2016 IFP. Broker Cycle Guide. Effective: January 1, 2016

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1 2016 IFP Broker Cycle Guide Effective: January 1, 2016

2 Hello, Thank you for your commitment to the members we serve. You play a critical role helping Californians access affordable health coverage, and we appreciate all you do. I want to share with you changes and improvements to 2016 plans across the state: New this year We are introducing three new medical plans available for purchase only through Blue Shield. These plans have different benefits than the standardized Covered California plans, and are intended for consumers shopping for more affordable options and great coverage: Silver Seven 3750 PPO Silver 1850 PPO Bronze 5550 PPO These plans are described in more detail in this document. We will also offer a new lower-cost vision plan, the Ultimate Vision 15/25/120.* At less than $15 per month for an individual of any age, you can offer even your most price-sensitive clients valuable vision coverage to complement their health plan. Statewide IFP Exclusive PPO Network We are retiring our EPO Network and individual and family EPO plans. EPO plan members will be offered PPO plans with our larger Exclusive PPO Network. Additionally, we are reentering the Individual and Family Plans (IFP) PPO market in Alpine, Monterey, Sutter, and Yuba counties in That means Blue Shield is offering individual and family PPO plans in every California county. Rate changes We ve worked hard to hold rate increases to a minimum. We are proud to announce that nongrandfathered IFP medical plan rates will only increase an average of 4.6% statewide in Some members in our Silver plans will even receive a rate decrease. Members in our Dental PPO Plan will also experience a 14% rate decrease. There will be no rate increase for our other dental products and our current vision plan. We re here for you Our Producer Services team is always here for support at (800) We re ready to help you renew your members and sell new business. Regards, Jeff Smith Vice President and General Manager Individual and Family Plans * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Pending regulatory approval. 1

3 Table of contents What s new?... 3 Benefit changes...12 Reminders Client notifications Resources Sales materials and forms Sales support... 27

4 What s new? Rate changes Medical plans Members in non-grandfathered individual and family medical plans will experience an average rate increase of 4.6%, while members in individual and family grandfathered medical plans will experience an average rate increase of 9.2%. Most non-grandfathered members in regions 11 and 15 will experience a rate decrease, as will most members in our popular Silver plans in regions 4, 11-15, and Our rate changes reflect increases in the costs of hospital care, physician services, pharmacy, and drug coverage, amongst other factors. As a result, you will see an increase in some regions and decreases in others: Regions 11 and 15 will each see substantial rate decreases. Specialty plans We are decreasing rates for our Dental PPO plan by 14% (as low as $37.40 per member, per month) and holding rates steady for all other dental, vision,* and individual term life insurance* plans. New medical plan offerings (off-exchange) We are excited to introduce three unique medical plans available for purchase only through Blue Shield: Silver Seven 3750 PPO Silver 1850 PPO Bronze 5550 PPO Aimed at non-subsidy eligible consumers looking for predictable costs and shopping for plans that are more affordable than Blue Shield s standard off-exchange Silver plan Offers predictability with a $7 copay for office visits, lab services, Tier 1 drugs, and lower copays on other services compared with our existing standard off-exchange Silver plan Priced competitively against Silver plans offered by our competitors Aimed at non-subsidy eligible consumers shopping for more affordable options than what they have, compared with our existing standard off-exchange Silver plan Offers a lower deductible than the standard off-exchange Silver plan Priced lower than the standard Silver and Silver Seven 3750 PPO plans Aimed at price-sensitive non-subsidy eligible consumers who don t use healthcare services often and want to spend less on premiums Priced lower than Blue Shield s standard off-exchange Bronze plan * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). 3

5 At a glance Silver PPO plans In-network benefits Silver 70 PPO (for reference) Silver Seven 3750 PPO Silver 1850 PPO Calendar-year medical deductible individual/family $2,250/$4,500 $3,750/$7,500 $1,850/$3,700 Calendar-year pharmacy deductible individual/family $250/$500 $250/$500 $250/$500 Calendar-year out-of-pocket maximum individual/family $6,250/$12,500 $6,500/$13,000 $6,500/$13,000 Office visit primary care doctor $45 $7 $45 Office visit specialty doctor $70 $35 $70 Preventive health benefits $0 $0 $0 Inpatient hospitalization Deductible + 20% Deductible + 30% Deductible + 30% Outpatient surgery 20% Deductible + 30% Deductible + 30% Lab $35 $7 Deductible + 30% X-ray $65 $35 Deductible + 30% Urgent care $90 $70 $90 Emergency room services not resulting in admission Deductible + $250 Deductible + 30% Deductible + 30% Emergency medical transportation Deductible + $250 Deductible + 30% Deductible + 30% Tier 1 drugs $15 $7 $15 Tier 2 drugs deductible + $50 deductible + $35 deductible + $50 Tier 3 drugs deductible + $70 deductible + $70 deductible + $70 Tier 4 drugs deductible + 20% up to $250 per prescription deductible + 30% up to $250 per prescription deductible + 30% up to $250 per prescription 4

