OEBB 2018-19 Insurance Committee Webinar Moda Health Agenda - - PowerPoint PPT Presentation

OEBB 2018-19 Insurance Committee Webinar

Moda Health

• Medical & Pharmacy
• Overview of networks & plan options
• Benefit changes
• CCM plans and Medical Homes
• Vision
• Overview of plan options
• Dental
• Overview of networks & plan options
• Benefit changes
• Member Resources

Agenda

Moda Health

Medical and Pharmacy

• Preferred Provider Organization (PPO) plans

− Connexus Network

• Service area is statewide
• Birch, Cedar, Dogwood, Evergreen and Fir plans

− Retirees & COBRA members living outside of Connexus service area use Moda’s rental networks

• Coordinated Care Model (CCM) plans

− Synergy or Summit Network

• Synergy Network available in western & central Oregon
• Summit Network available in eastern Oregon

− Alder, Birch, Cedar, Dogwood, Evergreen and Fir plans

Plan types and network options

Synergy Network is offered in the following counties:

Current & continuing Benton, Clackamas, Clark, Clatsop, Columbia, Coos, Crook, Curry Deschutes, Douglas, Hood River, Jackson, Jefferson, Josephine, Klamath, Lane, Lincoln, Linn, Marion, Multnomah, Polk, Tillamook, Wasco, Washington, and Yamhill

Summit Network is offered in the following counties:

Current & continuing Baker, Gilliam, Grant, Harney, Lake, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wheeler

CCM Service Area

Medical benefits changes

Medical Plan Deductible Out-of-Pocket Max Cost Share

In-Network (Per Person/Family) Out-of- Network In- Network Out-of- Network In- Network Out-of- Network Alder

CCM only

$400/$1,200 $800 $3,000 $6,000 $7,350 NA Birch

CCM & PPO

$800/$2,400 $1,600 $4,000 $8,000 $7,350 NA Cedar

CCM & PPO

$1,200/$3,600 $2,400 $5,000 $10,000 $7,350 NA Dogwood

CCM & PPO

$1,600/$4,800 $3,200 $6,850 $13,700 $7,350 NA Evergreen

CCM & PPO

$1,600/$3,200 $3,200 $6,550 $13,100 N/A NA Fir CCM & PPO $2,000/$4,000 $4,000 $6,650 $13,300 N/A N/A

CCM plan options (Synergy & Summit Networks)

Medical Plan Deductible Out-of-pocket Medical home Incentive care Medical home primary care Specialist care Urgent care Alder $400

$3,000

$10* $20* 20% $50* Birch $800

$4,000

$15* $30* 20% $50* Cedar $1,200

$5,000

$15* $30* 20% $50* Dogwood $1,600

$6,850

$15* $30* 20% $50* Evergreen (HDHP) $1,600

$6,550

20% 20% 20% 20%

PPO plan options (Connexus Network)

Medical Plan Deductible Out-of- pocket Incentive care Primary care Specialist care Urgent care MH Non-MH MH Non-MH Birch $800

$4,000

$15* 20%* $30* 20% 20% $50* Cedar $1,200

$5,000

$15* 20%* $30* 20% 20% $50* Dogwood $1,600

$6,850

$15* 20%* $30* 20% 20% $50* Evergreen (HDHP) $1,600

$6,550

20% 20% 20% 20% 20% 20% *Deductible waived Fir (HDHP) $2,000

$6,750

20% 20% 20% 20% Fir (HDHP) $2,000

$6,750

20% 20% 20% 20% 20% 20%

Pharmacy benefits

Applicable to Alder, Birch, Cedar, and Dogwood plan options

CCM PPO

Out-of-pocket maximum Accrues towards medical OOP limit Accrues towards Max Cost Share

Retail (31-day supply)

Value $0 $4 Select Generic $8 $12 Preferred 25% up to $50 25% up to $75

Mail (90-day supply)

Value $0 $8 Select Generic $16 $24 Preferred 25% up to $100 25% up to $150

Specialty (31-day supply)

Preferred 25% up to $100 25% up to $200

*Non-preferred brand and high cost generics are no longer covered. A formulary exception must be approved for those prescription medication.

Evergreen CCM Evergreen PPO Fir CCM Fir PPO Deductible (medical and Rx) $1,600 ind/$3,200 fam $2,000 ind/$4,000 fam Out-of-Pocket Maximum $6,550 ind/$13,100 fam $6,650 ind/$13,300 fam Value tier*

Retail (31-day supply)

$0 $4 $0 $4

Mail (90-day supply)

$0 $8 $0 $8 Major Medical Prescription Coverage 20% (subject to deductible)

Pharmacy benefits – New Fir HDHP!

• Applicable to Evergreen and Fir plan options
• Deductible waived on value tier medications

• High Performance Formulary

− High cost generic and non-preferred brand medications will not included on the formulary. − Certain medication will be “grandfathered” that have been identified as potentially unsafe to discontinue or change abruptly.

• Example: seizure medication, mental health medication, blood

thinners, and etc. − Members can ask for a formulary exception and Moda will review on a case by case basis.

• Choice 90 Program

− Members can purchase their medication up to a 90-day supply for all tiers at any participating Choice 90 retail pharmacy.

