for Employer Groups LIVE LIFE ASSURED

Transcription

1 for Employer Groups LIVE LIFE ASSURED 1

2 Live life assured Together, creating better health and better health care consumers Successfully providing excellent health benefits costeffectively requires a partner who understands your priorities. Health Tradition Health Plan helps employers design comprehensive health benefit plans that:» Engage people in the decision-making process, making them more capable consumers» Streamline» Incentivize healthy behaviors and support lifestyle improvement» Motivate wellness participation with appealing programming» Support employees in managing chronic conditions Mayo Clinic Health System quality care Our affiliation with the Mayo Clinic Health System network is one of many good reasons to choose Health Tradition. Members select an in-network primary care provider (PCP), using a proven model for optimizing outcomes through continuity of care. They are connected to a unique network of specialists through medically indicated referrals to La Crosse and Eau Claire, Wisconsin and Rochester, Minnesota. Spend less time on benefits management Health Tradition makes it easy to access timely reporting and documentation, and easy to reach us when a question arises. Our frequent accolades for responsiveness reflect a commitment to excellence that aligns with that of our provider network.* Our suite of plan options includes fully insured managed health plans, consumer-directed plans and pharmacy benefit management. We provide tools for easy implementation and enrollment, multipurse health care payment cards, real-time access to claims data, nondiscrimination testing and more. Maintaining affordability Our ongoing effort to bend the cost curve includes: Medical management Our team of specialists assures quality care and cost management through prior authorization, referral management, case management, concurrent review and discharge planning. Condition management A voluntary program that helps members better manage their conditions. The program includes a 24-hour toll-free phone line, evaluation, consultation and education. Reinsurance and underwriting With access to several reinsurance carriers, we provide competitive stop-loss coverage options. RNs available 24/7 Instant access to reliable health information improves utilization by helping members take appropriate action. Quality management All standards are developed to meet or exceed Healthcare Effectiveness Data and Information Set (HEDIS) benchmarks, National Committee for Quality Assurance (NCQA) and URAC guidelines to communicate and maintain our high standards of care. Plan design options In addition to the traditional HMO model, employers may choose a Point-of-Service (POS) plan or consumer-directed health plan with a high-deductible option, incorporating a health reimbursement account (HRA) or a health savings account (HSA). We offer professional advice on cost-effective plan design. We also provide plan administration for self-funded groups. *Health Tradition Customer Satisfaction Surveys Customized plan design and management We support customized plans with comprehensive management, reporting and analysis, including a state-ofthe-art Consumer-Directed Health (CDH) plan platform. ACCREDITED HEALTH PLAN HEALTH PLAN WITH HEALTH INSURANCE MARKETPLACE URAC accredited, Health Plan and Health Plan for Health Insurance Exchange (HIX)

3 Health Tradition s wellness benefits are member-friendly, relevant and provide exceptional outcomes Our wellness programming was developed by Mayo Clinic Health System experts based on the latest behavioral research. These proven programs engage, empower and direct resources where they will be most effective. Eat Well Move More Rebate This popular program offers up to $200 combined rebate per member household for healthy investments like fitness club dues and Community Supported Agriculture (CSA) fresh produce programs. Wellness at Work Challenges Wellness at Work encourages people to adopt healthy habits and motivate others around them, building momentum throughout the organization. Backed by Mayo Clinic research, these turnkey challenges focus on the biggest health benefits. See Health Tradition plans on Healthcare.gov Health Tradition HMO plans are available through the Small Business Health Options Program (SHOP) Marketplace at HealthCare.gov. SHOP is open to employers with 50 or fewer full-time equivalent (FTE) employees. With 25 or fewer FTEs covered by your plan, you may qualify for a small business health care tax credit worth up to 50% of premium costs. As of 2014, the tax credit is available only for plans purchased through SHOP. Or call us HEALTHCARE.GOV We will help you select a robust and costefficient health benefit for your group. (888) or (608) WellMe A quarterly update with workplace wellness topics, research and tips to create effective Wellness at Work challenges. Free 24/7 Nurse Line Reliable health information from experienced Mayo Clinic Health System registered nurses. The Nurse Line encourages appropriate use of health care resources. Tobacco Cessation This effective program combines personal counseling through the Mayo Clinic Tobacco Quitline with the use of Nicotine Replacement Therapy (NRT) aids. Online healthy living tools Powerful support for behavior change and condition management, a health reference library, decision guides and access to benefits information and claims history. Mayo Clinic Health Assessment Allows organizations to identify population risks and readiness to change, deliver follow-up interventions and track health trends over time. The assessment presents a personalized action plan for each participant. Available wellness support Turnkey solutions for a culture of wellness Complementing the core benefits, Mayo Clinic Health System experts can help you plan robust, data-driven wellness programming full operational plan, aggregate reporting, outcomes analysis, promotion tools and recommendations to affect targeted improvements. Healthwise U Multifaceted health education and behavior change resources, including workshops and presentations, award-winning videos and customized workplace health initiatives. A New Me: Healthy Balance Matters Better health through mindful choices, integrating nutrition, physical activity and stress management, A New Me includes pre and post assessments, biometric screening and follow up. This intensive lifestyle program is eligible for the Eat Well Move More rebate.

