An ACA Health Plan Solution for Employers and their Employees

Transcription

1 An ACA Health Plan Solution for Employers and their Employees Qualified Health Plans QHP

2 1M healthcare professionals 42+ serving the National Coverage Aliera Healthcare is a new and innovative healthcare organization offering its members a comprehensive model of care. Our healthcare programs are designed around the Direct Primary Care Medical Home model of care which puts the member at the center of care. Our nationwide healthcare programs include preventive, episodic, and urgent care services alongside a 24/7 telemedicine feature, supported by labs, x-rays & ancillary services, where needed. Best of all, Aliera Healthcare offers Qualified Health Plans that meet full compliance with the ACA for employers! states self-funded health plan market Why must I choose between medical coverage or paying a tax penalty? What exactly is Minimum Essential Coverage as defined by ACA? The Affordable Care Act (ACA) requires all individuals to have at least minimum essential coverage. If you do not have this minimum coverage, you may have to pay a penalty tax. By purchasing a plan with minimum essential coverage through your employer, you can avoid being taxed the Individual Mandate penalty tax. The U.S. government has issued a list of Preventive and Wellness Benefits outlining MEC requirements which this plan will cover 100% of when obtained from a network provider and 50% of when obtained from a non-network provider. There are over 60 preventive services, including immunizations, blood pressure screenings, diabetes and cholesterol screenings, prenatal visits, and more. See the Additional Information section at the end of this brochure for a list of the USPSTF recommended A and B preventive services. What exactly is a QHP as defined by ACA? A health plan meets this standard if it s designed to pay at least 60% of the total cost of medical services for a standard population, and if its benefits include substantial coverage of inpatient hospital and physician services. Individuals offered jobbased coverage that provides minimum value and is considered affordable are not eligible for a premium tax credit. Why should I choose an Aliera Healthcare QHP? When you choose one of Aliera s healthcare coverage plans, you will be choosing from some of the most robust programs offered today. Your benefits, depending on the plan choice, not only include preventive care as outlined in the ACA but also will include comprehensive care, including hospitalization, ambulatory care, in-patient and out-patient surgeries and many other services

3 Aliera QHP Bronze PPO Network Cigna or First Health or MultiPlan Minimum Essential Coverage Network Non-Network Wellness and Preventive Benefits required by ACA to avoid individual tax penalty. See the additional information in this guide for a list of the USPSTF recommended A and B preventive services. 100% 50% after deductible Minimum Value Plan Benefits Network Non-Network Deductible Individual/Family $6,000 / $12,000 $12,000 / $24,000 Out-of-Pocket Maximum Individual/Family $7,150 / $14,300 $14,300 / $28,600 Coinsurance 70% after deductible 50% after deductible Hospitalization In-Patient 70% after deductible 50% after deductible Hospitalization Out-Patient 70% after deductible 50% after deductible Emergency Room Services - Covers emergency room services including hospital facility and physician charges. For MRIs performed during emergency room visit, a separate copay will not be applied. If surgery, PT, or DME is required during emergency room visit, they will be covered under emergency room benefit. $500 copay $500 copay Primary Care Visit $50 copay 50% after deductible Specialist Visits $70 copay 50% after deductible Imaging - Covers charges for CT, PET scans, MRIs, and the charges for related supplies. Laboratory Outpatient and Professional Services - Covers professional components of labs, including office, outpatient, and inpatient charges. X-rays and Diagnostic Imaging - Covers the professional components of labs, including the office, outpatient, and inpatient charges. 70% after deductible 50% after deductible 70% after deductible 50% after deductible 70% after deductible 50% after deductible Generic Prescription Drugs $10 Not Covered Preferred Brand Drugs $50 Not Covered Non-Preferred Brand Drugs $100 Not Covered Mail-Order and Specialty Drugs $200 Not Covered Terms and Conditions The minimum enrollment in Level Funded is 25 employees; the minimum enrollment in the MEC is 3 employees. Health Plan and Network Fees include Medical Administration, Runout, Prescription Benefit Manager, PPO Access, Broker, Telemedicine, Implementation, SPDs, ID Cards, COBRA/HIPAA, and Utilization Review. Large Case Management fees are $135 per hour. Specific and Aggregate Covers Medical and Rx claims and includes Specific and monthly Aggregate Advancement Protection. The minimum aggregate attachment is 90% of the original enrollment. Employer is required to fund to the minimum aggregate deductible amount Final acceptance is subject to the approval of Stop Loss and will be based on data required, Individual Health Questionnaires and / or Disclosures. However, if the employer has 50+ persons enrolled in the health plan and if claims experience is available and utilized to produce rates, final acceptance will be on the completion of the Employer Disclosure Form. In this case, Individual Health Questionnaires will not be required. Note All plans are set up on plan year basis. For a list of all exclusions specific to each plan, please reference the plan document. State Exclusions Due to state laws, the employer must have a minimum of 51+ eligible employees for the following states: AK, AR, CA, CO, FL, KS, LA, ME, MD, MN, MO, NV, NH, NJ, NC, OK, OR, PE, RI, TN, UT, and WA. Note: All rates are subject to medical underwriting

