1. 2017 NH Broker Playbook: Individual Business

2. Agenda Who We Are / Our Value Product & Network
Value-Added Programs & Services
Discounts & Savings
Broker Portal & Support
Product Grids
Contact Information

3. Who we are, and why you can Count Us In
Harvard Pilgrim is a not-for-profit health services company founded by doctors in 1969
Local presence in each market served, including Manchester, NH
Consistently among the nation’s highest-rated health plans*
Our mission is to improve the quality and value of health care for the people and the communities we serve
We do that through the health plans we offer, as well as through:
- The Harvard Pilgrim Health Care Institute, a research and teaching collaboration with Harvard Medical School; and
- The Harvard Pilgrim Health Care Foundation, which provides tools, training, and leadership to help build healthy communities.
* Harvard Pilgrim Health Care of New England is currently rated 4.5 out of 5 for its private HMO/POS plans in NCQA’s Private Health Insurance Plan Ratings NCQA’s Private Health Insurance Plan Ratings NCQA’s Private Health Insurance Plan Rankings, , HMO/POS.
Important to emphasize the NON Profit. We also have a presence in the local community, with volunteer time and non profit support. located in the Portland – accessible, here with longevity.
Our HEDIS scores are among the highest in the nation
We have always been a leader in care innovation, as demonstrated by our NCQA performance.
Our Disease Management Programs have been reported as one of the “Most Effective Health Plan Disease Management Programs: Statewide or Regional Health Plans” with the “Best disease management outcomes in United States” by Health Industries Research Companies, an independent, nonpartisan organization that conducts strategic market research on trends in health care, pharmaceutical and managed care businesses
The Harvard Pilgrim Institute is the only appointing medical school department in the United States based in a health plan – a big differentiator for us among our competitors. Their Department of Population Medicine is a unique collaboration between Harvard Pilgrim and Harvard Medical School. Every day they put science to work for the communities Harvard Pilgrim serves. Through innovative research and teaching the Institute’s staff of leading physicians, researchers, clinicians and public health professionals focus on improving health care delivery and the health of society. Research conducted by the Institute has been featured in leading publications and news outlets throughout the world. Given the nation’s focus on improving health care quality and reducing health care costs, the Institute’s work is more relevant and important than ever before
We also have numerous Quality Programs across our provider network as well as new payment and delivery models that are transforming care and improving value in all of the markets we serve 3

4. The Harvard Pilgrim value proposition
Strong reputation and recognition for:
Customer satisfaction
Clinical quality and care management
Wellness programs
Commitment to diversity and inclusion; Eastern Harmony program
A leadership role in improving quality and value
Ease of doing business
Dedicated sales and customer service teams for you and your clients
HarvardPilgrim.org, the pathway to online tools and self-service 4

5. 2017 New Hampshire Individual Product and Plan Offerings

6. Individual plans on and off the exchange
Two defined network options available on and off the exchange
ElevateHealth Network with five plans across the metal spectrum including HSA plans
New Hampshire Network with three plans across the metal spectrum including one bronze HSA plan
One-tiered network option available off-Exchange only
ElevateHealth Options Network with a gold offering and a silver offering 6

7. Defined networks: How they work
Members must choose a PCP and receive all care through a defined network provider
Use our online directory to find a participating provider
Standard HMO rules apply – referrals needed for specialist visit
Member liable if out of network provider is seen, even if referred by PCP
Prior authorization from Harvard Pilgrim is required for complex specialty care not otherwise available within network
Exception – all emergency services are covered by the plan 7

8. Plan metal tier choice guide
CONSUMER
Willing to pay for richer benefits
CONSUMER
Subsidy eligible
Seeks value in coverage
CONSUMER
Healthy consumers
Buying coverage to avoid fines
GOLD HMO & HSA HMO
Highest premiums
Lowest cost share
Deductible range of $1,000-$1,500
Coinsurance range of 0%-20%
More copay services
SILVER HMO & HSA HMO
Lower premiums
Lower cost sharing
Deducible range of $2,500-$3,500
Coinsurance range of 15%-40%
BRONZE HMO & HSA HMO
Lowest premium
Highest cost share
Deductible range of $5,100-$6,300
Coinsurance range of 0%-40%
Update deductible information
Note: For HSA plans, a deductible applies before most services are covered. 8

9. New for 2017: ElevateHealth Options

10. ElevateHealth Options – A Full Tiered Network ProductME CT
Tier 2
Featuring the ElevateHealth network
ElevateHealth
Network
Tier 1 NH MA
ElevateHealth Options is a full network product that features two tiers of hospitals and providers
Tiered product allows consumer choice while maintaining the lowest possible premium for a full network product VT RI

