2018 NH Broker Playbook: Individual Business - Harvard Pilgrim
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2018 NH Broker Playbook: Individual Business
Agenda
Our mission
Our networks
Our products
– Medical plans
– Pharmacy
– General information about our plans
Discounts & savings
Broker support
2 © 2017 Harvard Pilgrim Health Care
Harvard Pilgrim Provider Networks
Harvard Pilgrim Standard (Full) Network Harvard Pilgrim's provider network is extensive. It encompasses MA, ME, NH, CT, RI, VT. Includes physicians practicing in a variety of settings including individual practices, small medical groups and large multi-specialty groups. Harvard Pilgrim has a growing network of over 182 hospitals and 70,000 doctors and clinicians. 4 © 2017 Harvard Pilgrim Health Care
Tiered Network Products
Places providers and hospitals in tiers based on
provider specialty or network
– Standard HMO rules and referrals apply
– Access to Harvard Pilgrim’s full HMO network
– Incents Members to use Tier 1 providers through lower cost
share
– ElevateHealth Options is a tiered network
5 © 2017 Harvard Pilgrim Health Care
Defined Network Products
Comprised of a subset of providers and hospitals from
the full HMO network
– Members receive all care through a limited network provider
– Standard HMO rules and referrals apply
– Member liable if out of network provider is seen, even if referred
by PCP
– Prior authorization from Harvard Pilgrim is required for care not
otherwise available within the limited network
– ElevateHealth is a defined network
6 © 2017 Harvard Pilgrim Health Care
Directory Sample
Standard (Full) Network
products include HMO
and PPO plans
Tiered/Limited Plans
7 © 2017 Harvard Pilgrim Health Care
New Hampshire Individual Products and Plan Offerings
Plan Metal Tier Choice Guide
CONSUMER CONSUMER CONSUMER
• Willing to pay for • Subsidy eligible • Healthy
richer benefits • Seeks value in consumers/low
coverage utilizers
GOLD HMO SILVER HMO BRONZE HMO
• Highest premiums • Lower premiums • Lowest premium
• Lowest cost share • Lower cost share • Highest cost share
• $1k Deductible on • Deducible range of
ElevateHealth plans
• $7k Deductible
$3k-$6k
• $1k/$4k Deductible • Coinsurance range of • 50% Coinsurance
on ElevateHealth 30%-40%
plans
• No coinsurance on
most services
• More copay services
9 © 2017 Harvard Pilgrim Health Care
Updates for 2018
Simplified portfolio, consistent plan designs
ElevateHealth no longer available in Belknap County,
and remains unavailable in Carroll County
NH Network plans discontinued for 2018
– More membership in ElevateHealth plans
– Elevate Health Plans support joint venture with Benevera Health
10 © 2017 Harvard Pilgrim Health CareIndividual Plans On and Off Exchange
Defined and tiered network options available off-
exchange
– ElevateHealth network with 3 plans across the metal spectrum
– ElevateHealth Options Network with 1 gold and 1 silver offering
Defined network option available on-Exchange
– ElevateHealth network with 1 gold and 1 silver offering
11 © 2017 Harvard Pilgrim Health CareElevateHealth HMO Plans
ElevateHealth HMO: Map
Smaller network for lower
premium
– 700+ primary care physicians
– 3,300+ specialists
19 Easy Access hospitals
– Network coverage in all NH counties
except Carroll & Belknap
– Includes Brattleboro Memorial
Hospital in Brattleboro VT
Note: Hospital admitting privileges are not an
indication of network participation. To find a
provider participating in this network please
use the ElevateHealth online directory
13 © 2017 Harvard Pilgrim Health CareElevateHealth HMO: Hospitals Alice Peck Day Memorial Hospital Littleton Regional Hospital Androscoggin Valley Hospital Monadnock Community Hospital Brattleboro Memorial Hospital (VT) New London Hospital Cheshire Medical Center Southern New Hampshire Medical Concord Hospital Center Cottage Hospital St. Joseph’s Hospital Dartmouth-Hitchcock Medical Upper Connecticut Valley Hospital Center Valley Regional Hospital Elliot Hospital Weeks Medical Center Exeter Hospital Wentworth-Douglass Hospital Frisbie Memorial Hospital 14 © 2017 Harvard Pilgrim Health Care
ElevateHealth HMO: How the Network Works ElevateHealth providers are called Easy Access providers. All members must choose a participating PCP, or one will be assigned to them. Specialty care is available with a referral from the PCP to an Easy Access specialist. Referrals are not necessary for some services, such as routine eye exams and most gynecological care. 15 © 2017 Harvard Pilgrim Health Care
