2016 Marketplace Purchaser Guide - Get Health Insurance ... · An ounce of prevention is worth a...

8101 West Jefferson Blvd.Fort Wayne, IN 46804

www.phpni.com

2016 MarketplacePurchaser GuideYour guide to buying PHP Marquee plans for individuals and families on the Indiana Health Insurance Marketplace.

©2016 PHPNI, Inc.October 2015 www.phpni.com

Our commitment to you.Excellence in customer service and greater freedomare only a few reasons our members are happywith PHP year after year. We are committed to providing you with the best service.

Because we are based right here in NorthernIndiana, we offer easy access to a large local net-work of healthcare providers. Go online towww.phpni.com/phpselect to search our exten-sive, open access network of providers

An ounce of prevention is worth a pound of cure.All of our plans pay 100% of many important preventive services including well-baby care,immunizations, mammograms, pap tests, andannual physical exams when ordered by a participating provider.

Providing you the tools to manage your healthcare.You have around-the-clock access to powerfulonline resources at www.phpni.com. Whether you arelooking for a physician, researching drug information,or checking your personal account for benefit andclaim information, our site allows you to manageyour health when it’s most convenient for you.

PHP Marquee Plans: Health coverage forindividuals and families, purchased throughthe Health Insurance Marketplace.

PHP Marketplace Plans

1

PHP Sales Area forMarketplace Plans

Applicants must reside in one of these Indiana counties to be eligible for coverage.

12

Emergency care benefits that apply anywhere in the world. While traveling, members are covered should emergency services be needed. Just show yourmember ID card at the time of service.

We’re here to help you choose the right coverage.PHP understands choosing the right health plancan be a complicated decision. Consider the following factors to select the right plan for you:

l Premium: The higher the level of benefits a plan offers, the higher the premium. Generally, the more you pay in monthly premiums, the more the plan pays toward your medical expenses.

l Benefits: Each metal level provides coverage for the same minimum essential health benefits and in-network preventive care services.

l Copays: Fixed flat fees for health services or medication. Not all plans have copays.

l Deductibles and Coinsurance: Deductibles and coinsurance will vary even among plans in the same metal level.

The next several pages will help you compare the various types of plans we have available on the Marketplace:Gold Plans Most like traditional plans with copays and/or lower coinsurance for medical services.

Silver Plans Traditional and HSA-qualified plan options that can provide cost-share reductions for some individuals, depending on financial qualifications.

Bronze Plans More cost effective plan offerings that, in most situations, can be coupled with an HSA for financial savings.

Catastrophic Plans Basic coverage for accident and illness with the lowest possible premium.

2

Phone NumbersVoice: (260) 432-6690, ext. 810Toll-free: 1-800-982-6257, ext. 810Hearing Impaired: (260) 459-2600

AddressAttn: Individual Product Physicians Health Plan8101 West Jefferson Blvd.Fort Wayne, IN 46804

[email protected] help us provide excellent service,be sure to include your name and yourdaytime phone number.

Web Addresswww.phpni.com

Eligibility Requirements

Individuals applying for PHP Marquee plans must do so through the Marketplace website,www.healthcare.gov. The Marketplace will determine you and your family’s eligibility to purchase coverage. Based on your financial circumstances, the Marketplace may apply Advance Premium TaxCredit (APTC), or cost-share reductions to help make your coverage more affordable. Keep in mind, the Marketplace can determine your eligibilty for these special tax credits.

11

Silver Plans

l Those wanting more control of how their healthcare dollars are spent

l Families who regularly schedule doctor’s appointments and well-child visits

l Those who prefer to pay less at the time of service

All Silver plans offer the same set of essential health benefits. Silver plans have a higher monthly premium andoften have lower out-of-pocket costs than Bronze and Catastrophic plans.

Silver Plans

MyNurse 24/7Health concerns don’t always arise while thedoctor’s office is open. Our members haveaccess to a toll-free, 24-hour nurse line servicefor noncritical situations. Members can speakwith experienced, knowledgeable nurses whoanswer questions with sound, clinically basedinformation day or night.

MyHealth 24/7This interactive, online resource acts as a 24-hourmedical advisor to help find solutions to commonhealth problems. Evaluate symptoms and overallhealth, use quizzes and calculators to improveand maintain weight, or search the pharmacysection to compare drugs and lower expenses.

