Network Availability by Rating Region

Transcription

1 HMO Networks: Health Network Option, Health Network HMO Network Availability by Rating Region PPO Networks: Open Choice PPO Rating Region Counties HMO Networks PPO Networks 1 Nye, Clark Health Network Option (Clark County and Southern Nye County) Health Network HMO (Clark County only) 2 Washoe Health Network Option (Southern Washoe County only) 3 Carson City, Douglas, Lyon, Storey ne 4 Esmeralda, Eureka, Humboldt, Lander, Lincoln, Elko, Mineral, Pershing, White Pine, Churchill ne Networks may not be available in all ZIP codes within Counties and/or Rating Regions. Check with your Word & Brown representative to verify Network availability. 16

2 CARRIER CONTACT INFORMATION Member Support Bilingual Support (HMO/HNO) (PPO/Indemnity) (DENTAL) (HMO/HNO) (PPO/Indemnity) Internet Support Provider Eligibility Verification Provider Services Broker Services Commissions Employer Support Adds/Terms Billing Pharmacy (Prompt 1 for Member) Mail Order Drug (Prompt 1 for Member) Claims Reimbursement EnrollmentSGW@aetna.com For urgent adds, call Answer Team HMO/HNO P.O. Box Fresno, CA Tax ID Number PPO/Indemnity P.O. Box El Paso, TX This may or may not match what is on the employee s ID card. M E D I C A L PayFlex (HSA Banking Partner) Member Services Employer Services Broker Services Website 17

3 PRODUCTS OFFERED HMO (1-50) PPO (1-50) Silver HNOption /50 Gold Health Network HMO $30/60 Silver Health Network HMO 2000 $30/60 Silver Health Network HMO 5000 $25/60 HMO (51-100) Health Network HMO 30/50 Health Network HMO /40 Health Network HMO /60 HNOption /50 Gold PPO 250 $25 Gold PPO /50 Gold PPO /50 Gold PPO /50 Silver PPO /50 Silver PPO /50 Silver PPO /50 Silver PPO Saver /70 Bronze PPO /50 Bronze PPO /70 CONSUMER-DIRECTED HEALTHCARE PPO (51-100) PPO Copay /70 PPO /50 PPO /50 PPO /50 PPO /50 PPO /50 PPO /50 PPO /50 PPO /50 PPO Saver /70 PPO /70 Indemnity (1-50) Silver Indemnity % Indemnity (51-100) Indemnity % HSA-Compatible PPO (1-50) Silver PPO /70 HSA Silver PPO /60 HSA Bronze PPO /50 HSA Bronze PPO /70 HSA HSA-Compatible PPO (51-100) PPO /60 HSA PPO /50 HSA 33 Additional plans available for AFA Level Fund Products. Please ask your W&B Representative. NETWORK AVAILABILITY HNO Health Network HMO PPO HMO Health Network HMO PPO Employer can pick a maximum of 5 plans for current and future hires. Only one plan is required to have enrollment. The 4 other plans can have zero member enrollment. The 5 Plans include any out-of-area PPO/Indemnity plans but not COBRA. COBRA participants will be added when there is a COBRA Enrollment UNDERWRITING & ENROLLMENT REQUIREMENTS Carrier's Effective Date Premium Amount Required for 15th? Applications must be dated within: Spouse/Domestic Partner Employees - 1 application or 2? Employee Waiver Cards Required at Enrollment? Are Telephone Interviews Conducted by Underwriting? Must Brokers Carry Errors & Omissions Insurance? Does Carrier Offer Open Enrollment? 1-50: 1st or 15th of the month; : 1st of the month 1 month Within 90 days prior to the effective date Either 1 or 2 applications 30 days before renewal anniversary FEES Enrollment Fee Amount Type of Enrollment Fee Monthly Administration Fee DEDUCTIBLE CREDIT Prior carrier deductible credit given? 4th quarter deductible carry-over credit given? ne ne HMO & HNO PPO & Indemnity; Deductible and max out-of-pocket credit for groups that take over mid year 24 HOUR COVERAGE Is Workers' Comp required on corporate officers, partners and sole proprietors? Is on-the-job covered for corporate officers, partners and sole proprietors? Is there a premium adjustment for 24 hour coverage? 18

