Consumer Direct - mtda.com · Oral Chemo and Diabetic Supplies (Rx covers needles, lancets, test...

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PROPRIETARY AND CONFIDENTIAL

Consumer Direct 2015 ACA Product Training

Contracted Brokers

4th Quarter 2014

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

This document was created for informational purposes only and is not intended to provide legal and/or accounting advice and should not be relied upon as such. Individuals should consult with their own accountants and/or legal counsel if they have any questions regarding the financial and legal impacts of the Affordable Care Act.”

CD Broker Training Q4 2014 V9

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Agenda:

ACA Review

2015 ACA Medical & Prescription Drug Product Updates & Portfolio

2015 ACA Dental & Vision Updates

Blue Rewards

2015 Key Differentiators & Selling Points

2015 Renewal Strategy

2015 Eligibility & Enrollment

Commissions

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ACA Review

(see this section in Resources for details)

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4 Tenets of the Affordable Care Act (ACA)

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• All individuals and families that are required to file a U.S. tax return are required to buy health insurance coverage under the ACA or face a tax penalty.

• The penalty is a tax at the greater of the minimum dollar amount or a percentage of income – as defined in the chart below.

Year 2014 2015 2016 & beyond

Adult Penalty Minimum $95.00 $325.00 $695.00

Child (under 18*) Penalty Minimum

(50% of Adult Penalty) $47.50 $162.50 $347.50

Family Maximum Up to $285 Up to $975 $2,085

% of Income 1% 2% 2.5%

Penalty Schedule for Individuals/Families without Health Insurance

Individual Mandate and Penalties

*A child becomes an adult for purposes of the penalty as of the month they turn 18. The child could pay the child amount for part of the year and the adult penalty for the rest of the year.

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2015 ACA Medical and Prescription Drug Product Updates and Portfolio


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Product Strategy Goals

2014 2015

• Offer lowest cost, lowest deductible plan in each metal level

• Offer no more than 15 plans

• Offer same plans on and off the Exchange

• Represent all metal levels

• Stabilize!

• Keep costs as low as possible

• No drastic changes to the portfolio

• Minimal benefit disruption and positive disruption (unless federally regulated otherwise)

• No product exits


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2015 Off Exchange Plan Options

In 2015, we will continue to offer the same 15 Off Exchange plan options

PLATINUM

NOTE: Benefits listed are for in-network services only. Out-of-network services have greater cost sharing.

BluePreferred

Platinum $0

HealthyBlue Platinum

$0 Catastrophic

(under 30 only)

BlueChoice Young Adult $6,600

HMO

$0 PCP/$0 Specialist

0% coinsurance

Rx: No charge after deductible

First dollar: 3 primary care office visits

Out-of-pocket maximum: $6,600

BluePreferred Gold

$500

BRONZE

SILVER

GOLD

BlueChoice HSA Bronze

$6,000

BlueChoice HSA Bronze

$4,000 BluePreferred HSA

Bronze $3,500

BlueChoice Plus

Bronze $5,500

BlueChoice Silver

$2,000 BlueChoice HSA Silver

$1,300

BluePreferred HSA Silver

$1,500

BlueChoice Plus

Silver $2,500

BlueChoice Gold $0 BlueChoice Gold

$1,000

HealthyBlue Gold

$1,500

HMO


30% coinsurance

Rx: 20%/30%/50%/50%


PPO


20% after deductible

No first dollar coverage

Integrated Rx: 20%/30%/50%/50%


PPO



Rx: 20%/30%/50%/50%


Point of Service


Hospital: $150 per day

Rx: $0/$45/$100/$200


HMO




Integrated Rx:

20%/30%/50%/50%


HMO


No charge after deductible


Integrated Rx: No charge after deductible


Point of Service



First dollar: PCP, urgent care, generics

Integrated Rx (Tiers 2-4):

$10/30%/40%/40%


PPO






HMO




Integrated Rx:

20%/30%/50%/50%


HMO





$10/30%/40%/40%


Point of Service




Separate $400 Rx deductible (Tiers 2-4) :

$10/30%/40%/40%


PPO






HMO





$10/30%/40%/40%


Point of Service


Hospital: $450 per day after deductible

First dollar: PCP, DXL , urgent care, ER, generics

Separate $400 Rx deductible (Tier s 2-4):

$0/$45/$200/$200


DXL – Diagnostic x-ray & lab


Key Prescription Drug Changes for 2015

Key Changes 2014 2015

Oral Chemo and Diabetic

Supplies (Rx covers

needles, lancets, test trips,

alcohol swabs; medical

covers glucose pumps,

meters)

Oral chemo and diabetic supplies

DC and VA

• Non-HSA plans: $0 copay, $0 deductible

• HSA plans: $0 copay, subject to deductible

MD

• Oral chemo covered on Tier 5; Diabetic

supplies are paid on appropriate tier

Oral chemo and diabetic supplies handled

consistently across all jurisdictions

MD, DC and VA:

• Non-HSA plans: $0 copay, $0 deductible

• HSA plans: $0 copay, subject to deductible

Number of Formularies Two Consumer Direct Formularies driven by

difference in how oral chemo/diabetic supplies

treated:

• One for DC/VA

• One for MD

ONE Consumer Direct Formulary

Drug Tiers 5 Tiers only (some tiers have same cost sharing) 4 Tiers: Generic, Preferred Brand, Non-Preferred

Brand and Specialty

Specialty Pharmacy

Coordination Program

Open Network Exclusive Network (MD HMO/POS plans, All DC

plans)

