2019 California Freelance Employee

Transcription

1 2019 California Freelance Employee

2 A Quick History of the PHBP PHBP is an employer funded group insurance plan providing health, vision, dental and disability coverage for eligible commercial production freelancers employed by Participating AICP General Member production companies. In 2007, The Plan s Trust was first funded by Participating Employers. In 2008, the Plan began offering medical coverage to freelance commercial employees in the Production department nationwide. In 2013, the Plan expanded to offer Vision and Dental Coverage.

3 A Quick History of the PHBP (cont.) In 2014, the Plan added greater stability to freelance health care by eliminating quarterly eligibility periods and replacing them with an annual award of Benefits. In 2016, the Plan added Short and Long Term disability coverage for additional income protection, including maternity leave. In 2017, the Plan greatly reduced the cost of Dependent coverage by subsidizing the cost of insuring your families. The cost of insuring a spouse and child dropped from nearly $1,400 to $350. In 2019, the Plan will add $25,000 in life insurance coverage for all Freelancers. To date, the Participating Employers have contributed over $100 Million to the fund.

4 PHBP s Commitment to Freelancers The Plan continues its commitment to provide FREE comprehensive coverage. In order to fulfill this commitment, additional medical coverage plans will be introduced to the array of benefits provided. Medical coverage remains with Anthem Blue Cross and all plans utilize the most extensive networks offered by Anthem Blue Cross and its affiliated Blue Card Blue Cross Blue Shield networks where available.

5 What s new for PHBP in 2019 Benefits will be provided based on newly established income Tiers. Income Tiers are based on PHBP reported annual income from Participating Companies. All participants will migrate to the medical plan associated with their Tier level on January 1 and participate in that plan for the duration of their current coverage period. Your current qualifying period will be used to determine the Tier level for the next coverage period beginning in Check your work history at PHBP.org for your specific qualifying period dates. A 13th month of coverage has been added to all participants current coverage period, whether or not you ve earned eligibility. This is so the plan has ample time to calculate Tiers and properly communicate with participants.

6 Tier 1 Tier 1 will be for freelance employees with PHBP reported income up to $75,000. The medical plan provided is the PHBP California Classic HMO.

7 Tier 2 Tier 2 will be for freelance employees with PHBP reported income of $75,000 - $110,000. The medical plan provided is the PHBP California Classic HMO. Participants have the option to Buy Up to the current PHBP Classic Premier PPO.

8 Tier 3 Tier 3 will be for freelance employees who earned $110,000 or more. The medical plan provided is the PHBP Classic Premier PPO. Participants may opt out of the PPO and choose the California Classic HMO and your 2019 annual enrollment fee will be waived.

9 PHBP CALIFORNIA CLASSIC HMO

10 How does the plan work? With an HMO, you must choose a Primary Care Physician (PCP) before receiving care. 80% of the PHBP Claims in California paid to current PPO providers were paid to Providers also in the HMO Network. Your PCP will be the provider with the best overall picture of your health and will be the one to coordinate additional care. If you need the care of a specialist, you must first see your PCP. Then, he or she would provide a referral to a specialist within the HMO s network.

11 How does the plan work? There is no deductible and preventive care is 100% covered. You will pay a fixed copay per visit for most services. You are protected with an annual out-of-pocket maximum. This is the most you will pay for covered services in a given year. Once you meet this amount, your plan covers eligible health care expenses at 100%.