4 Aliera QHP Silver PPO Network Cigna or First Health or MultiPlan Minimum Essential Coverage Network Non-Network Wellness and Preventive Benefits required by ACA to avoid individual tax penalty. See the additional information in this guide for a list of the USPSTF recommended A and B preventive services. 100% 60% after deductible Minimum Value Plan Benefits Network Non-Network Deductible Individual/Family $4,000 / $8,000 $8,000 / $16,000 Out-of-Pocket Maximum Individual/Family $7,150 / $14,300 $14,300 / $28,600 Coinsurance 80% after deductible 60% after deductible Hospitalization In-Patient 80% after deductible 60% after deductible Hospitalization Out-Patient 80% after deductible 60% after deductible Emergency Room Services - Covers emergency room services including hospital facility and physician charges. For MRIs performed during emergency room visit, a separate copay will not be applied. If surgery, PT, or DME is required during emergency room visit, they will be covered under emergency room benefit. $500 copay $500 copay Primary Care Visit $35 copay 60% after deductible Specialist Visits $55 copay 60% after deductible Imaging - Covers charges for CT, PET scans, MRIs, and the charges for related supplies. Laboratory Outpatient and Professional Services - Covers professional components of labs, including office, outpatient, and inpatient charges. X-rays and Diagnostic Imaging - Covers the professional components of labs, including the office, outpatient, and inpatient charges. 80% after deductible 60% after deductible 80% after deductible 60% after deductible 80% after deductible 60% after deductible Generic Prescription Drugs $10 Not Covered Preferred Brand Drugs $50 Not Covered Non-Preferred Brand Drugs $100 Not Covered Mail-Order and Specialty Drugs $200 Not Covered Terms and Conditions The minimum enrollment in Level Funded is 25 employees; the minimum enrollment in the MEC is 3 employees. Health Plan and Network Fees include Medical Administration, Runout, Prescription Benefit Manager, PPO Access, Broker, Telemedicine, Implementation, SPDs, ID Cards, COBRA/HIPAA, and Utilization Review. Large Case Management fees are $135 per hour. Specific and Aggregate Covers Medical and Rx claims and includes Specific and monthly Aggregate Advancement Protection. The minimum aggregate attachment is 90% of the original enrollment. Employer is required to fund to the minimum aggregate deductible amount Final acceptance is subject to the approval of Stop Loss and will be based on data required, Individual Health Questionnaires and / or Disclosures. However, if the employer has 50+ persons enrolled in the health plan and if claims experience is available and utilized to produce rates, final acceptance will be on the completion of the Employer Disclosure Form. In this case, Individual Health Questionnaires will not be required. Note All plans are set up on plan year basis. For a list of all exclusions specific to each plan, please reference the plan document. State Exclusions Due to state laws, the employer must have a minimum of 51+ eligible employees for the following states: AK, AR, CA, CO, FL, KS, LA, ME, MD, MN, MO, NV, NH, NJ, NC, OK, OR, PE, RI, TN, UT, and WA. Note: All rates are subject to medical underwriting

