Meritus 2015 Broker Handbook VNT LR

2015 Broker Handbook

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

for broker use only

October 2014

meritusaz.com • Broker Use Only Meritus Broker Manual 1

Table of ContentsWhen it comes to healthcare, we’re changing everything.

Starting with building great working relationships with brokers like you. Coming together to improve healthcare for Arizona.

Our goals are the same: to help Arizonans achieve better health through the kind of care they demand and deserve. Which is why 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’re 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.

Improving the health and wellbeing of Arizonans will take a team effort. Be a part of Meritus – Together for better health. Meritus products and services are provided through Meritus Mutual Health Partners (a PPO) and Meritus Health Partners (an HMO).

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

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

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

Understanding the Marketplace . . . . . . . . . . . . .15

Assistance: Making Healthcare Affordable for All . . . . . . . . .19

Meritus Rules Regarding Federal Marketplace . . . . . .21

Step by Step Guide to Individual and Family Application Process . . . . . . .25

Meritus Small Groups . . . . .37

Meritus Health Plans and Rates . . . . . . . . . . . . . . .61

Meritus Pricing Sheets . . . . .94

Meritus Pharmacy Benefits . . . . . . . . . . . . . . . .103

Broker Resources and Support . . . . . . . . . . . .105

2 Meritus Broker Manual 1.855.755.2700 | 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, we are 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, bringing a broad range of expertise and innovation to our efforts.


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.

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

• 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 2015?

• MeMD – 24/7 Telemedicine service at no charge to our members (see page 14)

• CVS Minute Clinics covered at a primary care copay (see page 14)

• New network options

• All new plans for both HMO, PPO & HSA

• Direct Enrollment to the Federal Marketplace – no need to enroll using Healthcare.gov

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


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, in every state. 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 has all new plans for 2015 based on feedback from Brokers

• We designed HMO and PPO products structured around copays for most services, no hidden fees and predictable out-of-pocket costs.

• We created a range of deductibles and copays.

• We designed plans with pharmacy benefits that provide generic maintenance medications without copays.

• We structured our plans with lower copays for primary care visits, sick visits or well visits, to help promote preventive care and wellness.

• We included complementary and alternative medicine benefits such as Acupuncture, Therapeutic Massage, Naturopathy and rewards for staying healthy, including up to $25 per month gym membership reimbursement. These benefits are included on all of our PPO plans and on Gold and Platinum HMO plans.

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.

• 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.


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’s 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 good.


Meritus PPO Network1

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.

PPO Network1 Contracted Hospitals

Meritus Provider Network Design

Building better health in communities through our Provider Network.

HMO • 3,569 physicians

• 30 Acute hospitals and 3 Behavioral Health hospitals

PPO • 10,941 physicians and

mid-level providers

• 45 Acute hospitals and 12 Behavioral Health hospitals

COUNTY CITY FACILITY NAME

Apache Ganado Sage Memorial Hospital Springerville White Mountain Regional Medical CenterCochise 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 CenterLa Paz Bouse La Paz Regional Hospital Parker La Paz Regional Hospital Parker La Paz Regional Hospital Quartzsite La Paz Regional Hospital Salome 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 Glendale Arrowhead Hospital Banner Thunderbird Medical Center St. Joseph’s Westgate Medical Center Goodyear West Valley Hospital Medical Center Mesa Arizona Spine & Joint Hospital Banner Baywood Medical Center Banner Desert Medical Center Banner Heart Hospital Cardon Children’s Medical Center Phoenix Arizona Heart Hospital Banner Estrella Medical Center Banner Good Samaritan Medical Center John C. Lincoln Hospital - Deer Valley John C. Lincoln Hospital - North Mtn Maricopa Medical Center Maryvale Hospital Medical Center Oasis Hospital Paradise Valley Hospital Phoenix Baptist Hospital Phoenix Children’s Hospital Select Specialty Hospital - Phoenix St. Joseph’s Hospital & Medical Center


Maricopa County

• Scottsdale Lincoln Health Network

• Banner Health

• Abrazo Health

• Maricopa Medical Center

• Dignity Health

• Phoenix Children’s Hospital

PPO Network1 Contracted Hospitals in Maricopa

Maricopa San Tan Valley Banner Ironwood Medical Center Scottsdale Scottsdale Healthcare Osborn Scottsdale Healthcare Shea Scottsdale Healthcare Thompson Peak Sun City Banner Boswell Medical Center Sun City West Banner Del E Webb Medical CenterMohave Bullhead City Western Arizona Regional 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 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

COUNTY CITY FACILITY NAME See page 8 for the Pima and Santa Cruz Counties PPO Network1 Contracted Hospital locations.


Let us help you find the right doctor.

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 any confusion that could result from using doctors that are not contracted in their Meritus plan.

When someone signs up for a Meritus plan, it is very important that the member understands where they are able to receive care and the importance of using doctors in their network.

Pima and Santa Cruz Counties

• Carondelet Health Network

• Tucson Medical Center

• Northwest Medical Center/ Oro Valley

PPO Network1 Contracted Hospitals in Pima and Santa Cruz Counties

Steps to View Providers

Please visit meritusaz.com for a complete listing of doctors and facilities by plan.

1. Visit meritusaz.com

2. Click on the Providers tab on the top of the Meritus homepage

3. Click the Find a Provider link

NogalesHoly Cross Hospital


Meritus Complete HMO Network2

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.

Meritus Community Networks

In order to offer low premiums and quality benefits to our members, Meritus also created community 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 Mohave Network - Western Arizona Regional Medical Center

Complementary and Alternative Medicine Network3

At Meritus, we know that health isn’t something that you only fix when it’s broken.

• Acupuncture • Naturopathy

• Therapeutic massage • Gym membership reimbursement4

These benefits are available to members in a number of individual and group plans and are designed to support overall health and well-being.

A complete listing of the participating Meritus HMO community networks of doctors can be found on our website at meritusazcom.

Due to the popularity of our three community network plans from 2014, we will continue to offer these plans in 2015 under new plan names:

Meritus Community network Pima is a plan in partnership with Carondelet Health Network

Meritus Community Network Phoenix is a plan in partnership with Banner Health

Meritus Neighborhood Network Maricopa is a plan in partnership with Maricopa Integrated Health System

Meritus Community Network Silver HMO Pima

Meritus Community Network Silver HMO Banner

Meritus Neighborhood Network Silver HMO MIHS

2015 PLAN

NAME

2015 PLAN

NAME

2015 PLAN

NAME

These are the only three plans which include Pediatric Dental.


Meritus Complete HMO Network2 Contracted Hospitals

NogalesHoly Cross Hospital

Maricopa County

• Scottsdale/ Lincoln Health Network

• Banner Health

• Abrazo Health



• Carondelet Health Network

• Tucson Medical Center


Meritus HMO MIHS Network

Meritus HMO Banner Network

Maricopa County


• Phoenix Cancer Center

• Arizona Burn Center

• McDowell Health Care Center

• 11 MIHS Family Health and Community Centers

Maricopa County

• All of the Banner hospitals

• MD Anderson Cancer Center

• Cardon Children’s Medical Center

• Banner Heart Hospital


Meritus HMO Abrazo Network

Meritus HMO Pima and Santa Cruz Network

Maricopa County

• Arizona Heart Hospital

• Arizona Heart Institute

• Arrowhead Hospital

• Maryvale Hospital

• Paradise Valley Hospital

• Phoenix Baptist Hospital

• West Valley Hospital


• St. Mary’s Hosptial

• St. Joseph’s Hospital - Tucson

• Carondelet Heart & Vascular Institute

• Carondelet Neurological Institute

• Holy Cross Hospital NogalesHoly Cross Hospital


Bullhead City

Mohave Valley

Lake Havasu City

Kingman

Peach Springs

Colorado City

Dolan Springs

Meritus HMO Mohave Network

• Western Arizona Regional Medical Center

If you have any questions about Meritus’ provider networks or need additional information, please call us at 602.957.2113 or toll free at 855.755.2700.

Hearing Impaired? Call the Arizona Relay Service at 711. Please have the Meritus’ phone number available for the relay operator.

© 2014 Meritus. Meritus products and services are provided through Meritus Mutual Health Partners – PPO and Meritus Health Partners – HMO.

1 PPO Networks ONLY: You are not required to go to a Preferred Provider. At the time of services, you may 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-pocket costs if you 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 my remain on your annual deductible. If you plan to use a non-network provider, you should inquire about the fees you can expect to be charged before you receive services.

2 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 that are arranged for the member due to provider network coverage.

3 Complimentary and Alternative Therapies (CAM) are not a covered benefit in all plans. CAM therapies include therapeutic Massage Therapy, Acupuncture and Naturopathy. CAM Therapies are limited to 12 visits per year.

4 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.

For a complete listing of benefits available for all plans as well as limitations and exclusions, please contact Meritus. This is an advertisement/informational flyer. A licensed 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.


More Healthcare Options Available to Members!

Introducing MeMD, one of our benefits!

