Napa County. Medicare Advantage Plans. (Medicare Part C Plans) Compliments of HICAP. (Health Insurance Counseling and Advocacy Program)

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1 2015 Napa County Medicare Advantage Plans (Medicare Part C Plans) HICAP Volunteer Counselors are available to help compare health plans in an objective and unbiased manner. They can help consumers understand the advantages and disadvantages of joining a Medicare Advantage Plan. In addition, the Volunteer Counselors have information on Medicare benefits, Medicare Supplement Plans, and other health insurance options. HICAP counseling appointments are free of charge and can be scheduled at locations throughout Lake, Marin, Mendocino, Napa, Solano, and Sonoma counties. HICAP is a non-profit program administered by Senior Advocacy Services and is funded by the California Department of Aging in partnership with the Area Agency on Aging (AAA). Compliments of HICAP (Health Insurance Counseling and Advocacy Program) A program of Senior Advocacy Services 1304 Southpoint Blvd. Suite 280 Petaluma, Ca * (707) Fax #: (707) Rev. 10/14/2014 1

2 2015 Medicare Advantage (MA 1 ) Part C Plans The rules to join, switch, or drop a Medicare Advantage (MA 1 ) Part C Plan are as follows: You must have Medicare Parts A and B to join a Medicare Advantage (MA 1 ) plan. Based on the enrollment opportunities listed below, your effective date will be the first day of the month following the date of your request. 1. Initial Coverage Election Period (ICEP): a. When you first become eligible for Medicare (usually first of the month of your 65 th birthday), you have the three months before eligibility, the month of eligibility, and three months after eligibility in Medicare (total of seven months) to choose a MA 1 plan. b. If you get Medicare due to a disability, you can join during the 7-month period that begins 3 months before your 25 th month of disability and ends 3 months after your 25 th month of disability. 2. Annual Election Period (AEP) October 15 to December 7 Each Year: a. If you request enrollment during this time, your effective date will be January 1. b. In most cases, when you enroll in a new MA 1 plan, your membership in your current plan will automatically be cancelled. c. If you enroll in a MA 1 HMO plan without a PDP 2, you cannot enroll in a stand-alone PDP 2 plan. d. If you enroll in a MA 1 PFFS plan without a PDP 2, you can enroll in a stand-alone PDP Annual Disenrollment Period (ADP) January 1 to February 14: a. You can disenroll from a MA 1 plan and return to Original Medicare (Medicare Parts A and B). b. If you switch to Original Medicare during this period, you will have until February 14 to enroll in a Medicare Prescription Drug (PDP) plan for your drug coverage. c. Your effective date will be the first day of the month following the date of your request. d. You cannot switch to another MA 1 plan nor can people in Original Medicare join an MA 1 plan. 4. Special Election Periods (SEPs) may allow You to Change MA 1 Plans during the Year: a. If your MA plan terminates on December 31, you have a SEP from October 1 to January 31 to enroll in a different MA or PDP plan or return to Original Medicare. Changes made before December 31 will be effective January 1; changes made before January 31 will be effective February 1. b. If you move out of the service area of the MA 1 plan, you have a 2-month SEP to enroll in a new plan offered in your new county. c. If your creditable prescription drug coverage through your employer health plan ends, you have a 2-month SEP starting the day you lose coverage. d. If you have full Medi-Cal benefits, you have an ongoing SEP to enroll in or change MA 1 plans. e. If