Meritus 2016 Broker Handbook

2016 Broker Handbook

Your resource to plans, services and support for groups, individuals and family plans.

for broker use only

meritusaz.com • Broker Use Only 2016 MERITUS BROKER MANUAL | 1

Working together to improve healthcare for ArizonaWe are excited about the third year of Open Enrollment and the opportunity to bring new innovations to the healthcare marketplace in Arizona.

We remain dedicated to helping you serve your clients through responsive service, user-friendly technology and accessible information. This handbook is one of many tools you can expect from us. Use it as a resource to learn about us, the Marketplace, our plans, services and more.

This year, Meritus has invested in technology enhancements that will allow for a more efficient management of member records and data, while giving us the tools necessary to meet the needs of our growing membership.

Working together, we can help Arizonans achieve better health through the kind of care they demand and deserve. We invite you to join us as we work together with brokers, healthcare professionals, organizations and our members to provide individuals, families and businesses with a wide array of affordable plans and benefits.

We invite you to become part of the effort - Meritus – Together for better health.

Questions? We’re here for you. meritusaz.com | 855.755.2700 | 602.957.2113

Table of Contents

About Meritus . . . . . . . . . . . . . . . . . . 2

Meritus Provider Networks . . . . . . . . 5

Summary of Pharmacy Benefits . . . 19

Understanding the Marketplace . . 21

Rules of Enrollment . . . . . . . . . . . . . 25

Plans to Meet All Your Needs . . . . 27

Individual and Family . . . . . . . . . . . 31

Enrollment Guide . . . . . . . . . . . . 33

Individual Plans . . . . . . . . . . . . . . 43

Exclusions and Limitations . . . . 59

Individual Rates . . . . . . . . . . . . . . 65

Group Plans . . . . . . . . . . . . . . . . . . . 77

Underwriting Guidelines . . . . . . 78

Group Enrollment Guide . . . . . . 81

Group Plans . . . . . . . . . . . . . . . . 101

Broker Resources and Support . . 113November 2015

Together for better health

Meritus products and services are provided through Meritus Mutual Health Partners (a PPO) and Meritus Health Partners (an HMO).

2 | 2016 MERITUS BROKER MANUAL 855.755.2700 | 602.957.2113

Focused on maximizing consumer value, not shareholder value.

Welcome to a whole new kind of healthcare.New to the market, but not to the healthcare world, Meritus is a non-profit health insurance company and Arizona’s first and only cooperative model.

We started as a community coalition, and we’ve been actively involved at the community level, working to create better access to affordable, quality healthcare choices for Arizonans. The Meritus team, comprised of experienced leaders in healthcare and the health insurance industry, brings a broad range of expertise and innovation to our efforts.

ABOUT MERITUS


About Meritus

How we’re different

We want our members to utilize their insurance coverage with confidence, helping them to be healthier than when they first joined us!

Our cooperative (CO-OP) model is different from traditional health insurance companies. As a member-governed organization, one in which members both serve and have the opportunity to vote on the Board of Directors, we answer to and focus on our members. We reinvest our excess revenue for the good of our members, helping to control premiums, improve benefits, promote wellness and encourage preventive care.

“Putting our members first” means:

• Affordable healthcare that Arizonans can count on.

• Focusing on maximizing consumer value, not shareholder value.

• Select innovative plans that include coverage for Naturopathy, Acupuncture, Massage Therapy and reward members for keeping healthy like reimbursement for a gym membership.

• Building strong broker partnerships.

What’s a CO-OP?

CO-OPs (Consumer Operated and Oriented Plans) exist to serve their members. A CO-OP must use excess revenue to support members through premium control, expanded benefits and innovations in service models. Rather than focusing on money-saving short cuts, we focus on quality care and services for our members. As a non-profit organization, we are prohibited by law from ever being sold or re-organized as a for-profit corporation. Meritus is Arizona-owned and operated, with headquarters in Tempe.

What’s New for 2016?

• New Pharmacy Tier Structure

• Improved Benefits

- Lab, pathology, radiology copay on a per visit basis.

- ER copay waived in the event of an accident.

• Pinal County Expansion - Meritus HMO Complete and Meritus HMO Banner Networks available in Pinal County.

• Mohave County - Meritus HMO Mohave Network name changed to Meritus HMO WARMC; Meritus HMO Complete Network added.

• Individual PPO Plans - Not offered ON Exchange. Only Silver and Bronze levels offered OFF Exchange.

Meritus At a Glance

• Headquartered in Tempe

• Organized in 2012, physician-founded local coalition

• Licensed by the Arizona Department of Insurance in 2013

• Arizona’s first and only health insurance cooperative

• Member-governed, non-profit consumer operated and oriented plan (CO-OP)

• Certified by the Federal Government as a Qualified Health Plan

ABOUT MERITUS


CO-OPs under the ACA

The CO-OP program under the Patient Protection and Affordable Care Act (ACA) is intended to foster the creation of new consumer-governed, private, non-profit health insurance issuers. Arizona’s insurance market is dominated by large commercial carriers; there is a need for competition and innovation. As a healthcare cooperative established under the ACA, Meritus is a new and different way of providing healthcare coverage.

The success of other health plan CO-OPs, such as Health Partners and Group Health, have served as a model for the design and development of Meritus. Our predecessors have demonstrated that the healthcare CO-OP model can realign the financial goals of providers, insurers, brokers and patients.

CO-OPs are subject to the same rules as all other insurance plans under healthcare reform. We’re fully licensed by the Department of Insurance and certified by the Federal Government as a Qualified Health Plan (QHP).

Meritus 2016 product offerings

• Our HMO and PPO products remain structured around copays for most services, no hidden fees and predictable out-of-pockets costs.

• We have plans with a range of deductibles and copays.

• Revised Pharmacy benefit tiers. Two levels of Generics: Adherence Generic Drugs and Other Generic Drugs. Adherence Generic Drugs includes those medications which promote heart health, treat high blood pressure, high cholesterol, along with oral diabetic medication.

• Complementary and alternative medicine benefits are included in all of our PPO plans and in our Platinum and Gold HMO plans. This includes Naturopathy, Acupuncture, Therapeutic Massage and rewards for staying healthy, including up to $25 per month gym membership reimbursement.

Meritus Financial Information

• Meritus is a Qualified Health Plan licensed as Meritus Health Partners (HMO) and Meritus Mutual Health Partners (PPO) in Arizona.

• Meritus is subject to the same reserve requirements as all carriers in the state of Arizona.

• Arizona Department of Insurance requires all carriers to maintain at least 300% risk based capital to ensure solvency – CMS requires Meritus to maintain 500% risk based capital – an even higher standard!

• Meritus is supported by a $90 million loan from CMS to ensure its capital position is strong.

• Meritus has reinsurance coverage from the federal government up to $250K per claim.

• Meritus also has commercial reinsurance coverage in excess of the federal limits.

ABOUT MERITUS


Building better health in communities through our Provider Networks.

We believe in developing long-term partnerships with providers by working

together to improve health outcomes and better control healthcare costs

for our members and the people of Arizona.

It is this friendly approach to achieving real change that we believe creates

a positive payer/provider dynamic - one we believe will change healthcare

as we know it, for the better.

Meritus Provider Networks


Meritus Provider Network Design

Building better health in communities through our Provider Networks.

HMO • 7,200 physicians

• 37 Acute Hospitals and 7 Behavioral Health Hospitals

PPO • 11,700 physicians and

mid-level providers

• 68 Acute Hospitals and 14 Behavioral Health Hospitals

Source: Arizona Foundation

Source: Meritus Contracted Network

Meritus built our Complete HMO network of doctors with the help from our primary care physicians. Working in partnership with these PCPs, we reached out to other physicians, specialists and hospitals to create a broad and complimentary HMO network for our members.

HMO Networks ONLY

There are no out-of-network benefits for an HMO. The only out-of-network services are for emergencies or for services which are arranged by Meritus for the member due to provider network coverage.

Maricopa County

Meritus Complete HMO Network . . . . . . . . . . . . . . . . . . 7

Meritus HMO Abrazo Network . . . . . . . . . . . . . . . . . . . . 9

Meritus HMO Banner Network . . . . . . . . . . . . . . . . . . . 10

Meritus HMO MIHS Network . . . . . . . . . . . . . . . . . . . . 11

Mohave County


Meritus HMO WARMC Network . . . . . . . . . . . . . . . . . . 11

Pima and Santa Cruz Counties


Meritus HMO Pima Network . . . . . . . . . . . . . . . . . . . . . 12

Pinal County


Meritus HMO Banner Network . . . . . . . . . . . . . . . . . . . 10

Meritus Complete HMO Network

Page

PROVIDER NETWORKS


PROVIDER NETWORKS


Hospitals/Facilities

• Carondelet Health Network

• Tucson Medical Center


NogalesHoly Cross Hospital


• Honor Health Network

• Banner Health

• Abrazo Health

• Maricopa Medical Center

Maricopa County



Bullhead City

FortMohave

Lake Havasu City

Kingman

Peach SpringsDolan Springs

Colorado City

Wikieup

Meadview

Needles


• Western Arizona Regional Medical Center

• Havasu Regional Medical Center

• Valley View Medical Center

Mohave County

MaricopaFlorence

MammothArizona City

Apache Junction

Casa Grande

Kearny

CoolidgeDudleyville

San TanValley

Cold Canyon

Oracle


• Banner Hospitals

• Banner Clinics

• Banner Children’s Clinics

Pinal County

PROVIDER NETWORKS


Other Meritus HMO NetworksIn order to offer low premiums and quality benefits to our members, Meritus also created other HMO network options in partnership with some of the best hospital based healthcare systems in Arizona.

• Meritus HMO MIHS Network - Maricopa Integrated Healthcare Systems

• Meritus HMO Banner Network - Banner Health System

• Meritus HMO Pima Network - Carondelet Health Network

• Meritus HMO Abrazo Network - Abrazo Health System

• Meritus HMO WARMC Network - Western Arizona Regional Medical Center

Meritus HMO Abrazo Network

Maricopa County

Three popular community network plans from 2014 and 2015 will continue to be offered in 2016:

• Meritus Neighborhood Network Silver HMO MIHS

• Meritus Community Network Silver HMO Banner

• Meritus Community Network Silver HMO Pima

These are the only three individual plans which include Pediatric Dental.

Hospitals/Networks

• Arizona Heart Hospital

• Arizona Heart Institute

• Arrowhead Hospital

• Maryvale Hospital

• Paradise Valley Hospital

• Phoenix Baptist Hospital

• West Valley Hospital

PROVIDER NETWORKS


Meritus HMO Banner NetworkServing both Maricopa and Pinal Counties


• All of the Banner Hospitals

• MD Anderson Cancer Center

• Cardon Children’s Medical Center

• Banner Heart Hospital

Maricopa County

MaricopaFlorence

MammothArizona City

Apache Junction

Casa Grande

Kearny

CoolidgeDudleyville

San TanValley

Cold Canyon

Oracle


• Banner Hospitals

• Banner Clinics

• Banner Children’s Clinics

Pinal County

PROVIDER NETWORKS


Meritus HMO MIHS Network



• Phoenix Cancer Center

• Arizona Burn Center

• Behavior Health

• McDowell Health Care Center

• 16 MIHS/DMG Family Health and Community Centers

Maricopa County

Bullhead City

FortMohave

Lake Havasu City

Kingman

Peach SpringsDolan Springs

Colorado City

Wikieup

Meadview

Needles


• Western Arizona Regional Medical Center

• Valley Health System, Las Vegas

- Centennial Hills Hospital Medical Center

- Desert Springs Hospital Medical Center

- Spring Valley Hospital Medical Center

- Summerlin Hospital Medical Center

- Valley Hospital Medical Center

Mohave County

Meritus HMO WARMC Network

PROVIDER NETWORKS


© 2015 Meritus. Meritus products and services are provided through Meritus Mutual Health Partners – PPO and Meritus Health Partners – HMO.

For a complete listing of benefits available for all plans as well as limitations and exclusions, please contact Meritus. Meritus Mutual Health Partners – PPO and Meritus Health Partners – HMO are licensed only in Arizona and are Qualified Health Plan issuers in the Health Insurance Marketplace.


Meritus HMO Pima Network


• St. Mary’s Hospital

• St. Joseph’s Hospital - Tucson

• Cardonelet Heart & Vascular Institute

• Carondet Neurological Institute

• Holy Cross Hospital


PROVIDER NETWORKS


COUNTY CITY FACILITY NAME

Apache Ganado Sage Memorial Hospital Springerville White Mountain Regional Medical CenterCochise Benson Benson Hospital Bisbee Copper Queen Community Hospital Douglas Southeast Arizona Medical Center Sierra Vista Sierra Vista Regional Health Center Willcox Northern Cochise Community HospitalCoconino Flagstaff Flagstaff Medical Center Page Page Hospital Tuba City Tuba City Regional HealthcareGila Globe Cobre Valley Regional Medical Center Payson Payson Regional Medical Center Safford Mt Graham Regional Medical CenterGraham & Greenlee Safford Mt. Graham Regional Medical Center La Paz Parker La Paz Regional Hospital Maricopa Chandler Arizona Orthopedic & Surgical Specialty Chandler Regional Medical Center Gilbert Banner Gateway Medical Center Banner MD Anderson Cancer Center Mercy Gilbert Medical Center - Dignity Glendale Abrazo Arrowhead Campus Banner Thunderbird Medical Center St. Joseph’s Westgate Medical Center - Dignity Goodyear Abrazo West Campus Laveen Village Arizona General Hospital - Dignity

The Arizona Foundation for Medical Care Network is the backbone of the Meritus PPO Network. We contract directly with additional providers to make up our entire PPO network. We have a provider search tool on our website at meritusaz.com where you can find a complete list of doctors and facilities that are part of the Meritus PPO network.

Meritus Complete PPO Network

Continued on page 14

PROVIDER NETWORKS


Maricopa Mesa Arizona Spine & Joint Hospital Banner Baywood Medical Center Banner Desert Medical Center Banner Heart Hospital Cardon Children’s Medical Center Mountain Vista Medical Center Phoenix Abrazo Arizona Heart Hospital Abrazo Central Campus Abrazo Maryvale Campus Abrazo Scottsdale Campus Banner Estrella Medical Center Banner University Medical Center HonorHealth Deer Valley Medical Center HonorHealth John C. Lincoln Hospital Medical Center Maricopa Medical Center Oasis Hospital Phoenix Children’s Hospital Select Specialty Hospital - Phoenix St. Joseph’s Hospital & Medical Center - Dignity St. Luke’s Medical Center San Tan Valley Banner Ironwood Medical Center Scottsdale HonorHealth Scottsdale Osborn Medical Center HonorHealth Scottsdale Shea Medical Center HonorHealth Scottsdale Thompson Peak Medical Center Sun City Banner Boswell Medical Center Sun City West Banner Del E Webb Medical Center Tempe Tempe St. Luke’s Hospital Wickenburg Wickenburg Community HospitalMohave Fort Mohave Valley View Medical Center Kingman Kingman Regional Medical Center Lake Havasu City Havasu Regional Medical CenterNavajo Show Low Summit Healthcare Regional Medical Center Winslow Little Colorado Medical CenterPima Tucson Carondelet St. Joseph’s Hospital Carondelet St. Mary’s Hospital Northwest Medical Center Tucson Medical Center Oro Valley Oro Valley HospitalPinal Apache Junction Banner Goldfield Medical Center Casa Grande Banner Casa Grande Medical Center Florence Florence Hospital at Anthem Sacaton Hu Hu Kam Memorial Hospital Santa Cruz Nogales Carondelet Holy Cross HospitalYavapai Cottonwood Verde Valley Medical Center Prescott Yavapai Regional Medical Center Prescott Valley Mountain Valley Regional Rehab Hospital Yavapai Regional Medical Center-EastYuma Yuma Yuma Regional Medical Center

PPO Networks ONLY

Members are not required to go to a an in-network provider. At the time of services, they may obtain treatment from an in-network provider or an out-of-network provider. However, to maximize the benefit reimbursement level under a policy, an in-network provider should be used. The insured will incur higher out-of-pocket costs if they choose to receive services from an out-of-network provider, and will be responsible for the difference between billed charges and the amount paid by Meritus, other than copayments, co-insurance, or any amounts that may remain on their annual deductible. If they plan to use a non-network provider, they should inquire about the fees they can expect to be charged before they receive services.

COUNTY CITY FACILITY NAME


Continued from page 13

PROVIDER NETWORKS

Our PPO network offers the convenience of utilizing the PHCS Network outside of Arizona. Our PPO members can use the PHCS Network to access in-network providers and facilities for their care needs.

Meritus PPO Out-of-State Network


Hospitals/Networks

• Honor Health Network

• Banner Health

• Abrazo Health


• Dignity Health

• Phoenix Children’s Hospital

Hospitals/Networks

• Carondelet Health Network

• Tucson Medical Center

• Northwest Medical Center/ Oro Valley


Maricopa County



PROVIDER NETWORKS


It is very important for us to help our members find doctors that are in their network. We want to help them avoid unnecessary medical bills and confusion that could result from using doctors that are not contracted in their Meritus plan.

Steps to View Providers

• Go to meritusaz.com

• Click the Find a Provider button

• Click Meritus Provider Directory or Meritus Facility Directory. See the screen shot shown below.