Meritus has teamed up with MeMD to deliver online telehealth services to you. It’s simple! Visit www.MeMD.me/meritus, login using your Meritus ID. You will be connected to a medical provider over the phone or by webcam to discuss minor conditions, medication refills, or even a second opinion.

MeMD is the fastest, most convenient way to see a medical provider online or by phone for common conditions like:

• Sinus Infections

• Seasonal Allergies

• Sprains & Strains

• Medication Refills

• Cold & Flu Symptoms

• Pink Eye

• Urinary Tract Infections

• Sore Throats

• Skin Infections

• And more!

Receive treatment from home, the office or even when you’re on vacation!

MeMD.me/meritus 844.399.5341

cvs.com/minuteclinic/clinics/Arizona

Adding the benefit of the Minute Clinic, brings care to your client’s neighborhood

Your clients want to make the best choice for their family.

You may already know how convenient Minute Clinics are:

• Open 7 days a week, including evenings and weekends

• No appointment necessary

• Located in select CVS/pharmacy® stores nationwide

• Adding new clinics and services all the time

• Plus, the Minute Clinics accept Meritus plans

You might not know that CVS Minute Clinics offer a broad range of services. In addition to diagnosing and treating illnesses, injuries and skin conditions, they also provide all kinds of wellness services, including vaccinations, physicals, screenings and monitoring for chronic conditions.

The Minute Clinics family of nurse practitioners and physician assistants provide services for both adults and children, 18 months and older. And they can send a summary of your visit to your primary care provider, with your permission.

We hope you choose Minute Clinic to help with your family’s health care needs.


The health insurance market as we know it has changed.

Understanding the Marketplace.The ACA includes several provisions geared to create greater access

to health insurance benefits to more people. Beginning in 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.


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 $11,670 to $46,680 per year for an individual and $23,850 to $95,400 per year for a family of four (see income table on page 20).

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 subsidy 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 20).

Penalties for Uninsured Individuals

In 2014, legal U.S. citizens who do not carry a minimum amount of health coverage will receive a penalty. Each year through 2016, penalties will increase.

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)


Individual Shared Responsibility Payment Amounts for 2014 and 2015 Tax Years

The amount of the individual shared responsibility payment increases between 2014 and 2015. It is important that you communicate this policy and the increase in payment amounts to your clients.

• 2014: The annual individual shared responsibility payment is the greater of

- 1% 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 $95 per adult and $47.50 per child, limited to a family maximum of $285.

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 2014.

• 2015: The annual individual responsibility payment is the greater of

- 2% 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 $325 per adult and $162.50 per child, limited to a family maximum of $975.

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 2015.

The calculations above 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.

The same method of calculation is used in 2016 and later years. In 2016, the payment is the greater of 2.5% of income over the filing threshold, or $695 per person ($347.50 per child under 18). After 2016, the payment is adjusted for inflation.

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:

- Live in the United States

- 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 20)


In addition to the metal level plans, issuers can offer catastrophic plans. Eligibility for catastrophic plans is limited to:

• Individuals under age 30

• Individuals who otherwise do not have an affordable coverage option, or who may qualify for a hardship exemption to the minimum essential coverage requirement

If an individual qualifies for enrollment in a catastrophic plan, the catastrophic plan counts as minimum essential coverage.

There is no set AV for catastrophic plans. Instead, enrollees in catastrophic plans have a higher deductible limit than enrollees in Bronze, Silver, Gold, or Platinum plans.

The Marketplace is the Federally Facilitated Marketplace at Healthcare.gov.

Using the Meritus online enrollment tool, you can accurately determine if an Individual or Family will qualify for Advance Premium Tax Credit (APTC).

Meritus now features a Direct Enrollment tool allowing applicants to apply for On Marketplace purchases with the ability to receive APTC avoiding applying through Healthcare.gov.

With you as their guide, individuals and small businesses can compare health plans, get answers to questions and find out if they are eligible for tax credits.

Catastrophic Less Than 60% Coverage

Bronze 60% Coverage

Silver 70% Coverage

Gold 80% Coverage

Platinum 90% Coverage

Purchasing Health Insurance: On & Off the Marketplace

Standard benefits packages

There are five levels of plans, four represented by “metal” values and one catastrophic, and are defined by the percentage each plan will pay toward healthcare expenses for an average person, known as the actuarial value (AV). Health insurers offering QHPs must offer at least one plan at the Silver level and one plan at the Gold level on the Marketplace. Under each metal level there can be several plans available, which will vary according to the deductibles, co-insurance and copays offered.

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


Assistance: Making Healthcare Affordable for AllTo address the needs of those who fall in certain income levels and cannot afford insurance, the law includes provisions for federal subsidies to reduce the cost of premiums.

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 $11,670 to $46,680 per year for an individual and $23,850 to $95,400 per year for a family of four (see income table on page 20).

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).

How to determine your income for 2015?

When your client applies for premium tax credits and other savings in the Marketplace, they’ll need to estimate their income for 2015.

Your client can start by adding up the following items:

• Your client and spouses income, if they’re married and filing joint tax return

• Any dependents who make enough to file a tax return

Which income sources to include

For each of the following sources, estimate what your client’s income will be in 2015. If they’re not sure what their income will be, have them make their best estimate.

• Wages

• Salaries

• Tips

• Net income from any self-employment or business (generally the amount of money taken in from a business minus business expenses)

• Unemployment compensation

• Social Security payments, including disability payments - but not Supplemental Security Income (SSI)

• Alimony

Other items to include when estimating your client’s 2015 income are: retirement income, investment income, pension income, rental income, and other taxable income such as prizes, awards, and gambling winnings.

Don’t include the following kinds of income:

• Child support

• Gifts

• Supplemental Security Income (SSI)

• Veterans’ disability payments

• Workers’ compensation

• Proceeds from loans (like student loans, home equity loans, or bank loans)


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

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

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 $6,600 $1,000 $2,250 $5,200

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 $17,505)

CSR Plan for 151-200% FPL ($17,505 to $23,340)

CSR Plan for 201-250% FPL ($23,340 to $29,175)

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 subsidy 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.

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. . .

$11,670 - $46,680

$15,730 - $62,920

$19,790 - $79,160

$23,850 - $95,400

$27,910 - $111,640

$31,970 - $127,880

1 2 3 4 5 6

$11,670 - $29,175

$15,730 - $39,325

$19,790 - $49,475

$23,850 - $59,625

$27,910 - $69,775

$31,970 - $79,925

$16,105 $21,707 $27,310 $32,913 $38,516 $44,119

$11,670 $15,730 $19,790 $23,850 $27,910 $31,970Med

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Number of people in your household


Meritus Rules Regarding Federal Marketplace Enrollments

Enrollment, Termination, Special Enrollment Periods and Plan Changes


*Minimum Essential Coverage | ** Advanced Premium Tax Credit

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 qualify for a Special Enrollment Period and if this will lower 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

Not eligible for an SEP or eligible for the following SEPs:

1. Move to a new exchange service area

2. Release from incarceration

3. Becoming lawfully present

4. Gain status as an Indian

Between the 1st and 15th day of the month (1/1/15 and 3/15/15)

First day of the following month

Between the 16th and last day of the month (1/16/15 and 3/31/15)

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




Meritus makes it

easier than ever to

help you sell and

retain clients on

Individual and Small

Group Affordable

Care Act (ACA)

health plans.

On Market Enrollee-Initiated Terminations

Enrollees have the right to terminate their coverage in a QHP. On Market members must either go online through their FFM account or contact Healthcare.gov to terminate their coverage. Upon termination, individuals will be unable to enroll in a new QHP unless they qualify for a SEP.

NOTE: Consumers who are notified that their enrollment has been canceled by the issuer for non-payment of premiums will need to create a new account, complete an application and make a new plan selection. The effective date of coverage will be based on the date of the new plan selection under the regular effective date schedule.

Flexibility to Change Plans at the Same Metal Level

CMS allows enrollees to change plans during the Initial Open Enrollment Period after the effective date of their enrollment under certain conditions.

This process can be used for individuals who have paid their first month’s premium and whose coverage is already effective. Plan changes may be made provided the change meets ALL of the following criteria:

• Change is to another plan offered by the same issuer.

• Change is to another plan offered at the same metal level and Cost-Sharing Reduction (CSR) level, if applicable (i.e. Silver to Silver, CSR87 to CSR87, etc).

• Change is made in order to move to a plan with a more extensive provider network or for other isolated circumstances determined by CMS.

• Change is being requested within the Initial Open Enrollment Period. The individual who makes a change that meets the criteria above must notify Meritus who will initiate the plan change. Meritus will determine the effective date for the plan change.



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 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, select Broker Sales Portal Login, or use your Meritus populated broker link. 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. The Direct Enrollment tool will assist in determining APTC information for clients, verify eligibility with Healthcare.gov and to complete the 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.


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 33.

For those qualified for On Market, go to Direct Enrollment link on page 30.

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. See page 30.

Individual & Family Application Due Dates:

On Market Due on or before the 15th of the month to be live on the 1st of the following month

Off Market Due on or before the 15th of the month to be live on the 1st of the following month.