HealthNEWS NewsletterMembers receive a quarterly newsletter that offershealth and wellness information from nutrition andexercise, to seasonal health concerns and medicalnews. Each issue includes an update of our providernetwork as well as local events and member discounts.

Value-added services included with every PHP Marketplace health plan

Smoking Cessation In keeping with our mission of encouraging preventive health maintenance, we offer coverageto help you in your goal to quit smoking. Additionalinformation on the Indiana Quitline, tobacco inter-vention programs, community classes, and supportgroups to quit smoking are also provided.

Member DiscountsOur members are eligible to receive a variety ofspecial discounts at select area health clubs, community classes, and facilities such as:

• Free trial memberships, discounts on enrollmentfees, annual memberships, and training packages

• Discounts on medically supervised programs• Discounts on prescription eyewear• Sporting event discounts

A complete listing of member discounts is availablein HealthNEWS, and also online at www.phpni.com.

Think you might qualify for a subsidy or tax credit?

Low and moderate income individuals and families may qualify for premium tax credits and cost-sharingreductions through the Marketplace at www.healthcare.gov. If you qualify, a tax credit may be used topay a portion of your premium. If you qualify for a cost-sharing subsidy, you will get a deduction of out-of-pocket costs from the federal government. Visit our website, www.phpni.com to find out moreinformation regarding tax credits that may be available to you and your family.

Financial assistance from the federal government is only available if you purchase coverage through theMarketplace. Individuals are not eligible for premium subsidies or cost-sharing reductions if they are eligiblefor Medicare, Medicaid, or an affordable employer-sponsored health plan with comprehensive coverage.

3

Choose the best payment option for you.Initial Payments may be made by checking or savings account, credit or debit card, or you mayreceive an invoice to pay by check or money order.

Ongoing Payments can be made several different ways. For your convenience, you may set-up amonthly automatic payment from your checking or savings account. You will receive an email prior tothe due date notifying you of the amount that will be deducted from your account if you select thisoption.

You may also elect to receive a monthly invoice, either by U.S. mail or email. Once you receive theinvoice, you may pay by check, money order, or make an online payment using your checking or savings account, credit or debit card.

Try us out.We want you to be satisfied and confident with your PHP Marketplace Plan. That’s why you have a “free-look” period to examine your policy when it is received. If for any reason within the free-lookperiod you decide you no longer want the policy, simply return it to us and the policy will be cancelledand your premium refunded.10

*Services are subject to the Medical Deductibleand apply toward the Medical Out-of-Pocket limit.

Covered Benefits Marquee Silver 2000

Base Plan **73% CSR Version ** 87% CSR Version **94% CSR Version

CHOOSE YOUR COVERAGE LEVEL:

Single (Deductible/Out-of-Pocket Max)

Family (Deductible/Out-of-Pocket Max)

Preventive ServicesServices rated ‘A’ or ‘B’ by the U.S. PreventiveServices Task Force, and immunizations recom-mended by the Advisory Committee onImmunization Practices of the Centers forDisease Control and Prevention. Preventive careand screenings for women and children as rec-ommended by the Health Resources andServices Administration. For a complete list,please visit our website.

No charge Deductible waived




Doctor’s Office VisitIllness, injury, or sickness $30 each for 3 visits per

covered person, then 20%* $30 each for 3 visits per


covered person, then 10%*$30 each for 3 visits per

covered person, then 10%*

Other Practitioner Visits 20%* 20%* 10%* 10%*

DiagnosticRoutine radiology and lab services (ex. chest x-ray,MRI, blood and urine tests). 20%* 20%* 10%* 10%*

Outpatient Services 20%* 20%* 10%* 10%*

Inpatient Services $500 per stay plus 20%* ofremaining charges

$500 per stay plus 20%* ofremaining charges



Hospital Emergency RoomDiagnosis must be emergent in nature $300 per visit plus 20%* of

remaining charges$300 per visit plus 20%* of



remaining charges

Urgent Care Center20%* 20%* 10%* 10%*

Ambulance Service

20%* 20%* 10%* 10%*

MaternityBenefits based on service

settingBenefits based on service



setting

Diabetes ServicesBenefits based on service




setting

Durable Medical Equipment,Prosthetics, Orthotic Appliances, and Ostomy Supplies 20%* 20%* 10%* 10%*

Prescription DrugsUp to 30 day supply, including diabetic supplies,per prescription or refill. Two over-the-countervials of insulin. One-unit limit for inhaler aiddevices such as aerochambers, inspirease, etc.

