CoOportunity Health Products and Information

Transcription

1 Prvider Training Materials COprtunity Health Prducts and Infrmatin Brief prduct verviews, features, and sample identificatin cards fllw. Prduct Overview COprtunity Health ffers three prducts: COprtunity Premier in Iwa and Nebraska COprtunity Chice UI Health Alliance in Iwa COprtunity Preferred UI Health Alliance in Iwa COprtunity Premier This preferred prvider rganizatin (PPO) prduct uses the Midlands Chice netwrk f cntracting prviders. This prduct is available t residents f Iwa and Nebraska and businesses that are dmiciled in Iwa and Nebraska. COprtunity Chice UI Health Alliance This pen access three-tier prduct is available in Iwa nly. Tier 1 cnsists f Midlands Chice facilities and prviders wh are part f the University f Iwa Health Alliance and designated Midlands Chice prviders in Iwa. Tier 2 includes Midlands Chice prviders wh are nt a part f this subset. Members have higher ut-f-pcket csts when receiving care frm Tier 2 prviders. Tier 3 prviders are nncntracting. Members have the highest ut-f-pcket csts fr Tier 3 prvider services. COprtunity Preferred UI Health Alliance This exclusive prvider rganizatin (EPO) prduct uses Tier 1 Chice facilities r prviders (described abve). Our Preferred prduct is being marketed in 76 Iwa cunties and des nt prvide benefits utside f the Preferred netwrk except fr necessary emergency care. Health Savings Accunt (HSA) Optin All three COprtunity Health prducts include a qualified high-deductible ptin that wrks in cmbinatin with a health savings accunt (HSA). The HSA plans are ffered in the brnze, silver, and gld levels, described belw. Individuals can make yearly tax-free cntributins int an HSA accunt. Yearly cntributins cannt exceed the limit set by the Internal Revenue Service, but amunts can carry ver frm ne year t the next. The 2014 amunts are $3,300 fr single cverage and $6,550 fr family cverage. COprtunity Health HSA plans use aggregate medical deductibles. This means that if the plan cvers mre than ne family member, benefits d nt begin fr any single family member until the

2 Prvider Training Materials family deductible is met. Out-f-pcket maximum amunts are als aggregate, requiring the family ut-f-pcket maximum t be met befre services are cvered in full fr any single family member. Plan Levels The Metals Within each f the three plans, COprtunity Health ffers plan levels with different amunts f member liability, als referred t as metal levels. Catastrphic Has the highest member ut-f-pcket csts; available nly t thse yunger than 30 years f age. Brnze Cvers apprximately 60 percent f healthcare csts. Silver Cvers apprximately 70 percent f healthcare csts. Gld Cvers apprximately 80 percent f healthcare csts. Platinum Cvers apprximately 90 percent f healthcare csts. Iwa Marketplace Chice Plan: Medicaid Expansin COprtunity Health is ne f tw cmpanies in the State f Iwa apprved t prvide health insurance cverage t individuals eligible fr the new Iwa Marketplace Chice Plan, ften referred t as Medicaid Expansin. Family cverage is nt available under this plan. If mre than ne family member qualifies, each ne will be enrlled as an individual. Members access care using the Iwa Marketplace Chice Plan prvider directry. Nte: Children under age 19 are nt eligible fr this cverage. If the rest f the family qualifies, children under age 19 will be cvered by Medicaid r hawk-i, the Children s Health Insurance Prgram (CHIP) in Iwa. Nebraska is nt participating in the Medicaid Expansin Prgram at this time. Prduct Features Unless therwise nted, the fllwing infrmatin applies t all prducts described abve. Referrals and PCPs All COprtunity Health plans prvide access t specialty prviders withut a referral frm a primary care prvider (PCP). Althugh members are nt required t select a PCP, COprtunity Health encurages them t establish a relatinship with a primary care prvider t facilitate ptimal care crdinatin. Preventive Care Benefits Preventive care benefits are cvered at 100 percent f the allwed amunt and are nt subject t the deductible r ther member cst-sharing amunts.

3 Prvider Training Materials Essential Health Benefits In additin t requiring cverage with n lifetime and n annual dllar limits, the Affrdable Care Act requires cverage f ten categries f essential health benefits in all individual and small grup plans: Emergency services Hspitalizatin Maternity and Newbrn Care Mental Health and Substance Use Disrder Services Prescriptin Drugs Rehabilitative and Habilitative Services and Devices Labratry Services Preventive and Wellness Services, Chrnic Disease Management Pediatric Dental and Visin Care* Ambulatry Patient Services *COprtunity Health plans d nt include pediatric dental benefits. Dental cverage is available n the Iwa and Nebraska Health Insurance Marketplace and can be purchased as a stand-alne cverage. Unique COprtunity Health Benefits COprtunity Health plans ffer unique member benefits nt required by the Affrdable Care Act. Three fr Free Sme members have a three fr free benefit fr ffice visits. This means that COprtunity Health waives each cvered persn s ffice visit cpayment fr the first three nn-preventive ffice calls each calendar year. Things t knw: Our cntracts cver preventive services withut a member cst-share amunt; therefre, a preventive ffice visit is nt included in the three fr free. This benefit applies t the first three ffice visits CPT cdes prcessed by COprtunity Health. Office visits submitted by primary r specialty care prviders and/r utpatient behaviral health prviders are eligible. This benefit is nt included in the Catastrphic r Brnze level f cverage (described abve).

4 Prvider Training Materials The secure prtal will identify the usual benefit, such as a $20 cpayment, fr an ffice visit. T identify whether r nt we have prcessed claims that exhausted a member s 3 fr Free benefit, cntact Member Services. Iwa Marketplace Chice Plan members d nt have an ffice visit cst-share amunt.

5 Prvider Training Materials Rewards fr Healthy Living When a member cmpletes a physical examinatin with his r her primary care physician, and fllws the visit by cmpleting an nline health assessment, the member will receive a ne-time $100 Healthy Rewards gift card (available t members 18 years f age and lder). A Healthy Rewards Card All members receive a card that prvides access t discunts frm retail and nline services, such as hearing tests and supplies, visin services, lifestyle health caching, and fitness club memberships. COprtunity Health Member Identificatin Cards Sample Card Frnt ) COprtunity Health lg 2) Member ID number and Name 3) Grup Number 4) Plan Name 5) Prvider r Netwrk lg 6) Cpay benefit infrmatin and RxBIN

6 Prvider Training Materials Sample Card Back ) Member Services phne number 2) Precertificatin fr ut-f-netwrk admissins 3) Nurse line 4) COprtunity Health URL 5) Administrative Services Prvider 6) Date ID card was issued 7) URL fr EDI infrmatin 8) Paper Claims Submissin Address 9) URL fr Frmulary 10) URL fr Natinal Netwrk Prvider search

7 Prvider Training Materials Card samples fr each f the plans fllw. PLAN NAMES: COprtunity Preferred UIHA, COprtunity Preferred HSA UIHA Offered in Iwa PLAN NAMES: COprtunity Chice UIHA, COprtunity Chice HSA UIHA Offered in Iwa

8 Prvider Training Materials PLAN NAMES: COprtunity Premier, COprtunity Premier HSA Offered in Iwa and Nebraska Fr sme members, benefits may vary between primary and specialty care. In these cases, the card will indicate Primary r Specialty fr the cpay. Belw are tw examples.