2016
INDIVIDUAL AND FAMILY
HEALTH INSURANCE
WE SPEAK YOUR LANGUAGE
844.635.1322 • networkhealth.com/individual
W
e understand you have a lot of choices when it comes to health insurance for you and your family. And, you probably have a lot of questions, too. Network Health can help with that. Network Health is a different kind of insurance company. We call Wisconsin home, and we’re accountable to customers, not shareholders. We don’t use confusing health insurance jargon, and can make sure you find the right coverage at the right price.
Let Us Be Your Guide In this kit, you will find— 1.................Why You Need Health Insurance See how Network Health can help protect you and your family 3.................Health Care Reform Basics Find out how the government can help pay for your health care costs, when you can enroll and what the Marketplace is 7.................Available Plans Compare plans offered by Network Health 12...............Why Network Health? Discover the personal, local service you’ll receive and see what our members are saying 13...............Doctors and Hospitals You Can Use Learn about the high-quality doctors and hospitals that are part of our network 15...............How to Enroll When you’re ready to get a quote and enroll, follow these simple steps
Southeast Wisconsin n Milwaukee n Ozaukee n Racine n Washington n Waukesha
WHY YOU NEED HEALTH INSURANCE
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I
t was always a good idea to have health insurance, but now it’s a federal law. The individual mandate is the part of health care reform that requires most Americans (and their dependents) to have insurance or pay a penalty.
Signing up for a Network Health plan can help ensure your tax refund isn’t penalized, plus you’ll have peace of mind knowing you’re protecting your health and your wallet. Check out the scenario on the next page to see how Network Health could have you covered.
Meet the Connors
networkhealth.com/individual
844.635.1322
Too bad the Connors don’t realize they and many Americans may qualify for financial assistance from the government to help cover the cost.
One day, Jim is on his way to work. He feels a pain in his stomach. He goes to the emergency room. Unfortunately, it’s his appendix and it needs to be removed. Because Jim doesn’t have health insurance, he has to pay for his three-day hospital stay. This results in a $30,000 bill. This is almost as painful as his appendectomy.*
If Jim had been covered by Network Health, he wouldn’t have had to worry about paying for all the unexpected medical costs himself. Network Health offers affordable coverage that protects you in these situations. Our health insurance coverage lets you focus on life and avoid financial stress.
*Note – This scenario is provided for educational purposes only. It is not a guarantee of coverage or costs.
844.635.1322
networkhealth.com/individual
WHY YOU NEED HEALTH INSURANCE
Jim and Lisa Connor know health insurance is important, but they don’t think their family can afford it. Since they are pretty healthy anyway, they decide not to enroll.
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HE ALTH CARE REFORM BASICS
t Network Health, we know insurance and health care reform can be confusing. But, we’re here to translate things into easy-to-understand terms. We can make sure you understand the available options and find the plan that fits you best. Plus, we’ll help you avoid a tax penalty.
First of all, what is the Affordable Care Act and how does it affect me?
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The Patient Protection and Affordable Care Act (often called ACA) was signed into law on March 23, 2010. The goal of the law was to make health care more accessible and affordable. One thing the law does is provide financial help to those with lower income. These monies are called subsidies, and the government provides these dollars to help people afford health insurance. The Affordable Care Act’s individual mandate went into effect on January 1, 2014. This is a rule that requires most Americans to get health insurance or pay a tax penalty. For every full month you (or a family member) do not have the required health insurance coverage, you may be charged a fee which must be paid on your federal income tax return. The fee will vary based on your income and family size.
Free Preventive Care
BENEFITS OF THE AFFORDABLE CARE ACT
Health Insurance Marketplace
Coverage for Preexisting Conditions
Financial Assistance
When can I enroll?
OPEN ENROLLMENT PERIOD For individuals and families, open enrollment is November 1, 2015 – January 31, 2016. This is generally the only time during the year when you can enroll or change your plan. The first date your coverage can start is January 1, 2016.
