Starmark Preventive PlusSM

Transcription

1 Compliant with the Affordable Care Act as it applies to self-funded plans Starmark Preventive PlusSM Minimum Essential Coverage Plan Designs Self-Funded Health Plan Designs and Stop-Loss nsurance for Small to Mid-Size Businesses ~ AStarmarK Trustmark Company PERSONAL. FLEXBLE. TRUSTED. Trustrnark LFE NSURANCE COMPANY

2 Starmark Preventive Plus SM A wellness plan design to help employees stay healthy. Starmark Preventive Plus self-funded health plan designs provide affordable preventive-only healthcare benefits to help your employees stay healthy. These plan designs are a low-cost alternative to major medical coverage, and offer health and wellness benefits to fulfill the Affordable Care Act (ACA) individual requirement to maintain minimum essential coverage. With Starmark Preventive Plus, you ll have the opportunity to receive a refund if your group s claims for this preventive plan design are lower than expected and funded. To learn more about self-funding and how your financial risk is minimized with stop-loss insurance, refer to the separate brochure, Self-Funding: A guide for small to mid-size businesses. Why Starmark Preventive Plus? Easy-to-understand plan design for preventive health and wellness benefits First-dollar benefit for covered in-network preventive care services Provider discounts for covered in-network services exclusively through PHCS, a MultiPlan Network Stop-loss insurance protection on only aggregate claims Traditional Cash Surplus option offers the opportunity for a refund if covered claims under Preventive Plus are lower than funded Experience the Difference Seamless integration of plan administration, stop-loss insurance and claim payment with your self-funded plan administered by Starmark, and stop-loss insurance coverage provided by Trustmark Life nsurance Company Satisfies the ACA individual mandate provision to maintain minimum essential coverage Starmark Preventive Plus must be offered to all eligible employees along with a major medical plan that provides minimum value and is affordable. Employees select one plan design and are covered by the benefits specific to the plan design selected. Self-funded plans are administered by Star Marketing & Administration, nc. (Starmark), and stop-loss insurance coverage is provided by Trustmark Life nsurance Company. 2 Exceptional personal service to ensure satisfaction, and self-service capabilities enabling employers and members to access tailored healthcare benefit resources online 24/7 A smooth transition to self-funding with employer tools to simplify plan administration, including utilization reports to better manage healthcare costs

3 Starmark Preventive Plus SM 3 Plan Design Choices Coverage is for in-network services only, except for emergency services when Package 2 is selected. Standard OR Package 1 OR Package 2 Preventive Care 100% coverage for ACA-Compliant 100% coverage for ACA-Compliant 100% coverage for ACA-Compliant Preventive Care Benefits Preventive Care Benefits Preventive Care Benefits Teladoc Telemedicine Services $45 fee per consult 1 The consult fee is subject to change during the plan year. ' ' ' $20 copay* per consult $20 copay* per consult Prescription Drug Benefit Prescription drug card for generic drugs Prescription drug card for generic drugs RxSavingsPlus SM discount card 1 Retail Copay: $15* (up to a 30-day supply) Mail Service Copay: $38* Mail Service Copay: $38* (up to a 90-day supply) (up to a 90-day supply) Physician/Specialist Office Visits $20 copay* per visit; maximum of $20 copay* per visit; maximum of Not covered ' ' ' 3 in-network only visits per plan year 3 in-network only visits per plan year Not covered Not covered ' ' ' Retail Copay: $15* (up to a 30-day supply) Emergency Room $150 copay* for one emergency room visit per covered person, per year Benefit Period (Choose one) n-network Out-of-Pocket Limit (individual/family) Calendar Year The 12-month period from January 1 to December 31 during which covered expenses can be applied toward the in-network out-of-pocket limit. The accumulation period resets every January 1. Plan Year The 12-month period during which covered expenses can be applied toward the in-network out-of-pocket limit. The plan year begins with the group s effective date and the accumulation period resets 12 months later, on the plan s anniversary. For 2018 plan years: $7,350/$14,700 For 2019 plan years: $7,900/$15,800 The individual in-network out-of-pocket limit is the amount of covered charges the member must pay each year. Preventive care services required under the ACA are covered at 100 percent and are not subject to the in-network out-of-pocket limit. Expenses that apply to the in-network out-of-pocket limit vary by plan design as noted with an asterisk Lifetime Maximum Benefit Unlimited Exclusions and limitations apply. 1 This is not a plan benefit. Expenses do not apply to the in-network out-of-pocket limit. * n-network expenses apply to the in-network out-of-pocket limit. MPORTANT NOTCE: Starmark Preventive Plus plan designs do not meet minimum value and are not comprehensive major medical plan designs; these plan designs cover preventive care services only. These preventive benefits plan designs currently fulfill an individual s requirement under the Affordable Care Act to maintain minimum essential coverage, subject to revision of applicable law, regulation and regulatory interpretation. Benefits are limited to the coverage described in the Plan Document. Exclusions and limitations apply. This plan design does not meet Minimum Creditable Coverage requirements for MA residents under the Massachusetts Health Care Reform Act. 3

