Geisinger Gold 2015 Product Line for Ocean & Monmouth Counties, NJ

Transcription

1 OPERATIONS BULLETIN Date: February 27, 2015 To: Geisinger Gold Participating Providers in Ocean and Monmouth counties, NJ Re: Geisinger Gold 2015 Geisinger Gold 2015 Product Line for Ocean & Monmouth Counties, NJ Meridian Health has partnered with Geisinger Health Plan to bring Geisinger Gold, one of the top ten Medicare Advantage plans in the nation, to Medicare Beneficiaries in Monmouth and Ocean Counties in New Jersey. NCQA s Medicare Health Insurance Plan Rankings for named Geisinger Gold the #1 ranked Medicare Advantage plan in Pennsylvania and among the top 10 in the nation. Geisinger Health Plan is nationally recognized for its disease management programs. Our Geisinger Gold HMO and PPO plans carry a 4.5 and 4.0 CMS Star rating respectively. Plans for 2015 include: Classic Rx (HMO) Preferred Rx (PPO) Reserve 100 (MSA) Medicare Part D Rx Drug Coverage All plans except Reserve 100 (MSA) are available with Deductible prescription drug coverage. Fixed, predictable copays in the initial coverage level and cost sharing up to the coverage gap. Members will receive coverage through the gap for tier 1 generic drugs at a $3 or $6 copay, 55% discount on brand drugs and 35% discount on generic drugs (for all generics not covered on our tier 1), as well as the Geisinger Gold contracted rates (discount from retail) on prescriptions while in the coverage gap. Supplemental Benefits Classic Rx (HMO) and Preferred Rx (PPO) plans feature built-in supplemental benefit coverage for the following: World-wide emergency room & urgent care Coverage for preventive dental, routine vision exams, eyewear, hearing exams and hearing aids, foot care, annual wellness visits and a 24 hour nurse line Fitness reimbursement (up to $90 allowance per quarter) o Submit receipts to Geisinger Gold Claims Department, PO Box 8200, Danville, PA o Questions: please call Customer Service at (800) Medicare Covered Preventive Services The following Medicare covered preventive services are available at no cost to Gold members (except Reserve; Reserve members must meet annual deductible first): Abdominal Aortic Aneurysm Screening Annual Wellness Visit Bone Mass Measurement Cancer Screenings Cardiovascular Disease Screening Cardiovascular Disease Behavioral Therapy Depression Screening Diabetes Screenings Diabetes Self-Management Training Glaucoma Screening HIV Screening Immunizations Medical Nutritional Therapy Welcome to Medicare Exam Screening & Counseling Alcohol Misuse Screening for Sexually Transmitted Infections Tobacco Use Cessation Counseling Obesity Screening & Counseling HPPNM17 Warehouse/Gold_PA_and_NJ_bulletins_091514/GOL D_2015_provider _bulletin_nj_1214.doc Dev. 12/14 1

2 Sample ID Card: Gold 2015 NJ Service Area: 2

3 Classic Rx Plan Type HMO 2014 Star Rating 4.5 Out of Pocket Max $6,700 PCP $5 Physician Specialist $15 Inpatient Hospital - Acute $345/day (days 1-5) /day (days 6-90) Inpatient Psychiatric Hospital $305/day (days 1-5) /day (days 6-90) /day (days 1-20) SNF $156/day (days 21-63) (No prior hospital stay required) Cardiac/Pulmonary Rehab $10 per day (72 day limit) Emergency Care $65 (Waived if admitted) Urgent Care $15 (Waived if admitted) Worldwide Coverage $65 (Waived if admitted) $25,000 worldwide benefit limit Home Health Services (includes related medical supplies) Chiropractic Services (Original Medicare Benefit) $20 Podiatry (Original Medicare Benefits) $15 Podiatry - Routine Nail Trimming /4 per year Occupational Therapy $20 Physical & Speech Therapy $20 per day Outpatient All Other Diagnostic Procedures/Tests 20% Outpatient Lab $15 Outpatient X-Rays $25 Outpatient MRI, CT, PET Scans 20% Outpatient Radiation Therapy, Nuclear Medicine 20% Outpatient All Other Therapeutic Radiology 20% Ultrasound Diagnostic 20% Other Diagnostic/General Imaging 20% Outpatient Hospital/ASC Services 30% Outpatient Mental Health $20 group/$40 individual Ambulance $200 (Waived if admitted) Part B Drugs 20% Durable Medical Equipment (DME) 20% Prosthetics and Related Supplies 20% Diabetes Supplies - Preferred Brand Glucometer Preferred Brand Glucometer every 2 years all other test strips, lancets & non-preferred brand Diabetes Supplies - All Other glucometers (prior auth required for non-preferred brand meters & strips) Diabetes - Therapeutic Shoes or Inserts 20% Acupuncture & Other Alternative Therapies (Non-Medicare Covered) Not Covered Supplemental Preventive Health Svc - Annual Routine Physical Exams $5 Supp Education/Health Mgmt Progs - Health Club $90/quarter Supp Education/Health Mgmt Progs - Nursing Hotline 3

4 Classic Rx Dental Services (Preventive): Oral Exam with or without cleaning Dental Services (Preventive): Dental X-Rays ; every 6 months bitewing only; panoramic & all other types, limit 1 per year Comprehensive Dental (Original Medicare-Covered Benefit only) $10 Comprehensive Dental (Non-Medicare Covered) No Benefit Vision Exam (Medical): for glaucoma screen - office visit copay may apply $20 Vision Exam (Routine) $20; 1 per year Original Medicare-Covered Eyewear (Post-Cataract Surgery) Only Medicare-covered (Basic frames and lenses) Eyewear: Routine Eyewear, Non-Medicare Covered. Contact Lenses, Eyeglasses, Lenses and Frames $200 benefit max every 2 years Hearing Exams - Diagnostic Only $20 Routine Hearing Exams $20; 1 per year Hearing Aids/Fitting for Hearing Aids $1,000 Maximum Benefit every 3 years (fitting/eval. falls under this limit) Part D Deductible Tier 1 Preferred Generics (30 day) $6 Tier 2 Non-preferred Generics (30 day) $20 Tier 3 Preferred Brand (30 day) $39 Tier 4 Non-preferred Brand (30 day) $85 Tier 5 Specialty (30 day) 33% Gap Coverage - Tier 1 Generic $6 4