4 PLAN ELIGIBILITY REQUIREMENTS WRAP* REQUIREMENTS ENROLLMENT GROUP SIZE AFTER INITIAL ISSUE Min. # of employees Max. # of employees 1* 100 1* * A group of 2 with one valid waiver due to other group coverage, individual or Medicare. MINIMUM EMPLOYER CONTRIBUTION Employees For Dependents % of Total Cost: n-contributory % 100% of eligible Employees excluding valid waivers Dependents GROUP SIZE Pick-A-Plan Two Options: 1) 50% of the employee rate for plan employee selects; 2) Defined contribution of at least $120 or the actual cost of the plans picked, whichever is less PARTICIPATION GROUP SIZE Contributory Employees Dependents 60% excluding valid waivers 75% excluding valid waivers 100% COVERAGE RESTRICTIONS Are commission-only employees allowed? must be full-time employee, have an employer/employee relationship and have workers' comp coverage. Need to submit wage and tax reports for proof Are 1099 employees allowed? Are employees covered if traveling out of USA? Emergency services only Is coverage available for out-of-state employees? HNO and HMO: PPO: There may be state exceptions that will be determined by underwriting Indemnity: except in HI & VT Max. percentage of employees residing out-of-state allowed PPO only - Group must be headquarter in NV with 1 Nevada W2 EE enrolled on the plan GROUP Can be written with another SIZE carrier's PPO or indemnity plan? GROUP Can be written with another SIZE carrier's HMO or HNO? * Indicates flexibility in being offered with products of another carrier. SPECIAL CONSIDERATIONS Groups will go through the re-verification annually. sends out the documentation 6 months prior to the effective date. Dependents who reside separately from the employee and are not in an approved service area will be enrolled on the subscriber's HMO plan and will need to access care via the selected Primary Care Physician in the subscriber's/family's HMO service area (except for urgent and emergency care). Any dependent that is currently enrolled in the out-of-area dependent PPO plan will not be impacted by this change so long as they remain eligible for coverage. M E D I C A L 19

5 DIABETIC & SELF-INJECTABLE DRUG BENEFITS Are the following items covered under the or the Durable Medical Equipment Benefit of the member s selected plan design? DIABETES BENEFITS Insulin Needles & Syringes Chem-Strips and/or Testing Agents Insulin Pump Supplies Insulin Pump Glucose Monitor Rx Drug Benefit Medical/Durable Medical Equipment Benefit* Vendors for Diabetes Equipment: For Insulin Pumps please see DocFind. Glucose Monitors can be obtained at any retail pharmacy SELF-INJECTABLE DRUG BENEFITS Are self-injectable drugs (other than insulin) covered under the or Medical Benefit? Is pre-authorization required? Must self-injectables (other than insulin) be purchased via the carrier-contracted mail order Rx vendor? State-mandated HMO plans Medical Benefit Health Network-HMO Plans HNO plans PPO & Indemnity Plans * Check 's Rx formulary at These services may change at any time without notice. Please contact your Word & Brown rep for specific inquiries on listed services PRESCRIPTIONS Choose GENERIC (MG) If the member or the physician request brand when generic is available, the member pays applicable copay plus the difference between the generic price and the brand price. FORMULARY VS. NON-FORMULARY Does carrier use Rx formulary? Are non-formulary drugs available? higher non-formulary copay applies MAIL ORDER HMO: 2.5 x retail copay - 90 day supply available HNO & PPO plans: 2.5X retail copay - 90 day supply available Indemnity: Varies. Contact your Word & Brown representative BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REPRESENTATIVE FOR DETAILS. 20