Open Access HMO. CareSelect EASY ACCESS, MORE CHOICE. Introducing. 51 to 499 Employees 51 to 499 Employees 51 to 499 Employees 51 to 499 Employees

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1 51 to 499 Employees 51 to 499 Employees 51 to 499 Employees 51 to 499 Employees Open Access HMO EASY ACCESS, MORE CHOICE Introducing CareSelect

2 Yellow We ve Made the Color of Confidence Service Everything AvMed does is backed by our trademark personalized service for members, businesses and agents. Trust AvMed is one of the oldest and largest not-for-profit plans in Florida. Our bottom line is the health of our members. Choice Choose from a wide selection of plan options customized to fit your business needs. 2

3 Mid-Market Group Open Access HMO Ideal for: Employers who want to offer easy, referral-free access to doctors in AvMed s vast network and the predictability of co-pays for office visits, urgent care and pharmacy. All Plans Feature: No referrals to see a specialist No Primary Care Physician designation required Large provider network Choice of deductible levels ranging from $1,500 to $5,000 for individuals Prescription drug benefits included $0 co-pay for preventive screenings Dental benefits available Introducing CareSelect This product empowers members to save on health care costs based on where they choose to receive care. Members pay lower co-payments for outpatient services at designated independent Ambulatory Surgery Centers and Diagnostics Testing Facilities. 3

4 Does Your Health Plan... Rate consistently above statewide competitors for overall satisfaction with health plans?* Offer your employees service and a Nurse On Call 24/7, 365 days a year? Offer quick, accurate problem resolution with decision-makers based in Florida? Reach out to members with wellness education and incentives to live healthy? AvMed is the health plan with your health in mind. Go with a plan that puts your interests ahead of everything else. *Highest overall rating of statewide plans reporting Health Maintenance Organization (HMO) and Point of Service (POS) product data to the National Committee for Quality Assurance (NCQA) for the Consumer Assessment of Healthcare Providers and Systems (CAHPS). CAHPS is a registered trademark of the Agency of Healthcare Research and Quality (AHRQ). 4

5 Florida-based and Florida-focused We re here when you need us. AvMed has been serving Florida businesses for over 40 years. All decisions are made locally and our trademark service sets the standard for plans in Florida. Members can talk to Member Service Representatives who focus solely on their specific needs. Both Member Services and the Nurse On Call program are available 24/7, 365 days a year. 5

6 A Healthy Employee We reach out to members all year long, helping them get involved in their own health care and focused on living healthy, productive lives. By giving members the resources and motivation to make better health decisions and encouraging positive lifestyle changes, we help employers promote workplace wellness and get healthy employees. That s not just good for business, it s good for everyone. Take a look at these benefits reported by other employers with wellness programs. Decreased absenteeism up to 20 percent fewer sick days 22 percent fewer hospital admissions 29 percent shorter hospital stays 40 percent reduction in long-term disabilities Reduction in medical costs $3.80 cost benefit for every dollar invested Source: Corporate Wellness Makes Bottom-Line Difference: The Cost Benefit of Worksite Wellness. The Wellness Councils of America, AvMed is Here to Help at Every Step The AvMed Well 4 Life program provides members with educational resources related to weight control, exercise, tobacco cessation and other tools to achieve health goals. Members can also take advantage of discounts on wellness-related services, including: Fitness center memberships Nutritional counseling WeightWatchers discounts Stress-reduction initiatives such as yoga, acupuncture and massage therapy 6

7 A Productive Employee We care about and invest in member wellness. We Make Staying Healthy Easy Preventive screenings offered at no out-of-pocket costs include: A Sampling of Covered Preventive Services Breast Cancer Screening Cervical Cancer Screening Colon Cancer Screening Osteoporosis Screening (in postmenopausal women) HIV Screening Breast and Ovarian Cancer Generic Risk Test Depression Screening Obesity Screening Tobacco Use and Tobacco-Caused Disease Counseling High Blood Pressure Screening 7

8 Benefits At-a-Glance 1 The CareSelect product empowers members to save on health care costs based on where they choose to receive care. Members pay lower co-payments for outpatient services at designated independent Ambulatory Surgery Centers and Diagnostics Testing Facilities. CARESELECT AVAILABLE DEDUCTIBLE LEVELS SINGLE DEDUCTIBLE FAMILY DEDUCTIBLE CALENDaR YEAR OUT-OF-POCKET MAXIMUM 2 $1,500 $3,000 $5,000 $2,500 $5,000 $5,000 $5,000 $10,000 $5,000 APPLICABLE TO ALL DEDUCTIBLE LEVELS Primary Care Physician Visit $30 per visit (not subject to deductible) Specialist Visit $50 per visit (not subject to deductible) Hospital Inpatient (prior authorization required) Outpatient (prior authorization required) $250 per day for the first 5 days, per admission, after deductible; 100% coverage thereafter $400 Co-payment at an Independent ambulatory surgery center or physician s office, not subject to deductible -OR- $500 Co-payment at all other ambulatory surgery centers, after deductible Emergency Room $200 Co-payment (not subject to deductible) Urgent Care Center $50 Co-payment (not subject to deductible) Complex Diagnostic Imaging Including, but not limited to CAT Scan, PET Scan, MRI Prescription Drugs Retail Mail Order (up to 90 days) $200 Co-payment at an Independent diagnostic testing facility or physician s office (not subject to deductible) -OR- $300 Co-payment at all other diagnostic testing facilities, after deductible Varies 1 This is not all-inclusive. The above is a sampling of available plans. For more specific information on benefits, exclusions and limitations refer to the contract or contact your AvMed representative. 2 Out-of-Pocket Maximum does not include deductible. 8

