Massachusetts Small Group Benefit Designs First Quarter - 2017 The following are the Massachusetts Small Group Benefit Designs for the First Quarter of 2017. Please note: - Best Buy HSA (HMO & PPO) 2000 & Best Buy HSA (HMO & PPO) 3000 do not have additional cost sharing after deductible - All plans are Plan Year, except Affordable HMO 25, Focus Network MA - Affordable 25 and Affordable PPO 25 (Calendar Year) - All plans are Medicare Minimum Creditable compliant and Mass Minimum Creditable compliant - Introduction of new plans, as noted on the grid. For discontinued plans, please see Page 12 - There is no limit to number of Chiropractic visits - All plans have telemedicine benefit for urgent care available at Primary Care Provider cost sharing - 3-Tier Pharmacy plans, Core Coverage HMO 1750, and Best Buy HMO 2000 are also offered on the Connector - All plans include Pedi-Vision benefit - All plans may be sold with or without Pedi-Dental benefit, except the 3-Tier Pharmacy plans which must include Pedi-Dental benefit - Separate benefit limits for PT/OT based on rehabilitative and habilitative services (60 visits each) - All plans include cost sharing for labs and x-rays, except Standard Platinum
MA Small Group Benefit Designs 1st Quarter 2017 - Effective Jan 1, 2017 through Mar 31, 2017
Affordable HMO Plans Product Name
Office Visit Deductible
Annual Out Of Pocket Max
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT)
Affordable HMO 25
$25/$40
$2,000/$4,000
None
$125
None/None
ER: $125
IP: $1,000
Platinum
UC: $40
MD0000004360/RX0000001291
Conv: $25 Day: $500
Affordable HMO 40
$40/$60
None/None
Embedded $3,000/$6,000
None
ER: $300
IP: $1,000
Gold
UC: $60
MD0000004383/RX0000010868
Conv: $40 Day: $750
$25
$40
$300
$25
$40
$40
$50
Embedded
Retail: $5/$25/$40/$60/20% (T5 $250/script max)
50% coinsurance
Mail: $12.50/$62.50/$100/$180/20% (T5 $750/script max) RX OOPM: $1,000/$2,000
No Deductible
Dental OOPM: $1,350/$2,700 DN0000010123 Retail: $5/$25/$75/$100/20% (T5 50% coinsurance $250/script max) Mail: No Deductible $12.50/$62.50/$187.50/$300/20 % (T5 $750/script max) RX OOPM: $2,000/$4,000 Dental OOPM: $1,350/$2,700 DN0000010098
Best Buy HMO Plans Product Name
Office Visit Deductible
Annual Out Of Pocket Max
Best Buy HMO 1000
$25/$40
$5,250/$10,500 None
$1,000/$2,000
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
ER: $200
IP: Ded then Ded then CIF $25
Gold
UC: $40
MD0000004363/RX0000001295
Conv: $25 Day: Ded then CIF
Best Buy HMO 1000 with Coinsurance Gold
$30/$50
Embedded Embedded $1,000/$2,000 $5,250/$10,500 20%
MD0000004371/RX0000010863 New Plan Best Buy HMO 2000
$25/$40
Embedded Embedded $2,000/$4,000 $5,250/$10,500 None
ER: $300
Ded then $200
Conv: $30 Day: Ded then 20%
RX OOPM: Medical OOPM applies
Gold
UC: $40
Retail: $5/$15/$40/$70/20% (T5 $250/script max) Mail: $12.50/$37.50/$100/$210/20% (T5 $750/script max)
MD0000004359/RX0000001293
Conv: $25 Day: Ded then $200
RX OOPM: Medical OOPM applies
Embedded
Embedded
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Page 2 of 12
Ded then $200
Ded then $50 20%
Retail: $5/$25/$50/$70/20% (T5 $250/script max) Mail: $12.50/$62.50/$125/$210/20% (T5 $750/script max) RX OOPM: Medical OOPM applies
UC: $50
IP: Ded then Ded then $250 $25
Ded then 20%
Ded then $40 $25
Retail: $5/$25/$60/$90/20% (T5 $250/script max) Mail: $12.50/$62.50/$150/$270/20% (T5 $750/script max)
ER: $200
IP: Ded then Ded then 20% 20%
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT)
Ded then $40 $25
50% coinsurance No Deductible
Dental OOPM: $1,350/$2,700 DN0000010098 50% coinsurance No Deductible
Dental OOPM: $1,350/$2,700 DN0000010098 50% coinsurance No Deductible
Dental OOPM: $1,350/$2,700 DN0000010098
UC - Urgent Care; Conv - Convenience Care; Chiro - Chiropracture
