Annual Notice of Changes for 2015

Transcription

1 Kaiser Permanente Senior Advantage Medicare Medicaid Plan (HMO SNP) offered by Kaiser Foundation Health Plan of Georgia, Inc. Annual Notice of Changes for 2015 You are currently enrolled as a member of Kaiser Permanente Senior Advantage Medicare Medicaid Plan. Next year, there will be some changes to our plan's costs and benefits. This booklet tells about the changes. Additional Resources This information is available for free in other languages. Please contact our Member Services number at for additional information. (TTY users should call 711.) Hours are 8 a.m. to 8 p.m., seven days a week. Member Services also has free language interpreter services available for non-english speakers. Se puede obtener esta información gratis en otros idiomas. Si desea información adicional, por favor llame al número de nuestros Servicios a los Miembros al (Los usuarios de TTY deben llamar al 711.) El horario es de 8 a.m. a 8 p.m., los siete días de la semana. Servicios a los Miembros también cuenta con servicios gratuitos de interpretación para las personas que no hablan inglés. This information is available in a different format for the visually impaired by calling Member Services. About Kaiser Permanente Senior Advantage Medicare Medicaid Plan Kaiser Permanente is an HMO SNP plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in Kaiser Permanente depends on contract renewal. When this booklet says "we," "us," or "our," it means Kaiser Foundation Health Plan of Georgia, Inc. (Health Plan). When it says "plan" or "our plan," it means Kaiser Permanente Senior Advantage Medicare Medicaid Plan (Senior Advantage Medicare Medicaid Plan). H1170_014_34 accepted PBP 008

2 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes 1 Think about your Medicare coverage for next year Medicare allows you to change your Medicare health and drug coverage. It's important to review your coverage each fall 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 Sections 1.6 and 2 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 our plan: If you want to stay with us next year, it's easy you don't need to do anything. If you don't make a change, you will automatically stay enrolled in our plan. If you decide to change plans: If you decide other coverage will better meet your needs, you can switch at any time. If you enroll in a new plan, your new coverage will begin on the first day of the month after you request the change. Look in Section 3.2 to learn more about your choices , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

3 2 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes Summary of important costs for 2015 The table below compares the 2014 costs and 2015 costs for our plan 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 2014 (this year) 2015 (next year) Monthly plan premium* *Your premium may be higher or lower than this amount. See Section 1.1 for details. Doctor office visits Inpatient hospital stays Includes inpatient acute, inpatient rehabilitation, 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. $24.60 if you do not qualify for "Extra Help." Primary care visits: *$0 or $5 per visit. Specialist visits: *$0 or $10 per visit. *$0 or $85 per day, for days 1 8. $26.00 if you do not qualify for "Extra Help." Primary care visits: $0 per visit. Specialist visits: *$0 or $3 per visit. *$0 or $12 per admission. Part D prescription drug coverage Preferred cost-sharing during the Initial Coverage Stage (up to a 30-day supply) if you do not qualify for "Extra Help": (See Section 1.6 for details.) Drug Tier 1: $5 Drug Tier 2: $14 Drug Tier 3: $44 Drug Tier 4: $75 Drug Tier 5: 25% Drug Tier 6: $0 Drug Tier 1: $5 Drug Tier 2: $16 Drug Tier 3: $44 Drug Tier 4: $85 Drug Tier 5: 33% Drug Tier 6: $0 Maximum out-of-pocket amount 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.) $3,400 $1,000 *Cost-sharing varies depending upon your level of Medicaid eligibility.

4 Annual Notice of Changes for 2015 Table of Contents Think about your Medicare coverage for next year... 1 Summary of important costs for Section 1. Changes to benefits and costs for next year... 4 Section 1.1. Changes to the monthly 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 medical services...5 Section 1.6. Changes to Part D prescription drug coverage...7 Section 2. Other changes Section 3. Deciding which plan to choose Section 3.1. If you want to stay in our plan...10 Section 3.2. If you want to change plans...11 Section 4. Deadline for changing plans Section 5. Programs that offer free counseling about Medicare Section 6. Programs that help pay for prescription drugs Section 7. Questions? Section 7.1. Getting help from our plan...12 Section 7.2. Getting help from Medicare...13 Section 7.3. Getting help from Medicaid...13

