Your health plan 2022 Open Enrollment - City of Manitowoc - Manitowoc.org
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Your health plan 2022 Open Enrollment Your medical plan benefits . . . . . . . . . . . . . . 3 Extra support . . . . . . . . . . . . . . . . . . . . . . . . . . 7 City of Manitowoc
Your more-than-
a-plan partner
Robin represents the coming of spring. Rebirth. And the start of
something new. A new way of thinking. A change in how you think about
your health. This is Robin with HealthPartners. And our commitment is to
help you live a healthier life. We are dedicated to building and nurturing
relationships, and connecting with you on a personal level to provide the
specific support you need, when you need it. Because we bring your care
and coverage together.
21-1213441-1292007 (07/21) © 2021 HealthPartners
2
Getting started
The more you know about your plan, the easier it is to make
good decisions for your health and wallet. We’re happy
you’re trusting HealthPartners. Here are some tips.
Understand your costs Check out your extras
You’ll likely see these terms during Your health plan does more than just
enrollment and throughout the year. process claims. Read on to learn more
Knowing how these costs work about some of the services, resources
with your plan will help you avoid and discounts you have available to
unexpected charges. help you live your best life.
• Premium – how much you pay
for your plan, usually taken out of Use your online account
your paycheck.
With an online account, you can
• Deductible – the amount you’re get up-to-date personal health plan
What to do next responsible to pay for care before information in one simple place.
your plan helps cover costs, not
• Call us with questions at including your premium. • See claims and how much you
855-813-3888 could owe.
• Copay – a set amount you pay
each time you visit the doctor or • Search for doctors in your network.
• Sign in or create an account at
healthpartners.com/robin get a prescription. • Check your deductible or
• Coinsurance – a percent of the bill out-of-pocket maximum spending.
We can help you make choices you'll you pay. Your plan covers the rest. • View your member ID card.
feel good about.
• Out-of-pocket maximum – the • Get cost estimates for care.
most you’ll pay for covered care
each year. • Compare prescription costs.
• Summary of Benefits and Coverage • Manage your health on the go with
(SBC) – lists out the specific benefit the myHP mobile app.
costs for your plan.
I'm thankful I had someone to help me understand my own health
insurance. I can walk you through your plan now, so you're prepared
when you use it later.
Lauren, Member Services
21-1122153-1129227
3HSA plan with the
Robin focused network
Set aside pretax money in a health savings account (HSA) to
cover your medical costs throughout the year. Plus, you get
access to a network of the highest-quality doctors.
What you’ll pay Where you can get care
The Robin focused network helps you
Deductible, then coinsurance choose from the best local doctors,
This plan has a lower premium but a clinics and hospitals in northeast
higher deductible. That means you’ll Wisconsin, featuring Bellin Health,
pay more for care before your plan ThedaCare and other high-quality
helps cover costs. After you reach your doctors. Plus, access thousands more
deductible, you may pay coinsurance, choices across the country.
which is a percent of the bill.
How to get more info Empower HSA SM
Out-of-pocket maximum
• See plan details in your Summary of plan highlights
Benefits and Coverage (SBC) in your An out-of-pocket maximum limits your
costs. Once you hit the max, your health This plan allows you to contribute
enrollment materials
plan pays for all in-network care. money to an HSA before taxes are taken
out. Add up what you spent on health
• Call us with questions at
care expenses last year to get an idea of
855-813-3888 What your plan pays for how much to put in next year.
• Search the network for your This plan fully pays for in-network
Use your HSA to pay for things like:
doctor or find a new one at preventive care, even before you’ve
paid your deductible. • Doctor visits and lab fees
healthpartners.com/robin/focused
After you hit your deductible, your plan • Prescription and select
helps cover things like: over-the-counter medicines
• Dental care and braces
• Convenience care and
telemedicine services • Vision care and LASIK surgery
TIP: Protect yourself from the
• Specialty care (no referrals needed) HSA money can:
unexpected. Put some of the money
you’re saving on premiums into your • Prescriptions • Earn interest or be invested
HSA – either on your own or through • Pay for medical expenses before or
direct deposit. after you reach your deductible
• Stay with you year after year,
even if you switch jobs – you
own the account
21-1144553-1145986
4Skip the clinic trip
with online care
Save time and money by getting treated right from
your smartphone, tablet or computer. Your plan covers
two options.