4 Covered Preventive Care Services This is a preventive care benefit plan design and is not a major medical plan design. Benefits are limited. The covered preventive care services identified below will be paid under your self-funded plan at 100 percent when received in-network. 1 n no event will benefits for preventive care services be less than that which is required by state or federal law, as applicable. This list is subject to change as required by the Affordable Care Act. Recommended populations, age and frequency schedules apply. Additionally, this plan design may use reasonable medical management techniques to determine appropriate frequency, method or setting for a preventive service. For a complete list and description of preventive care services, visit and uspstf-a-and-b-recommendations. Out-of-network services are not covered. Preventive Services for Adults (Men and Women, unless otherwise specified) Abdominal aortic aneurysm screening (one-time for men ages 65-75, who have ever smoked) Alcohol misuse screening and counseling Aspirin daily use (must meet certain age or risk factors) Blood pressure screening Cholesterol screening (must meet certain age or risk factors) Colorectal cancer screening (ages 50-75; under age 50 must meet certain risk factors) including pre-procedure consultation, bowel preparation kits and pathology exam Depression screening Diabetes (Type 2) screening (must meet certain age or risk factors) Diet counseling (must be at higher risk for chronic disease) Falls Prevention exercise interventions (must meet certain age, population and risk factors) Hepatitis B screening (must meet certain risk factors) Hepatitis C screening (must meet certain age or risk factors) Human immunodeficiency virus (HV) screening (one-time for ages 15-65; must meet certain risk factors for more frequent screenings) mmunizations (vaccines based on age/population) Lung cancer screening (must meet certain age and risk factors) Obesity screening and counseling Sexually transmitted infection (ST) prevention counseling (must be at high risk) Skin cancer behavioral counseling (must meet certain age and risk factors) Statins (Low to Moderate Dose): Preventive medication (must meet certain age and risk factors), generics only (if a generic version is not available or appropriate, coverage will be provided for a brand name drug) Syphilis screening (must be at high risk) Tobacco use screening (includes cessation intervention) Tuberculosis screening (must be at high risk) Preventive Services for Women Breast cancer genetic test (BRCA): Counseling about genetic testing for breast cancer (must be at higher risk), and if indicated, testing for harmful BRCA mutations Breast cancer preventive medications (must be at higher risk) Chemoprevention breast cancer counseling (must be at higher risk) Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies (must be pregnant or nursing) Cervical cancer screening (ages 21-29: pap smear every 3 years; ages 30-65: pap smear every 3 years and human papillomavirus (HPV) testing every 5 years; or for women ages who want to lengthen the screening interval, pap smear and HPV testing every 5 years) Chlamydia infection screening (must meet certain age or risk factors) Contraception: FDA-approved contraceptive methods, sterilization procedures, patient education and counseling Domestic and interpersonal violence screening and counseling Folic acid supplements (for women who may become pregnant) Gestational diabetes screening (must meet certain risk factors) Gonorrhea screening (must be at higher risk) Hepatitis B screening (must be pregnant) Human immunodeficiency virus (HV) screening and counseling (must be sexually active) Mammography breast cancer screening (every 1 to 2 years; must be over 40) Osteoporosis screening (must meet certain age and risk factors) Preeclampsia prevention: Aspirin (must be pregnant and at high risk for preeclampsia) Preeclampsia screening (must be pregnant with blood pressure measurements throughout pregnancy) Rh incompatibility screening (must be pregnant) and follow up testing (must be at higher risk) Sexually transmitted infection (ST) prevention counseling (must be sexually active) Syphilis screening (must be pregnant or at higher risk) Tobacco use screening (includes cessation intervention; expanded counseling if pregnant) Urinary tract or other infection screening (must be pregnant) Well-woman visits for recommended preventive services for women under Preventive care benefits are in accordance with guidelines from the U.S. Preventive Services Task Force, Health Resources and Services Administration, and the Advisory Committee on mmunization Practices of the Centers for Disease Control and Prevention.

