Annual Open Enrollment Information Update Mark Nicholson, Key Account Executive April/May, 2017
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, 2018 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! Harvard Pilgrim Health Care is proud to be your group health plan choice once again for 2017 2018! 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. 3
Open Enrollment Overview of Plan Options The Value Plan options will no longer be offered. CURRENT HMO VALUE PLAN 6/1/17 Choices: Best Buy $1000 Plan Best Buy $1000 Focus Network Plan CURRENT HMO FOCUS NETWORK VALUE PLAN 6/1/17 Choices: Best Buy $1000 Plan Best Buy $1000 Focus Network Plan CURRENT HMO BEST BUY $1000 PLAN 6/1/17 Choices: Best Buy $1000 Plan Best Buy $1000 Focus Network Plan Red = Default Plan if you do not wish to change 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 to harvardpilgrim.org) go Harvard Pilgrim Enrollment Area 5
HMO Best Buy $1000 Benefits at a Glance (same Benefits for HMO Best Buy $1000 Focus Network Plan) Benefit HMO Best Buy $1000 Plan Requires PCP & Referrals PCP Non-routine Visits Preventive Care / Annual Exam Specialist Visits Annual Deductible Chiropractic Emergency Room Hospital Inpatient Day Surgery High Tech Imaging (MRI, CAT, PET) Durable Medical Equipment Retail Prescription co-pays Mail Order Prescriptions co-pays Out of Pocket Maximum $25 co-payment $0 co-payment $25 co-payment $1,000/Ind., $2000/Family 12 Visits per Plan Year, OV co-pay applies Deductible then $100 copayment Covered in full after Deductible Covered in full after Deductible Covered in full after Deductible 20% Coinsurance after Deductible $5 / $20 / $30 / $50 / $100 (30-day supply) $10 / $40 / $60 / $100 / $300 (90-day supply) $2000 per member or $4000 per family per PY 6
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. 8
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) 9
10
Deductible Accounting - example In-Network $1000 Individual and $2000 Family Deductible Claim Order Family Member Deductible Applied First John $1000 Second John $ 0 Third Mary $ 500 Fourth Susie $ 500 $2000 On the 1 st 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 3 rd claim, Mary has a $500 claim subject to her deductible. On the 4 th 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.
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 12
Activity Summary gives members easier-to-understand information! 13
Focus Network - MA Enrollment Area MA excluding the Cape and Islands 14
Focus Network SM - MA How it Works Specifically designated providers contracted with the Focus Network are placed in two groups 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 15
Focus Network SM 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 16
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 17
Health Reimbursement Arrangement Your HRA reimburses the 2 nd 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 18
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. 20
Key facts about our Value Formulary Pharmacy Cost trends are escalating significantly goal is to continue to provide affordable options without impacting quality Excludes certain medications that have FDA-approved alternatives Harvard Pilgrim Pharmacy and Therapeutics Committee will review new-to-market drugs on an individual basis to determine coverage on the Value formulary. Utilization Management (Prior Authorization, Step Therapy, Quantity Limitations) still applies to some covered drugs www.harvardpilgrim.org/rx has a clearly identified Value formulary section ~ <1% of members will be affected by a medication that is in Tier 5 Important : There is always an alternative to an excluded drug 21
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 22
Helpful Rx resources @ harvardpilgrim.org 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 *If your ID card has five price levels for Rx, you have a Value 5-Tier Program. *Note: The Diocese has a Value 5-tier RX Program when looking up a prescription on our website. 23
What is Eat Right Rewards? Everyday Savings Benefit Program 1. Designed to educate participants on healthy foods 2. Promote better health and reduce the risk of chronic disease 1. Designed to make a healthy lifestyle more affordable 2. Provides incentives to make healthy choices 3. Driven by relationships with Retailers, Consumer Package Goods (i.e., General Mills, Perdue), Growers and wellness program providers Measurable Solution 1. Helps mitigate rising health care costs 2. Drives employee engagement and education 3. Delivers measurable risk avoidance in terms of several screening factors 24
Your Member Savings Helping our members to stay healthy for less!
Count us in for discounts to help members maintain a healthier lifestyle Save on many products and services: 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)
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 Threads TM by Spirited Sisters 15% off Hug Patrol comforting therapeutic and weighted products (formerly Sense-Able) 27
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). * $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. 28
Innovation Electronic tools to make life easier for you!
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 30
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 31
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 bloodthinner 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 32
New! 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 33
Service Count on us for service that s best in class from everyday administration to member questions
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 35
Questions? 36