WPS Individual Preferred Plans. Effective January 1, Be Happy. Live Healthy.

Transcription

1 WPS Individual Preferred Plans Effective January 1, 2015 Be Happy. Live Healthy.

2 Here for you and your peace of mind A good health plan is more than protection for your health and financial security. It s also peace of mind! Since 1946, WPS mission has been to provide affordable, comprehensive health coverage for our friends and neighbors here in Wisconsin. If you re looking for a strong, stable company to provide the protection and security you and your family need, WPS is here for you. As Wisconsin s leading not-for-profit health insurer, WPS has served residents in the Midwest with highquality health plans for more than 67 years. Everything we offer our members, like affordable plans, provider networks, and member services, stems from our values as a Wisconsin-based health insurance company. World-class service, close to home When you call WPS, you ll talk to highly trained professionals who live and work right here in Wisconsin not in another country. We promise to resolve your questions quickly, with a friendly professionalism that reflects our Midwestern values. We know your time is valuable so we make it easy to get started! CALL US: Contact your local authorized WPS agent or call and talk to one of our friendly individual plan consultants. VISIT US: To learn more about individual and family plans, go to our website at REQUEST A FREE QUOTE: Visit our website or call the number above for a free, no-obligation quote! 2

3 3 individual tips for buying your health plan 1 Make sure your plan fits your needs. A good health plan keeps you covered so you can focus on your health and not have to worry about your financial security. Your health plan should fit your needs and your budget. So you should ask yourself, what kind of person are you? Young and healthy: If you re relatively young and rarely need to see a doctor, your best value may be in a high-deductible plan with a low monthly premium. Families with young children: If you re in need of health insurance for more than just yourself, you might want to consider a plan with a higher premium that will reduce your out-of-pocket expenses (deductibles and coinsurance). Older adults or those with health problems: If you visit the doctor more frequently, you might want to consider a comprehensive health plan with a higher premium. If you wind up in the hospital, the out-of-pocket deductible and coinsurance you ll pay could well exceed any premium savings a lower-cost plan would provide. WPS offers a variety of plans to fit all of your needs. Peace of mind is right around the corner. Turn the page for more details! 2 Consider your coverage. Another major factor to consider when buying a health plan is the coverage it provides. Take some time to think about your needs and then research the coverage provided by your health plan. WPS health plans provide comprehensive coverage. WPS covers 100% of the costs for routine preventive care services such as annual exams, eye exams, well-child visits, screenings, and immunizations when you see an in-network doctor. You ll also enjoy benefits for a wide range of medical services including inpatient and outpatient services, -rays, and emergency room care. Don t wait until you re sick to make sure you re covered! 3 Choose the doctors you want to see. When you review health plans and what they offer, you want to know you can see the doctors you trust and go to the medical facilities you re used to when you need care. You want them to be in your health plan s provider network. Provider Network: Group of doctors, hospitals, and other health care professionals that an insurance company contracts with to provide high-quality, cost-effective services to members. Because WPS individual and family plans are preferred provider organization (PPO) plans, they allow convenient access to the physicians and health care facilities you know and trust. In addition to a broad selection of high-quality in-network providers, you ll also enjoy out-of-network benefits. Unlike an HMO, you aren t required to select a primary care physician and you don t have to obtain a referral to see a specialist. You also don t need prior approval for most medical services. 3

4 WPS Individual Preferred Plan Types Traditional PPO plans Whether you re looking for a health plan with prescription drug benefits and low out-of-pocket costs, an economical plan with a low premium, or something in between, our traditional PPO plans bring you dependable protection with benefits that closely resemble many employer-based plans. What you get: Comprehensive benefits for a wide range of medical services, including inpatient and outpatient services, -rays, and emergency room care Prescription drug coverage options, with or without cost sharing (copays) Convenient copays for office visits,* including chiropractic visits 100% coverage for preventive care Ideal for: People interested in a traditional plan with richer benefits, including prescription drug coverage Individuals and families interested in the predictability of copays for routine care Those interested in lower annual deductibles and out-of-pocket costs Traditional PPO Multiple copay options for office visits: 1. Copay 2. Free Primary Care 100% coverage for in-network preventive care Prescription drug coverage option Prescription drug copay option Tax-favored savings account In- and out-of-network benefits Choice of regional and statewide provider networks Health Savings Account (HSA) Dental coverage option Vision and health club discount program Online health center *Office visit copay applies only to certain deductible levels. See plan policy for details. 4