MA Small Group Benefit Designs 1st Quarter 2017 - Effective Jan 1, 2017 through Mar 31, 2017
Best Buy HMO Plans Product Name
Office Visit Deductible
Annual Out Of Pocket Max
Best Buy HMO 2000 with Coinsurance Silver
$35/$65
$6,300/$12,600 20%
$2,000/$4,000
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
MD0000004369/RX0000010862
Best Buy HMO 3000
$30/$50
Embedded Embedded $3,000/$6,000 $5,250/$10,500 None
UC: $65
Retail: $5/$25/$80/$100/20% (T5 50% coinsurance $350/script max) Mail: No Deductible $12.50/$62.50/$200/$300/20% (T5 $1,050/script max)
Conv: $35 Day: Ded then 20%
RX OOPM: Medical OOPM applies
ER: $500
ER: $300
IP: Ded then Ded then 20% 20%
IP: Ded then Ded then $500 $30
Silver
UC: $50
MD0000004367/RX0000001071
Conv: $30 Day: Ded then $500 Embedded
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT) Ded then 20%
Ded then $300
Ded then $50 20%
Ded then $50 $30
Retail: $5/$25/$75/$100/20% (T5 $350/script max) Mail: $12.50/$62.50/$187.50/$300/20 % (T5 $1,050/script max) RX OOPM: Medical OOPM applies
Embedded
Dental OOPM: $1,350/$2,700 DN0000010098 50% coinsurance No Deductible
Dental OOPM: $1,350/$2,700 DN0000010098
Focus Network MA - HMO and HSA HMO Plans Product Name
Office Visit Deductible
Annual Out Of Pocket Max
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT)
Focus Network MA- Affordable HMO 25 Platinum
$25/$40
$2,000/$4,000
None
$125
None/None
IP: $1,000
$25
$40
Conv: $25 Day: $500
Ded then $40/$65
$3,100/$6,200
Embedded $6,400/$12,800 None
ER: Ded IP: Ded then Ded then then $750 20% $40
Bronze
UC: Ded then $65
MD0000004378/RX0000001498
Conv: Ded Day: Ded then $40 then $1,000
New Plan
$25
UC: $40
MD0000004362/RX0000001291
Focus Network MA - Best Buy HSA HMO 3100
ER: $125
Non-Embedded Embedded
Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care and its affiliates. Harvard Pilgrim Health Care of New England and HPHC Insurance Company.
Page 3 of 12
Ded then $750
Ded then Ded then $40 $50
Retail: $5/$25/$40/$60/20% (T5 $250/script max) Mail: $12.50/$62.50/$100/$180/20% (T5 $750/script max) RX OOPM: $1,000/$2,000
Retail: Ded then $5/$25/50%/50%/50% (T3 $250/script max, T4 $250/script max, T5 $250/script max) Mail: Ded then $12.50/$62.50/50%/50%/50% (T3 $625/script max, T4 $625/script max, T5 $750/script max) RX OOPM: Medical OOPM applies
50% coinsurance No Deductible
Dental OOPM: $1,350/$2,700 DN0000010123 50% coinsurance
No Deductible
Dental OOPM: $150/$300 DN0000000257
UC - Urgent Care; Conv - Convenience Care; Chiro - Chiropracture
MA Small Group Benefit Designs 1st Quarter 2017 - Effective Jan 1, 2017 through Mar 31, 2017
Core Coverage HMO Plans Product Name
Office Visit Deductible
Annual Out Of Pocket Max
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
Core Coverage HMO 1750
$35 Copay $1,750/$3,500 for the first 3 visits per mem (6 per fam). All other visits Ded then 20%
$6,400/$12,800 20%
ER: $250
IP: Ded then Ded then 20% 20%
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT) Ded then 20%
$35 Copay for the first 3 visits per mem (6 per fam). All other visits Ded then 20%
$35 Copay Retail: $5/$25/$80/$110/20% (T5 50% coinsurance for the first 3 $500/script max) visits per mem (6 per fam). All other visits Ded then 20%
Silver
UC: $35 Copay for the first 3 visits per mem (6 per fam). All other visits Ded then 20%
Mail: $12.50/$62.50/$200/$330/20% (T5 $1,500/script max)
No Deductible
MD0000004330/RX0000010857
Conv: $35 Day: Ded Copay for then 20% the first 3 visits per mem (6 per fam). All other visits Ded then 20%
RX OOPM: Medical OOPM applies
Dental OOPM: $750/$1,500
Embedded
DN0000000255
Embedded
Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care and its affiliates. Harvard Pilgrim Health Care of New England and HPHC Insurance Company.
