Multnomah Bar Association - In partnership with Aldrich Advisors 2021 Open Enrollment
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Multnomah Bar Association
In partnership with Aldrich Advisors
2021 Open Enrollment
© 2020 Private & Confidential
Providence St. Joseph Health
+ 3rd Largest Non-Profit Integrated Delivery System in the U.S.
119k 5m
Caregivers Unique Patients Served
51 1,085
Hospitals Clinics
25k 38k
Physicians Nurses
2.1m $1.6b
Covered lives Community benefit
© 2020 Private & Confidential 2
Integrated Delivery
Providence leverages our own network of doctors, facilities, and trusted partners to deliver True Population Health.
We can intervene earlier, improve outcomes, lower costs, and better the health of our entire community.
+ Integrated Delivery System:
+ As an integrated delivery system, PHS hospitals and clinics, physicians and
nurses, our health plan, and pharmacy benefit management are all part of the
same healthcare system.
+ Our delivery systems are not separate companies with competing agendas.
+ At Providence, both provider and payer “sit at the same table”.
+ We share a common mission with complementary goals.
+ We share processes and best practices.
+ Collaboration, coordination of care, and accountability are woven into the
fabric of our healthcare system.
© 2020 Private & Confidential 3
Multnomah Bar Association
Benefits 2021
+ Because healthcare isn’t a commodity service, it’s a community pursuit.
© 2020 Private & Confidential
Providence Provider Networks
What is a provider network?
+ A provider network is a group of doctors,
hospitals, and other providers that have
agreed to accept a specific price for their
services. Providence offers a choice of four
networks, Signature, Extend, Choice, and
Connect.
+ Signature and Extend Networks: nationwide
provider networks commonly referred to as a
Preferred Provider Organization or PPO.
+ Choice and Connect Networks: These
“medical home” networks use a patient-
centered model of care. Treatment is
coordinated through a medical home primary
care provider and team to coordinate your
medical care.
© 2020 Private & Confidential 5
Signature Network
+ A PPO network provides Coast to
Coast coverage with access to
over 1 million physicians and
hospitals
+ This is a non-referral based
network, which means you can
choose to see any participating
provider without a referral
+ To find a provider go to:
www.providencehealthplan.org/members
© 2020 Private & Confidential 6
Extend PPO Network
+ The Providence Extend PPO
network offers the largest
number of providers and
facilities of any Providence
network. In addition to the
coast-to-coast providers in the
Signature network, you have
access to OHSU, Legacy,
Adventist healthcare systems,
and more.
© 2020 Private & Confidential 7
Connect Network
+ The Connect network is a Portland area network
available in Washington, Multnomah, Clackamas
and Hood River counties and the city of
Newberg in Yamhill County
+ The Connect Network consists of more than 94
patient-centered medical homes including
Providence Medical Group providers and select
independent physician groups
+ Connect is a referral-based network which
means access to providers and specialists
outside of the medical home will require a
referral from your medical home team Counties Medical Homes
*Independent physicians include: Broadway Medical Clinic, Northwest
Primary Care, Pacific Medical Group, Oregon Pediatrics, Metropolitan
Pediatrics, Sunset Pediatrics
© 2020 Private & Confidential 8
Choice Network
+ The Choice network is a statewide
network with 415 patient-centered
medical homes throughout Oregon
and SW Washington
+ Choice is a referral-based network,
which means access to providers
and specialists outside of the
medical home will require a referral
from your medical home team
Counties Medical Homes
© 2020 Private & Confidential 9
Providence Medical Plans
What is a medical plan?
+ Providence offers a number of
different medical plans. The plan
that you choose is going to dictate
the amount you pay for premiums,
the benefits your receive and your
provider choice.
+ A Preferred Provider Organization (PPO) plan
provides more provider choices.
+ A Medical Home Plan offers hundreds of medical
homes from which to choose. The doctor you see
must be part of the medical home.