Generic Drug: $15Formulary Brand: $45

Non-formulary Brand: 50%*Specialty: 50%*







Mail Order Prescription DrugsUp to 90 day supply, including diabetic supplies,per prescription or refill. Six over-the-countervials of insulin.


Non-formulary Brand: 50%*Specialty: Not Covered







$1,810/$5,450$3,620/$10,900

$2,000/$6,850$4,000/$13,700

$800/$1,850

$1,600/$3,700

Features of our plans:• Preventive Services covered at 100% for all

plans (Complete list of services found at www.phpni.com)

• All plans available as an Individual or Family Policy

• Many value-added benefits automatically included: 24-hour nurse line, various online health resources, member discounts for health facilities and more

• Prescription drug coverage available with all plans

• Competitive premium rates • Negotiated provider costs to save you money • Exceptional customer service to help you

understand and make the most of your health coverage

$250/$700

$500/$1,400

Silver plans continued on next page.

We are here to help you decide which of ourplans is the right fit for you and your family.













covered person, then 30%* $25 each for 3 visits per covered

person, then 10%*$25 each for 3 visits per covered

person, then 10%*




Inpatient Services30%* 30%* 10%* 10%*





remaining charges


Ambulance Service

30%* 30%* 10%* 10%*





setting





setting













Non-formulary Brand: 30%*Specialty: Not covered







$2,500/$6,850$5,000/$13,700

$2,500/$5,450$5,000/$10,900

$800/$2,150$1,600/$4,300

$275/$725$550/$1,450

4 9

Covered BenefitsAdditional Plans

Gold Plan Catastrophic Plan




Preventive ServicesServices rated ‘A’ or ‘B’ by the U.S. Preventive Services Task Force, andimmunizations recommended by the Advisory Committee onImmunization Practices of the Centers for Disease Control andPrevention. Preventive care and screenings for women and children asrecommended by the Health Resources and Services Administration.For a complete list, please visit our website.



Doctor’s Office VisitIllness, injury, or sickness $35 per visit

No Coinsurance*Deductible waived for

first 3 primary care visits only.

Other Practitioner Visits10%* No Coinsurance*

DiagnosticRoutine radiology and lab services (ex. chest x-ray, MRI, blood and urinetests). 10%* No Coinsurance*

Outpatient Services10%* No Coinsurance*

Inpatient Services$500 per visit plus 10%* of remaining charges No Coinsurance*

Hospital Emergency RoomDiagnosis must be emergent in nature $300 per visit plus 10%* of remaining charges No Coinsurance*

Urgent Care Center10%* No Coinsurance*

Ambulance Service

10%* No Coinsurance*

MaternityBenefits based on service setting Benefits based on service setting

Diabetes Services

Benefits based on service setting Benefits based on service setting

Durable Medical Equipment, Prostetics, OrthoticAppliances, and Ostomy Supplies 10%* No Coinsurance*

Prescription DrugsUp to 30 day supply, including diabetic supplies, per prescription or refill.Two over-the-counter vials of insulin. One-unit limit for inhaler aid devicessuch as aerochambers, inspirease, etc.



No Coinsurance*

Mail Order Prescription DrugsUp to 90 day supply, including diabetic supplies, per prescription orrefill. Six over-the-counter vials of insulin.



No Coinsurance*Specialty: Not Covered

$6,850/$6,850$13,700/$13,700

$1,250/$6,850$2,500/$13,700

*Services are subject to the Medical Deductible and apply toward the Medical Out-of-Pocket limit.*Services are subject to the Medical Deductibleand apply toward the Medical Out-of-Pocket limit.


Marquee Catastrophic 6850Marquee Gold 1250

8

Additional Plans offered by PHP

PHP also offers Gold and Catastrophic tiered plans. Depending on your financial situation one of these plansmay be better suited for you and your family.

Gold Plans are designed for individuals who don’t mind paying higher premiums to have a larger percentageof their medical costs covered and paid at the time of service. Gold plans appeal to individuals who expect tosee doctors and providers frequently and are concerned with being responsible for high coinsurance rates.