12 PHBP California Classic HMO Annual Deductible In-Network Member pays: Out-of-Network Member pays: Individual/Family None Not Applicable Annual Out-of-Pocket Maximum Individual/Family $2,000/$4,000 Not Applicable Physician Services Office Visit copay $10 Not covered Preventive Care 100% covered Not covered Diagnostic Lab/X-Ray 100% covered Not covered Imaging (CT/PET/MRIs) $100 copay per test Not covered Rehabilitation/Habilitation Chriopractic Care/ $10 copay Not covered Accupuncture

13 PHBP California Classic HMO Prescription Drugs In-Network Member pays: Out-of-Network Member pays: Tier 1 (Generic Formulary) $5 min/$20 max 50% uo to $250 Tier 2 (Preferred Brand Formulary) $40 50% uo to $250 Tier 3 (Non-Preferred Brand Formulary) $65 50% uo to $250 Tier 4 (Specialty) 30% up to $250 50% uo to $250 Mail Order T1: $12.50/ T2: $120 50% uo to $250 T3: $165/ T4: $30% up to $250 50% uo to $250 Individual/Family $2,00/$4,000 Not Applicable

14 PHBP California Classic HMO Hospital Facility Charges In-Network Member pays: Out-of-Network Member pays: Inpatient Services $250 copay/admit Not covered Outpatient Surgery in Hospital $125 copay/admit Not covered Emergency Services Emergency Room/ Transport/ Ambulance $100 copay Covered as in-network Urgent Care $10 copay Covered as in-network Diagnostic Lab/X-Ray 100% covered Not covered Imaging (CT/PET/MRIs) $100 copay per test Not covered Rehabilitation/Habilitation Chriopractic Care/ Accupuncture $10 copay Not covered

15 PHBP California Classic HMO In-Network Members pays: Out-of-Network Member pays: Mental Health Outpatient $10 copay Not covered Inpatient $250 copay/admit Not covered

16 PHBP California Classic HMO In-Network Out-of-Network Maternity Prenatal and Postnatal Care $10 copay Not covered Delivery and Inpatient Services $250 copay/admit Not covered

17 PHBP CLASSIC PREMIER PPO

18 PHBP Classic Premier PPO In-Network Member pays: Out-of-Network Member pays: Annual Deductible Individual/Family $500/$1,000 $1,500/$3,000 Annual Out-of-Pocket Maximum Individual/Family $2,500/$5,000 $5,000/$10,000

19 PHBP Classic Premier PPO Physician Services In-Network Out-of-Network Office Visit copay $25 50% coinsurance Preventive Care 100% covered 50% coinsurance Diagnostic Lab/X-Ray 20% coinsurance 50% coinsurance Imaging (CT/PET/MRIs) 20% coinsurance 50% coinsurance Rehabilitation/Habilitation 20% coinsurance 50% coinsurance Chriopractic Care $20 copay 50% coinsurance Accupuncture $25 copay 50% coinsurance

20 PHBP Classic Premier PPO In-Network Out-of-Network Member pays: Member pays: Prescription Drugs Tier 1 (Generic Formulary) $10 $ % coinsurance Tier 2 (Preferred Brand Formulary) $30 $ % coinsurance Tier 3 (Non-Preferred Brand Formulary) $50 $ % Coinsurance Tier 4 (Specialty) $500 deductible 30% up to $150 50% coinsurance Mail Order T1: $10/ T2: $60 50% coinsurance T3: $100/ T4: $30% up to $300 50% coinsurance

21 PHBP Classic Premier PPO In-Network Out-of-Network Hospital Facility Charges Impatient Services Outpatient Surgery in Hospital 20% coinsurance 50% coinsurance Emergency Services Emergency Room $150+20% coinsurance $150+20% coinsurance Emergency Transport/ Ambulance 20% coinsurance 20% coinsurance Urgent Care $25 copay 50% coinsurance

22 PHBP Classic Premier PPO In-Network Members pays: Out-of-Network Member pays: Mental Health Outpatient $20 copay 50% coinsurance Inpatient 20% coinsurance 50% coinsurance

23 HMO VS PPO

24 HMO VS PPO-Deductibles & Out-Of- Pocket Max PHBP CA Classic HMO PHBP Classic Premier PPO DEDUCTIBLE In -Network Non-Network In-Network Non-Network Individual $0 Not Applicable $500 $1,500 Family $0 Not Applicable $1,000 $3,000 OUT-OF-POCKET MAX In -Network Non-Network In-Network Non-Network Individual OOP $2,000 Not Applicable $2,500 $5,000 Family OOP $4,000 Not Applicable $5,000 $10,000

