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Transcription:

Small Business Small Group Product Portfolio

2014 HPN Small Group HMO Metallic Benefit Standards Silver Standards: Lab and X-ray: $20-25/$40-50 ER: $500 OP ASC: $150 + $150 Physician; OP @ Facility: CYD and Coinsurance Rx Tiers: 20/40/70/250 Gold Standards: Lab and X-ray: $20/40 ER: $350 OP ASC: $150 + $150 Physician; OP @ Facility: CYD and Coinsurance Rx Tiers: 15/35/65/250 Platinum Standards: Urgent : $35 Lab and X-ray: $5/15 ER: $150 OP ASC: $100 + $100 Physician; OP @ Facility: Coinsurance (not subject to CYD) Rx Tiers: 10/30/60/250 [2] Bronze Standards: Lab and X-ray: $30/75 ER: CYD and Coinsurance OP ASC: $150 + $150 Physician; OP @ Facility: CYD and Coinsurance Rx Tiers: 25/55/85/250 w/tiers 2-4 are subject to applicable plan medical deductible

Health Plan of Nevada Small Group HMO Portfolio Effective Date: January 1, 2014 Plan Name HPN Solutions HMO Platinum 15/0/90% HMO Platinum 15/0/90% HPN Solutions HMO Gold 15/500/80% HPN Solutions HMO Gold 30/500/80% HMO Gold 15/500/80% HMO Gold 30/500/80% HPN Solutions HMO Gold 20/1000/70% HPN Solutions HMO Gold 25/1000/80% HMO Gold 20/1000/70% HMO Gold 25/1000/80% HPN Solutions HMO Silver 25/1500/80% HPN Solutions HMO Silver 40/1500/70% HMO Silver 25/1500/80% HMO Silver 40/1500/70% HPN Solutions HMO Silver35/2000/80% HMO Silver 35/2000/80% HPN Solutions HMO Bronze 40/5000/70% HMO Bronze 40/5000/70% Deductible (CYD) Coinsurance Out of Pocket Maximum PCP Specialist Convenient Clinic Physician Extender NowClinic Lab X-Ray Urgent Emergency Room* Inpatient Facility* O/P Surg Copay - at ASC Facility* I/P Physician Surgical Services* $0 10% $3,500 $15 $15 $5 $5 $5 $5 $15 $35 $150 $300 / $900 max $100 10% $100 $0 10% $3,500 $15 $15 $5 $5 $5 $5 $15 $35 $150 $300 / $100 10% $100 $900 max $500 20% $4,500 $15 $30 $5 $5 $5 $20 $40 $50 $350 20% $150 20% $150 $500 20% $4,500 $30 $60 $20 $20 $20 $20 $40 $50 $350 20% $150 20% $150 $500 20% $4,500 $15 $30 $5 $5 $5 $20 $40 $50 $350 20% $150 20% $150 $500 20% $4,500 $30 $60 $20 $20 $20 $20 $40 $50 $350 20% $150 20% $150 $1,000 30% $4,750 $20 $40 $10 $10 $10 $20 $40 $50 $350 30% $150 30% $150 $1,000 20% $4,500 $25 $50 $15 $15 $15 $20 $40 $50 $350 20% $150 20% $150 $1,000 30% $4,750 $20 $40 $10 $10 $10 $20 $40 $50 $350 30% $150 30% $150 $1,000 20% $4,500 $25 $50 $15 $15 $15 $20 $40 $50 $350 20% $150 20% $150 $1,500 20% $6,250 $25 $50 $15 $15 $15 $20 $40 $50 $500 20% $150 20% $150 $1,500 30% $6,250 $40 $80 $30 $30 $30 $25 $50 $50 $500 30% $150 30% $150 $1,500 20% $6,250 $25 $50 $15 $15 $15 $20 $40 $50 $500 20% $150 20% $150 $1,500 30% $6,250 $40 $80 $30 $30 $30 $25 $50 $50 $500 30% $150 30% $150 $2,000 20% $6,250 $35 $70 $25 $25 $25 $25 $50 $50 $500 20% $150 20% $150 $2,000 20% $6,250 $35 $70 $25 $25 $25 $25 $50 $50 $500 20% $150 20% $150 $5,000 30% $6,250 $40 $80 $30 $30 $30 $30 $50 $50 30% 30% $150 30% $150 $5,000 30% $6,250 $40 $80 $30 $30 $30 $30 $75 $50 30% 30% $150 30% $150 O/P Physician Surgical Services* Notes: Family Deductible and OOPM Mulipliers are 2x Individual. Member Cost share applies to the OOPM (Deductible, Copays, Coinsurance, Rx). Preventive Services are covered at 100%. Any deductible does not apply. Bronze level plans for HMO plans have a combined Medical and Rx CYD. Prescription Drug Coverage is provided under a 4-Tier format which categorizes covered drugs based on cost and efficiency instead of generic or brand name status. Plans within an inpatient per day copay have a maximum of 3 days per admit. This is a summary of Covered Services. Please refer to the HPN Evidence of Coverage, Form No. NV-HPN- SBEOC-(2014), Attachment A Benefit Schedules (see page 10 for benefit schedule form numbers), Outpatient Prescription Drug Rider (see page 10 for drug rider form numbers), and Vision Riders (See page 10 for vision plan form numbers). For additional information, limitations and exclusions of coverage, copies of these documents are available upon request. Plan documents govern in resolving any benefit questions or payments. [ 3 ] *After CYD where applicable

