2017 small group individual & family and medicare ... · consulting nurse service—free to...
TRANSCRIPT
Welcome 2017 Small Group
Individual & Family, and
Medicare Advantage plans
Agenda
• Welcome
• What’s new?
• 2017 Small Group
• 2017 Individual and Family
• 2017 Medicare Advantage
• Questions and discussion
2
Virtual Care
Group Health is changing how we cover virtual care
effective January 1, 2017
Virtual care –
• Includes phone visit, online (CareNow) or secure
messaging via MyGroupHealth
Applies to commercial business
• I&F, SBG, Large, PEBB and FEHB
No charge for virtual care –
• Except for H.S.A. plans
• IRS regulations require cost share
For In-network patients
• Group Health delivery system, contracted network, First
Choice and First Health only
3
Access care multiple ways: phone
Consulting Nurse Service—free to health plan members
• Call 24/7 for advice and health education, including triage
of acute/chronic conditions and care coordination
• Home care advice and prescriptions available for a limited
set of illnesses
Scheduled phone visit—available to health plan members
• Covered as virtual care 1/1/17
• Set a phone visit with your doctor or
care team
• Get diagnosis and treatment information via phone
4
Access care multiple ways: online
CareNow
• Covered as virtual care 1/1/17
• Interact online with a clinician for common conditions
• Get your diagnosis and treatment plan based on your
responses to questions
• Available 9 a.m.—7 p.m. (Pacific) response guaranteed
within one hour
Secure messaging—free to health plan members
• Covered as virtual care 1/1/17
• Email your care team for simple answers and advice
• Response typically within one business day
5
Access care multiple ways: face to face
CareClinic—$110 visit / $15 lab to health plan members (open to all)
• Walk-in clinic for minor injuries and illnesses, vaccines
• Currently available at 10 Bartell Drugs locations (no appointment
necessary)
• Self-pay/no insurance copay: $75
• Sports/camp physicals: $50
Urgent care—member cost share varies by location (open to all)
• Walk in clinic for conditions that require prompt attention, no
appointment necessary
• Available at Bellevue, Olympia, Seattle, Silverdale,
and Tacoma Group Health Medical Centers
Clinic visit—cost share varies by plan
• Schedule an appointment to see your family doctor or
a specialist
• Limited same-day appointments at Group Health
Medical Centers
6
2017
Small Group
Small group service area
Small group plans provide access to an extensive network
of providers that includes hospitals, specialty practices,
primary care clinics, and individual practitioners
8
SMALL GROUP
2017 PORTFOLIO OF PLANS
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Core network plans
Group Health Cooperative
Access PPO network plans
Group Health Options, Inc.
Bronze HSA Access PPO Bronze HSA
Silver HSA Access PPO Silver HSA
Silver Access PPO VisitsPlus Silver
VisitsPlus Silver Access PPO VisitsPlus Silver-EO NEW!
VisitsPlus Silver—EO Access PPO VisitsPlus Gold
Gold Access PPO VisitsPlus Platinum
VisitsPlus Gold HD NEW!
VisitsPlus Gold
VisitsPlus Gold—EO
VisitsPlus Platinum
EO = employee only contract; no spouse or dependent coverage
HD = High Deductible
2017 small group portfolio snapshot
10
Core plans for small groups
Core HMO Plans
Group Health Physician Network
• 25 Group Health Medical Centers locations*
• More than 1,000 Group Health doctors*
- Primary and Specialty
• 9,000 contracted providers
• Urgent care at 5 locations; 3 locations 24/7
• Pharmacy Services
• Other services:
- Eye care; mental health; hearing centers;
speech, language and learning centers;
and occupational health
* OIC Provider Network Form A 11
Access PPO is similar to the PPOs you’re used to:
• Primary Care Provider not required, but recommended for guidance
• No health plan referrals required
• Prior Authorization required for standard limited set of services
• Separate Deductible and OOP Max for out-of-network providers
Access PPO’s added bonuses:
• Provides access to Group Health Medical Centers.
