I want a local partner that understands my needs.

Transcription

1 Your Guide to 2019 Small Group Coverage I want a local partner that understands my needs. Guiding Connecticut to better health. From Woodstock to Greenwich and everywhere in between, our Hartford-based team has cultivated strong relationships with local providers, businesses and organizations across Connecticut. As the only not-for-profit health insurer in Connecticut, our mission lets us focus on what matters most: healthier people and healthier communities. Connecticut Small Group Product Guide Plan Year 2019 The individual shown is representative only. The comment is a composite of sentiments often expressed by our brokers.

2 Table of contents 2 Why Harvard Pilgrim? 3 Core Benefits 4 Additional Benefits & Tools 5 Optional Care 6 Network Overview 7 Prescription Drug Coverage & Behavioral Health Product Change Highlights 10 Product Grids 28 HPHConnect for Brokers 29 Broker/Employer Service Team 30 Business Rules 31 Important Legal Information

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4 Our promise: Guide people and communities to better health. We help you guide your clients to the best solution. Harvard Pilgrim has a full range of insurance solutions offering outstanding coverage, choice and value. We have plans to meet the needs of small businesses and large corporations, with fully and self-insured options available. Full Network Plans Our HMO and PPO products are built around outstanding local providers who deliver high-quality care at an excellent value. New England & National Coverage Our regional network has more than 70,000 doctors and other clinicians, and 182 hospitals. Our PPO plans give members access to providers across the United States. Self-Insured Solutions Our affiliate, Health Plans, Inc. (HPI), is the largest third-party administrator of self-funded plans in New England. 70,000 DOCTORS & CLINICIANS 182 HOSPITALS We re committed to our communities. Service is more than good business. As a not-for-profit, service inspires our social mission. We re driven by a human concern for the particular health challenges our Connecticut neighbors and communities face and a dedication to helping resolve them. Funding Programs in Connecticut Harvard Pilgrim is the only not-for-profit health plan in Connecticut. In 2017, the Harvard Pilgrim Health Care Foundation supported local non-profit agencies and health initiatives with more than $2.3 million in grants and sponsorships regionally, and $466,000 in our local Connecticut community. Serving Our Community Service is a core value to Harvard Pilgrim that we abide deeply. In Connecticut, employees volunteered 240 hours of service in 2017 at locations including the Keney Park Sustainability Project, The Wish School, and Northwest Boys & Girls Club. Projects included painting seating for an outdoor kitchen, building raised garden beds, landscaping, constructing picnic benches and cubbies, and painting murals. $466,000 GRANTS & SPONSORSHIPS 2

5 What we cover Core benefits No matter which plan a member chooses, all of our plans include these benefits. Ambulatory patient services Outpatient care without hospital admission Mental health and substance use services Counseling and psychotherapy Pregnancy, maternity, and newborn care Care before, during and after pregnancy Emergency services Trips to the emergency room (ER), when medically necessary Pediatric dental and vision Covers children up to age 19 Rehabilitation & habilitative services and devices Rehab services, hospital beds, crutches, oxygen tanks Laboratory services Blood work, screenings, etc. Hospitalization Inpatient services, such as surgery Prescriptions Access to safe, effective medications Preventive care & chronic disease management Doctor visits for wellness exams, shots, screenings, health maintenance, etc. 3

6 Additional plan information Tools & resources The right set of tools helps your clients get the most out of their health care. Harvard Pilgrim offers a number of online tools and resources to help our members save money, stay healthy, and seek guidance for health concerns and conditions. Members can access all tools through their member accounts on harvardpilgrim.org. Guiding members to well-being Good health looks different for everyone. Whether one s wellness goals focus on nutrition, fitness, stress management or all of the above, our free wellness site is packed with tools to help our members achieve wellness however they define it. Customize by goals Chat with others for tips and advice harvardpilgrim.org/wellbeingforall Sync to a wearable device Connect with a personal health coach A personal health coach puts goals within reach Personal coaching can give that extra boost to finally achieve wellness goals. Through one-onone coaching sessions over the phone and check-ins, our certified health and wellness coaches work with members to: Set realistic personal health goals Health care cost estimator Too often, patients are unaware of their medical costs until the bill arrives. Our online cost estimator tool helps members understand what costs to expect beforehand. They can even compare costs among different providers, helping to save money on treatment and avoid any unwanted surprises. The care your clients need, when they need it When their primary care providers offices aren t open, members who need medical care for a non-life-threatening injury or illness have alternatives that cost less and are more convenient than an emergency room. Identify and address any personal barriers preventing positive lifestyle changes Monitor progress toward reaching goals 4

