Individual Member Guide IDAHO 2018

Transcription

1 Individual Member Guide IDAHO 2018

2 Choosing a Plan That s Right for You We offer a variety of plan designs to fit your needs and budget. As you shop, it s important to understand how our plans are categorized. Follow these four steps to help you enroll on the plan that's right for you. Follow these four steps to find the perfect plan: FIND OUT IF YOU QUALIFY FOR A TAX CREDIT CHOOSE A PLAN GET TO KNOW YOUR NETWORK MAKE YOUR FIRST PAYMENT 1 FIND OUT IF YOU QUALIFY FOR A TAX CREDIT OR COST-SHARE REDUCTION ADVANCED PREMIUM TAX CREDIT ESTIMATOR If you qualify for a subsidy, the federal government will pay a portion of your monthly premium. Visit selecthealth.org/applyonline and enter some simple information, including family size and household income, to see if you qualify and get an estimate. COST-SHARE REDUCTION In addition to a tax credit, you may be eligible for costsharing reduction plans that lower the amount you pay out of pocket for s, coinsurance, and copays. Members of a federally recognized American Indian tribe may also qualify for additional cost-sharing benefits. 2 CHOOSE A PLAN We offer plans by metal tiers Bronze, Silver, or Gold. These levels are defined on healthcare.gov and indicate how much you ll spend on benefits. We also offer a Catastrophic plan. BRONZE The health plan pays 60% on average. You pay about 40%. EXPANDED BRONZE The health plan pays 65% on average. You pay about 35%. SILVER The health plan pays 70% on average. You pay about 30%. GOLD The health plan pays 80% on average. You pay about 20%. CATASTROPHIC: Catastrophic coverage plans pay less than 60% of the total average cost of care. TRADITIONAL PLANS Traditional plans are a popular choice for those who'd like a traditional or "classic" plan, including coverage for medical services, preventive care, and prescription drugs. Choose a and benefits that work for you. Some of these plans have a waiver or a limited waiver for Primary Care, Mental Health, and Specialty Care office visits. On these plans, the only applies for some or a limited number of office visits. SELECTHEALTH HEALTHSAVE Most HealthSave SM plans are designed to be paired with a Health Savings Account (HSA). With a HealthSave plan, you have more control over your healthcare dollars. Some HealthSave plans are cost-share reduction plans; however, not all cost-share reduction plans are eligible for an HSA. WHAT IS AN HSA? An HSA is similar to a personal savings account, with a few differences. For HSA-eligible individuals, money contributed to an HSA is tax-exempt and can be used for certain medical expenses (as defined by the IRS) such as s, copays, and coinsurance. Our preferred HSA vendor is HealthEquity. Please visit healthequity.com for more information about an HSA. CATASTROPHIC PLAN If you are younger than age 30, or if you qualify for a hardship exemption, you may consider purchasing a catastrophic health plan. These plans have lower premiums, higher s and out-of-pocket maximums, making them ideal for those who only want protection from very high medical costs. These plans are not eligible for a premium subsidy. 2 selecthealth.org selecthealth.org 3

3 Choosing a Network That s Right for You 4 MAKE YOUR FIRST PAYMENT Visit selecthealth.org/applyonline to use our convenient online application. The application must be completed and signed electronically. If you need help with your application, call Individual Sales at , or you can call your agent. You ll need to make your first month s payment before you will receive an ID card. ALL YOUR INFO IN ONE PLACE Once enrolled, you ll have access to My Health. Here you ll have important health and benefit information at your fingertips whenever and wherever you need it. We also provide a number of health resources, including LiVe Well tools, to help you achieve your wellness goals. Learn more about My Health on page 10. QUESTIONS? Call us. MEMBER SERVICES Our Member Services representatives are available six days a week to answer questions about your benefits and claims. To contact Member Services, call weekdays, from 7:00 a.m. to 8:00 p.m., and Saturdays, from 9:00 a.m. to 2:00 p.m. TTY users, please call GET TO KNOW YOUR NETWORK Our expansive network, which includes St. Luke s Health Partners and BrightPath, gives you access to the best hospitals, clinics, and doctors throughout the state. You will have access to more than 4,700 providers and healthcare professionals, and 65 hospitals, surgery centers, and skilled nursing facilities throughout the state of Idaho. Our plans also provide members with nonparticipating benefits in Idaho. However, the cost to see a nonparticipating provider is usually higher than what you pay for services from participating providers and hospitals. BONNER KOOTENAI BENEWAH LATAH NEZ PERCE LEWIS ADAMS SHOSHONE CLEARWATER IDAHO LEMHI BOUNDARY WASHINGTON VALLEY NEED HELP SHOPPING FOR A PLAN? We re happy to help you find the right plan. Call your agent, or contact our Individual Sales team at QUICK TIP PAYETTE CANYON GEM ADA BOISE ELMORE CAMAS GOODING CUSTER LINCOLN JEROME BLAINE MINIDOKA BUTTE POWER CLARK FREMONT JEFFERSON BINGHAM MADISON TETON BONNEVILLE CARIBOU OWYHEE TWIN FALLS CASSIA ONEIDA BANNOCK FRANKLIN BEAR LAKE 4 selecthealth.org selecthealth.org 5