ElevateHealth HMO: Authorized Access In the rare event that pediatric specialty care cannot be provided by an ElevateHealth provider, a member can request access to Boston Children’s Hospital and some of its affiliated physicians. PCP or specialist must obtain Prior Approval from the Plan. Prior Approval will be provided when it has been determined that no Easy Access Provider has the professional expertise needed to provide the required services. 16 © 2017 Harvard Pilgrim Health Care
ElevateHealth HMO: 2018 Individual Plans
3 ElevateHealth HMO plans offered
ElevateHealth Gold 1000
- Offered both on and off exchange
ElevateHealth Silver 3500
- Offered both on and off exchange
ElevateHealth Bronze 7000
- Off exchange only
17 © 2017 Harvard Pilgrim Health CareTo find ElevateHealth participating providers, visit www.harvardpilgrim.org 1. At the harvardpilgrim.org homepage, click on Find a Provider at the top of the page. 2. Select ElevateHealth HMO under the Tiered/Limited plans section 3. Various search functions available 18 © 2017 Harvard Pilgrim Health Care
ElevateHealth Options Plans
ElevateHealth Options – A Full Tiered Network
Product
Featuring the Tier 2
ElevateHealth Network ME CT
Tier 1
ElevateHealth
NH MA
Network
VT RI
20 © 2017 Harvard Pilgrim Health CareElevateHealth Options: How it works
Member can choose a PCP in either tier
Same PCP referral process as other full network
products
*Authorized Access process not applicable
Member responsible for cost share associated
with providers tier
Behavioral Health defaults to Tier 1
21 © 2017 Harvard Pilgrim Health CareElevateHealth Options: Plan Design Highlights
Tier 1 cost share
Lower deductible
Most services apply a copay
Lab covered in full
Tier 2 cost share
Higher deductible
Deductible and co-insurance applies to all services
Emergency Room
Tier 1 deductible then $300 copay regardless of facility
tier
22 © 2017 Harvard Pilgrim Health CareElevateHealth Options: Non-Tiered Benefits
The following services do not have tiered network cost sharing.
Preferred Cost Share
• Acupuncture • Low protein foods
• Ambulance • Maternity Care (routine)
• Applied behavioral analysis • Mental Health and drug and alcohol
rehabilitation services
• Chiropractic • Medical formulas
• Durable medical equipment (DME) • Ostomy
• Emergency Room • Prosthetics
• Hearing Aids • Wigs
23 © 2017 Harvard Pilgrim Health CareElevateHealth Options: Deductible Design
Cross-accumulating Tier
deductible 1
– Deductible met in one tier
applies toward the other Tier
tier’s deductible
2
Maximum deductible is equal
to the Tier 2 deductible
24 © 2017 Harvard Pilgrim Health CareElevateHealth Options: Map • ElevateHealth hospitals shown at right are all in Tier 1 • All other hospitals in Harvard Pilgrim’s network – NH, MA, ME, VT and CT – are in Tier 2 25 © 2017 Harvard Pilgrim Health Care
ElevateHealth Options: 2018 Individual Plans
Two plans with the ElevateHealth Options
network offered off-Exchange
ElevateHealth Options Gold 1000
ElevateHealth Options Silver 3000
26 © 2017 Harvard Pilgrim Health CareTo find ElevateHealth Options participating providers, visit www.harvardpilgrim.org 1. At the harvardpilgrim.org homepage, click on Find a Provider at the top of the page. 2. Select ElevateHealth Options under the Tiered/Limited plans section 3. Various search functions available 27 © 2017 Harvard Pilgrim Health Care
Pediatric
Vision Coverage - New Hampshire under 19
First $100 covered in full then 50% coinsurance
First order
Frames 6 month
of contact
and lenses supply of
OR lenses OR
every 12 disposable
every 12
months lens
months
Does not cover contact or glasses supplies, fitting charges
All members are covered for eye exams under their plan
No network – purely member reimbursement program
Reimbursement form is available on HPHC.org or from Member Services
28 © 2017 Harvard Pilgrim Health CarePediatric
Pediatric Dental - New Hampshire under 19
Type 1
• Preventive
Services
Covered at 50% coinsurance
Type 2 • Minor Restorative Off Exchange plans are
Services available with or without
pediatric dental
Type 3 • Major Restorative
Services Members will receive
separate Dental ID card
Type 4 • Medically Necessary
Orthodontia
Services
29 © 2017 Harvard Pilgrim Health CareIncluded in all Individual Plans
Acupuncture – 20 visits per calendar year
– Must use a participating provider
– Access to discount programs once benefit limit is reached
