2018 NH Broker Playbook: Individual Business

Transcription

1 2018 NH Broker Playbook: Individual Business

2 Agenda Our mission Our networks Our products Medical plans Pharmacy General information about our plans Discounts & savings Broker support 2

3 Harvard Pilgrim Provider Networks

4 Harvard Pilgrim Standard (Full) Network Harvard Pilgrim's provider network is extensive. It encompasses MA, ME, NH, CT, RI, VT. Includes physicians practicing in a variety of settings including individual practices, small medical groups and large multi-specialty groups. Harvard Pilgrim has a growing network of over 182 hospitals and 70,000 doctors and clinicians. 4

5 Tiered Network Products Places providers and hospitals in tiers based on provider specialty or network Standard HMO rules and referrals apply Access to Harvard Pilgrim s full HMO network Incents Members to use Tier 1 providers through lower cost share ElevateHealth Options is a tiered network 5

6 Defined Network Products Comprised of a subset of providers and hospitals from the full HMO network Members receive all care through a limited network provider Standard HMO rules and referrals apply Member liable if out of network provider is seen, even if referred by PCP Prior authorization from Harvard Pilgrim is required for care not otherwise available within the limited network ElevateHealth is a defined network 6

7 Directory Sample Standard (Full) Network products include HMO and PPO plans Tiered/Limited Plans 7

8 New Hampshire Individual Products and Plan Offerings

9 Plan Metal Tier Choice Guide CONSUMER Willing to pay for richer benefits CONSUMER Subsidy eligible Seeks value in coverage CONSUMER Healthy consumers/low utilizers GOLD HMO Highest premiums Lowest cost share $1k Deductible on ElevateHealth plans $1k/$4k Deductible on ElevateHealth plans No coinsurance on most services More copay services SILVER HMO Lower premiums Lower cost share Deducible range of $3k-$6k Coinsurance range of 30%-40% BRONZE HMO Lowest premium Highest cost share $7k Deductible 50% Coinsurance 9

10 Updates for 2018 Simplified portfolio, consistent plan designs ElevateHealth no longer available in Belknap County, and remains unavailable in Carroll County NH Network plans discontinued for 2018 More membership in ElevateHealth plans Elevate Health Plans support joint venture with Benevera Health 10

11 Individual Plans On and Off Exchange Defined and tiered network options available offexchange ElevateHealth network with 3 plans across the metal spectrum ElevateHealth Options Network with 1 gold and 1 silver offering Defined network option available on-exchange ElevateHealth network with 1 gold and 1 silver offering 11

12 ElevateHealth HMO Plans

13 ElevateHealth HMO: Map Smaller network for lower premium 700+ primary care physicians 3,300+ specialists 19 Easy Access hospitals Network coverage in all NH counties except Carroll & Belknap Includes Brattleboro Memorial Hospital in Brattleboro VT Note: Hospital admitting privileges are not an indication of network participation. To find a provider participating in this network please use the ElevateHealth online directory 13

14 ElevateHealth HMO: Hospitals Alice Peck Day Memorial Hospital Androscoggin Valley Hospital Brattleboro Memorial Hospital (VT) Cheshire Medical Center Concord Hospital Cottage Hospital Dartmouth-Hitchcock Medical Center Elliot Hospital Exeter Hospital Frisbie Memorial Hospital Littleton Regional Hospital Monadnock Community Hospital New London Hospital Southern New Hampshire Medical Center St. Joseph s Hospital Upper Connecticut Valley Hospital Valley Regional Hospital Weeks Medical Center Wentworth-Douglass Hospital 14

15 ElevateHealth HMO: How the Network Works ElevateHealth providers are called Easy Access providers. All members must choose a participating PCP, or one will be assigned to them. Specialty care is available with a referral from the PCP to an Easy Access specialist. Referrals are not necessary for some services, such as routine eye exams and most gynecological care. 15

16 ElevateHealth HMO: Authorized Access In the rare event that pediatric specialty care cannot be provided by an ElevateHealth provider, a member can request access to Boston Children s Hospital and some of its affiliated physicians. PCP or specialist must obtain Prior Approval from the Plan. Prior Approval will be provided when it has been determined that no Easy Access Provider has the professional expertise needed to provide the required services. 16

17 ElevateHealth HMO: 2018 Individual Plans 3 ElevateHealth HMO plans offered ElevateHealth Gold Offered both on and off exchange ElevateHealth Silver Offered both on and off exchange ElevateHealth Bronze Off exchange only 17

18 To find ElevateHealth participating providers, visit 1. At the harvardpilgrim.org homepage, click on Find a Provider at the top of the page. 2. Select ElevateHealth HMO under the Tiered/Limited plans section 3. Various search functions available 18

19 ElevateHealth Options Plans

20 ElevateHealth Options A Full Tiered Network Product Featuring the ElevateHealth Network ME Tier 2 CT NH Tier 1 ElevateHealth Network MA VT RI 20

