Medicare. Medicare Overview. Medicare Part D Prescription Plans. Medicare
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1 58 requires enrollment as soon as a retiree, spouse or dependent of a retiree is eligible for. Parts A & B MUST be elected. Overview There are three parts to : Hospital Insurance (also called Part A. Your enrollment is automatic upon turning age 65. Medical Insurance (also called Part B ), which is partly financed by monthly premiums paid by individuals who choose to enroll. You MUST enroll, if you are eligible. Prescription Drug Insurance (also called Part D: ). Do NOT enroll unless you qualify for financial assistance for retirees on limited incomes. If you meet the limited income criteria, please contact the Office of Benefits, Leaves and Retirement. An individual is automatically enrolled in Part B when he/ she becomes entitled to Part A, if receiving social security benefits due to either age or disability. However, because an individual must pay a monthly premium for Part B coverage, he/she has the option of refusing the coverage. Note: If you deny coverage you will not be permitted to continue participation in a BCPS sponsored plan. If you are no longer actively employed and do not enroll in Part B within three months after reaching age 65 you must wait until the next general enrollment period (January 1 through March 31) to sign up. Coverage would begin the following July. There is a 10% monthly premium penalty for each twelve-month period that you were eligible for Part B, but did not enroll. (Note: You are covered under a spouse s group health plan, enrollment in Part B may be delayed. You will not be required to wait for a general enrollment period or pay the 10% premium surcharge for late enrollment.) Three months prior to becoming eligible, you will be sent a letter instructing you of the steps necessary to insure you will not be penalized. Once eligible for, you, your spouse or dependent, will be eligible to enroll in a Supplemental Plan through. As soon as you are enrolled in, please notify the Office of Benefits, Leaves and Retirement, so we can insure that your records are updated and that no claim problems will result. For additional information about benefits, please contact them directly at MEDICARE ( ) or online at It is Important to Read the Annual Notice of Change Announcement Each Year. Retirees are notified each year, by mail, of the enrollment dates and plan offerings for the next year. Rates for the upcoming year are also included in that packet. This is the only way Baltimore County Public Schools routinely notifies you of plan and/or rate changes. Part D Prescription Plans Federal legislation created prescription drug benefits for enrollees that took effect on January 1, The new benefits are called Part D plans. Retirees who choose to enroll in a Part D plan will pay a monthly premium for their prescription coverage. They will be required to pay the deductibles and coinsurance amounts required by the plan they selected. Standard Part D plans have a provision called the doughnut hole that allows the plan to stop paying toward prescription drugs for an enrollee after they have incurred annual prescription drug costs of $3,310. The plans resume paying when the prescription expenses reach $4,850 for calendar year These amounts are adjusted annually by CMS (Center for Medicaid & Services). Employers who offered prescription benefits for their retirees had a number of options once the new program was in place. chose to continue BCPS prescription benefits for retirees. The benefits provided under the plans are at least as good as those provided under the standard Part D plan and do not contain a doughnut hole provision.
2 59 For retirees/spouses who chose Cigna Surround Plan, prescription coverage is included. It is administered by Cigna-HealthSpring Rx (PDP). The member pays 20% for brand or generic drugs at a retail pharmacy or a $20 copay for generic, $40 copay for brand drugs at mail order. Your share of the cost is paid directly to the pharmacy. The remainder of the cost is paid by BCPS. There is no doughnut hole or deductibles in BCPS prescription coverage plan.* Cigna Home Delivery Pharmacy also offers the convenience of mail-order service for your maintenance medications. If you chose the Kaiser Plus plan, you will continue to have prescription coverage through Kaiser for a small copay amount. Required Disclosures to Beneficiaries must provide a notice of creditable prescription drug coverage to beneficiaries who are covered by, or who apply for, prescription drug coverage under any of the Baltimore County Public Schools plans. For a copy of this notice, please visit our Website at: or *The doughnut hole refers to the gap in many Prescription Drug Programs (Part D) during which the consumer must pay 100 percent out-of-pocket for drug purchase costs.
3 60 Supplemental Plan Supplemental Plan The Cigna Surround Plan offered through is health care coverage which will pay after. This plan requires you to have Part A & B in order to receive supplemental benefits. When treated in a doctor s office or a hospital, always present your card and your Cigna card ID Cards In addition to your card, your Surround card will be provided by Cigna and your pharmacy card will be provided by Cigna-HealthSpring. Don't forget to show your new cards starting 1/1/16. When seeking medical care, you will have the least out-ofpocket costs when you are seen by a physician who accepts assignment. Please note that all physicians must submit your claims to ; however, not all physicians have to accept assignment. In other words, the physician who does not accept assignment may charge you up to 15% above the allowed amount for services, also defined as the limiting amount. You may be asked to pay the bill in full at the time of service. Once you have been seen by the physician, the claim will be submitted to. After the claim is paid, you will receive a explanation of benefits. Since Cigna is your supplemental or secondary insurance plan, the claim is then filed with us. Cigna also sends an Explanation of Health Care Benefits (EOHB) which states the amount the provider may bill if he accepts assignment. (See How to file claims that follows for more details.) The benefit chart within this booklet will show you the type of service, and how it is paid by and Cigna. As a member of Cigna Surround Plan, you are covered for services in Maryland, in the United States, and even outside the U.S. You are also eligible to seek alternative therapies and wellness services at a discount rate through the Cigna Healthy Rewards Program. For more information about the providers and services, you may call Cigna's Member Services toll free number (800) or by visiting the online directory on Cigna's Website www. mycigna.com. also offers a prescription plan through Cigna. You will be enrolled in the prescription plan once you enroll in the Cigna Surround Plan. Note: When seeking medical care, please show both your card and your Cigna card.