7 The care your clients need, when they need it When their primary care providers offices aren t open, members who need medical care for a non-life-threatening injury or illness have alternatives that cost less and are more convenient than an emergency room. Typical out-of-pocket costs Common symptoms Telemedicine services Real-time virtual visit with Doctor on Demand providers via smartphone, tablet or computer $ Members pay their PCP-level cost sharing for telemedicine services 1 Coughs, colds Sore/strep throat Flu Pediatric issues Sinus and allergies Nausea/diarrhea Rashes and skin issues Women s health: UTI s, yeast infections Sports injuries Eye issues Convenience care/retail clinic Walk-in, convenience care or retail clinic (e.g. MinuteClinic inside of CVS pharmacy) $ Members typically pay a copayment for going to a participating clinic 1 Bronchitis Ear infections Eye infections Skin conditions like poison ivy and ringworm Strep throat Freestanding urgent care clinic Walk-in clinic for urgent care (e.g., ConvenientMD, Clear Choice or Concentra) $$ Members typically pay a copayment for urgent care, sometimes a higher one than for an office visit or convenience care clinic visit 1 Minor injuries Infections Respiratory infections Coughs, cold and flu Sprains and strains Burns, rashes, bites, cuts and bruises Hospital-based urgent care clinic Walk-in clinic for urgent care $$$ Members typically pay their deductible, then a hospital-based urgent care copay 1 Minor injuries Infections Respiratory infections Coughs, cold and flu Sprains and strains Burns, rashes, bites, cuts and bruises Emergency room (ER) Part of a local hospital Members who think they are having medical emergencies should call 911 or go to the nearest ER. $$$$ Members typically pay a higher copayment than an office visit, plus ER services are often subject to a deductible 1 Choking Convulsions Heart attack Loss of conciousness Major blood loss Seizures Severe head trauma Shock Stroke 1 What you pay out-of-pocket depends on your specific Harvard Pilgrim plan. If you have an HSA plan, your deductible and any additional cost sharing applies. Please refer to your plan documents for your specific benefit information. 5

8 Your local partner with the strength of a national network ME VT NH MA CT National Network through UnitedHealthcare Harvard Pilgrim Health Care Network 70,000+ DOCTORS AND CLINICIANS 182 HOSPITALS 830,000 PROVIDERS 5,818 HOSPITALS How members can find a provider Visit harvardpilgrim.org Select the appropriate plan Click on Find a Provider Search by preferred provider type 6

9 Prescription drug coverage High-quality coverage Our prescription drug coverage focuses on choice and value to help members get the most out of their benefits and keep premiums affordable. TIER Tier 1 VALUE 4-TIER Lower-cost generics Harvard Pilgrim s Connecticut small group plans include a 4-tier prescription drug benefit: the lower the tier, the less members pay. Cost sharing for prescriptions may include a combination of copayments, coinsurance and a deductible, with the option of getting prescriptions filled at a retail pharmacy or through the mail. Tier 2 Tier 3 Tier 4 Higher-cost generics Preferred brands (some higher-cost generics) Non-preferred brands and preferred specialty (some higher-cost generics) Is a prescription covered? Finding out is easy for members with our online Prescription Drug Lookup tool available at harvardpilgrim.org. It takes just two steps! Members just select their plan and then look up drugs by tier or by category. VALUE $5/15/30/50 PLAN TYPE PLAN TIERS Discounts & Savings Harvard Pilgrim members can save on a wide range of products and services to keep them healthy. Vision Hearing Healthy Eating Fitness Dental Holistic Wellness Smoking Cessation Family & Senior Care Fitness does a body and a wallet good. Members get up to a $150 annual reimbursement on fees for health and fitness club membership and classes. To qualify, a member or one of their dependents must be an active member of the fitness club for at least four months within a calendar year. 2 2 There is a $150 maximum reimbursement per Harvard Pilgrim policy in a calendar year per individual or family contract. Must be currently enrolled in Harvard Pilgrim at the time of reimbursement. Restrictions apply. For tax information, consult your tax advisor. 7

10 2019 product change highlights We ve made several changes to the 2019 portfolio based on feedback from brokers and employers. Talk to your sales or account executive for more details on these and other product changes for NEW PLANS FOR 2019 DISCONTINUED PLANS HMO 2500 Hospital Best Buy HSA PPO /70 HMO 3000 Hospital Best Buy PPO CB HMO HSA 2800 Best Buy HSA PPO CB PPO CB PPO CB HMO with Coinsurance Plans The 2019 portfolio still includes our HMO plans with Coinsurance! HMO 2000 with Coinsurance (40%) HMO 5000 with Coinsurance (50%) Lower price than HMO without coinsurance No referrals needed! Seamless New England network Coverage across CT, MA, NH, ME, VT and RI Access to Harvard Pilgrim s network 8