Catastrophic Plans are designed to be a more affordable option for those seeking lower premiums, and protection from high healthcare costs that may occur. Catastophic plans still include coverage for many preventive services at no out-of-pocket costs. Eligibility restrictions do apply for Catastrophic Plans.

Additional Plans

5











Doctor’s Office VisitIllness, injury, or sickness No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

Other Practitioner Visits No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

DiagnosticRoutine radiology and lab services (ex. chest x-ray,MRI, blood and urine tests). No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

Outpatient Services No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

Inpatient ServicesNo Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

Hospital Emergency RoomDiagnosis must be emergent in nature

$300 Copay per visit,remaining charges apply

toward deductible*

$300 Copay per visit, remaining charges apply

toward deductible*


toward deductible*


toward deductible*

Urgent Care CenterNo Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

Ambulance Service

No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*





setting





setting

Durable Medical Equipment,Prosthetics, Orthotic Appliances, and Ostomy Supplies No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*



Mail Order Prescription DrugsUp to 90 day supply, including diabetic supplies,per prescription or refill. Six over-the-countervials of insulin. No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

$3,500/$4,500$7,000/$9,000

$3,100/$4,000$6,200/$8,000

$1,200/$2,100$2,400/$4,200

$500/$1,400$1,000/$2,800

*Services are subject to the Medical Deductible and apply toward the Medical Out-of-Pocket limit.

Open Enrollment for 2016

Generally you and your family can only purchase new coverage during the annual open enrollment period.For 2016, this period is November 1, 2015 through January 31, 2016. Outside of this annual open enrollment period, you may still be eligible to purchase coverage if you experience a qualified special enrollment event, such as a marriage, birth of a child, change in employment, etc.

The Marketplace will help you verify your eligibilty. More information is available through theMarketplace at www.healthcare.gov or at 1-800-318-2596.

6

Bronze Plans are best suited for:

l Those wanting more control of how their healthcare dollars are spentl Anyone willing to trade a higher deductible for lower premiums while

maintaining basic coverage for accident and illness

Bronze plans allow you to pay less for your monthly premium in exchange for a higher deductible when seekingcare. PHP has a broad list of benefits and deductibles available in the bronze metal tier. If choosing a lowmonthly premium is important and you are willing to pay higher out-of-pocket costs when you see a doctor ormedical provider, one of the bronze plan options may be right for you.

Bronze Plans

7

Covered Benefits Bronze Plans Bronze Choice PlanMarquee Bronze

3750Marquee Bronze

5000Marquee Bronze

6000In-Network Out-of-Network




Preventive ServicesServices rated ‘A’ or ‘B’ by the U.S. PreventiveServices Task Force, and immunizations rec-ommended by the Advisory Committee onImmunization Practices of the Centers forDisease Control and Prevention. Preventivecare and screenings for women and childrenas recommended by the Health Resources andServices Administration. For a complete list,please visit our website.





50%*

Doctor’s Office VisitIllness, injury, or sickness 40%*

$50 each for 3 visits percovered person, then



50%* 50%*

Other Practitioner Visits 40%* 50%* No Coinsurance* 50%* 50%*

DiagnosticRoutine radiology and lab services (ex. chest x-ray, MRI, blood and urine tests).

40%*50%*

No Coinsurance* 50%* 50%*

Outpatient Services40%* 50%* No Coinsurance* 50%* 50%*

Inpatient Services40%* $500 per visit plus 50%*

of remaining charges No Coinsurance*$500 per visit plus50%* of remaining

charges

$500 per visit plus 50%*of remaining charges

Hospital Emergency RoomDiagnosis must be emergent in nature $300 per visit plus 40%*

of remaining charges$300 per visit plus 50%*

of remaining charges


toward deductible*

$300 per visit plus50%* of remaining

charges

Covered as In-Network benefit

Urgent Care Center40%* 50% No Coinsurance* 50%* 50%*

Ambulance Service40%* 50%* No Coinsurance* 50%* Covered as

In-Network benefit

MaternityBenefits based on

service settingBenefits based on




service setting

Diabetes ServicesBenefits based on





service setting

Durable Medical Equipment,Prostetics, Orthotic Appliances, and Ostomy Supplies 40%* 50%* No Coinsurance* 50%* 50%*


40%*

Generic Drug: $25Formulary Brand:

50%*Non-formulary Brand:

50%*Specialty: 50%*

No Coinsurance*



50%*Specialty: 50%*

Not Covered

Mail Order Prescription DrugsUp to 90 day supply, including diabetic sup-plies, per prescription or refill. Six over-the-counter vials of insulin.