2014 HPN Small Group POS Metallic Benefit Standards Small Group Plroduct Portfolio Tier 1 Silver and Gold POS Standards: No CYDs NowClinic $5 less than applicable plan PCP OV Copay PCP and Specialists - $15-25/$35-$45 Lab and X-ray: $10-15/$25 ER: $150-$350 OP ASC: $100-$200 + $100-$200 Physician Services OP @ Facility: $250-$350 + $150-$250 Physician Services Rx Tiers: 15/35/65/250 Tier 2 Silver and Gold POS Standards: PCP - $15 more than Tier 1 PCP Specialists - $15 more than Tier 1 Specialist Lab and X-ray: $25-35/$40 OP ASC, OP @ Facility and Physician: Tier 2 CYD and Coinsurance Tier 3 Silver and Gold POS Standards: All Covered Services subject to applicable plan CYD and 50% of EME Coverage for certain services is only available under HMO Tier 1 (and/or the Tier 1 Cost Share applies): Evisits, Telemedicine, Emergency Room, Urgent, Ambulance, Gastric Surgery, Transplants, Post Cataract Surgery Materials, Hospice and Respite, DME, Prosthetics, Orthotics, Genetic Disease Testing, Infertility Evaluations, Self Management and Treatment of Diabetes, Special Food Products and Enteral Formulas, TMJ, Hearing Aids, ABA for Treatment of Autism, Pediatric Vision and Dental [4]