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12 HMO PRODUCT NAME PLATINUM HMO 25/35 COPAY MD , RX GOLD HMO 2250 HOSPITAL MD , RX OFFICE VISIT $25/$35 $25/$35 DEDUCTIBLE None/None $2,250/$4,500 ANNUAL OUT OF POCKET MAX $2,000/$4,000 $5,000/$10,000 COINSURANCE None None MEDICAL EMERGENCY SERVICES IN THE ER* $200 Ded then $200 HOSPITAL BASED URGENT CARE $75 $75 FREESTANDING URGENT CARE $75 $75 INPATIENT $500 Per Day Ded then CIF DAY SURGERY $250 Ded then CIF LABS $10 $10 X-RAYS $40 $35 SCANS: CT, MRI, PET $75, Max $375 Per Year $75, Max $375 Per Year PT/OT/ST $25 PT/OT: $25 ST: $35 ACUPUNCTURE $35 $35 RX COST SHARING (VALUE FORMULARY) Retail: $5/30%/40%/40% (T2 $50/script max, T3 $250/script max, T4 $500/script max) Retail: $5/30%/40%/40% (T2 $50/script max, T3 $250/script max, T4 $500/script max) Mail: $10/30%/40%/40% (T2 $100/script max, T3 $500/script max, T4 $1,000/script max) Mail: $10/30%/40%/40% (T2 $100/script max, T3 $500/script max, T4 $1,000/script max) 10

13 Pending regulatory approval by the Connecticut Insurance Department GOLD HMO 2500 HOSPITAL MD , RX GOLD HMO 2000 WITH COINSURANCE MD , RX $25/$50 $25/$35 $2,500/$5,000 $2,000/$4,000 $5,500/$11,000 $4,500/$9,000 20% 40% 20%, Max $350 Ded then 40% 20%, Max $175 $75 20%, Max $175 $75 Ded then 20% Ded then 40% Ded then 20% Ded then 40% $10 40% $40 40% Ded then 20% Ded then 40% PT/OT: $25 ST: $50 Ded then 40% $50 $35 Retail: $5/30%/40%/40% (T2 $50/script max, T3 $250/script max, T4 $500/script max) Retail: $5/30%/40%/40% (T2 $50/script max, T3 $250/script max, T4 $500/script max) Mail: $10/30%/40%/40% (T2 $100/script max, T3 $500/script max, T4 $1,000/script max) Mail: $10/30%/40%/40% (T2 $100/script max, T3 $500/script max, T4 $1,000/script max) 11

14 HMO (continued) PRODUCT NAME SILVER HMO 3000 HOSPITAL MD , RX SILVER HMO 5000 WITH COINSURANCE MD , RX OFFICE VISIT $35/$50 $40/$50 DEDUCTIBLE $3,000/$6,000 $5,000/$10,000 ANNUAL OUT OF POCKET MAX $7,900/$15,800 $7,900/$15,800 COINSURANCE 40% 50% MEDICAL EMERGENCY SERVICES IN THE ER* Ded then 40% HOSPITAL BASED URGENT CARE $75 $75 FREESTANDING URGENT CARE $75 $75 INPATIENT Ded then 40% DAY SURGERY Ded then 40% LABS Ded then 40% 50% X-RAYS Ded then 40% 50% SCANS: CT, MRI, PET Ded then 40% PT/OT/ST PT/OT: $35 ST: $50 ACUPUNCTURE $50 $50 RX COST SHARING (VALUE FORMULARY) Retail: $5/30%/40%/50% (T2 $50/script max, T3 $250/script max, T4 $750/script max) Mail: $10/30%/40%/50% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) Retail: $5/30%/40%/50% (T2 $50/script max, T3 $250/script max, T4 $750/script max) Mail: $10/30%/40%/50% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) 12

15 HMO HSA SILVER SILVER Pending regulatory approval by the Connecticut Insurance Department BRONZE HMO HSA 2800 MD , RX HMO HSA 3000 MD , RX HMO HSA 4000 WITH COINSURANCE MD , RX Ded then 20% Ded then $35/$50 Ded then $35/$45 $2,800/$5,600 $3,000/$6,000 $4,000/$8,000 $4,500/$9,000 $6,650/$13,300 $6,650/$13,300 20% None 30% Ded then 20% Ded then $200 Ded then 30% Ded then 20% Ded then $75 Ded then $75 Ded then 20% Ded then $75 Ded then $75 Ded then 20% Ded then $500 Per Day/ Max $2,000 Per Admit Ded then 30% Ded then 20% Ded then $500 Ded then 30% Ded then 20% Ded then $10 Ded then 30% Ded then 20% Ded then $40 Ded then 30% Ded then 20% Ded then $75 Ded then 30% Ded then 20% PT/OT: Ded then $30 ST: Ded then $50 Ded then 30% Ded then 20% Ded then $50 Ded then $45 Retail: Ded then $5/30%/40%/50% (T2 $50/script max, T3 $250/script max, T4 $750/script max) Mail: Ded then $10/30%/40%/50% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) Retail: Ded then $5/30%/40%/50% (T2 $50/script max, T3 $250/script max, T4 $750/script max) Mail: Ded then $10/30%/40%/50% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) Retail: Ded then $5/30%/40%/50% (T2 $50/script max, T3 $250/script max, T4 $750/script max) Mail: Ded then $10/30%/40%/50% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) 13

