Community HealthEssentials Guide

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Community HealthEssentials - Summary

Community HealthEssentials is the new name for Community Health Plan of Washington’s (CHPW) individual commercial products offered inside the Washington State Health Benefits Exchange in 2014.

Open enrollment begins October 1, 2013 and coverage begins January 1, 2014.

Community HealthEssentials is offered in the 26 counties where Community Health Centers with medical clinics are located in Washington State. The following counties are not included: Asotin, Clallam, Columbia, Garfield, Island, Jefferson, Kittitas, Klickitat, Lincoln, Mason, San Juan,

Skamania and Whitman.

Community HealthEssentials is offered by Community Health Plan of Washington and administered by

First Choice Health.

CHPW has partnered with First Choice Health (FCH) to serve as the Preferred Provider Organization (PPO) network and Third Party Administrator (TPA) for Community HealthEssentials commercial products. Administrative services include Customer Service, Utilization Management and Case Management, Claims and Benefits Administration, and Level 1 Appeals. For NCQA and delegation oversight purposes, all Level 2 Appeals will be handled by CHPW.

All other plans offered by CHPW will continue to be administered by CHPW and use CHPW’s provider network.

Customer Service

Members and providers can call First Choice Health Customer Service at 1-800-930-0132 Monday through Friday between 8:00 AM and 5:00 PM Pacific Time.

Members can access the member portal www.myFirstChoice.fchn.com to find specific information about their benefits, claims, and deductibles. They can also download a copy of their Community HealthEssentials ID card from the portal at any time.

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Provider offices can verify eligibility of Community HealthEssentials members by accessing OneHealthPort or by calling First Choice Health Customer Service at 1-800-930-0132.

Utilization Management and Case Management

Community HealthEssentials is a PPO product that allows members the freedom to choose the providers they want to see. Members are not assigned to a Primary Care Provider and no referrals are required for members to see a specialist.

Pre-authorizations are required for inpatient admissions and for certain procedures and services. The First Choice Health pre-authorization

list is used for Community HealthEssentials members and it is different from the CHPW pre-authorization list. You can find the First Choice

Health pre-authorization list at www.fchn.com.

For Pre-authorizations, please call the appropriate number below:

Medical: 1-800-808-0450

Mental Health/Substance Use: 1-800-640-7682

Claims and Benefits Administration

Claims for Community HealthEssentials members will be processed and paid by FCH. The Payor ID for electronic claims submission is 91131. You can also mail claims to:

Community HealthEssentials @ FCH P.O. Box 12659

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1st_{Level Appeals}

For appeals questions, please call First Choice Health at 1-877-749-2031 Mailing Address for Appeals:

Attn: Appeals Coordinator 600 University Street, #1400 Seattle, WA 98101

Fax: (206) 268-2920

Member ID Cards

Member ID cards will look different from CHPW member ID cards. You will be able to recognize Community HealthEssentials members by the logo on the top left hand corner of the ID card and by the group name Community HealthEssentials.

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What to Expect With Community HealthEssentials Enrollment in the 2014 Exchange

Community HealthEssentials Benefit Summaries

The following includes an example of the standard Summary of Benefit Coverage (SBC) for Community HealthEssentials Gold, Silver and Bronze plans. Each metal level plan covers the same Essential Health Benefits that are required by Health Care Reform in 2014. Please note that although the benefits are the same, there are multiple cost sharing variations that are based on the premium subsidy and level of cost sharing each

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Community HealthEssentials Bronze

Summary of Benefits and Coverage:

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Community Health Plan of Washington:

Community HealthEssentials Bronze

Coverage Period: 01/01/2014 – 12/31/2014

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family |Plan Type: PPO

This is only a summary.

If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.myfirstchoice.fchn.com or by calling 1-800-930-0132.

Important Questions Answers Why this Matters:

What is the overall

deductible?

For network providers:

$5,000

person/

$10,000

family.

For non-network providers:

$5,000

person/

$10,000

family.

Doesn’t apply to preventive care. Copayments and coinsurance don’t count toward the deductible.

You must pay all the costs up to the deductible amount before thisplan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles

for specific services? No.

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out–of–pocket

limit on my expenses? Yes:

$6,350

person/

$12,700

family.

The out-of-pocket limit is the most you could pay during a coverage period

(usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the

out–of–pocket limit?