21 ElevateHealth Options: How it works Member can choose a PCP in either tier Same PCP referral process as other full network products *Authorized Access process not applicable Member responsible for cost share associated with providers tier Behavioral Health defaults to Tier 1 21

22 ElevateHealth Options: Plan Design Highlights Tier 1 cost share Lower deductible Most services apply a copay Lab covered in full Tier 2 cost share Higher deductible Deductible and co-insurance applies to all services Emergency Room Tier 1 deductible then $300 copay regardless of facility tier 22

23 ElevateHealth Options: Non-Tiered Benefits The following services do not have tiered network cost sharing. Preferred Cost Share Acupuncture Low protein foods Ambulance Maternity Care (routine) Applied behavioral analysis Mental Health and drug and alcohol rehabilitation services Chiropractic Medical formulas Durable medical equipment (DME) Ostomy Emergency Room Prosthetics Hearing Aids Wigs 23

24 ElevateHealth Options: Deductible Design Cross-accumulating deductible Deductible met in one tier applies toward the other tier s deductible Tier 1 Tier 2 Maximum deductible is equal to the Tier 2 deductible 24

25 ElevateHealth Options: Map ElevateHealth hospitals shown at right are all in Tier 1 All other hospitals in Harvard Pilgrim s network NH, MA, ME, VT and CT are in Tier 2 25

26 ElevateHealth Options: 2018 Individual Plans Two plans with the ElevateHealth Options network offered off-exchange ElevateHealth Options Gold 1000 ElevateHealth Options Silver

27 To find ElevateHealth Options participating providers, visit 1. At the harvardpilgrim.org homepage, click on Find a Provider at the top of the page. 2. Select ElevateHealth Options under the Tiered/Limited plans section 3. Various search functions available 27

28 Vision Coverage - New Hampshire Pediatric under 19 First $100 covered in full then 50% coinsurance Frames and lenses every 12 months OR First order of contact lenses every 12 months OR 6 month supply of disposable lens Does not cover contact or glasses supplies, fitting charges All members are covered for eye exams under their plan No network purely member reimbursement program Reimbursement form is available on HPHC.org or from Member Services 28

29 Pediatric Dental - New Hampshire Pediatric under 19 Type 1 Services Type 2 Services Type 3 Services Type 4 Services Preventive Minor Restorative Major Restorative Medically Necessary Orthodontia Covered at 50% coinsurance Off Exchange plans are available with or without pediatric dental Members will receive separate Dental ID card 29

30 Included in all Individual Plans Acupuncture 20 visits per calendar year Must use a participating provider Access to discount programs once benefit limit is reached Chiropractic care 12 visits per calendar year Must use a participating provider Access to discount programs once benefit limit is reached Routine eye exam Once every 2 years for adults Once per year for pediatric Plus free eyewear and discount programs available Physical, occupational and speech therapies 20 visits per calendar year for each 30

31 Premium Assistance Program (PAP) Premium Assistance Program is a Medicaid expansion program managed by the New Hampshire Department of Health and Human Services (NH DHHS) Available to NH residents between the ages of Eligibility is determined by DHHS Consumer enrollment questions should be referred to DHHS DHHS:

32 Premium Assistance Program (PAP) continued PAP members may enroll in an ElevateHealth Network plan Two cost share options Minimal cost share plan No cost share plan Deductible is paid by the DHHS PAP members have access to all the HPHC discount programs available to other commercial members 32

33 General Information About our Plans

34 Preventive Services Preventive services are covered in full Routine physicals and annual gynecological exams Outpatient prenatal care Many common preventive tests, including (but not limited to): mammogram and pap smear routine urinalysis immunizations for children and adults non-diagnostic colonoscopy certain tests recommended based on age and habits Complete list available to members on their secure online account 34

35 Urgent care For minor illness and injury when PCP is not available Hospital- based urgent care Telemedicine Convenience care $ Free-standing urgent care $$ $$$ 35

36 Telemedicine Services: Doctor on Demand Convenient, cost-effective alternative to ER for minor urgent care Real-time virtual visit via smartphone, tablet or computer On-demand virtual visits for minor issues (ex. cough, rash, sinus issues) PCP cost-sharing applies for medical urgent care Scheduled behavioral health virtual visits Outpatient therapy cost sharing applies for behavioral health No referral or authorization needed 36

37 Embedded Deductible Example: $2,500 individual deductible; $5,000 family deductible There is a $2,500 cap on any individual family member s deductible responsibility If one family member ends up in the hospital on the first day of the plan year, Harvard Pilgrim caps his or her deductible responsibility at $2,500 The other family members must incur an additional $2,500 before satisfying the $5,000 family deductible Once the family deductible of $5,000 is met, the deductible is met for the entire family for the remainder of the year 37

38 Out of Area (OOA) Dependent Coverage All our HMO plans include coverage for dependent children under the age of 26 living outside the enrollment area The subscriber must call Member Services to register the OOA dependent (888) Routine and non-routine services are covered Elective services are not covered OOA (i.e. Bariatric or reconstructive surgery) Must use out-of-area dependent providers for services outside of the enrollment area 38

