Humana, Healthcare Reform and You What you need to know

Transcription

1 Humana, Healthcare Reform and You What you need to know

2 About Humana Headquartered in Louisville, KY Over 50 years experience in the health industry Diverse portfolio of products Over 12.1 million medical members nationwide Over 4 million Medicare members nationwide Over 11 million members in specialty products Corporate Social Responsibility Humana Foundation KaBOOM Walkit Challenge Arbor Day Foundation Habitat for Humanity 2

3 Plan Designs Descriptions

4 Essential Health Benefits Plans must cover 10 categories of mandated essential health benefits: Essential Health Benefit Categories Ambulatory patient services Emergency Services Maternity and newborn care Pediatric services including dental and vision care Rehabilitative/ habilitative services and devices Mental health and substance use disorder services, including behavioral health treatment Preventive and wellness services and chronic disease management Hospitalization Prescription Drugs Laboratory services 4

5 Plans on the Exchange How are the plans categorized? Plan tiers are categorized by actuarial value What is actuarial value? As an example, a Gold Plan has an actuarial value of 80%. That means, for a standard population: The plan will pay 80% of their health care expenses The enrollees themselves will pay 20% through a combination of deductibles, copays, and coinsurance Catastrophic plans are lower cost with limited benefits for people under 30 or people with financial hardship*. *Financial hardship: above 400% FPL, but would pay premium exceeding 8% of income for lowest-priced Bronze Plan. 5

6 Product Descriptions Humana Preferred (PPOs) LOCAL-Humana s PPO gives members the choice to go to their preferred healthcare provider within a local geographic area NATIONAL-Humana s PPO gives members the choice to go to their preferred healthcare provider within a national framework

7 Humana Local Preferred (PPOx) Humana Local Preferred: Memphis, Nashville, Knoxville (30 counties total) Referral not required Out-of-network coverage Local Medical Network (PPOx) Rx network (Walmart, Sam s Club, CVS, Rightsource) Closed RX5 formulary Allows for OON coverage and does not require a referral Offered in markets where we are competitively priced Offered in all metallic tiers + catastrophic

8 Humana Local Preferred (PPO)

9 Humana Local Preferred (PPO) Humana Preferred Plans give consumers the freedom to choose any doctor, hospital or specialist so that they can receive care from any healthcare provider (But consumers receive the most benefit when they utilize an in-network provider) Benefits of Humana Preferred products Good for consumers using doctors and hospitals in our PPOx network Access to out-of-network doctors, specialists and hospitals Freedom of choice For a family, there is only a Family deductible and Family OOP, which is twice the single deductible / OOP

10 Benefit Med. Deductible (IN) Coinsurance (IN/OON) Max OOP (IN) TN-Humana Local Preferred (On and Off Marketplace ) Basic 6350/6350 $6350 single Bronze 6300/6300 HSAQ $6300 single Silver 4600/6300 $4600 single Gold 2500/3500 $2500 single Platinum 1000/1500 $1000 single 100%/75% 100%/75% 80%/60% 80%/60% 80%/60% $6350 single $6300 single $6300 single $3500 single Preventive Services 100% 100% 100% 100% 100% $1500 single PCP/Specialists/ Urgent Care $35 PCP copay (3); all else Ded. Deductible/ Coinsurance $25 /$35/$50 $25 /$35/$50 $25 /$35/$50 RX Deductible/ Coinsurance Deductible/ Coinsurance $10/20/50/ 50%/50% $1500 Rx ded Tiers 3-5 $5/10/20/ 35%/35% $500 Rx ded Tiers 3-5 $5/10/20/ 35%/35% $500 Rx ded Tiers 3-5 The above represents only a summary; please consult benefit summary for full details. Out of Network Deductible and Out of Network Out-of-Pocket are considerably higher than the in-network counterparts Off Marketplace plans have embedded Pediatric Dental always included; coverage is 50% after deductible, up to the OOP Limit

11 Cost Sharing Subsidy For clients who are 100% to 250% FPL Protects your clients from high out-of-pocket costs at point of service Consumer will have the option to purchase this subsidized plan in addition to benefiting from the Advance Premium Tax Credit If a consumer does not choose to purchase the Silver cost-sharing plan, then they will not receive the cost-sharing subsidy However, consumer is still eligible for the Advance Premium Tax Credit for any plan she purchases on the exchange X

