welcome to a new era in health care coverage for tennessee.

WELCOME TO A NEW ERA IN
HEALTH CARE COVERAGE
FOR TENNESSEE.
Quality Health Plans for Individuals and Families in Tennessee.
™
TABLE OF CONTENTS
INTRODUCTION.........................1
Who are we?.................................................. 1
What is a CO-OP?..........................................1
Our business model is unique........................1
FINANCIAL ASSISTANCE...........2
Am I eligible for premium credits?.................. 2
How much premium credit will I qualify for ?.. 3
Why types of plans are available?.................. 3
How does the premium credit work?.............. 4
Who is eligible for cost sharing assistance?...4
How does cost-sharing assistance work?...... 4
CHOOSING A PLAN .................5
Understanding plan coverage.........................5
Our commitment to quality............................. 5
Privacy information.........................................5
PRIMARY CARE PROVIDER.......6
Partnering with you to keep you healthy.........6
Provider network............................................ 6
Go online to find an in-network provider........ 6
Preventive care.............................................. 7
Specialty care................................................ 7
Prior authorizations........................................7
Nurseline........................................................7
PHARMACY BENEFITS...............8
Understanding your pharmacy benefits......... 8
Save Money!.................................................. 8
GLOSSARY............................... 9
Need Assistance? Contact Customer Service:
800-580-8574
www.chatn.org
With Community Health Alliance (CHA), you are part of a community dedicated
to your best health. CHA is the only choice that gives you, the consumer, a true voice
in your health care. We are mission-based and the needs of you and your family
remain at the center of everything we do.
INTRODUCTION
TABLE OF CONTENTS
WHY COMMUNITY HEALTH ALLIANCE?
WHO ARE WE?
Community Health Alliance is the only local,
nonprofit, statewide, CO-OP option for
Tennessee residents.
We are member-governed. Members have
the opportunity to serve on the board of
directors. Finally, YOU have a voice.
We are member-governed and memberfocused. Community Health Alliance is licensed
by the Tennessee Department of Commerce
and Insurance. We are subject to all state and
federal regulations and guidelines set forth
by the Centers for Medicare and Medicaid
Services (CMS).
We focus on prevention. You work with your
doctor to create the best treatment plan.
Our statewide network of accredited hospitals
and providers provides a medical home option
for our members, allowing the member and
their primary care provider to create the best
pathway to good health.
We have individual and small group plans just
right for you, your family or employees both on
and off the Health Insurance Marketplace.
WHAT IS A CO-OP?
We are proud to be the only health insurance
Consumer Operated and Oriented Plan (COOP) in the state. There are 23 CO-OPs in 26
states across the U.S.
The purpose of a CO-OP is to offer individuals,
families and businesses more high-quality,
affordable health insurance options. CO-OPs
also give members a voice in how their health
care coverage is delivered.
OUR BUSINESS MODEL IS UNIQUE
We are nonprofit. Our savings go back into the
health plan to keep it high quality and to lower
premiums or increase benefits.
Need Assistance? Contact Customer Service:
800-580-8574
www.chatn.org
1
FINANCIAL ASSISTANCE
Gone are the days when only select groups of people had access to health
insurance. You and your family can now get health insurance that’s just right for
your needs. Through the federal Health Insurance Marketplace, low to moderate
income people may be eligible for tax credits and cost-sharing to help pay the cost
of premiums and out-of-pocket expenses.
HOW MUCH PREMIUM CREDIT WILL I QUALIFY FOR?
Premium credits are based on household income. Larger credits go to those who earn less.
The individual or family is expected to contribute a share of their income toward the cost
of coverage. The amount a person or family contributes is based on a sliding scale. For
example, an individual with an annual income of $23,000, which equals 200 percent of the
poverty level, has an expected contribution of 6.3 percent of his income, or $121 a month.
WHAT KINDS OF PLANS ARE AVAILABLE WITH THIS FINANCIAL ASSISTANCE?
AM I ELIGIBLE FOR PREMIUM CREDITS?
Monthly Cost
Cost When You
Get Care
Good Option If
You...
Individuals and families with incomes between 100 and 400 percent of the federal poverty
level are eligible for premium tax credits.