5 Health Savings Account (HSA) plans Take control of your health care spending with an HSA-qualified, high-deductible health plan (HDHP) from WPS. An HSA acts like a personal savings account, except the money is used exclusively to pay for medical expenses. You can build your savings and pay for qualified medical expenses completely tax-free. Your money accumulates from year-to-year and your account travels with you, whether you change jobs, become unemployed, or switch insurance carriers. How it works: Save money each month with a higher deductible that reduces your premium. Invest the money you save, tax-free, into your HSA. Pay for your initial health care costs (except preventive care) until you meet your plan s deductible.** Once you reach your deductible, the plan starts paying for covered expenses. What you get: 100% coverage for preventive care Comprehensive benefits for a wide range of medical services, including inpatient and outpatient services, -rays, and emergency room care Lower premiums than traditional plans Tax-favored savings account to budget for medical expenses or for retirement after 65 Prescription drug coverage Ideal for: People interested in trading higher out-of-pocket costs for lower premiums Those interested in the tax benefits of a Health Savings Account (HSA) Those interested in a personal savings account to pay for qualified medical expenses **Once your deductible has been met, cost sharing in the form of coinsurance may apply. 5

6 Using your health plan Wisconsin-based service When you call WPS, you talk to highly trained professionals who live and work right here in Wisconsin not in another country. We promise to resolve your questions quickly, with a friendly professionalism that reflects our Midwestern values. Free preventive care* WPS plans cover 100% of the costs for routine preventive care services such as annual exams, eye exams, well-child visits, screenings, and immunizations when you see an in-network doctor. You won t pay a penny toward your deductible or coinsurance! Freedom to choose your doctor Unlike an HMO, you won t be required to choose a primary care physician. You won t need a referral to see a specialist. And you ll enjoy benefits both in and out of network. (That means we pay for covered services regardless of the physician or facility you choose!) You ll receive richer benefits (WPS will pay more of your costs) when you visit health care providers within the network. Prescription drug coverage Save money on prescription drugs by home delivery or at more than 63,000 pharmacies nationwide. Take your choice of a separate deductible or upgrade to our convenient copay option to keep your costs predictable. $0 copay preventive drugs WPS provides $0 copay on select preventive drugs that target common conditions such as high blood pressure, cholesterol, heart conditions, and asthma. These popular drugs go above and beyond preventive care specific drugs outlined by the ACA. Save on vision care and eyewear Take advantage of our vision care discount program to save on eye exams, frames, lenses, and even laser vision correction when you visit providers from the EyeMed Vision Care Network. Your WPS ID card is all you need to receive your discount. For details about providers and discounts, call toll-free Fitness program reimbursement You have full access to a robust network of fitness locations with a wide range of amenities through our partnership with Healthways. Go to reimbursement.healthways.com for a list of participating fitness locations. Optional dental coverage WPS partners with Delta Dental of Wisconsin the largest dental benefits provider in the state, featuring more than 90% of Wisconsin dental practitioners to offer you optional dental coverage at an attractive rate. Choose any Delta Dental of Wisconsin dentist you like for a variety of routine and major dental services, from cleanings and -rays to fillings and crowns. *Preventive services include routine exams, screenings, immunizations, and other services ranked A or B by the U.S. Preventive Services Task Force. 6 6

