SMART Humana Group Medicare

Transcription

1 SMART Humana Group Medicare Group Medicare GHHHNYFEN 0813

2 Overview of Humana Medicare Medicare is the largest government-sponsored health insurance program in the United States, serving more than 49 million people. It s administered by the Centers for Medicare & Medicaid Services (CMS) under the U.S. Department of Health and Human Services (HHS). Medicare covers Americans age 65 and older and others who qualify due to disability. Medicare beneficiaries can choose to receive Original Medicare coverage administered by CMS or Medicare Advantage plans administered by private companies. Beneficiaries make a Medicare health plan choice when they first become eligible for Medicare. Humana s Medicare Advantage Solution Original Medicare Part A and Part B Medicare Part D Prescription Plan Supplement plan Med Supps or Medigap or Humana Group Medicare Advantage (Part C) Humana Group Medicare Advantage plans combine all of the benefits of Original Medicare, Part A and Part B, in a single plan which Humana underwrites and administers. Humana plans include additional benefits such as wellness programs and case management services. Most of these plans include an integrated Part D prescription drug plan (PDP), which eliminates the need for free-standing pharmacy benefits. NOTE: Medicare Advantage plans are not the same as Medicare supplement plans, which are also referred to as Medigap plans. Like MA plans, Medicare supplement plans are sold by private health insurance companies. 2

3 Overview of Humana Medicare Original Medicare and Medicare Advantage Compared Original Medicare (Parts A and B) Medicare Advantage (Part C) Administrative services Claims payment Monitoring for fraud and abuse Basic health coverage benefits Inpatient and outpatient hospital care Skilled nursing facility care Emergency services nationwide Basic preventive services Bone mass measurement Colorectal screening exams Immunizations Pap tests and pelvic exams Prostate cancer screening exams Enhanced benefits Low-cost copayments for doctor s office visits Annual out-of-pocket maximums Emergency care worldwide Discounts for dental, vision, and hearing services available; certain restrictions may apply Focused on improving outcomes Proactive identification of members who may need additional support Care management programs Wellness services such as senior-focused fitness programs 3

4 Overview of Humana Medicare Original Medicare Part A details Medicare Part A helps cover the following: Inpatient care in hospitals, including critical access hospitals and inpatient rehabilitation facilities Inpatient stays in a skilled nursing facility but not custodial or long-term care Hospice care services Home healthcare services Inpatient care in a religious non-medical healthcare institution coverage related to non-medical, non-religious parts of care Most beneficiaries don t pay a monthly premium for Part A coverage if they or their spouse paid Medicare taxes while working. If the person isn t eligible for premium-free Part A, he or she may be able to buy it after meeting certain conditions. Original Medicare Part B details Part B helps cover medically necessary services like: Doctors services Outpatient care Other medical services Part A doesn t cover, including some physical and occupational therapy services and some home healthcare, if these services are medically necessary Many preventive services Most beneficiaries pay the standard premium amount for Medicare Part B. However, some beneficiaries pay more or less, depending on yearly income. Beneficiaries also pay a Part B deductible each year before Medicare starts to pay its share. Part C (Medicare Advantage) details Medicare Part C, also known as Medicare Advantage (MA), is another way to receive Medicare benefits. These plans, which are offered by private insurance companies that have contracts with Medicare, must cover at least all of the medically necessary services Original Medicare (Part A and Part B) covers. However, MA plans can charge different copayments, coinsurance, and deductibles for these services. The member s out-of-pocket costs vary depending on the services received. MA plan members don t need to buy a Medicare Supplement policy. Most MA plans offer extra benefits and services such as: Health and wellness programs Hearing services Vision services Dental services Some MA plans also include Medicare prescription drug coverage (MAPD) MA plan members pay their monthly Part B premium in addition to the MA plan premium, if one is charged. Medicare Advantage plans often have provider networks that require members to use providers contracted with their plan. Plan members must follow plan rules. For example, an MA HMO may require members to get prior authorization for certain procedures. Each year, the plan sends members an Evidence of Coverage (EOC) that provides details about what the plan covers, how much members pay, how to file an appeal, and more. Each fall, the plan sends renewing members an Annual Notice of Change (ANOC) that spells out any changes in benefits, costs, or service area that will be effective in January. The notice for MAPD plans also includes changes to the formulary. Beneficiaries in a Group Medicare Advantage plan can enroll in or switch plans based on their group s open enrollment or eligibility guidelines. Most plans have a Jan. 1 effective date. 4