• Under the box marked PLAN scroll down to select the network you wish to access, and click on the desired network

Accessing the Meritus PPO and HMO Networks

The Meritus Networks are:

• Meritus PPO Complete Network - all PPO Plans

• Meritus HMO Complete Network

• Meritus HMO Abrazo

• Meritus HMO Banner

• Meritus HMO MIHS

• Meritus HMO WARMC

• Meritus HMO Pima

• Enter the Provider’s Zip Code

SUGGESTION: Google the provider’s name to obtain the correct spelling and zip code

• You must select either Primary Care Physician (PCP) or a Specialist

• See Quick Links on the right side of the page for easy website navigation options

PROVIDER NETWORKS


A Quality Holistic Provider Network that works for you.At Meritus, we know that health isn’t something that you only fix when it’s broken. That’s why we’ve teamed up with Complementary and Alternative Medicine (CAM) experts including Naturopathic Medical Doctors, Licensed Acupuncturists and Licensed Massage Therapists who can partner with you to create a personalized wellness plan to help you achieve a healthier lifestyle as well as address specific conditions when you are ill. Check out the current list of CAM providers on meritusaz.com under Find a Provider.*

Our network providers are experts in holistic and integrative medical care and have extensive training in CAM benefits including: medical nutrition, acupuncture, counseling and stress management, bio-identical hormones and other natural therapies.

Whether your goal is to have more energy, decrease pain, reduce stress, learn to eat better or to simply stay healthy and active, our CAM benefits were created to support your overall health and well-being.

You asked for health plan benefits with CAM choices and Meritus listened. Benefits include 12 visits of each modality at a $20 copay per visit*: naturopathy, acupuncture and therapeutic massage, and up to a $25/month gym membership reimbursement.**

Meritus is putting healthcare back into health insurance, by promoting wellness, lowering healthcare costs and providing easy access to quality care. We want our members healthier than when they first joined us.

Acupuncture $20 copay per visit*

Therapeutic Massage Therapy $20 copay per visit*

Naturopathy $20 copay per visit*

Gym Membership** Up to $25/month reimbursement

* Complimentary and Alternative Therapies (CAM) are limited to 12 visits per year for each modality. In-network providers must be used for this benefit.

** The $25/Month Gym Reimbursement is only available for certain plan options. In order to obtain a gym membership reimbursement, you must submit a claim. Meritus will pay up to $25 per month for each covered person, age 18 and above, who has a gym membership. “Gym” means a business licensed by the state or +local government to conduct business as: (1) a gym; (2) fitness center; or (3) health club. The gym must have exercise/fitness equipment and have personnel to assist gym members.

Complementary and Alternative Lifestyle Benefits

Plus

+Plus is available on Meritus Healthy Platinum and Gold HMO, Meritus Choice Gold, Silver and Bronze PPO, and Meritus Saver Gold, Silver and Bronze PPO plans.

PROVIDER NETWORKS


More Healthcare Options Available to Members!

PROVIDER NETWORKS

Easy as1-2-3!

AvailableNationwide

Receive treatment from home, the of�ceor even when you’re on vacation!

*MinuteClinic® employs physician assistants in MN, NC, NV andTX. **When medically appropriate.†Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a �xed amount or other charge, with the balance, if any paid by a Plan.Your privacy is important tous. Our employees are trained regarding the appropriate way to handle your private health information. 106-3411Ob 030615

Convenient, quality health care for the entire family.

Certi�ed nurse practitioners and physician assistants* diagnose, treat and write prescriptions.**

Visit summary is sent to your primary care doctor, with your permission.

Open every day, evenings and weekends. No appointment necessary.

• Open extended hours and weekends

• Adults and children (18 months and older) for most services

• Routine lab tests

• Walk-ins Welcome

• Same Copay as a PCP Visit

• Visit a Nearby Location Today

From ah-choo! allergies to vaccinations and more. . .

Close to home or work.

Get a dose of careat MinuteClinic®.


Pharmacy benefit programs are an important aspect of any healthcare

coverage plan, and are a significant contributor to medical costs. Meritus

has easy-to-use pharmacy benefits built into our various plans.

Summary of Pharmacy Benefits


Metal Level Platinum Gold SilverSilver

NEIGHBORHOOD & COMMUNITY PLANS

Bronze

RX Deductible -Does not apply to Generics

$0 $0 $300 $250 $300

ACA Preventative $0 Copay - Retail

$0 Copay - Retail

$0 Copay - Retail

$0 Copay - Retail

$0 Copay – Retail

Adherence Generic

$0 Copay - Retail

$0 Copay - Retail

$5 Copay - Retail

$0 Copay - Retail

$10 Copay - Retail

Other Generic $2 Copay - Retail

$5 Copay - Retail

$15 Copay - Retail

$20 Copay - Retail

$30 Copay - Retail

Preferred Brand $15 Copay - Retail

$30 Copay - Retail

$60 Copay - Retail

$72 Copay - Retail

$90 Copay - Retail

Non-Preferred Brand

$60 Copay - Retail

$75 Copay - Retail

$150 Copay - Retail

$150 Copay - Retail

$200 Copay - Retail

Specialty – Preferred and Non-Preferred

50% Copay - Retail

50% Copay - Retail

50% Copay - Retail

40% Copay - Retail

50% Copay - Retail

CVS Caremark Contracted Pharmacies include, but are not limited to the following (please check meritusaz.com for the nearest contracted pharmacy):

Please see plan descriptions for more detailed benefit information.

Mail order is available for 90 day prescriptions and the member cost share is 3 times the 30-day retail copay utilizing CVS Caremark’s mail order service.

Meritus has moved to a 6-tier pharmacy benefit offered through CVS Caremark. There are two Generic Drug tier classifications for 2016 which are “Adherence Generic” and “Other Generic.”

Adherence Generic drugs include certain medications for chronic conditions. This tier includes those medications which promote heart health, treat high blood pressure, high cholesterol, along with oral diabetic medications as provided in the Meritus drug formulary.

2016 Formulary Tier Guide

Tier 0 – ACA Preventative Drugs

Tier 1 – Adherence Generic Drugs

Tier 2 – Other Generic Drugs

Tier 3 – Preferred Brand Drugs

Tier 4 – Non-Preferred Brand Drugs

Tier 5 – Preferred Specialty Drugs

Tier 6 – Non-Preferred Specialty Drugs

2016 Pharmacy Benefits

SUMMARY OF PHARMACY BENEFITS

• Albertsons

• Bashas’

• Costco

• CVS Pharmacies

• Food City

• Fry’s

• K-Mart

• Osco

• Safeway

• Sam’s Club

• Sav-on

• Target

• Walmart

• Walmart Neighborhood Market

HSA Plans Under the HSA plan benefits, RX benefits are subject to the medical plan deductible, coinsurance and out-of-pocket maximums.

*IMPORTANT: Walgreens is NOT in the Meritus pharmacy network. For more information on the contracted pharmacies and to view the Meritus drug formulary, please visit meritusaz.com.


The health insurance market as we know it has changed.

The ACA includes several provisions geared to create greater access to

health insurance benefits to more people. As of 2014, most Americans

must purchase a minimum amount of health insurance or be taxed by

the government. This tax is paid through Federal Income Tax reporting

in April each year.

For more details about the ACA, visit Healthcare.gov.

Understanding the MarketplaceUnderstanding the Marketplace


Marketplace Benefit to Consumers

Advanced Premium Tax Credit (APTC) and Cost-Sharing Reductions (CSR) will provide many Arizonans with access to affordable health insurance.

Consumers can get lower costs on coverage

Our online quoting tool allows you and your clients to find out if they are eligible for subsidies or tax credits to help lower the cost of their monthly premiums or out-of-pocket costs for private insurance. You’ll also learn if they qualify for free or low-cost coverage through AHCCCS.

Pre-existing conditions are covered

Plans are not able to deny consumers coverage or charge them more due to pre-existing health conditions, including a pregnancy or disability.

Eligibility for Tax Credits & Cost-Sharing Reductions

Individuals or families who purchase coverage in the Marketplace are eligible for a tax credit as long as their household income is up to 400 percent of federal poverty level guidelines; that equals $11,770 to $47,080 per year for an individual and $24,250 to $97,000 per year for a family of four (see income table on page 24).

The assistance amount that a person can receive varies with income. The tax credit may be applied to any plan level (Catastrophic, Bronze, Silver, Gold or Platinum).

Cost-Sharing Reductions

Those who earn up to 250 percent of federal poverty guidelines and enroll at the Silver level only may also be eligible for cost-sharing reductions (CSR). The CSR amount will vary according to income. Examples of cost-sharing that may be reduced include deductibles, co-insurance, copayments or similar charges and do not include balance billing for non-network providers or spending on non-covered services. (See table on page 24).

Penalties for Uninsured Individuals

Legal U.S. citizens who do not carry a minimum amount of health coverage will receive a penalty. The annual penalty for not having minimum essential coverage will be greater of a percentage of the individual’s taxable income or a flat dollar amount per individual. For any dependent under the age 18, the penalty is one half of the individual amount.

Understanding the Marketplace

Under the ACA, each state is required to operate a Health Insurance Marketplace, or in Arizona’s case, the Federally Facilitated Marketplace (FFM) – also known as an Exchange. People can purchase coverage from private companies like Meritus that have been approved as Qualified Health Plans (QHPs). All QHPs must offer the same core set of benefits called “essential health benefits.” The difference between plans will be in what and how they offer “non-essential” health benefits, their deductibles, copayments and co-insurance, and value added benefits.

Essential health benefits package must include services and items for the following categories of care:*

1. Ambulatory patient services

2. Emergency services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services, including behavioral health treatment

6. Prescription drugs

7. Rehabilitative and habilitative services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision care

*Healthcare.gov: Essential health benefits (accessed October 2012)

UNDERSTANDING THE MARKETPLACE


2016: The annual individual responsibility payment is the greater of

- 2.5% of the taxpayer’s household income that is above the tax return filing threshold for the taxpayer’s filing status,

or

- The taxpayer’s flat dollar amount, which is $695 per adult and $347.50 per child.

However, the total payment amount is capped at the cost of the national average premium for a Bronze level health plan available through the Marketplaces in 2016.

Key Information for Consumers:

• Purchasing insurance using the Marketplace provides “guaranteed coverage”

• All pre-existing conditions are covered and companies can’t charge more for a policy because of past or present health conditions

• To be eligible for health coverage through the Marketplace, consumers must:

- Reside in the state in which coverage is being applied for

- Be a U.S. citizen or national (or be lawfully present)

- Not be currently incarcerated

• You might be eligible for tax subsidies (see chart on page 24)


These calculations represent the amount of the payment for not having health insurance coverage for the entire year. Individuals will owe 1/12th of the annual payment for each month they (or their dependents) do not have coverage and are not exempt. Individuals without coverage for less than three consecutive months during the year may qualify for the short coverage gap exemption and will not have to make a payment for those months. The short coverage gap exemption only applies to the first coverage gap during a year.

After 2016, the same method of calculation will be used, and the payment will be adjusted for inflation.


Actuarial Value 70% AV 94% AV 87% AV 73% AV

Deductible (Individual) $4,000 $150 $500 $2,300

Coinsurance 30% 0% 0% 30%

Office Visit – PCP/ $30 copay/ $0 copay/ $0 copay/ $20 copay/ Non-PCP $60 copay $10 copay $30 copay $60 copay

Max Out-of-Pocket $6,800 $1,200 $2,250 $5,450

Example Meritus Healthy Silver $4,000 Network benefits including CSR benefit levels

Standard Silver – No CSR

CSR Plan for up to 150% FPL (up to $17,655)

CSR Plan for 151-200% FPL ($17,655 to $23,540)

CSR Plan for 201-250% FPL ($23,540 to $29,425)

How your clients can get coverage.

Connecting Individuals and Families to coverage, benefits and services.

You may qualify for lower premiums on a Marketplace Insurance plan if your yearly income is between. . .

See next row if your income is at the lower end of this range.

You may qualify for lower premiums AND lower out-of-pocket costs for Marketplace insurance if your yearly income is between. . .

If your state is expanding Medicaid in 2014: You may qualify for Medicaid coverage if your yearly income is between. . .

If your state isn’t expanding Medicaid in 2014: You may not qualify for any Marketplace savings programs if your yearly income is between. . .

$11,770 - $47,080

$15,930 - $63,720

$20,090 - $80,360

$24,250 - $97,000

$28,410 - $113,640

$32,570 - $130,280

1 2 3 4 5 6

$11,770 - $29,425

$15,930 - $39,825

$20,090 - $50,225

$24,250 - $60,625

$28,410 - $71,025

$32,570 - $81,425

$16,242 $21,983 $27,724 $33,465 $39,205 $44,946

$11,770 $15,930 $20,090 $24,250 $28,410 $32,570Med

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Number of people in your household

Cost-Sharing Reductions

Those who earn up to 250 percent of federal poverty guidelines and enroll at the Silver level only may also be eligible for cost-sharing reductions (CSR). The CSR amount will vary according to income. Examples of cost-sharing that may be reduced include deductibles, co-insurance, copayments or similar charges and do not include balance billing for non-network providers or spending on non-covered services.



Meritus Rules Regarding Federal Marketplace Enrollments

Enrollment, Termination, Special Enrollment Periods and Plan Changes

Rules of Enrollment


*Minimum Essential Coverage

Rules for Special Enrollment Period changes (SEP)

If a client applies on the FFM, and they qualify for a SEP to change plans or enroll for the first time, they will have 60 days from the life event to enroll. After reporting life changes to the Marketplace, they will get a new eligibility notice that will explain if they have a Qualifying Life Event (QLE), are eligible for a Special Enrollment Period, and are allowed to re-enroll. At this time, they may select a new plan that might lower their costs.

If your client qualifies for a SEP, you can assist them by phone with the FFM or through your Meritus direct link. When the application is finished and they get to the “To-do list” page, you’ll see a statement that they can enroll only if they have a SEP. You can then continue the process and enroll in a plan.

Type of SEPTermination Date of Existing Enrollment, if currently Enrolled

Plan Selection Date Effective Date

Eligible for the following QLE:

1. Move to a new exchange service area

2. Release from incarceration

3. Becoming lawfully present

4. Gain status as an Indian

First day of the following month

First day of the second following month

Day before effective date.

Loss of MEC* and gaining a dependent through marriage SEP

Future loss of MEC* (loss up to 60 days in the future)

Birth, adoption, or placement for adoption or foster care SEP

Day before effective date



First day of the following month

First day of the month following the date of the loss of MEC

Day the child was born, adopted, or placed for adoption or foster care

Any day of the month



Between the 1st and 15th day of the month

Between the 16th and last day of the month

RULES OF ENROLLMENT


Affordable coverage that Arizonans can count on.

With a focus on health and wellness, our plans have a strong, competitive

benefit packages that are designed to provide Arizonans with the kind of

coverage they want and deserve. This includes access to affordable, quality

care, as well as added benefits offering coverage for prescription drugs,

pediatric vision and Complementary and Alternative Medicine including

Naturopathy, Acupuncture and Therapeutic Massage.*

*Available in specified plans.

Plans to Meet All Your Needs.


Meritus Plans and Rates*

Covered Benefits

Once enrolled, members will receive a Summary of Benefits and Coverage and a Comprehensive Health Policy including information about:

• Benefits that are covered and not covered

• Copayments and other charges for which they are responsible

They will also have access to their own secure area of the online Member Portal to find this information.

Basic List of Benefits*

• Primary care doctor visits for wellness or to treat an injury or illness

• Specialist doctor visits

• Preventive care, screening and immunization

• Prescription drugs

• Hospitalizations

• Emergency room services

• Urgent care services

• Maternity care services

• Lab and X-ray services

• Mental health, behavioral health and substance abuse services

• Home healthcare

• Rehabilitation services

• Habilitation services

• Skilled nursing facilities

• Durable medical equipment

• Hospice services

• Eye exams and glasses for children

• Hearing aids

Meritus benefits and services are offered by Meritus Health Partners - HMO and Meritus Mutual Health Partners - PPO.

Non-Covered Benefits

Benefits not included in your health insurance plan would also include any service that is not medically necessary.

What is medically necessary?

These are services which will be covered to prevent, diagnose, correct, improve or cure conditions that endanger life, cause pain, result in illness or could cause or worsen a handicap or physical defect. In addition, these services must be appropriate for the specific health issue or when no other equally effective care is an option.

Other services not covered by your Meritus Health Insurance Plan include, but are not limited to:

• Elective cosmetic surgery

• Experimental and/or investigational drugs, procedures or equipment

• Infertility treatment

• Prescriptions not on our list of covered medications, unless approved by Meritus

The lists above are not complete lists. If your clients have questions about benefits, please call Customer Care at 602.957.2113 or toll-free at 1.855.755.2700. TTD/TTY users should call 7.1.1.

PLAN DESIGNS


The Meritus Plans

Meritus Plans are separated into four health plan categories consistent with the Federal Marketplace – Bronze, Silver, Gold and Platinum – (Meritus does not offer a Catastrophic level plan) based on the percentage the plan pays of the average overall cost of providing essential health benefits to members. The plan category chosen affects the total amount Meritus members will likely spend for essential health benefits during the year. The percentages Meritus will spend, on average, are 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum, HMO only). This isn’t the same as coinsurance, in which your client pays a specific percentage of the cost of a specific service.

* Select the Find a Provider option at meritusaz.com to see a complete list of physicians and facilities. ** Complementary and Alternative Medicine includes Naturopathy, Acupuncture and Therapeutic Massage, are available on certain

Individual and Group plans, check outlines of Coverage for details. In-network providers must be used for this benefit.

PLAN DESIGNS

Catastrophic Less Than 60% Coverage

Bronze 60% Coverage

Silver 70% Coverage

Gold 80% Coverage

Platinum 90% Coverage

Metal Levels

Gold

Silver

Bronze

Platinum

MONTHLY PREMIUM OUT-OF-POCKET COST

$$$$ $

$$$ $$

$$ $$$

$ $$$$

Our HMO products are structured to provide more predictable out of pocket costs and fixed out of pocket costs for copays. Our HMO network is not as broad as our PPO network. The HMO products include low copays for primary care in most plans and Gold and Platinum plans include Complementary and Alternative Medicine (Naturopathy, Acupuncture and Massage Therapies).

