Effective April 1, Your Guide. to Choosing a LifeWise Health Plan

Transcription

1 Effective April 1, 2012 Your Guide to Choosing a LifeWise Health Plan

2 Part Live of smart! your plan Here s why you ll like us... Our plans focus on wellness, prevention, choice and value. We re dedicated to service excellence. Our customer service and sales representatives are ready to help. Our extensive provider network gives you easy access to thousands of healthcare providers and facilities in Oregon and nationwide. We provide powerful, simpleto-use online tools to manage your coverage and protect your health. You take responsibility for your health and you expect real value. LifeWise Health Plan of Oregon delivers. We re here with service and support that works for you.

3 Important With LifeWise Health Plan of Oregon questions to consider Important questions to consider Our plans are flexible enough to fit your needs and your budget. Plus, they offer the best way to protect your health. Here are some important things to think about as you look over the information on these pages: How much coverage do I need? Do you need just a few office visits per year or more? Do you need prescription coverage? Or are you willing to pay for the few prescriptions you might need on your own? Our easy to review charts on pages 4-7 will help you find the plan that offers the coverage for services you use the most. What cost options work best for me? Want to lower your out-of-pocket cost when you need care? Look at our low deductible plans. Looking to keep your monthly rate low and are willing to pay more out-of-pocket when you need care? Consider a higher deductible plan. What monthly rate works for you? See the enclosed Monthly Rates brochure. Close to making a choice but need a little more information? You ll find more details about our plans at lifewiseor.com including a Supplemental Guide that shares information about: Privacy Policies Provider Organization Key Utilization Management Procedures Pharmaceutical Management Procedures You can also contact your producer or give us a call toll free at lifewiseor.com

4 Staying healthy Extensive coverage for preventive office visits and screenings* Preventive medical screenings are one of the best ways to help you and your family stay healthy. These important screenings help your doctors detect diseases early when they are easiest to treat. All LifeWise plans offer comprehensive preventive care coverage and you ll pay the least out-ofpocket when you visit an in-network provider. However, you can see a non-preferred provider, but your cost will be higher. The list below shows the most common preventive care services we cover when you meet the frequency, age, risk, and gender guidelines. Covered Immunizations Hepatitis A and B Rotavirus Herpes Shingles HPV Measles, Mumps and Rubella Flu Meningococcal and Pneumococcal Chicken Pox Tetanus, Diptheria, Pertussis Polio Preventive Exams Sports physicals Women s and men's health exams Routine physicals Well baby exams Covered Preventive Screenings Osteoporosis: Bone density screening Breast Cancer: Mammogram Colorectal Cancer: Colonoscopy or sigmoidoscopy Diabetes: Glucose test High Blood Pressure, Hypertension, Heart Disease, or Cholesterol: Lipid panel, lipoprotein, or cholesterol screening Prostate Cancer: PSA Blood Test Anemia: Hemoglobin (iron) test Cervical Cancer: PAP Smear Infectious and Sexually Transmitted Diseases: Antibody or antigen screening You ll also have access to: Online tools Go to our secure website to help you assess, manage and improve your health. Tools include a health assessment, treatment cost estimator, claims status, your plan benefits, symptom checker and more. Nationwide network coverage The LifeWise network includes thousands of physicians, naturopaths, specialists and facilities in Oregon so you have a choice when it comes to your medical care. You re also covered when you travel nationwide by visiting a preferred provider with our partner network, PHCS/MultiPlan. Visit lifewiseor.com and select "Find a Doctor" for more information. 24-Hour NurseLine The Nurseline is staffed by registered nurses who can answer questions about symptoms and conditions. They'll also give you home treatment suggestions and helpful advice about where to get care. Alternative care Our plans cover acupuncture and chiropractic alternative care services. Health support and disease management LifeWise supports your health and helps you get the most from your healthcare providers. We offer a variety of information and services including personalized support from an outreach nurse when you re faced with complex care needs. 24-hour coverage On and off the job, you'll have 24-hour coverage for all enrolled family members. This includes coverage for occupational conditions not covered by workers compensation or other industrial insurance provided by your employer. Member discounts Save money with special discount offers on health products and services. Visit lifewiseor.com/discounts. * A full list of preventive screenings, tests and other preventive services, is available on lifewiseor.com. 2