11. ElevateHealth Options: How it works
Member can choose a PCP in either tier
Same PCP referral process as other full network products
Authorized Access provider not applicable
Member responsible for cost share associated with providers tier
Rx is not tiered
Behavioral Health defaults to Tier 1

12. ElevateHealth Options: Deductible design
Maximum deductible is equal to the Tier 2 deductible
Tier 2
Tier 1
Cross-accumulating deductible
Deductible met in one tier applies toward the other tier’s deductible 12

13. ElevateHealth Options: Deductible design
Cross-accumulating deductible
Deductible met in one tier applies toward the other tier’s deductible
Services are covered when the deductible amount in each tier is met
Deductible amount depends upon the tier of the provider
Maximum deductible is equal to the Tier 2 deductible 13

14. ElevateHealth Options map
ElevateHealth hospitals shown at right are all in Tier 1
All other hospitals in Harvard Pilgrim’s network – NH, MA, ME, VT and CT – are in Tier 2 14

15. ElevateHealth Options
Two plans with the ElevateHealth Options network offered off-Exchange
ElevateHealth Options Gold 1000
ElevateHealth Options Silver 3000 15

16. ElevateHealth Options sample ID card16

17. To find ElevateHealth Options participating providers, visit www
To find ElevateHealth Options participating providers, visit
Click on Find a Doctor
Make sure the ElevateHealth Options plan is selected
Search by preferred provider type 2 3 17

18. Tier designation in the directory

19. ElevateHealth Network

20. ElevateHealth Smaller network for lower premium
700+ primary care physicians
3,300+ specialists
18 Easy Access hospitals
Network coverage in all NH counties except Carroll
Includes Brattleboro Memorial Hospital in Brattleboro VT
Note: hospital admitting privileges is not an indication of network participation. To find a provider participating in this network please use the ElevateHealth online directory 20

21. Our 2017 ElevateHealth individual plans
Five plans with the ElevateHealth network offered on and off-Exchange
ElevateHealth Gold HSA 1500
ElevateHealth Silver 3500 ElevateHealth Silver HSA 3000
ElevateHealth Bronze 5750 ElevateHealth Bronze HSA 6300 21

22. Features of ElevateHealth Bronze 5750
Individual deductible of $5750 and family of $11,500
40% coinsurance
First four office visits per member are subject to copay only
Maximum of eight office visits per family at copay
Office visits exceeding this are subject to deductible and coinsurance
Preventive services are covered in full 22

23. ElevateHealth ID card 23

24. To find ElevateHealth participating providers, visit www
To find ElevateHealth participating providers, visit
Click on Find a Doctor
Make sure the ElevateHealth plan is selected
Search by preferred provider type 2 3 24

25. New Hampshire Network

26. New Hampshire Network All 26 New Hampshire hospitals
Brattleboro Memorial Hospital in Vermont
*Provider groups associated with these hospitals
Only available for our individual members
*Note: hospital admitting privileges is not an indication of network participation. To find a provider participating in this network please use the NH Network online directory 26

27. Our 2017 New Hampshire individual plans
Three plans with the New Hampshire Network offered on and off Exchange
NH Network Gold 1000
NH Network Silver 2500 Premium
NH Network HSA Bronze 5100 27

28. New Hampshire Network ID card28

29. To find New Hampshire Network participating providers, visit www
To find New Hampshire Network participating providers, visit
Click on Find a Doctor
Make sure the New Hampshire Network plan is selected
Search by preferred provider type 2 3 29

30. General information about our plans

31. Benefits – preventive services
Preventive services are covered in full
Routine physicals and annual gyn exams
Outpatient prenatal care
Many common preventive tests, including (but not limited to):
mammogram and pap smear
routine urinalysis
immunizations for children and adults
non-diagnostic colonoscopy
certain tests recommended based on age and habits
Complete list is at 31

32. New! Telemedicine services: Doctor on Demand
Convenient, cost-effective alternative to ER for minor urgent care
Real-time virtual visit via smartphone, tablet or computer
No referral needed; PCP cost-sharing applies
Standard benefit for fully insured and self-insured group plans 32

33. $$$ $$ $ Urgent care Hospital- based urgent care
For minor illness and injury when your PCP is not available
Telemedicine and convenience care
Free-standing urgent care
Hospital- based urgent care
$$$ $$ $ 33

34. Out-of-area dependent coverage
All of our HMO plans include coverage for dependent children under the age of 26 living outside the enrollment area
The subscriber must call Member Services to register the O-O-A dependent (888)  
Routine and non-routine services are covered 34

35. Out-of-area dependent coverage
Prior approval is needed from Harvard Pilgrim before receiving certain services
Please see member handbook for additional information or call us
Subscribers are referred to the PPO online directory to find Option providers and avoid balance billing issues from non-plan providers
Option providers may not balance bill 35