5 4 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes Section 1. Changes to benefits and costs for next year Section 1.1. Changes to the monthly premium Cost 2014 (this year) 2015 (next year) Monthly premium (You must also continue to pay your Medicare Part B premium, unless it is paid for you by Medicaid.) $24.60 if you do not qualify for "Extra Help." $26.00 if you do not qualify for "Extra Help." Your monthly plan premium will be more if you are required to pay a late enrollment penalty. If you ever lose your low income subsidy ("Extra Help"), you must maintain your Part D coverage or you could be subject to a late enrollment penalty if you ever choose to enroll in Part D in the future. If you have a higher income, as reported on your last tax return ($85,000 or more), you may have to pay an additional amount each month directly to the government for your Medicare prescription drug coverage. Your monthly plan 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 the maximum out-of-pocket amount, you generally pay nothing for covered Part A and Part B services (and other health care services not covered by Medicare as described in Chapter 4 of the Evidence of Coverage) for the rest of the year. Cost 2014 (this year) 2015 (next year) Maximum out-of-pocket amount Because our members also get assistance from Medicaid, very few members ever reach this out-of-pocket maximum. Your costs for covered medical services (such as copayments) count toward your maximum out-of-pocket amount. Your plan premium and your costs for prescription drugs do not count toward your maximum out-of-pocket amount. $3,400 $1,000 Once you have paid $1,000 out-of-pocket for covered Part A and Part B services (and certain health care services not covered by Medicare), you will pay nothing for these covered services for the rest of the calendar year , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

6 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes 5 Section 1.3. Changes to the provider network There are changes to our network of doctors and other providers for next year. An updated Provider Directory is located on our website at kp.org. You may also call Member Services for updated provider information or to ask us to mail you a Provider Directory. Please review the 2015 Provider Directory to see if your providers 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. 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. Our network includes pharmacies with preferred cost-sharing, which may offer you lower cost-sharing than the standard cost-sharing offered by other pharmacies within the network. There are changes to our network of pharmacies for next year. An updated Pharmacy Directory is located on our website at kp.org. You may also call Member Services for updated provider information or to ask us to mail you a Pharmacy Directory. Please review the 2015 Pharmacy Directory to see which pharmacies are in our network. Section 1.5. Changes to benefits and costs for medical services Please note that the Annual Notice of Changes only tells you about changes to your Medicare benefits and costs. 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, "Benefits Chart (what is covered and what you pay)," in your 2015 Evidence of Coverage. A copy of the Evidence of Coverage is included in this booklet , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

7 6 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes Cost *2014 (this year) *2015 (next year) Ambulance services You pay $0 or $100 per one-way trip. Emergency room visits You pay $0 or $65 per visit. You pay $0 or $40 per one-way trip. You pay $0 or $35 per visit. Inpatient care Note: If you are admitted to the hospital in 2014 and are not discharged until sometime in 2015, the 2014 cost-sharing will apply to that admission until you are discharged from the hospital or transferred to a skilled nursing facility. Interactive video visits Interactive video visits for professional services when care can be provided in this format as determined by a plan provider. Generic Medicare Part B drugs Up to a 30-day supply from a pharmacy located at a Kaiser Permanente facility (a pharmacy that offers preferred costsharing). You pay $0 or $85 per day, for days 1 8. Not covered. You pay $0 or $14 per prescription. You pay $0 or $12 for each hospital stay. No charge. You pay $0 or $16 per prescription. Outpatient surgery You pay $0 or $85 per procedure. You pay $0 or $3 per procedure. Outpatient X-rays, lab, and radiology services provided in a hospital Primary care office visits You pay $0 or $10 per encounter. You pay $0 or $5 per visit. You pay $0 or $3 per encounter. You pay $0 per visit. *Cost-sharing varies depending upon your level of Medicaid eligibility.

8 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes 7 Cost *2014 (this year) *2015 (next year) Skilled nursing facility Note: If a benefit period begins in 2014 for you and does not end until sometime in 2015, the 2014 cost-sharing will continue until the benefit period ends. Per benefit period, you pay: $0 per day, for days $0 or $50 per day, for days You pay $0 per benefit period. Specialty and urgent care visits Most specialty care, including cardiac care, podiatry, therapeutic radiological services, substance abuse, eye exams, and hearing exams. Specialty scans (including MRI, CT, and PET) You pay $0 or $10 per visit. You pay $0 or $100 per encounter in a medical office and $0 or $150 in all other settings. You pay $0 or $3 per visit. You pay $0 or $3 per encounter in all settings. Section 1.6. Changes to Part D prescription drug coverage Changes to basic rules for our plan's Part D drug coverage Effective June 1, 2015, before your drugs can be covered under the Part D benefit, CMS will require your doctors and other prescribers to either accept Medicare or to file documentation with CMS showing that they are qualified to write prescriptions. Changes to our Drug List Our list of covered drugs is called a formulary, or Drug List (Kaiser Permanente 2015 Abridged Formulary). 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. The Drug List we included in this envelope includes many but not all of the drugs that we will cover next year. If you don't see your drug on this list, it might still be covered. You can get the complete Drug List (Kaiser Permanente 2015 Comprehensive Formulary) by calling Member Services (see the back cover) or visiting our website (kp.org/seniormedrx). *Cost-sharing varies depending upon your level of Medicaid eligibility.

