2015 Concordia Health Plan for Medicare Members

Transcription

1 2015 Cocordia Health Pla for Medicare Members A summary of the beefits, discouts, ad programs for members of the Cocordia Health Pla with Medicare supplemetal coverage.

2 Cocordia Health Pla for Medicare Members Whe Cocordia Health Pla (CHP) members retire ad qualify for postretiremet health coverage, Medicare becomes the primary payor of medical claims o the first of the moth i which they reach age 65 (or the first of the prior moth if their birthday is o the first of the moth). If they have already reached age 65 at the time of retiremet, Medicare is the primary payor o the first of the moth after they retire. Medicare also becomes the primary payor for depedets of deceased members at the time the depedet reaches age 65. Oce Medicare becomes primary, the beefits available uder the CHP will supplemet the beefits provided by Medicare. Eligible persos for CHP Medicare supplemetal coverage are those who: are o loger employed full time by a participatig LCMS employer; participated i the CHP as a active worker at least five cosecutive years immediately prior to retiremet OR, if the employer participated i The Church s Pla, participated i the CHP as a active worker at least oe year immediately prior to retiremet ad had at least five years of Retiree Medical Supplemet credits; ad are eligible for Medicare, ad Medicare has the primary paymet resposibility for their medical care. Reerollmet of retired members may be allowed uder certai coditios (see FAQ 1 o page 14). Medicare is govermet-provided medical care for those age 65 ad over; those drawig Social Security disability beefits for two years or more; or those sufferig from chroic kidey disease. Erollmet i Medicare ca be completed at your local Social Security Admiistratio office. It is suggested that you do so two to three moths prior to your 65th birthday. It is importat to eroll i both Medicare Parts A ad B because a perso who is ot i Medicare will still be cosidered a Medicare Member by Cocordia Pla Services, if eligible. Medicare beefits will the be estimated for purposes of determiig the CHP beefits. You are also urged to use doctors who accept assigmet of beefits for charges covered by Medicare because medical expeses above the Medicare-approved amout will ot be covered by the CHP. Your erolled depedets are eligible for CHP Medicare supplemetal coverage if: (Both must apply) You are a CHP member. They are age 65 or older. 2

3 Iformatio to Keep i Mid Medicare has primary paymet resposibility for their medical care. CHP is desiged to supplemet Medicare coverage. Services are covered per oe caledar year. CHP provides prescriptio drug coverage for Medicare members with copays ad o coverage gap. Medical claims are processed by Blue Cross Blue Shield of Miesota. Prescriptio drug beefits are admiistered by Express Scripts. Hearig care discouts are icluded i the CHP. Expeses ot covered iclude detal, custodial care, over-thecouter drugs, ad others (refer to the CHP Official Pla Documet). Eve if you are ot receivig Social Security beefits, you ca still purchase Medicare coverage. Should you die, your erolled depedets are give the opportuity to cotiue CHP coverage as survivig depedets. The 2015 cost for CHP Medicare supplemetal coverage is $309 per moth, per perso. Medicare Part B premiums vary o the basis of icome. Medicare Part D premiums are also adjusted o the basis of icome. The chart below shows the costs based o icome ad icome tax filig status: Idividual Filig Status Married Filig Joitly Mothly Part B Cost Mothly Part D Additioal Cost Icome Up to $85,000 Up to $170,000 $ Your pla premium $85,001 $107,000 $170,001 $214,000 $ $107,001 $160,000 $214,001 $320,000 $ $160,001 $214,000 $320,001 $428,000 $ More tha $214,000 More tha $428,000 $ $ your pla premium $ your pla premium $ your pla premium $ your pla premium 3

4 Part A: Hospital Isurace Pla Services/Medical Expeses Medicare Pays Hospital Expeses: Semi-private room ad board, geeral ursig ad miscellaeous hospital services ad supplies. Days 1-60 Days Days * with lifetime reserve Days without reserve days Beyod 150 days All but $1,260 All but $315/day All but $630/day *60 reserve days may be used oly oce. Days are ot reewable. Post-Hospital Skilled Nursig Facility Care Days 1-20 Days Beyod 100 days 100% All but $157.50/day Home Health Care (Medically ecessary care ad prescribed by a physicia) 100% 80% of approved amout for durable medical equipmet Hospice Care All but limited costs for outpatiet drugs ad ipatiet respite care Blood All but first 3 uits 4