Virtuwell® Doctor On Demand
(online questionnaire) (video chat)
• Easy. In fact, 99% of Virtuwell • Convenient. Get started when
users say it's simple and 98% and where it works for you at
highly recommend it. Answer a doctorondemand.com. Video
few questions at virtuwell.com capabilities are required.
anytime, anywhere.*
• Quick. See a doctor in minutes.
• Fast. Get a treatment plan Live video visits include
Questions about benefits? and prescription from a nurse assessment, diagnosis and
practitioner. They can help with prescriptions when necessary.
Member Services can answer your more than 60 common conditions,
benefits and coverage questions. • Affordable. A visit to treat conditions
and it usually takes just one hour.
Call us at 855-813-3888 like colds, the flu and allergies**
• Guaranteed. You’re only charged costs less than a clinic visit. It’s
if Virtuwell can treat you. Plus free to sign up and easy to check
follow-up calls about your your coverage when you register.
treatment are free. If you need to
be seen in person, we'll let you
know – but it's not usually needed.
The next time you’re
• Affordable. Virtuwell visits are a
sick, your health plan has
fraction of the cost of walk-in, urgent
affordable options to help
or primary care visits. Use your
you get better, faster.
member ID card to check your cost at
virtuwell.com/cost/healthpartners. Julie, RN, Nurse Navigator
*Available anywhere in the U.S. to residents of AZ, CA, CO, CT, IA, MI, MN, NY, ND, PA, SD, VA and WI.
**The cost for behavioral health services varies depending on the services provided and duration of service.
21-1148109-1148244
5Care today for a
healthy tomorrow
Prevent problems before they start so you can enjoy the
things you love. Your health plan covers in-network
preventive care at 100%; you don't pay anything.
Protect your health with Preventive care includes
routine visits • Blood pressure, diabetes and
Even if you’re not sick, it’s smart cholesterol tests
for you and your family to go in for • Colorectal, breast and cervical
regular checkups, screenings and cancer screenings
well-child visits. If there are any
• Routine pre- and post-natal care
issues, you can catch them early –
when treatment is most effective. • Vaccines
Questions about benefits? • Weight, alcohol and tobacco
screenings
Member Services can answer your
benefits and coverage questions. • And more!
Call us at 855-813-3888
Visit healthpartners.com/preventive to
find out what care is recommended
for you.
I always encourage members to go in for their screenings.
If you’re ever wondering whether a service counts as routine
preventive care, give us a call.
Renae, Member Services
21-1149037-1149553
6Here for you, 24/7
Call us at one of these numbers if you have questions about
your health or what your plan covers. We're ready to help.
Member Services
For questions about: Monday – Friday,
• Your coverage, claims or plan balances 7 a.m. to 6 p.m. CT
• Finding a doctor, dentist or specialist in your network Call the number on the back
• Finding care when you’re away from home of your member ID card,
• Health plan services, programs and discounts 855-813-3888
Interpreters are available if you
need one.
Español: 866-398-9119
healthpartners.com/robin
Member Services can help you reach:
Nurse For questions about: Monday – Friday,
NavigatorSM • Understanding your health care 7:30 a.m. to 5 p.m. CT
program and benefits
• How to choose a treatment
Pharmacy For questions about: Monday – Friday,
Navigators • Your medicines or how much they cost 8 a.m. to 5 p.m. CT
• Doctor approvals to take a medicine
(prior authorization)
• Your pharmacy benefits
• Transferring medicine to a mail order
pharmacy
Behavioral Health Navigators
For questions about: Monday – Friday,
• Finding a mental or chemical health care 8 a.m. to 5 p.m. CT
professional in your network 888-638-8787
• Your behavioral health benefits
CareLineSM service nurse line
For questions about: 24/7, 365 days a year
• Whether you should see a doctor 800-551-0859
One thing I love about • Home remedies
my job is how my team • A medicine you’re taking
helps people all day, BabyLine phone service
every day.
For questions about: 24/7, 365 days a year
Rachel, Registered
• Your pregnancy 800-845-9297
Nurse, CareLine • The contractions you’re having
• Your new baby
21-1144553-1145434
7Take charge of your health plan
You go online to research, plan and follow up on big
decisions. A HealthPartners online account makes it just
as easy to stay on top of your health care and insurance.
Get personalized information when and where you
need it
With an online account, you have real-time access to your personal health plan
information in one simple place. No more guessing or waiting until business
hours to get answers to your questions.
Top 5 ways to use your online
account and mobile app
1. See recent claims, what your plan covered
Sign in to your account and how much you could owe.
2. NEW! Access your Living Well dashboard
Manage your health and your plan at
to check your program progress, take the 1
healthpartners.com/robin.
health assessment and complete activities.
