2016 Annual Notice of Changes & Evidence of Coverage

Transcription

1 2016 Annual Notice of Changes & Evidence of Coverage UCare for Seniors Classic (HMO-POS) Minnesota H2459_082815_2 CMS Accepted ( )

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3 UCare for Seniors Classic (HMO-POS) offered by UCare Minnesota Annual Notice of Changes for 2016 You are currently enrolled as a member of UCare for Seniors Classic. Next year, there will be some changes to the plan s costs and benefits. This booklet tells about the changes. You have from October 15 until December 7 to make changes to your Medicare coverage for next year. Additional Resources Customer Services has free language interpreter services available for non-english speakers (phone numbers are in Section 6.1 of this booklet). Upon request, we can also give you information in Braille, in large print, or other alternate formats if you need it. About UCare for Seniors Classic UCare for Seniors is an HMO-POS plan with a Medicare contract. Enrollment in UCare for Seniors depends on contract renewal. When this booklet says we, us, or our, it means UCare Minnesota. When it says plan or our plan, it means UCare for Seniors Classic. U4995 (08/15)

4 Think about Your Medicare Coverage for Next Year Each fall, Medicare allows you to change your Medicare health and drug coverage during the Annual Enrollment Period. It s important to review your coverage now to make sure it will meet your needs next year. Important things to do: Check the changes to our benefits and costs to see if they affect you. Do the changes affect the services you use? It is important to review benefit and cost changes to make sure they will work for you next year. Look in Section 1 for information about benefit and cost changes for our plan. Check the changes to our prescription drug coverage to see if they affect you. Will your drugs be covered? Are they in a different tier? Can you continue to use the same pharmacies? It is important to review the changes to make sure our drug coverage will work for you next year. Look in Section 1.6 for information about changes to our drug coverage. Check to see if your doctors and other providers will be in our network next year. Are your doctors in our network? What about the hospitals or other providers you use? Look in Section 1.3 for information about our Provider Directory. Think about your overall health care costs. How much will you spend out-of-pocket for the services and prescription drugs you use regularly? How much will you spend on your premium? How do the total costs compare to other Medicare coverage options? Think about whether you are happy with our plan. If you decide to stay with UCare for Seniors Classic: If you want to stay with us next year, it s easy - you don t need to do anything. If you decide to change plans: If you decide other coverage will better meet your needs, you can switch plans between October 15 and December 7. If you enroll in a new plan, your new coverage will begin on January 1, Look in Section 2.2 to learn more about your choices

5 Summary of Important Costs for 2016 The table below compares the 2015 costs and 2016 costs for UCare for Seniors Classic in several important areas. Please note this is only a summary of changes. It is important to read the rest of this Annual Notice of Changes and review the attached Evidence of Coverage to see if other benefit or cost changes affect you. Cost Monthly plan premium* 2015 (this year) 2016 (next year) $168 $181 *Your premium may be higher or lower than this amount. See Section 1.1 for details. Maximum out-of-pocket amount $3,400 $3,400 This is the most you will pay out-of-pocket for your covered Part A and Part B services. (See Section 1.2 for details.) Doctor office visits Inpatient hospital stays Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor s order. The day before you are discharged is your last inpatient day. Part D prescription drug coverage (See Section 1.6 for details.) Primary care visits: $0 per visit. Specialist visits: $20 per visit. $200 copayment each Medicare-covered hospital stay until discharge. Deductible: Not applicable. Copayments during the Initial Coverage Stage: Drug Tier 1: $4 copayment Drug Tier 2: $20 copayment Drug Tier 3: $40 copayment Drug Tier 4: $80 copayment Drug Tier 5: 25% coinsurance Primary care visits: $0 per visit. Specialist visits: $20 per visit. $200 copayment each Medicare-covered hospital stay until discharge. Deductible: Not applicable. Copayments during the Initial Coverage Stage: Drug Tier 1: $5 copayment Drug Tier 2: $12 copayment Drug Tier 3: $40 copayment Drug Tier 4: $80 copayment Drug Tier 5: 25% coinsurance

6 Annual Notice of Changes for 2016 Table of Contents Think about Your Medicare Coverage for Next Year...2 Summary of Important Costs for SECTION 1 Changes to Benefits and Costs for Next Year...5 Section 1.1 Changes to the Monthly Premium... 5 Section 1.2 Changes to Your Maximum Out-of-Pocket Amount... 5 Section 1.3 Changes to the Provider Network... 5 Section 1.4 Changes to the Pharmacy Network... 6 Section 1.5 Changes to Benefits and Costs for Medical Services... 6 Section 1.6 Changes to Part D Prescription Drug Coverage... 8 SECTION 2 Deciding Which Plan to Choose Section 2.1 If you want to stay in UCare for Seniors Classic Section 2.2 If you want to change plans SECTION 3 Deadline for Changing Plans SECTION 4 Programs That Offer Free Counseling about Medicare SECTION 5 Programs That Help Pay for Prescription Drugs SECTION 6 Questions? Section 6.1 Getting Help from our Plan Section 6.2 Getting Help from Medicare

