Enrollment & Benefits Guide 2016 Individual and Family Coverage Indiana University Health Plans Marketplace
Health insurance coverage from a name you trust IU Health Plans is a part of Indiana University Health, Indiana’s most trusted name in healthcare. With some of the lowest prices in your area you can get the highest quality care at an incredible value. When you choose healthcare coverage from IU Health Plans, you get: Low-priced coverage—from a name you know and trust Access to primary care, specialists and hospitals of IU Health, including
Riley Hospital for Children at Indiana University Health, one of the nation’s top children’s hospitals Access to other providers and hospitals throughout Indiana that are
close to home, including Deaconess Health System A wide range of plan options to meet your needs, including plans with dental and vision coverage Free yearly check-ups, screenings and vaccines Affordable doctor office visit copays Prescriptions at a low cost to you, including $0 preventive care drugs
See for yourself how low our plans are priced. Go online to get a Quick Quote or call us for free help with finding the right plan for you. IUHealthPlansGuide.org 866.321.8963
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Having the right plan makes all the difference
IU Health Plans is a new individual health insurance option for Hoosiers. It’s coverage driven by the highly skilled physicians of IU Health, who are experts at keeping you well. When you choose health insurance coverage from IU Health Plans, you get:
LOW-PRICED COVERAGE With some of the lowest prices for health insurance in your area, and a wide range of plan options to choose from—IU Health Plans provides the tools that put you in charge of choosing the health plan that best meets your needs and budget. And you may qualify for a financial discount to help cover your monthly insurance premium.
ACCESS TO PROVIDERS CLOSE TO HOME IU Health Plans covers primary care physicians, specialists and hospitals in your community. You will get the convenience of having direct, local access to the highly skilled doctors of IU Health and Riley Physicians Primary Care and other providers close to home, including Deaconess Health System and other health systems throughout Indiana. Plus you’ll have access to Riley Hospital for Children at IU Health, one of the nation’s top children’s hospitals.
AFFORDABLE DOCTOR OFFICE VISITS Your primary care physician (PCP) is not only there for you to see when you’re sick. Your PCP is your partner in keeping you and your family well. With IU Health Plans, PCP office visit copays are affordable, too. If you or your family gets sick, you won’t have to worry about large medical bills.
PRESCRIPTION DRUGS AT LOW COSTS All IU Health Plans choices have prescription drug coverage. Generic prescriptions are available at low cost to you and some preventive care prescriptions are available at no cost to you.
FREE PREVENTIVE CARE Preventive care services such as annual check-ups, vaccines and screenings are covered at no cost to you. We want to keep you and your family healthy so you can avoid emergencies and costly medical procedures.
COVERED HEALTH BENEFITS IU Health Plans covers all of your essential healthcare needs, such as vaccines, screenings and other preventive services, as well as behavioral health services and prescription drugs, just to name a few. IU Health Plans has plan options that include dental and vision coverage, too.
COVERAGE IS GUARANTEED Past or present health conditions will not prevent you from getting coverage. 3
Your plan choices All IU Health Plans are grouped into three different categories -- Bronze, Silver and Gold. The different categories do not reflect the quality or amount of care you can expect to receive. Each category has a different level of cost sharing, or what you and your plan will pay as a certain percentage of costs of medical care, including deductible, coinsurance and copayments. In general terms, monthly premiums will go up as IU Health Plans pays more of your health costs.
In general, this is how the costs of the plans break down:
BRONZE
SILVER
GOLD
Your health plan pays 60%
Your health plan pays 70%
Your health plan pays 80%
You pay 40%
You pay 30%
You pay 20%
Keep in mind, if you are eligible for a Special Enrollment Period you may qualify for financial discounts to help pay for your coverage.
How do you decide whether to go with Bronze, Silver or Gold? It’s difficult to predict your entire healthcare needs for the upcoming year. You should try to pick a plan that fits your budget and meets your family’s expected needs. If you don’t expect to use regular medical services, such as going to the doctor, and don’t take regular prescriptions, you may want a Bronze plan. These plans have a lower monthly premium but pay less of your costs when you need care. If you expect to occasionally use medical services and take prescriptions, you may want a Silver plan. These plans balance the monthly premium with the other costs of care that you may need. If you expect to use a lot of medical services or need regular prescriptions, you may want a Gold plan. The monthly premiums will be higher, but the plan will pay more of the costs when you need care. 4
Frequently asked health insurance questions Is there a plan to fit my budget? IU Health Plans has some of the lowest-priced plan options available in your area. And you may qualify for financial discounts to help cover your monthly insurance premium.