Some things to remember:
• You cannot get premium credits if you are eligible for Medicare or Medicaid.
• If your employer offers coverage, you may only qualify for premium credits if that
coverage does not meet minimum essential value as a qualified health plan or if it costs
more than the 9.5 percent of your annual income.
Premium credits are also available to legal immigrants with incomes below 100 percent of
the poverty line, but who are not eligible for Medicaid because they have lived in the United
States for less than five years.
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FINANCIAL ASSISTANCE
MAKING HEALTH INSURANCE AFFORDABLE
Need Assistance? Contact Customer Service:
800-580-8574
www.chatn.org
BRONZE
SILVER
GOLD
PLATINUM
$
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Do not plan
to need a lot
of health care
services.
Need to
balance
monthly
premium with
out-of-pocket
costs.
Want to save
Plan to use a
on monthly
lot of health
costs and keep care services.
out-of-pocket
costs low.
There are four types of plans that can be offered on the Health Insurance Marketplace –
Platinum, Gold, Silver and Bronze. Community Health Alliance offers Gold, Silver and Bronze
plans on the Marketplace. The level of benefits covered in each plan may vary, as well as
the amount you pay for deductibles, coinsurance and/or copay amounts, and out-of-pocket
maximums.
Premium credits are based on the cost of the second lowest cost Silver plan available in the
county or service area where the applicant lives. The credit can be applied to a lower cost
plan at a reduced cost or a higher cost plan at an additional cost. While a Gold plan may cover
more, you would have to pay the difference between the cost of the Gold plan selected and the
second lowest cost Silver plan used to determine the subsidy.
HOW DOES THE PREMIUM CREDIT WORK?
Premium credits are actually tax credits that can be given in advance. The credits lower your
monthly premium costs for health insurance. Depending on your household earnings you may
also earn cost-sharing assistance, making your plan benefits better, too. Better plans for a
better price! Again, this is based on your household income. The credits are paid directly to
the insurer, with individuals responsible for the remaining premium amount.
Need Assistance? Contact Customer Service:
800-580-8574
www.chatn.org
3
FINANCIAL ASSISTANCE
People with incomes less than 250 percent of the poverty level ($29,175 for an individual,
$59,625 for a family of four) will also receive additional assistance to help ensure that everyone
can afford the care they need.
HOW DOES COST-SHARING ASSISTANCE WORK?
CHOOSING A PLAN
Choosing the right health plan is an important task. You want one that’s right
for you and offers the right benefits for your life and health.
OUR COMMITMENT TO QUALITY
Premium credits allow individuals to buy a Silver plan which has a 70 percent actuarial value,
meaning that the plan will cover approximately 70 percent of the costs for covered medical
services with the covered individual paying the other 30 percent. Someone with an income
below 250 percent of the poverty level will not have to pay the full 30 percent of the cost of
covered services, ultimately giving them a plan with an actuarial value higher than 70 percent.
Individuals with incomes below 150 percent of the poverty line ($17,505 for an individual,
$35,775 for a family of four) will have plans that have an actuarial value of 94 percent.
Plans for individuals with incomes between 150 percent and 200 percent of the poverty
line ($17,505 - $23,340 for individuals, $35,775 - $47,700 for a family of four) will have
an actuarial value of 87 percent. These higher actuarial values mean that low-income
individuals and families will be able to enroll in plans with lower deductibles, copayments
and/or total out-of-pocket costs thanks to cost-sharing assistance.
UNDERSTANDING PLAN COVERAGE
Before choosing a health plan, please
review the coverage details outlined in
the Summary of Benefits and Coverage
(SBC) – provided for your consideration
at the time of enrollment. You may access
the SBC for any plan at www.chatn.org,
view them on the federal marketplace,
request them from your agent or broker,
or request help by calling 800-580-8574.
When you become a member of
Community Health Alliance and after your
first payment has been received, you will
receive a new member packet with an
ID card and additional plan documents.
These are important documents that
provide more detail about coverage,
limitations, exclusions, notification
requirements and other information
to assist you in accessing your health
insurance benefits. You may also call
Customer Service to ask questions about
your plan and benefits at 800-580-8574.