6 At a glance Bronze PPO plans In-network benefits Calendar-year medical deductible individual/family Calendar-year pharmacy deductible individual/family Calendar-year out-of-pocket maximum individual/family Office visit primary care doctor Office visit specialty doctor Bronze 60 PPO (for reference) Bronze 5550 PPO $6,000/$12,000 $5,550/$11,100 $500/$1,000 N/A $6,500/$13,000 $6,500/$13,000 $70 1st 3 visits, then deductible + $70 $90 1st 3 visits, then deductible + $90 $70 1st 3 visits, then deductible + $70 Deductible + 30% Preventive health benefits $0 $0 Inpatient hospitalization Deductible + 100% Deductible + 30% Outpatient surgery Deductible + 100% Deductible + 30% Lab $40 Deductible + 30% X-ray Deductible + 100% Deductible + 30% Urgent care Emergency room services not resulting in admission Emergency medical transportation Tier 1 drugs Tier 2 drugs Tier 3 drugs Tier 4 drugs $120 1st 3 visits, then deductible + $120 $120 1st 3 visits, then deductible + $120 Deductible + 100% Deductible + 30% Deductible + 100% Deductible + 30% deductible + 100% up to $500 per prescription deductible + 100% up to $500 per prescription deductible + 100% up to $500 per prescription deductible + 100% up to $500 per prescription Deductible + 30% up to $500 per prescription Deductible + 30% up to $500 per prescription Deductible + 30% up to $500 per prescription Deductible + 30% up to $500 per prescription 5

7 Specialty products updates Dental plan networks Dental HMO We are adding 141 points of access to our already large dental HMO network, for a total of 22,800 points of access in California. Dental PPO Our dental PPO network will gain 2,180 points of access including network gains of more than 15% in Orange and Los Angeles counties for a total of 32,600 points of access throughout California. Additionally, covered diagnostic and preventive services (such as X-rays and routine cleanings) will no longer count toward the annual coverage limit for Dental PPO and Specialty Duo SM Dental Plans.* This provides more coverage for other services before reaching the annual limit. New vision plan Not long ago we introduced our first vision plan with Specialty Duo, SM, * a package plan that included both dental and vision. Then, in 2014 we introduced our first standalone vision plan: the Ultimate Vision 15/25/150.* Now, we are expanding our vision product to include a new, lower price-point plan: the Ultimate Vision 15/25/120.* At less than $15 per person, per month, it is a true value for your clients. Ultimate Vision 15/25/120 is different from the Ultimate Vision 15/25/150 plan in two ways: A lower frame allowance Leaner benefit on covered lens options and treatments. Standard lenses continue to be covered at 100%, but fewer covered lens options such as anti-reflective coating, progressive and photochromatic lenses All of our vision plans and dental + vision packages are available for purchase with or without a medical plan, and are priced for value and affordability. Not only are our vision plans competitively priced, but with 6,725 points of access statewide, Blue Shield offers the largest network in California. Here s a comparison of our three vision plans: Benefit Ultimate Vision 15/25/150 NEW Ultimate Vision 15/25/120 Specialty Duo Vision (purchased with dental) Eye exam copay $15 $15 $0 Materials copay $25 $25 $25 Frames $150 allowance (every 12 months) $120 allowance (every 12 months) $100 allowance (every 24 months) Lenses Standard single vision, lined bifocal, or lined trifocal with 100% 100% 100% scratch coating Lens options and treatments Polycarbonate lenses Up to a maximum of $100 Up to a maximum of $100 Up to a maximum of $100 (only for dependent children) Polycarbonate lenses Up to a maximum of $160 Progressive lenses (no-line bifocals) Up to a maximum of $140 Anti-reflective lens coating Up to a maximum of $50 Photochromic lenses for adults and dependents Contact lenses Up to a maximum of $115 $200 Medically necessary 100% 100% 100% Elective (cosmetic or convenience) Up to a maximum of $120 Up to a maximum of $120 Up to a maximum of $120 Diabetes management referral 100% 100% 100% * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Ultimate Vision 15/25/120 and Specialty Duo are pending regulatory approval. 6

8 Our IFP Exclusive PPO Network goes statewide We have been working to improve provider access for members in our individual and family plans since we debuted these plans in Now, in 2016, we are retiring our EPO plans and EPO Network so we can offer PPO plans and our larger Exclusive PPO Network in every county throughout the state, including Alpine, Monterey, Sutter, and Yuba counties. With their new Exclusive PPO plan, members will also have the flexibility to receive services from providers outside of the Exclusive PPO Network without a referral for most covered services at an additional cost. That s in addition to urgent and emergency care across the United States through the BlueCard Program IFP EPO Network and Exclusive PPO Network 2016 IFP Exclusive PPO Network Del Norte Siskiyou Modoc Del Norte Siskiyou Modoc Humboldt Trinity Shasta Lassen Humboldt Trinity Shasta Lassen Tehama Plumas Tehama Plumas Mendocino Glenn Colusa Lake Sutter Butte Yuba Nevada Sierra Placer Mendocino Glenn Colusa Lake Sutter Butte Yuba Nevada Sierra Placer Amador Stanislaus Calaveras Mariposa Mono Yolo El Dorado Sonoma Napa Sacramento Alpine Solano Marin San Contra Tuolumne Joaquin Costa San Francisco Alameda San Mateo Santa Clara Merced Santa Cruz Madera Yolo El Dorado Sonoma Napa Sacramento Alpine Solano Marin San Contra Tuolumne Joaquin Costa San Francisco Alameda San Mateo Santa Clara Merced Santa Cruz Madera Amador Stanislaus Calaveras Mariposa Mono San Benito Fresno San Benito Fresno Inyo Inyo Monterey Kings Tulare Monterey Kings Tulare San Luis Obispo Kern San Luis Obispo Kern Santa Barbara Ventura Los Angeles San Bernadino Santa Barbara Ventura Los Angeles San Bernadino Orange Riverside Orange Riverside Exclusive PPO Network San Diego Imperial Exclusive PPO Network San Diego Imperial EPO Network No IFP plans offered 7

