Thank you... for your interest in our Medicare Advantage plans With us, you'll get more than just a health care plan.

Transcription

1 Thank you... for your interest in our Medicare Advantage plans With us, you'll get more than just a health care plan. No two people are alike. Each of us has unique interests and plans for the future. Whether you see yourself traveling the seven seas, reading to grandkids, volunteering in your community, or all of the above, we look forward to the chance to join your journey. And we think you ll agree: including us in your plans is a smart way to go. After all, in us you will find an advocate who is committed to helping you maintain and even improve your health and wellness. What s more, our vast range of coverage choices and support options qualifies us to succeed in this mission. This goes well beyond the many popular benefits in our plans. It also includes personalized care programs and dedicated member assistance teams with a single focus helping ensure that your health care goals are met. If you have questions about our plans, please contact your agent. We also have included helpful contact information on the last page of this section WPSENMUB_036 Y0071_14_16845_U_036 CMS Accepted 10/01/2013 H5854_005_CT 1

2 The differences between Medicare Advantage, Part D and Original Medicare Medicare comes in Parts. Parts A and B are Original Medicare which is run by the government. Parts C and D are offered by private insurers, like us. Original Medicare Part A is hospital coverage that helps cover the costs for: 1 Inpatient care in hospitals and skilled nursing facilities (not custodial or long-term care). 1 Hospice and some home health care services. Original Medicare Part B is medical care coverage that helps cover the costs for: 1 Doctors services, hospital outpatient care and some home health care services, as well as lab tests and durable medical equipment. 1 Most preventive services, including a yearly wellness exam. You can replace Medicare Parts A and B with Medicare Part C, also called Medicare Advantage. Unlike Original Medicare Parts A and B, Medicare Part C is offered by private insurers that have been approved by Medicare. Medicare Advantage plans offer similar coverage to Part A (hospital) and Part B (medical), and typically offer additional benefits. 1 1 Some of these additional benefits may require an additional fee. Read on for more details. 2

3 Medicare Part D is stand-alone prescription drug coverage Medicare Part D is only offered by private issurers approved by Medicare. These plans: 1 Help pay for many brand-name and generic prescribed drugs. 1 Give you access to retail drugstores and mail-order options. + Medicare Part C + Part D = Medicare Advantage and Prescription Drug (MAPD) MAPD is our most popular Medicare Advantage plan. Members prefer this type of plan because it offers coverage for: 1 Hospital services such as those in Part A 1 Medical services such as those in Part B 1 Prescription drug coverage such as in Part D OSB Optional Supplemental Benefits These benefits may be added to most of our Medicare Advantage plans. They allow you to enhance the level of dental or dental and vision coverage you receive to better meet your specific needs. 1 The plan in this booklet is a Medicare Advantage and Prescription Drug (MAPD) plan. It includes hospital, medical and drug benefits in one plan. 1 Optional supplemental benefits require an additional fee. See the Summary of Benefits section in this booklet for more details. Optional Supplemental Benefits may not be available with every Medicare Advantage plan in this booklet. 3

4 Words to help you understand your medical benefits 1 Premium The payment you make on a regular basis, usually monthly, to Medicare, an insurance company, or a health care plan for coverage. 1 Deductible The amount you must pay for health care or prescriptions, before Original Medicare or other insurance begins to pay. 1 Copayment/copay The specific dollar amount you have to pay for certain covered services after you pay any plan deductibles. 1 Coinsurance The percentage of the covered charges you have to pay for covered services or drugs after you pay any plan deductibles. For example, if covered charges are $100 and the coinsurance amount is 20%, you would pay $20. 1 Out-of-pocket limit Your out-of-pocket limit is the most you will pay during the plan year for deductibles, copayments and coinsurance. Your premium payments do not apply to the out-of-pocket limit. 1 Inpatient hospital care Health care that you get when you are admitted to a hospital or skilled nursing facility. 1 Primary care provider (PCP) The doctor you see first for most health problems. He or she also may speak to other doctors and health care providers about your care and may refer you to them. 1 Specialist A doctor with training and expertise in a specific branch of medicine or surgery. For example, a specialist in cardiology treats heart conditions. 4

