annual open enrollment information update · 2019-09-19 · harvard pilgrim health care is proud to...

Annual Open Enrollment – Information Update

Mark Nicholson, Key Account Executive

April/May, 2018

© 2011 Harvard Pilgrim Health Care

Why are We Here?

What is Open Enrollment? – It’s the time in the year when you can enroll or change your benefit

elections. Due to plan changes, employees will need to make a decision on which benefit plan to choose.

What if you don’t make any changes? – If you are not currently enrolled, your next opportunity will be June 1,

2019 unless you have a Qualifying Event.

– Examples of a Qualifying Event are:

• Birth or Adoption

• Death

• Marriage or Divorce

• Loss of Job or Reduction of Hours

– Must notify Sr. Joan within 30 Days from Date of Change. Also notify Sr. Joan of any Beneficiary changes.


Thank You Diocese of Worcester!

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Harvard Pilgrim Health Care is proud to be your group health plan choice once again for 2018 – 2019!

Once again, there will be two health plan options to choose from for the new plan year:

- HMO Best Buy $1000 Plan (Full Network)

- HMO Best Buy $1000 Focus Network Plan (Smaller Network)

Same core HMO rules for each plan: 1) Must choose PCP 2) Must obtain referrals to Specialists.

© 2011 Harvard Pilgrim Health Care 4

More of the doctors and hospitals your employees know and trust accept us

Doctors and hospitals virtually everywhere accept Harvard Pilgrim, including those near where you and your employees live and work.

>53,000 Drs. and clinicians

179 Hospitals in the region

(to find a provider in our network, go go to harvardpilgrim.org)

Harvard Pilgrim Enrollment Area


Benefit

HMO Best Buy $1000 Plan

Requires PCP & Referrals

PCP Non-routine Visits $25 co-payment

Preventive Care / Annual Exam $0 co-payment

Specialist Visits $25 co-payment

Annual Deductible $1,000/Ind., $2000/Family

Chiropractic 12 Visits per Plan Year, OV co-pay applies

Emergency Room Deductible then $100 copayment

Hospital Inpatient Covered in full after Deductible

Day Surgery Covered in full after Deductible

High Tech Imaging (MRI, CAT, PET) Covered in full after Deductible

Durable Medical Equipment 20% Coinsurance after Deductible

Retail Prescription co-pays $5 / $20 / $30 / $50 / $100 (30-day supply)

Mail Order Prescriptions co-pays $10 / $40 / $60 / $100 / $300 (90-day supply)

Out of Pocket Maximum $2000 per member or $4000 per family per PY

HMO Best Buy $1000 – Benefits at a Glance (same Benefits for HMO Best Buy $1000 Focus Network Plan)


Important Terms

Deductible

An Amount you pay each Plan Year for certain services. Once the deductible has been met, most services that are subject to the deductible are covered in full for the balance of the plan year. (Exception is for ER services, once deductible has been met, there is a $100 co-pay for ER services).

Co-payment

A Fixed Dollar Amount that you pay the Provider each time you have a service. (PCP and Specialist Office Visits, Retail pharmacy and mail order RX).

IMPORTANT POINT: You pay the “co-payment” at the time of the service, but you do not pay the “deductible” at the time of the service.


DEDUCTIBLE AMOUNTS

INDIVIDUAL DEDUCTIBLE - $1,000

The maximum Deductible expenses for any one member is $1,000.

FAMILY DEDUCTIBLE - $2,000

The Family Deductible can be made up of any combination of Deductible expenses by members on a Family contract not to exceed $1,000 per Family member.