4
Need Assistance? Contact Customer Service:
800-580-8574
www.chatn.org
Need Assistance? Contact Customer Service:
CHOOSING A PLAN
WHO IS ELIGIBLE FOR COST-SHARING ASSISTANCE?
Community Health Alliance is proud
to have earned Interim Accreditation
from the National Committee for
Quality Assurance
(NCQA),a
private, nonprofit
organization
dedicated to
improving
health care
quality. You
can be assured that we are always
working to improve the service we
provide to you.
PRIVACY INFORMATION
Community Health Alliance complies
with federal and state laws regarding the
confidentiality of medical records and
personal information about our members.
Our policies and procedures help ensure
that the collection, use and disclosure
of information complies with the law.
We give members access to their own
information consistent with applicable
laws and standards. Our policies and
practices support appropriate and
effective use of information, internally
and externally, and enable us to serve
and improve the health of our members,
while being sensitive to privacy.
For a copy of our Notice of Privacy
Practices, please visit www.chatn.org or
call Customer Service at 800-580-8574.
800-580-8574
www.chatn.org
5
PRIMARY CARE PROVIDER
GO ONLINE TO FIND AN
IN-NETWORK PROVIDER
Every great team is made up of different players and you need a team to help keep
you in the best health possible. By partnering with Community Health Alliance
and your primary care provider, you can stay in the game, and keep your health
the #1 goal!
• It’s easy to find a provider in the Community
Health Alliance network.
• Go to www.chatn.org and select your
provider network.
• Choose Find and select a doctor in your area.
• You’ll be able to search for providers that
participate in the Community Health Alliance
provider network in which you are enrolled,
using a variety of search options.
PARTNERING WITH YOU TO KEEP YOU HEALTHY
While it’s not required, CHA encourages our members to select a Primary Care Provider or
PCP. A PCP is your main health care provider in non-emergency situations.
Your PCP’s role is to:
• Provide preventive care and teach healthy lifestyle choices.
• Identify and treat common medical conditions.
• Assess the urgency of your medical problems and direct you to the best place for that care.
• Coordinate your care with medical specialists when necessary.
Learn more about primary care at www.chatn.org or by calling Customer Service at 800-580-8574.
PROVIDER NETWORK
The Community Health Alliance provider network is an open access network, meaning you
may choose to see any doctor in our network without a referral. We ask that you choose a
PCP from our network when you enroll. If you do not choose a PCP, we will choose one for
you. Your PCP will coordinate your care.
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PRIOR-AUTHORIZATIONS
Out-of- network services are processed at a separate deductible and higher co-insurance
except in the event of a medical emergency. Note that benefits received for an out-of-network
provider could result in you being billed for the excess of the contractually allowed amount.
Only providers in your CHA network (Choice or Select) have agreed not to bill you for this
additional amount.
Need Assistance? Contact Customer Service:
800-580-8574
www.chatn.org
It is important that you get the care you
need in the right setting. Preauthorization
is the process we use to decide if certain
services are medically necessary.
Some covered benefits or services must be
preauthorized. Some of these are:
• In-patient hospital stays
• Skilled nursing center care
• Home health services
PREVENTIVE CARE
• Advanced testing such as MRIs
(magnetic resonance imaging)
A little bit of prevention goes a long way to
keeping you and your family healthy.
NURSELINE
Community Health Alliance plans cover the
following preventive services without charging
you a copayment or coinsurance, even if you
haven’t met your yearly deductible. That means
it’s affordable to see your in-network PCP to
keep you at your healthiest.
The Community Health Alliance Nurseline
is one-on-one health support, at no
additional cost to you.
• Screenings recommended for women and
children
Your Community Health Alliance Health
Coach will support you and your family
as you work with your doctor to make the
best health choices. There is no question
too big or too small for your Health Coach
and the call is free. Call a Health Coach
today at 1-888-256-8029.
• Wellness visits for children and adults
Call a Health Coach to:
• Preventive prostate screening
• Get information on a variety of health
topics.
• Immunizations
• Preventive mammography
• Learn about resources to help you make
healthy changes — from losing weight to
sleeping well.
