New Hampshire Core Coverage HMO March 2010

© 2009 Harvard Pilgrim Health Care2 New Hampshire Core Coverage  2 Core Coverage HMO Plans –$1,500 –$2,500  Start Sell February 1, 2010  Effective date April 1, 2010

© 2009 Harvard Pilgrim Health Care3 New Hampshire Core Coverage HMO plan with:  Limited number of office visits with $40 co-pay prior to deductible and coinsurance –3 Medical visits per member, 6 per Family contract before deductible applies –3 Behavioral Health visits per member, 6 per Family contract before deductible applies –Medical visits include preventive, routine and sick visits  20% coinsurance after deductible, up to OOP Maximum  $1,500 DME limit per calendar year  $250 ER co-pay –ER room care is not subject to the Deductible or coinsurance  $10 Allergy shot co-pay  Calendar year plans  PCP’s and referrals required Features of NH Core Coverage

© 2009 Harvard Pilgrim Health Care4 New Hampshire Core Coverage $1,500 and $2,500 $1,500 – ( U-LW)  $1,500 Deductible per member, $4,500 Deductible per family PCY  OOP Maximum $3,000 per member, $6,000 per family PCY $2,500 – (V-LW)  $2,500 Deductible per member, $7,500 Deductible per family PCY  OOP Maximum $5,000 per member, $10,000 per family PCY No 4 th Qtr deductible rollover Both Plans are Mass Minimum Creditable Coverage compliant

© 2009 Harvard Pilgrim Health Care5 Rx Coverage (86)  Cost sharing for retail - up to 30-day supply: –Tier 1:$15 copayment –Tier 2:50% coinsurance –Tier 3:50% coinsurance  Cost sharing for mail order/90-day supply: –Tier 1:$30 copayment –Tier 2:50% coinsurance –Tier 3:50% coinsurance ▪ Out of Pocket Maximum $2,000 per member, then covered in full

© 2009 Harvard Pilgrim Health Care6 How It Works 1.Some services received during a medical office visit may be subject to a calendar year deductible. 2.Examples of outpatient medical office visits include routine care; preventative care; sick visits; eye examinations; family planning; consultations with specialists; physical, speech and occupational therapies; and chiropractic care. 3.Copayment amounts for office visits, emergency services and allergy injections are different. Please note: Blood glucose monitors, insulin pumps and supplies, and infusion devices are covered in full. No copayments, deductibles or coinsurance are applied. These benefits do not apply towards the DME benefit limit.

© 2009 Harvard Pilgrim Health Care7 Example  Jim, Mary & baby Jill on contract  Baby Jill has already been to the pediatrician 3 times  This is Jim’s 3 rd visit, subject to an OV copayment = 6 th Medical OV as a family  The next & subsequent medical visits by a member/s on the contract will be subject to the deductible, then coinsurance  Once annual deductible has been met, the member is responsible for 20% coinsurance up to the OOP Maximum

© 2009 Harvard Pilgrim Health Care8 Copayments  First 3 individual or 6 family visits have a cost sharing of a $40 copayment  HPHC does not know when a provider has been seen until we receive the claim –What happens is the first 3/6 claims received will have the $40 copayment applied Example  Let’s assume the member has seen a specialist on their 3rd visit and the following week they see their PCP.  The member believes that the specialists visit will be covered at the $40 OV copayment  However, the PCP submits his claim in a more timely manner than the specialist  The $40 copay will be assigned to the PCP’s visit as it’s associated claim came to HPHC first and the specialists office visit will go to the members’ deductible

© 2009 Harvard Pilgrim Health Care9 HPHC ID Card Sample

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