Page 4 of 12
UC - Urgent Care; Conv - Convenience Care; Chiro - Chiropracture
MA Small Group Benefit Designs 1st Quarter 2017 - Effective Jan 1, 2017 through Mar 31, 2017
Core Coverage HMO Plans Product Name
Office Visit Deductible
Annual Out Of Pocket Max
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
Core Coverage HMO 3000
$35 Copay $3,000/$6,000 for the first 3 visits per mem (6 per fam). All other visits Ded then 10%
$5,250/$10,500 10%
ER: $250
IP: Ded then Ded then 10% 10%
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT) Ded then 10%
$35 Copay for the first 3 visits per mem (6 per fam). All other visits Ded then 10%
$35 Copay Retail: $5/$25/$80/$110/20% (T5 50% coinsurance for the first 3 $500/script max) visits per mem (6 per fam). All other visits Ded then 10%
Silver
UC: $35 Copay for the first 3 visits per mem (6 per fam). All other visits Ded then 10%
Mail: $12.50/$62.50/$200/$330/20% (T5 $1,500/script max)
No Deductible
MD0000004365/RX0000001312
Conv: $35 Day: Ded Copay for then 10% the first 3 visits per mem (6 per fam). All other visits Ded then 10%
RX OOPM: Medical OOPM applies
Dental OOPM: $1,350/$2,700
Embedded
DN0000010098
Embedded
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Page 5 of 12
UC - Urgent Care; Conv - Convenience Care; Chiro - Chiropracture
MA Small Group Benefit Designs 1st Quarter 2017 - Effective Jan 1, 2017 through Mar 31, 2017
Best Buy HSA HMO Plans Product Name
Office Visit Deductible
Annual Out Of Pocket Max
Best Buy HSA HMO 2000
Ded then CIF
$5,250/$10,500 None
$2,000/$4,000
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
ER: Ded then CIF
IP: Ded then Ded then CIF CIF
Gold
UC: Ded then CIF
MD0000004373/RX0000001497
Conv: Ded Day: Ded then CIF then CIF
New Plan Best Buy HSA HMO 2000 with Coinsurance
Ded then $30/$45
$2,000/$4,000
$5,750/$11,500 20%
ER: Ded then CIF
IP: Ded then Ded then 20% 20%
UC: Ded then $45
MD0000004381/RX0000010867
Conv: Ded Day: Ded then $30 then 20%
New Plan
Ded then Ded then CIF CIF
Ded then 20%
Ded then Ded then 20% 20%
Non-Embedded Embedded Ded then CIF
$3,000/$6,000
$6,000/$12,000 None
ER: Ded then CIF
IP: Ded then Ded then CIF CIF
Silver
UC: Ded then CIF
MD0000004375/RX0000010865
Conv: Ded Day: Ded then CIF then CIF
New Plan Best Buy HSA HMO 3100
Ded then CIF
Non-Embedded Embedded
Silver
Best Buy HSA HMO 3000
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT)
Ded then CIF
Ded then Ded then CIF CIF
Non-Embedded Embedded Ded then $40/$65
$3,100/$6,200
$6,400/$12,800 None
ER: Ded IP: Ded then Ded then then $750 20% $40
Bronze
UC: Ded then $65
MD0000004377/RX0000010866
Conv: Ded Day: Ded then $40 then $1,000 Non-Embedded Embedded
Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care and its affiliates. Harvard Pilgrim Health Care of New England and HPHC Insurance Company.