39 Discounts & Savings Helping Members to stay healthy, for less!

40 Count us in for discounts to help members maintain a healthier lifestyle Fitness Up to $150 fitness reimbursement per individual or family contract 15% off on athletic footwear at Marathon Sports (MA) 15% off on regularly priced footwear at Runner s Alley (NH) 20% off Appalachian Mountain Club membership Discounts on exercise equipment rentals & services; Workout Fitness Store (So. Portland, ME) Vision FREE designated eyewear & discounts at Visionworks (MA, NH, RI) Discounts at JCPenney Optical, LensCrafters, Pearle Vision, Sears Optical and Target Optical Laser Vision Correction discounts through QualSight LASIK, Davis Vision, US Laser Network Holistic Wellness Save 10-30% on complementary & alternative medicine from Healthways WholeHealth Network on acupuncture, chiropractic care, yoga, Chinese herbal medicine, etc. Hug Patrol Center for Mindfulness; Discounts on Mindfulness-based Stress Reduction & Mindfulness-based Cognitive Therapy courses 10% Happier Dental 30 50% off all procedures at participating dentists through Universal Dental Plan Save up to 28% on membership fees Healthy Eating Jenny Craig DASH for Health idiet Savor Health Quit Smoking Craving to Quit QuitSmart Family and Senior Care Care.com Senior Assist (Senior Resource Center, Inc.) CareScout Elder Advocacy Program Home Instead Senior Care Vigorous Mind Hearing Hearing Aids through Amplifon Hearing Health Care More information: harvardpilgrim.org, click Discounts & Savings at the bottom of the page. 40

41 Pharmacy Information

42 Value Formulary Tiers Individual Plans Value 4-Tier Tier 1 Generics only Tier 2 Tier 3 Tier 4 Preferred Brands (some high-cost generics) Non-preferred brands and preferred specialty (some higher-cost generics) Non-preferred specialty drugs (very high-cost brand and generic drugs) 42

43 Mail Order Program Our mail order program is for maintenance medications and health products The program includes a 90-day supply of medication delivered to members homes Certain medications such as controlled substances, may be subject to dispensing limitations Can order online, by mail or by phone 43

44 Enrollment and Renewal Guidelines

45 Dates and Deadlines Open enrollment is November 1, 2017 December 15, 2017 January 1, 2018 is the only available effective date Enrollments and plan changes must be submitted by December 15 th in order to be eligible for a January 1 effective date Payment deadline (both on and off Exchange) is January 10,

46 Renewal Support Renewal report displaying your existing book of business Sample discontinuation and renewal letter packages 2017 to 2018 Benefit Comparisons Product Mapping Grid of 2017 products to 2018 products Consumer Sales support at (844)

47 Renewal Report Name, address and Harvard Pilgrim ID of member Marketplace versus Buy Direct 2017 premium and product 2017 Average Premium Tax Credit (APTC) 2018 premium and new product (mapped) 47

48 Renewal Report Rates vs Premium The 2017 rate shown is the base rate and does not include APTC. In the example below the 2017 billed premium would be $ The 2018 rate also does not contain APTC. The estimated 2018 premium would be $

49 2018 Renewal Process - OFF Exchange Off-Exchange members CANNOT make their plan change on Harvardpilgrim.org - they MUST call the consumer sales team Members have 2 options: Passive Renewal: Do Nothing. Members automatically renewed as long as they continue to pay monthly premium. Active Renewal: Take Action if the 2017 is discontinued with no mapping OR the members don t like the 2018 plan we chose for them Consumer Sales will review plans and make change via the phone OR. Consumer Sales will mail a quote and a paper enrollment form 49

50 2018 renewal process On Exchange On Exchange plan changes must be completed on HealthCare.gov Changes must be made by December 15, Members have 3 options: Passive Enrollment - Member likes 2018 plan changes presented in renewal letter, and there are no changes to Marketplace application information Do Nothing. Member automatically enrolled and continues to pay monthly premium. Active Enrollment - Member likes 2018 plan changes presented in renewal letter, but there are changes to Marketplace application information Member must go back to the Marketplace to update information and re-enroll. Active Enrollment Member s 2017 plan was discontinued with no mapping or member does not like 2018 that we chose for him or her Take Action - Visit HealthCare.gov and look at other Marketplace plans. 50

51 On Exchange Renewals - Payment If Subscribers are enrolled on Auto Pay, they will need to visit the PaySpan Web site and re-enroll in Auto Pay between December 5 and December 20, 2017, in order for automatic payments to carry forward into the new contract year. The auto pay they establish during this time period will apply to their February 2018 premium January premium payment must be made before autopay can be re-started. Payment can be made via check or through PaySpan. Instructions for re-enrolling in Auto Pay are in their renewal package Failure to re-enroll in Auto Pay could result in a lapse in coverage 51

52 Off-Exchange Enrollment Off-Exchange Quotes and enrollments can be done via Online payment capability Enter NPN or vendor ID to be linked to subscriber View book of business with corresponding statuses 52