Annual Notice of Changes for 2018

Transcription

1 EmbemHeath VIP God (HMO) offered by HIP Heath Pan of New York (HIP)/EmbemHeath Annua Notice of Changes for 2018 You are currenty enroed as a member of EmbemHeath VIP God (HMO). Next year, there wi be some changes to the pan s costs and benefits. This booket tes about the changes. You have from October 15 unti December 7 to make changes to your Medicare coverage for next year. What to do now 1. ASK: Which changes appy to you Check the changes to our benefits and costs to see if they affect you. It s important to review your coverage now to make sure it wi meet your needs next year. Do the changes affect the services you use? Look in Section 1.5 for information about benefit and cost changes for our pan. Check the changes in the booket to our prescription drug coverage to see if they affect you. Wi your drugs be covered? Are your drugs in a different tier, with different cost-sharing? Do any of your drugs have new restrictions, such as needing approva from us before you fi your prescription? Can you keep using the same pharmacies? Are there changes to the cost of using this pharmacy? Review the 2018 Drug List and ook in Section 1.6 for information about changes to our drug coverage. Check to see if your doctors and other providers wi be in our network next year. Are your doctors in our network? What about the hospitas or other providers you use? Look in Section 1.3 for information about our Provider Directory.

2 Think about your overa heath care costs. How much wi you spend out-of-pocket for the services and prescription drugs you use reguary? How much wi you spend on your premium and deductibes? How do your tota pan costs compare to other Medicare coverage options? Think about whether you are happy with our pan. 2. COMPARE: Learn about other pan choices Check coverage and costs of pans in your area. Use the personaized search feature on the Medicare Pan Finder at website. Cick Find heath & drug pans. Review the ist in the back of your Medicare & You handbook. Look in Section 3.2 to earn more about your choices. Once you narrow your choice to a preferred pan, confirm your costs and coverage on the pan s website. 3. CHOOSE: Decide whether you want to change your pan If you want to keep EmbemHeath VIP God (HMO), you don t need to do anything. You wi stay in EmbemHeath VIP God (HMO). To change to a different pan that may better meet your needs, you can switch pans between October 15 and December ENROLL: To change pans, join a pan between October 15 and December 7, 2017 If you don t join by December 7, 2017, you wi stay in EmbemHeath VIP God (HMO). If you join by December 7, 2017, your new coverage wi start on January 1, Additiona Resources This document is avaiabe for free in Spanish. ATTENTION: If you speak other anguages, anguage assistance services, free of charge, are avaiabe to you. Ca, (TTY users shoud ca 711). ATENCIÓN: Si usted haba españo, tiene a su disposición, gratis, servicios de ayuda para idiomas. Lame a, (TTY users shoud ca 711). Pease contact our Customer Service number at for additiona information. (TTY users shoud ca 711.) Hours are Monday to Sunday, 8:00 am to 8:00 pm. This information is aso avaiabe in aternate formats such as arge print and Braie. Pease ca Customer Service at the above numbers for more information.

3 Coverage under this Pan quaifies as minimum essentia coverage (MEC) and satisfies the Patient Protection and Affordabe Care Act s (ACA) individua shared responsibiity requirement. Pease visit the Interna Revenue Service (IRS) website at for more information. About EmbemHeath VIP God (HMO) HIP Heath Pan of New York (HIP) is an HMO pan with a Medicare contract. Enroment in HIP depends on contract renewa. HIP is an EmbemHeath company. When this booket says we, us, or our, it means HIP/EmbemHeath. When it says pan or our pan, it means EmbemHeath VIP God (HMO). H3330_ CMS Approved

