SOLO Member Guidebook

2017
ConnectiCare Solo
®
Individual plans
Welcome to ConnectiCare
This guide includes information about ConnectiCare’s 2017 plans. We’re pleased
to offer you a range of plan options, giving you the benefits you need to stay healthy.
No matter which plan you choose, you can count on ConnectiCare to provide you with
personalized service and easy access to care that have helped
make us the top choice in Connecticut for individual health plans.1
This year, ConnectiCare celebrates 35 years of helping make Connecticut
a healthier place to live and work. Being a local company, our employees
live and work in the same communities as our members, so we’re able to
do more for them, whether it’s helping find a doctor or providing new,
easier ways to get care and service, including:
• New way to get care at CliniSanitas Medical Centers,
only for ConnectiCare members
• New ConnectiCare center in Manchester
Take a look at all we have to offer in this guide. When you’re ready, you can enroll
directly with us by calling 1-800-723-2986. Or, call your broker.
Thank you again for considering ConnectiCare.
Sincerely,
Terri Guidone
Vice President, Sales & Account Management
ConnectiCare, Inc. & Affiliates
1-800-723-2986
1
New, easier ways to get care and service
Benefits you need
CliniSanitas Medical Centers,
only for ConnectiCare members
In this guide, you’ll see a wide range of plan options. No matter which plan you choose,
These medical centers offer ConnectiCare
members one convenient place to get primary
care, see specialists, get lab work, urgent care,
and customer service for their ConnectiCare
plan. With Spanish and English speaking staff,
easy-to-schedule appointments and convenient
hours, CliniSanitas really makes it easier to get
care. Three centers will open in the fall of 2016
in Newington, Orange and Bridgeport.
you’ll get:
Primary care: family
medicine, internal medicine,
pediatrics and gynecology
Specialists:
cardiology, dermatology,
orthopedics and more
Urgent care walk-in
including observation units
Free preventive care2 for covered
services like your annual checkup,
screenings and more
RX
Prescription drug benefits
Vision benefits
Telemedicine through MDLIVE
– virtual doctor visits from home,
office or on the go
Pediatric dental benefits
Emergency and urgent care
anywhere in the world
Access to our broad network
including EVERY hospital in CT
®3
Extras that don’t cost extra
Onsite laboratory
and diagnostics
As a ConnectiCare member, you’ll get more than just health insurance. You’ll have
Care programs: diabetes,
COPD, asthma, weight
management and more
Vision Discount Program
access to discounts and savings that can make a big difference!
If you wear glasses or contacts, you can save hundreds of dollars each year with
discounts of up to 30% when you purchase frames, lenses and prescription contacts
from a participating optician.
ConnectiCare center in Manchester
Opening in the fall of 2016, our new center is a place where members can enjoy educational
and community events, pay their bill, or simply get answers to questions. And, starting
in 2017, members can also get preventive care like flu shots and health assessments.
Stop by and check it out: 1487 Pleasant Valley Road, Manchester, CT 06042.
Healthy Alternatives Program
You can get discounts up to 30% off select health
and wellness products and services from acupuncture
to exercise classes and more!
College Tuition Rewards®4
You can save thousands on college tuition just for being
a member. With this program, you can earn up to one
full year’s tuition at more than 340 private colleges and
universities. Find out more at tuitionrewards.com/cci.
2
chooseconnecticare.com
1-800-723-2986
3
ConnectiCare® Solo Choice plans
Prescription drug benefits
With ConnectiCare Solo, you have a range of plans to choose from.
These plans let you manage your care, your way, giving you the freedom to see a
specialist without a referral.
Choice HMO plans cover in-network services only, except for emergency and
urgent care, which are covered worldwide.
Choice POS plans give you coverage with lower copays and coinsurance for
in-network medical services, plus coverage for out-of-network medical services.
There are also Choice plans available with Health Savings Accounts (HSAs). An HSA
is a savings account that you can fund with pre-tax dollars and use to pay for qualified
health care expenses, including prescriptions.