• Reduced costs for members when they utilize their enhanced benefit
with high-performing providers in Washington state for:
- Office visits
- Prescriptions
Access PPO for small groups
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Our networks are anchored on
high-performing providers
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Access PPO network
PREFERRED PROVIDER NETWORK
OUT OF
NETWORK
In Network Enhanced Providers
(Lower member cost shares)
In Network Standard
Providers
Thousands of select providers,
including:
• The 1,000+ Group Health Physicians*
• CareUnity (GH, CMA & Providence
Spokane)
• Walla Walla Clinic
• Family Care Network
• Family Care Network in
North Sound area
• Kadlec Clinics in Tri-Cities
• Memorial Physicians in Yakima
Also includes:
• Group Health pharmacies
• Group Health pharmacy Mail Order
• Extensive network of
Washington providers
contracted with Group Health
• First Choice Health providers
in Oregon, Idaho, Montana,
Alaska, and Washington
• First Health Network providers
in all other states
• OptumRx pharmacies
• All other
licensed
providers
in the U.S.
* OIC Provider Network Form A 14
Access PPO includes some of the area’s top providers
• Seattle Children’s
• Swedish Physicians
• The Polyclinic
• UW Medicine
• Seattle Cancer Care Alliance
• Franciscan Health System
• Harrison Health Partners
• Overlake Medical Center & Clinics
• Proliance Surgeons
• The Everett Clinic
• Multi Care
• Virginia Mason
• Providence Health Care
• Family Care Network
• Pacific Medical Centers
• Minor & James Medical
• Pediatric Associates
• Evergreen Health Medical Center
In addition to Group Health medical centers, our PPO includes access
to a large number of providers and well known medical groups:
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Access PPO includes these medical groups in Spokane
• Group Health Physicians
• Columbia Medical Associates
• Providence
• Rockwood Health Systems
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Access PPO for small groups includes these medical groups in Central Washington
• Kadlec Regional Medical Center
• Lourdes Health Network
• PMH Medical Center
• Kittitas Valley Healthcare
• Sunnyside Community Hospital
and Clinics
• Yakima Regional Medical
and Cardiac Center
• Yakima Valley Memorial Hospital
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2017 DENTAL PLANS
SMALL GROUP
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We continue team up with Delta Dental in 2017
• Largest dental provider network in Washington State
– Includes Delta Dental Premier® and Delta Dental PPOSM networks
• For new groups and renewing groups (at renewal)
• Pediatric coverage is required
– All plans satisfy the ACA Essential Health Benefits requirements
for members under the age of 19
– Must choose pediatric-only plan if no adult/family plan selected
• Cannot waive even if the member/group has other coverage
• Plans will Coordinate Benefits (COB)
• Pediatric Benefits/premiums are no longer embedded in medical
coverage
2017 Small Group Dental Information
*Exceptions: I&F HealthPays Connect Bronze, SBG Core and Connect Bronze HSA’s; pediatric dental offered by Group Health
Options, Inc. and administered by United Concordia Dental will continue to be embedded in medical plan for 2016. Coverage provided
by Delta Dental of Washington 19
Two Adult/Family Dental plans available
• Plans include mandated pediatric coverage
• Common Enrollment (Medical/Dental)
• No waiting period for services
• Basic Adult/Family Dental Plan
- $1,000 Annual Maximum and coverage at 100%/50%/50%
• Standard Adult/Family Dental Plan
- $1,500 Annual Maximum and coverage at 100%/80%/50%
Pediatric-Only Plan (up to age 19)
• No annual maximum
• $350 individual/$700 family out-of-pocket maximum per year,
applicable to participating providers only
• Required if no Adult/Family plan is chosen
2017 Small Group Dental Options
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2017 Small Group Dental Rates
Monthly Rates Basic Standard
Employee only $32.56 $39.81
Employee + spouse $65.12 $79.61
Employee + child(ren) $85.77 $99.67
Employee + family $139.73 $163.53
Rates for child(ren) or family members under the age of 19 include pediatric dental coverage
and rates.
