2017 plan overview - providence health plans/media/files/providence hp/pdfs...individuals &...

2017 Plan Overview

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Resources to keep you well

Our FitTogether™ wellness programs and services include:

• Access to ProvRN for free health advice, 24/7, from a registered nurse

• Tobacco cessation programs to help tobacco users quit for good

• Award-winning care managers who provide education and support for chronic conditions, such as asthma and diabetes

• Health and wellness classes to help you manage stress, achieve a healthy weight, begin a yoga practice and more

• An award-winning newsletter packed with health and wellness information from Providence health experts

Tools to maintain and improve health

With myProvidence, our secure member portal and complete source for health, wellness and benefits information, you can:

• Get a baseline of your overall health with a personal health assessment

• Improve your health with Wellness Central, an integrated health and wellness hub that offers a personalized dashboard, health trackers and assessments, a library of health videos and articles, meal plans and medication information

• Search the online directory to find in-network providers, review your claims history and calculate how much of your deductible you’ve met

• Manage your health costs with our treatment cost calculator and online bill pay options

• Order a replacement member ID card

Health-enhancing extras for better fitness and more fun

As a Providence Health Plan member, you can enjoy savings on:

• Exclusive recreation discounts through LifeBalance for:

° Popular local and national family attractions, such as zoos and amusement parks

° Hundreds of fitness facilities throughout Oregon

° Discounted tickets to local events, savings at hotels nationwide and more

• Board-certified LASIK vision correction or custom LASIK through our partner, TruVision

• Hearing aids (up to 50 percent off the average retail price) through our partner, TruHearing

Alternative care options

You can see a naturopath or other alternative care provider for covered benefits, including periodic exams and well-baby care. These services are covered at the same rate as they would be for a primary care provider, as long as the alternative care provider is licensed to perform the services.

With the Balance, Choice and Connect plans, chiropractic manipulation and acupuncture are covered with a $25 copay when you use an in-network provider.

Flexibility to change plans

We get it. Life throws curve balls that can change your circumstances. When you buy directly from Providence, you can switch to a medical plan with a lower premium once during the contract year.

This booklet offers an overview of our individual and family plans and premiums, which are subject to change every year. For more information about plan benefits and enrollment requirements, limitations and exclusions, see the plan contract or contact our sales team or your insurance producer. To view a benefit summary, go to ProvidenceHealthPlan.com/sbc.

Providence Health Plan Sales Department

503-574-5000 or 800-988-0088 (TTY: 711)

8 a.m. to 5 p.m., Monday – Friday

ProvidenceHealthPlan.com

Your partner in health and wellnessAs you evaluate health insurance plans, consider one that not only pays for treatments when

you’re sick but works actively to help you feel better and live well. Providence Health Plan offers

a range of coverage choices that help you manage your overall health as well as your costs.

Why choose Providence? You’ll find a plan and options to fit your unique needs.

• Choose from a broad range of plan types with different levels of deductibles, coinsurance and copayments. Our networks range from a local base of medical home providers to nearly 1 million providers nationwide.

Everyone deserves better health.

• It’s our Mission to take care of people in need, so we invest in programs to create healthier communities.

• Since 2001, we have awarded $65 million in grants or donations to a wide variety of local organizations.

• We’re a local, not-for-profit health plan that understands the specific issues and challenges of Oregonians.

Experience and innovation mean better care for you.

• We’re part of Providence Health & Services, one of the nation’s top 10 most-integrated health care providers, serving the Pacific Northwest for 160 years.

• Patients ranked Providence Express Care Virtual, our on-demand web-based health care service, 4.8 out of 5 stars for satisfaction.

• With innovative telemedicine, bundled care packages (e.g., one price guaranteed for certain procedures) and close coordination between our hospitals and clinics, you get better care.

We’re easy to work with.

• Our friendly, local customer service representatives answer your calls quickly and efficiently – 94 percent of calls are resolved the first time.

• For clean claims, 96 percent are processed within 30 days.

• You can get online claims and benefits information easily through myProvidence, a one-stop resource that can help you better understand and use your health plan benefits.

You get more for your health and your health care dollar.

• You’ll receive discounts on massage therapy, fitness classes, gym memberships, travel, entertainment and more, through LifeBalance.

• You can attend online classes and seminars, many of which are free or discounted for members.

97%

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Selling areasTo apply for a Providence Individual and Family plan, you must reside in

our selling area for each plan type (counties indicated below).

Please note that the selling area for each plan may be different from the provider network. See the plan pages for the provider network maps.

Balance, Dental, HSA Qualified and Standard plans

Plans

BalanceHSA

StandardDental

Available in these counties:

Balance: Benton, Clackamas, Clatsop, Columbia, Lane, Lincoln, Linn, Marion, Multnomah, Polk, Tillamook, Washington, Yamhill

HSA: Benton, Clackamas, Clatsop, Columbia, Lane, Lincoln, Linn, Marion, Multnomah, Polk, Tillamook, Washington, Yamhill

Standard and Dental: All counties in Oregon

Choice plans


Clackamas, Clatsop, Hood River, Marion, Multnomah, Polk, Washington, Yamhill

Connect plans


Clackamas, Multnomah, Washington

Where to buy plansPurchase the right Providence plan for you at ProvidenceHealthPlan.com, or ask a Providence

representative or your insurance producer for help. Providence plans are also available through

the Federal Health Insurance Marketplace at HealthCare.gov.

Plan name and metal tierPlans available directly

from Providence or your producer

Plans available from the Federal Health

Insurance Marketplace at HealthCare.gov

Balance 2500 Silver • •Balance 7150 Bronze • •Choice 2500 Silver • •Choice 7150 Bronze • •Connect 2500 Silver • •Connect 7150 Bronze • •Providence Oregon Standard Gold Plan • •Providence Oregon Standard Silver Plan • •Providence Oregon Standard Bronze Plan • •HSA Qualified 2800 Silver •HSA Qualified 6000 Bronze • •Providence Progressive Dental Plan •

Compare plans. • Check rates. • Apply and enroll online.

