Eligible for Medicare and Medicaid? Be treated like the VIP you are

Transcription

1 Eligible for Medicare and Medicaid? Be treated like the VIP you are Y0093_PRE_2503_Accepted_

2 Introduction Keystone First VIP Choice (HMO-SNP) is a Medicare Advantage HMO Plan for individuals enrolled in both Medicare and Medicaid. Keystone First VIP Choice is a separate health insurance plan from any other health plan that uses the Keystone name. Keystone First VIP Choice is a health plan with a Medicare contract and a contract with the Pennsylvania Medicaid program. Keystone First VIP Choice sales agents are not employed by Medicare or state Medicaid. The representative is a licensed insurance agent. A commission may be paid to each sales agent who enrolls individuals into a Keystone First VIP Choice Medicare Advantage Plan. You are under no obligation to join a Medicare Advantage Plan. You have given permission to discuss our Medicare Advantage Plan with you. 2 Keystone First VIP Choice

3 Keystone First VIP Choice Marketing Information The Keystone First VIP Choice agent will present and make available the following documents: Enrollment application Summary of Benefits Formulary Provider & Pharmacy Directory Multi Language Insert Scope of Appointment Form Star Ratings Document 3

4 About Keystone First VIP Choice Contracted with the Centers for Medicare and Medicaid Services (CMS) and the State Medicaid agency Keystone First VIP Choice is funded by the Federal Government to manage Medicare benefits for our members Keystone First VIP Choice covers all Medicare benefits Our benefits include: - Prescription drug coverage - Dental and vision coverage - Transportation, health club membership, over the counter (OTC) medications 4

5 Medicare Basics Part A Part B Part C Part D Hospital insurance Medical insurance Medicare Advantage Plans (like HMOs and PPOs). Includes Part A and B and sometimes Part D coverage. Medicare prescription drug coverage 5

6 Medicare Basics Your Initial Enrollment Period lasts seven months - Begins 3 months before your 65 th birthday - Includes the month you turn 65 - Ends 3 months after you turn 65 Enrollment is automatic if you get Social Security or Railroad Retirement Board (RRB) benefits; not automatic if still actively working To enroll with Social Security visit a local office; Call ; Online at If retired from the Railroad, enroll with the Railroad Retirement Board (RRB) visit local office; Call ; Online at There are other times you may enroll, but you may pay a penalty if you delay enrollment to the Part B and Part D program. 6

7 Medicaid Basics Federal-state health insurance program - For people with limited income/resources - Certain people with disabilities - Covers most health care costs Eligibility determined by State Application processes and benefits vary by State State office names vary Apply if you think you MIGHT qualify 7

8 Medicare Savings Program and Low Income Subsidy Medicare Savings Program (MSP) Help from Medicaid paying Medicare costs - Pays Medicare premiums - May pay Medicare deductibles and coinsurance Income limits change each year Some states offer their own programs Low Income Subsidy (LIS) - Extra Help Help paying prescription drug costs Social Security or State makes determination Some groups automatically qualify - People with Medicare and Medicaid - Supplemental Security Income (SSI) only - Medicare Savings Programs You or someone on your behalf can apply - The local Social Security Office - Local County Assistance Office 8