ConnectiCare’s networks include thousands of doctors,
All ConnectiCare Solo plans include prescription drug benefits. To see if your drugs are covered,
look at the ConnectiCare Freedom Formulary at chooseconnecticare.com for the most
up-to-date list of covered drugs.
Covered prescription drugs are grouped
into sections or tiers. A drug “tier” is a
group of medicines within a similar price
range. With the six-tier drug list, the
categories of generic, brand-name and
specialty drugs are each divided into tiers
labeled “preferred” and “non-preferred.”
Preferred drugs are clinically-proven
medicines that will generally cost you
less than non-preferred medicines.
How much you pay for drugs in each
tier can be found on pages 6-9.
Drug Tier
Drug Class
Tier 1
Preferred Generic Drugs
Tier 2
Non-Preferred Generic Drugs
Tier 3
Preferred Brand Drugs
Tier 4
Non-Preferred Brand Drugs
Tier 5
Preferred Specialty Drugs
Tier 6
Non-Preferred Specialty Drugs
pharmacies and EVERY hospital in Connecticut.
Metal levels
Solo plans are grouped by “metal” level to help you better understand how much of your
medical expenses they will cover. Listed below are descriptions for premium ranges and
out-of-pocket costs for each metal level.
Metal Level
Premiums
Your Out-of-Pocket Costs
Plan Pays*
Bronze plans
Lowest
Highest
60%
Silver plans
Moderate
Moderate
70%
Gold plans
Higher
Lower
80%
Review our plans and let us know if you have
any questions.
By phone: 1-800-723-2986
Monday - Friday, 8 a.m. to 5 p.m.,
or call your broker
*Average amount plan pays for covered services
4
In person: At a ConnectiCare center
Online: chooseconnecticare.com
chooseconnecticare.com
1-800-723-2986
5
Choice Solo POS
Coins.
$2,500/$5,000 upfront ded.
Silver
Choice Solo POS HSA
$6,000/$12,000 ded.
Bronze
Choice Solo HMO HSA
$5,850/$11,700 ded.
Bronze
Choice Solo POS
Copay/Coins.
$5,000/$10,000 ded.
Silver
Deductible (Individual/Family)
$6,000/$12,000*
$5,850/$11,700*
$5,000/$10,000*
$2,500/$5,000*
Maximum Out-of-Pocket Limit (Individual/Family)
$6,550/$13,100
$6,550/$13,100
$7,150/$14,300
$6,500/$13,000
$0
$0
$0
$0
Primary Care Physician (PCP)
Office Visits & Telemedicine
$0 after deductible
$0 after deductible
Specialist Office Visits
$0 after deductible
$0 after deductible
Vision
$0
(deductible waived)
$0
(deductible waived)
Walk-In/Urgent Care Center
$0 after deductible
$0 after deductible
Worldwide Emergency Coverage
$0 after deductible
$0 after deductible
Inpatient Hospital Coverage
$0 after deductible
$0 after deductible
Hospital Outpatient Facilities
$0 after deductible
$0 after deductible
Outpatient Surgery Free Standing Locations
$0 after deductible
$0 after deductible
Lab Services
$0 after deductible
$0 after deductible
X-Rays
$0 after deductible
$0 after deductible
Advanced Imaging (CT Scans & MRI)
$0 after deductible
$0 after deductible
$30 copay
(deductible waived)
$50 copay
(deductible waived)
$50 copay