Member Notices Limited More Expanded

PCP Copays for all

participating retail health

clinics

Not covered Covered retail health clinics for conditions such as

minor fever/colds, ear/sinus pain, skin conditions,

cough/sore throat, minor illness/injury, and

vaccinations

Blue Rewards for all plan Only available to HealthyBlue Products Available on all plans

Drug Search Tool website

www.carefirst.com/acarx

2014 data displayed 2014 & 2015 data displayed at

www.carefirst.com/acarx

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http://www.carefirst.com/acarx

2015 Benefit Changes – Bronze / Catastrophic 2014 2015

BluePreferred HSA Bronze

$3,500

MD/DC/VA: Retail Health Clinic: $40 copay after deductible MD/DC/VA: Retail Health Clinic: $30 copay after deductible

MD: Oral chemo and diabetic supplies under drug benefit are covered under appropriate drug tier

MD: Oral chemo and diabetic supplies: $0 after deductible

MD: AI/IVF physician: $40 copay after deductible MD: AI/IVF physician: $30 copay after deductible

BlueChoice HSA Bronze $4,000




DC: MH/SA office visit: $30 copay, no deductible DC: MH/SA office visit: $30 copay after deductible

BlueChoice Plus Bronze $5,500

MD/DC/VA: Retail Health Clinic: $45 copay after deductible MD/DC/VA: Retail Health Clinic: $35 copay, no deductible

MD/DC/VA: Preferred Generics: $10 copay, no deductible Non-Preferred Generics: 20% after deductible

MD/DC/VA: Generic Drug Copay: $10 copay, no deductible


MD: Oral chemo and diabetic supplies: $0, no deductible

BlueChoice HSA Bronze $6,000



BlueChoice Young Adult

$6,600

MD/DC/VA: Deductible and OOP maximum: $6,350 for individual/$12,700 for family coverage

MD/DC/VA: Deductible and OOP maximum: $6,600 for individual/$13,200 for family coverage

MD/DC/VA: Vision services for individuals under the age of 19 are not subject to the deductible.

MD/DC/VA: Vision services for individuals under the age of 19 are subject to the deductible.

MD/DC/VA: Orthodontia benefits for individuals under the age of 19 are not subject to the deductible.

MD/DC/VA: Orthodontia benefits for individuals under the age of 19 are subject to the deductible.



10 PROPRIETARY AND CONFIDENTIAL

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2015 Benefit Changes – Silver

2014 2015

BlueChoice HSA Silver $1,300

MD/DC/VA: Retail Health Clinic: $40 copay after deductible




BluePreferred HSA Silver $1,500






BlueChoice Silver $2,000


MD/DC/VA: Retail Health Clinic: $30 copay, no deductible


MD/DC/VA: All Generics: $10 copay, no deductible



BlueChoice Plus Silver $2,500


MD/DC/VA: Retail Health Clinic: $20 copay, no deductible





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2014 2015

BlueChoice Gold $0

MD/DC/VA: Retail Health Clinic: $30 copay MD/DC/VA: Retail Health Clinic: $20 copay


MD: Oral chemo and diabetic supplies: No charge

BluePreferred Gold $500





BlueChoice Gold $1,000






HealthyBlue Gold $1,500

MD/DC/VA: Retail Health Clinic: $40 copay, no deductible MD/DC/VA: Retail Health Clinic: $0, no deductible

MD: Out-of-network outpatient mental health and substance abuse (non- office visit): $40 copay after deductible

MD: Out-of-network outpatient mental health and substance abuse (non-office visit): No charge after deductible



DC: In-network outpatient mental health/substance abuse services are subject to a deductible.

DC: In-network outpatient mental health/substance abuse services are not subject to a deductible.

2015 Benefit Changes – Gold

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MD DC VA Abortion* • On Exchange- Included in all plans

except multi-state plans • Off Exchange- Included in all plans

• Included in all plans except multi-state plans

• On Exchange- Excluded from all plans • Off Exchange- Included in all plans

Acupuncture • Covered as therapeutic service when medically necessary

• Covered for anesthesia only • Not Covered

AI/IVF • Covered • Not Covered • Not Covered

Bariatric Surgery • Covered • Not Covered • Covered

Birthing Centers • Covered • Covered • Not Covered

Chiropractic Services • Covered • Only spinal manipulation for musculoskeletal conditions of spine

• Only spinal manipulation for musculoskeletal conditions of spine

Exclusive Specialty Pharmacy Network

• Applicable for HMO/POS plans only •Applicable for all plans • Not Applicable

Habilitative Services • Covered for all ages; Limits for adults 19 and over

• Covered for all ages; Limits for adults 21 and over

• Covered for all ages; Limits for all ages

Hearing Aids • Covered • Not Covered • Not Covered

Home Duty Private Nursing

• Not Covered • Not Covered • Covered • Note: Limit is $500 or 16 hours per benefit

period

Out of Country Non-Emergency Care

• Not Covered • HMO – not covered • POS – covered out-of-network • PPO – covered in-network

• HMO – not covered • POS – covered out-of-network • PPO – covered in-network

Pulmonary Rehab Covered Covered Not Covered Nutritional Counseling Covered Covered Covered but limited to diabetes education,

wellness visit, hospice Nutritional therapy related to obesity

Covered Covered Not Covered

Reversal of sterilization Not Covered Covered Not Covered

Transgender Surgery Not Covered Covered- medically necessary only Not Covered

Jurisdictional Differences – Covered Benefits

*Due to differences in abortion coverage, all on and off Exchange rates differ in VA and on and off Exchange multi-state plan rates differ in MD.