5 Aliera QHP Gold PPO Network Cigna or First Health or MultiPlan Minimum Essential Coverage Network Non-Network Wellness and Preventive Benefits required by ACA to avoid individual tax penalty. See the additional information in this guide for a list of the USPSTF recommended A and B preventive services. 100% 70% after deductible Minimum Value Plan Benefits Network Non-Network Deductible Individual/Family $2,000 / $4,000 $4,000 / $8,000 Out-of-Pocket Maximum Individual/Family $5,000 / $10,000 $10,000 / $20,000 Coinsurance 90% after deductible 70% after deductible Hospitalization In-Patient 90% after deductible 70% after deductible Hospitalization Out-Patient 90% after deductible 70% after deductible Emergency Room Services - Covers emergency room services including hospital facility and physician charges. For MRIs performed during emergency room visit, a separate copay will not be applied. If surgery, PT, or DME is required during emergency room visit, they will be covered under emergency room benefit. $300 Copay $300 Copay Primary Care Visit $35 copay 70% after deductible Specialist Visits $55 copay 70% after deductible Imaging - Covers charges for CT, PET scans, MRIs, and the charges for related supplies. Laboratory Outpatient and Professional Services - Covers professional components of labs, including office, outpatient, and inpatient charges. X-rays and Diagnostic Imaging - Covers the professional components of labs, including the office, outpatient, and inpatient charges. 90% after deductible 70% after deductible 90% after deductible 70% after deductible 90% after deductible 70% after deductible Generic Prescription Drugs $5 Not Covered Preferred Brand Drugs $35 Not Covered Non-Preferred Brand Drugs $75 Not Covered Mail-Order and Specialty Drugs $150 Not Covered Terms and Conditions The minimum enrollment in Level Funded is 25 employees; the minimum enrollment in the MEC is 3 employees. Health Plan and Network Fees include Medical Administration, Runout, Prescription Benefit Manager, PPO Access, Broker, Telemedicine, Implementation, SPDs, ID Cards, COBRA/HIPAA, and Utilization Review. Large Case Management fees are $135 per hour. Specific and Aggregate Covers Medical and Rx claims and includes Specific and monthly Aggregate Advancement Protection. The minimum aggregate attachment is 90% of the original enrollment. Employer is required to fund to the minimum aggregate deductible amount Final acceptance is subject to the approval of Stop Loss and will be based on data required, Individual Health Questionnaires and / or Disclosures. However, if the employer has 50+ persons enrolled in the health plan and if claims experience is available and utilized to produce rates, final acceptance will be on the completion of the Employer Disclosure Form. In this case, Individual Health Questionnaires will not be required. Note All plans are set up on plan year basis. For a list of all exclusions specific to each plan, please reference the plan document. State Exclusions Due to state laws, the employer must have a minimum of 51+ eligible employees for the following states: AK, AR, CA, CO, FL, KS, LA, ME, MD, MN, MO, NV, NH, NJ, NC, OK, OR, PE, RI, TN, UT, and WA. Note: All rates are subject to medical underwriting