16 PPO PLATINUM PRODUCT NAME PPO 25/35 COPAY MD , RX OFFICE VISIT $25/$35 Ded then 30% DEDUCTIBLE None/None $2,000/$4,000 ANNUAL OUT OF POCKET MAX $2,000/$4,000 $4,000/$8,000 COINSURANCE None 30% MEDICAL EMERGENCY SERVICES IN THE ER* $200 $200 HOSPITAL BASED URGENT CARE $50 Ded then 30% FREESTANDING URGENT CARE $50 Ded then 30% INPATIENT $500 Per Day Ded then 30% DAY SURGERY $250 Ded then 30% LABS $10 Ded then 30% X-RAYS $40 Ded then 30% SCANS: CT, MRI, PET $75, Max $375 Per Year Ded then 30% PT/OT/ST $35 Ded then 30% ACUPUNCTURE $35 Ded then 30% RX COST SHARING (VALUE FORMULARY) Retail: $5/30%/40%/40% (T2 $50/script max, T3 $250/script max, T4 $500/script max) Mail: $10/30%/40%/40% (T2 $100/script max, T3 $500/script max, T4 $1,000/script max) 14

17 Pending regulatory approval by the Connecticut Insurance Department PLATINUM GOLD PPO 750 HOSPITAL MD , RX PPO 1500 MD , RX $20/$40 Ded then 40% $30/$45 $750/$1,500 $1,500/$3,000 $1,500/$3,000 $3,000/$6,000 $3,250/$6,500 $6,500/$13,000 $5,000/$10,000 $10,000/$20,000 None 40% None 50% $200 $200 Ded then $200 Ded then $200 $50 Ded then 40% $75 $50 Ded then 40% $75 Ded then CIF Ded then 40% Ded then $500 Per Day/ Max $1,500 Per Admit Ded then CIF Ded then 40% Ded then $500 $10 Ded then 40% Ded then $10 $40 Ded then 40% Ded then $40 $75, Max $375 Per Year Ded then 40% Ded then $75, Max $375 Per Year PT/OT: $20 ST: $40 Ded then 40% PT/OT: $30 ST: $45 $40 Ded then 40% $45 Retail: $5/30%/40%/40% (T2 $50/script max, T3 $250/script max, T4 $500/script max) Mail: $10/30%/40%/40% (T2 $100/script max, T3 $500/script max, T4 $1,000/script max) Retail: $5/30%/40%/40% (T2 $50/script max, T3 $250/script max, T4 $500/script max) Mail: $10/30%/40%/40% (T2 $100/script max, T3 $500/script max, T4 $1,000/script max) 15

18 PPO (continued) GOLD PRODUCT NAME PPO 1500 WITH COINSURANCE MD , RX OFFICE VISIT $25/$40 DEDUCTIBLE $1,500/$3,000 $3,000/$6,000 ANNUAL OUT OF POCKET MAX $5,000/$10,000 $10,000/$20,000 COINSURANCE 40% 50% MEDICAL EMERGENCY SERVICES IN THE ER* Ded then 40% Ded then 40% HOSPITAL BASED URGENT CARE $75 FREESTANDING URGENT CARE $75 INPATIENT Ded then 40% DAY SURGERY Ded then 40% LABS Ded then 40% X-RAYS Ded then 40% SCANS: CT, MRI, PET Ded then 40% PT/OT/ST PT/OT: $25 ST: $40 ACUPUNCTURE $40 RX COST SHARING (VALUE FORMULARY) Retail: $5/30%/40%/40% (T2 $50/script max, T3 $250/script max, T4 $500/script max) Mail: $10/30%/40%/40% (T2 $100/script max, T3 $500/script max, T4 $1,000/script max) 16

19 Pending regulatory approval by the Connecticut Insurance Department SILVER SILVER PPO 3600 MD , RX PPO 3600 WITH COINSURANCE MD , RX $40/$50 $35/$50 $3,600/$7,200 $7,200/$14,400 $3,600/$7,200 $7,200/$14,400 $7,900/$15,800 $15,800/$31,600 $7,900/$15,800 $15,800/$31,600 None 50% 40% 50% Ded then $200 Ded then $200 Ded then 40% Ded then 40% $75 $75 $75 $75 Ded then $500 Per Day/ Max $2,000 Per Admit Ded then 40% Ded then $500 Ded then 40% Ded then $10 Ded then 40% Ded then $40 Ded then 40% Ded then $75, Max $375 Per Year Ded then 40% PT/OT: $30 ST: $50 PT/OT: $30 ST: $50 $50 $50 Retail: $5/30%/40%/50% (T2 $50/script max, T3 $250/script max, T4 $750/script max) Mail: $10/30%/40%/50% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) Retail: $5/30%/40%/50% (T2 $50/script max, T3 $250/script max, T4 $750/script max) Mail: $10/30%/40%/50% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) 17