7 SECTION 1 Changes to Benefits and Costs for Next Year Annual Notice of Changes in Classic for 2016 Section 1.1 Changes to the Monthly Premium Cost Monthly premium 2015 (this year) 2016 (next year) $168 $181 (You must also continue to pay your Medicare Part B premium.) Dental premium $19 $24 Your monthly plan premium will be more if you are required to pay a late enrollment penalty. If you have a higher income, you may have to pay an additional amount each month directly to the government for your Medicare prescription drug coverage. Your monthly premium will be less if you are receiving Extra Help with your prescription drug costs. Section 1.2 Changes to Your Maximum Out-of-Pocket Amount To protect you, Medicare requires all health plans to limit how much you pay out-of-pocket during the year. This limit is called the maximum out-of-pocket amount. Once you reach this amount, you generally 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 medical services (such as copays) count toward your maximum outof-pocket amount. Your plan premium and your costs for prescription drugs do not count toward your maximum out-of-pocket amount (this year) 2016 (next year) $3,400 $3,400 Once you have paid $3,400 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services for the rest of the calendar year. Section 1.3 Changes to the Provider Network There are changes to our network of providers for next year. An updated Provider Directory is located on our website at You may also call Customer Services for updated provider information or to ask us to mail you a Provider Directory. Please review the 2016 Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network. It is important that you know that we may make changes to the hospitals, doctors, and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan but if your doctor or specialist does leave your plan, you have certain rights and protections summarized below: Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists

8 Annual Notice of Changes in Classic for 2016 When possible, we will provide you with at least 30 days notice that your provider is leaving our plan so that you have time to select a new provider. We will assist you in selecting a new qualified provider to continue managing your health care needs. If you are undergoing medical treatment, you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted. If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed, you have the right to file an appeal of our decision. If you find out your doctor or specialist is leaving your plan, please 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 plans have a network of pharmacies. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. There are changes to our network of pharmacies for next year. An updated Pharmacy Directory is located on our website at You may also call Customer Services for updated provider information or to ask us to mail you a Pharmacy Directory. Please review the 2016 Pharmacy Directory to see which pharmacies are in our network. Section 1.5 Changes to Benefits and Costs for Medical Services We are changing our coverage for certain medical services next year. The information below describes these changes. For details about the coverage and costs for these services, see Chapter 4, Medical Benefits Chart (what is covered and what you pay), in your 2016 Evidence of Coverage. Cost Emergency Care 2015 (this year) 2016 (next year) You pay a $65 copayment per visit. You pay a $75 copayment per visit. Urgently Needed Care Worldwide Emergency and Urgently Needed Care (outside the United States and its territories) Vision Care (Diabetic Retinopathy Exam) You pay a $25 copayment per visit. You pay a $65 copayment per visit. $20 copayment for each Medicare-covered diabetic retinopathy exam. You pay a $35 copayment per visit. You pay a $75 copayment per visit. $0 copayment for each Medicare-covered diabetic retinopathy exam

9 Change in Out-of-Network Coverage for Eyewear after Cataract Surgery Annual Notice of Changes in Classic for 2016 There is a change to the out-of-network coverage for eyeglasses or contact lenses after cataract surgery. See Chapter 4 of your 2016 Evidence of Coverage for more detailed information. The following table describes changes to the Vision care benefit, under the Out-of-Network column. Cost Vision Care One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) 2015 (this year) 2016 (next year) This service is not covered out-of-network. You are responsible for the entire cost. 20% coinsurance for one pair of standard Medicarecovered eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. Change in UCare Comprehensive Dental Benefit Package Our UCare for Seniors Classic Plan offers the option of purchasing the UCare Comprehensive Dental benefit package at certain times of the year. See Chapter 4, Section 2.2, Extra optional supplemental benefits you can buy in your 2016 Evidence of Coverage, for more detailed information. The following table describes changes to the UCare Comprehensive Dental benefit package. Cost UCare Comprehensive Dental Benefit Package 2015 (this year) 2016 (next year) Annual Deductible Annual Maximum $25 per calendar year (does not apply to diagnostic or preventive services covered under your Evidence of Coverage). You must pay the deductible on covered dental services before coverage begins. $1,000 benefit maximum per calendar year. This is the maximum amount we will pay for covered dental services. $50 per calendar year (does not apply to diagnostic or preventive services covered under your Evidence of Coverage). You must pay the deductible on covered dental services before coverage begins. $1,200 benefit maximum per calendar year. This is the maximum amount we will pay for covered dental services