Health Plan of Nevada Small Group POS Portfolio Effective Date: January 1, 2014 Plan Name Calendar Year Deductible (CYD) Plan Coinsurance Out of Pocket Max Tier I Network Cost Shart HPN Solutions POS Gold $25/0/500/80% HPN Direct Solutions POS Gold $25/0/500/80% HPN Solutions POS Gold $15/0/1000/80% Network (Tier I) Network (Tier II) Tier I Tier II Tier I Tier II Single Single Single Single Single Single PCP Specialist Convenient Clinic Physician Extender Now- Clinic Lab X-ray Urgent Emergency Room Inpatient Facility Outpatient Facility $0 $500 20% 20% $3,500 $6,250 $25 $45 $20 $20 $20 $15 $25 $50 $150 20% $200 $200 $150 $0 $500 20% 20% $3,500 $6,250 $25 $45 $20 $20 $20 $15 $25 $50 $150 20% $200 $200 $150 $0 $1,000 0% 20% $4,000 $6,250 $15 $35 $10 $10 $10 $10 $25 $50 $250 $500 $100 $150 $100 I/P Phys Surg Svcs O/P Phys Surg Svcs HPN Direct Solutions POS Gold $15/0/1000/80% HPN Solutions POS Gold $25/0/1500/80% $0 $1,000 0% 20% $4,000 $6,250 $15 $35 $10 $10 $10 $10 $25 $50 $250 $500 $100 $150 $100 $0 $1,500 20% 20% $4,500 $6,250 $25 $45 $20 $20 $20 $15 $25 $50 $300 20% $200 $250 $200 HPN Direct Solutions POS Gold $25/0/1500/80% HPN Solutions POS Silver 25/0/2000/70% $0 $1,500 20% 20% $4,500 $6,250 $25 $45 $20 $20 $20 $15 $25 $50 $300 20% $200 $250 $200 $0 $2,000 0% 30% $4,500 $6,250 $25 $45 $20 $20 $20 $15 $25 $50 $350 $1,000 $200 $250 $200 HPN Direct Solutions POS Silver $25/0/2000/70% $0 $2,000 0% 30% $4,500 $6,250 $25 $45 $20 $20 $20 $15 $25 $50 $350 $1,000 $200 $250 $200 Notes: Family Deductible and OOPM multipliers are 2x Individual. Out of Network CYD/OOPM is 2x Tier II amounts; Out of Network Coinsurance is 50%. Member Cost share including CYD, Copayments, Coinsurance and Rx amounts apply to the applicable Tier OOPM. Tier I out of pocket expenses also apply to Tier II OOPM, but Tier II out of pocket expenses do not apply to the Tier I OOPM. Preventive Services are covered at 100% under Tier I and Tier II. No deductible applies. Plan name with (IP$) Indicates a Tier 1 Copay for Inpatient Facility Charges. Bronze level plans for POS plans have a combined Medical and Rx CYD. Prescription Drug Coverage is provided under a 4-Tier format which categorizes covered drugs based on cost and efficiency instead of generic or brand name status. This is a summary of Covered Services. For additional information, limitations and exclusions of coverage, please refer to the SHL Certificate of Coverage, Form No. SHLSBCERT(2014), the Attachment A Benefit Schedules (see page 10 for benefit schedule form numbers), the Attachment B List of Services Requiring Prior Authorization, Form No. SHL-AttBPA( 01/2014), the Outpatient Prescription Drug Riders (See page 10 for prescription drug plan form numbers), and Vision Riders (See page 10 for vision plan form numbers). Copies of these documents are available upon request. Plan documents govern in resolving any benefit questions or payments. [ 5 ]

2014 SHL Small Group PPO Metallic Benefit Standards Bronze Tier 1 Standards: ER: CYD and Coinsurance Complex Diagnostic: CYD + $350 Lab / X-ray: $25/$75 OP ASC, OP @ Facility and Physician: CYD and Coinsurance Rx Tiers: 25/55/85/250 w/ tiers 2-4 are subject to Medical CYD Silver Tier 1 Standards: ER: $500 Complex Diagnostic: CYD + $350 Lab / X-ray: $25/50 OP ASC, OP @ Facility and Physician: CYD and Coinsurance Rx Tiers: 20/40/70/250 Gold Tier 1 Standards: ER: $350 Complex Diagnostic: CYD + $200 Lab / X-ray: $20/40 OP ASC, OP @ Facility and Physician: CYD and Coinsurance Rx Tiers: 15/35/65/250 Platinum Tier 1 Standards: Urgent : $35 ER: $150 Complex Diagnostics: CYD + $100 Lab / X-ray: $5/10 OP ASC, OP @ Facility and Physician: CYD and Coinsurance Rx Tiers: 10/30/60/250 Medical CYD applies to all services except preventive (including Rx) Family CYDs and OOPM are 2x Individual and are non-embedded Employer contribution impacts plan actuarial value and metallic level status [ 6 ]

