2018 ME Broker Playbook Individual Business Agenda Who

2018 ME Broker Playbook: Individual Business

Agenda § Who we are / our value § Our mission § Our networks § Our products – Medical plans – Pharmacy – General information about our plans § Discounts & savings § Broker portal & support 2 © 2017 Harvard Pilgrim Health Care

Who we are and our value § Harvard Pilgrim is a leading not-for-profit health services company founded by doctors in 1969 § Local presence in each market served § Consistently among the nation’s highest-rated health plans § We achieve that through the health plans we offer, as well as: - The Harvard Pilgrim Health Care Institute, a research and teaching collaboration with Harvard Medical School - The Harvard Pilgrim Health Care Foundation, which provides tools, training and leadership to help build healthy communities 3 © 2017 Harvard Pilgrim Health Care

Our Mission To improve the quality and value of health care for the people and the communities we serve. Continuing to offer high-quality, high-value health insurance options that meet the varying needs of our members is consistent with our mission and values. 4 © 2017 Harvard Pilgrim Health Care

Harvard Pilgrim Provider Networks

Our Provider Network - More of the Doctors and Hospitals You Know and Trust Harvard Pilgrim's provider network is extensive. It encompasses MA, ME, NH, CT, RI, VT Access to Harvard Pilgrim’s regional network of more than 80, 000 providers (doctors and ancillary providers) plus every hospital in Maine. Includes physicians practicing in a variety of settings including individual practices, small medical groups and large multi-specialty groups Behavioral health and ancillary providers (for example labs) are also included 6 © 2017 Harvard Pilgrim Health Care Harvard Pilgrim Provider Network Includes

Tiered Network Products § Places providers and hospitals in tiers based on provider specialty or network – Standard HMO rules and referrals apply – Access to our full HMO network – Incents members to use Tier 1 providers through lower cost share – Maine’s Choice and Elevate. Health Options are examples of Harvard Pilgrim tiered networks 7 © 2017 Harvard Pilgrim Health Care

Maine Networks – Two Choices § Our full network HMO with access to Harvard Pilgrim’s network with over 80, 000 providers plus every hospital in Maine § A Tiered HMO network - Maine’s Choice with access to over 800 Primary Care Providers and all our specialists 8 © 2017 Harvard Pilgrim Health Care

Maine Individual Products and Plan Offerings

All Individual Plans Include the Following: § Acupuncture – 20 visits per calendar year – Must use a network participating provider – Access to discount programs once benefit limit is reached § Chiropractic care – 40 visits per calendar year – Must use a network participating provider – Access to discount programs once benefit limit is reached § Routine eye exam every 12 months 10 © 2017 Harvard Pilgrim Health Care

Pediatric Vision Coverage - Maine under 19 First $50 covered in full, then *50% coinsurance Frames and lenses every 24 months First order 6 month of contact supply of OR lenses OR disposable every 24 lens months Does not cover contact or glasses supplies, fitting charges All Members (Children and Adults) are covered for an Annual Eye Exam No network – purely member reimbursement program Reimbursement form is available on our website or from Member Services *Deductible may apply

Pediatric Dental - Maine 12 under 19 Type 1 Services • Preventive • 20% coinsurance § $100 individual/$200 family deductible Type 2 Services • Minor restorative • 50% coinsurance § Off-Exchange plans are available with or without pediatric dental Type 3 Services • Major Restorative • 50% coinsurance § Members will receive separate dental ID card Type 4 Services • Medically necessary orthodontia • 50% coinsurance

Plan Choice Guide CONSUMER • Willing to pay for richer benefits • Subsidy eligible • Seeks value in coverage • Healthy consumers • Buying coverage to avoid fines GOLD HMO SILVER HMO BRONZE HMO & HSA HMO* Highest premiums • Lowest cost share • Deductible $1, 500 • Coinsurance 20% • More copay services • Lower premiums • Lower cost sharing • Deducible range of $2, 500 - $4, 500 • Coinsurance range of 20%-30% *Bronze HSA HMO only available in Aroostook, Penobscot, Piscataquis, Somerset, Washington, Hancock and counties 13 © 2017 Harvard Pilgrim Health Care • Lowest premium • Highest cost share • Deductible range of $5, 000 - $6, 500 • Coinsurance - 30%50%

