2016 plan overview - providence health plans/media/files...fitness classes, massage therapy, weight...

2016 Plan Overview

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Select the Plan That’s Right for Your BusinessMany things are factored into selecting the right health benefits

for your business – plan designs, networks, customer service,

member extras and, of course, cost.

We’ve taken into consideration all of your needs, and we feel confident that we have the right plan for your business. This guide provides an overview of health plans available to meet your business and employee needs for benefits effective Jan. 1, 2016.

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Why Choose Providence?Here are five great reasons to partner with Providence Health Plan.

We help you manage costs.

• For the past six years, our trend has been consistently below market – 7.6 percent trend in January 2015.

• With a large product portfolio, nearly limitless plan design options and a broad provider network, choice and options are yours.

• We have one of the nation’s best pharmacy utilization rates – 91 percent for generic utilization.

• We’re recognized for reducing unnecessary emergency room visits – nearly 40 percent reduction over the last 10 years.

We are integrated.

• We offer a cohesive approach to member and patient care founded on the Providence Mission and core values of respect, compassion, justice, excellence and stewardship.

• Electronic systems keep members, physicians and the health plan connected, making it easy to share information. For example:

° ProvRN nurses electronically notify providers after a member’s ProvRN call.

° Health eXpress providers electronically share the after-visit summary with physicians.

We are innovative.

• Health eXpress, our Web-based health care service, delivers high-quality care on demand and is ranked 4.8 out of five stars for patient satisfaction.

• Our unique partnerships with northwest businesses and Providence Health & Services achieve optimal health and cost savings.

• Our joint care packages, which offer bundled payments, improve patient experiences, coordinate care and ultimately lower costs without compromising quality.

We are good at what we do, and we’re recognized by our peers.

• The National Committee for Quality Assurance has awarded Providence Health Plan an accreditation status of Commendable for its Oregon Commercial PPO plans. This signifies Providence Health Plan’s service and clinical quality meet or exceed NCQA’s rigorous requirements for consumer protection and quality improvement.

• For 10 years in a row, Portland Business Journal has recognized us as one of Oregon’s most admired companies.

• We provide accurate and timely claims processing. We accurately processed 97 percent of all claims within 30 days in 2014, 2013 and 2012.

We care.

• We live the Providence Mission every time we talk with a member, ensuring each person is cared for in the most genuine, compassionate way.

• Last year Providence outreach programs supported five community priorities:

1. Preventive and primary care needs

2. Mental health and substance use

3. Chronic conditions and disease management

4. Oral health

5. Basic needs, such as hunger, housing and transportation

97%

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What really matters? It’s what’s in it for YOU . . .

• Your health care dollars are invested wisely.

• You’ll benefit from our relationship with Providence Health & Services, making sure you have access to high-quality care in a convenient and compassionate way.

• You’ll share in our commitment to the Triple Aim as we work to provide improved health, the best care experience and affordable services.

• You’ll be given free tools, resources and support to achieve your health goals.

• You’ll be treated with dignity and respect because we take time to listen and learn about your needs.

• You’ll have fewer hassles because we do things right – the first time.

• You’ll find what you need and, if you don’t, we’ll help until you do.

Who is Providence Health Plan?

Providence Health Plan is part of Providence Health & Services, an integrated delivery system

that has been caring for Northwest communities for nearly 160 years. We offer health insurance

for commercial groups, Medicare, Medicaid, individuals and families, and we serve more

than 500,000 members nationwide. Compassionate and innovative care along with unique

partnerships with physicians, hospitals and pharmacies help us achieve the Triple Aim:

Improved health Best care experience Affordability

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What you get with Providence?

Exclusive health improvement resources

Healthy employees make for a healthy business.

Providence is home to FitTogether™, a comprehensive suite of health management solutions. It offers a unique blend of medical management, health improvement and workforce wellness to support members’ specific health needs.

Health Management Consultants. We offer the expertise of our health management consultants to design tailored wellness campaigns with aggregate reports available if more than 50 members participate in campaigns.

• Work site wellness challenges. Members can participate in work site wellness challenges with various health focuses. Choose from nutrition, weight management or health improvement topics that bring people together and encourage them to use tools and resources for better health.

• Customized solutions. All Providence work site challenges are customizable. Add participation incentives and weekly challenge support activities to encourage challenge engagement.

Health coaching. Members can receive 12 one-on-one health coaching sessions each calendar year at no cost. The programs are designed to help members lose weight, improve diet, manage stress, exercise, stop using tobacco or just feel better every day.

Care management. Members partner with registered nurses to improve health outcomes. When health improves, costs typically go down. Our nurse care coordinators provide education and support for a broad spectrum of health conditions, discuss treatment options, review medications and address lifestyle modifications.

On-demand health and wellness resources. Our secure member website, myProvidence.com, provides a complete source for health, wellness and benefits information. Wellness Central, Providence’s integrated online health and wellness hub, available through myProvidence, helps members move from a vision of health to an actionable plan for health. Take advantage of the personal health assessment, health trackers, health education resources and much more.

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Extras for employeesYou and your employees get more value from your health care dollar with Providence.

Our extra values and discounts help your employees stay active and healthy and save money.

