Transcript The Power of Blue

Individual & Family
Medical, Dental & Life
Plans
March 2009
PPO Plans
 SmartSense
 Lumenos CDHPs
 PPO Share
 RightPlan PPO 40
 3500 Deductible PPO
 PPO 3500 HSA-Compatible
 Basic PPO (2500/1000)
Benefits shown on slides that follow are in-network
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PPO Plans
SmartSense
 Reliable protection with some of our lowest rates
 Choice of deductible
 Choice of generic or comprehensive drug coverage
 “Embedded” family deductible and out-of-pocket maximum
 3 office visits before deductible
 4th quarter deductible carryover
 $7 million lifetime benefits
 No maternity coverage
 Member-level-rated
2-year anniversary date rate guarantee on 5000 deductible plans
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SmartSense
Annual Out-of-Pocket Maximum
Single/Family
$2,500/$5,000 (family out of pocket can be satisfied by 2 or more members)
(in addition to deductible)
$500, $1,500, $2,500 or $5,000 (single)
$1,000, $3,000, $5,000 or $10,000 (family deductible can be satisfied by 2 or
more members)
Annual Deductible
Office Visits
3 before deductible w/ $30 copay, then 30% after deductible
30% after deductible
HealthyCheck Centers: $25/$75 copay for basic/ premium screenings, with
deductible waived
Preventive Care
Hospital In/Outpatient
30% after deductible
Drug Benefits
Generic plan
Comprehensive plan
4th Quarter Deductible Carryover
Maternity
Generic:
$15 copay or 40%, whichever is greater
Generic:
Brand name:
$15 copay or 40%, whichever is greater
$500 annual brand deductible (2-member maximum),
then $15 copay or 40%, whichever is greater (up to $500
maximum per prescription) — $4,500 maximum annual
out-of-pocket in addition to brand deductible
For last 3 months of calendar year for expenses incurred in the 4 th quarter
that are less than the deductible
Not covered
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PPO Plans
Lumenos®
Consumer-Driven Health Plans (CDHPs)
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HSA-compatible, HIA and HIA Plus plans
Deductible waived in-network (no cost to member) for
nationally recommended preventive care services
Choice of no maternity plans or one maternity plan
After deductible, member pays 0% or 30% co-insurance
(depending on plan) for most covered services
Generic and brand drugs – member pays 0% or 30% after
annual deductible (depending on plan)
$7 million lifetime maximum (no maternity plans),
$5 million lifetime maximum (maternity plan)
Member-level-rated
Powerful online health management tools
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Lumenos Health Savings Account (HSA)-Compatible
Without Maternity
HSA Account
Annual Out-of-Pocket
Maximum
(in addition to deductible)
 Funded by subscriber, up to maximum limit set by U.S. Treasury
 Unused dollars rollover year-to-year
 Subscriber “owns” HSA
Single: $3,500/$2,000/$0
Family: $7,000/$4,000/$0 (aggregate)
Annual Deductible
$1,500/$3,000/$5,000 (single)
$3,000/$6,000/$10,000 (family maximum)
Coinsurance after
deductible
30%/30%/0%
Office Visits
30%/30%/0% after deductible
Preventive Care
(nationally recommended
services)
$0 (deductible waived)
Hospital In/ Outpatient
30%/30%/0% after deductible
Maternity
Drug Benefits
Not covered
30%/30%/0% after deductible
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Lumenos Health Savings Account (HSA)-Compatible
With Maternity
HSA Account
Annual Out-of-Pocket
Maximum/Member
 Funded by subscriber, up to maximum limit set by U.S. Treasury
 Unused dollars rollover year-to-year
 Subscriber “owns” HSA
$0
(in addition to deductible)
Annual Deductible
$5,000 (single)
$10,000 (family maximum)
Coinsurance after
deductible
0%
Office Visits
$0 after deductible
Preventive Care
