Testing the abilities - Regence BlueShield

Regence RealValue SM
Producer Training
April 2012
© 2012 Regence. Private and Confidential.
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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.
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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.
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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.
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Regence RealValue
BENEFIT DESIGN
© 2012 Regence. Private and Confidential.
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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.
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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.
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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.
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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.
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Network Service Area - Regence BlueShield
© 2012 Regence. Private and Confidential.
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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.
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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.
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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.
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Regence RealValue
NETWORKS
© 2012 Regence. Private and Confidential.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Regence RealValue
NETWORK COVERAGE SCENARIOS
© 2012 Regence. Private and Confidential.
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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.
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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.
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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.
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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.
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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.
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Regence RealValue
PRICING & ADMINISTRATIVE DETAILS
© 2012 Regence. Private and Confidential.
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Pricing
Rates
• Approved
Annual renewal in October along with the rest of the Evolve plans
© 2012 Regence. Private and Confidential.
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Application Changes
Regence RealValue has been added to the individual
application:
© 2012 Regence. Private and Confidential.
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Member Card
© 2012 Regence. Private and Confidential.
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RealValue EOB
© 2012 Regence. Private and Confidential.
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RealValue EOB
© 2012 Regence. Private and Confidential.
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RealValue EOB
© 2012 Regence. Private and Confidential.
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Regence RealValue
MARKETING
© 2012 Regence. Private and Confidential.
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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.
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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.
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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.
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Questions
Q&A
Producer Support
800-557-0555
© 2012 Regence. Private and Confidential.
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