4 Care Options Before scheduling an appointment, consider the following care options. They could save you money and a trip to the doctor! ST. LUKE'S NURSE LINE A phone call could save you money and an emergency room visit. Instead of relying on the internet for selfdiagnosis, pick up the phone and talk to a registered nurse any time. This 24/7 service is available through St. Luke s nurse line, which is staffed by registered nurses. It's free and can help you make sense of your symptoms and determine how and where to get the best care. To reach a nurse, call Free! URGENT CARE They re open late in some locations and are a great choice for sore throats, broken bones, sprains, headaches, stomachaches, earaches, and other urgent medical conditions. With locations throughout Idaho, there s a site near you. Visit stlukesonline.org or use our mobile app to find the closest facility. See your benefits on the next page for more information. EMERGENCY CARE In emergencies, you should call 911 or go to the nearest hospital. Though copays are the same at all emergency rooms, you will save money by visiting participating hospitals. To view participating facilities visit selecthealth.org/find-a-doctor. See your benefits on the next page for more information. OUTSIDE THE STATE OF IDAHO If you have an emergency or need urgent care outside of Idaho or Utah, participating benefits apply to services received in a doctor s office, urgent care facility, or emergency room. You may save money on out-of-area services by using Multiplan or PHCS providers and facilities. To find one, call or visit multiplan.com. See your benefits on the next page for more information. SELECTHEALTH MEMBER ADVOCATES SelectHealth Member Advocates can help you find a doctor or schedule an appointment. QUICK TIP Call weekdays, from 7:00 a.m. to 8:00 p.m., and Saturdays, from 9:00 a.m. to 2:00 p.m. 6 selecthealth.org selecthealth.org 7

5 Preauthorization is required for certain services. This chart is not a complete list of benefits. If you have questions, visit selecthealth.org or call Member Services at IDAHO PLAN Catastrophic SelectHealth HealthSave 2, 3 Standard Deductible Limited Office Visit Waiver 1 Office Visits No Deductible Catastrophic 7350 Bronze 6650 Bronze 6200 Expanded Bronze 3225 Silver 3000 Expanded Bronze 2600 Silver 2500 Bronze 6700 Expanded Bronze Copay Expanded Bronze 3850 Silver 3000 Silver Copay Gold 2000 Deductible Single $7,350 $6,650 $6,200 $3,225 $3,000 $2,600 $2,500 $6,700 $4,825 $3,850 $3,000 $4,000 $2,000 Family $14,700 $13,300 2 $12,400 2 $6,450 2 $6,000 2 $5,200 $5,000 $13,400 $9,650 $7,700 $6,000 $8,000 $4,000 Out-of-Pocket Max Single $7,350 $6,650 $6,650 $6,650 $6,650 $7,350 $7,350 $7,350 $7,350 $7,350 $7,350 $7,350 $6,000 Family $14,700 $13,300 3 $13,300 3 $13,300 3 $13,300 3 $14,700 $14,700 $14,700 $14,700 $14,700 $14,700 $14,700 $12,000 Primary Care Provider (PCP) $35 for first 3 PCP and/or mental health office visits, then covered $35 after $25 after $25 after $35 after $35 after $50 for first 4 visits, then $50 after $35 for first 4 visits, then $35 after $35 for first 4 visits, then $35 after $30 for first 4 visits, then $30 after $25 $25 Secondary Care Provider (SCP) Preventive Care and Immunizations Minor Diagnostic Tests 4 Inpatient Hospital Services Outpatient Services Emergency Room Rx Deductible Per Person Tier 1 Drugs Tier 2 Drugs Tier 3 Drugs Tier 4 Drugs $50 after $40 after $40 after $60 after $60 after $65 after $60 after $60 after $50 after $50 $40 Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% 30% after 30% after 30% after 30% after $600 after $400 after $400 after $500 after $500 after 4 4 $550 per day after (up to five days) 4 4 Covered 100% 4 Covered 100% 4 30% after 30% after $550 per day after (up to five days) Medical and Rx Combined $1,250 $1,250 $1,250 $2,500 $1,500 $1,250 $2,500 $500 $15 after $15 after $15 after $15 $15 $20 $25 $15 $15 $15 $15 30% after 25% after 25% after 50% after 50% after 50% after 50% after $600 after 30% after pharmacy $600 after $45 after pharmacy $55 after pharmacy $600 after $350 after pharmacy 30% after $600 after $45 after pharmacy $55 after pharmacy pharmacy 20% after 20% after $350 after 30% after pharmacy 1 The is waived for the first four in-network Primary Care Provider and/or Mental Health office visits combined per year. Each of these four visits is subject to a copay only. Starting with the fifth visit, the and copay will apply. 2 When two or more are enrolled on a HealthSave plan, only the family applies. 3 When two or more are enrolled, no single person in a family will pay more than the single out-of-pocket maximum. 4 Minor diagnostic testing covered at 100% with the office visit copay. Please note: The coverage and benefit details presented here do not include out-of-network cost-share details. Please refer to selecthealth.org for out-of-network cost-share information. DEFINITIONS DEDUCTIBLE An amount a member must pay to providers or facilities before the plan begins to pay for eligible charges. COINSURANCE An amount that is calculated as a percentage of the allowed amount for a service. For example, a member pays 30% and the plan pays 70%. COPAY A fixed amount that members must pay for covered services to providers or facilities. OUT-OF-POCKET MAXIMUM An amount a member will pay for services covered by the plan. Amounts paid toward the, coinsurance, and copays apply to the out-of-pocket maximum. PRESCRIPTION (Rx) DEDUCTIBLE A separate that only applies to prescription drug coverage. Members must pay this amount before their plan begins to pay for prescriptions. PRESCRIPTION (Rx) COPAY The fixed dollar amount members pay for certain tiers of drugs. 8 selecthealth.org selecthealth.org 9

