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

OEBB 2018-19 Insurance Committee Webinar Moda Health

Agenda • 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

Medical and Pharmacy Moda Health

Plan types and network options • 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

CCM Service Area 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

Medical benefits changes Medical Plan Deductible Out-of-Pocket Max Cost Share In-Network Out-of- In- Out-of- In- Out-of- (Per Network Network Network Network Network Person/Family) Alder $400/$1,200 $800 $3,000 $6,000 $7,350 NA CCM only Birch $800/$2,400 $1,600 $4,000 $8,000 $7,350 NA CCM & PPO Cedar $1,200/$3,600 $2,400 $5,000 $10,000 $7,350 NA CCM & PPO Dogwood $1,600/$4,800 $3,200 $6,850 $13,700 $7,350 NA CCM & PPO Evergreen $1,600/$3,200 $3,200 $6,550 $13,100 N/A NA CCM & PPO Fir $2,000/$4,000 $4,000 $6,650 $13,300 N/A N/A CCM & PPO

CCM plan options (Synergy & Summit Networks) Medical Medical home Medical home Specialist Urgent Deductible Out-of-pocket Plan Incentive care primary care care care $3,000 Alder $400 $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% $6,750 Fir (HDHP) $2,000 20% 20% 20% 20% PPO plan options (Connexus Network) Incentive care Primary care Medical Out-of- Specialist Urgent Deductible Plan pocket care 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% Fir (HDHP) $2,000 $6,750 20% 20% 20% 20% 20% 20% *Deductible waived

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.

Pharmacy benefits – New Fir HDHP! • Applicable to Evergreen and Fir plan options Evergreen Evergreen Fir Fir CCM PPO CCM 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 20% Coverage (subject to deductible) • Deductible waived on value tier medications

Pharmacy Changes • 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 order benefit which is two copays. • Generic statins are covered at no cost sharing for members 40 years and older.

Other benefit changes • Discontinue Healthy Futures • 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

Medical Plan Highlights • 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 Homes • 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 order 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 Home selection • 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.

Vision Moda Health

Vision plan options – no changes! Vision Plan Options Opal Pearl Quartz Benefit Maximum $600 $400 $250 What members pay Eye examinations 0% Frequency: Once per plan year Lenses Frequency: Contacts or one pair of lenses 0% per plan year Frames Frequency: One pair per plan year for members under age 17; One pair per 0% every two plan years for members age 17 and older

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

Dental Delta Dental

Delta Dental highlights • 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 of 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.

Overview of plan options • 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.

Dental 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 30% - 0% 50% 50% 20% -Implants 30% – 0% 50% 50% 20% Orthodontic 20% 20% N/A 20% (Lifetime maximum - $1,800) Occlusal guards 50% 50% 50% 50% (night guards* and athletic mouth guards) Nitrous Oxide 50% 50% 50% 50% *$250 maximum, once every 5 years.