SPECIAL ENROLLMENT PERIOD There are special circumstances (called qualifying events) which allow you to enroll in a health insurance plan outside of open enrollment. A Special Enrollment Period may be available to you if one or more of the following applies.* n You had a baby or adopted a child n You got married n You moved n You lost coverage under a previous plan *
For a complete list of qualifying events, you can find them at HealthCare.gov.
networkhealth.com/individual
844.635.1322
A
lso known as the health insurance exchange, the Marketplace is an organized website where you can purchase health insurance. The site is operated by the government to help families and individuals more easily compare their coverage options. For a Network Health plan, you can start shopping at networkhealth.com/individual. Our plans are available on the Marketplace at HealthCare.gov as well. When you use the Marketplace to purchase your health insurance coverage, you can also find out if you qualify for coverage through Medicaid or the Children’s Health Insurance Program (CHIP). Find out more about these programs at HealthCare.gov.
Want to learn more? Check out the Reform 101 section of our blog at CoPilot.com for helpful educational tools and articles. 844.635.1322
networkhealth.com/individual
HE ALTH CARE REFORM BASICS
What is the Marketplace?
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HE ALTH CARE REFORM BASICS
What is a subsidy?
A subsidy is financial help provided by the government to help people afford health insurance. There are two types of subsides: tax credits and cost sharing reduction.
1. Premium Tax Credit This is an amount of money provided by the government that you can put toward your health insurance premium. It can help make your monthly payment lower. You can choose to apply the entire amount toward your premium each month (often called Advanced Premium Tax Credit, or APTC), or wait until the end of the year and get the money back at tax time. You may qualify for this credit if you purchase a plan on the Marketplace and have an income below a certain level. The government pays a portion of your health insurance directly to your insurance company every month.
Use the money toward your monthly premium (called APTC)
or Purchase a Network Health plan on the Marketplace
Qualify to receive money from the government for your premium
Get lump sum with tax return
2. Cost Sharing Reduction (CSR) This lowers the amount you pay for health insurance deductibles, coinsurance and copayments when you receive health care. You may qualify for lower costs if you purchase a silver plan on the Marketplace and have an income below a certain level.
Silver Purchase a Network Health silver plan on the Marketplace
Qualify for a cost sharing reduction
You pay less for deductibles, coinsurance and copayments
You must purchase health insurance through the Marketplace to be eligible for lower costs. networkhealth.com/individual
844.635.1322
See if you qualify for lower costs
View the chart below to see at a quick glance if you might qualify. To verify that you’re eligible and get your savings estimate, start your
W O L T S CO
quote at networkhealth.com/individual.
This process can take up to 30 minutes. You will need a recent pay stub, your W2 and income information.
SAVINGS ESTIMATE Number of people in your household You may qualify for lower premiums on a $11,770 Marketplace insurance plan if your annual $47,080 income is between $11,770 You may qualify for lower premiums $29,425 and lower out-of-pocket costs on a Marketplace insurance plan if your annual income is between Wisconsin did not adopt the Medicaid $11,770 expansion. You may qualify for Marketplace savings programs if your annual income is below
844.635.1322
$15,930 $63,720
$20,090 $80,360
$24,250 $97,000
$28,410 $113,640
$32,570 $130,280
$15,930 $39,825
$20,090 $50,225
$24,250 $60,625
$28,410 $71,025
$32,570 $81,425
$15,930
$20,090
$24,250
$28,410
$32,570
networkhealth.com/individual
HE ALTH CARE REFORM BASICS
Depending on your household income and size, you may qualify for financial assistance from the government (known as subsidies) to help pay for your health insurance premiums and out-of-pocket costs. If your financial situation changes, your subsidy level may change.
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AVAILABLE PLANS
Everyone’s insurance needs are different.
That’s why we offer a variety of options to make sure you have the coverage you need at an affordable cost.
Prestige Bronze 20 If you’re looking for a low monthly premium and quality coverage when the unexpected happens, this plan offers 20 percent coinsurance and you’ll pay $0 for preventive services.
