Testing the abilities - Regence BlueShield

wa.regence.com

Testing the abilities - Regence BlueShield

Regence RealValue SM

Producer Training

April 2012

© 2012 Regence. Private and Confidential.

1


In Today’s Presentation

• Overview of new product offering and timing

• Benefit design

• Network make-up

• Network coverage scenarios

• Marketing

© 2012 Regence. Private and Confidential.

2


New WA Products

• Quote date 4/15/12

• Effective date 5/1/12

Regence RealValue

• Paired with a New narrow network- Regence RealValue Network

• Available only to residents of King, Kitsap, Pierce, Skagit,

Snohomish, and Thurston Counties

© 2012 Regence. Private and Confidential.

3


Regence RealValue

Regence RealValue is designed for individual consumers interested in a

basic, low premium high deductible health insurance plan to provide

coverage in the event of large, unexpected medical bills.

• Target Market

‣ Ages 19-35

‣ Healthy with minimal anticipated medical needs

‣ Lost or not provided employer group health insurance

‣ Cannot afford to purchase plans with more comprehensive benefit designs

‣ Looking for lower premium alternatives to their existing insurance coverage

© 2012 Regence. Private and Confidential.

4


Regence RealValue

BENEFIT DESIGN

© 2012 Regence. Private and Confidential.

6


Regence RealValue

Deductibles

Calendar Year Coinsurance

Maximum

Network

Individual deductible options per calendar year for each

member:

$3,500, $5,000, $7,500, $10,000

No family deductible

Individual coinsurance maximum per calendar year for each

member:

$7,500

No family coinsurance maximum

Regence RealValue

Annual Maximum $2,000,000

• RealValue: Available only to residents of King, Kitsap, Pierce, Skagit,

Snohomish, and Thurston Counties

• Services covered for In-Network providers only

© 2012 Regence. Private and Confidential.

7


Regence RealValue

In-Network

Upfront Office Visits

Upfront office visits: first two per calendar year

Not subject to deductible

Preventive Care and Immunizations

Not subject to the deductible

Member Responsibility

Coinsurance applies after deductible is met and until

coinsurance maximum is reached

$35 copay

0%

Professional Services

Deductible applies after upfront office visit benefit

35%

limit is met. Office and inpatient services and

supplies.

Outpatient Radiology and Laboratory 35%

Complex Outpatient Imaging (CT Scan, MRI,

PET, MRA, SPECT, Bone Density)

Hospice

Respite care limited to 14 days inpatient/outpatient

per lifetime

50%

35%

© 2012 Regence. Private and Confidential.

8


Regence RealValue

In-Network

Member Responsibility

Coinsurance applies after deductible is met and until

coinsurance maximum is reached

Mental Health Treatment 35%

Skilled Nursing Facility

30 days per calendar year

Hospital Services/Ambulatory Surgical Center

Inpatient and outpatient services and supplies

Emergency Room Services

$200 copay per ER visit (waived if directly admitted).

Prescription Medication Coverage

35%

35%

35%

Rx discount program only

(includes generic & brand formulary drugs)

© 2012 Regence. Private and Confidential.

We cover certain preventive medications according to United

States Preventive Services Task Force (USPSTF) guidelines

at 100%, no deductible, no copay at participating pharmacies

only. Member must have a prescription.

We cover self-administered chemotherapy medications at

100% according to state law.

9


Regence RealValue

Exclusions

• Acupuncture

• Chemical Dependency

• Detoxification

• Dialysis

• Discretionary Surgery

• Durable Medical Equipment, except for life saving equipment and insulin pump and pump supplies

• Family Planning

• Home Health

• Immunizations if the Insured receives them only for purposes of travel, occupation or residency in a

foreign country.

• Maternity (and Complications)

• Neurodevelopmental Therapy

• Orthotics (except for Diabetic)

• Protheses

• Routine Eye Exam and Hardware

• Telemedicine

• Spinal Manipulations

• Termination of Pregnancy

© 2012 Regence. Private and Confidential.

10


Network Service Area - Regence BlueShield

© 2012 Regence. Private and Confidential.

11


Outside the Service Area

• Outside the service area, covered services of the plan will be provided for

emergency room, ambulance and urgent care services.

• Urgent care services mean covered services of the plan that are provided

outside of the service area and are not PPACA preventive or any other

preventive care services.

• Preventive care is not covered outside the service area

• Benefits will be subject to the same deductible, copay, coinsurance and

coinsurance maximum levels as apply to those covered services when

provided by a RealValue provider inside the service area.

• Member must contact Regence within 24 hours or as soon as reasonably

possible when admitted to a hospital outside the service area for inpatient

hospital admissions outside the service area to be covered

© 2012 Regence. Private and Confidential.

12


Out-of-Network Providers Within the Service Area

• No benefits are provided for services received from providers outside

the RealValue Network within the Regence service area except for

ambulance, emergency room, and inpatient hospital services when

admitted directly from an emergency room

• Urgent care services are not covered when received from providers

outside the RealValue Network within the Regence service area.