7 Online health tools and account management resources Telehealth benefit This great new benefit provides you with high-quality, safe, cost-effective, and convenient access to doctors straight from your phone or tablet. Telehealth uses technology to reduce costs and improve access to doctors and prescription drugs without the wait. Manage your health plan and improve your health with easy-to-use tools and our health and wellness blog featuring tips, news, educational articles, and more. Visit for instant access to easyto-use web tools that help you manage your health and health care. Member Area Manage your account online. Find a doctor, view your claims and benefits, request a new ID card, or check eligibility coverage. You can even comparison-shop for prescription drugs. Health Center Consult an array of powerful online resources to make better health decisions including action-oriented tools and information to help manage chronic conditions such as asthma and diabetes. Learning Center Access information and interactive tools, from articles and checklists to glossaries and guides, to better understand health insurance and more effectively manage your family s health and wellness. Your Health Matters Blog Join the conversation in a fun, friendly place where you can find the facts you need to make better decisions about your health care and health insurance coverage. 7 7

8 You have questions Q: What are the individual plan options offered by WPS? A: We offer two individual plan options, a traditional preferred provider organization plan and an HSAqualified plan. Our traditional plan option features a variety of benefit choices, including a wide range of deductibles, copays for office visits, and drug coverage. The HSA-qualified option features a tax-advantaged personal savings account that you control and use to pay for qualified medical expenses. (see pages 4-5 for more information). Q: What does PPACA compliant mean? A: All of our 2015 WPS health plans comply with the requirements of the Patient Protection and Affordable Care Act (PPACA). This means our plans include all essential health benefits, continue to provide FREE preventive care services, and allow everyone guaranteed issue. Q: Is free preventive care really free? A: Yes! WPS plans cover 100% of the costs for routine preventive care services such as annual exams, well-child visits, screenings, and immunizations when you see an in-network doctor. You won t pay a penny toward your deductible or coinsurance. Q: What does guaranteed issue mean? A: Guaranteed issue means that anyone can purchase a health plan regardless of health status or other factors. Anyone who applies for coverage during the annual open enrollment must be accepted. 8

9 We have answers. Q: Can I choose my own doctor? A: Yes! Both types of plan options provide convenient access to physicians and health care facilities you know and trust throughout Wisconsin.. WPS Statewide Network: Offers you the freedom of choice and the broadest access to providers in Wisconsin. Cost-Effective Regional Network: Your local network strikes a healthy balance between choice and cost, permitting broad access while encouraging the use of preferred providers close to home. National Network: Available with the Statewide Network and most regional options, this network gives you access to thousands of hospitals and clinics nationwide. Q: Will I be able to get the prescription drugs I need? A: Of course. Save money on your prescription drugs by mail or at more than 63,000 pharmacies nationwide. You can choose a separate deductible or upgrade to our convenient copay option to keep your costs predictable. Q: What about vision care? A: We ve got you covered. Your WPS ID card entitles you to substantial savings on vision care, including exams, frames, lenses, and even laser vision correction through our EyeMed Vision Care discount program (see page 6 for more information). Q: Is dental care covered? A: We offer optional dental coverage through our partnership with Delta Dental of Wisconsin the largest dental benefits provider in the state. They feature more than 90% of Wisconsin dental practitioners. Choose any dentist you like for a variety of routine and major dental services, from cleanings and -rays to fillings and crowns. Q: What other resources are available? A: To help you manage your health plan and improve your health, we offer a variety of easy-to-use tools and resources. See page 7 for details. Q: Do I need a referral to see a specialist? A: No. We strive to ensure easy access to the doctors, specialists, and hospitals you want to see. No referrals required! 9

10 WPS individual and family health plans comply with the Affordable Care Act (ACA) WPS has always given you more for your money with comprehensive coverage and rich benefits that competing plans just couldn t match. Now, you can select from a variety of health plans that meet the ACA s requirements. An individual health insurance plan from WPS provides the comfort of knowing that you re protected so you can focus on other things and avoid the ACA s penalty tax. So whether you want a bronze or silver health insurance plan, you can get exactly what you need from WPS. 10