Prestige Silver 20 If you’re looking for a plan with a reasonable deductible, an affordable monthly premium and low copayments for common medical services, this could be a good fit. Plus, just like all of our plans, you’ll pay $0 for preventive care.
Prestige Silver 0 This plan offers broad coverage—you pay $0 for most services once you meet your deductible. If you know you and your family will be using medical services often, Prestige Silver 0 provides the quality coverage you need.
Prestige Gold 10 This plan offers our lowest deductible. With Prestige Gold 10, you’ll also get affordable coinsurance and comprehensive coverage, including six $0 doctor visits.
844.635.1322
networkhealth.com/individual
PLAN COMPARISON
OUT-OFPOCKET LIMIT
BENEFITS
Prestige Silver 0
Prestige Gold 10
Monthly Premium Coinsurance
$
$ $
$ $
$ $ $
20%
20%
0%
10%
Individual
$4,500
$2,750
$3,500
$1,000
Family
$9,000
$5,500
$7,000
$2,000
Individual
$6,850
$6,850
$6,850
$6,850
Family
$13,700
$13,700
$13,700
$13,700
Preventive Care Primary Care Doctor Visit
$0 20% after deductible
$0 $25 per visit
$0 0% after deductible
Specialist Visit Hospital Stay Maternity Care Emergency Room X-ray, Lab and Pathology Ambulance
20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible
$50 per visit 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible
0% after deductible 0% after deductible 0% after deductible 0% after deductible 0% after deductible 0% after deductible
$0 Six $0 visits then 10% after deductible 10% after deductible 10% after deductible 10% after deductible 10% after deductible 10% after deductible 10% after deductible
PET scans, MRIs, MRAs, CT scans and stress tests Chiropractic Urgent Care
20% after deductible
0% after deductible
10% after deductible
20% after deductible 20% after deductible
$100 plus 20% coinsurance $25 per visit $75 per visit
0% after deductible 0% after deductible
10% after deductible 10% after deductible
Preventive Drugs 30-Day Supply
$0 per prescription or refill
$0 per prescription or refill
$0 per prescription or refill
$0 per prescription or refill
WHAT’S THAT?
$ 844.635.1322
Prestige Silver 20
Typically, as plans go up in metal level (bronze, silver, gold) you’ll pay more for your monthly premium and get more coverage. Your exact monthly premium will depend on the financial assistance you may be eligible for. To find out what your premium will be, get a quote at
networkhealth.com/individual.
networkhealth.com/individual
AVAILABLE PLANS
DEDUCTIBLE
Prestige Bronze 20
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Prescription drug coverage
With our Network Health Prestige plans, you’ll enjoy built-in drug coverage. Check out the chart below to see how prescriptions are covered.
PHARMACY BENEFIT COMPARISON Prestige Bronze 20
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AVAILABLE PLANS
Preventive Drugs
RETAIL 30-DAY SUPPLY
$0 per prescription or refill Adherence Generics $2 per (limited only to categories prescription or refill of antidiabetics, statins and RAS antagonists) Generics 20% coinsurance after deductible Preferred Brand Drugs 20% coinsurance after deductible Non-Preferred 35% coinsurance after deductible Brand Drugs Preferred Specialty Drugs Non-Preferred Specialty Drugs
30% coinsurance after deductible 40% coinsurance after deductible
Prestige Silver 20
Prestige Silver 0
Prestige Gold 10
$0 per prescription or refill $2 per prescription or refill
$0 per prescription or refill $2 per prescription or refill
$0 per prescription or refill $2 per prescription or refill
$15
$15
$15
$40
$40
$40
35% coinsurance after deductible
35% coinsurance after deductible
35% coinsurance after deductible
30% coinsurance after deductible 40% coinsurance after deductible
30% coinsurance after deductible 40% coinsurance after deductible
30% coinsurance after deductible 40% coinsurance after deductible
Save More Using Mail Order
You may also save additional money on your prescriptions by ordering a 90-day supply through the mail. Plus, then you’ll have the convenience of your medications delivered right to your home.