We can help you find the right plan for you. Apply and enroll:

• Online at ProvidenceHealthPlan.com

• Over the phone with a Providence representative, 8 a.m. to 5 p.m.

– Portland metro area 503-574-5000

– All other areas 800-988-0088

• With your insurance producer

Apply during open enrollment from Nov. 1, 2016, through Jan. 31, 2017. After the open enrollment period ends, you must have a qualifying life event to enroll in a health insurance plan. Qualifying life events include losing employer coverage, marriage and the birth of a child. See a list of qualifying life events at ProvidenceHealthPlan.com/qe.

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BalanceBalance plans offer a balance of cost-saving features and

coverage for the services you use the most.

The plans include:

• Provider choice, in or out of the Providence Signature Network

• Deductible waived in-network on the Balance Silver plan for primary doctor and specialist visits, urgent care, lab and X-ray services, and generic and preferred brand-name drugs

• A deductible you can apply to the out-of-pocket maximum

• Pediatric vision services covered in full for routine exams and hardware

• Adult vision coverage (routine exams and hardware)

• Pediatric dental coverage and optional family dental coverage

• Deductible waived on the Silver plan for covered services needed to treat an accidental injury within 90 days of injury

A Balance plan may be right for you if access to the widest range of providers is your top priority.

Providence Signature Network: A network of nearly 1 million health care providers nationwide, both in Providence facilities and in other locations

For a listing of our Signature Network providers, visit ProvidenceHealthPlan.com/findaprovider.

Balance

Balance 2500 Silver Balance 7150 Bronze

In-network Out-of-network In-network Out-of-network

Annual deductible Individual/Family $2,500/$5,000 $10,000/$20,000 $7,150/$14,300 $28,600/$57,200

Annual out-of-pocket maximum Individual/Family $7,150/$14,300 $28,600/$57,200 $7,150/$14,300 $28,600/$57,200

Accidental injury benefit: The deductible is waived for all covered services required to treat an accidental injury within 90 days of injury.

Covered Covered Not covered Not covered

After meeting your deductible, you pay the following amounts for covered services. The deductible does not apply for some covered services. These are marked with ✓

Preventive Care

Periodic health exams and well-baby care (from any provider licensed to perform the service) Covered in full✓ 50% Covered in full✓ 0%

Maternity prenatal care Covered in full✓ 50% Covered in full✓ 0%

Gynecological exams; Pap tests Covered in full✓ 50% Covered in full✓ 0%

Mammograms Covered in full✓ 50% Covered in full✓ 0%

Colorectal cancer screenings (preventive, age 50 and over) Covered in full✓ 50% Covered in full✓ 0%

Balance 2500 Silver Balance 7150 Bronze


Office Visits for Medical Services

Personal physician/provider $25✓ 50% $50✓ 0%

Personal physician/provider by phone or video $0✓ Not covered $0✓ Not covered

Alternative care provider $25✓ 50% $50✓ 0%

Specialist $50✓ 50% $0 0%

Hospital Services

Inpatient hospital services and maternity care 30% 50% 0% 0%

Emergency/Urgent Care

Emergency services $250 then 30% $250 then 30% 0% 0%

Urgent care services $75✓ 50% 0% 0%

Outpatient Diagnostic Services

X-ray and lab services 30%✓ 50% 0% 0%

High-tech imaging services (such as PET, CT, MRI) 30% 50% 0% 0%

Mental Health and Substance Abuse

Inpatient and residential services 30% 50% 0% 0%

Outpatient provider visits $25✓ 50% $50✓ 0%

Other Covered Services

Outpatient surgery at an ambulatory surgery center or hospital-based facility 30% 50% 0% 0%

Chiropractic manipulation and acupuncture (limited to three visits combined per calendar year) $25✓ 50% $25✓ 0%

Prescription Drugs

Preferred generic $20✓ Not covered $30✓ Not covered

Non-preferred generic $35✓ Not covered $60✓ Not covered

Preferred brand name $75✓ Not covered $0 Not covered

Non-preferred brand name 50% Not covered 0% Not covered

Specialty 50% Not covered 0% Not covered

Pediatric Vision Services (children aged 18 years and younger)

Routine eye exams (limited to one exam per calendar year) Covered in full✓ Covered✓ Covered in full✓ Covered✓

Vision hardware (frames, lenses, contact lenses); limits apply Covered in full✓ Covered✓ Covered in full✓ Covered✓

Adult Vision Services

Routine eye exams (limited to one exam per calendar year) $30✓ Covered✓ $30✓ Covered✓

Vision hardware (frames, lenses, contact lenses); limits apply Covered✓ Covered✓ Covered✓ Covered✓

Pediatric Dental Services* (children aged 18 years and younger)

Preventive services (includes routine exams, cleanings, X-rays, topical fluoride) Covered in full✓ 30%✓ Covered in full✓ 30%✓

Basic services (restorative fillings) 50% 70% 0% 0%

Major services (includes oral surgery, crowns, periodontics, endodontics, denture and bridge work) 50% 70% 0% 0%

✓Deductible does not apply for these services

*Dental services subject to medical deductible and out-of-pocket maximum

Balance (continued)

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ChoiceChoice plans use a medical home model that provides a team of health professionals

dedicated to your overall well-being. Members select a medical home from the Providence

Choice Network. The medical home team then works to support all aspects of your

health, from wellness and prevention to active management of chronic conditions.

Choice plans offer:

• More than 275 medical home clinics in Oregon and southwest Washington that provide patient-focused, coordinated care

• Access to specialists via referral from the medical home in order to receive coverage at the in-network level

• Deductible waived in-network on the Choice Silver plan for primary doctor and specialist visits, urgent care, lab and X-ray services, and generic and preferred brand-name drugs

• Deductible waived for in-network chiropractic manipulation and acupuncture


• Adult vision coverage (exams and hardware)


Providence Choice Network: A network of more than 275 primary care clinics located throughout Oregon and southwest Washington designated as medical homes

The network is available in shaded counties only.

