feel good about your choices - wellcare

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CHOOSE WELLCARE. CHOOSE A NEW YORK STATE OF HEALTH™ PLAN TO FIT YOUR NEEDS.

Information on individual and family plans

New York Exchange Plans

Albany, Bronx, Dutchess, Kings, New York, Orange, Queens, Rensselaer, Rockland, Ulster

FEEL GOOD ABOUT YOUR CHOICES

FEEL BETTER ABOUT YOUR PLAN.

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At WellCare, our goal is to give our members quality care. We focus on government-sponsored health programs, like Medicare and Medicaid. Our mission is to help people who need it most.

For 2016, WellCare has been certified as a Qualified Health Plan to offer plans on the Marketplace.

As you read through this booklet, you’ll see how many benefits you can get with a WellCare health plan.

Feel better about your privacy. Keeping your Protected Health Information (PHI) safe is very important to us. We have policies to protect it. Your PHI can only be seen by those who need it to do their work. For more detailed information, ask for a copy of the member policy.

WellCare, provides plans with care for those that need it most, when they need it most. If you’ve trusted us before or if you’re looking at our plans for the first time, let us help you feel good about your decision.

WHAT IS THE MARKETPLACE?

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The Affordable Care Act created an easier way to compare, shop for and buy health insurance coverage with an online tool called the Marketplace. In your area, the Marketplace is called New York State of Health. On the Marketplace, you can compare benefit packages and prices. You can learn if you are eligible for a government program, and you can find out if you qualify for help paying for the coverage you choose. You can apply online, or you can apply over the phone.

You can also find out if your income makes you eligible for a tax credit and other financial help to make your health insurance more affordable. It’s important to know that the tax credit is available to a wide range of income levels. So even if you think your income might be too high to qualify, you might be surprised.

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THE MARKETPLACE OFFERS PLANS TO FIT ALL BUDGETS.

BRONZE

PLAN PAYS 60% FOR COVERED SERVICES

YOU PAY 40%

LOWEST PREMIUMSHIGHEST COST-SHARING

The availability of plans may vary by state and by county. Visit us at www.WellCarePlans.com to see which options are available in your area. Benefit grids provided in the back of this brochure.

SILVER


YOU PAY 30%

MODERATE PREMIUMSMODERATE COST-SHARING

GOLD


YOU PAY 20%

HIGHER PREMIUMS LOWER COST-SHARING

PLATINUM


YOU PAY 10%

HIGHER PREMIUMS LOWEST COST-SHARING

The Affordable Care Act implemented four metal levels of coverage:

Bronze plans offer the lowest monthly premium, but typically have the highest deductibles, coinsurance and/or co-pays. Platinum plans generally have the highest monthly premium, but you have lower out-of-pocket costs when you receive health care services.

In addition, Catastrophic (basic) coverage will be available at a lower cost for those under 30 years of age or for people facing financial hardship.

To choose the plan that’s right for you, you should consider each plan’s co-pays, deductibles, coinsurance and maximum out-of-pocket costs. The differences in these amounts determine the monthly premium you will pay.

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WELLCARE HAS THE RIGHT PLAN FOR YOU.

WellCare works with you to help you manage your health care costs. We make it easy to compare plans so that you can select the one that best fits your needs and budget. Our plans offer:

• Preventive and wellness services

• Outpatient (ambulatory) care

• Emergency services, like going to the ER or urgent care center

• Inpatient care (overnight stay in a hospital)

• Laboratory services

• Prescription drug coverage

• Rehabilitative and habilitative services (Habilitative services help a person learn, keep or improve skills that may not be developing normally.)

• Mental health and substance abuse services

• Maternity (pregnancy) and newborn care

• Pediatric services (health care for children)

• And much more!

Financial assistance may be available to lower the cost of health insurance.

You may be able to get lower costs on monthly medical insurance premiums or out-of-pocket, costs like deductibles, coinsurance and co-pays, depending on your income and family size. When you apply for coverage through the Marketplace, you’ll learn if you’re eligible for these savings. You can see what your premium, deductible and out-of-pocket costs will be before you make a decision to enroll.

Every situation is different. Call 1-855-582-6172 (TTY 1-855-582-6171) Monday–Friday, 8 a.m. to 8 p.m., to speak to a representative who can explain your options in detail and help you find the coverage that’s right for you.

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AS A WELLCARE MEMBER, YOU WILL ENJOY:

• Choice: We offer a variety of plans to choose from. Compare our plans to find the coverage you need at the cost that works best for you and your family.

• Cost Savings: Access to WellCare’s network of doctors, pharmacies and hospitals. Network discounts provide greater savings for you. No matter which WellCare plan you select, you’ll have many providers to choose from. With a large percentage of doctors and hospitals participating in our networks, chances are good that your current health care providers are included.