5 Overview of Humana Medicare Part D (prescription drug plan) details Medicare Part D, also known as Medicare prescription drug coverage, helps beneficiaries pay for medications intended to provide better physical and mental health. Most beneficiaries don t get Part D automatically, so they have to select it in one of two ways: 1) A stand-alone Medicare prescription drug plan (PDP) 2) A Medicare Advantage plan that covers prescription drugs, also known as an MAPD plan, or another Medicare health plan that includes drug coverage Medicare drug plans must provide at least a standard level of coverage set by Medicare. All plans may have up to four stages or phases of coverage, and members have different out-of-pocket costs in each stage: Stage 1: Members pay their yearly deductible before their plan begins to pay for covered prescriptions. Some drug plans charge no deductible. Stage 2: During this phase, members pay copayments or coinsurance for covered prescriptions, and the plan pays the rest. Stage 3: This phase is known as the coverage gap (or donut hole ). A member reaches this stage once their costs and the carrier s costs reach the Initial Coverage Limit (ICL). All plans have a coverage gap, but a plan sponsor can choose a plan with full coverage through the gap. Stage 4: After members true out-of-pocket (TrOOP) spending reaches the annual limit, they move into the catastrophic coverage phase, during which the plan pays most or all of the costs for covered drugs. The premium for Part D is usually separate from the Part B premium. Premiums and out-of-pocket costs vary depending on: The plan the member or group chooses Drugs the member uses Whether the member qualifies for extra help paying Part D costs 5

6 Overview of Humana Medicare Eligibility for Original Medicare Part A coverage starts automatically on the first day of the month in which an eligible person turns 65 even if the person is still working. People under 65 who have received Social Security Administration (SSA) or Railroad Retirement Board (RRB) disability benefits for 24 months get Part A automatically. To get Part B, a Medicare-eligible person must sign up and pay a monthly premium. People who get benefits from SSA or RRB get Part B automatically, starting the first day of the month they turn 65. Other Medicareeligibles must apply for Part B coverage and arrange for making payments. Humana s dedicated Group Medicare enrollment team is trained to communicate with seniors and understand their special needs. Eligibility for Medicare Advantage plans To be eligible for Humana Group Medicare Advantage coverage, a retiree or dependent must be enrolled in both Medicare Part A and Plan B* through age or disability, and they must continue to pay their Medicare premiums. People living abroad or who are incarcerated are not eligible. They do not reside in the plan s service area. Retirees and dependents approaching age 65 can enroll in a Medicare Advantage health plan: Within the three months before turning 65 During the month they turn 65 Within the three months after turning 65 *Exceptions do apply 6

7 You are in Stage 1. Contact us During this payment stage, the plan pays its share of the cost of your drugs and you (or others on your behalf) pay your share of the cost Reasons why Group Medicare Advantage makes good sense Why Humana s Group MA may be right for you Experience Today, Medicare Advantage and Part D programs are among the most critical and rapidly growing parts of Humana s business. We made a major corporate commitment to be and to remain a trusted administrator of senior health insurance products. Humana offered our first Medicare plan in 1985 and we introduced our first Group Medicare plan in We have a longstanding relationship with the Centers for Medicare & Medicaid Services (CMS). Humana remained a major Medicare insurer after the Balanced Budget Act of 1997, when many other insurers backed away from Medicare Advantage (MA) plans. More efficient - and often less costly - benefits Moving from Original Medicare plus secondary coverage to full-replacement Group Medicare Advantage can often reduce per-member per-month costs, giving clients potential for annual savings and reduced Financial Accounting Satandards Board (FASB) or Governmental Accounting Standards Board (GASB) liability. By administering an integrated plan, Humana gains a deeper understanding of members medical and claims data. This helps plan sponsors identify members who may benefit from clinical programs designed to improve care management and reduce trends. Extra services and benefits We offer a suite of clinical programs that addreses members health and benefits needs. Humana s proprietary tools and methods identify those in need of special care or at risk for health problems. Humana Active Outlook our exclusive suite of wellness services and life-enrichment programs that focuses on body fitness, nutrition, exercise, motivation, caregiving, and an overall healthful lifestyle, as well as programs focused on fitness and tobacco cessation HumanaFirst Nurse Advice Line - provides a toll-free, 24-hour assistance for members with general questions about their health SmartSummary Humana s award-winning proprietary health finance and benefits statement, a comprehensive overview of personal health benefits and health spending that helps members use their benefits with confidence and success SilverSneakers or Silver&Fit Fitness program that offers a fitness center membership and classes specifically for seniors Services and benefits vary based on the type of plan. Your personal prescription and medical benefits statement Rx PCN or Rx Member name: Jane Doe Member ID: H Plan name: Humana Group Medicare RPPO R Group Number: Statement date: January 1-31, 2011 This summary is your Explanation of Benefits (EOB) for your This summary includes: Medicare prescription drug coverage (Part D). Please review this Sections 1-8 summary and keep it for your records. (This is not a bill.) Your 2011 medical spending 1: Your medical plan...2 $21.08 payment stage are you...3 in? What you paid 2: Which drug What Humana paid $0.00 Humana discounts $ Excluded costs $0.00 3: Your medical claims...4 4: Your prescription claims...6 Your 2011 prescription spending billed charges $ : Your out-of-pocket costs and total...7 drug costs (amounts and definitions) 6: Updates to the plan s Drug List that will...8 What you paid $0.00 affect drugs you take What Humana paid $ : If you see mistakes on this summary or...8 have questions, what should you do? Humana discounts $ Average retail price $ : Important things to know about your...9 drug coverage and your rights If you have questions or need help contact us free of charge. Benefit questions visit Humana.com or call (TTY 711) Hours of operation Monday to Friday 8 a.m.- 9 p.m. EST. For large print or another format HDBOOKA To get this material in other formats, or ask for 123 EAST MAIN STREET language translation services, call Humana LOUISVILLE KY Customer Service at the number on this page. PDP 2011 Humana Inc., Patent Pending Y0040_GHA07HHHHd CMS Approved 01/13/2011 7