Ben

ton

Clackamas

Clatsop

Columbia

Crook

Deschutes

Douglas

Gilliam

Harney

Hood River

Jackson

Jefferson

Josephine Klamath

Lane

Linn

Marion

Multnomah

PolkWasco

Washington

Wheeler

Yamhill

Lin

coln

Coos

Curry

Lake

Malheur

Sher

man

Tillam

ook

MorrowUnion

Baker

Grant

KlickitatSkam

aniaCowlitz

Clark

Wahkiakum

Umatilla Wallowa

For a complete list of medical homes and providers by location, visit ProvidenceHealthPlan.com/findaprovider. To see if your provider is in one of our medical homes, select "Medical Home Primary Care Providers" under "Provider Type" when you filter search results.

A Choice plan might be right for you if you value the convenience of a medical home and a centralized team dedicated to your health. Choice is best suited to members who live within 30 miles of a Providence medical home.

Choice

Choice 2500 Silver Choice 7150 Bronze







Preventive Care






Choice 2500 Silver Choice 7150 Bronze






Specialist $50✓ 50% $0 50%

Hospital Services














Prescription Drugs











Vision hardware (frames, lenses, contact lenses); limits apply Covered✓ Covered✓ Covered✓ Covered✓




Major services (includes oral surgery, crowns, periodontics, endodontics, denture and bridge work) 50% 70% 0% 0%

✓Deductible is waived for these services


Choice (continued)

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Connect 2500 Silver Connect 7150 Bronze






Specialist $50✓ 50% $0 50%

Hospital Services














Prescription Drugs











Vision hardware (frames, lenses, contact lenses); limits apply Not covered Not covered Not covered Not covered




Major services (includes oral surgery, crowns, periodontics, endodontics, denture and bridge work)

50% 70% 0% 0%



Note: In order to access the in-network cost shares, you must work through your medical home.

ConnectConnect plans combine a medical home model of care with a tailored provider

network to achieve substantial premium savings. You choose a medical home from

our Portland metro-area Providence Connect Network. The medical home model

provides a team of health professionals that supports all aspects of your overall well-

being, from wellness and prevention to helping you manage chronic conditions.

Connect plans offer:

• Some of the lowest premiums of any Providence Individual and Family plans

• More than 70 medical home clinics in the Portland metro area

• Access to specialists via referral from the medical home in order to receive coverage at the in-network level

• A deductible that applies to the out-of-pocket maximum

• Deductible waived in-network on the Connect Silver plan for primary doctor and specialist visits, urgent care, lab and X-ray services, and generic and preferred brand-name drugs



Providence Connect Network: A Portland-area network of more than 70 primary care clinics in Clackamas, Multnomah and Washington counties designated as medical homes

For a complete list of medical homes and providers by location, visit ProvidenceHealthPlan.com/findaprovider. To see if your provider is in one of our medical homes, select "Medical Home Primary Care Providers" under "Provider Type" when you filter search results.

A Connect plan might be right for you if a lower premium is your top priority and you also value the convenience of a medical home team dedicated to your health.

Connect

Connect 2500 Silver Connect 7150 Bronze







Preventive Care






Connect (continued)

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StandardBenefits for Standard plans are defined by the state of Oregon. Choose a

Gold, Silver or Bronze plan with deductibles starting at $1,000.

Standard plans offer:

• Copays starting as low as $10 and deductibles as low as $1,000



• The option to add dental coverage with the Providence Progressive Dental Plan, as long as you buy a plan directly from Providence Health Plan or through a producer

A Standard plan might be right for you if you want to minimize your health coverage costs while receiving more streamlined benefits.

Note: Standard plans do not cover chiropractic manipulation, acupuncture, adult routine vision exams and vision hardware, or pediatric dental services.



Standard

Providence Oregon Standard Gold

Providence Oregon Standard Silver

Providence Oregon Standard Bronze

In-network Out-of-network In-network Out-of-

network In-network Out-of-network

Annual deductible Individual/family

$1,000/ $2,000

$4,000/ $8,000

$2,500/ $5,000

$10,000/ $20,000

$7,150/ $14,300

$28,600/ $57,200

Annual out-of-pocket maximum Individual/family

$6,850/ $13,700

$27,400/ $54,800

$6,850/ $13,700

$27,400/ $54,800

$7,150/ $14,300

$28,600/ $57,200

After meeting your deductible, you pay the following amounts for covered services. The deductible does not apply

for some covered services. These are marked with ✓

Preventive Care

Periodic health exams and well-baby care (from any provider licensed to perform the service)

Covered in full✓ 50% Covered in

full✓ 50% Covered in full✓ 0%

Maternity prenatal care Covered in full✓ 50% Covered in


Gynecological exams; Pap tests Covered in full✓ 50% Covered in


Mammograms Covered in full✓ 50% Covered in


Colorectal cancer screenings (preventive, age 50 and over)

Covered in full✓ 50% Covered in


Providence Oregon Standard Gold

Providence Oregon Standard Silver

Providence Oregon Standard Bronze

In-network Out-of-network In-network Out-of-

network In-network Out-of-network


Personal physician/provider $20✓ 50% $35✓ 50% $70✓ 0%

Personal physician/provider by phone or video $0✓ Not covered $0✓ Not covered $0✓ Not covered

Alternative care provider $40✓ 50% $70✓ 50% $115✓ 0%

Specialist $40✓ 50% $70✓ 50% $115✓ 0%

Hospital Services

Inpatient hospital services and maternity care 20% 50% 30% 50% 0% 0%


Emergency services 20% 20% 30% 30% 0% 0%

Urgent care services $60✓ 50% $70✓ 50% $100✓ 0%


X-ray and lab services 20% 50% 30% 50% 0% 0%

High-tech imaging services (such as PET, CT, MRI) 20% 50% 30% 50% 0% 0%


Inpatient and residential services 20% 50% 30% 50% 0% 0%

Outpatient provider visits $20✓ 50% $35✓ 50% $70✓ 0%


Outpatient surgery at an ambulatory surgery center or hospital-based facility 20% 50% 30% 50% 0% 0%

Chiropractic manipulation and acupuncture Not covered Not covered Not covered Not covered Not covered Not covered