ProvRN

Get free medical advice 24 hours a day, seven days a week. Members speak with a registered nurse who can answer health questions and determine the type of care needed. (Not available for residents of California.)

503-574-6520 or 800-700-0481 TTY: 711

LifeBalance Program

Members enjoy savings on health club memberships, fitness classes, massage therapy, weight loss programs, and recreational, cultural and wellness events, including family activities, movies, travel and more.

888-754-5433 www.LifeBalanceProgram.com

TruVision

Members save on contact lenses, which will be mailed to their home, and on LASIK (laser vision correction).

877-315-2020 www.truvision.com

Visionworks

Members enjoy discounts on vision exams, eyeglass frames and lenses at Oregon and southwest Washington locations.

800-669-1183 www.visionworkseyewear.com

ChooseHealthy™

Members save on acupuncture, chiropractic care, massage therapy and dietitian services with discounted rates available from ChooseHealthy providers.

877-335-2746 www.choosehealthy.com

Health education classes

Members can sign up for free or discounted Providence Health & Services classes, including weight management, childbirth preparation, yoga, smoking cessation and more.

503-574-6595 www.providence.org/classes

TruHearing

Members receive discounted hearing aids. A discount is also available to members’ parents and grandparents who are not enrolled with Providence Health Plan.

877-253-4040 www.truhearing.com

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Selling areasFind the right plan for your business.

Open Option, Core Advantages, Personal Option and HSA Qualified Plans are available statewide and in southwest Washington.

Businesses located anywhere in Oregon and southwest Washington can partner with Providence Health Plan for their employees’ health coverage. Most plans – including Open Option, Core Advantages, Personal Option and HSA Qualified plans – are available statewide in Oregon and in Clark, Skamania and Klickitat counties in Washington.

Providence Choice is available throughout most of Oregon and in select Washington state counties.

Providence Choice plan utilizes a medical home model for care. Medical homes are available in most counties in Oregon and select counties in southwest Washington. Please refer to the Providence networks section for a description of Providence Choice and to see a map of where medical homes are located in Oregon and southwest Washington.

Choice network: select counties in Oregon and southwest Washington: Baker Benton Clackamas Clark (WA) Clatsop Coos Crook

Curry Deschutes Douglas Hood River Jackson Josephine Klamath

Lane Lincoln Linn Malheur Marion Multnomah Polk

Umatilla Union Wallowa Washington Yamhill

Providence Connect is available in Multnomah, Clackamas and Washington county in Oregon.

Connect plans combine a medical home model of care with a tailored provider network to achieve substantial premium savings. Available in Multnomah, Clackamas and Washington counties in Oregon, Connect Plan serves employees who work or reside in one of these counties.

For the most up-to-date list of providers in any PHP network, visit our

provider directory at www.ProvidenceHealthPlan.com/providerdirectory.

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Networks Ensuring access to high-quality health care while controlling costs – that’s been

a shared goal for several years and likely a shared goal for many more to come.

Whatever your cost management strategy, Providence Health Plan is taking steps

to help manage costs that translate into savings for your business. We’ve created

a range of networks that allow you to select what fits your budget and employee

needs while still providing access to providers your employees know and trust.

Providence Signature Network

The Providence EPO Network has a new name: The Providence Signature Network. Select a plan that features the Providence Signature Network, and your employees can access the broadest selection of health care providers with in-network benefits. Featuring nearly 1 million providers nationwide – including more than 10,000 specialists throughout Oregon and southwest Washington – the Providence Signature Network is available to members enrolled in an Open Option, Core Advantages, Personal Option or HSA Qualified plan. Enrolled employees get exceptional care from Providence providers and affiliated providers in and outside of the Northwest. Consider a plan with this network if you have employees who work outside of Oregon.

Signature network: nationwide

Providence Choice Network

With the Providence Choice Network, members choose a medical home from more than 235 primary care clinics in most counties in Oregon and select counties in southwest Washington. Clinics in the Choice network are recognized by the Oregon Health Authority as Patient-Centered Primary Care Homes based on access, coordination, quality and cost measures.

Choice network: select counties in Oregon and southwest Washington: Baker Benton Clackamas Clark (WA) Clatsop Coos Crook

Curry Deschutes Douglas Hood River Jackson Josephine Klamath

Lane Lincoln Linn Malheur Marion Multnomah Polk

Umatilla Union Walla Walla (WA) Wallowa Washington Yamhill

Providence Connect Network

With the Portland-area Providence Connect Network, members choose a medical home from more than 65 primary care clinics in Multnomah, Washington and Clackamas counties. As with the Choice network, participating clinics partner with Providence to improve the quality of care and reduce medical costs.

Connect network: Clackamas, Multnomah and Washington counties in Oregon

All Providence networks offer access to Providence physicians, specialists and other caregivers. We also partner with individual providers and provider groups outside of the Providence family. Your employees can choose from a range of health care experts to best meet their health needs.

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Plan comparison

The information in this guide is intended to provide an overview of the plans available to Oregon and southwest Washington employers with 51 or more employees. For specific plan details, please refer to the plan’s benefit summary. Some benefit limitations and exclusions apply. For a complete list of benefits and exclusions, please see the plan contract documents.