9 8 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes 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, and complaints)" or call Member Services. Find a different drug that we cover. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. In some situations, we will cover a one-time, temporary supply. (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. Because our formulary includes all drugs that can be covered under a Medicare Part D prescription drug plan, it is not likely that we made a formulary exception for you during 2014 to cover a drug that is not on our Drug List. However, in the rare case that we did make a formulary exception during 2014, the exception may continue into 2015 as long as your network provider continues to prescribe the drug for you. 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 does not apply to you. We will send 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 Rider"), which tells you about your drug coverage. If you get "Extra Help" and haven't received this insert by December 31, 2014, please call Member Services and ask for the "LIS Rider." Phone numbers for Member Services are in Section 7.1 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 in your Summary of Benefits or at Chapter 6, Sections 6 and 7, in the attached Evidence of Coverage.) , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

10 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes 9 Changes to the Deductible Stage Cost 2014 (this year) 2015 (next year) Stage 1: Yearly Deductible Stage 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. Changes to your copayments in the Initial Coverage Stage Cost 2014 (this year) 2015 (next year) Stage 2: Initial Coverage Stage During this stage, the plan 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) supply when you fill your prescription at a network pharmacy. For information about the costs for a longterm supply or 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. Your cost for a one-month supply filled at a network pharmacy if you do not qualify for "Extra Help." Tier 1 Preferred generic drugs: Preferred cost-sharing: You pay $5 per prescription. Standard cost-sharing: You pay $10 per prescription. Tier 2 Nonpreferred generic drugs: Preferred cost-sharing: You pay $14 per prescription. Standard cost-sharing: You pay $30 per prescription. Tier 3 Preferred brandname drugs: Preferred cost-sharing: You pay $44 per prescription. Standard cost-sharing: You pay $45 per prescription. Tier 4 Nonpreferred brand-name drugs: Preferred cost-sharing: You pay $75 per prescription. Standard cost-sharing: You pay $85 per prescription. Your cost for a one-month supply filled at a network pharmacy if you do not qualify for "Extra Help." Tier 1 Preferred generic drugs: Preferred cost-sharing: You pay $5 per prescription. Standard cost-sharing: You pay $10 per prescription. Tier 2 Nonpreferred generic drugs: Preferred cost-sharing: You pay $16 per prescription. Standard cost-sharing: You pay $30 per prescription. Tier 3 Preferred brandname drugs: Preferred cost-sharing: You pay $44 per prescription. Standard cost-sharing: You pay $45 per prescription. Tier 4 Nonpreferred brand-name drugs: Preferred cost-sharing: You pay $85 per prescription. Standard cost-sharing: You pay $90 per prescription , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

11 10 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes Cost 2014 (this year) 2015 (next year) Tier 5 Specialty-tier drugs: You pay 25% of the total cost (Plan Charges) per prescription. Tier 6 Injectable Part D vaccines: You pay $0 per prescription. Once your total drug costs have reached $2,850, you will move to the next stage (the Coverage Gap Stage). Tier 5 Specialty-tier drugs: You pay 33% of the total cost (Plan Charges) per prescription. Tier 6 Injectable Part D vaccines: You pay $0 per prescription. Once your total drug costs have reached $2,960, 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 your Summary of Benefits or at Chapter 6, Sections 6 and 7, in your Evidence of Coverage. Section 2. Other changes Cost 2014 (this year) 2015 (next year) Quantity limits on Medicare Part D prescription drugs. Not applicable. We may limit the amount of a drug (number of pills, etc.) we will cover during a particular time period. Drugs with a quantity limit are identified in the Kaiser Permanente 2015 Comprehensive Formulary. Section 3. Deciding which plan to choose Section 3.1. If you want to stay in our plan 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, you will automatically stay enrolled as a member of our plan for , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