Prescription Drugs

Generic $10✓ Not covered $15✓ Not covered $35✓ Not covered

Preferred brand name $30✓ Not covered $50✓ Not covered $0 Not covered

Non-preferred brand name 50%✓ Not covered 50%✓ Not covered 0% Not covered

Specialty 50%✓ Not covered 50%✓ Not covered 0% Not covered


Routine eye exams (limited to one exam per calendar year)

Covered in full✓ Covered✓ Covered in

full✓ Covered✓ Covered in full✓ Covered✓

Vision hardware (frames, lenses, contact lenses); limits apply

Covered in full✓ Covered✓ Covered in

full✓ Covered✓ Covered in full✓ Covered✓


Routine eye exams (limited to one exam per calendar year) Not covered Not covered Not covered Not covered Not covered Not covered

Vision hardware (frames, lenses, contact lenses); limits apply Not covered Not covered Not covered Not covered Not covered Not covered


Preventive services (includes routine exams, cleanings, X-rays, topical fluoride) Not covered Not covered Not covered Not covered Not covered Not covered

Basic services (restorative fillings) Not covered Not covered Not covered Not covered Not covered Not covered


Not covered Not covered Not covered Not covered Not covered Not covered



Standard (continued)

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HSA QualifiedThese high-deductible health plans have lower premiums. You get affordable

coverage and the flexibility to choose any provider in the Signature Network.

With an HSA Qualified plan, paired with a tax-exempt health savings account,

you save pre-tax dollars to pay for future health care expenses.

HSA Qualified plans offer:

• A preferred rate when you open a health savings account with HealthEquity®, a partner of Providence Health Plan

• Care from specialists without a referral

• Lower premiums with most services subject to the deductible

• In-network preventive care and adult routine vision services that are covered before the deductible




An HSA Qualified plan might be right for you if you actively manage your health care and would like to use pre-tax dollars to help do it.



HSA Qualified

HSA Qualified 2800 Silver HSA Qualified 6000 Bronze




After meeting your deductible, you pay the following amounts for covered services. The deductible does not apply

for some covered services. These are marked with ✓

Preventive Care






HSA Qualified 2800 Silver HSA Qualified 6000 Bronze



Personal physician/provider 20% 50% 20% 50%

Personal physician/provider by phone or video $0 Not covered $0 Not covered

Alternative care provider 20% 50% 20% 50%

Specialist 20% 50% 20% 50%

Hospital Services



Emergency services 20% 20% 20% 20%

Urgent care services 20% 50% 20% 50%


X-ray and lab services 20% 50% 20% 50%




Outpatient provider visits 20% 50% 20% 50%



Chiropractic manipulation and acupuncture Not covered Not covered Not covered Not covered

Prescription Drugs

Preferred generic 20% Not covered 20% Not covered

Non-preferred generic 20% Not covered 20% Not covered

Preferred brand name 20% Not covered 20% Not covered








Vision hardware (frames, lenses, contact lenses); limits apply Not covered Not covered Not covered Not covered





50% 70% 50% 70%



HSA Qualified (continued)

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Compare our 2017 plans side-by-side.

Plan name Balance 2500 Silver

Balance 7150 Bronze

Choice 2500 Silver

Choice 7150 Bronze

Connect 2500 Silver

Connect 2500 Silver

Connect 7150 Bronze

Providence Oregon

Standard Gold Plan

Providence Oregon

Standard Silver Plan

Providence Oregon

Standard Bronze Plan

HSA Qualified 2800 Silver

HSA Qualified 6000 Bronze

Metal level Silver Bronze Silver Bronze Silver Silver Bronze Gold Silver Bronze Silver Bronze

Where to buyAll plans are available through Providence Health Plan or your insurance producer. All plans except HSA Qualified 2800 Silver and Providence Progressive Dental are

also available through the Federal Marketplace at HealthCare.gov.

All plans are available through Providence Health Plan or your insurance producer. All plans except HSA Qualified 2800 Silver and Providence Progressive Dental are also available through the Federal Marketplace at HealthCare.gov.

Annual deductible Individual/Family

$2,500/$5,000 $7,150/$14,300 $2,500/$5,000 $7,150/$14,300 $2,500/$5,000 $7,150/$14,300 $1,000/$2,000 $2,500/$5,000 $7,150/$14,300 $2,800/$5,600 $6,000/$12,000

Annual out-of-pocket maximum Individual/Family

$7,150/$14,300 $7,150/$14,300 $7,150/$14,300 $7,150/$14,300 $7,150/$14,300 $7,150/$14,300 $6,850/$13,700 $6,850/$13,700 $7,150/$14,300 $5,000/$10,000 $6,550/$13,100

Accidental injury benefit The deductible is waived for all covered services required to treat an accidental injury within 90 days of injury.

Covered Not covered Covered Not covered Covered Not covered Not covered Not covered Not covered Not covered Not covered

Personal physician/provider office visit $25✓ $50✓ $25✓ $50✓ $25✓ $50✓ $20✓ $35✓ $70✓ 20% 20%

Specialist office visit $50✓ $0 $50✓ $0 $50✓ $0 $40✓ $70✓ $115✓ 20% 20%

Outpatient diagnostic lab and X-ray 30%✓ 0% 30%✓ 0% 30%✓ 0% 20% 30% 0% 20% 20%

Chiropractic manipulation and acupuncture* $25✓ $25✓ $25✓ $25✓ $25✓ $25✓ Not covered Not covered Not covered Not covered Not covered

Preferred generic prescription drugs (generic for Standard)

$20✓ $30✓ $20✓ $30✓ $20✓ $30✓ $10✓ $15✓ $35✓ 20% 20%

Preferred brand-name prescription drugs $75✓ $0 $75✓ $0 $75✓ $0 $30✓ $50✓ $0 20% 20%

Inpatient hospital 30% 0% 30% 0% 30% 0% 20% 30% 0% 20% 20%

Emergency services $250 then 30% 0% $250 then 30% 0% $250 then 30% 0% 20% 30% 0% 20% 20%