Premiums, balance-billed charges, out-of-network coinsurance, and health care this plan doesn’t cover

Even though you pay these expenses, they don’t count toward the

out-of-pocket limit.

Is there an overall annual

limiton what the plan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a

network of providers?

Yes. See www.fchn.com or call 1-800-930-0132 for a list of participating

providers.

If you use an in-network doctor or other health care provider, thisplan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participatingfor providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers Do I need a referral to see

a specialist? No. You don’t need a referral to see a specialist You can see the specialist you choose without permission from this plan.

Are there services this

plan doesn’t cover? Yes.

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Community Health Plan of Washington:

Community HealthEssentials Bronze

Coverage Period: 01/01/2014 – 12/31/2014

Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if

the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 30% would be $200. This may change if you haven’t met your deductible.

The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the

allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and

the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and co-insurance amounts.

Common

Medical Event Services You May Need

Your cost if you use a

Limitations & Exceptions Network

Provider Non Network Provider

If you visit a health care provider’s office or clinic

Primary care visit to treat

an injury or illness $45 co-pay/visit 50% co-insurance Network providers not subject to deductible. Specialist visit $75 co-pay/visit 50% co-insurance Network providers not subject to deductible. Other practitioner office

visit $75 co-pay/visit 50% co-insurance

Network providers not subject to deductible. Limited to 12 visits per calendar year for acupuncture, and 10 visits per calendar year for chiropractic.

Preventive care/

screening/immunization No charge 50% co-insurance Network providers not subject to deductible.

If you have a test

Diagnostic test (x-ray,

blood work) No charge 50% co-insurance –––––––––––none––––––––––– Imaging (CT/PET scans,

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Community Health Plan of Washington:

Community HealthEssentials Bronze

Coverage Period: 01/01/2014 – 12/31/2014

Common

If you need drugs to treat your illness or condition

More information about

prescription drug

coverage is available at

www.express-scripts.com.

Generic drugs $25 copay/ _prescription Not covered.

Generic drugs not subject to deductible. Covers up to a 30 day supply at retail pharmacies only. Preferred brand drugs 50% co-insurance Not covered.

Specialty drugs 50% co-insurance Not covered.

If you have outpatient surgery

Facility fee (e.g.,

ambulatory surgery center) No charge 50% co-insurance Pre-authorization is required for certain services or claim will be denied.

Physician/surgeon fees No charge 50% co-insurance

If you need immediate medical attention

Emergency room services $500 co-pay/visit $500 co-pay/visit –––––––––––none–––––––––––

Emergency medical

transportation No charge 50% co-insurance –––––––––––none–––––––––––

Urgent care $75 co-pay/visit. 50% co-insurance Network providers not subject to deductible.

If you have a hospital stay

Facility fee (e.g., hospital

room) No charge 50% co-insurance Pre-authorization is required or claim will be denied.

Physician/surgeon fee No charge 50% co-insurance

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health

outpatient services No charge 50% co-insurance –––––––––––none––––––––––– Mental/Behavioral health

inpatient services No charge 50% co-insurance Pre-authorization is required or claim will be denied. Substance use disorder

outpatient services No charge 50% co-insurance –––––––––––none––––––––––– Substance use disorder

inpatient services No charge 50% co-insurance Pre-authorization is required or claim will be denied.

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Community Health Plan of Washington:

Community HealthEssentials Bronze

Coverage Period: 01/01/2014 – 12/31/2014

Common

Delivery and all inpatient

services No charge 50% co-insurance –––––––––––none–––––––––––

If you need help recovering or have other special health needs

Home health care No charge 50% co-insurance Coverage is limited to 130 visits per calendar year. Pre-authorization is required or claim will be denied.

Rehabilitation services No charge 50% co-insurance

Coverage is limited to 30 days per calendar year for inpatient rehabilitation, and 25 visits per calendar year for outpatient rehabilitation. Pre-authorization is required for inpatient

rehabilitation or claim will be denied. Habilitation services No charge 50% co-insurance

Coverage is limited to 30 days per calendar year for inpatient habilitation, and 25 visits per calendar year for outpatient habilitation. Pre-authorization is required for inpatient habilitation or claim will be denied.

Skilled nursing care No charge 50% co-insurance Coverage is limited to 60 days per calendar year. Pre-authorization is required or claim will be denied.