9 Other open access hmo plans 1 HM-OA-5231 HM-OA-5083 HM-OA-5077 HM-OA-5078 Deductible Per Individual Family Aggregate $2,500 $5,000 $5,000 $10,000 $1,500 $3,000 $2,500 $5,000 Out-of-Pocket Maximum 2 Per Individual Family Aggregate $4,000 $8,000 $3,000 $9,000 $2,000 $4,000 $2,500 $5,000 Primary Care Physician Office Visit $25 $25 $25 $25 Specialist Office Visit $50 $50 $50 $50 Hospital Inpatient (prior authorization required) Co-insurance/Co-payment 30% after Calendar Year Deductible Outpatient (prior authorization required) Co-insurance/Co-payment 30% after Calendar Year Deductible Emergency Room $100 Urgent Care $40/60* $50/75* $50/75* $50/75* Complex Diagnostic Imaging Including but not limited to CAT scan, PET scan, MRI 30% of Contracted Rate Prescription Drugs Retail Mail Order (up to 90 days) Varies Varies Varies Varies 1 This is not all-inclusive. The above is a sampling of available plans. For more specific information on benefits, exclusions and limitations refer to the contract or contact your AvMed representative. 2 The Out of Pocket Maximum includes Co-payment and Co-insurance amounts unless otherwise excluded. * In Network and Out of Network respectively. Terms You Should Know Calendar Year Deductible: An annual dollar amount that you are responsible for before AvMed begins paying for eligible expenses. Co-insurance: A percentage a member is responsible for toward the cost of covered services once the deductible has been met. Out-of-Pocket Maximum: The maximum dollar amount of co-payments and co-insurance the member will pay in a calendar year, not including the deductible. Once the out-of-pocket maximum has been met, AvMed pays 100 percent of covered expenses for the remainder of that calendar year. Co-payment: A fixed fee paid by the member to the provider network for covered medical services. 9

10 Underwriting Guidelines Employer Eligibility Must have a physical address in AvMed Health Plans approved Service Area Must have, and be willing to prove, the existence of an employer/employee relationship (employee leasing companies and PEOs are ineligible for coverage) Must meet or exceed AvMed Health Plans minimum participation and employer contribution requirements Employer Contribution Requirements The employer must contribute a minimum of 50 percent of the single premium rate The employer may fund up to 50 percent of the employee s deductible for the CDHP/HDHP plan designs Participation Requirements For exclusive accounts, 75 percent of all eligible employees, excluding those with qualifying other coverage, and no fewer than percent of all eligible employees, including those with qualifying other coverage, must enroll in the AvMed Health Plans product offering(s) Employee Eligibility Eligible employees are those employees who are permanent and work on a full-time basis with a normal work week of at least 25 hours, who live or work in AvMed Health Plans Service Area (some exceptions apply), and who have met any authorized waiting period requirements Coverage must be extended to all employees meeting the underlying conditions Part-time, temporary, seasonal or substitute employees are not eligible for coverage Domestic Partner Coverage Domestic partner coverage is available as a separate eligibility rider with an associated premium charge Retiree Coverage Retiree coverage is available subject to underwriting approval COBRA-eligible Employees COBRA-eligible employees are not included when determining group size; however, they are included in the medical underwriting of the group Eligibility Restrictions No more than 10 percent COBRA No more than 10 percent retirees No more than 5 percent out-of-state Quote Submission Requirements Census (including COBRA eligibles and retirees, if applicable): eligibility status, age/date of birth, date of hire, gender, dependent status and home ZIP code Current rates and benefits (renewal rates and benefits, if available) Completed Employer Risk Questionnaire signed and dated by an authorized company representative Claims experience including shock claims information, if available (mandatory for groups of 400 or more) Miscellaneous information: five-year carrier history and employer contribution methodology For a complete list of Underwriting Assumptions, visit the AvMed Web Site at Click on Forms located under the Login area at the right side of the page. 10

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12 51 to 499 Employees 51 to 499 Employees 51 to 499 Employees 51 to 499 Employees AvMed Health Plans Health plans with your health in mind. AvMed Health Plans Service Areas CENTRAL REGION Orlando Market 1800 Pembrook Dr. Suite 190 Orlando, FL Tampa Market 1511 N. Westshore Blvd. Suite 450 Tampa, FL NORTH REGION Jacksonville Market 1300 Riverplace Blvd. Suite 640 Jacksonville, FL Gainesville Market 4300 N.W. 89th Blvd. Gainesville, FL SOUTH REGION Miami Market 9400 S. Dadeland Blvd. Suite 370 Miami, FL Fort Lauderdale Market W. Sunrise Blvd. Suite 370 Sunrise, FL MP-5722(07/11) 1652AVM