You can end your membership in Aetna Better Health Premier Plan at any time.

Transcription

1 Aetna Better Health SM Premier Plan (Medicare-Medicaid Plan) offered by Aetna Annual Notice of Changes for 2016 You are currently enrolled as a member of Aetna Better Health Premier Plan. Next year, there will be some changes to the plan s benefits and rules. This section tells you about the changes. You can end your membership in Aetna Better Health Premier Plan at any time. Additional Resources n You can get this information in Spanish, or speak with someone about this information in other languages, for free. Call Member Services at (TTY: 711), 24 hours a day, 7 days a week. The call is free. Puede obtener esta información en otros idiomas de manera gratuita. Llame al (TTY: 711), 24 horas al dia, siete dias de la semana. Esta llamada es gratuita. n You can get this section for free in other formats, such as large print, braille, or audio. Call Member Services at (TTY: 711), 24 hours a day, 7 days a week. The call is free. About Aetna Better Health Premier Plan n Aetna Better Health Premier Plan is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. n This Aetna Better Health Premier Plan plan is offered by Aetna Better Health of Illinois. When this Annual Notice of Changes says we, us, or our, it means Aetna Better Health of Illinois. When it says the plan or our plan, it means Aetna Better Health Premier Plan. H2506_16_011_ANOC IL

2 Disclaimers Aetna Better Health Premier Plan is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. It is for people with both Medicare and Medicaid. Limitations and restrictions may apply. For more information, call Aetna Better Health Premier Plan Member Services or read the Aetna Better Health Premier Plan Member Handbook. This means that you may have to pay for some services and that you need to follow certain rules to have Aetna Better Health Premier Plan pay for your services. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can get this document in Spanish, or speak with someone about this information in other languages for free. Call (TTY: 711). The call is free. Uste puede obtener este document en espanol, o hablar gratuitamente con una persona en otros idiomas sobre esta informacion. Llame (TTY: 711). La llamada es gratis. Think about Your Medicare and Medicaid Coverage for Next Year It is important to review your coverage now to make sure it will still meet your needs next year. If it does not meet your needs, you can leave the plan at any time. If you leave our plan, you will still be in the Medicare and Medicaid programs. You will have a choice about how to get your Medicare benefits (go to page 10 to see your options). You will get your Medicaid benefits through fee-for-service or remain in our plan to get your Medicaid long term services and supports benefits (go to page 10 for more information). 2 IL H2506_16_011_ANOC

3 Important things to do: n Check if there are any changes to our benefits that may affect you. Are there any changes that affect the services you use? It is important to review benefit changes to make sure they will work for you next year. Look in Section B for information about benefit changes for our plan. n Check if there are any changes to our prescription drug coverage that may affect you. Will your drugs be covered? Are they in a different tier? Can you continue to use the same pharmacies? It is important to review the changes to make sure our drug coverage will work for you next year. Look in Section B for information about changes to our drug coverage. n Check to see if your providers and pharmacies will be in our network next year. Are your doctors in our network? What about your pharmacy? What about the hospitals or other providers you use? Look in Section A for information about our Provider and Pharmacy Directory. n Think about your overall costs in the plan. How do the total costs compare to other coverage options? n Think about whether you are happy with our plan. If you decide to stay with Aetna Better Health Premier Plan: If you want to stay with us next year, it s easy you don t need to do anything. If you don t make a change, you will automatically stay enrolled in our plan. If you decide to change plans: If you decide other coverage will better meet your needs, you can switch plans at any time. If you enroll in a new plan, your new coverage will begin on the first day of the following month. Look in Section E to learn more about your choices. H2506_16_011_ANOC IL

4 Table of Contents Disclaimers...2 Think about Your Medicare and Medicaid Coverage for Next Year...2 A. Changes to the network providers and pharmacies...5 B. Changes to benefits for next year...5 Changes to benefits for medical services Changes to prescription drug coverage...7 C. Other changes...8 D. Deciding which plan to choose...9 If you want to stay in Aetna Better Health Premier Plan...9 If you want to join a different Medicare-Medicaid Plan...9 If you don t want to join a different Medicare-Medicaid Plan...9 E. Getting help...11 Getting help from Aetna Better Health Premier Plan...11 Getting help from Illinois Client Enrollment Services...11 Getting help from the Illinois Long Term Care Ombudsman Program...12 Getting help from the Senior Health Insurance Program (SHIP)...12 Getting help from Medicare...12 Getting help from Medicaid IL H2506_16_011_ANOC

5 A. Changes to the network providers and pharmacies Our network of providers and pharmacies has changed for next year. An updated Provider and Pharmacy Directory is located on our website at illinois. You may also call Member Services at (TTY: 711) for updated provider information or to ask us to mail you a Provider and Pharmacy Directory. It is important that you know that we may also make changes to our network during the year. If your provider does leave the plan, you have certain rights and protections. For more information, see Chapter 3 of your Member Handbook. We strongly encourage you to review our current Provider and Pharmacy Directory to see if your providers or pharmacy are still in our network. An updated Provider and Pharmacy Directory is located on our website at You may also call Member Services at (TTY: 711) for updated provider information or to ask us to mail you a Provider and Pharmacy Directory. B. Changes to benefits for next year Changes to benefits for medical services We are changing our coverage for certain medical services next year. The table below describes these changes (this year) 2016 (next year) Cell phone benefit Cell phone benefit is not covered. Cell phone benefit is covered for free calls to the Plan s Member Services preprogrammed number, free health-related texts and texts from the health plan for members who qualify for the federal free cell phone program. Eye exams Eye exam is covered every year Eye exam is covered every year or as medically necessary H2506_16_011_ANOC IL