Durable medical

equipment No charge 50% co-insurance Pre-authorization required if purchase over $2,000 or rental over $500/month, or claim will be denied. Hospice service No charge 50% co-insurance

Coverage for respite care is limited to 14 days lifetime maximum. Pre-authorization required or claim will be denied.

If your child needs dental or eye care

Eye exam No charge No charge Coverage is limited to 1 exam per calendar year. _{Not subject to deductible.} Glasses No charge No charge Coverage is limited to one pair of lenses and one pair of frames per calendar year. Not subject to

deductible.

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Community Health Plan of Washington:

Community HealthEssentials Bronze

Coverage Period: 01/01/2014 – 12/31/2014

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Bariatric surgery Cosmetic surgery

Dental care (Adult and child) Hearing aids

Infertility treatment Long-term care

Non-emergency care when traveling outside the U.S. Private-duty nursing

Routine eye care (Adult) Routine foot care Weight loss programs

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Acupuncture Chiropractic care

Your Rights to Continue Coverage:

Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:

You commit fraud

The insurer stops offering services in the State You move outside the coverage area

For more information on your rights to continue coverage, contact the insurer at (800) 930-0132. You may also contact your state insurance department at (800) 562-6900.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can the Washington State Office of the Insurance Commissioner at (800) 562-6900.

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does

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Community Health Plan of Washington:

Community HealthEssentials Bronze

Coverage Period: 01/01/2014 – 12/31/2014

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This

health coverage does meet the minimum value standard for the benefits it provides.

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Community Health Plan of Washington:

Community HealthEssentials Bronze

Coverage Period: 01/01/2014 – 12/31/2014

Coverage Examples Coverage for: Family |Plan Type: PPO

Having a baby

(normal delivery)

Managing type 2 diabetes

(routine maintenance of

a well-controlled condition)

About these Coverage

Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

 _{Amount owed to providers: $7,540}  _{Plan pays $2,320}

 _{Patient pays $5,220}

Sample care costs:

Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540 Patient pays: Deductibles $5,000 Co-pays $20 Co-insurance $0 Limits or exclusions $200 Total $5,220

 _{Patient pays $1,980}

Prescriptions $2,900

Medical Equipment and Supplies $1,300 Office Visits and Procedures $700

Education $300

Laboratory tests $100 Vaccines, other preventive $100

Total $5,400 Patient pays: Deductibles $100 Co-pays $1,800 Co-insurance $0 Limits or exclusions $80 Total $1,980

This is

not a cost

estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for

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Community Health Plan of Washington:

Community HealthEssentials Bronze

Coverage Period: 01/01/2014 – 12/31/2014

Questions and answers about the Coverage Examples:

What are some of the

assumptions behind the

Coverage Examples?

Costs don’t include premiums.

Sample care costs are based on national averages supplied by the U.S.

Department of Health and Human Services, and aren’t specific to a

particular geographic area or health plan. The patient’scondition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network

providers, costs would have been higher.

What does a Coverage Example

show?

For each treatment situation, the Coverage Example helps you see how deductibles,

co-payments, and co-insurance can add up. It

also helps you see what expenses might be left up to you to pay because the service or

treatment isn’t covered or payment is limited.

Does the Coverage Example

predict my own care needs?



No.

Treatments shown are just examples. The care you would receive for this

condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example

predict my future expenses?



No.

Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your

providers charge, and the reimbursement

your health plan allows.

Can I use Coverage Examples

to compare plans?



Yes.

When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the planprovides.

Are there other costs I should

consider when comparing

plans?



Yes.

An important cost is the premium

you pay. Generally, the lower your

premium, the more you’ll pay in

out-of-pocket costs, such as co-payments,

deductibles, and co-insurance. You

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Community HealthEssentials Silver

Summary of Benefits and Coverage:

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Community Health Plan of Washington:

Community HealthEssentials Silver

Coverage Period: 01/01/2014 – 12/31/2014

This is only a summary.

deductible?

$2,000

person/

$4,000

family. For

non-network providers:

$5,000

person/

$10,000

family.

Doesn’t apply to preventive care. Copayments and coinsurance don’t count toward the deductible.

for specific services? No.

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

$6,350

person/

$12,700

family.

limiton what the plan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a

providers.

