2020 Retail Readiness - Health Insurance Software …...2019/09/09 · Houston, TX 77096 Medium...

2020 Retail Readiness

Retail Markets Product Training

September 2019

The content contained within this guide is proprietary information and is intended for contracted and appointed agents and brokers of Blue Cross and Blue Shield of Illinois (BCBSIL). It should not be shared with members or prospects. This guide is for training purposes only. Do not use without permission.

© Copyright 2019

Division of Health Care Service Corporation. A Mutual Legal Reserve Company, an independent Licensee of the Blue Cross Blue Shield Association

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Before we get started…

• This presentation focuses on areas in the individual market.

• This presentation, and the information contained within it, is current as of September 4, 2019. It is subject to change based on subsequent federal and state laws, regulations and guidance.

• This presentation, and the information contained within it, is being shared for informational purposes only. It does not constitute legal, compliance or tax advice. If you have questions, please contact your legal, compliance or tax professionals.

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Partnerships for Progress

We value our producers and will continue to:

• Offer access to a sustainable product line

• Provide premier service and support

• Offer the tools and materials necessary to succeed

THANK YOU!

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Contents

2020 Updates

Network Overview

MyBlue Health HMO

Medical & Dental QHPs

Prescription & Pharmacy Benefits

Supplemental Non-ACA Products

Member Wellness Campaigns

Keeping your Book

Enrollment

Payment Reminders

Regulations & Reminders

Tools & Resources

2020 Updates

Overview of 2020 Product Changes

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Overview of 2020 Product Changes

• Retaining/Renewing all 2019 QHPs

• Offering products statewide in all markets

• Expanding product offering with two new BlueCare Direct (Advocate Health) HMO plans

• Service area reduction for BlueCare Direct (Advocate Health) in Kendall & Will counties

• Updated out-of-pocket maximums per regulations to $8,150 (individual) and $16,300 (family)

• Attractive silver cost-sharing-reduction plans

• No major changes for ACA Dental

MEDICAL & DENTAL QHPs NETWORK

PRESCRIPTION & PHARMACY

• Introducing a Bronze and Gold Plan on BlueCare Direct HMO network

• Service area reduction for Blue Care Direct in Will and Kendall counties

• Sam’s Club now in Preferred Pharmacy Network

• Annual Drug List Changes

Network Overview

2020 Network Overview

BCBSIL Contracted Provider Networks

BlueCare Direct Changes

Preferred Site of Care

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2020 Network Offerings: On and Off-Exchange

Blue Choice Preferred PPO Blue Advantage HMO Blue Advantage PPO** Community HMO Blue Preferred PPO

Blue Precision HMO Blue Advantage POS (Product)

Blue Preferred PPO Blue Focus POS

BlueCare Direct HMO MyBlue Health HMO*

Blue FocusCare HMO

IL TX OK NM MT

NETWORK CHANGES

*TX: MyBlue Health available to Retail only members in Dallas and Harris

**OK: Blue Advantage PPO: Expanded into Cotton, Nowata, and Washington

RETAIL

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2020 BCBSIL Contracted Provider Networks

Blue Choice Preferred PPO (BCE)

• Existing network is Statewide

• On and Off Exchange

• Metallic Plans: Gold, Silver, Bronze, Catastrophic

Blue Precision HMO (BAV)

• Existing network in Peoria / Bloomington


• Metallic Plans: Gold, Silver, Bronze

Approximately 84 hospitals and 16,500 professionals


Legend: Existing Service Area New Service Area

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2020 BCBSIL Contracted Provider Networks

BlueCare Direct HMO (BHD)

• Existing network in Chicago Area


• Metallic Plans: Silver

BlueFocus Care HMO (BFC)

• Existing network in Cook County






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2020 BCBSMT Contracted Provider Networks

Blue Preferred PPO (PPO)

• Existing statewide network



Network includes approximately 66 hospitals and 5,400 professionals

Blue Focus POS (BLC)

• Existing network in Billings and Missoula





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2020 BCBSNM Contracted Provider Networks

Blue Community HMO (CNN)






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2020 BCBSOK Contracted Provider Networks

Blue Preferred PPO (EPP)





Blue Advantage PPO (BVP)

• Expanded network in Cotton, Nowata, Washington Counties





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2020 BCBSTX Contracted Provider Networks

Blue Advantage HMO (BAV) & Blue Advantage Plus

• Statewide existing network




MyBlue Health HMO (BFT)

• Network in Dallas and Harris Counties





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Preferred Site of Care

• A cost share differential encourages members to go to lower-cost facilities for certain outpatient services

• Members will have higher out-of-pocket costs when going to a hospital-based facility

• Members will have lower out-of-pocket costs when going to a freestanding outpatient facility

• Cost share differential will apply to either the copay, per occurrence deductible, or coinsurance level, depending on plan design

• Members can use Provider Finder to find locations of Freestanding Outpatient Facilities

- 16 - Confidential and Proprietary

Blue Cross Blue Shield of Texas & Sanitas Medical Center

Here. For You. August 29th, 2019

16


Agenda

• Commitment to Primary Care

• Overview of Collaboration

• Enhancement of Customer Experience

• Convenient Access

• Holistic Engagement

• Connected Experience


Primary Care – The Front Door to the Health Care System

The primary care physician is a key part of

the health care ecosystem…

We cannot afford not to champion primary care

Yet represents a small percentage of

overall health care spend.

Adults with a primary care provider have

19% LOWER ODDS

of premature death than those who

only see specialists

4-7% Of health care dollars go

towards primary care

Source: The Commonweatlh Fund


Commitment to Primary Care

Through collaboration with Sanitas Medical Center

10 advanced primary care medical centers

Exclusive to Blue Cross Blue Shield card

holders

Sanitas Medical Centers designed for more

face-to-face time with care teams

Furthers Blue Cross Blue Shield

commitment to more accessible and

affordable care

A Unique Collaboration… To Enhance Customer Experience

Convenient Access

Connected Experience

Holistic Engagement


Here. For You.