4 Standard HMO Group Plans Covered Services Platinum / /80 w/copay 2500/80 w/copay 2000/ /70 w/copay 6000/80 Annual Deductible Indiv/Family Annual Out-of-Pocket Maximum Indiv/Family $1,000/$2,000 $1,000/$2,000 $1,000/$2,000 $2,500/$5,000 $2,000/$4,000 $1,500/$3,000 $6,000/$12,000 $1,000/$2,000 $2,500/$5,000 $2,600/$5,200 $6,350/$12,700 $6,000/$12,000 $4,200/$8,400 $6,350/$12,700 Preventive Care* 100% coverage 100% coverage 100% coverage 100% coverage 100% coverage 100% coverage 100% coverage Routine Eye Exam One per member per coverage year. Limits apply. Routine Hearing Exam Annual. Limits apply. After meeting your deductible you pay (copays do not apply to deductible) Office Visits 20% 30% $75 copay/ $125 specialist 20% Chiropractic $30 copay 20% $30 copay $30 copay 30% $75 copay 20% Urgent Care** $30 copay 20% $30 copay $30 copay 30% $75 copay 20% Emergency Room Services ** $100 copay 30% coinsurance 30% coinsurance 20% Ambulance Hospitalization Inpatient/Outpatient Outpatient Lab/ Radiology Durable Medical Equipment Skilled Nursing Facilities with prior authorization Home Health Care Rehabilitation Services Prenatal/postnatal care Delivery and all inpatient services Mental/Behavioral Health, Outpatient Mental/Behavioral Health, Inpatient $30 copay 20% $30 copay $30 copay 30% $75 copay 20% Prescription Drug Coverage Based on the Health Tradition Formulary Generic $30 / Brand $70 / Non-formulary $150 Generic $30 / Brand $60 / Non-formulary $100 * This Benefit Plan provides 100% coverage for preventive health services. Coverage may be subject to reasonable medical management techniques to determine the frequency, method, treatment, or setting for receipt of preventive health services and as defined in Section 1001 of the Patient Protection and Affordable Care Act, with no cost sharing. ** Out-of-network medical emergencies, urgent care and plan prior approved referrals are covered as in-network benefit. See Certificate of Coverage for plan detail.

5 HMO Qualified High-Deductible Plans compatible with Health Savings Accounts HDHP 100 HDHP 90 HDHP 80 HDHP 80 HDHP 60 HDHP 50 $2,000/$4,000 $3,000/$6,000 $2,000/$4,000 $4,500/$9,000 $4,000/$8,000 $3,000/$6,000 $2,000/$4,000 $4,400/$8,800 $6,350/$12,700 $6,350/$12,700 $6,350/$12,700 $6,350/$12, % coverage 100% coverage 100% coverage 100% coverage 100% coverage 100% coverage In addition to meeting your deductible you pay 0% Generic 5% / Brand 10% / Non-formulary 20% Specialty 10% Generic 20% / Brand 20% / Generic 20% / Brand 20% / Generic 40% / Brand 40% / Non-formulary 60% 50% These Health Tradition plans are also available through the Health Insurance Marketplace at HealthCare.gov If the level of coverage is anything other than single, the entire family deductible must be met by either one member solely, or all members collectively, before plan payment begins.