© 2020 Private & Confidential 10Option Advantage Plus Plans
GOLD Benefits SILVER Benefits
(In-Network) (In-Network)
+ Fully covered Express Care clinics Individual /Family Annual
$1000/ $3000 $2500 /$7500
and Express Care virtual visits Deductible
Individual / Family Annual
$7350 / $14,700 $7350/ $14,700
Out-of-Pocket Maximum
+ Deductibles waived for many
services such as primary care, Coinsurance 20%/40% 30%/50%
specialists, urgent care, and
Primary Care Provider (PCP) 35 35
physical therapy.
Specialty 35 35
+ Lab and X-ray services covered in
full first $500 per calendar year Urgent Care 45 45
then deductible and copays apply Diagnostic Lab & X-ray
Covered in full up to the first Covered in full up to the
$500 then 20 % first $500 then 30%
+ Plans can be paired with Signature High Tech Imaging (CT, MRI,
PET)
20% 30%
or Extend Networks.
Emergency Room $250 $250
Deductible waived
© 2020 Private & Confidential 11Connect Plans
Connect Platinum Gold
(In-Network) (In-Network)
Individual /Family Annual
+ You must select a medical home Deductible
$500 $1500
clinic, which can be different for Individual / Family Annual Out-of-
$5850 $7350
each family member, at the time Pocket Maximum
of enrollment in order for services Coinsurance 20%/50% 20%/50%
to pay in network
Primary Care Provider (PCP) $20 35
+ If you wish to see a provider
outside of your medical home, Specialty $40 70
you’ll need a referral
Urgent Care $40 $70
+ Fully covered Express Care clinics Diagnostic Lab & X-ray 20% 20%
and Express Care virtual visits High Tech Imaging (CT, MRI, PET) 20% 20%
Emergency Room $250 $250
© 2020 Private & Confidential 12Choice Plans
Choice Platinum Benefits Gold Benefits
+ You must select a medical (In-Network) (In-Network)
home clinic - which can be Individual /Family Annual
$500 $1500
Deductible
different for each family
Individual / Family Annual Out-of- $7350
member –at the time of Pocket Maximum
$5850
enrollment in order for Coinsurance 20%/50% 20%/50%
services to pay in network
Primary Care Provider (PCP) $20 $35
+ If you wish to see a provider
outside of your medical Specialty $40 $70
home you’ll need a referral
Urgent Care $40 $70
+ Fully covered Express Care Diagnostic Lab & X-ray 20% 20%
clinics and Express Care
High Tech Imaging (CT, MRI, PET) 20% 20%
virtual visits
Emergency Room $250 $250
Deductible Waived
© 2020 Private & Confidential 13Prescription Drug Coverage
+ NEW and Improved RX coverage! 2021 Tier
2021 Tier Drug Mix Copay
Description
+ Cost Tier Drug Formulary: Tier 0 ACA Preventive $0
+ Drug list is essentially the same, drugs are just
on different tiers Tier 1 All generic $0
+ Tier numbers refer to drug cost-sharing tiers,
Tier 2 Mostly all generic $10
rather than drug type tiers (brand, generic,
specialty) High value, first line Brand +
Tier 3 $15
Generic
+ Generic drugs may be in any tier 1-4, primarily
based on their total cost All other Brand +
Tier 4 $45
high cost Generics
Tier 5 Specialty (brand + generic) 50% up to $200
Tier 6 Specialty (brand + generic) 50% up to $200
© 2020 Private & Confidential 14Health Savings Account Qualified Plans
HSA Benefits HSA Embedded Benefits
(In-Network) (In-Network)
+ The Providence HSA Qualified plan
is a lower premium, high Individual /Family
$6650 / $13,300 $3,500 / $7000
Annual Deductible
deductible health plan that
provides affordable coverage and Individual / Family
the flexibility to choose any Annual Out-of- $6650 / $13,300 $6750 / $13,500
provider in the Signature network Pocket Maximum
Coinsurance 0% - 0% 50% - 50%
+ Select preventive medications are
not subject to the deductible. Look Primary Care 50%
0%
for the symbol SH on our online Provider (PCP)
formulary “P”
https://healthplans.providence.org/m Specialty 0% 50%
embers/pharmacy-resources/
Urgent Care 0% 50%
+ Save for future health care needs
via a tax advantaged health Diagnostic Lab & X-
0% 50%
savings account if offered by your ray
employer High Tech Imaging
0% 50%
(CT, MRI, PET)
Emergency Room 0% 50%
© 2020 Private & Confidential 15Health Savings Account Qualified Plan:
Prescription Drug Coverage
+ Most prescriptions are covered after the medical deductible has been met, with some
