2015 Exchange Products

Missouri Products

October 29, 2014

2

• Kansas City PPOx– Cass, Clay, Jackson, and Platte– Product is offered to individuals only on and off exchange

• SW Missouri PPOx– Jasper, Newton, and Greene– Product is offered to individuals only on and off exchange

Missouri-On Exchange Counties

3

Humana On-Marketplace Offering for Missouri

Confidential- Agent Use Only

4

• Kansas City PPOx • Built around St. Luke’s Health System, also includes Excelsior Springs Medical

Center and Twin Rivers• Physician network is made up of doctors employed/ affiliated with St. Luke’s

Health System as well as other independent health care providers such as KCIM, Clay Platte , Blue Springs Family Care and Swope Health

• S.W. Missouri PPOx • Built around Mercy • Physician network is primarily comprised of physicians employed/affiliated

with the Mercy PHO

Humana PPOx Network Cont.

Platinum

Gold

Silver

Bronze

The Four Metallic Tiers

• What’s the difference?– Platinum plans generally have the highest

monthly premium, but offer lower out-of-pocket costs when health care services are received.

– Bronze plans are designed with the lowest monthly premium, but typically have the highest deductibles, coinsurance and/or copayments.

– In addition, catastrophic (i.e., basic) coverage is available at a lower cost for those under 30 years of age or for those individuals facing a financial hardship.

5

6

Humana Marketplace Plans for Missouri

Confidential- Agent Use Only

• Applies only to individuals enrolled in a qualified health plan through the Marketplace.

• The individual must receive the federal subsidy Advanced Premium Tax Credit (APTC).

• Member must have paid his or her share of the first-month premium.

• If the member meets these criteria, he or she cannot be terminated during the grace period.

• The member will continue to display as eligible.

• Precertification will remain the same during the grace period.

90-day Grace Period – How Does It Work?

7

• Claims during the first month of the grace period will be processed with no delay.

• Claims during the second and third month of the grace period will be pended.

• Provider will receive notification letter for claims that pend during second and third month.

90-day Grace Period – How Does It Work? Cont’d

8

• If a member does NOT pay the outstanding premium before the grace period ends, claims may not be paid.

• If a member pays the outstanding premium during the grace period, claims will process as normal.

• If a member does NOT pay the outstanding premium before the grace period ends, the coverage will be terminated back to day 31 of the grace period and claims (for days 31 to 90) will not be paid or a refund may be requested.

90-day Grace Period – How Does It Work? Cont’d

9

• Health care providers may call customer service or use Humana’s interactive voice response (IVR) system to determine the premium status for APTC members.

• Similar functionality is in development for Humana.com and Availity.

How does the Provider determine if the member is in default?

10

- The IVR will prompt the caller to enter the member’s Humana ID number. • Press the * for any letter in the member’s ID. For example, key

“H123456789” as “*123456789” on your phone. Note: This is a very important step for PPOx membership.

• If the member is in his or her grace period, the IVR message will be “member is in the grace period and claims may be denied since the member is in the grace period.”

• If the member is not within the grace period and the PPOx plan premium is up to date, the IVR will not have a message about the grace period.

• If the provider wishes to obtain additional information, such as an authorization, the call will be directed to the specific area that handles PPOx membership.

How does the Provider determine if the member is in default? (cont’d)

11

Exchange open enrollment timeline

2015 open enrollment period (Nov. 1, 2014 through Feb. 15, 2015)• If an individual’s application is finalized between Nov. 15, 2014, and Dec. 15,

2014, the effective date is Jan. 1, 2015.• If an individual’s application is finalized between Dec. 16, 2014, and Jan. 15,

2015, the effective date is Feb. 1, 2015.• If an individual’s application is finalized between Jan. 16, 2015, and Feb. 15,

2015, the effective date is March 1, 2015.

Outside of open enrollment• Only qualifying life events, which trigger a special enrollment period

12

How Do Members Enroll?

For federally-facilitated and partnership marketplaces

3 ways to enroll online:

1 Humana’s website

2 Custom Agent Link

3 Marketplace website

Thank You!