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MD DC VA AI/IVF • AI: 6 attempts per live birth

• IVF: 3 attempts per live birth • Not Covered • Not Covered

Bereavement Services • None • Covered only within 90 days following death of deceased

• None

Cardiac Rehab • 90 visits per therapy, per benefit period • 90 days per benefit period • None Chiropractic/Spinal Manipulation

• 20 visits (per illness/injury) per benefit period

• None • 30 visits per benefit period

Habilitative Services • Age 19+: Limited to 30 visits (per injury) for PT, 30 visits for OT and 30 visits for ST

• Age 21+: Limited to 30 visits (per injury) for PT, 30 visits for OT and 30 visits for ST

• All ages: limited to 30 visits combined between PT/OT and 30 visits for ST

Hair Prosthesis • Limited to one per benefit period • Limited to one per benefit period • Limited to one per benefit period

Hearing Aids • 1 hearing aid per ear every 36 months • Up to age 18 only

• Not Covered • Not Covered

Home Duty Private Nursing • Not Covered • Not Covered • $500 or 16 hours per benefit period

Home Health Services • None • 90 visits per “episode of care”* • 100 visits per benefit period

Inpatient Hospice Services • None • Limited to 60 days per hospice eligibility period

• Limited to 180 days per hospice eligibility period

Inpatient Hospitalization solely for rehabilitation

• None • Limited to 90 days per benefit period • None

Occupational Therapy • 30 visits (per illness/injury) per benefit period

• None • 30 visits per benefit period combined with PT

Outpatient Hospice Services

• None • Limited to a 180 day hospice eligibility period


Physical Therapy • 30 visits (per illness/injury) per benefit period

• None • 30 visits per benefit period combined with OT

Pulmonary Rehab • 1 pulmonary rehab program per lifetime • 1 pulmonary rehab program per lifetime

• Not Covered

Respite Care • None • Limited to a 180 day hospice eligibility period


Speech Therapy • 30 visits (per illness/injury) per benefit period

• None • 30 days per benefit period

Skilled Nursing Facility • 100 days per benefit period • 60 days per benefit period • 100 days per admission

Jurisdictional Differences – Visit Limits

*Episode of care begins if the member does not receive Home Health Care for the same or a different condition for 60 consecutive days

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Two Party/Family Policies

• Family deductibles and OOP maximums are always twice the individual amount • Unstacked or Aggregate deductibles and OOP maximums

o Applicable for all HSA plans* o The entire family deductible must be met before any member starts paying copays or

coinsurance. The entire family OOP maximum must be met before any member of the family is covered at 100%.

o The deductible and OOP max may be met by one member or any combination of members. • Stacked or Separate deductibles and OOP maximums

o Applicable for all non-HSA plans* o One family member who meets the individual deductible can start paying copays or

coinsurance. One family member who meets the individual OOP maximum will then be covered at 100%.

o This one family member cannot contribute more than the individual deductible or OOP maximum.

o The expenses of all remaining family members can be combined until the family deductible and OOP maximum is met.

*EXCEPTION- Silver HSA base plans have reduced cost sharing variations that make the plans non-HSA; these non-HSA cost sharing variation plans will have unstacked/aggregate deductibles and out-of-pocket maximums.


2015 ACA Dental & Vision Updates

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Embedded Dental On and Off Exchange

Pediatric Dental (all plans except BlueChoice Young Adult $6,600)

Individual

Deductible

Deductible Applies

Class I

Coinsurance

Class II

Coinsurance

Class III

Coinsurance

Class IV

Coinsurance

Class V

Coinsurance

Medically

Necessary Ortho

In Out In Out In Out In Out In Out In Out

$25 $50 2, 3 & 4 (In & Out) 100% 80% 80% 60% 80% 60% 50% 35% 50% 35%

Pediatric Dental (BlueChoice Young Adult $6,600 only)

Individual

Deductible

Deductible Applies

Class I

Coinsurance

Class II

Coinsurance

Class III

Coinsurance

Class IV

Coinsurance

Class V

Coinsurance

Medically

Necessary Ortho

In Out In Out In Out In Out In Out In Out

Combined with

Medical 2, 3 & 4 (In & Out) 100% 80% 100% 60% 100% 60% 100% 35% 100% 35%

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Service/Material In-Network Out-of-Network

Eye Exam $0 copay Plan reimburses up to $40

Frames $0 copay for Pediatric Frame Selection Plan reimburses up to $70

Spectacle Lenses $0 copay Plan reimburses up to: $40 for single vision, $60

for bifocal, $80 for trifocal and $100 for lenticular

Contact Lenses $0 copay for Pediatric Contact Lens

Selection

Plan reimburses up to $105

Medically Necessary Contact Lenses $0 copay Plan reimburses up to $225

Low Vision Eye Exam $0 copay Plan reimburses up to $300

Low Vision Follow Up Care $0 copay Plan reimburses up to $100

Low Vision Aids including high-power

spectacles, magnifiers and telescopes

$0 copay Plan reimburses up to $600

Embedded Vision On and Off Exchange

Pediatric Vision

Adult Vision Service/Material In-Network Out-of-Network

Eye Exam $0 copay Plan reimburses up to $40

Frames and Lenses Discounts available Not applicable

NOTE: In the Young Adult (Catastrophic) Plan, pediatric vision benefits are subject to the deductible,

adult vision benefits are not subject to the deductible.