Urgent care visits $75✓ 0% $75✓ 0% $75✓ 0% $60✓ $70✓ $100✓ 20% 20%

Mental health - outpatient visits $25✓ $50✓ $25✓ $50✓ $25✓ $50✓ $20✓ $35✓ $70✓ 20% 20%

Adult vision exams $30✓ $30✓ $30✓ $30✓ $25✓ $25✓ Not covered Not covered Not covered $25✓ $25✓

Pediatric vision (exams and hardware) Covered in full✓ Covered in full✓ Covered in full✓ Covered in full✓ Covered in full✓ Covered in full✓ Covered in full✓ Covered in full✓ Covered in full✓ Covered in full✓ Covered in full✓

Pediatric dental Covered Covered Covered Covered Covered Covered Not covered Not covered Not covered Covered Covered

Premium examples for non-tobacco users for rating Region A

Single, 26 years old $284 $230 $272 $220 $261 $211 $345 $285 $232 $262 $194

Single, 55 years old $619 $500 $593 $459 $569 $459 $751 $620 $506 $571 $422

Family: parents aged 38 and 40, children aged 7 and 10

$1,053 $851 $1,009 $817 $968 $782 $1,279 $1,055 $861 $970 $718

Networks Signature Network Choice Network Connect Network Signature Network

A network of nearly 1 million health care providers nationwide, both in

Providence facilities and in other locations

A network of more than 275 primary care clinics located throughout Oregon and southwest Washington

designated as medical homes

Ben

ton

Clackamas

Clatsop

Columbia

Crook

Deschutes

Douglas

Gilliam

Harney

Hood River

Jackson

Jefferson

Josephine Klamath

Lane

Linn

Marion

Multnomah

PolkWasco

Washington

Wheeler

Yamhill

Lin

coln

Coos

Curry

Lake

Malheur

Sher

man

Tillam

ook

MorrowUnion

Baker

Grant

KlickitatSkam

aniaCowlitz

Clark

Wahkiakum

Umatilla Wallowa

A Portland-area network of more than 70 primary care

clinics in Clackamas, Multnomah and Washington counties

designated as medical homes

A network of nearly 1 million health care providers nationwide, both in Providence facilities and in other locations✓Deductible is waived for these services

*Limited to three visits combined per calendar year

PLEASE NOTE: Benefit examples shown above are for in-network coverage only. For the full listing of in-network and out-of-network benefits, visit ProvidenceHealthPlan.com.

For a listing of providers, visit ProvidenceHealthPlan.com/findaprovider.

18 19

For medical advice and quick care, we've got you covered, wherever you are and whenever you need us.Getting the right care, at the right place, at the right time – that’s what you get with our

range of services designed to save you money and time. For example, you can have an on-

demand phone or video visit with a health care provider for common conditions from sinus

infections to sprains, at no cost to you. Just to compare, an urgent care clinic visit might

cost as much as $100 for those conditions and you might have to wait a while to be seen.

Here are some of the services we offer for your care, from minor conditions to emergency issues.

ProvRN Express Care Virtual

Express Care clinic

Primary care clinic Urgent care Emergency

When 24/7 8 a.m. to midnight,

seven days a week

7 a.m. to 7 p.m. or 8 a.m. to

8 p.m., seven days a week

Hours vary by location

Hours vary by location

24/7

Where On the phone Online In your neighborhood

With your personal physician/provider

Various locations Various locations

What you get

A phone consultation

with a registered

nurse for health advice and a

recommendation for what to do

next

A video visit for common conditions,

such as sinus, ear and eye infections,

coughs, colds, flu, rashes, allergies

A local clinic visit for same-day, walk-in care

for basic health conditions, such

as headaches, sprains, strains,

abrasions, nausea, vomiting

A clinic where you see a personal physician/provider

for normal medical services

and health concerns

A health center for urgent

medical needs that aren’t life-

threatening, such as minor cuts or burns, ear,

nose and throat issues, sprains,

strains, stomach aches, headaches,

dizziness

An emergency department, usually in a hospital, for life-threatening health issues, including

heart attack, acute abdominal pain,

stroke, severe chest pain, poisoning, loss

of consciousness, bleeding that does

not stop

In-network costs for all plans except HSA Qualified (✓ means deductible does not apply)

$0✓ $0✓ $20-$70✓ $20-$70✓ $60-$100✓ or 0%

$250 then 30% or 0%-30%

In-network costs for HSA Qualified plans (deductible applies)

$0✓ $0 20% 20% 20% 20%

Refer to the plan overview or a benefit summary for the specific costs for your plan.

Providence Progressive Dental Plan option Providence Progressive Dental provides comprehensive benefits that promote good

health with coverage for preventive care, such as X-rays and cleanings. Basic and

major services, including extractions, crowns and dentures, are also covered. Through

the plan, you have access to more than 2,300 in-network dental provider listings in

Oregon and southwest Washington and more than 270,000 in-network provider listings

nationwide. To search for a dentist, visit ProvidenceHealthPlan.com/findaprovider.

Providence Progressive Dental Plan features:

• Progressive benefits reward proper dental care by reducing your costs in subsequent years of service.

• You may be treated by any licensed dentist, but your out-of-pocket costs will be lower if you use an in-network provider.

• There are no waiting periods for dental coverage.

• In-network diagnostic and preventive care services, such as exams, cleanings and X-rays, are covered in full. You are also covered for more extensive services, including root canals, crowns, bridges and dentures.

• Rate: $30 per member per month

Providence Progressive Dental Plan

In-network Out-of-network

Deductible (per person) $25 $50

Deductible (per family) $75 $150

Annual maximum benefit (per person)* $1000

Waiting period None None

Below is the amount you pay after you have met your deductible. The deductible is waived for some covered services. These are marked with ✓

In-network Out-of-network

Year 1 Year 2 Year 3 Year 1 Year 2 Year 3

Diagnostic and preventive services (includes routine exams, X-rays, cleanings, topical fluoride [age 16 and younger])

Covered in full✓

Covered in full✓

Covered in full✓ 10%✓ 10%✓ 10%✓

Basic services (includes restorative fillings) 50% 40% 20% 70% 50% 30%

Major services (includes oral surgery, crowns, endodontics, periodontics, denture and bridge work) 75% 65% 50% 90% 80% 60%

* Preventive services do not apply to the annual maximum benefit.