• Choose Your PCP: You will need to choose a primary care provider (PCP). After you choose, you can change at any time. This is an HMO product. For more information, ask for a copy of the member policy.

• Online Resources: Convenient website tools to help you manage your coverage.

• 24/7 Nurse Advice Line: Provides you access to registered nurses who will listen to your health concerns and give you health information and tips at no additional cost.

• More Value: Enjoy added value with programs and services that are included for each of our members at no additional cost.

WellCare gives you choices to make sure your coverage is a great fit for you. Learn more about our plans by visiting www.WellCarePlans.com or by contacting a licensed agent.

Look over the plans and benefits WellCare offers in your area. Do you need help comparing plans? Call now. Speak to someone who can help. There is no obligation to enroll.

Call 1-855-582-6172 (TTY 1-855-582-6171) Monday–Friday, 8 a.m.–8 p.m.

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METAL LEVEL STANDARD CATASTROPHIC

STANDARD BRONZE

STANDARD SILVER

Individual Deductible $6,850 $3,500 $2,000

Family Deductible $13,700 $7,000 $4,000

Note Medical and Rx Combined Medical and Rx Combined Medical Only

Individual Maximum Out of Pocket $6,850 $6,850 $5,500

Family Maximum Out of Pocket $13,700 $13,700 $11,000

Note Medical and Rx Combined Medical and Rx Combined Medical and Rx Combined

MEDICALInpatient Hospital Care 0% after Ded 50% after Ded $1,500 after Ded

Emergency Care 0% after Ded 50% after Ded $150 after Ded

Urgent Care 0% after Ded 50% after Ded $70 after Ded

Outpatient Hospital Services 0% after Ded 50% after Ded $100 after Ded

X-rays/Labs PCP: 0% after Ded SPC: 0% after Ded

OP Facility: 0% after Ded

PCP: 50% after Ded SPC: 50% after Ded

OP Facility: 50% after Ded

PCP: $30 after Ded SPC: $50 after Ded

OP Facility: $50 after Ded

Advanced Imaging PCP: 0% after Ded SPC: 0% after Ded


PCP: 50% after Ded SPC: 50% after Ded

OP Facility: 50% after Ded$50 after Ded

PCP Office Visits Visits 1–3: 0% (Ded Waived) Visits 4+: 0% after Ded

50% after Ded $30 after Ded

Specialist Office Visits 0% after Ded 50% after Ded $50 after Ded

OTHER SERVICESDental – Adult Not Covered Not Covered Not Covered

Dental – Pediatric Covered Covered Covered

Vision – Pediatric Covered Covered Covered

Over-the-Counter Not Covered Not Covered Not Covered

Acupuncture Not Covered Not Covered Not Covered

PHARMACY†*

Generic 0% after Ded $10 after Ded $10 (Ded Waived)

Preferred Brand 0% after Ded $35 after Ded $35 (Ded Waived)

Non-Preferred Brand and Specialty Drugs** 0% after Ded $70 after Ded $70 (Ded Waived)

†You must use a pharmacy that accepts our plan. Co-pays may apply for most medications. *Co-pays are for a 1-month supply. ** Specialty drugs are not available at retail locations. 30-day supply of specialty drugs available through mail order only.