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Community Health Plan of Washington:

Community HealthEssentials Silver

Coverage Period: 01/01/2014 – 12/31/2014

Common

Limitations & Exceptions Network Provider Non Network _Provider

Preventive care/

blood work) 30% co-insurance 50% co-insurance –––––––––––none––––––––––– Imaging (CT/PET scans,

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Community Health Plan of Washington:

Community HealthEssentials Silver

Coverage Period: 01/01/2014 – 12/31/2014

Common

Generic drugs not subject to deductible. Covers up to a 30 day supply at retail pharmacies only. Preferred brand drugs $50 copay/ _prescription Not covered.

Facility fee (e.g.,

ambulatory surgery center) 30% co-insurance 50% co-insurance Pre-authorization is required for certain services or claim will be denied.

Physician/surgeon fees 30% co-insurance 50% co-insurance

Emergency room services $250 co-pay/visit $250 co-pay/visit Not subject to deductible. Emergency medical

transportation 30% co-insurance 50% co-insurance –––––––––––none–––––––––––

room) 30% co-insurance 50% co-insurance Pre-authorization is required or claim will be denied.

Physician/surgeon fee 30% co-insurance 50% co-insurance

outpatient services 30% co-insurance 50% co-insurance –––––––––––none––––––––––– Mental/Behavioral health

inpatient services 30% co-insurance 50% co-insurance Pre-authorization is required or claim will be denied. Substance use disorder

outpatient services 30% co-insurance 50% co-insurance –––––––––––none––––––––––– Substance use disorder

inpatient services 30% co-insurance 50% co-insurance Pre-authorization is required or claim will be denied.

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Community Health Plan of Washington:

Community HealthEssentials Silver

Coverage Period: 01/01/2014 – 12/31/2014

Common

services 30% co-insurance 50% co-insurance –––––––––––none–––––––––––

Home health care 30% co-insurance 50% co-insurance Coverage is limited to 130 visits per calendar year. Pre-authorization is required or claim will be denied.

Rehabilitation services 30% co-insurance 50% co-insurance

rehabilitation or claim will be denied. Habilitation services 30% co-insurance 50% co-insurance

Skilled nursing care 30% co-insurance 50% co-insurance Coverage is limited to 60 days per calendar year. Pre-authorization is required or claim will be denied.

Durable medical

equipment 30% co-insurance 50% co-insurance Pre-authorization required if purchase over $2,000 or rental over $500/month, or claim will be denied. Hospice service 30% co-insurance 50% co-insurance

deductible.

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Community Health Plan of Washington:

Community HealthEssentials Silver

Coverage Period: 01/01/2014 – 12/31/2014

Excluded Services & Other Covered Services:

Your Rights to Continue Coverage:

You commit fraud

Your Grievance and Appeals Rights:

Does this Coverage Provide Minimum Essential Coverage?

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Community Health Plan of Washington:

Community HealthEssentials Silver

Coverage Period: 01/01/2014 – 12/31/2014

Does this Coverage Meet the Minimum Value Standard?

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Community Health Plan of Washington:

Community HealthEssentials Silver

Coverage Period: 01/01/2014 – 12/31/2014

Having a baby

(normal delivery)

Managing type 2 diabetes

About these Coverage

Examples:

 _{Patient pays $3,080}

Anesthesia $900

Prescriptions $200

Radiology $200

Total $7,540 Patient pays: Deductibles $2,000 Co-pays $80 Co-insurance $800 Limits or exclusions $200 Total $3,080

 _{Patient pays $1,380}

Education $300

Total $5,400 Patient pays: Deductibles $100 Co-pays $1,200 Co-insurance $0 Limits or exclusions $80 Total $1,380

This is

not a cost

estimator.

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Community Health Plan of Washington:

Community HealthEssentials Silver

Coverage Period: 01/01/2014 – 12/31/2014

Questions and answers about the Coverage Examples:

What are some of the

assumptions behind the

Coverage Examples?

What does a Coverage Example

show?

Does the Coverage Example

predict my own care needs?



No.

Does the Coverage Example

predict my future expenses?



No.

Can I use Coverage Examples

to compare plans?



Yes.

Are there other costs I should

consider when comparing

plans?



Yes.