6 Standard Point of Service Group Plans There is coverage for both in-network and out-of-network provider services. Please see plan documents for out-of-network coverage. Covered Services Platinum 1000 POS 1000/80 POS 1000/80 w/copay POS 1500/70 w/copay POS 2000/70 POS 2500/80 w/copay POS Annual Deductible Indiv/Family Annual Out-of-Pocket Maximum Indiv/Family $1,000/$2,000 $1,000/$2,000 $1,000/$2,000 $1,500/$3,000 $2,000/$4,000 $2,500/$5,000 $1,000/$2,000 $2,500/$5,000 $2,600/$5,200 $4,200/$8,400 $6,000/$12,000 $6,350/$12,700 Preventive Care* 100% coverage 100% coverage 100% coverage 100% coverage 100% coverage 100% coverage Routine Eye Exam One per member per coverage year. Limits apply. Routine Hearing Exam Annual. Limits apply. After meeting your deductible you pay (copays do not apply to deductible) Office Visits 20% $75 copay/ $125 specialist 30% Chiropractic $30 copay 20% $30 copay $75 copay 30% $30 copay Urgent Care** $30 copay 20% $30 copay $75 copay 30% $30 copay Emergency Room Services ** $100 copay 30% coinsurance 30% coinsurance Ambulance Hospitalization Inpatient/Outpatient Outpatient Lab/ Radiology Durable Medical Equipment Skilled Nursing Facilities with prior authorization Home Health Care Rehabilitation Services Prenatal/postnatal care Delivery and all inpatient services Mental/Behavioral Health, Outpatient Mental/Behavioral Health, Inpatient $30 copay 20% $30 copay $75 copay 30% $30 copay Prescription Drug Coverage Based on the Health Tradition Formulary Generic $30 / Brand $70 / Non-formulary $150 Out-of-network services Emergency room, ambulance and urgent care benefit is same as in-network. Other services may not be covered, or covered at a different rate or copay amount. * This Benefit Plan provides 100% coverage for preventive health services. Coverage may be subject to reasonable medical management techniques to determine the frequency, method, treatment, or setting for receipt of preventive health services and as defined in Section 1001 of the Patient Protection and Affordable Care Act, with no cost sharing. ** Out-of-network medical emergencies, urgent care and plan prior approved referrals are covered as in-network benefit. See Certificate of Coverage for plan detail.

7 Point of Service High-Deductible Plans compatible with Health Savings Accounts HDHP 100 POS HDHP 90 POS HDHP 80 POS HDHP 80 POS HDHP 60 POS HDHP 50 POS $2,000/$4,000 $3,000/$6,000 $2,000/$4,000 $4,500/$9,000 $4,000/$8,000 $3,000/$6,000 $2,000/$4,000 $4,400/$8,800 $6,350/$12,700 $6,350/$12,700 $6,350/$12,700 $6,350/$12, % coverage 100% coverage 100% coverage 100% coverage 100% coverage 100% coverage In addition to meeting your deductible you pay 0% Generic 5% / Brand 10% / Non-formulary 20% Specialty 10% Generic 20% / Brand 20% / Generic 20% / Brand 20% / Generic 40% / Brand 40% / Non-formulary 60% 50% Emergency room, ambulance and urgent care benefit is same as in-network. Other services may not be covered, or covered at a different rate or copay amount. These Health Tradition plans are not available through the Health Insurance Marketplace. If the level of coverage is anything other than single, the entire family deductible must be met by either one member solely, or all members collectively, before plan payment begins.

8 Mayo Clinic Health System primary and specialty care The relationship at the center of excellent care Each member selects a local Primary Care Provider (PCP) from network doctors, physician assistants or nurse practitioners. The PCP gets to know the member and coordinates care for an excellent patient experience, continuity of care and better outcomes. The PCP may consult with specialists within Mayo Clinic Health System or outside the network and refer when medically indicated. Required referrals for specialty care The member s care team works closely with Health Tradition to ensure the most appropriate care is given at the most appropriate facility. A referral from the PCP may be to a Mayo Clinic specialist practicing locally. When medically indicated, the member may be referred to Mayo Clinic in Rochester or another out-of-network provider. These referrals require written plan approval before services are received. Health Tradition keeps members informed by letter of out-of-network services being considered and those that are approved. Your primary and specialty care provider network La Crosse Eau Claire Rochester More than 70 locations 1808 East Main Street Onalaska, WI P.O. Box 188 La Crosse, WI (888) (toll-free) or (608) (local) Health Tradition Health Plan HTHP-V625 (09/14)