Blue Cross Blue Shield of Texas, in collaboration with Sanitas Medical

Center, is offering a unique combination of services

Blue Cross Blue Shield of Texas Here, with…

Sanitas Medical Center Here, with…

Face-to-face customer service

Benefits coordination – spend less time

worrying about how to access care

In-Network Benefits for Sanitas

medical centers Starting in 2020

Same week primary care doctor

appointments

Longer Hours, including weeknights

and weekends

Onsite lab facilities, X-Ray services,

and urgent care

Medical team for your health care

needs


Why is this Collaboration Different?

The unique combination of services is aimed at helping members have better

access to care, improved quality outcomes, and reduced unnecessary costs

Improved Access Expected

INCREASES in:

• Preventive Care

• PCP Visits

• Member Engagement

Enhanced Quality

Expected

INCREASES and

DECREASES in:

• Patient Satisfaction

• Inpatient Admission

Reduced Costs Expected

DECREASES in:

• Medical Loss Ratio

• ER Visits


Convenient Access

Access for Blue Cross Blue Shield Members – Dallas County

Location Size Core Services

Richardson 350 S Plano Rd.

Richardson, TX 75081

Medium Primary Care

Advanced Urgent Care

Lab + Imaging

Las Colinas 6500 N MacArthur

Blvd. Irving, TX 75039

Medium Primary Care


Lab + Imaging

Irving 3917 W Airport Fwy.

Irving, TX 75062

Medium Primary Care

Urgent Care Walk-Ins

Lab + Imaging

Mesquite 2021 N Town East

Blvd. Suite 500

Mesquite, TX 75150

Medium Primary Care


Lab + Imaging


Convenient Access

Access for Blue Cross Blue Shield Members – Harris County

Location Size Core Services

Spring 18532 Kuykendahl Rd.

Spring, TX 77379

Small Primary Care


Lab + Imaging

Willowbrook 12302 Jones Rd.

Houston, TX 77070

Small Primary Care


Lab + Imaging

Katy 2610 Mason Rd. Katy,

TX 77449

Large Primary Care


Lab + Imaging

Briarforest 12586 Westheimer Rd.

Houston, TX 77077

Large Primary Care


Lab + Imaging

Meyerland 10101 S Post Oak Rd.

Houston, TX 77096

Medium Primary Care


Lab + Imaging

Southbelt 12823 Gulf Fwy.

Houston, TX 77034

Medium Primary Care


Lab + Imaging


Holistic Engagement

Sanitas Medical Center ‘one stop shop’ concept, paired with Blue Cross

Blue Shield care programs and advocacy, drive end to end engagement

End to End

Engagement Foundational

Care Programs

‘One Stop

Shop’ Concept Personalized

Care & Advocacy


Holistic Engagement – ‘One Stop Shop’ Concept

Collaboration with Santias Medical Center offers Blue Cross Blue Shield

members more services in one location

‘One Stop Shop’

Concept

Primary Care

Comprehensive primary care for the

entire family. Plus a mix of high-volume specialists

Urgent Care

Unique urgent care services, including observation

beds to prevent unnecessary visits to the ER, to

treat a wide range of illnesses, injuries and common

conditions

Onsite Lab & Imaging

Onsite services to help our medical team diagnose

and treat members quickly

and effectively


Blue Cross Blue Shield of Texas & Sanitas Medical Center

Here. For You.

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About Sanitas

27

A multinational leader in healthcare with

more than 40 years dedicated to helping

people improve their health and well-

being

4.1 million Members/Patients

9 Countries

15,600 Employees

276 Owned Facilities

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28

Vision

An organization that people

trust to improve their health and

care for them throughout their

life.

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Services

29

The only provider

in the network

exclusive to

members of

Blue Cross and

Blue Shield of Texas

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What Makes Us Different?

30

1. Sanitas Medical Centers are exclusive to Blue Cross Blue Shield of Texas members

2. More time with your medical team. Carefully listening to your needs is at the heart of everything we do. That's why our doctors spend more time with you.

3. Here for you when you need us most. Get an appointment, even on weekends, or just download our app to chat with a doctor right away.

4. More services in one location. No matter your health and wellness needs, you only need one care team—Sanitas. Preventive care, chronic disease care, urgent care, lab and diagnostics under one roof.

Feel the Sanitas difference.

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Book Appointment Scheduling appointments for your clients is as easy as 1, 2, 3.

31

1 Choose doctor

type

2 Select Sanitas

location

3 Choose doctor

and available

date/time

ACA Portfolio: Medical & Dental

2020 On- and Off-Exchange Product Offering

2020 Dental Plans Product Offering and Reminders

Sizzle Sheet

Virtual Visits

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2020 Portfolio Overview

33

Overall, we made minimal portfolio changes across our 5 states to our existing products

We are launching a new product/network in Texas

• Introduced Bronze/Gold on Blue Care Direct

•Removing Blue Care Direct in Will and

Kendall Counties

• Introducing MyBlue Health in Dallas and

Houston

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IL HMO BlueCare Direct Product Availability

34

Key: Rating Area 1

Rating Area 2

Rating Area 3

Rating Area 4

Rating Area 1

Cook County Lake and

McHenry County Kane and Dupage

Will and Kendall County

Rating Area 2 Rating Area 3 Rating Area 4

Cook County

Cook County

Lake and McHenry County

Lake and McHenry County

Kane and Dupage

Kane and Dupage



BlueCare

Direct Bronze

401 with

Advocate

BlueCare

Direct Silver

212 with

Advocate

BlueCare

Direct Gold 409

with Advocate

Not

Offered

Not

Offered

Removed from BlueCare Direct

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TX New Product - MyBlue Health

35

Sanitas Medical Group is a In-

Network Medical Group for MyBlue

Health.

Sanitas Partnership MyBlue Health will be available in the

Houston and Dallas MSAs both on

and off the Healthcare.gov market

exchange

Service Area

MyBlue Health Bronze 402

MyBlue Health Silver 405

MyBlue Health Gold 403

Product Offerings A PCP Benefit ($0 cost share) is being

offered to members who select a

Sanitas provider as their PCP.

