Health Insurance: Plans, Basics, and Terminology

Overview of Health First Health Plans and AdventHealth Advantage Plans Broker Training Module 2 04152021

Module Description This module is designed to: Review health insurance basics Provide an overview of plan types offered Provide an overview of the relationship between Health First Health Plans and AdventHealth Highlight the value-added services

Health Insurance Basics Most Americans are insured through one of four ways: 3 Medicare Insurance is provided through a federal health insurance program for those who are 65 or older, younger than 65 with certain disabilities, or any age with End- Stage Renal Disease. 4 Medicaid This state- administered health insurance program is for specific low- income individuals and families (not offered by Health First Health Plans or AdventHealth Advantage Plans). 1 Group Insurance A person receives healthcare insurance because he/she or a family member is employed in a workplace that offers health insurance as part of the benefit package. 2 Individual Insurance can be purchased through a broker, a health insurance company, or the state or federal Marketplace.

Common Terms Cost Share Any member responsibility that includes copay, deductible and coinsurance. Copay Fixed amount a member pays for a covered service. Deductible Amount owed for covered services before the health plan begins to pay. Coinsurance Member s share of costs toward a covered service calculated as a percent. Maximum Out of Pocket (MOOP) Maximum amount a member will pay out of their pocket within a calendar year. Once MOOP is met, plan pays 100% of covered services. Does not include monthly premiums or any service the plan does not cover.

Health Maintenance Organization (HMO) Type of plan for members to use In-Network Providers (providers that have agreed to lower their rates for plan members and meet quality standards) for covered services except for urgent or emergent situations Referrals not required by Health Plan for Primary Care Physicians or Specialist Expenses only covered if provider within the network is seen Urgent and Emergent Care covered outside of coverage area

Point of Service (POS) Type of managed care plan that is a hybrid of an HMO and PPO (Preferred Provider Organization) plan. Like an HMO, members are designated an in- network physician to be their primary care provider. Like a PPO plan, members may go outside of the provider network for health care services. Going outside of your network is allowed, but at a greater out of pocket cost.

Third-Party Administrator (TPA) / Administrative Services Only (ASO) Large employers may decide to self-insure their healthcare costs instead of having the health plan fully-insure the costs. Self-Insured Fully Insured HFHP becomes the Third-Party Administrator and is hired to perform administrative services such as: Customer Service Claims Medical Management The employer group makes rules about benefits and exclusions. Federal guidelines apply, however, state rules may not. Employer group pays HFHP a monthly premium based on the number of employees enrolled in the plan. In exchange for the premium, HFHP covers employees and covered dependents, minus their cost sharing for all covered services. Employer group assumes financial risk HFHP assumes the financial risk. Checks to providers come from HFHP, not the employer group funds. Checks to providers come from employer s group fund, not HFHP.

Health Reimbursement Account (HRA) Employer decides how much funding employees receive. Members can use HRA funds to pay qualified medical expenses not paid by insurance such as deductibles and coinsurance. Funds not used at the end of the year may be carried over to the following year. Funds revert to the employer upon employee termination

Health First Health Plans Offers a variety of health insurance plans, including Medicare Advantage, Small and Large Group, and Individual (both on and off the Marketplace exchange). All our products are supported by our Health First Integrated Delivery Network (IDN). This network encompasses: Wellness and prevention Community-based care Access to a physician group and hospital care With the strength of the Health First IDN, Health First Health Plans is uniquely positioned to meet the healthcare needs of our community.

Health First Health Plans Offered by County Individual & Family HMO Brevard Commercial Group HMO, POS, Access POS Brevard Medicare Advantage HMO & POS Plans Brevard, Indian River Third-Party Administration (TPA) / Administrative Services Only (ASO) Brevard

AdventHealth Consists of 29 hospitals, 40 urgent care centers, two pediatric urgent care centers and a network of more than 4,000 physicians and multiple ancillary providers from coast to coast. AdventHealth serves the needs of patients from Tampa to Daytona, which includes the entirety of the Orlando area. AdventHealth provides a wide range of health services, including many nationally and internationally recognized programs: Cardiology Oncology Women's medicine Neurosciences Diabetes Orthopedics Pediatrics Transplant Advanced surgical programs

AdventHealth Our commitment to providing unsurpassed health and wellness services has expanded to meet the increasing needs of our ever- growing population. Our heritage of whole-person health, achieving wellness of the mind, body and spirit for our patients is of paramount importance to each member of our exceptionally talented clinical staff.