9 Medicare Savings Program Eligibility Categories for Keystone First VIP Choice D-SNP Enrollment STATE QMB QMB+ SLMB SLMB+ QI FBDE QDWI PA X X X Medicare Savings Program Definitions Qualified Medicare Beneficiary with Comprehensive Medicaid Benefits (QMB+): An individual entitled to Medicare Part A, with income of 100% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and who is eligible for full Medicaid. Specified Low-Income Medicare Beneficiary with Comprehensive Medicaid Benefits (SLMB+): An individual entitled to Medicare Part A, with an income that exceeds 100% FPL but less than 120% FPL, with resources that do not exceed twice the SSI limit, and who is not otherwise eligible for Medicaid. The individuals are entitled to payment of the Medicare Part B premium, in addition to full State Medicaid benefits. These individuals often qualify for Medicaid by meeting Medically Needy standards or by spending down excess income to the Medically Needy level. Medicaid Only Dual Eligibles (Non QMB, SLMB, QDWI, QI-1, or QI-2): These individuals are entitled to Medicare Part A and/or Part B and are eligible for full Medicaid benefits. They are not eligible for Medicaid as a QMB, SLMB, QDWI, QI-1, or QI-2. Typically, these individuals need to spend down to qualify for Medicaid or fall into a Medicaid eligibility poverty group that exceeds the limits listed above. Medicaid provides full Medicaid benefits and pays for Medicaid services provided by Medicaid providers, but Medicaid will only pay for services also covered by Medicare if the Medicaid payment rate is higher than the amount paid by Medicare, and, within this limit, will only pay to the extent necessary to pay the beneficiary's Medicare cost sharing liability. Payment by Medicaid of Medicare Part B premiums is a State option; however, States may not receive FFP for Medicaid services also covered by Medicare Part B for certain individuals who could have been covered under Medicare Part B had they been enrolled. FFP equals FMAP. 9

10 Medicare Savings Program Income Limits Medicare Savings Program Individual Monthly Income Limit Low Income Subsidy (LIS) Extra Help Married Couple Monthly Income Limit Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) $1, $1, $1, $1,

11 Three different types of special needs plans are authorized by CMS. A Brief Overview of Special Needs Plans (SNPs) 1. D-SNP (Dual Eligible SNP) Beneficiaries who qualify for both Medicare and Medicaid. Approximately 75% of all members enrolled in SNPs are members of D-SNPs. 2. C-SNP (Chronic SNP) Are available only to people with Medicare Parts A and B, who are diagnosed with at least one of the 15 chronic conditions. C-SNPs may only enroll people who have one or more co-morbid and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes, and require specialized delivery systems across domains of care. 3. I-SNP (Institutional SNP) Serve people who live in residential facilities, such as nursing homes. I-SNPs may also choose to serve people living at home but only if they meet the residential setting level of care criteria. 11

12 Medicare Advantage Enrollment Process and Dates Date Description Action October 1 October 15 th December 7 th January 1 st - February 14 th February 15 th October 14 th January 1 st December 31 st Plans can begin to share new benefits for the coming year Annual Enrollment Period (AEP) Medicare Advantage Disenrollment Period (MA-DP) Lock-In Special Election Period (SEP) Initial Coverage Election Period (ICEP) Medicare beneficiaries can begin to review plan information before making a decision. Medicare beneficiaries can select and enroll into a Medicare Advantage Prescription Drug (MA-PD) Plan, a Prescription Drug Plan (PDP) and/or leave a MA-PD or PDP. Medicare beneficiaries may disenroll from a Medicare Advantage Plan and return to original Medicare and enroll in a Prescription Drug Plan. Medicare beneficiaries must remain in current plan until AEP. *Does not apply to Dual Eligible Members. Medicare beneficiaries can choose their effective date of enrollment. The date can vary from the first day of the following month or January 1 st of the following year. 12

13 Special Election Period Special Election Period (SEP) SEP constitute periods outside the usual AEP, IEP, or MADP when an individual may elect a plan or change his or her current plan election. Typically, you must remain enrolled in a Medicare Advantage plan for the calendar year starting the date your coverage begins (sometimes referred to as lock-in.) You may be able to join, switch or disenroll from a Medicare Advantage plan at other times. Special Election Period situations: Loss of creditable coverage (insurance through an employer) Move into or out of a plan service area Eligible for Medicaid (dual-eligibility) Loss of Medicaid eligibility Qualify for or have a change to your Low Income Subsidy (LIS) You live in a long-term care facility Qualify for a Special Needs Plan 13