9 Moving IFP members from EPO to PPO plans We will start notifying affected members the week of September 21, 2015, that their current EPO plan will no longer be available after December 31, We will recommend an equivalent metal level PPO plan they can transition to. If members decide to accept our recommendation, there is no action to take. They simply pay their January bill, and coverage under the new recommended PPO plan will begin January 1, If subscribers prefer a different plan (all openly marketed plans are available to them), they just need to make the request through customer service by December 15, You can also request the plan on their behalf in the Broker Renewal Tool. We will suggest these equivalent PPO plans: 2015 EPO plan New 2016 PPO plan Platinum Platinum 90 EPO Platinum 90 PPO Gold Gold 80 EPO Gold 80 PPO Silver Silver 70 EPO Silver 70 PPO Silver 94 EPO Silver 94 PPO Silver 87 EPO Silver 87 PPO Silver 73 EPO Silver 73 PPO Bronze Bronze 60 EPO Bronze 60 PPO Bronze 60 HSA EPO Bronze 60 HSA PPO Minimum Coverage Minimum Coverage EPO Minimum Coverage PPO American Indian/Alaskan Native Platinum 90 EPO AI-AN Platinum 90 PPO AI-AN Gold 80 EPO AI-AN Gold 80 PPO AI-AN Silver 70 EPO AI-AN Silver 70 PPO AI-AN Bronze 60 EPO AI-AN Bronze 60 PPO AI-AN Bronze 60 HSA EPO AI-AN Bronze 60 HSA PPO AI-AN $0 Cost Share EPO AI-AN $0 Cost Share PPO AI-AN 8

10 Some grandfathered plans retired Effective January 1, 2016, 11 grandfathered medical plans will be withdrawn, affecting fewer than 175 members. Blue Shield is updating our membership and claims systems technology platform. This technology platform transition was needed to: Help us stay current with changes brought by new healthcare regulations Process claims and manage our network of providers with greater efficiency Improve the enrollment process With this change, these 11 grandfathered medical plans in the old system will be discontinued and coverage will not be available after December 31, Beginning September 25, we will send affected members a withdrawal notice clearly stating that their plan will no longer be available after December 31, The notice will also include a suggestion for a replacement plan that: Is ACA-compliant Has a lower premium than their grandfathered plan If your clients agree to transfer to a suggested plan, no further action is required on their part. They simply pay their bill and Blue Shield will transfer them into the new plan effective January 1, If a member prefers a different plan (all openly marketed plans are available to them), they need to make the request through customer service by December 15, You can also request the plan on their behalf. Please remind your clients that if they choose another plan, they must let us know. Grandfathered plan IFP Access Plus Value HMO-G HMO Individual Conversion-G IFP Individual Conversion-G Shield Spectrum PPO Conversion Plan 2000 IFP Blue Shield HMO Plan-G IFP Personal HMO Plan-G IFP $2000 Coronet Major Benefits +-G Senior Guard-G IFP Preferred Open $500-G IFP Preferred Open $1000-G IFP Preferred Open $2000-G Suggested 2016 plan Platinum 90 PPO Platinum 90 PPO Platinum 90 PPO Platinum 90 PPO or Gold 80 PPO Platinum 90 PPO Platinum 90 PPO Platinum 90 PPO Platinum 90 PPO Platinum 90 PPO Platinum 90 PPO Platinum 90 PPO Continuation of Easy$Pay enrollment Due to the withdrawal of the EPO plans and some grandfathered plans, plan subscribers enrolled in Easy$Pay SM will have their Easy$Pay cancelled and moved to direct bill unless they log in to their online account at blueshieldca.com to re-enroll into Easy$Pay for their new Blue Shield Exclusive PPO plan. If the subscriber does not use their online account feature and would like to re-establish Easy$Pay and avoid receiving a paper bill, Blue Shield will need the subscriber to contact Blue Shield by phone at the number on the back of the member s ID card by December 15, 2015, to avoid receiving a paper bill. Durable plastic ID cards In 2016, medical plan members will receive new Blue Shield member ID cards. Blue Shield will mail new member ID cards in mid- December, along with more details about programs and resources. 9

11 Easier online renewals Blue Shield has enhanced tools for both you and your clients to make online renewals easier. Member Renewal Tool Starting October 1, your clients can use the Member Renewal Tool to renew their plan or shop for a different plan. Off-exchange members can change their plan directly through the tool, while on-exchange members must contact Covered California once they have chosen a new plan. Broker tools Renewals will be easier for you as well, with new tools to use starting October 12. Broker Renewal Tool The Broker Renewal Tool offers you three ways to make open enrollment renewals faster and easier for 2016: Easy plan renewals and changes Keep a member s current plan by submitting passive renewals on behalf of your clients who are with on-exchange, off-exchange, or grandfathered plans. When you renew on their behalf, your clients receive an automatic notification about their 2016 plan. You can also request a plan change for nongrandfathered, off-exchange plan clients. Automatic alerts You ll receive automatic alerts when your client renews via the Member Renewal Tool, or when your client s fails. template library We have a new library of templates to help you educate your clients about: Health plan renewals People turning age 26 who are no longer eligible to be on a parent s plan Proactive renewals for clients eligible to renew into the same plan Late payments All 2016 plans and rates will be available on the online Broker Renewal Tool to help you help your clients. Client list Your Client List will now include: Renewal activity for subscribers with realtime status Ability to map rates based on deeper member-level information Two new alerts: Client renewal through member portal and broker delivery failure Confirmation s when you renew on a client s behalf Overall, you ll have an improved ability to communicate with clients at every stage of the renewal process. Easier application process Starting November 1, you and off-exchange direct customers will be able to use our new Help Me Choose feature in our online application and in the renewal tool. After they answer four simple questions about their healthcare needs, the tool will help them choose a plan that best fits their needs, based on the way they answered the questions. You will receive an alert through the Client List each time one of your clients uses this tool so you can offer them further assistance if needed. Additionally, all customers who apply through Covered California will be able to check their application status through blueshieldca.com. 10

