How To Get The Most Out Of An Mpm Health Care Plan

Transcription

1 MVP HEALTH CARE 2016 MEDICARE ADVANTAGE HEALTH PLANS Y0051_ /2015

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3 MVP Health Care: Proudly Serving Medicare Members for Over 30 Years MVP Medicare Advantage is cost-effective. I ve always gotten good value from my MVP plan. Curt L., MVP member Are you: Call MVP and get started today. Turning 65? Becoming Medicare eligible? Looking to switch health plans? Over 65 and getting ready to retire? New to the area? MVP s expert Medicare Products Advisors are your best resource for everything Medicare. We re ready to answer your questions about prescriptions, doctors, costs, and benefits. Enroll in an MVP Medicare Advantage plan during the annual Open Enrollment period, October 15 December 7. Monday Friday, 8 am 8 pm Eastern Time TTY: MVP Medicare information meetings are held throughout our service area. Call us or visit our website to reserve your seat. A salesperson will be present with information and applications. Call MVP for accommodation of persons with special needs at sales meetings. Enroll online anytime! Visit to enroll anytime, day or night. For more information about Original Medicare benefits and services, or about Medicare Part D prescription drug benefits, call MEDICARE ( ) 24 hours a day, seven days a week. TTY:

4 Expertise You Can Rely On MVP Medicare Advantage health plans provide coverage with valuable benefits that work for you and how you live. MVP works hard to provide high quality health plans with a focus on service and satisfaction. Our continuing commitment in these areas is proven in the 4.5 Star quality rating (out of 5 Stars) we receive from Medicare. MVP Medicare Advantage plans are exclusively for people who are enrolled in Medicare Parts A and B as a result of age or medical disability. Our plans are simple to use and easy to understand. A few of the benefits that add even more value to your health care experience include: Low or no cost generic drugs and select vaccines. No specialist referrals. Worldwide coverage for emergency room and urgently needed care. 19,000 MVP doctors and hospitals, from Buffalo, New York to Burlington, Vermont. Freedom to see any doctor (you may pay more for doctors who are not contracted with MVP). Full coverage for preventive care, like annual physicals and mammograms. A Healthways SilverSneakers Fitness Program membership, at no added cost to you! Coverage for acupuncture services. $100 allowance each year to use toward health, wellness, and fitness programs, from Aerobics to ZUMBA Gold. A dedicated team experienced in Medicare Advantage health plans. Medicare Rules Medicare allows you to be a member of only one Medicare Advantage plan at a time. MVP offers the convenience of both medical coverage and Part D coverage together in one plan! If you join an MVP Medicare Advantage HMO-POS or PPO plan and later choose a Part D drug plan from another insurance or pharmacy company, Medicare will: 1) Enroll you in that drug plan for your Part D drug coverage, 2) Automatically disenroll you out of your MVP plan, and 3) Enroll you into the Original Medicare (Parts A and B only) health plan for your medical coverage for the remainder of the year, along with the other drug plan you chose. If you do not join a Medicare Part D plan when you first become eligible, or do not have coverage as good as Medicare s, you may have to pay a penalty if you join at a later date. The penalty can be one percent of the current premium for every month you delay enrollment. This penalty will apply for as long as you are enrolled in Part D coverage. Things to Remember About Medicare Drug Coverage For MVP plans that include Medicare Part D prescription drug coverage, note the following: Not all Part D drugs are available through the mail. Refer to the MVP Formulary (list of Part D covered drugs) for more details. You pay a 10 percent coinsurance for OneTouch, FreeStyle, and Precision brand blood glucose tests trips; and a 20 percent coinsurance for all other blood glucose test strips. Drugs purchased outside the U.S. are not Medicare approved and are not covered.