5 CHP Pays Idividual Pays $1,260 $315/day $630/day 100% 100% 80% or ($126/day) 20% or ($31.50/day) 100% 80% of charges ot paid by Medicare 20% of charges ot paid by Medicare 80% of charges ot paid by Medicare 20% of charges ot paid by Medicare 80% of cost for first 3 uits 20% of cost for first 3 uits 5

6 Part B: Medical Expeses Services/Medical Expeses Medicare Pays Caledar year deductible: $147 Physicia s services for hospital, surgery, aesthesia, outpatiet hospital care; physicia visits; radiology ad pathology; ambulace services; durable medical equipmet, etc. 80%* of Medicare-approved eligible expeses Outpatiet Physical ad Occupatioal Therapy** 80%* of Medicareapproved expeses Outpatiet Metal Health Treatmet (e.g., couselig) 80%* of Medicareapproved expeses Blood 80% of approved amout after first 3 uits Prevetive Services such as mammogram, Pap smear, prostate cacer screeig, colorectal cacer screeig, vacciatios (Flu, Hepatitis B, Peumococcal), etc. Check details i your Medicare & You hadbook, provided by Medicare, or go to Medicare s website: *Medicare s actual percetage of paymet fluctuates based o the type of outpatiet services performed. I situatios where Medicare pays more or less tha 80% of the approved eligible amout, the CHP will adjust its reimbursemet to pick up the remaiig balace of the approved eligible amout. **Limits may apply i Cotact the Ceters for Medicare ad Medicaid Services at or call 800-MEDICARE ( ) for more iformatio. 6

7 CHP Pays Idividual Pays* $147 The 20% ot paid by Medicare The 20% ot paid by Medicare The 20% ot paid by Medicare 20% of Medicare-approved amout after first 3 pits First 3 uits, ad ay amout ot approved by Medicare** Ay portio of Medicare-approved expeses ot paid by Medicare *Charges above Medicare-approved amout: If your provider does ot accept the Medicare assigmet, you are resposible for ay charges above the Medicareapproved amout; however, this is ormally limited to o more tha 15% above the Medicare-approved amout. **First three uits of blood received o a outpatiet basis are ot covered. 7

8 Prescriptio Drug Beefits Medicare Part D There is o eed to sig up for Medicare Part D, Medicare s Prescriptio Drug Program, uless you qualify for special assistace through the govermet s low-icome drug subsidy. The CHP provides more comprehesive prescriptio drug coverage tha the stadard Part D beefits ad is cosidered creditable coverage uder Medicare Part D regulatios. Prescriptio Drugs CHP Medicare members have prescriptio drug coverage through the CHP Medicare Prescriptio Drug Pla (CHP PDP) admiistered directly through Express Scripts. Short-term prescriptios (for a 34-day supply or less through a local pharmacy) Geeric drug: $15 copay Brad-ame formulary* drug: $30 copay Brad-ame o-formulary drug: $60 copay Log-term prescriptios (for a day supply through Express Scripts mail order program) Geeric drug: $25 copay Brad-ame formulary* drug: $60 copay Brad-ame o-formulary drug: $120 copay Maiteace prescriptios (90-day supply) usig retail pharmacies who have siged a agreemet with Express Scripts to provide 90-day supplies of maiteace medicatios. Copays at Maiteace Drug Program (MDP) pharmacies: Geeric drug: $45 copay Brad-ame formulary* drug: $90 copay Brad-ame o-formulary drug: $180 copay 8

9 Prescriptio Drug Beefits Specialty drugs for complex coditios are available through the Accredo Pharmacy, a ehaced program through Express Scripts. A list of specialty drugs ca be foud at CocordiaPlas.org. Geeric drug: $8 copay Brad-ame formulary* drug: $20 copay Brad-ame o-formulary drug: $40 copay Specialty drugs ca also be purchased at a retail pharmacy for the applicable copay listed o page 8. The CHP PDP also provides catastrophic coverage for prescriptio drugs. If a member reaches the aual Part D limit as desigated by the Ceters for Medicare ad Medicaid Services ($4,700 for 2015), copays for the remaider of the year are: Geeric drug: $2.65 copay All brad-ame drugs: $6.60 copay While a member is i the coverage gap, the Pla will cover Part D bradame formulary ad o-formulary drugs at a amout equal to half his/ her regular cost-sharig amout util you qualify for the Catastrophic Coverage Stage. The coverage gap is the amout members pay above $2,960 i out-of -pocket prescriptio drug costs ad below $4,700. *A formulary is a preferred list of brad-ame drugs selected by Express Scripts based o their ability to meet patiet eeds at a lower cost. A Medicare Preferred Formulary is available for viewig by visitig ad clickig o Healthcare > Cocordia Health Pla (Medicare) > Prescriptio Drug Beefit. 9