10 Annual Notice of Changes in Classic for 2016 Change in Out-of-Pocket Maximum for Out-of-Network Services Coverage is available for certain covered services provided by out-of-network providers and facilities under the Point-of-Service benefit at the out-of-network cost-sharing level. See Chapter 4 of your 2016 Evidence of Coverage for more detailed information. The following table describes changes to the Point-of-Service benefit. Cost Point-of-Service Benefit (Annual Member Out-of-Pocket Cost Maximum) 2015 (this year) 2016 (next year) Under the Point-of-Service benefit, there is a $20,000 annual member out-ofpocket cost maximum. Under the Point-of-Service benefit, there is a $10,000 annual member out-ofpocket cost maximum. Section 1.6 Changes to Part D Prescription Drug Coverage Changes to Our Drug List Our list of covered drugs is called a Formulary or Drug List. A copy of our Drug List is in this envelope. We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure your drugs will be covered next year and to see if there will 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 plan to make an exception to cover the drug. -- To learn what you must do to ask for an exception, see Chapter 9 of your Evidence of Coverage (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) or call Customer Services. Work with your doctor (or other prescriber) to find a different drug that we cover. You can call Customer Services to ask for a list of covered drugs that treat the same medical condition. In some situations, we are required to cover a one-time, temporary supply of a non-formulary in the first 90 days of coverage of the plan year or coverage. (To learn more about when you can get a temporary supply 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 supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. If you fill your prescription within the first 90 days of the calendar year and discover it is no longer on the Drug List, in most cases you can obtain a transition fill. After the transition fill, you will receive a letter about your options including speaking with your physician about changing drugs or how to request an exception. Utilization management exceptions are assigned for a given timeframe at the time of authorization. You should contact Customer Services to learn what you or your provider would need to do to get coverage for the drug once the exception has expired. Changes to Prescription Drug Costs Note: If you are in a program that helps pay for your drugs ( Extra Help ), the information about costs for Part D prescription drugs may not apply to you. We sent you a separate insert, called the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also called the Low Income Subsidy Rider or the LIS - 8 -

11 Annual Notice of Changes in Classic for 2016 Rider ), which tells you about your drug costs. If you get Extra Help and haven t received this insert by September 30, 2015, please call Customer Services and ask for the LIS Rider. Phone numbers for Customer Services are in Section 6.1 of this booklet. 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 look in Chapter 6, Section 2 of your Evidence of Coverage for more information about the stages.) The information below shows the changes for next year to the first two stages the Yearly Deductible Stage and the Initial 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, look at Chapter 6, Sections 6 and 7, in the attached Evidence of Coverage.) Changes to the Deductible Stage Stage Stage 1: Yearly Deductible Stage 2015 (this year) 2016 (next year) Because we have no deductible, this payment stage does not apply to you. Because we have no deductible, this payment stage does not apply to you

12 Changes to Your Cost-sharing in the Initial Coverage Stage Annual Notice of Changes in Classic for 2016 To learn how copayments and coinsurance work, look at Chapter 6, Section 1.2, Types of out-of-pocket costs you may pay for covered drugs in your Evidence of Coverage. Stage Stage 2: Initial Coverage Stage During this stage, the plan pays its share of the cost of your drugs and and you pay your share of the cost. The costs in this row are for a one-month (30- day) supply when you fill your prescription at a network pharmacy that provides standard cost-sharing. For information about the costs for a long-term supply or for mail-order prescriptions, look 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 will be in a different tier, look them up on the Drug List (this year) 2016 (next year) Your cost for a one-month supply filled at a network pharmacy with standard cost-sharing: Preferred generic drugs: You pay $4 per prescription. Non-preferred generic drugs: You pay $20 per prescription. Preferred brand-name drugs: You pay $40 per prescription. Your cost for a one-month supply filled at a network pharmacy with standard cost-sharing: Preferred generic drugs: You pay $5 per prescription. Generic drugs: You pay $12 per prescription. Preferred brand-name drugs: You pay $40 per prescription. Non-preferred brand-name drugs: You pay $80 per prescription. Specialty drugs: You pay 25% of the total cost. Once your total drugs costs have reached $2,960, you will move to the next stage (the Coverage Gap Stage). Non-preferred brand-name drugs: You pay $80 per prescription. Specialty drugs: You pay 25% of the total cost. Once your total drugs costs have reached $3,310, you will 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 people 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, look at Chapter 6, Sections 6 and 7, in your Evidence of Coverage