exceptions…
+ Affordable Care Act (ACA) preventive prescriptions are covered in full and not subject to
deductible or coinsurance
+ Examples are fluoride and pre-natal vitamins
+ Safe Harbor medications are not subject to the deductible, but would be subject to
coinsurance
+ Examples are Insulin and ACE inhibitors
+ Please see our formulary listing to confirm if your generic, name brand or specialty drug is
covered. The formulary listing is available in your myProvidence.com account, or our
customer service team would be happy to assist
© 2020 Private & Confidential 16Chiropractic & Acupuncture Benefits
+ Plan Features:
+ Covers chiropractic manipulation and
acupuncture
+ Must use participating providers
$25 co-pay + No referral required
+ Lab work, x-rays, and other covered
services are covered under your medical
benefits when you receive them from a
$1,000 Calendar Year naturopath, chiropractor, acupuncturist or
Benefit Maximum other alternative care provider licensed to
perform the service
© 2020 Private & Confidential 17NEW!
Employee Assistance Program For All Plans
+ Providence EAP offers:
+ information, guidance, and support to
help you and your family reach your
personal and professional goals.
3 visits Per Episode
+ It is part of the benefits and is available
at no cost.
© 2020 Private & Confidential 18Integrated Mental Healthcare
+ Our commitment to mental health will be
strengthened in 2021 by bringing mental
health services in-house
+ This will result in seamless customer service
and integrated care management
+ 24/7 crisis management
+ You can find your behavioral health providers in the
Providence online directory
+ Also find the directory using your myProvidence.com
account for in-network providers
© 2020 Private & Confidential 19Providence Health Plan is about
Absolute Health
Providence offers many added values to help keep our members healthy and happy
© 2020 Private & ConfidentialGet the right care at the right time
in the right place
ProvRN ExpressCare ExpressCare Primary Care Urgent Care Emergency
Free Virtual Clinics $ $$ $$$
+ Connect with a
Free Free + Your primary + When you need help + When you think you
registered nurse 24/7 healthcare partner for right away and can’t may be in danger
+ Talk with a provider + Same-day, in-person
check-ups, managing wait for an
+ Easy first step when from anywhere using treatment + Available 24/7
chronic conditions, and appointment
you have symptoms your tablet,
+ With many convenient specialist referrals
and want to know if smartphone, or + Hours vary by location
computer locations throughout
you need face-to-face + Appointment required
the Portland Metro
care + Available nationwide area. it’s easy to find a
clinic near you
If you ever think your life or well-being could be in serious danger, call 911 immediately.
*ExpressCare Virtual and ExpressCare Clinic services are free with most plans. HSA plan members must first meet their plan deductible; then services are covered in full.
© 2020 Private & Confidential 21Express Care Virtual
+ See a provider in minutes, from anywhere
+ Live video visits from your smartphone or computer
+ No appointment necessary
+ Board-certified providers treat many common conditions such
as cough, cold/flu, sinus/ear/eye infections, etc.
+ Extended hours
+ 8 a.m. to 8 p.m. in OR, WA, MT, AK, CA and 24/7 nationwide
through our network partner
+ Covered in full on all plans except HSA
Get Started
+ Low cost care option for those on HSA qualified plans Visit virtual.providence.org or download the
+ $49 app from the App Store or Google Play, sign
up, and start your visit!
© 2020 Private & Confidential 22More ways to reach true health
Active&Fit Direct Health Coaching ChooseHealthy
Access 10,000 participating Providence health coaches We want to give you every
fitness centers and YMCAs are here to support each opportunity to achieve your
nationwide through Active&Fit member’s journey to a health goals. Save big on
Direct for $25 a month (plus a healthier, happier life. fitness and wellness products,
$25 enrollment fee and services, and memberships.
applicable taxes; 3-month
commitment required).