10 Health ad Welless Programs CareAllies Welless Programs CHP provides access to health ad welless programs through CareAllies at o additioal cost. You ca go olie at (password LCMS or use your idividual logi iformatio), or call Health Assessmet ad Health Advisor Program The Health Assessmet is a secure, olie questioaire that will provide participats with a assessmet of their health targetig high blood pressure, high cholesterol, pre-diabetes, stress, weight maagemet, ad tobacco use. Oce the risks are calculated, the results ca be prited ad discussed with a physicia or with a professioal Health Advisor, who will set up a program to help reduce or maage those risks. Lifestyle Maagemet Programs CHP Medicare members ca also take part i the Lifestyle Maagemet Programs for help with weight loss, smokig cessatio, ad stress maagemet. These programs make available a persoal coach who will help set up a program to achieve success i these areas. 24-Hour Nurse Lie Registered urses are ready to help you wheever you have a health care questio or cocer, such as whe ad where to seek medical attetio, eed a explaatio of medical terms, or obtai iformatio about treatmet optios. They are there for you ad your family members. SilverSeakers Fitess Program The SilverSeakers Fitess Program provides a free, basic fitess membership to more tha 12,000 gym/health club locatios atiowide. Eve if you do t have access to a SilverSeakers participatig fitess club, you ca still take advatage of welless resources olie at com/member. The SilverSeakers website icludes: Iformatio o how to order a free at-home fitess kit Nutritious recipes ad shoppig lists Exercise demostratio videos Exercise ad utritio plas 10

11 Hearig Care Discouts Hearig Care discouts are admiistered by HearUSA Hearig Care Network. HearUSA has the largest etwork of credetialed audiologists i the atio. Whe admiistered or purchased from etwork providers, hearig tests, hearig aids, ad services are offered at the followig discouted prices: Services Comprehesive Audiometry Testig Cost/Discout $49 Acoustic Immittace Testig $35 Digital Hearig Aids Related Products, Replacemet Ear Molds, ad Repairs Member pays fixed discouted prices: Premium Digital Hearig Aid - $2,500 Advaced Digital Hearig Aid - $1,995 Mid-Level Digital Hearig Aid - $1,600 Value Digital Hearig Aid - $1,300 Basic Digital Hearig Aid - $995 20% discout off provider s usual ad customary fees. 10% discout for accessories, warraties, ad related products at Coverage also icludes a three-year maufacturer s warraty, icludig loss ad damage; a oe-year supply of batteries (up to 48 cells); aual ispectio, cleaig ad check of hearig aids, mior service ad i-office repairs for the lifetime of the hearig aid; ad routie follow-up appoitmets for oe year, all at o charge. Members ca call HearUSA at to request a list of audiologists i their area ad a Discout Summary Form. Foreig Hospital ad Medical Care; Private Duty Nursig The CHP pays 80% of cost, ad the member pays 20% for: Private-duty ursig care by a licesed graduate urse (R.N., L.P.N., or L.V.N.) other tha a spouse, child, brother, sister, or paret of the pla participat. Hospital ad medical care outside the U.S. that would have bee covered by Medicare had the charges bee icurred i the U.S. ad that are icurred while temporarily travelig outside the U.S. 11

12 Detal Discouts The CigaPlus Savigs program offers detal discouts to Medicare members through Ciga Detal. Because this is a discout program rather tha detal isurace, there are o claims to file, deductibles to meet, waitig periods, beefit maximums, age limits, or restrictios o pre-existig coditios. Discouts o services may vary ad average 35 percet* off most commoly performed detal services icludig: Cleaigs Root caals Crows Filligs Detures The followig chart provides examples of possible savigs available: Services Usual Fee** Discouted Fee** Savigs** Two periodic exams $93 $62 $31 Two routie cleaigs $168 $112 $56 Resi composite fillig $142 $92 $50 Full set of detures $1,196 $810 $386 Members must preset the CigaPlus Savigs ID card to the detal office ad pay the reduced fee (based o the Ciga Detal cotracted fee schedule) i full directly to the detal office. A ID card MUST be preseted at the detal office so that the discout ca be applied. To obtai a ID card or for more iformatio o detal discouts, visit or call *Average discout percetages are calculated by comparig atiowide average cotracted rates to atioal average charges data. Actual savigs will vary o the basis of the procedure, geographic locatio, ad Ciga Detal specific cotracted rate set up with the detist/specialist. **Usual fees ad discouted amouts may vary by regio ad from the sample listed above. Check with a etwork detist for pricig ad discouts i your area. 12