• Member must contact Regence within 24 hours or as soon as

reasonably possible when admitted to an Out-of-Network hospital for

Out-of-Network inpatient hospital admissions to be covered

© 2012 Regence. Private and Confidential.

13


Dental Options

As with the Evolve suite of products, the following dental options

are available with the RealValue products:

• Dental Rewards Option

• When you incur services less than $750, you may be rewarded with an additional

benefit of $250 the following year, not to exceed a total benefit of $1,500

• No deductible for preventive care

• Discounts available through the Regence Dental Network

• Dental Option 2

• Annual maximum of $750 (basic, restorative and major services combined)

• Coinsurance is 0% for the first $200 and then 50% up to the $750 calendar year

maximum

• No deductibles

• Discounts available through the Regence Dental Network

© 2012 Regence. Private and Confidential.

14


Regence RealValue

NETWORKS

© 2012 Regence. Private and Confidential.

15


Regence RealValue Network

• The RealValue network includes competitively priced hospitals and providers

in six counties (Skagit, Snohomish, King, Kitsap, Pierce, Thurston).

• Approximately 13,000 providers including professionals, facilities, and

ancillary providers.

• The network is an in/out network design similar to an “Exclusive Provider

Organization” (EPO) so members receive benefits only if they go to a

RealValue network provider.

• No benefits are provided to RealValue members if they go out of network,

except for except for ambulance, emergency room, inpatient hospital services

when admitted directly from an emergency room

• Provider Search will be updated with these providers in time for 4/15

Quote/Enroll

© 2012 Regence. Private and Confidential.

16


King County Hospital Participation

Participating:

1) Auburn Regional Medical

Center

202 North Division Street

Auburn, WA 98001

And all affiliated professional

providers

2) Evergreen Hospital Medical

Center

12040 NE 128th Street

Kirkland, WA 98034

And all affiliated professional

providers

3) Franciscan Health System

St. Francis Hospital

34515 Ninth Avenue S

Federal Way, WA 98003

And all affiliated professional

providers

4) St. Elizabeth Hospital

1455 Battersby Avenue

Enumclaw, WA 98022

And all affiliated

professional providers

5) Harborview Medical

Center

325 Ninth Avenue

Seattle, WA 98104

And all affiliated

professional providers

6) Highline Medical

Center

16251 Sylvester Road SW

Burien, WA 98166

And all affiliated

professional providers

© 2012 Regence. Private and Confidential.

17


King County Hospital Participation (cont’d)

Participating:

7) Northwest Hospital & Medical

Center

1550 North 115th Street

Seattle, WA 98133

And all affiliated professional

providers

9) Virginia Mason Medical

Center

1100 9th Avenue

Seattle, WA 98101

And all affiliated professional

providers

8) Overlake Hospital Medical

Center

1035 116th Avenue NE

Bellevue, WA 98004

And all affiliated professional

providers

Not Participating:

Swedish Medical Center (First Hill, Cherry Hill, Ballard, Issaquah hospitals) and affiliated professional providers,

including PolyClinic

Providence Health Systems and affiliated professional providers

University of WA Medical Center and affiliated professional providers

Valley Medical Center (Renton, WA) and affiliated professional providers

© 2012 Regence. Private and Confidential.

18


Pierce County Hospital Participation

Participating:

Franciscan Health System

1) St. Joseph Medical Center

1717 S. J Street

Tacoma, WA 98405

And all affiliated professional providers

2) St. Anthony Hospital

11567 Canterwood Blvd. NW

Gig Harbor, WA 98332

And all affiliated professional providers

3) St. Clare Hospital

11315 Bridgeport Way SW

Lakewood, WA 98499

And all affiliated professional providers

Not Participating:

MultiCare Health Systems and all affiliated professional providers

© 2012 Regence. Private and Confidential.

19


Snohomish County Hospital Participation

Participating:

1) Valley General Hospital

14701 179th Avenue SE

Monroe, WA 98272

And all affiliated professional providers

Not Participating:

Providence Everett Hospital and all affiliated professional providers

Cascade Valley Hospital and all affiliated professional providers

The Everett Clinic and all affiliated professional providers

© 2012 Regence. Private and Confidential.

20


Skagit County Hospital Participation

Participating:

1) Island Hospital

1211 24th Street

Anacortes, WA 98221

And all affiliated professional providers

2) Skagit Valley Hospital

1415 East Kincaid

Mount Vernon, WA, 98273

And all affiliated professional providers

3) United General Hospital

2000 Hospital Drive

Sedro-Woolley WA 98284

And all affiliated professional providers

© 2012 Regence. Private and Confidential.

21


Kitsap and Thurston Counties Hospital Participation

Kitsap County Participating:

1) Harrison Medical Center

2520 Cherry Avenue

Bremerton, WA 98310

And all affiliated professional providers

Thurston County Participating:

1) Capital Medical Center

3900 Capital Mall Drive SW

Olympia, WA 98502

And all affiliated professional providers

Thurston County Not Participating:

Providence St. Peter Hospital and all affiliated

professional providers

© 2012 Regence. Private and Confidential.

