HMO-POS Y0076_HMO HMO POS FF BRO CMS APPROVED CY

Transcription

1 HMO-POS Y0076_HMO HMO POS FF BRO CMS APPROVED CY

2 What do you want from your health plan? Live life healthy. Live life secure. Achieving and maintaining good health starts with finding a health partner that looks out for your well-being, and a health plan that combines benefits, services and programs that support a healthy lifestyle. A healthy way of thinking. At HAP, our focus on healthy living starts with ensuring you have access to a full range of qualified doctors, hospitals and other health care providers. We work closely with them gathering and analyzing critical information, measuring and sharing results to continuously improve health care quality and patient safety. We work closely with you, too, providing information and resources that can help you better control chronic conditions and prevent disease before it starts. You can also take advantage of the added services and benefits we offer to help you stay physically active and fit. Our goal is to help you achieve good health, so you can live the way you want and enjoy doing everything you love to do. A plan that s your health partner. That s HAP Senior Plus (hmo-pos)-expanded Network. HAP Senior Plus-Expanded Network is offered by Health Alliance Plan (HAP), a 50-year-old Michigan-based company. We have been serving Medicare beneficiaries for more than 20 years, building on what we have learned to make our health plans more responsive to our members. And because we are a nonprofit health plan, we continually reinvest to improve our services and benefits. Many health plans focus their attention on providing medical care when you are sick or hurt. That s important. But a health plan can offer even more value by helping you achieve and maintain good health, so you can do all the things you enjoy. With HAP, you have the peace of mind that comes from knowing you have a dedicated partner here in southeast Michigan. 3

3 Support for healthy living. When you are a member of HAP Senior Plus-Expanded Network, you can feel secure knowing that we are here as your health partner, looking out for your well-being. A dedicated team. Quality care starts with a doctor you trust someone you can rely on to provide you with the care you need. That s why HAP Senior Plus-Expanded Network includes more than 7,600 qualified doctors and specialists, along with more than 40 area hospitals and dozens of other health care facilities. HAP works with our network of providers to ensure that they have access to the medical and health information and resources they need. Together, our goal is to continuously improve the quality of care, help you better control chronic conditions and uncover medical conditions before they lead to more serious health issues. Responsive customer service. At HAP, personal customer service is part of who we are and everything we do. Have fun. Get fit. As a member of HAP Senior Plus-Expanded Network, you receive a Flexible Health Options benefit of up to $40 monthly ($480 annually)* a benefit you can use for qualified activities, programs and services that help you get active, stay in shape and feel good. The Flexible Health Options benefit is part of your health plan. You can use your Flexible Health Options benefit for any qualified program or service you choose anywhere. You select the program, service or activity you want: Membership at a gym, health club or fitness center of your choice where you can choose the type of exercise you like best swimming, yoga, aerobics, Tai Chi, weight training and more. If you travel, choose a membership with a nationwide or worldwide network of facilities Qualified weight management programs such as Weight Watchers or Jenny Craig Health services that work for you chiropractic services (not otherwise covered by Medicare) and acupuncture * Amount varies by plan. See chart on pages 8 and 9. Unused amounts cannot be carried over month to month. The Flexible Health Options benefit may not be available in group-purchased plans. Throughout your first two years as a member, you will have your own Personal Service Coordinator someone who is fully trained in our Medicare plans. Your Personal Service Coordinator is here for you, ready to answer questions, provide assistance, explain plan details and introduce you to special programs designed to help you improve and maintain your health. After the first two years, whenever you want extra assistance or information, you can call any of our Medicare Customer Service Representatives dedicated employees who specialize in Medicare and live and work here in southeast Michigan. Use your Flexible Health Options benefit for any qualified program or service you choose anywhere. 5