13 Additioal Discout Savigs I additio to the detal discouts, CigaPlus Savigs also provides CHP Medicare members access to Ciga s Healthy Rewards discout program. Healthy Rewards offers you discouts o health ad welless services, savig you moey. Examples of Healthy Rewards savigs iclude: Type of Service Average Savigs Percetage Laser Visio Correctio Savigs up to 15% Hearig Care Savigs up to 65% Chiropractic Care Savigs up to 25% Acupucture Savigs up to 25% Weight Maagemet Savigs up to 25% Tobacco Cessatio Savigs up to 10% Fitess Club Memberships At least 10% Massage Therapy Savigs up to 25% Natural Supplemets Savigs up to 40% Health ad Welless Products Savigs up to 5% per order No erollmet is ecessary. All Medicare members who are participatig i the CHP will automatically be set a CigaPlus Savigs ID card for this volutary discout program. Oce you have your CigaPlus Savigs ID card, you will simply eed to preset the card to the service provider to receive the applicable Healthy Rewards discouts. If you eed a replacemet card or for more iformatio, visit or call Ciga s Healthy Rewards lie tollfree at NOTE: Participatig providers may ot be available i all areas. 13

14 Medicare Member FAQs Medicare Member FAQs What if I decide ot to eroll i the CHP Medicare supplemetal coverage? Ca I eroll at a later date? I accordace with the Pla provisios, reerollmet as a retired member is allowed if you meet either of the two sets of requiremets described below: termiate CHP coverage after July 1, 1999, to joi a Medicare Advatage pla sposored ad approved by the govermet, maitai cotiuous coverage i a Medicare Advatage pla, ad provide proof of cotiuous coverage i a Medicare Advatage pla, OR otherwise meet the defiitio of Medicare member, ad maitai cotiuous health care coverage, for the five years prior to the reerollmet request through: 1. the CHP, 2. a qualified health pla through a America Health Beefit Exchage uder the Affordable Care Act (ACA), or 3. his/her spouse s group health pla meetig the requiremets for miimum essetial coverage uder the ACA. Uless oe of these two sets of requiremets are met, reerollmet as a retired member will ot be possible. Whe I m eligible for Medicare, will I receive a ew medical card from CHP? Yes, a ew medical ID card will be provided by Blue Cross Blue Shield. You will also receive a ew prescriptio drug card from Express Scripts. 14

15 Medicare Member FAQs Where do I fid iformatio o Medicare beefits? The Ceters for Medicare & Medicaid Services (CMS) admiisters the Medicare program. Iformatio regardig CMS ca be accessed or You ca also call 800-MEDICARE ( ) to speak to a Medicare Customer Service Represetative. Are detal beefits available with the CHP Medicare supplemetal coverage? I order to keep the cost of retiree medical coverage as affordable as possible, detal beefits are ot icluded i the CHP Medicare supplemetal coverage. Though curret cotributios will ot support offerig detal beefits, the CigaPlus Savigs detal discout program is available to members participatig i the CHP Medicare supplemetal coverage. This discout program provides o average a 35% savigs off most commoly performed detal procedures. Refer to page 12 for more iformatio. 15

16 Gradfathered Status Notice The Cocordia Health Pla (CHP) is a gradfathered health pla uder the Patiet Protectio ad Affordable Care Act (the Affordable Care Act, or ACA). As permitted by the ACA, a gradfathered health pla ca preserve certai basic health coverage that was already i effect whe that law was eacted. Beig a gradfathered health pla meas that the CHP may ot iclude certai cosumer protectios of the ACAthat apply to other plas for example, the requiremet to provide a iteral ad exteral appeal review process. However, gradfathered health plas must comply with certai other cosumer protectios i the ACA (for example, the elimiatio of lifetime limits o beefits). Questios regardig which protectios apply ad which protectios do ot apply to a gradfathered health pla ad what might cause a pla to chage from gradfathered health pla status ca be directed to Cocordia Pla Services at You also may cotact the U.S. Departmet of Health ad Huma Services at This is oly a summary. For a detailed descriptio of CHP beefits, please see the official pla documet o our website uder Resources > Pla Booklets or cotact us. Cocordia Pla Services The Luthera Church Missouri Syod P.O. Box St. Louis, MO I St. Louis: ifo@cocordiaplas.org Website: