Allegian Advantage (HMO) H8554_ Accepted

Transcription

1 Allegian Advantage (HMO) H8554_ Accepted

2 IMPORTANT This presentation is for the exclusive use of Allegian Advantage (HMO) Allegian Health Plans is an HMO plan with a Medicare contract. Enrollment in Allegian Health Plans depends on contract renewal.

3 WHAT YOU CAN EXPECT FROM THIS PRESENTATION PART 1 Introduction Your Experiences, Your Story PART 3 Your Summary of Benefits Our Prescription Drug Benefits PART 2 Understanding Medicare Basics: Parts A, B, C and D Introducing Allegian Advantage (HMO) Benefits at a Glance Prescriptions Eligibility PART 4 Enrollment/ What Happens Next? Grievances and Appeals Low Income Subsidy (LIS) You May Qualify for Extra Help

4 PART 1 A FEW WORDS ABOUT ME I m an authorized representative of Allegian Advantage (HMO), a local, Texas health plan. I m licensed to sell insurance in Texas, have completed the annual agent Medicare training and I am certified as an Allegian Advantage (HMO) Agent. I may be compensated based on your enrollment.

5 PART 1 A FEW WORDS ABOUT THIS APPOINTMENT I will be providing information about only the Medicare Advantage Plan specified in the Scope of Appointment discussed over the phone or signed prior to this appointment. Materials You May Receive During this Appointment Enrollment Kit Allegian Advantage Brochures My Business Card

6 PART 1 YOUR EXPERIENCES, YOUR STORY What Coverage Do You Have? What Do You Like About Your Coverage? Why Are You Interested in Allegian Advantage (HMO)? Does Someone Help You with Your Healthcare Decisions? No Pressure: It s Okay to Say NO

7 PART 2 UNDERSTANDING MEDICARE THE BASICS: Medicare is the United States national health insurance program administered by the federal government. WHO QUALIFIES? People age 65 or older Some people under the age of 65 with certain disabilities (restrictions may apply) People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant) YOUR CHOICES: Original Medicare plus a Prescription Drug Plan (PDP) Medicare Advantage Plan Medicare Advantage Plan with Prescription Drug Coverage.

8 PART 2 UNDERSTANDING MEDICARE (CONTINUED) PART A Hospital insurance with basic coverage for hospital stays, nursing home facilities, home health and hospice care. PART B Medical insurance to cover many of the fees associated with doctor visits, laboratory testing, and outpatient services and supplies. PART C A Medicare Advantage Plan that includes Part A and Part B. PART D Medicare Prescription Drug Coverage insurance to help pay for outpatient prescription drugs, vaccines, and some supplies not covered by Medicare Part A or Part B.

9 PART 2 GETTING PRESCRIPTION DRUG COVERAGE (PART D) A Stand-alone Prescription Drug Plan (PDP) Former Employer or Union Group Medicare Advantage Plan with Prescription Drug A Coverage (MAPD) like Allegian Advantage (HMO)

10 PART 2 INTRODUCING ALLEGIAN ADVANTAGE (HMO) History Local, personalized service Well founded and continually expanding Provider Network Open access to in-network specialists More than 1,200 network doctors and specialists and 13 hospitals Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with our plan to deliver covered services to our members. WHAT WE RE NOT: Allegian Advantage (HMO) is not a Medicare Supplement plan. A Medicare Supplement plan (Medigap) is a health insurance sold by private insurance companies to fill the gaps in Original Medicare Plan coverage. Medigap policies help pay some of the healthcare costs that the Original Medicare Plan doesn t cover.