Meritus is carrying over three Individual plans from 2015: Meritus Neighborhood Network Silver HMO MIHS, Meritus Community Network Silver HMO Banner, and Meritus Community Network Silver HMO Pima; which include pediatric dental for children under the age of 19. Meritus will utilize Delta Dental’s provider network for these benefits. Dental providers can be found at deltadentalaz.com.

Our PPO products are designed similar to the HMO products, but offer an out-of-network benefit at higher out-of-pocket costs. Our PPO plans utilize a very broad network (a variation of the Arizona Foundation for Medical Care Network*). The PPO products include low copays for primary care in most plans as well as Complementary and Alternative Medicine** and up to a $25 gym reimbursement.

A Range of Options

Some plans offer lower monthly premiums that may charge more out-of-pocket fees for care, while others offer higher-premium plans that cover more costs when members need care. Others fall in between.


Deductibles

EMBEDDED – Our HMO plans, PPO plans, Silver PPO HSA plan and Bronze PPO HSA plan include embedded deductibles. An embedded deductible works like a traditional PPO health plan deductible. Benefits begin for a single family member once the individual deductible is met – whichever comes first. For example, for a family of four with an individual embedded deductible of $2000 and a family deductible of $4000, plan benefits begin for a single family member after the $2,000 deductible has been met for that person. Any combination of the remaining three family members can incur claims that will apply towards the remaining $2,000 to meet the Family deductible. Once a total of $4,000 has been applied toward the family deductible, benefits begin for all family members.

PLAN DESIGNS

AGGREGATE (For the Group Gold HSA plan only) – To qualify as a tax-advantaged Health Savings Account – HSA – the Meritus Gold PPO HSA Plan has an aggregate (non-embedded) deductible. An Aggregate deductible works differently than traditional PPO plans. When covering more than one person, the family deductible must be met first before anyone in the family is covered for services. For example, if the family deductible is $3,000, there must be $3,000 paid to meet the deductible before the plan pays any benefits for any family member. Out-of Pocket maximum amounts are also aggregate, requiring the family out-of-pocket maximum to first be met before services are covered in full for any single family member in accordance with the plan policy.


Here is a step-by-step guide to help you through Individual and Family enrollment.

The following pages contain instructions on how to process a quote or

application using a Meritus populated link, or the Meritus Broker Sales

Portal at meritusaz.com for Individuals and Families.

Individual and Family



Individual and Family Enrollment Guide

1 ProposalEnter demographic information, select plan and create proposal.

2 ApplicationFill out the enrollment application and sign form.

3 Sent to MembershipApplications is sent to membership for processing.

4 MemberIndividual is now an active member.


The Quote and Enrollment Process

To quote and enroll Individual and Family plans, go to the meritusaz.com website, click on the Broker tab, and select Broker Sales Portal Login. After you access the Broker Portal, you will see the online Meritus Dashboard where you can select the Individual or Tools tabs.

Individual and Family Applications for both On and Off the Marketplace

You can sell both On or Off Market plans with Meritus. Your Meritus Broker Sales Portal can be used for Off Market enrollment and/or help determine whether your client may qualify for assistance from the FFM. The Meritus Direct Enrollment tool can be utilized for quick and efficient placement for On Market business during Open Enrollment. The Direct Enrollment tool will assist in determining APTC information for clients, verifying eligibility with Healthcare.gov and completing enrollment.

1Proposal

Determining Marketplace Eligibility

Primary Subscriber and ACA Eligibility

From the main Meritus Dashboard, select Tools and then click on ACA Individual Calculator to initiate the Individual quote process. The ACA Calculator will determine whether your client is eligible for premium assistance credits or cost-sharing reductions and it will calculate their shared responsibility penalty.

INDIVIDUAL AND FAMILY ENROLLMENT


Using the ACA Calculator, you can determine if affordable employer coverage is available or there is a certificate of exemption from the Marketplace.

The ACA Individual Calculator will present estimates and show results for Individual and Family profiles, shared responsibility (tax penalty) and coverage and assistance eligibility.

For those who do not qualify, continue with Off Market, on page 39.

For those qualified for On Market, go to Direct Enrollment link on page 36.

NOTE: If your client appears to be eligible for an On Market plan, please proceed to the instructions of how to assist clients with the Broker Direct Enrollment Tool during Open Enrollment. See page 39.



On Market Direct Enrollment Tool – During Open Enrollment

The Direct Enrollment tool will allow you to assist your clients to apply with the FFM and qualify for a tax credit and/or to determine whether they may qualify for plans with cost-sharing reductions. This online process will help you to streamline the FFM/CMS qualification process and connect you directly back to Meritus for an online application.

How to Access The Direct Enrollment Tool

Once you have set up your Broker Sales Portal you will be able to access the Direct Enrollment tool to assist your clients who wish to apply On the Market.

2Direct Enrollment - On Market Application

Step 1: Direct Enrollment Application

Enter your client’s first and last name and then click the Marketplace button only if your client will qualify for a plan with the FFM.

Set Up

Log onto your Broker Sales Portal by going to meritusaz.com and then click on My Account. It is recommended to use Google Chome when utilizing the Direct Enrollment tool.

After clicking on My Account, fill in the fields including your National Producer Number (NPN) and your Federal Marketplace User ID (this is the ID you used to access portal.cms.gov). Now save the information and you are ready to assist your client on the FFM for assistance and apply for a Meritus plan.



Step 2: Redirection to FFM Site

You will now be taken to HealthCare.gov where your User Name will be auto-populated. Now enter in your Marketplace password, which is the password you used to access portal.cms.gov. Now click on LOG IN.

Step 3: Start the FFM Eligibility Application on HealthCare.gov.

NOTE: It is recommended to bypass all “optional” questions as this may hinder your client’s application.

The Next Steps page will describe what happens next and what you’ll need to complete the application with the FFM. Click Next.



Step 6: Selecting the Plan

Click on Browse Plans to continue the enrollment, and you will be redirected to Meritus.

You will be able to assist your client and help them choose the plan and complete the Meritus application.

Step 5: Now click the Return to Enrollment Website button to return to your Broker Sales Portal.

Step 4: View Eligibility.

Once you reach the Eligibility Results, click on View Eligibility Results.

This will display, showing you your client’s Premium Tax Credits and whether they also qualify for a Cost-Sharing Reduction plan. These amounts will match the Eligibility Results which were displayed on the Healthcare.gov page.

Now proceed to picking a plan.



Proposal and Application

The Proposal screen will allow you to:

• Make any necessary edits prior to sending the quote.

• SAVE the client’s name and proposal so you can work on it or refer back to the quote at a later date.

• Email the proposal to your client.

• Save and send the proposal as a PDF.

• Start the application. Be sure not to select the marketplace application.

Select and Compare Plans

Compare plans (see above) by checking the small Compare box next to each plan that you would like to compare, and then click on one of the large Compare buttons to display your results. Note, that you can only compare up to four plans at any one time.

Then select the desired plan(s) for quoting by clicking on Select or for initiating an email or enrollment of a final plan with an application.

Plan Choices

You will be presented with a list of eligible plans for the Individual subscriber and household. You may further Filter Results to customize plan selection views for your clients based on:

• Benefit (metal) level

• Premium range

• Deductible

• Out-of-pocket (OOP)

• Office visit copays

• Lifestyle benefits

• HSA compatibility

• Provider network type

2 Off Market Application



Electronic Signature

After reviewing sections and completing the Electronic Signature, the client’s name needs to be typed into the box under E-Sign section.

Now you are ready to proceed to the Payment page.

Fill out all required fields as indicated and then click on the Complete this Section button on the lower right side of the screen.

Payment

The next step in the Individual Application process is to select the method for the Initial Premium Payment. This is the final step of submitting the application.

NOTE: A debit card is considered the same as a credit card in our payment system.


Initial Payament with the application does NOT establish a reoccurring payment


On Market

Click on Continue on the lower right side of the Collect Payment screen. The application has now been submitted to Meritus through the FFM.

NOTE: You will not be able to see FFM submissions on your Broker Sales Portal. Please allow 7 – 10 business days before checking to see if the submission has been noted in our Customer Care system.

Off Market

Click on Continue on the lower right side of the Collect Payment screen. The application has now been submitted to Meritus and can be seen in your Broker Sales Portal. To see this, click on Individual and then click on Applications.

3Sent to Membership

Direct Enrollment Tool Updates

For the latest updates, on the Direct Enrollment Tool, go to meritusaz.com, click on Broker, click on Resources and click on Direct Enrollment Tool.

NOTE: The application will be approved within 5 – 7 business days, at which time, you can look in your Broker Sales Portal under Individual and then click on Members.



On Market

Once the application is sent through the FFM, the Member will be assigned a Member number by our Customer Care system within 7 – 10 business days. When the binder payment is received by Meritus the Membership Packet will then be mailed out to them in 7 – 10 business days.

NOTE: If a Member does not receive their Meritus card and packet prior to their live date, the Member may call Meritus Customer Care (877.755.2700) for instructions on how to proceed until their card is received. Please also note that the Member will only be effectuated by Meritus once their binder payment has been received. It is also important to remember that ID Cards will not be sent until initial payment has been made.

Off Market

Once the application is approved, the Member will be assigned a Member number by our Customer Care system. When the binder payment is received by Meritus the Membership Packet will then be mailed out in 7 – 10 business days.

NOTE: If a Member does not receive their Meritus card and packet prior to their live date, the Member may call Meritus Customer Care (877.755.2700) for instructions on how to proceed until their card is received. Please also note that the Member will only be effectuated by Meritus once their binder payment has been received. It is also important to remember that ID Cards will not be sent until initial payment has been made.

4Member



Individual Plans

PLAN TYPE - METAL NAME PAGES

HMO - Platinum Meritus Healthy Platinum Complete HMO Plus 500 44

Meritus Healthy Platinum HMO Plus Abrazo 500 44

Meritus Healthy Platinum HMO Plus Banner 500 44

Meritus Healthy Platinum HMO Plus MIHS 500 44

Meritus Healthy Platinum HMO Plus Pima 500 44

Meritus Healthy Platinum HMO Plus WARMC 500 44

HMO - Gold Meritus Healthy Gold Complete HMO Plus 2000 45

Meritus Healthy Gold HMO Plus Abrazo 2000 45

Meritus Healthy Gold HMO Plus Banner 2000 45

Meritus Healthy Gold HMO Plus MIHS 2000 45

Meritus Healthy Gold HMO Plus Pima 2000 45

Meritus Healthy Gold HMO Plus WARMC 2000 45

HMO - Silver Meritus Neighborhood Network Silver HMO MIHS - Pediatric Dental Included 46 - 49

Meritus Community Network Silver HMO Banner - Pediatric Dental Included 46 - 49

Meritus Community Network Silver HMO Pima - Pediatric Dental Included 46 - 49

Meritus Healthy Silver Complete HMO 4000 50 - 53

Meritus Healthy Silver HMO Abrazo 4000 50 - 53

Meritus Healthy Silver HMO Banner 4000 50 - 53

Meritus Healthy Silver HMO MIHS 4000 50 - 53

Meritus Healthy Silver HMO Pima 4000 50 - 53

Meritus Healthy Silver HMO WARMC 4000 50 - 53

HMO - Bronze Meritus Healthy Bronze Complete HMO 6800 54

Meritus Healthy Bronze HMO Abrazo 6800 54

Meritus Healthy Bronze HMO Banner 6800 54

Meritus Healthy Bronze HMO Pima 6800 54

Meritus Healthy Bronze HMO WARMC 6800 54

PPO Meritus Choice Silver Complete PPO Plus 4000 - OFF Market Only 55

Meritus Choice Bronze Complete PPO Plus 6800 - OFF Market Only 56

PPO HSA Meritus Saver Silver Complete PPO HSA Plus 2750 - OFF Market Only 57

Meritus Saver Bronze Complete PPO HSA Plus 6300 - OFF Market Only 58

HMO PROVIDER NETWORKS - Counties Served

Meritus Complete HMO Network - Maricopa, Mohave, Pima, Pinal and Santa Cruz Counties

Meritus Community Network Abrazo - Maricopa County

Meritus Community Network Banner - Maricopa and Pinal Counties

Meritus Neighborhood Network MIHS - Maricopa County

Meritus Community Network Pima - Pima County

Meritus Community Network WARMC - Mohave County

INDIVIDUAL AND FAMILY PLANS


Deductible - per calendar year $500 single/$1,000 family

Out-of-Pocket Maximum (includes deductible and copays) - per calendar year $2,000 single/$4,000 family

Office Visit Primary Care Physician $5 copay per visit

Specialist $30 copay per visit

Prenatal and Postnatal Care $5 copay per visit

Preventative Care, including Well Baby Care $0 copay per visit

Telemedicine - MeMD $0 copay per visit

In-Store Health Care Clinic $5 copay per visit

Emergency Urgent Care $30 copay per visit

Emergency Room - copay waived if admitted, copay waived if accident $200 copay per visit

Ambulance - Medical Emergency $150 copay per transport

Hospital Inpatient and Outpatient hospital services 10%, after deductible

Ambulatory Surgical Center $200 copay per visit

Outpatient Laboratory/Pathology

Performed in a physician’s office or free-standing independent lab facility $25 copay per visit

Performed in a hospital 10%, after deductible

Outpatient Radiology - General

Performed in a physician’s office $50 copay per visit

Performed in an independent, non-hospital-affiliated radiology facility $150 copay per visit


Outpatient Radiology/Imaging & Testing - Including, but not limited to, CT scans, MRIs, MRAs and PET/SPECT scans


Performed in an independent, non-hospital affiliated radiology facility $200 copay per visit


Chiropractic Care - Maximum 20 visits per calendar year $30 copay per visit

Short Term Physical Therapy, Occupational Therapy, Speech Therapy Limited to 60 visits per calendar year combined $30 copay per visit

Office Psychiatric and Substance Abuse Visits $30 copay per visit

Pediatric Vision Exam - one exam per calendar year $25 copay per exam

Glasses or Contacts - one item per calendar year $25 copay per item

Naturopathy - Maximum 12 visits per calendar year $20 copay per visit

Acupuncture - Maximum 12 visits per calendar year $20 copay per visit

Therapeutic Massage - Maximum 12 visits per calendar year $20 copay per visit

Gym Membership Reimbursement Up to $25 per month

Outpatient Prescription Drugs - Quantity limits may apply.

Prescription Deductible - per calendar year $0 single/$0 family

Up to a 30 Day Prescription - Retail, 90 Day Prescription-Mail Order 30 Day Retail 90 Day Mail Order

ACA $0 Preventative $0 copay $0 copay

Adherence Generic* $0 copay $0 copay

Other Generic $2 copay $6 copay

Preferred Brand $15 copay $45 copay

Non-Preferred Brand $60 copay $180 copay

Specialty – Preferred and Non-Preferred 50% 50%

Meritus Healthy PlatinumNetworks: Complete HMO Plus 500 • HMO Plus Abrazo 500 • HMO Plus Banner 500 • HMO Plus MIHS 500 HMO Plus Pima 500 • HMO Plus WARMC 500

Pediatric Dental NOT included.

Plus

*Adherence Generic drugs include those medications which promote heart health, treat high blood pressure, high cholesterol, along with oral diabetic medication.See page 59 for disclaimers, exclusions and limitations.

INDIVIDUAL HMO


Deductible - per calendar year $2,000 single/$4,000 family










































INDIVIDUAL HMO

Meritus Healthy Gold Networks: Complete HMO Plus 2000 • HMO Plus Abrazo 2000 • HMO Plus Banner 2000 • HMO Plus MIHS 2000 HMO Plus Pima 2000 • HMO Plus WARMC 2000


Plus














Hospital Inpatient hospital services $1,000 copay per admission, after deductible

Outpatient hospital services $500 copay per admission




Performed in a hospital $100 copay per visit








Performed in a hospital $600 copay per visit, after deductible






Pediatric Dental Class I - limit 1 visit every 6 months 0%

Class II 45%

Class III 65%

Orthodontia - 24 month waiting period 50%



Up to a 30 Day Prescription - Retail, 90 Day Prescription-Mail Order. 30 Day Retail 90 Day Mail Order




Preferred Brand $67 copay** $201 copay**

Non-Preferred Brand $150 copay** $450 copay**

Specialty – Preferred and Non-Preferred 40%** 40%**

Meritus Neighborhood Network Silver HMO MIHS Meritus Community Network Silver HMO Banner Meritus Community Network Silver HMO Pima

*Adherence Generic drugs include those medications which promote heart health, treat high blood pressure, high cholesterol, along with oral diabetic medication.**After separate prescription drug deductible. See page 59 for disclaimers, exclusions and limitations.

