Wellesley College
PPO Plus HSA Plan for 2015
Components of the PPO Plus HSA Plan
 Two parts:
• A qualified High Deductible Health Plan
• A Health Savings Account (HSA)
o Administered by WageWorks
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Common Terms
 Allowed Amount
– The maximum amount on which payment is based for covered health
care services. This may be called “eligible expense,” “payment
allowance" or "negotiated rate." If your provider charges more than the
allowed amount, you may have to pay the difference.

Balance Billing from Non-Preferred Providers
– The difference between the provider’s charge and the allowed amount.
For example, if the provider’s charge is $100 and the allowed amount
is $70, the provider may bill you for the remaining $30. A preferred
provider may not balance bill you for covered services.

Copayment
– A fixed amount (for example, $20) that you pay for a covered health
care service, usually when you receive the service. The amount can
vary by the type of covered health care service.
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Common Terms
 Deductible
– The amount you owe for plan services before the plan begins to pay.
For example, if your deductible is $1,500, the plan won’t pay anything
until you’ve met your $1,500 deductible for covered health care
services subject to the deductible. The deductible may not apply to all
services.
 Network
– The facilities, providers and suppliers the plan has contracted with to
provide health care services.
 Non-Preferred Provider
– A provider who doesn’t have a contract with the plan to provide
services to you. You’ll pay more to see a non-preferred provider.
 Out-of-network Co-insurance
– The percent (for example, 40%) you pay of the amount for covered
health care services to providers who do not contract with the plan.
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Common Terms
 Out-of-Pocket Limit
– The most you pay during the year before the plan begins to pay 100%
of the allowed amount. This limit never includes your premium,
balance-billed charges or health care services the plan doesn’t cover.
 Primary Care Provider
– A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic
Medicine), nurse practitioner, clinical nurse specialist or physician
assistant, as allowed under state law, who provides, coordinates or
helps a patient access a range of health care services.
 Specialist
– A physician specialist who focuses on a specific area of medicine or a
group of patients to diagnose, manage, prevent or treat certain types of
symptoms and conditions. A non-physician specialist is a provider who
has more training in a specific area of health care.
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PPO Plus HSA Plan Design
 No need to designate a primary care physician
(PCP)
 No referral needed for specialist care
 Full access to our local network, plus United Health
Care’s national network of more than 650,000
providers
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The PPO Plus HSA Plan Puts You in Control
 Access care from providers outside the network
(with higher cost-sharing)
 Access emergency care anywhere in the world at
the in-network benefit level
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Preventive Services
 Select in-network preventive services are not subject to
the deductible
– Covered in full: routine physicals, annual gyn visits,
mammograms, pap smears, immunizations, routine blood work
and urinalysis, and certain disease screenings
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PPO Plus HSA Plan
 All diagnostics and treatments are subject to deductible:
•
•
•
•
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Visits for illness or injury
Imaging and outpatient services
Inpatient services
Prescription drugs
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Prescription Drugs
 Subject to in-network deductible
 Payment is due at the time of purchase
 Once you reach the deductible, a copay
applies
– $5 / $20 / $30 /$50 retail
– $10/$40/$60/$150 mail order
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PPO Plus HSA Plan Summary
Plan Provision
In-Network Benefits
Out-of-Network Benefits
Annual Deductible
$1,500 – Individual contract
$3,000 – Family contract
HSA College Funding
(50% of deductible)
$750 – Individual contract
$1,500 – Family contract
Annual Out-of-Pocket Maximum
$5,000 – Individual contract
$10,000 – Family contract
Preventive care including:
 Adult annual visit
 Well child visit
 Annual gynecological visit
 Immunization, including flu shot
100%
No deductible applies
Emergency Room
Other Services
 Office visit for illness or injury
 Lab test, diagnostic procedures
 In and out patient hospital services
 Treatment and procedures, such
as surgeries, chemotherapy,