Plan features Open Option

Core Advantages

Personal Option

HSA Qualified Choice Connect

Provider Network

Network name Signature Signature Signature Signature Choice Connect

Broad PPO-style network • • • •Local medical home model • •Specialist referrals required • •Benefits

Combined in- and out-of-network deductibles and out-of-pocket maximums • • •

Deductible applies to out-of-pocket maximum • • • • • •

Most preventive care covered in full • • • • • •Deductible waived for personal physician/provider and specialist visits • • • • •

Deductible waived for Health eXpress visits • • • • •

Deductible waived for urgent care visits • • • • •Deductible waived for emergency services for emergency medical conditions • •

Specialist visit copay same as personal physician/provider office visit copay • •

Deductible waived for in-network lab and X-ray • • • •

Diagnostic lab and X-ray covered in full for first $500 of in-network services •

Deductible waived for in-network high-tech imaging services • •

Alternative care provider office visit copay same as personal physician/ provider office visit copay*

• • • • • •

Higher cost shares for select services • •Health and Wellness Program

ProvRN free medical advice line • • • • • •Disease management for chronic conditions • • • • • •Telephonic health coaching • • • • • •LifeBalance discount program • • • • • •Integrated HSA, HRA and FSA administration

Option to pair with an integrated vendor, Health Equity HRA and/or FSA • • • • •

Option to pair with an integrated vendor, HealthEquity HSA •

*Chiropractic manipulation and acupuncture services covered only if a separate rider is purchased.

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Open Option PlansOpen Option plans provide a premier level of coverage with full access

to the Providence Signature network and non-network providers.

These plans are easy to use and offer predictable costs for members.

Plan features

• Specialist visits without a referral

• Predictable out-of-pocket costs through upfront coverage and low copay and coinsurance options

• Plan designs with combined or separate in- and out-of-network deductible and out-of-pocket maximums

• In-network deductible waived for many services, including office visits, health exams, diagnostic services, women’s health services, routine immunization and maternity prenatal care

• Deductible applied to out-of-pocket maximum

• Includes coverage for Health eXpress, our Web-based health care service offering convenient, on-demand visits on your smartphone, tablet or computer without an appointment

Plan network

Providence Signature Network: A national network with nearly 1 million providers nationwide, with Providence facilities, affiliated provider groups and individual providers

Plan selling area

Business must be located in Oregon or in Clark, Skamania or Klickitat counties in Washington state.

Benefit design options

Deductible*

$250

$500

$750

$1,000

$1,500

$2,000

$2,500

$3,000

$5,000

Out-of-Pocket Max*

$2,000

$2,500

$3,000

$3,500

$4,000

$5,000

$6,850

Copay Options

$10

$15

$20

$25

$35

Coinsurance Options

10% / 20%

20% / 30%

20% / 40%

30% / 50%

* Individual amounts are shown. The family out-of-pocket maximum and family deductible are two times the individual amounts.

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Open Option Plans: Benefit Highlights

✓ No deductible needs to be met prior to receiving this benefit.$ Copay applies% Coinsurance applies

In-network copay or coinsurance*

Out-of-network copay or

coinsurance*

Preventive Care Services What the member pays:

Periodic health exams and well-baby care Covered in full ✓ % ✓

Routine immunizations and shots Covered in full ✓ % ✓

Colonoscopy (age 50+) Covered in full ✓ %

Gynecologic exams; Pap tests Covered in full ✓ % ✓

Mammograms Covered in full ✓ %

Tobacco cessation, counseling/classes and deterrent medications Covered in full ✓ Not covered

Physician/Provider Services

Office visits $/visit ✓ % ✓

Health eXpress $/visit ✓ Not covered

Office visits to alternative care providers (does not include chiropractic manipulation or acupuncture services) $/visit ✓ % ✓

Allergy shots, serums, infusions, injectable medications % %

Inpatient hospital visits % %

Surgery, anesthesia % %

Diagnostic Services

X-ray and lab services % ✓ %

High-tech imaging services (such as PET, CT or MRI scans) % ✓ %

Sleep studies % ✓ %

Emergency and Urgent Care Services

Emergency services (for emergency medical conditions only; if admitted to the hospital, all services are subject to inpatient benefits) $250 ✓ $250 ✓

Urgent care services (non-life-threatening illness/minor injury) $/visit ✓ % ✓

Emergency medical transport (air or ground) % %

Hospital Services

Inpatient/observation care % %

Rehabilitative care (limited to 30 days per calendar year) % %

Skilled nursing facility (limited to 60 days per calendar year) % %

Outpatient Services

Outpatient surgery, dialysis, infusion, chemo and radiation therapy % %

Outpatient rehabilitative services: physical, occupational or speech therapy (limited to 30 visits per calendar year) % %

Maternity Services

Prenatal office visits Covered in full ✓ %

Delivery and postnatal services 10x OV/delivery ✓ %

Inpatient hospital/facility services % %

Routine newborn nursery care % ✓ %

* After deductible where no checkmark is indicated

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Core Advantages PlansWith a Core Advantages plan, members enjoy robust benefits and first-dollar coverage

for certain preventive and frequently used services with some upfront premium savings.