(nationally recommended
services)
$0 (deductible waived)
Hospital In/ Outpatient
$0 after deductible
Maternity
$0 after deductible
Drug Benefits
$0 after deductible
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Lumenos Health Incentive Account (HIA)
Without Maternity
HIA Account
Annual Out-of-Pocket
Maximum/member
(in addition to deductible)
 Funded through financial incentives earned through Healthy Rewards
 Must be actively enrolled in HIA plan to access HIA account funds
Single: $3,500/$2,000/$0
Family: $7,000/$4,000/$0 (aggregate)
Annual Deductible
$1,500/$3,000/$5,000 (single)
$3,000/$6,000/$10,000 (family maximum)
Coinsurance after
deductible
30%/30%/0%
Office Visits
30%/30%/0% after deductible
Preventive Care
(nationally recommended
services)
$0 (deductible waived)
Hospital In/ Outpatient
30%/30%/0% after deductible
Maternity
Drug Benefits
Not covered
30%/30%/0% after deductible
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Lumenos Health Incentive Account (HIA)
With Maternity
HIA Account
Annual Out-of-Pocket
Maximum
 Funded through financial incentives earned through Healthy Rewards
 Must be actively enrolled in HIA plan to access HIA account funds
$0
(in addition to deductible)
Annual Deductible
$5,000 (single)
$10,000 (family maximum)
Coinsurance after
deductible
0%
Office Visits
$0 after deductible
Preventive Care
(nationally recommended
services)
$0 (deductible waived)
Hospital In/ Outpatient
$0 after deductible
Maternity
$0 after deductible
Drug Benefits
$0 after deductible
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Lumenos Health Incentive Account Plus (HIA+)
Without Maternity
HIA+ Account
Annual Out-of-Pocket
Maximum/Member
(in addition to deductible)
 Funded through health plan allocation of $500/$1000 per year
single/family and financial incentives earned through Healthy Rewards
 Must be actively enrolled in HIA plan to access HIA account funds
Single: $3,500/$2,000/$0
Family: $7,000/$4,000/$0 (aggregate)
Annual Deductible
$1,500/$3,000/$5,000 (single)
$3,000/$6,000/$10,000 (family maximum)
Coinsurance after
deductible
30%/30%/0%
Office Visits
30%/30%/0% after deductible
Preventive Care
(nationally recommended
services)
$0 (deductible waived)
Hospital In/ Outpatient
30%/30%/0% after deductible
Maternity
Drug Benefits
Not covered
30%/30%/0% after deductible
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Lumenos Health Incentive Account Plus (HIA+)
With Maternity
HIA+ Account
Annual Out-of-Pocket
Maximum/Member
 Funded through health plan allocation of $500/$1000 per year
single/family and financial incentives earned through Healthy Rewards
 Must be actively enrolled in HIA+ plan to access HIA+ account funds
$0
(in addition to deductible)
Annual Deductible
$5,000 (single)
$10,000 (family maximum)
Coinsurance after
deductible
0%
Office Visits
$0 after deductible
Preventive Care
(nationally recommended
services)
$0 (deductible waived)
Hospital In/ Outpatient
$0 after deductible
Maternity
$0 after deductible
Drug Benefits
$0 after deductible
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PPO Plans
PPO Share (5000/2500/1500)
Comprehensive PPO plans
 Once deductible is met, member pays 30%
co-insurance for most covered services
 Deductible waived for office visits, annual
physical exam and preventive care
 Maternity coverage
 $5 million lifetime maximum
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PPO Share (5000/2500/1500)
Annual Out-of-Pocket
Maximum
(in addition to deductible)
(2-member maximum, par/non-par)
Annual Deductible
(2-member maximum)
Office Visits
Preventive Care
(deductible waived)
5000
2500
$2,500
per member
$5,000
per member
$5,000
per member
$2,500
per member
$1,500
per member
$40 copay
deductible waived
$35 copay
deductible waived
