WPS HealthyChoices Group Guide. Effective January 1, Be Happy. Live Healthy.

Transcription

1 WPS HealthyChoices Group Guide Effective January 1, 2015 Be Happy. Live Healthy.

2 Table of Contents: Introduction 2 Choose 4 Save 5 Control 6 Covered Benefits 7 2

3 With high-quality coverage, affordable plan designs, and the ability to offer your employees a wide range of benefit and network choices, you have all the tools you need to create a customized health plan that strikes the right balance between cost and coverage. As a business owner, you know that healthy and happy employees are key to your company s success. With WPS HealthyChoices, you no longer have to choose between a healthy workforce and a healthy bottom line. Now you can afford to offer health benefits that will attract and retain employees, boost productivity, and maintain morale all while protecting your employees health and your company s, too. Choose Your Coverage Options We make it easy for you to choose with this handy guide. Start by choosing either a traditional copay plan or a lower-premium HSA-qualified plan tied to a health savings account that your employees own and control. From there, see the savings you get with our engaging wellness programs, extraordinary network flexibility, and pharmacy benefits. Then check out our optional dental coverage and non-medical benefits. Let s get started! Call us today! For more information and a quote, contact your local authorized WPS agent or call to reach one of our regional sales offices. Visit us online at 3

4 YOU CHOOSE: WPS HealthyChoices PPO Plans Let WPS help you protect your employees health and your bottom line with flexible and affordable plans that are good for everyone. HealthyChoices Reduce your employees out-of-pocket costs with comprehensive, customizable protection. Choose from a wide range of deductibles, coinsurance, and copay options that meet your employees needs and protect your bottom line. This traditional plan features coverage for a broad array of medical services, including first-dollar coverage for preventive services such as annual exams, lab tests, and screenings. Our prescription drug benefit offers tiered copayments to maximize cost efficiency and value. HealthyChoices HSA Developed in response to employer concerns about rising health care costs, this consumerdriven health plan features lower premiums and is health savings account (HSA) qualified, empowering employees to budget and pay for qualified medical expenses using tax-free dollars. The employee-owned and employeecontrolled funds can be rolled over from year to year and the account moves with the employees, increasing their sense of security. Network Coverage A range of focused, regional networks coupled with comprehensive statewide and national networks, empowers employees to choose the network coverage that s right for them at a price that s right for you. How it works: 1. WPS works closely with integrated care systems to establish focused, regional PPO networks that give your employees access to the full spectrum of health care services at reduced fees. 2. You offer an affordable regional network as the base option of your health plan(s). 3. Your employees may choose this base network or, if they prefer, they can buy up to the increased choice and flexibility of our Statewide Network. Because all WPS HealthyChoices plans are preferredprovider organization (PPO) plans, your employees have access to the best physicians and health care facilities, both in-network and out. No need to select a primary care physician and no referral necessary to see a specialist! Regional Networks (Base Option) Strikes a health balance between choice and cost, permitting broad access while encouraging the use of preferred providers. Statewide Network (Available at increased employee cost) Offers employees the broadest access to providers throughout Wisconsin. National Network (Included with Statewide network and some regional networks) Gives your out-of-state employees access to thousands of hospitals and clinics with our National Network wrap. 4