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HPHC HMO BEST BUY $1000 - Plan Design

NO CHARGE

Select Preventive Tests and Services – Adult annual physical, well child visit, annual GYN exams

SUBJECT TO CO-PAYMENT – Exams for illness or injury

– Consultation with Specialists

– Routine Hearing and Vision Exams

SUBJECT TO DEDUCTIBLE, then NO CHARGE – Hospital Inpatient services

– Hospital Outpatient services and Day Surgery

– Treatments and procedures (chemotherapy, dialysis, surgery)

– Diagnostic Procedures (MRI, X-RAY, CAT, PET)

– Emergency Room ($100 co-pay > Deductible has been met)


In-Network

Deductible Accounting - example

$1000 Individual and $2000 Family Deductible

On the 1st claim of the benefit period, John has a $1000 claim applied to his deductible. John no

longer has to pay deductible for the rest of his plan year, so on his second claim he pays $0. On the family’s 3rd claim, Mary has a $500 claim subject to her deductible. On the 4th claim, Susie also pays a $500 claim subject to her deductible. Mary and Susie haven’t yet met their individual deductible limits, but because the family deductible limit of $2000 has now been reached, no one in the family has to pay any further deductible expenses until the next benefit period.

Claim Order Family Member Deductible Applied

First John $1000

Second John $ 0

Third Mary $ 500

Fourth Susie $ 500

$2000


Examples of how the Best Buy HMO plan works:

Doctor’s Office Visit for routine annual physical

Routine Physical – covered in full (preventive care)

Urinalysis – covered in full (preventive care)

You inform Dr. you have been feeling fatigued lately

Blood test – subject to the deductible (diagnostic)

EKG* – subject to the deductible (diagnostic)

*member may want to discuss with Dr. the value of EKG based

on age, family history, etc.

Your child injures her wrist on the playground

Visit to your PCP – OV co-payment

X-Ray of wrist – subject to the deductible

Splint and/or Sling – subject to the deductible

Follow-up visit with PCP – OV co-payment

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© 2011 Harvard Pilgrim Health Care 12 12

Activity Summary gives members easier-to-understand information!


Focus Network - MA Enrollment Area MA excluding the Cape and Islands

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Focus NetworkSM - MA – How it Works

Specifically designated providers contracted with the Focus Network are placed in two groups

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Statewide Easy Access providers

• 57 Hospitals

• 7,300 PCPs

• 19,700 Specialists

• Full Behavioral Health Network is included, regardless of location

• Emergency Care provided at any facility

Authorized Access providers

• Available for highly specialized care that is not available through Easy Access providers. Limited access to specialists at these hospitals for rare occasion when condition cannot be handled by Easy Access providers

– Children’s Hospital - Boston

– U-MASS Memorial Medical Center


Focus NetworkSM – MA: hospitals

Addison Gilbert Hospital

Anna Jaques Hospital

Athol Hospital

Baystate Medical Center

Berkshire Medical Center

Beth Israel Deaconess Hospital – Milton

Beth Israel Deaconess Hospital – Needham Campus

Beth Israel Deaconess Medical Center

Beverly Hospital

Boston Children’s Hospital at Lexington

Boston Children’s Hospital at Peabody

Boston Children’s Hospital at Waltham

Boston Medical Center

Cambridge Health Alliance

Carney Hospital

Charlton Memorial Hospital

Clinton Hospital

Dana-Farber Cancer Institute

Emerson Hospital

Fairview Hospital

Floating Hospital for Children

Franklin Medical Center

Good Samaritan Medical Center

Harrington Healthcare at Hubbard

Harrington Memorial Hospital

HealthAlliance Hospital – Burbank

HealthAlliance Hospital – Leominster

Heywood Hospital

Holy Family Hospital

Holyoke Medical Center

Jordan Hospital

Lahey Clinic Hospital

Lawrence General Hospital

Lawrence Memorial Hospital

Lowell General Hospital

Marlborough Hospital

Mary Lane Hospital

Massachusetts Eye and Ear Infirmary

Melrose-Wakefield Hospital

Mercy Medical Center

Merrimack Valley Hospital

Metrowest Medical Center – Framingham Union

Metrowest Medical Center – Leonard Morse

Morton Hospital

Mt. Auburn Hospital

Nashoba Valley Medical Center

New England Baptist Hospital

Noble Hospital

Norwood Hospital

Quincy Medical Center

St. Anne’s Hospital

St. Elizabeth’s Medical Center

St. Luke’s Hospital

Saints Medical Center (now part of Lowell General Hospital)