Adult/Family rates
Pediatric rates
Monthly Rates SBG 2017 Pediatric Dental Rates (DDWA)
Indiv 1 (<19) $38.17
Indiv 2 (<19) $76.35
Indiv 3+ (<19) $114.52
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SMALL GROUP
ADDITIONAL UPDATES
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Conditions of offering for small groups
Coverage is offered on a sole-carrier basis
Participation and contribution rules:
• Group determines eligibility requirements (no minimum hour requirement
from Group Health)
• Groups 1‒3: 100 percent of eligible employees not covered
by similar existing plans; waivers required
– Note: Groups of one required to be a common law employee
• Groups 4‒50: No minimum participation requirements;
no waivers required
• Minimum 50 percent employer contribution for employee premium
• No enrollment or premium contribution requirements for dependents
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Conditions of offering for small groups
Residency Requirements:
• Core network plans:
- 100% of covered employees must reside within the service area
• Access PPO Plans:
- 90% of covered employees must reside within the service area
Groups of 10 or more employees can offer one or two plans:
• No plan combination requirements
• Core network and Access PPO network plans can be combined
Enrollment minimums if offering two plans:
• 10–24 employees (at least 3 employees on each plan)
• 25–50 employees (at least 5 employees on each plan)
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Friendly reminders…
Cut off dates
• Renewals –10th of the month
• New sales – 20th of the month
ID cards
Census Enrollment Template
• Preferred option for new groups
Delta Dental contracts
• Producer email (Contract, Signature Page, Booklet request form)
SBC and Welcome Letter emails
• Regulation and purpose
Lean daily management model
• Staff contact and response
Producer Portal line
• Provides web support
Provider Directory
Staff Contact sheet 25
2017
Individual & Family
What’s new? Washington Healthplanfinder: new offerings and resources
Optional family dental coverage options for 2017
– More details provided in dental section of today’s presentation.
Pay Now pilot available during open enrollment
– Allows new enrollees and existing enrollees making a plan change
or adding dental to pay premiums at the time of application.
Quality rating system
– Determined by The Centers for Medicare and Medicaid services.
Displayed ratings are based on customer surveys and clinical data.
– Group Health achieves 4 out of 5 Stars
CMS rates qualified health plans (QHPs) offered through the Marketplaces using the Quality Rating
System (QRS), which is based on third-party validated clinical measure data and QHP Enrollee Survey
response data. CMS calculates rating each year (on a 5-star scale), and ratings may change from one
year to the next. For more information, please see CMS’ Health Insurance Marketplace Quality Initiatives
website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/QualityInitiativesGenInfo/Health-Insurance-Marketplace-Quality-Initiatives.html.
27
Individual Market trends – National and Regional
Real variation in market and carrier performance (2014):
1. Plans based on narrower network (HMO) performed better than broad
plans (PPO).
2. Variation continued in 2015 with larger aggregate losses.
– Plans report higher Medical Loss Ratio in 2015 than 2014 (a
combination of risk selection and people using their benefits); and
– Reinsurance wear-off
3. Carrier reaction for 2016 and 2017:
– Withdraw from the Individual market
– Movement toward narrower network (ACO) and/or
EPO/HMO plans.
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Individual Market trends – WA state
Washington Carrier reaction for 2016 and 2017:
• Withdrew from individual market (e.g. MODA – 2016, Columbia United
Providers- 2016, United – 2017).
• Exiting certain WA counties (Premera/ Lifewise in 2017)
• Movement toward narrower/provider partner specific networks
(Regence/BridgeSpan) and/or EPO plans (Premera/LifeWise).
• Filed average rate increases for 2017 of 12+%
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Individual & Family GHO, Inc. plans
Financial performance has been declining since Q1 2015
• Took steps remediate performance replacing poor performing
Connect POS products with Access PPO portfolio.
• Based on 2016 experience, portfolio continues to experience high
utilization and adverse selection.
• Reinsurance and risk adjustment programs are not offsetting the
costs incurred.
• Like many carriers in Washington and nationally sustaining broad
network plans in the I&F market is becoming financially challenging.
• More and more consumers are selecting narrow network plans at
lower premiums
30
2017 Individual & Family Access PPO plans Group Health will NOT actively market the Individual & Family
Access PPO plans
What does this mean?
• Current I&F Access PPO members plan’s WILL renew.
– Dependents can be added to existing coverage
• Decision is limited to the I&F Market and not a reflection of Access PPO
performance offered in Large and Small Group.
• Focus on promoting our competitive Individual & Family Core HMO
portfolio of plans to best meet consumer demand.
