Employee Health Plan Changes
Effective July 1, 2015
PCPS AND REFERRALS REQUIRED!
HARVARD PILGRIM INDEPENDENCE PLAN AND TUFTS HEALTH PLAN NAVIGATOR
In keeping with the Centered Care Initiative, Harvard Pilgrim Independence Plan and Tufts Health Plan Navigator will become Point-of-Service (POS) plans. With a POS Plan, members must select a Primary Care Provider (PCP) to manage their care and obtain referrals to specialists to receive care at the in-network level of coverage. Members who get care from specialists without a PCP referral will have higher out-of-pocket costs. Current members of these plans will stay in the plan if they do not switch plans during Annual Enrollment and will receive additional details of this transition from their plan.
ALL HEALTH PLANS
Rules for Enrolling in Health Plans and Adding Dependents: In compliance with federal and state law for pre-tax benefits, the GIC will be tightening up our rules and instituting deadlines for enrolling in health plans and adding dependents. As always, required documentation (e.g., birth certificates and marriage certificates) must accompany the change forms. See Modifications to Rules for Enrolling in and Changing Plans for more information.
Deductible: The current calendar year deductible will increase to $300 individual; $600 two-person family; and $900 three or more person family coverage. The carryover provision into 2016 for deductible-related charges incurred October – December 2015 has been eliminated. The deductible will transition to a fiscal year deductible to make it easier for members to change health plan carriers at future annual enrollments. See Deductible Page for additional details.
Other Benefits That Accrue on a Calendar Year will transition during FY16 to a fiscal year accrual. For 2015, they will accrue on a calendar year; from January 1 – June 30, 2016, they will accrue on a half-calendar year; from July 1, 2016 – June 30, 2017, they will accrue on a fiscal year. Details vary slightly by plan; contact the plan for details:
- Out-of-pocket maximum
- Inpatient copay
- Day limits for other inpatient medical facilities (skilled nursing, rehab, etc.)
- Outpatient surgery copay
- Physical and Occupational Therapy
- Outpatient mental health
- Smoking cessation counseling
- Hearing aids
- Fitness reimbursement
- Nutritional counseling
- Vision hardware for certain conditions
- Vision exam
- Chiropractic visits
- Speech therapy
- Private Duty nursing
- Hospital-based personal emergency response systems
Specialist Tiering: Copays for specialists will increase for all plans: $30 Tier 1; $60 Tier 2; $90 Tier 3.
Fallon Health Direct Care will tier specialists based on quality and/or cost-efficiency for the first time.
Inpatient Hospital Care Copay: For plans that do not tier hospitals (Fallon Health Direct, Health New England, Neighborhood Health Plan, UniCare State Indemnity Plan/Basic, and UniCare Community Choice), the copay will increase to $275. Tufts Health Plan Navigator will change to three tier hospital copays $275, $500 and $1,500. Tier 1 and Tier 3 copays will increase or change for all plans that have three hospital tiers (Fallon Health Select, Harvard Pilgrim Independence Plan and UniCare PLUS): Tier 1: $275 and Tier 3: $1,500. For Harvard Pilgrim Primary Choice, Tier 1 will increase to $275.
Outpatient Surgery Copay: The copay will increase to $250 for all plans except UniCare Community Choice and PLUS.
Prescription Drug Copays: All prescription drug copays except for Tier 1 retail will increase to: Tier 2 $30 and Tier 3 $65 retail up to a 30-day supply; Tier 1 $25; Tier 2 $75 and Tier 3 $165 mail order up to a 90-day supply.
In-Network Out-of-Pocket Maximum: The out-of-pocket maximum ($5,000 per individual and $10,000 per family) will now include prescription drugs for Harvard Independence and Primary Choice, Tufts Navigator and Spirit. (This already applies to the other GIC HMOs.) The out-of-pocket maximum for UniCare State Indemnity Plan/Basic, Community Choice and PLUS will change to $4,000 per individual and $8,000 per family for medical and mental health benefits and $1,500 per individual and $3,000 per family for prescription drug benefits.
Other Health Plan Changes
NEIGHBORHOOD HEALTH PLAN:
- NHP Care will now be called NHP Prime.
- Prosthetics and orthotics with Durable Medical Equipment (DME) will be subject to the deductible, but not coinsurance.
- Hearing aid benefits for members over age 22 will no longer be subject to coinsurance.
TUFTS HEALTH PLAN NAVIGATOR AND SPIRIT: Mental Health/Substance Abuse: Outpatient mental health visits up to 26 visits without prior authorization; thereafter, visits subject to prior authorization for medical necessity.
UNICARE STATE INDEMNITY PLAN/BASIC, COMMUNITY CHOICE AND PLUS:
- Prescription Drug Program: CVS/caremark was selected to continue as the pharmacy benefit manager. Prior authorization will be required for certain high-cost drugs. See the Prescription Drug page for additional information.
- Certain Oral, Injectable, Infused and Inhaled Specialty Drugs: After the first fill of certain specialty drugs, you must get refills through CVS/caremark’s specialty pharmacy. The first fill may be limited to up to a 14-day supply with a prorated copay.
- Mental Health/Substance Abuse: One visit with a PCP for mental health/substance abuse will now be covered. Outpatient mental health visits up to 26 visits without prior authorization; thereafter, visits subject to prior authorization for medical necessity.
This information provided by the Group Insurance Commission .
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