allergy treatments, dialysis
DME
100% after deductible
100% after deductible
80% after deductible
80% after the deductible
Prescription drug – retail
Prescription drug – mail order
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80%
No deductible applies
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$5/$20/$30/$50 after in-network deductible
$10/$40/$60/$150 after in-network deductible
PPO Plus HSA Premium Comparison to HMO
(non union)
Annual Plan Premium and HSA Comparison
HMO
PPO Plus
HSA
Premium
Savings
HSA
College
Contribution
Individual
$1,917
$1,466
$450
$750
$1,200
Family
$5,195
$3,973
$1,222
$1,500
$2,722
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Total
(savings and
HSA)
Reimbursement for Medical Claims
You pay
provider (you
can use HSA
funds)
Step 1
You visit
provider
Provider
submits
claim
Provider
bills you
Harvard
Pilgrim
processes
claim
All reimbursements to network providers are based on
the negotiated amount
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HMO vs PPO Plus HSA
HMO
PPO Plus HSA
(in-network)
PCP
Yes
No
Referrals
Yes
No
OON benefits
No
Yes
None
$1,500 per individual
contract or $3,000 per
family contract
Covered in full
Covered in full
PCP visit
$25 copay
Deductible, then 100%
Specialist visit
$25 copay
Deductible, then 100%
Covered in full
Deductible, then 100%
$75 copay
Deductible, then 100%
Deductible
Select preventive
Lab
Imaging
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HMO vs PPO Plus HSA
HMO
PPO Plus HSA
(in-network)
Emergency
$100 copay
Deductible, then 100%
Day surgery
$250 copay, deductible
Deductible, then 100%
Inpatient
$500 copay, deductible
Deductible, then 100%
Outpatient Rehab
$25 copay
Deductible, then 100%
Behavioral health
$25 copay
Deductible, then 100%
Copay, then 100%
Deductible, then 100%
Deductible, then 80%
Deductible, then 80%
Prescriptions
Copay
Deductible, then copay
Health Savings Account
None
$750 per individual
contract or $1,500 per
family contract
Chiropractic
DME
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Becoming a Better Health Care Consumer
 Determine when you need to access care
 Choose the appropriate site of service
– Medical appropriateness
– Find lower-cost, high-quality providers
– Compare hospitals
 Research online with Now iKnow
 Read your Harvard Pilgrim Activity Summaries
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Activity Summary
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HPHConnect
 View all claims, authorizations, prescription drug history
and monthly Activity Summaries
 Compare provider cost and quality
 Create a personal medical record
 Research a condition
 Review your plan documents
– Schedule of Benefits and Benefit Handbook
– Pharmacy program
– Much more
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Now iKnow
Harvard Pilgrim's Cost Transparency Tool
Now iKnow Overview
 A secure online cost and quality tool that supports HPHC
commercial members in making informed health care
purchasing decisions
 Offers cost and quality information to help members
understand and plan for their potential out-of-pocket
expenses related to their treatment options
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Now iKnow Highlights
 Utilizes secure sign-on through
HPHConnect
 Displays real-time accumulator
snapshots of out-of-pocket utilization
 Estimates are based on member’s
plan design
 Shows costs for simple procedures
and complex bundled treatments
 Allows browsing functionality and
provider comparisons based on
location, treatment or condition
 Displays physician and hospital quality
 Displays member messages
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Now iKnow Provider Search Results
 Includes specific cost estimate or
an estimated range, based on
amount spent to date
 Gives side-by-side provider
comparison
 Filters based on Harvard Pilgrim
provider directory
 Displays quality ratings for
physicians and hospitals
 Incorporates tiered/limited
provider networks
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Now iKnow Provider Price Details
 Uses Google maps to
display provider
locations/directions
 Shows what is and is not
included in the estimate
 Breaks out price by facility
and professional costs
 Includes specific cost
estimate or an estimated
range
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PPO Plus HSA Plan vs. HMO
Scenario 1: Single Coverage – Sue
The Basics: Annual PPO deductible: $1,500
HSA: College contributes $750; Sue contributes $275
Sue has some preventive care (covered in full by either plan), goes to the doctor for strep and
purchases generic medication. If Sue chooses the PPO Plus HSA Plan, she pays $1,466 for the
coverage and still has $852 in her HSA for future medical expenses. Under the HMO, she will pay
$1,947 for the year (for coverage and copays).