6 Aliera QHP Platinum PPO Network Cigna or First Health or MultiPlan Minimum Essential Coverage Network Non-Network Wellness and Preventive Benefits required by ACA to avoid individual tax penalty. See the additional information in this guide for a list of the USPSTF recommended A and B preventive services. 100% 80% after deductible Minimum Value Plan Benefits Network Non-Network Deductible Individual/Family $1,000 / $2,000 $1,000 / $3,000 Out-of-Pocket Maximum Individual/Family $2,500 / $5,000 $3,000 / $9,000 Coinsurance 100% after deductible 80% after deductible Hospitalization In-Patient 100% after deductible 80% after deductible Hospitalization Out-Patient 100% after deductible 80% after deductible Emergency Room Services - Covers emergency room services including hospital facility and physician charges. For MRIs performed during emergency room visit, a separate copay will not be applied. If surgery, PT, or DME is required during emergency room visit, they will be covered under emergency room benefit. $300 Copay $300 Copay Primary Care Visit $25 Copay 80% after deductible Specialist Visits $45 Copay 80% after deductible Imaging - Covers charges for CT, PET scans, MRIs, and the charges for related supplies. Laboratory Outpatient and Professional Services - Covers professional components of labs, including office, outpatient, and inpatient charges. X-rays and Diagnostic Imaging - Covers the professional components of labs, including the office, outpatient, and inpatient charges. 100% after deductible 80% after deductible 100% after deductible 80% after deductible 100% after deductible 80% after deductible Generic Prescription Drugs $5 Not Covered Preferred Brand Drugs $35 Not Covered Non-Preferred Brand Drugs $75 Not Covered Mail-Order and Specialty Drugs $150 Not Covered Terms and Conditions The minimum enrollment in Level Funded is 25 employees; the minimum enrollment in the MEC is 3 employees. Health Plan and Network Fees include Medical Administration, Runout, Prescription Benefit Manager, PPO Access, Broker, Telemedicine, Implementation, SPDs, ID Cards, COBRA/HIPAA, and Utilization Review. Large Case Management fees are $135 per hour. Specific and Aggregate Covers Medical and Rx claims and includes Specific and monthly Aggregate Advancement Protection. The minimum aggregate attachment is 90% of the original enrollment. Employer is required to fund to the minimum aggregate deductible amount Final acceptance is subject to the approval of Stop Loss and will be based on data required, Individual Health Questionnaires and / or Disclosures. However, if the employer has 50+ persons enrolled in the health plan and if claims experience is available and utilized to produce rates, final acceptance will be on the completion of the Employer Disclosure Form. In this case, Individual Health Questionnaires will not be required. Note All plans are set up on plan year basis. For a list of all exclusions specific to each plan, please reference the plan document. State Exclusions Due to state laws, the employer must have a minimum of 51+ eligible employees for the following states: AK, AR, CA, CO, FL, KS, LA, ME, MD, MN, MO, NV, NH, NJ, NC, OK, OR, PE, RI, TN, UT, and WA. Note: All rates are subject to medical underwriting

7 Preventive and Wellness 15 Preventive Services for Adults (ages 18 and older) 1. Abdominal Aortic Aneurysm one time screening for age Alcohol Misuse screening and counseling 3. Aspirin use for men ages and women ages to prevent CVD when prescribed by a physician 4. Blood Pressure screening 5. Cholesterol screening for adults 6. Colorectal Cancer screening for adults age 50 to 75 limited to one every 5 years 7. Depression screening 8. Type 2 Diabetes screening 9. Diet Counseling 10. HIV screening 11. Immunizations vaccines (Hepatitis A & B, Herpes Zoster, Human Papillomavirus, Influenza (flu shot), Measles, Mumps Rubella, Meningococcal, Pneumococcal, Tetanus, Diptheria, Pertussis, Varicella) 12. Obesity screening and counseling 13. Sexually Transmitted Infection (STI) prevention counseling 14. Tobacco Use screening and cessation interventions 15. Syphilis screening 21 Preventive Services for Women, Including Pregnant Women 1. Anemia screening on a routine basis for pregnant women 2. Bacteriuria urinary tract or other infection screening for pregnant women 3. BRCA counseling and genetic testing for women at higher risk 4. Breast Cancer Mammography screenings every year for women age 40 and over 5. Breast Cancer Chemo Prevention counseling for women 6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women 7. Cervical Cancer screening 8. Chlamydia Infection screening 9. Domestic and Interpersonal Violence screening and counseling for all women 10. Folic Acid supplements for women who may become pregnant when prescribed by a physician 11. Gestational Diabetes screening 12. Gonorrhea screening 13. Hepatitis B screening for pregnant women 14. Human Immunodeficiency Virus (HIV) screening and counseling 15. Human Papillomavirus (HPV) DNA Test: HPV DNA testing every three years for women with normal cytology results who are 30 or older 16. Osteoporosis screening age 65 and older and younger women with a fracture risk greater than that of a 65 year old woman 17. Rh Incompatibility screening for all pregnant women and follow-up testing 18. Tobacco Use screening and interventions and expanded counseling for pregnant tobacco users 19. Sexually Transmitted Infections (STI) counseling 20. Syphilis screening 21. Well-woman visits to obtain recommended preventive services (Includes routine prenatal visits for pregnant women.) 26 Services for Children 1. Alcohol and Drug Use assessments 2. Autism screening for children limited to two screenings up to 24 months 3. Behavioral assessments for children limited to 5 assessments up to age Blood Pressure screening 5. Cervical Dysplasia screening 6. Congenital Hypothyroidism screening for newborns 7. Depression screening for adolescents age 12 and older 8. Developmental screening for children under age 3, and surveillance throughout childhood 9. Dyslipidemia screening for children 10. Fluoride Chemo Prevention supplements for children without fluoride in their water source when prescribed by a physician 11. Gonorrhea preventive medication for the eyes of all newborns 12. Hearing screening for all newborns 13. Height, Weight and Body Mass Index measurements for children 14. Hematocrit or Hemoglobin screening for children 15. Hemoglobinopathies or Sickle Cell screening for newborns 16. HIV screening for adolescents 17. Immunization vaccines for children from birth to age 18; doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis, Hepatitis A & B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Rotavirus, Varicella, Haemophilus influenzae type b 18. Iron supplements for children up to 12 months when prescribed by a physician 19. Lead screening for children 20. Medical History for all children throughout development Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years 21. Obesity screening and counseling 22. Oral Health risk assessment for young children up to age Phenylketonuria (PKU) screening in newborns 24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents 25. Tuberculin testing for children 26. Vision screening for all children under the age of 5

