for Employer Groups 2016

Transcription

1 for Employer Groups

2 Together. Health Tradition and Mayo Clinic create exceptional group health benefit solutions A partner who understands your priorities With access to the resources of one of the most respected medical institutions in the world, Health Tradition is meeting the challenge of providing attractive, benefit-rich health plans, cost-effectively. Your provider network and health plan on the same team Health Tradition is Mayo Clinic-owned and physician-led, incorporating best practices across insurance operations and clinical care. We are guided by the same values: excellence, compassion and responsiveness. Just as the Mayo Clinic model of patient care became the template for effective health care delivery, new population health research and a proven, outcomes-based approach to wellness have become essential to a well-designed health benefit. Wellness benefits developed and tested by Mayo Clinic experts bring care decisions closer to the individual:» Engaging people in the decision-making process, making them more capable consumers» Streamlining» Incentivizing healthy behaviors and supporting lifestyle improvement» Motivating wellness participation with appealing programming» Supporting employees in managing chronic conditions Plan design options In addition to the traditional HMO model, employers may choose a Point-of-Service (POS) plan or consumer-directed health plan with a high-deductible option and incorporate a health reimbursement account (HRA) or a health savings account (HSA). We offer professional advice on cost-effective plan design, including self-funded options. Customized plan design and management Options include fully insured managed health plans, selffunded plans, consumer-directed plans and pharmacy benefit management. Our plan administration partner is Mayo Clinic Health Solutions, a prominent TPA and leader in comprehensive solutions for self-funded groups. We offer full support with customized reporting and analysis, a state-of-the-art Consumer-Directed Health (CDH) plan platform, tools for easy implementation and enrollment, multipurse health care payment cards, real-time access to claims data, nondiscrimination testing and more. Initiatives to bend the cost curve Medical management Our team of specialists assures quality care and cost management through prior authorization, referral management, case management, concurrent review and discharge planning. Condition management A voluntary program that helps members better manage their conditions. The program includes a 24-hour toll-free phone line, evaluation, consultation and education. Reinsurance and underwriting With access to several reinsurance carriers, we provide competitive stop-loss coverage options. RNs available 24/7 Instant access to reliable health information improves utilization by helping members take appropriate action. Quality management All standards are developed to meet or exceed Healthcare Effectiveness Data and Information Set (HEDIS) benchmarks, National Committee for Quality Assurance (NCQA) and URAC guidelines to communicate and maintain our high standards of care. URAC accredited, Health Plan and Health Plan for Health Insurance Exchange (HIX) 2

3 Health Tradition s wellness benefits are member-friendly and provide exceptional outcomes Our wellness programming was developed by Mayo Clinic Health System experts based on the latest research. These proven programs engage, empower and direct resources where they will be most effective. Eat Well Move More Rebate This popular program offers up to $200 combined rebate per member household for healthy investments like fitness club or Weight Watchers dues and Community Supported Agriculture (CSA) fresh produce programs. Wellness at Work Backed by Mayo Clinic research, ready-to-launch wellness challenges focus on actions with the biggest health benefits. Wellness at Work encourages employees to adopt healthy habits and motivate others around them, building momentum. WellMe A quarterly update with workplace wellness topics, research and tips to create effective Wellness at Work challenges. HEALTHCARE.GOV See Health Tradition plans on HealthCare.gov Health Tradition HMO plans are available through the Small Business Health Options Program (SHOP) Marketplace at HealthCare.gov. Free 24/7 Nurse Line Reliable information from Mayo Clinic Health System registered nurses. The Nurse Line provides reassurance plus encourages appropriate use of health care resources. Tobacco Cessation This effective program combines personal counseling through the Mayo Clinic Tobacco Quitline with the use of Nicotine Replacement Therapy (NRT) aids. Mayo Clinic Healthy Living Online Powerful support for behavior change and condition management, integration with popular fitness tools such as FitBit, a health reference library, decision guides and access to benefits information and claims history. Mayo Clinic Health Assessment Allows organizations to identify population risks and readiness to change, deliver follow-up interventions and track health trends over time. The assessment presents a personalized action plan for each participant. Talk with a Health Tradition agent, or call us We will help you design an attractive and cost-efficient health benefit for your group or HealthTradition.com Available wellness support Implementation-ready solutions for a culture of wellness Mayo Clinic Health System experts can help you plan robust, data-driven wellness programming with aggregate reporting, outcomes analysis, promotion tools and recommendations to affect targeted improvements. Healthwise U Multifaceted health education and behavior change resources, including workshops and presentations, award-winning videos and customized workplace health initiatives. A New Me: Healthy Balance Matters Better health through mindful choices, integrating nutrition, physical activity and stress management, A New Me includes assessments, biometric screening and follow up. This intensive lifestyle program is eligible for the Eat Well Move More rebate. 3