PPO Plus HSA Plan
Cost of
Care
Service
HMO (in-network)
Sue Pays
Plan Pays
Out-of-Pocket
From HSA
Plan Pays
Sue Pays
(copays)
Routine physical and flu
shot (preventive)
$200
$200
$0
$0
$200
$0
Doctor’s visit (strep throat)
$150
$0
$0
$150
$125
$25
Medication (generic)
$23
$0
$0
$23
$18
$5
$373
$200
$343
$30
Totals
$173
Annual Medical Premium*
$1,466
$1,917
Sue’s Total Cost
$1,466*
$1,947
Remaining HSA Balance
+ $852
N/A
*Note
that the College contributed $750 to Sue’s HSA, so she did not have to use any of her own HSA
contributions
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PPO Plus HSA Plan vs. HMO
Scenario 2: Family Coverage – John
The Basics: Annual PPO deductible: $3,000
HSA: College contributes $1,500; John contributes $750
John’s family uses some preventive care and has other doctor’s visits, a generic prescription and outpatient
surgery. If John chooses the PPO Plus HSA Plan, he pays $3,973 for the coverage and $115 out-ofpocket, with $2,250 coming from the HSA. With the HMO, he pays $5,195 for coverage and $315 out-ofpocket.
PPO Plus HSA Plan
Service
Cost of
Care
HMO (in-network)
John Pays
Plan Pays
Out-of-Pocket
From HSA
Plan Pays
John Pays
(copays)
Routine physical for son
$200
$200
$0
$0
$200
$0
Doctor’s visit for John
$150
$0
$0
$150
$125
$25
$2,000
$0
$0
$2,000
$1,750
$250
Doctor’s visit for spouse
$150
$0
$50
$100
$125
$25
Medication (generic)
$65
$0
$65
$0
$50
$15
$2,565
$200
$2,250
$315
Outpatient surgery
Totals
$2,365
Annual Medical Premium*
$3,973
$5,195
John’s Total Cost
$4,838*
$5,510
$0
N/A
Remaining HSA Balance
*Note
that the HSA paid $2,250 in medical expenses with $1,500 due to the College’s contributions
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PPO Plus HSA Plan vs. HMO
Scenario 3: Family Coverage – Theresa
The Basics: Annual PPO deductible: $3,000
HSA: College contributes $1,500
Theresa’s family has two preventive visits, outpatient surgery and an MRI. If Theresa chooses the PPO
Plus HSA Plan, she pays $3,973 for the coverage and $1,500 out-of-pocket, with another $1,500
coming from the College contribution to her HSA. With the HMO, she pays $5,195 for coverage and
$325 out-of-pocket.
PPO Plus HSA Plan
Service
Cost of
Care
HMO (in-network)
Theresa Pays
Plan Pays
Out-of-Pocket
From HSA
Plan Pays
Theresa
Pays
(copays)
Routine physical for self
$200
$200
$0
$0
$200
$0
Routine physical for son
$200
$200
$0
$0
$200
$0
MRI
$3,000
$2,000
$1,500
$1,500
$2,025
$75
Outpatient surgery
$2,000
$2,000
$0
$0
$1,750
$250
$5,400
$2,400
$4,175
$325
Totals
$3,000
Annual Medical Premium*
$3,973
$5,195
Theresa’s Total Cost
$5,473*
$5,520
$0
N/A
Remaining HSA Balance
*Note
that the College contributed $1,500 to Theresa’s HSA and this paid $1,500 of the family’s medical expenses
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QUESTIONS?
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