5 About your Medical Benefits Health care is personal... and we'll help make sure it feels that way Your health goals and needs are unique. What s right for one person is not always right for another. Maybe you re managing a health condition. Or maybe you want to stay healthy, eat better or get in shape. Whatever your needs, Anthem Blue Cross and Blue Shield gives you a choice of programs, benefits and support options that revolve around your goals. It s a personal approach to health care that helps you live your life to the fullest, now and all along your journey. Here are just a few of the benefits you can look forward to: 1 Premiums as low as $ One plan and one card for your covered medical, and hospital and Part D drug benefits 2 1 Predictable copayments for doctors office visits, as low as $ Out-of-pocket limits to protect you from high, unexpected medical costs 1 Access to large provider networks 1 Preventive care at no extra cost to you 2 1 Online resources and discounts. These are just some of the benefits you will have if you choose us. For details on each covered service, see the Summary of Benefits section in this booklet. 1 You must continue to pay your Medicare Part B premium. To find out more about covered benefits, see the Summary of Benefits section in this booklet. 2 If you use an out-of-network provider, your share of the costs for your covered services may be higher. Benefits, formulary, pharmacy network, provider network, premium, and/or co-payments/co-insurance may change on January 1 of each year. The benefit information provided is a brief summary, not a complete description, of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. 5

6 Access to care made easy Your primary care provider is your main health care provider Having the same primary care provider (PCP) works best for your care. Your PCP: 1 Knows you and your health needs when you go for your routine visits and checkups. 1 Keeps a record of your medical history. 1 Can refer you to the right specialists. Find a primary care provider in our network We want you to be happy with your primary care provider. First, find out if your current PCP is in your HMO plan s network. If your PCP is not in the network, you would need to choose a network provider to get covered benefits. 1 To choose a network provider, please use our online Provider Finder or directory. It s important to note that a provider s participation in the network can change at any time, so please make sure that the provider is still part of the network before you receive care. Simply call the provider s office, or call the Customer Service number on your member ID card. One card is all you need Your Medicare Advantage plan ID card from us is all you need to see your doctor(s), go to your network pharmacy or get other covered benefits. You don t need your red, white and blue Medicare card for accessing your benefits. Keep it, though, in case you need it in the future. Use our Provider Finder 1 Go to - Click "Start here!" - Under Useful Tools, choose "Find a Doctor." 1 If you need emergency care or urgent care, go to the nearest health care provider that can help you. In most situations, you must use network providers to get covered medical care, with the exceptions of emergencies, urgently needed care when network providers are not available (generally, when you are out of the service area) or out-of-area dialysis services. If you get routine care from out-of-network providers, neither Medicare nor Anthem Blue Cross and Blue Shield will be responsible for the cost. 6

7 Other ways we support your Good Health Supporting your good health is part of the plan When you join our plan, you can count on many layers of support from us. You have a choice of personalized programs that can help you meet your health goals and fit your lifestyle at no cost to you. We will be there for and with you at every step of your journey to better health. Health survey: The sooner we know you, the sooner we can help If you are a first-time member, we want to know what your health needs are as soon as possible. That way, we can help you get the best level of care right away for any medical conditions you may have. We learn about your care needs by having a telephone service call you to fill out a health survey within 90 days after your plan takes effect. If you cannot be reached by phone, you will get a mailed copy of the survey and/or directions to fill out an online version. Whether you respond by phone, online or by mail will not affect your health care coverage. Your survey answers will allow us to see if any of our many health programs may benefit you. The earlier you respond, the sooner we can help. A registered nurse can help you by phone any time, any day We ensure help is just a phone call away for all our members. Our plan offers a 24/7 NurseLine that gives you access to trained registered nurses any time of the day or night to help: 1 Answer your general health questions. 1 Assess your symptoms. 1 Help you determine the right care at the right time. 7