11 Contact us today for more information on individual and family plans! CALL US: Contact your local authorized WPS agent or call and talk to one of our friendly individual plan consultants. VISIT US: To learn more about individual and family plans, go to our website at REQUEST A FREE QUOTE: Visit our website or call the number above for a free, no-obligation quote! 11

12 Values you can trust Our commitment to ethical service has earned us recognition worldwide. In 2014, the international Ethisphere Institute named WPS one of the World s Most Ethical Companies for the FIFTH year in a row! 1 We are the only health insurance company to earn this distinction five times and we re eager to put our good values to work for you World s Most Ethical Companies Ranking, Ethisphere Institute, Wisconsin Physicians Service Corporation. All rights reserved

13 WPS Individual Preferred Plan Summary A traditional PPO plan for individuals and families featuring in- and out-of-network benefits and a wide range of plan design options. To request a quote, please see an agent, visit the WPS website at or have one of our licensed health insurance agents find the solution for you by calling Routine care covered, with no calendar year maximum Dependent children: to age 26 (see policy for eligibility requirements) Plan Options In-Network Options Metal Tier Individual Deductible 1 Coinsurance 2 Out-of-Pocket Limit Convenient Care Clinic or Telehealth Visit PCP Visit Specialist Visit ER Visit Free PCP Visit Prescription Plan Preventive/Generic/Preferred Brand/Brand/Specialty Silver 2,000 80% 6, $0/$20/$50/$75/25% to $500 Silver 2,500 80% 5, $0/$20/$50/$75/25% to $500 Silver 3,000 90% 6, $0/$20/$50/$75/25% to $500 Silver 3,000 70% 6, $0/$20/$50/$75/25% to $500 Silver 4, % 6, $0/$20/$50/$75/25% to $500 Silver 4,000 70% 6, $0/$20/$50/$75/25% to $500 Silver 2,000 80% 6,600 D/C D/C D/C D/C 3 $0/$20/$50/$75/25% to $500 Bronze 4,500 70% 6,600 D/C D/C D/C D/C 3 $0 preventive, D/C all others Bronze 5,000 80% 6,600 D/C D/C D/C D/C 3 $0 preventive, D/C all others Bronze 6, % 6,600 D/C D/C D/C D/C 3 $0 preventive, D/C all others Catastrophic* 6, % 6,600 D/C D/C D/C D/C 3 $0 preventive, D/C all others D/C = Deductible and Coinsurance PCP = Primary Care Physician **Applies only to persons under age 30 or have hardship exemption from the Federally Facilitated Marketplace (FFM). 1 Family deductible is 2x the individual. Out-of-Network deductible is 2x the applicable In-Network deductible. 2 Out-of-network coinsurance is 20 percentage points lower than in-network. For example, if you choose a plan with 100% in-network coinsurance, your out-of-network coinsurance is 80% (100-20=80). Convenient Care Clinic: a medical clinic that is located in a retail store, supermarket or pharmacy. The convenient care clinic must provide covered health care services by: (1) nurse practitioners; (2) physician assistants; or (3) physicians. They must provide those services within the scope of their respective licenses. Primary Care Physician: non-specialized physicians whose primary practice is one of the following: Family Practice, Internal Medicine, General Practice, Obstetrics/Gynecology and Pediatrics. Specialty Physician: any physician whose primary practice is other than one of the following: Family Practice, Internal Medicine, General Practice, Obstetrics/ Gynecology and Pediatrics. Telehealth: the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using the Internet, interactive audio, video, or data communications, to include all types of telephonic communication and electronic mail. All services are subject to terms and conditions of the policy. Certain drug limitations may apply, please review the full policy. Please see plan policy for a complete list of exclusions and other covered services