5 YOU SAVE: No matter which WPS HealthyChoices plan you choose, you and your employees will enjoy generous benefits that include: Wisconsin-based service. When you call WPS, you talk to highly trained professionals who live and work right here in Wisconsin not in another country. We promise to resolve your questions quickly, with a friendly professionalism that reflects our Midwestern values. 100% coverage for in-network preventive care. Promote employee health with first-dollar coverage for common services such as annual exams, well-child visits, screenings, and immunizations. PPO convenience. Unlike an HMO, our plans don t require referrals to see a specialist, and your employees won t have to choose a primary care physician. Wellness programs. Now you have the tools to control long-term cost trends by encouraging healthy lifestyles. We offer select groups optional on-site health risk appraisals, biometric screenings, telephonic wellness coaching focused on smokingcessation, weight loss, stress reduction, and more. Online health resources. Take advantage of our online Health Center and planning guides. Educational articles, self-help tools, and a comprehensive health encyclopedia to empower employees to make better health decisions. Pharmacy benefits. WPS partners with a leading pharmacy benefits manager and home delivery pharmacy. Our customers enjoy lower drug costs than the national average, while clinical pharmacy programs help improve patient outcomes and reduce the incidence of adverse drug events. We help you save by automatically substituting lower-cost generic alternatives for more costly brand-name drugs, and by carefully monitoring the delivery of specialty medications. Our home delivery program helps members save time and money when ordering and managing prescriptions. Online pharmacy tools enable members to research drug information and discover ways to save. Telehealth This great new benefit provides you with highquality, safe, cost-effective, and convenient access to doctors straight from your phone or tablet. Telehealth uses technology to reduce costs and improve access to doctors and prescription drugs without the wait. $0 copay preventive drugs WPS provides $0 copay preventive drugs that target common conditions, such as high blood pressure, cholesterol, heart conditions, and asthma. These inexpensive drugs go above and beyond preventive care-specific drugs outlined by the ACA. You get great savings no matter which plan you choose! Those savings are passed along to your employees, without compromising on quality. 5

6 YOU CONTROL: To round out your group health plan, you can select additional, optional coverage. Optional Dental Coverage. WPS partners with Delta Dental of Wisconsin the largest dental benefits provider in the state, featuring more than 90% of Wisconsin dental practitioners 1 to offer you a full complement of group dental products. When you combine Delta Dental benefits with your WPS health plan, we make life simpler by sending you a convenient, single health and dental bill. 1 Delta Dental, Optional Non-Medical Benefits. The EPIC Life Insurance Company, a WPS subsidiary, has been a leading provider of non-medical group benefits for more than 25 years, offering term life, Rapid Pay Income ReplacementSM (short-term disability), longterm disability, vision, and voluntary benefits all backed by superior personalized service. EPIC s non-medical plans are designed to be flexible, fit easily into your employees budgets, and offer an easy solution for enhancing employee benefits packages. Valuable premium discounts are applied when you combine EPIC non-medical benefits with WPS health plans. Ask your EPIC representative for details. 6

7 CONGRATULATIONS! You re well on your way to great coverage with a WPS HealthyChoices plan. With your choice of plan designs, built-in savings from our benefits, and optional, additional coverage you control, you get a healthy return on your investment. But that s not all! In addition, all group plans include essential, covered health benefits, including: Ambulatory patient services (outpatient care without being admitted to the hospital) Emergency care Hospitalization Maternity and newborn care Mental health and substance abuse disorder (including counseling and psychotherapy) Prescription drugs Laboratory services Preventive care, wellness services, and chronic disease management Pediatric services Give us a call today for more information! Contact your local, authorized WPS agent or call to reach one of our regional sales offices. Visit us online at 7

8 WPS Health Plans Are Good for Business. Ethics and integrity aren t words people typically associate with health insurance companies. But at WPS, they form the core of our values. Based right here in Wisconsin, WPS has protected the health and financial security of businesses and individuals for more than 65 years. A not-for-profit company, we make decisions based on what s right for our members not for stock analysts or shareholders. To our great honor, we are the only health insurance company in the world to be named one of the World s Most Ethical Companies for five consecutive years. 1 As Wisconsin s trusted health plan partner with a long history of serving businesses, we understand that finding the right health insurance can be challenging. We re here to make it easier with flexible plans, straightforward options, and coverage you can count on. How can we help you today? World s Most Ethical Companies Ranking, Ethisphere Institute, Wisconsin Physician s Service Insurance Corporation. All rights reserved