13 Annual Notice of Changes in Classic for 2016 SECTION 2 Deciding Which Plan to Choose Section 2.1 If you want to stay in UCare for Seniors Classic To stay in our plan you don t need to do anything. If you do not sign up for a different plan or change to Original Medicare by December 7, you will automatically stay enrolled as a member of our plan for Section 2.2 If you want to change plans We hope to keep you as a member next year but if you want to change for 2016, follow these steps: Step 1: Learn about and compare your choices You can join a different Medicare health plan, OR-- You can change to Original Medicare. If you change to Original Medicare, you will need to decide whether to join a Medicare drug plan and whether to buy a Medicare supplement (Medigap) policy. To learn more about Original Medicare and the different types of Medicare plans, read Medicare & You 2016, call your State Health Insurance Assistance Progam (see Section 4), or call Medicare (see Section 6.2). You can also find information about plans in your area by using the Medicare Plan Finder on the Medicare website. Go to and click Find health & drug plans. Here, you can find information about costs, coverage, and quality ratings for Medicare plans. As a reminder, UCare offers other Medicare health plans. These other plans may differ in coverage, monthly premiums, and cost-sharing amounts. Step 2: Change your coverage To change to a different Medicare health plan, enroll in the new plan. You will automatically be disenrolled from our plan. To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will automatically be disenrolled from our plan. To change to Original Medicare without a prescription drug plan, you must either: Send us a written request to disenroll. Contact Customer Services if you need more information on how to do this (phone numbers are in Section 6.1 of this booklet). or Contact Medicare, at MEDICARE ( ), 24 hours a day, seven days a week, and ask to be disenrolled. TTY users should call SECTION 3 Deadline for Changing Plans If you want to change to a different plan or to Original Medicare for next year, you can do it from October 15 until December 7. The change will take effect on January 1, Are there other times of the year to make a change? In certain situations, changes are also allowed at other times of the year. For example, people with Medicaid, those who get Extra Help paying for their drugs, and those who move out of the service area are allowed to make a change at other times of the year. For more information, see Chapter 10, Section 2.3 of the Evidence of Coverage

14 Annual Notice of Changes in Classic for 2016 If you enrolled in a Medicare Advantage plan for January 1, 2016, and don t like your plan choice, you can switch to Original Medicare between January 1 and February 14, For more information, see Chapter 10, Section 2.2 of the Evidence of Coverage. SECTION 4 Programs That Offer Free Counseling about Medicare The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In Minnesota, the SHIP is called Senior LinkAge Line. Senior LinkAge Line is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. Senior LinkAge Line counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call Senior LinkAge Line at (toll free). TTY users should call (toll free) or 711. You can learn more about Senior LinkAge Line by visiting their website ( SECTION 5 Programs That Help Pay for Prescription Drugs You may qualify for help paying for prescription drugs. Extra Help from Medicare. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay up to 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not have a coverage gap or late enrollment penalty. Many people are eligible and don t even know it. To see if you qualify, call: MEDICARE ( ). TTY users should call , 24 hours a day/seven days a week; The Social Security Office at between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call (applications); or Your State Medicaid Office (applications). Prescription Cost-sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost-sharing assistance through the ADAP in Minnesota. Contact information for ADAP in Minnesota: HIV/AIDS Programs Department of Human Services P.O. Box St. Paul, MN For information on eligibility criteria, covered drugs, or how to enroll in the program, please call Monday-Friday, 8:30 a.m. 4:30 p.m.:

15 Annual Notice of Changes in Classic for 2016 Twin Cities Metro area: (voice) (fax) Statewide: (voice)(toll free) (TTY) SECTION 6 Questions? Section 6.1 Getting Help from our Plan Questions? We re here to help. Please call Customer Services at or (toll free). TTY only, call (toll free). We are available for phone calls 24 hours a day, seven days a week. Read your 2016 Evidence of Coverage (it has details about next year s benefits and costs) This Annual Notice of Changes gives you a summary of changes in your benefits and costs for For details, look in the 2016 Evidence of Coverage for UCare for Seniors Classic. The Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your rights and the rules you need to follow to get covered services and prescription drugs. A copy of the Evidence of Coverage is included in this envelope. Visit our Website You can also visit our website at As a reminder, our website has the most up-to-date information about our provider network (Provider Directory) and our list of covered drugs (Formulary/Drug List). Section 6.2 Getting Help from Medicare To get information directly from Medicare: Call MEDICARE ( ) You can call MEDICARE ( ), 24 hours a day, seven days a week. TTY users should call Visit the Medicare Website You can visit the Medicare website ( It has information about cost, coverage, and quality ratings to help you compare Medicare health plans. You can find information about plans available in your area by using the Medicare Plan Finder on the Medicare website. (To view the information about plans, go to and click on Find health & drug plans. ) Read Medicare & You 2016 You can read the Medicare & You 2016 Handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don t have a copy of this booklet, you can get it at the Medicare website ( or by calling MEDICARE ( ), 24 hours a day, seven days a week. TTY users should call