2
Don't have an account yet? It's quick 3. View your HealthPartners member ID card
and easy to sign up– you'll just need and fax it to your doctor’s office. 3
your member ID card.
4. Check your balances, including how much
4
you owe before your plan starts paying
(deductible) and the most you’ll have to pay
5
(out-of-pocket maximum).
5. Compare pharmacy costs to find the best
place to get your medicines.
I love directing members to their online accounts and the mobile app.
You can easily get your health plan info, even when I’m not in the office.
Marissa, Member Services
21-1149037-1149563
8Get the most from your meds
Knowing what you’ll pay for your medicine is important. Use
these tools and resources to understand your costs and get
support if your medicine isn’t working for you.
Check your formulary Search for the lowest cost
A formulary, also called a drug list, Medicine prices can change from
tells you what medicines are covered pharmacy to pharmacy. Shop around.
by your health plan and generally how See what your costs are at different
much you’ll pay. You’ll also learn if there pharmacies. Members can get started
are any requirements before you can with the prescription shopping tool at
start a medicine. healthpartners.com/pharmacy.
Your formulary is called PreferredRx.
1. Go to healthpartners.com/
Talk with a
preferredrx. Pharmacy Navigator
Questions about benefits? 2. Search by the name or type One call will give you answers to your
Member Services can answer your of medicine. questions around benefits, coverage,
benefits and coverage questions. costs, formularies and more. Call
3. Use your Summary of Benefits and
Call us at 855-813-3888 Member Services at the number on the
Coverage (SBC) in your enrollment
back of your member ID card. Ask to
materials to understand how each
talk with a Pharmacy Navigator.
type of medicine is covered.
Try generics Meet with a pharmacist
In a one-on-one visit, a pharmacist will
Generics are just as safe and effective as
review your medicines with you to make
brand-name medicines, but cost a lot
sure they’re working and are right for you.
less. Talk to your doctor or pharmacist
Plus, it’s free. Visit healthpartners.com/
about switching to a generic medicine.
mtminfo to learn more.
Our team is here to support you. If you can’t find your medicine on
the formulary or shopping tool, give us a call. We’ll help you find it
or an alternative that’s covered.
Kerry, Pharmacy Navigator
21-1122153-1129245
9Medicine delivered to
your door
Skip the trip to the pharmacy. Get your prescriptions mailed
to your home with WellDyne.
5 great things about
TIP: You can track the status of your
mail order order every step of the way, from
1. You’ll never pay for standard shipping. receipt and processing to shipping
and delivery.
2. Refilling your medicine online or
with our mobile app is easy. To check the status of your order, sign
3. All orders are sent in a tamper into your online account or call our
resistant, plain package to make it automated phone system.
more private.
4. Safety is important. You’ll get the
best quality medicine.
How to get started
5. You'll get your medicine delivered
within seven to 10 days.
• Call 800-591-0011
• Visit healthpartners.com/mailorder
It’s hard to get to the pharmacy each month. Mail order pharmacy
delivers your meds quickly and easily to you, just like your
favorite stores.
Dave, Pharmacist
21-1122153-1129247
10Get the right care
at the right price
Your health plan covers lots of options when you need care.
Knowing the differences between the options can help you
choose where to get care at the best cost.
When you need Go to Average cost Average time spent
Health advice from a CareLineSM service Free
registered nurse for: Call 24/7 at 15
• At-home remedies 800-551-0859 minutes
• When to go in for care
Treatment and Virtuwell®* or $
prescriptions for minor Doctor On Demand
medical issues, like: 24/7 online care
• Bladder infection 15
minutes
• Pink eye Convenience clinics
• Upper respiratory (found in retail and
Find in-network care infections grocery stores)
Manage your health and your plan at A regular checkup or Primary care clinics $$
special care during the
healthpartners.com/robin. day for things like: 30
minutes
• Diabetes management
Don't have an account yet? It's quick • Vaccines
and easy to sign up– you'll just need Care for urgent problems Urgent care clinics $$$
your member ID card. when your doctor’s office
is closed, like: 45
minutes
• Cuts that need stitches
• Joint or muscle pain
Help in an emergency, Emergency room $$$$
such as:
• Chest pain or 60
minutes
shortness of breath
• Head injury
Still not sure where to go? We’ll help you figure out the
best place based on the urgency of your care needs.
Call CareLine at 800-551-0859.