Embedded Deductible § Example: – $2, 500 individual deductible; $5, 000 family deductible § There is a $2, 500 cap on any individual family member’s deductible responsibility – If one family member ends up in the hospital on the first day of the plan year, Harvard Pilgrim caps his or her deductible responsibility at $2, 500 § The other family members must incur an additional $2, 500 before satisfying the $5, 000 family deductible § Once the family deductible of $5, 000 is met, the deductible is met for the entire family for the remainder of the year 14 © 2017 Harvard Pilgrim Health Care

Maine’s 2018 Individual Plans

Our 2018 HMO Individual Plans Four Plans Offered On/Off-Exchange Gold HMO 1500 Silver HMO Bronze HMO 6500 Best Buy HMO 5400 Only available in the following counties: Aroostook, Hancock, Penobscot, Piscataquis, Somerset & Washington 16 © 2017 Harvard Pilgrim Health Care

To find Maine providers: Visit www. harvardpilgrim. org 1. 1. Click on Find a Provider 2. 2. Make sure the correct plan is selected 3. 3. Search by preferred provider type 17 © 2017 Harvard Pilgrim Health Care

Maine’s Choice 2018 Individual Plans

Our 2018 Maine’s Choice Individual Plans Four Plans Offered On/Off-Exchange Maine’s Choice Casco Silver Maine’s Choice Sebago Silver Maine’s Choice Pemaquid Silver Maine’s Choice HSA HMO 5000 Only available in the following counties: Androscoggin, Cumberland, Franklin, Kennebec, Knox, Lincoln, Oxford, Sagadahoc, Waldo & York 19 © 2017 Harvard Pilgrim Health Care

Maine’s Choice – How it Works § Primary Care Providers (PCP) are only available in the Preferred Network. Each enrolled member must choose a PCP in the Preferred Network in order to obtain covered benefits. § When members receive services from a Preferred provider, they pay less. Costs increase when receiving services from a Standard provider. Tier Preferred Standard Hospital Cost Share $ $$ PCP OV Copay $ N/A* Specialist OV Copay $ $$ Deductible $ $$ Coinsurance $ $$ *All members will need to select a PCP in the Preferred Tier 20 © 2017 Harvard Pilgrim Health Care

Maine’s Choice Tiered Network HMO Partnership Harvard Pilgrim partnering with leading health care providers in Southern and Central Maine to bring a high-value, tiered network HMO product Members visiting Preferred providers (some listed below) benefit from lower health care costs. Maine. Health and its affiliates Intermed, Martin’s Point, York Hospital and others 21 © 2017 Harvard Pilgrim Health Care

Maine’s Choice Tiered Network HMO Two-Tiered Network Plan Preferred Standard Harvard Pilgrim Provider Network: Access to Harvard Pilgrim’s regional network of nearly 80, 000 providers (doctors, hospitals, ancillary providers) including every hospital in Maine. Behavioral health and ancillary providers (for example labs • Members visiting Preferred tier providers are also included). benefit from lower health care costs. • Standard tier providers include Harvard Pilgrim’s extensive network. Helps members save on premiums 22 © 2017 Harvard Pilgrim Health Care

Available in 10 Maine Counties Enrollment Area: § Androscoggin § Lincoln § Cumberland § Oxford § Franklin § Sagadahoc § Kennebec § Waldo § Knox § York 23 © 2017 Harvard Pilgrim Health Care

Cost sharing – How it works Deductibles are separate Preferred Tier $2, 000 Out-of-Pocket Maximums Cross-Accumulate Tier Deductible OOP Max (Indiv) Preferred $2, 000 $6, 800 Standard $5, 400 $7, 350 X Standard Tier $5, 400 Preferred Tier Standard Tier $6, 800 $7, 350 Preferred Tier $6, 800 Standard Tier $7, 350 24 © 2017 Harvard Pilgrim Health Care

Using the plan The following services will ALWAYS default to the Preferred cost share level (either copay or deductible) Preferred Cost Share • Acupuncture • Low protein foods • Applied behavioral analysis • Medical formulas • Chiropractic • Methadone maintenance • Dialysis • Mental health • Durable medical equipment (DME) • Non-emergency transport ambulance • Emergency services ER & ambulance • Ostomy • Hearing aids • Prosthetics • Home health care • Vision hardware for special conditions • Hospice outpatient 25 © 2017 Harvard Pilgrim Health Care