Sierra Health and Life Small Group PPO Portfolio Effective Date: January 1, 2014 Plan Name Deductible (CYD) Out of Pocket Maximum Network Cost Share Platinum 10/100/90% Gold 25/500/80% Gold 35/500/70% Gold 20/1000/80% Network Non-Network Network Non-Network Single Single Single Single PCP Specialist Convenient / Extender NowClinic Lab X-ray Urgent Emergency Room Inpatient Facility* Outpatient Facility* $100 $200 $3,000 $6,000 $10 $10 $10 $10 $5 $10 $35 $150 10% 10% 10% $500 $1,000 $4,250 $8,500 $25 $50 $15 $15 $20 $40 $50 $350 20% 20% 20% $500 $1,000 $4,500 $9,000 $35 $70 $25 $25 $20 $40 $50 $350 30% 30% 30% $1,000 $2,000 $4,750 $9,500 $20 $40 $10 $10 $20 $40 $50 $350 20% 20% 20% Phys Surg Svcs* Gold 30/1000/80% Silver 35/1500/70% Silver 35/2000/80% Silver 40/2000/70% Bronze 35/5000/70% $1,000 $2,000 $5,000 $10,000 $30 $60 $20 $20 $20 $40 $50 $350 20% 20% 20% $1,500 $3,000 $6,250 $12,500 $35 $70 $25 $25 $25 $50 $50 $500 30% 30% 30% $2,000 $4,000 $6,250 $12,500 $35 $70 $25 $25 $25 $50 $50 $500 20% 20% 20% $2,000 $4,000 $6,250 $12,500 $40 $80 $30 $30 $25 $50 $50 $500 30% 30% 30% $5,000 $10,000 $6,350 $12,700 $35 $85 $25 $25 $25 $75 $50 30% 30% 30% 30% Notes: Family Deductible and OOPM Mulipliers are 2x Individual. Out of Network Ded/OOPM is 2x Network Amount; Out of Network Coinsurance is 50%. Network and Non-Network Member Cost share applies to the applicable OOPM (Deductible, Copays, Coinsurance, Rx). Preventive Services are covered at 100% for tier I. The deductible does not apply. Bronze level plans for PPO plans have a combined Medical and Rx CYD. This is a summary of Covered Services. Please refer to the SHL Certificate of Coverage, Form No. SHLSBCERT(2014), the Attachment A Benefit Schedules (see page 10 for benefit schedule form numbers), the Attachment B List of Services Requiring Prior Authorization, Form No. SHL-AttB-PA(01/2014), the Outpatient Prescription Drug Rider (See page 10 for vision plan form numbers), and Vision Riders (See page 10 for vision plan form numbers). For additional information, limitations and exclusions of coverage, copies of these documents are available upon request. Plan documents govern in resolving any benefit questions or payments *After CYD [ 7 ]

Sierra Health and Life Small Group HSA Portfolio Effective Date: January 1, 2014 Plan Name Calendar Year Out of Pocket Maximum Deductible Network Non-Network Network Non-Network Coinsurance (Network) After CYD SHL Solutions HSA PPO Gold 1500/80% - $1000 SHL Solutions HSA PPO Silver 1500/80% - $0 SHL Solutions HSA PPO Gold 3500/70% - $2000 SHL Solutions HSA PPO Silver 3500/70% - $900 SHL Solutions HSA PPO Bronze 3500/70% - $0 Single Single Single Single PCP Specialist Convenient Clinic Physician Extender NowClinic Lab X-ray Urgent Emergency Room Inpatient Facility Outpatient Facility $1,500 $3,000 $5,000 $10,000 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% $1,500 $3,000 $5,000 $10,000 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% $3,500 $7,000 $6,350 $12,700 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% $3,500 $7,000 $6,350 $12,700 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% $3,500 $7,000 $6,350 $12,700 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% Phys Surg Svcs Notes: Family Deductible and OOPM Mulipliers are 2x Individual amounts are not embedded. Out of Network Ded/OOPM is 2x Network Amount; Out of Network Coinsurance is 50%. Network and Non-Network Member Cost share applies to the applicable tier OOPM (Deductible, Copays, Coinsurance, Rx). Preventive Services are covered at 100% for tier I. The deductible does not apply. Bronze level plans for HSA plans have a combined Medical and Rx CYD. Prescription Drug Coverage is provided under a 4-Tier format which categorizes covered drugs based on cost and efficiency instead of generic or brand name status. This is a summary of Covered Services. Please refer to the SHL Certificate of Coverage, Form No. SHLSBCERT(2014), the Attachment A Benefit (see page 10 for benefit schedule form numbers), the Attachment B, List of Services Requiring Prior Authorization, Form No. SHL-AttB-PA(01/2014), the Outpatient Prescription Drug Rider (See page 10 for vision plan form numbers), and Vision Riders (See page 10 for vision plan form numbers). For additional information, limitations and exclusions of coverage, Copies of these documents are available upon request. Plan documents govern in resolving any benefit [ 8 ]