LifeBalance ID Protection Emergency Travel
Get discounts on the things Get peace of mind with Assist Assistance
you love to do from movies to America Identity Theft Get emergency medical help
travel to a night on the town. Protection’s fraud monitoring, while traveling away from
LifeBalance provides savings warning, and resolution. home, or even internationally,
on more than 20,000 travel, with Assist America Travel
cultural, recreational, and Assistance.
other fun activities.
© 2020 Private & Confidential 23Health Coaching
+ Standard Health Coaching program + Healthy Eating and Active Lifestyle (H.E.A.L.)
+ Guidance to help members identify and take program
action toward healthier lifestyle and behavior + Our diabetes prevention program received full
choices recognition by the CDC in 2019
+ Empower members to lose weight, + Designed to prevent Type 2 diabetes and
improve diet, manage stress, exercise or promote moderate weight loss
stop using tobacco
+ Yearlong program with 26 sessions
+ Evidence-based coaching techniques
+ Offered in multiple formats
+ Sessions are 1:1
Telephonic E-mail Combo Group
Telephonic E-mail Combo
© 2020 Private & Confidential 24Tips to Help You Save
+ Tip 1: Know your benefits + Tip 4: Maximize your pharmacy benefits
+ Maximize your benefits by understanding your + Get a 90-day supply of maintenance medications from
coverage a preferred retail or participating mail-order pharmacy
+ Tip 2: Choose an in-network provider + Tip 5: Access the most appropriate care
+ You'll typically pay less for services received + Knowing when and where to get care is essential to
from in-network providers – visit our online your health and your wallet
provider directory to find a provider near you
+ Tip 6: Compare costs
+ Tip 3: Use your preventive care benefits + Use the treatment cost calculator to learn about a
+ Providence covers certain preventive services in facility or doctor and the estimated costs of your
full when received from an in-network provider – treatment
use your preventive service benefits to help + Costs are customized to you based on your medical
achieve good health plan, the providers in your network, and how much
you’ve accumulated toward your deductible and out-
of-pocket maximum
© 2020 Private & Confidential 25Resources on the Web
+ Tools available on our website include:
+ Searchable Provider Directory
+ myProvidence, secure member portal
+ Numerous wellness tools & resources
+ Pharmacy resources
+ More information about discounts,
programs, and services available as a
Providence member
Get Started
Go to www.providencehealthplan.com to explore
the tools and resources available to you online.
© 2020 Private & Confidential 26myProvidence
myProvidence
Connect to • Your personal Access exclusive
your personal connection to member discounts on fitness
health plan information benefit memberships, travel and more
information and
Take a personal health health & wellness
Easily manage
assessment to find out what tools your health plan
you’re doing well and where with user preferences
you can improve • Mobile optimized
• Claims & out-of-
pocket maximum Visit Wellness Central,
Estimate the cost of
accumulation a personal health and
care or prescriptions before
wellness hub to track
you receive them information your health goals
Get Started
Sign up for your account at
myProvidence.com
© 2020 Private & Confidential 27Prescription Drug Cost Estimator
+ Provides estimated medication costs
+ Ability to compare costs at multiple
pharmacies
+ Estimates based on your plan,
accumulator status, and the rates of the
pharmacy chosen
Get Started
The prescription drug cost estimator is accessible
through our secure member portal, myProvidence. Visit
myProvidence.com to sign up for your account.
© 2020 Private & Confidential 28Member ID Cards
+ You will receive your member ID cards in the mail
+ Watch for a plain white envelope
+ Cards will be provided for subscriber and all dependents on the plan
Member ID Card ID Card App
Take your ID card with you when you receive Your ID card is also available on your
care. It includes important information for you smartphone with our mobile app.
and your provider, including your network Download the app from the App Store
information and important phone numbers. or Google Play today so you're ready
when you need care.
© 2020 Private & Confidential 29Connect with Providence
Online http://www.providencehealthplan.com/members
503-574-7500
By Phone 800-878-4445
TTY: 711
Monday to Friday, 8 a.m. to 5 p.m. (Pacific Time)
By Email Send us a message
© 2020 Private & Confidential 30THANK YOU
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