you lose your full Medi-Cal benefits, you have a 3-month SEP to change MA 1 plans. f. If you are eligible for Extra Help, Low-Income Subsidy (LIS), you have an ongoing SEP. g. If you lose the Extra Help (LIS), you have a 2-month SEP to change to another MA or PDP plan. h. If you live in, or move into or out of an institution (like a nursing home) Star Special Enrollment Period December 8, 2012 to November 30, 2013: a. Starting December 8, 2012, you can switch to a 5-star MA 1 Plan at any time up to November 30, b. Your effective date will be first of the month following the date you enroll in the 5-Star plan. c. You can only join a 5-star MA 1 plan if one is available and only once each year. 1 End Stage Renal Disease (ESRD): You can be denied enrollment in a MA plan if you have End Stage Renal Disease (ESRD), also known as kidney failure. If you develop ESRD while enrolled in a MA plan, the MA plan cannot disenroll you. 2 PDP = Prescription Drug Plan (PDP) and is referring to the stand-alone Medicare Part D prescription drug plans. Rev. 10/14/2014 2

3 Napa County 2015 Medicare Advantage Plans Company Name: Plan Name: Plan Type: Phone Numbers: Website: Kaiser Permanente Senior Advantage ***** HMO (H ) Non-Members: Members: Kaiser Permanente Senior Advantage ***** HMO SNP (H ) Non-Members: Members: Monthly Premium: $73 (+ Medicare Part B premium) $0 (You must have full Medi-Cal) 2. Doctor and Hospital Choice: Plan Doctors Only Plan Doctors only 3. Calendar Year Deductible: $0 $0 4. Out-of-Pocket Limit: $4,400 $3, PART A: Inpatient Hospital Stays: Days 1-7: $255 copay per day; $0 copay for additional hospital days $0 copay with unlimited days each benefit period 6. Skilled Nursing Facility Days 1-10: $25 copay per day Days 1-100: $0 copay Care: Days : $50 copay per day 7. Home Health Care: $0 copay for Medicare-covered visit $0 copay for Medicare-covered visit 8. Hospice Care: Medicare-certified hospice only Medicare-certified hospice only 9. PART B: Calendar Year Deductible: See appropriate copayments/ coinsurance amounts below. See appropriate copayments/ coinsurance amounts below. 10. Ambulance Services: $200 copay $0 copay 11. Chiropractic Care: $20 copay for Medicare-covered visit $0 copay for Medicare-covered visit 12. Diagnostic Tests, X-Rays, $45-$45-$170 copay $0 copay Lab, Radiology Services: 13. Doctor s Office Visits: 2 PCP: $25 copay per visit $0 copay Specialist: $25 copay per visit 14. Durable Medical 20% for Medicare-covered items $0 copay Equipment (DME): 15. Emergency Room (E.R.): $65 copay for Medicare-covered visit $0 copay 16. Urgent Care Services: $25-$65 copay for Medicare-covered $0 copay visit 17. Worldwide Services: Worldwide coverage Worldwide coverage 18. Outpatient Mental $25 copay individual therapy visit; $0 copay Health Care Per Visit: $12 copay for group therapy visit 19. Outpatient Services/ $250 ambulatory surgical center visit; $0 copay Surgery: $0-$250 for outpatient hospital visit 20. Preventive Care Services: See Summary of Benefits or call plan See Summary of Benefits or call plan 21. Routine Hearing Exams: See Summary of Benefits or call plan See Summary of Benefits or call plan 22. Routine Vision Exams: See Summary of Benefits or call plan See Summary of Benefits or call plan 23. PART D: Medicare Rx Prescription Drug Coverage: Initial Coverage: $5-$15-$45-$95-33% to $2,850 for formulary drugs. Coverage Gap: $5-$10 generic drugs; 47.5% brand drugs until your out-of-pocket costs reach $4,700. Catastrophic Cov.: $5-$12 copay Initial Coverage: Based on your copays agreed to by the Extra Help program to $2,850 for formulary drugs. Coverage Gap: Same as above. Catastrophic Cov.: Same as above. 24. Optional Supplemental Benefits: NOTE: This is a brief description of benefits. Please contact plan for details and Summary of Benefits. 1 PCP = Primary Care Provider ***** Member Satisfaction Rating (1 Star=Poor; 2 Stars=Below Average; 3 Stars=Average; 4 Stars=Above Average; 5 Stars=Excellent) Rev. 10/14/

