to make smart decisions. For more information about our health plan options, contact our Individual Sales department at SelectHealth. All rights reserved /18