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METAL LEVELSTANDARD

SILVER 200% – 250% FPL

STANDARD SILVER

150% – 200% FPL

STANDARD SILVER

100% – 150% FPLIndividual Deductible $1,500 $250 $0

Family Deductible $3,000 $500 $0

Note Medical Only Medical Only Medical Only

Individual Maximum Out of Pocket $5,450 $2,000 $1,000

Family Maximum Out of Pocket $10,900 $4,000 $2,000

Note Medical and Rx Combined Medical and Rx Combined Medical and Rx Combined

MEDICALInpatient Hospital Care $1,500/Stay after Ded $250 after Ded $100

Emergency Care $150 after Ded $75 after Ded $50

Urgent Care $70 after Ded $50 after Ded $30

Outpatient Hospital Services $100 after Ded $75 after Ded $25

X-rays/Labs PCP: $30 after Ded SPC: $50 after Ded


PCP: $15 after DedSPC: $35 after Ded


PCP: $10SPC: $20

OP Facility: $20

Advanced Imaging $50 after Ded $35 after Ded $20

PCP Office Visits $30 after Ded $15 after Ded $10

Specialist Office Visits $50 after Ded $35 after Ded $20

OTHER SERVICESDental – Adult Not Covered Not Covered Not Covered

Dental – Pediatric Covered √ √

Vision – Pediatric Covered √ √

Over-the-Counter Not Covered Not Covered Not Covered

Acupuncture Not Covered Not Covered Not Covered

PHARMACY†*

Generic $10 (Ded Waived) $9 (Ded Waived) $6

Preferred Brand $35 (Ded Waived) $20 (Ded Waived) $15

Non-Preferred Brand and Specialty Drugs** $70 (Ded Waived) $40 (Ded Waived) $30

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METAL LEVEL STANDARD GOLD STANDARD PLATINUM

Individual Deductible $600 $0

Family Deductible $1,200 $0

Note Medical Only Medical Only

Individual Maximum Out of Pocket $4,000 $2,000

Family Maximum Out of Pocket $8,000 $4,000

Note Medical and Rx Combined Medical and Rx Combined

MEDICALInpatient Hospital Care $1,000/Stay after Ded $500/Stay

Emergency Care $150 after Ded $100

Urgent Care $60 after Ded $55

Outpatient Hospital Services $100 after Ded $100



PCP: $15 SPC: $35

OP Facility: $35

Advanced Imaging $40 after Ded $35

PCP Office Visits $25 after Ded $15

Specialist Office Visits $40 after Ded $35

OTHER SERVICESDental – Adult Not Covered Not Covered

Dental – Pediatric Covered Covered

Vision – Pediatric Covered Covered

Over-the-Counter Not Covered Not Covered

Acupuncture Not Covered Not Covered

PHARMACY†*

Generic $10 (Ded Waived) $10

Preferred Brand $35 (Ded Waived) $30

Non-Preferred Brand and Specialty Drugs** $70 (Ded Waived) $60


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METAL LEVEL NON-STANDARD SILVER

NON-STANDARD SILVER

200% – 250% FPLIndividual Deductible $2,000 $2,000

Family Deductible $4,000 $4,000


Individual Maximum Out of Pocket $5,500 $4,600

Family Maximum Out of Pocket $11,000 $9,200


MEDICALInpatient Hospital Care 30% after Ded 30% after Ded

Emergency Care 30% after Ded 30% after Ded

Urgent Care $55 after Ded $45 after Ded

Outpatient Hospital Services 30% after Ded 30% after Ded



PCP: $0 after Ded SPC: $45 after Ded


Advanced Imaging $55 after Ded $45 after Ded

PCP Office Visits $0 (Ded Waived) $0 (Ded Waived)

Specialist Office Visits $55 after Ded $45 after Ded

OTHER SERVICESDental – Adult Covered Covered

Dental – Pediatric Covered Covered

Vision – Pediatric Covered Covered

Over-the-Counter Covered Covered

Acupuncture Covered Covered

PHARMACY†*

Generic $10 (Ded Waived) $10 (Ded Waived)

Preferred Brand $35 after Ded $35 after Ded

Non-Preferred Brand and Specialty Drugs** $70 after Ded $70 after Ded


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METAL LEVEL NON-STANDARD BRONZE

Individual Deductible $6,500

Family Deductible $13,000

Note Medical Only

Individual Maximum Out of Pocket $6,600

Family Maximum Out of Pocket $13,200

Note Medical and Rx Combined

MEDICALInpatient Hospital Care $0 after Ded

Emergency Care $0 after Ded

Urgent Care $75 (Ded Waived)

Outpatient Hospital Services $0 after Ded



Advanced Imaging $75 after Ded

PCP Office Visits $35 (Ded Waived)

Specialist Office Visits $75 (Ded Waived)

OTHER SERVICESDental – Adult Covered

Dental – Pediatric Covered

Vision – Pediatric Covered

Over-the-Counter Covered

Acupuncture Covered

PHARMACY†*

Generic $15 (Ded Waived)

Preferred Brand $75 (Ded Waived)

Non-Preferred Brand and Specialty Drugs** $130 (Ded Waived)


THERE ARE MANY OPTIONS TO CHOOSE FROM. CHOOSE THE PLAN THAT CARES.WELLCARE IS PROUD TO BE YOUR PARTNER IN HEALTH CARE.

Speak with a representative who can explain your options in detailand help you find the coverage that makes you feel better.

Plan compare: www.WellCarePlans.com. Price your plan today.

NY031362_HIX_BOV_ENG Internal Approved 12102015 ©WellCare 2015 NY_08_15 NY6BOVHIX70276E_0815

ENROLL NOW.

HELP LINE: 1-855-355-5777nystateofhealth.ny.gov

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NY030658_HIX_INS_MLT Internal Approved 07142015 ©WellCare 2015 NY_07_15 NY5HIXLAN68405M_0715 68

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If you speak a different language or need something in Braille or audio, don’t worry. We can provide translations and alternate formats at no cost to you. Just give us a call toll-free at 1-855-582-6172 (TTY 1-855-582-6171).

Si usted habla un idioma diferente o necesita algo en Braille o audio, no se preocupe. Nosotros podemos proporcionarle traducciones y formatos alternativos sin costo para usted. Simplemente, llámenos sin cargo al 1-855-582-6172 (TTY 1-855-582-6171).

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