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Stand-alone ACA Dental Differences between 2014 and 2015

2014 2015

ACA stand-alone dental

plans

BlueDental Preferred BlueDental Preferred – High Option

BlueDental Preferred – Low Option

Deductible Applies to Classes 2, 3 & 4

Individual: $25 IN/$50 OON

Family: $75 IN/$150 OON

High Option:

Applies to Classes 2, 3 & 4

Individual: $60 IN/$120 OON


Low Option:

Applies to Classes 1-4

Individual : $100 IN/$200 OON


Out of pocket maximum MD/DC: $1,000 for one member,

$2,000 for 2+ members

VA: $700 for one member, $1,400

for 2+ members

$350 for one member, $700 for 2+ members

Rating methodology Tiers:

Individual

Individual + Child(ren)

Individual + Adult

Family

Member level:

MD: 0-19 and 20+

VA/DC: 0-20 and 21+

NOTE: Non-ACA dental plans remain tier rated

On Exchange VA only VA/DC – enroll on exchange electronically

MD – enroll via link to paper application

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Stand-alone ACA Dental On and Off Exchange, MD/DC/VA

BlueDental Preferred – High Option

MD DC

VA

PG & Montgomery Counties Baltimore Metro Western MD

Eastern & Southern

MD High Option Child Rate3

Adult Rate3 $27.99 $25.05

$28.83 $25.81

$26.57 $23.78

$27.42

$24.54 $24.99

$26.62

$27.08

$26.29

Low Option

Child Rate3 Adult Rate3

$22.74

$21.49

$23.43

$22.15

$21.59

$20.41

$22.28

$21.06

$19.78

$23.19

$21.87

$22.95

Monthly Rates (billed annually

or quarterly)

Individual

Deductible

Family

Deductible Deductible Applies

Annual

Maximum for

Class I, II, III &

IV

Members Over

19

Out-of-Pocket

Maximum

Members Under

19

Class I

Coinsurance1

Class II

Coinsurance1

Class III

Coinsurance1

Class IV

Coinsurance1

Class V

Coinsurance1

Members Under

19, Medically

Necessary Ortho2

In Out In Out In Out In Out In Out In Out In Out

$60 $120 $180 $360 2, 3 & 4 (In & Out) $1,000

$350 for 1

member, $700

for 2+ members 100% 80% 80% 60% 80% 60% 50% 35% 50% 35%

BlueDental Preferred – Low Option

Individual

Deductible

Family

Deductible Deductible

Applies

Annual Maximum

for Class I, II, III &

IV

Members Over 19

Out-of-Pocket

Maximum

Members Under

19

Class I

Coinsurance1

Class II

Coinsurance1

Class III

Coinsurance1

Class IV

Coinsurance1

Class V Coinsurance1

Members Under 19,

Medically Necessary

Ortho2

In Out In Out In Out In Out In Out In Out In Out

$100 $200 $300 $600 1-4

(In & Out) $1,000

$350 for 1

member, $700

for 2+ members 100% 80% 80% 60% 80% 60% 50% 35% 50% 35%

1 Coinsurance shown is the percentage the plan pays 2 Qualifications to be medically necessary vary by jurisdiction 3MD: Child is 0-19, Adult is 20+; DC/VA: Child is 0-20, Adult is 21+

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MD Exchange Process – Stand-alone Dental

• The dental landing page on marylandhealthconnection.gov will show a list of all available carriers with the

URL to the carrier site for enrollment. CareFirst’s URL is www.carefirst.com/bluedentalpreferredmd and

links directly to the application. Consumers will print the application, complete it, and mail it to CareFirst.

• A plan comparison chart and rate comparison chart will be below the URLs..

• Maryland On Exchange does NOT have a re-enrollment waiting period.

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Impact of Rating Methodology Change – Stand-alone Dental

2014 BlueDental Preferred vs. 2015 BlueDental Preferred – High Option

In general, single parents with one child or families with one or two children will have a rate decrease.

Single parents with more than one child and families with more than two children will have a rate increase.

Examples:

1.) VA adult, no children

2014 annual rate: Individual tier $312

2015 annual rate: $26.29 x 12 = $315.48

2.) DC single parent, one child age 15

2014 annual rate: Individual & Child tier $720

2015 annual rate: $26.62 + $24.99 = $51.61 x 12 = $619.32

3.) Baltimore family of 4, children ages 5 and 10

2014 annual rate: Family tier $1,536

2015 annual rate: (2 adults x $25.81) + (2 children x $28.83) = $109.28 x 12 = $1,311.36

4.) Montgomery County family of 5, children ages 15, 18, 22

2014 annual rate: Family tier $1,476

2015 annual rate: (3 adults x $25.05) + (2 children x $27.99) = $131.13 x 12 = $1,573.56

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Stand-alone Dental and Vision Plans

Product Name Availability

Individual Select DHMO Off Exchange

Individual Select Preferred Dental Off Exchange

Individual Select Preferred Dental Plus Off Exchange

BlueDental Preferred – High Option – (ACA) Both On and Off Exchange

BlueDental Preferred – Low Option (ACA) Both On and Off Exchange

BlueVision (offered only to members who have a CareFirst

MediGap plan)

Off Exchange

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Blue Rewards


HealthyBlue/Blue Rewards Incentive Evolution

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Outcomes based incentives

• HealthyBlue Dual and Triple Option

Participation based incentives

• HealthyBlue 2.0, HealthyBlue Advantage

Participation based incentives

• Blue Rewards added on all Risk offerings

• Launched the first version of HealthyBlue Dual and Triple Option in 2010, HealthyBlue 2.0 in 2011, HealthyBlue Advantage in 2012 and ACA version of HealthyBlue in 2014.

