Operations Bulletin Date: December 26, 2012 To: Participating Providers Subject: Geisinger Gold 2013 Meridian Health and Geisinger Health Plan are pleased to introduce the 2013 Geisinger Gold Medicare Advantage Plan products. Meridian Health has partnered with Geisinger Health Plan to bring Geisinger Gold, A Medicare Advantage Plan ranked 6 th best in the Nation,* to Medicare Beneficiaries in Monmouth and Ocean Counties in New Jersey. Plans offered in New Jersey for 2013: Classic 100 (HMO POS) Preferred 100 (PPO) Classic 300 (HMO) Preferred 200 (PPO) Secure 200 (HMO SNP) Reserve 100 (MSA) Classic Custom (HMO) Preferred Custom (PPO) The Member cost-sharing grids in this Bulletin include more details on our 2013 plans. Additional information about Geisinger Gold, including tools to verify benefits and Member eligibility can be found in the Provider Service Center at www.thehealthplan.com. If you have any questions about Geisinger Gold, or would like additional reference materials for your office or patients, please contact the Gold Customer Service Team at (800) 498-9731, or your Provider Relations Representative at (800)876-5357. *NCQA s Medicare Health Insurance Plan Rankings 2012-2013. For more information about the rankings, please visit: http://www.ncqa.org/reportcards/healthplans/healthinsuranceplanrankings /HealthInsurancePlanRankings201213/2012MedicaidandMedicareHealthPlan Rankings.aspx 2013 Plan Highlights Meridian Health has partnered with Geisinger Health Plan to bring Geisinger Gold, A Medicare Advantage Plan ranked 6 th best in the Nation,* to Medicare beneficiaries in Monmouth and Ocean counties. With Geisinger Gold, Members get comprehensive coverage, superb wellness and preventive care programs, extensive disease management programs, and affordable rates. Our PPO, HMO POS, and MSA plans offer the flexibility of both in and out-of-network coverage. *NCQA s Medicare Health Insurance Plan Rankings 2012-2013. Sample Geisinger Gold Member Identification Cards The front of Gold Member Identification Cards will display the Member s PCP, SCP, and ER copays, pharmacy benefit information, as well as a No Referrals Required notice if applicable.
Geisinger Gold 2013 Plans Classic 100 Plus (HMO POS) - A Geisinger Gold HMO Plan with a Point-of-Service Feature An HMO plan with a Point-of-Service (POS) feature that allows the flexibility of obtaining covered services in-network, or for an additional cost, out-of-network. In addition to Medicare-covered services, Classic 100 Plus also includes coverage toward eyeglasses, hearing aid and preventive dental benefits, SilverSneakers fitness membership, worldwide emergency room coverage, and nationally accredited Health and Wellness programs. Like our other HMO plans, Classic 100 Plus Members choose a PCP who will provide most routine care and who will help arrange or coordinate specialty care. Members may choose to see any provider who is eligible to participate in Medicare, however, the Member s share of the cost will usually be more for covered services obtained out-of-network than for services obtained in-network. The plan has an annual in-network out-of-pocket maximum of $6,700 (only services obtained in-network apply to the innetwork out-of-pocket maximum limit), and a separate out-of-network annual out-of-pocket maximum of $10,000 (only services obtained out-of-network apply to the out-of-network out-of-pocket maximum limit). Classic 300 (HMO) - Must use a Participating Provider No Premiums. No Deductible. A $0 Deductible Part D Rx plan is included. Classic 300 covers routine office visits, immunizations, diagnostic tests and x-rays. In addition to Medicare-covered services, the plan also provides coverage towards routine eyeglasses, hearing aid and preventive dental benefits, SilverSneakers fitness center coverage, $0 Annual Wellness Visits, Medicare preventive services at $0 copay, worldwide emergency room coverage, and nationally accredited Health and Wellness programs. This plan also features an out-of-pocket maximum of $6,700. Classic Custom (HMO) - An HMO Plan with Customized Benefits for Employer Groups Geisinger Gold Classic Custom (HMO) is an Employer or Union Group HMO Medicare Advantage Plan with customized benefits. Based on Geisinger Gold s Classic 100 or Classic 300 plans, the employer group may design a group plan with customized cost sharing and/or supplemental benefits. Reserve 100 (MSA) - A Medicare Medical Savings Account Plan A Medicare Advantage Plan that combines a high-deductible health plan with a personal medical savings account. The plan deposits $1,500 from Medicare into the Member s MSA Plan savings account at the beginning of each year. The Reserve 100 (MSA) Plan has an annual deductible of $3,000, but no monthly premium. Members can go to any doctor or hospital that accepts Medicare. No referrals are necessary. Providers should bill Geisinger Gold. Once the annual deductible is met, the plan pays for Medicarecovered medical expenses in full. (Please note: Medicare does not allow MSA plans to provide first-dollar coverage for any benefit. All covered benefits are subject to the $3,000 annual deductible.) Members may use funds from their MSA account to pay for any IRS qualified medical expense, but only expenses incurred for Medicare-covered services count toward the annual deductible. Any money remaining in the MSA bank account at the end of the year will roll over for use toward qualified medical expenses next year. This plan does not include prescription drug coverage. Members may join a separate Medicare Part D Prescription Drug plan from the carrier of their choosing, for additional cost. - Premiums do not apply towards the annual out-of-pocket maximum. - All plans require Members to continue to pay their monthly Medicare Part B premium, and live in the service area. - Medicare beneficiaries with ESRD are generally not eligible to join Medicare Advantage Plans unless they were a plan Member prior to developing ESRD. More information is available at www.medicare.gov. - Refer to Provider Service Center at www.thehealthplan.com to verify benefits and cost-sharing.