14 Understanding Late Enrollment Penalty and Disenrollment Late Enrollment Penalty Voluntary and Involuntary Disenrollment Certain individuals are subject to a late enrollment penalty if they do not enroll in a Part D- Prescription Drug program Individuals enrolled in Keystone First VIP Choice are typically not subject to the late enrollment penalty because, due to income level, they are likely to qualify for Extra Help A late enrollment penalty on individuals who do not receive Extra Help would apply Dual Eligible beneficiaries can voluntarily disenroll at any time Involuntary disenrollment from Keystone First VIP Choice may apply if the member Moves out of the service area Loses Medicare Part A or B Eligibility status changes with Medicaid 14

15 Understanding How Keystone First VIP Choice Works

16 Understanding Keystone First VIP Choice Service Area and Eligibility Criteria Enrolled in Medicare Part A and Part B Lives in our service area Enrolled in the Pennsylvania Medicaid program (Medical Assistance) Does not have end stage renal disease (except for limited circumstances such as enrollment before illness developed) Keystone First VIP Choice is a separate health insurance plan from any other health plan that uses the Keystone name 5 counties: Bucks Chester Delaware Montgomery Philadelphia 16

17 Understanding Keystone First VIP Choice Your Premium and Understanding Cost-sharing Premium $0 premium Cost-sharing (sometimes referred to as copay or coinsurance) Cost share is an amount that you pay when you visit a provider, hospital or specialist. You pay no cost-sharing or deductibles for Medical Services Medicaid eligibility status changes, you could be subject to cost-sharing or premiums 17

18 Understanding Keystone First VIP Choice Using your HMO network Keystone First VIP Choice is an HMO-SNP plan which requires a primary care provider (PCP). We ask you to select a PCP to assist with coordination of your health care needs. We will assign a PCP if you do not select one. You must use network doctors, specialists and hospitals. You may be required to pay out of pocket to use providers who are not included in our network. We will provide you our most up-to-date provider directory that is available in print, on our website or by calling member services as we add additional providers in your area. Our network of providers are updated on the online provider directory daily. Emergency services are not subject to out-of-network costs. Your PCP will refer you to Keystone First VIP Choice specialists, home health, durable medical equipment, hospitals and any other providers. Keystone First VIP Choice will reimburse PCPs, specialists, hospitals and other providers who provide your care. 18

19 Understanding Keystone First VIP Choice Using your HMO network Let s now discuss your current providers. This may include your family, heart, and pain management doctor. 19

20 Understanding Keystone First VIP Choice How Your Benefits Work Hospital Benefits No Deductible Plan covers 90 days per benefit period Up to 190 days of inpatient psychiatric hospital care for lifetime (same as Original Medicare) In network ambulatory surgical center and outpatient hospital facility visit - $0 copay Doctor Benefits Doctor office visit: PCP: $0 copay Specialist: $0 copay Podiatry: (In network only and medically necessary) $0 copay Outpatient Mental Health Care: In-network requirement $0 copay for individual therapy or group visit for therapy or psychiatrist 20

21 Understanding Keystone First VIP Choice Emergency and Urgent Care Benefits Emergency Care Coverage for a medical emergency when you believe your health is in serious danger Examples severe pain, sudden illness or a medical emergency without improvement in your condition Call 911 or go to your nearest emergency room Covered anywhere in the United States or its territories $0 copay for emergency room visits Urgent Care Urgently needed care is a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care Illness, injury or condition that was not anticipated and medical care is immediately needed Due to the nature of your condition, it may not be possible for you to obtain care from your primary care provider or a network provider $0 copay for urgent care visits 21

22 Understanding Keystone First VIP Choice Referrals PCPs are involved in the total management of medical care. They assist members with selecting network specialists to obtain services. Referrals are not required for in network PCP and specialists visits. 22