12 New marquee providers In addition to Cedars Sinai Medical Center and Community Memorial Hospital of San Buenaventura, we are adding nine new hospitals from the UC Health System to our Exclusive PPO Network offering even more access to providers. Provider name County Region Covered CA exchange rate region Cedars Sinai Medical Center Los Angeles 16 Los Angeles South Community Memorial Hospital of San Buenaventura Ventura 12 Central Coast Medical Center at UCSF San Francisco 4 San Francisco Ronald Reagan UCLA Medical Center Los Angeles 16 Los Angeles South Santa Monica UCLA Medical Center Los Angeles 16 Los Angeles South UC Davis Medical Center Sacramento 3 Greater Sacramento Region UCSD La Jolla Thornton Hospital San Diego 19 San Diego UCSD Medical Center San Diego 19 San Diego UCSF Medical Center at Mission Bay San Francisco 4 San Francisco UCSF Medical Center at Mount Zion San Francisco 4 San Francisco University of California Irvine Medical Center Orange 18 Orange 11

13 2016 benefit changes Prescription drug tier structure For 2016, all health plans are required to provide a more transparent and accessible formulary to improve the member experience. The formulary tier structure will consist of Tier 1 through Tier 4. A pharmacy deductible will correspond to the new tiered structure. Additionally, to improve access to Tier 4 drugs, plans must move one drug to a lower tier if there are at least three drugs for the same drug class and condition. For example, if there are three drugs used to treat multiple sclerosis in one drug class and they are all Tier 4, then one of those three drugs will be placed in a lower tier tier name 2016 tier name Description Generic Tier 1 Most generic drugs or low-cost, preferred brand drugs Preferred Brand Tier 2 Preferred brand drugs or non-preferred generic drugs Non-Preferred Brand Tier 3 Non-preferred brand drugs or non-preferred generic drugs Specialty Tier 4 Specialty drugs or net drug cost per prescription >$600 All non-grandfathered medical plans Non-network deductibles If a plan has a calendar-year medical deductible, the combined network and non-network deductible will change to two separate deductibles: one for network and a second for non-network, meaning network and non-network deductibles accrue separately. All non-network services (except embedded pediatric vision and dental) will be subject to the member s non-network deductible. Non-network cap on inpatient facility charges For all plans, Blue Shield will increase the daily non-network cap amount on non-network facility charges to $2,000 for inpatient benefits only. Members will be responsible for 50% of the $2,000 per day, plus all charges in excess of $2,000. MHPAEA compliance Cost-sharing changes were made to nonroutine outpatient mental health and substance abuse services to comply with the Mental Health Parity and Addiction Equity Act (MHPAEA). Covered California allows plans to deviate from cost-sharing in standard plan designs to comply with MHPAEA. Cost-sharing amounts will vary by plan. 12

14 Benefit changes: Specific plans Platinum 90 PPO (on-exchange and off-exchange) New pharmacy cost-share maximum In 2015, IFP pharmacy plan designs did not have a cost-share maximum per prescription. In 2016, Covered California requires all health carriers to provide a more affordable pharmacy benefit by establishing a maximum cost-share per prescription for plans with coinsurance designs. We are adding a $250 per prescription cap for a 30-day supply of Tier 4 drugs. Platinum 90 PPO change Network Non-network Network Non-network Tier 4 drugs 10% 10% up to $250 per prescription Changes are indicated in blue. Gold 80 PPO (on-exchange and off-exchange) Reduced out-of-pocket maximum The network out-of-pocket maximum will be reduced from $6,250 to $6,200 per individual and $12,500 to $12,400 for families, in accordance with Covered California plan designs. We will reduce the out-of-pocket maximum for non-network providers from $9,250 to $9,200 per individual and $18,500 to $18,400 for families. Office visits The copay for network primary care doctor visits will increase from $30 to $35. The network copay for specialty doctors will increase from $50 to $55. New pharmacy cost-share maximum In 2015, IFP pharmacy plan designs did not have a cost-share maximum per prescription. In 2016, Covered California requires all health carriers to provide a more affordable pharmacy benefit by establishing a maximum cost-share per prescription for plans with coinsurance designs. We are adding a $250 per prescription cap for a 30-day supply of Tier 4 drugs. Lab copay The copay for network lab tests will increase from $30 to $35. Gold 80 PPO changes Network Non-network Network Non-network Calendar-year out-of-pocket maximum, individual/family $6,250/$12,500 $9,250/$18,500 $6,200/$12,400 $9,200/$18,400 Office visit primary care doctor $30 50% $35 50% Office visit specialty doctor $50 50% $55 50% Tier 4 drugs 20% 20% up to $250 per prescription Changes are indicated in blue. 13