Can I choose my doctor? Yes. You will have your choice of a wide variety of highly skilled doctors located in your community. You may choose to see any type of doctor that you need to, without a referral, as long as the doctor is in the IU Health Plans network. See our directory of physicians at iuhealthplans.org/individual.
If I get sick, how much do I have to pay? When you team with IU Health Plans, you get access to care driven by leading physicians. Your IU Health primary care physician (PCP) is your partner in keeping you and your family well. If you or your family gets sick, you won’t have to worry about large medical bills. PCP office copays are affordable, too. Please see the chart on pages 6 – 7 for more information on PCP office copays.
What health benefits are covered?
All IU Health Plans options cover the following essential health benefits: Emergency services Ambulatory patient services Hospitalization Prescription drugs Maternity and newborn care
Pediatric services including vision care Preventive and wellness services Mental health and substance abuse disorder services Rehabilitative services and devices Laboratory services
Do I have to pay for yearly check-ups, vaccines or screenings? No, preventive and wellness services are free.
Are providers outside of IU Health covered by IU Health Plans? Yes. IU Health Plans network includes physicians and hospitals that are part of other healthcare systems and that are conveniently located in your community. You can find the nearest ones at iuhealthplans.org/individual.
What if I visit a physician or hospital that is not part of the IU Health Plans network? There is no coverage for out-of-network physicians or hospitals, with the exception of emergency care services. IU Health Plans covers emergency care services at any hospital when there is a true emergency, such as a vehicle accident, difficulty breathing or severe bleeding.
What should I do if I need medical care after hours? Many doctor’s offices have after-hour care or a doctor on call. If you have an urgent question, contact your doctor first. If you have a true emergency, call 911 or go to the nearest emergency room. With IU Health Plans, you also have access to urgent care centers. To find the nearest facility, see our directory at iuhealthplans.org/individual.
What should I do if I need medical care when I’m away from home? Contact your doctor first for help with routine or urgent care questions. If you have a true emergency, please call 911 or go to the nearest emergency room.
Enroll now or learn more at IUHealthPlansGuide.org or 866.321.8963.
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Here is a breakdown of what each IU Health Plans option offers: See the Key health insurance and medical definitions section of this guide for helpful explanations of some of this chart’s words and terms. Keep in mind, you may qualify for financial discounts to help pay for your coverage. Plan Name
BRONZE HSA Simple BRONZE HSA
BRONZE Value
BRONZE Value Plus Dental & Vision
SILVER HSA
SILVER Copay
SILVER Value
SILVER Enhanced
SILVER Enhanced Plus Dental & Vision
GOLD Value
GOLD Value Plus Dental & Vision
Deductible (Individual/Family)
$6,500/$13,000
$4,500/$9,000
$6,000/$12,000
$6,000/$12,000
$3,000/$6,000
$2,500/$5,000
$2,500/$5,000
$2,000/$4,000
$2,000/$4,000
$750/$1,500
$750/$1,500
Out-of-Pocket Maximum (Individual/Family)
$6,500/$13,000
$6,200/$12,400
$6,850/$13,700
$6,850/$13,700
$4,500/$9,000
$5,000/$10,000
$6,350/$12,700
$5,750/$11,500
$5,750/$11,500
$6,000/$12,000
$6,000/$12,000
Coinsurance
0% after deductible
30% after deductible
30% after deductible
30% after deductible
20% after deductible
30% after deductible
30% after deductible
30% after deductible
30% after deductible
20% after deductible
20% after deductible
Primary Care Office Visit
0% after deductible
30% after deductible
$40 copay for first 4 visits then 30% coinsurance
$40 copay for first 4 visits then 30% coinsurance
20% after deductible
$30 copay
$40 copay
$30 copay
$30 copay
$20 copay
$20 copay
Specialist Care Office Visit
0% after deductible
30% after deductible
30% after deductible
30% after deductible
20% after deductible
$60 copay
30% after deductible
30% after deductible
30% after deductible
$50 copay
$50 copay
Behavioral Health Professional Visit
0% after deductible
30% after deductible
$40 copay for first 4 visits then 30% coinsurance