5 Review your plan options What do you expect from your health plan? WiseOptimum Plan Offers the widest range of covered benefits. This benefitrich plan gives you up-front coverage for your first four visits to a primary care provider at the lowest copay. Plus, you get coverage for unlimited visits to specialists at copay. This plan also covers brand-name and generic drugs, vision, maternity and has a supplemental accident benefit. A nice option if you re looking to cover all your bases. WiseValue Plus Plan Offers great essential coverage. A good choice if you want a low rate and more up-front coverage for routine care. This plan covers your first three office visits at copay only, and it covers generic prescriptions and has a supplemental accident benefit. WiseValue Plus Rx Plan Provides more coverage for the services you use the most. A nice choice with a low rate and up-front coverage for your first four visits to a primary care provider at copay. Plus, it covers four visits to specialists at copay. This plan also has a supplemental accident benefit and covers brand-name and generic drugs. WiseHSA Plan Offers great essential coverage and the chance to save money pre-tax for future healthcare expenses. This plan covers office visits, prescriptions, and most other common services at deductible then coinsurance. lifewiseor.com

6 Choose the best plan for you PCY = Per Calendar Year Calendar year maximum = $2 million Annual Deductible PCY (choose one) (Family is 3x the individual deductible) WiseOptimum Plan Preferred Providers Non-Preferred Providers $1,000 / $2,500 / $5,000 2x individual deductible Coinsurance 1 (what you pay) 20% 50% Annual Coinsurance Maximum (family = 2x individual) 2 $3,000 $6,000 Preventive Care Exams (routine medical exam, sports physical and women s health exams/well baby) Preventive Screenings 4 (includes mammograms, colonoscopies, PAP & PSA screenings) Covered in full 3 Immunizations (includes HPV vaccine) Office Visit including Urgent Care and Naturopathy (with general physician, pediatrician, internist, nurse practitioner, gynecologist, obstetrician, and naturopath) Office Visit with Specialist (those not listed above) DEDUCTIBLE WAIVED, you pay $10 on first 4 visits PCY; additional visits subject to deductible, then 20% DEDUCTIBLE WAIVED, you pay $75 (unlimited visits) Other Outpatient and Inpatient Professional Services Deductible, then 20% Supplemental Accident Benefit (Services must be received within 90 days of the injury) Deductible waived, you pay 20% (unlimited) Chiropractic & Acupuncture 12 visits each PCY DEDUCTIBLE WAIVED, $30 Copay Outpatient Diagnostic Imaging and Lab Services Deductible, then 20% Pharmacy Retail: 30-day supply Mail Order: 90-day supply Select Drug List 5 (applies to WiseOptimum and WiseValue Plus Rx) Emergency Room Care (copay waived if direct admit to an inpatient facility) Ambulance Transportation Air (unlimited); Ground ($5,000 PCY limit) Inpatient and Outpatient Facility Care Skilled Nursing Facility 45 days PCY; includes room and board, ancillaries and professional fees Maternity Care (includes professional and facility care) Vision Care Hearing Hardware $5,000 in a consecutive 48-month period; age limits apply Generics/Brand Retail: $15/50% Mail Order: $45/50% Preventive generic drugs: Covered in full Not covered $100 Copay, then subject to preferred provider deductible, then 20% Preferred provider deductible, then 20% Deductible, then 20% Deductible, then 20% Routine Vision Exam: DEDUCTIBLE WAIVED, $30 Copay. (1 exam PCY) $50 for frames, lenses, and contact lenses per 2 calendar years Preferred provider deductible, then 20% Home Medical Equipment and Supplies Home Health Care 130 visits PCY Hospice Care Inpatient: 10 days, Outpatient Respite: 240 hours per 6 months lifetime maximum Rehabilitation (Includes Physical, Occupational & Speech Therapy, Cardiac & Pulmonary Rehab; & Chronic Pain) Outpatient: 20 visits PCY; Inpatient: 8 days PCY) Transplants (Organ & Bone Marrow) 24-month waiting period; Donor and travel limits apply Deductible, then 20% 1 A member s cost for covered services after deductible 2 Does not include deductible. 3 Benefits provided at 100% of maximum allowable amount. This is not subject to deductible or coinsurance. 4 A full list of preventive screenings, tests and other preventive services, is available on lifewiseor. com. These preventive services are covered in full if you use preferred providers and meet the frequency, age, risk and gender guidelines outlined in the list. 4