$0 PCP Benefit @ Sanitas

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2020 MyBlue Health Plan Designs

36

All coinsurance are subject to after the deductible

MyBlue Health Bronze 402

MyBlue Health Silver 405 MyBlue Health

Gold 403

MyBlue Health Bronze 60% Silv er 7 0 % Silv er 7 3 % Silv er 8 7 % Silv er 9 4 % Gold 80%

Deductible $7,400 $3,300 $1,600 $75 $50 $1,100 Coinsurance 50% 40% 40% 40% 30% 40% OPX $8,150 $8,150 $6,500 $2,700 $1,500 $8,150 Office Visits

Sanitas - Primary Care Physician Office Visit $0 $0 $0 $0 $0 $0 IN – Network Primary Care Physician Office Visit $50 $25 $25 $15 $5 $20 Specialist Visit 50% 40% 40% 40% 30% 40% Mental/Behavioral Health Office Visit 40% 30% 30% 30% 20% 30% Urgent Care $60 $50 $40 $25 $10 $45 Facility /Serv ices

Emergency Room Services $950 and 50% $950 and 40% $950 and 40% $500 and 40% $500 and 30% $950 and 40% All Inpatient Hospital Services $850 and 50% $850 and 40% $850 and 40% $250 and 40% $250 and 30% $850 and 40% Imaging (CT/PET Scans, MRIs) 40% 30% 30% 30% 20% 20% Laboratory Outpatient and Professional Services 40% 30% 30% 30% 20% 20% X-rays and Diagnostic Imaging 40% 30% 30% 30% 20% 20% Outpatient Facility Fee $600 and 60% $400 and 30% $400 and 30% $100 and 30% $100 and 20% $600 and 20% Drugs

Preferred Generics $15 $5 $5 $5 $5 $0 Non-Preferred Generics $25 $15 $15 $15 $15 $10 Preferred Brand Drugs 30% 30% 30% 30% 30% 20% Non-Preferred Brand Drugs 35% 35% 35% 35% 35% 35% Preferred Specialty Drugs 45% 45% 45% 45% 45% 45% Non-Preferred Specialty Drugs 50% 50% 50% 50% 50% 50%

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Sanitas PCP Benefit

37

Benefit Rules Sanitas Providers: Any member with BCBSTX can utilize Sanitas Providers (without Sanitas PCP Benefit) Sanitas PCP Benefit: The Sanitas PCP Benefit is only for members who select TX MyBlue Health (Dallas/Harris Counties) policy & select a PCP from the Sanitas Medical Group Product Type: HMO (H.S.A. is excluded) Places of Services: Office Line of Business: Retail QHP Plans On & Off Exchange Network ID: BFT

MyBlue Health Services Sanitas PCP- Services received at any level Clinic ( Low/Med/High)

In-Network Non-Sanitas PCP Notes/Comments

Office Visit/Services

PCP Office Visit $0 Standard Benefit

Certain X-rays, Ultrasound, ECG (requested & rendered by Sanitas) $0 Standard Benefit • Any Ultrasound with OB/GYN is not covered at $0

Allergy Testing (only testing) $0 Standard Benefit • Injections/Treatment not included at $0

Minor in office procedures, ie. biopsy, wart removal, etc. $0 Standard Benefit

Select immunizations & Administration $0 Standard Benefit

Chronic Disease Management Programs $0 Standard Benefit

Health Education Programs/Wellness Services $0 Standard Benefit

Mental/Behavioral Health Office Visit $0 Standard Benefit

• Sanitas does not currently have BH provider however if the Sanitas PCP bills a BH service it will be included at $0

• This information will be silent in the Booklets & SBC

TeleHealth (with Sanitas) $0 Standard Benefits

Other Services

Specialist Visit Standard Benefit Standard Benefit

Advanced Diagnostics Standard Benefit Standard Benefit

Urgent Care Standard Benefit Standard Benefit • Member walks in needs to see PCP- Covered $0 • Member needs stiches (Urgent Care)- Standard Benefit

Emergency Room Services Standard Benefit Standard Benefit

All Inpatient Hosptial Services Standard Benefit Standard Benefit

Outpatient Surgery Physician/Surgical Services Standard Benefit Standard Benefit

MDLive Standard Benefit Standard Benefit

*CPT list being created which will list out all services with a $0 co-pay at Sanitas locations with Sanitas PCP selection

• All services (excluded

from or not listed as

included at $0) will apply

general plan benefits

• All services provided

outside of Sanitas

Medical Group would

apply general plan

benefits (even if referred

from a Sanitas PCP)

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BlueCare Direct Changes

• Renewing Silver plan

• Adding 1 Gold plan and 1 Bronze plan

• Service Area Reduction for Kendall and Will Counties o Members will not receive discontinuation notices

o Members will get postcards and renewal packages about network changes and remind them about OE options

o Some passively renewing members may be auto-assigned new PCPs but can contact us to reselect original PCPs

Plan Name On or Off Exchange

New or Renewing

Rating Areas and Counties

BlueCare Direct Bronze 401 with Advocate Both NEW Rating Areas 1 and 3

Counties: Cook, Dupage, Kane

BlueCare Direct Silver 212 with Advocate Both Renewing Rating Areas 1, 2 and 3

Counties: Cook, Lake, McHenry, Dupage, Kane

BlueCare Direct Gold 409 with Advocate Both NEW Rating Areas 1 and 3

Counties: Cook, Dupage, Kane

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Product Offering: Illinois

39

Notes: • Asterisk (*) denotes an HSA plan • All RX coinsurance percentages are subject to the deductible

Plan Name ON/OFF

Exchange Deductible OPX Coins PCP OV

Preferred Generic (Tier 1)

Non-Preferred Generic (Tier 2)

Preferred Brand

(Tier 3)

Blue Choice Preferred PPO

Blue Choice Preferred Bronze PPO 201 ON/OFF $6,000 $7,900 --> $8,150 50% $40 for first 2 visits $10 $20 30%

Blue Choice Preferred Bronze PPO 302* OFF Only $6,000 $6,650 --> $6,750 40% 40% 20% 25% 30%

Blue Choice Preferred Bronze PPO 202* ON/OFF $3,150 --> $3,500 $6,650 --> $6,750 40% 40% 20% 25% 30%

Blue Choice Preferred Silver PPO 303 OFF Only $2,200 $7,900 --> $8,150 50% $10 $5 $15 30%