Plan features


• Predictable out-of-pocket costs through upfront coverage and low copay and coinsurance options


• In-network deductible waived for many services, including office visits, health exams, diagnostic services, women’s health services, routine immunization and maternity prenatal care

• In-network X-ray and lab services covered in full for the first $500 in a calendar year

• Cost-sharing differential for services provided by specialists versus personal physician/provider, meaning out-of-pocket costs are higher for specialist visits, keeping premiums manageable


• Includes coverage for Health eXpress, our Web-based health care service offering convenient on-demand visits on your smartphone, tablet or computer without an appointment

Plan network


Plan selling area

Business must be located in Oregon or in Clark, Skamania or Klickitat counties in Washington state.


Out-of-Pocket Max*

$3,500

$4,000

$5,000

$6,850

Copays

$10/$20

$15/$25

$20/$30

$25/$35

$35/$45

Coinsurance

10% / 20%

20% / 30%

20% / 40%

20% / 50%

30% / 50%

Deductible*

$250

$500

$750

$1,000

$1,500

$2,000

$2,500

$3,000

$5,000


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Core Advantages Plans: Benefit Highlights



Out-of-network copay or

coinsurance*

Preventive Care Services What the member pays:

Periodic health exams and well-baby care Covered in full ✓ % ✓

Routine immunizations and shots Covered in full ✓ %


Gynecologic exams; Pap tests Covered in full ✓ % ✓




Office visits to personal physician/provider $/visit ✓ % ✓

Office visits to specialists $/visit ✓ % ✓

Health eXpress $/visit ✓ Not covered

Office visits to alternative care providers (does not include chiropractic manipulation or acupuncture services) $/visit ✓ % ✓




Diagnostic Services

X-ray and lab services (Covered in full for the first $500 of in-network services in a calendar year) % %

High-tech imaging services (such as PET, CT or MRI scans) % %

Sleep studies % %


Emergency services (for emergency medical conditions only; if admitted to the hospital, all services are subject to inpatient benefits) $250 $250

Urgent care services (non-life-threatening illness/minor injury) $ specialist OV/visit ✓ %

Emergency medical transport (air or ground) % %

Hospital Services




Outpatient Services



Maternity Services


Delivery and postnatal services % %


Routine newborn nursery care % %


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Personal Option PlansWith a Personal Option plan, members get excellent coverage and predictable costs

along with premium savings based on coverage specifically with in-network providers

in our Providence Signature Network.

Plan features


• Deductible waived for many services, including office visits, health exams, diagnostic services, women’s health services, routine immunizations and maternity prenatal care



Plan network


Plan selling area

Your business must be located in Oregon or in Clark, Skamania or Klickitat counties in Washington state.


Copays

$10

$15

$20

$25

$35

Coinsurance

10%

20%

30%

40%

Deductible*

$250

$500

$750

$1,000

$1,500

$2,000

$2,500

$3,000

$5,000

Out-of-Pocket Max*

$2,000

$2,500

$3,000

$3,500

$4,000

$5,000

$5,500

$6,850


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Personal Option Plans: Benefit Highlights



Preventive Care ServicesWhat the

member pays:

Periodic health exams and well-baby care Covered in full ✓

Routine immunizations and shots Covered in full ✓

Colonoscopy (age 50+) Covered in full ✓

Gynecologic exams; Pap tests Covered in full ✓

Mammograms Covered in full ✓

Tobacco cessation, counseling/classes and deterrent medications Covered in full ✓


Office visits $/visit ✓

Health eXpress $/visit ✓

Office visits to alternative care providers (does not include chiropractic manipulation or acupuncture services) $/visit ✓

Allergy shots, serums, infusions, injectable medications %

Inpatient hospital visits %

Surgery, anesthesia %

Diagnostic Services

X-ray and lab services % ✓

High-tech imaging services (such as PET, CT or MRI scans) % ✓

Sleep studies % ✓


Emergency services (for emergency medical conditions only; if admitted to the hospital, all services are subject to inpatient benefits) $250 ✓

Urgent care services (non-life-threatening illness/minor injury) $/visit ✓

Emergency medical transport (air or ground) %

Hospital Services

Inpatient/observation care %

Rehabilitative care (limited to 30 days per calendar year) %

Skilled nursing facility (limited to 60 days per calendar year) %

Outpatient Services

Outpatient surgery, dialysis, infusion, chemo and radiation therapy %

Outpatient rehabilitative services: physical, occupational or speech therapy (limited to 30 visits per calendar year) %

Maternity Services

Prenatal office visits Covered in full ✓

Delivery and postnatal services 10x OV/delivery ✓

Inpatient hospital/facility services %

Routine newborn nursery care % ✓


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HSA Qualified Plans These high-deductible health plans give members affordable coverage

and the flexibility to choose any provider. They also help members save

for future health care needs via a tax-advantaged health savings account.

Members can keep this account even if they change employers.

Plan features

• Provider choice in and out of the Providence Signature network


• Most visits subject to the deductible, helping manage premiums


• In-network preventive care covered in full before the deductible


• Integrated health savings account administered through HealthEquity, simplifying employee account setup and contributions (please see page 28 for information about integrated accounts)

• A seamless member experience for tracking and paying HSA qualified plan expenses through integrated claims processing, available with HealthEquity

Plan network


Plan selling area

Your business must be located in Oregon or in Clark, Skamania or Klickitat counties in Washington state.