• Breastfeeding support and counseling
from trained providers, and access to
breastfeeding supplies, for pregnant and
nursing women
• Identified contraception devices or services
SPECIALTY CARE
You do not need a referral to receive specialty
care. It’s always a good idea to discuss
treatment options with your PCP first. He or
she may recommend that you see a specialist
for certain conditions.
Need Assistance? Contact Customer Service:
PRIMARY CARE PROVIDER
PRIMARY CARE PROVIDERS
If you think you may have a medical
emergency, call your doctor or
911 immediately.
Health Coaches DO NOT provide
clinical services and should not be
used in emergency situations.
800-580-8574
www.chatn.org
7
PHARMACY BENEFITS
GLOSSARY
UNDERSTANDING YOUR PHARMACY BENEFITS
Here are a few definitions that may make understanding your benefits
a little easier.
Your pharmacy benefits are one of the keys
to keeping you healthy.
The Community Health Alliance drug plan
has a five-tier closed formulary structure.
The amount you pay for your prescription
depends on the tier or category in which
your medication is listed, and what plan you
are enrolled in at the time. These five tiers
are generic, preferred brand, non-preferred
brand, specialty and preventive.
Choosing a generic or preferred drug when
appropriate can help reduce your health
care costs. Non-preferred and specialty
drugs generally have higher out-of-pocket
expenses. Coverage for preventive drugs
on the formulary is mandated by law and
covered at 100 percent.
Our website has information about pharmacy
benefits, including the drug formulary and
quarterly updates. A formulary is a listing
TIER 1
GENERIC
TIER 2
PREFERRED
TIER 3
NON-PREFERRED
TIER 4
SPECIALTY DRUGS
TIER 5
PREVENTIVE
of the drugs covered by Community Health
Alliance. You can also visit Catamaran
online, our Pharmacy Benefit Manager:
www.mycatamaranrx.com.
On their site, members can search for an
in-network pharmacy, review information
on drugs such as interactions and side
effects, calculate prices on their prescription
medications, view their own pharmacy
history, order mail-order prescriptions, and
much more.
GLOSSARY
PHARMACY BENEFITS
COINSURANCE
Coinsurance is a fixed percentage of the allowed amount. Typically, the plan pays a portion
and the member pays a portion.
COPAYMENT
Your copayment, sometimes called a copay, is a set dollar amount you pay each time you
receive a health service. For example, your plan might have a $30 copay for a visit to your
doctor. You pay this amount directly to the doctor’s office during your visit.
Through the Catamaran network, we have
over 65,000 pharmacies nationwide in our
pharmacy network. The only way to receive
covered benefits for your prescriptions is to
use an in-network pharmacy.
DEDUCTIBLE
Members can receive up to a 30 day supply
of all medications at retail or up to a 90
day supply of maintenance medications at
retail. A 90 day supply at retail is 2 times
the 30-day copay.
OUT-OF-POCKET COSTS
SAVE MONEY!
PRIMARY CARE PROVIDER
Use generic drugs any time they’re available.
Generic drugs are safe and save you money.
The next time you get a prescription for a
brand-name medication, ask if a generic
equivalent option is available and if it might
be right for you. Generic medications are
covered under your pharmacy benefits, while
some of their brand-name versions are not.
A Primary Care Provider (PCP) is your main health care provider in non-emergency situations.
The amount you owe for health care services your health insurance or plan covers before
your health insurance or plan begins to pay. For example, if your deductible is $1,000, your
plan won’t pay anything until you’ve met your $1,000 deductible for covered health care
services subject to the deductible. The deductible may not apply to all services.
Out-of-pocket costs are costs that your health plan doesn’t pay for, and are expenses
paid by the member. Plans vary, but would include your deductible, coinsurance and
copayments for covered services.
With Community Health Alliance, you can choose a PCP from the following practice
types:
• Family Medicine
• Internal Medicine
• Pediatrics
• OB/GYN
SPECIALIST
FIVE TIER DRUG PLAN The five tiers dictate what you will pay
A Specialist is a health care provider who focuses on treating certain conditions.
for your prescription drugs.
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Need Assistance? Contact Customer Service:
800-580-8574
www.chatn.org
Need Assistance? Contact Customer Service:
800-580-8574
www.chatn.org
9
© Community Health Alliance Mutual Insurance Company
www.chatn.org