ssm health’s range of health care assetsfeature ssm health facilities and physicians with select...
TRANSCRIPT
Care Delivery Health Plan Other Ancillary
• 400,000 Lives Covered in WI• 20 County Service Area• 4,500+ Plan Practitioners• 30 Plan Hospitals• 840+ PCP and Specialty Clinics
• Presence in OK, IL, MO, and WI• 24 SSM Health Hospitals • 39 Affiliate Hospitals• 110 Service Locations including urgent care
and pediatric care locations• 11,000 Providers• 40,000 Employees
• Focused on coverage outside of Wisconsin• Brand utilized for SSM Employee Coverage• ACA membership in STL
• Established in 1904 and based in Madison, WI
• PBM: Pharmacy Benefit Manager • 5.4 Million Covered Lives• National Presence• Fully Transparent, Pass-Through PBM
Do not distribute – for training purposes only – pending CMS approval
SSM Health’s Range of Health Care AssetsSSM has a unique collection of health care assets allowing us to holistically care for our patients from insurance to care delivery to pharmacy benefit management
SSM’s Health Plan Overview
BY THE NUMBERS
SSM’s Health Plan is one of the largestand most diversified regional HMOs in the Midwest, utilizing our Integrated Delivery Network consisting our Health Plan working in collaboration with our owned hospitals, medical providers and other owned assets.
$1.43 Billion Total Revenue,
2018
98.3% Retention Rate for Commercial
Groups, 2018
420K+ Total Membership (DHP/P360), 2019
1,400+Employer Groups
Insured
We offer a robust product portfolio, servicing over 459K+ members across both government and commercial business.
Membership Breakdown
Commercial BusinessLarge Group, Small Group, Individual (ACA),
Large Group ASO
Government BusinessMedicare Advantage, Medicaid,
Medicaid ASO
~184K Members Covered by a Government Plan
~274K Members Covered by a Non - Government Plan
Do not distribute – for training purposes only – pending CMS approval
SSM Medical Group with other select providers
Health Plan
SSM Health
Hospitals
WellFirst in St. Louis
MA Network Overview: In 2020, WellFirst Health will predominantly feature SSM Health facilities and physicians with select provider partners (i.e. Signature Medical, SLU Care, St Luke's Hospital System)
• Launched ACA individual and family plans in St Charles county, St Louis County and St Louis City
• Began administering all health benefits for SSM employees, equating to more than 40K new group members
• Built system wide networks and coordinated care model in STL
2020 Review
New for 2021
• Applying to expand our current ACA product into neighboring IL counties (Madison and St Clair counties)
• Launching only Provider Sponsored MA Plan in the STL Area
• Building new sales distribution model to be most beneficial for member, agent, and physician
• Partnering with celebrity spokesman, Ozzie Smith
MA Footprint
Do not distribute – for training purposes only – pending CMS approval
Achieved Success
Excellent NCQA Accreditation StatusAs assessed by the National Committee for Quality Assurance*
4.5 Out of 5 Star Ratings (Medicare Cost and MAPD)Rated by the Centers for Medicare and Medicaid Services for 2019-2020
4-Star Rating from ETFHighest quality rating scored by the State of WI Employee Trust Funds for 2019
Rated 4.5 Out of 5 Overall by NCQARated by NCQA’s Private Health Insurance Plan Ratings 2019–2020
*The National Committee for Quality Assurance (NCQA) is a private, nonprofit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations and recognizes clinicians in key clinical areas.NCQA’s HEDIS® is the most widely used performance measurement tool in healthcare. NCQA's website (www.ncqa.org) contains information to help consumers, employers and others make informed health care choices.
Strong Quality performance for 2019-2020
Dean Health Plan, our sister company, is one of the highest-rated private health insurance plans in the nation.