Page 6 of 12
Ded then $750
Ded then Ded then $40 $50
Retail: Ded then $5/$25/$40/$60/20% (T5 $250/script max) Mail: Ded then $12.50/$62.50/$100/$180/20% (T5 $750/script max)
50% coinsurance
RX OOPM: Medical OOPM applies Preventive RX applies to Retail & Mail Retail: Ded then $5/$25/$40/$60/20% (T5 $250/script max) Mail: Ded then $12.50/$62.50/$100/$180/20% (T5 $750/script max)
Dental OOPM: $1,300/$2,600 DN0000000167
RX OOPM: Medical OOPM applies Preventive RX applies to Retail & Mail Retail: Ded then $5/$25/$65/$90/20% (T5 $350/script max) Mail: Ded then $12.50/$62.50/$162.50/$270/20 % (T5 $1,050/script max)
Dental OOPM: $800/$1,600 DN0000000260
RX OOPM: Medical OOPM applies Preventive RX applies to Retail & Mail Retail: Ded then $5/$25/50%/50%/50% (T3 $250/script max, T4 $250/script max, T5 $250/script max)
Dental OOPM: $550/$1,100 DN0000000166
Mail: Ded then $12.50/$62.50/50%/50%/50% (T3 $625/script max, T4 $625/script max, T5 $750/script max) RX OOPM: Medical OOPM applies
No Deductible
No Deductible
50% coinsurance
No Deductible
50% coinsurance
No Deductible
50% coinsurance
Dental OOPM: $150/$300 DN0000000257
UC - Urgent Care; Conv - Convenience Care; Chiro - Chiropracture
MA Small Group Benefit Designs 1st Quarter 2017 - Effective Jan 1, 2017 through Mar 31, 2017
Affordable PPO Plans Product Name
Office Visit Deductible
Affordable PPO 25
IN: $25/$40 OON:
Platinum
MD0000004361/RX0000001291 Ded then 20%
Affordable PPO 40 Gold
IN: $40/$60 OON:
MD0000004384/RX0000010868 Ded then 20%
Annual Out Of Pocket Max
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT)
IN: None/None IN: $2,000/$4,000 OON: OON:
IN: None
ER: $125
IN: $25
IN: $125
IN: $25
IN: $40
OON:
IN: UC: $40
OON:
OON:
OON:
OON:
$500/$1,000
$3,000/$6,000
20%
IN: Conv: $25
Ded then 20%
Ded then 20%
Ded then Ded then 20% 20%
Embedded
Embedded
IN: None/None IN: $3,000/$6,000 OON: OON:
IN: None OON:
IN: IP: $1,000
IN: Day: $500
OON: Ded OON: Ded then 20% then 20% ER: $300 IN: IP: $1,000 IN: UC: $60
$1,000/$1,500
$5,000/$10,000 20%
IN: Conv: $40
IN: Day: $750
Embedded
Embedded
OON: Ded OON: Ded then 20% then 20%
Retail: $5/$25/$40/$60/20% (T5 $250/script max) Mail: $12.50/$62.50/$100/$180/20% (T5 $750/script max) RX OOPM: $1,000/$2,000
IN/OON: 50% coinsurance No Deductible
Dental OOPM: $1,350 /$2,700 (Combined IN/OON) DN0000010124
IN: $40
IN: $300
IN: $40
IN: $50
OON:
OON:
OON:
OON:
Ded then 20%
Ded then 20%
Ded then Ded then 20% 20%
Retail: $5/$25/$75/$100/20% (T5 $250/script max) Mail: $12.50/$62.50/$187.50/$300/20 % (T5 $750/script max) RX OOPM: $2,000/$4,000
IN/OON: 50% coinsurance No Deductible
Dental OOPM: $1,350 /$2,700 (Combined IN/OON) DN0000010125
Best Buy PPO Plans Product Name
Office Visit Deductible
Annual Out Of Pocket Max
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT)
Best Buy PPO 1000
IN: $25/$40
IN: $1,000/$2,000
IN: $5,250/$10,500
IN: None
ER: $200
IN: Ded then $25
IN: Ded IN: Ded then $200 then $25
IN: $40
Retail: $5/$25/$50/$70/20% (T5 $250/script max)
IN/OON: 50% coinsurance
Gold
OON:
OON:
OON:
OON:
IN: UC: $40
OON:
OON:
OON:
OON:
No Deductible
20%
IN: Conv: $25
Ded then 20%
Ded then Ded then 20% 20%
Mail: $12.50/$62.50/$125/$210/20% (T5 $750/script max) RX OOPM: Medical OOPM applies
MD0000004364/RX0000001295 Ded then 20%
$2,000/$4,000 $10,500/$21,000
Embedded
Embedded
Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care and its affiliates. Harvard Pilgrim Health Care of New England and HPHC Insurance Company.