12 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes 11 Section 3.2. If you want to change plans We hope to keep you as a member next year, but if you want to change for 2015, 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 2015, call your State Health Insurance Assistance Program (see Section 5), or call Medicare (see Section 7.2). 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, Kaiser Permanente 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 Member Services if you need more information on how to do this (phone numbers are in Section 7.1 of this booklet). Or contact Medicare at MEDICARE ( ), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call Section 4. Deadline for changing plans Because you are eligible for both Medicare and Medicaid, you can change your Medicare coverage at any time. You can change to any other Medicare health plan (either with or without Medicare prescription drug coverage) or switch to Original Medicare (either with or without a separate Medicare prescription drug plan) at any time , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

13 12 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes Section 5. 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 Georgia, the SHIP is called GeorgiaCares. GeorgiaCares 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. GeorgiaCares 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 GeorgiaCares at You can learn more about GeorgiaCares by visiting their website (mygeorgiacares.org). Section 6. 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/7 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). Section 7. Questions? Section 7.1. Getting help from our plan Questions? We're here to help. Please call Member Services at (TTY only, call 711.) We are available for phone calls seven days a week, 8 a.m. to 8 p.m. Calls to these numbers are free. Read your 2015 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 2015 Evidence of Coverage for our plan. 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 booklet. Visit our website You can also visit our website at kp.org. As a reminder, our website has the most up-to-date information about our provider network (Provider Directory) and our list of covered drugs (Kaiser Permanente 2015 Comprehensive Formulary) , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

14 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes 13 Section 7.2. Getting help from Medicare To get information directly from Medicare: Call MEDICARE ( ) You can call MEDICARE ( ), 24 hours a day, 7 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 2015 You can read the Medicare & You 2015 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, 7 days a week. TTY users should call Section 7.3. Getting help from Medicaid To get information from Medicaid, you can call the Medicaid office in your county at the phone numbers listed below. Georgia Medicaid Agencies by County Cherokee County DFCS 105 Lamar Haley Parkway P.O. Box 826 Canton, GA Phone: Clayton County DFCS 877 Battlecreek Road Jonesboro, GA Phone: Cobb County DFCS 325 Fairground Street, SE Marietta, GA Phone: Coweta County DFCS 533 Highway 29 North Newnan, GA Phone: Fayette County DFCS 905 Highway 85 South Fayetteville, GA Phone: Forsyth County DFCS 426 Canton Road, P.O. Box 21 Cumming, GA Phone: Fulton County DFCS Northwest Service Center 1249 Donald Lee Hollowell Parkway Atlanta, GA Phone: Gwinnett County DFCS 446 West Crogan Street, Suite 300 Lawrenceville, GA Phone: , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

15 14 Senior Advantage Medicare Medicaid Plan 2015 Annual Notice of Changes Georgia Medicaid Agencies by County DeKalb County DFCS 178 Sams Street Decatur, GA Phone: Douglas County DFCS 8473 Duralee Lane Suite 100 Douglasville, GA Phone: Henry County DFCS 125 Henry Parkway McDonough, GA Phone: Paulding County DFCS 1387 Industrial Blvd. North P.O. Box 168 Dallas, GA Phone: , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

16 January 1 December 31, 2015 Evidence of Coverage Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Kaiser Permanente Senior Advantage Medicare Medicaid Plan (HMO SNP) This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 to 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, Kaiser Permanente Senior Advantage Medicare Medicaid Plan, is offered by Kaiser Foundation Health Plan of Georgia, Inc. (Health Plan). When this Evidence of Coverage says "we," "us," or "our," it means Health Plan. When it says "plan" or "our plan," it means Kaiser Permanente Senior Advantage Medicare Medicaid Plan (Senior Advantage Medicare Medicaid Plan). Kaiser Permanente is an HMO SNP plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in Kaiser Permanente depends on contract renewal. This information is available for free in other languages. Please contact our Member Services number at for additional information. (TTY users should call 711.) Hours are 8 a.m. to 8 p.m., seven days a week. Member Services also has free language interpreter services available for non-english speakers. Se puede obtener esta información gratis en otros idiomas. Si desea información adicional, por favor llame al número de nuestros Servicios a los Miembros al (Los usuarios de TTY deben llamar al 711.) El horario es de 8 a.m. a 8 p.m., los siete días de la semana. Servicios a los Miembros también cuenta con servicios gratuitos de interpretación para las personas que no hablan inglés. This information is available in a different format for the visually impaired by calling Member Services (phone numbers are printed on the back cover of this booklet). Benefits, formulary, pharmacy network, premium, and/or copayments/coinsurance may change on January 1, H1170_014_34 accepted PBP 008