22


Regence RealValue

NETWORK COVERAGE SCENARIOS

© 2012 Regence. Private and Confidential.

23


Network Service Area - Definitions

• Out of Area (OOA) or Outside the Service Area - is outside the specific counties that RealValue is

available

• Out of Network (OON) is when we do not have a contracted provider providing the service

© 2012 Regence. Private and Confidential.

24


Emergency, Urgent Care and Preventive Services

Out of Network

In Service Area

Out of Area

Emergency Covered Covered

Urgent Care Not Covered Covered

Preventive Service Not Covered Not Covered

• Urgent Care Services

• Outside-the-service-area is covered regardless of where it is provided

• Within the service area members must obtain urgent care from a

RealValue contracted facility

• Preventive Services (PPACA and non-PPACA Preventive)

• Outside-the-service-area is not covered

• Within the service area members must obtain preventive care from a

RealValue contracted facility

© 2012 Regence. Private and Confidential.

25


Covered services received Within- The-Service-Area

Examples

• A Seattle RealValue member receives care from a RealValue

network provider at Harborview Medical Center:

• The Member is subject to applicable in-network copay,

deductible and coinsurance

• A Seattle RealValue member receives ER care at Swedish Medical

Center:

• The member is subject to applicable in-network copay,

deductible and coinsurance.

• Member may be balance billed

© 2012 Regence. Private and Confidential.

26


Covered services received Outside-Of-Service Area

Example

• RealValue member is traveling in Montana and receives Urgent Care

in a physicians office:

• Urgent Care is covered outside of the RealValue service area

regardless of place of service.

• Preventive Services received during this visit will not be covered

• Member subject to in-network applicable copay, deductible and

coinsurance.

• Member may be balance billed.

© 2012 Regence. Private and Confidential.

27


Referral to an Out-of-Network Provider

There will be occasions when a RealValue member will require treatment for a

covered service, from specialty provider or facility not included in the

RealValue provider network.

Example

• A RealValue pediatric member requires surgery (for a covered service) at Seattle

Children’s or Mary Bridge Children’s: The RealValue network has in-network

pediatricians, but no pediatric hospitals, the pediatrician will need to refer the patient for

medically necessary surgery to an out-of-network facility

• Single case agreement is negotiated with the non-contracted

provider/facility- Services covered @ contracted rates; member subject to

applicable copay, deductible and coinsurance.

• Negotiated single case agreement is not reached- Member subject to

applicable copay, deductible and coinsurance. Regence will pay billed charges

to ensure the member is not balanced billed. (OIC requirement)

© 2012 Regence. Private and Confidential.

28


Regence RealValue

PRICING & ADMINISTRATIVE DETAILS

© 2012 Regence. Private and Confidential.

29


Pricing

Rates

• Approved

Annual renewal in October along with the rest of the Evolve plans

© 2012 Regence. Private and Confidential.

30


Application Changes

Regence RealValue has been added to the individual

application:

© 2012 Regence. Private and Confidential.

31


Member Card

© 2012 Regence. Private and Confidential.

32


RealValue EOB

© 2012 Regence. Private and Confidential.

33


RealValue EOB

© 2012 Regence. Private and Confidential.

34


RealValue EOB

© 2012 Regence. Private and Confidential.

35


Regence RealValue

MARKETING

© 2012 Regence. Private and Confidential.

36


Value Proposition

• For…

- Individual consumers recently priced-out of the market and those considering

leaving the market

• Who want…

- basic medical insurance with attractive premium price-points

• We offer…

- catastrophic medical coverage to protect individual financial exposure in the event of

larger than expected medical bills

• Instead of…

- a comprehensive plan with a high premium medical plan that many consumers

cannot afford with benefit offerings that they do not want

• We deliver…

- an attractively priced basic health plan with value added member service and

support

© 2012 Regence. Private and Confidential.

37


Key Messages

• More of what you need, less of what you don’t

• Basic medical insurance with affordable premium price-points

• Catastrophic medical coverage protects individual financial exposure

during a medical emergency

• Although the plan is not for everyone, the RealValue product is part of

our ongoing efforts to provide greater choice and access to high-quality

health plans to our community

• Access to quality providers through limited network

• Designed to encourage members to achieve additional savings

through the use of in-network providers on the exclusive RealValue

network

© 2012 Regence. Private and Confidential.

38


Marketing

• Collateral updates

• Product Brochure

• Comparison Brochure

• Flyer

• Plan Highlights

• Individual “Fast Track”

shopping experience

updates with new design-

Live 4/15/12

• Agent toolkit on

regence.com updates

© 2012 Regence. Private and Confidential.

39


Questions

Q&A

Producer Support

800-557-0555

© 2012 Regence. Private and Confidential.

40

More magazines by this user
Similar magazines