Small Group & Individual Products 2014

Transcription

1 Small Group & Individual Products 2014

2 Individual Products

3 Agenda Medical and Dental Benefits Rates Administrative Guidelines Current Member Communications Member Resources Compensation Sales Materials & Contacts 3 LifeWise Health Plan of Oregon 2013

4 Medical Benefits

5 Ten Essential Health Benefits 1. Ambulatory Patient Services 2. Emergency Services 3. Hospitalization 4. Maternity & Newborn Care 5. Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment 6. Prescription Drugs 7. Rehabilitative & Habilitative Services & Devices 8. Laboratory Services 9. Preventive/Wellness Services & Chronic Disease Management 10. Pediatric Services, including Oral and Vision Care under 19 Section years of age title 5 LifeWise Health Plan of Oregon 2013

6 Medical Plans In and Out of the Exchange LifeWise Essential Plans Essential Gold 500, 1000 Package VA Essential Silver 2000, 3000 Essential Bronze 6350 Package VA LifeWise Essentials HSA Bronze 5250 Standard Gold, Silver and Bronze In Exchange Only Silver Cost Share Reduction Plans American Indian / Alaska Native Plans 6 LifeWise Health Plan of Oregon 2013

7 Adult Vision and Alternative Care Included on Gold $1,000 and Bronze $6,350 Package VA Vision Exam and Hardware 1 exam per calendar year; specialist copay Gold copay - $40 Bronze copay - $50 $150 hardware benefit per calendar year Alternative Care $1,500 maximum benefit per calendar year Shared limit acupuncture, chiropractic, and naturopath 7 LifeWise Health Plan of Oregon 2013

8 1 Tier Pharmacy Benefit Used with Essential Bronze 6350 and Essential Bronze HSA 5250 Formulary name: X1 (deductible + coinsurance) Formulary generics Formulary brand Formulary specialty Non-Formulary drugs Non-formulary brands and specialty is covered when a medical necessity approval or prior authorization is obtained 8 LifeWise Health Plan of Oregon 2013

9 4 Tier Pharmacy Benefit Formulary name: X4 Tier 1 = formulary generics Tier 2 = formulary preferred brand Tier 3 = formulary non-preferred brand Tier 4 = formulary specialty Non-Formulary drugs Non-formulary brands and specialty is covered when a medical necessity approval or prior authorization is obtained Cost shares will match drug tier formulary 9 LifeWise Health Plan of Oregon 2013

10 Pharmacy Administrative Rules Rx counts toward medical out-of-pocket maximums HCR preventive drugs are still covered in full Specialty drugs Subject to medical deductible and cost shares (in most cases) Must use contracted pharmacies: Accredo and Walgreens Limited to 30-day supply Section title 10 LifeWise Health Plan of Oregon 2013

11 Medical Plans In and Out of the Exchange LifeWise Essential Plans Essential Gold 500, 1000 VA Package Essential Silver 2000, 3000 Essential Bronze 6350 VA Package LifeWise Essentials HSA Bronze 5250 Standard Gold, Silver and Bronze 11 LifeWise Health Plan of Oregon 2013

12 Dental Benefits

13 Individual Adult Dental Copay Plan For ages 19 and older Features: Choice of deductible $50 or $75 deductible Predictability of costs Member has a set copay for each of over 200 covered services $1000 benefit limit Common enrollment required Coverage for most commonly used preventive diagnostic, basic and major dental services Choice of providers from a growing statewide network 13 LifeWise Health Plan of Oregon 2013

14 Pediatric Dental Plan This benefit applies to children under age 19 Embedded in the LifeWise Essential plans (excluding state Standard plans) Medical deductibles apply No waiting periods Class I Preventive Covered in full Class II Basic Medical Deductible, then, 30% Class III Major Medical Deductible, then, 50% Orthodontics Medical Deductible, then, 50% Routine Exams 2 PCY Cleanings 2 PCY FluorideTreatment 2 PCY Sealants limit age 15 & under; limit 1 Complete Series or panoramic 1 every 5 calendar years Bitewings 1 PCY Fillings Simple Extractions Stainless Steel Crowns Periodontal Maintenance 2 PCY Periodontal scaling & root planning 1 every 2 CY Endodontics Periodontal Surgery Crowns Repair of Crown / Bridgework Replacement 1 every 7 years Dentures 1 every 3 calendar years Implants Not Covered Complex oral surgery Cleft Palate or Cleft Lip only with prior authorization 14 LifeWise Health Plan of Oregon 2013