5 Preventive Services for Children Alcohol and drug use assessment (adolescents) Autism screening (at 18 and 24 months of age) Behavioral assessment (at specified ages) Blood pressure screening (at specified ages) Cervical dysplasia screening (sexually active females) Depression screening (adolescents) Developmental screening (under age 3) Dyslipidemia screening (must be at high risk of lipid disorders; at specified ages) Fluoride chemoprevention supplements (for children without fluoride in water source) Gonorrhea preventive medication for the eyes (newborns) Hearing screening (newborns) Height, weight and body mass index measurements (at specified ages) Hematocrit or Hemoglobin screening Hemoglobinopathies or sickle cell screening (newborns) Human immunodeficiency virus (HV) screening (adolescents at higher risk) Hypothyroidism screening for newborns mmunizations (vaccines from birth to age 18; doses, recommended ages, and recommended populations vary) Lead screening (if risk of exposure) Medical history throughout development (at specified ages) Obesity screening and counseling Oral health risk assessments (at specified ages) Phenylketonuria (PKU) screening (newborns) Sexually transmitted infection (ST) prevention counseling and screening (adolescents at higher risk) Skin cancer behavioral counseling (must meet certain age and risk factors) Tuberculin testing (must be at higher risk of tuberculosis; at specified ages) Vision screening Plan Design Features Starmark Preventive Plus SM plan designs include coverage for preventive services plus additional features to help employees stay healthy. Talk to a Doctor Anytime with Teladoc Teladoc gives members 24/7/365 access to U.S. board-certified doctors via phone or video. The consult fee is the lesser of $45 * or the office visit copay, if applicable. t s a convenient and affordable option: When considering an urgent care or ER visit for a nonemergency issue On vacation or away from home For short-term prescription refills Availability and services may vary by state. Teladoc consults do not apply toward the physician/specialist office visit limit for Package 1 and Package 2. * The consult fee is subject to change during the plan year. Teladoc, nc. is not an affiliate of Starmark or Trustmark Life nsurance Company. Teladoc is a registered trademark of Teladoc, nc. Physician/Specialist Office Visit n Package 1 and Package 2 only $20 copay for up to 3 in-network office visits per person per plan year Covered charges are paid in full after the in-network physician/specialist office visit copay. This includes charges for the consultation, professional fees for allergy injections and certain nonsurgical injections performed at the same office visit, and billed by the attending physician. Additionally, the copay applies to in-network manipulative therapy provided at the office visit. Copays apply to the in-network out-of-pocket limit. The physician/specialist office visit copay does not apply to preventive care services, allergy testing and allergy serum, any surgical procedure, or visits exceeding the 3-visit limit. Coverage for preventive care services is described in the Covered Preventive Care Services section of this brochure. Emergency Room n Package 2 only $150 copay for one emergency room visit per person per plan year Covered charges are paid in full after the copay. The copay applies toward the in-network out-of-pocket limit. Covered charges for out-of-network emergency room services apply to the in-network out-of-pocket limit and will be equal to the greatest of the rate payable to in-network providers, the Reasonable Fee 1 or the amount that would be paid under Medicare. The copay is not waived if admitted as inpatient. The following services are not covered: Transportation, inpatient services, visits exceeding the 1-visit limit, charges for non-emergency treatment received in the emergency room, and treatment, services and supplies received at an urgent care center. time services are provided. May vary by state. Refer to the proposal for details. 5 1 Reasonable Fee is the lesser of the provider s actual charge, negotiated fee, or 150, 200 or 500 percent (depending on the service) of the Medicare reimbursement rate in effect at the

