2019 SONM BENEFITS AND SERVICES PRESENTATION NATIONAL HMO PLAN 2019 PRESBYTERIAN HEALTH INSURANCE BENEFITS
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1 2019 SONM BENEFITS AND SERVICES PRESENTATION NATIONAL HMO PLAN 2019 PRESBYTERIAN HEALTH INSURANCE BENEFITS
2 Presbyterian s Bet On Integration In integrated systems where providers and insurers are the same entity, a single perspective enables providers to take actions in one place that will cut costs or lift performance in another. -- Clayton Christensen, PhD, Business Week, March 4,
3 Founded in ,518 INDIVIDUAL CUSTOMERS served 474,624 Presbyterian Health Plan MEMBERS ,000+ HOSPITALS HOSPITAL BEDS CLINICS throughout New Mexico HEALTHCARE PROFESSIONALS throughout New Mexico 3
4 Award Winning Healthcare Highest Level 3 Recognition for Central NM PMG Primary Care Clinics cccccc $4.5M Grant Recipient Medicare Advantage HEDIS Reporting cccccc Top Scoring Proposal Best Healthcare Organization Best Doctors Best Health Plan Best Hospital Best ER Best Urgent Care Sources: December 2017 Albuquerque Metro Consumer Survey, 2018 ABQ Journal Reader s Choice Awards 4
5 New Mexico and National Network 5
6 Extensive Statewide Network Over 9,000 Providers in 554 Locations 2,200 Primary Care Physicians 7,000 Specialists No Referrals Required Over 600 hospitals and other facilities Hiring of providers to meet the increased healthcare needs of New Mexicans. Ongoing facility investments that offer convenient and innovative care to New Mexicans.
7 When You Need a Nationwide Network Traveling outside of the state for vacation/work Dependents live outside of the state Out of state students Specialized care for complex issues
8 Presbyterian Nationwide Network 900,000 National Providers 4,000 Facilities Nationwide Access to Centers of Excellence Facilities Mayo Clinic, MD Anderson Johns Hopkins University, and many more. Logos on the back of your ID card Always In-Network Nationwide HMO
9 2019 Benefits Nationwide HMO 9
10 Nationwide HMO Benefits Effective 1/1/19 Deductible $350 / $700 / $1,050 Out-of-Pocket (OOP) Maximum (Calendar Year) $3,750 / $7,500 / $11,250 (pharmacy combined with medical expenses to meet medical OOP) Office Visit Preventive Care $0* PCP/Gyn Care $25* Specialist (no referral) $45* Lab Work (non Preventive) 20% Outpatient Surgery 20% MRI-PET-CT Scans 20% up to $200 per test Durable Medical Equipment 23% *Deductible not applicable Hospital Inpatient $600 Maternity Care $25 (1 st visit) Delivery $500 In/Out of Network Emergency $275 Urgent Care $55 Chiro / Acup $50* (combined 25 visit limit) Naprapathy $55* ($500 annual limit) This is a summary illustration only. For a full Summary of Benefits including benefit limitations and maximums, please refer to the Presbyterian SONM Summary Plan Description. 10
11 Access and Innovation 11
12 Access To Care Appropriate and Affordable Options for Care SmartExam Member Advocate Team Presbyterian Customer Service Center 12
13 Quick Care Virtual Care 13
14 PresRN Your Nurse Advise Line Speak to a registered nurse by phone 24/7, 365 days a year, even in Spanish. With PresRN, members have: Direct access to Presbyterian nurses Minimum 10 years clinical experience or No fee for members to access this service. Use national protocol to triage, diagnose and treat. Nurses have access to your plan info and electronic health record for past and current health conditions, treatments and Rx. Navigate you to appropriate care based on your diagnosis. Capture the details of your care in MyChart. Automatically message your PCP, Specialist or Care Coordinator. 14
15 Video Visits Video Conference with a Healthcare Provider Skype with a healthcare provider 24 hours a day, 365 days a year. With Video Visits, members can: Schedule a Video Visit on any computer, tablet or smart phone. Use at home, work or when travelling. Get diagnosis and treatment for common health issues like earaches, cold/flu symptoms and allergies within 1 hour. Receive prescriptions to the pharmacy of your choice. Receive a text or summary of your visit. View the details of the Video Visit in MyChart. Receive a doctor s note for school or work via . No fee for members to access this service. 15
16 MyChart: Be An Active Part of Your Care Team Presbyterian Health Plan members have secure online access to their Presbyterian electronic health records. With MyChart, members can: Send and receive messages with their care team. Schedule primary care appointments, confirm or cancel appointments. View lab and test results. Request prescription renewals. View visit summaries, health summary, care plan, allergies and immunizations. Receive health reminders. Pay doctor and hospital bills. No fee for members to access this service. 16
17 17
18 Member Advocate Team: Presbyterian Customer Service Center Member Advocate Team Locate a Provider - within PMG or Contracted Network including Specialists, Facilities, Behavioral Health and Multiplan. Contact and consult with the Provider for availability to ensure a good fit for the member. Schedule an appointment using the members preference for dates, times etc. Integrated Dedicated Customer Service Team Located in New Mexico Claims, Benefits, General Questions Patient Financial Services (505) or ASK PRES info@phs.org 18
19 Transition of Care Had a surgical procedure & undergoing follow-up care/therapy Have an upcoming surgical procedure Have serious medical condition that requires ongoing care Undergoing dialysis treatment In the 2 nd or 3 rd trimester of pregnancy Complex medical care Case Management: For Acute Conditions Transplant services High-risk pregnancy management Transition of Care Disease Management: For Chronic Conditions Diabetes Coronary Artery Disease Asthma
20 Disrupting the Industry Innovative Outcomes Lower Costs Increased Convenience 20
21 Presbyterian Investment in New Mexico Expanding Highest Quality of Care and Access OCTOBER 2018 COMING
22 Investments in Access Presbyterian Santa Fe Medical Center Opened October 2018 Urgent Care 24/7 Emergency Services General Surgery Orthopedics Podiatry Physical, Occupational and Speech Therapies Lab and Imaging, including CT and MRI 30 Adult Inpatient Beds, some licensed ICU beds 6-Bed Birthing Unit Telehealth Services 22
23 Urgent Care/Emergency Care Clinics 24 Hour Access Reduce cost by up to 10x for services 4 Locations Albuquerque Metro Area
24 Ambulatory Surgical Centers Member satisfaction Effective outcomes Cost Ambulatory Surgical Centers Lower Cost Setting: 30-50% Reduction Increased Member Satisfaction Effective Services 3 Locations Albuquerque Metro Area 24
25 Value Added Benefits Member Only Discounts on gym memberships, weight loss programs and more. Hearing Hardware Vision Massage Therapy Chiropractic Acupuncture Meals on Wheels Buy One Get One Free Isotopes Tickets 25
26 Value of Presbyterian Non-Profit Organization Only Nationwide HMO Option Investing in New Mexico Lowest Premium and Lowest Out-of-Pocket Costs Quick Care / Virtual Care Video Visits, Online Visits PresRN, MyChart, UC Scheduling Expanding Access and Improving Outcomes for New Mexicans Innovative Access to Care 24hr UC/ER Centers, Ambulatory Surgical Centers, Santa Fe Medical Center Emergency and Urgent Care Nationwide 26
27 Questions? 27
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