NCQA’s Private Health Insurance Plan Ratings 2019-2020
Do not distribute – for training purposes only – pending CMS approval
WellFirst Health Product Portfolio Overview
5
• All WellFirst Health plans have a $0 premium• All WellFirst Health MAPD plans have the same cost sharing for standard Part C benefits – on par with competition:
In-Network Out-of-Network
All MAPD Plans MA-Only Plan HMO-POS Plans
Maximum Out-of-Pocket $2500 $2500 $5000
Part C Deductible $0 $0 $0
PCP Copays $0 $0 $0
Specialist Copays $35 $35 $60
Hospital Copays $325per day for days 1-7
$300per day for days 1-7
$500per day for days 1-7
Outpatient Surgery Copays
$275 in-hospital
$175 ASC
$250 in-hospital
$150 ASC20%
Telehealth Covered at same cost-share as in-person services if offered by provider
Product Objectives
• Offer Competitive Plans as a
New Market Entrant
• Promote Experience and
Member Retention
• Advance IDN Engagement and
Outcomes
Do not distribute – for training purposes only – pending CMS approval
WellFirst Health Product Portfolio Overview
6
SSM UnityHMO MAPD
SSM CompanionHMOMAPD
SSM IntegrityHMO-POS
MAPD
SSM HarmonyHMO-POS MA-Only
Part D Coverage -
Out-of-Network Coverage - -
Premium $0 $0 $0 $0
Part B Premium Reduction $35 - - $50
Papa Pals Benefit - -
Comprehensive Dental Benefit
All Market Parity Benefits
Differentiation across the 4-plan portfolio in 4 dimensions:
Do not distribute – for training purposes only – pending CMS approval
➢ Part D Coverage ➢ Out-of-Network Coverage
➢ Part B Premium Reduction
➢ Papa Pals Benefit
WellFirst Health Competitive Supplemental Benefits
7
Our plans offer supplemental benefits on par with or of greater value than the current market:
$60 OTC benefit
Eyewear + $0 eye exams
Hearing aids + $0 exams
Fitness benefit
Transportation
Post-discharge meals
Market Parity: ALL PLANS
Part B Premium Reduction
• Benefit reduces premium burden for moderate income members
Comprehensive Dental
• Premier dental partnership
• Higher benefit maximum than competition
• $0 preventive + simple copay structure for comprehensive
In-Home Support & Companionship
• Address loneliness and social isolation
• Provide help in-person or virtually
• Secured 3-year benefit exclusivity in STL service area
Market-Leading: Varies by Plan
Do not distribute – for training purposes only – pending CMS approval
Part B Premium Reduction
8
WellFirst Health is offering plans with Part B premium reductions to reduce the economic burden for members
Part B Premium Reduction – featured on 2 plans:
SSM Unity Plan (HMO) $35 per month
SSM Harmony Plan (HMO-POS) MA-Only $50 per month
Part B Premium Reduction
• Members in $0 MA plans still pay $144.60 Part B premium (expected to increase for 2021)
• States cover Part B premium for low income beneficiaries
• Benefit reduces premium burden for moderate income members
• Members will automatically see increase in their Social Security check equal to the amount of the premium reduction
Also Known As:
• Part B Buy-Back
• Part B Buy-Down
• Part B Give Back
• Part B Rebate
Do not distribute – for training purposes only – pending CMS approval
Comprehensive Dental
9
WellFirst Health has partnered with Delta Dental of Wisconsin to build an exclusive Medicare Advantage network of dentists in the St. Louis market
Preventive & Diagnostic Services
$0 copay per visit
Two routine preventive dental exams and cleanings per calendar year.
One x-ray and fluoride treatment per calendar year.
Comprehensive Services
$45 copay per procedure
Periodontal ServicesGum disease maintenance and bridge/implants/dentures repairs.
$95 copay per procedure
Restorative ServicesFillings, gum disease treatment, and extractions.
$595 copay per procedure
EndodonticsRoot canals, bridges, implants, dentures, and crowns.
Maximum Coverage/Year
$1500
Waiting Periods
None
Deductible
$0
Coinsurance
Copays only
Additional Benefits
Members will also have access to Delta Dental’s evidence-based dentistry. People with certain health conditions may be eligible for up to two additional cleanings and one fluoride treatment per calendar year.