30% of negotiated fee,
deductible waived
Annual physical exam:
HealthyCheck Centers:
Routine mammogram, Pap,
PSA ordered by physician:
Well Child:
30% of negotiated fee
40% of negotiated fee
30% of negotiated fee
Maternity
30% of negotiated fee
(Anthem Blue Cross Formulary)
(2-member maximum for brand
deductible)
$15 generic;
$35 brand copay after
$750 brand deductible
$4,500
per member
30% of negotiated fee, or
$25/$75 copay for basic/premium screenings
Hospital In/ Outpatient
Drug Benefits
1500
$10 generic;
$30 brand copay after
$500 brand deductible
$10 generic;
$30 brand copay after
$250 brand deductible
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PPO Plans
RightPlan PPO 40
Our no-deductible PPO plan
 No deductible
 $40 office visit copay, 40% share of costs
 3 prescription drug options:
 None
 Generic only
 Comprehensive (generic and brand)
 Single policy coverage (each family member gets their own policy)
 No maternity
 $5 million lifetime maximum
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RightPlan PPO 40
Annual Out-of-Pocket
Maximum (par/non-par)
$7500/subscriber
Annual Deductible
No deductible
Office Visits
Preventive Care
Hospital In/Outpatient
Maternity
Drug Benefits
(Anthem Blue Cross Formulary)
$40 copay
HealthyCheck Centers:
$25/$75 copay for basic/ premium screenings
Routine mammogram, Pap,
PSA ordered by a physician: $40 office visit plus 40% of negotiated fee
Well Child:
$40 office visit plus 40% of negotiated fee
Inpatient:
40% of negotiated fee plus $500 copay/day;
4-day maximum copay per admission
Outpatient:
40% of negotiated fee plus $500 copay per
outpatient surgery admission
Not covered
No coverage (P958), or
Generic coverage (PE48) - $15 generic, or
Comprehensive coverage (PE49) - $15 generic, $35 brand copay after $500
brand deductible
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PPO Plans
PPO 3500 (HSA-Compatible)
HSA-Compatible plan
 HSA-compatible
 Most services covered at 100% after deductible is met
($100 copay for emergency services after deductible; waived if admitted)
 Deductible waived for HealthyCheck screenings
 No maternity
 Generic and brand drug coverage after annual deductible is met
 Member-level-rated
 $5 million lifetime maximum
2-year anniversary date rate guarantee
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PPO 3500 (HSA-Compatible)
Annual Out-of-Pocket
Maximum
(in addition to deductible)
$1500/member, $3,000/family (aggregate)
(Medical/Pharmacy
combined, par/non-par)
Annual Deductible
(Medical/Pharmacy combined,
par/non-par)
Office Visits
$3500/member, $7,000/family (aggregate)
$0 after deductible
HealthyCheck Centers:
Preventive Care
Hospital In/Outpatient
Maternity
Drug Benefits
(Anthem Blue Cross Formulary)
$25/$75 copay for basic/ premium
screenings, deductible waived
Routine mammogram, Pap,
PSA ordered by physician:
Well Child:
$0 after deductible
$0 after deductible
$0 after deductible
Not covered
$15 generic; $35 brand copay
after Medical/Pharmacy deductible met
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PPO Plans
3500 Deductible PPO
Another affordable plan for individuals and families
 Most services covered at 100% after deductible is met
($100 copay for emergency services after deductible; waived if admitted)
 Out-of-pocket maximum met in-network when deductible is met
 Deductible waived for HealthyCheck screenings
 No maternity
 Member-level-rated
 Generic and brand drug coverage
 $5 million lifetime maximum
2-year anniversary date rate guarantee
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3500 Deductible PPO
Annual Out-of- Pocket Maximum
(in addition to deductible)
(2-member maximum, par/non-par)
Annual Deductible
(2-member maximum)
Office Visits
Satisfied in-network once annual deductible is met