(deductible waived)
$75 copay
(deductible waived)
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
$10 copay
(deductible waived)
$40 copay
(deductible waived)
20% coinsurance
after deductible
$30 copay
(deductible waived)
50% coinsurance
after deductible
50% coinsurance
after deductible
50% coinsurance
after deductible
50% coinsurance
after deductible
50% coinsurance
after deductible
50% coinsurance
after deductible
50% coinsurance
after deductible
50% coinsurance
after deductible
50% coinsurance
after deductible
50% coinsurance
after deductible
$10,000/$20,000
N/A
$10,000/$20,000
$5,000/$10,000
50%
N/A
50%
50%
$20,000/$40,000
N/A
$20,000/$40,000
$15,000/$30,000
Plan has integrated
deductible with medical
(see above)*
Plan has integrated
deductible with medical
(see above)*
$5 copay after deductible
$5 copay after deductible
50% coinsurance
$200 maximum per prescription
after deductible
50% coinsurance
$200 maximum per prescription
after deductible
$60 copay after deductible
$60 copay after deductible
Tier 4 – Non-Preferred Brand Drugs
50% coinsurance
$200 maximum per prescription
after deductible
50% coinsurance
$200 maximum per prescription
after deductible
Plan has integrated
deductible with medical
(see above)*
$5 copay
(deductible waived)
50% coinsurance
$200 maximum per prescription
after deductible
$60 copay
(deductible waived)
50% coinsurance
$200 maximum per prescription
after deductible
Plan has integrated
deductible with medical
(see above)*
$5 copay
(deductible waived)
50% coinsurance
$200 maximum per prescription
after deductible
$60 copay
(deductible waived)
50% coinsurance
$200 maximum per prescription
after deductible
Tier 5 – Preferred Specialty Drugs
50% coinsurance
$500 maximum per prescription
after deductible
50% coinsurance
$500 maximum per prescription
after deductible
50% coinsurance
$500 maximum per prescription
after deductible
50% coinsurance
$500 maximum per prescription
after deductible
Tier 6 – Non-Preferred Specialty Drugs
50% coinsurance
$750 maximum per prescription
after deductible
50% coinsurance
$750 maximum per prescription
after deductible
50% coinsurance
$750 maximum per prescription
after deductible
50% coinsurance
$750 maximum per prescription
after deductible
Choice Solo plans
Plan Name/Metal Level
PLAN/MEDICAL DEDUCTIBLE
IN-NETWORK MEDICAL BENEFITS
Preventive Care/Screenings/Immunizations
OUT-OF-NETWORK MEDICAL BENEFITS
Deductible (Individual/Family)
Coinsurance
Maximum Out-of-Pocket Limit (Individual/Family)
PRESCRIPTION DRUG BENEFIT
Prescription Drug Deductible (Individual/Family)
Tier 1 – Preferred Generic Drugs
Tier 2 – Non-Preferred Generic Drugs
Tier 3 – Preferred Brand Drugs
6
chooseconnecticare.com
*Integrated medical and prescription drug deductible.
1-800-723-2986
7
Choice Solo POS
Copay/Coins.
$4,500/$9,000 ded.
Silver
Choice Solo POS HSA
Coins.
$3,000/$6,000 ded.
Silver
Choice Solo POS
Copay/Coins.
$1,000/$2,000 ded.