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17 January 1 December 31, 2016 Evidence of Coverage Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of UCare for Seniors Classic (HMO-POS) This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 December 31, It explains how to get coverage for the health care services and prescription drugs you need. This is an important legal document. Please keep it in a safe place. This plan, UCare for Seniors Classic, is offered by UCare Minnesota. (When this Evidence of Coverage says we, us, or our, it means UCare Minnesota. When it says plan or our plan, it means UCare for Seniors Classic.) UCare for Seniors is an HMO-POS plan with a Medicare contract. Enrollment in UCare for Seniors depends on contract renewal. Customer Services has free language interpreter services available for non-english speakers (phone numbers are printed on the back cover of this booklet). Upon request, we can also give you information in Braille, in large print, or other alternate formats if you need it. Benefits, formulary, pharmacy network, provider network, premium, and/or copayments/ coinsurance may change on January 1 of each year. U4871 (08/15)

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19 2016 Evidence of Coverage Table of Contents This list of chapters and page numbers is your starting point. For more help in finding information you need, go to the first page of a chapter. You will find a detailed list of topics at the beginning of each chapter. Chapter 1. Getting started as a member...3 Explains what it means to be in a Medicare health plan and how to use this booklet. Tells about materials we will send you, your plan premium, your plan membership card, and keeping your membership record up to date. Chapter 2. Important phone numbers and resources...15 Tells you how to get in touch with our plan and with other organizations including Medicare, the State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), programs that help people pay for their prescription drugs, and the Railroad Retirement Board. Chapter 3. Using the plan s coverage for your medical services...35 Explains important things you need to know about getting your medical care as a member of our plan. Topics include using the providers in the plan s network and how to get care when you have an emergency. Chapter 4. Medical Benefits Chart (what is covered and what you pay)...46 Gives the details about which types of medical care are covered and not covered for you as a member of our plan. Explains how much you will pay as your share of the cost for your covered medical care. Chapter 5. Using the plan s coverage for your Part D prescription drugs...98 Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan s List of Covered Drugs (Formulary) to find out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan s programs for drug safety and managing medications. Chapter 6. What you pay for your Part D prescription drugs Tells about the three stages of drug coverage (Initial Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains the five cost-sharing tiers for your Part D drugs and tells what you must pay for a drug in each cost-sharing tier. Tells about the late enrollment penalty. Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services or drugs. Chapter 8. Your rights and responsibilities Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if you think your rights are not being respected. Table of Contents 1

20 Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Tells you step-by-step what to do if you are having problems or concerns as a member of our plan. Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon. Explains how to make complaints about quality of care, waiting times, customer service, and other concerns. Chapter 10. Ending your membership in the plan Explains when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership. Chapter 11. Legal notices Includes notices about governing law and about non-discrimination. Chapter 12. Definitions of important words Explains key terms used in this booklet. 2 Table of Contents

21 Chapter 1. Getting started as a member Explains what it means to be in a Medicare health plan and how to use this booklet. Tells about materials we will send you, your plan premium, your plan membership card, and keeping your membership record up to date. CHAPTER 1 Getting started as a member Chapter 1. Getting started as a member 3

22 Chapter 1. Getting started as a member SECTION 1 Introduction5 Section 1.1 You are enrolled in UCare for Seniors Classic, which is a Medicare HMO Point-of-Service Plan...5 Section 1.2 What is the Evidence of Coverage booklet about?...5 Section 1.3 Legal information about the Evidence of Coverage...5 SECTION 2 What makes you eligible to be a plan member? 6 Section 2.1 Your eligibility requirements...6 Section 2.2 What are Medicare Part A and Medicare Part B?...6 Section 2.3 Here is the plan service area for our plan...6 SECTION 3 What other materials will you get from us? 7 Section 3.1 Your plan membership card Use it to get all covered care and prescription drugs...7 Section 3.2 The Provider Directory: Your guide to all providers in the plan s network...7 Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network...8 Section 3.4 The plan s List of Covered Drugs (Formulary)...8 Section 3.5 The Part D Explanation of Benefits (the Part D EOB ): Reports with a summary of payments made for your Part D prescription drugs...9 SECTION 4 Your monthly premium for the UCare for Seniors Classic plan 9 Section 4.1 How much is your plan premium?...9 Section 4.2 There are several ways you can pay your plan premium...10 Section 4.3 Can we change your monthly plan premium during the year? SECTION 5 Please keep your plan membership record up to date 12 Section 5.1 How to help make sure that we have accurate information about you...12 SECTION 6 We protect the privacy of your personal health information 13 Section 6.1 We make sure that your health information is protected...13 SECTION 7 How other insurance works with our plan 13 Section 7.1 Which plan pays first when you have other insurance? Evidence of Coverage for Classic