5 Generic Drugs at Low or No Cost! Check for Generic Drug and Select Vaccine Pricing on the MVP Medicare Advantage Plan You Choose Generic drugs have the same active ingredients, strength, and effectiveness as the brand-name versions, but generally at a much lower cost. What could you save? A lot. Here are three things you can do: 1. Talk about generic drugs with your doctor. 2. See if you both agree that one of MVP s generic drugs would be right for you. Do not stop taking a prescribed drug before consulting with your doctor. 3. Do the math to check the savings. Here s an example of brand name drugs you may recognize, and generic drug options used to treat the same condition: If you re taking this brand name drug To treat Ask your doctor about this generic drug You could save this much each year by switching to a generic drug* Altoprev High cholesterol lovastatin $420 $1,080 Crestor Lescol XL Livalo pravastatin simvastatin Save money on these common vaccines! Shingles vaccine Vaccine for tetanus and combination tetanus/diphtheria/pertussis Zostavax Adacel Boostrix Tdap Tenivac Tetanus-Diphtheria Toxoids Always ask your doctor to process your Part D vaccine claims through a service called TransactRx. If your doctor does not process your claim using TransactRx, you will have to pay out-of-pocket for your vaccine and submit the claim to CVS/caremark for reimbursement. MVP will reimburse vaccine claims up to MVP s allowed amount. If your doctor chooses to charge more than the allowed amount, you will be responsible for paying the difference. If your doctor does not use the TransactRx service, consider getting your vaccination right at the pharmacy, if offered. * If your coverage is through your former employer, your savings may vary.

6 2016 MVP Preferred Generic Drugs To Control Blood Pressure atenolol/chlorthalidone tabs atenolol tabs benazepril/hydrochlorothiazide tabs benazepril tabs bisoprolol fumarate/hydrochlorothiazide tabs bisoprolol fumarate tabs carvedilol tabs enalapril maleate/hydrochlorothiazide tabs enalapril maleate tabs fosinopril/hct furosemide tabs hydrochlorothiazide caps and tabs indapamide tabs lisinopril/hydrochlorothiazide tabs lisinopril tabs losartan potassium tabs losartan potassium/hydrochlorothiazide tabs metoprolol/hydrochlorothiazide tabs metoprolol tartrate tabs nadolol tabs propranolol/hydrochlorothiazide tabs propranolol tabs quinapril tabs ramipril caps spironolactone tabs spironolactone/hydrochlorothiazide tabs triamterene/hydrochlorothiazide caps and tabs To Treat Osteoporosis/Bone Health alendronate sodium 35 mg and 70 mg tabs To Control High Cholesterol lovastatin tabs pravastatin tabs simvastatin tabs To Treat Diabetes glimepiride tabs glipizide tabs glipizide ER tabs glipizide XL metformin tabs metformin ER tabs (generic Glucophage XR only) To Treat Heartburn/Ulcers famotidine (RX) tabs ranitidine (RX) caps and tabs To Treat Glaucoma latanoprost solution timolol drops (other forms of timololsolution, i.e. gel-forming, are in Tier 2, Generic Drugs) To Treat Pain ibuprofen (RX) tabs meloxicam tabs naproxen (RX) tabs and suspension naproxen (RX) DR tabs naproxen sodium (RX) tabs To Treat Thyroid Conditions levothyroxine tabs To Treat Mental Health Conditions buspirone tabs citalopram tabs and oral solution paroxetine tabs sertraline tabs and oral concentrate Miscellaneous acyclovir 200mg caps allopurinol tabs This is not a complete list of drugs covered by our plans. For a complete listing, please call the MVP Medicare Customer Care Center at (TTY: ) or visit for the most up-to-date list of MVP s Medicare Part D covered drugs and other helpful prescription information. Reference to any brand name products does not constitute an endorsement or recommendation. This information is not an attempt to replace professional medical advice. Please talk with a qualified medical professional (your doctor or pharmacist) if you have any questions about taking generic drugs.