$3500/member
$0 after deductible
HealthyCheck Centers:
Preventive Care
Hospital In/Outpatient
Maternity
Drug Benefits
(Anthem Blue Cross Formulary)
$25/$75 copay for basic/premium
screenings, deductible waived
Routine mammogram, Pap,
PSA ordered by physician: $0 after deductible
Well Child:
$0 after deductible
$0 after deductible
Not covered
$15 generic; $35 brand copay after $500 brand deductible
(2-member maximum)
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PPO Plans
Basic PPO (2500/1000)
Our most basic and affordable plan
 In-hospital coverage in the event of catastrophic illness
or injury
 Office visit only after out-of-pocket maximum is met
 Prescription drugs in the hospital only
 Available with or without $1,000 Term Life
 No maternity
 $5 million lifetime maximum
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Basic PPO (2500/1000)
Annual Out-of-Pocket
Maximum
(in addition to deductible)
(2-member maximum, par/non-par)
Annual Deductible
(2-member maximum)
Office Visits
$2500
$2500
$2500/member
$1000/member
No office visit benefits until out-of-pocket maximum is met, then
plan pays 100% of negotiated fee
HealthyCheck Centers:
$25/$75 copay for basic/ premium
screenings
Preventive Care
(deductible waived)
Hospital In/Outpatient
Routine mammogram, Pap,
PSA ordered by physician:
20% of negotiated fee
20% of negotiated fee
Maternity
Not covered
Drug Benefits
Not covered
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HMO Plans
 HMO Saver
 Individual HMO
 Select HMO
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HMO Plans
HMO Saver, Individual HMO, Select HMO
 First dollar coverage on:
 Office visits
 Generic drugs
 Preventive care
 Unlimited office visits with set copays
 Coverage for services from doctors and hospitals in HMO
network
 Comprehensive drug plan
 Maternity coverage
 Lifetime maximum - unlimited
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HMO Plans
HMO Saver
Annual Out-of-Pocket
Maximum
(in addition to deductible)
(2-member maximum)
Annual Deductible
$3,000
$1,500/member for
Inpatient, Outpatient and
ASCs only
No deductible
$10 copay/visit
$25 copay/visit
$10 copay
$25 copay
Preventive Care
(specific services)
$1,500 deductible, then:
Inpatient:
20% of negotiated fee
Outpatient:
20% of negotiated fee
(emergency & non-emergency
services subject to deductible)
Maternity
See Office visits and
In/Outpatient
(subject to deductible)
Drug Benefits
(Anthem Blue Cross formulary)
Select HMO
$1500/member
Office Visits (unlimited)
Hospital In/Outpatient
Individual HMO
Inpatient:
20% of negotiated fee
Outpatient:
20% of negotiated fee
Office visits: $10 copay
Inpatient: no charge
Outpatient: 20% of
negotiated fee
Inpatient:
$250 copay/day first 4 days;
then covered at 100%
Outpatient:
20% of negotiated fee,
$250/surgery
See Office visits and
In/Outpatient
$10 generic; $30 brand copay after $250 brand deductible
(2-member maximum)
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Plan Options Based on Prospect’s Needs
If Main Need Is:
Recommended Plans:
Budget
Basic PPO, SmartSense
Immediate coverage for office
visits before deductible
PPO Share and HMO (unlimited)
SmartSense (up to three)
No deductible
RightPlan PPO 40
Individual HMO or Select HMO
100% coverage of most services
after deductible
Lumenos HSA/HIA/HIA+ (0% coinsurance plans)
3500 Deductible PPO or PPO 3500 (HSA-Compatible)
Control over finances, including
health care expenses
Lumenos
PPO 3500 (HSA-Compatible)
Maternity coverage
Lumenos with maternity
PPO Share
HMO
2-year anniversary date rate lock
SmartSense 5000, 3500 HSA, 3500 PPO
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Rating Methodology Summary
AnniversaryRated?
MemberLevel or
Contract
Rated?
Gender-Rated?