15 Silver 70 PPO (on-exchange and off-exchange) Increased network deductible The network deductible will increase from $2,000 per individual to $2,250 per individual, and from $4,000 per family to $4,500 per family. Non-network deductible In 2015, there was not a separate non-network deductible (network and non-network claims accrued to the same deductible). For 2016, there will be a separate non-network deductible: $4,500 per individual or $9,000 per family. Most non-network benefits will be subject to the non-network deductible. Specialty office visits The specialty office visit copay is increasing from $65 to $70. Lab copay reduction The laboratory copay is decreasing from $45 to $35. New pharmacy cost-share maximums In 2015, IFP pharmacy plan designs did not have a cost-share maximum per prescription. In 2016, Covered California requires all health carriers to provide a more affordable pharmacy benefit by establishing a maximum cost-share per prescription for plans with coinsurance designs. We are adding a $250 per prescription cap for Tier 4 drugs. For example, a Silver 70 PPO subscriber filling a monthly $1,500 Tier 4 drug prescription would pay: First month: The calendar-year pharmacy deductible of $250, plus 20% of the cost of the drug up to a maximum of $250. Total out-of-pocket cost: $500. Each remaining month through the calendar year: The deductible is met, so the member pays only 20% to a maximum of $250. Total out-of-pocket cost: $250. Silver 70 PPO changes Network Non-network Network Non-network Calendar-year medical deductible, individual/family $2,000/$4,000 N/A $2,250/$4,500 $4,500/$9,000 Office visit primary care doctor $45 50% $45 Deductible + 50% Office visit specialty doctor $65 50% $70 Deductible + 50% Inpatient hospitalization Deductible + 20% 50% Deductible + 20% Deductible + 50% Outpatient surgery 20% 50% 20% Deductible + 50% Lab $45 50% $35 Deductible + 50% X-ray $65 50% $65 Deductible + 50% Urgent care $90 50% $90 Deductible + 50% Tier 4 drugs Changes are indicated in blue. deductible + 20% deductible + 20% up to $250 per prescription 14

16 Silver 73 PPO (on-exchange) Increased network deductible The network deductible will increase from $1,600 per individual to $1,900 per individual, and from $3,200 per family to $3,800 per family. Non-network deductible In 2015, there was not a separate non-network deductible (non-network claims accrued to the network deductible), but one is being added for 2016: $3,800 per individual or $7,600 per family. Specialty office visits The specialty office visit copay is increasing from $50 to $55. Lab copay reduction The laboratory copay is decreasing from $40 to $35. Drug copays We are increasing the copay for Tier 2 drugs from $35 to $45 and for Tier 3 drugs from $60 to $70. Drug cap We are adding a prescription drug cap of $250 to Tier 4 drugs. Silver 73 PPO changes Network Non-network Network Non-network Calendar-year medical deductible, individual/family $1,600/$3,200 N/A $1,900/$3,800 $3,800/$7,600 Calendar-year out-of-pocket maximum, individual/family $5,200/$10,400 $8,250/$16,500 $5,450/$10,900 $8,450/$16,900 Office visit primary care doctor $40 50% $40 Deductible + 50% Office visit specialty doctor $50 50% $55 Deductible + 50% Outpatient surgery 20% 50% 20% Deductible + 50% Lab $40 50% $35 Deductible + 50% X-ray $50 50% $50 Deductible + 50% Urgent care $80 50% $80 Deductible + 50% Tier 2 drugs Tier 3 drugs Tier 4 drugs Changes are indicated in blue. deductible + $35 deductible + $60 deductible + 20% deductible + $45 deductible + $70 deductible + 20% up to $250 per prescription 15

17 Silver 87 PPO (on-exchange) Increased network deductible We are raising the network deductible from $500 per individual to $550 per individual, and from $1,000 per family to $1,100 per family. Non-network deductible In 2015, there was not a separate non-network deductible (non-network claims accrued to the network deductible), but one is being added for 2016: $1,100 per individual or $2,200 per family. Specialty office visits The specialty office visit copay is increasing from $20 to $25. X-ray copay The copay for X-rays is increasing from $20 to $25. Drug copays We are increasing the copay for Tier 2 drugs from $15 to $20 and for Tier 3 drugs from $25 to $35. Drug cap We are adding a prescription drug cap of $150 to Tier 4 drugs. Silver 87 PPO changes Network Non-network Network Non-network Calendar-year medical deductible, individual/family $500/$1,000 N/A $550/$1,100 $1,100/$2,200 Office visit primary care doctor $15 50% $15 Deductible + 50% Office visit specialty doctor $20 50% $25 Deductible + 50% Outpatient surgery 15% 50% 15% Deductible + 50% Lab $15 50% $15 Deductible + 50% X-ray $20 50% $25 Deductible + 50% Urgent care $30 50% $30 Deductible + 50% Tier 2 drugs Tier 3 drugs Tier 4 drugs Changes are indicated in blue. deductible + $15 deductible + $25 deductible + 15% deductible + $20 deductible + $35 deductible + 15% up to $150 per prescription 16

18 Silver 94 PPO (on-exchange) Network deductible We are adding a network deductible of $75 per individual and $150 per family. Non-network deductible We are adding a non-network deductible of $150 per individual and $300 per family. Most non-network benefits will be subject to the non-network deductible. Office visits The primary care office visit copay is increasing from $3 to $5, and the specialty office visit copay is increasing from $5 to $8. Laboratory copay The copay for laboratory is increasing from $3 to $8. X-ray copay The copay for X-rays is increasing from $5 to $8. Emergency services The emergency room services copay (not resulting in admission) is increasing from $25 to $30, and is now subject to the deductible. Emergency medical transportation The emergency medical transportation copay is also increasing from $25 to $30, and is now subject to the deductible. Drug copays We are increasing the copay for Tier 2 drugs from $5 to $10 and for Tier 3 drugs from $10 to $15. Drug cap We are adding a prescription drug cap of $150 to Tier 4 drugs. Silver 94 PPO changes Network Non-network Network Non-network Calendar-year medical deductible, individual/family $0 N/A $75 / $150 $150 / $300 Office visit primary care doctor $3 50% $5 Deductible + 50% Office visit specialty doctor $5 50% $8 Deductible + 50% Inpatient hospitalization 10% 50% Deductible + 10% Deductible + 50% Outpatient surgery 10% 50% 10% Deductible + 50% Lab $3 50% $8 Deductible + 50% X-ray $5 50% $8 Deductible + 50% Urgent care $6 50% $6 Deductible + 50% Emergency room services not resulting in admission $25 $25 Deductible + $30 Deductible + $30 Emergency medical transportation $25 $25 Deductible + $30 Deductible + $30 Tier 2 drugs $5 $10 Tier 3 drugs $10 $15 Tier 4 drugs 10% 10% up to $150 per prescription Changes are indicated in blue. 17