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Community HealthEssentials Gold

Summary of Benefits and Coverage:

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Community Health Plan of Washington:

Community HealthEssentials Gold

Coverage Period: 01/01/2014 – 12/31/2014

This is only a summary.

deductible?

$500

person/

$1,000

family. For non-network

providers:

$5,000

person/

$10,000

family. Doesn’t apply to preventive care. Copayments and coinsurance don’t count toward the deductible.

for specific services? No. You don’t have to meet starting on page 2 for other costs for services this plan covers. deductibles for specific services, but see the chart

$4,800

person/

$9,600

family.

limiton what the plan pays? No.

The chart starting on page 2 describes any limits on what the plan will pay for

specific covered services, such as office visits. Does this plan use a

providers.

Are there services this

plan doesn’t cover? Yes.

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Community Health Plan of Washington:

Community HealthEssentials Gold

Coverage Period: 01/01/2014 – 12/31/2014

Common

Preventive care/

blood work) 20% co-insurance 50% co-insurance –––––––––––none––––––––––– Imaging (CT/PET scans,

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Community Health Plan of Washington:

Community HealthEssentials Gold

Coverage Period: 01/01/2014 – 12/31/2014

Common

Generic drugs not subject to deductible. Covers up to a 30 day supply at retail pharmacies only. Preferred brand drugs $40 copay/ _prescription Not covered.

Facility fee (e.g.,

ambulatory surgery center) 20% co-insurance 50% co-insurance Pre-authorization is required for certain services or claim will be denied.

Physician/surgeon fees 20% co-insurance 50% co-insurance

Emergency room services $250 co-pay/visit $250 co-pay/visit Not subject to deductible. Emergency medical

transportation 20% co-insurance 50% co-insurance –––––––––––none–––––––––––

room) 20% co-insurance 50% co-insurance Pre-authorization is required or claim will be denied.

Physician/surgeon fee 20% co-insurance 50% co-insurance

outpatient services 20% co-insurance 50% co-insurance –––––––––––none––––––––––– Mental/Behavioral health

inpatient services 20% co-insurance 50% co-insurance Pre-authorization is required or claim will be denied. Substance use disorder

outpatient services 20% co-insurance 50% co-insurance –––––––––––none––––––––––– Substance use disorder

inpatient services 20% co-insurance 50% co-insurance Pre-authorization is required or claim will be denied.

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Community Health Plan of Washington:

Community HealthEssentials Gold

Coverage Period: 01/01/2014 – 12/31/2014

Common

services 20% co-insurance 50% co-insurance –––––––––––none–––––––––––

Home health care 20% co-insurance 50% co-insurance Coverage is limited to 130 visits per calendar year. Pre-authorization is required or claim will be denied.

Rehabilitation services 20% co-insurance 50% co-insurance

rehabilitation or claim will be denied. Habilitation services 20% co-insurance 50% co-insurance

Skilled nursing care 20% co-insurance 50% co-insurance Coverage is limited to 60 days per calendar year. Pre-authorization is required or claim will be denied.

Durable medical

equipment 20% co-insurance 50% co-insurance Pre-authorization required if purchase over $2,000 or rental over $500/month, or claim will be denied. Hospice service 20% co-insurance 50% co-insurance

deductible.

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Community Health Plan of Washington:

Community HealthEssentials Gold

Coverage Period: 01/01/2014 – 12/31/2014

Excluded Services & Other Covered Services:

Your Rights to Continue Coverage:

You commit fraud

Your Grievance and Appeals Rights:

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does

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Community Health Plan of Washington:

Community HealthEssentials Gold

Coverage Period: 01/01/2014 – 12/31/2014

Does this Coverage Meet the Minimum Value Standard?

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Community Health Plan of Washington:

Community HealthEssentials Gold

Coverage Period: 01/01/2014 – 12/31/2014

Having a baby

(normal delivery)

Managing type 2 diabetes

About these Coverage

Examples:

 _{Patient pays $1,650}

Anesthesia $900

Prescriptions $200

Radiology $200

Total $7,540 Patient pays: Deductibles $500 Co-pays $50 Co-insurance $900 Limits or exclusions $200 Total $1,650

 _{Patient pays $1,080}

Education $300

Total $5,400 Patient pays: Deductibles $100 Co-pays $900 Co-insurance $0 Limits or exclusions $80 Total $1,080