• The 90 day supply will have three copays as opposed to the mail
• rder benefit which is two copays.
• Generic statins are covered at no cost sharing for members 40

years and older.

Pharmacy Changes

Other benefit changes

• Nutritional therapy is covered for all disorders when medically

necessary.

• Vitamins and Minerals are only covered if they require a

prescription and are not available without a prescription. These changes will take effect October 1, 2018

• Discontinue Healthy Futures

• Virtual Visits

− Members can get urgent care from their home. − Virtual Visits connects the member with a licensed Oregon Health & Science University (OHSU) doctor, physician assistant or nurse practitioner via their computer or mobile device.

• Use Virtual Visits for:
• A cold, sore throat, stuffy nose, cough, the flu, congestion and nausea
• Allergies, poison ivy or oak
• Bites, stings and more
• As a Moda Health OEBB member, members receive the Virtual Visit

benefit for a $10 copay, not subject to the deductible. Members on the Evergreen and Fir plan will have a $10 copay after the deductible.

• To schedule a Virtual Visit, go to ohsu.edu/virtualvisits.com. The

member will be asked to use an OHSU myChart account to log in to the system. Members can create an account online, if necessary.

Medical Plan Highlights

• CCM plans require selection of a medical home for each

covered individual.

• Each family member can select a different medical home.
• Must use designated medical home for primary care services in
• rder to receive in-network benefits.

− Primary care services received outside of member’s selected medical home will be paid at the out-of-network benefit level.

Medical Homes

• Step-by-step guide will be included with ID card.
• Already have a medical home selected?

− No action required, unless members want to make a change.

Medical Home selection

Moda Health

Vision

Vision Plan Options Opal Pearl Quartz Benefit Maximum $600 $400 $250 What members pay Eye examinations

Frequency: Once per plan year

0% Lenses

Frequency: Contacts or one pair of lenses per plan year

0% Frames

Frequency: One pair per plan year for members under age 17; One pair per every two plan years for members age 17 and older

0%

Vision plan options – no changes!

• Members may see any licensed ophthalmologist, optometrist,
• r optician
• Benefits run on a plan year basis (October 1 – September 30)
• Benefit maximum includes exam and hardware

Vision – key things to remember

Delta Dental

Dental

• Delta Dental Premier Network is the largest dental network in

Oregon and nationwide

− Over 2,400 providers in Oregon & over 154,000 providers nationwide

• Last year, we added a Delta Dental PPO Network plan option

− Over 1,300 providers in Oregon and over 108,000 providers nationwide − The Exclusive PPO plan uses this network option

• Evidence-based approach to dentistry with a focus on preventive care
• Health through Oral Wellness

− Comprehensive, patient-centered wellness program designed to help members maintain optimal oral health through education, risk assessment and evidence-based models of care. − The program uses an oral health assessment to find out the member’s risk

• f tooth decay, gum disease and oral cancer. Based on the member’s risk

score, they may qualify for additional cleanings, fluoride treatments, sealants, and periodontal maintenance.

Delta Dental highlights

• Continue offering Plan 1, 5, 6, and Exclusive PPO
• Exclusive PPO plan

− $1,500 constant plan − Uses Delta Dental PPO Network − No out-of-network benefits; members must use a PPO provider on this plan

• Incentive Levels

− When a member moves from one incentive level plan to another incentive plan, the incentive levels will follow the member. − Both plans 1 and 5 are incentive level plans, therefore incentive levels will transfer.

Overview of plan options

Plan Options Plan 1 Plan 5 Plan 6 Exclusive PPO

Network Delta Dental Premier Delta Dental PPO Deductible $50 $50 $50 $50 Benefit Maximum $2,200 $1,700 $1,200 $1,500 In-network, members pay Preventive/diagnostic 30% - 0% 30% - 0% 0% 0% Restorative 30% - 0% 30% - 0% 20% 10% Major Restorative

• Crowns/onlays

30% - 0% 30% 50% 20% Prosthodontic

• Implants

30% - 0% 30% – 0% 50% 50% 50% 50% 20% 20% Orthodontic

(Lifetime maximum - $1,800)

20% 20% N/A 20% Occlusal guards

(night guards* and athletic mouth guards)

50% 50% 50% 50% Nitrous Oxide 50% 50% 50% 50%

Dental Plan Options

*$250 maximum, once every 5 years.

Other benefit changes

• Composite restorations are covered on the posterior teeth.
• Nitrous Oxide is covered at 50% for all plans. There is a 12

month waiting period for new members. The waiting period will apply to members who didn’t enroll when first eligible on the plan.

• Coverage for night-guards has increased to a $250 maximum.
• Space maintainers are a benefit once per space for members

under age 14. These changes will take effect October 1, 2018

Moda Health

Member Resources

www.modahealth.com/oebb

Looking for a provider? Want to learn more about health coaching? Need to access your personal member website?

• Search for providers in your network
• Medical – Connexus, Synergy, and Summit
• Dental – Delta Dental Premier and Delta Dental PPO

Find Care

Thinking about the Exclusive PPO plan for dental? Use Find Care to search for providers

• Medical/Vision

−866.923.0409

• Pharmacy

−866.923.0411

• Dental

−866.923.0410

Or email the customer service teams by using OEBBquestions@modahealth.com

Customer Service