40%*Specialty: Not Covered

Generic Drug: $75Formulary Brand: $180Non-formulary Brand:






Not Covered


Thinking of opening a Health Savings Account?

Many of our Bronze Plans are qualified high deductible health plans that can be used in conjunction with aHealth Savings Account (HSA). An HSA can be obtained from the bank of your choice, and funds in yourHSA grow tax-free. Also, there is not a requirement to use the funds within a specified timeframe so youcan save for future healthcare expenses.

Like our other plans, when you purchase a qualified high deductible health plan you can see any providerin our network. The Marquee plans that are qualified high deductible health plans are: Marquee Silver3500, Marquee Bronze 3750, and Marquee Bronze 6000.

$6,000/$6,550$12,000/$13,100

$5,000/$6,850$10,000/$13,700

$3,750/$6,550$7,500/$13,100

$5,000/$6,850

$10,000/$13,200$10,000/$20,000

$20,000/$40,000

6

Bronze Plans are best suited for:

l Those wanting more control of how their healthcare dollars are spentl Anyone willing to trade a higher deductible for lower premiums while

maintaining basic coverage for accident and illness

Bronze plans allow you to pay less for your monthly premium in exchange for a higher deductible when seekingcare. PHP has a broad list of benefits and deductibles available in the bronze metal tier. If choosing a lowmonthly premium is important and you are willing to pay higher out-of-pocket costs when you see a doctor ormedical provider, one of the bronze plan options may be right for you.

Bronze Plans

7

Covered Benefits Bronze Plans Bronze Choice PlanMarquee Bronze

3750Marquee Bronze

5000Marquee Bronze

6000In-Network Out-of-Network




Preventive ServicesServices rated ‘A’ or ‘B’ by the U.S. PreventiveServices Task Force, and immunizations rec-ommended by the Advisory Committee onImmunization Practices of the Centers forDisease Control and Prevention. Preventivecare and screenings for women and childrenas recommended by the Health Resources andServices Administration. For a complete list,please visit our website.





50%*

Doctor’s Office VisitIllness, injury, or sickness 40%*




50%* 50%*

Other Practitioner Visits 40%* 50%* No Coinsurance* 50%* 50%*

DiagnosticRoutine radiology and lab services (ex. chest x-ray, MRI, blood and urine tests).

40%*50%*

No Coinsurance* 50%* 50%*

Outpatient Services40%* 50%* No Coinsurance* 50%* 50%*

Inpatient Services40%* $500 per visit plus 50%*

of remaining charges No Coinsurance*$500 per visit plus50%* of remaining

charges

$500 per visit plus 50%*of remaining charges

Hospital Emergency RoomDiagnosis must be emergent in nature $300 per visit plus 40%*

of remaining charges$300 per visit plus 50%*

of remaining charges


toward deductible*

$300 per visit plus50%* of remaining

charges

Covered as In-Network benefit

Urgent Care Center40%* 50% No Coinsurance* 50%* 50%*

Ambulance Service40%* 50%* No Coinsurance* 50%* Covered as

In-Network benefit

MaternityBenefits based on





service setting

Diabetes ServicesBenefits based on





service setting

Durable Medical Equipment,Prostetics, Orthotic Appliances, and Ostomy Supplies 40%* 50%* No Coinsurance* 50%* 50%*


40%*



50%*Specialty: 50%*

No Coinsurance*



50%*Specialty: 50%*

Not Covered

Mail Order Prescription DrugsUp to 90 day supply, including diabetic sup-plies, per prescription or refill. Six over-the-counter vials of insulin.


Generic Drug: $75Formulary Brand: $180Non-formulary Brand:






Not Covered


Thinking of opening a Health Savings Account?

Many of our Bronze Plans are qualified high deductible health plans that can be used in conjunction with aHealth Savings Account (HSA). An HSA can be obtained from the bank of your choice, and funds in yourHSA grow tax-free. Also, there is not a requirement to use the funds within a specified timeframe so youcan save for future healthcare expenses.