Deductible*

$1,500

$2,500

$3,000

$3,500

$5,000

$6,550

Out-of-Pocket Max*

$3,500

$4,000

$5,500

$6,550

Coinsurance

20% / 40%

50% / 50%


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HSA Qualified Plans: Benefit Highlights

✓ No deductible needs to be met before receiving this benefit% Coinsurance applies

In-network coinsurance*

Out-of-network coinsurance*

Preventive Care What the member pays:

Periodic health exams and well-baby care Covered in full ✓ %



Gynecologic exams; Pap tests Covered in full ✓ %




Office visits to primary physician/provider % %

Health eXpress % %

Office visits to specialist % %

Office visits to alternative care providers (does not include chiropractic manipulation or acupuncture services) % %




Prescription Drugs (up to a 30-day supply/retail and preferred retail pharmacies; 90-day supply/mail-order and preferred retail pharmacies)

Preventive generic and brand-name drugs under ACA Covered in full ✓ Not covered

Generic and brand-name drugs % Not covered

Compounded drugs % Not covered

Diagnostic Services

X-ray and lab services % %


Sleep studies % %

Emergency and Urgent Services

Emergency services (for emergency medical conditions only; if admitted to the hospital, all services are subject to inpatient benefits) % %

Urgent care services (non-life-threatening illness/minor injury) % %

Emergency medical transportation (air or ground) % %

Hospital Services




Outpatient Services



Maternity Services

Prenatal care Covered in full ✓ %




*After deductible where no checkmark is indicated

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Providence Choice Plans Choice plans use a collaborative medical home model that provides members a team

of health professionals dedicated to their overall well-being. Members select a medical

home from the Providence Choice Network at the time of enrollment. The medical

home team then works collaboratively to support all aspects of a member’s health,

from wellness and prevention to active management of chronic conditions.

Plan features

• More than 235 medical homes in Oregon and southwest Washington that provide a patient-focused, coordinated care experience

• Access to a broad network of specialists and facilities via referral from the medical home in order to receive coverage at the in-network level


• Higher cost shares for selected services, such as knee and hip replacement, sleep studies and sinus surgery

• Separate deductibles and out-of-pocket maximums in- and out-of-network


Plan network

Providence Choice Network: More than 235 medical home clinics in Oregon and southwest Washington designated as medical homes provide a patient-focused,

coordinated care experience. For a complete list of available medical homes and providers by location, visit www.ProvidenceHealthPlan.com/providerdirectory

Plan selling area

Providence Choice Plans are available in select counties within Oregon and southwest Washington. Providence Choice plans use a medical home model to provide care. Recognized medical homes are not available in all Oregon and southwest Washington counties. To ensure coverage for members outside the Choice Network service area, a Choice plan must be paired with another Providence health plan that uses the Providence Signature Network (such as an Open Option, Core Advantages, Personal Option or HSA Qualified plan).


Deductible*†

$250

$500

$750

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

Out-of-Pocket Max*†

$2,000

$2,500

$3,000

$3,500

$4,000

$5,000

$5,500

$6,850

Copays

$10/$20

$15/$30

$20/$40

$25/$50

$30/$60

$35/$70

Coinsurance

10% / 30%

20% / 30%

20% / 40%

30% / 50%

* There are separate out-of-pocket maximums for in-network and out-of-network expenses, and separate in-network and out-of-network deductibles. Out-of-network values = 2x the in-network values.

† There are separate deductibles and out-of-pocket maximums for in-network and out-of-network services. Out-of-network values = 2x the in-network values.

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Choice Plans: Benefit Highlights

✓ No deductible needs to be met before receiving this benefit$ Copay applies% Coinsurance applies

In-network copay or coinsurance from your medical home

with a referral*

Out-of-network copay or coinsurance from a non-network

provider or without a referral*









Office visits to primary physician/provider $ / visit ✓ %

Health eXpress $ / visit ✓ %

Office visits to specialist $ / visit ✓ [2x PPP OV] %

Office visits to alternative care providers (does not include chiropractic manipulation or acupuncture services) $ / visit ✓ %



Surgery; anesthesia % %

Diagnostic Services


High-tech imaging services (such as PET, CT or MRI scans) % ✓ %



Urgent care services (non-life-threatening illness/minor injury) $(specialist OV) / visit ✓ %


Hospital Services




Outpatient Services



Maternity Services






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Connect PlansConnect plans combine a medical home model of care with a tailored provider network

to achieve substantial premium savings. Members select a medical home from our

Portland metro-area Providence Connect Network. The medical home model provides

a team of health professionals dedicated to the member’s overall well-being. Medical

home team members work collaboratively to support all aspects of a member’s health,

from wellness and prevention to active management of chronic conditions.