36. All individual plans share the following:
Most deductibles (HSA and Non HSA) are embedded
The most an individual family member will contribute to the family deductible is the Individual deductible
All Out-of-pocket Maximums cross accumulate
Emergency Care covered in network and out of network
Always covered at the “in-network” benefit level 36

37. Value-added programs Acupuncture – 20 visits per calendar year
Must use a network participating provider
Access to discount programs once benefit limit is reached
Chiropractic care – 12 visits per calendar year
Routine eye exam every 24 months - Plus free eyewear and discount programs available
Many discount and savings programs – expanded fitness reimbursement eligibility 37

38. Prescription Drug Benefit

39. Standard Rx
All Rx costs apply to the single Medical/Rx out-of-pocket maximum
Value Formulary
Only excludes drugs that have more cost-effective, FDA-approved alternatives
On average <5% of members have medications that are not covered on the Value formulary
4-tier structure
If the cost of the medication is less then the copay, the member only pays the cost of the medication
Includes generic brands, preferred brands, non-preferred and specialty brands, and non-preferred specialty bands
With the Value formulary, you’ll always find a drug alternative to non-covered drugs. More specifically, 70% of drugs excluded from our Value formulary have covered generic equivalents.
Harvard Pilgrim Pharmacy and Therapeutics Committee will review new-to-market drugs on an individual basis to determine coverage on the Value formulary.
Utilization Management (Prior Authorization, Step Therapy, Quantity Limitations) still apply to some covered drugs
has clearly identified Value formulary section 39

40. Value Formulary tiers – individual plans
Value 4-Tier
Generics only
Preferred Brands (some high cost generics)
Non-preferred brands and preferred specialty (some higher cost generics)
Non-preferred specialty drugs (very high cost brand and generic drugs)
Tier 1
Tier 2
Tier 3
Tier 4 40

41. Helping members stay healthy, for less!
Discounts & Savings
UPDATE YMS section – add web address of where this is
Helping members stay healthy, for less!

42. Count us in for discounts to help members maintain a healthier lifestyle
$150 reimbursement per Harvard Pilgrim policy holder; expanded club/facility eligibility
15% off footwear at Runner’s Alley (NH) 20% off
Appalachian Mountain Club membership
Jenny Craig
Weight Watchers
Diet.com
iDiet
Meals to Heal
Nutrition
Fitness
Complementary and alternative medicine
Eye and Ear
FREE eyewear program at Visionworks
Discounts at Visionworks, JCPenny Optical, LensCrafters, Pearle Vision, Sears Optical and Target Optical
Hearing aids
10-30% off acupuncture, chiropractic care, yoga, Chinese herbal medicine and more
Massage Envy
Mindful magazine
RESPerRATE blood pressure therapy

43. Disease and care management: Our programs to support a culture of health
Acute Conditions
Post Hospitalization Calls
Clinical Transitions
Shared Decision Making
High Cost Outreaches
Social Work Program
Chronic Conditions
Cardiac Disease – CAD & CHF
Chronic Lung – Asthma & COPD
Diabetes
Complex care for co-morbidities
Highest Risk
Oncology
Chronic Kidney Disease/ESRD
Rare Diseases
Complex Care
Gender Transition
Utilization Management
Medical Necessity
Pharmacy
Radiology
Home Care / SNF
Spine Management
Outpatient Therapy Review
Harvard Pilgrim wellness
Lifestyle Management & Coaching
Hypertension /Cholesterol
Smoking Cessation
Obesity/ Weight Management
Stress Management
Nutrition
Diabetes
Mind the Moment
ADD BENEVERA here – John how would you incorporate

44. Improving our member Web site experience (www.harvardpilgrim.org)
Major redesign based on extensive member research
Task-oriented navigation; personalized with info based on member’s specific plan
Improved accessibility – mobile, tablet and desktop friendly; better support for use of assistive technologies
Launch scheduled for Q4 2016
Harvard Pilgrim is making a significant investment in upgrading and redesigning our corporate Web site to improve the online experience for our members. We’ve partnered with an experiential design agency to help us define our “member-first” strategy for the new site. The strategy has been informed by extensive research and analysis, including interviews and usability testing with real members and by thorough examination of the questions most commonly received in our Member Services Department.
We’re making the site more task-oriented and personalized, while improving accessibility. The goal is to deliver a much improved, personalized experience for our members, enabling them to get quick access to easy-to-understand information they need to effectively manage health care for themselves and for their families.
The new member site is slated to be introduced in the fall of 2016. 44