6 Prescription Drugs RxSavingsPlus SM Standard only The RxSavingsPlus prescription drug discount card from CVS/caremark TM provides savings of up to 70%, with average prescription savings of 22%, off the regular retail price to help make prescription drugs more affordable. This prescription drug discount program is not insurance and can be used for the entire family, including pets. t s easy to save, just visit any participating pharmacy to receive the discount. There are no forms to fill out and nothing to mail in. Prescription drug expenses do not apply toward the in-network out-of-pocket limit. Prescription Drug Card Package 1 and Package 2 only A prescription drug card for generic drugs filled at a designated pharmacy is included when Package 1 or Package 2 is selected. Prescription drug copays accumulate toward the in-network out-of-pocket limit. Preferred brand and nonpreferred brand drugs are not covered, and expenses do not apply toward the in-network out-of-pocket limit. Retail Copay for Generics: $15 (up to a 30-day supply) Mail Service Copay for Generics: $38 (up to a 90-day supply) Visit a Designated Pharmacy to Maximize Benefits Package 1 and Package 2 only Designated pharmacies have contracted with our contracted pharmacy benefit manager to charge a discounted amount for prescription drugs. Nondesignated pharmacies may charge a price significantly above this amount, which may mean higher prescription expenses for members. When a nondesignated pharmacy is used, the member pays the full price of the prescription drug at the time of purchase. Prescription Safeguards To encourage the safe and appropriate use of prescription drugs, our plan designs utilize quantity limits and prior authorization for certain drug classes covered by the prescription benefit. These limits and prior authorizations are intended to ensure proper prescription utilization and clinically appropriate quantities. Additionally, Specialty Guideline Management, provided by our designated specialty pharmacy, helps to ensure members receive the most appropriate specialty medication for managing their complex medical conditions. Note: When Package 1 or Package 2 is selected, only generic specialty drugs are covered when ordered using a designated specialty pharmacy. Generic specialty drugs not obtained through the designated specialty pharmacy may not be covered. Healthy Foundations Helps Members Get and Stay Healthy Healthy Foundations provides a comprehensive suite of health and wellness management tools to help members get and stay healthy, which can help control your plan costs. Healthy Foundations includes: MyNurse 24/7 SM, a URACaccredited nurse line; online support tools and the Healthy Foundations wellness e-newsletter. These resources can help employees protect their most important asset their health. To learn more, visit Healthy Foundations is a registered trademark of Trustmark nsurance Company. MyNurse 24/7 SM is a service mark of Health Fitness Corporation. 6