19 Bronze 60 PPO (on-exchange and off-exchange) In 2016 the Bronze 60 PPO will change to comply with the Covered California standard benefit design. For many services, the member will pay the full cost of the service until they reach the individual/ family out-of-pocket maximum. Increased network deductible We are raising the network deductible from $5,000 per individual to $6,000 per individual, and from $10,000 per family to $12,000 per family. Non-network deductible In 2015, there was not a separate non-network deductible (network and non-network claims accrued to the same deductible). For 2016, there will be a separate nonnetwork deductible: $9,500 per individual or $19,000 per family. Most non-network benefits will be subject to the nonnetwork deductible. Out-of-pocket maximum We are raising the network out-of-pocket maximum from $6,250 to $6,500 per individual, and from $12,500 to $13,000 per family. We are also raising the non-network out-ofpocket maximum from $9,250 to $9,500 per individual, and from $18,500 to $19,000 per family. New pharmacy deductible Prescription drugs were subject to the medical plan deductible, but now we are adding a separate prescription drug deductible of $500 per individual and $1,000 per family. Primary care office visits The primary care office visit copay is increasing from $60 for the first three visits prior to meeting the calendar-year medical deductible to $70 for the first three visits prior to meeting the calendar-year medical deductible. The copay cost after meeting the deductible is also increasing from $60 to $70. Specialty doctor office visits The specialty doctor office visit copay is increasing from $70 to $90 for the first three visits prior to meeting the calendar-year medical deductible. The member pays 100% of the cost until the calendar-year medical deductible is met. After the calendar-year medical deductible is met, the member will pay $90 per specialty doctor office visit. Inpatient hospitalization We are increasing the coinsurance from 30% to 100% for network inpatient hospitalization, which means the member is responsible for 100% of the cost until they reach the network, out-of-pocket maximum. The member will also pay 100% of the nonnetwork inpatient hospitalization until they reach the non-network out-ofpocket maximum. Outpatient surgery We are increasing the coinsurance from 30% to 100% for network outpatient surgery, which means members are responsible for 100% of the cost until they reach the network, out-ofpocket maximum. We are also increasing the coinsurance from 50% to 100% for nonnetwork outpatient surgery, which means the member is responsible for 100% of the cost until they reach the non-network outof-pocket maximum. Lab The cost-share for network lab work is changing from 30%, subject to the deductible, to $40 and not subject to the deductible. Non-network coverage for lab work continues to have a coinsurance but is increasing from 50% to 100%, which means members are responsible for 100% of the cost until they reach the non-network, out-of-pocket maximum. X-ray We are increasing the coinsurance from 30% to 100% for network X-rays, which means members are responsible for 100% of the cost until they reach the network out-of-pocket maximum. We are also increasing the coinsurance from 50% to 100% for non-network X-rays, which means the member is responsible for 100% of the cost until they reach the non-network outof-pocket maximum. 18

20 Urgent care We are increasing the coinsurance from 50% to 100% for nonnetwork urgent care visits, which means members are responsible for 100% of the cost until they reach the non-network, individual/family out-of-pocket maximum. Emergency services The emergency room services cost-share (not resulting in admission) is changing from $300 to 100% for network and non-network emergency services, which means a member is responsible for 100% of the cost until the network/non-network, out-of-pocket maximum is reached. Emergency medical transportation Emergency medical transportation costshare is also changing from $300 to 100% for network and non-network emergency services, which means a member is responsible for 100% of the cost until the network/non-network, out-of-pocket maximum is reached. New pharmacy cost-share maximums In 2015, pharmacy plan designs did not have a cost-share maximum per prescription. In 2016, Covered California requires all health carriers to provide a more affordable pharmacy benefit by establishing a maximum cost-share per prescription for plans with coinsurance designs. Tier 1, Tier 2, Tier 3, and Tier 4 Drugs We are adding a $500 per prescription cap for all prescription tiered drugs. This means a member is responsible for 100% of the cost of the drug until the pharmacy deductible is reached. For example, a Bronze 60 PPO member who is filling a monthly $1,000 drug prescription would pay the following in any of the four listed drug tiers: First month: The calendar-year pharmacy deductible of $500, plus 100% of the cost of the drug up to a maximum of $500. Total out-of-pocket cost: $1,000 Each remaining month through the calendar year: The deductible is met, so the member pays only 100% to a maximum of $500. Total out-of-pocket cost per individual: $