5 Preferred Rx Plan Type PPO 2014 Star Rating 4.5 in-network out-of-network Out of Pocket Max $6,700 $10,000 PCP $10 $15 Physician Specialist $25 $30 Inpatient Hospital - Acute $225/day (days 1-8) 20% Inpatient Psychiatric Hospital $210/day (days 1-7) 20% SNF (no prior hospital stay required) /day (days 1-20) $156/day (days 21-63) 20% Cardiac/Pulmonary Rehab $10 per day (72 day limit) 20% Emergency Care $65 (Waived if admitted) $65 (Waived if admitted) Urgent Care $25 (Waived if admitted) $25 (Waived if admitted) Worldwide Coverage $65 (Waived if admitted) $65 (Waived if admitted) $25,000 benefit limit $25,000 benefit limit Home Health Services (includes related medical supplies) 20% Chiropractic Services (Original Medicare Benefit) $20 20% Podiatry (Original Medicare Benefits) $25 $30 Podiatry - Routine Nail Trimming /up to 4 visits per year $30 / up to 4 visits per year Occupational Therapy $25 per day 20% Physical & Speech Therapy $25 per day 20% Outpatient All Other Diagnostic Procedures/Tests 20% 20% Outpatient Lab $10 20% Outpatient X-Rays $25 20% Outpatient MRI, CT, PET Scans 30% 35% Outpatient Radiation Therapy, Nuclear Medicine 20% 30% Outpatient All Other Therapeutic Radiology 20% 30% Ultrasound Diagnostic 20% 20% Other Diagnostic/General Imaging 20% 20% Outpatient Hospital Surgery/ASC $250 20% Outpatient Mental Health $10 group/$25 individual 20% Ambulance $200 (Waived if admitted) 200 (Waived if admitted) Part B Drugs 20% 25% Durable Medical Equipment (DME) 20% 20% Prosthetics and Related Supplies 20% 20% Diabetes Supplies - Preferred Brand Glucometer Diabetes Supplies - All Other Preferred Brand Glucometer every 2 years all other test strips, lancets & non-preferred brand glucometers Preferred Brand Glucometer every 2 years Diabetes - Therapeutic Shoes or Inserts 20% 20% Acupuncture & Other Alternative Therapies (Non- Medicare Covered) Not Covered Not Covered Supplemental Preventive Health Svc - Annual Routine Physical Exams $10 $15 Supp Education/Health Mgmt Progs - Health Club $90/quarter $90/quarter Supp Education/Health Mgmt Progs - Nursing Hotline 25% 5

6 Preferred Rx Dental Services (Preventive): Oral Exam with or without cleaning Dental Services (Preventive): Dental X-Rays in-network out-of-network ; every 6 months 20%; every 6 months bitewing only; panoramic & all other types, limit 1 per year Comprehensive Dental (Original Medicare- Covered Benefit only) $25 $30 Vision Exam (Medical): for glaucoma screen - office visit copay may apply $35 $30 Vision Exam (Routine) $25; 1 per year $30; 1 per year Original Medicare-Covered Eyewear (Post- Only Medicare-covered Cataract Surgery) (Basic frames and lenses) 20% Eyewear: Routine Eyewear, Non-Medicare Covered. Contact Lenses, Eyeglasses, Lenses and $200 benefit max every 2 years Frames 20% $200 benefit max every 2 years Hearing Exams - Diagnostic Only $25 $30 Routine Hearing Exams $25; 1 per year $30; 1 per year Hearing Aids/Fitting for Hearing Aids $1,000 Maximum Benefit; every 3 years (fitting/eval. falls under this limit) Part D Deductible Tier 1 Preferred Generics (30 day) $3 Tier 2 Non-preferred Generics (30 day) $18 Tier 3 Preferred Brand (30 day) $39 Tier 4 Non-preferred Brand (30 day) $85 Tier 5 Specialty (30 day) 33% Gap Coverage - Tier 1 Generic $3 $1,000 Maximum Benefit; every 3 years (fitting/eval. falls under this limit) 6

7 Reserve 100 premium $1,200 deposit $3,900 deductible what member pays after deductible Reserve MSA is a Medicare Advantage Plan that combines a high-deductible health plan with a personal medical savings account. The plan deposits $1,200 from Medicare into the Member s MSA Plan savings account at the beginning of each year. The Reserve (MSA) Plan has an annual deductible of $3,900, but no monthly premium. Members can go to any doctor or hospital that accepts Medicare. No referrals are necessary. Providers should bill Geisinger Gold. Once the annual deductible is met, the plan pays for Medicare-covered medical expenses in full. (Please note: Medicare does not allow MSA plans to provide first-dollar coverage for any benefit. All covered benefits are subject to the $3,900 annual deductible.) Members may use funds from their MSA account to pay for any IRS qualified medical expense, but only expenses incurred for Medicare-covered services count toward the annual deductible. Any money remaining in the MSA bank account at the end of the year will roll over for use toward qualified medical expenses next year. This plan does not include prescription drug coverage. Members may join a separate Medicare Part D Prescription Drug plan from the carrier of their choosing for additional cost. 7