Rachel, Registered Nurse, CareLine
*Available anywhere in the U.S. to residents of AZ, CA, CO, CT, IA, MI, MN, NY, ND, PA, SD, VA and WI.
21-1146372-1146567
11Living healthier just got
a little less expensive
Get special savings from handpicked retailers as a
HealthPartners member. There are lots of products
and services available to you at a discounted rate –
all designed to help you live healthy every day.
Save big by showing Discounts on
your member ID card to gym memberships
participating retailers GlobalFit’s Gym Network 360
Provides discounts on memberships at
Save money on:
more than 11,000 fitness centers, weight
• Eyewear loss programs and wellness brands
See where you can save • Exercise equipment
The Active&Fit Direct™ program
Visit healthpartners.com/discounts • Fitness and well-being classes Offers more than 11,000 fitness centers
for a list of participating retailers and • Eating well nationwide for a flat monthly fee
discounts.
• Healthy mom and baby products
• Hearing aids
• Orthodontics
• Pet insurance
• Swim lessons
• And more!
Making healthy choices is easier when it doesn’t break the bank.
I always say taking advantage of these discounts is a great way
to make the most out of your health plan.
Dan, Member Services
The HealthPartners family of health plans is underwritten and/or administered by HealthPartners Inc., Group Health Inc., HealthPartners Insurance
21-1149037-1149557NoWB (07/21) © 2021 HealthPartners Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company.
12Assist America®
Travel anywhere, worry-free
Whether you’re traveling abroad or just out of town for
the weekend, you can feel confident you’re in good hands
when the unexpected happens.
Get 24/7 help
Assist America provides all the support you need when
you’re more than 100 miles from home.
• Coordinating transport to care facilities or back home
• Filling lost prescriptions
• Finding good doctors
• Getting admitted to the hospital
• Pre-trip info, like immunization and visa requirements
How to get started
• Tracking down lost luggage
• Download your Assist America
ID card at healthpartners.com/ • Translator referrals
getcareeverywhere • And more!
• Get the Assist America app and
enter HealthPartners reference
number 01-AA-HPT-05133 The Assist America mobile app makes traveling much easier.
You can make calls right from the app when you need support.
Jamie, Member Services
21-1149037-1149561
13Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2022 - 12/31/2022
Robin with HealthPartners:$2,000 Deductible-80% HSA Robin Focused Non--Embedded Coverage for: All Coverage Levels | Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-855-813-3888 or visit us at
www.healthpartners.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call 1-855-813-3888 to request a copy.
Important Questions Answers Why This Matters:
In-network: $2,000 Individual,
$4,000 Family contract Generally, you must pay all of the costs from providers up to the deductible amount before this
What is the overall
plan begins to pay. If you have other family members on the policy, the overall family deductible
deductible? Out-of-network: $4,000 Individual, must be met before the plan begins to pay.
$8,000 Family contract
Yes. Services marked with * and This plan covers some items and services even if you haven’t yet met the deductible amount. But
Are there services
benefits with no charge under a copayment or coinsurance may apply. For example, this plan covers certain preventive services
covered before you meet
What You Will Pay are not subject without cost-sharing and before you meet your deductible. See a list of covered preventive
your deductible?
to deductible services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific No. You don’t have to meet deductibles for specific services.
14
services?
In-network: $4,250 Individual,
$8,500 Family contract
What is the out-of-pocket (Individual OOP within the The out-of-pocket limit is the most you could pay in a year for covered services. If you have other
limit for this plan? contract structure $8,150). family members in this plan, the overall family out-of-pocket limit must be met.
Out-of-network: $8,500 Individual,
$17,000 Family contract
Premium, balance-billed charges
What is not included in (unless balanced billing is
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
the out-of-pocket limit? prohibited), and health care this
plan doesn't cover.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will
Yes. See
pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the
Will you pay less if you https://www.healthpartners.com/netw
difference between the provider’s charge and what your plan pays (balance billing). Be aware your
use a network provider? orks or call 1-855-813-3888 for a list
network provider might use an out-of-network provider for some services (such as lab work). Check with
of in-network providers.
your provider before you get services.
Do you need a referral to
No. You can see the specialist you choose without a referral.
see a specialist?
36464-WI208-20220101-20210910134434 1 of 5All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
Office Visit: 20%
Office Visit: 40%
coinsurance
coinsurance
Primary care visit to treat an Convenience Care: 20%
Convenience Care: 40% None
injury or illness coinsurance
coinsurance
If you visit a health virtuwell: 20%
virtuwell: Not covered
care provider’s office coinsurance
or clinic Specialist visit 20% coinsurance 40% coinsurance None
You may have to pay for services that aren’t
Preventive care/screening/ preventive. Ask your provider if the services
No charge 40% coinsurance
immunization you need are preventive. Then check what
your plan will pay for.