4 Sub1: 24 pt. / 27 HAP Senior Pluspt. Leading Expanded Network. Sun Regular Your health partner. Reversed Out HAP Senior Plus-Expanded Network is a Health Maintenance Organization with a Point-of- Service benefit (POS) that serves people with Medicare who live in Wayne, Oakland, Macomb, Genesee, Lapeer, Livingston, Monroe, St. Clair or Washtenaw county. You have coverage anywhere in the world for urgent and emergency care at the same copay you pay at home. When you travel outside the nine-county service area, the Point-of-Service benefit also provides some coverage for routine services from any Medicare-participating doctor or hospital. A personal approach to quality. When you join HAP Senior Plus-Expanded Network, you choose your Personal Care Physician (known as a PCP) from our extensive group of qualified physicians. Your PCP is your primary health partner, a physician who: Knows your medical history Guides you to specialists when you need them Coordinates all your care if you become sick or injured to make sure you get the care you need, at the right time and in the right setting Your choice of PCP determines whether you are in an Integrated Delivery System or an Open Delivery System. In the Integrated Delivery System, your PCP coordinates your care and makes arrangements for you, as necessary, to see other affiliated doctors and hospitals. Open Delivery System All other providers and hospitals in the HAP Senior Plus-Expanded Network operate as an Open Delivery System. In the Open Delivery System, your PCP also coordinates your care. However, you may seek needed care from any HAP Senior Pluscontracted specialist, and you may use any HAP Senior Plus-contracted hospital. Helping you protect your health. There are lots of ways to stay healthy, and plenty of reasons you want to, whether it s to spend time with family, travel, play a sport, enjoy a hobby or take a walk through your neighborhood. That s why HAP brings you the latest health-related information in our magazine, Prime Time Living. You also have access to health and wellness programs and benefits that can help you: Special programs and services such as CareTrack are available to help people with chronic disease stick with their prescribed treatment plan. Additional health plan options. If you live in Wayne, Oakland or Macomb county, you may prefer to enroll in HAP Senior Plus (hmo)-henry Ford, which gives you different options and pricing advantages. To discuss this plan or other plan choices, or to request a free information package, call your HAP Medicare Sales Representative at the phone number shown on the back cover. Integrated Delivery System You are in one of our Integrated Delivery Systems if your PCP is part of: Learn the fundamentals of good health Eat healthier Detroit Medical Center (DMC) Quit smoking Genesys Physician Hospital Organization (Genesys PHO) Prevent disease Henry Ford Medical Group (HFMG) 7

5 Which option is right for you? Monthly Plan Premium* Maximum Out-Of-Pocket cost** Hospital and Part B deductibles (must be paid before coverage begins) Original Medicare HAP Senior Plus-Expanded Network Option 1 Option 2 Option 3 Medicare Part B Premium $95 $105 $158 No limit $3,400 $1,132 per hospital stay, $162 annually for medical services No deductible This chart summarizes some of the key benefits for each HAP Senior Plus-Expanded Network plan option. On the pages that follow, you will find additional information about prescription drug benefits, optional dental plans, out-ofarea routine care and preventive services. Primary doctor s/specialist s office visits Hospital coverage 20% of Medicare-approved amount $1,132 deductible Days 61-90: $283 per day Days : $566 per day 150-day limit Doctor s services not included $20/$35 per visit $15/$30 per visit $15/$35 per visit $350 per admission $325 per admission Unlimited days Doctor s services included Please review the Summary of Benefits to learn more about each plan option before making a decision about your coverage. Skilled nursing facility Days 1-20: $0 per day Days : $ per day Minimum 3-day prior hospital stay Days 1-20: $0 per day Days : $ per day No prior hospital stay required * You must continue to pay your Medicare Part B premium. Your HAP monthly premium may be reduced if you qualify for extra financial assistance. ** Limit on the total of copays or coinsurance you might pay for Part A and Part B services during the calendar year. After you have reached the Maximum Out-Of-Pocket cost for covered services, you will have no more copays or coinsurance for the rest of the year. Your monthly plan premiums, costs for the out-of-area routine care benefit, prescription drug costs and non-medicare-covered services such as dental or eyewear do not count toward your Maximum Out-Of-Pocket cost. See page 17 for more information. *** Original Medicare coverage is available only within the United States, except under limited circumstances for medical emergencies. These are 2011 amounts amounts may be higher. Unused amounts cannot be carried over from month to month. Except for approved lab services. Home health care Standard x-rays and lab tests Preventive services Hospital outpatient/ambulatory surgery center Eyeglasses or contacts Out-of-area routine care Worldwide emergency/urgent care Ambulance Flexible Health Options Prescription coverage (Copays shown for 30-day supply) $0 $0 20% $0 Limitations on coverage 20% coinsurance Only after cataract surgery Varies by service 20% coinsurance Coverage only within U.S.*** $0/Office visit copay (See page 16 for details) $75 facility fee $25 copay for radiation/chemo/esrd One pair every 2 years and after cataract surgery Only after cataract surgery 20% for up to $1,000 benefit (costs may be higher than in-network) $65/$35 copay, worldwide coverage Copay is waived if you are admitted to the hospital 20% coinsurance $75 None None Benefit up to $25/month ($300/year) None $25 deductible $6/$10/$45/32%/32% See page 10 for details Up to $40/month ($480/year) $50 deductible $4/$10/$40/31%/31% Coverage in gap 9