Like our other plans, when you purchase a qualified high deductible health plan you can see any providerin our network. The Marquee plans that are qualified high deductible health plans are: Marquee Silver3500, Marquee Bronze 3750, and Marquee Bronze 6000.

$6,000/$6,550$12,000/$13,100

$5,000/$6,850$10,000/$13,700

$3,750/$6,550$7,500/$13,100

$5,000/$6,850

$10,000/$13,200$10,000/$20,000

$20,000/$40,000

8

Additional Plans offered by PHP

PHP also offers Gold and Catastrophic tiered plans. Depending on your financial situation one of these plansmay be better suited for you and your family.

Gold Plans are designed for individuals who don’t mind paying higher premiums to have a larger percentageof their medical costs covered and paid at the time of service. Gold plans appeal to individuals who expect tosee doctors and providers frequently and are concerned with being responsible for high coinsurance rates.

Catastrophic Plans are designed to be a more affordable option for those seeking lower premiums, and protection from high healthcare costs that may occur. Catastophic plans still include coverage for many preventive services at no out-of-pocket costs. Eligibility restrictions do apply for Catastrophic Plans.

Additional Plans

5











Doctor’s Office VisitIllness, injury, or sickness No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

Other Practitioner Visits No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

DiagnosticRoutine radiology and lab services (ex. chest x-ray,MRI, blood and urine tests). No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

Outpatient Services No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

Inpatient ServicesNo Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

Hospital Emergency RoomDiagnosis must be emergent in nature


toward deductible*


toward deductible*


toward deductible*


toward deductible*

Urgent Care CenterNo Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

Ambulance Service






setting





setting

Durable Medical Equipment,Prosthetics, Orthotic Appliances, and Ostomy Supplies No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*



Mail Order Prescription DrugsUp to 90 day supply, including diabetic supplies,per prescription or refill. Six over-the-countervials of insulin. No Coinsurance* No Coinsurance* No Coinsurance* No Coinsurance*

$3,500/$4,500$7,000/$9,000

$3,100/$4,000$6,200/$8,000

$1,200/$2,100$2,400/$4,200

$500/$1,400$1,000/$2,800


Open Enrollment for 2016

Generally you and your family can only purchase new coverage during the annual open enrollment period.For 2016, this period is November 1, 2015 through January 31, 2016. Outside of this annual open enrollment period, you may still be eligible to purchase coverage if you experience a qualified special enrollment event, such as a marriage, birth of a child, change in employment, etc.

The Marketplace will help you verify your eligibilty. More information is available through theMarketplace at www.healthcare.gov or at 1-800-318-2596.













covered person, then 30%* $25 each for 3 visits per covered

person, then 10%*$25 each for 3 visits per covered

person, then 10%*




Inpatient Services30%* 30%* 10%* 10%*





remaining charges


Ambulance Service

30%* 30%* 10%* 10%*





setting





setting




















$2,500/$6,850$5,000/$13,700

$2,500/$5,450$5,000/$10,900

$800/$2,150$1,600/$4,300

$275/$725$550/$1,450

4 9

Covered BenefitsAdditional Plans

Gold Plan Catastrophic Plan




Preventive ServicesServices rated ‘A’ or ‘B’ by the U.S. Preventive Services Task Force, andimmunizations recommended by the Advisory Committee onImmunization Practices of the Centers for Disease Control andPrevention. Preventive care and screenings for women and children asrecommended by the Health Resources and Services Administration.For a complete list, please visit our website.



Doctor’s Office VisitIllness, injury, or sickness $35 per visit

No Coinsurance*Deductible waived for

first 3 primary care visits only.

Other Practitioner Visits10%* No Coinsurance*

DiagnosticRoutine radiology and lab services (ex. chest x-ray, MRI, blood and urinetests). 10%* No Coinsurance*

Outpatient Services10%* No Coinsurance*

Inpatient Services$500 per visit plus 10%* of remaining charges No Coinsurance*

Hospital Emergency RoomDiagnosis must be emergent in nature $300 per visit plus 10%* of remaining charges No Coinsurance*

Urgent Care Center10%* No Coinsurance*

Ambulance Service


MaternityBenefits based on service setting Benefits based on service setting

Diabetes Services

Benefits based on service setting Benefits based on service setting

Durable Medical Equipment, Prostetics, OrthoticAppliances, and Ostomy Supplies 10%* No Coinsurance*

Prescription DrugsUp to 30 day supply, including diabetic supplies, per prescription or refill.Two over-the-counter vials of insulin. One-unit limit for inhaler aid devicessuch as aerochambers, inspirease, etc.