23 Prior Authorization is advance approval from your provider before beneficiary receives services. Understanding Keystone First VIP Choice Prior Authorizations Provider must request Prior Authorization for the following services: Inpatient Hospital Inpatient Psychiatric Hospital Home Health Cardiac and Pulmonary Rehab Skilled Nursing Facility Outpatient Hospital Services Partial Hospitalization Ambulatory Surgical Center (ASC) Services Occupational Therapy Physical Therapy Diabetes Services and Supplies Durable Medical Equipment and prosthetic devices Certain Diagnostic tests (for example MRIs and radiology services) 23

24 Understanding Keystone First VIP Choice Your Prescription Drug Plan Our plan provides low-cost prescription drug coverage through Part D and Part B Part D Coverage: Drugs listed in Formulary Drug classified in 5 tiers -Tier 1 (Preferred Generic) -Tier 2 (Generic) -Tier 3 (Preferred Brand) -Tier 4 (Non-Preferred Brand) -Tier 5 (Specialty Tier) There is no annual deductible for Part D drugs Copays will vary $ $8.35 depending upon the drug and subsidy level Most Medicare plans apply three coverage periods to prescription drug coverage: Initial Coverage Limit, Coverage Gap, and Catastrophic Coverage These coverage periods may not apply to you due to the low copays you incur as a member. Part B Coverage: Certain medications are covered under Part B: - Oral anti-cancer drugs or an injectable drug administered by your doctor. - $0 cost share for Part B chemotherapy drugs and other Part B drugs. 24

25 Understanding Keystone First VIP Choice Your Prescription Drug Plan Standard Retail Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) One-month supply Two-month supply Three-month supply For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.25 copay; or $3.35 copay For all other drugs, either: $0 copay; or $3.70 copay; or $8.35 copay 25

26 Understanding Keystone First VIP Choice Prescription Drug Plan Benefits Let s now discuss your current list of medications. The Formulary will show what tier your medication is in which will help explain how your medications are covered. Remember, your Low Income Subsidy or Extra Help level will lower the cost of your prescription copays. 26

27 Understanding Keystone First VIP Choice Prescription Drug Plan Coverage Rules Prior Authorization Quantity Limits Step Therapy Transition Process Certain drugs require prior authorization. You or your provider must contact <Keystone First VIP Choice> before you can fill certain prescriptions because we must ensure that such drugs are medically necessary for your condition. These are limits on the amounts of prescription drugs you can obtain at one time. Try certain less expensive drugs that have been proven effective for most people with your condition. If your provider believes a coverage rule should not apply, contact Keystone First VIP Choice for an exception Certain circumstances you are entitled to a transition supply of prescription medications if there is a change in your status by having a one time temporary supply of non-formulary Part D drug filled. Examples: A change in treatment setting, moving from an acute-care hospital to a Long-Term Care facility or enrollment in a new Medicare Advantage Plan. 27

28 We provide extra benefits not provided by Original Medicare Health Club/ Fitness Club membership Transportation 24/7 telephone access to nurses to answer your healthcare questions No additional charge for extra benefits Extra Benefits from Keystone First VIP Choice 28

29 Extra Benefits Vision Preventive Dental Comprehensive Dental Hearing $0 copay for Medicarecovered diagnosis and treatment for diseases and conditions of the eye $0 copay for up to 1 routine vision exam every year 1 pair of Medicare-covered eyeglasses or contact lenses after cataract surgery In addition to the cataract surgery benefit the plan will cover up to $200 every two years towards eyeglasses or contact lenses Oral exams 1 every 6 months $0 copay Cleaning 1 every 6 months $0 copay Fluoride treatment 1 every 6 months $0 copay Dental x-rays 1 every year $0 copay $1,000 plan coverage limit for comprehensive dental benefits every two years which includes coverage for minor restorations (such as fillings), simple extractions, dentures and denture repair $0 copay for Medicarecovered diagnostic hearing exams $0 copay for up to 1 Supplemental routine hearing exam every year $0 copay for 1 fitting evaluation for a hearing aid every three years $0 copay for up to 1 hearing aid every three years $1,000 allowance for hearing aids every 3 years 29