INDIVIDUAL HMO


Meritus Neighborhood Network Silver HMO MIHS - CSR73 Meritus Community Network Silver HMO Banner - CSR73 Meritus Community Network Silver HMO Pima - CSR73

ON

MARKET

ONLY

INDIVIDUAL HMO












Hospital Inpatient hospital services $1,000 copay per admission




















Class II 45%

Class III 65%














ON

MARKET

ONLY

Deductible - per calendar year $400 single/$800 family











Hospital Inpatient hospital services $500 copay per admission




















Class II 45%

Class III 65%












INDIVIDUAL HMO



ON

MARKET

ONLY

INDIVIDUAL HMO












Hospital Inpatient hospital services $150 copay per admission




















Class II 45%

Class III 65%










































Naturopathy - Maximum 12 visits per calendar year Not Covered

Acupuncture - Maximum 12 visits per calendar year Not Covered

Therapeutic Massage - Maximum 12 visits per calendar year Not Covered

Gym Membership Reimbursement Not Covered


Prescription Deductible - per calendar year - Does not apply to Generic Drug Tiers $300 single/$600 family








Meritus Healthy Silver Networks: Complete HMO 4000 • HMO Abrazo 4000 • HMO Banner 4000 • HMO MIHS 4000 HMO Pima 4000 • HMO WARMC 4000

Pediatric Dental NOT included.*Adherence Generic drugs include those medications which promote heart health, treat high blood pressure, high cholesterol, along with oral diabetic medication.**After separate prescription drug deductible. See page 59 for disclaimers, exclusions and limitations.

INDIVIDUAL HMO


Meritus Healthy Silver - CSR73 Networks: Complete HMO 4000 • HMO Abrazo 4000 • HMO Banner 4000 • HMO MIHS 4000 HMO Pima 4000 • HMO WARMC 4000

ON

MARKET

ONLY











































INDIVIDUAL HMO

Pediatric Dental NOT included.*Adherence Generic drugs include those medications which promote heart health, treat high blood pressure, high cholesterol, along with oral diabetic medication.See page 59 for disclaimers, exclusions and limitations.














































ON

MARKET

ONLY

INDIVIDUAL HMO



ON

MARKET

ONLY











































INDIVIDUAL HMO














Ambulance - Medical Emergency 0%, after deductible


Ambulatory Surgical Center 0%, after deductible









Performed in a physician’s office 0%, after deductible

Performed in an independent, non-hospital affiliated radiology facility 0%, after deductible



Short Term Physical Therapy, Occupational Therapy, Speech Therapy Limited to 60 visits per calendar year combined 0%, after deductible

















Meritus Healthy Bronze Networks: Complete HMO 6800 • HMO Abrazo 6800 • HMO Banner 6800 • HMO Pima 6800 • HMO WARMC 6800


INDIVIDUAL HMO


INDIVIDUAL PPO

Meritus Choice Silver Complete PPO Plus 4000Networks: Meritus Complete PPO


Plus


Deductible - per calendar year $4,000 single/$8,000 family $12,000 single/$24,000 family

Out-of-Pocket Maximum (includes deductible and copays) - per calendar year $6,800 single/$13,600 family $20,400 single/$40,800 family

Office Visit Primary Care Physician $30 copay per visit 50%, after deductible

Specialist $60 copay per visit 50%, after deductible

Prenatal and Postnatal Care $30 copay per visit 50%, after deductible

Preventative Care, including Well Baby Care $0 copay per visit 50%, after deductible


In-Store Health Care Clinic $30 copay per visit 50%, after deductible

Emergency Urgent Care $60 copay per visit 50%, after deductible

Emergency Room - copay waived if admitted, copay waived if accident $500 copay per visit $500 copay per visit

Ambulance - Medical Emergency $250 copay per transport $250 copay per transport

Hospital Inpatient and Outpatient hospital services 30%, after deductible 50%, after deductible

Ambulatory Surgical Center $500 copay per visit 50%, after deductible


Performed in a physician’s office or free-standing independent lab facility $25 copay per visit 50%, after deductible

Performed in a hospital 30%, after deductible 50%, after deductible


Performed in a physician’s office $50 copay per visit 50%, after deductible

Performed in an independent, non-hospital-affiliated radiology facility $150 copay per visit 50%, after deductible




Performed in an independent, non-hospital affiliated radiology facility $500 copay per visit 50%, after deductible


Chiropractic Care - Maximum 20 visits per calendar year $60 copay per visit 50%, after deductible

Short Term Physical Therapy, Occupational Therapy, Speech Therapy Limited to 60 visits per calendar year combined $60 copay per visit 50%, after deductible

Office Psychiatric and Substance Abuse Visits $30 copay per visit 50%, after deductible

Pediatric Vision Exam - one exam per calendar year $50 copay per visit 50%, after deductible

Glasses or Contacts - one item per calendar year $50 copay per item 50%, after deductible

Naturopathy - Maximum 12 visits per calendar year $20 copay per visit Not Covered

Acupuncture - Maximum 12 visits per calendar year $20 copay per visit Not Covered

Therapeutic Massage - Maximum 12 visits per calendar year $20 copay per visit Not Covered



Prescription Deductible - per calendar year - Does not apply to Generic Drug Tiers $300 single/$600 family Combined with Medical Ded

Up to a 30 Day Prescription - Retail, 90 Day Prescription-Mail Order 30 Day Retail 90 Day Mail

ACA $0 Preventative $0 copay $0 copay 50%, after deductible

Adherence Generic* $5 copay $15 copay 50%, after deductible

Other Generic $15 copay $45 copay 50%, after deductible

Preferred Brand $60 copay** $180 copay** 50%, after deductible

Non-Preferred Brand $150 copay** $450 copay** 50%, after deductible

Specialty – Preferred and Non-Preferred 50%** 50%** 50%, after deductible

Benefits In-Network Out-of-Network

OFF

MARKET

ONLY


Meritus Choice Bronze Complete PPO Plus 6800Networks: Meritus Complete PPO


Plus

*Adherence Generic drugs include those medications which promote heart health, treat high blood pressure, high cholesterol, along with oral diabetic medication.**After separate prescription deductible. See page 62 for disclaimers, exclusions and limitations.












Ambulance - Medical Emergency 0%, after deductible 0%, after deductible


Ambulatory Surgical Center 0%, after deductible 0%, after deductible









Performed in a physician’s office 0%, after deductible 0%, after deductible

Performed in an independent, non-hospital affiliated radiology facility 0%, after deductible 0%, after deductible



Short Term Physical Therapy, Occupational Therapy, Speech Therapy Limited to 60 visits per calendar year combined 0%, after deductible 0%, after deductible


Pediatric Vision Exam - one exam per calendar year $50 copay per visit 0%, after deductible

Glasses or Contacts - one item per calendar year $50 copay per visit 0%, after deductible














INDIVIDUAL PPO

OFF

MARKET

ONLY


INDIVIDUAL PPO

Meritus Saver Silver Complete PPO HSA Plus 2750Networks: Meritus Complete PPO


Plus





Office Visit Primary Care Physician 30%, after deductible 50%, after deductible

Specialist 30%, after deductible 50%, after deductible

Prenatal and Postnatal Care 30%, after deductible 50%, after deductible


Telemedicine - MeMD 30%, after deductible

In-Store Health Care Clinic 30%, after deductible 50%, after deductible

Emergency Urgent Care 30%, after deductible 50%, after deductible

Emergency Room 30%, after deductible 30%, after deductible





Performed in a physician’s office or free-standing independent lab facility 30%, after deductible 50%, after deductible




Performed in an independent, non-hospital-affiliated radiology facility 30%, after deductible 50%, after deductible






Chiropractic Care - Maximum 20 visits per calendar year 30%, after deductible 50%, after deductible


Office Psychiatric and Substance Abuse Visits 30%, after deductible 50%, after deductible

Pediatric Vision Exam - one exam per calendar year 30%, after deductible 50%, after deductible

Glasses or Contacts - one item per calendar year 30%, after deductible 50%, after deductible






Prescription Deductible - per calendar year Combined with Medical Ded Combined with Medical Ded

Up to a 30 Day Prescription - Retail, 90 Day Prescription-Mail Order. 30 Day Retail 90 Day Mail

ACA $0 Preventative $0 copay 50%, after deductible

Adherence Generic* 30%, after deductible 50%, after deductible

Other Generic 30%, after deductible 50%, after deductible

Preferred Brand 30%, after deductible 50%, after deductible

Non-Preferred Brand 30%, after deductible 50%, after deductible

Specialty – Preferred and Non-Preferred 30%, after deductible 50%, after deductible

OFF

MARKET

ONLY


INDIVIDUAL PPO

Meritus Saver Bronze Complete PPO HSA Plus 6300 Networks: Meritus Complete PPO


Plus













































OFF

MARKET

ONLY


HMO PlansExclusions and Limitations

These Outlines of Coverage are only a brief summary of the major benefits. For more information, please refer to the Schedule of Benefits, the Comprehensive Health Insurance Policy, or call Meritus at 602-957-2113. In the event of an error, the Schedule of Benefits and Comprehensive Health Insurance Policy will prevail.

Meritus products and services are provided through Meritus Mutual Health Partners – PPO and Meritus Health Partners – HMO. A licensed health insurance producer may contact you to discuss enrollment in a Meritus health plan. Meritus Mutual Health Partners – PPO and Meritus Health Partners – HMO are licensed only in Arizona and are Qualified Health Plan issuers in the Health Insurance Marketplace.

All prescription drugs must be prescribed by a Physician and purchased at a Preferred Pharmacy (retail) or the Preferred Mail Order Pharmacy. No benefits are provided for prescription drugs purchased from a Non-Preferred Pharmacy or Non-Preferred Mail Order Pharmacy.

INDIVIDUAL AND GROUP HMO – EXCLUSIONS AND LIMITATIONS

No benefits will be paid for the following:

1. Care for health conditions that are required by state or local law to be treated in a public facility.

2. Care for military service disabilities treatable through governmental services if the Member is legally entitled to such treatment and facilities are reasonably available.

3. Treatment of an illness or Injury which is due to war, declared or undeclared.

4. Charges for which the Covered Person is not obligated to pay or for which the Covered Person is not billed or would not have been billed except that he or she was covered under this Policy.

5. Assistance in the activities of daily living, including, but not limited to, eating, bathing, dressing or other custodial or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care.

6. Any Services and Supplies which are experimental, investigational or unproven. These services may be related to medical, surgical, diagnostic, psychiatric, substance abuse or other health care technologies, supplies, treatments, procedures, drug therapies or devices that are determined by the Plan to be: a. Not approved by the U.S. Food and Drug

Administration (FDA) to be lawfully marketed for the proposed use and not recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopoeia Drug Information, The American Medical Association

Drug Evaluations; or the American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal;

b. The subject of review or approval by an Institutional Review Board for the proposed use;

c. The subject of an ongoing clinical trial that meets the definition of a phase I, II or III Clinical Trial as set forth in the FDA regulations, regardless of whether the trial is subject to FDA oversight (except as set forth in the Cancer Clinical Trials provision of this plan under Covered Benefits and Supplies; or

d. Not demonstrated, through existing peer reviewed literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed.

7. Cosmetic surgery or surgical procedures primarily for the purpose of altering appearance, except for necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. The exclusions include surgical excision or reformation of any sagging skin on any part of the body, including, the eyelids, face, neck, abdomen, arms, legs or buttocks; and services performed in connection with the enlargement, reduction, implantation, or change in appearance of portion of the body, including, the breast, face, lips, jaw, chin, nose, ears or genital; hair transplantation; chemical face peels or abrasion of the skin; electrolysis depilation; or any other

EXCLUSIONS AND LIMITATIONS


surgical or non-surgical procedures which are primarily for the purpose of altering appearance. This does not exclude services or benefits that are primarily for the purpose of restoring normal bodily function such as surgery required to repair bodily damage a person receives from an injury. Non-life threatening complications of a non- covered cosmetic surgery are not covered. This includes, but is not limited to, subsequent surgery for reversal, revision or repair related to the procedure.

8. Dental treatment of the teeth, gums or structures directly supporting the teeth, including dental x-rays, examinations, repairs, orthodontics including braces, periodontics, casts, splints and services for dental malocclusion, for any condition. However, charges made for services or supplies for a continuous course of dental treatment started within six months of an accidental injury to sound natural teeth are covered. Sound natural teeth are defined as natural teeth that are free of active clinical decay, have at least 50% bony support and are functional in the arch.

9. The following bariatric procedures are excluded: open vertical banded gastroplasty, laparoscopic vertical banded gastroplasty, open sleeve gastrectomy, laparoscopic sleeve gastrectomy, and open adjustable gastric banding.

10. Unless otherwise included as a covered expense, reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses, and court ordered, forensic, or custodial evaluations.

11. Court ordered treatment or hospitalization, unless such treatment is being sought by a Physician or otherwise covered under the Plan under Covered Benefits and Supplies.

12. Transsexual surgery including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery.

13. Treatment of erectile dysfunction and sexual dysfunction.

14. Medical and hospital care and costs for the infant child of a Dependent, unless this infant child is otherwise eligible under the Plan.

15. Non-medical ancillary services including, but not limited to, vocational rehabilitation,

behavioral training, sleep therapy, employment counseling, driving safety, and services, training or educational therapy for learning disabilities, developmental delays, and mental retardation.

16. Therapy to improve general physical condition including, but not limited to, routine long term care.

17. Consumable medical supplies, including but not limited to, bandages and other disposable medical supplies, skin preparations and test strips, except as specified in the Inpatient Hospital Services, Outpatient Facility Services, Home Health Services, Diabetic Services and Supplies, or Breast Reconstruction, Ostomy Supplies and Breast Prostheses.

18. Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered by the Plan.

19. Personal or comfort items such as television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of Illness or Injury.

20. The following services and supplies are excluded: (a) elastic/compression stockings; (b) garter belts; (c) corsets; (d) dentures; (c) wigs; (d) hair pieces; (e) hair transplants; and (f) treatment of alopecia or hair loss.

21. Except as provided for Pediatric Vision Care in this Policy, no coverage will be provided for: (a) eyeglass lenses and frames and contact lenses (except for the first pair of contacts for treatment of keratoconus or post-cataract surgery); (b) routine refraction; and (c) eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy.

22. Acupuncture treatment unless shown as a Covered Benefit in the Schedule of Benefits.

23. Except as otherwise provided under this Policy, all of the following are excluded: (a) non-injectable prescription drugs; (b) non-prescription drugs; and (c) investigational and experimental drugs.

24. Unless Medically Necessary, routine foot care, including: (a) the paring and removing of corns and calluses; or (b) trimming of nails.



25. Membership costs or fees associated with health clubs (unless “Gym Membership Reimbursement” is shown as a Covered Benefit in the Schedule of Benefits), and weight loss programs for persons with a BMI under 25.

26. Amniocentesis, ultrasound, or any other procedures requested solely for gender determination of a fetus, unless Medically Appropriate to determine the existence of a gender-linked genetic disorder.

27. Services rendered by a midwife for the purpose of home delivery.

28. Genetic testing and therapy including germ line and somatic unless determined Medically Appropriate by the Plan for the purpose of making treatment decisions.

29. Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in our opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.

30. Blood administration for the purpose of general improvement in physical condition.

31. Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks, except as otherwise referenced as covered in this Policy.

32. Cosmetics, dietary supplements, nutritional formula (except for treatment of malabsorption syndromes), and health and beauty aids.

33. Expenses incurred for or in connection with an injury or illness arising out of, or in the course of, any employment for wage or profit.

34. Phase 3 Cardiac rehabilitation. 35. Massage therapy (unless shown as a Covered

Benefit in the Schedule of Benefits), health spas, mineral baths, or saunas.

36. Coverage for any services incurred prior to the effective date of the policy for the Covered Person or after the termination date of the policy for the Covered Person.

37. Charges made by a Hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military service-connected Sickness or Injury.

38. To the extent that payment is unlawful where the Covered Person resides when the expenses are incurred.

39. To the extent of the exclusions imposed by any certification requirement.

40. Charges for supplies, care, treatment or surgery which is not considered essential for the necessary care and treatment of an Injury or Illness, as determined by Our Utilization Review Management Program.

41. Charges made by any Participating Provider who is a member of the Covered Person’s family.

42. Manipulations under anesthesia. This does not include reductions of fractures and/or dislocations done under anesthesia.

43. Surgery for correction of Hyperhidrosis. 44. Biofeedback except for Mental Health and

Substance Abuse only for pain management. 45. Any medical treatment and/or prescription

related to infertility once diagnosed. 46. The following Autism Spectrum Disorder

services are excluded: (a) Sensory Integration; (b) LOVAAS Therapy; and (c) Music Therapy.

47. Purchase or rental of durable medical equipment and prosthetics are not covered when due to misuse, damage and replacement when lost.

48. Costs for services while traveling outside the United States, except in the case of an emergency.

Circumstances Beyond Our Control

To the extent that: 1. A natural disaster; 2. A riot or civil insurrection; 3. War; 4. An epidemic; or 5. Any other emergency or similar event; not

within Our control that results in Our facilities, personnel, or financial resources being unavailable to provide or arrange for: 1. The provisions of a basic or supplemental

health service; or 2. Supplies in accordance with this Policy.

We will make a good faith effort to provide or arrange for the provision of the services or supplies, taking into account the impact of the event.



PPO & PPO HSA PlansExclusions and Limitations

These Outlines of Coverage are only a brief summary of the major benefits. For more information, please refer to the Schedule of Benefits, the Comprehensive Health Insurance Policy, or call Meritus at 602-957-2113. In the event of an error, the Schedule of Benefits and Comprehensive Health Insurance Policy will prevail.

Meritus products and services are provided through Meritus Mutual Health Partners – PPO and Meritus Health Partners – HMO. A licensed health insurance producer may contact you to discuss enrollment in a Meritus health plan. Meritus Mutual Health Partners – PPO and Meritus Health Partners – HMO are licensed only in Arizona and are Qualified Health Plan issuers in the Health Insurance Marketplace.

All prescription drugs must be prescribed by a Physician and purchased at a Preferred Pharmacy (retail) or the Preferred Mail Order Pharmacy. No benefits are provided for prescription drugs purchased from a Non-Preferred Pharmacy or Non-Preferred Mail Order Pharmacy.