To find Maine’s Choice providers: Visit www. harvardpilgrim. org 1. 1. Click on Find a Provider 2. 2. Make sure the Maine’s Choice HMO plan is selected 3. 3. Search by preferred provider type 26 © 2017 Harvard Pilgrim Health Care

Maine’s Choice HMO preferred hospitals Hospitals: Physician Organizations: § Maine. Health System – – – – – Franklin Memorial Hospital Lincoln. Health – Miles Campus Lincoln. Health – St. Andrew’s Campus Maine Medical Center Penobscot Bay Medical Center Southern Maine Health Care – Biddeford and Sanford campuses Spring Harbor Hospital Stephens Memorial Hospital The Memorial Hospital – North Conway, NH Waldo County General Hospital § Maine. Health System Affiliates – Maine. General Medical Center – Midcoast Hospital – St. Mary’s Regional Medical Center § Additional Hospitals – York Hospital 27 © 2016 Harvard Pilgrim Health Care – Maine Medical Center Physician- Hospital Organization § Maine. Health System Affiliates – St. Mary’s Health System – Kennebec Regional Health Alliance § Additional Physician Groups – – – – Dermatology Associates Inter. Med Martin’s Point Health Care Rheumatology Associates Spectrum Medical Group Tribal Health Centers Western Maine PHO York Hospital Physicians For more tiered 1 physicians visit the Maine’s Choice provider directory at: https: //www. providerlookuponline. com/harvardpilgrim Free Standing ancillary providers are preferred. Hospital-based ancillary providers take on the tier of the hospital

Pharmacy Information

Value Formulary Tiers – Individual Plans Value 4 -Tier 29 Tier 1 Generics only Tier 2 Preferred Brands (some high-cost generics) Tier 3 Non-preferred brands and preferred specialty (some higher-cost generics) Tier 4 Non-preferred specialty drugs (very high-cost brand generic drugs) © 2017 Harvard Pilgrim Health Care

Mail Order Program § Our mail order program is for maintenance medications and health products § The program includes a 90 -day supply of medication delivered to members’ homes § Certain medications such as controlled substances, may be subject to dispensing limitations § Can order online, by mail or by phone 30 © 2017 Harvard Pilgrim Health Care

General Information about our Plans

Benefits – Preventive Services § Preventive services are covered in full – Routine physicals and annual gynecological 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 available to members on their secure online account 32 © 2017 Harvard Pilgrim Health Care

Urgent care For minor illness and injury when PCP is not available Hospital- based urgent care 1. Telemedicine 2. Convenience care 3. Free-standing urgent care $ 33 © 2017 Harvard Pilgrim Health Care $$

Telemedicine Services: Doctor on Demand § Convenient, cost-effective alternative to ER for minor urgent care § Real-time virtual visit via smartphone, tablet or computer § On-demand virtual visits for minor issues (ex. cough, rash, sinus issues) – PCP cost-sharing applies for medical urgent care § Scheduled behavioral health virtual visits – Outpatient therapy cost sharing applies for behavioral health § No referral or authorization needed 34 © 2017 Harvard Pilgrim Health Care

Out of Area (OOA) Dependent Coverage § All 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 OOA dependent (888) 333 -4742) § Routine and non-routine services are covered § Elective services are not covered OOA (i. e. Bariatric or reconstructive surgery) § Must use out-of-area dependent providers for services outside of the enrollment area 35 © 2017 Harvard Pilgrim Health Care

Discounts & Savings Helping Members to stay healthy, for less!