• For 2015 and beyond, we will be launching Blue Rewards which will add an incentive to all Risk products.

• Blue Rewards is incorporated as part of the medical contract filed with the regulators for plans with 1/1 effective dates.

2010 2015


Blue Rewards Incentive Process

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*Members outside the service area can select any PCP-like specialty

Participation-based Reward

Adult (18+) $150

Children (2-17) $50

Family maximum $400

Complete within 120 days from your effective date

2+ 18+ 18+ 2+

Select a

Patient-Centered

Medical Home

(PCMH) PCP

Provide e-consent

for wellness

communications

Complete a health

assessment

Go to selected PCMH

PCP and complete a

health evaluation

+ + +

Earn a Blue Reward when you:


HealthyBlue Incentive vs. Blue Rewards Incentive

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Background: • CareFirst is launching a new wellness incentive program across all products and segments, effective

1/1/15 upon renewal – Blue Rewards. Blue Rewards will be replacing the current HealthyBlue incentive program.

HealthyBlue - Current Blue Rewards – 2015

Incentive Steps • Select a PCP • Complete Health Assessment with

consent to share the results with your PCP

• Complete Health and Wellness Evaluation Form (Participation-based)

• Select a PCMH PCP • Complete Health Assessment

with consent to share the results with your PCP

• Provide wellness-related e-consent

• Complete Health and Wellness Evaluation Form (Participation)

Incentive Type • Gift card to be used toward premiums, medical expenses and health-related expenses

• Rolls over each year

• Medical Expense Debit Card to be used toward premiums and medical expenses only

• Use it or lose it

Incentive Amount • Participation-Based: • $200/Adult • $500/Family

• Participation-Based: • $150/Adult $400/Family

Must complete incentive within…

• 180 Days • 120 Days


Reward Type: HSA vs Non-HSA

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Type of Plan Reward Type Reward Usage

• HSA plans Blue Rewards Card

• Before the $1,300 IND/$2,600 FAM IRS minimum deductible

• Monthly Premium • After the $1,300 IND/$2,600 FAM IRS minimum

deductible • Copayment, coinsurance, deductible OOP expenses

related to : • Medical • Prescription Drug • Dental • Vision

• Non-HSA plans

Blue Rewards Card

• Monthly premium • Copayment, coinsurance, deductible OOP expenses

related to : • Medical • Prescription Drug • Dental • Vision


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How does the Blue Reward card work?

Subscriber completes incentive

Card mailed within 7-10

business days Subscriber and

dependents can use card

Point of Sale

Reimbursement

$$

Consumer Direct

Who can use the card • Subscriber and family members

When can the card be used • At point of sale during the benefit period once the reward has been earned

When can the REWARD FUNDS be used

• For any expense that was incurred during the benefit period • Members will have a 90 day grace period from the end of the benefit

period to submit expenses

Do the funds rollover? • No – the funds are “use it or lose it.”

How card can be used • Premium • Copays, coinsurance, deductible expenses for medical, prescription drug,

dental and vision


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HSA COBRA, retiree medical

insurance premiums, LTC premiums and expenses

FSA

Expenses related to the medical , prescription drug, dental and vision plan including medical plan premiums.

Blue Reward / HSA / FSA Comparison

• FSAs and HSAs can be used for qualified medical expenses governed by the IRS.

• The Blue Rewards incentive card is the most limited in terms of how the funds can be used.

o Eligible expenses for the incentive card need to be covered by the health plan.

Eligible Medical Expenses – 213(d) • Examples: diagnostic services, hospital services,

durable medical equipment, psychologist, physical therapy etc.

Eligible Medical Expenses – 213(d) • Examples: diagnostic services, hospital services,

durable medical equipment, psychologist, physical therapy etc.

Healthcare and wellness related expenses: • Deductibles, copays, coinsurance for medical services • Recreational:

• Gym memberships • Sports stores (Dicks sporting goods, Sports Authority etc.)

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2015 Key Differentiators & Selling Points

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CareFirst Key Differentiators

• Brand & Longevity o We carry a name that protected you when you were a child, protected your

parents and grandparents o Insuring MD, DC and VA residents for over 70 years

• Flexibility o We give you flexibility to choose the doctors you want to see. o One of the largest provider networks o Open access plans- no referrals

• Rewards o We reward you for a healthy lifestyle with money towards your premium and

deductibles. o A health plan that gives you money back for visiting your doctor.

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Key Plan Selling Points

• A Blue Rewards program—earn $150 (families get up to $400) by completing four steps • $0 benefits—pay nothing when you use one of our in-network providers for: adult physicals

, well-child exams and immunizations, OB/GYN visits and pap tests, mammograms, prostate and colorectal screenings, routine pre-natal maternity services and $0 generics for some plans.

• Mail Service Pharmacy • Interactive Pharmacy Tools • 28,000+ providers and 68+ hospitals— one of the largest doctor and hospital networks in

the region • 68,000+ pharmacies nationwide and convenient mail order services • No referrals to see specialists • Vision care—get one $0 eye exam each year plus discounts* on contact lenses, laser vision

correction surgery and glasses when you use a provider within our vision network • Comprehensive dental and vision coverage for kids under 19 • National coverage available either through the BlueCard PPO network or with Away From

Home Care™—limitations may apply • 24 hour nurse advice line • My Account & My Account mobile app—account information in the palm of your hand

*Some providers in MD may not accept these discounts.

