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 Contents
When 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 Center
Cochise Bisbee Copper Queen Community Hospital
Douglas Southeast Arizona Medical Center
Sierra Vista Sierra Vista Regional Health Center
Willcox Northern Cochise Community Hospital
Coconino Flagstaff Flagstaff Medical Center
Page Page Hospital
Tuba City Tuba City Regional Healthcare
Gila Globe Cobre Valley Regional Medical Center
Payson Payson Regional Medical Center
Safford Mt Graham Regional Medical Center
La 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 Center
Mohave Bullhead City Western Arizona Regional Medical Center
Kingman Kingman Regional Medical Center
Lake Havasu City Havasu Regional Medical Center
Navajo Show Low Summit Healthcare Regional Medical Center
Winslow Little Colorado Medical Center
Pima Tucson Carondelet St. Joseph’s Hospital
Carondelet St. Mary’s Hospital
Northwest Medical Center
Tucson Medical Center
Oro Valley Oro Valley Hospital
Pinal 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 Hospital
Yavapai Cottonwood Verde Valley Medical Center
Prescott Yavapai Regional Medical Center
Prescott Valley Mountain Valley Regional Rehab Hospital
Yavapai Regional Medical Center-East
Yuma 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
Nogales
Holy 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
Nogales
Holy Cross Hospital
Maricopa County
• Scottsdale/ Lincoln
Health Network
• Banner Health
• Abrazo Health
Center
Pima and Santa Cruz
Counties
• Carondelet Health
Network
• Tucson Medical
Center

Meritus HMO MIHS Network
Meritus HMO Banner Network
Maricopa County
Center
• 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
Pima and Santa Cruz
Counties
• St. Mary’s Hosptial
• St. Joseph’s Hospital
- Tucson
• Carondelet Heart &
Vascular Institute
• Carondelet
Neurological Institute
• Holy Cross Hospital Nogales
Holy Cross Hospital

Bullhead City
MohaveValley
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 All
To 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
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)
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 $31,970
MedicaidcoveragePrivateMarketplacehealthplans
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 SEP
Termination 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
Day before
effective date
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 Proposal
Enter demographic information,
select plan and create proposal.
2 Application
Fill out the enrollment application and sign form.
3 Sent to Membership
Applications is sent to membership
for processing.
4 Member
Individual 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
2Off 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 WT 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 Proposal
Enter company and employee information,
select plans and create proposal.
2 Application
Fill out the group application and submit.
3 Carrier Approval
Carrier reviews and approves group application.
4 Open Enrollment
Employees/agents select plans and enroll.
5 Review Submit
Approve and submit employee enrollments.
6 Sent to Membership
System sends employee enrollment
information to membership.
7 Active Group
Group 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
Proposal
Page 43
Application
Page 48
Carrier Approval
Page 51
Open Enrollment
Page 52
Review Submit
Page 57
Sent to Membership
Page 58
Active Group
Page 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 Platinum
Networks: 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.
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

Deductible - per calendar year $0 single/$0 family
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
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
Prescription Deductible per person per calendar year - Does not apply to Generic Drug Tiers $300
Preferred Brand $60 copay** $180 copay**
Non-Preferred Brand $150 copay** $450 copay**
Specialty 50%** 50%**
*1st 3 MH/SA visits at $0 copay for Gold and Silver plans - does not apply for HSAs. **After separate prescription drug deductible.
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

Meritus 2015 Broker Handbook VNT LR

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