4 Standard HMO Small Group Plans Covered Services Platinum / /80 w/copay 2000/ / /70 w/copay 2000/70 Annual Deductible Indiv/Family $1,500/ $3,000 Annual Out-of-Pocket Maximum Indiv/Family $2,500/ $5,000 $3,000/ $6,000 $2,350/ $4,700 $4,500/ $9,000 $6,000/ $12,000 Preventive Care* 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage Routine Eye Exam One per member per coverage year. Limits apply. Routine Hearing Exam Annual. Limits apply. After meeting your deductible you pay (copays do not apply to deductible) Office Visits 1 $75 primary/ $125 specialist 3 Chiropractic $30 copay $30 copay 1 $75 copay 3 Urgent Care** $30 copay $30 copay 1 $75 copay 3 Emergency Room Services ** and and 1 and 3 and 3 Ambulance Hospitalization Inpatient/Outpatient Outpatient Lab/Radiology Durable Medical Equipment Skilled Nursing Facilities with prior authorization Home Health Care Rehabilitation Services Prenatal/Postnatal Care Delivery and all Inpatient Services Mental/Behavioral Health, Outpatient Mental/Behavioral Health, Inpatient $30 copay $30 copay 1 $75 copay 3 Prescription Drugs Health Tradition Formulary G=Generic B=Brand, N=Non-formulary S=Specialty $25 G $60 B $80 N $30 G $70 B $150 N These Health Tradition plans are also available through the Health Insurance Marketplace at HealthCare.gov * This Benefit Plan provides 10 coverage for preventive health services. Coverage may be subject to reasonable medical management techniques to determine the frequency, method, treatment, or setting for receipt of preventive health services and as defined in Section 1001 of the Patient Protection and Affordable Care Act, with no cost sharing. ** Out-of-network medical emergencies, urgent care and plan prior approved referrals are covered as in-network benefit. See Certificate of Coverage for plan detail. 4

5 HMO Qualified High-Deductible Plans compatible with Health Savings Accounts 2000/ /80 w/copay 6000/ /100 HDHP 90 HDHP 100 HDHP 50 HDHP 60 HDHP 80 $2,500/ $5,000 $6,000/ $12,000 $3,000/ $6,000 $4,125/ $8,250 $3,500/ $7,000 / $8,000 $5,000/ $10,000 $6,350/ $12,700 $4,400/ $8,800 $4,125/ $8, coverage 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage After meeting your deductible you pay (copays do not apply to deductible) In addition to meeting your deductible you pay and G B $30 G $75 B $150 N 5% G 1 B N 1 S 5 4 G 4 B 6 N G B These Health Tradition plans are also available through the Health Insurance Marketplace at HealthCare.gov Once a member of a family plan meets the individual deductible or maximum out-of-pocket, Health Tradition begins paying for covered services for that person, regardless of whether the family deductible or out-of-pocket maximum has been met. 5