A Covered Person is not required to go to a Preferred Provider. At the time of services, the Covered Person my obtain treatment from a Preferred Provider or a Non-Preferred provider. However, to maximize the benefit reimbursement level under a policy, a Preferred Provider must be used. The insured will incur higher out-of-pockets costs if they chose to receive services from an out-of-network provider, and will be responsible for the difference between billed charges and the amount allowed by Meritus, other than copayments, coinsurance or any amounts that may remain on your annual deductible.

INDIVIDUAL AND GROUP PPO – EXCLUSIONS AND LIMITATIONS

No benefits will be paid for the following:

1. Care for health conditions that are required by state or local law to be treated in a public facility.

2. Care for military service disabilities treatable through governmental services if the Member is legally entitled to such treatment and facilities are reasonably available.

3. Treatment of an illness or Injury which is due to war, declared or undeclared.

4. Charges for which the Covered Person is not obligated to pay or for which the Covered Person is not billed or would not have been billed except that he or she was covered under this Policy.

5. Assistance in the activities of daily living, including, but not limited to, eating, bathing, dressing or other custodial or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care.

6. Any Services and Supplies which are experimental, investigational or unproven. These services may be related to medical, surgical, diagnostic, psychiatric, substance abuse or other health care technologies, supplies, treatments, procedures, drug therapies or devices that are determined by the Plan to be: a. Not approved by the U.S. Food and Drug

Administration (FDA) to be lawfully marketed for the proposed use and not recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopoeia Drug Information, The American Medical Association Drug Evaluations; or the American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal;

b. The subject of review or approval by an Institutional Review Board for the proposed use;

c. The subject of an ongoing clinical trial that meets the definition of a phase I, II or III Clinical Trial as set forth in the FDA regulations, regardless of whether the trial is subject to FDA oversight (except as set forth in the Cancer Clinical Trials provision of this plan under Covered Benefits and Supplies; or

d. Not demonstrated, through existing peer reviewed literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed.



7. Cosmetic surgery or surgical procedures primarily for the purpose of altering appearance, except for necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. The exclusions include surgical excision or reformation of any sagging skin on any part of the body, including, the eyelids, face, neck, abdomen, arms, legs or buttocks; and services performed in connection with the enlargement, reduction, implantation, or change in appearance of portion of the body, including, the breast, face, lips, jaw, chin, nose, ears or genital; hair transplantation; chemical face peels or abrasion of the skin; electrolysis depilation; or any other surgical or non-surgical procedures which are primarily for the purpose of altering appearance. This does not exclude services or benefits that are primarily for the purpose of restoring normal bodily function such as surgery required to repair bodily damage a person receives from an injury. Non-life threatening complications of a non- covered cosmetic surgery are not covered. This includes, but is not limited to, subsequent surgery for reversal, revision or repair related to the procedure.

8. Dental treatment of the teeth, gums or structures directly supporting the teeth, including dental x-rays, examinations, repairs, orthodontics including braces, periodontics, casts, splints and services for dental malocclusion, for any condition. However, charges made for services or supplies for a continuous course of dental treatment started within six months of an accidental injury to sound natural teeth are covered. Sound natural teeth are defined as natural teeth that are free of active clinical decay, have at least 50% bony support and are functional in the arch.

9. The following bariatric procedures are excluded: open vertical banded gastroplasty, laparoscopic vertical banded gastroplasty, open sleeve gastrectomy, laparoscopic sleeve gastrectomy, and open adjustable gastric banding.

10. Unless otherwise included as a covered expense, reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses, and court ordered, forensic, or custodial evaluations.

11. Court ordered treatment or hospitalization, unless such treatment is being sought by a Physician or otherwise covered under the Plan under Covered Benefits and Supplies.

12. Transsexual surgery including medical or

psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery.

13. Treatment of erectile dysfunction and sexual dysfunction.

14. Medical and hospital care and costs for the infant child of a Dependent, unless this infant child is otherwise eligible under the Plan.

15. Non-medical ancillary services including, but not limited to, vocational rehabilitation, behavioral training, sleep therapy, employment counseling, driving safety, and services, training or educational therapy for learning disabilities, developmental delays, and mental retardation.

16. Therapy to improve general physical condition including, but not limited to, routine long term care.

17. Consumable medical supplies, including but not limited to, bandages and other disposable medical supplies, skin preparations and test strips, except as specified in the Inpatient Hospital Services, Outpatient Facility Services, Home Health Services, Diabetic Services and Supplies, or Breast Reconstruction, Ostomy Supplies and Breast Prostheses.

18. Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered by the Plan.

19. Personal or comfort items such as television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of Illness or Injury.

20. The following services and supplies are excluded: (a) elastic/compression stockings; (b) garter belts; (c) corsets; (d) dentures; (c) wigs; (d) hair pieces; (e) hair transplants; and (f) treatment of alopecia or hair loss.

21. Except as provided for Pediatric Vision Care in this Policy, no coverage will be provided for: (a) eyeglass lenses and frames and contact lenses (except for the first pair of contacts for treatment of keratoconus or post-cataract surgery); (b) routine refraction; and (c) eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy.

22. Acupuncture treatment unless shown as a Covered Benefit in the Schedule of Benefits.

23. Except as otherwise provided under this Policy, all



of the following are excluded: (a) non-injectable prescription drugs; (b) non-prescription drugs; and (c) investigational and experimental drugs.

24. Unless Medically Necessary, routine foot care, including: (a) the paring and removing of corns and calluses; or (b) trimming of nails.

25. Membership costs or fees associated with health clubs (unless “Gym Membership Reimbursement” is shown as a Covered Benefit in the Schedule of Benefits), and weight loss programs for persons with a BMI under 25.

26. Amniocentesis, ultrasound, or any other procedures requested solely for gender determination of a fetus, unless Medically Appropriate to determine the existence of a gender-linked genetic disorder.

27. Services rendered by a midwife for the purpose of home delivery.

28. Genetic testing and therapy including germ line and somatic unless determined Medically Appropriate by the Plan for the purpose of making treatment decisions.

29. Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in our opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.

30. Blood administration for the purpose of general improvement in physical condition.

31. Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks, except as otherwise referenced as covered in this Policy.

32. Cosmetics, dietary supplements, nutritional formula (except for treatment of malabsorption syndromes), and health and beauty aids.

33. Expenses incurred for or in connection with an injury or illness arising out of, or in the course of, any employment for wage or profit.

34. Phase 3 Cardiac rehabilitation. 35. Massage therapy (unless shown as a Covered

Benefit in the Schedule of Benefits), health spas, mineral baths, or saunas.

36. Coverage for any services incurred prior to the effective date of the policy for the Covered Person or after the termination date of the policy for the Covered Person.

37. Charges made by a Hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military service-

connected Sickness or Injury. 38. To the extent that payment is unlawful where the

Covered Person resides when the expenses are incurred.

39. To the extent of the exclusions imposed by any certification requirement.

40. Charges for supplies, care, treatment or surgery which is not considered essential for the necessary care and treatment of an Injury or Illness, as determined by Our Utilization Review Management Program.

41. Charges made by an assistant surgeon or co-surgeon in excess of the PPO Network contracted rate.

42. Charges made by any Participating Provider who is a member of the Covered Person’s family.

43. Manipulations under anesthesia. This does not include reductions of fractures and/or dislocations done under anesthesia.

44. Surgery for correction of Hyperhidrosis. 45. Biofeedback except for Mental Health and

Substance Abuse only for pain management. 46. Any medical treatment and/or prescription

related to infertility once diagnosed. 47. The following Autism Spectrum Disorder

services are excluded: (a) Sensory Integration; (b) LOVAAS Therapy; and (c) Music Therapy.

48. Purchase or rental of durable medical equipment and prosthetics are not covered when due to misuse, damage and replacement when lost.

49. Costs for services while traveling outside the United States, except in the case of an Emergency.

Circumstances Beyond Our Control

To the extent that: 1. A natural disaster; 2. A riot or civil insurrection; 3, War; 4. An epidemic; or 5. Any other emergency or similar event; not

within Our control that results in Our facilities, personnel, or financial resources being unavailable to provide or arrange for:1. The provisions of a basic or supplemental

health service; or 2.Supplies in accordance with this Policy.

We will make a good faith effort to provide or arrange for the provision of the services or supplies, taking into account the impact of the event.



Individual Rates


2016 Meritus Healthy HMO PlansMaricopa County | All rates are for NON Tobacco user rates - increase by 10%

0-20 $188.06 $156.47 $169.63 $151.96 $158.55 $132.02

21-24 $296.16 $246.42 $267.14 $239.32 $249.69 $207.92

25 $297.34 $247.40 $268.20 $240.27 $250.68 $208.75

26 $303.26 $252.33 $273.55 $245.06 $255.68 $212.91

27 $310.37 $258.24 $279.96 $250.80 $261.67 $217.90

28 $321.92 $267.85 $290.38 $260.14 $271.41 $226.00

29 $331.40 $275.74 $298.92 $267.79 $279.40 $232.66

30 $336.14 $279.68 $303.20 $271.62 $283.39 $235.98

31 $343.24 $285.60 $309.61 $277.37 $289.39 $240.97

32 $350.35 $291.51 $316.02 $283.11 $295.38 $245.96

33 $354.79 $295.21 $320.03 $286.70 $299.12 $249.08

34 $359.53 $299.15 $324.30 $290.53 $303.12 $252.41

35 $361.90 $301.12 $326.44 $292.44 $305.12 $254.07

36 $364.27 $303.09 $328.58 $294.36 $307.11 $255.74

37 $366.64 $305.06 $330.71 $296.27 $309.11 $257.40

38 $369.01 $307.03 $332.85 $298.19 $311.11 $259.06

39 $373.75 $310.98 $337.13 $302.02 $315.10 $262.39

40 $378.49 $314.92 $341.40 $305.85 $319.10 $265.72

41 $385.60 $320.83 $347.81 $311.59 $325.09 $270.71

42 $392.41 $326.50 $353.96 $317.09 $330.83 $275.49

43 $401.88 $334.39 $362.50 $324.75 $338.82 $282.14

44 $413.73 $344.24 $373.19 $334.33 $348.81 $290.46

45 $427.65 $355.83 $385.75 $345.57 $360.55 $300.23

46 $444.24 $369.63 $400.71 $358.98 $374.53 $311.88

47 $462.89 $385.15 $417.53 $374.05 $390.26 $324.97

48 $484.22 $402.89 $436.77 $391.28 $408.24 $339.94

49 $505.24 $420.39 $455.74 $408.27 $425.97 $354.71

50 $528.94 $440.10 $477.11 $427.42 $445.94 $371.34

51 $552.33 $459.57 $498.21 $446.33 $465.67 $387.77

52 $578.10 $481.01 $521.45 $467.15 $487.39 $405.85

53 $604.16 $502.69 $544.96 $488.21 $509.36 $424.15

54 $632.30 $526.10 $570.34 $510.94 $533.08 $443.90

55 $660.43 $549.51 $595.72 $533.68 $556.80 $463.66

56 $690.94 $574.89 $623.23 $558.33 $582.52 $485.07

57 $721.74 $600.52 $651.02 $583.22 $608.49 $506.70

58 $754.61 $627.87 $680.67 $609.78 $636.21 $529.78

59 $770.90 $641.43 $695.36 $622.94 $649.94 $541.21

60 $803.77 $668.78 $725.01 $649.51 $677.65 $564.29

61 $832.20 $692.44 $750.66 $672.48 $701.62 $584.25

62 $850.86 $707.96 $767.49 $687.56 $717.35 $597.35

63 $874.26 $727.43 $788.59 $706.47 $737.08 $613.77

64+ $888.48 $739.26 $801.42 $717.96 $749.07 $623.76

AgeMeritus Healthy

Platinum Complete HMO Plus 500

Meritus Healthy Platinum HMO

Plus Abrazo 500


Plus Banner 500

Meritus Healthy Platinum HMO Plus MIHS 500

Meritus Healthy Gold Complete HMO Plus 2000

Meritus Healthy

Gold HMO Plus Abrazo 2000

INDIVIDUAL RATES



0-20 $143.07 $128.23 $129.27 $107.11 $116.34 $103.95

21-24 $225.31 $201.95 $203.58 $168.69 $183.22 $163.71

25 $226.21 $202.75 $204.39 $169.36 $183.95 $164.36

26 $230.71 $206.79 $208.46 $172.73 $187.61 $167.63

27 $236.12 $211.64 $213.35 $176.78 $192.01 $171.56

28 $244.91 $219.51 $221.29 $183.36 $199.16 $177.95

29 $252.12 $225.98 $227.80 $188.76 $205.02 $183.19

30 $255.72 $229.21 $231.06 $191.46 $207.95 $185.81

31 $261.13 $234.06 $235.94 $195.51 $212.35 $189.73

32 $266.54 $238.90 $240.83 $199.56 $216.74 $193.66

33 $269.92 $241.93 $243.88 $202.09 $219.49 $196.12

34 $273.52 $245.16 $247.14 $204.78 $222.42 $198.74

35 $275.32 $246.78 $248.77 $206.13 $223.89 $200.05

36 $277.13 $248.39 $250.40 $207.48 $225.36 $201.36

37 $278.93 $250.01 $252.03 $208.83 $226.82 $202.67

38 $280.73 $251.62 $253.66 $210.18 $228.29 $203.98

39 $284.34 $254.86 $256.91 $212.88 $231.22 $206.60

40 $287.94 $258.09 $260.17 $215.58 $234.15 $209.22

41 $293.35 $262.93 $265.06 $219.63 $238.55 $213.15

42 $298.53 $267.58 $269.74 $223.51 $242.76 $216.91

43 $305.74 $274.04 $276.25 $228.91 $248.62 $222.15

44 $314.75 $282.12 $284.40 $235.65 $255.95 $228.70

45 $325.34 $291.61 $293.96 $243.58 $264.56 $236.39

46 $337.96 $302.92 $305.37 $253.03 $274.83 $245.56

47 $352.15 $315.64 $318.19 $263.66 $286.37 $255.87

48 $368.38 $330.18 $332.85 $275.80 $299.56 $267.66

49 $384.37 $344.52 $347.30 $287.78 $312.57 $279.28

50 $402.40 $360.68 $363.59 $301.28 $327.23 $292.38

51 $420.20 $376.63 $379.67 $314.60 $341.70 $305.31

52 $439.80 $394.20 $397.38 $329.28 $357.64 $319.56

53 $459.63 $411.97 $415.30 $344.12 $373.76 $333.96

54 $481.03 $431.16 $434.64 $360.15 $391.17 $349.52

55 $502.44 $450.34 $453.98 $376.17 $408.58 $365.07

56 $525.64 $471.14 $474.95 $393.55 $427.45 $381.93

57 $549.08 $492.15 $496.12 $411.09 $446.50 $398.96

58 $574.08 $514.56 $518.72 $429.82 $466.84 $417.13

59 $586.48 $525.67 $529.91 $439.10 $476.92 $426.13

60 $611.49 $548.09 $552.51 $457.82 $497.25 $444.30

61 $633.12 $567.47 $572.05 $474.01 $514.84 $460.02

62 $647.31 $580.20 $584.88 $484.64 $526.39 $470.33

63 $665.11 $596.15 $600.96 $497.97 $540.86 $483.27

64+ $675.93 $605.85 $610.74 $506.07 $549.66 $491.13

AgeMeritus Healthy

Gold HMO Plus Banner 2000

Meritus Healthy Gold HMO

Plus MIHS 2000

Meritus Healthy Silver Complete

HMO 4000

Meritus Healthy Silver HMO

Abrazo 4000

Meritus Healthy Silver HMO Banner 4000

Meritus Healthy Silver HMO MIHS 4000

INDIVIDUAL RATES


0-20 $121.32 $109.98 $118.19 $97.94 $106.37

21-24 $191.06 $173.20 $186.13 $154.24 $167.52

25 $191.82 $173.89 $186.87 $154.85 $168.19

26 $195.64 $177.35 $190.59 $157.94 $171.54

27 $200.23 $181.51 $195.06 $161.64 $175.56

28 $207.68 $188.26 $202.32 $167.65 $182.09

29 $213.79 $193.81 $208.27 $172.59 $187.45

30 $216.85 $196.58 $211.25 $175.06 $190.13

31 $221.43 $200.73 $215.72 $178.76 $194.15

32 $226.02 $204.89 $220.19 $182.46 $198.17

33 $228.88 $207.49 $222.98 $184.77 $200.68

34 $231.94 $210.26 $225.96 $187.24 $203.36

35 $233.47 $211.65 $227.45 $188.48 $204.70

36 $235.00 $213.03 $228.93 $189.71 $206.04

37 $236.53 $214.42 $230.42 $190.94 $207.38

38 $238.06 $215.80 $231.91 $192.18 $208.72

39 $241.11 $218.57 $234.89 $194.65 $211.41

40 $244.17 $221.34 $237.87 $197.11 $214.09

41 $248.76 $225.50 $242.34 $200.82 $218.11

42 $253.15 $229.49 $246.62 $204.36 $221.96

43 $259.26 $235.03 $252.57 $209.30 $227.32

44 $266.91 $241.96 $260.02 $215.47 $234.02

45 $275.89 $250.10 $268.77 $222.72 $241.89

46 $286.59 $259.80 $279.19 $231.36 $251.28

47 $298.62 $270.71 $290.92 $241.07 $261.83

48 $312.38 $283.18 $304.32 $252.18 $273.89

49 $325.94 $295.47 $317.53 $263.13 $285.78

50 $341.23 $309.33 $332.42 $275.47 $299.19

51 $356.32 $323.01 $347.13 $287.65 $312.42

52 $372.94 $338.08 $363.32 $301.07 $326.99

53 $389.76 $353.32 $379.70 $314.64 $341.74

54 $407.91 $369.78 $397.38 $329.30 $357.65

55 $426.06 $386.23 $415.06 $343.95 $373.56

56 $445.74 $404.07 $434.24 $359.84 $390.82

57 $465.61 $422.08 $453.59 $375.88 $408.24

58 $486.82 $441.31 $474.25 $393.00 $426.84

59 $497.32 $450.83 $484.49 $401.48 $436.05

60 $518.53 $470.06 $505.15 $418.60 $454.64

61 $536.87 $486.69 $523.02 $433.41 $470.73

62 $548.91 $497.60 $534.75 $443.13 $481.28

63 $564.00 $511.28 $549.45 $455.31 $494.51

64+ $573.18 $519.60 $558.39 $462.72 $502.56

Age

Meritus Community

Network Silver HMO Banner

Meritus Neighborhood Network Silver

HMO MIHS

Meritus Healthy Bronze Complete

HMO 6800

Meritus Healthy Bronze HMO Abrazo 6800

Meritus Healthy Bronze HMO Banner 6800

Age


INDIVIDUAL RATES


0-20 $174.52 $147.99 $147.13 $124.86

21-24 $274.84 $233.07 $231.71 $196.63

25 $275.93 $234.00 $232.63 $197.41

26 $281.43 $238.66 $237.27 $201.34

27 $288.03 $244.25 $242.83 $206.06

28 $298.75 $253.34 $251.86 $213.73

29 $307.54 $260.80 $259.28 $220.02

30 $311.94 $264.53 $262.99 $223.17

31 $318.53 $270.12 $268.55 $227.89

32 $325.13 $275.72 $274.11 $232.61

33 $329.25 $279.21 $277.58 $235.56

34 $333.65 $282.94 $281.29 $238.70

35 $335.85 $284.81 $283.14 $240.28

36 $338.05 $286.67 $285.00 $241.85

37 $340.25 $288.54 $286.85 $243.42

38 $342.45 $290.40 $288.71 $245.00

39 $346.84 $294.13 $292.41 $248.14

40 $351.24 $297.86 $296.12 $251.29

41 $357.84 $303.45 $301.68 $256.01

42 $364.16 $308.81 $307.01 $260.53

43 $372.95 $316.27 $314.43 $266.82

44 $383.95 $325.59 $323.69 $274.69

45 $396.86 $336.55 $334.58 $283.93

46 $412.26 $349.60 $347.56 $294.94

47 $429.57 $364.28 $362.16 $307.33

48 $449.36 $381.06 $378.84 $321.49

49 $468.87 $397.61 $395.29 $335.45

50 $490.86 $416.26 $413.83 $351.18

51 $512.57 $434.67 $432.13 $366.71

52 $536.48 $454.95 $452.29 $383.82

53 $560.67 $475.46 $472.68 $401.12

54 $586.78 $497.60 $494.70 $419.80

55 $612.89 $519.74 $516.71 $438.48

56 $641.20 $543.75 $540.57 $458.73

57 $669.78 $567.99 $564.67 $479.18

58 $700.29 $593.86 $590.39 $501.01

59 $715.40 $606.68 $603.14 $511.82

60 $745.91 $632.55 $628.86 $533.65

61 $772.30 $654.92 $651.10 $552.53

62 $789.61 $669.61 $665.70 $564.91

63 $811.32 $688.02 $684.00 $580.45

64+ $824.52 $699.21 $695.13 $589.89

AgeMeritus Healthy


Meritus Healthy Platinum HMO Plus Pima 500



Plus Pima 2000

2016 Meritus Healthy HMO PlansPima and Santa Cruz Counties County | All rates are for NON Tobacco user rates - increase by 10%

INDIVIDUAL RATES


0-20 $119.96 $101.35 $106.30 $109.68 $92.67

21-24 $188.92 $159.62 $167.41 $172.73 $145.95

25 $189.67 $160.25 $168.07 $173.42 $146.53

26 $193.45 $163.45 $171.42 $176.87 $149.45

27 $197.98 $167.28 $175.44 $181.02 $152.95

28 $205.35 $173.50 $181.97 $187.75 $158.64

29 $211.40 $178.61 $187.33 $193.28 $163.31

30 $214.42 $181.16 $190.01 $196.04 $165.65

31 $218.95 $184.99 $194.02 $200.19 $169.15

32 $223.49 $188.83 $198.04 $204.33 $172.65

33 $226.32 $191.22 $200.55 $206.93 $174.84

34 $229.34 $193.77 $203.23 $209.69 $177.18

35 $230.86 $195.05 $204.57 $211.07 $178.35

36 $232.37 $196.33 $205.91 $212.45 $179.51

37 $233.88 $197.60 $207.25 $213.83 $180.68

38 $235.39 $198.88 $208.59 $215.22 $181.85

39 $238.41 $201.44 $211.27 $217.98 $184.18

40 $241.43 $203.99 $213.94 $220.74 $186.52

41 $245.97 $207.82 $217.96 $224.89 $190.02

42 $250.31 $211.49 $221.81 $228.86 $193.38

43 $256.36 $216.60 $227.17 $234.39 $198.05

44 $263.92 $222.98 $233.87 $241.30 $203.89

45 $272.80 $230.49 $241.74 $249.42 $210.75

46 $283.38 $239.43 $251.11 $259.09 $218.92

47 $295.28 $249.48 $261.66 $269.97 $228.11

48 $308.88 $260.97 $273.71 $282.41 $238.62

49 $322.29 $272.31 $285.60 $294.67 $248.99

50 $337.41 $285.08 $298.99 $308.49 $260.66

51 $352.33 $297.69 $312.21 $322.14 $272.19

52 $368.77 $311.57 $326.78 $337.16 $284.89

53 $385.39 $325.62 $341.51 $352.36 $297.73

54 $403.34 $340.78 $357.42 $368.77 $311.60

55 $421.29 $355.95 $373.32 $385.18 $325.46

56 $440.75 $372.39 $390.56 $402.97 $340.50

57 $460.39 $388.99 $407.97 $420.94 $355.68

58 $481.36 $406.71 $426.56 $440.11 $371.88

59 $491.75 $415.49 $435.76 $449.61 $379.90

60 $512.72 $433.20 $454.35 $468.78 $396.10

61 $530.86 $448.53 $470.42 $485.37 $410.11

62 $542.76 $458.58 $480.96 $496.25 $419.31

63 $557.69 $471.19 $494.19 $509.89 $430.84

64+ $566.76 $478.86 $502.23 $518.19 $437.85

AgeMeritus Healthy Silver Complete

HMO 4000

Meritus Healthy Silver HMO Pima 4000

Meritus Community

Network Silver HMO Pima


HMO 6800

Meritus Healthy Bronze HMO Pima 6800

Age

2016 Meritus Healthy HMO PlansPima and Santa Cruz Countries | All rates are for NON Tobacco user rates - increase by 10%

INDIVIDUAL RATES


0-20 $244.48 $190.13 $206.12 $160.47

21-24 $385.01 $299.43 $324.60 $252.72

25 $386.55 $300.62 $325.89 $253.73

26 $394.25 $306.61 $332.39 $258.78

27 $403.49 $313.80 $340.18 $264.85

28 $418.50 $325.48 $352.84 $274.70

29 $430.82 $335.06 $363.22 $282.79

30 $436.98 $339.85 $368.42 $286.83

31 $446.22 $347.03 $376.21 $292.90

32 $455.46 $354.22 $384.00 $298.96

33 $461.24 $358.71 $388.87 $302.75

34 $467.40 $363.50 $394.06 $306.80

35 $470.48 $365.90 $396.66 $308.82

36 $473.56 $368.29 $399.25 $310.84

37 $476.64 $370.69 $401.85 $312.86

38 $479.72 $373.08 $404.45 $314.88

39 $485.88 $377.88 $409.64 $318.93

40 $492.04 $382.67 $414.83 $322.97

41 $501.28 $389.85 $422.62 $329.04

42 $510.13 $396.74 $430.09 $334.85

43 $522.45 $406.32 $440.48 $342.94

44 $537.85 $418.30 $453.46 $353.04

45 $555.95 $432.37 $468.72 $364.92

46 $577.51 $449.14 $486.90 $379.08

47 $601.77 $468.00 $507.34 $395.00

48 $629.49 $489.56 $530.72 $413.19

49 $656.82 $510.82 $553.76 $431.14

50 $687.62 $534.78 $579.73 $451.35

51 $718.04 $558.43 $605.37 $471.32

52 $751.53 $584.48 $633.61 $493.30

53 $785.42 $610.83 $662.18 $515.54

54 $821.99 $639.28 $693.02 $539.55

55 $858.57 $667.72 $723.85 $563.56

56 $898.22 $698.57 $757.29 $589.59

57 $938.26 $729.71 $791.05 $615.87

58 $981.00 $762.94 $827.08 $643.93

59 $1,002.18 $779.41 $844.93 $657.83

60 $1,044.91 $812.65 $880.96 $685.88

61 $1,081.87 $841.39 $912.12 $710.14

62 $1,106.13 $860.26 $932.57 $726.06

63 $1,136.54 $883.91 $958.21 $746.02

64+ $1,155.03 $898.29 $973.80 $758.16

AgeMeritus Healthy



Plus WARMC 500



Plus WARMC 2000

2016 Meritus Healthy HMO PlansMohave County | All rates are for NON Tobacco user rates - increase by 10%

INDIVIDUAL RATES


0-20 $168.05 $129.93 $153.65 $118.79

21-24 $264.65 $204.62 $241.97 $187.08

25 $265.70 $205.43 $242.93 $187.82

26 $271.00 $209.53 $247.77 $191.56

27 $277.35 $214.44 $253.58 $196.05

28 $287.67 $222.42 $263.02 $203.35

29 $296.14 $228.96 $270.76 $209.34

30 $300.37 $232.24 $274.63 $212.33

31 $306.72 $237.15 $280.44 $216.82

32 $313.08 $242.06 $286.25 $221.31

33 $317.05 $245.13 $289.88 $224.12

34 $321.28 $248.40 $293.75 $227.11

35 $323.40 $250.04 $295.68 $228.61

36 $325.51 $251.68 $297.62 $230.10

37 $327.63 $253.31 $299.55 $231.60

38 $329.75 $254.95 $301.49 $233.10

39 $333.98 $258.23 $305.36 $236.09

40 $338.22 $261.50 $309.23 $239.08

41 $344.57 $266.41 $315.04 $243.57

42 $350.66 $271.12 $320.61 $247.88

43 $359.13 $277.66 $328.35 $253.86

44 $369.71 $285.85 $338.03 $261.35

45 $382.15 $295.47 $349.40 $270.14

46 $396.97 $306.93 $362.95 $280.62

47 $413.64 $319.82 $378.19 $292.40

48 $432.70 $334.55 $395.62 $305.87

49 $451.49 $349.08 $412.80 $319.15

50 $472.66 $365.45 $432.15 $334.12

51 $493.57 $381.61 $451.27 $348.90

52 $516.59 $399.41 $472.32 $365.18

53 $539.88 $417.42 $493.61 $381.64

54 $565.02 $436.86 $516.60 $399.41

55 $590.16 $456.30 $539.59 $417.18

56 $617.42 $477.37 $564.51 $436.45

57 $644.95 $498.65 $589.68 $455.91

58 $674.32 $521.37 $616.53 $476.67

59 $688.88 $532.62 $629.84 $486.96

60 $718.26 $555.33 $656.70 $507.73

61 $743.66 $574.98 $679.93 $525.69

62 $760.33 $587.87 $695.17 $537.48

63 $781.24 $604.03 $714.29 $552.26

64+ $793.95 $613.86 $725.91 $561.24


HMO 4000

Meritus Healthy Silver HMO

WARMC 4000


HMO 6800

Meritus Healthy Bronze HMO WARMC 6800

2016 Meritus Healthy HMO PlansMohave County | All rates are for NON Tobacco user rates - increase by 10%

INDIVIDUAL RATES


0-20 $185.61 $167.43 $156.48 $141.21

21-24 $292.31 $263.67 $246.44 $222.38

25 $293.47 $264.72 $247.42 $223.26

26 $299.32 $269.99 $252.35 $227.71

27 $306.34 $276.32 $258.26 $233.05

28 $317.74 $286.60 $267.88 $241.72

29 $327.09 $295.04 $275.76 $248.84

30 $331.77 $299.26 $279.70 $252.40

31 $338.78 $305.59 $285.62 $257.73

32 $345.80 $311.92 $291.53 $263.07

33 $350.18 $315.87 $295.23 $266.41

34 $354.86 $320.09 $299.17 $269.96

35 $357.20 $322.20 $301.14 $271.74

36 $359.54 $324.31 $303.12 $273.52

37 $361.87 $326.42 $305.09 $275.30

38 $364.21 $328.53 $307.06 $277.08

39 $368.89 $332.75 $311.00 $280.64

40 $373.57 $336.97 $314.95 $284.20

41 $380.58 $343.29 $320.86 $289.53

42 $387.31 $349.36 $326.53 $294.65

43 $396.66 $357.80 $334.41 $301.76

44 $408.35 $368.34 $344.27 $310.66

45 $422.09 $380.73 $355.85 $321.11

46 $438.46 $395.50 $369.66 $333.57

47 $456.88 $412.11 $385.18 $347.57

48 $477.92 $431.10 $402.92 $363.59

49 $498.68 $449.82 $420.42 $379.38

50 $522.06 $470.91 $440.14 $397.17

51 $545.15 $491.74 $459.61 $414.73

52 $570.58 $514.68 $481.05 $434.08

53 $596.31 $537.88 $502.73 $453.65

54 $624.08 $562.93 $526.14 $474.78

55 $651.85 $587.98 $549.56 $495.90

56 $681.95 $615.14 $574.94 $518.81

57 $712.35 $642.56 $600.57 $541.94

58 $744.80 $671.83 $627.92 $566.62

59 $760.88 $686.33 $641.48 $578.85

60 $793.32 $715.60 $668.83 $603.53

61 $821.39 $740.91 $692.49 $624.88

62 $839.80 $757.52 $708.02 $638.89

63 $862.89 $778.35 $727.49 $656.46

64+ $876.93 $791.01 $739.32 $667.14

AgeMeritus Healthy



Plus Banner 500



Plus Banner 2000

2016 Meritus Healthy HMO PlansPinal County | All rates are for NON Tobacco user rates - increase by 10%

INDIVIDUAL RATES


0-20 $127.59 $114.83 $119.74 $116.65 $104.99

21-24 $200.93 $180.84 $188.58 $183.71 $165.34

25 $201.73 $181.56 $189.33 $184.44 $166.00

26 $205.75 $185.18 $193.10 $188.11 $169.30

27 $210.57 $189.52 $197.63 $192.52 $173.27

28 $218.41 $196.57 $204.98 $199.69 $179.72

29 $224.84 $202.35 $211.02 $205.57 $185.01

30 $228.05 $205.25 $214.03 $208.51 $187.66

31 $232.87 $209.59 $218.56 $212.91 $191.62

32 $237.70 $213.93 $223.09 $217.32 $195.59

33 $240.71 $216.64 $225.91 $220.08 $198.07

34 $243.92 $219.53 $228.93 $223.02 $200.72

35 $245.53 $220.98 $230.44 $224.49 $202.04

36 $247.14 $222.43 $231.95 $225.96 $203.36

37 $248.75 $223.87 $233.46 $227.43 $204.69

38 $250.35 $225.32 $234.97 $228.90 $206.01

39 $253.57 $228.22 $237.98 $231.84 $208.65

40 $256.78 $231.11 $241.00 $234.78 $211.30

41 $261.61 $235.45 $245.53 $239.19 $215.27

42 $266.23 $239.61 $249.86 $243.41 $219.07

43 $272.66 $245.39 $255.90 $249.29 $224.36

44 $280.69 $252.63 $263.44 $256.64 $230.97

45 $290.14 $261.13 $272.30 $265.27 $238.75

46 $301.39 $271.26 $282.87 $275.56 $248.01

47 $314.05 $282.65 $294.75 $287.13 $258.42

48 $328.52 $295.67 $308.32 $300.36 $270.33

49 $342.78 $308.51 $321.71 $313.40 $282.07

50 $358.86 $322.98 $336.80 $328.10 $295.29

51 $374.73 $337.26 $351.70 $342.61 $308.35

52 $392.21 $352.99 $368.10 $358.60 $322.74

53 $409.89 $368.91 $384.70 $374.76 $337.29

54 $428.98 $386.09 $402.61 $392.22 $353.00

55 $448.07 $403.27 $420.53 $409.67 $368.70

56 $468.76 $421.89 $439.95 $428.59 $385.73

57 $489.66 $440.70 $459.56 $447.70 $402.93

58 $511.96 $460.78 $480.50 $468.09 $421.28

59 $523.02 $470.72 $490.87 $478.19 $430.38

60 $545.32 $490.79 $511.80 $498.58 $448.73

61 $564.61 $508.16 $529.90 $516.22 $464.60

62 $577.27 $519.55 $541.79 $527.79 $475.02

63 $593.14 $533.83 $556.68 $542.31 $488.08

64+ $602.79 $542.52 $565.74 $551.13 $496.02


HMO 4000

Meritus Healthy Silver HMO Banner 4000

Meritus Community

Network Silver HMO Banner


HMO 6800

Meritus Healthy Bronze HMO Banner 6800

Age

2016 Meritus Healthy HMO PlansPinal County | All rates are for NON Tobacco user rates - increase by 10%

INDIVIDUAL RATES


0-20 $169.65 $156.93 $162.12 $138.60

21-24 $267.18 $247.14 $255.32 $218.27

25 $268.24 $248.12 $256.34 $219.14

26 $273.59 $253.07 $261.44 $223.50

27 $280.00 $259.00 $267.57 $228.74

28 $290.42 $268.64 $277.53 $237.25

29 $298.97 $276.54 $285.70 $244.24

30 $303.24 $280.50 $289.78 $247.73

31 $309.66 $286.43 $295.91 $252.97

32 $316.07 $292.36 $302.04 $258.21

33 $320.08 $296.07 $305.87 $261.48

34 $324.35 $300.02 $309.95 $264.97

35 $326.49 $302.00 $312.00 $266.72

36 $328.63 $303.98 $314.04 $268.47

37 $330.76 $305.95 $316.08 $270.21

38 $332.90 $307.93 $318.12 $271.96

39 $337.18 $311.89 $322.21 $275.45

40 $341.45 $315.84 $326.29 $278.94

41 $347.86 $321.77 $332.42 $284.18

42 $354.01 $327.46 $338.29 $289.20

43 $362.56 $335.36 $346.46 $296.19

44 $373.25 $345.25 $356.68 $304.92

45 $385.80 $356.87 $368.68 $315.18

46 $400.77 $370.71 $382.98 $327.40

47 $417.60 $386.27 $399.06 $341.15

48 $436.83 $404.07 $417.44 $356.87

49 $455.80 $421.62 $435.57 $372.36

50 $477.18 $441.39 $456.00 $389.83

51 $498.29 $460.91 $476.17 $407.07

52 $521.53 $482.41 $498.38 $426.06

53 $545.04 $504.16 $520.85 $445.27

54 $570.42 $527.64 $545.10 $466.00

55 $595.81 $551.12 $569.36 $486.74

56 $623.33 $576.57 $595.66 $509.22

57 $651.11 $602.28 $622.21 $531.92

58 $680.77 $629.71 $650.55 $556.15

59 $695.46 $643.30 $664.59 $568.15

60 $725.12 $670.73 $692.93 $592.38

61 $750.77 $694.46 $717.44 $613.33

62 $767.60 $710.03 $733.53 $627.08

63 $788.71 $729.55 $753.70 $644.33

64+ $801.54 $741.42 $765.96 $654.81

AgeMeritus Choice Silver Complete PPO Plus 4000

Meritus Choice Bronze Complete

PPO Plus 6800

Meritus Saver Silver Complete

PPO HSA Plus 2750

Meritus Saver Bronze Complete

PPO HSA Plus 6300

2016 Meritus PPO Choice and Saver HSA PlansMaricopa County | All rates are for NON Tobacco user rates - increase by 10%

INDIVIDUAL RATES


0-20 $152.69 $141.24 $145.91 $124.73

21-24 $240.46 $222.43 $229.79 $196.44

25 $241.42 $223.31 $230.70 $197.22

26 $246.23 $227.76 $235.30 $201.15

27 $252.00 $233.10 $240.81 $205.86

28 $261.38 $241.78 $249.78 $213.53

29 $269.07 $248.89 $257.13 $219.81

30 $272.92 $252.45 $260.81 $222.95

31 $278.69 $257.79 $266.32 $227.67

32 $284.46 $263.13 $271.84 $232.38

33 $288.07 $266.47 $275.28 $235.33

34 $291.91 $270.03 $278.96 $238.47

35 $293.84 $271.80 $280.80 $240.04

36 $295.76 $273.58 $282.64 $241.62

37 $297.68 $275.36 $284.48 $243.19

38 $299.61 $277.14 $286.31 $244.76

39 $303.46 $280.70 $289.99 $247.90

40 $307.30 $284.26 $293.67 $251.05

41 $313.07 $289.60 $299.18 $255.76

42 $318.60 $294.71 $304.47 $260.28

43 $326.30 $301.83 $311.82 $266.56

44 $335.92 $310.73 $321.01 $274.42

45 $347.22 $321.18 $331.81 $283.65

46 $360.69 $333.64 $344.68 $294.66

47 $375.83 $347.65 $359.16 $307.03

48 $393.15 $363.67 $375.70 $321.17

49 $410.22 $379.46 $392.02 $335.12

50 $429.46 $397.25 $410.40 $350.84

51 $448.45 $414.83 $428.55 $366.36

52 $469.37 $434.18 $448.55 $383.45

53 $490.53 $453.75 $468.77 $400.73

54 $513.38 $474.88 $490.60 $419.39

55 $536.22 $496.01 $512.43 $438.06

56 $560.99 $518.92 $536.10 $458.29

57 $586.00 $542.06 $559.99 $478.72

58 $612.69 $566.75 $585.50 $500.52

59 $625.91 $578.98 $598.14 $511.33

60 $652.60 $603.67 $623.65 $533.13

61 $675.69 $625.02 $645.70 $551.99

62 $690.84 $639.04 $660.18 $564.37

63 $709.83 $656.61 $678.34 $579.89

64+ $721.38 $667.29 $689.37 $589.32

AgeMeritus Choice Silver Complete PPO Plus 4000

Meritus Choice Bronze Complete

PPO Plus 6800

Meritus Saver Silver Complete

PPO HSA Plus 2750

Meritus Saver Bronze Complete

PPO HSA Plus 6300

2016 Meritus PPO Choice and Saver HSA PlansPima and Santa Cruz Counties | All rates are for NON Tobacco user rates - increase by 10%

INDIVIDUAL RATES


Meritus Group Underwriting Guidelines 2-50 Employees

A step-by-step guide to help you

through the group process.

The following pages contain instructions on how to process a group

quote, complete an online Employer Group application, begin/close

employee Open Enrollment and submit a completed group for

enrollment into Meritus utilizing the Meritus Broker Sales Portal at

meritusaz.com for Group.

Group Plans for Small Businesses


Group (2-50 Employees) Underwriting Requirements

• Minimum of 2 eligible enrolling employees

• Minimum of 70% participation excluding valid waivers

- Valid waivers include Medicare, TriCare, AHCCCS, Indian Health Services and Spousal Coverage

- Individual coverage is a valid waiver

• Out-of-Area Employees – 75% or more of eligible employees must reside in the Meritus Arizona service area (Maricopa, Pima or Santa Cruz, Pinal or Mohave County). A PPO plan would be the only option for Out-of-Area employees (less than 25% of the eligible employees).

• Employer may choose to offer up to three (3) Plans

• Employer Contribution – Minimum 50% of the employee-only premium cost across all plans offered

• First of the Month effective dates only and new hire waiting periods cannot exceed 90 days. Waiting period options are:

- FOMF Date of Hire

- FOMF 30 Days

- FOMF 60 Days

• Group Application must be submitted by the 23rd of the month prior to the effective date. Enrollment must be completed by the 28th of the month.

Group Eligibility

• Full-Time Employee Definition – Employer determines definition of full-time status; no full-time status defined as less than 20 hours per week.

• 1099 Employees

- Sole contract with Group – must have Employer/Employee relationship

- Work hour requirement equal to that of eligible W-2 employees

- Employer must provide working environment

• Domestic Partners allowed

• Current Quarterly Wage & Tax Report (Form UC018) Required – For new employees not listed on the report, indicate names and dates of hire on the W&T report or separate sheet.

• Newly Formed Group – Will accept a newly formed group provided two weeks of payroll is submitted.

• Owners & Partners – Applies when owners are not on the quarterly wage & tax report. Must submit legal ownership documents that show affiliation with the group and Articles of Incorporation. If LLC, all owners must be listed.

• Workers Compensation – All employees, except those not required by law, must be covered by workers’ compensation.

• Common Ownership – We require a copy of the Articles of Incorporation and a letter from the owner confirming common ownership.

GROUP UNDERWRITING


Meritus Rules for Small Business Health Options Program (SHOP) plans on the Marketplace

In 2016, small businesses that offer coverage through the Federally-Facilitated SHOP (FF-SHOP) will be able to choose a Qualified Health Plan (QHP) to offer their employees.

Eligibility Requirements for SHOP

Employer’s business must:

• Be located in a SHOP’s service area.

• Have at least one eligible employee on payroll (generally excludes owners, including sole proprietors, and owners’ spouses and dependents on payroll).

• Have no more than 99 full-time equivalent (FTE) employees on payroll.*

• Offer coverage to all full-time employees (full-time status is defined as working more than 30 hours per week).

Eligibility Requirements for the Small Business Tax Credit

The small business must:

• Have an average of fewer than 25 FTE employees (based on a 40-hour work week and excluding owners, owner’s family members and seasonal employees).

• Have average annual employee wages below $50,000.

• Pay a uniform percentage (at least 50%) of the cost of each employee’s health insurance.

• Offer coverage to all full-time employees (full-time status is defined as working more than 30 hours per week).

* Part-time workers must be counted as fractions of an FTE when determining employer size, even if part-time workers are not offered coverage, but does not include seasonal employees who work fewer than 120 days per year.

GROUP UNDERWRITING


As an Agent or Broker, you may receive additional questions from employers regarding their SHOP eligibility. Some additional requirements to consider include:

• Employers that are part of the same controlled group must count all employees at the combined entities when answering eligibility questions.

• Employers must have at least one common-law employee. Sole proprietors reporting on Schedule C cannot form a group health plan without having a common-law employee.

• A group cannot consist solely of S corporation shareholders or spouses (S corporations are corporations that pass corporate income, losses, deductions and credit through to their shareholders for federal tax purposes).

• Under the common-law standard, an employer-employee relationship exists when the business has the right to direct and control the worker.

Enrollment and Annual Renewal in SHOP

For the employer to be able to offer coverage to employees, at least 70% of the total number of employees must participate and sign up for coverage (excluding employees who have other creditable coverage, such as another group plan or public health insurance). If an employer offers affordable coverage to an employee, the employee is ineligible for premium tax credits in the individual Marketplace. Employer-sponsored insurance is considered unaffordable if an employee’s share of the self-only coverage is more than 9.5% of the worker’s household income.

Under the Affordable Care Act, employers participating in SHOP are not required to offer dependent coverage. Dependents covered through a SHOP plan are ineligible for premium tax credits and cost-sharing reductions in the individual Marketplace as well.

An employer must submit the application for SHOP with the first month’s premium by the 15th of the month for coverage to begin the first of the following month.

GROUP UNDERWRITING


Group Enrollment Guide

1 ProposalEnter company and employee information, select plans and create proposal.

2 ApplicationFill out the group application and submit.

3 Carrier ApprovalCarrier reviews and approves group application.

4 Open EnrollmentEmployees/agents select plans and enroll.

5 Review & SubmitApprove and submit employee enrollments.

6 Sent to MembershipSystem sends employee enrollment information to membership.

7 Active GroupGroup is active.


Group Enrollment Guide

Group Enrollment Document and Information Checklist

When preparing a proposal and/or enrolling a group, having the following pieces of information will streamline the process.

Completed Meritus Employee census template

Group quote or create one

Most recent Wage and Tax report

1

2

3

4

5

6

7

ProposalPage 83

ApplicationPage 88

Carrier ApprovalPage 91

Open EnrollmentPage 92

Review & SubmitPage 98

Sent to MembershipPage 99

Active GroupPage 100

GROUP ENROLLMENT


To quote Meritus Group plans, go to the meritusaz.com website and enter the Broker Portal to login or use your Meritus populated broker link. At the Meritus Dashboard, select >Group >New Quote.

Step 1 – Company Information

1Proposal

Click Next to move through the steps

GROUP ENROLLMENT

Quotes provided by Meritus are a plan preview and price estimation. It’s not an application for Meritus coverage.

• The health plan premiums shown here are estimates based on some basic information.

• After you find a plan(s) you like, you can start a Meritus application. You’ll provide more detailed information at that time.

• After your group submits the Application, rates are re-calculated based on the fully completed census.

• After your group completes the Open Enrollment process, Final Rates are calculated based on the enrollment selections of your employees and their dependents. Final rates are based on final enrollment.


Step 2 – Enter Company Employees and Profiles or upload completed Meritus Census

The Company Employees screen will launch. Here, you will need to provide information about the employees who will be offered coverage. There are two ways to supply employee information:

1. Simply enter additional employee(s) by clicking on the Add Employee button; or

2. Import the formatted Meritus Excel census file – a template of the file is available online.

To use the import feature for employee information, click on See a sample file. An Excel template form will open. Complete the provided fields and save the file.

Then return to the import option in the Proposal: Company Employees screen and when prompted choose the Excel file you have saved.

The census information will populate the employee fields instantaneously.

Whichever process you use, the information will look like the screen to the right. Click Next.

Do not keep current employee entries

Upload an Excel spreadsheet. See a sample file.

GROUP ENROLLMENT


Step 4 – Select Contribution

Next, the Contributions screen will launch and you will be asked to enter the monthly employer contribution for the Employee and Dependents for each Employee Class defined. The annual HSA amount is not required. Click Next.

Step 3 – Benefit Choices

The Benefit Choices screen will launch – click on the Medical button to elect to quote medical plans. (This screen will allow us to offer other benefits in the future). Click Next.

NOTE: You can also click on the Switch Contribution to PERCENT button to switch employer contribution to percent or click on the Switch Contribution to DOLLAR button to switch employer contribution back to dollar amounts.

GROUP ENROLLMENT


Step 6 – Proposal Review

After plans have been selected, you can create a Group Proposal, which can be:

• Saved for later review (make sure you save it so that it stays in your Broker Portal)

• Sent as a proposal to the employer as an email or as a PDF

When the Group decides to enroll with Meritus, select up to three plans they will offer their employees, click Apply to move to the Group application, shown to the right.

Step 5 – Select Plan Choices

The Plan Choices screen will appear, showing all plan choices that are available.

Here, you can do the following:

• Filter results based on benefit level, deductible, Out-of-Pocket Limits, Office visit copays, Lifestyle Benefits and line of business.

• Compare up to four plans at a time by checking the Add to Compare box under each plan.

• Select plans to quote. The number of plans selected will display next to the shopping cart icon and the plan name will display below the shopping cart. Employers may choose up to three plans to offer their employees.

Click Next.

NOTE: The selected plan names are shown at the top left of the screen under Selected Items.

GROUP ENROLLMENT


GROUP ENROLLMENT


After a Group Proposal has been created and plan options have been chosen (up to three), you can start a Group Application by selecting the Apply button in the proposal. Click Next to move through the pages of the application.

Step 1 – General Information

Step 2 – Enrollment

Information will be required for the date coverage begins, start date, length of the Enrollment Period, and eligibility information.

2Application

NOTE: The Group Application must be completed and submitted by the 23rd of the month in order for the group to be effective on the 1st of the following month.

Complete the required information. In the Notes field, indicate the waiting period for new hires. The choices are:

• First of Month Following Date of Hire

• First of Month Following 30 Days

• First of Month Following 60 Days

Reminder

When preparing a proposal and/or enrolling a group, having the following pieces of information will streamline the proces:

Completed Meritus Employee census template

Group quote or create one

Most recent Wage and Tax report

GROUP ENROLLMENT


Step 3 – Primary Contact

Enter the primary company contact. You can add additional company contacts as needed by selecting the Add Contact button.

Step 4 – Primary Address

Enter company address information. If you need to add other addresses for the company, click on the Add Address button.

Step 5 – Employees

Confirm contribution amounts listed for Employees and Dependents as well as confirm employees are all included. There will be a green Complete box next to each employee provided the information is complete.

Any employee with a red box needs additional information. Click on the red box and add the information requested.

Should all the employees have a red box, cancel the application and complete the Meritus Excel Census file and re-upload the information into the proposal.

GROUP ENROLLMENT

Select whether the employer wants the contribution amounts to be shown to employees, and whether emails should be sent directly to employees for online enrollment.


Step 6 – Documents

Upload the most recent company Quarterly Wage & Tax report – Form UC-018. Make sure that all employees are accounted for on the Wage & Tax and employee listing.

Step 7 – Benefits Summary

Choose Submit once you have reviewed the Benefits Summary and Application Status display, which shows all sections required for the application as complete.

Check to make sure no more than three (3) plans are chosen.

GROUP ENROLLMENT


Meritus will review the group to ensure eligibility criteria are met. Once the group is approved, the employer will receive an email to set up their employer portal account where they review and approve employee enrollments. A broker can also do this on behalf of the employer through the broker portal.

3Carrier Approval

At the close of open enrollment, once the employer has approved all employees, the employer or broker will submit the enrollments to Meritus and submit initial payment.

IMPORTANT NOTE: Click on link to set up Employer Portal account. The Employer Verification screen will launch for the Employer to verify their identity and move on to creating their portal.

GROUP ENROLLMENT


Employee Enrollment

The evening prior to the Open Enrollment, each employee will receive an email notifying them that Open Enrollment is about to start. The email contains a link and an access code.

Clicking on the link, the employee is asked to register. Once registered, the link can also be used to log back in.

Your Next Steps

Once a group application is submitted to Meritus, the underwriter reviews the group and either approves, requests additional information or declines. Following this approval, an email is sent to the Employer and Broker notifying them of the approval and the dates for open enrollment.

4

The Employer email contains a link to set up their employer portal account. The employer needs to do this in order to approve or deny employee enrollments. This is discussed following employee enrollment.

Open Enrollment

GROUP ENROLLMENT


Once the employee fills in their last name and last four digits of their Social Security Number (SSN), they are taken to a registration screen.

Once registered, the employee is taken to their dashboard where they can make a plan selection and perform other tasks.

From the Quick Links box the employee can perform the following tasks:

1) Account Setting – update their password and security questions

2) View Personal Data – update name, address and phone number

3) Upload a Document

4) Uniform Glossary of Terms

Dashboard

From the No Benefits Selected box, the employee can select:

1) Browse Plans to view the plans their employer is offering

2) Help Me Choose a Plan

3) I’m declining coverage

The first time all employees log on they are asked to verify their personal information.