14 Common Medical Event If you visit a health care provider's office or clinic If you have a test If you need drugs to treat your illness If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Primary care office visit Specialist office visit Other practitioner office visit Preferred Provider Copay or Copay or Copay or Your cost if you use a Non-Preferred Provider Limitations & Exclusions If you have a copay plan, for preferred providers, you pay a $10 copay/visit to a convenient care clinic or for a telehealth visit None If you have a copay plan, for preferred providers, you pay a $10 copay/visit to a convenient care clinic or for a telehealth visit Preventive care/screening $0 None Immunizations $0 $0 Immunizations for travel are not covered Diagnostic test (x-ray/blood work) in an office or outpatient department of a hospital Imaging (CT/PET scans, MRI s) Coinsurance; If no copay: Deductible/ Coinsurance Coinsurance; If no copay: Deductible/ Coinsurance None Prior approval is required for PET scans Preventive drugs $0 None Generic drugs Preferred brand-name drugs Brand name drugs Specialty drugs Outpatient hospital - facility and physician/surgeon fees Copay or Preferred Provider Deductible & Coinsurance 30- day supply limit for retail and all specialty drugs; home delivery 90-day supply for 2.5 retail copay; drugs may require pre-authorization; several drugs to treat common illnesses will be available at no cost to you None Emergency room services Copay or Preferred Provider None Related emergency room services Emergency medical transportation Inpatient hospital -Facility and physician/surgeon fees Mental health/substance abuse outpatient office visits Mental health/substance abuse inpatient services Mental health/substance abuse transitional treatment Maternity services, including prenatal and postnatal care, delivery and all inpatient services Preferred Provider Coinsurance or Preferred Provider Preferred Provider None Prior approval is required for non-emergency transport* Prior approval is required for elective inpatient stays* Copay or Prior approval is required for elective inpatient stays* None None None Home health care Up to 60 visits per year Habilitative services (therapy): Office setting Outpatient hospital setting Rehabilitative services (therapy): Office setting Outpatient hospital setting Skilled nursing in a skilled nursing facility Copay or Copay or Durable medical equipment Prosthetics Limited to 20 visits per year as stated in the policy Limited to 20 visits per year as stated in the policy Up to 30 days per confinement; prior approval is required* Rental or purchase require prior approval if the equipment is over $1,000 or rental is more than $750 per month*; limited to a single purchase of each type every three years Prosthetics over $5,000 require prior approval*; limited to a single purchase of each type every three years Routine eye exam $0 None Glasses $0 Not Covered Limited selection of frames and lenses Dental check-up Not Covered Not Covered Not Covered * - If a prior approval is required and one is not obtained, a 50% penalty reduction in benefits will be applied.