45. Members can make the most of their plan by logging in to their secure account to:
Look up their benefits, copays, claims history, deductible status, and authorization and referral activities
Take advantage of discounts and savings on eyeglasses and contact lenses, dental care, nutrition and weight management programs, sneakers, fitness clubs and much more
Learn how their plan covers preventive care and conditions such as asthma, diabetes, COPD and high blood pressure 
Access helpful tools and resources: find a doctor or a specialist, take a personal health assessment, ask a pharmacist about over-the-counter medicines, connect with a personal health coach, participate in a guided mindfulness course, and more
(beginning Q4 2016)
HPHConnect makes it so easy to manage your HPHC benefits…go online 24 hours a day, 7 days a week. It’s also a highly secure and confidential system. HPHConnect lets you…
read through slide
Our system is simple, secure and free…it’s just one of the many ways we’re making great health care easier!
We’re also continually updating our web site, with new features that are innovative, exciting and reliable…log on today to see what’s new!

46. Individual Business – Broker Support

47. Open Enrollment Dates and Deadlines
Open Enrollment: November 1, 2016 – January 31, 2017 47

48. 2017 renewal process – how it’s going to work
Brokers will receive a renewal report for their existing book of business
Sample renewal letters
Product Mapping Grid of 2016 products to 2017 products
Renewal Hot Line
Consumer Sales Team will assist with questions regarding benefit changes
Off-Marketplace renewals can be conducted via:
Phone enrollments by Consumer Sales Team – (844)
Broker will remain broker of record unless Harvard Pilgrim is notified otherwise 48

49. 2017 renewal process tools
Renewal report will be ed to Brokers & Agencies with their renewal book of business containing:
Name of Customer and HP ID#
2016 Premium and Product
2016 Average Premium Tax Credit
2017 Premium and New Product (mapped)
DELETE 49

50. 2016 Renewal Process Tools - OFF EXCHANGE
Off Exchange Renewal - INSTRUCTIONS
Off Exchange members CANNOT make their plan change on Harvardpilgrim.org - they MUST call consumer sales team
Off Exchange members must make a plan change by December 15,  If no changes made, member will automatically renew
Members have 2 options:
Passive Enrollment - Member likes 2017 plan changes presented in renewal letter
 Do Nothing. Member automatically enrolled and continues to pay monthly premium.
Active Enrollment - Member does not like 2017 plan changes presented in renewal letter
Take Action.  Member has 2 ways to find other plans and enroll
HPHC will review plans and make change via the phone OR.
HPHC will mail a quote and a paper enrollment form 50

51. 2016 renewal process tools – Marketplace
MARKETPLACE RENEWALS - INSTRUCTIONS
Marketplace Renewals must be completed on the Marketplace to avoid member disruption
Harvard Pilgrim can provide assistance with 2017 benefit questions but any plan changes must be completed on the Marketplace
Marketplace changes must be made by December 15,  If no changes made, member will automatically renew
Members have 3 options:
Passive Enrollment - Member likes 2017 plan changes presented in renewal letter, and there are no changes to Marketplace application information
 Do Nothing. Member automatically enrolled and continues to pay monthly premium.
Active Enrollment - Member likes 2016 plan changes presented in renewal letter, and there are changes to Marketplace application information
Take Action.  Member must go back to the Marketplace to update information and re-enroll.
Active Enrollment - Member does not like 2017 plan changes presented in renewal letter
Take Action.  Member has 2 ways to find other plans and enroll
Visit HealthCare.gov and look at other Marketplace plans.
Visit HealthCare.gov and see if qualify for Medicaid or the Children’s Health Insurance Program. 51

52. Marketplace Renewals - Payment
For January 2017 renewals: If NH or ME subscribers receive coverage through the Marketplace and are on Auto Pay, they will need to visit the PaySpan Web site and re-enroll in Auto Pay between December 5 and December 20, 2016, in order for automatic payments to carry forward into the new contract year.
PaySpan is Harvard Pilgrim’s online payment vendor
Instructions for re-enrolling in Auto Pay are in their renewal.
Failure to re-enroll in Auto Pay could result in a lapse in coverage 52

53. Broker support – tracking enrollments
Consumer Enrollment Tracker
Available on Broker Web page at harvardpilgrim.org/broker
Brokers will be able to:
Track applications that are submitted
View status of an enrollment
Application received /Waiting for payment = application on hold waiting for binder payment
Under manual review = missing information requires manual intervention
Processing = Harvard Pilgrim has all information and binder is being processed
Enrolled = Successfully processed application
Cancelled = never received binder payment within 10 days post effective date
Termed = Terminated membership with Harvard Pilgrim 53

54. Consumer enrollment tracker
Broker Name
Displays book of business on and off exchange
Use tool bar on left to enter search criteria
Enter in Username and password provided by Broker Relations click “Login” 54