lachip affordable plan overview of benefits

1. LaCHIP Affordable Plan Malcolm Veazie OGB Deputy Assistant Secretary

3. OGB Capacity & Capabilities PPO Plan – 48,691 enrollees 74,218 lives (including dependents) Network – 16,000 medical professionals & 130 LA hospitals under contract Call Centers – Members: 550 calls per day Providers: 600 calls per day Claims Processing – 7,500 claims per day

4. Level 0 Plan Benefits Enrollee financial responsibility capped at 5% of annual family income After enrollee reaches 5% threshold: Enrollee pays no premium Benefits paid at 100% for all family members Qualified Native Americans begin at Level 0

5. Level 1 Plan Benefits “PPO plan with no deductibles” Plan pays 90% of OGB fee schedule Enrollee pays 10% Doctor visits Hospital services Lab, X-rays, other ancillary services Chemotherapy / radiation Physical / speech / occupational therapy

6. Level 1 Plan Benefits $5 million lifetime maximum for ALL health care expenses Annual out-of-pocket maximum: $1,000 or 5% of annual family income, whichever comes first

7. Medical Benefits No physician referrals required Enrollee pays 10% of contracted rate for network doctors Contracted rate is about $80 for simple visits up to about $160 for high-level visits. Enrollee cost is about $8 to $16, depending on visit. Most visits cost about $8 to $12.

8. Medical Benefits Enrollee pays 10% of contracted rate for services until annual out-of-pocket maximum is reached: MRI/CAT scans Sonograms Chemotherapy & radiation therapy Cardiac rehabilitation

9. Wellness Care Benefits(Ages 0-18) Covered at 100% for network providers Routine physical exams Related radiology & pathology Immunizations

10. Prescription Drug Benefits No formulary Enrollee pays 50% of cost at network pharmacies $50 maximum for each 30-day fill Annual out-of-pocket maximum $1,200 or 5% of family income; then brand drugs $15 & generics $0 Mail order available (same as above)

11. Hospital Benefits Pre-certification required for inpatient admission $150 deductible for emergency room treatment (waived if admitted) Enrollee pays 10% of contracted rate at network hospitals

12. Out-of-NetworkHospital Benefits Emergency care No additional cost for emergency medical services Non-emergency care Enrollee pays 30% of fee schedule plus balance of billed charges

13. Inpatient Mental Health & Substance Abuse Benefits $200 deductible Pre-certification required $50 per day up to 5 days; maximum 45 days per person per year Enrollee pays 20% of contracted rate in-network & 30% of contracted rate out-of-network plus balance of billed charges

14. Outpatient Mental Health & Substance Abuse Benefits Maximum 52 visits per year per person Pre-certification required Network provider Enrollee pays 20% of contracted rate Out-of-network provider Enrollee pays 30% of contracted rate plus balance of charges billed

15. Disease Management Services Engage & educate enrollees to promote self-management of chronic diseases: Diabetes Asthma Chronic arterial disease (CAD) Congestive heart failure (CHF) Chronic obstructive pulmonary disease (COPD) Increase compliance with physician-prescribed treatment & care

16. OGB Contact Information Enrollee Customer Service Line 1-800-272-8451 (outside BR) 225-925-6625 (Baton Rouge) Provider Line 1-800-215-1093 (outside BR) 225-922-0218 (Baton Rouge)

17. Questions?