7 To review a complete list of covered plan benefits, visit lifewiseor.com/healthplans. Deductible, coinsurance and copay represent what you pay. All covered services are based on maximum allowable amounts. Benefits apply after you meet your calendar year deductible, unless you see deductible waived, copay, or covered in full. WiseValue Plus WiseValue Plus Rx Preferred Providers Non-Preferred Providers Preferred Providers Non-Preferred Providers $2,500 / $5,000 2x Individual Deductible $1,000 / $2,500 / $5,000 / $7,500 / $10,000 2x Individual Deductible 35% 50% 30% 50% $5,000 $10,000 $5,000 $10,000 Covered in Full 3 Covered in Full 3 DEDUCTIBLE WAIVED, you pay $35 on first 3 visits PCY; additional visits subject to deductible, then 35% DEDUCTIBLE WAIVED, you pay $20 on first 4 visits PCY; additional visits subject to deductible, then 30% DEDUCTIBLE WAIVED, you pay $75 on first 4 visits PCY; additional visits subject to deductible, then 30% Deductible, then 35% Deductible, then 30% Deductible waived, you pay 35% ($15,000 PCY limit) Deductible waived, you pay 30% ($15,000 PCY limit) DEDUCTIBLE WAIVED, $35 copay DEDUCTIBLE WAIVED, $30 copay Basic Imaging/Lab Services: Deductible, then 35%; Complex Imaging (PET, CT, MRA, & MRI): Deductible, Basic Imaging/Lab Services: Deductible, then 30%; Complex Imaging (PET, CT, MRA, & MRI): Deductible, Generics: Deductible waived, you pay 50% Brand: Not covered Not covered Generics: DEDUCTIBLE WAIVED, you pay 50% Brand: $100 Not covered $100 Copay, then subject to preferred provider deductible, then 35% $100 Copay, then subject to preferred provider deductible,then 30% Preferred provider deductible, then 35% Preferred provider deductible, then 30% Deductible, then 35% Deductible, then 30% Deductible, then 35% Deductible, then 30% Routine Vision Exam: DEDUCTIBLE WAIVED, $35 copay (1 exam PCY) Routine Vision Exam: DEDUCTIBLE WAIVED, $30 copay (1 exam PCY) Preferred provider deductible, then 35% Preferred provider deductible, then 30% Deductible, then 35% Deductible, then 30% 5 Medicines with many over-the-counter (OTC) alternatives and brand name drugs with generic options are not on the Select Drug List. These medicines are not covered. Examples include cough and cold, antihistamines & heartburn/acid reflux medicines. This is only a summary of the major benefits provided by our plans. This is not a contract. See pages 6-7 for Health Savings Account (HSA)-qualified plans lifewiseor.com

8 Get the tax advantage with a The WiseHSA health plan What is a Health Savings Account (HSA)? A HSA is an individually-owned bank account that you set up, manage and fund. It lets you set aside funds to pay for your healthcare on a tax-advantaged basis and works in conjunction with HSA-qualified health plans. Before you can open an HSA bank account, you must first be covered by a qualified high-deductible health plan. What are the benefits of a HSA? With your HSA bank account, you put money in and take it out, just like you would with a regular savings account. The difference is the money may be tax-free if you use it to cover qualified medical expenses. Your HSA can provide a triple tax advantage because: Contributions are made on a tax-advantaged basis Money can be withdrawn tax-free when you use it to pay for qualified medical expenses. Unused funds rollover from year to year and grow tax-deferred. A HSA offers interest and investment options. Once you meet the minimum balance you can invest in mutual fund families. And you can save up your HSA funds for certain future healthcare expenses, including those in retirement. We offer integrated banking through UMB Bank n.a., a member of the FDIC. Founded in 1913 and an industry leader in financial healthcare accounts since 1997, UMB Bank is one of the largest independent banks in America. Your account offers: no monthly service fees a healthcare payment (debit) card 24-7 online access, giving you the added convenience to track and manage your qualified healthcare expenses. More than a medical plan it s a financial plan, too The WiseHSA health plan might be the right fit if you want to: Save and invest for future healthcare expenses Decrease the amount of taxes you pay. How to enroll 1 2 Apply for the WiseHSA health plan Enroll in the WiseHSA plan described on the next page. Open a HSA bank account LifeWise has established a relationship with UMB Bank, n.a. to give you an integrated banking experience. To open your account, visit lifewiseor.com to download the short authorization form. You can also call us at or contact your producer. 3 Start contributing to your HSA account Watch your money grow year-to-year. You can manage your HSA online by visiting lifewiseor.com and logging in. This material is not intended to provide tax or legal advice. Individuals and families should consult with their own legal and tax advisors before taking action. For more detailed information on HSAs, refer to IRS Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans, by visiting the IRS Web site. You can also use other qualified banks, such as HSA Bank. 6 Find a complete list of covered plan benefits at lifewiseor.com/healthplans.