17 Table of Contents 2015 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... 1 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 Tells you how to get in touch with our plan (Senior Advantage Medicare Medicaid 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 our plan's coverage for your medical services Explains important things you need to know about getting your medical care as a member of our plan. Topics include using the providers in our plan's network and how to get care when you have an emergency. CHAPTER 4. Benefits Chart (what is covered and what you pay) 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 our plan's coverage for your Part D prescription drugs Explains rules you need to follow when you get your Part D drugs. Tells how to use our Kaiser Permanente 2015 Abridged Formulary and Kaiser Permanente 2015 Comprehensive 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 our plan's programs for drug safety and managing medications , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

18 Table of Contents 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, and Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains the six 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. CHAPTER 9. What to do if you have a problem or complaint (coverage decisions, appeals, and 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 our plan Explains when and how you can end your membership in our plan. Explains situations in which our plan is required to end your membership. CHAPTER 11. Legal notices Includes notices about governing law and about nondiscrimination. CHAPTER 12. Definitions of important words Explains key terms used in this booklet. kp.org

19 Chapter 1: Getting started as a member 1 CHAPTER 1. Getting started as a member SECTION 1. Introduction... 3 Section 1.1 You are enrolled in Senior Advantage Medicare Medicaid Plan, which is a specialized Medicare Advantage Plan (Special Needs Plan)... 3 Section 1.2 What is the Evidence of Coverage booklet about?... 3 Section 1.3 What does this chapter tell you?... 4 Section 1.4 What if you are new to Senior Advantage Medicare Medicaid Plan?... 4 Section 1.5 Legal information about the Evidence of Coverage... 4 SECTION 2. What makes you eligible to be a plan member?... 5 Section 2.1 Your eligibility requirements... 5 Section 2.2 What are Medicare Part A and Medicare Part B?... 5 Section 2.3 What is Medicaid?... 5 Section 2.4 Here is our plan service area for Senior Advantage Medicare Medicaid Plan... 6 SECTION 3. What other materials will you get from us?... 6 Section 3.1 Your plan membership card use it to get all covered care and prescription drugs... 6 Section 3.2 The Provider Directory: Your guide to all providers in our network... 7 Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network... 8 Section 3.4 Our plan's Kaiser Permanente 2015 Abridged 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 our 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 Section 4.3 Can we change your monthly plan premium during the year? SECTION 5. Please keep your plan membership record up-to-date Section 5.1 How to help make sure that we have accurate information about you SECTION 6. We protect the privacy of your personal health information Section 6.1 We make sure that your health information is protected , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

20 Chapter 1: Getting started as a member 2 SECTION 7. How other insurance works with our plan Section 7.1 Which plan pays first when you have other insurance? kp.org

21 Chapter 1: Getting started as a member 3 SECTION 1. Introduction Section 1.1 You are enrolled in Senior Advantage Medicare Medicaid Plan, which is a specialized Medicare Advantage Plan (Special Needs Plan) You are covered by both Medicare and Medicaid: Medicare is the federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with end-stage renal disease (kidney failure). Medicaid is a joint federal and state government program that helps with medical costs for certain people with limited incomes and resources. Medicaid coverage varies depending on the state and the type of Medicaid you have. Some people with Medicaid get help paying for their Medicare premiums and other costs. Other people also get coverage for additional services and drugs that are not covered by Medicare. You have chosen to get your Medicare health care and your prescription drug coverage through our plan, Kaiser Permanente Senior Advantage Medicare Medicaid Plan. There are different types of Medicare health plans. Senior Advantage Medicare Medicaid Plan is a specialized Medicare Advantage Plan (a Medicare "Special Needs Plan"), which means its benefits are designed for people with special health care needs. Senior Advantage Medicare Medicaid Plan is designed specifically for people who have Medicare and who are also entitled to assistance from Medicaid. Because you get assistance from Medicaid, you will pay less for some of your Medicare health care services. Medicaid may also provide other benefits to you by covering health care services, prescription drugs, long term care, and/or home and community based services that are not usually covered under Medicare. You may also receive "Extra Help" from Medicare to pay for the costs of your Medicare prescription drugs. Our plan will help manage all of these benefits for you, so that you get the health care services and payment assistance that you are entitled to. Kaiser Permanente Senior Advantage Medicare Medicaid Plan is run by a nonprofit organization. Like all Medicare Advantage Plans, this Medicare Special Needs Plan is approved by Medicare. The plan also has a contract with the Georgia Medicaid program to coordinate your Medicaid benefits. We are pleased to be providing your Medicare health care coverage, including your prescription drug coverage. 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 our plan , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