4 EmbemHeath VIP God (HMO) Annua Notice of Changes for Summary of Important Costs for 2018 The tabe beow compares the 2017 costs and 2018 costs for EmbemHeath VIP God (HMO) in severa important areas. Pease note this is ony a summary of changes. It is important to read the rest of this Annua Notice of Changes and review the encosed Evidence of Coverage to see if other benefit or cost changes affect you. Cost 2017 (this year) 2018 (next year) Monthy pan premium* * Your premium may be higher or ower than this amount. See Section 1.1 for detais. Maximum out-of-pocket amount This is the most you wi pay out-of-pocket for your covered Part A and Part B services. (See Section 1.2 for detais.) $78.00 $78.00 $6, $6, Doctor office visits Inpatient hospita stays Incudes inpatient acute, inpatient rehabiitation, ong-term care hospitas and other types of inpatient hospita services. Inpatient hospita care starts the day you are formay admitted to the hospita with a doctor s order. The day before you are discharged is your ast inpatient day. Primary care visits: $0 per visit Speciaist visits: $25 per visit $195/days 1-10, $0/days Primary care visits: $0 per visit Speciaist visits: $25 per visit $195/days 1-10, $0/days 11-90

5 EmbemHeath VIP God (HMO) 2 Annua Notice of Changes for 2018 Cost 2017 (this year) 2018 (next year) Part D prescription drug coverage (See Section 1.6 for detais.) Deductibe: $ Copayment/Coinsurance during the Initia Coverage Stage: Drug Tier 1: $0/$3 Drug Tier 2: $10/$20 Drug Tier 3: $40/$47 Drug Tier 4: 23%/25% Drug Tier 5: 25% Deductibe: $ Copayment/Coinsurance during the Initia Coverage Stage: Drug Tier 1: $0/$3 Drug Tier 2: $10/$20 Drug Tier 3: $40/$47 Drug Tier 4: $95/$100 Drug Tier 5: 29%

6 EmbemHeath VIP God (HMO) Annua Notice of Changes for Annua Notice of Changes for 2018 Tabe of Contents Summary of Important Costs for SECTION 1 Changes to Benefits and Costs for Next Year...4 Section 1.1 Changes to the Monthy Premium... 4 Section 1.2 Changes to Your Maximum Out-of-Pocket Amount... 4 Section 1.3 Changes to the Provider Network... 5 Section 1.4 Changes to the Pharmacy Network... 5 Section 1.5 Changes to Benefits and Costs for Medica Services... 6 Section 1.6 Changes to Part D Prescription Drug Coverage... 6 SECTION 2 Administrative Changes...8 SECTION 3 Deciding Which Pan to Choose...10 Section 3.1 If you want to stay in EmbemHeath VIP God (HMO) Section 3.2 If you want to change pans SECTION 4 Deadine for Changing Pans...11 SECTION 5 Programs That Offer Free Counseing about Medicare...11 SECTION 6 Programs That Hep Pay for Prescription Drugs...12 SECTION 7 Questions?...13 Section 7.1 Getting Hep from EmbemHeath VIP God (HMO) Section 7.2 Getting Hep from Medicare... 13

7 EmbemHeath VIP God (HMO) 4 Annua Notice of Changes for 2018 SECTION 1 Changes to Benefits and Costs for Next Year Section 1.1 Changes to the Monthy Premium Cost Monthy premium (You must aso continue to pay your Medicare Part B premium.) 2017 (this year) 2018 (next year) $78.00 $78.00 Your monthy pan premium wi be more if you are required to pay a ifetime Part D ate enroment penaty for going without other drug coverage that is at east as good as Medicare drug coverage (aso referred to as "creditabe coverage") for 63 days or more if you enro in Medicare prescription drug coverage in the future. If you have a higher income, you may have to pay an additiona amount each month directy to the government for your Medicare prescription drug coverage. Your monthy premium wi be ess if you are receiving "Extra Hep" with your prescription drug costs. Section 1.2 Changes to Your Maximum Out-of-Pocket Amount To protect you, Medicare requires a heath pans to imit how much you pay out-of-pocket during the year. This imit is caed the maximum out-of-pocket amount. Once you reach this amount, you generay pay nothing for covered Part A and Part B services for the rest of the year. Cost Maximum out-of-pocket amount Your costs for covered medica services (such as copays) count toward your maximum out-of-pocket amount. Your pan premium and your costs for prescription drugs do not count toward your maximum out-of-pocket amount (this year) 2018 (next year) $6, $6, Once you have paid $6, out-of-pocket for covered Part A and Part B services, you wi pay nothing for your covered Part A and Part B services for the rest of the caendar year.

