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 2 © 2009 Harvard Pilgrim Health Care 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. 3 © 2009 Harvard Pilgrim Health Care 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. 4 © 2009 Harvard Pilgrim Health Care 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. 5 © 2009 Harvard Pilgrim Health Care 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 6 © 2009 Harvard Pilgrim Health Care 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 7 © 2009 Harvard Pilgrim Health Care 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 8 © 2009 Harvard Pilgrim Health Care PPO Plus HSA Plan All diagnostics and treatments are subject to deductible: • • • • 9 Visits for illness or injury Imaging and outpatient services Inpatient services Prescription drugs © 2009 Harvard Pilgrim Health Care 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 10 © 2009 Harvard Pilgrim Health Care 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 11 80% No deductible applies © 2009 Harvard Pilgrim Health Care $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 12 © 2009 Harvard Pilgrim Health Care 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 13 © 2009 Harvard Pilgrim Health Care 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 14 © 2009 Harvard Pilgrim Health Care 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 15 © 2009 Harvard Pilgrim Health Care 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 16 © 2009 Harvard Pilgrim Health Care Activity Summary 17 © 2009 Harvard Pilgrim Health Care 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 18 © 2009 Harvard Pilgrim Health Care 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 20 © 2009 Harvard Pilgrim Health Care 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 21 © 2009 Harvard Pilgrim Health Care 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 22 © 2009 Harvard Pilgrim Health Care 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 23 © 2009 Harvard Pilgrim Health Care 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 © 2009 Harvard Pilgrim Health Care 24 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 © 2009 Harvard Pilgrim Health Care 25 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 © 2009 Harvard Pilgrim Health Care 26 QUESTIONS? 27 © 2009 Harvard Pilgrim Health Care