Plan features• Some of the lowest premiums of any

Providence plan for groups sized 100-plus

• More than 65 medical home clinics in the Portland metro area

• Access to specialists and facilities with referral from the medical home with coverage at the in-network level


• Higher cost shares for select services, such as knee and hip replacement, sleep studies and sinus surgery

• Separate deductibles and out-of-pocket maximums in- and out-of-network


Plan network

Providence Connect Network: A Portland-area network of more than 65 primary care clinics in

Multnomah, Washington and Clackamas counties designated as medical homes. For a complete list of available medical homes and providers by location, visit www.ProvidenceHealthPlan.com/providerdirectory

Plan selling area

To be eligible for a Connect plan, your business must be located in Washington, Multnomah or Clackamas counties in Oregon. To ensure coverage for members outside the Connect Network selling/service area, a Connect plan must be paired with another Providence health plan that uses the Providence Signature network (Open Option, Core Advantages, Personal Option or HSA Qualified plans).


Out-of-Pocket Max*†

$2,000

$2,500

$3,000

$3,500

$4,000

$5,000

$5,500

$6,850

Copays

$10 / $20

$15 / $30

$20 / $40

$25 / $50

$30 / $60

$35 / $70

Coinsurance

10% / 30%

20% / 30%

20% / 40%

30% / 50%

Deductible*†

No deductible

$250

$500

$750

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500


† There are separate deductibles and out-of-pocket maximums for in-network and out-of-network services. Out-of-network values = 2x the in-network values.

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Connect Plans: Benefit Highlights

✓ No deductible needs to be met before receiving this benefit$ Copay applies% Coinsurance applies

In-network copay or coinsurance from your medical home

with a referral

Out-of-network copay or coinsurance from a non-network

provider or without a referral









Office visits to primary physician/provider $ / visit ✓ %

Health eXpress $ / visit ✓ %

Office visits to specialist $ / visit ✓ [2x PPP OV] %

Office visits to alternative care providers (does not include chiropractic manipulation or acupuncture services) $ / visit ✓ %




Diagnostic Services





Urgent care services (non-life-threatening illness/minor injury) $(specialist OV) / visit ✓ %


Hospital Services


Rehabilitative care (30 days per calendar year) % %

Skilled nursing facility (60 days per calendar year) % %

Outpatient Services



Maternity Services


Delivery and postnatal services – primary care provider or certified nurse midwife

10% less than plan coinsurance %

Delivery and postnatal services – OB-GYN % %




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Pharmacy Benefit PlansProvidence Health Plan offers a number of pharmacy benefit plans with two different

broad formulary options to supplement your employee medical plan coverage.

All plans include:

• Preventive prescription medications covered in full on ACA preventive prescriptions

• Access to more than 26,000 participating pharmacies

• Access to a 90-day pharmacy transition period for most prescriptions that normally require prior authorization for newly enrolled members

• No separate out-of-pocket maximum

• Care management for members with chronic conditions, including support for medication adherence, help identifying harmful drug interactions and help identifying opportunities to reduce health care costs

New for 2016: 5-tier pharmacy plans:

• Prescription cost-shares do not apply to the medical deductible, but do go toward the medical plan out-of-pocket maximum

• Coverage for preventive, preferred generic, generic, preferred brand-name and brand-name, specialty and compound medication

• 90-day supply of maintenance medication through the preferred retail or mail-order service for two times the cost of a 30-day supply at a retail pharmacy

RX 0/10/15/20/50

RX 0/15/20/30/50

RX 0/15/20/45/50

RX 0/20/25/40/50

RX 0/25/30/50/50

5-tier Pharmacy Plans

1. ACA preventive $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

2. Preferred generic $10 $20 $15 $30 $15 $30 $20 $40 $25 $50

3. Generic $15 $30 $20 $40 $20 $40 $25 $50 $30 $60

4. Preferred brand-name $20 $40 $30 $60 $45 $90 $40 $80 $50 $100

5. Brand-name, specialty and compound drugs

– Brand-name 50% to $100

50% to $200

50% to $100

50% to $200

50% to $100

50% to $200

50% to $100

50% to $200

50% to $100

50% to $200

– Specialty* and compound drugs (limited to a 30-day supply)

50% to $100 — 50% to

$100 — 50% to $100 — 50% to

$100 — 50% to $100 —

* Specialty prescription drugs are not available with the mail-order/maintenance benefit, are limited to a 30-day supply, and must be obtained through the Providence Health Plan participating specialty pharmacy.

**90-day supplies of maintenance medication can only be obtained through a preferred retail pharmacy or the mail-order service.

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Two-tier prescription drug plans

Our integrated standard prescription drug plans include a robust formulary,

support for retail and mail-order fulfillment, and multiple cost-sharing options.

Plan feature

Preventive prescription medications covered in full on ACA preventive prescription medication

• Two-tier pharmacy copays start as low as $10 for a 30-day supply of generic medications.

• RXtra plans are available with many different copay levels.

• RXtra plans allow members to purchase up to a 90-day supply of each prescription maintenance medication at one time for the cost of two copays through preferred retail and mail-order services.

• Specialty prescription drug benefits are obtained through Providence Health Plan participating specialty pharmacies. They are not available with the mail-order/maintenance service or through preferred retail pharmacies, and are limited to a 30-day supply.

