Group Medicare Plans at a Glance

Transcription

1 GROUP MEDICARE PLANS Group Medicare Plans at a Glance for Employer Groups 2015 Toll-free ext TTY: 711 HealthAlliance.org mkt-grpmedplansbro-1014

2 Coverage You Know and Trust If you ve worked with Health Alliance before, you know that member satisfaction is our top priority. We are constantly seeking to expand our network of providers and enhance our plan offerings. With our group Medicare plans, we have numerous stock options to choose from and for groups of 25 or more, we can build a custom plan, as well. Local, Personal Customer Service We provide local, personal customer service in the heart of Central Illinois. When members call, they ll speak with a friendly and knowledgeable Health Alliance Medicare representative in Champaign, IL. Our local customer service representatives are available between 8 a.m. and 8 p.m., Monday through Friday. Large Provider Network Our provider network grows all the time and when you choose Health Alliance Medicare for your retirees, you choose our network of doctors, hospitals and other health care professionals, giving them access to the services they need when and where they need them. Members can call us to request a provider directory or visit our website, HealthAlliance.org. Formulary The Medicare Part D Formulary is a list of drugs covered by Health Alliance Medicare. Generally, we only cover drugs listed in the formulary. Visit HealthAlliance.org to view our formulary. Extras Health Alliance Medicare offers a host of extras at no extra cost to help members save money and get healthy. See Extras Section for more information.

3 About Our Group Medicare Plans Group Medicare Plans from Health Alliance Medicare can help you support your employees once they become Medicare eligible. This is the next step in benefit offerings. It will help you retain talent or show appreciation for those who gave you their best years. How it Works Employer Contribution toward Premium Employers can contribute anything from $0 to the full amount toward enrollee premiums. If retirees within the organization qualify for different levels of employer contribution, the employer can establish those levels. And Health Alliance Medicare can do a group bill or bill members individually. Dedicated Employer Group Client Consultant Employers have a single point of contact for any questions about group Medicare benefits. This representative can help with every aspect of your plan. Low-Income Subsidy Members may qualify for extra help paying for prescription drug coverage. This help is available from the federal government for paying their monthly premium and prescription drug copayments. If retirees qualify for assistance, the premium billed for those members will be reduced by the amount of the assistance they receive. This can vary from member to member, and employers must pass the subsidy to the member s portion of the premium. State help may also be available. We Make It Easy Plans that Fit We work with you to find your employees and retirees the plan that fits your organization best. There are several stock plans to choose from and we can custom build a plan for groups of 25 or more. We also have plan options for employers with retirees who live outside Illinois. And all our plans help reduce FASB/GASB liabilities and expenditures. Less Paperwork We administer the plan, which means less paperwork for you. Member Materials We send plan materials, including an ID card and policy (called an Evidence of Coverage) to all new members and upon renewal. Employees on a Medicare plan with pharmacy coverage receive a monthly Explanation of Benefits detailing monthly and year-to-date drug expenses. No Enrollment Lock-In Retirees can enroll in Health Alliance Medicare at any time during the year. They are not limited to the Annual Election Period imposed upon individuals. Eligibility Retirees, as well as employees with Medicare as primary, are eligible for group coverage. Underwriting isn t required. Individuals with End Stage Renal Disease are generally not eligible to enroll in Health Alliance Medicare unless they are members of our organization and have been since their dialysis began.* Members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicare or by another third party. *Special exceptions apply for employer-sponsored plans. Medicare Supplement and Stand-Alone Prescription Drug Plans only Medicare Advantage HMO and PPO, Medicare Supplement and Stand-Alone Prescription Drug Plans Medicare Advantage PPO, Medicare Supplement and Stand-Alone Prescription Drug Plans Please note: If you have retirees who live outside Illinois, talk with your client consultant about coverage options.