15 WPS Individual HSA-Qualified HDHP Plan Summary An HSA-qualified high-deductible health plan (HDHP) for individuals and families featuring in and out-of-network benefits and a wide range of plan design options. To request a quote, please see an agent, visit the WPS website at or have one of our licensed health insurance agents find the solution for you by calling Routine care covered, with no calendar year maximum Dependent children: to age 26 (see policy for eligibility requirements) Plan Options In-Network Options Metal Tier Individual Deductible 1 Coinsurance 2 Out-of-Pocket Limit Convenient Care Clinic or Telehealth Visit PCP Visit Specialist Visit ER Visit Prescription Plan Preventive/Generic/Preferred Brand/ Brand/Specialty Silver 1,400 70% 6,450 D/C D/C D/C D/C $0 preventive, D/C all others Silver 2,000 80% 4,000 D/C D/C D/C D/C $0 preventive, D/C all others Silver 2,000 80% 6,450 D/C D/C D/C D/C $0 preventive, D/C all others Silver 2,500 80% 4,500 D/C D/C D/C D/C $0 preventive, D/C all others Silver 3, % 3,000 D/C D/C D/C D/C $0 preventive, D/C all others Silver 3, % 3,500 D/C D/C D/C D/C $0 preventive, D/C all others Bronze 3,500 70% 6,450 D/C D/C D/C D/C $0 preventive, D/C all others Bronze 4,500 90% 6,450 D/C D/C D/C D/C $0 preventive, D/C all others Bronze 5,500 80% 6,450 D/C D/C D/C D/C $0 preventive, D/C all others Bronze 6, % 6,000 D/C D/C D/C D/C $0 preventive, D/C all others D/C = Deductible and Coinsurance PCP = Primary Care Physician 1 Family deductible is 2x the individual. Out-of-Network deductible is 2x the applicable In-Network deductible. 2 Out-of-network coinsurance is 20 percentage points lower than in-network. For example, if you choose a plan with 100% in-network coinsurance, your out-of-network coinsurance is 80% (100-20=80). Non-embedded deductible: This plan features a non-embedded deductible. Family deductible must be satisfied before this plan will pay benefits. One person can satisfy the family deductible. Deductibles and out-of-pocket maximums apply annually. HSA is administered and/or maintained by a participating financial institution. WPS does not operate or administer HSAs. Convenient Care Clinic: a medical clinic that is located in a retail store, supermarket or pharmacy. The convenient care clinic must provide covered health care services by: (1) nurse practitioners; (2) physician assistants; or (3) physicians. They must provide those services within the scope of their respective licenses. Primary Care Physician: non-specialized physicians whose primary practice is one of the following: Family Practice, Internal Medicine, General Practice, Obstetrics/Gynecology and Pediatrics. Specialty Physician: any physician whose primary practice is other than one of the following: Family Practice, Internal Medicine, General Practice, Obstetrics/ Gynecology and Pediatrics. Telehealth: the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using the Internet, interactive audio, video, or data communications, to include all types of telephonic communication and electronic mail. All services are subject to terms and conditions of the policy. Certain drug limitations may apply, please review the full policy. Please see plan policy for a complete list of exclusions and other covered services

16 Common Medical Event If you visit a health care provider's office or clinic If you have a test If you need drugs to treat your illness or condition** If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Preferred Provider Your cost if you use a Non-Preferred Provider Primary care office visit * - If a prior approval is required and one is not obtained, a 50% penalty reduction in benefits will be applied Wisconsin Physicians Service Corporation. All rights reserved Limitations & Exclusions Telehealth visits with a preferred provider are covered Specialist office visit None Other practitioner office visit Telehealth visits with a preferred provider are covered Preventive care/screening $0 None Immunizations $0 $0 Diagnostic test (x-ray/blood work) in an office or outpatient department of a hospital Immunizations for travel are not covered None Imaging (CT/PET scans, MRI s) Prior approval is required for PET scans Preventive drugs $0 None Generic drugs Preferred brand-name drugs Brand name drugs Specialty drugs Outpatient hospital - facility and physician/surgeon fees Preferred Provider Deductible & Coinsurance 30- day supply limit for retail and all specialty drugs; home delivery 90-day supply; specialty drugs may require pre-authorization; several drugs to treat common illnesses will be available at no cost to you None Emergency room services Preferred Provider None Emergency medical transportation Inpatient hospital -Facility and physician/surgeon fees Mental health/substance abuse outpatient office visits Mental health/substance abuse inpatient services Mental health/substance abuse transitional treatment Maternity services, including prenatal and postnatal care, delivery and all inpatient services Preferred Provider Prior approval is required for nonemergency transport* Prior approval is required for elective inpatient stays* None Prior approval is required for elective inpatient stays* None None Home health care Up to 60 visits per year Habilitative services (therapy): Office setting, Outpatient hospital setting Rehabilitative services (therapy): Office setting, Outpatient hospital setting Skilled nursing in a skilled nursing facility Durable medical equipment Prosthetics Limited to 20 visits per year as stated in the policy Limited to 20 visits per year as stated in the policy Up to 30 days per confinement; prior approval is required* Rental or purchase require prior approval if the equipment is over $1,000 or rental is more than $750 per month*; limited to a single purchase of each type every three years Prosthetics over $5,000 require prior approval*; limited to a single purchase of each type every three years Routine eye exam $0 None Glasses $0 Not Covered Limited selection of frames and lenses Dental check-up Not Covered Not Covered Not Covered