IN: IP: Ded then CIF
IN: Day: Ded Ded then then CIF 20%
OON: Ded OON: Ded then 20% then 20%
Page 7 of 12
Dental OOPM: $1,350 /$2,700 (Combined IN/OON) DN0000010125
UC - Urgent Care; Conv - Convenience Care; Chiro - Chiropracture
MA Small Group Benefit Designs 1st Quarter 2017 - Effective Jan 1, 2017 through Mar 31, 2017
Best Buy PPO Plans Product Name
Office Visit Deductible
Annual Out Of Pocket Max
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
Best Buy PPO 1000 with Coinsurance
IN: $30/$50
IN: $1,000/$2,000
IN: $5,250/$10,500
IN: 20%
ER: $300
Gold
OON:
OON:
OON:
OON:
IN: UC: $50
40%
IN: Conv: $30
MD0000004372/RX0000010863 Ded then 20%
$2,000/$4,000
New Plan
Embedded
Embedded
IN: $2,000/$4,000 OON:
IN: $5,250/$10,500 OON:
Best Buy PPO 2000 Gold
IN: $25/$40 OON:
MD0000004366/RX0000001293 Ded then 20%
$10,500/$21,000
$4,000/$8,000
IN: None OON:
20% $10,500/$21,000
Embedded
Embedded
IN: Conv: $25
IN: $2,000/$4,000
IN: $6,300/$12,600
IN: 20%
Silver
OON:
OON:
OON:
OON:
IN: UC: $65
40%
IN: Conv: $35
Best Buy PPO 3000 Silver
IN: $30/$50 OON:
MD0000004368/RX0000001071 Ded then 20%
$4,000/$8,000 $12,600/$25,200
Embedded
Embedded
IN: $3,000/$6,000 OON:
IN: $5,250/$10,500 OON:
IN: None OON:
20% $6,000/$12,000 $10,500/$21,000
Embedded
Embedded
Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care and its affiliates. Harvard Pilgrim Health Care of New England and HPHC Insurance Company.
Retail: $5/$25/$60/$90/20% (T5 $250/script max)
IN/OON: 50% coinsurance
OON:
OON:
OON:
No Deductible
Ded then 40%
Ded then Ded then 40% 20%
Mail: $12.50/$62.50/$150/$270/20% (T5 $750/script max) RX OOPM: Medical OOPM applies
IN: Ded then $25 OON:
Page 8 of 12
Dental OOPM: $1,350 /$2,700 (Combined IN/OON)
IN: Ded IN: Ded then $200 then $25 OON: OON:
Ded then 20%
IN: $40 OON:
Ded then Ded then 20% 20%
Retail: $5/$15/$40/$70/20% (T5 $250/script max) Mail: $12.50/$37.50/$100/$210/20% (T5 $750/script max) RX OOPM: Medical OOPM applies
IN/OON: 50% coinsurance No Deductible
Dental OOPM: $1,350 /$2,700 (Combined IN/OON) DN0000010125
IN: Ded IN: Ded then 20% then 20%
IN: Ded IN: $50 then 20%
Retail: $5/$25/$80/$100/20% (T5 IN/OON: 50% $350/script max) coinsurance
OON:
OON:
OON:
Ded then 40%
Ded then Ded then 40% 20%
Mail: $12.50/$62.50/$200/$300/20% (T5 $1,050/script max) RX OOPM: Medical OOPM applies
OON:
No Deductible
Dental OOPM: $1,350 /$2,700 (Combined IN/OON) DN0000010125
IN: Ded then $30 OON:
IN: Day: Ded Ded then then $500 20%
OON: Ded OON: Ded then 20% then 20%
OON:
DN0000010125
IN: Day: Ded Ded then then 20% 40%
OON: Ded OON: Ded then 20% then 40% ER: $300 IN: IP: Ded then $500 IN: UC: $50
IN: Conv: $30
IN: Ded IN: $50 then 20%
IN: Day: Ded Ded then then $200 20%
OON: Ded OON: Ded then 20% then 20% ER: $500 IN: IP: Ded then 20%
IN: $35/$65
IN: Ded IN: Ded then 20% then 20%
IN: Day: Ded Ded then then 20% 40%
OON: Ded OON: Ded then 20% then 40% ER: $200 IN: IP: Ded then $250 IN: UC: $40
Best Buy PPO 2000 with Coinsurance
MD0000004370/RX0000010862 Ded then 20%
IN: IP: Ded then 20%
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT)
IN: Ded IN: Ded then $300 then $30 OON: OON:
Ded then 20%
IN: $50 OON:
Ded then Ded then 20% 20%
Retail: $5/$25/$75/$100/20% (T5 $350/script max) Mail: $12.50/$62.50/$187.50/$300/20 % (T5 $1,050/script max)
IN/OON: 50% coinsurance No Deductible
RX OOPM: Medical OOPM applies
Dental OOPM: $1,350 /$2,700 (Combined IN/OON) DN0000010125