4 Comprehensive Medicare Advantage Plans PPO The Numbers: 1. Five PPO Rx Plans (includes prescription coverage) 2. One PPO plan without Rx 3. $0 Tier 1 Preferred Generic Drugs at Walmart and Sam s Club (Rx plan members only) The Reasons: 1. Most Benefit-Rich Plans 2. Pay less at the time of service 3. Ability to see out-of-network providers 4. No in-network deductible 5. Health and savings extras included 6. Can be sold to employers domiciled in Illinois with at least 51% of eligible employees residing in Medicare Advantage licensed counties Bonus Info: PPO Option 1, PPO Option 2 and PPO Option 3 all offer prescription drug coverage through the gap. HMO The Numbers: 1. Two HMO Rx Plans (includes prescription coverage) 2. $0 Tier 1 Preferred Generic Drugs at Walmart and Sam s Club (Rx plan members only) The Reasons: 1. Most cost-effective 2. Likes having a single doctor help manage their care 3. Access to Emergency and Urgent Care providers nationwide 4. No in-network deductible 5. Health and savings extras included 6. Can be sold to employers domiciled in Illinois with at least 51% of eligible employees residing in Medicare Advantage licensed counties Bonus Info: HMO Option 1 offers prescription drug coverage through the gap. Drug Plans and Medicare Supplement Our most popular choice combines a PDP and a Medicare Supplement plan. Stand-Alone Prescription Drug Plans (PDP) The Numbers: 1. Two PDP options 2. $0 Tier 1 Preferred Generic Drugs at Walmart and Sam s Club (Rx plan members only) The Reasons: 1. Nation-wide prescription coverage 2. Can be paired with with a Medicare Supplement plan 3. Can be sold to employers nationwide, and retirees may reside anywhere in the U.S. Bonus Info: PDP Option 2 offers prescription drug coverage through the gap. + Medicare Supplement The Numbers: 1. Three coverage options The Reasons: 1. Ability to see any provider in Illinois who accepts Medicare without a referral 2. Most plans have no copayments 3. Can be paired with a stand-alone PDP 4. Employer Group must be in Illinois, retirees may reside anywhere in the U.S. Bonus Info: Health Alliance Medicare Supplement members can still get a slight discount at the pharmacy when they present their ID card.

5 Medicare Advantage PPO PPO Option 1 PPO Option 2 PPO Option 3 Monthly Premium $206 $264 $311 Medical Benefits In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Plan Year Deductible $0 $200 $0 $200 $0 $200 Plan Year Out-of-Pocket Maximum $3,400 $5,100* $3,400 $5,100* $3,400 $5,100* total in- and out-of-network* Be Healthy Annual Physical and Preventive $0 copayment $30 copayment $0 copayment $30 copayment $0 copayment $30 copayment Services Immunizations, annual physical exam, mammograms, Pap smears, cancer screenings and more. Age/frequency schedules apply. Primary Care Office Visit $20 copayment $30 copayment $20 copayment $30 copayment $20 copayment $30 copayment Specialist Office Visit $30 copayment $40 copayment $30 copayment $40 copayment $30 copayment $40 copayment Laboratory Services and Diagnostic Tests $0 copayment $30 copayment $0 copayment $30 copayment $0 copayment $30 copayment Outpatient Surgery $150 copayment $200 copayment $150 copayment $200 copayment $150 copayment $200 copayment Inpatient Hospital Care Unlimited days each benefit period Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility) $100 each day for days 1-8, $0 for each day(s) 9 and beyond $75 $200 each day for day(s) 1-8, $0 each day for day(s) 9-60, $150 each day for day(s) $125 $100 each day for days 1-8, $0 for each day(s) 9 and beyond Days : $75 $200 each day for day(s) 1-8, $0 each day for day(s) 9-60, $150 each day for day(s) per day Days : $125 $100 each day for days 1-8, $0 for each day(s) 9 and beyond Days : $75 $200 each day for day(s) 1-8, $0 each day for day(s) 9-60, $150 each day for day(s) Days : $125 Emergency Department Visits $65 copayment $65 copayment $65 copayment $65 copayment $65 copayment $65 copayment Durable Medical Equipment and 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance Prosthetic Devices Prescription Drugs These plans do not have a pharmacy deductible. Tier 1-Preferred Generic at Walmart $0 copayment Coverage for $0 copayment Coverage for $0 copayment Tier 1 Preferred Generic Elsewhere $20 copayment other drugs $15 copayment other drugs is $10 copayment is available available in special Tier 2 Non-Preferred Generic $40 copayment in special $30 copayment circumstances. $20 copayment Tier 3 Preferred Brand $40 copayment circumstances. $30 copayment $20 copayment Tier 4 Non-Preferred Brand $50 copayment $50 copayment $40 copayment Tier 5 Specialty $60 copayment $60 copayment $50 copayment Prescription Drug Coverage continues through Medicare s Coverage Gap. Post-Coverage Gap Benefit Rich Plans After member s yearly out-of-pocket drug costs reach $4,700, member pays the greater of: $2.65 copay for Tier 1 and Tier 2 drugs and $6.60 copay for all other drugs, or 5% coinsurance. Coverage for other drugs is available in special circumstances.