11 BENEFITS AT A GLANCE PART 2 Maximum Out-of-pocket (MOOP) $4,000 annual limit Premium $0 Primary Care Visit $0 co-pay Specialist Inpatient Hospitalization $30 co-pay $175/Day Days 1-6 $0/Day Days 7-90 Urgent Care $30 co-pay Vision Exam $10 co-pay Over-the counter (OTC) $25 per quarter Prescription Coverage Yes

12 PART 2 PRESCRIPTIONS Tier Levels Co-pay for 30-day supply Co-pay for 60-day supply Co-pay for 90-day supply Preferred Generic $4.00 $8.00 $12.00 Non-Preferred Generic $10.00 $20.00 $30.00 Preferred Brand $45.00 $90.00 $ Non-Preferred Brand $95.00 $ $ Specialty Tier 33% Cost Sharing 33% Cost Sharing 33% Cost Sharing

13 ALLEGIAN ADVANTAGE (HMO) OFFERS DIABETIC PROGRAMS AND SUPPLIES, INCLUDING: PART 2 ORIGINAL MEDICARE ALLEGIAN ADVANTAGE (HMO) 20% coinsurance $0 co-pay for diabetes self-management training 20% coinsurance $0 co-pay for diabetes monitoring supplies 20% coinsurance $20% of the cost for therapeutic shoes and inserts

14 PART 2 WHEN YOU CHOOSE ALLEGIAN ADVANTAGE (HMO) WE PROMISE TO: Provide you with information in a way that works for you, (in languages other than English, in Braille, in large print, or other alternative formats) Treat you with fairness and respect at all times Ensure that you get timely access to your covered services and drugs Protect the privacy of your personal health information Give you information about the plan, its network of providers, and your covered services Support your right to make decisions about your healthcare

15 PART 2 MEMBERS OF ALLEGIAN ADVANTAGE (HMO) ALSO RECEIVE SUPPORT FROM CARING PROFESSIONALS WE HELP YOU: Change your Primary Care Provider, if required Ensure that you have continuous prescription drug coverage Manage the prior authorization process for previously scheduled doctor visits, post-operative care and surgery Coordinate your health care if you have a complex or chronic condition

16 PART 2 ELIGIBILITY Members must be entitled to Medicare Part A and enrolled in Medicare Part B, not have End Stage Renal Disease (ESRD) and live in one of the following Texas counties: Cameron Hidalgo Willacy You must continue paying your Medicare Part B premium.

17 PART 3 YOUR SUMMARY OF BENEFITS $0 Premium $4,000 Low Maximum Out-of-Pocket (MOOP) Doctor/Hospital Choice $175 /Day, 1-6 Days - Inpatient Hospital Skilled Nursing Facility, Home Health, and Hospice Care $0 Doctor Visits $10 Vision Exam Benefit $65/30 Emergency and Urgent Care Outpatient Medical Services and Supplies Preventative Services and Wellness Education Prescription Drug Coverage

18 PART 3 OUR PRESCRIPTION DRUG BENEFITS SAVE YOU MONEY $4, $8 and $12 co-pays for a 30, 60 or 90-day supply of preferred generic drugs SAVE YOU TIME Mail order prescriptions available Mail order discounts give you a 90-day supply for the same low co-pay as a 60-day supply YOUR PROVIDERS AND PRESCRIPTIONS AT YOUR FINGERTIPS Refer to the Provider/Pharmacy Directory Refer to the Comprehensive Formulary Go online to Call Member Services (855) , TTY: 711 We re always happy to help!

19 ENROLLMENT IN ALLEGIAN ADVANTAGE (HMO) WHEN CAN YOU ENROLL? You can enroll in Allegian Advantage (HMO) during the Annual Enrollment Period (AEP) between October 15 and December 7, During the AEP, MA-eligible individuals may enroll in or disenroll from an MA plan. The last enrollment request made, determined by the application date, will be the enrollment request that takes effect. There are special circumstances that allow you to enroll in a Medicare Advantage Plan outside of this period. This is called Special Enrollment Periods (SEP). Special Enrollment Periods constitute periods outside of the usual IE, AEP or MADP when an individual may elect a plan or change his or her current plan election. There are various types of SEPs, including SEPs for dual eligibles, and for individuals whose current plan terminates, who change residence and who meet exceptional conditions as CMS may provide. Source: Medicare Managed Care Manual