8 EmbemHeath VIP God (HMO) Annua Notice of Changes for Section 1.3 Changes to the Provider Network An updated Provider Directory is ocated on our website at You may aso ca Customer Service for updated provider information or to ask us to mai you a Provider Directory. Pease review the 2018 Provider Directory to see if your providers (primary care provider, speciaists, hospitas, etc.) are in our network. It is important that you know that we may make changes to the hospitas, doctors and speciaists (providers) that are part of your pan during the year. There are a number of reasons why your provider might eave your pan, but if your doctor or speciaist does eave your pan you have certain rights and protections summarized beow: Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to quaified doctors and speciaists. We wi make a good faith effort to provide you with at east 30 days notice that your provider is eaving our pan so that you have time to seect a new provider. We wi assist you in seecting a new quaified provider to continue managing your heath care needs. If you are undergoing medica treatment you have the right to request, and we wi work with you to ensure, that the medicay necessary treatment you are receiving is not interrupted. If you beieve we have not furnished you with a quaified provider to repace your previous provider or that your care is not being appropriatey managed, you have the right to fie an appea of our decision. If you find out your doctor or speciaist is eaving your pan, pease contact us so we can assist you in finding a new provider and managing your care. Section 1.4 Changes to the Pharmacy Network Amounts you pay for your prescription drugs may depend on which pharmacy you use. Medicare drug pans have a network of pharmacies. In most cases, your prescriptions are covered ony if they are fied at one of our network pharmacies. Our network incudes pharmacies with preferred cost-sharing, which may offer you ower cost- sharing than the standard cost-sharing offered by other network pharmacies for some drugs. There are changes to our network of pharmacies for next year. An updated Pharmacy Directory is ocated on our website at You may aso ca Customer Service for updated provider information or to ask us to mai you a Pharmacy Directory. Pease review the 2018 Pharmacy Directory to see which pharmacies are in our network.

9 EmbemHeath VIP God (HMO) 6 Annua Notice of Changes for 2018 Section 1.5 Changes to Benefits and Costs for Medica Services We are changing our coverage for certain medica services next year. The information beow describes these changes. For detais about the coverage and costs for these services, see Chapter 4, Medica Benefits Chart (what is covered and what you pay), in your 2018 Evidence of Coverage. Outpatient Surgery/Hospita Ambuatory Surgery Routine Eye Wear Routine Eye Wear Pan Limit 2017 (this year) 2018 (next year) You pay 20% coinsurance You pay 10% coinsurance You pay a $25 copay for one pair per year You pay a $295 copay You pay a $200 copay You pay a $0 copay for one pair per year No pan benefit imit Pan benefit imit of $300 every year Section 1.6 Changes to Part D Prescription Drug Coverage Changes to Our Drug List Our ist of covered drugs is caed a Formuary or "Drug List." We made changes to our Drug List, incuding changes to the drugs we cover and changes to the restrictions that appy to our coverage for certain drugs. Review the Drug List to make sure your drugs wi be covered next year and to see if there wi be any restrictions. If you are affected by a change in drug coverage, you can: Work with your doctor (or other prescriber) and ask the pan to make an exception to cover the drug. We encourage current members to ask for an exception before next year. o To earn what you must do to ask for an exception, see Chapter 9 of your Evidence of Coverage (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)) or ca Customer Service. Work with your doctor (or other prescriber) to find a different drug that we cover. You can ca Customer Service to ask for a ist of covered drugs that treat the same medica condition. In some situations, we are required to cover a one-time, temporary suppy of a non-formuary drug in the first 90 days of the pan year or the first 90 days of membership to avoid a gap in therapy. (To earn more about when you can get a temporary suppy and how to ask for one, see Chapter 5, Section 5.2 of the Evidence of Coverage.) During the time when you are getting a temporary suppy of a drug, you shoud tak with your doctor to decide what to do when your