Saint Vincent Hospital

Signature Healthcare

Brockton Hospital

Somerville Hospital

Tobey Hospital

Tufts Medical Center

Whidden Hospital

Winchester Hospital

Wing Memorial Hospital


Health Reimbursement Arrangement

The Diocese is introducing and providing you with a Health Reimbursement Arrangement, or HRA

– IOU that you can “cash” to help pay a portion of your deductible expenses

– It’s funded with employer money

– Easy access to reimbursements

Your HRA administrator is HRCTS – A Harvard Pilgrim Preferred Partner based in New

Hampshire


Health Reimbursement Arrangement

Your HRA reimburses the 2nd half of your deductible.

Individual contract

– Plan Year Deductible: $1,000

– HRA reimburses You: Up to $500 after you pay the initial $500 of deductible

Family contract

– Plan Year Deductible: $2,000

– HRA reimburses You: Up to $1000 after you pay the initial $1000 of deductible

Harvard Pilgrim Prescription Drug Program


More ways to fill prescriptions easily

Large network of pharmacies

– More than 65,000 pharmacies nationwide

– Members have in-network access to independent stores and major chains (e.g., CVS Pharmacy, Eckerd, Hannaford Pharmacy, K-Mart Pharmacy, Rite Aid, Walgreens and Wal-Mart).

– Online pharmacy search

Mail service program

– Order prescriptions on the Web

– Home delivery convenience

– Members receive cost-savings for many medications*

– Plan members receive a 90-day supply for the same cost as a 60-day supply at the retail pharmacy.


Prescription Drug co-payments

30 Day Retail:

– Tier 1 $ 5 Lower-cost generics

– Tier 2 $ 20 Higher-cost generics

– Tier 3 $ 30 Mostly preferred brand name RX

– Tier 4 $ 50 Mostly non-preferred brand name RX

– Tier 5 $100 Mostly non-preferred Specialty RX

90 Day Mail Order:

– Tier 1 $ 10 Lower-cost generics

– Tier 2 $ 40 Higher-cost generics

– Tier 3 $ 60 Mostly preferred brand name RX

– Tier 4 $100 Mostly non-preferred brand name RX

– Tier 5 $300 Mostly non-preferred Specialty RX


Helpful Rx resources @ harvardpilgrim.org

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Drug tier look-up

View or print drug list

- Alphabetically or by

- Drug category

Reliable prescription and over-the-counter drug information

Unbiased drug reports and recommendations from Consumer Reports Best Buy Drugs

*Note: The Diocese has a “Value 5-tier RX” Program when looking up a prescription on our website.

*If your ID card has five price levels for Rx, you have a Value 5-Tier

Program.

https://www.harvardpilgrim.org/portal/page?_pageid=213,7276132&_dad=portal&_schema=PORTAL




Helping our members to stay healthy for less!

Your Member Savings


Count us in for discounts to help members maintain a healthier lifestyle

Eye and Ear

– FREE eyewear program at Visionworks

– Discounts at many popular locations like Visionworks,, JCPenny Optical, LensCrafters, Pearle Vision, Sears Optical and Target Optical

– Laser vision correction

– Hearing aids

Dental

– Universal Dental Plan : save 20% – 50% on all procedures at participating dentists in MA, ME, NH and CT, plus up to 28% on membership fees

Fitness reimbursement

- Up to $150 per individual or family policy

Complementary and alternative medicine

– 10-30% off acupuncture, chiropractic care, yoga, Chinese herbal medicine and more

– Headspace: save on subscription for online meditation tools

– 15% off Ivy Child mindfulness programs for children

– Massage Envy Spa : save on massage therapy

– 25% off subscription to Mindful magazine

– Mindfulness-based Stress Reduction course at UMass Medical (Shrewsbury, MA)

Nutrition – Dash for Health online program

– Diet.com

– iDiet

– Jenny Craig

– 10% off meals for cancer patients and caregivers through Savor Health (formerly Meals to Heal)

Save on many products and services:


Want even more member discounts?

