Transcript PHR-Overview - My Mobile GA
Caring for Small Business in New York EmblemHealth’s 2014 Portfolio
November 2013
Today’s Discussion
• Overview • 2014 SG Off Exchange Product Portfolio • Select Care Network • SA Commissions • Portal Renewal Functionality • Manual Transactions for EH Conversions
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“Not Business as Usual”
EmblemHealth is transforming to compete in the commercial market “NY Marketplace” on and off-exchange products Neighborhood Care – Care Café SelectCare - AdvantageCare Physician Groups – tailored high performance network Focused on distribution channel and business relationships
“We are committed to the small group market and you our valued partners”
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Small Group Product Summary
Service HMO 40/60 (Gold) Select Care network HMO 35/55 (Silver) Select Care network In Network Only (except for emergency care) 30% Coinsurance (member responsibility) 10% Annual deductible (individual/family) No deductible $2,000/$4,000 $4,000/$8,000 $6,000 /$12,000 Annual out-of-pocket maximum (individual/family) Annual/lifetime maximum benefit Preventive services (e.g., well-child care including immunizations; annual physical; mammography; prostate exam; bone density screening; colonoscopy and more) Unlimited Covered in full Unlimited Covered in full HMO HD6300 (Bronze) Select Care network 0% $6,300/$12,600 $6,300/$12,600 Unlimited Covered in full Office visit copay (primary care/ specialist) Diagnostic lab and radiology Inpatient hospital admission Emergency room facility Emergency ambulance Urgent care facility Ambulatory surgery facility Pediatric vision exams Pediatric vision lenses and frames $40/$60 copay $60 copay $1,500 copay per admission $200 copay $100 copay $60 copay $150 copay $40 copay 10% coinsurance $35/$55 copay $55 copay 30% coinsurance after deductible $200 copay $150 copay $60 copay 30% coinsurance after deductible $35 copay 30% coinsurance Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible Durable medical equipment (DME) Gym Reimbursement 10% coinsurance 30% coinsurance Covered in full after deductible Subscriber reimbursed up to $200 per six-month period and 50 exercise facility visits. Covered spouse reimbursed up to $100 per six-month period and 50 exercise facility visits. Prescription Drugs — Retail (30 Day Supply) Prescription Drugs — Mail Order (90 Day Supply) $100 deductible per person must be met by either Retail or Mail Order, before the following copay applies (Tier 1/Tier 2/Tier 3)*: $15 / $35 / $75 $100 deductible per person must be met by either Retail or Mail Order, before the following copay applies (Tier 1/Tier 2/Tier 3)*: $38 / $88 / $188 Covered in full after deductible Covered in full after deductible
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Small Group Rates
Rating Region Rate Tier HMO 40/60 (Gold) Employee $460.08 Bronx, Kings, New York, Queens, Richmond, Westchester, Rockland and Orange counties. Employee/spouse $920.16 Employee/children $782.14 Family $1,311.23 HMO 35/55 (Silver) $392.54 $785.08 $667.32 $1,118.74 HMO HD6300 (Bronze) $342.74 $685.48 $582.66 $976.81 Nassau and Suffolk counties. Employee $522.86 Employee/spouse $1,045.72 Employee/children $888.86 Family $1,490.15 $446.10 $892.20 $758.37 $1,271.39 $389.51 $779.02 $662.17 $1,110.10
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Small Group Underwriting Guidelines Highlights
• • • • •
No Participation Requirement Submission Deadline – 23 rd of the prior month Husband/Wife – Must go to the Exchange Requalification will begin 2Q of 2014 Multiple Plan Offerings
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Up to 4 enrolled = 1 plan 5 to 20 enrolled = up to 3 plans
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Groups of 21+ enrolled = up to 4 plans
2014 Commission Schedule
Selling Agent
Commissions for Groups covering up to 50 eligible employees
General Agent
Competitive Commissions for all New Small Group Plans
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2014 Incentive Opportunity
7 Small Group Individual Selling Agent
Q1 2014 per contract payout for New Business
- $40 Per Contract
January 2014 conversion of existing business
- $40 Per Contract
Additional
$1,000 per group
with more than 10 enrolled subscribers
General Agent
Marketing Fee – To Be Announced
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Select Care Network
COUNTY Bronx Kings Nassau New York Orange Queens Richmond Rockland Suffolk Westchester
Grand Total
Non-Physician Specialist 698 187 371 268 24 299 64 13 149 105
2178
PCP 810 349 439 594 24 572 86 21 160 269
3324
Specialist 1113 495 1072 1378 230 747 295 61 339 530
6260
Grand Total 2621 1031 1882 2240 278 1618 445 95 648 904
11762