Diagnostic test (x-ray, blood
20% coinsurance 40% coinsurance None
If you have a test work)
Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance None
If you need drugs to Generic drugs 20% coinsurance 40% coinsurance at retail,
15
30 day supply retail / 90 day supply mail order
treat your illness or Formulary brand drugs 20% coinsurance mail not covered
condition
Non-formulary brand drugs 20% coinsurance Preventive Drugs: $0 copay*/prescription
More information about
prescription drug
coverage is available at
40% coinsurance at retail,
www.healthpartners.co Specialty drugs 20% coinsurance None
mail not covered
m/hp/pharmacy/druglist/
preferredrx/index.html
Facility fee (e.g., ambulatory
If you have outpatient 20% coinsurance 40% coinsurance None
surgery center)
surgery
Physician/surgeon fees 20% coinsurance 40% coinsurance None
Out-of-network services apply to the in-
Emergency room care 20% coinsurance 20% coinsurance
network deductible
If you need immediate
Emergency medical Out-of-network services apply to the in-
medical attention 20% coinsurance 20% coinsurance
transportation network deductible
Urgent care 20% coinsurance 40% coinsurance None
Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance None
2 of 5Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
If you have a hospital
Physician/surgeon fees 20% coinsurance 40% coinsurance None
stay
If you need mental
Outpatient services 20% coinsurance 40% coinsurance None
health, behavioral
health, or substance
Inpatient services 20% coinsurance 40% coinsurance None
use disorder services
Office visits No charge 40% coinsurance None
Childbirth/delivery professional
20% coinsurance 40% coinsurance None
If you are pregnant services
Childbirth/delivery facility
20% coinsurance 40% coinsurance None
services
In-network: 100 visit maximum; Out-of-
Home health care 20% coinsurance 40% coinsurance
network: 100 visit maximum
60 visit limit/year combined in and out-of-
If you need help Rehabilitation services 20% coinsurance 40% coinsurance
network
recovering or have
Habilitation services 20% coinsurance 40% coinsurance Out-of-network: 20 visit limit/year
other special health
Skilled nursing care 20% coinsurance 40% coinsurance 60 maximum days per confinement
16
needs
Limited to one wig per year for cancer
Durable medical equipment 20% coinsurance 40% coinsurance
treatment only.
Hospice services 20% coinsurance 40% coinsurance None
Children’s eye exam Not covered Not covered None
If your child needs
Children’s glasses Not covered Not covered None
dental or eye care
Children’s dental check-up Not covered Not covered None
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Acupuncture Hearing aids Private-duty nursing
Cosmetic surgery Infertility treatment Routine eye care (adult)
Dental care (Adult) Long-term care Routine foot care
Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Bariatric surgery Non-emergency care when traveling outside the Routine eye care (Adult)
Chiropractic care U.S.
3 of 5:
Your Rights to Continue Coverage There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies
is: Your plan at:1-855-813-3888 or the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323
x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance
Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,
contact:Your plan at: 1-855-813-3888.
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet Minimum Value Standards? Yes.
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-866-398-9119.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-813-3888.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-855-813-3888.
17
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-813-3888.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––
4 of 5About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)
The plan’s overall deductible $2,000 The plan’s overall deductible $2,000 The plan’s overall deductible $2,000
Specialist coinsurance 20% Specialist coinsurance 20% Specialist coinsurance 20%
Hospital (facility) coinsurance 20% Hospital (facility) coinsurance 20% Hospital (facility) coinsurance 20%
Other coinsurance 20% Other coinsurance 20% Other coinsurance 20%
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
18
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)
Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $2,000 Deductibles $2,000 Deductibles $2,000
Copayments $0 Copayments $0 Copayments $0
Coinsurance $1,700 Coinsurance $700 Coinsurance $200
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $3,760 The total Joe would pay is $2,720 The total Mia would pay is $2,200
5 of 5Our approach to protecting personal information
Robin® complies with all applicable laws regarding privacy of health and other information about our members and former members. When
needed, we get consent or authorization from our members (or an authorized member representative when the member is unable to give
consent or authorization) for release of personal information. We give members access to their own information consistent with applicable law
and standards. Our policies and practices support compliant, appropriate and effective use of information, internally and externally, and enable us
to serve and improve the health of our members, our patients and the community, while being sensitive to privacy. For a copy of our Notice of
Privacy Practices, visit our website or call Member Services.