Blue Choice Preferred Silver PPO 203 ON/OFF $2,200 $7,900 --> $8,150 50% $10 $5 $15 30%

Blue Choice Preferred Gold PPO 204 ON/OFF $750 $7,900 --> $8,150 30% $15 $0 $10 20%

Blue Precision HMO

Blue Precision Bronze HMO 205 ON/OFF $6,000 --> $7,200 $7,900 --> $8,150 40% $50 10% 15% 20%

Blue Precision Silver HMO 306 OFF Only $2,600 --> $2,800 $7,900 --> $8,150 50% $10 $5 $15 30%

Blue Precision Silver HMO 206 ON/OFF $2,500 --> $2,800 $7,900 --> $8,150 50% $30 0% 10% 20%

Blue Precision Gold HMO 208 OFF Only $3,250 $7,900 --> $8,150 20% $30 $0 $10 $50 --> 30%

Blue Precision Gold HMO 207 ON/OFF $500 --> $750 $7,900 --> $8,150 30% $20 10% 15% 20%

BlueCare Direct HMO

NEW - BlueCare Direct Bronze 401 w/Advocate ON/OFF $7,200 $8,150 40% $50 10% 15% 20%

BlueCare Direct Silver 212 with Advocate ON/OFF $2,500 --> $2,800 $7,900 --> $8,150 50% $30 0% 10% 20%

NEW - BlueCare Direct Gold 409 w/Advocate ON/OFF $500 $8,150 30% $20 10% 15% 20%

Blue FocusCare HMO

Blue FocusCare Bronze 209 ON/OFF $6,000 --> $7,200 $7,900 --> $8,150 40% $50 10% 15% 20%

Blue FocusCare Silver 210 ON/OFF $4,150 $7,900 --> $8,150 30% $30 10% 15% 20%

Blue FocusCare Gold 211 ON/OFF $500 $7,900 --> $8,150 30% $20 10% 15% 20%

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Product Offering: Texas

40


Plan Name ON/OFF

Exchange Deductible OPX PCP OV



Preferred Brand

(Tier 3)

Blue Advantage HMO

Blue Advantage Bronze HMO 204 ON/OFF $6,000 $7,900 --> $8,150 $40 $15 $25 30% Blue Advantage Bronze HMO 301 ON/OFF $7,900 --> $8,150 $7,900 --> $8,150 0% 0% 0% 0% Blue Advantage Bronze HMO 302* OFF Only $6,000 $6,650 --> $6,750 40% 20% 25% 30% Blue Advantage Silver HMO 306 OFF Only $2,000 $7,900 --> $8,150 $25 $5 $15 30% Blue Advantage Silver HMO 205 ON/OFF $1,900 $7,900 --> $8,150 $25 $5 $15 30% Blue Advantage Gold HMO 206 ON/OFF $350 --> $750 $7,900 --> $8,150 $30 $0 $10 20% Blue Advantage Gold HMO 207 OFF Only $0 $7,900 --> $8,150 $20 $0 $10 $50

Blue Advantage Plus POS

Blue Advantage Plus Bronze 305 ON/OFF $5,000 $7,900 --> $8,150 40% 20% 25% 30% Blue Advantage Plus Bronze 303 ON/OFF $3,900 $7,900 --> $8,150 $40 $10 $15 $50 --> 30% Blue Advantage Plus Bronze 201* OFF Only $3,150 --> $3,550 $6,650 --> $6,750 40% 20% 25% 30% Blue Advantage Plus Silver 306 OFF Only $2,000 $7,900 --> $8,150 $25 $5 $15 30% Blue Advantage Plus Silver 202 ON/OFF $1,100 $7,900 --> $8,150 $10 $5 $15 30% Blue Advantage Plus Gold 203 ON/OFF $750 $7,900 --> $8,150 $15 $0 $10 20%

MyBlue Health HMO

NEW - MyBlue Health Bronze 402 ON/OFF $7,400 $8,150 $0/$50 $5 $15 30%

NEW - MyBlue Health Silver 405 ON/OFF $3,400 $8,150 $0/$25 $5 $15 30%

NEW - MyBlue Health Gold 403 ON/OFF $1,100 $8,150 $0/$20 $5 $15 30%

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Product Offering: Oklahoma

41


Plan Name ON/OFF




Preferred Brand

(Tier 3)

Blue Preferred PPO

Blue Preferred Bronze PPO 302 OFF Only $6,000 $6,650 --> $6,750 40% 40% 20% 25% 30%

Blue Preferred Bronze PPO 206 ON/OFF $5,000 $7,900 --> $8,150 50% 40% 20% 25% 30%

Blue Preferred Silver PPO 306 OFF Only $1,500 $7,900 --> $8,150 50% 40% 20% 25% 30%

Blue Preferred Silver PPO 201 ON/OFF $1,100 $7,900 --> $8,150 50% $10 $5 $15 30%

Blue Preferred Gold PPO 205 ON/OFF $200 $7,900 --> $8,150 40% 40% $0 $10 20%

Blue Advantage PPO

Blue Advantage Bronze PPO 202 ON/OFF $5,000 $7,900 --> $8,150 50% 40% 20% 25% 30%

Blue Advantage Bronze PPO 203* ON/OFF $3,150 --> $3,550 $6,650 --> $6,750 40% 40% 20% 25% 30%

Blue Advantage Silver PPO 306 OFF Only $1,500 $7,900 --> $8,150 50% 40% 20% 25% 30%

Blue Advantage Silver PPO 204 ON/OFF $1,500 $7,900 --> $8,150 50% 40% 20% 25% 30%

Blue Advantage Gold PPO 309 ON/OFF $1,200 $7,900 --> $8,150 25% $25 $5 $10 $50 --> 30%

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Product Offering: Montana

42


Plan Name ON/OFF




Preferred Brand

(Tier 3)

Blue Preferred PPO

Blue Preferred Bronze PPO 301 ON/OFF $7,900 --> $8,150 $7,900 --> $8,150 0% 0% 0% 0% 0%

Blue Preferred Bronze PPO 302* OFF Only $4,900 $6,650 --> $6,750 30% 30% 20% 25% 30%