On Market Direct Enrollment Tool

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.

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 Chrome 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. 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 as noted on page 33 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 proposal for work at a later date. Be sure to SAVE your proposal so you can refer back to the quote at a later time.

• Email the proposal to your client.

• Save and send the proposal as a pdf.

• Start the 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.


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.

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 2 – 3 business days. The Membership Packet will then be mailed out to them in 5 – 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 (602.957.2113) 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.

Off Market

Once the application is approved, the Member will be assigned a Member number by our Customer Care system. 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 (602.957.2113) 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.

4Member


Meritus Small Group Underwriting Guidelines

And a step-by-step guide to help you through the group process.The following pages contain instructions on how to process a small

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 Small Group.


Group 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 not 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, 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 30th 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.


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

In 2015, 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 50 full-time equivalent (FTE) employees on payroll.1

• 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).

1 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.


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.


Small 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.


Small 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

Small Group quote or create one

Most recent Wage and Tax report

1

2

3

4

5

6

7

ProposalPage 43

ApplicationPage 48

Carrier ApprovalPage 51

Open EnrollmentPage 52

Review & SubmitPage 57

Sent to MembershipPage 58

Active GroupPage 59


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

The ACA Group Calculator will help determine if a group qualifies for Small Business Health Options Program (SHOP) and will display results for:

• Company overview (equivalent full-time employees, average annual wage)

• 2015 Shared Responsibility (subject to)

• Tax credit, if eligible

NOTE: To qualify, an employer must contribute 50% of the employee’s premium for all eligible employees and enroll in coverage through SHOP.

1Proposal

Click Next to move through the steps


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.


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.


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)

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

When the Small Group decides to enroll with Meritus, select up to 3 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 for 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 3 plans to offer their employees.

Click Next.

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



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 – Group 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


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.


Step 6 – Documents

Upload the most recent company Quarterly Wag & Tax report – Form UC018. 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 Applications Summary display, which shows all sections required for the application as complete.

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


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 account where they review and approve employee enrollments. A broker can also do this on behalf of the employer.

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.

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.


Employee Enrollment

The evening prior to the Open Enrollment, each employee will receive an email notifying them 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 account. The employer needs to do this in order to approve or deny employee enrollments. This is discussed following employee enrollment.

Open 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 selecting either of these, the employee is asked to verify their personal information.


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.

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


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.


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.


When all the employees are approved, then the employer will click on the Review Complete 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. 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.


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


7Active Group

The group is now active and 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!



Affordable coverage that Arizonans can count on.

Plans designed to meet all needs. With a focus on health and wellness, our plans are 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.


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.


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.

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 some with Complementary and Alternative Medicine (Naturopathy, Acupuncture and Massage Therapies).

Meritus is carrying over three plans from 2014, Meritus Neighborhood Network Silver HMO MIHS, Meritus Community Network Silver HMO Banner, and Meritus Community Network Silver HMO Pima, that include pediatric dental for children under the age of 19. Meritus will utilize Delta Dental’s provider network for these benefits and 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 Network1). The PPO products include low copays for primary care in most plans as well as Complementary and Alternative Medicine2 and $25 gym reimbursement.

1 Select the Find a Provider option at meritusaz.com to see a complete list of physicians and facilities. 2 Complementary and Alternative Medicine includes Naturopathy, Acupuncture and Theraputic Massage, are available on cer-

tain Individual and Group plans, check outlines of Coverage for details.

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 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.

AGGREGATE – To qualify as a tax-advantaged Health Savings Account – HSA – the Meritus Gold PPO HSA and Silver PPO HSA plans have 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 $4,000, there must be $4,000 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.


Group & Individual Plans

PLAN TYPE - METAL NAME PAGES

HMO - Platinum Meritus Healthy Platinum Complete HMO Plus 500 65

Meritus Healthy Platinum HMO Plus Abrazo 500 65

Meritus Healthy Platinum HMO Plus Banner 500 65

Meritus Healthy Platinum HMO Plus MIHS 500 - Group Market Only 65

Meritus Healthy Platinum HMO Plus Pima 500 - Individual On FFM Market & SHOP Only 65

Meritus Healthy Platinum HMO Plus Mohave 500 65

HMO - Gold Meritus Healthy Gold Complete HMO Plus 2000 66

Meritus Healthy Gold HMO Plus Abrazo 2000 66

Meritus Healthy Gold HMO Plus Banner 2000 66

Meritus Healthy Gold HMO Plus MIHS 2000 - Group Market Only 66

Meritus Healthy Gold HMO Plus Pima 2000 - Individual On FFM Market & SHOP Only 66

Meritus Healthy Gold HMO Plus Mohave 2000 66

HMO - Silver Meritus Neighborhood Network Silver HMO MIHS - Individual Market Only, Pediatric Dental Included 67 - 70

Meritus Community Network Silver HMO Banner - Individual Market Only, Pediatric Dental Included 67 - 70

Meritus Community Network Silver HMO Pima - Individual On FFM Market Only, Pediatric Dental Included 67 - 70

Meritus Healthy Silver Complete HMO 4000 71 - 74

Meritus Healthy Silver HMO Abrazo 4000 71 - 74

Meritus Healthy Silver HMO Banner 4000 71 - 74

Meritus Healthy Silver HMO MIHS 4000 71 - 74

Meritus Healthy Silver HMO Pima 4000 - Individual On FFM Market & SHOP Only 71 - 74

Meritus Healthy Silver HMO Mohave 4000 71 - 74

HMO - Bronze Meritus Healthy Bronze Complete HMO 6000 75

Meritus Healthy Bronze HMO Abrazo 6000 75

Meritus Healthy Bronze HMO Banner 6000 75

Meritus Healthy Bronze HMO MIHS 6000 - Group Market Only 75

Meritus Healthy Bronze HMO Pima 6000 - Individual On FFM Market & SHOP Only 75

Meritus Healthy Bronze HMO Mohave 6000 75

PPO Meritus Choice Gold PPO Plus 2000 79

Meritus Choice Silver PPO Plus 4000 80 - 83

Meritus Choice Bronze PPO Plus 6000 84

PPO HSA Meritus Saver Gold PPO HSA Plus 1500 85

Meritus Saver Silver PPO HSA Plus 2000 86 - 89

Meritus Saver Bronze PPO HSA Plus 6300 90

HMO PROVIDER NETWORKS

Meritus Complete HMO Network

Meritus Community Network Abrazo

Meritus Community Network Banner

Meritus Neighborhood Network MIHS

Meritus Community Network Pima - Individual On FFM Market & SHOP Only

Meritus Community Network Mohave


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, including OB/GYN $5 copay per visit

Specialist $30 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 $200 copay per visit

Ambulance - Medical Emergency $150 copay per transport

Hospital Inpatient hospital services 10%, after deductible

Outpatient hospital services 10%, after deductible

Ambulatory Surgical Center $200 copay per surgery

Outpatient Laboratory/Pathology

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

Performed in a hospital 10%, after deductible

Outpatient Radiology - General

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

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


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

Performed in a physician’s office $200 copay per scan

Performed in an independent, non-hospital-affilialiated radiology facility $200 copay per scan


Maternity Prenatal and Postnatal Care $5 copay per visit

Delivery and All inpatient services for Maternity 10%, after deductible

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

Outpatient /Office Psychiatric and Substance Abuse Visits* $30 copay per visit

DME/Supplies/Prosthetics $100 copay per item

Vision Pediatric Only - Exam - one exam per calendar year $30 copay per visit

Pediatric Only - Glasses or Contacts - one item per calendar year $30 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

Theraputic 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 person per calendar year per calendar year $0

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

Generic Maintenance $0 copay $0 copay

Non-maintenance Generic $5 copay $15 copay

Preferred Brand $15 copay $45 copay

Non-Preferred Brand $60 copay $180 copay

Specialty 50% 50%

*1st 3 MH/SA visits at $0 copay for Gold and Silver plans - does not apply for HSAs. See page 76 for disclaimers, exclusions and limitations.

Group & Individual HMOMeritus Healthy PlatinumNetworks: Complete HMO Plus 500 • HMO Plus Abrazo 500 • HMO Plus Banner 500 • HMO Plus Mohave 500 Individual On FFM Market & SHOP Only: HMO Plus Pima 500 • Also available with Group Plans Only: HMO Plus MIHS 500

Pediatric Dental NOT included.


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
































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

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

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

Gym Membership Reimbursement Up to $25 per month


Prescription Deductible per person per calendar year $0






Specialty 50% 50%


Group & Individual HMOMeritus Healthy Gold Networks: Complete HMO Plus 2000 • HMO Plus Abrazo 2000 • HMO Plus Banner 2000 • HMO Plus Mohave 2000 Individual On FFM Market & SHOP Only: HMO Plus Pima 2000 • Also available with Group Plans Only: HMO Plus MIHS 2000













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

Outpatient hospital services $500 copay per visit/surgery




Performed in a hospital $100 copay per test








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


Delivery and All inpatient services for Maternity $1,000 copay per admission, after deductible







Pediatric Dental - Class I 0%

Class II 45%

Class III 65%

Orthodontia 50%


Prescription Deductible per person per calendar year - Does not apply to Generic Drug Tiers $250




Preferred Brand $72 copay** $216 copay**

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

Specialty 40%** 40%**

*1st 3 MH/SA visits at $0 copay for Gold and Silver plans - does not apply for HSAs. **After separate prescription drug deductible. See page 76 for disclaimers, exclusions and limitations.

