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New York’s only CO-OP. Consumer Operated and Oriented Plan 501(c)29 non-profit organization, a signature program of the Affordable Care Act Over half.

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Presentation on theme: "New York’s only CO-OP. Consumer Operated and Oriented Plan 501(c)29 non-profit organization, a signature program of the Affordable Care Act Over half."— Presentation transcript:

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2 New York’s only CO-OP. Consumer Operated and Oriented Plan 501(c)29 non-profit organization, a signature program of the Affordable Care Act Over half our board are enrollees, elected by enrollees Monitored and audited by state and federal government Profits are mandated to go toward lowering premiums and improving benefits 2 Our focus is where is should be — on our members.

3 3 Our regulatory oversight. Certificate of authority under article 43 of the New York State Insurance Law Certified as a Qualified Health Plan on the New York State Health Benefit Exchange for 2014 and 2015 Contracts with U.S. Center for Consumer Information and Insurance Oversight — stipulates how we operate and how funds are used

4 4 Our partners. Network MagnaCare Extra Additional PCMH-certified FQHCs and ACOs More than 70,000 providers Medical and Claims Management The POMCO Group (URAC Accredited) Based in Syracuse, NY Pharmacy Benefits Manager US Script (URAC Accredited) Billing and Enrollment Morneau-Shepell

5 5 The Counties we Serve. AlbanyOntario BronxOrange ChautauquaOrleans ColumbiaPutnam DelawareQueens DutchessRensselaer ErieRockland EssexSaratoga GreeneSchenectady HamiltonStaten Island KingsSuffolk ManhattanSullivan MonroeUlster NassauWarren NiagaraWashington OnondagaWestchester

6 Target members. Small businesses with fewer than 50 employees, including sole proprietors Independent contractors and freelancers Budding entrepreneurs Boomerang kids (29+ and living with parents) Working uninsured 6 Image FPO

7 Our products. 7 ESSENTIALCARE New York State “Standard” Plans, with mandated front-end deductibles and co-payment levels Platinum, Gold, Silver, Bronze & Catastrophic metal tiers PRIMARYSELECT Encouraged to select a primary physician — $0 copay for visits to that designated physician Platinum, Gold, & Silver metal tiers PRIMARYSELECT EPO Required to select a primary physician from narrow menu of primary care medical homes Silver metal tier, only in seven counties

8 Our products. 8 All products meet or exceed requirements for Essential Health Benefits under the Affordable Care Act and New York State All preventive services recommended by the U.S. Preventive Services Task Force are available at no charge The drug formulary includes at least two choices in every category, as required in the Essential Health Benefits package

9 EssentialCare Benefit Design Highlights 9

10 EssentialCare. 10 Health Republic’s New York “Standard Plans” Mandated for every qualified health plan participating on the New York State Health Benefit Exchange Provides consumers with an “apples to apples” comparison among all the participating plans No benefit differences between Health Republic’s standard plan and other plans, such as Excellus, Independent Health, MVP or CDPHP, at any metal tier

11 11 Deductibles and Maximums PlatinumGoldSilver Deductible (Single)$0$600$2000 Max Out of Pocket Limit (Single-Incl. Deductible)$2000$4000$5500 Cost Sharing-Medical Services After deductible is met PlatinumGoldSilver Inpatient/SNF/Hospice-Facility (per admission)$500$1,000$1,500 Outpatient- Facility$100 Surgeon (Inpatient, Outpatient)$100 PCP$15$25$30 Specialist$35$40$50 PT/OT/ST-rehabilitative and habilitative therapies$25$30 ER$100$150 Ambulance$100$150 Urgent Care$55$60$70 DME/Medical Supplies10%20%30% ESSENTIALCARE

12 12 Outpatient Services After deductible is met PlatinumGoldSilver Diagnostic and Routine Laboratory and Pathology $35$40$50 Diagnostic and Routine Imaging $35$40$50 Chemotherapy $15$25$30 Radiation Therapy $15$25$30 Dialysis $15$25$30 Mental/Behavioral Healthcare $15$25$30 Substance Abuse Disorder Services $15$25$30 Home Health Care $15$25$30 Hospice $15$25$30 Prescription Drugs PlatinumGoldSilver Tier I (Selected Generics) $10 Tier II (Other Generics) $30$35 Tier III (Brand and Specialty Generics) $60$70 ESSENTIALCARE

13 13 High Deductible Plans BronzeCatastrophic Deductible (Single) $3000$6,350 Max Out of Pocket Limit (Single-Incl. Deductible) $6350$6,350 Cost Sharing (All Parameters) 50%0% Prescription Drugs $10 / $35 / $700% High deductible plans. ESSENTIALCARE

14 14 Region PlatinumGoldSilverBronze Capital$426.04$362.34$310.10$253.67 Western$398.81$339.19$290.28$237.46 Hudson$478.53$407.51$348.33$284.95 NYC/Westchester$561.14$477.24$408.44$334.11 Long Island$561.14$477.24$408.44$334.11 Rochester$392.06$333.44$285.36$233.44 Central$414.04$352.13$301.36$246.52 North Country$402.87$342.64$293.24$239.82 Approved monthly premium rates. ESSENTIALCARE — SMALL GROUP Premiums above are for Single Adults (employee only) Employee + Spouse – Multiply by 2.0 Employee + Child(ren) – Multiply by 1.70 Employee + Family – Multiply by 2.85 ESSENTIALCARE

15 15 Region PlatinumGoldSilverBronzeCatastrophic Capital Lowest Western Lowest 2 nd Lowest Hudson Lowest 2 nd Lowest NYC/Westchester 2 nd Lowest 3 rd Lowest Long Island 2 nd Lowest 3 rd Lowest Rochester Lowest Central Lowest North Country Lowest Price point position. ESSENTIALCARE

16 16 Enhanced member support. Discounted access to: Fitness centers throughout the state 40 different types of complementary and alternative providers, including nutritionists, massage therapists, and mind-body practitioners Patient support program: Wellness Navigators to help link members to well-matched providers and community resources Reminders, notifications and alerts for both preventive and chronic care needs Linkage to case management for high-risk members

17 Competitive Advantage 17 Image FPO

18 18 Our niche. We are focused on the small business market that has not received sufficient attention from health insurers. 9 plans statewide serving small groups on the New York Exchange Consumer Operated and Oriented (CO-OP) Plan Members vote for Board and make decisions Reasonable administrative expenses Right-sized, resourceful organization Benefits decrease barriers and increase access to care Primary physician relationship encouraged Members represent members.


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