8 Other ways we support your good health - continued Fully covered preventive care: Early detection means early treatment One of the most important ways to stay in control of your health is through preventive care services. And there s no reason not to get them. When you use a network provider, your yearly wellness exams, flu and pneumonia shots, even smoking-cessation counseling, are covered 100%! See what types of preventive care won t cost you a penny in the Summary of Benefits section. To support you in this effort, each year, we will send you a personalized Healthy Checklist to remind you about the preventive care that may be right for you. It s best to go over the checklist with your doctor to find out what other health tests you may need. MyHealth Advantage keeps track of your health and progress Through MyHealth Advantage, a free, interactive online tool, we can review your health claims on a regular basis. If we detect risk issues from the drugs you re taking, we will alert you and your doctor right away. We can track your routine tests and checkups. You will get mailings to remind you to make your next appointment or to take other preventive care actions. You even get tips that may help cut the costs of your prescribed drugs. We have care teams working for you Our medical management program is designed for you: 1 Utilization management - Trained nurses help to ensure that you get the right care at the right time in the right setting. You and your doctor can work with these nurses to help you follow your plan of care and reach your wellness goals in a cost-effective way. 1 Preauthorization - You, your doctor or specialist must first contact Medical Management (via phone or ) to get an OK before you get some types of care. 1 Case management - A team of trained nurses, social workers and dietitians can help you: - Coordinate your preventive care. - Learn how to keep your symptoms under control. - Cope with one or more health conditions. - Access community resources you may qualify for. 1 Discharge planning - Our case manager coordinates a discharge plan with your doctor during a hospital stay. This ensures you have access to medically necessary services at the time of your discharge. 8

9 Special values to make you feel good Enjoy discounts and savings through our online SpecialOffers program When you become a plan member, you can order online products that can help you feel good and keep money in your pocket. Discounted products range from health and beauty items to eyeglasses to hearing aids. Get help reaching your health goals through: 1 1 Vitamins and supplements. 1 Gym and health club memberships. 1 Nutritionists and massage therapy. 1 NEW! Discounts from CONTACTS and Glasses.com. Check out for a complete list of our SpecialOffers. Ask us for details on all our special values We ll gladly walk you through our full range of no-cost services and programs that can help you on your quest for better health. Just call us. 1 Vendors and offers are subject to change without prior notice. Anthem Blue Cross and Blue Shield does not endorse and is not responsible for the products, services or information offered by the vendors or providers. We negotiated the arrangements and discounts with each independent vendor or provider in order to assist our members. 9

10 About your Drug Benefits Making medications easier to swallow Many of us 65 and over are finding that medications play a growing role in maintaining our health and wellness. If you can relate, you ll find value in our Medicare Advantage Prescription Drug coverage. It can help you better predict and control your costs at the pharmacy for many brand-name and generic drugs. This also has a soothing effect on your mind, especially considering it also provides access to more than 69,000 network pharmacies across the country, including more than 11,000 preferred pharmacies that offer our members increased cost savings. Need a full list of covered drugs or to find a pharmacy? 1 Go to - Click "Start here!" - Under "Useful Tools," click on "Find your covered drugs" or "Find a Pharmacy." 1 Or you may call Customer Service toll-free. 10

11 Part D terms and tips to help you on your way Some helpful terms about your drug benefits 1 Formulary This is a list of all the drugs your plan covers. The list tells you what tier your drug is in and if there are any requirements or limits for coverage. 1 Drug tiers Every drug on the formulary is in a cost-sharing tier. What you pay for your prescription depends, in part, on which tier your drug is in. 1 Brand-name drugs These are drugs that are developed by a company who holds the rights to sell them. When the rights expire, other drug companies can make their own version of the drugs. (See generic drugs below.) 1 Generic drugs Generics are copies of brand-name drugs with the same active ingredients. The U.S. Food and Drug Administration requires that generic drugs meet the same standards for purity, quality, safety and strength. 1 Coverage gap This is the coverage stage that may have the highest out-of-pocket costs for you. Understanding all of the coverage stages can help you plan for the coverage gap. Tips for saving money on your prescription drugs 1 Choose generic. The U.S. Food and Drug Administration requires generic drugs to meet the same safety and quality standards as brand-name drugs, but generics often cost less. 1 Take covered drugs. Look for your prescription drug in the formulary to see if it is covered and if it has any requirements (such as prior authorization) before your plan will cover it. There may be other drug options that will work for you. And they may even cost less. Ask your doctor. 1 Stay in-network. Go to a pharmacy in your plan s network whenever possible. For increased cost-savings, choose a preferred pharmacy. Using a preferred pharmacy network You are never far from one of our network pharmacies; but to pay a lower amount, you should go to one of the preferred pharmacies. 1 Preferred retail pharmacies: We contract with these pharmacies to offer our members extra cost savings. 1 Network retail pharmacies: Are still in our network and your drugs will be covered, but the cost will be higher than if you went to a preferred pharmacy. 11