30 Extra Benefits Transportation Over the counter pharmacy (OTC) Additional Programs $0 copay for up to 30 one-way trips per year to your providers Car, shuttle, van services Scheduling rules apply Typically includes medicines or products that alleviate or treat injuries or illness. No statement from a medical provider required or documentation of a diagnosis to use the benefit $70 every three months (Aspirin, cold and flu treatments, and vitamins) Benefit does not carry over quarter to quarter Health Club/ Fitness Club Membership /Fitness Classes. o o o o Nursing Hotline Attend a health club or fitness class at a plan approved location. $0 for the cost of a membership for plan members. The benefit is limited to coverage of the membership fee. Start date is effective on the date of enrollment into the fitness facility. The goal of the benefit is to encourage a healthy lifestyle, improve your health status and help manage chronic conditions. Smoking and Tobacco Use Cessation Programs 30

31 Using Keystone First VIP Choice s Healthcare Services Present your Keystone First VIP Choice ID Card and your state Medicaid ID Card when you receive medical services or fill prescriptions You do not need to use your Medicare Red, White and Blue Card Store your Medicare Red, White and Blue Medicare Card in a safe place. 31

32 Key Points to Remember Our history and mission demonstrate that we care about your health care needs. We will provide high quality customer service and care management services. We will advocate for your care. 32

33 As a Keystone First VIP Choice member: You will not lose Medicare coverage by joining Keystone First VIP Choice You will receive Medicare benefits from Keystone First VIP Choice rather than directly from the Federal Government Key Points to Remember We provide the following benefits: You will receive extra benefits to help pay for dentures, denture repairs Choice of a primary care physician in our network No monthly plan premium Drug coverage with low or no cost-sharing Comprehensive Formulary No co-payments for doctor visits As a reminder, Keystone First VIP Choice is a separate health insurance plan from any other health plan that uses the Keystone name. 33

34 Easy Enrollment Process Easy enrollment process Complete the enrollment application Sign the application Keep a copy of the application for your records We will forward the enrollment application to Medicare What happens next You will receive an Outbound Eligibility Verification (OEV) letter from Keystone First VIP Choice within 15 days of the application date to verify your enrollment Enrollment acknowledgement and confirmation letter Welcome Kit with enrollment materials and information on your benefits Member ID Card Health Risk Assessment Complete and return to help us plan how to meet your health care needs 34

35 Medicare & You Handbook Other resources MEDICARE ( ) TTY

36 Thank You Call Toll-free: TTY Users Call Toll-free days a week from 8 a.m. to 8 p.m. Keystone First VIP Choice is an HMO-SNP with a Medicare contract and a contract with the Pennsylvania Medicaid program. Enrollment in Keystone First VIP Choice depends on contract renewal. The Plan is available to anyone who has both Medical Assistance from the State and Medicare. The information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and copayments may change on January 1 of each year. You must continue to pay your Medicare Part B premium, unless otherwise covered by your Pennsylvania Medicaid benefits. Premiums, copays, coinsurance, and deductible may vary based on the level of Extra Help you receive. Please contact the plan for further details. The Formulary, pharmacy network, and provider network may change at any time. You will receive notice when necessary.

37 Discrimination is Against the Law Keystone First VIP Choice complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Keystone First VIP Choice does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Keystone First VIP Choice: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Keystone First VIP Choice Member Services at < > (TDD/TTY: 711). We are available from <8 am to 8 pm, 7 days a week>. If you believe that Keystone First VIP Choice has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Keystone First VIP Choice Appeals & Grievances Department, P.O. Box 337, Essington, PA 19029, Phone: < > (TDD/TTY: 711), Fax: < >. You can file a grievance by mail, fax, or phone. If you need help filing a grievance, Keystone First VIP Choice Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at

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