21 Bronze 60 PPO changes Calendar-year medical deductible, individual/family Calendar-year pharmacy deductible, individual/family Calendar-year out-of-pocket maximum, individual/family Office visit primary care doctor Network Non-network Network Non-network $5,000/$10,000 $6,000/$12,000 $9,500/$19,000 N/A $500/$1,000 $6,250/$12,500 $9,250/$18,500 $6,500/$13,000 $9,500/$19,000 $60 1st 3 visits, then deductible + $60 Deductible + 50% Office visit specialty doctor Deductible + $70 Deductible + 50% $70 1st 3 visits, then deductible + $70 $90 1st 3 visits, then deductible + $90 Deductible + 100% Deductible + 100% Inpatient hospitalization Deductible + 30% Deductible + 50% Deductible + 100% Deductible + 100% Outpatient surgery Deductible + 30% Deductible + 50% Deductible + 100% Deductible + 100% Lab Deductible + 30% Deductible + 50% $40 Deductible + 100% X-ray Deductible + 30% Deductible + 50% Deductible + 100% Deductible + 100% Urgent care Emergency room services not resulting in admission Emergency medical transportation $120 1st 3 visits, then deductible + $120 Deductible + 50% $120 1st 3 visits, then deductible + $120 Deductible + 100% Deductible + $300 Deductible + $300 Deductible + 100% Deductible + 100% Deductible + $300 Deductible + $300 Deductible + 100% Deductible + 100% Tier 1 drugs Deductible + $15 Tier 2 drugs Deductible + $50 Tier 3 drugs Deductible + $75 Tier 4 drugs Deductible + 30% Changes are indicated in blue. deductible + 100% up to $500 per prescription deductible + 100% up to $500 per prescription deductible + 100% up to $500 per prescription deductible + 100% up to $500 per prescription 20

22 Bronze 60 HSA PPO (on-exchange and off-exchange) Calendar-year medical deductible In 2015, there was not a separate network and non-network deductible. In 2016, a nonnetwork deductible of $9,000 per individual and $18,000 per family has been added. Additionally, we are changing the calendar-year medical deductible from aggregate to embedded. An aggregate family deductible means the entire family deductible must be met before Blue Shield begins payment for covered services for any member on the policy. In contrast, an embedded family deductible means Blue Shield will pay benefits for an individual member on the policy once that member meets the individual deductible amount. If a family has two members, each member must meet the individual deductible amount to satisfy the family deductible. If the family has three or more members, the family deductible can be satisfied by two or more members. Calendar-year-out-of-pocket maximum We are raising the network out-of-pocket maximum from $6,250 to $6,500 per individual, and from $12,500 to $13,000 per family. We are also raising the non-network out-of-pocket maximum from $9,250 to $9,500 per individual and from $18,500 to $19,000 per family. Bronze 60 HSA PPO changes Calendar-year medical deductible Calendar-year out-of-pocket maximum Changes are indicated in blue. Network Non-network Network Non-network $6,250/$12,500 aggregate $4,500/$9,000 aggregate $9,250/$18,500 aggregate $4,500/$9,000 embedded $6,500/$13,000 embedded $9,000/$18,000 embedded $9,500/$19,000 embedded Minimum Coverage PPO plans (on-exchange and off-exchange) Calendar-year medical deductible Will change from combined network and nonnetwork $6,600/$13,200 to separate network $6,850/$13,700 and separate non-network $9,850/$19,700. Calendar-year out-of-pocket maximum The network out-of-pocket maximum will change from $6,600/$13,200 to $6,850/$13,700 and the non-network out-of-pocket maximum will change from $9,600/$19,200 to $9,850/$19,700. Minimum Coverage PPO changes Calendar-year medical deductible Calendar-year out-of-pocket maximum Changes are indicated in blue. Network Non-network Network Non-network $6,600/$13,200 $6,850/$13,700 $9,850/$19,700 $6,600/$13,200 $9,600/$19,200 $6,850/$13,700 $9,850/$19,700 21

23 Reminders Open enrollment Open enrollment for 2016 off-exchange plans begins November 1, 2015, for prospective members and continues through January 31, Your Covered California clients are currently able to compare health plan features for However, they cannot change plans until renewals begin mid-october. Covered California will begin transmitting renewals to Blue Shield on November 1, but your client may select or change plans anytime before December 15, 2015, for a January 1, 2016, effective date. Effective dates If your clients choose to change their Blue Shield plan during open enrollment, the plan s effective date will differ depending on whether the new plan is purchased through Blue Shield or Covered California. If a new health plan is purchased directly from Blue Shield, the plan s effective date will be the first day of the month following the change request. For example, a request to change plans received on January 25 will be given a February 1 effective date. This will give our off-exchange members the opportunity to be in their new plan sooner. If a new Blue Shield health plan is purchased through Covered California, the plan effective date is based on the date we receive the completed application. Applications received between the 1 st and 15 th day of the month will be effective on the first day of the next month. Requests received between the 16th and last day of the month will be effective the first of the next following month. For example, a change request received on January 14 will be given a February 1 effective date, while a request received on January 17 will be given a March 1 effective date. Broker certification Brokers must be certified by Covered California to sell plans through Covered California. Covered California hosts in-person training and certification events throughout the state. Go to agents/training/ for details. If you have been certified by Covered California in the past, you will not be required to be recertified to sell plans through Covered California for 2016 open enrollment. Premium assistance Subsidies in the form of tax credits to help pay monthly premiums, and cost-sharing reductions to lower out-of-pocket expenses for medical care are available for individuals whose annual income meets certain federal poverty-level criteria, and who meet other applicable guidelines. Individuals must purchase their coverage through Covered California to take advantage of these subsidies. To be eligible, individuals: Must not be eligible for public coverage, including Medi-Cal, the Children s Health Insurance Program, Medicare, or military coverage; Cannot be enrolled in eligible health insurance through an employer; Do not have access to health insurance through an employer, unless the employer plan does not cover at least 60% of covered benefits on average, or the employee s share of the premium exceeds 9.5% of the employee s income. 22