15 Rates

16 Geographic Rate Area Area 1 Portland Clatsop Columbia Clackamas, Multnomah, Washington, Yamhill Area 2 Benton, Lane, Linn Area 3 Marion, Polk Area 4 Deschutes, Klamath, Lake Area 5 Clatsop, Columbia, Coos, Curry, Lincoln, Tillamook Eugene Salem Central Coastal Tillamook Washington Lincoln Yamhill Polk Benton Lane Marion Linn Multnomah Clackamas Hood River Wasco Jefferson Deschutes Sherman Morrow Gilliam Wheeler Crook Grant Umatilla Union Baker Wallowa Area 6 Eastern Baker, Crook, Gilliam, Grant, Harney, Hood River, Jefferson, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco, Wheeler Coos Douglas Lake Harney Malheur Area 7 Medford Douglas, Jackson, Josephine Josephine Jackson Klamath Curry 16 LifeWise Health Plan of Oregon 2013

17 Rates Rates are determined by the county in which the subscriber/policyholder lives Area 1 (Metro Portland) Area 4 (Central) Areas 2, 3, 5, 6, 7 (All other) Single age bands Capped at first 3 dependents 20 and under Tobacco vs. Non-Tobacco 17 LifeWise Health Plan of Oregon 2013

18 Premium Assistance Credit Available only through the Exchange Individuals and families eligible if income is between 100% and 400% of the Federal Poverty Level Individual 100% FPL = $11, % = $45,960 Family of 4 100% FPL = $23, % = $94,200 Receive credit toward premium cost Premium credit is $ 18 LifeWise Health Plan of Oregon 2013

19 Cost-Sharing Reduction Subsidy Cost-Sharing subsidy dramatically reduces out-of-pocket costs Cost-Sharing Subsidy Must purchase a Silver Plan to access Cost-Sharing Subsidy Reduces eligible participant s out-of-pocket expenses by increasing the actuarial value of the plan they qualify for: Federal Poverty Level Maximum Actuarial Value Cost Share Reduction Name 100% 150% 94% CSR 3 150% 200% 87% CSR 2 200% 250% 73% CSR 1 Qualified individuals and families can access both the Premium Assistance Credit and Cost-Sharing Subsidy 19 LifeWise Health Plan of Oregon 2013

20 Silver Cost Share Reduction Plan 20 LifeWise Health Plan of Oregon 2013

21 Administrative Guidelines

22 Primary Care Provider Encouraging deeper relationships between our members and their physicians Office Visit Copays Incentive Selecting a PCP Changing a PCP PCP provider types General Physician Naturopath Pediatrician Family Physicians Internist Geriatrics Nurse Practitioner ARNP/Physician Assistant Gynecologist Obstetrician 22 LifeWise Health Plan of Oregon 2013

23 Prior Authorization Effective 2014 for Individual No surprises. Prior authorization guarantees coverage to eligible members before certain services are provided Highest quality care. Members know that medical services are reviewed for quality and cost-effectiveness appropriate for their medical needs Cost control. Prior authorization helps contain costs for members and providers and ensures fast claim payment Protection. Prior authorization protects members from risk and harm by avoiding services that do not show benefit If prior authorization is not obtained for required services, services will not be covered whether medically necessary or not. Member will be liable for all charges. 23 LifeWise Health Plan of Oregon 2013

24 Prior Authorization Examples of services that require prior authorization Planned admission into hospital (excludes maternity) Some planned outpatient procedures Non-emergency ground or air ambulance transport Advanced imaging other than X-ray Transplant and donor services Some injectable medications you get in a provider s office Prosthetics and orthotics other than foot orthotics or orthopedic shoes A more complete list is available online at: 24 LifeWise Health Plan of Oregon 2013

25 Annual Enrollment Period First year: October 1, 2013 March 31, 2014 Second year: October 15, 2014 December 7, 2014 All LifeWise members on non-grandfathered plans must select a new plan no later than an April 1 effective date. - One time deductible carry-over LifeWise members can choose to move before April 1 25 LifeWise Health Plan of Oregon 2013

26 Applying For Coverage OUTSIDE THE EXCHANGE Applications Online Online Enrollment Tool Your personal link How to register Paper Effective Dates 1 st and 15 th of the month Apply up to last day before effective date 26 LifeWise Health Plan of Oregon 2013

27 Applying For Coverage INSIDE THE EXCHANGE Applications Online Paper Effective Dates 1 st of the month Enroll By Oct 1 to Dec 15 Dec 16 to Jan 15 Jan 16 to Feb 15 Feb 16 to Mar 15 Mar 16 to Mar 31 Effective Date January 1 st February 1 st March 1 st April 1 st May 1st 27 LifeWise Health Plan of Oregon 2013