Meritus Neighborhood Network Silver HMO MIHS Meritus Community Network Silver HMO Banner Meritus Community Network Silver HMO Pima - Individual On FFM Market Only

Individual HMO












Hospital Inpatient hospital services $1,000 copay per admission













Performed in a hospital $500 copay per scan, after deductible


Delivery and All inpatient services for Maternity $1,000 copay per admission








Class II 45%

Class III 65%

Orthodontia 50%








Specialty 40% 40%


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

Individual HMO


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










Hospital Inpatient hospital services $500 copay per admission













Performed in a hospital $250 copay per scan


Delivery and All inpatient services for Maternity $500 copay per admission








Class II 45%

Class III 65%

Orthodontia 50%








Specialty 40% 40%


Individual HMOMeritus Neighborhood Network Silver HMO MIHS - CSR87 Meritus Community Network Silver HMO Banner - CSR87 Meritus Community Network Silver HMO Pima - CSR87












Hospital Inpatient hospital services $150 copay per admission













Performed in a hospital $125 copay per scan


Delivery and All inpatient services for Maternity $150 copay per admission








Class II 45%

Class III 65%

Orthodontia 50%








Specialty 40% 40%


Meritus Neighborhood Network Silver HMO MIHS - CSR94 Meritus Community Network Silver HMO Banner - CSR94 Meritus Community Network Silver HMO Pima - CSR94

Individual HMO


































Naturopathy - Maximum 12 visits per calendar year Not Covered

Acupuncture - Maximum 12 visits per calendar year Not Covered

Theraputic Massage - Maximum 12 visits per calendar year Not Covered

Gym Membership Reimbursement Not Covered










Group & Individual HMOMeritus Healthy Silver Networks: Complete HMO 4000 • HMO Abrazo 4000 • HMO Banner 4000 • HMO MIHS 4000 • HMO Mohave 4000 Individual On FFM Market & SHOP Only: HMO Pima 4000














































Specialty 50% 50%


Individual HMOMeritus Healthy Silver - CSR73 Networks: Complete HMO 4000 • HMO Abrazo 4000 • HMO Banner 4000 • HMO MIHS 4000 • HMO Mohave 4000 Individual On FFM Market Only: HMO Pima 4000



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











































Specialty 40% 40%


Individual HMOMeritus Healthy Silver - CSR87 Networks: Complete HMO 4000 • HMO Abrazo 4000 • HMO Banner 4000 • HMO MIHS 4000 • HMO Mohave 4000 Individual On FFM Market Only: HMO Pima 4000



Individual HMO




























Short Term Physical Therapy, Occupational Therapy, Speech Therapy - Limited to 60 visits per calenar year combined $10 copay per visit
















Specialty 40% 40%


Meritus Healthy Silver - CSR94 Networks: Complete HMO 4000 • HMO Abrazo 4000 • HMO Banner 4000 • HMO MIHS 4000 • HMO Mohave 4000 Individual On FFM Market Only: HMO Pima 4000



Group & Individual HMO










Ambulance - Medical Emergency 50%, after deductible



Ambulatory Surgical Center 50%, after deductible









Performed in a physician’s office 50%, after deductible

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




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

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


DME/Supplies/Prosthetics 50%, after deductible

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

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














Meritus Healthy Bronze Networks: Complete HMO Plus 6000 • HMO Plus Abrazo 6000 • HMO Plus Banner 6000 • HMO Plus Mohave 6000 Individual On FFM Market & SHOP Only: HMO Plus Pima 6000 • Also available with Group Plans Only: HMO Plus MIHS 6000



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


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.Costs for services while traveling outside the United States.

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.


Group & Individual PPO

Benefits In-Network Out-of-Network

Deductible - per calendar year $2,000 single/$4,000 family $6,000 single/$12,000 family

Out-of-Pocket Maximum (includes deductible and copays) - per calendar year $4,500 single/$9,000 family $13,500 single/$27,000 family

Office Visit Primary Care Physician, including OB/GYN $15 copay per visit 50%, after deductible

Specialist $40 copay per visit 50%, after deductible

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

Telemedicine - MeMD $0 copay per visit $0 copay per visit/MeMD

In-Store Health Care Clinic $15 copay per visit 50%, after deductible

Emergency Urgent Care $40 copay per visit 50%, after deductible

Emergency Room - copay waived if admitted $300 copay per visit $300 copay per visit

Ambulance - Medical Emergency $200 copay per transport $200 copay per transport

Hospital Inpatient hospital services 20%, after deductible 50%, after deductible

Outpatient hospital services 20%, after deductible 50%, after deductible

Ambulatory Surgical Center $300 copay per visit 50%, after deductible


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

Performed in a hospital 20%, after deductible 50%, after deductible


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

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



Performed in a physician’s office $300 copay per scan 50%, after deductible

Performed in an independent, non-hospital-affilialiated radiology facility $300 copay per scan 50%, after deductible


Maternity Prenatal and Postnatal Care $15 copay per visit 50%, after deductible

Delivery and All inpatient services for Maternity 20%, after deductible 50%, after deductible

Chiropractic Care $40 copay per visit 50%, after deductible

Short Term Physical Therapy, Occupational Therapy, Speech Therapy - Limited to 60 visits per calendar year combined $40 copay per visit 50%, after deductible

Outpatient /Office Psychiatric and Substance Abuse Visits* $40 copay per visit 50%, after deductible

DME/Supplies/Prosthetics $125 copay per item 50%, after deductible

Vision Pediatric Only - Exam - one exam per calendar year $40 copay per visit 50%, after deductible

Pediatric Only - Glasses or Contacts - one item per calendar year $40 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

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

Gym Membership Reimbursement Up to $25 per month Up to $25 per month


Prescription Deductible per person per calendar year $0 Not Covered

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

Generic Maintenance $0 copay $0 copay Not Covered

Non-maintenance Generic $10 copay $30 copay Not Covered

Preferred Brand $30 copay $90 copay Not Covered

Non-Preferred Brand $75 copay $225 copay Not Covered

Specialty 50% 50% Not Covered


Meritus Choice Gold PPO Plus 2000


Network: Arizona Foundation for Medical Care









































Prescription Deductible per person per calendar year - Does not apply to Generic Drug Tiers $300 Not Covered




Preferred Brand $60 copay** $180 copay** Not Covered

Non-Preferred Brand $150 copay** $450 copay** Not Covered

Specialty 50%** 50%** Not Covered


Meritus Choice Silver PPO Plus 4000




Individual PPO















































Meritus Choice Silver PPO Plus 4000 - CSR73




Individual PPO


Deductible - per calendar year $500 single/$1,000 family $12,000 single/$24,000 family












































*1st 3 MH/SA visits at $0 copay for Gold and Silver plans - does not apply for HSAs See page 91 for disclaimers, exclusions and limitations.





Individual PPO


Deductible - per calendar year $150 single/$300 family $12,000 single/$24,000 family




























































Ambulance - Medical Emergency 50%, after deductible 50%, after deductible



Ambulatory Surgical Center 50%, after deductible 50%, after deductible









Performed in a physician’s office 50%, after deductible 50%, after deductible

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




Chiropractic Care 50%, after deductible 50%, after deductible

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


DME/Supplies/Prosthetics 50%, after deductible 50%, after deductible

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

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










Preferred Brand $90 copay** $270 copay** Not Covered

Non-Preferred Brand $200 copay** $600 copay** Not Covered

Specialty 50%** 50%** Not Covered


Meritus Choice Bronze PPO Plus 6000






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


Office Visit Primary Care Physician, including OB/GYN 10%, after deductible 50%, after deductible

Specialist 10%, after deductible 50%, after deductible



In-Store Health Care Clinic 10%, after deductible 50%, after deductible

Emergency Urgent Care 10%, after deductible 50%, after deductible

Emergency Room - copay waived if admitted 10%, after deductible 50%, after deductible






Performed in a physician’s office or free-standing independent lab facility 10%, after deductible 50%, after deductible




Performed in an independent, non-hospital-affiliated radiology facility 10%, after deductible 50%, after deductible






Maternity Prenatal and Postnatal Care 10%, after deductible 50%, after deductible




Outpatient /Office Psychiatric and Substance Abuse Visits* 10%, after deductible 50%, after deductible











Generic Maintenance 10%, after deductible Not Covered

Non-maintenance Generic 10%, after deductible Not Covered

Preferred Brand 10%, after deductible Not Covered

Non-Preferred Brand 10%, after deductible Not Covered

Specialty 10%, after deductible Not Covered


Meritus Saver Gold PPO HSA Plus 1500



















































Meritus Saver Silver PPO HSA Plus 2000




Individual PPO






























Outpatient /Office Psychiatric and Substance Abuse Visits* 10% 50%, after deductible

















Meritus Saver Silver PPO HSA Plus 2000 - CSR73




Individual PPO

















































CSR87 plan does not qualify as an HSA plan.Network: Arizona Foundation for Medical Care


Individual PPO


Deductible - per calendar year - Aggregate $400 single/$800 family $6,000 single/$12,000 family

Out-of-Pocket Maximum (includes deductible and copays) - per calendar year $400 single/$800 family $13,500 single/$27,000 family











































*1st 3 MH/SA visits at $0 copay for Gold and Silver plans - does not apply for HSAs See page 91 for disclaimers, exclusions and limitations.