Important information about dental coverage:

You must purchase a PHP medical plan in order to purchase the Providence Progressive Dental Plan. You may not purchase our dental plan if you get your Providence medical plan through the Marketplace.

If you apply for this dental plan, everyone enrolled on the application will be included on the dental plan. If anyone in your family wishes to have just medical and not dental, you must submit a separate application.

Our optional Providence Progressive Dental Plan provides benefits for adults and children for an additional monthly premium per person, per month. If you choose Providence Progressive Dental, all people on the policy will be enrolled and charged the dental premium amount in addition to the medical plan premium. In order to purchase the Providence Progressive Dental Plan, you must also purchase a Providence Health Plan medical plan.

If you purchase a Providence Health Plan Standard medical plan, adding the Providence Progressive Dental Plan for children aged 18 and younger does not satisfy the ACA pediatric dental Essential Health Benefit (EHB) requirement.

For more details on the Providence Progressive Dental Plan, visit ProvidenceHealthPlan.com.

20 21

Other things to know as you consider your coverageSpecial enrollment

To apply for 2017 medical coverage or make a change to your current plan outside of the open enrollment period, you must qualify for special enrollment. You can apply for and get health insurance coverage during the special enrollment period if you lose your medical coverage or experience certain life events, such as marriage or adoption. For more information and a list of qualifying events, visit ProvidenceHealthPlan.com/qe.

Application and premium payment dates

Your paper or online application submitted directly to Providence Health Plan needs to be received by the requested effective date.

When you start coverage, your first health insurance premium is due by the end of the first day of coverage. For example, if your coverage start date is Feb. 1, your payment must be received by Providence Health Plan by the close of business on Feb. 1. On a monthly, ongoing basis, your premium is due the first day of the month. For your convenience, you can set up auto-pay with your financial institution or through your myProvidence account.

Eligibility

To purchase one of our plans, you must live in the service area and be a legal resident of the state of Oregon.

In order to be eligible to enroll in the Providence Progressive Dental Plan, you must enroll in a Providence Health Plan Individual and Family medical plan.

Providence is non-duplication with Medicare on Individual and Family plans. Someone who is entitled to Medicare part A or enrolled in part B is not eligible to enroll in a PHP Individual and Family plan.

Privacy policy

Visit ProvidenceHealthPlan.com to learn about Providence Health Plan privacy practices. You may obtain

a copy of our Providence Health Plan Notice of Privacy Practices by going to ProvidenceHealthPlan.com

and selecting “Privacy Notices & Policies” or by calling customer service at 800-878-4445.

Individual and Family Plan rates for 2017Several factors make up your monthly premium rate:

• Your age

• Whether or not you use tobacco

• The county where you live

To determine the premium for yourself as an individual, go to the rate pages for the county in which you live and your tobacco-user status, find your age and choose the plan that fits your needs.

To determine the premium for you and your family, go to the rate pages for the county in which you live and choose the plan that fits your needs, then use the ages for each person to be covered. Please note that if any person aged 21 and older is a tobacco user, you will need to add 10% to that person's rate. Add the premium amounts for each family member to determine your total. If you’re covering more than three children 20 years of age and younger, only add the premiums for your first three children.

PLEASE NOTE: Tobacco use is defined as the use of tobacco products in any form for an average of four or more times per week within the past six months.

Providence rates are grouped by county as follows:

Group A: Clackamas, Gilliam, Hood River, Marion, Morrow, Multnomah, Polk, Sherman, Wasco, Washington, Wheeler, Yamhill

Group B: Benton, Lane, Linn

Group C: Clatsop, Columbia, Lincoln, Tillamook

Group D: Coos, Curry

Group E: Douglas, Jackson, Josephine

Group F: Deschutes, Klamath, Lake

Group G: Baker, Crook, Grant, Harney, Jefferson, Malheur, Umatilla, Union, Wallowa

22 23

Individual and Family Plan Rates, Group A: Non-tobacco userTobacco users age 21 and older need to add 10% to the rates shown below.*

Group A counties: Clackamas, Gilliam, Hood River, Marion, Morrow, Multnomah, Polk, Sherman, Wasco, Washington, Wheeler, Yamhill

Purchase these plans directly from Providence at ProvidenceHealthPlan.com or your insurance producer. The HSA Qualified 2800 Silver plan may not be purchased through the Federal Marketplace.

Plan Name 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 6465

and Over

Balance 2500 Silver 377 388 401 416 434 454 473 496 518 542 566 593 619 648 676 707 722 753 780 797 819 834 834 Balance 7150 Bronze 304 313 324 337 351 367 383 401 418 438 458 479 500 523 547 572 584 609 631 645 662 672 672 Choice 2500 Silver 361 372 384 399 416 435 454 475 496 519 543 568 593 621 648 678 692 722 747 764 785 798 798 Choice 7150 Bronze 292 301 311 323 336 352 367 384 401 420 439 459 480 502 524 548 560 584 605 618 635 645 645 Connect 2500 Silver 346 356 368 382 399 417 435 455 476 498 520 544 569 595 621 650 664 692 716 733 753 765 765 Connect 7150 Bronze 280 288 298 309 322 337 352 368 384 402 420 440 459 481 502 525 536 559 579 592 608 618 618 HSA Qualified 2800 Silver 347 357 369 384 400 418 436 457 477 499 522 546 571 597 623 652 666 694 719 735 755 768 768 HSA Qualified 6000 Bronze 257 264 273 284 296 309 323 338 353 369 386 404 422 442 461 482 493 514 532 544 559 567 567 Providence Oregon Standard Gold Plan 457 471 487 505 527 551 575 602 628 658 687 719 751 786 821 859 877 915 947 968 995 1011 1011 Providence Oregon Standard Silver Plan 377 388 402 417 435 455 474 497 519 543 567 594 620 649 678 709 724 755 781 799 821 834 834 Providence Oregon Standard Bronze Plan 308 317 327 340 354 371 387 405 423 443 463 484 506 529 553 578 590 615 637 651 669 681 681