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2015 Renewal Strategy


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MD and VA Off Exchange Renewals

• Members will be a passively renewed.

o Exception: BlueChoice Young Adult members who are aging out.

• BlueChoice Young Adult $6,350 Members:

o Members who are still under 30 will be renewed into the 2015 version of their plan, BlueChoice Young Adult $6,600

o Members who turned 30 in 2014 will be renewed into BlueChoice Bronze $6,000, which is the closest match to their old BCYA plan

o Members who were over 30 but had a hardship exemption for 2014 will be renewed into BlueChoice Bronze $6,000, which is the closest match to their old BCYA plan

• If they still qualify for a hardship exemption, members need to go back to their exchange to re-qualify.

• January premium bill (mailed early December) – invoice will include a bill stuffer that will:

o Remind members this bill reflects their 2015 rate

o Remind members about deductible and OOP max resets as of 1/1

o Inform them of their range of payment options with an emphasis on recurring payments

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MARYLAND On Exchange

Members with subsidies: • 2014 subsidies will NOT carry over to 2015 – all members MUST go back to the MHBE to be re-determined

o In order to get 2015 subsidies beginning January 1, they must re-determine by December 18. o If they do not re-determine until after December 18, subsidies will apply to the next month but NOT

previous months. For example, a member re-determines January 14. The subsidy amount will apply to February and beyond but they would have to pay the full January bill.

• Members with CSR will be renewed into their base plan, without the cost sharing reductions unless they complete the re-determination process.

BlueChoice Young Adult $6,350 Members: • Members who are still under 30 will be renewed into the 2015 version of their plan, BlueChoice Young Adult $6,600. • Members who turned 30 in 2014 will be renewed into BlueChoice Bronze $6,000, which is the closest match to their old

BCYA plan. • Members who were over 30 but had a hardship exemption for 2014 will be rerenewed into BlueChoice Bronze $6,000,

which is the closest match to their old BCYA plan. o If they still qualify for a hardship exemption, they need to go back to the MHBE to re-qualify.

January premium bill (mailed early December) – invoice will include a bill stuffer that will: • Remind members this bill reflects their 2015 rate. • Remind members about deductible and OOP max resets as of 1/1. • Members with a subsidy:

o Will be reminded that they MUST go back to the MHBE to be re-determined for subsidies. o Will be told their recurring payments have been stopped and they will need to re-enroll.

• Members without a subsidy will be reminded that they have the option to enroll in a CareFirst Off Exchange plan. • Inform them of their range of payment options with an emphasis on recurring payments.

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VIRGINIA On Exchange

Members with subsidies: • 2014 subsidy amounts will initially be carried over automatically, regardless of tax authorization status.

o Members who did NOT allow for tax authorization and do not complete re-determination will be rebilled the full premium once FFM confirms these members.

o Members with a CSR reduction plan who did NOT allow for tax authorization and do not complete re-determination will be moved to the base plan once FFM confirms these members.

• However, we recommend all members go back to the Exchange to requalify for their subsidy if their household or financial situation has changed since the time they applied (in case they are eligible for a higher or lower subsidy). o Want to make sure members are receiving the proper subsidy because of tax implications.

BlueChoice Young Adult $6,350 Members:

• Members who are still under 30 will be renewed into the 2015 version of their plan, BlueChoice Young Adult $6,600. • Members who turned 30 in 2014 will be renewed into BlueChoice Bronze $6,000, which is the closest match to their

old BCYA plan. • Members who were over 30 but had a hardship exemption for 2014 will be renewed into BlueChoice Bronze $6,000,

which is the closest match to their old BCYA plan. o If they still qualify for a hardship exemption, they need to go back to the FFM to re-qualify.

January premium bill (mailed early December) – invoice will include a bill stuffer that will:

• Remind members this bill reflects their 2015 rate • Remind members about deductible and OOP max resets as of 1/1 • Members with a subsidy will be reminded to go back to the FFM if:

o Their household or financial situation has changed since they time they applied o They believe they may be eligible in 2015.

• Members without a subsidy will be reminded that they have the option to enroll in a CareFirst Off Exchange plan. • Inform them of their range of payment options with an emphasis on recurring payments.

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DC On Exchange

Members with subsidies: • 2014 subsidy amounts will initially be carried over automatically.

o In late December, an updated 834 file will come over with 2015 subsidy amounts based on DC conducting an automatic redetermination.

o Members with a CSR plan will be moved to the base plan if they no longer qualify. • However, we recommend members go back to DC Health Link to requalify for their subsidy if their household or financial

situation has changed since the time they applied (in case they are eligible for a higher or lower subsidy) o Want to make sure members are receiving the proper subsidy because of tax implications.

o

BlueChoice Young Adult $6,350 Members: • Members who are still under 30 will be renewed into the 2015 version of their plan, BlueChoice

Young Adult $6,600 • Members who turned 30 in 2014 were sent a letter in late September saying they will be terminated and told they need to

go back to DC Health Link to apply for a new plan • Members who were over 30 but had a hardship exemption for 2014 were sent a letter in late September saying they will

be terminated and told they need to go back to DC Health Link to apply for a new plan o If they still qualify for a hardship exemption, they need to go back to DC Health Link to re-qualify.

• DC Health Link made a decision after our letters were mailed that they wanted these members migrated to the BlueChoice HSA Bronze $6,000 plan. o DC Health Link will be handling follow-up communication with the 32 impacted members. They will send these

members to CF in a passive renewal file.