4 61 Prescription Drugs Coverage for Prescription Drugs The Cigna Surround Plan does provide coverage for outpatient prescription drugs. The prescription plan is administered through Cigna-HealthSpring Rx (PDP). This Plan is an approved Part D Plan. The Plan has been deemed creditable and is equal to or better than the Part D Plan. Therefore, Baltimore County Public School retirees in the Cigna Surround Plan do not need to enroll in an Independent Part D prescription plans. Because you have employersponsored prescription benefits, late enrollment penalties will not apply if you need a prescription plan in the future. The plan covers federal legend drugs prescribed for FDA and Manufacturer approved diagnoses. Diabetic supplies are also covered under the prescription plan. Drugs that are excluded from coverage include over-thecounter medications, diet drugs, cosmetic drugs and drugs prescribed for a condition not approved by the FDA as appropriate for that condition. Medical devices are not included in prescription coverage those claims should be submitted to and then to Cigna for payment. Allergy serum claims should be submitted directly to Cigna for coverage under your health benefits. Certain medications require that an appropriate diagnosis be submitted to Cigna-HealthSpring Rx (PDP) before they can be filled. You and your physician can contact Cigna- HealthSpring Rx (PDP) by phone at or using the internet for a current listing of medications requiring prior authorization. Your Share of the Cost of Outpatient Prescriptions: There is no deductible or doughnut hole coverage gap that applies to this prescription plan. Cigna Home Delivery Pharmacy also provides a convenient mail-order service for maintenance medications. These are medications you are using, in the same strength, for a three month period. Contact Cigna Home Delivery at for more information on mail order service, for order forms, and for a determination of what your medication(s) will cost using mail order. What is Step Therapy? Step therapy is a program which encourages the use of lower cost generic medications for treatment of medical conditions which require regular use of medications. Some examples of medical conditions that step therapy focuses on are high blood pressure, high cholesterol, and gastrointestinal conditions. It helps you get an effective medication to treat your condition while keeping your costs as low as possible. The next time your doctor writes a prescription for you, ask your doctor if a generic medication listed by your plan as a front-line drug 1 is right for you. It makes good sense to ask for these drugs because, for most everyone, they work as well as brand-name drugs and they almost always cost less. If you ve already tried a front-line drug, or your doctor decides one of these drugs isn t appropriate for you, then your doctor can prescribe a back-up drug. 2 Ask your doctor if one of the lower-cost brands (Step 2 drugs) listed by your plan is appropriate. In some cases, you may be required to try more than one first line drug. Remember, you can always get a higher-cost brand-name drug at a higher copayment if the front-line or Step 2 back-up drugs aren t right for you. 1 The first step are generic drugs proven to be safe, effective and affordable. These drugs should be tried first because they can provide the same health benefit as more expensive drugs, at a lower cost. 2 Step 2 and 3 drugs are brand-name drugs. There are lower-cost brand drugs (Step 2) and higher-cost brand drugs (Step 3). Back-up drugs typically cost more than front-line drugs. Local Pharmacy 20% coinsurance per prescription Mail Order $20 copay for generic drugs; $40 copay for any brand-name drug Prior Authorization Quantity Limits, or Step Therapy applies in some cases
5 62 Health Benefits Summary Inpatient Hospital/Facility Services Room & Board (ICU/CCU (other special care units), and Ancillary Services (incl. nursery charges) Extended Care Facility/Skilled Nursing Care Inpatient Professional/Practitioner Services Physician Surgical Services Anesthesia, Assistant Surgeon Consultation (including follow-visits) & Physician Visits (Includes ECF) Radiation Therapy, Chemotherapy, and Renal Dialysis Outpatient Hospital/Facility Services Minor/All Surgery (includes hospital based and freestanding surgical centers) Preadmission Testing Radiation Therapy, Chemotherapy, and Renal Dialysis Physical & Speech Therapy Occupational Therapy Diagnostic Tests Outpatient/Office Professional Services Minor/All Surgery Anesthesia, Assistant Surgeon Diagnostic Tests Office Visit for Illness, Injury or consultation Allergy Tests Allergy and Other Covered Injections administration of injections Physical therapy & Acupuncture Speech & Occupational Therapy Preventive/Well Care (Routine) Annual Adult Physicals, Immunizations and Diagnostic Tests: age 18 & older Annual GYN Services (includes pap smear) rendered in the office Mammography Screening (provider must be American College of Radiology [ACR] approved) Prostate Cancer Screening (including PSA test) Pays: 100% of the approved amount after inpatient deductible Days 1 20: 100% of the approved amount; Days : 100% of the approved amount after per day deductible. Note: pays 100% of the approved amount for clinical laboratory services.. Note: pays 100% of the approved amount for clinical laboratory services. Speech therapy: 80% of the approved amount after annual deductible. Note: Occupational therapy limited to $1,920 per year. Speech & physical therapy limited to $1,920 per year. 100% of the approved amount. One "Welcome" visit within 12 months of becoming eligible for A & B deductibles and coinsurance apply. 100% of the approved amount after annual deductible. Note: Limited to one every two years and pap smear is not subject to annual deductible. 100% of the approved amount. Note: Limited to one screening annually after age % of the approved amount after annual deductible. Note: Limited to one exam annually after age 50 and PSA is not subject to coinsurance or deductible.