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2017 Individual & Family Access PPO plans Group Health will NOT actively market the Individual & Family
Access PPO plans
What does this mean?
• Commissions will be paid on 2016 members that renew for 2017
• No commissions paid on new 2017 Individual & Family Access PPO
sales.
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INDIVIDUAL & FAMILY
2017 PORTFOLIO OF PLANS
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2017 Individual & Family plan renewal snapshot
• All Core HMO offerings, whether purchased on or off-exchange from
Group Health will renew.
– No benefit changes
– Deductible and out of pocket maximum revisions
– Specialty RX copay on Flex Gold decreases from 50% to 40%
• All Access PPO offerings will renew.
– No benefit changes
– Deductible and out of pocket maximum revisions
– Specialty RX copay on Access PPO Gold decreases from 50%
to 40%
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2016 to 2017 individual and family plan comparison and mapping
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2017 Individual & Family plans
Core network plans* offered off and on the Washington Healthplanfinder
Core network plans* only offered on
the Washington Healthplanfinder
Bronze—NEW! Core Basics Plus Catastrophic
Flex Bronze Core Silver HSA 73, 87, and 94
Core Bronze HSA Flex Silver 73, 87, and 94
Core Silver HSA VisitsPlus Silver HD 73, 87, and 94
VisitsPlus Silver HD—NEW! Plans for American Indians and Alaska
Natives (AIAN)
Flex Silver
Flex Gold
*All plans are offered through Group Health Cooperative
**We have American Indian and Alaska Native (AIAN) versions for all the HBE plans
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New Core network plans for 2017
Silver VisitsPlus HD features unlimited office visits for only a copay:
– $7,150 / $14,300 individual/family deductible
Deductible not applicable to the following benefits:
– $30 copay Primary Care Provider
– $55 copay Specialty
– $12 Preferred Generic copay, $55 Preferred Brand copay
Bronze features catastrophic-like benefits and competitive rates
– $7,150 / $14,300 individual/family deductible
– 100% coverage after deductible has been met
– Preventive care covered at 100% (deductible not applicable)
37
Our Most Popular Core network plans
Flex plans
– Three metal tiers: Bronze, Silver, Gold
– Upfront visits offer a handful (3, 4, or 5) of office visits not subject
to the deductible
– For the Flex Bronze, upfront visits can be used for primary care.
Flex Silver and Gold, the upfront visits can be utilized for primary
or specialty care.
– Preventive care is covered in full and doesn’t count toward upfront
visit.
– All plans include first dollar coverage for generic prescriptions
HSA compatible plans
– Two metal tiers: Bronze and Silver
38
HealthPays Connect Bronze H.S.A. discontinued
HealthPays Connect Bronze HSA
– Approximately 2,700 members enrolled
• Members will be mapped to the Access PPO HSA Bronze, but can
change to any other offering, including Core HMO plan offerings
• Members will now have the option to select a Delta Dental pediatric
dental and adult/family plans.
Coverage provided by Group Health Options, Inc.
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INDIVIDUAL & FAMILY
2017 DENTAL PLANS
Delta Dental Pediatric-only dental plan for Individual & Family
We continue to team up with Delta Dental in 2017
The pediatric-only plan for dependents up to age 19 is available when a medical plan is purchased off-exchange with Group Health.
Changes
• Deductible (per member), moves from $75 to $85
Pediatric-only dental plan rates have increased by 10.9%:
• 1 member = $36.55
• 2 members = $73.10
• 3+ members = $109.65
How to maintain, add, change or cancel dental during
open enrollment
• See 90-day member important information flyer for details
Coverage provided by Delta Dental of Washington 41
Delta Dental Adult/family dental plan for Individual & Family
The off exchange adult/family option includes pediatric dental
benefits for those under age 19 and adult dental benefits for family
members aged 19 and older.
No benefit or cost share changes for 2017
Adult family rates decreased by 1.5%
• Individual $42.67
• Individual and spouse $85.36
• Individual and children $94.91
• Family $150.91
How to maintain, add, change or cancel dental
during open enrollment
• See 90-day member important information flyer for details
Coverage provided by Delta Dental of Washington
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New Family Dental through the exchange
Washington Healthplanfinder now includes family dental coverage
options for 2017:
• Members and mutual clients 19 years of age and older can now purchase
family dental coverage (includes pediatric dental) through
wahealthplanfinder.org.