CSR94 plan does not qualify as an HSA plan.Network: Arizona Foundation for Medical Care




Deductible - per calendar year - Embedded $6,300 single/$12,600 family $12,600 single/$25,200 family













































Meritus Saver Bronze PPO HSA Plus 6300




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.

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.


0-20 $158.72 $143.20 $141.65 $133.32 $120.34 $119.04

21-24 $249.95 $225.52 $223.07 $209.95 $189.52 $187.47

25 $250.95 $226.41 $223.96 $210.79 $190.27 $188.21

26 $255.95 $230.92 $228.42 $214.99 $194.06 $191.96

27 $261.95 $236.34 $233.77 $220.03 $198.61 $196.46

28 $271.69 $245.13 $242.47 $228.21 $206.00 $203.77

29 $279.69 $252.35 $249.61 $234.93 $212.06 $209.77

30 $283.69 $255.96 $253.18 $238.29 $215.10 $212.77

31 $289.69 $261.37 $258.53 $243.33 $219.64 $217.27

32 $295.69 $266.78 $263.88 $248.37 $224.19 $221.77

33 $299.44 $270.16 $267.23 $251.52 $227.04 $224.58

34 $303.44 $273.77 $270.80 $254.88 $230.07 $227.58

35 $305.44 $275.58 $272.58 $256.56 $231.58 $229.08

36 $307.44 $277.38 $274.37 $258.24 $233.10 $230.58

37 $309.44 $279.18 $276.15 $259.92 $234.62 $232.08

38 $311.44 $280.99 $277.94 $261.60 $236.13 $233.58

39 $315.43 $284.60 $281.51 $264.96 $239.16 $236.58

40 $319.43 $288.20 $285.07 $268.31 $242.20 $239.58

41 $325.43 $293.62 $290.43 $273.35 $246.75 $244.08

42 $331.18 $298.80 $295.56 $278.18 $251.10 $248.39

43 $339.18 $306.02 $302.70 $284.90 $257.17 $254.39

44 $349.18 $315.04 $311.62 $293.30 $264.75 $261.89

45 $360.93 $325.64 $322.10 $303.17 $273.66 $270.70

46 $374.92 $338.27 $334.59 $314.92 $284.27 $281.20

47 $390.67 $352.48 $348.65 $328.15 $296.21 $293.01

48 $408.67 $368.71 $364.71 $343.27 $309.85 $306.50

49 $426.41 $384.72 $380.55 $358.17 $323.31 $319.81

50 $446.41 $402.76 $398.39 $374.97 $338.47 $334.81

51 $466.15 $420.58 $416.01 $391.55 $353.44 $349.62

52 $487.90 $440.20 $435.42 $409.82 $369.93 $365.93

53 $509.89 $460.04 $455.05 $428.30 $386.61 $382.43

54 $533.64 $481.47 $476.24 $448.24 $404.61 $400.23

55 $557.38 $502.89 $497.43 $468.19 $422.61 $418.04

56 $583.13 $526.12 $520.41 $489.81 $442.13 $437.35

57 $609.12 $549.57 $543.60 $511.65 $461.84 $456.85

58 $636.87 $574.60 $568.36 $534.95 $482.88 $477.66

59 $650.62 $587.01 $580.63 $546.50 $493.30 $487.97

60 $678.36 $612.04 $605.39 $569.80 $514.34 $508.78

61 $702.36 $633.69 $626.81 $589.96 $532.53 $526.77

62 $718.10 $647.90 $640.86 $603.18 $544.47 $538.58

63 $737.85 $665.71 $658.48 $619.77 $559.44 $553.39

64+ $749.85 $676.54 $669.19 $629.85 $568.54 $562.39

Meritus Healthy Platinum Complete

HMO Plus 500

Meritus Healthy Platinum HMO

Plus Banner 500


Plus Abrazo 500

Meritus Healthy Gold Complete HMO Plus 2000

Meritus Healthy Gold HMO Plus

Banner 2000

Meritus Healthy Gold HMO Plus

Abrazo 2000Age

2015 Meritus Healthy HMO PlansIndividual Pricing Sheet - Maricopa County

All rates are for NON Tobacco user rates - increase by 10%


0-20 $108.59 $102.52 $97.73 $96.64 $87.70 $82.35

21-24 $171.01 $161.46 $153.91 $152.20 $138.12 $129.69

25 $171.68 $162.10 $154.52 $152.80 $138.66 $130.20

26 $175.10 $165.33 $157.59 $155.84 $141.43 $132.79

27 $179.21 $169.21 $161.29 $159.50 $144.74 $135.91

28 $185.88 $175.50 $167.29 $165.43 $150.13 $140.96

29 $191.35 $180.67 $172.22 $170.30 $154.55 $145.11

30 $194.09 $183.25 $174.68 $172.74 $156.76 $147.19

31 $198.19 $187.13 $178.37 $176.39 $160.07 $150.30

32 $202.29 $191.00 $182.06 $180.04 $163.39 $153.41

33 $204.86 $193.42 $184.37 $182.32 $165.46 $155.36

34 $207.60 $196.01 $186.84 $184.76 $167.67 $157.43

35 $208.96 $197.30 $188.07 $185.98 $168.77 $158.47

36 $210.33 $198.59 $189.30 $187.19 $169.88 $159.51

37 $211.70 $199.88 $190.53 $188.41 $170.98 $160.55

38 $213.07 $201.17 $191.76 $189.63 $172.09 $161.58

39 $215.80 $203.76 $194.22 $192.06 $174.30 $163.66

40 $218.54 $206.34 $196.69 $194.50 $176.51 $165.73

41 $222.64 $210.22 $200.38 $198.15 $179.82 $168.84

42 $226.58 $213.93 $203.92 $201.65 $183.00 $171.83

43 $232.05 $219.10 $208.84 $206.52 $187.42 $175.98

44 $238.89 $225.55 $215.00 $212.61 $192.94 $181.16

45 $246.93 $233.14 $222.23 $219.76 $199.43 $187.26

46 $256.50 $242.18 $230.85 $228.29 $207.17 $194.52

47 $267.27 $252.36 $240.55 $237.87 $215.87 $202.69

48 $279.59 $263.98 $251.63 $248.83 $225.81 $212.03

49 $291.73 $275.44 $262.55 $259.64 $235.62 $221.24

50 $305.41 $288.36 $274.87 $271.81 $246.67 $231.61

51 $318.92 $301.11 $287.03 $283.84 $257.58 $241.86

52 $333.79 $315.16 $300.41 $297.08 $269.59 $253.14

53 $348.84 $329.37 $313.96 $310.47 $281.75 $264.55

54 $365.09 $344.71 $328.58 $324.93 $294.87 $276.87

55 $381.33 $360.05 $343.20 $339.39 $307.99 $289.19

56 $398.95 $376.68 $359.05 $355.06 $322.22 $302.55

57 $416.73 $393.47 $375.06 $370.89 $336.58 $316.03

58 $435.71 $411.39 $392.14 $387.78 $351.91 $330.43

59 $445.12 $420.27 $400.60 $396.15 $359.51 $337.56

60 $464.10 $438.19 $417.69 $413.05 $374.84 $351.95

61 $480.51 $453.69 $432.46 $427.66 $388.09 $364.40

62 $491.29 $463.86 $442.16 $437.24 $396.80 $372.57

63 $504.79 $476.62 $454.32 $449.27 $407.71 $382.82

64+ $513.00 $484.37 $461.70 $456.57 $414.34 $389.04

Age



Meritus Healthy Silver Complete

HMO 4000

Meritus Community

Network Silver HMO Banner

Meritus Healthy Silver HMO Banner 4000

Meritus Healthy Silver HMO

Abrazo 4000

Meritus Neighborhood Network Silver

HMO MIHS

Meritus Healthy Silver HMO MIHS 4000


0-20 $98.67 $88.80 $87.81

21-24 $155.38 $139.85 $138.29

25 $156.00 $140.40 $138.84

26 $159.11 $143.20 $141.61

27 $162.84 $146.55 $144.93

28 $168.90 $152.01 $150.32

29 $173.87 $156.48 $154.74

30 $176.36 $158.72 $156.96

31 $180.09 $162.08 $160.28

32 $183.81 $165.43 $163.59

33 $186.14 $167.53 $165.67

34 $188.63 $169.77 $167.88

35 $189.87 $170.89 $168.99

36 $191.12 $172.01 $170.09

37 $192.36 $173.12 $171.20

38 $193.60 $174.24 $172.31

39 $196.09 $176.48 $174.52

40 $198.58 $178.72 $176.73

41 $202.30 $182.07 $180.05

42 $205.88 $185.29 $183.23

43 $210.85 $189.77 $187.66

44 $217.07 $195.36 $193.19

45 $224.37 $201.93 $199.69

46 $233.07 $209.76 $207.43

47 $242.86 $218.57 $216.14

48 $254.05 $228.64 $226.10

49 $265.08 $238.57 $235.92

50 $277.51 $249.76 $246.98

51 $289.78 $260.80 $257.91

52 $303.30 $272.97 $269.94

53 $316.97 $285.28 $282.11

54 $331.74 $298.56 $295.24

55 $346.50 $311.85 $308.38

56 $362.50 $326.25 $322.63

57 $378.66 $340.79 $337.01

58 $395.91 $356.32 $352.36

59 $404.45 $364.01 $359.96

60 $421.70 $379.53 $375.31

61 $436.62 $392.96 $388.59

62 $446.41 $401.77 $397.30

63 $458.68 $412.81 $408.23

64+ $466.14 $419.53 $414.86

Meritus Healthy Bronze Complete

HMO 6000

Meritus Healthy Bronze HMO Banner 6000

Meritus Healthy Bronze HMO Abrazo 6000

Age



Meritus Healthy Individual HMO Plans by Networks in Maricopa County

Meritus Complete HMO Network . . . . . . . .10

Meritus Healthy Platinum Complete HMO Plus 500 . . . . . . . . . . . . .65

Meritus Healthy Gold Complete HMO Plus 2000 . . . . . . . . . . . .66

Meritus Healthy Silver Complete HMO 4000 . . . . . . . . . . . . 71 - 74

Meritus Healthy Bronze Complete HMO 6000 . . . . . . . . . . . . . . . .75

Meritus HMO Abrazo Network . . . . . . . . . .12

Meritus Healthy Platinum HMO Plus Abrazo 500 . . . . . . . . . . . . . . . .65

Meritus Healthy Gold HMO Plus Abrazo 2000 . . . . . . . . . . . . . . .66

Meritus Healthy Silver HMO Abrazo 4000 . . . . . . . . . . . . . . . 71 - 74

Meritus Healthy Bronze HMO Abrazo 6000 . . . . . . . . . . . . . . . . . . .75

Meritus HMO Banner Network . . . . . . . . . .11

Meritus Healthy Platinum HMO Plus Banner 500 . . . . . . . . . . . . . . . .65

Meritus Healthy Gold HMO Plus Banner 2000 . . . . . . . . . . . . . . .66

Meritus Community Network Silver HMO Banner . . . . . . . . . . . . . . 67 - 70

Meritus Healthy Silver MO Banner 4000 . . . . . . . . . . . . . . . . 71 - 74

Meritus Healthy Bronze HMO Banner 6000 . . . . . . . . . . . . . . . . . . .75

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

Meritus Neighborhood Network Silver HMO MIHS . . . . . . . . . . . . . . . 67 - 70

Meritus Healthy Silver HMO MIHS 4000 . . . . . . . . . . . . . . . . . . . . . 71 - 74

PAGE


0-20 $147.36 $123.83 $123.78

21-24 $232.07 $195.01 $194.93

25 $232.99 $195.78 $195.71

26 $237.64 $199.68 $199.61

27 $243.20 $204.36 $204.28

28 $252.26 $211.97 $211.89

29 $259.68 $218.21 $218.12

30 $263.39 $221.33 $221.24

31 $268.96 $226.01 $225.92

32 $274.53 $230.69 $230.60

33 $278.01 $233.61 $233.52

34 $281.73 $236.73 $236.64

35 $283.58 $238.29 $238.20

36 $285.44 $239.85 $239.76

37 $287.30 $241.41 $241.32

38 $289.15 $242.97 $242.88

39 $292.87 $246.09 $246.00

40 $296.58 $249.21 $249.12

41 $302.15 $253.89 $253.80

42 $307.49 $258.38 $258.28

43 $314.91 $264.62 $264.52

44 $324.20 $272.42 $272.31

45 $335.10 $281.58 $281.48

46 $348.10 $292.50 $292.39

47 $362.72 $304.79 $304.67

48 $379.43 $318.83 $318.71

49 $395.90 $332.67 $332.55

50 $414.47 $348.27 $348.14

51 $432.80 $363.68 $363.54

52 $452.99 $380.64 $380.50

53 $473.41 $397.80 $397.65

54 $495.46 $416.33 $416.17

55 $517.51 $434.85 $434.69

56 $541.41 $454.94 $454.77

57 $565.54 $475.22 $475.04

58 $591.30 $496.86 $496.68

59 $604.07 $507.59 $507.40

60 $629.83 $529.23 $529.03

61 $652.10 $547.95 $547.75

62 $666.73 $560.24 $560.03

63 $685.06 $575.64 $575.43

64+ $696.20 $585.00 $584.78

Meritus Healthy Platinum Complete

HMO Plus 500

Meritus Healthy Platinum HMO Plus Pima 500*


Age

2015 Meritus Healthy HMO PlansIndividual Pricing Sheet - Pima & Santa Cruz County


Meritus Healthy Individual HMO Plans by Networks in Pima and Santa Cruz Counties

Meritus Complete HMO Network . . . . . . . .10

Meritus Healthy Platinum Complete HMO Plus 500 . . . . . . . . . . . . .65

Meritus Healthy Gold Complete HMO Plus 2000 . . . . . . . . . . . .66

Meritus Healthy Silver Complete HMO 4000 . . . . . . . . . . . . 71 - 74

Meritus Healthy Bronze Complete HMO 6000 . . . . . . . . . . . . . . . .75

Meritus HMO Pima and Santa Cruz Network . . . . . . . . . . . . . . . .10

Meritus Healthy Platinum HMO Plus Pima 500 . . . . . . . . . . . . . . . . . .65

Meritus Healthy Gold HMO Plus Pima 2000. . . . . . . . . . . . . . . . .66

Meritus Healthy Silver HMO Pima 4000 . . . . . . . . . . . . . . . . . 71 - 74

Meritus Community Network Silver HMO Pima . . . . . . . . . . . . . . . . 67 - 70

Meritus Healthy Bronze HMO Pima 6000 . . . . . . . . . . . . . . . . . . . . .75

PAGE

*Individual On FFM Market Only.