Participating/Preferred Retail 30-day supply

Mail-Order/Preferred Retail90-day supply maintenance

prescriptionsRXtra

Available*Copays/Coinsurance Copays/Coinsurance

Generic Brand Generic Brand

Rx $10/$20 $10 $20 $30 $60 Y

Rx $10/$30 $10 $30 $30 $90 Y

Rx $10/50% $10 $50 $30 $50 Y**

Rx $15/$30 $15 $30 $45 $90 Y

Rx $15/$45 $15 $45 $45 $135 Y

Rx $15/50% $15 or 50%, whichever is greater 45 or 50%, whichever is greater Y***

Rx $15/$60 $15 $60 $45 $180 Y

Rx $15/$75 $15 $75 $45 $225 Y

Rx $20/$40 $20 $40 $60 $120 N

* RXtra plans provide standard 30-day prescriptions and allow members to purchase up to a 90-day supply of each prescription medication at one time through a preferred retail or mail-order pharmacy for the cost of two copays. For example, if a 30-day supply of a generic drug has a copay of $10, a 90-day supply of that same medication would, under RXtra, have a copay of $20 instead of $30.

** For the RXtra $10/50% plan, the copay for a 90-day supply of generic drugs is $20 or 50% for the brand drugs.

*** For the RXtra $15/50% plan, the copay for a 90-day supply of both generic and brand drugs is $30 or 50%, whichever is greater.

24

Providence Dental plansProvidence Dental Plans provide comprehensive benefits that help promote good health,

and are available when paired with a Providence medical plan. With Providence Dental,

members have access to more than 2,000 in-network dental provider listings in Oregon and

southwest Washington and more than 280,000 in-network provider listings nationwide.

Searching for a dentist is easy; visit www.ProvidenceHealthPlan.com/providerdirectory.

Plan features

• Eight dental plan options (four plans with orthodontia coverage and four without)

• Plus Plans available each offering an orthodontia benefit with a $1,500 lifetime maximum

• Robust coverage for services received both in and outside the network

• Access to our national network of dental providers with over 280,000 dentist listings

• No waiting periods

• No deductible for in- and out-of-network diagnostic and preventive services

• In-network diagnostic and preventive services covered in full

• Diagnostic and preventive services do not apply toward calendar year benefit maximum

Dental Plans: Benefit highlightsEssential, Classic and Premium Dental PlansServices on the following plans – Essential Dental, Classic Dental and Premium Dental – are reimbursed according to the Maximum Allowable Charge (MAC) – the negotiated fee the plan pays to providers. Balance billing may apply for out-of-network services.

Calendar year costs Essential Dental Classic Dental Premium Dental

Common deductible (per person) $50 $50 $50

Common deductible (per family) $150 $150 $150

Benefit maximum $1,000 $1,500 $2,000

Covered services You pay

In-network Out-of-network In-network Out-of-

network In-network Out-of-network

Preventive and diagnostic care (routine exams,

cleanings, bitewing X-rays, topical fluoride for age

16 and younger)*

$0; services covered in full 10% $0; services

covered in full 10% $0; services covered in full 10%

Basic care (restorative fillings and extractions) 20% 30% 20% 30% 20% 30%

Endodontics, periodontics, oral surgery, including

root canals20% 30% 20% 30% 20% 30%

Major care (crowns, dentures, bridge work) 50% 60% 50% 60% 50% 60%

Orthodontics – optional $1,500 lifetime maximum benefit available on Essential Plus, Classic Plus or Premium Plus plans

Reimbursement MAC** MAC** MAC** MAC** MAC** MAC**

* Services do not apply to member’s calendar year benefit maximum. **MAC is Maximum Allowable Charge by the provider.

Balance billing may apply for out-of-network services.

25

Classic Access Dental Plans

The following plan – Classic Access Dental – reimburses in-network services according to the Maximum Allowable Charge (MAC). Out-of-network services are reimbursed according to UCR – what is usual, customary and reasonable within a region.

Calendar year costs Classic Access Dental

Common deductible (per person) $50

Common deductible (per family) $150

Benefit maximum $1,500

Covered services You pay

In-network Out-of-network

Preventive and diagnostic care (routine exams, cleanings, bitewing X-rays, topical fluoride

for age 16 and younger)*

Covered in full Covered in full

Basic care (restorative fillings and extractions) 20% 20%

Endodontics, periodontics, oral surgery, including root canals 20% 20%

Major care (crowns, dentures, bridge work) 50% 50%

Orthodontics – optional $1,500 lifetime maximum benefit available on Classic Access Plus

Reimbursement (OON) MAC** 90% of UCR

* Services do not apply to member’s calendar year benefit maximum. **MAC is Maximum Allowable Charge by the provider.

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Vision plansProvidence offers vision benefits through Vision Service Plan (VSP), the largest nonprofit

vision benefits and services company in the U.S. The VSP Choice Network gives members

access to 50,000 highly skilled providers in more than 48,000 locations nationwide.