6 Medicare Part D Protection for today and tomorrow. Option 2 and Option 3 (see pages 8 and 9) include medical and prescription drug benefits. These Options ensure you have coverage for today s needs as well as protection for unexpected expenses tomorrow. HAP Senior Plus-Expanded Network Prescription Drug Benefits Option 2 Option 3 Deductible $25 $50 Initial coverage: The combined drug costs paid by you and the plan up to a combined total of $2,930** Coverage Gap*** (Donut Hole) Catastrophic coverage: After you pay $4,700 in annual out-of-pocket costs** 30-day supply*: $ 6 Preferred Generic $10 Non-Preferred Generic $45 Preferred Brand 32% Non-Preferred Brand 32% Specialty Tier 86% Preferred Generic 86% Non-Preferred Generic 30-day supply*: $ 4 Preferred Generic $10 Non-Preferred Generic $40 Preferred Brand 31% Non-Preferred Brand 31% Specialty Tier 30-day supply*: $ 4 Preferred Generic $10 Non-Preferred Generic 50% Brand (plus applicable dispensing fee) $2.60 Generic or 5% (whichever is greater) $6.50 all other drugs or 5% (whichever is greater) Convenient pharmacies. HAP Senior Plus-Expanded Network plans that include prescription drug benefits cover both Brand-Name and Generic prescription drugs at any of more than 2,000 pharmacies in our network, including retail, mail-order, medical center, longterm-care facility and Indian Health, Tribal and Urban pharmacies. If you travel, you can get your prescription drugs at any network pharmacy with nationwide locations (like CVS or Kmart). 90-day supplies are available at many of our network pharmacies and through mail-order, and can help you save time and money on medications you take on a regular basis. If you would like more information about receiving prescriptions by mail, call us at the number on this page. Your licensed HAP Medicare Sales Representative can answer questions about your options, our formulary, our pharmacy network and mail-order prescriptions. Questions? Call us toll-free at (800) or TTY/TDD (800) For your convenience from October 15 through February 14, our office hours are 8 a.m. to 8 p.m., seven days a week. During the rest of the year, our regular office hours are Monday through Friday, 8 a.m. to 8 p.m. and Saturday, 8 a.m. to noon. Outside of those business hours, you may access our Interactive Voice Recording system at the same number where you can leave your name and phone number. A HAP Medicare Customer Service Representative will return your phone call the next business day. Or you can write to us at: HAP Client Services Attn: Medicare 2850 W. Grand Boulevard Detroit, Michigan All drug prices are based on the HAP-negotiated price. You pay the lower of your copay or the actual cost of a covered drug. * A 90-day supply is available on most prescriptions filled through mail-order or select pharmacies at 2½ times the applicable 30-day copay. ** Excludes monthly premiums and costs of non-covered drugs, including costs of drugs purchased outside the U.S. *** See page 16 for more details about the Coverage Gap. 11