Gold
Deductible (Individual/Family)
$4,500/$9,000*
$3,000/$6,000*
$1,000/$2,000*
Maximum Out-of-Pocket Limit (Individual/Family)
$7,150/$14,300
$5,000/$10,000
$5,000/$10,000
$0
$0
$0
Choice Solo plans
Plan Name/Metal Level
PLAN/MEDICAL DEDUCTIBLE
IN-NETWORK MEDICAL BENEFITS
Preventive Care/Screenings/Immunizations
Primary Care Physician (PCP)
Office Visits & Telemedicine
Specialist Office Visits
Vision
Walk-In/Urgent Care Center
Worldwide Emergency Coverage
Inpatient Hospital Coverage
Hospital Outpatient Facilities
Outpatient Surgery Free Standing Locations
Lab Services
X-Rays
$30 copay
(deductible waived)
$45 copay
(deductible waived)
$45 copay
(deductible waived)
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance after deductible
20% coinsurance after deductible
20% coinsurance
(deductible waived)
20% coinsurance after deductible
20% coinsurance after deductible
20% coinsurance after deductible
20% coinsurance after deductible
20% coinsurance after deductible
20% coinsurance after deductible
20% coinsurance after deductible
$30 copay
(deductible waived)
$45 copay
(deductible waived)
$45 copay
(deductible waived)
$75 copay
after deductible
$200 copay
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
$500 copay
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance
after deductible
20% coinsurance after deductible
20% coinsurance
after deductible
$10,000/$20,000
$7,000/$14,000
$5,000/$10,000
50%
50%
50%
$12,500/$25,000
$15,000/$30,000
$10,000/$20,000
Plan has integrated
deductible with medical
(see above)*
Plan has integrated
deductible with medical
(see above)*
Plan has integrated
deductible with medical
(see above)*
$5 copay
(deductible waived)
$5 copay after deductible
50% coinsurance
$200 maximum per prescription
after deductible
50% coinsurance
$200 maximum per prescription
after deductible
$60 copay
(deductible waived)
$60 copay after deductible
Tier 4 – Non-Preferred Brand Drugs
50% coinsurance
$200 maximum per prescription
after deductible
50% coinsurance
$200 maximum per prescription
after deductible
$50 copay
(deductible waived)
50% coinsurance
$200 maximum per prescription
after deductible
Tier 5 – Preferred Specialty Drugs
50% coinsurance
$500 maximum per prescription
after deductible
50% coinsurance
$500 maximum per prescription
after deductible
50% coinsurance
$500 maximum per prescription
after deductible
Tier 6 – Non-Preferred Specialty Drugs
50% coinsurance
$750 maximum per prescription
after deductible
50% coinsurance
$750 maximum per prescription
after deductible
50% coinsurance
$750 maximum per prescription
after deductible
Advanced Imaging (CT Scans & MRI)
OUT-OF-NETWORK MEDICAL BENEFITS
Deductible (Individual/Family)
Coinsurance
Maximum Out-of-Pocket Limit (Individual/Family)
PRESCRIPTION DRUG BENEFIT
Prescription Drug Deductible (Individual/Family)
Tier 1 – Preferred Generic Drugs
Tier 2 – Non-Preferred Generic Drugs
Tier 3 – Preferred Brand Drugs
8
*Integrated medical and prescription drug deductible.
chooseconnecticare.com
$5 copay
(deductible waived)
50% coinsurance
$200 maximum per prescription
after deductible
1-800-723-2986
9
Important information about the
ConnectiCare Solo plans in this booklet
Language & Non-Discrimination Notice
®
ConnectiCare Solo is now guaranteed issue
Limited Open Enrollment:
Guaranteed issue simply means that your Solo health
insurance policy will be issued regardless of your health
status. There is no underwriting and there are no
medical questions on the application.
An individual can experience a qualifying event
that makes him/her eligible to apply for health care
coverage outside the Open Enrollment period. This
is called a Special Enrollment Period. If you have
experienced a qualifying event, you can apply for
coverage within 60 days following the event. Examples
of a Qualifying Event include:
Eligibility
You may apply for ConnectiCare Solo if you meet the
following criteria:
• Legal resident of Connecticut
• Be under age 65
• Not enrolled in Medicare
• Single or married, or one of the following:
– Dependent spouse
– Civil union/domestic partner*
– Dependent child to age 26 who is not covered
under a group health plan
*Domestic partners must submit the Domestic Partner
Verification Form or other satisfactory certification as
we determine. CAUTION: Domestic partners are not
recognized by the IRS as legal dependents for HSA
funding. You should consult with your ConnectiCare
agent and your tax advisor before establishing an HSA.
Renewal Provision
We can refuse to renew your active policy only when
we refuse to renew all individual plans in this State.
Nonrenewal will not affect an existing claim.
Eligibility Periods:
For 2017, Open Enrollment Period is November 1, 2016
through January 31, 2017.