20 PPO (continued) SILVER PRODUCT NAME PPO FREE MD , RX OFFICE VISIT CIF for the first 3 visits per mem. All other visits Ded then 40% DEDUCTIBLE $3,000/$6,000 $9,000/$18,000 ANNUAL OUT OF POCKET MAX $7,900/$15,800 $23,700/$47,400 COINSURANCE 40% 50% MEDICAL EMERGENCY SERVICES IN THE ER* Ded then 40% Ded then 40% HOSPITAL BASED URGENT CARE Ded then 40% FREESTANDING URGENT CARE Ded then 40% INPATIENT Ded then 40% DAY SURGERY Ded then 40% LABS Ded then 40% X-RAYS Ded then 40% SCANS: CT, MRI, PET Ded then 40% PT/OT/ST Ded then 40% ACUPUNCTURE Ded then 40% RX COST SHARING (VALUE FORMULARY) Retail: $5/30%/40%/50% (T2 $50/script max, T3 $250/script max, T4 $750/script max) Mail: $10/30%/40%/50% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) 18

21 PPO HSA SILVER PPO HSA 2700 MD , RX Pending regulatory approval by the Connecticut Insurance Department BRONZE PPO HSA 5500 MD , RX Ded then $25/$35 Ded then 30% $2,700/$5,400 $5,400/$10,800 $5,500/$11,000 $11,000/$22,000 $6,000/$12,000 $12,000/$24,000 $6,750/$13,500 $13,500/$27,000 50% 50% 30% 50% Ded then 30% Ded then 30% Ded then $75 Ded then 30% Ded then $75 Ded then 30% Ded then 30% Ded then 30% Ded then $10 Ded then 30% Ded then $35 Ded then 30% Ded then 30% PT/OT: Ded then $25 ST: Ded then $35 Ded then 30% Ded then $35 Ded then 30% Retail: Ded then $5/30%/40%/50% (T2 $50/script max, T3 $250/script max, T4 $750/script max) Mail: Ded then $10/30%/40%/50% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) Retail: Ded then $5/30%/40%/50% (T2 $50/script max, T3 $250/script max, T4 $750/script max) Mail: Ded then $10/30%/40%/50% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) 19

22 PPO CB Please contact CBIA for detailed plan designs. GOLD PRODUCT NAME PPO HOSPITAL CB MD , RX OFFICE VISIT $30/$45 DEDUCTIBLE $1,800/$3,600 $3,600/$7,200 ANNUAL OUT OF POCKET MAX $4,200/$8,400 $8,400/$16,800 COINSURANCE None 50% MEDICAL EMERGENCY SERVICES IN THE ER* $200 $200 HOSPITAL BASED URGENT CARE $75 FREESTANDING URGENT CARE $75 INPATIENT Ded then $500 Per Day/ Max $2,000 Per Admit DAY SURGERY Hosp: Ded then $500 Freestnd: $500 LABS $10 X-RAYS $40 SCANS: CT, MRI, PET Hosp: Ded then $75 Freestnd: $75, Max $375 Per Year PT/OT/ST PT/OT: $30 ST: $45 ACUPUNCTURE $45 RX COST SHARING (VALUE FORMULARY) Retail: Retail: $5/30%/40%/40% $2/$25/$65/35%/40% (T2 $50/script max, T3 $250/script (T4 $550/script max, T4 max, $500/script max) T5 $550 script max) Mail: $10/30%/40%/40% (T2 $100/script max, T3 Mail: $500/script $4/$50/$130/35%/40% max, T4 $1,000/script max) (T4 $1,100/script max, T5 $1,100/script max) 20