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Select Care Hospital Network
Bronx
Jacobi Medical Center Lincoln Medical and Mental Health Center Montefiore Medical Center - Henry and Lucy Moses Division Montefiore Medical Center - Jack D. Weiler Hospital of Albert Einstein College Division Montefiore Medical Center - North Division New York Westchester Square Medical Center - (OP Site) North Central Bronx Hospital St Barnabas Hospital
Kings
Beth Israel Medical Center - Kings Highway Division Brookdale University Hospital Medical Center Coney Island Hospital Kings County Hospital Center Lutheran Medical Center Woodhull Medical and Mental Health Center
New York City
Bellevue Hospital Center Beth Israel Medical Center - Petrie Campus Coler-Goldwater Specialty Hospital and Nursing Facility Harlem Hospital Center Hospital for Special Surgery Lenox Hill Hospital Metropolitan Hospital Center Mount Sinai Hospital Mount Sinai Hospital - Queens New York Eye and Ear Infirmary New York Presbyterian Hospital St Luke's Roosevelt Hospital Center - Roosevelt Division St Luke's Roosevelt Hospital Center - St. Luke's Division
Orange
Bon Secours Community Hospital St Anthony's Community Hospital
Westchester
Lawrence Hospital Center Northern Westchester Hospital Phelps Memorial Hospital Center St Joseph's Hospital Medical Center – Yonkers White Plains Hospital
Queens
Elmhurst Hospital Flushing Hospital Medical Center Forest Hills Hospital Jamaica Hospital Medical Center Queens Hospital Center
Richmond
Staten Island University Hospital – North Staten Island University Hospital – South Good Samaritan Hospital of Suffern
Nassau
Franklin Hospital Glen Cove Hospital Long Island Jewish Medical Center North Shore University Hospital – Manhasset North Shore University Hospital – Syosset Plainview Hospital
Suffolk
Eastern Long Island Hospital Huntington Hospital Peconic Bay Medical Center Southampton Hospital Southside Hospital
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Introducing AdvantageCare Physicians
AdvantageCare Physician brings together four legacy medical groups: • Manhattan’s Physician Group • Preferred Health Partners • Queens-Long Island Medical Group • Staten Island Physician Practice By joining forces, we are better able to cohesively: • • • Improve clinical quality outcomes through a model that enables team based and coordinated care Improve the patient experience – helping them better navigate the healthcare system to meet their health care needs Make health care more affordable – creating a sustainable future for our physicians and staff, our patients and our communities
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New Product Features
• Select Care network • PCP's/Referral required • RX Deductible (retail/mail): $100 per member; Retail: $15/$35/$75; Mail: $38.00/$88.00/$188 with Value Plus Formulary –Gold/Silver • Individual deductible can apply towards family deductible • Stand Alone PED Dental - DentCare (Dentcare Junior) • Pediatric Vision - GVS (exams & material), comprehensive professional Systems (materials only), EyeCare Advantage (materials only) • Optional Age 29 Rider
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New Business Cases
Submission process remains the same.
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HIP/HIPIC/Comprehealth Conversions
• Performed under Renewal Functionality within EH portal • Model Plans (compare all three plans) • Make Roster Changes when available • Allocate Subs for Multiple Plan Options – Must meet Underwriting guidelines NOTE: Brokers/GA’s obtain letter of instruction, signed rates, and roster changes from the group
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Small Group Renewal Process
HIP/HIPIC/CH Renewals:
1. Renewal Plan pre populated: Silver Except Select EPO/PPO Gold 2. Mode
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up to 3 Plans – Make Selection – subject to previous rules at this time 3. Submit to EH 4.
View/change PCP’s
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Groups without Member/Roster listing
HIP/HIPIC/CH Renewals:
1. Groups
without
roster/member listings will be unable to make any roster changes and only select one plan 2. Submit paperwork for all other transactions
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Subgroups – different LOB & Rider options
Groups with more than one benefit set, must each be processed individually.
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EH Product Conversions
• Manual Process • Requirements: 1.
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New Master App Latest NYS 45 3.
New Transaction forms (if needed) 4.
No Binder Checks • Email/mail documents to your dedicated EH representative • Enter as new business on the portal
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