0-20 $104.10 $100.82 $89.01 $84.35 $91.61 $76.64

21-24 $163.93 $158.77 $140.17 $132.83 $144.27 $120.70

25 $164.59 $159.40 $140.73 $133.36 $144.84 $121.18

26 $167.86 $162.58 $143.53 $136.02 $147.73 $123.59

27 $171.80 $166.39 $146.90 $139.20 $151.19 $126.49

28 $178.19 $172.58 $152.36 $144.38 $156.81 $131.20

29 $183.44 $177.66 $156.85 $148.64 $161.43 $135.06

30 $186.06 $180.20 $159.09 $150.76 $163.74 $136.99

31 $189.99 $184.01 $162.45 $153.95 $167.20 $139.89

32 $193.93 $187.82 $165.82 $157.14 $170.66 $142.78

33 $196.39 $190.20 $167.92 $159.13 $172.83 $144.59

34 $199.01 $192.74 $170.16 $161.25 $175.14 $146.52

35 $200.32 $194.01 $171.29 $162.32 $176.29 $147.49

36 $201.63 $195.28 $172.41 $163.38 $177.44 $148.45

37 $202.94 $196.55 $173.53 $164.44 $178.60 $149.42

38 $204.26 $197.82 $174.65 $165.50 $179.75 $150.39

39 $206.88 $200.36 $176.89 $167.63 $182.06 $152.32

40 $209.50 $202.90 $179.13 $169.76 $184.37 $154.25

41 $213.44 $206.71 $182.50 $172.94 $187.83 $157.14

42 $217.21 $210.37 $185.72 $176.00 $191.15 $159.92

43 $222.45 $215.45 $190.21 $180.25 $195.76 $163.78

44 $229.01 $221.80 $195.81 $185.56 $201.54 $168.61

45 $236.71 $229.26 $202.40 $191.80 $208.32 $174.28

46 $245.89 $238.15 $210.25 $199.24 $216.39 $181.04

47 $256.22 $248.15 $219.08 $207.61 $225.48 $188.65

48 $268.02 $259.58 $229.18 $217.18 $235.87 $197.34

49 $279.66 $270.86 $239.13 $226.61 $246.11 $205.91

50 $292.78 $283.56 $250.34 $237.23 $257.65 $215.56

51 $305.73 $296.10 $261.41 $247.73 $269.05 $225.10

52 $319.99 $309.91 $273.61 $259.28 $281.60 $235.60

53 $334.42 $323.88 $285.94 $270.97 $294.30 $246.22

54 $349.99 $338.97 $299.26 $283.59 $308.00 $257.68

55 $365.56 $354.05 $312.58 $296.21 $321.71 $269.15

56 $382.45 $370.40 $327.01 $309.89 $336.57 $281.58

57 $399.50 $386.91 $341.59 $323.70 $351.57 $294.13

58 $417.69 $404.54 $357.15 $338.45 $367.58 $307.53

59 $426.71 $413.27 $364.86 $345.75 $375.52 $314.17

60 $444.90 $430.89 $380.42 $360.50 $391.53 $327.57

61 $460.64 $446.13 $393.87 $373.25 $405.38 $339.15

62 $470.97 $456.14 $402.70 $381.62 $414.47 $346.76

63 $483.92 $468.68 $413.78 $392.11 $425.86 $356.29

64+ $491.79 $476.30 $420.50 $398.49 $432.79 $362.08

Meritus Healthy Gold HMO

Plus Pima 2000*

Meritus Healthy Silver Complete

HMO 4000

Meritus Community

Network Silver HMO Pima*

Meritus Healthy Silver HMO Pima 4000*

Meritus Healthy Bronze Complete

HMO 6000

Meritus Healthy Bronze HMO Pima 6000*

Age

2015 Meritus Healthy HMO PlansIndividual Pricing Sheet - Pima and Santa Cruz Counties


*Individual On FFM Market Only.