SmartSense
YES
MEMBER
YES
Lumenos
YES
MEMBER
YES
3500 HSA, 3500 PPO
YES
MEMBER
YES
RightPlan
YES
MEMBER
YES
PPO Share
YES
CONTRACT
NO
HMO
YES
CONTRACT
NO
Basic PPO
NO
CONTRACT
NO
Plan
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Short-Term Plans
Short-Term Plans
 Coverage from 30 to 180 days
 Choice of deductible level
 $3 million lifetime maximum
 Easy application process
 Streamlined underwriting
 No maternity
 Member-level-rated
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Short-Term Plans
Out-of-Pocket Maximum
Deductible
Hospital In/Outpatient
Ambulatory Surgical Center
and ER
Maternity
Drug Benefits
(Anthem Blue Cross Formulary)
$1,000 per member plus deductible
$250, $500, $1,000, $2,000
20% of negotiated fee
20% of negotiated fee
(Accidental injuries not subject to deductible)
Not covered
$10 generic; $30 brand name
Brand name maximum $500
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Dental Coverage Options
 Our New Dental Blue® PPO Plans
 Dental SelectHMO Plans
 SmileNet Dental Discount Program
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Dental Coverage Options
Dental Blue PPO Plans
 Power to choose from:
 Two networks (Dental Blue 100 or 200)
 Can even go to a dentist in DB 300 network and still be “in-network”
 Best to choose 200 Essential or 200 Plus plan if dentist is in
DB 300 network
 Four plans
 Key benefits:
 Negotiated discounts during waiting periods
 One of the largest PPO dental network in CA
 Negotiated discounts after exceeding the plan maximum
 Discounts on non-covered dental work such as teeth whitening,
implants and orthodontics
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Individual Dental – Dental Blue
100 Basic
Deductible
200 Essential
100 Plus
200 Plus
$50 single/$150 family
$25/person
(no family maximum)
The deductible is waived for covered in-network Diagnostic & Preventive services
Maximum Benefit
Waiting Periods
(months)
Diagnostic Care
(cleanings, exams,
X-rays)
$500/person/yr
$1000/person/yr
0
Basic services: 3 Basic services: 0 Basic services: 3
Major services: 12 Major services: 6 Major services: 12
100% in-network
(fee schedule out-of-network)
Basic Services
80% fillings;
50% stainless steel
crowns
(fee schedule OON)
Major Services
Not covered
Fee schedule
(e.g., $42 for filling)
100% in-network
(80% out-of-network)
80% (60% OON)
Fee schedule
Orthodontia
(e.g., $57 for
stainless steel crown)
50% (in-network and OON)
Not covered
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Individual Dental – DHMO, SmileNet
(3) DHMO Plans
Deductible
Maximum Benefit
Waiting Periods
None
Unlimited
$5
Routine Cleanings
$0
(oral exams, X-rays)
Orthodontia Coverage
Not an insurance plan;
a very simple, low-priced discount
dental program
None for most services
Office Visits
Diagnostic Care
SmileNet Dental Discount Program
$0
Yes
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Dental Coverage Options
What About Our Other (Previous) Dental PPO Plan?
 Sell Dental Blue 200 Essential Plan, which offers:
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Identical benefits to previous Dental PPO plan
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Access to much larger network
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Discounts during waiting periods and after exceed
plan maximum
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Discounts on non-covered dental work such as
teeth whitening, implants and orthodontics
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Individual Life Insurance
Term Life Insurance
 Anyone who qualifies for one of our Level 1 or
Level 1 + 25 medical plans can purchase:
 $15,000, $30,000, $50,000, $75,000 or $100,000 (if over age 19)
 $15,000 or $30,000 (ages 1-19)
 Basic PPO and PPO Saver plans include
$1,000 of Term Life insurance for:
 An additional $1 per month through age 49, or
 An additional $2 per month for ages 50-64
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Health • Dental • Life
Thank You for Selling
Anthem Blue Cross!
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