7 Healthy teeth can mean a healthier you. What will your total premium payments be? A. Which HAP Senior Plus-Expanded Network option fits your needs? Good dental health is important to your overall well-being. To make it easier to manage the costs of dental care and protect against unexpected expenses, dental coverage through Delta Dental is available to you as an optional benefit. With a Delta Dental plan, you can go to any dentist. Generally, your costs will be lower if you choose a dentist within the Delta Dental PPO network. The chart below summarizes the plan benefits you can receive when you pay the additional dental premium. HAP Senior Plus-Expanded Network Premium Option 1 $95 Option 2 $105 Option 3 $158 B. Do you need optional dental coverage? Which plan is right for you? Dental Plan 1 Member Pays Dental Plan 2 Member Pays Monthly premium $23.40/month* $44.90/month* Deductible none none Diagnostic and preventive services 50% 0% Emergency pain treatment 50% 0% X-rays 50% 30% Oral surgery services 50% 30% Fillings and other restorative services 50% 30% Crowns and other major restorative services 50% 50% Dental Plan 1 Plan Pays Dental Plan 2 Plan Pays Yearly maximum for all covered services $800 $1,500 Delta Dental Premium Dental Plan 1 $23.40 Dental Plan 2 $44.90 Add up your monthly premium payment for the plans you want: A. Health plan option $ B. Optional dental plan $ Your total monthly premium $ When you become a member of HAP Senior Plus-Expanded Network, you will receive one billing statement from HAP each month. If you choose to add the optional dental coverage, the dental premium will be included on your monthly billing statement. * The dental plan premium is paid in addition to your HAP Senior Plus-Expanded Network plan premium. The dental plan premium and services do not count toward your annual Maximum Out-Of-Pocket cost. Delta Dental is a registered trademark of the Delta Dental Plans Association. 13

8 What people ask us about HAP Senior Plus- Expanded Network. Am I covered when I travel? Yes. You are covered for: Emergencies and urgent care anywhere in the world Renal dialysis out-of-area but within the U.S. Routine care outside the nine-county service area with a 20% coinsurance for up to $1,000 of care (costs may be higher than in-network) Prescriptions at any pharmacy within our nationwide network if you have a plan with prescription drug coverage If you obtain other out-of-network services beyond those listed above, neither HAP nor Medicare will be responsible for the cost. Can I choose my own doctor? Yes, the choice is yours. You select your Personal Care Physician (PCP) from our network of providers. Depending on the PCP you choose, you will be in either an Integrated or an Open Delivery System. These two delivery systems operate differently, and it s important to understand the difference between them. See pages 6 and 7 for more information. In some cases, coverage for specialist services may require a referral from your PCP or authorization from HAP. If your doctor is not already a HAP Senior Plus-Expanded Network care provider, let us know, and we can talk with your doctor about joining our network. Am I eligible? You can join HAP Senior Plus-Expanded Network if you are enrolled in Medicare Part A and Part B and reside in Wayne, Oakland, Macomb, Genesee, Lapeer, Livingston, Monroe, St. Clair or Washtenaw county. You must continue to pay your Part B premium after you enroll. If you decide to have your monthly premiums paid as a withholding from your Social Security check, or move from that method to direct billing from HAP Senior Plus, it can take up to three months for the request to take effect. You will remain responsible for those premiums. Do I lose my Medicare benefits when I enroll in HAP Senior Plus? No. As a member of HAP Senior Plus-Expanded Network, you are still in the Medicare program. You still have all the benefits to which you are entitled under Medicare, including the preventive services Medicare covers at no cost to you, and they are all provided through your HAP Senior Plus-Expanded Network plan. You also receive additional benefits, such as Flexible Health Options and special health and wellness programs. You can use your HAP Senior Plus card for all your covered health care services. 15