6 PREVENTIVE CARE SELECTHEALTH ONLINE CHAT Regular wellness exams can help HEALTHY BEGINNINGS Get answers without picking up the you maintain optimal health. We Our prenatal care program provides phone. Chat is an easy way to ask provide educational information, emotional support and coaching for quick questions about your benefits, reminder calls, and mailings to expectant mothers from a team of such as: Discover the SelectHealth Experience help you schedule the appropriate exams, immunizations, and tests to detect and treat concerns early. Most preventive care is covered 100 percent. For more information about preventive care, visit selecthealth.org/stayhealthy. nurse care managers. In addition to pregnancy education materials and other over-the-phone screenings, the program includes high-risk care management when needed. > > How much of my has been met? > > Has SelectHealth received a claim from my doctor? > > Am I covered for a preventive visit? > > When is my original effective date? Is my plan still in effect? > > How do I order replacement ID cards? Make the most of your plan learn more about our member tools, programs, and discounts. > > Is my medication covered? If so, how? Visit selecthealth.org and log in to My Health. Click the SelectHealth link and scroll down you ll see a link to Chat with Us. We can t wait to MEDICAL COST ESTIMATOR SELECTHEALTH WEBSITE MY HEALTH hear from you! We make it easy to budget for Your health plan information is With My Health you'll have important medical costs: No phone calls, now even easier to access with our health and benefit information at codes, or math necessary. Here s how it works: 1. Log in to the SelectHealth section of My Health; choose Medical Cost Estimator. 2. Search by service, doctor, or hospital. 3. View a snapshot: You Pay, Plan Pays, Total Cost. 4. Break it down by provider cost, facility cost, labs, supplies, and more. Refine your search to include a geographic range or sort by cost. Try our most-requested member tool: Visit selecthealth.org and log redesigned SelectHealth website. Find plan documents, answers to frequently asked questions, doctors/ facilities, and more by visiting the all new selecthealth.org. your fingertips 24/7. We also provide a number of health resources, including online LiVe Well SM tools that can help you achieve your wellness goals. Log in to take your Health Assessment and start taking steps to improve your health. SELECTHEALTH MOBILE APP Log in to our mobile app to view benefits and claims or search for doctors and hospitals. Check yearto-date totals for s and out-of-pocket maximums; look up pharmacies and medications; and view, , or fax images of your ID card to your doctor. Available on Google Play and in the Apple App Store SM. SELECTHEALTH MEMBER ADVOCATES Whether you need help with behavioral or physical health, Member Advocates SM can help you find the right care for your needs. They can help you find the closest provider and even schedule an appointment. Call for help. MEMBER DISCOUNTS We know that embracing a healthy lifestyle is easier when it costs less. As a SelectHealth member, you will have access to discounts on everyday products and services that aren't generally covered by your plan. The process is simple no enrollment forms, fees, or payroll deductions just great savings when you mention you are a SelectHealth member and show your ID card. For more information, visit selecthealth.org/discounts. in to My Health to get started. 10 selecthealth.org selecthealth.org 11