25 HMO VS PPO-Physician Services PHBP CA Classic HMO PHBP Classic Premier PPO PHYSICIAN SERVICES In -Network Non-Network In-Network Non-Network Office Visit Copays $10 Not Covered $25 50% coinsurance Preventive Care $0 Not Covered $0 50% coinsurance Diagnostic Lab/X-Ray $0 Not Covered 20% coinsurance 50% coinsurance Imaging (CT/PET scans MRIs) $100 copay per test Not Covered 20% coinsurance 50% coinsurance Rehabilitation/ Habilitation $10 copay per test Not Covered 20% coinsurance 50% coinsurance Chriopractic Care $10 copay per test Not Covered $20 copay per visit 50% coinsurance Acuouncture $10 copay per test Not Covered $25 copay per visit 50% coinsurance

26 HMO VS PPO-Prescription Drugs PHBP CA Classic HMO PHBP Classic Premier PPO PRESCRIPTION DRUGS In -Network Non-Network In-Network Non-Network Tier 1 (Generic Formulary) $5/$20 50% up to $250 $10 $10+50% coinsurance Tier 2 (Preferred Brand) $40 50% up to $250 $30 $30+50% coinsurance Tier 3 (Non-Preferred Brand) $65 50% up to $250 $50 $50+50% coinsurance Tier 4 (Specialty Drugs) 30% up to $250 50% up to $250 $500 deductible, 30% up to $120 50% coinsurance T1: $12.50 T1: $12.50 Mail Order T2: $120 50% up to $250 T2:$120 T3: $165 T3: $165 T4: 30% up to $250 T4: 30% up to $250 50% coinsurance

27 HMO VS PPO-Hospital Facility Services PHBP CA Classic HMO PHBP Classic Premier PPO HOSPITAL FACILITY SERVICES in -Network Non-Network In-Network Non-Network Inpatient Hospital Services $250 copay per admit Not Covered 20% coinsurance 50% coinsurance Outpatient Surgery in a Hospital $125 copay per admit Not Covered 20% coinsurance 50% coinsurance Ambulatory Surgical Center $125 copay per admit Not Covered 20% coinsurance 50% coinsurance

28 HMO VS PPO-Emergency Services PHBP CA Classic HMO PHBP Classic Premier PPO EMERGENCY SERVICES In -Network Non-Network In-Network Non-Network Emergency Room $100 copay per visit Covered as in Network $150 copay per admit $150 copay per admit then 20% coinsurance then 20% coinsurance Emergency $100 copay per visit Covered as in Network 20% coinsurance 20% coinsurance Urgent Care $10 copay per visit Covered as in Network $25 copay per visit 50% coinsurance

29 HMO VS PPO-Mental Health/ Substance Use Disorder PHBP CA Classic HMO PHBP Classic Premier PPO MENTAL HEALTH/SUBSTANCE USE DISORDER In -Network Non-Network In-Network Non-Network Outpatient Services $10 copay per visit Not Covered $20 copay per visit 50% coinsurance Inpatient Services $250 copay per admit Not Covered 20% coinsurance 50% coinsurance

30 HMO VS PPO-Maternity PHBP CA Classic HMO PHBP Classic Premier PPO MENTAL HEALTH/SUBSTANCE USE DISORDER In -Network Non-Network In-Network Non-Network Outpatient Services $10 copay per visit Not Covered $20 copay per visit 50% coinsurance Inpatient Services $250 copay per admit Not Covered 20% coinsurance 50% coinsurance

31 Tier 2 Buy Up Option Tier 2 participants have the option to Buy Up to the current Classic Premier PPO by paying the cost differential. Your enrollment in the PPO will be for the duration of your coverage period. Monthly Buy Up costs for 2019: Employee Only: $200 Employee + Spouse: $425 Employee + Child(ren): $350 Employee + Family: $600

32 Tier 3 Opt Out option Tier 3 participants may opt out of the PPO and choose the California Classic HMO. If you chose the HMO your 2019 annual enrollment fee will be waived. All HMO rules apply. Your enrollment in the HMO will be for the duration of your coverage period.