Fitness

– Discounts at select clubs in MA, NH and ME

– 15% off footwear at Marathon Sports and Northampton Running Company (MA), Runner’s Alley (NH)

– Discounted rate at Genavix online Wellness Network

– Discount on exercise equipment and services from Workout Fitness Store (Portland, ME)

– 20% off Appalachian Mountain Club membership

– 23% off Boston Ski & Sports Club membership

Eldercare

– SeniorAssist for caregivers

– Home Instead Senior Care

– My Vigorous Mind web-based program

– CareScout Eldercare Advocacy Program

Safety and comfort care

–15% off the Original Healing ThreadsTM by Spirited Sisters

–15% off Hug Patrol comforting therapeutic and weighted products (formerly Sense-Able)

© 2011 Harvard Pilgrim Health Care 25 25

* $150 maximum reimbursement per Harvard Pilgrim policy. Restrictions apply. Reimbursement is not available to all members. Visit www.harvardpilgrim.org/reimbursement or call for details.

Fitness Reimbursement*

Up to $150 per Harvard Pilgrim policyholder (i.e., per subscriber) per calendar year

Harvard Pilgrim membership must be at least four months in a calendar year and coincide with at least four months of health club or fitness facility membership.

Qualified fitness facilities are full service, health clubs that include cardiovascular and strength-training equipment and facilities for exercising and improving physical fitness (most “traditional” health clubs, YMCAs and JCCs qualify)

Also included: fitness studios/facilities that offer yoga, Pilates, Zumba, aerobic/group classes, indoor cycling/spinning classes, kickboxing, CrossFit, strength training, tennis, indoor rock climbing and personal training (taught by a certified instructor).

Electronic tools to make life easier for you!

Innovation


Get it all right here … from anywhere

www.harvardpilgrim.org

Log in to your secure account from your desktop, tablet or phone to get quick, reliable answers to your questions and make the most of your plan

http://www.harvardpilgrim.org/



Now quicker and easier to get HPHConnect-ed

Members can quickly set up an HPHConnect for Members account and get instant access to our e-tools and resources

To set up an HPHConnect account, members need to:

– Visit www.harvardpilgrim.org and select “Members”

– Under “Your Account,” select “Create an account” and enter Harvard Pilgrim ID number, birth date, ZIP Code and last four digits of the subscriber’s Social Security number

– Choose a username and password to instantly activate their account



Count us in for support when our members need us most

Personalized care for members coping with:

– Diabetes

– Asthma

– Cancer

– Congestive heart failure

– Cholesterol management in cardiac disease

– Chronic kidney disease

– Depression

– High-risk pregnancy

– Anticoagulation management (for members taking blood-thinner medications)

– Conditions like seizure disorders, rheumatoid arthritis, multiple sclerosis and others

Personal health coaching can help you make informed decisions related to nutrition, exercise, smoking, stress, weight management, back pain, blood pressure and cholesterol management, and life balance


Telemedicine services: Doctor on Demand

Convenient, cost-effective alternative to ER for minor urgent care

Real-time virtual visit via smartphone, tablet or computer

Treatment and prescriptions for conditions including:

- Coughs, colds, sore/strep throat, flu

- Upper respiratory infections

- Pediatric issues

- Sinus and allergies

- Rashes and skin issues

No referral needed; PCP cost-sharing applies

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Count on us for service that’s best in class– from everyday administration to member questions

Service


Count us in to have your back, with more ways to serve you better

Access by phone - 1-888-333-4742

– Timely and accurate responses to your questions

– Interactive Voice Response (IVR) offers 24-hour access to general information

Access via www.harvardpilgrim.org - 24/7

– Self-service with your secure online account

– E-mail Member Services and get responses quickly


Questions?

annual open enrollment information update · 2019-09-19 · harvard pilgrim health care is proud to...

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