January premium bill (mailed early December) – invoice will include a bill stuffer that will: • Remind members this bill reflects their 2015 rate • Remind members about deductible and OOP max resets as of 1/1 • Members with a subsidy will be reminded to go back to DC Health Link if:

o Their household or financial situation has changed since they time they applied. o They believe they may be eligible in 2015

• Inform them of their range of payment options with an emp.hasis on recurring payments

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BlueDental Preferred Renewals

• Like ACA medical, all these members will renew on January 1.

• In mid- to late-October, members will receive a renewal letter for January 1, 2015 with the following information:

o Premium rate for 2015

o Benefit changes for 2015

o Information on the change to member level rating (MLR).

• Like ACA medical, each member will be rated individually and the rates will be combined to get the family rate.

• No more tiers (individual, family, etc.).

o BlueDental Preferred will now have a High and Low Option.

• All current members will be moved to the High option (closest match).

• They have the ability to explore their other dental options.

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2015 Eligibility & Enrollment

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On and Off Exchanges

• CareFirst will have direct interaction with three different Exchanges/online market places in order to enroll members who apply via the Exchange:

• Maryland (State-based) • DC (State-based) • Virginia (Federally Facilitated

Exchange)

• These Exchanges are referred to as “On Exchange.”

• Sales will only be accepted online, but navigators and in-person assistors will be available to assist those who do not have access to the internet.

• In addition to the Exchanges CareFirst will have our own CareFirst Private Exchange where shoppers can apply for medical and dental health care plans directly. This is referred to as “Off Exchange.”

• Sales will be accepted through various channels: o The CareFirst Private Exchange o Brokers o Sales representatives

In order to manage the enrollment processes we have streamlined several of the enrollment and eligibility guidelines for both on and off the exchange.

On Exchange

Off Exchange (Maryland & Virginia Only)

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Product Availability

Medical

Dental

MD DC VA

Off Exchange

On Exchange

NOTE: On Exchange MD dental will be quoted on the exchange, but applications will be sent direct to CareFirst.

43


Open Enrollment Overview

• Open Enrollment Periods are put in place as a result of the ACA law, which defines a set period of time when people can purchase and join in a particular health plan.

• The 2015 Open Enrollment Period is November 15, 2014 – February 15, 2015. Although the OEP is the same for everyone there are some jurisdictional differences to calculate effective dates:

o MD On Exchange – Follows the 18th of the month cut off rule

o DC On Exchange - Follows the 15th of the month cut off rule

o VA ON Exchange – Follows the 15th of the month cut off rule

o MD/VA Off Exchange – Based on the 20th of the month rule

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Enrollment Days and Effective Dates

MD ON EXCHANGE

• MD On Exchange effective dates will be calculated based on the 18th of the month rule .

• When the applicant applies on the exchange between November 15, 2014 through November 30, 2014 they will receive a January 1st effective date.

o Starting in December applicants applying between the 1st and 18th of the month will receive an effective date of the first day of the following month.

o Applicants applying from the 19th of the month through the end of the month will receive an effective date of the first of the second month.

Application/Data Received Effective Date

November 15, 2014 - December 18, 2014 January 1, 2015

December 19, 2014 - December 31, 2014 February 1, 2015

January 1, 2015 - January 18, 2015 February 1, 2015

January 19, 2015 - January 31, 2015 March 1, 2015

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MD On Exchange Timeline

Date Event

November 9th The exchange opens for quotes and estimates of financial assistance.

November 15th Events will begin throughout MD so you can receive assistance to sign up for a plan.

November 16th The call center will begin taking phone applications at 855-642-8572.

November 17th Brokers and navigators can begin to assist with sales.

November 18th Caseworkers at local health departments and departments of social services will begin to assist with applications.

November 19th The MHBE exchange will open to the public for 2015 enrollment.

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VA/DC ON EXCHANGE

• The VA On Exchange will calculate effective dates based on the 15th of the month rule.

o When the applicant submits an application on the exchange between November 15, 2014 through November 30, 2014 they will receive a January 1st effective date.


o Applicants applying from the 16th of the month through the end of the month will receive an effective date of the first of the second month.






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MD/VA OFF EXCHANGE

• The VA On Exchange will calculate effective dates based on the 20th of the month rule.

o When the applicant submits an application on the exchange between November 15, 2014 through November 30, 2014 they will receive a January 1st effective date.


o Applicants applying from the 21st of the month through the end of the month will receive an effective date of the first of the second month.






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CareFirst Private Exchange Timeline

• November 1, 2014 – November 14, 2014:

o Consumers can go to the site and receive a quote for January 1st.

o Agents can send quotes for January 1st.

o They cannot apply for the 2015 product portfolio.

• November 15, 2014 and onward consumers can apply for 2015 plans.

This applies to the ACA Medical plans as well as the ACA Dental plans.

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Overlap of OEP and LOEP/SEP

• During the Open Enrollment Period consumers will be able to apply for a January 1st effective date; however, if they qualify for a Limited Open Enrollment Period (LOEP) or Special Enrollment Period (SEP) they can still get an effective date in 2014.

o On Exchange the various exchanges will handle this determination and their effective date.

o Off Exchange we are making changes to the online experience to account for this overlap.

• If someone obtains a policy with a 2014 effective date they will be enrolled into a partial year plan and will be subject to the auto-renewal process which will include a new rates, slightly different benefits and reset of accumulators.

o We will send rate renewal notifications to this population.

o We will auto renew them with a January 1st effective date in the same manner we are handing all other renewals.

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Overlap of OEP & LOEP Portal Changes

November 1st – November 14th we will expand the “start coverage on” box to include effective dates for two months out.