0-20 $150.19 $126.22 $102.50 $93.14

21-24 $236.53 $198.77 $161.42 $146.68

25 $237.47 $199.56 $162.06 $147.26

26 $242.20 $203.54 $165.29 $150.19

27 $247.88 $208.31 $169.16 $153.71

28 $257.10 $216.06 $175.46 $159.43

29 $264.67 $222.42 $180.62 $164.12

30 $268.45 $225.60 $183.21 $166.47

31 $274.13 $230.37 $187.08 $169.99

32 $279.81 $235.14 $190.96 $173.51

33 $283.36 $238.12 $193.38 $175.71

34 $287.14 $241.30 $195.96 $178.06

35 $289.03 $242.89 $197.25 $179.23

36 $290.92 $244.48 $198.54 $180.40

37 $292.82 $246.07 $199.83 $181.58

38 $294.71 $247.66 $201.12 $182.75

39 $298.49 $250.84 $203.71 $185.10

40 $302.28 $254.02 $206.29 $187.44

41 $307.95 $258.79 $210.16 $190.96

42 $313.39 $263.37 $213.88 $194.34

43 $320.96 $269.73 $219.04 $199.03

44 $330.42 $277.68 $225.50 $204.90

45 $341.54 $287.02 $233.08 $211.79

46 $354.79 $298.15 $242.12 $220.01

47 $369.69 $310.67 $252.29 $229.25

48 $386.72 $324.98 $263.92 $239.81

49 $403.51 $339.10 $275.38 $250.22

50 $422.43 $355.00 $288.29 $261.95

51 $441.12 $370.70 $301.04 $273.54

52 $461.69 $387.99 $315.08 $286.30

53 $482.51 $405.48 $329.29 $299.21

54 $504.98 $424.37 $344.62 $313.14

55 $527.45 $443.25 $359.96 $327.07

56 $551.81 $463.72 $376.58 $342.18

57 $576.41 $484.39 $393.37 $357.44

58 $602.66 $506.46 $411.29 $373.72

59 $615.67 $517.39 $420.17 $381.78

60 $641.93 $539.45 $438.08 $398.06

61 $664.63 $558.53 $453.58 $412.14

62 $679.53 $571.06 $463.75 $421.38

63 $698.22 $586.76 $476.50 $432.97

64+ $709.57 $596.30 $484.25 $440.01


Plus Mohave 500

Meritus Healthy Gold HMO Plus Mohave 2000

Meritus Healthy Silver HMO Plus Mohave 4000

Meritus Healthy Bronze HMO Plus

Mohave 6000Age

2015 Meritus Healthy HMO PlansIndividual Pricing Sheet - Mohave County


Meritus Healthy Individual HMO Plans by Networks in Mohave County

Meritus HMO Mohave Network . . . . . . 13

Meritus Healthy Platinum HMO Plus Mohave 500 . . . . . 65

Meritus Healthy Gold HMO Plus Mohave 2000 . . . . . . . . 66

Meritus Healthy Silver HMO Plus Mohave 4000 . . . . 71 - 74

Meritus Healthy Bronze HMO Plus Mohave 6000 . . . . . . . . 75

PAGE


0-20 $152.08 $129.39 $119.27 $150.49 $127.67 $105.69

21-24 $239.50 $203.77 $187.82 $236.99 $201.06 $166.45

25 $240.46 $204.58 $188.57 $237.93 $201.86 $167.11

26 $245.25 $208.66 $192.33 $242.67 $205.88 $170.44

27 $250.99 $213.55 $196.83 $248.36 $210.71 $174.43

28 $260.33 $221.49 $204.16 $257.60 $218.55 $180.92

29 $268.00 $228.01 $210.17 $265.19 $224.98 $186.25

30 $271.83 $231.27 $213.17 $268.98 $228.20 $188.91

31 $277.58 $236.16 $217.68 $274.67 $233.03 $192.90

32 $283.33 $241.05 $222.19 $280.36 $237.85 $196.90

33 $286.92 $244.11 $225.01 $283.91 $240.87 $199.40

34 $290.75 $247.37 $228.01 $287.70 $244.08 $202.06

35 $292.67 $249.00 $229.52 $289.60 $245.69 $203.39

36 $294.58 $250.63 $231.02 $291.49 $247.30 $204.72

37 $296.50 $252.26 $232.52 $293.39 $248.91 $206.05

38 $298.41 $253.89 $234.02 $295.29 $250.52 $207.39

39 $302.25 $257.15 $237.03 $299.08 $253.73 $210.05

40 $306.08 $260.41 $240.03 $302.87 $256.95 $212.71

41 $311.83 $265.30 $244.54 $308.56 $261.78 $216.71

42 $317.33 $269.99 $248.86 $314.01 $266.40 $220.53

43 $325.00 $276.51 $254.87 $321.59 $272.84 $225.86

44 $334.58 $284.66 $262.38 $331.07 $280.88 $232.52

45 $345.84 $294.24 $271.21 $342.21 $290.33 $240.34

46 $359.25 $305.65 $281.73 $355.48 $301.59 $249.66

47 $374.34 $318.49 $293.56 $370.41 $314.25 $260.15

48 $391.58 $333.16 $307.08 $387.47 $328.73 $272.13

49 $408.58 $347.62 $320.42 $404.30 $343.00 $283.95

50 $427.74 $363.92 $335.45 $423.26 $359.09 $297.26

51 $446.66 $380.02 $350.28 $441.98 $374.97 $310.41

52 $467.50 $397.75 $366.62 $462.60 $392.46 $324.89

53 $488.58 $415.68 $383.15 $483.45 $410.16 $339.54

54 $511.33 $435.04 $400.99 $505.97 $429.26 $355.35

55 $534.08 $454.40 $418.84 $528.48 $448.36 $371.16

56 $558.75 $475.38 $438.18 $552.89 $469.07 $388.31

57 $583.66 $496.58 $457.72 $577.54 $489.98 $405.62

58 $610.24 $519.19 $478.56 $603.84 $512.29 $424.09

59 $623.41 $530.40 $488.89 $616.88 $523.35 $433.25

60 $650.00 $553.02 $509.74 $643.18 $545.67 $451.72

61 $672.99 $572.58 $527.77 $665.93 $564.97 $467.70

62 $688.08 $585.42 $539.60 $680.86 $577.64 $478.18

63 $707.00 $601.51 $554.44 $699.59 $593.52 $491.33

64+ $718.49 $611.30 $563.46 $710.96 $603.17 $499.32




Meritus Saver Gold PPO HSA

Plus 1500

Meritus Saver Silver PPO HSA

Plus 2000

Meritus Saver Bronze PPO HSA

Plus 6300Age

2015 Meritus Choice PPO & Saver PPO HSA PlansIndividual Pricing Sheet - Maricopa County



0-20 $141.34 $120.25 $110.84 $139.86 $118.65 $98.23

21-24 $222.59 $189.38 $174.56 $220.25 $186.86 $154.69

25 $223.47 $190.13 $175.25 $221.13 $187.61 $155.30

26 $227.93 $193.92 $178.74 $225.54 $191.34 $158.40

27 $233.27 $198.46 $182.93 $230.82 $195.83 $162.11

28 $241.95 $205.85 $189.74 $239.41 $203.11 $168.14

29 $249.07 $211.91 $195.33 $246.46 $209.09 $173.09

30 $252.63 $214.94 $198.12 $249.98 $212.08 $175.57

31 $257.97 $219.48 $202.31 $255.27 $216.57 $179.28

32 $263.32 $224.03 $206.50 $260.56 $221.05 $182.99

33 $266.65 $226.87 $209.12 $263.86 $223.86 $185.31

34 $270.22 $229.90 $211.91 $267.38 $226.85 $187.79

35 $272.00 $231.41 $213.31 $269.14 $228.34 $189.03

36 $273.78 $232.93 $214.70 $270.91 $229.83 $190.26

37 $275.56 $234.44 $216.10 $272.67 $231.33 $191.50

38 $277.34 $235.96 $217.49 $274.43 $232.82 $192.74

39 $280.90 $238.99 $220.29 $277.95 $235.81 $195.21

40 $284.46 $242.02 $223.08 $281.48 $238.80 $197.69

41 $289.80 $246.56 $227.27 $286.76 $243.29 $201.40

42 $294.92 $250.92 $231.28 $291.83 $247.59 $204.96

43 $302.05 $256.98 $236.87 $298.88 $253.57 $209.91

44 $310.95 $264.56 $243.85 $307.69 $261.04 $216.10

45 $321.41 $273.46 $252.06 $318.04 $269.82 $223.37

46 $333.87 $284.06 $261.83 $330.37 $280.29 $232.03

47 $347.90 $295.99 $272.83 $344.25 $292.06 $241.77

48 $363.92 $309.63 $285.40 $360.11 $305.51 $252.91

49 $379.73 $323.07 $297.79 $375.75 $318.78 $263.89

50 $397.53 $338.22 $311.75 $393.37 $333.73 $276.27

51 $415.12 $353.18 $325.54 $410.77 $348.49 $288.49

52 $434.48 $369.66 $340.73 $429.93 $364.75 $301.95

53 $454.07 $386.32 $356.09 $449.31 $381.19 $315.56

54 $475.21 $404.31 $372.67 $470.23 $398.94 $330.25

55 $496.36 $422.30 $389.26 $491.16 $416.69 $344.95

56 $519.29 $441.81 $407.23 $513.84 $435.94 $360.88

57 $542.44 $461.50 $425.39 $536.75 $455.37 $376.97

58 $567.14 $482.52 $444.76 $561.20 $476.11 $394.14

59 $579.38 $492.94 $454.36 $573.31 $486.39 $402.65

60 $604.09 $513.96 $473.74 $597.76 $507.13 $419.82

61 $625.46 $532.14 $490.50 $618.90 $525.07 $434.67

62 $639.48 $544.07 $501.49 $632.78 $536.84 $444.41

63 $657.07 $559.03 $515.28 $650.18 $551.60 $456.63

64+ $667.75 $568.12 $523.66 $660.75 $560.57 $464.06




Meritus Saver Gold PPO HSA