9 What people ask us continued. How does the Health Reform law improve my benefits in the Coverage Gap (Donut Hole)? The Health Reform law created drug savings programs for Medicare beneficiaries who reach the Coverage Gap (Donut Hole). To participate in the savings programs, you must choose a HAP Senior Plus-Expanded Network plan with Part D prescription drug coverage, either Option 2 or Option 3. Option 1 does not include Part D coverage. In 2012, for Generic drugs purchased in the Coverage Gap: With Option 2 you pay 86% of our negotiated price With Option 3 you pay whichever is lower: the fixed copay or 86% of our negotiated price For all Brand-Name drugs purchased in the Coverage Gap: With either option you pay 50% (half) of our negotiated price, plus the applicable pharmacy dispensing fee. Even though you pay only part of the costs, the full cost of Brand-Name drugs counts toward your annual total out-of-pocket cost for prescription drugs. This means you may exit the Coverage Gap and enter the Catastrophic Coverage period with its enhanced benefits more quickly Members who get Extra Help from the Social Security Administration for their prescription drugs do not have a Coverage Gap. Does the Health Reform law provide any other benefits? Under the Health Reform law, Original Medicare covers some preventive services at no cost to you. We also cover those services at no cost to you when you get them from network providers. Please refer to the Summary of Benefits for the list of preventive services available at no cost to you. For covered services not included in Medicare s subset of preventive services, you pay the office visit copay when you receive them from network providers. All covered services you receive through your out-of-area routine care benefit, including preventive services, are available at 20% of approved charges up to your maximum benefit of $1,000. Is a mail-order service available with HAP Senior Plus-Expanded Network? Yes. Mail-order is available for 90-day supplies and can help you save time and money on medications you take on a regular basis. If you prefer, you can obtain a 90-day supply with the same savings at select retail pharmacies. What advantage does the Maximum Out-Of-Pocket cost provide? HAP Senior Plus-Expanded Network members who need extensive health services have the added protection of paying no more than $3,400 total out-of-pocket costs in a calendar year for covered services (excludes your monthly plan premiums, costs for the out-of-area routine care benefit, prescription drug costs, and non-medicare covered services like dental services or eyewear). After you have paid the Maximum Out-Of-Pocket cost for Part A and Part B covered services, you will have no more copays or coinsurance for the rest of the calendar year for those covered services. Is Extra Help available for prescription drug coverage? People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay up to seventy-five (75) percent or more of your drug costs, including monthly prescription drug premiums, annual deductibles and coinsurance. Additionally, those who qualify will not be subject to the Coverage Gap or a late enrollment penalty. Many people are eligible for these savings and don t even know it. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: MEDICARE ( ). TTY users should call , 24 hours a day, 7 days a week; The Social Security Administration at (800) between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call (800) ; or Your state Medicaid office 17

10 Call today. To enroll in our Medicare plan, you can use one of the following five options: 1. Call a licensed HAP Medicare Sales Representative toll-free at: (800) or TTY/TDD (800) Monday through Friday, 8 a.m. to 5 p.m. 2. Mail a completed enrollment form to: HAP Medicare Division 2850 W. Grand Boulevard Detroit, Michigan Enroll online at the HAP website at 4. Enroll online through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at 5. Come to a HAP Medicare workshop where you can talk with other Medicare beneficiaries. A licensed HAP Medicare Sales Person will be present with information and applications. Call us toll-free for dates and locations near you, or for accommodation of persons with special needs at sales meetings: (800) or TTY/TDD (800) , Monday through Friday, 8 a.m. to 6 p.m. Important plan information. HAP Senior Plus (hmo-pos) and HAP Senior Plus (hmo) are health plans with a Medicare contract. Our Medicare contracts are renewed annually. The availability of coverage beyond the contract year is not guaranteed. You may be eligible to enroll if you are entitled to Medicare benefits under Part A and enrolled in Part B and reside within the service area of the plan. Medicare beneficiaries may enroll in a Medicare Advantage plan only during specific times of the year. For more information about enrollment rules, contact a HAP Medicare Sales Representative. Generally, HAP Senior Plus-Expanded Network prescription drug benefits are only available at HAP-contracted pharmacies, except in emergency or urgent care situations. Quantity limitations and restrictions may apply. With plan Options 2 and 3, you are covered throughout the U.S. at any of the pharmacies in our nationwide network of pharmacies. Medicare Advantage plan members must receive prescription drug coverage through their plan. If you enroll in a stand-alone Prescription Drug Plan, you will automatically lose your HAP Senior Plus-Expanded Network benefits. You can call Medicare at MEDICARE ( ), TTY You can call this number 24 hours a day, 7 days a week. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information, contact HAP. For more information, call us. Or visit us on the web at 19

11 Value. Choice. Experience. Count on it. Prospective members: If you have questions, or for full information about our benefits, enrollment periods or plan network, call a licensed HAP Medicare Sales Representative toll-free at: (800) or TTY/TDD (800) Current members: If you have any questions, please contact Client Services toll-free at: (800) or TTY/TDD (800) For your convenience, our office hours are: October 15 through February 14 8 a.m. to 8 p.m., seven days a week February 15 through October 14 8 a.m. to 8 p.m., Monday through Friday 8 a.m. to noon, Saturday Outside of those business hours, you may access our Interactive Voice Recording system at the same number and leave your name and phone number. A HAP Medicare Customer Service Representative will return your phone call the next business day. If you prefer, you can mail your questions to: HAP Client Services, Attn: Medicare 2850 W. Grand Boulevard Detroit, Michigan Improving health. Enhancing lives Health Alliance Plan of Michigan. A Nonprofit Company _29p