Chiropractic care – 12 visits per calendar year
– Must use a participating provider
– Access to discount programs once benefit limit is reached
Routine eye exam
– Once every 2 years for adults
– Once per year for pediatric
– Plus free eyewear and discount programs available
Physical, occupational and speech therapies
– 20 visits per calendar year for each
30 © 2017 Harvard Pilgrim Health CarePremium Assistance Program (PAP)
Premium Assistance Program is a Medicaid expansion
program managed by the New Hampshire Department
of Health and Human Services (NH DHHS)
Available to NH residents between the ages of 19 - 65
Eligibility is determined by DHHS
Consumer enrollment questions should be referred to
DHHS
– DHHS: 844-275-3447
– www.dhhs.state.nh.us/ombp/pap
31 © 2017 Harvard Pilgrim Health CarePremium Assistance Program (PAP)
continued
PAP members may enroll in an ElevateHealth Network
plan
Two cost share options
– Minimal cost share plan
– No cost share plan
Deductible is paid by the DHHS
PAP members have access to all the HPHC discount
programs available to other commercial members
32 © 2017 Harvard Pilgrim Health CareGeneral Information About our Plans
Preventive Services
Preventive services are covered in full
– Routine physicals and annual gynecological exams
– Outpatient prenatal care
– Many common preventive tests, including (but not limited to):
• mammogram and pap smear
• routine urinalysis
• immunizations for children and adults
• non-diagnostic colonoscopy
• certain tests recommended based on age and habits
– Complete list available to members on their secure online
account
34 © 2017 Harvard Pilgrim Health CareUrgent care
For minor illness and injury when PCP is not available
Hospital- based
urgent care
Free-standing
urgent care $$$
Telemedicine
Convenience
care
$$
$
35 © 2017 Harvard Pilgrim Health CareTelemedicine Services: Doctor on Demand
Convenient, cost-effective alternative
to ER for minor urgent care
Real-time virtual visit via smartphone,
tablet or computer
On-demand virtual visits for minor
issues (ex. cough, rash, sinus issues)
– PCP cost-sharing applies for medical
urgent care
Scheduled behavioral health virtual
visits
– Outpatient therapy cost sharing applies for
behavioral health
No referral or authorization needed
36 © 2017 Harvard Pilgrim Health CareEmbedded Deductible
Example:
– $2,500 individual deductible; $5,000 family deductible
There is a $2,500 cap on any individual family member’s
deductible responsibility
– If one family member ends up in the hospital on the first day of
the plan year, Harvard Pilgrim caps his or her deductible
responsibility at $2,500
The other family members must incur an additional
$2,500 before satisfying the $5,000 family deductible
Once the family deductible of $5,000 is met, the
deductible is met for the entire family for the remainder
of the year
37 © 2017 Harvard Pilgrim Health CareOut of Area (OOA) Dependent Coverage All our HMO plans include coverage for dependent children under the age of 26 living outside the enrollment area The subscriber must call Member Services to register the OOA dependent (888) 333-4742 Routine and non-routine services are covered Elective services are not covered OOA (i.e. Bariatric or reconstructive surgery) Must use out-of-area dependent providers for services outside of the enrollment area 38 © 2017 Harvard Pilgrim Health Care
Discounts & Savings Helping Members to stay healthy, for less!
Count us in for discounts to help members
maintain a healthier lifestyle
Fitness Dental
– Up to $150 fitness reimbursement per individual or family – 30 – 50% off all procedures at participating dentists through
contract Universal Dental Plan
– 15% off on athletic footwear at Marathon Sports (MA) • Save up to 28% on membership fees
– 15% off on regularly priced footwear at Runner’s Alley (NH)
– 20% off Appalachian Mountain Club membership Healthy Eating
– Discounts on exercise equipment rentals & services; – Jenny Craig
Workout Fitness Store (So. Portland, ME) – DASH for Health
– iDiet
Vision
– Savor Health
– FREE designated eyewear & discounts at Visionworks (MA,
NH, RI)
– Discounts at JCPenney Optical, LensCrafters, Pearle Quit Smoking
Vision, Sears Optical and Target Optical – Craving to Quit
– Laser Vision Correction discounts through QualSight – QuitSmart
LASIK, Davis Vision, US Laser Network
Family and Senior Care
– Care.com
Holistic Wellness
– Senior Assist (Senior Resource Center, Inc.)