– Ensures medical and dental coverage effective dates are consistent.
– One plan per family
• MEMBER ACTION REQUIRED: Approximately 1,300 members that have
obtained their Group Health medical coverage through the exchange, then
purchased dental off the exchange for 2016, will need to take action to maintain
dental coverage for 2017.
– Their current Delta Dental Adult/Family dental coverage will end
Dec. 31, 2016.
– Can select Delta Dental Family coverage or another dental offering
through the Washington Healthplanfinder.
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Notification timeline
Sept. 21, 2016
Producers receive access to 90-day notification letters for renewing and
non-renewing plans, plan update flyers, and cost sharing comparison
between 2016 and 2017 plans.
Oct. 1, 2016
Mutual clients receive their 90-day notification letter of renewal or
non-renewing plan and details about their 2017 plan updates or new
2017 plan. See the 2016–2017 benefit changes and plan mapping flyers
for additional details.
Oct. 28, 2016
Washington Healthplanfinder to send annual notification to recipients of
tax credits for eligibility redetermination.
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YouAreNotEligibleToEnrollinYourCatastrophicHealthPlanin2017OIC-2017-11
Page1
<OIC-2017-11-1><>
320WestlakeAve.N.Suite100 [Date]
Seattle,WA98109
<FNAME><LNAME> <Address Line 1><Address Line 2>
<City>, <State> <Zip code>
Important: You are not eligible for your catastrophic health plan in 2017. You must select a new plan during Open Enrollment.
Dear <PNAME>,
Why am I getting this letter?
In 2016, you enrolled in the Core Basics Plus catastrophic plan. You will not be eligible for the
plan in 2016 because you will be 30 years old and will no longer qualify. On December 31,
2016, we will end your coverage.
To ensure that you have health coverage in 2017, you must choose a new plan. This letter
explains the options available to you.
Options from Group Health Cooperative
We recommend the Flex Bronze plan. You will need to select this plan through the Washington Healthplanfinder, or you may purchase the plan directly from Group Health
Cooperative.
The premium for the Flex Bronze plan starts on January 1, 2017. If you don’ t qualify for
financial help through Washington Healthplanfinder, or if you purchase the plan directly from
Group Health Cooperative, you’ll pay $<premium> each month. To see information about
this rate, go to: www.insurance.wa.gov/health-rates/search.aspx.
If you do qualify for financial help, Washington Healthplanfinder will send you a letter
estimating how much your premium will cost, including any subsidy.
90-day notification material
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Important dates to remember
Nov. 1, 2016–Jan. 31, 2017
General open enrollment when mutual clients can enroll in health plans.*
Jan. 1, 2017
• Coverage begins for plans purchased through Washington
Healthplanfinder on or before Dec. 23, 2016.
• Coverage begins for plans purchased direct from Group Health
on or before Dec. 31, 2016.
*Certain qualifying events—such as losing health coverage, or if there’s a birth or adoption in the family—allow clients to
enroll in a health plan, or modify their coverage, at any time during the year, as long as it’s no more than 60 days from
the date of the qualifying event.
46
2017 Individual Mandate
What happens if individuals and families don’t obtain health care
coverage and are not exempt?
47
Year Per family member
OR Percent of
taxable income
2016
$695 per adult plus
$347.50 per child
($2,085 max per family)
2.5%
2017
and
beyond
The flat and maximum amounts will
adjust for inflation 2.5%
Whichever amount is greater
Visit ghc.org/if
Mutual clients will find
lots of information about:
• Group Health
• Group Health plans
• Subsidy calculator
• Dental plans
• Adding dependents
• Providers
• Qualifying event information
• Health care reform
• Premium payments
48
2017 Medicare Advantage
• Overall portfolio remains stable.
• Any changes made support our ongoing objective to offer competitive
and fiscally responsible plans.
• Rate adjustments on Basic, Essential, Harbor and Optimal plans due
to an increase in the demand for care in the 2015 plan year (last full
year of claims data required for Centers for Medicare and Medicaid
rate filing submission).