6 2015 (this year) 2016 (next year) Meal benefit Meal benefit is not covered. Meal benefit is covered for up to 10 home-delivered nutritional meals after an in-patient hospitalization or nursing home stay Nursing home Maximum patient pay amount: $6477 Maximum patient pay amount: $6962 Nutritional benefit Nutritional benefit is covered Nutritional benefit is not covered Over-the-Counter products Podiatry Preventive dental Over-the-counter products are covered: $20 per month for certain over-the-counter products through a mail order catalog service Podiatry services are covered for one (1) annual visit Covered for one (1) exam, cleaning and dental x-rays every six months. Over-the-counter products are covered: $10 per month for certain over-the-counter products through a mail order catalog service Podiatry services are covered for three (3) visits per year Covered for one (1) exam, cleaning, dental x-rays and fluoride every six months. Respite care Respite care is not covered 16 hours per month of in-home respite care is covered Silver & Fit Silver & Fit is covered Silver & Fit is not covered Tobacco cessation Weight management Tobacco Cessation Counseling for Pregnant Women covered for up to 12 sessions every year Adult weight management programs are not covered Tobacco Cessation Counseling for Pregnant Women covered unlimited sessions every year. Adult weight management programs (including health coaching) are covered. 6 IL H2506_16_011_ANOC

7 Changes to prescription drug coverage Changes to our Drug List We sent you a copy of our 2016 List of Covered Drugs in this envelope. The List of Covered Drugs is also called the Drug List. We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure your drugs will be covered next year and to see if there will be any restrictions. If you are affected by a change in drug coverage, we encourage you to: n Work with your doctor (or other prescriber) to find a different drug that we cover. You can call Member Services at (TTY/TDD: 711), 24 hours a day, 7 days a week to ask for a list of covered drugs that treat the same condition. This list can help your provider find a covered drug that might work for you. n Ask the plan to cover a temporary supply of the drug. In some situations, we will cover a one-time, temporary supply of the drug during the first 90 days of the plan year. (To learn more about when you can get a temporary supply and how to ask for one, see Chapter 5 of the Member Handbook) When you get a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. n For members in a nursing home or other long-term care facility: If your drug is no longer on our Drug List or is now restricted in some way, the plan will cover a temporary supply of your drug during the first 90 days of your membership or the first 90 days of the plan year, until we have given you at least a 91-day supply and may be up to a 98-day supply. If you have a current exception for a drug that is not on the Drug List, the exception is set to expire on December 31, If the drug is not on the 2016 Drug List, you can make a new request to Aetna Better Health Premier Plan to make an exception to cover the drug for H2506_16_011_ANOC IL

8 C. Other changes 2015 (this year) 2016 (next year) Alcohol misuse screening and counseling Ambulance services No prior authorization if using an in-network provider No prior authorization for emergency transport Prior authorization may be Prior authorization may be Medicare Part B RX drugs No prior authorization Prior authorization may be Outpatient surgery Requires prior authorization Prior authorization may be Partial hospitalization services Physician/provider services, including doctor s office visits Podiatry services Vision care Prior authorization is No prior authorization is Certain services require prior authorization Certain services may require prior authorization Prior authorization may be Prior authorization may be Prior authorization is No prior authorization Adult day service Prior authorization is No prior authorization Assisted living Prior authorization is No prior authorization Habilitation day Prior authorization is No prior authorization Home delivered meals Prior authorization is No prior authorization Home health aide Prior authorization is No prior authorization Home modifications Prior authorization is No prior authorization Homemaker services Prior authorization is No prior authorization 8 IL H2506_16_011_ANOC

9 2015 (this year) 2016 (next year) Nursing services Prior authorization is No prior authorization Personal assistant Prior authorization is No prior authorization Personal emergency response system Prior authorization is No prior authorization Respite care Prior authorization is No prior authorization Specialized durable medical equipment and supplies Prior authorization is No prior authorization Therapies Prior authorization is No prior authorization D. Deciding which plan to choose If you want to stay in Aetna Better Health Premier Plan We hope to keep you as a member next year. To stay in our plan you don t need to do anything. If you do not sign up for a different Medicare-Medicaid Plan, change to a Medicare Advantage Plan, or change to Original Medicare, you will automatically stay enrolled as a member of our plan for If you want to join a different Medicare-Medicaid Plan If you want to keep getting your Medicare and Medicaid benefits together from a single plan, you can join a different Medicare-Medicaid Plan. You can enroll in the new Medicare-Medicaid Plan by calling Illinois Client Enrollment Services at , from 8 a.m. to 7 p.m. Monday through Friday and 9 a.m. to 3 p.m. on Saturday. TTY/TDD users should call If you don t want to join a different Medicare-Medicaid Plan If you do not want to enroll in a different Medicare-Medicaid Plan after you leave Aetna Better Health Premier Plan, you will go back to getting your Medicare and Medicaid services separately. H2506_16_011_ANOC IL