9 WPS Group PPO Plan Summary A traditional PPO plan for groups, featuring in- and out-of-network benefits and a wide range of plan design options. To request a quote, please see an agent, visit the WPS website at or have one of our licensed health insurance agents find the solution for you and your employees by calling Routine care covered, with no calendar year maximum Dependent children: to age 26 (see policy for eligibility requirements) Plan Options In-Network Options Metal Tier Individual Deductible 1 Coinsurance 2 Out-of-Pocket Limit Convenient Care Clinic or Telehealth Visit PCP Visit Specialist Visit ER Visit Free PCP Visit Prescription Plan Preventive/Generic/Preferred Brand/ Brand/Specialty Platinum % 1, $0/$10/$35/$60/25% to $500 Platinum % 1, $0/$10/$35/$60/25% to $500 Platinum 0 90% 6,600 D/C D/C D/C D/C 3 $0/$10/$35/$60/25% to $500 Gold 1,000 80% 2, $0/$15/$40/$65/25% to $500 Gold 1,000 80% 4, $0/$15/$40/$65/25% to $500 Gold 1,500 90% 2, $0/$15/$40/$65/25% to $500 Gold 2, % 3, $0/$15/$40/$65/25% to $500 Gold 1,000 90% 2,500 D/C D/C D/C D/C 3 $0/$15/$40/$65/25% to $500 Gold 1, % 2,500 D/C D/C D/C D/C 3 $0/$15/$40/$65/25% to $500 Silver 2,000 80% 6, $0/$20/$50/$75/25% to $500 Silver 2,500 80% 5, $0/$20/$50/$75/25% to $500 Silver 3,000 90% 6, $0/$20/$50/$75/25% to $500 Silver 3,000 70% 6, $0/$20/$50/$75/25% to $500 Silver 4, % 6, $0/$20/$50/$75/25% to $500 Silver 4,000 70% 6, $0/$20/$50/$75/25% to $500 Silver 2,000 80% 6,600 D/C D/C D/C D/C 3 $0/$20/$50/$75/25% to $500 Bronze 4,500 70% 6,600 D/C D/C D/C D/C 3 $0 Preventive, D/C all others Bronze 5,000 80% 6,600 D/C D/C D/C D/C 3 $0 Preventive, D/C all others Bronze 6, % 6,600 D/C D/C D/C D/C 3 $0 Preventive, D/C all others D/C = Deductible and Coinsurance PCP = Primary Care Physician 1 Family deductible is 2x the individual. Family deductible is 2x the individual. Out-of-Network deductible is 2x the applicable In-Network deductible, except for the $0 deductible plan. (See below) The platinum plan with $0 In-Network deductible has a $1,000 Out-of-Network individual deductible and a $2,000 Out-of-Network family deductible 2 Out-of-network coinsurance is 20 percentage points lower than in-network. For example, if you choose a plan with 100% in-network coinsurance, your out-of-network coinsurance is 80% (100-20=80). Convenient Care Clinic: a medical clinic that is located in a retail store, supermarket or pharmacy. The convenient care clinic must provide covered health care services by: (1) nurse practitioners; (2) physician assistants; or (3) physicians. They must provide those services within the scope of their respective licenses. Primary Care Physician: non-specialized physicians whose primary practice is one of the following: Family Practice, Internal Medicine, General Practice, Obstetrics/Gynecology and Pediatrics. Specialty Physician: any physician whose primary practice is other than one of the following: Family Practice, Internal Medicine, General Practice, Obstetrics/ Gynecology and Pediatrics. Telehealth: the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using the Internet, interactive audio, video, or data communications, to include all types of telephonic communication and electronic mail. All services are subject to terms and conditions of the policy. Certain drug limitations may apply, please review the full policy. Please see plan policy for a complete list of exclusions and other covered services

10 Common Medical Event If you visit a health care provider's office or clinic If you have a test If you need drugs to treat your illness If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Primary care office visit Specialist office visit Other practitioner office visit Your cost if you use a Non-Preferred Preferred Provider Provider Copay or Copay or Copay or Limitations & Exclusions If you have a copay plan, for preferred providers, you pay a $10 copay/visit to a convenient care clinic or for a telehealth visit None If you have a copay plan, for preferred providers, you pay a $10 copay/visit to a convenient care clinic or for a telehealth visit Preventive care/screening $0 None Immunizations $0 $0 Immunizations for travel are not covered Diagnostic test (x-ray/blood work) in an office or outpatient department of a hospital Imaging (CT/PET scans, MRI s) Coinsurance; If no copay: Deductible/ Coinsurance Coinsurance; If no copay: Deductible/ Coinsurance None Prior approval is required for PET scans Preventive drugs $0 None Generic drugs 30- day supply limit for retail and all specialty drugs; Preferred brand-name drugs home delivery 90-day supply for 2.5X retail copay; Copay or Preferred Provider Deductible & Coinsurance drugs may require pre-authorization; several drugs Brand name drugs to treat common illnesses will be available at no cost Specialty drugs to you Outpatient hospital - facility and physician/surgeon fees None Emergency room services Copay or Preferred Provider None Related emergency room services Emergency medical transportation Inpatient hospital -Facility and physician/surgeon fees Mental health/substance abuse outpatient office visits Mental health/substance abuse inpatient services Mental health/substance abuse transitional treatment Maternity services, including prenatal and postnatal care, delivery and all inpatient services Preferred Provider Coinsurance or Preferred Provider Preferred Provider None Prior approval is required for non-emergency transport* Prior approval is required for elective inpatient stays* Copay or Prior approval is required for elective inpatient stays* None None None Home health care Up to 60 visits per year Habilitative services (therapy): Office setting Outpatient hospital setting Rehabilitative services (therapy): Office setting Outpatient hospital setting Skilled nursing in a skilled nursing facility Copay or Copay or Durable medical equipment Prosthetics Limited to 20 visits per year as stated in the policy Limited to 20 visits per year as stated in the policy Up to 30 days per confinement; prior approval is required* Rental or purchase require prior approval if the equipment is over $1,000 or rental is more than $750 per month*; limited to a single purchase of each type every three years Prosthetics over $5,000 require prior approval*; limited to a single purchase of each type every three years Routine eye exam $0 None Glasses $0 Not Covered Limited selection of frames and lenses Dental check-up Not Covered Not Covered Not Covered * - If a prior apporval is required and one is not obtained, a 50% penalty reduction in benefits will be applied.

11 WPS Group HSA Plan Summary An HSA-qualified high-deductible health plan (HDHP) for groups, featuring in- and out-of-network benefits and a wide range of plan design options. To request a quote, please see an agent, visit the WPS website at or have one of our licensed agents find a solution for you and your employees by calling Routine care covered, with no calendar year maximum Dependent children: to age 26 (see policy for eligibility requirements) Plan Options In-Network Options Metal Tier Individual Deductible 1 Coinsurance 2 Out-of-Pocket Limit Convenient Care Clinic or Telehealth Visit PCP Visit Specialist Visit ER Visit Prescription Plan Preventive/Generic/Preferred Brand/ Brand/Specialty Gold 2, % 2,000 D/C D/C D/C D/C $0 preventive, D/C all others Silver 1,400 70% 6,450 D/C D/C D/C D/C $0 preventive, D/C all others Silver 2,000 80% 4,000 D/C D/C D/C D/C $0 preventive, D/C all others Silver 2,000 80% 6,450 D/C D/C D/C D/C $0 preventive, D/C all others Silver 2,500 80% 4,500 D/C D/C D/C D/C $0 preventive, D/C all others Silver 3, % 3,000 D/C D/C D/C D/C $0 preventive, D/C all others Silver 3, % 3,500 D/C D/C D/C D/C $0 preventive, D/C all others Bronze 3,500 70% 6,450 D/C D/C D/C D/C $0 preventive, D/C all others Bronze 4,500 90% 6,450 D/C D/C D/C D/C $0 preventive, D/C all others Bronze 5,500 80% 6,450 D/C D/C D/C D/C $0 preventive, D/C all others Bronze 6, % 6,000 D/C D/C D/C D/C $0 preventive, D/C all others D/C = Deductible and Coinsurance PCP = Primary Care Physician 1 Family deductible is 2x the individual. Out-of-Network deductible is 2x the applicable In-Network deductible. 2 Out-of-network coinsurance is 20 percentage points lower than in-network. For example, if you choose a plan with 100% in-network coinsurance, your out-of-network coinsurance is 80% (100-20=80). Non-embedded deductible: This plan features a non-embedded deductible. Family deductible must be satisfied before this plan will pay benefits. One person can satisfy the family deductible. An out-of-network deductible of an equivalent amount to the in-network deductible applies. Deductibles and out-of-pocket maximums apply annually. In-network and out-of-network deductible and coinsurance amounts must be satisfied separately. HSA is administered and/or maintained by a participating financial institution. WPS does not operate or administer HSAs. Convenient Care Clinic: a medical clinic that is located in a retail store, supermarket or pharmacy. The convenient care clinic must provide covered health care services by: (1) nurse practitioners; (2) physician assistants; or (3) physicians. They must provide those services within the scope of their respective licenses. Primary Care Physician: non-specialized physicians whose primary practice is one of the following: Family Practice, Internal Medicine, General Practice, Obstetrics/Gynecology and Pediatrics. Specialty Physician: any physician whose primary practice is other than one of the following: Family Practice, Internal Medicine, General Practice, Obstetrics/Gynecology and Pediatrics. Telehealth: the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using the Internet, interactive audio, video, or data communications, to include all types of telephonic communication and electronic mail. All services are subject to terms and conditions of the policy. Certain drug limitations may apply, please review the full policy. Please see plan policy for a complete list of exclusions and other covered services