4 Company Name: Plan Name: Plan Type: Phone Numbers: Napa County 2015 Medicare Advantage Plans SCAN Heart First HMO - SNP (H ) Non-Members: SCAN - Balance HMO - SNP (H ) Non-Members: Website: 1. Monthly Premium: $20 (+ Medicare Part B premium) $20 (+ Medicare Part B premium) 2. Doctor and Hospital Choice: Plan Doctors Only Plan Doctors Only 3. Calendar Year Deductible: $0 $0 4. Out-of-Pocket Limit: $3,400 $3, PART A: Days 1-5: $195 copay per day Days 1-5: $195 copay per day Inpatient Hospital Stays: $0 copay for additional hospital days $0 copay for additional hospital days 6. Skilled Nursing Facility Days 1-20: $0 copay per day Days 1-20: $0 copay per day Care: Days $50 copay per day Days $50 copay per day 7. Home Health Care: $0 for copay $ 0 for copay 8. Hospice Care: Medicare-certified hospice only Medicare-certified hospice only 9. PART B: See appropriate copayments/ See appropriate copayments/ Calendar Year Deductible: coinsurance amounts below: coinsurance amounts below: 10. Ambulance Services: $300 copay one way $300 copay one way 11. Chiropractic Care: $15 copay (10 visits) $15 copay (10 visits) 12. Diagnostic Tests, X-Rays, $0 copay; see Summary of Benefits $0 copay; see Summary of Benefits Lab, Radiology Services: or call plan or call plan 13. Doctor s Office Visits: 3 PCP: $5 copay per visit 3 PCP: $5 copay per visit Specialist: $15 copay per visit Specialist: $15 copay per visit 14. Durable Medical 20% for Medicare-covered items $0 for Medicare-covered items Equipment (DME): 15. Emergency Room (E.R.): $65 copay for Medicare-covered $65 copay for Medicare-covered visit $0 if admitted visit $0 if admitted 16. Urgent Care Services: $35 copay US Only $35 copay US Only 17. Worldwide Services: Worldwide coverage Worldwide Coverage 18. Outpatient Mental $25 for copay $25 for copay Health Care Per Visit: 19. Outpatient Services/ $ copay for ambulatory $ copay for ambulatory Surgery: surgical visit surgical visit 20. Preventive Care Services: $0 copay for Medicare-covered $0 copay for Medicare-covered 21. Routine Hearing Exams: $0 copay (1 per year) $500 Aids $0 copay (1 per year) $500 Aids 22. Routine Vision Exams: $0 copay (1 per year) $ lens/fr $0 copay (1 per year) $0-175 lens/fr 23. PART D: Medicare Rx Prescription Drug Coverage (Part D): Optional Supplemental Benefits: Initial Coverage: $ % & $10 to $2,960 for formulary drugs. Catastrophic Cov.: $2.55/5% outof-pocket costs reach $4,700. See Plan Initial Coverage: $ % & $10 to $2,960 for formulary drugs. Catastrophic Cov.: $2.55/5% outof-pocket costs reach $4,700. See Plan Transport, Dental & Vision coverage available; contact plan for details and cost. NOTE: This is a brief description of benefits. For more details, please contact plan for Summary of Benefits. ***** Member Satisfaction Rating (1 Star=Poor; 2 Stars=Below Average; 3 Stars=Average; 4 Stars=Above Average; 5 Stars=Excellent) Rev. 10/14/14 4