AgeAge

Effective Jan. 1, 2017 – Dec. 31, 2017

Plan Name 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Balance 2500 Silver 176 278 278 278 278 279 284 291 302 311 315 322 328 333 337 339 341 344 346 350 355 361 368 Balance 7150 Bronze 142 224 224 224 224 225 230 235 244 251 255 260 265 269 272 274 276 278 280 283 287 292 297 Choice 2500 Silver 169 266 266 266 266 267 272 279 289 298 302 308 315 319 323 325 327 329 331 336 340 346 352 Choice 7150 Bronze 137 215 215 215 215 216 220 226 234 241 244 249 255 258 261 263 265 266 268 272 275 280 285 Connect 2500 Silver 162 255 255 255 255 256 261 267 277 285 289 296 302 305 310 312 314 316 318 322 326 332 338 Connect 7150 Bronze 131 206 206 206 206 207 211 216 224 231 234 239 244 247 250 252 253 255 257 260 263 268 273 HSA Qualified 2800 Silver 162 256 256 256 256 257 262 268 278 286 290 297 303 306 311 313 315 317 319 323 327 333 339 HSA Qualified 6000 Bronze 120 189 189 189 189 190 194 198 206 212 215 219 224 227 230 231 233 234 236 239 242 246 251 Providence Oregon Standard Gold Plan 214 337 337 337 337 338 345 353 366 377 382 391 399 404 409 412 414 417 420 425 431 439 446 Providence Oregon Standard Silver Plan 177 278 278 278 278 279 285 291 302 311 316 322 329 333 338 340 342 344 346 351 355 362 368 Providence Oregon Standard Bronze Plan 144 227 227 227 227 228 232 238 246 254 257 263 268 272 275 277 279 281 283 286 290 295 300

AgeAge

Plans available by county:

Balance: Clackamas, Marion, Multnomah, Polk, Washington, YamhillChoice: Clackamas, Hood River, Marion, Multnomah, Polk, Washington, YamhillConnect: Clackamas, Multnomah, WashingtonHSA Qualified: Clackamas, Marion, Multnomah, Polk, Washington, YamhillStandard: Clackamas, Gilliam, Hood River, Marion, Morrow, Multnomah, Polk, Sherman, Wasco, Washington, Wheeler, Yamhill

*Tobacco use is defined as the use of tobacco products in any form an average of four or more times per week within the past six months.

24 25

Individual and Family Plan Rates, Group B: Non-tobacco userTobacco users age 21 and older need to add 10% to the rates shown below.*

Group B counties: Benton, Lane, Linn

Group B plans: Balance, HSA Qualified, Standard


Plan Name 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 6465

and Over

Balance 2500 Silver 403 415 429 445 464 486 507 530 554 580 606 634 662 693 724 757 773 806 835 853 877 891 891 Balance 7150 Bronze 326 335 347 360 375 393 410 429 448 469 490 513 535 560 585 612 625 652 675 690 709 720 720 HSA Qualified 2800 Silver 371 382 395 411 428 448 467 489 511 534 558 584 610 639 667 697 713 743 769 786 808 822 822 HSA Qualified 6000 Bronze 275 283 292 304 316 331 345 362 378 395 413 432 452 472 493 516 527 550 569 582 598 606 606 Providence Oregon Standard Gold Plan 489 504 521 541 564 590 615 644 672 704 736 770 804 841 879 919 939 979 1013 1036 1064 1083 1083 Providence Oregon Standard Silver Plan 404 416 430 446 465 486 508 531 555 581 607 635 663 694 725 758 774 808 836 855 878 894 894 Providence Oregon Standard Bronze Plan 329 339 350 364 379 397 414 433 453 474 495 518 541 566 591 618 632 659 682 697 716 729 729

AgeAge


Plan Name 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Balance 2500 Silver 189 297 297 297 297 298 304 311 323 332 337 344 351 356 361 363 365 368 370 375 380 387 393 Balance 7150 Bronze 152 240 240 240 240 241 246 252 261 269 273 278 284 288 291 293 295 297 299 303 307 313 318 HSA Qualified 2800 Silver 174 274 274 274 274 275 280 287 298 306 311 317 324 328 332 335 337 339 341 345 350 356 363 HSA Qualified 6000 Bronze 129 202 202 202 202 203 207 212 220 227 230 235 240 243 246 247 249 251 252 256 259 264 268 Providence Oregon Standard Gold Plan 229 361 361 361 361 362 369 378 392 403 409 418 427 432 438 441 443 446 449 455 461 469 478 Providence Oregon Standard Silver Plan 189 298 298 298 298 299 305 312 323 333 338 345 352 356 361 364 366 368 371 375 380 387 394 Providence Oregon Standard Bronze Plan 154 243 243 243 243 244 248 254 264 272 275 281 287 291 295 297 298 300 302 306 310 316 321

AgeAge


26 27

Individual and Family Plan Rates, Group C: Non-tobacco userTobacco users age 21 and older need to add 10% to the rates shown below.*

Group C counties: Clatsop, Columbia, Lincoln, Tillamook

Group C plans: Balance, HSA Qualified, Choice, Standard


Choice plans are available in Clatsop County only.