Count us in for value-added discounts to help members maintain a healthier lifestyle Save on many products and services… Fitness – Up to $150 fitness reimbursement per individual or family contract – 15% off on athletic footwear at Marathon Sports (MA) – 15% off on regularly priced footwear at Runner’s Alley (NH) – 20% off Appalachian Mountain Club membership – Discounts on exercise equipment rentals & services; Workout Fitness Store (So. Portland, ME) Vision – FREE designated eyewear & discounts at Visionworks (MA, NH, – – RI) Discounts at JCPenney Optical, Lens. Crafters, Pearle Vision, Sears Optical and Target Optical Laser Vision Correction discounts through Qual. Sight LASIK, Davis Vision, US Laser Network Dental – 30 – 50% off all procedures at participating dentists through Universal Dental Plan • Save up to 28% on membership fees Healthy Eating – – – Jenny Craig Weight Watchers of Maine DASH for Health i. Diet Savor Health Quit Smoking Hearing – Hearing Aids through Amplifon Hearing Health Care – – Holistic Wellness – Save 10 -30% on complementary & alternative medicine from Family and Senior Care – – – Healthways Whole. Health Network on acupuncture, chiropractic care, yoga, Chinese herbal medicine, etc. 10% Happier Center for Mindfulness; Discounts on Mindfulness-based Stress Reduction & Mindfulness-based Cognitive Therapy courses Hug Patrol – – – Craving to Quit. Smart Care. com Senior Assist (Senior Resource Center, Inc. ) Care. Scout Elder Advocacy Program Home Instead Senior Care Vigorous Mind …and more!

Enrollment and Renewal Guidelines

Dates and Deadlines § Open enrollment is November 1, 2017 – December 15, 2017 § January 1, 2018 is the only available effective date § Enrollments and plan changes must be submitted by December 15 th in order to be eligible for a January 1 effective date § Payment deadline (both on and off Exchange) is January 10, 2018 39 © 2017 Harvard Pilgrim Health Care

Renewal Support § Renewal report displaying your existing book of business § Sample discontinuation and renewal letter packages § 2017 to 2018 Benefit Comparisons § Product Mapping Grid of 2017 products to 2018 products § Consumer Sales support at (855) 881 -4742 40 © 2017 Harvard Pilgrim Health Care

Renewal Support § Name, address and Harvard Pilgrim ID of member § Marketplace versus “Buy Direct” § 2017 premium and product § 2017 Average Premium Tax Credit (APTC) § 2018 premium and new product (mapped) 41 © 2017 Harvard Pilgrim Health Care

Renewal Report – Rates vs Premium § The 2017 rate shown is the base rate and does not include APTC. In the example below the 2017 billed premium would be $612. 71 § The 2018 rate also does not contain APTC. The estimated 2018 premium would be $572. 30 42 © 2017 Harvard Pilgrim Health Care

2018 Renewal Process - OFF Exchange § Off-Exchange members CANNOT make their plan change on Harvardpilgrim. org - they MUST call the consumer sales team § Members have 2 options: • Passive Renewal: Do Nothing. Members automatically renewed as long as they continue to pay monthly premium. • Active Renewal: Take Action if the 2017 is discontinued with no mapping OR the members don’t like the 2018 plan we chose for them – Consumer Sales will review plans and make change via the phone OR. – Consumer Sales will mail a quote and a paper enrollment form 43 © 2017 Harvard Pilgrim Health Care

2018 renewal process – On Exchange § On Exchange plan changes must be completed on Health. Care. gov § Changes must be made by December 15, 2017. § Members have 3 options: – Passive Enrollment - Member likes 2018 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 2018 plan changes presented in renewal letter, but there are changes to Marketplace application information • Member must go back to the Marketplace to update information and re-enroll. – Active Enrollment – Member’s 2017 plan was discontinued with no mapping or member does not like 2018 that we chose for him or her • Take Action - Visit Health. Care. gov and look at other Marketplace plans. 44 © 2017 Harvard Pilgrim Health Care

On-Exchange Renewals - Payment § If subscribers are enrolled on Auto Pay, they will need to visit the Pay. Span website and re-enroll in Auto Pay between December 5 and December 20, 2017, in order for automatic payments to carry forward into the new contract year. § Pay. Span is Harvard Pilgrim’s online payment vendor § Instructions for re-enrolling in Auto Pay are in the renewal package § Failure to re-enroll in Auto Pay could result in a lapse in coverage 45 © 2017 Harvard Pilgrim Health Care

Off-Exchange Enrollment § Off-Exchange Quotes and enrollments can be done via www. harvardpilgrim. org § Online payment capability § Enter NPN or vendor ID to be linked to subscriber § View book of business with corresponding statuses 46 © 2017 Harvard Pilgrim Health Care