12 Understanding Part D coverage stages How the coverage stages work 1. The initial coverage stage begins after you pay your deductible (if you have one). During this stage, you will pay your copays or coinsurance. 2. If you and your plan, together, spend a certain amount on covered drugs, you will enter the coverage gap stage. In 2014, this amount is $2,850 (the amount can change every year). What you pay in the coverage gap will depend on any Extra Help you receive, or assistance programs and discounts available for your drugs. 3. When a certain amount has been spent on your covered drugs, you will leave the coverage gap. In 2014, this amount is $4,550 (the amount can change every year). Then you will enter the catastrophic coverage stage. In this stage, you will pay a small copay or coinsurance for your covered drugs for the remainder of the year. Help when you reach the coverage gap Part D Brand-Name Drug Discount: In 2014, if you reach the coverage gap, you will get a 52.5% discount on covered brand-name drugs. There will be additional savings in the coverage gap each year through 2020, when the coverage gap is closed completely. When you need Extra Help 1 If you qualify for Medicare s Extra Help and are enrolled in a Medicare Advantage Prescription Drug plan, Medicare can help by paying a percentage of your prescribed drug costs. If you qualify, you will get the following: 1 Help paying your yearly deductible, if applicable, coinsurance and copays for covered prescription drugs. 1 No coverage gap. 1 No late enrollment penalty. For more information about Extra Help, please visit or We now have a preferred pharmacy network! 2 Using a preferred pharmacy means you get the lowest copays we have available. Kroger Pharmacy, Rite Aid Pharmacy, Walmart Kroger Co. participating preferred pharmacies include Kroger, FredMeyer, King Soopers, City Market, Fry s, Smith s, Dillons, Ralphs, QFC, Baker s, Scott s, Owen s, Pay Less, Gerbes, JayC. Walmart participating preferred pharmacies include Walmart, Neighborhood Market, Sam s Club. 1 You can t get Medicare Coverage Gap Discounts on brand-name drugs if you receive Extra Help. 2 Other pharmacies are available in our network. 12

13 Enjoy special Benefits Dental Package Package 1 - Preventive Dental Services Dental and Vision Package Package 2 - Dental Services plus Vision Care Enhanced Dental and Vision Package What are Optional Supplemental Benefits (OSB) packages? Our OSB packages provide benefits such as vision and dental, which are not covered under Medicare Advantage plans or Original Medicare. During a limited time period, you can add the package of your choice to most Medicare Advantage plans for a low, additional premium per month. 1 These special benefits are good for your health, in more ways than one By adding one of these packages to your plan, you can get coverage for the care you need to help maintain good health. 2 These options can also help keep your out-of-pocket costs under control. And, because there is no waiting period, you can start enjoying your benefits right away! If you have questions, please refer to the Summary of Benefits in this booklet, or contact your licensed sales agent. Package 3 - Expanded Dental Services and Vision Care Optional Supplemental Benefits may not be available with every Medicare Advantage plan in this booklet. 1 You must continue to pay your Medicare Part B premium. For details on OSB packages available with your plan, refer to your Summary of Benefits or contact the plan. OSB packages must be selected at the time of enrollment and/or prior to the close of AEP. 2 National Institute of Dental and Craniofacial Research: Oral Health in America, 2008, Surgeon General s Report on Oral Health in America,

14 About Enrolling Are you eligible for Medicare? Before you enroll, you ll want to confirm that you are eligible for Medicare program plans. You will also need to be enrolled in Medicare Parts A & B and live within the plan's service area. You are eligible to join this program if one of these items applies: 1. You are 65 or older. 2. You are under 65 with certain disabilities. 3. Original Medicare only: You are any age with end-stage renal disease (ESRD) permanent kidney failure requiring dialysis or kidney transplant. 1 Note: If you have ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig s disease), you automatically get Part A and Part B the month your disability benefits begin. And, if both of these items apply: 1. You or your spouse worked and paid Social Security taxes for at least 10 years. 2. You are a permanent resident of the U.S. or a legal citizen who lived in the U.S. for five years in a row. 1 If you have end-stage renal disease and have not had a kidney transplant, you usually can t join a Medicare Advantage plan. For more information about ESRD, view the booklet Medicare Coverage of Kidney Dialysis and Kidney Transplant Services at To ask for a copy, call MEDICARE ( ) or the TTY/TDD line , 24 hours a day, seven days a week. 14