7 Live Healthier. MVP Will Help You Do It. There are two ways to look at prosperity: by saving money and by feeling healthy. MVP Health Care helps me in both ways. Patricia C., MVP member When it comes to your health and well-being, consider MVP a valuable asset and partner. We offer these added benefits as part of your coverage at no added cost to you! And when you take advantage of these free and confidential programs, you and MVP are working together to help keep health care costs down. Have Fun, Get Fit, Stay Healthy with Healthways SilverSneakers Fitness Join us as MVP marks the 12th anniversary of the popular SilverSneakers Fitness Program! Designed exclusively for Medicareeligible adults, you can sign up for a gym membership at a SilverSneakers location to: Enjoy classes and programs, and use equipment at safe, friendly fitness centers. Benefit from fun group exercise to increase strength and flexibility. Talk with on-site staff who are ready to help you meet your wellness goals. Keep exercising when traveling SilverSneakers and partner locations, like Curves and LA Fitness, are found all over the country. Sign up for SilverSneakers FLEX classes and activities at parks, recreation centers, and other local venues. Exercise at home or on the go with a SilverSneakers Steps kit (choose from general fitness, walking, strength, or yoga kits). Visit or call MVP at to find a location near you! Get Support Anytime with Our 24/7 MVP Nurse Advice Line Call the Nurse Advice Line anytime day or night for answers to your health questions. You ll speak with a nurse who can help you (especially when your doctor s office is closed) with issues such as: A what do I do if health question, even if it s in the middle of the night. Finding information and resources about prevention and wellness, treatments, chronic conditions, and other health topics or concerns. Listen to selections from an audio library of more than 400 pre-recorded messages on general health topics, designed to help you make informed health decisions.

8 Get $100 Start every year with a $100 HealthDollars SM allowance to spend on healthy activities. It s easy simply fill out a form with an original receipt attached to put your allowance to work at a ZUMBA Gold class or a safe driving course. How about relaxing with Tai Chi or yoga? A fall prevention class can help keep you on your toes. Put your allowance toward a variety of health, wellness, or fitness programs. Unused HealthDollars can t carry over from one year to the next, so don t put off that healthy cooking class any longer! Manage Chronic Conditions with Help from MVP Get extra support if you are living with a physical or mental health concern. MVP has free, confidential programs to help you get the care you need, understand your treatment options, and make the most of your benefits when you are living with: Asthma Cancer Chronic Obstructive Pulmonary Disorder (COPD) Depression (managed by ValueOptions ) Diabetes Dialysis Heart attack or blockages Heart failure Lower back pain Join Us for a Free MVP Living Well Program! Discover some of the many MVP health education and physical activity classes at your fingertips, free or discounted to all MVP members. Held at locations throughout our communities: Eating right Managing stress Easy ways to take better care of yourself And include such activity classes as: ZUMBA Gold Yoga MVP Dance Moves MVP Chair Moves Tai Chi Argentine Tango Line and Contra Dancing Bokwa and many more! A Free House Call to Evaluate Your Health Say yes to a free MVP-Matrix Medical home health visit an important part of your membership that gives you the chance to discuss your health in detail in the comfort of your own home. A nurse practitioner will make a house call to evaluate your current health. Studies show that MVP members who take advantage of these home visits: Have lower medical expenses. Have fewer hospital admissions. Feel more informed and in charge of their health. Are more satisfied with their health plan. The information you discuss during the visit is shared with your doctor. Working together, we can help you take steps now to prevent health issues later. Get Peace of Mind with Our Medication Review Program Connect with an MVP pharmacist over the phone for a half-hour to review all of your medications and check to be sure they are working well together with no potentially harmful combinations of drugs. Together, you and an MVP pharmacist will: Review the drugs you are taking and why. Discuss lower-cost alternatives and if they are available and appropriate for you. Identify potential dangers you might experience when mixing drugs. Consider over-the-counter drugs and supplements, such as vitamins.