8 Humana s wide choice of products Who benefits from a Medicare Advantage plan with a prescription drug solution Are Humana s Group Medicare Advantage plans right for your group? You typically offer retiree benefits You want good benefits and cost control You re concerned about rising costs due to an aging population and healthcare trends You re trying to balance the desire for rich benefits with bottom-line concerns You want a simpler option You want to make it easy for retirees to use, understand, and appreciate their benefits You prefer to work with one company, and one contact for administration You place a high priority on health and wellness You support health fairs, wellness programs, etc. You want to help employees and retirees live healthier, happier lives 8

9 Glossary Common terms Access Only: Plans that have no employer contribution. Assignment: If a doctor, provider, or supplier accepts assignment, he or she agrees to the following conditions: To be paid by Medicare To accept only the amount Medicare approves for the services To only charge the beneficiary, or other insurance the beneficiary has, the Medicare deductible or coinsurance amount Coverage gap: The stage of Medicare prescription drug coverage between the initial coverage period and catastrophic coverage (often referred to as the donut hole ). Humana is required to cover 2.5 percent for name brand drugs in the coverage gap and 21 percent for generics. Therefore, members would pay 79 percent for generic and 97.5 percent for brand drugs in the gap. Creditable coverage: Prescription drug coverage, generally from an employer or union, that has been determined to be, on average, at least as good as the Medicare standard prescription drug coverage. Health Maintenance Organization (HMO): A type of Medicare Advantage plan that requires members to choose a primary care physician from a network of approved healthcare providers. If members need to see a specialist, they must have a referral from their primary care physician. Certain exceptions apply. High Option: A richer medical plan design with PDP and MAPD plans that cover generic and brand-name drugs during the coverage gap. Medicare Advantage (MA) plan: A Medicare-approved health plan from a private insurance company that provides medical coverage only. It doesn t include prescription drug coverage. Also called Medicare Part C. Medicare Advantage with prescription drug plan (MAPD): A Medicare-approved health plan from a private insurance company that provides medical coverage and prescription drug coverage. Original Medicare: A government-sponsored Medicare plan administered by the Centers for Medicare & Medicaid Services (CMS). Also known as traditional Medicare. Passive plan design: A Medicare PPO plan that pays the same level of benefit for care received in-network as out-of-network. Personal choice offering: When eligible members have multiple carriers and choices for the eligible members. Also called a slice offering. Preferred Provider Organization (PPO): A type of Medicare Advantage plan that allows members to see in-network or out-of-network doctors and other healthcare providers but members may save money by using providers in the plan s network. Prescription drug plan (PDP): An insurance plan that helps pay for medicines a doctor prescribes. A PDP can be a stand-alone plan that a member purchases from a Medicare-approved private insurer, or it can be part of a Medicare Advantage plan from a Medicare-approved private insurer. 9

10 Group health benefits Medicare Individual health Specialty benefits Pharmacy solutions Humana.com Humana is a Medicare Advantage organization and a stand-alone prescription drug plan with a Medicare contract. GHHHNYFEN 0813