Plus 1500

Meritus Saver Silver PPO HSA

Plus 2000

Meritus Saver Bronze PPO HSA

Plus 6300Age

2015 Meritus Choice PPO & Saver PPO HSA PlansIndividual Pricing Sheet - Pima and Santa Cruz Counties



Meritus Choice PPO and Saver PPO HSA Plans by Networks in Maricopa County

Meritus PPO Network . . . . . . . . . . . . . . . . . . .6

Meritus Choice Gold PPO Plus 2000 . . . . . . . . . . . . . . . . . . . . . .79

Meritus Choice Silver PPO Plus 4000 . . . . . . . . . . . . . . . . . . 80 - 83

Meritus Choice Bronze PPO Plus 6000 . . . . . . . . . . . . . . . . . . . . . .84

Meritus Saver Gold PPO Plus 1500 . . . . . . . . . . . . . . . . . . . . . .85

Meritus Saver Silver PPO HSA Plus 2000 . . . . . . . . . . . . . . 86 - 89

Meritus Saver Bronze PPO HSA Plus 6300 . . . . . . . . . . . . . . . . . .90

Meritus Choice PPO and Saver PPO HSA Plans by Networks in Pima and Santa Cruz Counties

Meritus PPO Network . . . . . . . . . . . . . . . . . . .6

Meritus Choice Gold PPO Plus 2000 . . . . . . . . . . . . . . . . . . . . . .79

Meritus Choice Silver PPO Plus 4000 . . . . . . . . . . . . . . . . . . 80 - 83

Meritus Choice Bronze PPO Plus 6000 . . . . . . . . . . . . . . . . . . . . . .84

Meritus Saver Gold PPO HSA Plus 1500 . . . . . . . . . . . . . . . . . .85

Meritus Saver Silver PPO Plus 2000 . . . . . . . . . . . . . . . . . . 86 - 89

Meritus Saver Bronze PPO HSA Plus 6300 . . . . . . . . . . . . . . . . . .90

2015 Meritus Choice PPO & Saver PPO HSA PlansIndividual Pricing on page 100

2015 Meritus Choice PPO & Saver PPO HSA PlansIndividual Pricing on page 101

PAGE PAGE


Summary of Pharmacy BenefitsPharmacy 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.

Many of our plan designs offer no copay for generic maintenance medications.

• Long-term medications or “maintenance medications” are taken regularly for chronic conditions such as high blood pressure, asthma, diabetes or high cholesterol and can be filled at one of our contracted retail pharmacies or through mail-order service.

• Short-term medications are generally taken for a limited amount of time and have a limited amount of refills, such as antibiotics, and can be filled at one of our contracted retail pharmacies.

Some of our contracted pharmacies:

• Albertson’s

• Bashas’

• Costco

• CVS Pharmacies

• Food City

• Fry’s

• K-Mart

• Osco

• Safeway

• Sam’s Club

• Sav-on

• Target

• Walmart

For more information on these contracted pharmacies and to view their drug formularies, please go to meritusaz.com.

Note: Mail order is for 90 days and is 3 times the 30-day retail copay utilizing CVS Caremark’s mail order service. Members may also obtain a 90 day supply at CVS pharmacies for the 90 day copay.

Rx Deductible - Does not apply to Generic Drugs

$0 $0 $300 $250 $300

Generic Maintenance Drugs

$0 Copay – Retail$0 Copay – Mail

$0 Copay - Retail$0 Copay - Mail




Generic Non-Maintenance

$5 Copay – Retail$15 Copay – Mail





Preferred Brand$15 Copay - Retail$45 Copay - Mail


After RX Deductible$60 Copay - Retail$180 Copay - Mail



Non-Preferred Brand$60 Copay - Retail$120 Copay - Mail





Specialty Drugs50% Copay - Retail50% Copay - Mail

50% Copay - Retail50% Copay - Mail

After RX Deductible50% Copay - Retail50% Copay - Mail



Group & Individual HMO Markets

Meritus Healthy Platinum Complete HMO Plus 500

Meritus Healthy Platinum HMO Abrazo Plus 500

Meritus Healthy Platinum HMO Banner Plus 500

Meritus Healthy Platinum HMO Pima Plus 500*

Meritus Healthy Platinum HMO Mohave Plus 500



Meritus Healthy Gold HMO Abrazo Plus 2000

Meritus Healthy Gold HMO Banner Plus 2000

Meritus Healthy Gold HMO Pima Plus 2000*

Meritus Healthy Gold HMO Mohave Plus 2000


Meritus Healthy Silver Complete HMO 4000

Meritus Healthy Silver HMO Abrazo 4000

Meritus Healthy Silver HMO Banner 4000

Meritus Healthy Silver HMO Pima 4000*

Meritus Healthy Silver HMO Mohave 4000

Meritus Healthy Silver HMO MIHS 4000

Individual HMO Market Only

Meritus Neighborhood Network Silver HMO MIHS

Meritus Community Network Silver HMO Banner

Meritus Community Network Silver HMO Pima


Meritus Healthy Bronze Complete HMO 6000

Meritus Healthy Bronze HMO Abrazo 6000

Meritus Healthy Bronze HMO Banner 6000

Meritus Healthy Bronze HMO Pima 6000*

Meritus Healthy Bronze HMO Mohave 6000

Meritus Healthy Bronze HMO MIHS 6000

Group HMO Market Only

Meritus Healthy Platinum HMO MIHS Plus 500


Meritus Healthy Gold HMO MIHS Plus 2000

Group & Individual PPO Markets





Meritus Healthy Bronze HMO MIHS 6000



*Individual On FFM Market & SHOP Only.



Changing everything, by providing easy, simple and helpful support.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.


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, 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 2015 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.

Certificate of CompletionSample Broker

123567

has successfully completed the followingcurriculum for agents/brokers:

Agent and Broker Individual Marketplace and SHOP Marketplace Curriculum, Plan Year 2015

on9/1/2014

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 Contracting Process

Completing and submitting your Create a Broker Account form initiates the Meritus Broker Contracting (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).

The broker contracting process consists of the following steps:

• Training in Meritus products, resources and tools are available.

• 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. Exhibit 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.

You will be able to adopt your signature style.

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.


When all fields are complete you will get a message indicating that All required fields complete. Click on the Confirm Signing button

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.

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.


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].

Commission Payments

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 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 for 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 suspended 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

• 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


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.

Internal Broker Service Team

Phone: 602.957.2113 Toll Free: 1.855.755.2700

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

Email: [email protected]

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

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

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 Partner - 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)