WHAT’S THAT?
Preventive drugs Like preventive care or services, preventive drugs can help you avoid many illnesses and conditions.
networkhealth.com/individual
844.635.1322
Take advantage of $0 prescriptions Network Health Prestige Plans Cover Preventive Drugs at $0
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AVAILABLE PLANS
Just make sure you have a prescription and you can even receive many over-the-counter drugs at no cost. Here are some common examples. Baby aspirin Nicotine patches and gum Contraceptive products for women Vitamin D (based on age)
You’ll also save money by using drugs on our formulary (or drug list). Make sure to check your drug is on the formulary before getting your prescriptions filled. You can view the formulary at networkhealth.com/benefits/ individualdruglist.php.
844.635.1322
networkhealth.com/individual
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Not sure what all the health insurance jargon means? Let us translate. Monthly Premium
What you pay (per month, usually) to keep your insurance active.
Coinsurance
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AVAILABLE PLANS
Some services are covered 100 percent by your plan. Some may be 80 percent covered. The remaining 20 percent is the coinsurance, the amount you pay.
Deductible
The amount of money you must pay before the insurance company begins paying for most services. It’s different and separate from a copayment, which is a fee paid at office visits or the pharmacy.
Out-of-Pocket Limit
The maximum amount you pay during a certain period (usually one year) for essential health benefits covered by your plan. Once the limit is reached, you pay nothing for essential health benefits for the rest of the period.
Preventive Care
Services that prevent illness or detect illness at an early stage, such as flu shots, blood pressure screenings and screening mammograms. Find a full list of services at HealthCare.gov/preventive-care-benefits.
EVERY PLAN INCLUDES n n n
Complete coverage for preventive care. You pay $0. Prescription drug coverage Local, personal customer service
All copayments and coinsurance (medical and pharmacy) are applied to the out-of-pocket maximum. These summaries are only intended to highlight and give a general description of some of the benefits available. For a complete description of benefits, limitations and exclusions, view plans at networkhealth.com/individual and refer to the policy at networkhealth. com/benefits/sbc/individualpolicy.pdf. This policy does not include pediatric dental services as required under the federal Patient Protection and Affordable Care Act. This coverage is available in the insurance market and can be purchased as a stand-alone product. Please contact your insurance carrier, agent or the Federally-Facilitated Exchange if you wish to purchase pediatric dental coverage or a stand-alone dental services product. Network Health does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. networkhealth.com/individual
844.635.1322
Wisconsin is Home
When you call Network Health, you’re going to get someone right here in Wisconsin—someone who knows how to pronounce Waukesha and Kaukauna. We live and work where you do, and we care about the communities we serve and speak your language. We’re Wisconsin-based and locally owned by Ministry Health Care and Froedtert Health, which means our focus is on making sure you have access to the care you need to get and stay healthy.
Every quarter you will receive a newsletter, called Balance. This publication provides helpful information on the topics of life, health and wellness and how to get the most out of your health insurance coverage.
Focused on You
Our health plans give you access to nurse care managers and helpful programs to manage health conditions. We believe in partnering with you for better health.
A PU BLIC ATIO N OF
S U M M E R
2 0 1 5
He’s a miracle, lookin
LIFE, H E A LT
H & W ELLNE
SS
g at him now, nob ody would ev er know he was si ck.
How Ne twork He helped alth Vin conquer cent Malchesk cancer. i
Local, Personal Service
One of the best things about Network Health is the one-on-one support you get. You can call us with any issue and we’ll make sure your questions are answered.
Here’s what people are saying— “As a parent, you want to do everything for your child. Network Health has given us the ability to say we did everything we could. It’s not just a health insurance company, it supports the life of my family.” -Julie B., Appleton, WI 844.635.1322
The experience has been outstanding. Network Health has provided an outstanding insurance product at a very competitive cost and their service has been excellent—second to none. -Greg W. Shawano, WI
Network Health surpassed any expectation I had. -Terry T., Appleton, WI networkhealth.com/individual
WHY NETWORK HEALTH?