No Coinsurance*

Mail Order Prescription DrugsUp to 90 day supply, including diabetic supplies, per prescription orrefill. Six over-the-counter vials of insulin.




$6,850/$6,850$13,700/$13,700

$1,250/$6,850$2,500/$13,700

*Services are subject to the Medical Deductible and apply toward the Medical Out-of-Pocket limit.*Services are subject to the Medical Deductibleand apply toward the Medical Out-of-Pocket limit.


Marquee Catastrophic 6850Marquee Gold 1250

3

Choose the best payment option for you.Initial Payments may be made by checking or savings account, credit or debit card, or you mayreceive an invoice to pay by check or money order.

Ongoing Payments can be made several different ways. For your convenience, you may set-up amonthly automatic payment from your checking or savings account. You will receive an email prior tothe due date notifying you of the amount that will be deducted from your account if you select thisoption.

You may also elect to receive a monthly invoice, either by U.S. mail or email. Once you receive theinvoice, you may pay by check, money order, or make an online payment using your checking or savings account, credit or debit card.

Try us out.We want you to be satisfied and confident with your PHP Marketplace Plan. That’s why you have a “free-look” period to examine your policy when it is received. If for any reason within the free-lookperiod you decide you no longer want the policy, simply return it to us and the policy will be cancelledand your premium refunded.10

*Services are subject to the Medical Deductibleand apply toward the Medical Out-of-Pocket limit.














covered person, then 10%*$30 each for 3 visits per

covered person, then 10%*




Inpatient Services $500 per stay plus 20%* ofremaining charges








remaining charges


Ambulance Service

20%* 20%* 10%* 10%*





setting





setting




















$1,810/$5,450$3,620/$10,900

$2,000/$6,850$4,000/$13,700

$800/$1,850

$1,600/$3,700

Features of our plans:• Preventive Services covered at 100% for all

plans (Complete list of services found at www.phpni.com)

• All plans available as an Individual or Family Policy

• Many value-added benefits automatically included: 24-hour nurse line, various online health resources, member discounts for health facilities and more

• Prescription drug coverage available with all plans

• Competitive premium rates • Negotiated provider costs to save you money • Exceptional customer service to help you

understand and make the most of your health coverage

$250/$700

$500/$1,400


We are here to help you decide which of ourplans is the right fit for you and your family.

2

Phone NumbersVoice: (260) 432-6690, ext. 810Toll-free: 1-800-982-6257, ext. 810Hearing Impaired: (260) 459-2600

AddressAttn: Individual Product Physicians Health Plan8101 West Jefferson Blvd.Fort Wayne, IN 46804

[email protected] help us provide excellent service,be sure to include your name and yourdaytime phone number.

Web Addresswww.phpni.com

Eligibility Requirements

Individuals applying for PHP Marquee plans must do so through the Marketplace website,www.healthcare.gov. The Marketplace will determine you and your family’s eligibility to purchase coverage. Based on your financial circumstances, the Marketplace may apply Advance Premium TaxCredit (APTC), or cost-share reductions to help make your coverage more affordable. Keep in mind, the Marketplace can determine your eligibilty for these special tax credits.

11

Silver Plans

l Those wanting more control of how their healthcare dollars are spent

l Families who regularly schedule doctor’s appointments and well-child visits

l Those who prefer to pay less at the time of service

All Silver plans offer the same set of essential health benefits. Silver plans have a higher monthly premium andoften have lower out-of-pocket costs than Bronze and Catastrophic plans.

Silver Plans

MyNurse 24/7Health concerns don’t always arise while thedoctor’s office is open. Our members haveaccess to a toll-free, 24-hour nurse line servicefor noncritical situations. Members can speakwith experienced, knowledgeable nurses whoanswer questions with sound, clinically basedinformation day or night.

MyHealth 24/7This interactive, online resource acts as a 24-hourmedical advisor to help find solutions to commonhealth problems. Evaluate symptoms and overallhealth, use quizzes and calculators to improveand maintain weight, or search the pharmacysection to compare drugs and lower expenses.

