CS VEBA 2016 UnitedHealthcare Medicare Advantage PPO Plan

Transcription

1 CS VEBA 2016 UnitedHealthcare Medicare Advantage PPO Plan

2 Replaced Senior Supplement Plan in 2016 UnitedHealthcare Group Medicare Advantage (PPO) plan. Also known as a Medicare Part C, this plan offers the convenience of a single plan that includes Medicare Parts A, B and D all in one plan. This plan also offers additional benefits beyond doctor and hospital visits. All the benefits of Part A Hospital stays Skilled nursing Home health All the benefits of Part B Doctor s visits Outpatient care Screenings and shots Lab tests Prescription drug coverage Included in many Medicare Advantage plans Additional benefits Are bundled with the plan

3 UnitedHealthcare Group Medicare Advantage (PPO) Plan Plan Features No annual plan deductible. You can use any doctor or hospital in the U.S. as long as they participate in Medicare and accept this plan Your co-pays and co-insurance remain the same regardless of whether the doctor or hospital is in UnitedHealthcare s network or outside the network. You do not need a referral to see a specialist This plan includes benefits and services beyond Original Medicare including: SilverSneakers fitness benefit 24 hour Nurseline Solutions for Caregivers to help make caring for a loved one easier

4 How the plan works How the plan works ID card UnitedHealthcare Group Medicare Advantage (PPO) Plan 1 ID card How claims are paid Family or individual coverage Doctors and hospitals UnitedHealthcare pays all claims directly to doctors, hospitals and pharmacies. Member pays his or her co-pay or co-insurance. Each eligible individual is covered separately and has his/her own plan. Can use any doctor or hospital in the U.S. that participates in Medicare and accepts this plan Referral to see specialist No

5 Benefit Coverage Benefit Coverage UnitedHealthcare Group Medicare Advantage (PPO) Plan Annual Deductible $0 Annual Out-of-Pocket Maximum Out of pocket costs capped at $6,700 combined for in and out of network. Primary Care Physician Cost capped at $5 per visit. Specialist Cost capped at $5 per visit. Urgent care $5 co-pay, waived if admitted within 24 hours for same condition

6 Benefit Coverage Benefit Coverage UnitedHealthcare Group Medicare Advantage (PPO) Plan Emergency room $50 co-pay Coverage provided for care considered emergency in nature by Medicare Inpatient Hospital Unlimited days. $0 per admit. Diabetic Monitoring Supplies $0

7 Prescription Drug Coverage Transitioned from Express Scripts to OptumRx Open refills were automatically transferred unless prescription was a narcotic, high risk medication, or compound drug Drugs on the formulary that require prior authorization Prior authorizations were transferred when possible If a prior authorization was not transferred, your doctor will need to take extra steps before we will cover the drug Prior authorizations typically need to be renewed annually at the time the prescription is renewed Full coverage in the coverage gap (no donut hole) Questions about mail service: OptumRx Mail Service: , 24 hours a day, 7 days a week

8 Your Part D plan benefits Prescription Drugs Your Cost Initial Coverage Stage Retail (30-day supply) Preferred Mail Order (90-day supply) Tier 1 (Generic) $5 co-pay $10 co-pay Tier 2 (Preferred Brand) $20 co-pay $40 co-pay Tier 3 (Non-Preferred Brand) $40 co-pay $80 co-pay Tier 4 (Specialty Tier) $40 co-pay $80 co-pay Coverage gap stage Catastrophic coverage stage After your total drug costs reach $3,310, the plan continues to pay its share of the cost of your drugs and you pay your share of the cost After your total out-of-pocket costs reach $4,850, you will pay $2.95 copay for generic, (including brand drugs treated as generic) $7.40 copay for brand name 18

9 Fitness program Stay physically fit and active at no additional cost. Join SilverSneakers and enjoy: Staying active with SilverSneakers Fitness Program. Choose a fitness center from more than 13,000 participating locations. (Find the nearest location at Classes, cardio equipment, resistance machines, free weights and heated pools (at certain locations). Amenities may vary at each location. Many women-only locations, including Curves nationwide. Don t live near a fitness center? SilverSneakers Steps is a personalized fitness program for members who can't get to a SilverSneakers location. Once you enroll in Steps, you may select one of the four kits that best fits your lifestyle and fitness level-general fitness, strength, walking or yoga. The Steps wellness tools can help you be active at home or on the go. 14

10 What to do If my provider will not accept the new plan Call Customer Service at To confirm provider status Request provider outreach to educate on the plan To get help finding a network provider Call CS VEBA Advocate line at If your Medicare provider ultimately refuses to accept the plan, you have the option of paying up front and submitting the following for reimbursement: Member s full name (as shown on the ID Card) ID Number (as shown on the ID Card) Signed letter explaining the reason for the request. Copy of the itemized invoice including CPT and Diagnosis codes. Proof of payment (i.e. canceled check, other credit card statement, cash receipt, etc.)

11 Coverage decisions If you have any questions about whether we will pay for any medical service or care that you are considering, you have the right to ask us whether we will cover it before you get it. You also have the right to ask for this in writing. If we say we will not cover your services, you have the right to appeal our decision not to cover your care. Your services (including medical care, services, supplies, and equipment) must be medically necessary. Medically necessary means that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. Like all Medicare health plans, we cover everything that Original Medicare covers. Requesting coverage decisions: Members can call Customer Service at Providers: or

12 Appealing coverage decisions If my requested services or prescription drugs are denied If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. You, your doctor, or your representative can call Customer Service at or write to the plan to request an appeal Fast appeals for medical services or Part D Prescription Drugs: we must give you our answer within 72 hours after we receive your appeal Standards appeals for medical services: we must give you an answer within 30 calendar days Standard appeals for prescription drugs: we must give you an answer within 7 calendar days

13 Questions? Just give us a call , TTY a.m. 8 p.m., Monday - Friday

14 This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium,if not otherwise paid for under Medicaid or by another third party. Consult a health care professional before beginning any exercise program. Availability of the SilverSneakers program varies by plan/market. Refer to your Evidence of Coverage for more details. Healthways, SilverSneakers and SilverSneakers Steps are registered trademarks of Healthways, Inc. and/or its subsidiaries Healthways, Inc. All rights reserved. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan s contract renewal with Medicare.