23 SECTION 1 Introduction Section 1.1 You are enrolled in UCare for Seniors Classic, which is a Medicare HMO Pointof-Service Plan You are covered by Medicare, and you have chosen to get your Medicare health care and your prescription drug coverage through our plan, UCare for Seniors Classic. There are different types of Medicare health plans. UCare for Seniors Classic is a Medicare Advantage HMO Plan (HMO stands for Health Maintenance Organization) with a Point-of-Service (POS) option approved by Medicare and run by a private company. Point-of-Service means you can use providers outside the plan s network for an additional cost. (See Chapter 3, Section 2.3 for information about using the Point-of-Service option.) Section 1.2 What is the Evidence of Coverage booklet about? This Evidence of Coverage booklet tells you how to get your Medicare medical care and prescription drugs covered through our plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan. The word coverage and covered services refers to the medical care and services and the prescription drugs available to you as a member of UCare for Seniors Classic. It s important for you to learn what the plan s rules are and what services are available to you. We encourage you to set aside some time to look through this Evidence of Coverage booklet. If you are confused or concerned or just have a question, please contact our plan s Customer Services (phone numbers are printed on the back cover of this booklet). Section 1.3 Legal information about the Evidence of Coverage It s part of our contract with you This Evidence of Coverage is part of our contract with you about how the plan covers your care. Other parts of this contract include your enrollment form, the List of Covered Drugs (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called riders or amendments. The contract is in effect for months in which you are enrolled in the plan between January 1, 2016 and December 31, Each calendar year, Medicare allows us to make changes to the plans that we offer. This means we can change the costs and benefits of the plan after December 31, We can also choose to stop offering the plan, or to offer it in a different service area, after December 31, Medicare must approve our plan each year Medicare (the Centers for Medicare & Medicaid Services) must approve our plan each year. You can continue to get Medicare coverage as a member of our plan as long as we choose to continue to offer the plan and Medicare renews its approval of the plan. Chapter 1. Getting started as a member 5

24 SECTION 2 What makes you eligible to be a plan member? Section 2.1 Your eligibility requirements You are eligible for membership in our plan as long as: You have both Medicare Part A and Medicare Part B (section 2.2 tells you about Medicare Part A and Medicare Part B) -- and -- you live in our geographic service area (section 2.3 below describes our service area) -- and -- you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated. Section 2.2 What are Medicare Part A and Medicare Part B? When you first signed up for Medicare, you received information about what services are covered under Medicare Part A and Medicare Part B. Remember: Medicare Part A generally helps cover services provided by hospitals (for inpatient services, skilled nursing facilities, or home health agencies). Medicare Part B is for most other medical services (such as physicians services and other outpatient services) and certain items (such as durable medical equipment and supplies). Section 2.3 Here is the plan service area for our plan Although Medicare is a Federal program, the plan is available only to individuals who live in our plan service area. To remain a member of our plan, you must continue to reside in the plan service area. The service area is described below. Our service area includes these counties in the State of Minnesota: Aitkin, Anoka, Becker, Benton, Blue Earth, Carlton, Carver, Cass, Chisago, Clay, Cook, Crow Wing, Dakota, Dodge, Faribault, Fillmore, Freeborn, Goodhue, Hennepin, Houston, Hubbard, Isanti, Kanabec, Lake, Le Sueur, Mille Lacs, Morrison, Mower, Nicollet, Olmsted, Pine, Ramsey, Rice, Scott, Sherburne, St. Louis, Stearns, Steele, Wabasha, Waseca, Washington, Watonwan, Winona, and Wright. If you plan to move out of the service area, please contact Customer Services (phone numbers are printed on the back cover of this booklet). When you move, you will have a Special Enrollment Period that will allow you to switch to Original Medicare or enroll in a Medicare health or drug plan that is available in your new location. It is also important that you call Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section Evidence of Coverage for Classic