Blue Preferred Bronze PPO 201 ON/OFF $2,850 $7,900 --> $8,150 50% $25 0% 10% 20%

Blue Preferred Bronze PPO 202* ON/OFF $2,900 --> $3,100 $6,650 --> $6,750 30% 30% 20% 25% 30%

Blue Preferred Silver PPO 306 OFF Only $4,500 $8,150 50% $25 $0 $10 $50

Blue Preferred Silver PPO 308 ON/OFF $7,900 --> $8,150 $7,900 --> $8,150 0% 0% $10 $15 $50

Blue Preferred Silver PPO 203 ON/OFF $650 $7,900 --> $8,150 50% 40% 20% 25% 30%

Blue Preferred Gold PPO 204 ON/OFF $450 --> $750 $7,900 --> $8,150 30% $10 $0 $10 $50

Blue Focus POS

Blue Focus Bronze POS 205 ON/OFF $4,400 $7,900 --> $8,150 50% $40 0% 10% 20%

Blue Focus Bronze POS 302 OFF Only $4,900 $6,650 --> $6,750 30% 30% 20% 25% 30%

Blue Focus Silver POS 306 OFF Only $4,500 $7,900 --> $8,150 50% $25 $0 $15 $50

Blue Focus Silver POS 206 ON/OFF $4,000 $7,900 --> $8,150 50% $25 $0 $10 $50

Blue Focus Gold POS 207 ON/OFF $0 $7,900 --> $8,150 40% 20% $0 $10 $50

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Product Offering: New Mexico

43


Plan Name ON/OFF Exchange Deductible OPX Coins PCP OV Preferred Generic (Tier 1)


Preferred Brand

(Tier 3)

Blue Community HMO

Blue Community Bronze HMO 201 ON/OFF $6,000 $7,900 --> $8,150 50% $40 $10 $20 30%

Blue Community Bronze HMO 302* OFF Only $6,000 $6,650 --> $6,750 40% 40% 20% 25% 30%

Blue Community Bronze HMO 202* ON/OFF $3,150 --> $3,500 $6,650 --> $6,750 40% 40% 20% 25% 30%

Blue Community Silver HMO 306 OFF Only $1,500 $7,900 --> $8,150 50% 40% 20% 25% 30%

Blue Community Silver HMO 308 ON/OFF $7,900 --> $8,150 $7,900 --> $8,150 0% $20 $5 $10 $50

Blue Community Silver HMO 203 ON/OFF $1,500 $7,900 --> $8,150 50% 40% 20% 25% 30%

Blue Community Silver HMO 204 ON/OFF $1,100 $7,900 --> $8,150 50% $10 $5 $15 30%

Blue Community Gold HMO 205 ON/OFF $350 --> 750 $7,900 --> $8,150 40% $30 $0 $10 20%

Blue Community Gold HMO 206 OFF Only $750 $7,900 --> $8,150 30% $15 $0 $10 20%

- 44 -

“Sizzle” Sheet

It lists talking points you can use with clients as they decide about their 2020 health care.

The “Sizzle” sheet for Plan Year 2020 highlights benefits of “buying blue” and provides at-a-glance features and benefits of enrolling in a retail QHP. 2020

Coming

Soon!

http://www.bcbsilcommunications.com/newsletters/files/producer/RetailSizzle-IL.pdf

- 45 - 45

2020 Dental Benefit Information

For 2020 – Standalone Dental Plans:

• No plans added or discontinued

• Pediatric dental benefit eligibility age is capped at age 19 for BlueCare Dental 4 Kids 1A and 1B

BlueCare Dental 1A and

BlueCare Dental 4 Kids

1A features:

BlueCare Dental 1B and

BlueCare Dental 4 Kids

1B features:

BlueCare Dental 2A

features:

Available in TX Only

- 46 -

2020 Dental Plans: Important Reminders

Enrollment Reminders • Members changing health plans for 2020 with a dental policy need to re-enroll for dental for

the upcoming plan year.

• When enrolling a member in medical coverage, review the dental coverage questions carefully.

• Consider encouraging a member to choose pediatric benefits (if applicable) so the policy is ACA compliant; member won’t get charged premiums for pediatric benefits.

Cancelation • Voluntary cancelation of a medical policy doesn’t generate an SEP (for medical or dental).

• Canceling a medical policy does not automatically cancel a dental policy. The dental policy will still be active.

Pediatric Dental Max Age is 19 • The Pediatric Dental (BlueCare Dental 4 Kids 1A and 1B) max age is 19.

• Those that aged off or will age off will receive communications that they can apply for adult dental coverage.

- 47 -

Virtual Visits

• Non-emergency medical consults 24/7/365 by phone and video

• Behavioral health consults 24/7/365 by video

• Not included on HMO, Included on PPO

• Utilized MDLIVE’s network of physicians

• English and Spanish speaking physicians available. Other languages available via translation services.

• Single sign-on to the MDLIVE portal from Blue Access for Members and mobile app

• Integrated with Provider Finder

• Warm transfers from Customer Advocates to MDLIVE

Disclaimer: Access to certain transparency products may not be available for all plans.

Examples of Non-emergency Medical Needs

Examples of Behavioral Health Needs

Sinusitis

Allergies

Cold and flu

Ear ache

Fever

Pink eye

Depression and anxiety

Marital problems

Child behavior and learning issues

Financial hardship

Coping with loss and grief

Stresses & challenges of everyday life

Prescription & Pharmacy Benefits Prescription Drug Benefit Structure

Prescription Drug List Changes

Preferred Pharmacy Network

Pharmacy versus Medical Coverage

90-day Delivery Options

Benefit Considerations & Exclusions

Finding a Preferred Pharmacy

- 49 -

Prescription Drug Benefit Structure

• Copay or Coinsurance after medical deductible

• Six-tier prescription benefit structure

• Generic, brand and specialty drugs each have preferred and non-preferred benefit levels

• Six-tier structure drives utilization towards preferred generic, preferred brand, and preferred specialty prescriptions