Summary of utilization management programs for medical plans
Our utilization management programs help ensure effective, accessible and high-quality health care. These programs are based on the most up-
to-date medical evidence to evaluate appropriate levels of care and establish guidelines for medical practices. Our programs include activities to
reduce the underuse, overuse and misuse of health services.
THESE PROGRAMS INCLUDE:
• Progression of care review and care coordination to support safe, • Evidence-based care guidelines for certain kinds of care.
timely care and transition from the hospital. • Prior authorization of select services – we require prior approval
• Outpatient case management to provide member support and for a small number of services and procedures. For a complete
coordination of care. list, visit our website or call Member Services.
Appropriate use and coverage of prescription medicines for medical plans
We provide coverage for medicines that are safe, high-quality and cost-effective.
TO HELP US DO THIS, WE USE:
• A formulary (drug list). These prescription medicines are • An opioid management program to support members in
continually reviewed and approved for coverage based on quality, managing their pain.
safety, effectiveness and value. • A patient alert program that provides a seamless transition to our
• A free, confidential one-on-one appointment (in person or over formulary. We allow coverage for a first-time fill of a qualifying
the phone) with an experienced clinical pharmacist. Our non-preferred medicine within the first three months of
Medication Therapy Management (MTM) program helps members becoming a member.
who use many different medicines get the results they need.
The formulary is available at healthpartners.com/formulary, along with information on how medicines are reviewed, the criteria used to
determine which medicines are added to the list and more. You may also get this information from Member Services.
21-1213441-1292016 (08/21) © 2021 HealthPartners Robin with HealthPartners plans are underwritten and/or administered by HealthPartners Insurance Company and HealthPartners Administrators, Inc.
19Important information on provider reimbursement Our goal in reimbursing providers is to provide affordable care for our members while encouraging quality care through best care practices and rewarding providers for meeting the needs of our members. Several different types of reimbursement arrangements are used with providers. All are designed to achieve that goal. Check with your individual provider to find out how they are paid. ARRANGEMENTS USED FOR MEDICAL PLANS: • Fee-for-service – the health plan pays the provider a certain set • Basis of the diagnosis/per diem – a set fee to treat certain kinds amount that corresponds to each type of service furnished by the of conditions, sometimes based on the number of days the provider. patient spent in the facility. • Discount – the provider sends us a bill, and we’ve already • Ambulatory Payment Classifications (APCs) – for outpatient negotiated a reduced rate on behalf of our members. We pay a services. We have a negotiated payment level based on the predetermined percentage of the total bill for services. resources and intensity of the services provided. Hospitals are • Case rate – the provider receives a set fee for a selected set of paid a set fee for certain kinds of services which is based on the services, up to an agreed upon maximum amount of services, for resources utilized to provide that service. a designated period of time. Alternatively, we may pay a case rate • Combination – more than one of the methods described are to a provider for all of the selected set of services needed during used. For example, we may pay a case rate to a provider for a an agreed upon period of time. selected set of services, up to an agreed upon maximum amount • Withhold – a portion of the provider’s payment is set aside until of services, and pay that same provider on a fee-for-service basis the end of the year. Withholds are sometimes used to pay for services not provided within the time period that exceed the specialty, referral or hospital providers who furnish services to maximum amount of services. We may also pay a provider such members. The provider usually receives all or a portion of the as a clinic using one type of reimbursement method, while that withhold based on performance of agreed upon criteria, which clinic may pay its employed providers using another may include patient satisfaction levels, quality of care and/or care reimbursement method. management measures. Conducting medical necessity reviews HealthPartners conducts medical necessity reviews for select services. These reviews ensure our members receive safe and effective care that aligns with the coverage outlined in the member’s contract. Medical necessity reviews can be conducted pre-service, before the service takes place; post-service, after the service has happened; or concurrently, while the service is taking place. Contracted providers are responsible for obtaining prior authorization from the health plan when it is required. Services that require prior authorization are listed on our website. Prior authorization is not required for emergency services. HealthPartners will inform both you and your provider of the outcome of our review. This plan may not cover all your health care expenses. Read your plan materials carefully to determine which expenses are covered. For details about benefits and services, go to healthpartners.com/robin or call Member Services at 855-813-3888. 21-1213441-1292016 (08/21) © 2021 HealthPartners Robin with HealthPartners plans are underwritten and/or administered by HealthPartners Insurance Company and HealthPartners Administrators, Inc.
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