Plan features

• No deductible

• An annual eye exam from participating providers after a low copay

• Basic lenses for adults covered in full $130 allowance toward frames or contacts*

• Progressive lenses are available with a $50 copay

• Full coverage for eye exam, lens and frames for children up to age 19 every 12 months with no copay**

• No referral required (out-of-pocket costs generally will be less with an in-network provider)

• Discounts on additional exams, extra features and options, such as lens tinting and nonprescription sunglasses

• No referral required (out-of-pocket costs will be less with an in-network provider)

• Discounts on additional exams, extra features and options, such as lens tinting and hardware, and nonprescription sunglasses

Vision Plans: Benefit highlights

Vision Plan Exam Frequency Lens Frequency Frame Frequency Exam CopayAdult Frame or Contact Lens

Allowance

Vision Exam 12 months N/A N/A $10 N/A

Vision Basic 12 months 24 months 24 months $10 $130

Vision Basic featuring Otis and

Piper Eyewear

12 months 24 months 24 months $10 $130

Vision Plus 12 months 12 months 24 months $10 $130

Vision Plus featuring Otis

and Piper Eyewear


Vision Premium 12 months 12 months 12 months $10 $130

Vision Premium featuring Otis

and Piper Eyewear


* Except for the Vision Exam plan, which does not cover frames or lenses

** Any frame from Otis and Piper Eyewear or the equivalent value can be applied toward any other frame.

27

Chiropractic manipulation and acupuncture plans with massage therapy option availableComplementary and alternative medicine is enjoying growing popularity among

consumers and greater clinical support by care providers. These treatments are

valued for their ability to quickly provide therapeutic benefits for members.

Providence offers two types of plans with benefit design options:

• Chiropractic Manipulation and Acupuncture plans (CHA)

• Chiropractic Manipulation and Acupuncture Plus plans (CHA Plus)

Our standard CHA plans provide benefits for medically necessary chiropractic and acupuncture services from in-network licensed providers. Our CHA Plus plans offer the same benefits from any licensed providers. For additional premium, massage therapy benefits can be added to any plan.

Plan features

• No provider referral is required

• No deductible needs to be met

• Copays do not apply toward the medical plan out-of-pocket maximum (except for on an HSA Qualified plan)


Standard CHA and CHA Plus plan options are available with the following copay and benefit combinations:

Copays Maximum calendar year benefit (per member)

$15 $500

$25 $1,000

$1,500

28

Integrated HSA, HRA or FSAAn integrated HSA, HRA or FSA can lower members’ costs and support

their choice and flexibility, and employers can benefit from tax advantages.

These plans also encourage members to be more judicious with their health

care dollars and make more informed health care decisions.

Providence Health Plan partners with HealthEquity® to provide best-in-class health care accounts delivered seamlessly with our health plans at a competitive price. Through a partnership with HealthEquity, the nation’s oldest and largest dedicated health savings trustee, Providence makes integrated HSA, HRA or FSA easy with:

• Live 24/7 customer service

• The ability to pay providers and view claims and payment information online, anytime, anywhere

• Integrated plan setup, enrollment, claims administration and billing so that health plan and member health care accounts are set up in one place

• A fully equipped employer portal that lets you manage contributions, view reporting and upload contribution information

• A free HealthEquity mobile app that gives members on-the-go access to account balances and

• Claims history and the ability to send payments and reimbursements, initiate and document claims, and manage debit card transactions

Account typeEmployee account

activation and setup

Monthly administration

Employer plan setup and annual plan maintenance

fee (payable to HealthEquity)

Health Savings Account Free$2.70 per account

(included in Providence invoice)

Free

Health Reimbursement Arrangement Free$3.45 per account

(included in Providence invoice)

$250 - $500

Flexible Spending Account Free$3.45 per

account (paid to HealthEquity)

$250 - $500

Limited Purpose Flexible Spending Account Free$1.95 per

account (paid to HealthEquity)

Free

29

Important contact informationResource Find it here

2016 large group benefit summaries ProvidenceHealthPlan.com/2016plansummaries

Ceridian ProvidenceHealthPlan.com/cobra

Providence Dental ProvidenceHealthPlan.com/largegroupdental

Employer training and forums ProvidenceHealthPlan.com/employerCE

Employer website ProvidenceHealthPlan.com/employers

HealthEquity HealthEquity.com/ed/providence

Health and wellness for members ProvidenceHealthPlan.com/findyourfit

myProvidence myProvidence.com

Pharmacy resources ProvidenceHealthPlan.com/2016pharmacyprogram

Producer compensation, news and notices ProvidenceHealthPlan.com/producernotices

Producer training and forums ProvidenceHealthPlan.com/producersCE

Producer website ProvidenceHealthPlan.com/producers

Providence Health Coaching ProvidenceHealthPlan.com/healthcoach

Provider directory ProvidenceHealthPlan.com/findaprovider

30

Reference Notes

31

Reference Notes

Our Mission As people of Providence, we reveal God’s love for all, especially the poor and vulnerable, through our compassionate service.

Our Core Values Respect, Compassion, Justice, Excellence, Stewardship

Dedicated customer service resources 503-574-7500 or 800-878-4445, TTY: 711 Monday – Friday, 8 a.m. to 5 p.m.

Sales 503-574-6300 or 877-245-4077

Providence Health & Services, a not-for-profit health system, is an equal-opportunity organization in the provision of health care services and employment opportunities.

© 2015 Providence Health Plan. All rights reserved.

HP15-90253 LRG-022A 10/15 Printed on paper that contains 10% post-consumer waste.

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