Plan Name 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 6465

and Over

Balance 2500 Silver 414 427 441 458 477 499 521 545 569 596 623 652 681 712 744 778 795 829 858 877 901 915 915

Balance 7150 Bronze 335 345 356 370 386 404 421 441 460 482 504 527 550 576 602 629 642 670 694 709 729 741 741

HSA Qualified 2800 Silver 382 393 406 422 440 460 480 503 525 549 574 601 628 657 686 717 733 764 791 809 831 843 843

HSA Qualified 6000 Bronze 282 291 301 312 325 340 355 372 388 406 425 444 464 486 507 530 542 565 585 598 615 624 624

Choice 2500 Silver Clatsop County Only 397 409 423 439 457 478 499 523 546 571 597 625 652 683 713 746 762 794 822 841 864 879 879

Choice 7150 Bronze Clatsop County only 321 331 342 355 370 387 404 423 442 462 483 505 528 552 577 603 616 643 665 680 699 711 711

Providence Oregon Standard Gold Plan 503 518 535 556 579 606 632 662 691 724 756 791 827 865 903 944 965 1006 1042 1065 1094 1113 1113

Providence Oregon Standard Silver Plan 415 427 442 459 478 500 522 546 570 597 624 653 682 714 745 779 796 830 860 879 903 918 918

Providence Oregon Standard Bronze Plan 338 348 360 374 390 408 426 445 465 487 509 533 556 582 608 636 649 677 701 717 736 747 747

AgeAge


Plan Name 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Balance 2500 Silver 194 305 305 305 305 307 313 320 332 342 347 354 361 366 371 373 376 378 380 385 390 398 405

Balance 7150 Bronze 157 247 247 247 247 248 253 259 268 276 280 286 292 296 300 302 304 306 308 311 315 321 327

HSA Qualified 2800 Silver 179 281 281 281 281 283 288 295 306 315 319 326 333 337 342 344 346 348 351 355 360 366 373

HSA Qualified 6000 Bronze 132 208 208 208 208 209 213 218 226 233 236 241 246 249 253 254 256 258 259 263 266 271 276

Choice 2500 Silver (Clatsop County only) 186 293 293 293 293 294 300 307 318 327 332 339 346 351 355 358 360 362 365 369 374 381 388

Choice 7150 Bronze (Clatsop County only) 150 237 237 237 237 238 242 248 257 265 269 274 280 284 287 289 291 293 295 299 303 308 314




AgeAge


28 29

Individual and Family Plan Rates, Group D: Non-tobacco userTobacco users age 21 and older need to add 10% to the rates shown below.*

Group D counties: Coos, Curry

Group D plans: Providence Oregon Standard Gold Plan Area D, Providence Oregon Standard Silver Plan Area D, Providence Oregon Standard Bronze Plan Area D

Purchase these plans directly from Providence at ProvidenceHealthPlan.com or your insurance producer.

Plan Name 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 6465

and Over

Providence Oregon Standard Gold Plan Area D 607 625 646 671 700 732 764 799 835 874 913 956 998 1044 1091 1140 1165 1215 1258 1286 1321 1342 1342

Providence Oregon Standard Silver Plan Area D 501 516 533 554 577 604 630 660 689 721 753 788 823 861 900 941 961 1002 1038 1061 1090 1107 1107

Providence Oregon Standard Bronze Plan Area D 408 421 435 452 470 492 514 538 561 588 614 643 671 702 734 767 784 817 846 865 889 902 902

AgeAge


Plan Name 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Providence Oregon Standard Gold Plan Area D 284 448 448 448 448 449 458 469 486 501 508 519 529 536 543 547 550 554 558 565 572 583 593

Providence Oregon Standard Silver Plan Area D 234 369 369 369 369 371 378 387 401 413 419 428 437 442 448 451 454 457 460 466 472 481 489

Providence Oregon Standard Bronze Plan Area D 191 301 301 301 301 302 308 315 327 337 342 349 356 361 365 368 370 373 375 380 385 392 399

AgeAge


Individual and Family Plan Rates, Group E: Non-tobacco userTobacco users age 21 and older need to add 10% to the rates shown below.*

Group E counties: Douglas, Jackson, Josephine

Group E plans: Providence Oregon Standard Gold Plan, Providence Oregon Standard Silver Plan, Providence Oregon Standard Bronze


Plan Name 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 6465

and Over




AgeAge


Plan Name 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42




AgeAge

30 31

Individual and Family Plan Rates, Group F: Non-tobacco userTobacco users age 21 and older need to add 10% to the rates shown below.*

Group F counties: Deschutes, Klamath, Lake

Group F plans: Providence Oregon Standard Gold Plan, Providence Oregon Standard Silver Plan, Providence Oregon Standard Bronze


Plan Name 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 6465

and Over




AgeAge


Plan Name 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42




AgeAge


Individual and Family Plan Rates, Group G: Non-tobacco userTobacco users age 21 and older need to add 10% to the rates shown below.*

Group G counties: Baker, Crook, Grant, Harney, Jefferson, Malheur, Umatilla, Union, Wallowa

Group G plans: Providence Oregon Standard Gold Plan Area G, Providence Oregon Standard Silver Plan Area G, Providence Oregon Standard Bronze Plan Area G


Plan Name 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 6465

and Over

Providence Oregon Standard Gold Plan Area G 631 649 671 697 726 760 793 830 867 907 948 992 1036 1084 1133 1184 1210 1261 1306 1335 1372 1394 1394

Providence Oregon Standard Silver Plan Area G 520 536 554 575 599 627 654 685 715 749 782 819 855 895 935 977 998 1041 1078 1102 1132 1149 1149

Providence Oregon Standard Bronze Plan Area G 424 437 451 469 489 511 533 558 583 610 638 667 697 729 762 797 814 848 878 898 923 937 937

AgeAge


Plan Name 0 to 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Providence Oregon Standard Gold Plan Area G 295 465 465 465 465 467 476 487 505 520 528 539 550 557 564 568 572 575 579 587 594 605 616

Providence Oregon Standard Silver Plan Area G 244 383 383 383 383 385 393 402 417 429 435 444 454 459 466 469 472 475 478 484 490 499 508

Providence Oregon Standard Bronze Plan Area G 199 313 313 313 313 314 320 328 340 350 355 362 370 374 379 382 384 387 389 394 400 407 414

AgeAge

Providence Health & Services, a not-for-profit health system, is an equal opportunity organization in the provision of health care services and employment opportunities.

© 2016 Providence Health Plan. All rights reserved.

Our Mission As people of Providence, we reveal God’s love for all, especially the poor and vulnerable, through our compassionate service.

Our Core Values Respect, Compassion, Justice, Excellence, Stewardship

Portland metro area 503-574-5000 All other areas 800-988-0088

Hours: 8 a.m. to 5 p.m., Monday – Friday

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