9 WiseHSA health plan Quality healthcare coverage and the opportunity to save money on a pre-tax basis for future qualified medical expenses. Make your money work for you with an HSA-qualified heath plan. Deductible, coinsurance and copay represent what you pay. All covered services are based on maximum allowable amounts. Benefits apply after you meet your calendar year deductible, unless you see deductible waived, copay, or covered in full. PCY = Per Calendar Year Calendar year maximum = $2 million Annual Deductible PCY (choose one) preferred and non-preferred share a deductible HSA-Qualified Health Plans Preferred Providers Non-Preferred Providers $3,000 Individual $5,950 Individual $3,000 Individual $5,950 Individual $6,000 Family 1 $11,900 Family 1 $6,000 Family 1 $11,900 Family 1 Coinsurance 2 (what you pay) 50% 0% 50% Annual Coinsurance Maximum 3 Preventive Care Exams (routine medical exam, sports physical and women s health exams/well baby) Preventive Screenings (includes mammograms, colonoscopies, PAP & PSA screenings) 5 Immunizations (includes HPV vaccine) Office Visit including Urgent Care, Specialists and Naturopathy Other Outpatient and Inpatient Professional Services Chiropractic & Acupuncture 12 visits each PCY Retail: 30-day supply Mail Order: 90-day supply Preventive generic drugs: Covered in full $2,000 Individual $4,000 Family $0 $4,000 Individual $8,000 Family $11,900 Individual $23,800 Family Covered in full 4 Covered in full 4 Deductible, Deductible, Deductible, then covered in full Deductible, then covered in full Outpatient Diagnostic Imaging and Lab Services Deductible, then covered in full Pharmacy Generics: Generics & Brand: Deductible, then Deductible, covered in full Not covered Emergency Room Care Ambulance Transportation Air (unlimited); Ground ($5,000 PCY limit) Inpatient and Outpatient Facility Care Skilled Nursing Facility 45 days PCY; includes room and board, ancillaries and professional fees Maternity Care (includes professional and facility care) Select Drug List 6 Deductible, Deductible, Brand: Not covered Deductible, then covered in full Deductible, then covered in full Preferred provider deductible, then preferred provider coinsurance Deductible, then covered in full Routine Vision Exam 1 exam PCY Deductible, then covered in full Hearing Hardware $5,000 in a consecutive 48-month period; age limits apply Home Medical Equipment and Supplies Home Health Care 130 visits PCY Hospice Care Inpatient:10 days, Outpatient Respite: 240 hours per 6 months lifetime maximum Rehabilitation (Includes Physical, Occupational & Speech Therapy, Cardiac & Pulmonary Rehab; & Chronic Pain) Outpatient: 20 visits PCY; Inpatient: 8 days PCY) Transplants (Organ & Bone Marrow) 24-month waiting period; Donor and travel limits apply Deductible, Preferred provider deductible, then preferred provider coinsurance Preferred provider deductible, then preferred provider coinsurance Deductible, then covered in full 1 Family equals individual plus one or more family members. Services for all family members covered under the same HSA-qualified plan are applied to the same deductible. The family deductible must be met before services are covered for any enrolled family members. 2 A member s cost for covered services after deductible 3 Does not include deductible 4 Benefits provided at 100% of maximum allowable amounts. This is not subject to deductible or coinsurance 5 A full list of preventive screenings, tests and other preventive services, is available on lifewiseor.com. You can receive these preventive services covered in full if you use preferred providers and are within the frequency, age, risk and gender guidelines outlined in the list. 6 Medicines with many over-the-counter (OTC) alternatives and brand name drugs with generic options are not on the Select Drug List. These medicines are not covered. Examples include cough and cold, antihistamines & heartburn/acid reflux medicines. lifewiseor.com

