Cracking the Code IV - Get Covered Tennessee

Report
Humana, Healthcare Reform
and You
What you need to know
About Humana
• Headquartered in Louisville, KY
• Over 50 years experience in the health industry
• Diverse portfolio of products
• Over 12.1 million medical members
nationwide
• Over 4 million Medicare members nationwide
• Over 11 million members in specialty products
• Corporate Social Responsibility
– Humana Foundation
– KaBOOM
– Walkit Challenge
– Arbor Day Foundation
– Habitat for Humanity
2
Plan Designs Descriptions
Essential Health Benefits
Plans must cover 10 categories of
mandated essential health benefits:
Essential Health Benefit Categories
Ambulatory
patient
services
Emergency
Services
Maternity and
newborn care
Pediatric
services
including
dental and
vision care
Rehabilitative/
habilitative
services and
devices
Mental health
and substance
use disorder
services,
including
behavioral
health
treatment
Preventive and
wellness
services and
chronic disease
management
Hospitalization
Prescription
Drugs
Laboratory
services
4
Plans on the Exchange
How are the plans categorized?
Plan tiers are categorized by “actuarial value”
What is “actuarial value”?
• As an example, a Gold Plan has an actuarial value of
80%. That means, for a standard population:
• The plan will pay 80% of their health care
expenses
• The enrollees themselves will pay 20% through
a combination of deductibles, copays, and
coinsurance
Catastrophic plans are lower
cost with limited benefits for
people under 30 or people with
financial hardship*.
*Financial hardship: above 400% FPL, but would pay premium
exceeding 8% of income for lowest-priced Bronze Plan.
5
Product Descriptions
Humana Preferred (PPOs)
• LOCAL-Humana’s PPO gives members the choice to go to
their preferred healthcare provider within a local
geographic area
• NATIONAL-Humana’s PPO gives members the choice to go
to their preferred healthcare provider within a national
framework
Humana Local Preferred (PPOx)
Humana Local Preferred: Memphis, Nashville, Knoxville (30
counties total)
•
•
•
•
•
Referral not required
Out-of-network coverage
Local Medical Network (PPOx)
Rx network (Walmart, Sam’s Club, CVS, Rightsource)
Closed RX5 formulary
Allows for OON coverage and does not require a referral
Offered in markets where we are competitively priced
Offered in all metallic tiers + catastrophic
Humana Local Preferred (PPO)
Humana Local Preferred (PPO)
Humana Preferred Plans give consumers the freedom to choose
any doctor, hospital or specialist so that they can receive care from
any healthcare provider
(But consumers receive the most benefit when they utilize an in-network
provider)
Benefits of Humana Preferred products
• Good for consumers using doctors and hospitals in our PPOx
network
• Access to out-of-network doctors, specialists and hospitals
• Freedom of choice
• For a family, there is only a Family deductible and Family OOP,
which is twice the single deductible / OOP
TN-Humana Local Preferred
(On and Off Marketplace )
Benefit
Basic
6350/6350
Bronze
6300/6300 HSAQ
Silver
4600/6300
Gold
2500/3500
Platinum
1000/1500
Med. Deductible (IN)
$6350 single
2x family
$6300 single
2x family
$4600 single
2x family
$2500 single
2x family
$1000 single
2x family
Coinsurance
(IN/OON)
100%/75%
100%/75%
80%/60%
80%/60%
80%/60%
Max OOP (IN)
$6350 single
2x family
$6300 single
2x family
$6300 single
2x family
$3500 single
2x family
$1500 single
2x family
Preventive Services
100%
100%
100%
100%
100%
PCP/Specialists/
Urgent Care
$35 PCP copay
(3); all else Ded.
Deductible/
Coinsurance
$25 /$35/$50
$25 /$35/$50
$25 /$35/$50
RX
Deductible/
Coinsurance
Deductible/
Coinsurance
$10/20/50/
50%/50%
$1500 Rx ded
Tiers 3-5
$5/10/20/
35%/35%
$500 Rx ded
Tiers 3-5
$5/10/20/
35%/35%
$500 Rx ded
Tiers 3-5
The above represents only a summary; please consult benefit summary for full details.