7 Your Prescription Benefits All of our Individual medical plans include prescription drug benefits, with access to more than 45,000 pharmacies nationwide. PRESCRIPTION DRUGS Coverage is divided into four tiers (levels). Each drug is covered under a specific tier that corresponds to a copay or coinsurance amount this is the amount you pay. Drugs on lower tiers may provide the treatment you need at the best value. Tier 1 Lowest cost (mostly generic drugs) Tier 2 Higher cost (generic and brand-name drugs) Tier 3 Highest cost (mostly brand-name drugs) Tier 4 Highest cost (Injectable drugs and specialty medications) PRESCRIPTION DRUG LIST (PDL) Individual plans use our RxCore PDL. Search for your drug on our website (see Pharmacy) to find the tier and any special requirements. You will receive a copy of the PDL with your member materials, but the online drug lookup is the most complete, current PDL. SPECIAL REQUIREMENTS Some drugs require step therapy or preauthorization before they will be covered by your plan. Step Therapy If your drug requires step therapy, your doctor must first prescribe an alternative drug. These are generally more cost effective and do not compromise clinical quality. Step therapy may be waived for medical necessity. Preauthorization This means that your doctor must contact us for approval before your drug will be covered. 90-DAY MAINTENANCE DRUG BENEFIT The 90-day maintenance drug benefit allows you to obtain a 90-day supply of certain generic medications. It applies to drugs that you have been using for at least one month and expect to continue using for the next year. Your member responsibility (e.g., copay or coinsurance amounts) may be lower when you fill prescriptions using the 90-day benefit. There are two ways to fill a 90-day prescription: A local pharmacy that participates in our Retail90 program (search for Retail90 pharmacies online) or the Intermountain Home Delivery Pharmacy (intermountainrx.org). ONLINE TOOLS It s easy to view your family s prescription history or find out how much a drug will cost. Log in to My Health at selecthealth.org to access these useful pharmacy tools: > > Review drug coverage. Use the search tool to see what drugs are covered under your prescription drug list. You can use this feature even without a My Health account by going to the Pharmacy Benefits page under the Pharmacy tab at selecthealth.org. Your prescription drug coverage is listed by tier for both 30-day (retail) and 90-day (maintenance) prescriptions. > > View claims. When you fill a prescription, the drug name, date filled, and total cost will be listed here. > > Compare drug prices. Use our drug lookup to find out how much your prescription will cost and view lower-cost alternatives. This feature will also indicate if the drug has special requirements. > > Find a pharmacy. Search for a participating pharmacy by location. We are contracted with most major chains and many privately owned pharmacies. > > Check for drug interactions. Avoid the unwanted side effects or reduced effectiveness that can occur if two drugs you are taking interact with one another. 12 selecthealth.org selecthealth.org 13

8 General Medical Information OUR PLANS Our plans are designed to provide coverage for hospital, medical, preventive care, and surgical expenses incurred as a result of a covered accident or illness. Coverage is provided through participating providers for daily hospital room and board, miscellaneous hospital services, anesthesia services, in-hospital medical services, and out-of-hospital care. Coverage is subject to any, copay provisions, or other limitations that may be set forth in your Contract. ELIGIBILITY You and your dependents may apply for coverage if you are a resident of Idaho and not eligible for Medicare. Eligible dependents include the insured s legal spouse, children younger than age 26, eligible disabled children older than age 26, and children who are under courtordered legal guardianship until legal guardianship ends. See your Contract for more details on guardianship. TERMINATION Your coverage will not terminate (end) for health reasons. However, your coverage may end according to the terms of your contract, including any of these reasons: > > Nonpayment of premiums > > Fraud or intentional misrepresentation of material fact > > You no longer reside, live, or work in the service area If we do not receive a premium or we are unable to collect a premium, you will be notified. EXCLUDED SERVICES EXCESS CHARGES These are charges from providers and facilities that exceed the SelectHealth allowed amount for covered services. You are responsible to pay for excess charges from nonparticipating providers and facilities. These charges do not apply to your out-of-pocket maximum. NONCOVERED SERVICE IN CONJUNCTION WITH A COVERED SERVICE When a noncovered service is performed as part of the same operation or process as a covered service, only the covered service charges will be considered. Allowed amounts may be calculated and fairly divided to exclude any charges related to the noncovered service. APPEALS/ UTILIZATION MANAGEMENT (UM) For information about what requires preauthorization, our care management programs, or how to file an appeal, see your member materials or visit our Member Resources page selecthealth.org/policy. SelectHealth complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a SelectHealth: (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 SelectHealth: (TTY: 711). Certain services are not covered by your plan. For a list of excluded services, see your member materials or visit selecthealth.org/exclusions. 14 selecthealth.org selecthealth.org 15

9 We re committed to helping you stay healthy by providing access to high-quality healthcare at an affordable cost, giving superior service, and offering the tools you need to make smart decisions. For more information about our health plan options for individuals, contact our Individual Sales department at It all starts with one good choice SelectHealth. All rights reserved /17