10 EmbemHeath VIP God (HMO) Annua Notice of Changes for temporary suppy runs out. You can either switch to a different drug covered by the pan or ask the pan to make an exception for you and cover your current drug. If you have a current formuary exception for 2017, you need to submit a new one for You may submit your request for a formuary exception for 2018 in advance of 2018, and if approved, your formuary exception wi be effective in Changes to Prescription Drug Costs Note: If you are in a program that heps pay for your drugs ( Extra Hep ), the information about costs for Part D prescription drugs may not appy to you. We sent you a separate insert, caed the Evidence of Coverage Rider for Peope Who Get Extra Hep Paying for Prescription Drugs (aso caed the Low Income Subsidy Rider or the LIS Rider ), which tes you about your drug costs. If you receive Extra Hep and haven t received this insert by September 30, 2017, pease ca Customer Service and ask for the LIS Rider. Phone numbers for Customer Service are in Section 6.1 of this booket. There are four drug payment stages. How much you pay for a Part D drug depends on which drug payment stage you are in. (You can ook in Chapter 6, Section 2 of your Evidence of Coverage for more information about the stages.) The information beow shows the changes for next year to the first two stages the Yeary Deductibe Stage and the Initia Coverage Stage. (Most members do not reach the other two stages the Coverage Gap Stage or the Catastrophic Coverage Stage. To get information about your costs in these stages, ook at Chapter 6, Sections 6 and 7, in the encosed Evidence of Coverage.) Changes to the Deductibe Stage Stage Stage 1: Yeary Deductibe Stage During this stage, you pay the fu cost of your drugs for 3 tier, 4 tier and 5 tier unti you have reached the yeary deductibe (this year) 2018 (next year) The deductibe is $ The deductibe is $ Changes to Your Cost-sharing in the Initia Coverage Stage To earn how copayments and coinsurance work, ook at Chapter 6, Section 1.2, Types of out-of-pocket costs you may pay for covered drugs in your Evidence of Coverage. Stage 2: Initia Coverage Stage Once you pay the yeary deductibe, you move to the Initia Coverage Stage. During this stage, 2017 (this year) 2018 (next year) Your cost for a one-month suppy at a network pharmacy with standard Your cost for a one-month suppy at a network pharmacy with standard

11 EmbemHeath VIP God (HMO) 8 Annua Notice of Changes for 2018 the pan pays its share of the cost of your drugs and you pay your share of the cost. The costs in this row are for a one-month (30-day) suppy when you fi your prescription at a network pharmacy that provides standard cost-sharing. For information about the costs for a ong-term suppy or for mai-order prescriptions, ook in Chapter 6, Section 5 of your Evidence of Coverage. We changed the tier for some of the drugs on our Drug List. To see if your drugs wi be in a different tier, ook them up on the Drug List (this year) 2018 (next year) cost-sharing/or preferred cost-sharing: Preferred Generic Drugs: Standard cost-sharing: You pay $3 per prescription. Preferred cost-sharing: You pay $0 per prescription. Generic Drugs: Standard cost-sharing: You pay $20 per prescription. Preferred cost-sharing: You pay $10 per prescription. Preferred Brand Drugs: Standard cost-sharing: You pay $47 per prescription. Preferred cost-sharing: You pay $40 per prescription. Non-Preferred Drugs: Standard cost-sharing: You pay 25% per prescription. Preferred cost-sharing: You pay 23% per prescription. Speciaity Drugs: You pay 25% per prescription. Once your tota drugs costs have reached $3,700, you wi move to the next stage (the Coverage Gap Stage). cost-sharing/or preferred cost-sharing: Preferred Generic Drugs: Standard cost-sharing: You pay $3 per prescription. Preferred cost-sharing: You pay $0 per prescription. Generic Drugs: Standard cost-sharing: You pay $20 per prescription. Preferred cost-sharing: You pay $10 per prescription. Preferred Brand Drugs: Standard cost-sharing: You pay $47 per prescription. Preferred cost-sharing: You pay $40 per prescription. Non-Preferred Drugs: Standard cost-sharing: You pay $100 per prescription. Preferred cost-sharing: You pay $95 per prescription. Speciaity Drugs: You pay 29% per prescription. Once your tota drug costs have reached $3,545.00, you wi move to the next stage (the Coverage Gap Stage) Changes to the Coverage Gap and Catastrophic Coverage Stages The other two drug coverage stages the Coverage Gap Stage and the Catastrophic Coverage Stage are for peope with high drug costs. Most members do not reach the Coverage Gap Stage or the Catastrophic Coverage Stage. For information about your costs in these stages, ook at Chapter 6, Sections 6 and 7, in your Evidence of Coverage. SECTION 2 Administrative Changes We are making improvements to better service you in 2018

