wellesley college ppo plus hsa plan for 2015. © 2009 harvard pilgrim health care components of the...

Wellesley College

PPO Plus HSA Plan for 2015

© 2009 Harvard Pilgrim Health Care

Components of the PPO Plus HSA Plan

Two parts:

• A qualified High Deductible Health Plan

• A Health Savings Account (HSA)o Administered by WageWorks

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Common Terms

Allowed Amount– The maximum amount on which payment is based for covered health

care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference.

Balance Billing from Non-Preferred Providers– The difference between the provider’s charge and the allowed amount.

For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

Copayment– A fixed amount (for example, $20) that you pay for a covered health

care service, usually when you receive the service. The amount can vary by the type of covered health care service.

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Common Terms

Deductible– The amount you owe for plan services before the plan begins to pay.

For example, if your deductible is $1,500, the plan won’t pay anything until you’ve met your $1,500 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Network– The facilities, providers and suppliers the plan has contracted with to

provide health care services.

Non-Preferred Provider – A provider who doesn’t have a contract with the plan to provide

services to you. You’ll pay more to see a non-preferred provider.

Out-of-network Co-insurance– The percent (for example, 40%) you pay of the amount for covered

health care services to providers who do not contract with the plan.

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Common Terms

Out-of-Pocket Limit– The most you pay during the year before the plan begins to pay 100%

of the allowed amount. This limit never includes your premium, balance-billed charges or health care services the plan doesn’t cover.

Primary Care Provider– A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic

Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

Specialist– A physician specialist who focuses on a specific area of medicine or a

group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

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PPO Plus HSA Plan Design

No need to designate a primary care physician (PCP)

No referral needed for specialist care

Full access to our local network, plus United Health Care’s national network of more than 650,000 providers

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The PPO Plus HSA Plan Puts You in Control

Access care from providers outside the network (with higher cost-sharing)

Access emergency care anywhere in the world at the in-network benefit level

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Preventive Services

Select in-network preventive services are not subject to the deductible– Covered in full: routine physicals, annual gyn visits,

mammograms, pap smears, immunizations, routine blood work and urinalysis, and certain disease screenings

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PPO Plus HSA Plan

All diagnostics and treatments are subject to deductible:

• Visits for illness or injury• Imaging and outpatient services• Inpatient services• Prescription drugs

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Prescription Drugs

Subject to in-network deductible

Payment is due at the time of purchase

Once you reach the deductible, a copay applies– $5 / $20 / $30 /$50 retail– $10/$40/$60/$150 mail order

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PPO Plus HSA Plan Summary

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Plan Provision In-Network Benefits Out-of-Network Benefits

Annual Deductible $1,500 – Individual contract$3,000 – Family contract

HSA College Funding(50% of deductible)

$750 – Individual contract$1,500 – Family contract

Annual Out-of-Pocket Maximum $5,000 – Individual contract$10,000 – Family contract

Preventive care including: Adult annual visit Well child visit Annual gynecological visit Immunization, including flu shot

100% No deductible applies

80%No deductible applies

Emergency Room 100% after deductible

Other Services Office visit for illness or injury Lab test, diagnostic procedures In and out patient hospital services Treatment and procedures, such

as surgeries, chemotherapy, allergy treatments, dialysis

100% after deductible 80% after deductible

DME 80% after the deductible

Prescription drug – retail $5/$20/$30/$50 after in-network deductible

Prescription drug – mail order $10/$40/$60/$150 after in-network deductible


PPO Plus HSA Premium Comparison to HMO (non union)

Annual Plan Premium and HSA Comparison

HMO PPO Plus HSA

Premium Savings

HSA College

Contribution

Total (savings and

HSA)

Individual $1,917 $1,466 $450 $750 $1,200

Family $5,195 $3,973 $1,222 $1,500 $2,722

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Reimbursement for Medical Claims

You visit provider

Provider submits

claim

Harvard Pilgrim

processes claim

Provider bills you

You pay provider (you can use HSA

funds)

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All reimbursements to network providers are based on the negotiated amount

Step 1


HMO vs PPO Plus HSA

HMO PPO Plus HSA

(in-network)

PCP Yes No

Referrals Yes No

OON benefits No Yes

Deductible None $1,500 per individual contract or $3,000 per

family contract

Select preventive Covered in full Covered in full

PCP visit $25 copay Deductible, then 100%

Specialist visit $25 copay Deductible, then 100%

Lab Covered in full Deductible, then 100%

Imaging $75 copay Deductible, then 100%

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HMO vs PPO Plus HSA

HMOPPO Plus HSA

(in-network)

Emergency $100 copay Deductible, then 100%

Day surgery $250 copay Deductible, then 100%

Inpatient $500 copay Deductible, then 100%

Outpatient Rehab $25 copay Deductible, then 100%

Behavioral health $25 copay Deductible, then 100%

Chiropractic Copay, then 100% Deductible, then 100%

DME 80% Deductible, then 80%

Prescriptions Copay Deductible, then copay

Health Savings Account None $750 per individual contract or $1,500 per

family contract

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Becoming a Better Health Care Consumer

Determine when you need to access care

Choose the appropriate site of service– Medical appropriateness– Find lower-cost, high-quality providers– Compare hospitals