Conditions include:• Cancer therapy• Gum disease• Diabetes• High-risk cardiac conditions• Weakened immune systems• Kidney failure or dialysis
Featured Benefit on
ALL PLANS
Do not distribute – for training purposes only – pending CMS approval
In-Home Support & Companionship: Papa Pals
10Do not distribute – for training purposes only – pending CMS approval
WellFirst Health has partnered with Papa to offer in-person and virtual services.Papa pairs older adults and families with Papa Pals for companionship and assistance with everyday tasks.
Papa Pals In-Home Support & Companionship
Featured on:SSM Companion Plan (HMO)SSM Harmony Plan (HMO-POS) MA-Only
Benefit 10 hours per month
Family On-Demand Assistance from a Distance
CompanionshipPlay board games, watch a movie, take a walk
TechnologyHow to use computers, smart phones, software, telehealth
House HelpLight cleaning, meal prep, organizing, pet help
TransportationDoctor appointments/pharmacy, grocery shopping, errands
Papa Pals• Enthusiastic and Compassionate• Strict vetting process
• Background checks• Covered by liability insurance
&
Part D Pharmacy Benefit
11Do not distribute – for training purposes only – pending CMS approval
WellFirst Health plans provide comprehensive prescription drug coverage. Our drug formulary covers a wide-ranging list of generic, brand name and specialty drugs with manageable copays and no deductibles.
Part DCost Sharing
Preferred Pharmacy
Standard Retail Pharmacy
Deductible $0 $0
30 day 90 day 30 day 90 day
Tier 1 $0 $0 $7 $7
Tier 2 $5 $10 $12 $24
Tier 3* $40 $100 $47 $117.50
Tier 4 $90 $270 $100 $300
Tier 5 33% 33%
Vaccine Tier(Incl. Coverage Gap)
$0 $0
Preferred Pharmacy Network
• Walmart, CVS, Target, Dierbergs, Schnucks, Medicine Shoppe, and many other local pharmacies
• SSM pharmacies
Standard Retail Pharmacy Network
• Most national pharmacy chains, including Walgreens• Many retail and grocery store pharmacies• Mail order pharmacy through Costco
Senior Savings Program Pilot: Insulin Savings
$30 copays for 30-day insulin prescriptions • Phase 1: Deductible• Phase 2: Pre-ICL• Phase 3: Coverage Gap (Donut Hole)
$30 fills at preferred pharmacy and $35 at standard retail pharmacy locations
WellFirst Health Product Portfolio Strategy
12
Best Plan Fit
Recommendation
Market-Leading Benefits
Dental Premium Reduction
Papa Pals
Out-of-Network
HMO or HMO-POS
Part D
MAPD or MA-Only
Do you need Part D pharmacy benefits?
Do you seek the flexibility to visit out-of-network
providers?
Would you prefer a premium reduction
or Papa Pals benefit?
SSM Unity HMO MAPD
SSM Companion HMO MAPD
HMO-POS has only the dental leading
benefit
SSM Integrity HMO-POS
MAPD
MA-Only has POS benefit
MA-Only has all leading benefits
SSM Harmony HMO-POS MA-Only
Do not distribute – for training purposes only – pending CMS approval
MAPD
Premium Reduction
HMO
MA-Only
HMO-POS
Papa Pals
Premium Reduction
Dental
HMO-POS
Key DecisionPoints
• Product portfolio thought process
• Recommended workflow with prospective members
WellFirst Health & Plan Advisors
13
Do not distribute – for training purposes only – pending CMS approval
To get appointed with WellFirst Health Medicare plans,complete your request for contracting at
planadvisorsfirst.com/wellfirst
Think Plan Advisors first when you want to offer your clients better plan options through WellFirst Health!
At Plan Advisors, our focus is on your business, partnering with you for success. We leverage our knowledge, expertise, and brand to provide you with the support you need to grow your business. Whether it’s agent onboarding, marketing initiatives, or preferred vendor pricing on lead generation and technology tools, we want you to think of Plan Advisors first!