6 Medicare Advantage PPO, continued PPO 10 Rx PPO 30 Rx PPO 30 Monthly Premium $155 $87 $50 Member Benefits In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Plan Year Deductible $0 $0 $0 $0 $0 $0 Plan Year Out-of-Pocket Maximum $3,400 $5,100* $3,500 $10,000* $4,500 $10,000* total in- and out-of-network* Be Healthy Annual Physical and $0 copayment $30 copayment $0 copayment $50 copayment $0 copayment $50 copayment Preventive Services Immunizations, annual physical exam, mammograms, Pap smears, cancer screenings and more. Age/frequency schedules apply. Primary Care Office Visit $20 copayment $30 copayment $15 copayment $50 copayment $20 copayment $50 copayment Specialist Office Visit $30 copayment $40 copayment $40 copayment $50 copayment $40 copayment $50 copayment Laboratory Services and Diagnostic Tests $0 copayment $30 copayment $40 copayment $50 copayment $40 copayment $50 copayment Outpatient surgery $100 copayment $200 copayment $150 copayment $200 copayment $150 copayment $200 copayment Inpatient hospital care Days 1-8, $100, Days 9 and beyond, $0 Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility) Emergency Department Visits $125 $65 copayment per visit Days 1-8, $200, days 9 and beyond, $0 Days 1 20: $75 $200 $65 copayment per visit Days 1-8, $150, Days 9-60 $0, 61-90, $100 Days 1 20: $0 $150 $65 copayment per visit Days 1-8, $200, days 9-60, $0, 61-90, $150 Days 1 20: $200 $400 $65 copayment per visit Days 1-8, $150, Days 9-60 $0, 61-90, $100 Days 1 20: $0 $150 $65 copayment per visit Days 1-8, $200, days 9-60, $0, 61-90, $150 Days 1 20: $200 $400 $65 copayment per visit Durable Medical Equipment and Prosthetic Devices 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance Prescription Drugs $200 deductible (Tiers 3,4,5 only) $260 deductible (Tiers 3,4,5 only) Tier 1-Preferred Generic at Walmart $0 copayment Coverage for other drugs $0 copayment Coverage for other drugs is This plan does not include prescription drug coverage. Tier 1 Preferred Generic Elsewhere $10 copayment is available $10 copayment available in in special special Tier 2 Non-Preferred Generic $33 copayment $33 copayment circumstances. circumstances Tier 3 Preferred Brand $45 copayment $45 copayment Tier 4 Non-Preferred Brand $95 copayment $95 copayment Tier 5 Specialty Pharmacy 28% coinsurance 26% coinsurance Coverage Gap Post-Coverage Gap From $2,960 until member s annual drug costs reach $4,700 65% percent for generic drugs and 45% percent for brand-name drugs Benefit Rich Plans $2.65 copayment for Tier 1 and 2 drugs and $6.60 copayment for all other drugs, OR 5% coinsurance.

7 Medicare Advantage HMO Our Cost-Effective Plans HMO Option 1 HMO 20 Rx Monthly Premium $191 $131 Member Benefits In-Network Only In-Network Only Plan Year Deductible $0 $0 Plan Year Out-of-Pocket Maximum $3,400 $2,700 Be Healthy Annual Physical and Preventive Services $0 copayment $0 copayment Immunizations, annual physical exam, mammograms, Pap smears, cancer screenings and more. Age/ frequency schedules apply. Primary Care Office Visit $20 copayment $20 copayment Specialist Office Visit $40 copayment $40 copayment Laboratory Services and Diagnostic Tests $0 copayment $0 copayment Outpatient Surgery $100 copayment $100 copayment Inpatient Hospital Care Unlimited days each benefit period $100 each day for day(s) 1-7, $0 each day for day(s) 8 and beyond $100 each day for days 1-7, $0 each day for day(s) 8-60, $50 each day for day(s) Emergency Department Visits $65 copayment $65 copayment Durable Medical Equipment and 20% coinsurance 20% coinsurance Prosthetic Devices Prescription Drugs Tier 1-Preferred Generic at Walmart No Pharmacy Deductible $0 copayment $220 deductible (Tiers 3,4,5 only) $0 copayment Tier 1 Preferred Generic Elsewhere $20 copayment $10 copayment Tier 2 Non-Preferred Generic $40 copayment $33 copayment Tier 3 Preferred Brand $40 copayment $45 copayment Tier 4 Non-Preferred Brand $50 copayment $95 copayment Tier 5 Specialty Pharmacy $60 copayment 27% coinsurance Coverage Gap Post-Coverage Gap Prescription Drug Coverage continues through Medicare s Coverage Gap. From $2,690 until member s annual drug costs reach $4,700, member pays 65 percent of generic drugs and 45 percent for brand-name drugs. After member s yearly out-of-pocket drug costs reach $4,700, member pays the greater of: $2.65 copay for Tier 1 and Tier 2 drugs and $6.60 copay for all other drugs, or 5% coinsurance.