33 2019 Ancillary Plan Options

34 Dental Deductible In Network Non-Network Individual $50 $50 Family 3x Individual Ded 3x Individual Ded Waived Tier for Deductible Tier Copays Tier 1 Diagnostic & Preventative 100% 100% Tier 2 Basic Services 80% 80% Tier 3 Major Services 50% 50% Tier 4 Orthodontia 50% 50% Tier 1-3 Benefot Maximum $1,500 $1,500 Tier 4 Benefir Maximum $1,500 $1,500

35 Vision Deductible In Network Copay Frequency Exams $10 12 Months Frames $200 allowance 12 Months Frame Allowance Single Vision $25 12 Months Bifocal $25 12 Months Trifocal $25 12 Months Polycarbonate $25 12 Months Anti-Reflective Coating up to $41-$85 copay 12 Months Standard Progressive Lenses up to $55 copay 12 Months

36 Short Term Disability Benefit Amount 60% Benefit Reduction? Reduced by amount paid by state disability Weekly Benefit Maximum $3,000 Benefit Duration 52 Weeks Elimination Period 7 days Preexisting Condition Period 3/12

37 Long Term Disability Benefit Amount 60% Benefit Reduction? Reduced by amount paid by disability polices Monthly Benefit Maximum $12,500 Benefit Duration Until Social Security Retirement age Elimination Period 365 days Preexisting Condition Period 3/12

38 Life Insurance Included for all covered Freelancers is a $25,000 Life Insurance Policy.

39 Singing Up

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41 CHOOSING A PRIMARY CARE PHYSICIAN WITHIN THE HMO

42 Choosing a Primary Care Physician (PCP) within the HMO Step 1: Start at : SCROLL DOWN to the bottom of the page to Search as a Guest and Click Continue

43 Choosing a PCP within the HMO Step 2: Under How Do I get my Insurance? select Through my employer Step 3: Under What State do you want to search? select California Step 4: Under What type of care are you searching for? select Medical Step 5: Under Select a plan/network select Blue Cross HMO (CACare)- Large Group Step 6: Click Continue

44 Choosing a PCP within the HMO Step 7: Under I m looking for a select Doctor/Medical Professional Step 8: You may search for a specific doctor by name to see if they are covered in the HMO Step 9: Under Who specializes in select from Family/General Practice, Inter Med or Pediatrician for your Primary Care Physician (PCP). Make sure you chose a Primary Medical Group/PCP for each of your dependents. EG, You may chose a Family/General Practice, Internal Med for yourself and a Pediatrician for a child.

45 Choosing a PCP within the HMO Step 10: Under Located near enter your zip code. Step 11: Make sure to check Accepting New Patients and Able to serve as PCP Step 12: Click Search

46 Choosing a PCP within the HMO Step 13: Click on your selected Care Provider.

47 Choosing a PCP within the HMO Step 14: Choose the PCP Affiliated Medical Group to manage your care. If more then one are listed, choose the one that best meets your needs, including location.

48 Choosing a PCP within the HMO Step 15: Find the PCP ID/ENROLLMENT ID (PAPER/ONLINE) NUMBER located under "MEDICAL GROUP" in the middle "AFFILIATION" column. The code is either a 3 or 6 digit code. Step 16: Use the PCP ID/ ENROLLMENT ID (PAPER/ONLINE) on the Enrollment Form.

49 Important to Remember for HMO HMO care is managed by the medical group you choose. Make sure the doctor you choose has a contract with the medical group you select. If you are trying to coordinate to have the opportunity to utilize a specific hospital, make sure that both the doctor and medical group have contracts with that hospital. However, it is up to the medical group as to which hospitals they utilize regardless of contracts.

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