UC - Urgent Care; Conv - Convenience Care; Chiro - Chiropracture
MA Small Group Benefit Designs 1st Quarter 2017 - Effective Jan 1, 2017 through Mar 31, 2017
Best Buy HSA PPO Plans Product Name
Office Visit Deductible
Annual Out Of Pocket Max
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT)
Best Buy HSA PPO 2000
IN: Ded then CIF
IN: $2,000/$4,000
IN: $5,250/$10,500
IN: None
ER: Ded then CIF
IN: Ded then CIF
IN: Ded then CIF
Gold
OON:
OON:
OON:
OON:
IN: UC: Ded then CIF
OON:
OON:
20%
IN: Conv: Ded then CIF
IN: Day: Ded Ded then then CIF 20%
OON: Ded then 20% ER: Ded then CIF
OON: Ded then 20% IN: IP: Ded then CIF
MD0000004374/RX0000001497 Ded then 20%
$4,000/$7,000
New Plan
Non-Embedded Embedded
$10,500/$21,000
Best Buy HSA PPO 3000
IN: Ded then CIF
IN: $3,000/$6,000
IN: $6,000/$12,000
IN: None
Silver
OON:
OON:
OON:
OON:
IN: UC: Ded then CIF
20%
IN: Conv: Ded then CIF
MD0000004376/RX0000010865 Ded then 20%
$6,000/$12,000 $12,000/$24,000
New Plan
Non-Embedded Embedded
Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care and its affiliates. Harvard Pilgrim Health Care of New England and HPHC Insurance Company.
IN: IP: Ded then CIF
IN: Ded then CIF
IN: Ded then CIF
OON:
OON:
IN: Day: Ded Ded then then CIF 20%
OON: Ded OON: Ded then 20% then 20%
Page 9 of 12
Ded then 20%
Ded then 20%
IN: Ded then Retail: Ded then CIF $5/$25/$40/$60/20% (T5 $250/script max) OON: OON: Mail: Ded then $12.50/$62.50/$100/$180/20% (T5 $750/script max) Ded then Ded then RX OOPM: Medical OOPM 20% 20% applies
IN/OON: 50% coinsurance
Preventive RX applies to Retail & Mail IN: Ded IN: Ded then Retail: Ded then then CIF CIF $5/$25/$65/$90/20% (T5 $350/script max) OON: OON: Mail: Ded then $12.50/$62.50/$162.50/$270/20 % (T5 $1,050/script max) Ded then Ded then RX OOPM: Medical OOPM 20% 20% applies
DN0000000168
IN: Ded then CIF
No Deductible
Dental OOPM: $1,300 /$2,600 (Combined IN/OON)
IN/OON: 50% coinsurance No Deductible
Dental OOPM: $550 /$1,100 (Combined IN/OON)
Preventive RX applies to Retail & DN0000000170 Mail
UC - Urgent Care; Conv - Convenience Care; Chiro - Chiropracture
MA Small Group Benefit Designs 1st Quarter 2017 - Effective Jan 1, 2017 through Mar 31, 2017
Best Buy HSA PPO Plans Product Name
Office Visit Deductible
Annual Out Of Pocket Max
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT)
Best Buy HSA PPO 3100
IN: Ded then $40/$65
IN: $3,100/$6,200
IN: $6,400/$12,800
IN: None
ER: Ded IN: IP: Ded then $750 then 20%
IN: Ded then $40
IN: Ded IN: Ded then $750 then $40
IN: Ded then Retail: Ded then IN/OON: 50% $50 $5/$25/50%/50%/50% (T3 coinsurance $250/script max, T4 $250/script max, T5 $250/script max)
Bronze
OON:
OON:
OON:
OON:
IN: UC: Ded then $65
OON:
OON:
OON:
OON:
20%
IN: Conv: Ded then $40
IN: Day: Ded Ded then then $1,000 20%
Ded then 20%
Ded then Ded then 20% 20%
OON: Ded then 20% ER: Ded then $750
OON: Ded then 20% IN: IP: Ded then $1,000
MD0000004379/RX0000010866 Ded then 20%
$6,100/$12,200 $12,800/$25,600
Non-Embedded Embedded Best Buy HSA PPO 4500
IN: Ded then $40/$65
IN: $4,500/$9,000
IN: $6,200/$12,400
IN: None
Bronze
OON:
OON:
OON:
OON:
IN: UC: Ded then $65
20%
IN: Conv: Ded then $40
MD0000004382/RX0000001298 Ded then 20%
$7,500/$15,000 $12,400/$24,800
Embedded
Embedded
Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care and its affiliates. Harvard Pilgrim Health Care of New England and HPHC Insurance Company.