8 Additional Benefits of an AlieraOne Plan THE BENEFITS LISTED BELEOW ARE IN ADDITION TO THE REQUIRED BENEFITS OF THE ACA. 1 Primary Care Services With your Aliera MEC plan you will receive the core primary care medical services you need to remain healthy and avoid unwanted and catostrophic health concerns. At Aliera Healthcare we believe every individual should have access to quality primary care without regard to the minimum requirements of the ACA and should take advantage of the servies of our plan. A few of the feateures include the following: 1. No Deductibles or Co-insurance required 2. Episodic Primary care services with both the HP Plus and Premium Plans 3. 3 Primary Care visits with your HP Plus plan and up to 5 vists with an HP Premium Plan 4. Concierge services are included in every plan to ensure you have a smooth healthcare experience. 5. Members are required to contact a telelmedcine provider prior to visiting a medical facility. 6. All appointments are made throught Aliera to ensure an efficient and homogenius medical services 2 Urgent Care Services At Aliera we think it is important to have access to not only your primary care provide but also the ability to get urgent care for those occassional unexpected medical events. Its important to understand that while preventive care is important, accidents do happen and you need coverage for just those occassions. A few of the features include the following: 1. Access to an Urgent Care facility included some extended hours at certain locations 2. No waiting time for most visit (be sure to call ahead to your local urgent to ensure wait time) 3. Walk-ins welcome 4. DME or Durable Medical Equipment is not included. 5. X-Rays (see x-rays below) 6. Labs and Diagnostics (see labs and diagnostics below) 3 Telemedicine Your telemedicine provider is your first line of defense to your health. Every member receives unlimited access to a telemedicine provider to help reduce the cost of healthcare and act as your 24/7/365 access to care. All of the doctors in our national network are U.S. board-certified family practitioners, PCPs, pediatricians and internists who use electronic health records to diagnose, treat, and write prescriptions, when necessary. Our quality process meets National Committee for Quality Assurance (NCQA) standards. A few of the feateures include the following: 1. 24/7/365 access to U.S. board-certified doctors 2. No consultation fees 3. Membership is good for the entire family 4. 96% resolution of most medical issues 5. Access via phone or video conference 6. Members are required to contact a telemedicine provider before attempting to visit a Primary or Urgent care provider. 4 Labs and Diagnostics Blood work covers tests such as Complete Metabolic Panel, Complete Blood Culture, Hemoglobin, Cholesterol and hundreds of others. All in all your plan covers over 180 different labs test including most biologic testing. 1. Most labs at your PCP and Urgent Care prover are covered. 2. Lifestyle test are not included. 5 X-Rays While most visit to the Urgent care facility do not require x-rays, your Aliera MEC covers that 1 in 10 incident that does require the use of an x-ray machine. Your x-ray is covered 100% at your in-network Urgent Care facility but it does not include an X-Ray read fee from outside sources. For these services there is an additional $25 read fee for each x-ray.