12 EmbemHeath VIP God (HMO) Annua Notice of Changes for Your EmbemHeath member number wi change effective January 1, You wi receive your new EmbemHeath identification card with your new member number in ate November. Pease destroy your od identification card and use your new card when getting heathcare services covered by our pan. We are upgrading our payment system effective January 1, Members who currenty use our Direct Debit option wi need to seect another method to pay their monthy premium. If you have any questions about your premium payment options pease contact Customer Service at , TTY users may ca 711, hours of operation are Monday to Sunday, 8:00am to 8:00pm.

13 EmbemHeath VIP God (HMO) 10 Annua Notice of Changes for 2018 SECTION 3 Deciding Which Pan to Choose Section 3.1 If you want to stay in EmbemHeath VIP God (HMO) To stay in our pan you don t need to do anything. If you do not sign up for a different pan or change to Origina Medicare by December 7, you wi automaticay stay enroed as a member of our pan for Section 3.2 If you want to change pans We hope to keep you as a member next year but if you want to change for 2018 foow these steps: Step 1: Learn about and compare your choices You can join a different Medicare heath pan, OR-- You can change to Origina Medicare. If you change to Origina Medicare, you wi need to decide whether to join a Medicare drug pan. To earn more about Origina Medicare and the different types of Medicare pans, read Medicare & You 2018, ca your State Heath Insurance Assistance Program (see Section 4), or ca Medicare (see Section 6.2). You can aso find information about pans in your area by using the Medicare Pan Finder on the Medicare website. Go to and cick Find heath & drug pans. Here, you can find information about costs, coverage, and quaity ratings for Medicare pans. As a reminder, EmbemHeath offers other Medicare Heath pans and Medicare-prescription drug pans. These other pans may differ in coverage, monthy premiums, and cost-sharing amounts. Step 2: Change your coverage To change to a different Medicare heath pan, enro in the new pan. You wi automaticay be disenroed from EmbemHeath VIP God (HMO). To change to Origina Medicare with a prescription drug pan, enro in the new drug pan. You wi automaticay be disenroed from EmbemHeath VIP God (HMO). To change to Origina Medicare without a prescription drug pan, you must either: o Send us a written request to disenro. Contact Customer Service if you need more information on how to do this (phone numbers are in Section 6.1 of this booket). o or Contact Medicare, at MEDICARE ( ), 24 hours a day, 7 days a week, and ask to be disenroed. TTY users shoud ca

14 EmbemHeath VIP God (HMO) Annua Notice of Changes for SECTION 4 Deadine for Changing Pans If you want to change to a different pan or to Origina Medicare for next year, you can do it from October 15 unti December 7. The change wi take effect on January 1, Are there other times of the year to make a change? In certain situations, changes are aso aowed at other times of the year. For exampe, peope with Medicaid, those who get Extra Hep paying for their drugs, those who have or are eaving empoyer coverage, and those who move out of the service area are aowed to make a change at other times of the year. For more information, see Chapter 10, Section 2.3 of the Evidence of Coverage. If you enroed in a Medicare Advantage pan for January 1, 2018, and don t ike your pan choice, you can switch to Origina Medicare between January 1 and February 14, For more information, see Chapter 10, Section 2.2 of the Evidence of Coverage. SECTION 5 Programs That Offer Free Counseing about Medicare The State Heath Insurance Assistance Program (SHIP) is a government program with trained counseors in every state. In New York State, the SHIP is caed Heath Insurance Information Counseing and Assistance Program (HIICAP). HIICAP is independent (not connected with any insurance company or heath pan). It is a state program that gets money from the Federa government to give free oca heath insurance counseing to peope with Medicare. HIICAP counseors can hep you with your Medicare questions or probems. They can hep you understand your Medicare pan choices and answer questions about switching pans. You can ca HIICAP at You can earn more about HIICAP by visiting their website (