HealthNEWS NewsletterMembers receive a quarterly newsletter that offershealth and wellness information from nutrition andexercise, to seasonal health concerns and medicalnews. Each issue includes an update of our providernetwork as well as local events and member discounts.

Value-added services included with every PHP Marketplace health plan

Smoking Cessation In keeping with our mission of encouraging preventive health maintenance, we offer coverageto help you in your goal to quit smoking. Additionalinformation on the Indiana Quitline, tobacco inter-vention programs, community classes, and supportgroups to quit smoking are also provided.

Member DiscountsOur members are eligible to receive a variety ofspecial discounts at select area health clubs, community classes, and facilities such as:

• Free trial memberships, discounts on enrollmentfees, annual memberships, and training packages

• Discounts on medically supervised programs• Discounts on prescription eyewear• Sporting event discounts

A complete listing of member discounts is availablein HealthNEWS, and also online at www.phpni.com.

Think you might qualify for a subsidy or tax credit?

Low and moderate income individuals and families may qualify for premium tax credits and cost-sharingreductions through the Marketplace at www.healthcare.gov. If you qualify, a tax credit may be used topay a portion of your premium. If you qualify for a cost-sharing subsidy, you will get a deduction of out-of-pocket costs from the federal government. Visit our website, www.phpni.com to find out moreinformation regarding tax credits that may be available to you and your family.

Financial assistance from the federal government is only available if you purchase coverage through theMarketplace. Individuals are not eligible for premium subsidies or cost-sharing reductions if they are eligiblefor Medicare, Medicaid, or an affordable employer-sponsored health plan with comprehensive coverage.

Our commitment to you.Excellence in customer service and greater freedomare only a few reasons our members are happywith PHP year after year. We are committed to providing you with the best service.

Because we are based right here in NorthernIndiana, we offer easy access to a large local net-work of healthcare providers. Go online towww.phpni.com/phpselect to search our exten-sive, open access network of providers

An ounce of prevention is worth a pound of cure.All of our plans pay 100% of many important preventive services including well-baby care,immunizations, mammograms, pap tests, andannual physical exams when ordered by a participating provider.

Providing you the tools to manage your healthcare.You have around-the-clock access to powerfulonline resources at www.phpni.com. Whether you arelooking for a physician, researching drug information,or checking your personal account for benefit andclaim information, our site allows you to manageyour health when it’s most convenient for you.

PHP Marquee Plans: Health coverage forindividuals and families, purchased throughthe Health Insurance Marketplace.

PHP Marketplace Plans

1

PHP Sales Area forMarketplace Plans

Applicants must reside in one of these Indiana counties to be eligible for coverage.

12

Emergency care benefits that apply anywhere in the world. While traveling, members are covered should emergency services be needed. Just show yourmember ID card at the time of service.

We’re here to help you choose the right coverage.PHP understands choosing the right health plancan be a complicated decision. Consider the following factors to select the right plan for you:

l Premium: The higher the level of benefits a plan offers, the higher the premium. Generally, the more you pay in monthly premiums, the more the plan pays toward your medical expenses.

l Benefits: Each metal level provides coverage for the same minimum essential health benefits and in-network preventive care services.

l Copays: Fixed flat fees for health services or medication. Not all plans have copays.

l Deductibles and Coinsurance: Deductibles and coinsurance will vary even among plans in the same metal level.

The next several pages will help you compare the various types of plans we have available on the Marketplace:Gold Plans Most like traditional plans with copays and/or lower coinsurance for medical services.

Silver Plans Traditional and HSA-qualified plan options that can provide cost-share reductions for some individuals, depending on financial qualifications.

Bronze Plans More cost effective plan offerings that, in most situations, can be coupled with an HSA for financial savings.

Catastrophic Plans Basic coverage for accident and illness with the lowest possible premium.

8101 West Jefferson Blvd.Fort Wayne, IN 46804

www.phpni.com

2016 MarketplacePurchaser GuideYour guide to buying PHP Marquee plans for individuals and families on the Indiana Health Insurance Marketplace.

©2016 PHPNI, Inc.October 2015 www.phpni.com

Date post:	10-Oct-2020
Category:	Documents
Upload:	others
View:	1 times
Download:	0 times

2016 Marketplace Purchaser Guide - Get Health Insurance ... · An ounce of prevention is worth a...

Documents