• After thoughtful analysis, we've also made the business decision to
discontinue offering the Haven plan in the Northwest counties.
Group Health Cooperative is an HMO plan with a Medicare contract. Enrollment in Group Health HMO
depends on contract renewal. This information is not a complete description of benefits. Contact the plan for
more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-
payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part
B premium. Other pharmacies, physicians, and providers are available in our network. The pharmacy network
and/or provider network may change at any time. You will receive notice when necessary.
2017 Medicare Advantage HMO overview
50
What’s new? New Pharmacy Benefit Manager
Effective Jan. 1, 2017
Medicare Advantage Part D plans will transition to OptumRX, our new
pharmacy benefit claims processor.
• Enhanced member tools (example: looking up prescription
drug costs)
• Broad pharmacy network
• Learnings from Commercial Jan. 1 2016 transition
– Increased testing for each step of the pharmacy benefit value stream
– Additional training involved in using the PBM
– Multiple communications with members, producers and others
51
What’s new? New Pharmacy Benefit Manager
Communication plan
• Member
– New member ID cards inserts
– Explanation of benefits inserts
– Fall issue of Northwest Health Magazine
– Digital heads up to members who have selected e-communications
• Network pharmacy and provider outreach
• Producer
– Producer Pulse related articles
– News you can use
– Medicare Certification plan specific training and testing
52
What’s new? New Pharmacy Benefit Manager
New member ID cards for Medicare Advantage
Prescription Drug plan members
• Members can expect their new member card in
December and before Jan. 1, 2017.
– Encourage mutual clients to begin using new
member ID card Jan.1 2017
• The new member ID card has updated information
so pharmacies can process claims accurately.
53
Overview of changes
Northwest
• Harbor
– Inpatient hospital copay increases from $250 per day (days 1–7)
too $375 per day (days 1–4).
– Reduced the Part D deductible from $360 to $325 (waived on
Tier 1 preferred generics).
Spokane
• Centennial: $200 medical deductible removed.
• Columbia: No substantial changes.
Coverage provided by Group Health Cooperative
54
Overview of changes
Puget Sound:
• Vital enhancements and rate remains at $28:
– Out-of- pocket limit decreases from $6,700 to $5,900
– Replaced co-insurance with set copays for Diagnostic Radiology,
Lab & X-ray and Outpatient Hospital Services.
• Essential: replace co-insurance with set copays for Diagnostic
Radiology.
All regions:
• Basic (no Part D)
– Out-of-pocket maximum decreases from $3,000 to $2,000
– Specialty office visit copay decreases from $35 to $30
Coverage provided by Group Health Cooperative
55
MAPD Haven plan discontinuance
Due to low enrollment and the objective to be fiscally responsible, the
Medicare Advantage Haven (HMO) plan will be discontinued.
• Effective Jan. 1, 2017.
• Impacts approximately 1,700 members in Island, San Juan, Skagit and
Whatcom counties.
• Impacted members provided special enrollment period that overlaps
with AEP and lasts until Feb. 28, 2017
Coverage provided by Group Health Cooperative
56
Notification timeline
Annual Notice of Changes (ANOC):
• Includes Evidence of Coverage (EOC)
• Members will be notified by Sept. 30
Medicare Advantage Haven (HMO) discontinuance:
• Members will be notified by Oct.1
• Notification includes 2017 options, including Basic, Harbor and
Medigap rights
Information made available to Producers the week of Sept. 12
57
58
2017 MEDICARE ADVANTAGE
DENTAL PLAN
2017 Medicare Advantage HMO: dental updates
Plans offered by Delta Dental of Washington.
• Monthly premium remains at $54 per month.
No changes to current benefits:
• $100 deductible per year
• $1,500 annual benefit maximum
• Preventive and diagnostic care, covered at 100% (deductible waived)
• Restorative dental expenses, covered at 80%
• Major expenses, covered at 50%
Coverage provided by Delta Dental of Washington
59
Visit medicare.ghc.org
Our mutual clients will find lots
of information about:
• Group Health
• Group Health Medicare
Advantage plans
• Providers
• Medicare in general
• Prescription drugs
• Helpful videos
• And more
60
Producer Blog Demo Launching in October 2016
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Thank you for your business!
ghc.org
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