24 Tax credits Individuals with an annual gross income between 138% and 400% of the federal poverty level (based on income and family size) are eligible for federal tax credits. These tax credits reduce the cost of monthly premiums and can be applied toward the purchase of any plan on the exchange except the Minimum Coverage PPO. Medi-Cal assistance is available to individuals with income levels at or below 138% of the federal poverty level. Individuals who are eligible for Medi-Cal are not eligible for tax credits. All members who received premium assistance in 2015 must validate their current income level and family size with Covered California to determine their 2016 subsidy eligibility and tax credit amount. The majority of Blue Shield members who signed up for 2015 coverage through Covered California gave permission for Covered California to automatically verify their income for In August, Covered California contacted subscribers who had previously not allowed automatic verification to request permission for Blue Shield also sent a follow-up communication as a reminder, encouraging these members to grant authorization to Covered California. Cost-sharing reductions In addition to advanced premium tax credits, individuals with an annual gross income between 138% and 250% of the federal poverty level who also meet other applicable guidelines are eligible for federal cost-sharing reductions. These credits help reduce out-of-pocket medical costs and are specific to these plans: Silver 94 PPO Silver 87 PPO Silver 73 PPO Members who qualify for one of these costsharing reduction plans will continue to qualify for tax credits. Tax penalties Uninsured consumers may be penalized if they don t enroll in coverage. For 2016, uninsured individuals may be required to pay a penalty of 2.5% of their modified adjusted gross income or $695 (whichever is greater). This is a significant increase from the penalties in 2014 and $95 per adult $325 per adult $695 per adult OR OR OR 1% of family income 2% of family income 2.5% of family income whichever is greater Client notifications We will start notifying your clients of rate, benefit, or plan changes starting in October. Clients that have grandfathered plans experiencing a withdrawal will be mailed their notice beginning September 27. Those who are in grandfathered plans that are not experiencing a plan withdrawal will receive notification of rate and benefit changes in late October. In our ongoing effort to protect the environment, members no longer receive paper copies of the contract, Summary of Benefits, and coverage documents. Your clients can go online to obtain these documents. If a printed version is needed, they can always call us at the number on their ID card to make the request. Important dates October 1 Member Renewal Tool is available. October 12 Broker Renewal Tool is available. We will send reminders to you and your clients as each date approaches. 23

25 Resources We want to make selling Blue Shield as easy as possible. Our knowledgeable support teams and professional materials are ready to help you succeed. Online resources Log in to Producer Connection whenever you need to access online resources to meet your business needs and reach your sales goals. Client List We have made significant improvements to the Client List. New features include: Alerts, including when a subscriber s is not on file Access to addresses for online correspondence with your clients Vision indicator, showing clients who are enrolled in vision coverage under their medical policy Premium rates for dental and vision Sorting and selection by subscriber type to see which clients are enrolled in on-exchange, off-exchange, or grandfathered plans An template library, covering topics such as health plan renewals, aging out (for members turning age 26), proactive renewals, and late payments You access your Member List by logging in to Producer Connection and clicking Access Member List & Process Renewals. Once there, you can find your complete Blue Shield IFP book of business, and you can check payment and member contact information. You can even export the information to Excel for marketing campaigns. All ACA plans, rates, and billing information will display. You will also now have access to member-level details including dependent names, date of birth, relationship, and gender to engage the client on a more personal level. Quote & Apply Tool Our Quote & Apply Tool lets you quickly generate quotes, applications directly to your clients, and monitor their application status. You can create a customized URL to make it easy for your new customers to pay their first month s dues and ensure you get credit for the sale. The Quote and Apply Tool will be available for your prospective clients beginning 11/01. To learn more, visit Producer Connection at blueshieldca.com/quoteandapply. 24

26 Sales materials and forms Download and print the latest sales materials and forms: Plans at a Glance Rates Benefit summaries Legal disclosure Dental, vision, and life insurance forms Benefit Summaries Benefit summaries are a convenient, detailed summary of our medical, dental, vision, and dental + vision package plans. Use these summaries for additional benefit details that are not included in the Plans at a Glance. Download the benefit summaries in both English and Spanish from Producer Connection (Spanish will be available by October). Plans at a Glance Our popular Plans at a Glance brochure is a valuable sales tool, providing your clients with a broad overview of our most popular medical plans and a side-by-side comparison. It also features information on our dental, vision and life insurance* plans. When you need a concise summary of our plan offerings, our Plans at a Glance brochure is the sales tool for you. This resource is available now for download in English (translations in Spanish, Chinese, Vietnamese, and Korean will be available the week of October 12). You may also order the printed English version starting October 1 and the printed Spanish version the week of October 12. IFP rate books The IFP rate books contain rates for our medical, dental, vision, and individual term life insurance* plans. Two versions are available: Standard metal level PPO plans American Indian/Alaskan Native PPO Both are available for download from Producer Connection. IFP and Medicare Supplement Plans Application and Underwriting Process Guide A16159 (7/15) Everything you need to know about submitting new IFP and Medicare applications can be found in this guide, from effective date rules to payment information. Off-Exchange Dental and Vision Plan application C36144 (1/16) Use this application for clients who would like to purchase a Blue Shield dental, vision, or dental + vision package plan without a medical plan. You can download it on Producer Connection or use the online Quote & Apply Tool. Individual term life insurance flier ABU5006 (1/14) This flier helps you present, quote, and sell individual term life insurance to provide more financial security to your clients with Blue Shield medical coverage. This resource is available for order and download. * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). 25