12 Common Medical Event If you visit a health care provider's office or clinic If you have a test If you need drugs to treat your illness or condition** If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your cost if you use a Preferred Provider Non-Preferred Provider Limitations & Exclusions Primary care office visit Telehealth visits with a preferred provider are covered Specialist office visit None Other practitioner office visit Telehealth visits with a preferred provider are covered Preventive care/screening $0 None Immunizations $0 $0 Immunizations for travel are not covered Diagnostic test (x-ray/blood work) in an office or outpatient None department of a hospital Imaging (CT/PET scans, MRI s) Prior approval is required for PET scans Preventive drugs $0 None Generic drugs 30- day supply limit for retail and Preferred brand-name drugs all specialty drugs; home delivery Preferred Provider Deductible & Coinsurance 90-day supply; specialty drugs may Brand name drugs require pre-authorization; several Specialty drugs drugs to treat common illnesses will be available at no cost to you Outpatient hospital - facility and physician/surgeon fees None Emergency room services Preferred Provider None Emergency medical transportation Preferred Provider Prior approval is required for nonemergency transport* Inpatient hospital -Facility and physician/surgeon fees Mental health/substance abuse outpatient office visits Mental health/substance abuse inpatient services Mental health/substance abuse transitional treatment Maternity services, including prenatal and postnatal care, delivery and all inpatient services Prior approval is required for elective inpatient stays* None Prior approval is required for elective inpatient stays* None None Home health care Up to 60 visits per year Habilitative services (therapy): Office setting, Outpatient hospital setting Rehabilitative services (therapy): Office setting, Outpatient hospital setting Skilled nursing in a skilled nursing facility Durable medical equipment Prosthetics Limited to 20 visits per year as stated in the policy Limited to 20 visits per year as stated in the policy Up to 30 days per confinement; prior approval is required* Rental or purchase require prior approval if the equipment is over $1,000 or rental is more than $750 per month*; limited to a single purchase of each type every three years Prosthetics over $5,000 require prior approval*; limited to a single purchase of each type every three years Routine eye exam $0 None Glasses $0 Not Covered Limited selection of frames and lenses Dental check-up Not Covered Not Covered Not Covered * - If a prior approval is required and one is not obtained, a 50% penalty reduction in benefits will be applied Wisconsin Physicians Service Corporation. All rights reserved