Prescription Tiers* Preferred Pharmacy

Copay Example Example‡

1 Generic: Preferred $0 Hydrochlorathiazide

2 Generic: Non-Preferred $10 Captopril

3 Brand: Preferred $35 Janumet XR

4 Brand: Non-Preferred $75 Bystolic

5 Specialty: Preferred $150 Humira

6 Specialty: Non-Preferred $250 Aranesp

* Some brands may be placed in generic tiers and some generics may be placed in brand tiers. ‡ Subject to change

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Prescription Drug List Changes

As part of the annual review of the drug list, some drugs will be:

• Added to the drug list

• Moved to a higher payment tier (i.e., moved from preferred to non-preferred status)

• Moved to a lower payment tier

• No longer eligible for coverage

o Members will be encouraged to try generics or brand name alternatives

o Members should talk to their doctors about therapeutic alternatives

• Included in Utilization Management programs, such as prior authorization, step therapy and dispensing limits

o For a list of commonly used drugs no longer covered and the generic alternatives available, click here

http://www.bcbsilcommunications.com/newsletters/files/producer/Retail-OE2020-DrugsNoLongerCovered-082719.pdf

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Why is it important?

• A preferred retail pharmacy network allows members to pay lower copay/coinsurance at a network of pharmacies designated as preferred

• Benefits contain a preferred retail pharmacy network (except BCBSIL HMO and 100% cost sharing plans)

What do you need to know?

• Members pay a higher copay/coinsurance at non preferred pharmacies, which is any pharmacy in the network not designated as preferred

• 90-day supply at retail is only available at the preferred network pharmacies

Preferred Pharmacy Network/Extended Supply Network

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Preferred Pharmacy Network/ESN

IL MT NM TX

Albertsons

Brookshire

Health Mart Atlas

HEB

LeaderNET

PPOK

Sam’s Club

Walgreens

Walmart

Changes for 2020:

• Sam’s Club is being added back to

the network

• Oklahoma Preferred Pharmacy

Network TBD due to recent legislative

changes

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Pharmacy Coverage versus Medical Coverage

REMINDER: Member Pay the Difference Program (MPTD) Some plans may require members who fill a brand name prescription for which there is an exact generic equivalent to pay the applicable copay or coinsurance plus the difference in cost between the brand and generic drug. Difference in cost between brand and generic applies to the OPX.

Pharmacy Coverage Medical Coverage

Self-administered medications (including self-injectables)

Physician administered medications (including infused medications)

Specialty drugs (if product IS self-administered)

Specialty drugs (if product IS NOT self-administered)

If a specialty drug is not on the list, members should refer to the medical benefit for possible coverage

See examples of drugs covered under pharmacy benefits vs drugs covered under medical benefits

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90-day Delivery Options

Members have two (2) options for obtaining a 90-day supply of medications:

1. Pharmacy in the limited Extended Supply Network (ESN)

Go to a pharmacy in the ESN

• Aligned with preferred pharmacies only

• Available at three times the 30-day retail copay

2. Mail Order Program

Use AllianceRx Walgreens Prime mail service

• Medication comes in the mail

• Available at three times the 30-day retail copay

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Prescription & Pharmacy Coverage

Benefit Considerations

• Insulin/syringes: copay applies for each one even if filled on the same day

• Oral oncology: $0 copay for oral cancer medications

• 30-day supply limit at retail, 90 days via mail or Extended Supply Network

• 50% out of network penalty, no out-of-network benefits for HMO members

• Select vaccines covered at select retail pharmacies

• Coupons (Retail): Manufacturer coupons will not be applied to the deductible or OPX amounts

• If HMO members fill prescriptions at out-of-network pharmacies, members need to pay the full amount. Then members can submit claims for their out-of-network eligible reimbursement, if applicable.

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Other Benefit Exclusions* The following items are excluded from the pharmacy benefit:

• Compound drugs

• Weight loss

• Impotency (except IL)

• Infertility (except IL)

• OTC equivalents

• Repackaged medications

• Medication not approved by the FDA

• Cosmetic alteration drugs

• Institutional Packs

• Vaccines – IL HMO only

• Any drug not listed in the Drug List

*Other exclusions may apply

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Prescription Drug Lists

To access drug lists, members should log in to Blue Access for Members. Producers can visit bcbsil.com and click on “View Prescription Drug Plan Details.”

• Select the Prescription Drug List for Metallic or Grandfathered & Transitional Individual Plans.

• Plan year 2020 drug lists will be available no later than November 1, 2019.

• The drug list gives you instruction on how to use the list and search for a specific drug.

The drug list also provides information about the following:

Step Therapy

Dispensing Limits

Limited Distribution

Specialty Drugs

Over-the-counter Exclusions

Compounded Medications

Repackaged Medications

Prior Authorization

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Finding a Preferred Pharmacy

1. Log on to www.myprime.com

2. Choose Pharmacy Network

3. Search by ZIP Code or City

4. Filter by Preferred Pharmacies

2

3

4

1

http://www.myprime.com/

Keeping your Book

Our Approach to Plan Renewals

60-Day Renewal Packets

Renewing Member Sites

Staying Covered: What Members Need to Do

Passive vs Active Affects POR Status

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Qualified Health Plan

Block of ACA business issued with an effective

date on or after 01/01/2014

Our Approach to Plan Renewals

Renewing QHP Plans

• All 2019 QHPs will be renewed for plan year 2020.

• All members will receive their renewal packets by Nov. 1, 2019.

Discontinued QHP Plans

As of August 29, 2019, no plans are being discontinued.

Grandfathered and Grandmothered Plans

Grandfathered and Grandmothered health plans are not affected.

Grandfathered Block of business effective prior to

the signing of ACA on 03/23/2010 Grandmothered

Non-Grandfathered Block of business effective

on or after ACA signing date of 03/23/2010 and prior to

ACA legislation effective date of 01/01/2014

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60-Day Renewal Packets

Packets Include:

Key dates

Plan Highlights

Benefit Changes

Monthly premiums

Steps to change plan

Remember:

Members will receive these by Nov. 1, 2019

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Renewing Member Sites

• Web pages that help members understand their options. A unique page displays based on segment:

o StayBlue: Renewing QHPs

o KeepMeBlue: Legacy Grandfathered/Grandmothered plans

• Email collection for helpful updates and reminders about Open Enrollment 2020 specific to members.