5 Napa County 2015 Medicare Advantage Plans Company Name: Plan Name: Plan Type: Phone Numbers: SCAN - Classic HMO (H ) Non-Members: Intentionally Blank Website: 1. Monthly Premium: $0 (+ Medicare Part B premium) 2. Doctor and Hospital Choice: Plan Doctors Only 3. Calendar Year Deductible: $0 4. Out-of-Pocket Limit: $3, PART A: Days 1-5: $150 copay per day Inpatient Hospital Stays: $0 copay for additional hospital days 6. Skilled Nursing Facility Care: Days 1-10: $0 copay per day Days 11-20: $25 Days $50 copay per day 7. Home Health Care: $0 for copay 8. Hospice Care: Medicare-certified hospice only 9. PART B: See appropriate copayments/ Calendar Year Deductible: coinsurance amounts below: 10. Ambulance Services: $200 copay 11. Chiropractic Care: $15 copay (10 visits) 12. Diagnostic Tests, X-Rays, $0 copay; see Summary of Benefits or Lab, Radiology Services: call plan 13. Doctor s Office Visits: 3 PCP: $5 copay per visit Specialist: $15 copay per visit 14. Durable Medical Equipment 20% for Medicare-covered items (DME): 15. Emergency Room (E.R.): $65 copay for Medicare-covered visit $0 if admitted 16. Urgent Care Services: $35 for Medicare-covered visit 17. Worldwide Services: Worldwide coverage 18. Outpatient Mental $25 for copay Health Care Per Visit: 19. Outpatient Services/ $75 copay for ambulatory surgical visit Surgery: 20. Preventive Care Services: $0 copay for Medicare-covered 21. Routine Hearing Exams: $0 copay (1 per year) $500 Aids 22. Routine Vision Exams: $0 copay (1 per year) $ lens/fr 23. PART D: Medicare Rx Prescription Initial Coverage: $3-$7-$45-$75-33% Drug Coverage (Part D): & $10 to $2,850 for formulary drugs. Catastrophic Cov.: $2.55/5% out-ofpocket costs reach $4,940. See Plan Optional Supplemental Benefits: Rev. 10/14/2014 5

6 Napa County Definitions of Medicare Advantage (MA) Plans: Beginning January 1, 2014, is (one) Medicare Advantage plans available. When you sign up for a Medicare Advantage plan, you assign your Medicare Part A and Part B over to the plan. Your plan determines what is covered and what is not covered. The definition for each of these plans is below: 1. Health Maintenance Organization (HMO) plan: HMO Plans must cover all Medicare Part A and Part B health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan s list except in an emergency. Your costs may be lower than in the Original Medicare Plan. 2. Private Fee for Service (PFFS) Plan: A type of Medicare Advantage plan (Part C) in which you may go to any Medicare-approved doctor or hospital that accepts the plan s payment. The insurance plan, rather than the Medicare program, decides how much it pays and what you pay for the services you will receive. You may pay more or less for Medicare-covered benefits and may have extra benefits than in the Original Medicare Plan. If your PFFS plan doesn t offer a Part D drug benefit, you can join a stand-alone Prescription Drug Plan (PDP). 3. Special Needs Plan (SNP): Medicare Special Needs Plans (SNP) are specially designed for people with certain chronic diseases and other specialized health needs. These plans are only available for specific groups of people, such as people living in certain long-term care facilities (like a nursing home), people eligible for Medicare and Medicaid (Medi-Cal in California), or people with certain chronic or disabling conditions. All Medicare SNPs provide Medicare Part D prescription drug coverage. About this Chart: All Medicare Advantage (MA) plans must adhere to the guidelines established by the Centers for Medicare & Medicaid Services (CMS) and must provide all of the benefits covered under Original Medicare. This Comparison Chart is a summary only and highlights the areas where these plans may differ in benefits. For more specific information, please contact each plan directly. MA plans are Individual Plans for people who do not qualify for an Employer Group Health Plan (EGHP). An EGHP may be very different from the plans listed in this chart. Converting an EGHP from actively working to a retiree plan, and going on Medicare may change your benefits and premiums. HICAP provides one-on-one counseling to help you compare your current EGHP plan with individual Medicare Advantage plans (HMO and PPO) and Medicare Supplement (Medigap) plans. Rev. 10/14/2014 6