HMO Attachment A Benefit Schedules Outpatient Prescription Drug Riders SB_HMO_B40500070(2014) SB_HMO_G1550080(2014) SB_HMO_G20100070(2014) SB_HMO_G25100080(2014) SB_HMO_G3050080(2014) SB_HMO_P15090(2014) SB_HMO_S25150080(2014) SB_HMO_S30300080(2014) SB_HMO_S35200080(2014) SB_HMO_S40150070(2014) SB_HMODIRECT_B40500070(2014) SB_HMODIRECT_G1550080(2014) SB_HMODIRECT_G20100070(2014) SB_HMODIRECT_G25100080(2014) SB_HMODIRECT_G3050080(2014) SB_HMODIRECT_P15090(2014) SB_HMODIRECT_S25150080(2014) SB_HMODIRECT_S30300080(2014) SB_HMODIRECT_S35200080(2014) SB_HMODIRECT_S40150070(2014) POS Attachment A Benefit Schedules SB_POS_G150100080(2014) SB_POS_G250150080(2014) SB_POS_G25050080(2014) SB_POS_S250200070(2014) SB_POSDIRECT_G150100080(2014) SB_POSDIRECT_G250150080(2014) SB_POSDIRECT_S250200070(2014) HPNSB-4TierRx 10/30/60/250-(2014) HPNSB-4TierRx 20/40/70/250-(2014) HPN-4TierRx 25/55/85/250 COMB-(2014) HPNSB-4TierRx 15/35/65/250-(2014) SHLSB-4TierRx 10/30/60/250-(2014) SHLSB-4TierRx 15/35/65/250-(2014) SHLSB-4TierRx 15/35/65/250-(2014) SHLSB-4TierRx 25/55/85/250 COMB-(2014) SHLSB-4TierRx 70/70/70/70 COMB-(2014) SHLSB-4TierRx 80/80/80/80 COMB-(2014) Vision Riders HPN AdultVisionRider SB OPT6 (2014) HPN AdultVisionRider SB OPT7 (2014) HPN AdultVisionRider SB OPT8 (2014) HPN AdultVisionRider SB OPT9 (2014) SHL AdultVisionRider SG OPT6S(2014) SHL AdultVisionRider SG OPT7S(2014) SHL AdultVisionRider SG OPT8S(2014) SHL AdultVisionRider SG OPT9S(2014) SHL AdultVisionRider SG OPT10S(2014) SHL AdultVisionRider SG OPT11S(2014) SHL AdultVisionRider SG OPT12S(2014) PPO Attachmnet A Benefit Schedules SB_PPO_B35500070(2014) SB_PPO_S45300070(2014) SB_PPO_G20100080(2014) SB_PPO_G30100080(2014) SB_PPO_S35150070(2014) SB_PPO_G2550080(2014) SB_PPO_P1010090(2014) SB_PPO_S40200070(2014) SB_PPO_G3550070(2014) SB_PPO_S35200080(2014) SB_PPO_S40200070(2014) HSA Attachment A Benefit Schedules SB_HDHP_B350070(2014) SB_HDHP_S350070(2014) SB_HDHP_G150080(2014) SB_HDHP_G350070(2014) SB_HDHP_S150080(2014) [ 9 ]

Building success takes determination and teamwork. Call your sales or account representative today at (702) 821-2200 or (800) 873-0004. 01NVUHC13537 (09/13) [ 10 ]

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