– Save 10-30% on complementary & alternative medicine
from Healthways WholeHealth Network on acupuncture, – CareScout Elder Advocacy Program
chiropractic care, yoga, Chinese herbal medicine, etc. – Home Instead Senior Care
– Hug Patrol – Vigorous Mind
– Center for Mindfulness; Discounts on Mindfulness-based Hearing
Stress Reduction & Mindfulness-based Cognitive Therapy – Hearing Aids through Amplifon Hearing Health Care
courses
– 10% Happier
More information: harvardpilgrim.org, click ‘Discounts & Savings’ at the bottom of the page.
40 © 2017 Harvard Pilgrim Health CarePharmacy Information
Value Formulary Tiers – Individual Plans
Value 4-Tier
Tier 1 Generics only
Tier 2 Preferred Brands
(some high-cost generics)
Non-preferred brands and
Tier 3 preferred specialty
(some higher-cost generics)
Non-preferred specialty drugs
Tier 4 (very high-cost brand and
generic drugs)
42 © 2017 Harvard Pilgrim Health CareMail Order Program Our mail order program is for maintenance medications and health products The program includes a 90-day supply of medication delivered to members’ homes Certain medications such as controlled substances, may be subject to dispensing limitations Can order online, by mail or by phone 43 © 2017 Harvard Pilgrim Health Care
Enrollment and Renewal Guidelines
Dates and Deadlines Open enrollment is November 1, 2017 – December 15, 2017 January 1, 2018 is the only available effective date Enrollments and plan changes must be submitted by December 15th in order to be eligible for a January 1 effective date Payment deadline (both on and off Exchange) is January 10, 2018 45 © 2017 Harvard Pilgrim Health Care
Renewal Support Renewal report displaying your existing book of business Sample discontinuation and renewal letter packages 2017 to 2018 Benefit Comparisons Product Mapping Grid of 2017 products to 2018 products Consumer Sales support at (844) 213-1592 46 © 2017 Harvard Pilgrim Health Care
Renewal Report Name, address and Harvard Pilgrim ID of member Marketplace versus “Buy Direct” 2017 premium and product 2017 Average Premium Tax Credit (APTC) 2018 premium and new product (mapped) 47 © 2017 Harvard Pilgrim Health Care
Renewal Report – Rates vs Premium The 2017 rate shown is the base rate and does not include APTC. In the example below the 2017 billed premium would be $612.71 The 2018 rate also does not contain APTC. The estimated 2018 premium would be $572.30 48 © 2017 Harvard Pilgrim Health Care
2018 Renewal Process - OFF Exchange
Off-Exchange members CANNOT make their plan
change on Harvardpilgrim.org - they MUST call the
consumer sales team
Members have 2 options:
• Passive Renewal: Do Nothing. Members automatically renewed as
long as they continue to pay monthly premium.
• Active Renewal: Take Action if the 2017 is discontinued with no
mapping OR the members don’t like the 2018 plan we chose for
them
– Consumer Sales will review plans and make change via the
phone OR.
– Consumer Sales will mail a quote and a paper enrollment form
49 © 2017 Harvard Pilgrim Health Care2018 renewal process – On Exchange
On Exchange plan changes must be completed on HealthCare.gov
Changes must be made by December 15, 2017.
Members have 3 options:
– Passive Enrollment - Member likes 2018 plan changes presented in
renewal letter, and there are no changes to Marketplace application
information
• Do Nothing. Member automatically enrolled and continues to pay monthly
premium.
– Active Enrollment - Member likes 2018 plan changes presented in renewal
letter, but there are changes to Marketplace application information
• Member must go back to the Marketplace to update information and
re-enroll.
– Active Enrollment – Member’s 2017 plan was discontinued with no
mapping or member does not like 2018 that we chose for him or her
• Take Action - Visit HealthCare.gov and look at other Marketplace plans.
50 © 2017 Harvard Pilgrim Health CareOn Exchange Renewals - Payment If Subscribers are enrolled on Auto Pay, they will need to visit the PaySpan Web site and re-enroll in Auto Pay between December 5 and December 20, 2017, in order for automatic payments to carry forward into the new contract year. The auto pay they establish during this time period will apply to their February 2018 premium January premium payment must be made before autopay can be re-started. Payment can be made via check or through PaySpan. Instructions for re-enrolling in Auto Pay are in their renewal package Failure to re-enroll in Auto Pay could result in a lapse in coverage 51 © 2017 Harvard Pilgrim Health Care
Off-Exchange Enrollment Off-Exchange Quotes and enrollments can be done via www.harvardpilgrim.org Online payment capability Enter NPN or vendor ID to be linked to subscriber View book of business with corresponding statuses 52 © 2017 Harvard Pilgrim Health Care
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