23 Pending regulatory approval by the Connecticut Insurance Department GOLD GOLD PPO HOSPITAL CB MD , RX PPO CB MD , RX $25/$50 $30/$50 $2,500/$5,000 $5,000/$10,000 $3,000/$6,000 $6,000/$12,000 $5,500/$11,000 $11,000/$22,000 $6,700/$13,400 $13,400/$26,800 20% 50% 25% 50% 20%, Max $350 20%, Max $350 Ded then 25% Ded then 25% 20%, Max $175 Ded then 25% 20%, Max $175 Ded then 25% Ded then $500 Per Day/ Max $2,000 Per Admit Ded then 25% Hosp: Ded then $500 Freestnd: Ded then $500 Hosp: Ded then 25% Freestnd: $500 $10 $10 $40 $40 Hosp: Ded then $75 Freestnd: $75, Max $375 Per Year Hosp: Ded then 25% Freestnd: $75, Max $375 Per Year PT/OT: $25 ST: $50 PT/OT: $30 ST: $50 $50 $50 Retail: $5/$35/$80/40%/45% Retail: $5/30%/40%/40% Retail: $5/$35/$80/40%/45% (T4 (T2 $550/script $50/script max, max, T3 $250/script max, T4 $500/script (T4 $550/script max) max, T5 $550 script max) T5 $550 script max) Mail: $10/30%/40%/40% Mail: (T2 $10/$70/$160/40%/45% $100/script max, T3 $500/script max, Mail: T4 $1,000/script $10/$70/$160/40%/45% max) (T4 $1,100/script max, (T4 $1,100/script max, T5 $1,100/script max) T5 $1,100/script max) Retail: $5/$35/$80/40%/45% Retail: $5/30%/40%/50% (T4 (T2 $550/script $50/script max, max, T3 $250/script max, T4 $750/script max) T5 $550 script max) Mail: $10/30%/40%/50% Mail: (T2 $10/$70/$160/40%/45% $100/script max, T3 $500/script max, T4 $1,500/script max) (T4 $1,100/script max, T5 $1,100/script max) 21

24 PPO CB (continued) Please contact CBIA for detailed plan designs. GOLD PRODUCT NAME PPO CB MD , RX OFFICE VISIT $40/$50 DEDUCTIBLE $3,500/$7,000 $7,000/$14,000 ANNUAL OUT OF POCKET MAX $7,900/$15,800 $15,800/$31,600 COINSURANCE 35% 50% MEDICAL EMERGENCY SERVICES IN THE ER* Ded then 35% Ded then 35% HOSPITAL BASED URGENT CARE Ded then 35% FREESTANDING URGENT CARE Ded then 35% INPATIENT Ded then 35% DAY SURGERY Hosp: Ded then 35% Freestnd: $500 LABS Ded then 35% X-RAYS Ded then 35% SCANS: CT, MRI, PET Hosp: Ded then 35% Freestnd: $75, Max $375 Per Year PT/OT/ST PT/OT: $30 ST: $50 ACUPUNCTURE $50 RX COST SHARING (VALUE FORMULARY) Retail: Retail: $5/30%/40%/50% $2/$25/$65/35%/40% (T2 $50/script max, T3 $250/script (T4 $550/script max, T4 max, $750/script max) T5 $550 script max) Mail: $10/30%/40%/50% Mail: $4/$50/$130/35%/40% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) (T4 $1,100/script max, T5 $1,100/script max) 22

25 Pending regulatory approval by the Connecticut Insurance Department SILVER SILVER PPO CB MD , RX PPO CB MD , RX $40/$50 $35/$50 $3,800/$7,600 $7,600/$15,200 $4,000/$8,000 $8,000/$16,000 $7,900/$15,800 $15,800/$31,600 $7,900/$15,800 $15,800/$31,600 30% 50% 50% 50% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Ded then 30% PT/OT: $30 ST: $50 $50 $50 Retail: Retail: $5/30%/40%/50% $2/$25/$65/35%/40% (T2 $50/script max, T3 $250/script (T4 $550/script max, T4 max, $750/script max) T5 $550 script max) Mail: $10/30%/40%/50% Mail: $4/$50/$130/35%/40% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) (T4 $1,100/script max, T5 $1,100/script max) Retail: Retail: $5/30%/40%/50% $2/$25/$65/35%/40% (T2 $50/script max, T3 $250/script (T4 $550/script max, T4 max, $750/script max) T5 $550 script max) Mail: $10/30%/40%/50% Mail: $4/$50/$130/35%/40% (T2 $100/script max, T3 $500/script max, T4 $1,500/script max) (T4 $1,100/script max, T5 $1,100/script max) 23

26 PPO HSA CB Please contact CBIA for detailed plan designs. SILVER PRODUCT NAME PPO HSA CB MD , RX OFFICE VISIT Ded then 20% DEDUCTIBLE $2,800/$5,600 $5,600/$11,200 ANNUAL OUT OF POCKET MAX $4,500/$9,000 $9,000/$18,000 COINSURANCE 20% 50% MEDICAL EMERGENCY SERVICES IN THE ER* Ded then 20% Ded then 20% HOSPITAL BASED URGENT CARE Ded then 20% FREESTANDING URGENT CARE Ded then 20% INPATIENT Ded then 20% DAY SURGERY Ded then 20% LABS Ded then 20% X-RAYS Ded then 20% SCANS: CT, MRI, PET Ded then 20% PT/OT/ST Ded then 20% ACUPUNCTURE Ded then 20% RX COST SHARING (VALUE FORMULARY) Retail: Ded Retail: then $2/$25/$65/35%/40% $5/30%/40%/50% (T2 $50/script max, (T4 T3 $550/script $250/script max, max, T4 $750/script T5 $550 max) script max) Mail: Ded Mail: then $4/$50/$130/35%/40% $10/30%/40%/50% (T2 $100/script max, (T4 $1,100/script T3 $500/script max, max, T4 $1,500/script T5 $1,100/script max) max) 24