Page 10 of 12
No Deductible
RX OOPM: Medical OOPM applies
Dental OOPM: $150 /$300 (Combined IN/OON)
DN0000000256 IN: Ded then $40
IN: Ded IN: Ded then $750 then $40
IN: Ded then Retail: Ded then IN/OON: 50% $50 $5/$25/50%/50%/50% (T3 coinsurance $250/script max, T4 $250/script max, T5 $250/script max)
OON:
OON:
OON:
OON:
Ded then 20%
Ded then Ded then 20% 20%
IN: Day: Ded Ded then then $1,000 20%
OON: Ded OON: Ded then 20% then 20%
Mail: Ded then $12.50/$62.50/50%/50%/50% (T3 $625/script max, T4 $625/script max, T5 $750/script max)
Mail: Ded then $12.50/$62.50/50%/50%/50% (T3 $625/script max, T4 $625/script max, T5 $750/script max) RX OOPM: Medical OOPM applies
No Deductible
Dental OOPM: $350 /$700 (Combined IN/OON)
DN0000000174
UC - Urgent Care; Conv - Convenience Care; Chiro - Chiropracture
MA Small Group Benefit Designs 1st Quarter 2017 - Effective Jan 1, 2017 through Mar 31, 2017
3-Tier Pharmacy (Standard Connector) Plans Product Name
Office Visit Deductible
Annual Out Of Pocket Max
Co-insurance ER/Urgent Inpatient/ Labs/ XCare Day Surgery Rays
Scans: CT, PT/OT/ Acupunture RX Cost Share (Value Formulary) Dental Cost MRI, PET ST (60 (20 visits) Sharing visits /Chiro combined PT/OT)
Standard Platinum
$25/$40
$3,000/$6,000
None
$150
None/None
Platinum MD0000004319/RX0000010845
Standard Gold
$30/$45
$1,000/$2,000
Embedded $5,000/$10,000 None
ER: Ded IP: Ded then Ded then then $150 $500 $20
$30/$50
Embedded Embedded $2,000/$4,000 $7,150/$14,300 None
$40
$40
Ded then $200
$45
$45
Ded then $500
$50
$50
UC: $50 Conv: $30 Day: Ded then $750
Ded then $25/$40
Embedded Embedded $2,750/$5,500 $7,150/$14,300 None
MD0000004329/RX0000010865
Conv: Ded Day: Ded then $25 then $750 Embedded
X-Rays: Ded then $175
Mail: $30/$60/$150 RX OOPM: Medical OOPM applies
No Deductible Dental OOPM: Medical OOPM applies DN0000000247 50% coinsurance
Retail: $20/$30/$50
Retail: $20/$60/$90
Ded then $40 $40
No Deductible Dental OOPM: Medical OOPM applies DN0000000248 50% coinsurance
Retail: Ded then $25/$75/$100
No Deductible Dental OOPM: Medical OOPM applies DN0000000249 50% coinsurance
Mail: Ded then $50/$150/$300
No Deductible
RX OOPM: Medical OOPM applies
Dental OOPM: Medical OOPM applies DN0000000254
Embedded
Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care and its affiliates. Harvard Pilgrim Health Care of New England and HPHC Insurance Company.
50% coinsurance
Mail: $40/$120/$270 RX OOPM: Medical OOPM applies
ER: Ded IP: Ded then Labs: Ded Ded then then $500 $1,000 then $50 $1,000 UC: Ded then $40
Retail: $15/$30/$50
Mail: $40/$60/$150 RX OOPM: Medical OOPM applies
ER: Ded IP: Ded then Ded then then $700 $1,000 $25
Bronze
New Plan
CIF
UC: $45 Conv: $30 Day: Ded then $250
Silver MD0000004321/RX0000010846
Standard Bronze
IP: $500
UC: $40 Conv: $25 Day: $500
Gold MD0000004320/RX0000001300
Standard Silver
ER: $150
Page 11 of 12
UC - Urgent Care; Conv - Convenience Care; Chiro - Chiropracture
MA Small Group Benefit Designs 1st Quarter 2017 - Effective Jan 1, 2017 through Mar 31, 2017 HPHC must receive complete applications including all required new business documents at least 10 days prior to the requested coverage effective date
Business Rules Minimum Number of Participating Subscribers: 75% of those employees who are eligible for health benefits must participate in a group health plan sponsored by the employer (not necessarily those provided by HPHC). At least 51% of FTEs in the account must work within Massachusetts.