If you enroll:
Your coverage
will be effective:
November 1, 2016 – December 15, 2016
January 1, 2017
December 16, 2016 – January 15, 2017
February 1, 2017
January 16, 2017 – January 31, 2017
March 1, 2017
chooseconnecticare.com
ConnectiCare:
• Provides free aids and services to people with disabilities to communicate
effectively with us, including qualified interpreters and information in
alternate formats.
• Provides free language services to people whose primary language is not
English, including translated documents and oral interpretation.
• An individual gains or becomes a dependent
through birth, adoption, or placement for adoption
If you need these services, contact ConnectiCare’s Committee for Civil Rights.
• An individual gains or becomes a dependent
through marriage
If you believe that ConnectiCare has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, you can
file a grievance with: The Committee for Civil Rights, ConnectiCare, 175 Scott Swamp
Road, Farmington, CT 06034, Phone: 1-800-251-7722, and TTY: 1-800-833-8134.
You can file a grievance in person or by mail. If you need help filing a grievance, The
Committee for Civil Rights is available to help you. You can also file a civil rights
complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department
of Health and Human Services, 200 Independence Avenue SW., Room 509F,
HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).
• An individual gained a dependent through court
order, including child support
• An individual experiences an error in enrollment
• The divorce or legal separation that results in a loss
of group health coverage
• A covered dependent loses group health coverage
because of a covered employee’s eligibility
for Medicare
• A dependent child loses coverage due to loss of
dependent status under an employee’s group
health plan
• New coverage becomes available to an individual
or enrollee that has permanently moved into the
ConnectiCare service area
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
• A dependent loses coverage because of the death
of a covered employee under a group plan
Open Enrollment
10
• An individual and/or any dependents lose
Minimum Essential Coverage (MEC) not resulting
from failure to pay a premium or providing false
information on a previous application
ConnectiCare complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex.
ConnectiCare does not exclude people or treat them differently because of race,
color, national origin, age, disability, or sex.
• The termination (other than for misconduct)
or reduction of hours of a covered employee’s
employment that results in a loss of group
health coverage
1-800-723-2986
11
12
chooseconnecticare.com
Questions?
By phone: 1-800-723-2986
Monday - Friday, 8 a.m. to 5 p.m.,
or call your broker
In person: At a ConnectiCare center
Online: chooseconnecticare.com
The Connecticut Mirror, 2015; HartfordBusiness.com, 2015; and Centers for Medicare & Medicaid Services (CMS) Monthly Summary
Report (Data as of August 2016).
2
“Free” preventive care means that you will not have a copay or have to pay money toward your deductible or coinsurance for the services.
Sometimes a preventive care visit leads to other medical care or tests, even at the same appointment. You should check with your doctor
or doctor’s staff during your visit to see if there are services you may be billed for.
3
MDLIVE does not replace the primary care physician. MDLIVE is not an insurance product nor a prescription fulfillment warehouse.
MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription
will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs, which may be
harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. MDLIVE
interactive audio consultations with store and forward technology are available 24/7/365, while video consultations are available during
the hours of 7 a.m. to 9 p.m., 7 days a week or by scheduled availability. MDLIVE and the MDLIVE logo are registered trademarks of
MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit www.mdlive.com/pages/terms.html.
4
Discount programs provide access to discounted tuition and are NOT insured benefits. These discounts are offered separate from your
health benefits. These arrangements do not represent an endorsement or guarantee on the part of ConnectiCare, Inc. You are responsible
for the full cost of the discounted tuition. Vendors such as Sage, LLC are independent contractors and are not agents of ConnectiCare
Specialty Services. Vendor participation may change without notice. Information is believed to be accurate as of the production date;
however, it is subject to change. For more information about Sage, LLC, refer to www.tuitionrewards.com/cci.
1
©2016 ConnectiCare, Inc. & Affiliates.
SOLOPRODBROC 1016