10 Enroll today! How to become a LifeWise member 1 Apply online at lifewiseor.com Get a quote, fill out your application and submit it electronically on our secure site. Prompts will guide you through the easy step-by-step process. 2 Apply by mail Fill out, sign and date your LifeWise enrollment application, then send it to us in the pre-addressed envelope provided. 3 Talk to a producer Find out more about which LifeWise health plan is right for you. Your producer can also help you submit an online application. As a LifeWise member You get access to our secure Web site where you can: Order new ID cards, check claims status, see your benefits and estimate treatment costs Choose your monthly payment option including automatic funds transfer, credit card or debit card. Visit lifewiseor.com for more details. Are you eligible? You must be a resident of the state of Oregon and not eligible for Medicare to apply. To review additional eligibility requirements, please refer to the application. Helpful definitions Balance billing Additional charges you may have to pay if you use a non-preferred provider. Benefit The portion of services your health plan pays for. Coinsurance Your share of the cost for a service once your deductible is met. If your plan s coinsurance share is 20%, you pay 20% of the maximum allowable amount and your plan pays the other 80% of the maximum allowable amount. Coinsurance maximum A preset limit. After you meet this limit, your plan will pay 100% of the maximum allowable amount. Copay A flat amount you pay for a specific service, like an office visit, at the time of service. Copays don t apply towards a deductible or coinsurance maximum. Covered in full Services your plan pays for in full. Benefits provided at 100% of the maximum allowable amount; not subject to deductible or coinsurance. Deductible The amount of money you pay every year before your plan will pay for certain services. Maximum allowable amount The most LifeWise will pay for a covered service. Network A group of doctors, hospitals and other healthcare providers that have been contracted to provide services and supplies at negotiated amounts called maximum allowable amounts. Preferred provider A physician, healthcare specialist, or medical facility that belongs to the LifeWise network. 8

11 General exclusions and limitations Some services may require prior authorization. Certain services must be prior authorized in writing before you receive care. If you do not request prior authorization when required, you will be subject to a penalty of 50% of the maximum allowable amount, up to a maximum of $500 per occurrence. Additionally, benefit plans typically have exclusions and limitations what the plans do not cover. The following are general exclusions and limitations for the LifeWise benefit plans. For a complete list of exclusions and limitations, please visit lifewiseor.com. What is not covered? Benefits are not provided for services, treatment, surgery, drugs or supplies for any of the following: Alcohol dependency treatment services (unless optional alcohol endorsement is purchased) Allergy and testing injections (on WiseValue Plus and WiseValue Plus Rx plan only) Biofeedback Chemical (drug addiction) dependency Conditions arising from acts of war or service in the military Cosmetic or reconstructive services, except as specifically provided in the contract Dental services (except when covered under a supplemental accident benefit) Experimental or investigative services Infertility Mental health Obesity/morbid obesity, including surgery, drugs, foods and exercise programs. Orthognathic surgery (unless it meets medical criteria and as required by ORS 743a.148) Out-of-network drug coverage Over-the-counter or non-prescription drugs Services determined not to be medically necessary Services in excess of specified benefit maximums Services payable by other types of insurance coverage Services received when you are not covered by this plan Sexual dysfunction Sterilization reversal Treatment for work-related conditions for which benefits are provided by Workers Compensation or similar coverage Treatment of temporomandibular joint (TMJ) disorder Vision hardware (except for WiseOptimum plan) Charges over the maximum allowable amount Waiting periods Pre-existing Condition LifeWise individual health benefit plans have a six-month waiting period for conditions you already have. That means we don t cover any conditions you already have in the first six months after your coverage begins. A pre-existing condition is any medical condition that you received advice, a diagnosis, care or treatment was recommended or received within six months prior to enrolling in the plan and the date your coverage started. These waiting periods are waived for children under age 19. Organ Transplant Benefit Exclusion Period A benefit exclusion period is a time when the plan does not cover certain treatment or services. LifeWise individual health benefit plans have a 24-month benefit exclusion period for organ transplant services. This period begins on the date your coverage starts. Creditable Coverage If you had healthcare coverage that ended less than 63 days before you enrolled in a LifeWise plan, it is creditable coverage. LifeWise will reduce your waiting periods by the amount of creditable coverage you have. Creditable coverage includes: Any group healthcare coverage (including the Federal Employees Health Benefits Plan and the Peace Corps) Individual healthcare coverage (including student healthcare coverage) Medicare or Medicaid TRICARE Indian Health Service or tribal organization coverage State high-risk pool coverage A public health plan as defined in 42 U.S.C. 300gg, as amended and in effect on July 1, You may be responsible for charges that exceed the maximum allowable amount for covered services provided by non-preferred providers. lifewiseor.com

12 Start enjoying the LifeWise advantage! Talk to your producer about the plan that s right for you. Or call us directly at: (TDD for the hearing-impaired) lifewiseor.com Please note that this brochure is not a contract, nor is it a complete explanation of plan benefits or exclusions and limitations for LifeWise Health Plan of Oregon plans. The complete terms of coverage are determined by the contract. LWOR IP.MBR ( ) LifeWise Health Plan of Oregon ( )