Out of Network Deductible and Out of Network Out-of-Pocket are considerably higher than the in-network counterparts
Off Marketplace plans have embedded Pediatric Dental always included; coverage is 50% after deductible, up to the OOP Limit
Cost Sharing Subsidy
• For clients who are 100% to 250% FPL
• Protects your clients from high out-of-pocket costs at point of service
• Consumer will have the option to purchase this subsidized plan in addition to
benefiting from the Advance Premium Tax Credit
• If a consumer does not choose to purchase the Silver cost-sharing plan, then
they will not receive the cost-sharing subsidy
• However, consumer is still eligible for the Advance Premium Tax Credit
for any plan she purchases on the exchange
X
Cost Sharing Impact to Plan Design
In network:
Silver
4600/6300
Silver
(200-250% FPL)
Silver
(150-200% FPL)
Silver
(100-150% FPL)
Med. Deductible
(IN)
$4600 single
2x family
$3250 single
2X Family
$900 single
2X Family
$500 single
2X Family
80%/60%
80%/60%
80%/60%
Coinsurance
(IN/OON)
80%/60%
Max OOP (IN)
$6300 single
2x family
$4750 single
2X Family
$1450 single
2X Family
$750 single
2X Family
100%
100%
100%
100%
$25 /$35/$50
$25 /$35/$50
$25 /$35/$50
$25 /$35/$50
Preventive
Services
PCP/Specialists/
Urgent Care
RX
$10/20/50/50%/50%
$10/20/50/50%/50% $10/20/50/50%/50% $10/20/50 50%/50%
$1500 Rx ded Tiers 3-5 $1000 Rx ded Tiers 3-5 $500 Rx ded Tiers 3-5 $250 Rx ded Tiers 3-5
Out of Network is considerably higher member cost-sharing and is the same as the Standard Silver plan.
Humana Smart Choice Dental
Humana Smart Choice Dental
Immediate and affordable benefits
Competitive adult/family rates
Comprehensive child coverage, additional coverage for major services
Also, a limited orthodontic benefit for kids is available
No annual max for kids!
Out of pocket protection: $700 max out of pocket per child, $1400 for
2+ children
Humana National Preferred
Off Exchange
•
•
•
•
Plans follow Metallic tiers (Same as On-Exchange)
National Choice Care PPO Network
Humana National Pharmacy Network (include major retailers)
Rx4 Open Formulary
Offered in Bronze and Silver metallic tiers + catastrophic
Offered off of the marketplace
TN-Humana National Preferred
(Off Marketplace)
Benefit
Basic
6350/
6350
Bronze
6300/6300
HSAQ
Bronze
4850/6350
Silver
3650/3650
HSAQ
Silver
4250/6250
Gold
2500/33500
Platinum
1000/1500
Med.
Deductible
(IN)
$6350
single
2x family
$6300 single
2x family
$4850 Single
2x family
$3650 single
2x family
$4250 single
2x family
$2500 single
2x family
$1000 Single
2x family
Coinsurance
(IN/OON)
100%/75%
100%/75%
80%/60%
100%/75%
80%/60%
80%/60%
80%/60%
Max OOP
(IN)
$6350
single
2x family
$6300 single
2x family
$6350
2x family
$3650 single
2x family
$6250
$3500
$1500
Preventive
Services
100%
100%
100%
100%
100%
100%
100%
PCP/
Specialists/
Urgent Care
$35 PCP
copay (3);
all else Ded
Deductible
$55/$80/$100
3 visit limit
then ded/coins
Deductible
$35/$60/$100
$25/$35/$50
$35/$60/$100
RX
Deductible
Deductible
$20/75/50%/50%
$1500 Rx ded
Tier 2-4
Deductible
$15/35/50/50%
$1500 Rx ded
Tiers 2-4
$5/10/15/35%
$500 Rx ded
Tiers 2-4
$5/10/15/35%
$500 Rx ded
Tiers 2-4
The above represents only a summary; please consult benefit summary for full details.
Out of Network Deductible and Out of Network Out-of-Pocket are considerably higher than the in-network counterparts
Off Marketplace plans have embedded Pediatric Dental always included. Coverage is 50% after deductible to OOP limit.
Summary of Benefits & Coverage
Name of plan
Type of plan
Plan Benefits
About the network
16
Summary of Benefits & Coverage
Referral requirement?
Plan Benefits –
Office Visits .
17
Summary of Benefits & Coverage
Prescription Drug
Categories and Benefits
Plan Benefits –
Urgent Care .
18
Summary of Benefits & Coverage
Plan Benefits –
All Other Categories .
19
Payment information
6350/6350
20
After Enrollment
Features of Humana
• One of the largest health plan providers in the
country
• Many choices
• MyHumana at Humana.com
• MyHumana mobile app
• HumanaFirst Nurse Advice Line:
– Toll free, 24/7
– Talk with a registered nurse
– Can help you decide which level of care is right for
you: Urgent care, convenient care center or the
emergency room
22
Tools and Resources for Navigators &
Stakeholders
• Humana Dedicated Support Line for certified
Navigators and Certified Application
Counselors - 888-891-0730
• Dedicated Customer Service line for preenrollment questions for clients - 888-7477650
• Coming soon – Tip Sheets and Newsletter
specific to Navigators and Certified Application
Counselors
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