7 Terminations Off-Anniversary Terminations f the stop-loss insurance contract terminates before the end of the contract period, there is no aggregate stop-loss insurance available for the months the contract was in force. As a result, the employer is responsible for reimbursing Trustmark Life nsurance Company for any advances, including all aggregate advances. Enrollment Annual Open Enrollment Period Eligible employees may enroll themselves and their eligible dependents during the annual open enrollment period, which is the month prior to the start of the new plan year. Waiting Period The waiting period is the amount of time the employee must wait before he or she is eligible for coverage under your selffunded plan. The waiting period cannot exceed 90 days. Timely Enrollees Timely enrollees are eligible employees who complete and sign an Employee Eligibility Statement for themselves and/or their dependents during the employer s waiting period and prior to the end of the initial enrollment period. The initial enrollment period is the 31 days following the waiting period. Special Enrollees Special enrollees are employees or dependents who previously waived self-funded coverage, but may now be eligible because they have involuntarily lost their other coverage, had a benefit/coverage change or had a lifechanging event. The enrollment period for a special enrollee is the 31 days following the special enrollment event (60 days for special enrollees who have lost their Medicaid or State Children s Health nsurance Program coverage). Special guidelines apply for special enrollees. For more details, refer to the mportant Notice (UW105 SF) or ask your broker. Exclusions and Limitations No benefits are payable under your Preventive Plus plan design for the following expenses: Charges not specifically listed as covered charges; services and supplies not prescribed by a physician or required to treat a covered condition, or in excess of the Reasonable Fee 1, or not medically necessary Treatment, services and supplies received at an urgent care center; treatment, services and supplies received at a retail clinic 2,6 ; telemedicine services, unless received through our contracted telemedicine services vendor; x-rays, diagnostic imaging tests and laboratory tests 2,3 Room, board and nursing care provided by a hospital or other facility; miscellaneous services and supplies provided by a hospital or other facility 2 ; durable medical equipment 2 ; therapies 2,4 ; emergency transportation; surgery 2 ; pregnancy 2 ; home healthcare; hospice care Charges the member is not legally required to pay; charges for missed appointments; surcharges for weekend nonemergency office visits and home visits by a physician; treatment rendered by a member of the member s family; treatment, services or supplies provided by a medical department, treatment center, or clinic operated by or sponsored by a member s employer; occupational sickness and injury, except for members who are not covered by workers compensation or similar coverage and are not required by law to have such coverage when Package 1 or Package 2 is selected Outpatient prescription drugs 2 ; non-prescription drugs 2 ; imported drugs; prescription drugs 2,5 and specialty drugs 2,5 ; any prescription drug containing bulk chemical powders; smoking deterrent medications 2 ; drugs, therapies and treatment for the restoration or enhancement of sexual activity Treatment received outside the United States 3 ; immunizations required for travel outside the United States; experimental/ investigational drugs or treatment; items for comfort or convenience; family or marriage counseling, nonmedical self-care or self-help programs; custodial care Suicide, attempted suicide or intentional self-inflicted injury, if not the result of a medical condition; injury resulting from one s own illegal use of alcohol, drugs or over-the-counter medications, if not the result of a medical condition Acts of war; participation in a riot; commission of or attempt to commit a felony; engaging in an illegal occupation 1 Reasonable Fee is the lesser of the provider s actual charge, negotiated fee, or 150, 200 or 500 percent (depending on the service) of the Medicare reimbursement rate in effect at the time services are provided. May vary by state. Refer to the proposal for details. 2 No benefits are payable under your self-funded plan design for these expenses, except as required under federal guidelines for preventive care. 3 When Package 2 is selected, these services may be covered as part of an emergency room visit. 4 Covered charges for manipulative therapy may be payable when Package 1 or Package 2 is selected. 5 Covered charges are payable for only generic drugs when Package 1 or Package 2 is selected. 6 Covered charges for a visit may be payable when Package 1 or Package 2 is selected. 7

8 Starmark The leader in self-funding for small groups. Self-funded plans are administered by Starmark, and stop-loss insurance coverage is provided by Trustmark Life nsurance Company. Trustmark : An employee benefits company for more than 100 years The Trustmark companies serve more than 2 million covered lives or plan participants. Trustmark Life nsurance Company is rated A- (Excellent) by A.M. Best. Trustmark is the brand name used to refer to certain subsidiaries of Trustmark Mutual Holding Company that provide insurance and other products and services. Starmark: Serving the healthcare benefit needs of employer groups for more than 30 years We administer self-funded health benefit plans, offering extensive plan design choices, exceptional personal service and nationwide provider access. Our mission: Helping people increase well-being through better health and greater financial security. MPORTANT NOTCE: Starmark Preventive Plus plan designs do not meet minimum value and are not comprehensive major medical plan designs; these plan designs cover preventive care services only. These preventive benefits plan designs currently fulfill an individual s requirement under the Affordable Care Act to maintain minimum essential coverage, subject to revision of applicable law, regulation and regulatory interpretation. Benefits are limited to the coverage described in the Plan Document. Exclusions and limitations apply. The information contained in this product brochure is a general description of features, benefits, requirements and restrictions of the self-funded preventive benefit plan designs. More details are provided in the self-funded plan document, which is the prevailing document and the basis for benefit payment. Plan designs are subject to change to comply with federal healthcare reform, as necessary. Plan design availability and/or stop-loss coverage may vary by state. Subchapter S corporations should consult their tax advisor as benefits from a self-funded plan may be taxable. Starmark is a registered trademark of Trustmark nsurance Company. L..~ StarmarK A Trustmark Company PERSON AL. FLEXBLE. TRUSTED. Trustrnark LFE NSURANCE COMPANY 400 Field Drive Lake Forest, L Star Marketing & Administration, nc. B680-MK134-er (4-19)