Life, Health and Wellness
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DOCTORS AND HOSPITALS YOU CAN USE
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Great Coverage Close to Home
With a Network Health Prestige plan, you have access to a quality network of doctors, hospitals, clinics and specialists. We have partnered with over 1,000 providers in southeast Wisconsin to offer you superior care at convenient locations. See the map and list for a glimpse of our network. For the most up-to-date complete list, or to find a specific doctor or facility, visit networkhealth.com/doctors-prestige-se and use the helpful Find a Doctor and Find a Facility search tools. These easy-to-use search features take the guesswork out of finding a doctor or facility in our network.
Our Southeast Wisconsin Service Area Our individual and family plan service area in southeast Wisconsin includes the five counties shown on the right. If you live in one of these counties, you’ll have access to a broad network of providers. See the next page for more detail, and make sure to visit networkhealth.com/doctors-prestige-se for a full list of locations and a large number and selection of specialists.
WASHINGTON
OZAUKEE
WAUKESHA
MILWAUKEE
RACINE
networkhealth.com/individual
844.635.1322
Medical College of Wisconsin Columbia St. Mary’s Columbia St. Mary’s Hospital Milwaukee, Inc. Columbia St. Mary’s Hospital Ozaukee, Inc. Orthopaedic Hospital of Wisconsin Sacred Heart Rehabilitation Institute, Inc. Madison Medical Affiliates, Inc. Wheaton Franciscan Healthcare Wheaton Franciscan Healthcare – Franklin, Inc. Wheaton Franciscan Healthcare – St. Francis, Inc. Wheaton Franciscan Healthcare – All Saints, Inc. Midwest Orthopedic Specialty Hospital, LLC Wheaton Franciscan – Home Health and Hospice Wheaton Franciscan Healthcare – Franciscan Woods, Inc. Wheaton Franciscan Medical Group, Inc. Wheaton Franciscan Medical Group – Sussex, Inc. Children’s Hospital and Health System, Inc. Children’s Hospital of Wisconsin – Milwaukee & Fox Valley Children’s Health System/Children’s Urgent Care Children’s Medical Group Children’s Service Society of Wisconsin Surgicenter of Greater Milwaukee Visit networkhealth.com/doctors-prestige-se for a complete listing.
844.635.1322
networkhealth.com/individual
DOCTORS AND HOSPITALS YOU CAN USE
Froedtert Health Froedtert Memorial Lutheran Hospital Community Memorial Hospital St. Joseph’s Community Hospital of West Bend Froedtert & MCW Community Physicians Froedtert Surgery Center, LLC West Bend Surgery Center, LLC
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HOW TO ENROLL
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Get a Quote
The first step is to get a quote for coverage specific to you. You can get started at networkhealth.com/ individual on your own or with the help of an agent.
See If You Qualify for Lower Costs
When you start your quote, you’ll have the option to enter income information to find out if you qualify for financial help. Enter your income to get an estimated savings amount. Our site will then take you to HealthCare.gov to create an account and verify your savings.
Choose Your Plan
View and compare all of our plans and select the one you want. At this point, you’ll be able to see what your total cost will be for the plan.
Enroll
Follow the instructions that appear to complete your enrollment. Once your application has been submitted, you’ll receive a confirmation email.
Need Help Enrolling?
If you’d like to enroll with the help of agent but need help finding one, call us at the number below. We work with hundreds of agents in Wisconsin who are happy to help. We’re also available to answer your questions. Call us at 844-635-1322, Monday through Friday, 8 a.m. to 8 p.m.
networkhealth.com/individual
844.635.1322
1570 Midway Pl. Menasha, WI 54952 844.635.1322 networkhealth.com/individual
HMO plans underwritten by Network Health Plan. POS plans underwritten by Network Health Insurance Corporation, or Network Health Insurance Corporation and Network Health Plan.