9 How Your MVP Coverage Works for You WE TRAVEL WITH YOU Emergency Room and Urgently Needed Care Around the Clock, Around the World From Albany to the Amazon, MVP covers you anywhere in the world for emergency room and urgently needed care. When seen in an emergency room or urgent care facility in the U.S., you simply pay your copay. When traveling outside of the U.S., you may need to pay upfront for the services and submit your bills to MVP when you return home. In the end, you are still only responsible for your emergency room or urgently needed care copay. Out-of-Network Benefits (Coverage by a Provider Without an MVP Contract) Each MVP Medicare Advantage plan includes coverage for routine care that is given by a provider without an MVP contract. You are able to choose providers anywhere in the U.S. who may or may not have a contract with MVP. You may pay more for care received from noncontracted providers. Put another way, you may see a doctor three miles from your home or 300 miles away in another state. The amount you pay for your care will depend on whether or not the doctor has a contract with MVP. Prescription Drug Coverage If your plan includes Part D, prescription drug coverage is available at any MVPcontracted pharmacy, many with nationwide locations, such as CVS, Kmart, Rite Aid, Sam s Club, Target, Walgreens, and Walmart. Notes:

10 How MVP Enrollment Works STEP 1: Apply to Join an MVP Medicare Advantage Plan You may apply to join an MVP Medicare Advantage plan: When you first become eligible for Medicare benefits, which includes the three months before your 65th birthday month, the month in which you turn 65, and the three months after your 65th birthday month. Due to a disability that qualifies you for Medicare. When you decide to retire or if you leave your employer-sponsored Medicare health plan coverage. When you move into the MVP service area from somewhere else and are losing your former Medicare health plan. If you are eligible for both Medicaid and Medicare. During the annual enrollment period which runs from October 15 through December 7 each year to begin your coverage on January 1. If none of the above applies to you, there are other reasons that may make you eligible to apply. Call us to find out more. The Medicare Advantage Disenrollment Period is January 1 February 14. During this period you may disenroll from your current Medicare Advantage plan and switch to Original Medicare. If you switch to Original Medicare during this period, you have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your coverage will begin the first day of the month after the plan receives your enrollment request. There are special Medicare rules for Medicare members with end-stage renal disease. If you have end-stage renal disease and are already an MVP member or have had a successful kidney transplant, you are eligible to enroll in an MVP Medicare Advantage plan. STEP 2: Choose How You Want to Pay Your Premium You can choose how to pay your premium: 1. Be billed monthly by paper invoice, OR 2. Have your premium automatically deducted from your monthly Social Security or Railroad Retirement Board benefit check. (The first deduction may take several months to begin. Continue to pay your bill until the deduction starts.) 3. You can access MVP s online Payment Center to pay your bill electronically each month or set up automatic recurring payments. Choose to go paperless and receive an notification when your monthly invoice is ready to view instead of getting a paper invoice in the mail. Log In or Register for an MVP online account at to get started. If you qualify for Extra Help* with your Medicare prescription drug coverage costs, Medicare will pay part of your monthly plan premium. MVP will bill you for the amount that Medicare does not cover. STEP 3: Apply this month for coverage to start next month Usually, we must receive your application no later than the last working day of the month to meet Medicare s deadline to be effective * Extra Help also called Low Income Subsidy (LIS) can help reduce your monthly prescription drug premium and drug copays. To see if you qualify for Extra Help, call MEDICARE ( ), TTY: hours a day, seven days a week. Or call the Social Security Office at Monday Friday, 7 am 7 pm (TTY: ). Or call your state Medicaid office.