6 Standard Point of Service Small Group Plans There is coverage for both in-network and out-of-network provider services. Please see plan documents for out-of-network coverage. Covered Services Platinum 1000 POS 1000/80 POS 1000/80 w/copay POS 2000/100 POS 2000/90 POS 1500/70 w/copay POS 2000/70 POS Annual Deductible Indiv/Family $1,500/ $3,000 Annual Out-of-Pocket Maximum Indiv/Family $2,500/ $5,000 $3,000/ $6,000 $2,350/ $4,700 $4,500/ $9,000 $6,000/ $12,000 Preventive Care* 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage Routine Eye Exam One per member per coverage year. Limits apply. Routine Hearing Exam Annual. Limits apply. After meeting your deductible you pay (copays do not apply to deductible) Office Visits 1 $75 primary/ $125 specialist 3 Chiropractic $30 copay $30 copay 1 $75 copay 3 Urgent Care** $30 copay $30 copay 1 $75 copay 3 Emergency Room Services ** and and 1 and 3 and 3 Ambulance Hospitalization Inpatient/Outpatient Outpatient Lab/Radiology Durable Medical Equipment Skilled Nursing Facilities with prior authorization Home Health Care Rehabilitation Services Prenatal/Postnatal Care Delivery and all Inpatient Services Mental/Behavioral Health, Outpatient Mental/Behavioral Health, Inpatient $30 copay $30 copay 1 $75 copay 3 Prescription Drugs Health Tradition Formulary G=Generic B=Brand, N=Non-formulary S=Specialty $25 G $60 B $80 N $30 G $70 B $150 N Out-of-network services Emergency room, ambulance and urgent care benefit is same as in-network. Other services may not be covered, or covered at a different rate or copay amount. These Health Tradition plans are not available through the Health Insurance Marketplace. * This Benefit Plan provides 10 coverage for preventive health services. Coverage may be subject to reasonable medical management techniques to determine the frequency, method, treatment, or setting for receipt of preventive health services and as defined in Section 1001 of the Patient Protection and Affordable Care Act, with no cost sharing. ** Out-of-network medical emergencies, urgent care and plan prior approved referrals are covered as in-network benefit. See Certificate of Coverage for plan detail. 6

7 Point of Service High-Deductible Plans compatible with Health Savings Accounts 2000/80 POS 2500/80 w/copay POS 6000/80 POS 6850/100 POS HDHP 90 POS HDHP 100 POS HDHP 50 POS HDHP 60 POS HDHP 80 POS $2,500/ $5,000 $6,000/ $12,000 $3,000/ $6,000 $4,125/ $8,250 $3,500/ $7,000 / $8,000 $5,000/ $10,000 $6,350/ $12,700 $4,400/ $8,800 $4,125/ $8, coverage 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage 10 coverage After meeting your deductible you pay (copays do not apply to deductible) In addition to meeting your deductible you pay and G B $30 G $75 B $150 N 5% G 1 B N 1 S 5 4 G 4 B 6 N G B Emergency room, ambulance and urgent care benefit is same as in-network. Other services may not be covered, or covered at a different rate or copay amount. These Health Tradition plans are not available through the Health Insurance Marketplace. Once a member of a family plan meets the individual deductible or maximum out-of-pocket, Health Tradition begins paying for covered services for that person, regardless of whether the family deductible or out-of-pocket maximum has been met. 7

8 Mayo Clinic Health System primary and specialty care The relationship at the center of excellent care Each member selects a local Primary Care Provider (PCP) from an extensive provider network. The PCP leads the care team, getting to know the member. The emphasis on this relationship creates an excellent patient experience, continuity and better outcomes. The PCP may consult with specialists within Mayo Clinic Health System or outside the network and refer when medically indicated. Referrals to specialists Your care team works closely with Health Tradition to ensure you receive the most appropriate care at the appropriate facility. A referral from your PCP may be to a Mayo Clinic specialist practicing locally. When medically indicated, you may be referred to Mayo Clinic in Rochester or another out-of-network provider. These referrals require written plan approval before services are received. Health Tradition will keep you informed by letter of out-of-network services being considered and those that are approved. Your primary and specialty care provider network La Crosse Eau Claire Rochester Hospital/Clinic Site Clinic Site Specialty Referral Center Service Area More than 70 locations Communities listed in bold type indicate a Mayo Clinic Health System site 1808 East Main Street Onalaska, WI P.O. Box 188 La Crosse, WI (toll free) or (local). HealthTradition.com 2015 Health Tradition Health Plan HTHP-V625 (10/15) 8