15 When enrolling timing matters Getting Medicare benefits is not always as simple as just turning 65. There are actions to take during preset enrollment periods. For example, if you are like most, you must sign up when you are first eligible to receive Part A, Part B and Part D to avoid coverage delays and premium penalties that last for as long as you have Medicare. Initial enrollment period 7 months surrounding your Medicare eligibility: This is the 3 months before you turn 65, the month when you turn 65, and the 3 months after. st nd rd st nd rd 3 months before 3 months after Annual election period (AEP) October 15 to December 7, The period you can enroll in or change your MA or MAPD plan. This is also the period you can enroll in, change or disenroll from a Part D plan. You may also switch to Original Medicare. New coverage will begin January 1, Special enrollment period (SEP) A common SEP is for those covered under their employer s health plans who retire after 65. In this case, you can enroll with no penalty during the three months before your Part B takes effect. Other more common examples include: if you qualify for Medicare s Extra Help for Part D (see the When you need Extra Help section in this booklet), if you qualify for both Medicaid and Medicare, or if you have moved outside of the plan s service area. 15

16 Tips for successful enrollment Enroll in time to avoid ongoing late enrollment penalties. A late enrollment penalty may cause your Medicare Part A premium to increase 10%, and you will have to pay the higher premium for twice the number of years you could have had Part A, but didn t sign up. Also, a late enrollment penalty may cause your Medicare Part B monthly premium to increase 10% for each full 12-month period that you could have had Part B, but didn t sign up. If you wait, and don t sign up for Medicare Part D when you re eligible or go more than 63 days without it, the Part D late enrollment penalty will become part of your premium for as long as you are enrolled in Part D. This amount may increase every year. You may not have to pay the Part D late enrollment penalty if you receive Extra Help, or if you can provide proof of other creditable prescription drug coverage (for example, from an employer or union). How to submit your enrollment form When you have made up your mind, you don t need to get a physical exam to sign up. You will need information from your Medicare card to fill out your enrollment form which you can find in the back of this booklet. Be sure to fill out the form carefully and completely. Your agent can help! When you are done, you can give a copy to your agent. Or, you can tear out a copy and submit the top copy of each page to the address listed on the first page of the application. You can also sign up online at Select your desired payment option If your plan has a premium, you can pay your premium in several ways. Simply choose your desired plan payment option on the enrollment application: Option 1: By check. If you choose to pay your premium directly to us, you will get a bill each month. Option 2: Taken out of your monthly Social Security check. 1 1 This payment option may take up to three months to set up. 16

17 After you've Enrolled What happens next? 1 You ll get a call from us to make sure you understand what a Medicare Advantage plan offers. The call is required by Medicare and will not affect your ability to enroll in the plan. Your sales representative will not be on the call. We will make a minimum of three attempts to contact you by telephone within fifteen (15) calendar days of receipt of the application. In addition to confirming that your application correctly reflects your wishes, we will also discuss: a. Which ID card to use for your health care services. b. Your share of the cost for services. c. Which providers to use to get your health care services. d. How to cancel your enrollment in our plan if you want to. 2 You ll get a letter with your proposed effective start date. This letter is your proof of membership until you get your member ID card. 3 Your application will be sent to the Centers for Medicare & Medicaid Services (CMS) for approval. 4 Once it is approved by CMS, you will get a welcome letter that confirms your effective start date. You will also get your member ID card and other new member materials, including your Evidence of Coverage and Welcome Kit. 5 Within 90 days after your health plan starts, you will get a call to fill out a health survey. This survey lets us know your health status so we can help you with your care needs as soon as possible. 17

18 How to Reach Us Sales Department TTY/TDD line a.m. to 8 p.m., seven days a week Customer Service TTY/TDD line a.m. to 8 p.m., seven days a week, October 1, 2013 to February 14, 2014 (except holidays); 8 a.m. to 8 p.m., Monday Friday, February 15 to September 30, 2014 (except holidays). Online benefits, discounts and health resources Find a doctor - Enroll online - Find a pharmacy - Find your covered drugs Star ratings... Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next. General Information about Medicare... In case of emergency, call 911. TTY/TDD lines are for those with a hearing or speech loss. 1 By calling this number, you will reach an authorized licensed insurance agent who can answer questions about our plans and enrollment. 18

19 Anthem Blue Cross and Blue Shield is an HMO plan with a Medicare contract. Enrollment in Anthem Blue Cross and Blue Shield depends on contract renewal. Anthem Blue Cross and Blue Shield is the trade name for Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.