10 How you will get Medicare services You will have three options for getting your Medicare services. By choosing one of these options, you will automatically end your membership in our Medicare-Medicaid Plan: 1. You can change to: A Medicare health plan (such as a Medicare Advantage Plan or Programs of All-inclusive Care for the Elderly (PACE) Here is what to do: 2. You can change to: Original Medicare with a separate Medicare prescription drug plan 3. You can change to: Original Medicare without a separate Medicare prescription drug plan NOTE: If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you tell Medicare you don t want to join. You should only drop prescription drug coverage if you get drug coverage from an employer, union or other source. If you have questions about whether you need drug coverage, call the Senior Health Insurance Program at Here is what to do: Call Medicare at MEDICARE ( ), 24 hours a day, seven days a week. TTY users should call If you need help or more information: Call the Senior Health Insurance Program (SHIP) at You will automatically be disenrolled from Aetna Better Health Premier Plan when your new plan s coverage begins. Here is what to do: Call Medicare at MEDICARE ( ), 24 hours a day, seven days a week. TTY users should call If you need help or more information: Call the Senior Health Insurance Program (SHIP) at You will automatically be disenrolled from Aetna Better Health Premier Plan when your Original Medicare coverage begins. Here is what to do: Call Medicare at MEDICARE ( ), 24 hours a day, seven days a week. TTY users should call If you need help or more information: Call the Senior Health Insurance Program (SHIP) at You will automatically be disenrolled from Aetna Better Health Premier Plan when your Original Medicare coverage begins. 10 IL H2506_16_011_ANOC

11 How you will get Medicaid services If you do not join a different Medicare-Medicaid Plan, you will get your Medicaid services through fee-for-service, with the following exception: If you are in a nursing facility or are enrolled in a Home and Community Based Service (HCBS) waiver, you will remain in our plan to get your Medicaid services. You will have 90 days to switch to another Medicaid-only health plan. If you are not in a nursing facility or enrolled in a HCBS waiver, you will be in Medicaid fee-for-service. This is how you received your Medicaid services before joining our plan. You can see any provider that accepts Medicaid and new patients. E. Getting help Getting help from Aetna Better Health Premier Plan Questions? We re here to help. Please call Member Services at (TTY: 711). We are available for phone calls 24 hours a day, 7 days a week. Calls to these numbers are free. Read your 2016 Member Handbook The 2016 Member Handbook is the legal, detailed description of your plan benefits. It has details about next year s benefits. It explains your rights and the rules you need to follow to get covered services and prescription drugs. An up-to-date copy of the 2016 Member Handbook is always available on our website at You may also call Member Services at (TTY: 711), 24 hours a day, 7 days a week to ask us to mail you a 2016 Member Handbook. Visit our website You can also visit our website at As a reminder, our website has the most up-to-date information about our provider and pharmacy network (Provider and Pharmacy Directory) and our Drug List (List of Covered Drugs). Getting help from Illinois Client Enrollment Services Illinois Client Enrollment Services is available to help you understand your healthcare choices. It is a good place to start if you have questions about the different plans available to you and how the plans work. You can call Illinois Client Enrollment Services at , from 8 a.m. to 7 p.m. Monday through Friday and 9 a.m. to 3 p.m. on Saturday. TTY users should call H2506_16_011_ANOC IL

12 Getting help from the Illinois Long Term Care Ombudsman Program The Illinois Long Term Care Ombudsman Program can help you if you are having a problem with Aetna Better Health Premier Plan. The Illinois Long Term Care Ombudsman Program is not connected with us or with any insurance company or health plan. The phone number for the Illinois Long Term Care Ombudsman Program is TTY users should call The services are free. Getting help from the Senior Health Insurance Program (SHIP) You can also call the Senior Health Insurance Program (SHIP). The SHIP counselors can help you understand your Medicare-Medicaid Plan choices and answer questions about switching plans. The SHIP is not connected with us or with any insurance company or health plan. The SHIP s services are free. The SHIP phone number is TTY users should call Getting help from Medicare To get information directly from Medicare: Call MEDICARE ( ). You can call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Visit the Medicare Website You can visit the Medicare website ( If you choose to disenroll from your Medicare- Medicaid Plan and enroll in a Medicare Advantage plan, the Medicare website has information about costs, coverage, and quality ratings to help you compare Medicare Advantage plans. You can find information about Medicare Advantage plans available in your area by using the Medicare Plan Finder on the Medicare website. (To view the information about plans, go to and click on Find health & drug plans. ) Read Medicare & You 2016 You can read Medicare & You 2016 Handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don t have a copy of this booklet, you can get it at the Medicare website ( or by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Getting help from Medicaid If you have questions about your Medicaid eligibility, you can contact the Illinois Department of Human Services: n Call n Visit 12 IL H2506_16_011_ANOC