GROUP ENROLLMENT


A confirm box will appear asking you to verify personal information. You should add or delete any dependents at this time.

GROUP ENROLLMENT


Once the employee selects a plan, a confirmation screen appears and the employee can begin enrollment.

When Browse Plans is selected, the employee will see a list of plans to select from.

GROUP ENROLLMENT


The first screen asks for personal information.

The second screen asks if the employee has any other coverage.

The third screen requests confirmation of the employee’s choices. If amendments are required, the employee can click on the tabs to go back.

GROUP ENROLLMENT


The Employee Enrollment is now complete!

The final screen asks for the employee’s electronic signature.

On completion, the employee receives an on screen confirmation and a confirmation email.

GROUP ENROLLMENT


When all the employees are approved, then the employer will click on the Submit Group Enrollment to Carrier button to submit the enrollment and move to the payment screen. As the broker, you may also complete these tasks for your client.

5Review & Submit

The employer will then need to Approve all of the employee enrollments in the Tasks tab. This can be done individually as employees complete the elections or all at one time.

Once the Open Enrollment has closed, the employer will need to go into their Employer Portal and ensure all employees have completed enrollment – whether they are enrolling or waiving coverage.

GROUP ENROLLMENT


The employee enrollment data will be transferred electronically to Meritus and uploaded into our enrollment system.

It is best to pay the binder premium directly online at the time of enrollment. The employer can later choose to have billing statements mailed to them or emailed depending on how the employer would prefer to handle the future monthly premium payments.

6Sent to Membership

PLEASE NOTE: If Employer selects “Mail” as a payment option, they should mail the binder payment to:

Meritus 2005 W. 14th St. Suite 113 Tempe, AZ 85281

Meritus does not mail initial binder billing statement.

GROUP ENROLLMENT


7Active Group

Once the group information is transferred to our enrollment department and loaded, the group becomes Active. Coverage will begin on the effective date selected. ID cards and welcome packets will be sent to the employee addresses supplied with the enrollment information within 10 business days. The group policy number is displayed in the Profile box. Welcome to Meritus!

GROUP ENROLLMENT


Group Plans

PLAN TYPE - METAL NAME PAGES

HMO - Platinum Meritus Healthy Platinum Complete HMO Plus 500 102

Meritus Healthy Platinum HMO Plus Abrazo 500 102

Meritus Healthy Platinum HMO Plus Banner 500 102

Meritus Healthy Platinum HMO Plus MIHS 500 102

Meritus Healthy Platinum HMO Plus Pima 500 102

Meritus Healthy Platinum HMO Plus WARMC 500 102

HMO - Gold Meritus Healthy Gold Complete HMO Plus 2000 103

Meritus Healthy Gold HMO Plus Abrazo 2000 103

Meritus Healthy Gold HMO Plus Banner 2000 103

Meritus Healthy Gold HMO Plus MIHS 2000 103

Meritus Healthy Gold HMO Plus Pima 2000 103

Meritus Healthy Gold HMO Plus WARMC 2000 103

HMO - Silver Meritus Healthy Silver Complete HMO 4000 104

Meritus Healthy Silver HMO Abrazo 4000 - Available OFF-Market Only 104

Meritus Healthy Silver HMO Banner 4000 104

Meritus Healthy Silver HMO MIHS 4000 104

Meritus Healthy Silver HMO Pima 4000 104

Meritus Healthy Silver HMO WARMC 4000 104

HMO - Bronze Meritus Healthy Bronze Complete HMO 6800 105

Meritus Healthy Bronze HMO Abrazo 6800 105

Meritus Healthy Bronze HMO Banner 6800 105

Meritus Healthy Bronze HMO MIHS 6800 105

Meritus Healthy Bronze HMO Pima 6800 105

Meritus Healthy Bronze HMO WARMC 6800 105

PPO Meritus Choice Gold Complete PPO Plus 2000 106

Meritus Choice Silver Complete PPO Plus 4000 107

Meritus Choice Bronze Complete PPO Plus 6800 108

PPO HSA Meritus Saver Gold Complete PPO HSA Plus 1500 109

Meritus Saver Silver Complete PPO HSA Plus 2750 110

Meritus Saver Bronze Complete PPO HSA Plus 6300 112

HMO PROVIDER NETWORKS - Counties Served

Meritus Complete HMO Network - Maricopa, Mohave, Pima, Pinal and Santa Cruz Counties

Meritus Community Network Abrazo - Maricopa County

Meritus Community Network Banner - Maricopa and Pinal Counties

Meritus Neighborhood Network MIHS - Maricopa County

Meritus Community Network Pima - Pima County

Meritus Community Network WARMC - Mohave County

GROUP PLANS


GROUP HMO

Meritus Healthy PlatinumNetworks: Complete HMO Plus 500 • HMO Plus Abrazo 500 • HMO Plus Banner 500 • HMO Plus MIHS 500 HMO Plus Pima 500 • HMO Plus WARMC 500

Plus













Ambulatory Surgical Center $200 copay per surgery






















Prescription Deductible per person per calendar year per calendar year $0 single/$0 family










GROUP HMO

Meritus Healthy Gold Networks: Complete HMO Plus 2000 • HMO Plus Abrazo 2000 • HMO Plus Banner 2000 • HMO Plus MIHS 2000 HMO Plus Pima 2000 • HMO Plus WARMC 2000

Plus



































Prescription Deductible per person per calendar year $0 single/$0 family










Meritus Healthy Silver Networks: Complete HMO 4000 • HMO Abrazo 4000 • HMO Banner 4000 • HMO MIHS 4000 HMO Pima 4000 • HMO WARMC 4000













Ambulatory Surgical Center $500 copay per surgery































GROUP HMO


Meritus Healthy Bronze Networks: Complete HMO 6800 • HMO Abrazo 6800 • HMO Banner 6800 • HMO MIHS 6800

HMO Pima 6800 • HMO WARMC 6800











Ambulance - Medical Emergency 0%, after deductible


Ambulatory Surgical Center 0%, after deductible









Performed in a physician’s office 0%, after deductible

Performed in an independent, non-hospital affiliated radiology facility 0%, after deductible



Short Term Physical Therapy, Occupational Therapy, Speech Therapy Limited to 60 visits per calendar year combined 0%, after deductible


















GROUP HMO


Meritus Choice Gold Complete PPO Plus 2000Network: Meritus Complete PPO

Plus






























Pediatric Vision Exam - one exam per calendar year $25 copay per exam 50%, after deductible







Prescription Deductible - per calendar year $0 single/$0 family Combined with Medical Ded





Preferred Brand $30 copay $90 copay 50%, after deductible

Non-Preferred Brand $75 copay $225 copay 50%, after deductible

Specialty – Preferred and Non-Preferred 50% 50% 50%, after deductible

GROUP PPO


GROUP PPO

Meritus Choice Silver Complete PPO Plus 4000Network: Meritus Complete PPO

Plus












































Specialty 50%** 50%** 50%, after deductible


GROUP PPO

Meritus Choice Bronze Complete PPO Plus 6800 Plus

Pediatric Dental NOT included.*Adherence Generic drugs include those medications which promote heart health, treat high blood pressure, high cholesterol, along with oral diabetic medication.**After separate prescription deductible. See page 62 for disclaimers, exclusions and limitations.


Network: Meritus Complete PPO












































GROUP PPO

Meritus Saver Gold Complete PPO HSA Plus 1500Network: Meritus Complete PPO

Plus



Deductible - per calendar year - Aggregate (Non-Embedded) $1,500 single/$3,000 family $4,500 single/$9,000 family











































GROUP PPO

Meritus Saver Silver Complete PPO HSA Plus 2750Network: Meritus Complete PPO

Plus














































GROUP PPO

Meritus Saver Bronze Complete PPO HSA Plus 6300Network: Meritus Complete PPO

Plus















































Why Partner with Meritus? • Easy to work with, enrollment systems and processes that are

easy to use

• Timely, efficient member management and application tracking

• Market friendly and competitive plan benefits

• Competitive commissions

• Dedicated, experienced broker/agent management team

• Local, giving us the ability to respond quickly to broker and member needs

• Innovation, harnessing technology to make processes and communication easier and more user friendly

We hope you’ll consider us for all your clients’ health insurance needs.

Broker Resources and Support


Working with Meritus

To become a Meritus contracted broker, you can initiate the process online at meritusaz.com, click on BROKERS, scroll down and click on Sign up to be a Broker.

Provide the requested information including your first and last name, phone number, business email address, National Producer Number (NPN), AZ Insurance License Number and expiration date, Federal Tax ID or SS number, whether you’re contracting with Meritus directly or through Black, Gould & Associates (BGA); a copy of your Errors and Omissions declarations page with the limits and expiration date and copy of your final 2016 FFM Certificate of Completion (see below sample).

Broker Resources

At meritusaz.com you will have access to the following broker tools:

• How to create your Broker Sales Portal & customized broker quote button

• Broker Sales Portal Login

• Broker User Training Registration and Contracting Instructions

• How to create a quote

• Access to our formulary

• How to find providers

• Employee Census Template

• Summary of Benefits and Coverage

• Broker Newsletters

• Outlines of Coverage

Responsible Selling

Just as we set the bar high for ourselves, we ask the same from our brokers. Our Meritus team has worked in healthcare for years, serving others tirelessly and selflessly. Our dedication to helping our members is at the center of everything we do.

Let’s work together to:

• Put the needs of your clients first

• Truthfully represent our products and services

• Stay informed and adhere to all insurance laws and regulations

• Protect client confidentiality

• Stay in contact with your clients and make sure their coverage meets their needs

• Maintain the highest level of ethical conduct in compliance with license requirements

We expect the best from ourselves and from you, too.

Registration Completion Certificate

Sample Broker

NPN(s): 123567

Individual Marketplace

Registration status for plan year 2016: Complete

If you are assigning commissions to an agency, both the agency and you must be FFM Certified.

You will be contacted by the Meritus Sales team on the next steps, which are how to set up your Broker Sales Portal and determining which type of contract you require, ie. Producer, Assignment of Commission or Agency with Assignment of Commission.

BROKER RESOURCES AND SUPPORT


Broker Contracting Process

Step 1 – Sign up to be a Broker

Go to meritusaz.com and sign up to be a broker, be sure to attach your E&O insurance certificate and 2016 FFM Certicate of Completion for both the producer and/or the agency. Completing and submitting your initial request initiates the Meritus Broker on boarding (and certification) process. In order to be eligible for payment of commissions and other compensation, you must be approved and contracted by Meritus to sell Meritus plans (both individual and group). You must complete all steps below to become a contracted broker.

Step 2 – Reply to email

You will receive an email which includes contract preferences that you will need to respond to, and you will receive information on Meritus product training, resources, tools and more. This will include instructions to set up your Broker Portal.

Step 3 – Broker contracting

This process consists of the following steps:

• Signing of Meritus standard broker/ producer agreement and exhibits utilizing DocuSign, an online tool that provides electronic signature technology and Digital Transaction Management services for facilitating electronic exchanges of contracts and signed documents. Exhibits include:

- Business Associate Agreement

- W-9

- Assignment of Commission Agreement (if applicable)

- Electronic Payment (ACH) Authorization Form (direct deposit)

- Agent Application

- Meritus Release Authorization and Fair Credit Reporting Act Disclosure

- Commission-Individual Sales Acknowledgement

- Agent Acknowledgement & Policy Signoff Form

Enter your NPN Number as the access code to view the document.

You will need to consent to use DocuSign – check the box indicating your agreement and click Review Documents.

Steps to Sign Your Agreement

You will receive an email from one of our Meritus associates via Docusign with the link to view and sign your Meritus contracting documents. You will need to use your NPN number to access your file.



From here, you will begin. Click on the Start button. Please be sure to complete each field. If the box does not apply, please type “N/A” and click Next. Continue this throughout the document.

You will be asked to upload two documents, a completed W-9 tax form and a voided copy of a check for ACH deposit. Please scan them and save on your computer to upload. Do not use the Fax feature in the document.

You will be able to adopt your signature style.



When all fields are complete you will get a message indicating that All required fields complete. Click on the Confirm Signing button. The Confirm Signing button will not appear if there are any blank sections.

You will receive a final message indicating you have completed your documents. This sends the file back to the Director of Sales for signature, then moves the files on to the Chief Executive Officer of Meritus for the final execution of the agreements.

Once complete, you will receive notification that the documents are fully executed and you may download and save a copy for your records by clicking on the View Document link in the email.

License Renewal

All Meritus broker representatives must maintain a valid Arizona Life and Health license. A copy of this license must be resubmitted to Meritus upon its renewal. It can be emailed to the Meritus Broker Sales team at [email protected].



Individual and Group Commissions

• All new eligible policies must result in the issuance of a new policy to a person that is not currently a policy of Meritus Individual or Group major medical insurance.

• Individual commissions are as-earned and based on 6% monthly premium for the first year and then 4% of the first year’s premium thereafter.

• Small Group is as-earned and based on 4% all years.

• Commissions will be paid by the 10th of the month following the month when the member’s policy or Group policy is effectuated.

Commissions For Members Who Receive Advanced Premium Tax Credits (APTC) as follows:

• We will pay commissions on the full premium on all approved, current and paid Memberships, including commissions on APTC amounts.

• Commissions are paid by the 10th of the next month if both the premium payment from the member and the APTC has been processed and reconciled by the 26th day of the month.

• Commissions will not be paid for members who have not paid their portion of the premium, even if Meritus received the member’s advanced premium tax credits (APTC) only.

• Payments reconciled after the 26th day of the month will be paid on the by the 10th of the month following 30 days.

Terminations and Suspensions

Commissions for members and/or dependents will be reduced the month following the termination or suspension by the amount of commission that resulted from the member’s and/or dependent’s premium.

If a member’s coverage is suspended because they enter into active duty status for the military or naval service of the United States or any other country and the Covered Person requests a resumption of coverage within 60 days of termination of active duty status, meets the eligibility requirements for the policy and pays any required premium, commission will be paid.

Commissions Paid on Members Cancelled Retroactively

In cases where commissions were paid for members who do not pay during the applicable grace period (90 days for members who receive APTC; 30 days for all other members) commission payments will be cancelled retroactively and reduced from subsequent commission payments.

Commission Rules for Members Who Re-enroll

If a Meritus member stays on the same plan, commission will be calculated based on the premium amounts for the prior year.

Reporting on a Broker’s 1099

Reporting of compensation from the Commission program and tax implications are the responsibility of the broker Meritus may amend the terms of the Commission program with written notification.

The broker must have an active contract, be in good standing with Meritus, and be up-to-date with the following requirements:

• Meritus broker training

• active AZ DOI license

• current Errors & Omissions insurance

• current Marketplace certifications on file for both broker and agency.

• and must meet all requirements imposed by the Marketplace.

To receive commissions, brokers must have:

• a valid Arizona Life and Health Insurance License

• Valid FFM Certification for On Market business for both broker and agency.

• A signed Meritus Broker/Agency Agreement.

Commission Payments



Meritus Privacy Notice

Our Meritus members’ private information is of the utmost importance. As our business partners, we look to you to help us ensure their privacy. Our disclosure policies secure our members’ personal health information, as well as ensure continued compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other privacy regulations. If your clients need your assistance with matters related to their Personal Health Information (PHI), they will need to sign the Meritus Authorization to Disclose Protected Health Information form.


This signed form allows Meritus to release certain information to you, such as:

• Medical identification (ID) number

• Detailed member claims, processing and payment information (specific dates of service and date ranges)

• Member-specific benefit information, plan type and effective dates, member PCP assignment


Internal Broker Service Team

Phone: 602.957.2113 Toll Free: 855.755.2700

Email: [email protected] Group Quote Requests: [email protected]

Broker Portal: enroll.meritusaz.com/ehpportal/eapp/login

For Your Clients

Meritus, Customer Care Team Phone: 1.855.755.2700

Contact the Customer Care Team for:

• Billing & Payment Inquiries

• Claims Information & Status

• Order New ID Cards

• Eligibility & Benefit Inquiries

Hours of Operation

8 am to 5 pm (M-F), except holidays

Support for Brokers

Recognized as one of the Phoenix Business Journal’s

Meritus Members Self-Service

How to Use Their Member Portal

Once members receive their mailing containing their member portal user name and temporary password, Meritus members can access:

• Home Screen Membership-at-a-Glance

• Coverage Details and Eligibility

• Order a New Card

• Order a New Member Handbook

• Print Member Cards

• View/Print Member Policy

• View Member/Family Accumulators

• View Payment History (Pertaining to individual plans only.)

• Search Claims History & View Claims

• Find a Provider

• Find a Facility

• Request to Change PCP

• File a Complaint

• File an Appeal

• Request a Copy of Health Records

• Authorize the Disclosure of Protected Health Information

• Request to Limit/Restrict Protected Health Information

• Certify an Appeal for Expedited Review

• Request a Gym Membership Reimbursement

Members log into their member portal by going to meritusaz.com, clicking Member, and then Member Portal.

address

2005 West 14th Street Suite 113

Tempe, Arizona 85281

website

meritusaz.com

email

[email protected] [email protected]

© 2015 Meritus. Meritus products and services are provided through Meritus Mutual Health Partners - PPO and Meritus Health Partners - HMO. Meritus Mutual Health Partners and Meritus Health Partners are licensed only in Arizona, and are Qualified Health Plan issuers in the Health Insurance Marketplace.

phone

602.957.2113

toll free

855.755.2700

tty

7.1.1

hours of operation

8 am to 5 pm (M-F)