28 Eligibility Requirements Individuals eligible to apply for a plan A resident of and has a principal residence in the state of Oregon Not entitled to Medicare Eligible dependents A spouse or registered same-sex domestic partner Natural or legally adopted children under the age of LifeWise Health Plan of Oregon 2013

29 Qualifying Events Applying outside of Open Enrollment 1) Newborn child of the policyholder or enrolled spouse 2) A child placed for adoption with the policyholder or enrolled spouse 3) A child who is designated as the legal ward of the policyholder or enrolled spouse (court-appointed guardianship) 4) A loss of employer sponsored coverage 5) A loss of Medicaid or other public program providing health benefits 6) A loss of coverage due to a dissolution of marriage 7) A loss of coverage due to a change in residence and your existing health plan does not provide coverage in your new area 29 LifeWise Health Plan of Oregon 2013

30 Qualifying Events Applying outside of Open Enrollment 8) A loss of minimum essential coverage 9) The Qualified Health Plan substantially violated a material provision of its policy 10)A loss of COBRA benefits 11)An individual enrolled or did not enroll due to an error or misrepresentation by Cover Oregon 12)An individual is newly eligible or newly ineligible for the premium tax credit, subsidy or cost-sharing reduction plan even if currently enrolled in a Qualified Health Plan 30 LifeWise Health Plan of Oregon 2013

31 Billing Payment Options Automatic withdrawal from bank Credit & Debit Card One-Time Recurring Monthly Bill-pay by check Payment grace periods Outside Exchange: 30-day grace period Inside Exchange: 90-day grace period 31 LifeWise Health Plan of Oregon 2013

32 2014 Contract Changes There is no longer a pre-existing clause; however, there is a Benefit Exclusion Period of 24 months for transplants. Creditable Coverage will reduce this period as long as there is not more than a 63 day break in coverage. Individual plans now cover mental health and chemical dependency the same as small group. Individual plans now cover Habilitation Therapy for members under age 19 diagnosed with Pervasive Developmental Disorder. On Non-HSA plans, all copays and coinsurance will apply to the out-of-pocket maximum, with the exception of cost shares from additional Vision and Alternative Care benefits on the Gold 1000 and Bronze Contracts have been reformatted and are easier to read. 32 LifeWise Health Plan of Oregon 2013

33 Grandfathered Plans Maintain current rating structure: Age banding Area rating Tiered Structure Renewal dates remain September 1 st Can purchase Qualified Health Plan during AEP 33 LifeWise Health Plan of Oregon 2013

34 Administrative Guide Re-Named Re-Tooled In-Depth Coming in October 34 LifeWise Health Plan of Oregon 2013

35 Current Members Communication

36 Current Members Communications NON-GRANDFATHERED Member communications July 24 Rate increase notice/reassurance Aug 28 Educational mailing Dec 2 Discontinuation/Change Packet March 4 Reminder Letter Plan Change Matrix Plan Change Tool 36 LifeWise Health Plan of Oregon 2013

37 Current Members Communications GRANDFATHERED Member communications November 24 Fee/Taxes Rate Mailing Portability Discontinuation Mailing Reassurance Messaging Plan change tool 37 LifeWise Health Plan of Oregon 2013

38 MEMBER RESOURCES

39 39 LifeWise Health Plan of Oregon 2013

40 Health Care Reform Made Simple 40 LifeWise Health Plan of Oregon 2013

41 ACTIVELY NORTHWEST 41 LifeWise Health Plan of Oregon 2013

42 Compensation

43 Compensation Medical plan commission $15 Per Member Per Month Dental plan commission $3 Per Member Per Month 43 LifeWise Health Plan of Oregon 2013

44 Sales Materials & Contacts

45 ORDERING SUPPLIES Sales Kits available: September 25, 2013 Process to order supplies: Supply order form has been updated Will be posted on website: 45 LifeWise Health Plan of Oregon 2013

46 INDIVIDUAL SALES & SERVICE TEAM Sales Leadership Sales and Account Management Producer Support Kelly Jones Regional Sales Manager W C kelly.jones@lifewisehealth.com John Reynolds Team Lead Producer Support john.reynolds@lifewisehealth.com John Mychalishyn Director of Sales john.mychalishyn@lifewisehealth.com Shelly Solorzano Sales Executive shelly.solorzano@lifwisehealth.com Marcy Klippenes Sales Executive marcy.klippenes@lifewisehealth.com Producer Support Team Laura Binder Lucy French Nicole Goodspeed , option 2 Fax: producer.support@lifewisehealth.com 46 LifeWise Health Plan of Oregon 2013

47 Questions & Answers 47

48 THANK YOU FOR JOINING US TODAY ( )