15 EmbemHeath VIP God (HMO) 12 Annua Notice of Changes for 2018 SECTION 6 Programs That Hep Pay for Prescription Drugs You may quaify for hep paying for prescription drugs. Beow we ist different kinds of hep: Extra Hep from Medicare. Peope with imited incomes may quaify for "Extra Hep" to pay for their prescription drug costs. If you quaify, Medicare coud pay up to 75% or more of your drug costs incuding monthy prescription drug premiums, annua deductibes, and coinsurance. Additionay, those who quaify wi not have a coverage gap or ate enroment penaty. Many peope are eigibe and don't even know it. To see if you quaify, ca: o MEDICARE ( ). TTY users shoud ca , 24 hours a day/7 days a week; o The Socia Security Office at between 7 am and 7 pm, Monday through Friday. TTY users shoud ca, (appications); or o Your State Medicaid Office (appications). Hep from your state s pharmaceutica assistance program. New York State has a program caed Edery Pharmaceutica Insurance Coverage (EPIC) Program that heps peope pay for prescription drugs based on their financia need, age, or medica condition. To earn more about the program, check with your State Heath Insurance Assistance Program (the name and phone numbers for this organization are in Section 4 of this booket). Prescription Cost-sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance Program (ADAP) heps ensure that ADAP-eigibe individuas iving with HIV/AIDS have access to ife-saving HIV medications. Individuas must meet certain criteria, incuding proof of State residence and HIV status, ow income as defined by the State, and uninsured/under-insured status. Medicare Part D prescription drugs that are aso covered by ADAP quaify for prescription cost-sharing assistance through the New York State Uninsured HIV Care Program. For information on eigibiity criteria, covered drugs, or how to enro in the program, pease ca New York State Uninsured HIV Care Program at (for New York State residents) or (for non-new York State residents) (for TTY pease use ), or write to the New York State Uninsured HIV Care Program, Empire Station, PO Box 2052, Abany, NY Or, go to the web at

16 EmbemHeath VIP God (HMO) Annua Notice of Changes for SECTION 7 Questions? Section 7.1 Getting Hep from EmbemHeath VIP God (HMO) Questions? We re here to hep. Pease ca Customer Service at (TTY ony, ca 711). We are avaiabe for phone cas Monday to Sunday, 8:00 am to 8:00 pm. Cas to these numbers are free. Read your 2018 Evidence of Coverage (it has detais about next year's benefits and costs) This Annua Notice of Changes gives you a summary of changes in your benefits and costs for For detais, ook in the 2018 Evidence of Coverage for EmbemHeath VIP God (HMO). The Evidence of Coverage is the ega, detaied description of your pan benefits. It expains your rights and the rues you need to foow to get covered services and prescription drugs. A copy of the Evidence of Coverage is incuded in this enveope. Visit our Website You can aso visit our website at As a reminder, our website has the most up-to-date information about our provider network (Provider Directory) and our ist of covered drugs (Formuary/Drug List). Section 7.2 Getting Hep from Medicare To get information directy from Medicare: Ca MEDICARE ( ) You can ca MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca Visit the Medicare Website You can visit the Medicare website ( It has information about cost, coverage, and quaity ratings to hep you compare Medicare heath pans. You can find information about pans avaiabe in your area by using the Medicare Pan Finder on the Medicare website. (To view the information about pans, go to and cick on Find heath & drug pans ). Read Medicare & You 2018 You can read the Medicare & You 2018 Handbook. Every year in the fa, this booket is maied to peope with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequenty asked questions about Medicare. If you don t have a copy of this booket, you can get it at the Medicare website ( or by caing

17 EmbemHeath VIP God (HMO) 14 Annua Notice of Changes for MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca

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20 H3330_ CMS Approved