On November 15, 2014 we will add a question, “Do you have a qualifying life event?”

o If you answer Yes, then you will see benefits and rates for the 2014 product portfolio.

o If you answer No, then you will receive a 2015 quote.

o There will be a question mark (?) and if you hover over it a pop up box will appear explaining why you would select Yes vs. No.

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Initial Premium Payments

• New enrollees must make their initial premium payment (IPP) in order to effectuate coverage. This is inclusive of those who had a break in coverage.

• Existing subscribers (Active Renewals) vary based on jurisdiction:

o MD/VA On Exchange

• If you change legal entities then we will be required to collect an IPP again (e.g. move from BlueChoice to GHMSI).

• In the state of MD if you are in a PPO plan and you move in or out of PG or Montgomery counties this is considered a legal entity change.

• New Group number will be assigned upon this change

o DC On Exchange

• You can make any plan change and it will not require an IPP.

o MD/VA Off Exchange

• You can make any plan change and it will not require an IPP.

• If you move from an on exchange to an off exchange policy we will require an IPP.

• If you move from one jurisdiction to another an IPP will be required.

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Exchange Situation IPP Required Group Number Changed

MD/VA On Exchange Existing subscriber moves from BlueChoice (BC) to BluePreferred (GHMSI) legal entity

Yes Yes

MD On Exchange

Existing subscriber moves from a BluePreferred (GHMSI) to a BluePreferred (CFMI) legal entity

Yes Yes

DC On Exchange Existing subscriber moves from BlueChoice (BC) to BluePreferred (GHMSI) legal entity

No No

DC On Exchange Existing subscriber moves from a BlueChoice (BC) to a BlueChoice (BC) legal entity

No No

MD/VA Off Exchange Existing subscriber moves from BlueChoice (BC) to BluePreferred (GHMSI) legal entity

No No

MD/VA Off Exchange

Existing subscriber moves from a BlueChoice (BC) to a BlueChoice (BC) legal entity

No No

For new enrollees in a MD /VA On Exchange plan will be enrolled into their new plan under the new group numbers.

53


Payment Methods

• Off Exchange Application Process

o Effective November 21ST make your initial premium payment by credit card online ONLY

o Set up recurring payments with your checking or savings account and the IPP will be withdrawn on the first of the month of your effective month. All subsequent payments will be taken on the 6th of the month.

• eBilling - They can enroll in My Account at www.carefirst.com and

o Set up recurring monthly payments with your checking account or debit/credit card. The IPP will be withdrawn on the first of the month of your effective month. All subsequent payments will be taken on the 6th of the month for Off Exchange and the 8th of the month for On Exchange.

o Make one-time payments with your checking account or debit/credit card

• New option to pay cash through CheckFreePay

o Available at Walmart

• Mail a check or money order to: CareFirst BlueCross BlueShield

PO Box 79749

Baltimore, MD 21279-0749

o Member must include your name, member ID and group number on the check/money order

NOTE: These payment methods apply to the IPP as well as ongoing payments unless stated otherwise.

http://www.carefirst.com/

54



The cash payment project team is creating a webpage to explain all of the payment options to our consumers/members, which will go live in mid- November.

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Cash Payment Option

• New option that will be available to the public in mid November.

o The vendor is Checkfree and will be available at 58 different Walmart locations within our jurisdiction.

• Go to www.checkfreepay.com/info/payinperson to find a location.

o Member must bring their invoice # to the store or call member services for the number(No membership # or group#).

o All members except MHIP can use this payment option.

o Members can use Walmart gift cards/debit cards or cash(No credit cards or checks).

o This option is free of charge for the member.

o Members can go to My account to see the payment(after 24 hours).

o Members need to keep the Walmart receipt for any disputes.

http://www.checkfreepay.com/info/payinperson

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Dental Enrollment Guidelines

• Dental enrollment guidelines will vary by product.

o A bulk of the differences are because the products sit on two different platforms.

o Others are contractual differences.

• All dental products require a binder payment in order to effectuate coverage; however, acceptance of the IPP varies.

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Commissions

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Commission Payment Considerations

• After effectuation of coverage, normal payment received by Producer could be 60-90 days

• Broker Contracting and Compliance must receive the Producer’s certification for jurisdiction(s) and any other required documentation before any commissions can be paid.

• Use of paper applications rather than using electronic causes errors and slows the process

o Incomplete tax ID for the GA and/or SS# for the Producer

o Illegible

o Needs to be re-keyed into the CareFirst system

• Calling multiple CareFirst areas to research commission issues slows process

• When the General Agent is provided on the enrollment file from the Exchange to CareFirst rather than the Producer, research must be completed. GA and Producer must work together to monitor existing blocks and new business to ensure commissions are paid accurately

• When the Member chooses to work with another Producer but does not advise the current one, commissions can be impacted.

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Commission Payment Considerations

• Commissions are not paid until plan premium payment is made and the plan is effectuated.

• Producer information on the file from the Exchange(s) has been inconsistent. Producer must ensure that the GA is aware of business sold on the Exchange.

• Producer should ensure that Broker Contracting and Compliance has their selected General Agent on file for payment of commission

• Any movement from one plan to the other by the Member will cause the current Producer to no longer be attached. Producer should ensure their existing business is assigning to them when making any change

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This document was created for informational purposes only and is not intended to provide legal and/or accounting advice and should not be relied upon as such. Individuals should consult with their own accountants and/or legal counsel if they have any questions regarding the financial and legal impacts of the Affordable Care Act.”

CD Broker Training Q4 2014 V9

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