11 the first day of the next month. For example, if we receive your application on January 31, your coverage will begin February 1. During the annual open enrollment period, we may receive your application October 15 December 7 for a January 1 start date. STEP 4: Check Your Mailbox Once you join MVP, expect the following in your mailbox: A confirmation letter from us in about 10 days, letting you know we received your application and that Medicare has approved your enrollment in your MVP Medicare Advantage plan. You can use this letter at doctor appointments to show you are an MVP member until your MVP Member ID card arrives. Your MVP Member ID card will arrive within one to two weeks. Always carry and show your MVP membership card when you visit your doctor or the pharmacy. Keep your Medicare card at home for your records. A dental plan Member ID card, if the MVP plan you choose includes dental coverage. A new member packet that includes your Evidence of Coverage (your MVP contract), and other important materials to read and keep for future reference. A verification letter from MVP If you are leaving an employer group plan as required by Medicare to verify that you are familiar with the terms of your new health plan. Take Note Once you enroll with MVP, you have been automatically disenrolled out of any other Medicare Advantage plan or Medicare Prescription Drug plan in which you were a member. Your medical care is covered by MVP. Your MVP plan takes the place of Medicare. If you signed up for Medicare Part D prescription drug coverage with MVP, your Medicare prescription drugs are covered by MVP. If you also have prescription drug coverage through a State Pharmaceutical Assistance Program or a Veterans Administration program, that coverage may continue as well. You will have very few claim forms to complete unless you receive services from non-contracted MVP providers. Emergency room, urgently needed care, post-stabilization services, and renal dialysis are covered worldwide. Plan premiums and benefits may change at the beginning of each calendar year. They will not change during the calendar year unless the change is to your advantage as an MVP member. Notes:

12 Call Us First We re Here to Listen Grievance and Appeal Procedures You have rights and responsibilities as an MVP Health Care member and as someone who is getting Medicare. MVP is committed to honor your rights, to take your problems and concerns seriously, and to treat you with respect. You have the right to voice concerns, make complaints, or ask MVP Health Care to reconsider decisions we have made about your coverage. If you have a problem or concern, please call us first. Your health and satisfaction are important to us. We will work with you to try to find a satisfactory solution to your problem. We re available to help, call the MVP Medicare Customer Care Center at , Monday Friday, 8 am 8 pm Eastern Time. Call seven days a week October 1 February 14, 8 am 8 pm. TTY: If you do not wish to call, or you called and were not satisfied, you can put your complaint in writing and send it to us at: MVP Health Care Attn: Member Appeals Department PO Box State Street Schenectady, NY Two Ways to Deal With Concerns Sometimes you might need to use a more formal process to address a concern or problem you are having as a member of our plan. There are two ways to formally handle these issues: For some issues you need to use the process for making a complaint, also called a grievance. For other issues, you need to use the process to question or challenge a coverage decision, also called an appeal. Which process should you use? That will depend on the type of problem you are having. Please call MVP first for help, or refer to the chapter of your Evidence of Coverage (your contract with MVP) entitled, What to do if you have a problem or complaint (coverage decisions, appeals, complaints) to help you decide which process to use and to find more details about grievances and appeals. Filing a Grievance A grievance is a complaint about the way your Medicare health plan is giving care or service. Issues that might lead you to file a grievance include concerns with: The service you receive from the MVP Medicare Customer Care Center. The quality of care you receive from a doctor, hospital, or other health care provider in MVP s network. Getting appointments when you need them, or waiting too long on the phone or to be seen. Cleanliness or conditions of doctors offices, clinics, or hospitals. To file a grievance, you must contact MVP within 60 days after the incident occurred. Filing an Appeal An appeal is the process you use if you disagree with certain kinds of decisions made by MVP. Issues that might lead you to file an appeal include: A claim being denied for a service you already received and which you believe is covered by your MVP contract. MVP not approving medical care that you believe is covered by your contract. You are asking MVP to cover a Part D drug that is not on our list of Medicareapproved covered drugs.