Research online with Now iKnow

Read your Harvard Pilgrim Activity Summaries

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Activity Summary

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HPHConnect

View all claims, authorizations, prescription drug history and monthly Activity Summaries

Compare provider cost and quality

Create a personal medical record

Research a condition

Review your plan documents– Schedule of Benefits and Benefit Handbook– Pharmacy program– Much more

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Now iKnow

Harvard Pilgrim's Cost Transparency Tool


Now iKnow Overview

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A secure online cost and quality tool that supports HPHC commercial members in making informed health care purchasing decisions

Offers cost and quality information to help members understand and plan for their potential out-of-pocket expenses related to their treatment options


Now iKnow Highlights

Utilizes secure sign-on through HPHConnect

Displays real-time accumulator snapshots of out-of-pocket utilization

Estimates are based on member’s plan design

Shows costs for simple procedures and complex bundled treatments

Allows browsing functionality and provider comparisons based on location, treatment or condition

Displays physician and hospital quality Displays member messages

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Includes specific cost estimate or an estimated range, based on amount spent to date

Gives side-by-side provider comparison

Filters based on Harvard Pilgrim provider directory

Displays quality ratings for physicians and hospitals

Incorporates tiered/limited provider networks

Now iKnow Provider Search Results

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Uses Google maps to display provider locations/directions

Shows what is and is not included in the estimate

Breaks out price by facility and professional costs

Includes specific cost estimate or an estimated range

Now iKnow Provider Price Details

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© 2009 Harvard Pilgrim Health Care 24

The Basics: Annual PPO deductible: $1,500 HSA: College contributes $750; Sue contributes $275

Sue has some preventive care (covered in full by either plan), goes to the doctor for strep and purchases generic medication. If Sue chooses the PPO Plus HSA Plan, she pays $1,466 for the coverage and still has $852 in her HSA for future medical expenses. Under the HMO, she will pay $1,947 for the year (for coverage and copays).

PPO Plus HSA Plan vs. HMOScenario 1: Single Coverage – Sue

ServiceCost of

Care

PPO Plus HSA Plan HMO (in-network)

Plan Pays

Sue Pays

Plan PaysSue Pays(copays)

Out-of-Pocket From HSA

Routine physical and flu shot (preventive)

$200 $200 $0 $0 $200 $0

Doctor’s visit (strep throat) $150 $0 $0 $150 $125 $25

Medication (generic) $23 $0 $0 $23 $18 $5

Totals $373 $200 $173 $343 $30

Annual Medical Premium* $1,466 $1,917

Sue’s Total Cost $1,466* $1,947

Remaining HSA Balance + $852 N/A

*Note that the College contributed $750 to Sue’s HSA, so she did not have to use any of her own HSA contributions


The Basics: Annual PPO deductible: $3,000 HSA: College contributes $1,500; John contributes $750

John’s family uses some preventive care and has other doctor’s visits, a generic prescription and outpatient surgery. If John chooses the PPO Plus HSA Plan, he pays $3,973 for the coverage and $115 out-of-pocket, with $2,250 coming from the HSA. With the HMO, he pays $5,195 for coverage and $315 out-of-pocket.

PPO Plus HSA Plan vs. HMOScenario 2: Family Coverage – John

ServiceCost of

Care


Plan Pays

John Pays

Plan PaysJohn Pays(copays)

Out-of-Pocket From HSA

Routine physical for son $200 $200 $0 $0 $200 $0

Doctor’s visit for John $150 $0 $0 $150 $125 $25

Outpatient surgery $2,000 $0 $0 $2,000 $1,750 $250

Doctor’s visit for spouse $150 $0 $50 $100 $125 $25

Medication (generic) $65 $0 $65 $0 $50 $15

Totals $2,565 $200 $2,365 $2,250 $315


John’s Total Cost $4,838* $5,510

Remaining HSA Balance $0 N/A*Note that the HSA paid $2,250 in medical expenses with $1,500 due to the College’s contributions


The Basics: Annual PPO deductible: $3,000 HSA: College contributes $1,500

Theresa’s family has two preventive visits, outpatient surgery and an MRI. If Theresa chooses the PPO Plus HSA Plan, she pays $3,973 for the coverage and $1,500 out-of-pocket, with another $1,500 coming from the College contribution to her HSA. With the HMO, she pays $5,195 for coverage and $325 out-of-pocket.

PPO Plus HSA Plan vs. HMOScenario 3: Family Coverage – Theresa

ServiceCost of

Care


Plan Pays

Theresa Pays

Plan PaysTheresa

Pays(copays)Out-of-Pocket From HSA

Routine physical for self $200 $200 $0 $0 $200 $0

Routine physical for son $200 $200 $0 $0 $200 $0

MRI $3,000 $0 $1,500 $1,500 $2,025 $75

Outpatient surgery $2,000 $2,000 $0 $0 $1,750 $250

Totals $5,400 $2,400 $3,000 $4,175 $325


Theresa’s Total Cost $5,473* $5,520

Remaining HSA Balance $0 N/A

*Note that the College contributed $1,500 to Theresa’s HSA and this paid $1,500 of the family’s medical expenses


QUESTIONS?

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wellesley college ppo plus hsa plan for 2015. © 2009 harvard pilgrim health care components of the...

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