12 Cost Sharing Impact to Plan Design In network: Med. Deductible (IN) Coinsurance (IN/OON) Max OOP (IN) Preventive Services Silver 4600/6300 $4600 single 80%/60% $6300 single Silver ( % FPL) $3250 single 2X Family Silver ( % FPL) $900 single 2X Family Silver ( % FPL) $500 single 2X Family 80%/60% 80%/60% 80%/60% $4750 single 2X Family $1450 single 2X Family $750 single 2X Family 100% 100% 100% 100% PCP/Specialists/ Urgent Care $25 /$35/$50 $25 /$35/$50 $25 /$35/$50 $25 /$35/$50 RX $10/20/50/50%/50% $10/20/50/50%/50% $10/20/50/50%/50% $10/20/50 50%/50% $1500 Rx ded Tiers 3-5 $1000 Rx ded Tiers 3-5 $500 Rx ded Tiers 3-5 $250 Rx ded Tiers 3-5 Out of Network is considerably higher member cost-sharing and is the same as the Standard Silver plan.

13 Humana Smart Choice Dental Humana Smart Choice Dental Immediate and affordable benefits Competitive adult/family rates Comprehensive child coverage, additional coverage for major services Also, a limited orthodontic benefit for kids is available No annual max for kids! Out of pocket protection: $700 max out of pocket per child, $1400 for 2+ children

14 Humana National Preferred Off Exchange Plans follow Metallic tiers (Same as On-Exchange) National Choice Care PPO Network Humana National Pharmacy Network (include major retailers) Rx4 Open Formulary Offered in Bronze and Silver metallic tiers + catastrophic Offered off of the marketplace

15 TN-Humana National Preferred (Off Marketplace) Benefit Med. Deductible (IN) Coinsurance (IN/OON) Max OOP (IN) Preventive Services Basic 6350/ 6350 $6350 single Bronze 6300/6300 HSAQ $6300 single Bronze 4850/6350 $4850 Single Silver 3650/3650 HSAQ $3650 single Silver 4250/6250 $4250 single Gold 2500/33500 $2500 single Platinum 1000/1500 $1000 Single 100%/75% 100%/75% 80%/60% 100%/75% 80%/60% 80%/60% 80%/60% $6350 single $6300 single $6350 $3650 single $6250 $3500 $ % 100% 100% 100% 100% 100% 100% PCP/ Specialists/ Urgent Care $35 PCP copay (3); all else Ded Deductible $55/$80/$100 3 visit limit then ded/coins Deductible $35/$60/$100 $25/$35/$50 $35/$60/$100 RX Deductible Deductible $20/75/50%/50% $1500 Rx ded Tier 2-4 Deductible $15/35/50/50% $1500 Rx ded Tiers 2-4 $5/10/15/35% $500 Rx ded Tiers 2-4 $5/10/15/35% $500 Rx ded Tiers 2-4 The above represents only a summary; please consult benefit summary for full details. Out of Network Deductible and Out of Network Out-of-Pocket are considerably higher than the in-network counterparts Off Marketplace plans have embedded Pediatric Dental always included. Coverage is 50% after deductible to OOP limit.

16 Summary of Benefits & Coverage Name of plan Type of plan Plan Benefits About the network 16

17 Summary of Benefits & Coverage Referral requirement? Plan Benefits Office Visits. 17

18 Summary of Benefits & Coverage Prescription Drug Categories and Benefits Plan Benefits Urgent Care. 18

19 Summary of Benefits & Coverage Plan Benefits All Other Categories. 19

20 Payment information 6350/

21 After Enrollment

22 Features of Humana One of the largest health plan providers in the country Many choices MyHumana at Humana.com MyHumana mobile app HumanaFirst Nurse Advice Line: Toll free, 24/7 Talk with a registered nurse Can help you decide which level of care is right for you: Urgent care, convenient care center or the emergency room 22

23 Tools and Resources for Navigators & Stakeholders Humana Dedicated Support Line for certified Navigators and Certified Application Counselors Dedicated Customer Service line for preenrollment questions for clients Coming soon Tip Sheets and Newsletter specific to Navigators and Certified Application Counselors 23