• Links to self-service support that can help members review their options like Blue Access for Members, Provider Finder, Pharmacy Updates & Retail Shopping Cart.

These sites allow members to learn about BCBSIL updates for 2020, compare plans and coverage options, review financial aid options and requirements.

What You Need to Know for 2020 Coverage

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Passive vs Active Affects Producer of Record Status

Passively Renew/Accept Mapped or Keep Existing Plan • Member keeps current renewing plan or accepts mapped plan. • No action for member. • You remain Producer of Record automatically.

Actively Renew/Choose New Plan • Member does not want current renewing plan or mapped plan. • When actively renewing or choosing a new plan, there is no automatic carryover of the Producer of Record. • Member shops for and chooses new plan. To retain Producer of Record status for active renewals,

one of the following needs to occur: 1. Client uses Retention Call Center for Producer-Sold Business when choosing a new plan (call center

number and hours of operation are included in the member’s renewal packet) 2. Client uses Retail Shopping Cart to choose new plan and adds you via Agent Finder while shopping

(see the next 2 pages for details) 3. Client uses Retail Shopping Cart to choose new plan but arrives via your Express Link or a Quote Link

from your Retail Producer Portal account 4. You complete the application process for your client via the Retail Producer Portal’s new “Enroll

Member” feature. This new feature saves significant time by prepopulating the online application with existing information from the active member’s record.

Enrollment Retail Shopping Cart

Retail Producer Portal

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2020 Updates to the Retail Shopping Cart include: • Paying initial premium before submitting

app no longer required!!

• Account creation and login enhancements

• Email confirmation required on new accounts

• Existing account holders must update their passwords

• Enhanced display of the dental plan

• Tax Credit Estimator update for 2020

• Dental plan Confirm and Enroll page updated to match the 2020 paper app

Retail Shopping Cart Updates

In case you missed it: For all the details about initial payment changes in the Retail Shopping Cart and Retail Producer Portal, CLICK HERE.

https://www.bcbsilcommunications.com/newsletters/files/producer/InitialPaymentsUpdate-07-19-19-IL.pdf

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Retail Producer Portal: Main Features

The portal allows you to:

Manage prospects

Design, create and deliver quotes

Enroll clients in new plans

Actively renew existing members in new plans

Look up client information

Serve and support active clients

Ask e-questions

Submit documentation

Create/save proposals

Create/save/print reports

Look up book of business

Upload completed applications, forms and documents

Download training, applications and forms

The Retail Producer Portal is a comprehensive business management and client service tool for U65 business.

https://osc.hcsc.net/ProducerPortal/login.aspx

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Retail Producer Portal: NEW Features

RPP Enrollment Changes

• Bill me Later payment option: Producer/Member can submit online application without payment

• Accepts Child Only and Personal Representative Applications

• Updated to support 2019 SEP and 2020 OE applications and enrollment

“Enroll Member” Function

• Expedites re-enrollment via the Client Info tab by prepopulating the online application with existing information from the active member’s record

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Retail Producer Portal: NEW Features

Send Quote and Proposal Enhancements

• Quotes and Proposals updated with new attractive design

• Proposals modified to present information clearly more concisely

New Reporting Enhancements

• New Application Source column in Application Status reports lets you know the channel in which it was received (Retail Shopping Cart, Retail Producer Portal, Paper, etc.)

• Renewal Indicator report tells you how your client renewed

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Retail Producer Portal: Enrollment Advantages

There are many advantages for using the portal to complete and submit applications: • Manage the entire application process.

• Stay attached to the application/policy throughout – avoid agent assignment issues.

• Enroll faster – the portal was designed for you so the process is streamlined with all steps on one page.

• Skip creating a Retail Shopping Cart account for each client – this pathway doesn’t require it.

• See all stages of the application’s progress; application is received and viewable in the portal within 24 hours.

• Start and save applications, complete and submit later (up to 90 days!) if needed.

• Give agency office personnel ability to submit subproducers’ apps.

• Reduce overall applicant-to-member timeframes.

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Retail Producer Portal: Detailed Guide

The portal is very intuitive.

However, we have a detailed guide which takes you step-by-step through all of the portal’s features and functions, including recent updates.

Text "rpp" to 33633 for a link to the portal and to the latest guide. Or, download the guide today!

JULY 24, 2018

http://www.bcbsilcommunications.com/newsletters/files/producer/RetailProducerPortalGuide.pdf

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Retail Producer Portal: Tips

Things to remember:

• Chrome is the recommended browser

• For optimal performance, fully expand browser window to 100% (lower and higher settings can affect performance and usage when creating reports)

• Resolution settings differ according to the type of mobile device used

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Using Express Link

What is Express Link? • Express Link is an HTML hyperlink, coded to a specific producer.

• Get your Express Link from your Retail Producer Portal account.

• When clients click on the code – in the form of a link or web button – it takes them to our Retail Shopping Cart census page.

• Quote Links are included in quotes developed in the Retail Producer Portal and take clients to a specific plan in the Retail Shopping Cart.

Tips for Express Links (and Quote Links): • Both Express Links and Quote Links attach your information to an

online shopping experience so you receive credit for those sales.

• When clients use your Express Link or Quote Link and access our Retail Shopping Cart, they should log in or create a new Retail Shopping Cart account to ensure you are linked to that user.

• If the client ends a shopping session before logging in or creating an account, the client must use your Express Link or Quote Link each time he or she returns to shop or until a shopping account is created.

Payment Reminders

Initial Premium with Online App Not Required

Initial Premium Payment Deadlines

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Initial Payment with Online App Not Required

During the last open enrollment, we saw these trends:

• Users started online apps but dropped to paper/PDF to avoid payment.

• Users completed online applications at the end of OE to postpone payment.

• The need to pay an initial premium as late as possible was especially true of existing members actively renewing.

It’s vital that consumers and producers utilize online enrollment channels

• To remove barriers to applying early and online, the initial payment requirement for online apps was eliminated.

• This business rule is valid for special enrollment and open enrollment.

• You’ll now see “bill me later” options when applying online via the Retail Shopping Cart and Retail Producer Portal.

