Beyond routine care and wellness, one of the major reasons for having health insurance is to protect yourself and your family in case of serious illness or injury. At Health Options, our medical management approach ensures that you also have a team of healthcare experts at your side in times of a serious medical crisis. In addition, our Care Managers are here for everyday wellness questions and at every step of recovery after a major medical incident.
Our Care Management Team partners with local agencies to find the help our Members need, from financial assistance to transportation, housing, and other issues affecting wellness and recovery. On-staff medical, pharmacy and healthcare experts help Members access medication and durable medical equipment, receive authorization support and assistance with provider outreach, and drug formulary education. The team also makes outbound calls to our Members to assist with chronic illness support or to provide post-discharge coordination from hospital stays. This collaborative approach to medical management focuses on improving care, creating positive health outcomes, and reducing the total cost of care.
What does a medical management approach look like to our Members? On a day-to-day basis, our in-house pharmacy team keeps Members updated about drug recall changes in medication availability and ways to access prescription medications at lower costs. Our team will also reach out to encourage immunizations, wellness visits, and other low-cost, or $0 cost-share benefits that can help our Members live their healthiest lives. In cases of hospitalizations and transitions to home, our medical management’s Site of Care Program offers Members the option to transition certain medications and infusions to a preferred site of care, including in-home care.
If a Member needs extra care for a particular condition, our team is instrumental in securing assistance. For example, one Member of our asthma outreach program had concerns about her condition combined with possible COVID-19 symptoms when the virus first emerged. Her COVID-19 symptoms kept her from seeing her primary care provider. After using a walk-in clinic for testing to determine she was COVID-19 negative, she continued to have a cough, low-grade fever, and fatigue. Our Care Management team was able to quickly find her an in-network pulmonologist who treated her with antibiotics for suspected pneumonia. She also had her asthma medications adjusted, and her condition improved.
Our hands-on strategies have resulted in more than $12.1+ million saved through Care Management programs since 2017, a 48 percent total reduction in our hospital readmission rate from 2018 to 2020. Our Script Saver program, led by in-house pharmacists, provided personal outreach to Members that led to out-of-pocket savings of $98,000 on medications in 2020. All of these efforts combined help improve health and reduce costs for our Members.
Call us if you have a question about prescription drug costs, need support for an upcoming medical procedure, or have a serious medical crisis. Our medical management team is in your corner, and they can be reached through Member Services at (855)624-6463, or use our secure email messaging.
Fall is a time for back to school, state fairs, “leaf-peepers,” and thinking about your healthcare insurance. Open Enrollment season, as we call it in the business, begins November 1 and lasts through January 15, 2022. This season brings some positive changes in health insurance including changes in Health Options’ plans.
First, all health insurance carriers in the individual/family marketplace will offer Clear Choice plans to bring more transparency to the buying process. These plans are designed to make it easier for Maine people to compare options across health insurance carriers. Clear Choice plans have a standard cost-sharing design, meaning they have the same deductible, co-pays, and co-insurance for medical services across all health insurance carriers in the state. All Health Options’ Clear Choice plans are designated with “CC” in the plan name. It is important to note there may be some differences between carriers in clear choice plans, so you will want to look beyond the cost-sharing. For example, Health Options offers a chronic illness support plan to reduce the cost of care for Members with asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes, and hypertension in many clear choice plans, and other carriers do not have this exact benefit.
Also, for 2022, Health Options is pleased to add a tiered provider network to some of our individual/family HMO plans. In our tiered plans, primary care providers, imaging, labs, and out-patient hospital services are categorized by a preferred or standard tier. The preferred tier offers high quality, lower cost-share providers and service options. Plan Members are easily directed to preferred tier providers and locations when completing a provider search. Tiered plan Members can continue receiving services from a standard tier provider with a standard co-pay.
In another change to our provider network selections, we offer several plans that include national in-network coverage through First Health®. These plans are ideal for individuals and families who spend time outside the New England region and need reliable coverage both at home and on the road. Other plan enhancements include $0 cost for urgent care telehealth on non-HSA plans through our partnership with Amwell®. Health Options will also be offering Maine’s only Platinum health plan in the individual/family marketplace, which has the lowest deductible and cost-share across plans and offers co-pays with no deductible for in-network primary care, specialists, behavioral health visits, and urgent care facilities.
Finally, there are some legislative changes affecting health insurance in Maine. If you’ve used Healthcare.gov to learn about tax credits and other cost reductions, you will now be using CoverME.gov, Maine’s new online Health Insurance Marketplace. CoverME.gov is operated by the Maine Department of Health and Human Services. With the American Rescue Plan enacted earlier this year by the Biden Administration, more Mainers than ever are now eligible for advance premium tax credits (APTC) to help pay for coverage. Be sure to visit our storefront (healthoptions.org) to check your eligibility for tax credits and go to CoverME.gov after November 1, 2021, to January 15, 2022, to apply for the APTC and/or for cost-sharing reduction credits.
While these changes are all good news, we know how hard it can be to navigate health insurance decisions. As always, we are here for you. Our Member Services team can address any questions you have regarding your 2022 healthcare coverage. If you need help selecting a plan, go to healthoptions.org or call Member Services at (855) 624-6463, Monday through Friday, 8:00 a.m. to 6:00 p.m. You can also reach out to your trusted broker.