$40 copay for first 4 visits then 30% coinsurance
20% after deductible
$30 copay
$40 copay
$30 copay
$30 copay
$20 copay
$20 copay
Urgent Care Visit
0% after deductible
$100 copay after deductible
$100 copay
$100 copay
$100 copay after deductible
$100 copay
$100 copay
$100 copay
$100 copay
$100 copay
$100 copay
Preventive Care
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
FREE
Essential Health Benefits
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Provider Services
Health Benefits
Vision and Dental Services Pediatric Vision
Covered
Adult Vision
Covered
Covered
Covered
Pediatric Dental
Covered
Covered
Covered
Adult Dental
Covered
Covered
Covered
Prescription Drug Coverage Tier 1 (Preferred Generic)
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0% after deductible
$10 copay after deductible
$10 copay
$10 copay
$5 copay after deductible
$5 copay
$5 copay
$5 copay
$5 copay
$5 copay
$5 copay
Tier 2 (Non-Preferred 0% after deductible Generic)
$25 copay after deductible
$25 copay
$25 copay
$15 copay after deductible
$15 copay
$15 copay
$15 copay
$15 copay
$15 copay
$15 copay
Tier 3 (Preferred Brand)
0% after deductible
30% after deductible
30% after deductible
30% after deductible
20% after deductible
20% after deductible
20% after deductible
20% after deductible
20% after deductible
20% after deductible
20% after deductible
Tier 4 (Non-Preferred 0% after deductible Brand)
40% after deductible
40% after deductible
40% after deductible
30% after deductible
30% after deductible
30% after deductible
30% after deductible
30% after deductible
30% after deductible
30% after deductible
Tier 5 (Specialty)
0% after deductible
40% after deductible
40% after deductible
40% after deductible
30% after deductible
30% after deductible
30% after deductible
30% after deductible
30% after deductible
30% after deductible
30% after deductible
Tier 6 (ACA Zero Cost Preventive)
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
Go to IUHealthPlansGuide.org or call 866.321.8963 for full plan details.
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Important enrollment information Who is eligible to enroll in an individual health insurance plan? You currently don’t have healthcare insurance You’re self-employed You don’t have job-based coverage You’re retiring early You’re simply looking for a better individual insurance plan The law now requires everyone to have health coverage. If you do not get a health plan you may have to pay a penalty, unless you qualify for an exemption. If you are 65 or older, you are not eligible to use the marketplace to buy a health or dental plan.
Who is eligible to enroll through a Special Enrollment Period on the Marketplace? In the Health Insurance Marketplace, you qualify for a Special Enrollment Period following certain life events that involve a change in family status or loss of other health coverage. If you qualify for a Special Enrollment Period you may be eligible for financial discounts to help pay for your coverage. Visit healthcare.gov for official guidance related to Special Enrollment Period.
How do I enroll? You can enroll with IU Health Plans by visiting IUHealthPlansGuide.org or calling 866.321.8963.
What are the important dates to remember? Nov. 1, 2015 – Jan. 31, 2016 Open Enrollment on the Health Insurance Marketplace for 2016 coverage is closed.
Special Enrollment Period If you qualify for a Special Enrollment Period, you and your family can still enroll in IU Health Plans coverage outside of the open enrollment period. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact us at 866.321.8963. Indiana University Health Plans is a qualified health plan issuer through the Health Insurance Marketplace. Indiana University Health Plans 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. © 2016 IUHEXG_197
Will I qualify for financial discounts?
You might be eligible for a financial discount if you: Are a single person earning $47,080 or less Are a couple with a combined income of $63,720 or less Are a family of three with a total income below $80,360 Are a family of four with a total income below $97,000 Are a family of five with a total income below $113,640 Are a family of six with a total income below $130,280 Incomes that qualify for lower costs plans are set forth by Healthcare.gov. These numbers reflect the latest guidelines as of September 2015.