22 Chapter 1: Getting started as a member 4 This plan, Kaiser Permanente Senior Advantage Medicare Medicaid Plan, is offered by Kaiser Foundation Health Plan of Georgia, Inc. (Health Plan). When this Evidence of Coverage says "we," "us," or "our," it means Health Plan. When it says "plan" or "our plan," it means Kaiser Permanente Senior Advantage Medicare Medicaid Plan (Senior Advantage Medicare Medicaid Plan). The words "coverage" and "covered services" refer to the medical care and services and the prescription drugs available to you as a member of our plan. Section 1.3 What does this chapter tell you? Look through Chapter 1 of this Evidence of Coverage to learn: What makes you eligible to be a plan member? What is our service area? What materials will you get from us? What is your plan premium and how can you pay it? How do you keep the information in your membership record up-to-date? Section 1.4 What if you are new to Senior Advantage Medicare Medicaid Plan? If you are a new member, then it's important for you to learn what our 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 Member Services (phone numbers are printed on the back cover of this booklet). Section 1.5 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 our plan covers your care. Other parts of this contract include your enrollment form, our Kaiser Permanente 2015 Abridged Formulary and Kaiser Permanente 2015 Comprehensive 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 the months in which you are enrolled in Senior Advantage Medicare Medicaid Plan between January 1, 2015, 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 our 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, kp.org

23 Chapter 1: Getting started as a member 5 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 our plan and Medicare renews its approval of our plan. 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 live in our geographic service area (Section 2.3 below describes our service area). and you have both Medicare Part A and Medicare Part B. 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. and you meet the special eligibility requirements described below. Special eligibility requirements for our plan Our plan is designed to meet the needs of people who receive certain Medicaid benefits. (Medicaid is a joint federal and state government program that helps with medical costs for certain people with limited incomes and resources.) To be eligible for our plan you must be eligible for both Medicare and Medicaid. 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 physician's services and other outpatient services) and certain items (such as durable medical equipment and supplies). Section 2.3 What is Medicaid? Medicaid is a joint federal and state government program that helps with medical costs for certain people who have limited incomes and resources. Each state decides what counts as income and resources, who is eligible, what services are covered, and the cost for services. States also can decide how to run their program as long as they follow the federal guidelines , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

24 Chapter 1: Getting started as a member 6 In addition, there are programs offered through Medicaid that help people with Medicare pay their Medicare costs, such as their Medicare premiums. These "Medicare Savings Programs" help people with limited income and resources save money each year: Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost-sharing (like deductibles, coinsurance, and copayments). (Some people with QMB are also eligible for full Medicaid benefits (QMB+).) Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums. (Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).) Qualified Individual (QI): Helps pay Part B premiums. Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums. Section 2.4 Here is our plan service area for Senior Advantage Medicare Medicaid Plan Although Medicare is a federal program, our 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 Georgia: Cherokee, Clayton, Cobb, Coweta, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, and Henry. Our service area also includes these parts of Paulding County in Georgia, in the following ZIP codes only: 30127, 30134, and If you plan to move out of the service area, please contact Member 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 5. SECTION 3. What other materials will you get from us? Section 3.1 Your plan membership card use it to get all covered care and prescription drugs While you are a member of our plan, you must use your membership card for our plan whenever you get any services covered by our plan and for prescription drugs you get at network pharmacies. Here's a sample membership card to show you what yours will look like: kp.org

25 Chapter 1: Getting started as a member 7 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 Senior Advantage 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 Member Services right away and we will send you a new card. Phone numbers for Member Services are printed on the back cover of this booklet. Section 3.2 The Provider Directory: Your guide to all providers in our network The Provider Directory lists our network providers. All of our network providers accept both Medicare and Medicaid. In the event that you need a service not covered by our plan that is covered by Medicaid, we may refer you to the state Medicaid agency to locate an out-of-network provider who can provide your Medicaid-covered care. What are "network providers"? Network providers are the doctors and other health care professionals, medical groups, 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 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 care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers. See Chapter 3, "Using our plan's coverage for your medical services," for more specific information about emergency, out-ofnetwork, and out-of-area coverage , seven days a week, 8 a.m. to 8 p.m. (TTY 711)