Standard Connector (3 Tier Value Formulary) Business Rules: These plans may only be offered alongside any other Standard Connector plan for groups with 6 or more eligible employees. A PPO plan may be offered exclusively for out-of-area subscribers regardless of group size. The Standard Connector plans must be purchased with pediatric dental coverage.
Minimum Enrollment Requirements (excluding waivers due to spousal or dependent coverage):
Focus Network Business Rules: Available for accounts located in the Focus Network-MA Service area. An employee and enrolling dependents must reside within the Focus Network-MA Employee Enrollment Area in order to enroll in the plans.
Group Size 1-5 FTEs: 6-50 FTEs (PPO): 6-50 FTEs (HMO):
Eligibility Requirements 100% of FTEs 75% of FTEs Renewals: 50% of FTEs, 75% for side by side options Prospects: 75% of FTEs
HMO and PPO Side by Side Business Rules: Side by side options are not permitted for employers with less than 6 Full Time Equivalents (FTEs) except in cases when a PPO plan is offered exclusively for out-of-area subscribers. Dual and Triple Option Business Rules: For 6 or more Full Time Equivalents (FTEs) dual option and for 20 or more FTEs triple option are available. With the exception of Standard Connector plans, any plan can be offered alongside any other plan.
Embedded Deductible/OOPM: Embedded Deductible refers to a family plan that has two components, an individual deductible and a family deductible. The maximum contribution by an individual towards the family deductible is limited to the individual deductible amount and allows for the individual to receive benefits before the family component is met. When any number of members collectively meet the family deductible, services for the entire family are covered for the remainder of the year. Embedded OOPM refers to a family plan that has two components, an individual OOPM and a family OOPM. The maximum contribution by an individual towards the family OOPM is limited to the individual OOPM and once met, has no additional cost sharing for the remainder of the year. When any number of members collectively meet the family OOPM, then all members have no additional cost sharing for the remainder of the year. Non-Embedded Deductible/OOPM refer to family plans where no member is eligible for covered benefits until the family component is met. There is no limit on the individual contribution. Employer's HRA Business Rules: HRA50% of the value of any Rx coinsurance amount under the related group health plan (the "50% Limit"). If the 50% limit is exceeded, HPHC may stop providing Employer's HRA contribution may not exceed Employer's HRA claims information to the HRA administrative service provider and/or terminate the Employer Agreement. Employer's HRA contribution information provided to HPHC is subject to HPHC's audit and verification. Massachusetts Minimum Creditable Coverage (MCC) standards: All of the Small Group plans meet the Massachusetts Minimum Creditable Coverage (MCC) Standards.
Medicare Creditable Coverage (MCC) standards: All of the Small Group Plans meet Medicare Creditable Coverage standards.
The following 2016 plans will be discontinued for 2017. Employers offering these plans, and their enrolled subscribers, will be notified. - Best Buy HSA PPO 2000 w/ Coins (MD3839) - Affordable HMO 20 (MD3815) - Focus Network - MA Best Buy HMO 1000 (MD3838) - Affordable PPO 20 (MD3826) - Best Buy HSA HMO 2000 (MD3824) - Focus Network - MA Best Buy HMO 2000 (MD 3822) - Best Buy HSA PPO 2000 (MD3834) - Focus Network - MA Best Buy HMO 2000 w/ Coins (MD3840) - Best Buy HSA HMO 2900 (MD3825) - Focus Network - MA Best Buy HMO 3000 (MD3823) - Best Buy HSA PPO 2900 (MD3835) - Focus Network MA - Best Buy Copayment HMO 1000 (MD3806)
Due to a change in metallic tier, these 2016 plans also require notification of discontinuation. Plans with the same name and similar benefits will be available in 2017. - Affordable HMO 40 (MD3817) - Best Buy HMO 3000 (MD3818) - Affordable PPO 40 (MD3828) - Best Buy PPO 3000 (MD3831)
Notes: Please note that this document provides an overview of small group benefit designs only. Complete plan designs are defined in the applicable Evidence of Coverage (EOC). If there are discrepancies between this document and EOC, the terms of the EOC apply. For any questions on the application of these rules to a specific account, please call your HPHC representative. Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care and its affiliates. Harvard Pilgrim Health Care of New England and HPHC Insurance Company.
Page 12 of 12
UC - Urgent Care; Conv - Convenience Care; Chiro - Chiropracture