20 PART 4 ENROLLMENT IN ALLEGIAN ADVANTAGE (HMO) EXAMPLES OF SPECIAL CIRCUMSTANCES (NOT A COMPLETE LIST) Change in residence Employer/Union Group Health Plan (EGHP) Disenroll from Part D to enroll in Creditable Coverage Full and partial dual eligible Other Low Income Subsidy Retroactive notice of Medicare entitlement Program of All-inclusive Care for the Elderly (PACE) Source: Medicare Managed Care Manual

21 PART 4 ENROLLING IS SIMPLE WE WILL WALK YOU THROUGH THE PROCESS By paper application. Contact the plan to get an application, fill it out, and return it to the plan. Visit the plan s website. Access and begin the enrollment process online. Medicare s Website. Access By phone. Call the plan you want to join, or call MEDICARE ( ). TTY users should call

22 PART 4 WHAT CAN I EXPECT NOW THAT I AM A MEMBER? WHAT YOU GET HOW YOU GET IT DESCRIPTION Copy of Enrollment Form Agent Confirms You Submitted an Enrollment Form. Enrollment Verification Enrollment Confirmation and Acknowledgement Letter Member ID Card and Your Welcome Kit Over-the-Counter Card Phone Mail Mail Mail Verifies that the Medicare Advantage Plan was fully explained by your sales agent. Notice Medicare has approved your enrollment form and acknowledge that your enrollment is complete. Bring your ID card when you visit your doctor, hospital or pharmacy. Includes important information about your benefits. Includes your Evidence of Coverage and Provider/Pharmacy Directory. Your OTC will be sent in a separate mailing; you will need to activate your card prior to use.

23 GRIEVANCES AND APPEALS PART 4 As a member of Allegian Advantage (HMO) you have the right to: Request an organization determination if you want us to provide or pay for an item or service that you believe should be covered Request a coverage determination, which is a coverage decision about your prescription drugs File an appeal if we deny coverage for an item or service File a grievance if you are unhappy about any other aspect of the health plan, our providers or pharmacies

24 HOW CAN I DISENROLL? IF YOU WOULD LIKE TO SWITCH FROM OUR PLAN TO: Another Medicare Health Plan THIS IS WHAT YOU SHOULD DO: Enroll in the new Medicare Health Plan. You will automatically be disenrolled from our plan when your new plan s coverage begins. Original Medicare with a separate Medicare prescription drug plan Original Medicare without a separate Medicare prescription drug plan. Note: if you disenroll from a Medicare prescription drug plan and go without credible prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. Enroll in the new Medicare prescription drug plan. You will automatically be disenrolled from our plan when your new plan s coverage begins. Send us written request to disenroll. Contact Member Services if you need more information on how to do this. You can also contact MEDICARE ( ), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call You will be disenrolled from our plan when your coverage in Original Medicare begins.

25 LOW INCOME SUBSIDY (LIS) YOU MAY QUALIFY FOR EXTRA HELP Need help paying for prescription drugs or Medicare Part A and Part B premiums? You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. Medicare provides Extra Help to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you get help paying for any Medicare drug plan s monthly premium, yearly deductible, and prescription co-payments. This Extra Help also counts toward your out-of-pocket costs. People with limited income and resources may qualify for Extra Help. Find out if you qualify for assistance by calling: MEDICARE ( ). TTY users should call , 24 hours a day/7 days a week and visit to review Programs for People with Limited Income and Resources in the publication Medicare & You. The Social Security Administration at between 7 a.m. and 7 p.m., Monday through Friday. TTY: PART 4

26 PART 4 DISCLAIMERS Allegian Health Plans is an HMO plan with a Medicare contract. Enrollment in Allegian Health Plans depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. Limitations, co-payments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium, and/or co-payments/co-insurance may change on January 1, of each year. For more information, contact the plan. You must continue to pay your Medicare Part B Premium. This information is available for free in other languages. Please contact our Member Services number at (855) for additional information. (TTY users should call 711). Hours are seven days a week, 8 a.m. to 8 p.m. Esta información está disponible gratuitamente en otros lenguajes. Por favor llame a servicio al miembro al (855) para información adicional. (Usuarios de TTY llamar al 711). Horario es siete días a la semana de 8 a.m. a 8 p.m.