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Initial Premium Payment Deadlines

OFF EXCHANGE

Initial Payment Deadline

ON EXCHANGE

Initial Payment Deadline The initial premium payment due date is either

30 calendar days from the first payment request or the effective date of the policy

whichever is greater • The 30-calendar-day period begins the day we

send the payment deadline letter. • If the payment deadline isn’t met, the application

is withdrawn. • If the applicant pays by the deadline, the effective

date remains Jan. 1, 2020.

The initial premium payment due date is either

30 calendar days from application receipt or the effective date of the policy

whichever is greater • The 30-calendar-day period begins the day we

receive the application. • If the payment deadline isn’t met, the

application is withdrawn. • If the applicant pays by the deadline, the

effective date remains Jan. 1, 2020.

For all the details about initial payment changes in the Retail Shopping Cart and Retail Producer Portal, CLICK HERE.

https://www.bcbsilcommunications.com/newsletters/files/producer/InitialPaymentsUpdate-07-19-19-IL.pdf

Regulations & Reminders

2020 OPX, HPHP and HSA Limits

Per Occurrence Deductibles

Producer Agreement Reminders

Guidance When Selling in the Marketplace

In the Know

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2020 OPX, HDHP and HSA Limits

Notice of Benefit and Payment Parameters with OPX for 2020 were issued in April 2019. HSA contribution limits and HDHP minimum deductibles amounts take effect Jan. 1, 2020.

2020 Individual Coverage

2020 Family Coverage

HSA Contribution Limits

$3,550 $7,100

HDHP Minimum Deductible

$1,400 $2,800

OPX $8,150 $16,300

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Per Occurrence Deductibles

What are Per Occurrence Deductibles? They are typically paid by the member at the time of service. After the member pays the per occurrence deductible, the remainder of the bill is subject to annual deductible and coinsurance

• Per occurrence deductible amounts may vary by plan design • Not all plans have per occurrence deductibles • Not all services listed have per occurrence deductibles on each plan

What can they apply to? Emergency Room Inpatient per Admission Outpatient Surgery Imaging (CT/PET/MRI) Lab Services X-Ray & Diagnostic Imaging

What does it mean for the member? • Member will not pay more than the original claim amount • Per occurrence deductibles do not accumulate toward annual deductible • Per occurrence deductibles do accumulate toward OPX

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Guidance When Selling in the Marketplace

Below are guidelines you are expected to follow as a licensed producer doing business or selling in the Marketplace:

a. The requirement to provide information in a fair, accurate, and impartial manner

b. Conflict of interest requirements

c. Rules about accepting payment and providing gifts

d. Rules about unsolicited direct contact with consumers, including “robo-calls”

e. Rules about nondiscrimination and providing culturally and linguistically appropriate services and services accessible to consumers with disabilities

f. Explain to consumers/members that you are not acting as a tax advisor or attorney when providing assistance as an agent or broker, and cannot provide tax or legal advice within your capacity as an agent or broker.

EXAMPLE: If consumers or members ask questions requiring answers from legal or tax professionals, communicate to them that you are not an attorney or a tax advisor and cannot answer those questions.

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In the Know: Congressional and Federal Updates

Surprise Medical Billing

Congress is exploring the problem of surprise bills for non-network emergency and hospital-based services

• Proposals would ban balance bills and set payment limits

• What’s next: Congress is expected to continue consideration in September

• Customer impact: Nothing would change until legislation is enacted

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Prescription Drugs

Congress is exploring options to address high drug costs, including easier access to generics and greater price transparency from manufacturers

• What’s next: Congress is expected to continue consideration in September

• Customer impact: Nothing would change until legislation is enacted

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Health Reimbursement Arrangement (HRA)

A new federal rule allows employers to offer employees a Health Reimbursement Arrangement (HRA) that pays premiums for a retail health plan instead of group coverage

• What’s next: The rule takes effect January 1, 2020

• Customer impact: It’s not clear yet how popular this new option will be with employers

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1332 Waivers

CMS and Treasury have approved a new reinsurance program for Montana jointly funded by the state and federal governments

• What’s next: The Montana Reinsurance Board continues work on implementing the program

• Customer impact: Retail customers of BCBS and other Montana issuers will have more affordable premiums for the 2020 plan year

Tools & Resources Consumer Tool: BCBSIL App for Mobile

Consumer Tool: MyPrime

Producer Tool: Selling Collateral At A Glance

Producer Tool: Blue Access for Producers

Producer Tool: Supply Portal

Producer Contact Infographic

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Consumer Tool: BCBSIL App for Mobile

Blue Access Mobile is designed to help members make more informed decisions regarding their care, including the ability to:

• Chat live with Customer Advocates

• View Prior Authorizations and Referral Request status

• Find an in-network doctor, hospital or urgent care facility

• Access your claims, coverage and deductible information

• View and email your member ID card

• Log in securely with your fingerprint (with compatible phones)

• Access Health Care Accounts and Health Savings Accounts

• Download and share your Explanation of Benefits*

• Get Push Notifications and access to Message Center**

• Available in Spanish

Smartphone and tablet app provides access to information for consumers shopping for coverage and plan members.

* Currently only available on iPhone®. iPhone is a registered trademark of Apple Inc.

** Message and data rates may apply. Terms and conditions and privacy policy at https://www.bcbsil.com/mobile/text-messaging.

https://www.bcbsil.com/mobile/text-messaging



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Consumer Tool: MyPrime

• Find medicines: See cost and coverage information for your medicines

• Find a pharmacy: Search pharmacies in your network

• See prescription history: Review your prescription history and costs

• Home delivery: Skip the lines at the pharmacy

• Manage on the go: Use website with mobile devices; manage your medications anytime, anywhere

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Producer Tool: Selling Collateral At A Glance

Enroll, Track, Service & Other Tools

• Retail Producer Portal • BCBSIL App • Provider Finder • Blue Access for ProducersSM • MyPrime.com

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2020 Retail Readiness - Health Insurance Software …...2019/09/09 · Houston, TX 77096 Medium...

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Transcript of 2020 Retail Readiness - Health Insurance Software …...2019/09/09 · Houston, TX 77096 Medium...