8 Stand-Alone Prescription Drug Plans (PDP) Our Most Popular Plans Combine a PDP and a Medicare Supplement Plan Prescription Drug Plan 1 Monthly Premium $57 Member Benefits from a retail pharmacy or through mail order until total drug costs (both the member s costs and the plan s costs) reach $2,960. Coverage Gap Post-Coverage Gap In-Network $0 for Tier 1 Preferred Generic at Walmart and Sam s Club $20 for Tier 1 Preferred Generic Elsewhere $40 for Tier 2 Non-Preferred Generic $40 for Tier 3 Preferred Brand $50 for Tier 4 Non-Preferred Brand $60 for Tier 5 Specialty Pharmacy Out-of-Network Covered drugs are available in special circumstances, including illness and while traveling outside the plan s service area where there is no network pharmacy. Members may incur an additional cost. From $2,690 until member s annual drug costs reach $4,700. Member pays 65% for generic drugs and 45% for brand-name drugs. After member s yearly out-of-pocket drug costs reach $4,700, member pays the greater of: $2.65 copay for Tier 1 and Tier 2 drugs and $6.60 copay for all other drugs, or 5% coinsurance. Prescription Drug Plan 2 $107 In-Network $0 for Tier 1 Preferred Generic at Walmart and Sam s Club $15 for Tier 1 Preferred Generic Elsewhere $30 for Tier 2 Non-Preferred Generic $30 for Tier 3 Preferred Brand $50 for Tier 4 Non-Preferred Brand $60 for Tier 5 Specialty Pharmacy Out-of-Network Covered drugs are available in special circumstances, including illness and while traveling outside the plan s service area where there is no network pharmacy. Members may incur an additional cost. Coverage continues through the gap After member s yearly out-of-pocket drug costs reach $4,700, member pays the greater of: $2.65 copay for Tier 1 and Tier 2 drugs and $6.60 copay for all other drugs, or 5% coinsurance.

9 Medicare Supplement Plan Design Plan A Plan F Plan N Services/Benefits Physician Services Member Pays with Health Alliance Medicare Supplement Plans Part B deductible, then all excess charges above Medicare-approved amounts $0 $20 copayment after the Part B deductible is met; up to $65 copayment for emergency room Hospitalization (first 60 days) Part A deductible $0 $0 Laboratory Services and $0 $0 $0 Diagnostic Tests Annual Out-of-Pocket Maximum N/A N/A N/A If spouses sign up at the same time for the same plan, they get a seven percent discount. Premiums listed are for Illinois residents who live outside of Cook, DuPage, Kane, Lake, McHenry or Will counties. Your client consultants can provide premium information for retirees in those Chicago areas. Monthly Premium* $ $ $ Age<65 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $252.76

10 Extras Health Programs For HMO and PPO plan members only SilverSneakers You can do it with Healthways SilverSneakers Fitness Program, one of the benefits you ll receive when you join Health Alliance Medicare. Achieve your health and fitness goals with access to more than 11,000 fitness locations, where you can: Use all basic amenities plus take SilverSneakers classes. Have guidance and assistance from a Program Advisor. SM Silver Sneakers is a registered trademark of Healthways, Inc Health Ways, Inc. Assist America When Health Alliance Medicare members are more than 100 miles from home, Assist America can help with: Guaranteed hospital admission. Prescription assistance, if they forget or lose a prescription medication. Transportation for a loved one to join the member if hospitalized for more than seven days. Return of mortal remains, in the unfortunate event that a member passes away while traveling. Be Your Best These programs include newsletters, brochures and reminders about important condition-specific topics like asthma, COPD, diabetes, blood pressure and cholesterol, as well as help to quit smoking. Visit HealthAlliance.org and select Extras for a list of programs. Be Healthy To encourage Health Alliance Medicare members to seek preventive care, we cover 100 percent of charges for an annual exam (in-network for PPO members) and medically appropriate screenings. Be Fit To help members in their health and fitness efforts, Health Alliance Medicare has partnered with a host of programs and facilities to offer discounts on weight-loss programs and fitness club memberships. Case Management Health Alliance Medicare members who are eligible have free access to case managers who help make coping with hospital stays and chronic illnesses easier. Case managers can help: Explain a diagnosis, test results and treatment options. Take the confusion out of hospital discharge notices and other documents. Assist with home health care, skilled nursing facility stays and durable medical equipment. Drug Programs For all members with drug coverage $0 Copay at Walmart and Sam s Club Members with Part D coverage can receive their Tier 1 drugs for $0 at Walmart and Sam s Club. Tier 1 drugs are some of our most commonly used drugs. Members can continue to receive drugs at other network pharmacies. Medication Therapy Management This program helps members who take multiple medications use them safely and effectively. Health Alliance Medicare is an HMO, PPO and PDP plan with a Medicare contract. Enrollment in Health Alliance Medicare depends on contract renewal. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1 of each year. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. GROUP MEDICARE PLANS Toll-free ext TTY/TDD 711 HealthAlliance.org