25 SECTION 3 What other materials will you get from us? Section 3.1 drugs Your plan membership card Use it to get all covered care and prescription While you are a member of our plan, you must use your membership card for our plan whenever you get any services covered by this plan and for prescription drugs you get at network pharmacies. Here s a sample membership card to show you what yours will look like: Issuer: ID: Name: JOHN Q DOE DOB: 01/02/1947 Rx BIN: Rx PCN: MD Rx Grp: MNUA RxID: Svc Type: MEDICAL/DENTAL Group Number: RICLAB Care Type: UCare for Seniors Classic H2459 xxx Coverage Year 2016 ucare.org FOR MEMBER USE Emergency Care: Go to the nearest hospital or call 911. Call UCare s Customer Services Department as soon as you are able if you receive emergency services and require hospital admission. Customer Services: or , TTY (Hearing Impaired): or UCare 24/7 Nurse Line: , TTY (Hearing Impaired): Complaints or Appeals: Call UCare: or , TTY (Hearing Impaired): or Co-pays Primary Care Office Visit: $xx Specialty Office Visit: $xx Urgent Care: $xx Emergency Room: $xx Inpatient: $xx Primary Rx Preferred Generic: $xx Generic: $xx Preferred Brand: $xx Non-Preferred Brand: $xx Specialty: xx% FOR PROVIDER USE Submit medical claims to: UCare, P.O. Box 70, Minneapolis, MN Submit prescription drug claims to: Express Scripts, Inc., Attn: Med D Accts. P.O. Box 2858, Clinton, IA Submit chiropractic claims to: Chiropractic Care of Minnesota, Inc., SAMPLE c/o Landmark Healthcare, Inc., P.O. Box 13977, Sacramento, CA UCare Provider Line: or Express Scripts Pharmacy Help Desk: Issued: MM/DD/YYYY As long as you are a member of our plan you must not use your red, white, and blue Medicare card to get covered medical services (with the exception of routine clinical research studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in case you need it later. Here s why this is so important: If you get covered services using your red, white, and blue Medicare card instead of using your plan membership card while you are a plan member, you may have to pay the full cost yourself. If your plan membership card is damaged, lost, or stolen, call Customer Services right away and we will send you a new card. (Phone numbers for Customer Services are printed on the back cover of this booklet.) Section 3.2 The Provider Directory: Your guide to all providers in the plan s network The Provider Directory lists our network providers and durable medical equipment suppliers. What are network providers? Network providers are the doctors and other health care professionals, medical groups, durable medical equipment suppliers, hospitals, and other health care facilities that have an agreement with us to accept our payment and any plan cost-sharing as payment in full. We have arranged for these providers to deliver covered services to members Chapter 1. Getting started as a member 7

26 in our plan. Why do you need to know which providers are part of our network? It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the plan authorizes use of out-of-network providers. See Chapter 3 (Using the plan s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage. You can also obtain certain covered services from out-of-network providers through the Point-of-Service (POS) benefit at the out-of-network cost-sharing level. See the Medical Benefits Chart in Chapter 4 for more information about the POS benefit. If you don t have your copy of the Provider Directory, you can request a copy from Customer Services (phone numbers are printed on the back cover of this booklet). You may use the Find a Doctor tool at for more information about the qualifications of network providers, such as medical school attended, residency completed, and board certification status. You can also call Customer Services for information about network providers. Both Customer Services and the website can give you the most up-to-date information about changes in our network providers. Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network What are network pharmacies? Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for our plan members. Why do you need to know about network pharmacies? You can use the Pharmacy Directory to find the network pharmacy you want to use. There are changes to our network of pharmacies for next year. An updated Pharmacy Directory is located on our website at You may also call Customer Services for updated provider information or to ask us to mail you a Pharmacy Directory. Please review the 2016 Pharmacy Directory to see which pharmacies are in our network. If you don t have the Pharmacy Directory, you can get a copy from Customer Services (phone numbers are printed on the back cover of this booklet). At any time, you can call Customer Services to get up-to-date information about changes in the pharmacy network. You can also find this information on our website at Section 3.4 The plan s List of Covered Drugs (Formulary) The plan has a List of Covered Drugs (Formulary). We call it the Drug List for short. It tells which Part D prescription drugs are covered under the Part D benefit included in the plan. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the plan Drug List. The Drug List also tells you if there are any rules that restrict coverage for your drugs. We will send you a copy of the Drug List. To get the most complete and current information about which drugs are covered, you can visit the plan s website ( or call Customer Services (phone numbers are printed on the back cover of this booklet) Evidence of Coverage for Classic