27 Pending regulatory approval by the Connecticut Insurance Department SILVER PPO HSA CB MD , RX Ded then 30% $3,500/$7,000 $7,000/$14,000 $5,500/$11,000 $11,000/$22,000 30% 50% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Ded then 30% Retail: Ded Retail: then $2/$25/$65/35%/40% $5/30%/40%/50% (T2 $50/script max, (T4 T3 $550/script $250/script max, max, T4 $750/script T5 $550 max) script max) Mail: Ded Mail: then $4/$50/$130/35%/40% $10/30%/40%/50% (T2 $100/script max, (T4 $1,100/script T3 $500/script max, max, T4 $1,500/script T5 $1,100/script max) max) 25

28 PPO HSA CB (continued) Please contact CBIA for detailed plan designs. BRONZE PRODUCT NAME PPO HSA CB MD , RX OFFICE VISIT DEDUCTIBLE $5,000/$10,000 $10,000/$20,000 ANNUAL OUT OF POCKET MAX $6,550/$13,100 $13,100/$26,200 COINSURANCE 50% 50% MEDICAL EMERGENCY SERVICES IN THE ER* HOSPITAL BASED URGENT CARE FREESTANDING URGENT CARE INPATIENT DAY SURGERY LABS X-RAYS SCANS: CT, MRI, PET PT/OT/ST ACUPUNCTURE RX COST SHARING (VALUE FORMULARY) Retail: Ded Retail: then $2/$25/$65/35%/40% $5/30%/40%/50% (T2 $50/script max, (T4 T3 $550/script $250/script max, max, T4 $750/script T5 $550 max) script max) Mail: Ded Mail: then $4/$50/$130/35%/40% $10/30%/40%/50% (T2 $100/script max, (T4 $1,100/script T3 $500/script max, max, T4 $1,500/script T5 $1,100/script max) max) 26

29 Pending regulatory approval by the Connecticut Insurance Department BRONZE PPO HSA CB MD , RX Ded then 10% $6,500/$13,000 $13,000/$26,000 $6,750/$13,500 $13,500/$27,000 10% 50% Ded then 10% Ded then 10% Ded then 10% Ded then 10% Ded then 10% Ded then 10% Ded then 10% Ded then 10% Ded then 10% Ded then 10% Ded then 10% Retail: Ded Retail: then $2/$25/$65/35%/40% $5/30%/40%/50% (T2 $50/script max, (T4 T3 $550/script $250/script max, max, T4 $750/script T5 $550 max) script max) Mail: Ded Mail: then $4/$50/$130/35%/40% $10/30%/40%/50% (T2 $100/script max, (T4 $1,100/script T3 $500/script max, max, T4 $1,500/script T5 $1,100/script max) max) 27

30 All you need at harvardpilgrim.org with HPHConnect for Brokers Your one-stop shop for information on our plans, tools and services Our online platform makes it easy to get instant, accurate quotes for new business and renewals and to help manage your clients. 28 Access HPHConnect 24/7 to: Request quotes online Renew business online Receives commissions and statements electronically Perform administrative functions on behalf of your clients

31 Contact us We re at your service. And your clients, too. Dedicated service Live chat Live chat for Brokers with the Broker/Employer Service Team One phone number for all Broker needs: Broker/Employer Service Team, Broker Relations, Consumer Sales, Medicare Sales, Member Services: (800) For Employers: (800)

