Open Enrollment Presentation. Effective Date: January 1, 2014

Transcription

1 Open Enrollment Presentation Effective Date: January 1, 2014

2 Agenda Welcome to Tufts Health Plan Provider Network Plan Design Emergency/Urgent care Prescription Coverage Transition of Care Value Added Benefits Customer Service Member Enrollment Kit Explanation 2

3 Welcome to Tufts Health Plan! Tufts Health Plan in business for 30 years Headquartered in Watertown, Ma with regional offices in Worcester, Springfield, and Providence, RI. Ranked in the Top 10 nationally by the NQCA for our HMO and PPO plan out of 350 plans nationally #2 Ranked Plan by JD Power for Member Satisfaction in the New England Region First health plan in the Northeast to be nationally (NCQA) accredited in Wellness and Health Promotion 3

4 Provider Network Tufts Health Plan HMO 90 hospitals, and over 30,000+ physicians Network throughout MA, RI and southern NH Search providers at Choose the HMO / POS / PPO network from the drop-down menu under Standard Network plans CARELINK PPO 6,000 hospitals and 700,000 providers nationally One of the Top 3 largest networks in the country Search providers at Choose CareLink PPO from the drop-down menu under National Network plans 4

5 Medical Plan Routine preventive examination: covered in full Office visit copay: $25 Advantage HMO Emergency room: subject to deductible, no copay applies Plan year deductible: $3,000 per Individual and $6,000 per Family Deductible applies to: inpatient & outpatient hospitalization, diagnostic lab work & x-rays, speech & short term therapies Out of pocket maximum: $5,000 per Individual and $10,000 per Family Prescription Drug Plan Retail (up to 30-day supply) prescription copays: $10 / $25 / $45 Mail order (maintenance Rx s) prescription copays: $20 / $50 / $90 5

6 HMO Referral Process Referral Process it s easy! Required for most specialty care within network (dermatology, orthopedic) Obtained through Primary Care Physician (PCP) More than 90% of referrals happen on-line No pre-existing condition exclusions; all current conditions transferable to Tufts Health Plan 6

7 HMO Referral Process Services that DO NOT require referrals: Routine Eye Exams Inpatient Mental Health / Substance Abuse Services through Designated Facilities Annual OB/GYN Examination as well as most OB/GYN follow-up care Chiropractic Care 7

8 CareLink Advantage PPO Medical Plan Routine preventive examinations: covered in full Office visit copay: $25 Emergency room copay: subject to deductible; no copay applies Deductible: $3,000 Individual or $6,000 Family Deductible applies to inpatient & outpatient hospitalization, diagnostic lab work & x-rays, speech & short term therapies Coinsurance: In-network providers: 100% Out-of-network providers: 80% OOP Max: $5,000 Individual or $10,000 Family (includes deductible & coinsurance) Prescription Drug Plan Retail (up to 30-day supply) prescription copays: $10 / $25 / $45 Mail order (maintenance Rx s) prescription copays: $20 / $50 / $90 8

9 Emergency Services 100% worldwide coverage Emergency Room copay applies in-network or out-of-network (waived if admitted to the hospital) Claim form needed if out-of-network ER facility 9

10 Prescription Drug Coverage Retail Available at 99% of pharmacies nationwide 59,000 including CVS, Rite Aid, Walgreens, Target, Wal-Mart, etc. 30-day supply filled at the retail pharmacy remember to show your ID card to pharmacist after January 1 st. Check your prescription tiers at -Prior Authorization, Step Therapy, and dispensing limits may apply to some prescriptions Benefits to Fast Start (90-supply for most maintenance medications): - No forms to complete to start prescriptions by mail - Save time and money on your prescriptions - Home delivery including free standard shipping to your home - Re-order prescriptions by phone, via mail, or online Refill your prescriptions prior to January 1 st, if possible 10

11 Vision Services Tufts Health Plan Vision Benefits through EyeMed network: Routine Eye Exams (covered once every 12 months) Eyewear discounts on lenses, frames & contact lenses (15-35% off) Discounts available for LASIK procedures through network providers 11

12 Transition of Care Assistance (for Ongoing Medical Services) Transition of Care is needed anytime a member is in the middle of a care plan and needs additional resources to ensure continuity of care. Examples include: scheduled surgery or procedures already pre-approved Simply contact Tufts Health Plan Member Services to coordinate care Each case is reviewed individually and Tufts Health Plan will communicate with you and your providers if necessary 12

13 Fitness & Weight Management Benefit $150 Fitness Reimbursement Discounts at local participating Fitness Centers Curves Fitness Together Personal Training 13

14 Value Added Benefits Hospital-based wellness programs ex. nutrition, smoking cessation, stress management (up to 30% off) Boys & Girls Clubs (20% off) Acupuncture & Massage Therapy discounts (25% off) Healthyroads online health/wellness shopping (up to 40% off) Pregnancy Benefits and Childbirth Class reimbursements New Balance Discount 15% off all products at their stores Well magazine! 14

15 Website Decision Support Tools Need to register 24/7 access Provider look-up Your authorizations information Your benefit Information Hospital performance comparisons with Select Quality Care Information on conditions and symptoms Medical & pharmacy claims Health & Wellness calculators 15

16 HMO Member Services Line (800) or CareLink Member Services Line (866) Monday-Thursday: 8am 7pm (EST) Friday: 10am 5pm (EST) 24 hour answering service AT&T Language Line (140 languages) Member Services Benefit questions, new ID card, or transition of care questions 16

17 Important Reminders (!) All employees and their dependents will receive new medical ID Cards Subscriber: Spouse: Dependents: xxxxxx-01 xxxxxx-02 xxxxxx-03 Start using new cards as of January 1 st! 17

18 Question and Answers We look forward to working with 18