13 To file an appeal, you must contact MVP within 60 days from the date on the denial letter that we send you. Both the grievance and the appeal processes have been approved by the Medicare program. To ensure fairness and prompt handling of your concerns, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. Refer to your Evidence of Coverage (your contract) for further details on appeals and grievances. Fraud, Waste and Abuse Prevention Fraud, waste, and abuse prevention programs benefit all Medicare beneficiaries, the Center for Medicare & Medicaid Services (CMS), and MVP. MVP is committed to preventing and detecting potential cases of fraud, waste, and abuse. If you suspect a case of fraud, waste, or abuse, call the MVP Special Investigations Unit Hotline toll free at All messages are confidential. A Note About Prior Authorization Prior authorization is a process in which MVP works with you and your doctors to make sure you receive medicallynecessary, high quality medical treatment at a reasonable cost. Some services require prior authorization by MVP regardless of whether these services are given by MVP contracted or non-contracted providers. Some examples of services needing prior authorization include: Diagnostic services, such as CT scans and MRIs Admissions to transitional care units, acute rehabilitation, and skilled nursing facilities Durable medical equipment Home care services Implants and internal prosthetics Select prescription drugs Most often, your family doctor will begin the process and request authorization whenever it is needed. If you need or want a medical service not available from a provider who contracts with MVP, you may refer yourself to a non-contracted provider. Remember, it may cost you more to receive medical services from a non-contracted provider.

14 Know Your Medicare ABCs and D Part A is for Hospital If you are entitled to Part A, Part A helps cover basic hospitalization for no monthly premium, but you may still have to pay outof-pocket costs for some services, including a deductible. Part B is for Doctor Visits Part B helps cover medical services such as visits to a doctor s office, outpatient care, and some prescription drugs. Some services will require that you pay a percentage of the cost in addition to a yearly deductible. You pay a monthly premium, based on income, for Part B, which is usually deducted directly from your Social Security check. Part C You Must Have A and B to Enroll in C Part C is a special kind of Medicare choice called a Medicare Advantage plan. MVP offers Medicare Advantage plans. Medicare Advantage plans are administered by private health insurance companies and may include all the benefits of Parts A and B, plus more. You usually pay a monthly premium to the health insurance company for a Part C plan, and continue to pay your Part B premium that is deducted from your Social Security check each month. Part D is for Prescription Drug Coverage There is generally a monthly premium for Part D coverage. There are different drug plan options including adding it to your Medicare Part C plan for one monthly premium. Based on income, you may pay a Part D surcharge to Medicare, deducted from your Social Security check. If you are low income or on both Medicare and Medicaid, you may be eligible for extra help with Part D drug coverage. If you don t join Part D when you first become eligible, or do not have coverage as good as Medicare s, you may have to pay a penalty if you join at a later date. Notes:

15 Estimate Your Annual Health Care Costs Your Estimated Annual Health Care Costs With an MVP Medicare Advantage Plan Annual cost of premiums Monthly premium of $ x 12 months = è $ Visits to Primary Care Provider Copay $ x visits per year = è $ Visits to a Specialist Copay $ x visits per year = è $ Your Estimated Annual Health Care Costs With Another Health Plan Annual cost of premiums Monthly premium of $ x 12 months = è $ Visits to Primary Care Provider Copay $ x visits per year = è $ Visits to a Specialist Copay $ x visits per year = è $ Prescription drug costs per year Prescription drug costs per year Estimated total per year è $ Estimated total per year è $ Other medical services used often Other medical services used often Service: Copay: è $ Service: Copay: è $ Service: Copay: è $ Service: Copay: è $ Service: Copay: è $ Service: Copay: è $ Service: Copay: è $ Service: Copay: è $ $100 HealthDollars SM $ 0 $ SilverSneakers membership $ 0 $ Preventive screenings $ 0 $ Add the estimates from above Total estimated annual cost $ Add the estimates from above Total estimated annual cost $

16 MVP Health Plan, Inc. is an HMO-POS/PPO/MSA organization with a Medicare contract. Enrollment in MVP Health Plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B premium. 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