AdventHealth Advantage Plans Offered by County Individual & Family HMO Volusia, Flagler, Seminole Commercial Group HMO, POS Volusia, Flagler Medicare Advantage HMO Volusia, Flagler, Seminole, Highlands, Hardee

Sales Office Locations Office Location Services Available Main Office: 6450 U.S. Highway 1 Rockledge, FL 32955 Customer Service All Sales functions General office hours: Weekdays, 8 a.m. to 5 p.m. AdventHealth Advantage Plans: 1425 W. Granada Blvd., Suite 4 Ormond Beach, FL 32174 AdventHealth Advantage Plans Medicare Sales only General office hours: Weekdays, 8 a.m. to 5 p.m.

Partnership The Partnership between Health First Health Plans and AdventHealth: Started in 2014 when AdventHealth was known as Florida Hospital. Offers Central Florida a delivery network with local leadership Allows for growth due to an expanded sales territory

Service Area vs. Provider Network What is the difference between service area and provider network? Service Area The service area defines which counties are eligible for either Health First Health Plans or AdventHealth Advantage Plans coverage. For example, a member residing in Brevard County would only be eligible for the Health First Health Plans-brand products. Provider Network The provider network combines all providers contracted with both Health First Health Plans and AdventHealth Advantage Plans into a single network. Contracted providers will be accessible to all members, regardless of service area.

Commercial Service Area

Medicare Service Area

Fitness Program Active & Fit For fully-insured Group and Individual / Family members (age restrictions and requirements vary by gym) Includes Health First s Pro-Health & Fitness Centers in Brevard Silver & Fit For all Medicare Advantage members Includes Health First s Pro-Health & Fitness Centers in Brevard Offers a choice of a Home Fitness Program or Fitness Center Program Includes a nationwide network of participating fitness centers Offers a choice of a Home Fitness Program or Fitness Center Program Includes a nationwide network of participating fitness centers Individual Marketplace plans will have options with and without the fitness membership.

Identity Protection Experian IdentityWorks offers more protection and the option to enroll at any time at no cost. Once enrolled in IdentityWorks, a person will have access to: Experian credit report at sign-up: A person can see what information is associated with his or her credit file. Credit Monitoring: Actively monitors the Experian credit file for indicators of identity theft. Internet Surveillance: Technology searches the web, chat rooms and bulletin boards 24/7 to identify trading or selling of personal information on the Dark Web. Identity Restoration: Identity Restoration specialists are immediately available to address credit- and non-credit-related identity theft. Up to $1 Million Identity Theft Insurance. Provides coverage for certain costs and unauthorized electronic fund transfers. Lost Wallet: Assistance with canceling/replacing lost or stolen credit, debit and medical cards. Child Monitoring: For up to 10 children up to 18 years old, internet surveillance and monitoring to determine whether enrolled minors in the household have an Experian credit file are available. Also included are Identity Restoration and up to $1 million Identity Theft Insurance.

Complex Case Management Complex case management includes assessment, planning, implementation, monitoring, evaluation and coordination of medical services. CCM nurses collaborate with various providers to ensure quality, cost-effective care. For members with complex or serious medical conditions.

Healthy Living This is a free program offered to all members to help them stay healthy and manage their current health issues. Available to members 24/7 online by accessing the healthy living portal on the health plans site. Includes: Health Risk Assessment (HRA) My personal health record Healthy Living Programs and health challenges Provides access to registered nurses and health coaches via telephone and email.

Medication Therapy Management Targets Medicare members who may benefit from added support with their medication therapies. Offered free to MAPD (Medicare Advantage Plan that offers prescription drug coverage) and PDP (Stand alone Medicare Part D prescription drug plan) members who meet the following qualifications: 1. Member must accumulate total drug costs exceeding a quarterly threshold 2. Beneficiary must have filled seven or more chronic-covered Part D drugs, and 3. Must have documented illnesses in at least two chronic conditions

Signify Medical Network Partnered with Signify Medical Network to provide in-home and facility medical assessments that are offered to our Medicare members at no cost. One assessment per calendar year is covered. The assessment includes health-related questions and a mini-physical exam performed by a licensed and credentialed nurse practitioner. Results are forwarded to the member s primary care physician.

Thank You! Please continue to the next module: Module 3 Health First Hospitals