32 Business rules Harvard Pilgrim reserves the right to change premium rates at any time before the effective date of the policy if there is a change in applicable state laws or regulations. Changes to rates after the effective date of coverage are governed by the employer agreement. All 2019 Small Group plans are plan year. Minimum number of participating subscribers: Minimum Subscriber Enrollment # Eligible Requirements in Harvard Pilgrim Employees Commercial Products % % All eligible employees of a sold small group who are not participating in a Harvard Pilgrim plan are required to complete and sign a waiver form. Waivers due to Spouse, Dependent, Medicare, Medicaid and Military coverage are acceptable waivers and are excluded from the participation calculation. Waivers due to coverage through a second employer are considered acceptable waivers and are excluded from the participation calculation. Waivers due to individual/non group policies through the Exchange and coverage through a second employer are considered acceptable waivers and are excluded from the participation calculation. Waivers due to Veterans Coverage or individual/non group not through the Exchange are not considered acceptable waivers and are included in the participation calculation. Side-by-side rules: The following rules apply for determining allowable sideby-side options: 1) The maximum number of plans that can be sold to a group is 3. 2) An account cannot offer the same plan design configured with and without HRA or HSA funding side-by-side Extraterritorial Locations: All quotes are contingent upon state eligibility requirements concerning employee residency and employer office locations. For each new group enrollment or annual renewal, employers must disclose to Harvard Pilgrim Health Care all out-of-state office locations and the state residency for each subscriber at those locations. Preventive Medications with a High Deductible Health Plan: If a member has a high deductible health plan, the deductible may not apply to certain medications used for preventive care. Please see the ID card and Schedule of Benefits to determine if a member has this coverage. The ID card will include the words Preventive Drug Benefit if a member has this coverage. If a plan exempts preventive medications from the deductible and the health care provider prescribes one of the designated preventive medications, the deductible will not apply to that prescription. However, a member will be required to pay the applicable coinsurance amount for the drug. The plan may change the listing of designated preventive medications from time to time. For a current list of designated preventive medications, please visit our web site at harvardpilgrim.org. Essential Health Benefit Pediatric Dental Coverage: Pediatric dental services are required by the Patient Protection and Affordable Care Act. If an employer group purchases health plan coverage provided by Harvard Pilgrim or its affiliates (the health plan ) that DOES NOT include coverage for pediatric dental services, then by purchasing the health plan, the employer declares that it is aware that the health plan does not include pediatric dental coverage and that the employer is aware that a certified pediatric dental plan is available on or off the Exchange. Upon request, the employer group agrees to provide Harvard Pilgrim with documentation necessary to verify that each person covered under the Health Plan is also covered by the dental plan. Embedded Deductibles: Embedded deductible refers to a family plan that has two deductible components, an individual deductible and a family deductible. The maximum contribution by an individual toward the family deductible is limited to the individual deductible amount and allows for the individual to receive benefits before the family component is met. When any number of members collectively meet the family deductible, services for the entire family are covered for the remainder of the year. Out-of-area Dependents: For 2019, out-of-area dependents on an HMO plan will have coverage for urgent and emergent care only. 30

33 Important legal information What s not covered in our plans For a full list of services not covered, please refer to plan documents. Typically, exclusions include: CT HMO and PPO Alternative services and treatments Dental care, except as described in your policy. Any devices or special equipment needed for sports or occupational purposes. Experimental, unproven, or investigational services or treatments Routine foot care, except for preventive foot care for members with diabetes. Delivery outside the Service Area after the 37th week of pregnancy, or after you have been told that you are at risk for early delivery. DISPLAY FOR HMO ONLY Educational services or testing. Cosmetic services or treatment. Bariatric surgery. Commercial diet plans and weight loss programs. Nutritional or cosmetic therapy using vitamins, minerals or elements, and other nutrition-based therapy. Charges for services which were provided after the date on which your membership ends. Charges for any products or services related to non-covered benefits. Services or supplies provided by (1) anyone related to you by blood, marriage or adoption, or (2) anyone who ordinarily lives with you. Infertility treatment for members who are not medically infertile. Costs for any services for which you are entitled to treatment at government expense. Costs for services for which payment is required to be made by a Workers Compensation plan or an Employer under state or federal law. Custodial care. Private duty nursing. Vision services, except as described in your policy. Services that are not medically necessary. Transportation other than by ambulance, except as described in your policy. 31

34 General Notice About Nondiscrimination and Accessibility Requirements Harvard Pilgrim Health Care complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Harvard Pilgrim Health Care does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Harvard Pilgrim Health Care: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, other formats). Provides free language services to people whose primary language is not English, such as qualified interpreters. If you need these services, contact our Civil Rights Compliance Officer. If you believe that Harvard Pilgrim Health Care has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Civil Rights Compliance Officer, 93 Worcester St, Wellesley, MA 02481, (866) , TTY service: 711, Fax: (617) , civil_rights@harvardpilgrim.org. You can file a grievance in person or by mail, fax or . If you need help filing a grievance, the Civil Rights Compliance Officer is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C (800) , (800) (TDD) Complaint forms are available at Limitations for Connecticut Small Group Plans Chiropractic 20 visits per year Acupuncture 20 visits per year Early Intervention No benefit limit Therapy Services 40 visits per year combined Skilled nursing facility and inpatient rehabilitation 90 days per year combined Routine eye exam 1 exam per year 32

35 Language Assistance Services 33

36 Contact us Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care, Harvard Pilgrim Health Care of Connecticut, Harvard Pilgrim Health Care of New England and HPHC Insurance Company. 185 Asylum Street, Hartford CT harvardpilgrim.org Brokers: (800) Employers: (800) cc7501_sg_ct 9_18