6 63 Cigna Surround Plan Pays: 100% of inpatient deductible day 1-60; The benefit will reduce to 80% after day 61 unless a new benefit period begins Day 1-20: covers at 100% - no Cigna payment is necessary; Day : 100% of the per day deductible; Days : 100% of the allowed benefit 80% of the balance due after including the deductible 80% of the balance due after including the deductible 80% of the balance due after including the deductible 80% of the balance due after including the deductible 80% of the balance due after including the deductible
7 64 Health Benefits Summary Pays: Emergency Care Accidental Injury/First Aid Medical Emergency or Life Threatening Event Follow-Up Visits to an Accidental Injury or Medical Emergency Ambulance Ground (public or private) Mental Health Inpatient Hospital/Facility and Professional Services Outpatient Facility, Professional Services Prosthetic Devices & Orthopedic Braces Purchase, repair or replacement Durable Medical Equipment Medical Supplies Hearing Aids Home Health Care Facility/Agency Outpatient Private Duty Nursing (Non-custodial; pre-authorization required) Hospice Care (Inpatient or At Home) Cardiac Rehabilitation Organ Transplants Kidney, Cornea, Bone Marrow Heart, Heart-Lung, Single or Double Lung, Pancreas, and Liver Prescription Drugs Outpatient Prescription Drugs Drugs dispensed by medical provider in office Routine Vision Dental Additional Information Deductible (Part A, Part B) Out-of-Pocket Maximum Lifetime Maximum 100% of the approved amount after inpatient deductible Note: Coverage limited to 190 lifetime days. 100% of the approved amount 100% of the approved amount 100% of the approved amount except $5 per outpatient prescription and 5% of inpatient respite care Verify with. Deductibles change yearly. Not applicable Not applicable Note: This benefit matrix is intended for comparison/informational purposes and is not meant to be a binding contract. Specific benefit inquiries or quotes for benefits should be directed to the appropriate customer service department.
8 65 Cigna Surround Plan Pays: 80% of the balance due after including the deductible 80% of the balance due after including the deductible 80% of the balance due after including the deductible 80% of the balance due after including the deductible 80% of the balance due after including the deductible 100% up to $2800 every three years covers 100% of the allowed amount - no Cigna payment necessary covers 100% of the allowed amount - no Cigna payment necessary covers 100% of the allowed amount - no Cigna payment necessary 80% of the balance due after including the deductible 80% of the balance due after including the deductible Not applicable $650 $300,000 (applies to Part B expenses) Note: Cigna will pay up to the approved amount if the provider accepts assignment. Cigna will not pay above the limiting amount if the doctor does not accept assignment.
9 66 How to File Medical Claims Care Rendered in or outside of Maryland Provider will file claim to Part A or B for processing Claim is automatically forwarded to Cigna for eligible supplemental payments If the provider accepts assignment, and Cigna payments are sent directly to the provider. If provider does NOT accept assignment, the and Cigna payments are sent directly to you. You will receive: 1) Explanation of Benefits 2) Cigna Explanation of Health Care Benefits To find doctors who accept, or to learn more about benefits and services, visit or call MEDICARE ( ) 24 hours a day, 7 days a week. TTY/TDD users call
10 67 Understanding Your Explanation of Benefits This is an Explanation of Benefits for a resident of Maryland. You May Be Billed You May Be Billed: This amount represents your deductible or coinsurance under. Do not pay this amount to the provider at the time you receive this notice. When you receive care in Maryland the claim will automatically be filed to Cigna for review and payment of eligible supplemental plan benefits. Approved Paid Provider Approved: The amount medicare approves for a certain service or supply. A provider who accepts assignment will accept this amount as payment in full. A provider who does not accept assignment can bill an additional 15% over this amount. Paid Provider: The amount of the payment made by directly to the provider of care.
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