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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© 2009 Harvard Pilgrim Health Care
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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© 2009 Harvard Pilgrim Health Care
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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© 2009 Harvard Pilgrim Health Care
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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© 2009 Harvard Pilgrim Health Care
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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© 2009 Harvard Pilgrim Health Care
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
© 2009 Harvard Pilgrim Health Care
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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© 2009 Harvard Pilgrim Health Care
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
© 2009 Harvard Pilgrim Health Care
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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© 2009 Harvard Pilgrim Health Care
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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© 2009 Harvard Pilgrim Health Care
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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© 2009 Harvard Pilgrim Health Care
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
© 2009 Harvard Pilgrim Health Care
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
© 2009 Harvard Pilgrim Health Care
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
© 2009 Harvard Pilgrim Health Care 25
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
PPO Plus HSA Plan HMO (in-network)
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
Annual Medical Premium* $3,973 $5,195
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
© 2009 Harvard Pilgrim Health Care 26
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
PPO Plus HSA Plan HMO (in-network)
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
Annual Medical Premium* $3,973 $5,195
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
© 2009 Harvard Pilgrim Health Care
QUESTIONS?
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