Where is IU Health Plans coverage available? IU Health Plans offers a variety of plan options for those living in the following counties: Bartholomew
Elkhart
Knox
Orange
Starke
Benton
Fountain
Kosciusko
Owen
Sullivan
Blackford
Gibson
LaGrange
Parke
Tippecanoe
Boone
Grant
La Porte
Perry
Tipton
Brown
Greene
Lawrence
Pike
Vanderburgh
Carroll
Hamilton
Madison
Porter
Vermillion
Cass
Hancock
Marion
Posey
Vigo
Clay
Hendricks
Marshall
Pulaski
Warren
Clinton
Henry
Martin
Putnam
Warrick
Crawford
Jackson
Monroe
Randolph
White
Daviess
Jay
Montgomery
Shelby
Delaware
Jennings
Morgan
Spencer
Dubois
Johnson
Noble
St. Joseph
Enroll now or get a Quick Quote: IUHealthPlansGuide.org
866.321.8963
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Key health insurance and medical definitions
Network: The facilities, providers and suppliers your health insurer or plan has contracted with to provide healthcare services.
Deductible: The amount you owe for healthcare services your health insurance or plan covers before your health insurance or plan begins to pay.
Out-of-pocket (OOP) costs: Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance and copayments for covered services plus all costs for services that aren't covered.
Copayment: A fixed amount you pay for a covered healthcare service, usually at the time when you get the service. Amounts vary by plans and services.
Coinsurance: Your share of the costs of a covered healthcare service, calculated as a percentage of the allowed amount by your plan. You pay coinsurance plus any deductibles you owe.
Essential health benefits: Comprehensive care that covers all your healthcare needs, including emergency services, mental health services and prescription drug coverage.
Preventive care: Preventive services that can help you avoid illness and improve your health, including yearly check-ups, vaccines and screenings.
Health Savings Account (HSA): HSA plans allow you to contribute funds to a personal savings account on a pre-tax basis, which can be used to pay for eligible medical expenses until your deductible is met.
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Understanding more about IU Health Plans benefits IU Health Plans in-network benefit IU Health Plans covers healthcare services for physicians and hospitals that are in network only. You can see our directory of covered physicians and hospitals at iuhealthplans.org/individual. If you have a true emergency, your care is covered at any hospital. A true emergency is when you have a serious medical condition that could cause lasting harm or loss of life if you do not seek care immediately, such as a vehicle accident, difficulty breathing or severe bleeding.
IU Health Plans programs To make sure you are receiving the best care possible, IU Health Plans has several programs that are focused on your health and wellness. Sometimes these programs are called Utilization Management, or UM, programs. The UM programs provide the following types of services: IU Health Plans may review information before your doctor or hospital visit to make sure you are getting the best quality care at the right time and place. This is called prior authorization of services. If you visit the hospital, IU Health Plans may work with a team of providers to make sure you receive the right services and coordinated care to help you get better and stay well. If you have multiple chronic conditions, IU Health Plans may support your doctor with identifying the services you need to get well and maintain your health. It is important that you know that UM decision making is based only on appropriateness of care and service and existence of coverage. IU Health Plans does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
IU Health Plans pharmacy services All IU Health Plans choices have prescription drug coverage. You can access our formulary directory to see what medications are covered at iuhealthplans.org/individual. Each plan option has six different levels or tiers of drug coverage. In general, the amount you have to pay for a medication will go up as the tiers get higher, with the exception of Tier 6. The type of medication covered is also different for each tier. Generic and preventive medications are generally covered in Tier 1 at lower cost to you, whereas, specialty medications are generally covered in Tier 5 at higher cost to you. Some preventive care medications are covered in Tier 6 at no cost to you. A team of healthcare professionals, including nurses, pharmacists and physicians, determines prescription drug coverage and what medications are assigned to each tier. If you have questions regarding whether a particular medication is covered and at what tier, please call IU Health Plans at 866.321.8963. To request a medication that is not on the formulary, your healthcare provider can contact Provider Services at 855.413.2434 to request a drug exception review or an expedited drug exception review. You can also contact Member Services at 855.413.2432 for additional information on this process.
IU Health Plans language assistance To request information or get assistance in Spanish or another language, please call IU Health Plans at 866.321.8963.
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Visit our website or go online for free help with finding the right plan for you: IUHealthPlansGuide.org
866.321.8963 © 2016 IUHealth 2/16 IUH#21090