27 Section 3.5 The Part D Explanation of Benefits (the Part D EOB ): Reports with a summary of payments made for your Part D prescription drugs When you use your Part D prescription drug benefits, we will send you a summary report to help you understand and keep track of payments for your Part D prescription drugs. This summary report is called the Part D Explanation of Benefits (or the Part D EOB ). The Part D Explanation of Benefits tells you the total amount you, or others on your behalf, have spent on your Part D prescription drugs and the total amount we have paid for each of your Part D prescription drugs during the month. Chapter 6 (What you pay for your Part D prescription drugs) gives more information about the Part D Explanation of Benefits and how it can help you keep track of your drug coverage. A Part D Explanation of Benefits summary is also available upon request. To get a copy, please contact Customer Services (phone numbers are printed on the back cover of this booklet). SECTION 4 Your monthly premium for the UCare for Seniors Classic plan Section 4.1 How much is your plan premium? As a member of our plan, you pay a monthly plan premium. For 2016, the monthly premium for UCare for Seniors Classic is $181. In addition, you must continue to pay your Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party). In some situations, your plan premium could be less The Extra Help program helps people with limited resources pay for their drugs. Chapter 2, Section 7 tells more about this program. If you qualify, enrolling in the program might lower your monthly plan premium. If you are already enrolled and getting help from one of these programs, the information about premiums in this Evidence of Coverage may not apply to you. We send you a separate insert, called the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also known as the Low Income Subsidy Rider or the LIS Rider ), which tells you about your drug coverage. If you don t have this insert, please call Customer Services and ask for the LIS Rider. (Phone numbers for Customer Services are printed on the back cover of this booklet.) In some situations, your plan premium could be more In some situations, your plan premium could be more than the amount listed above in Section 4.1. These situations are described below. If you signed up for extra benefits, also called optional supplemental benefits, then you pay an additional premium each month for these extra benefits. (UCare for Seniors Classic members have the option of purchasing the UCare Comprehensive Dental benefit package. The monthly premium for this optional supplemental benefit is $24. If you have any questions about your plan premiums, please call Customer Services (phone numbers are printed on the back cover of this booklet). Some members are required to pay a late enrollment penalty because they did not join a Medicare drug plan when they first became eligible or because they had a continuous period of 63 days or more when they didn t have creditable prescription drug coverage. ( Creditable means the drug coverage is expected to pay, on average, at least as much as Medicare s standard prescription drug coverage.) For these members, the late enrollment penalty is added to the plan s monthly premium. Their premium amount will be the monthly plan Chapter 1. Getting started as a member 9

28 premium plus the amount of their late enrollment penalty. If you are required to pay the late enrollment penalty, the amount of your penalty depends on how long you waited before you enrolled in drug coverage or how many months you were without drug coverage after you became eligible. Chapter 6, Section 9 explains the late enrollment penalty. If you have a late enrollment penalty and do not pay it, you could be disenrolled from the plan. Many members are required to pay other Medicare premiums In addition to paying the monthly plan premium, many members are required to pay other Medicare premiums. As explained in Section 2 above, in order to be eligible for our plan, you must be entitled to Medicare Part A and enrolled in Medicare Part B. For that reason, some plan members (those who aren t eligible for premium-free Part A) pay a premium for Medicare Part A. And most plan members pay a premium for Medicare Part B. You must continue paying your Medicare premiums to remain a member of the plan. Some people pay an extra amount for Part D because of their yearly income. This is known as Income Related Monthly Adjustment Amounts, also known as IRMAA. If your income is greater than $85,000 for an individual (or married individuals filing separately) or greater than $170,000 for married couples, you must pay an extra amount directly to the government (not the Medicare plan) for your Medicare Part D coverage. If you are required to pay the extra amount and you do not pay it, you will be disenrolled from the plan and lose prescription drug coverage. If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a letter telling you what that extra amount will be. For more information about Part D premiums based on income, go to Chapter 6, Section 10 of this booklet. You can also visit on the Web or call MEDICARE ( ), 24 hours a day, seven days a week. TTY users should call Or you may call Social Security at TTY users should call Your copy of Medicare & You 2016 gives information about the Medicare premiums in the section called 2016 Medicare Costs. This explains how the Medicare Part B and Part D premiums differ for people with different incomes. Everyone with Medicare receives a copy of Medicare & You each year in the fall. Those new to Medicare receive it within a month after first signing up. You can also download a copy of Medicare & You 2016 from the Medicare website ( Or, you can order a printed copy by phone at MEDICARE ( ), 24 hours a day, seven days a week. TTY users call Section 4.2 There are several ways you can pay your plan premium There are three ways you can pay your plan premium. Payment options are listed on the enrollment form and can be selected when filling out the form. Or, you can contact us directly and request a payment option. If you want to change your payment option, please contact us by calling Customer Services or in writing. If you decide to change the way you pay your premium, it can take up to three months for your new payment method to take effect. While we are processing your request for a new payment method, you are responsible for making sure that your plan premium is paid on time. Option 1: You can pay by check You may decide to pay your monthly plan premium directly to us with a check made payable to UCare. We will send you a monthly plan premium bill via U.S. mail; you submit payment by check made payable to UCare. The mailing address for payments for Minnesota residents is P.O. Box 9122, Minneapolis, MN Premium payments are due on the 1st of each month Evidence of Coverage for Classic