Preferred 100 (PPO) No Primary Care Provider selection or referrals for specialists (in or out-of-network) are required with this plan. No Deductible. Preferred 100 has an in-network $150 inpatient copay per day for days 1-6 each hospital stay; fixed $10/$20 copays for in-network PCP/Specialist visits; out-of-network PCP/Specialist visits $15/$25. Includes coverage towards eyeglasses, hearing aid, SilverSneakers fitness center coverage, $0 Medicare preventive services, $0 annual wellness visits, worldwide emergency room coverage, $0 copay for covered in-network preventive dental benefits and nationally accredited Health and Wellness programs. Annual in-network out of pocket maximum is $4,000. Combined in and out-of-network out of pocket maximum is $10,000. Preferred 200 (PPO) No Primary Care Provider selection or referrals for specialists (in or out-of-network) are required with this plan. No Deductible. Similar to Preferred 100, with lower premium and higher cost sharing for Member. Annual in-network out of pocket maximum is $5,000. Combined in and out-of-network out of pocket maximum is $10,000. Preferred Custom (PPO) - A PPO Plan with Customized Benefits for Employer Groups Geisinger Gold Preferred Custom (PPO) is an Employer or Union Group PPO Medicare Advantage Plan with customized benefits. Based on Geisinger Gold s Preferred 100 or Preferred 300 plans, the employer group may design a group plan with customized cost sharing and/or supplemental benefits. Secure 200 (HMO SNP) - Special Needs Plan for people with Diabetes Designed for Medicare beneficiaries with Type I or Type II Diabetes. Secure 200 offers low PCP office copays to encourage Members with diabetes to regularly see their PCP. Secure 200 also includes coverage for diabetic supplies at $0 copay as well as enhanced $0 deductible Part D prescription drug coverage, SilverSneakers fitness center coverage, worldwide emergency services, $0 Medicare preventive services and annual wellness visits, and coverage towards eyeglasses, hearing aid and preventive dental benefits. Eligible beneficiaries can join Secure 200 any time of the year. Members must see a participating provider. - Premiums do not apply towards the annual out-of-pocket maximum. - All plans require Members to continue to pay their monthly Medicare Part B premium, and live in the service area. - Medicare beneficiaries with ESRD are generally not eligible to join Medicare Advantage Plans unless they were a plan Member prior to developing ESRD. More information is available at www.medicare.gov. - Refer to Provider Service Center at www.thehealthplan.com to verify benefits and cost-sharing.
GEISINGER GOLD MEDICARE PART D PRESCRIPTION DRUG COVERAGE Classic 100, Preferred 100, and Preferred 200 Plans are available with or without the Medicare Part D $0 Deductible Rx prescription drug coverage described below. Classic 300 and Secure 200 plans include the Medicare Part D $0 Deductible Rx Coverage described below. Reserve (MSA) does not include Medicare Part D prescription drug coverage; Reserve Members may join a separate Medicare Part D Prescription Drug plan from the carrier of their choosing for additional cost. The Geisinger Gold $0 Deductible Rx Medicare Enhanced Part D Coverage benefit has no deductible, and five coverage tiers: Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Preferred Generic Drugs - $3 Copay for up to a 34-day supply Non-preferred Generic Drugs - $7 Copay for up to a 34-day supply Preferred Brand Drugs - $39 Copay for up to a 34-day supply Non-Preferred Brand Drugs - $69 Copay for up to a 34-day supply Specialty Drugs - 33% Coinsurance Tier 1 generic drugs ($3 Copay) are covered through the coverage gap. Tier 2 - Tier 5 cost sharing listed above applies up to the coverage gap. In 2013, Members will receive 52.5% brand drug coverage and 21% coverage on Tier 2 Generics while in the coverage gap. A 90-day supply of some of the prescription drugs on our formulary is also available via mail order for the convenience of Members. Additional information about the Geisinger Gold Medicare Part D $0 Deductible Rx prescription drug plan and formulary is available at www.thehealthplan.com. - Premiums do not apply towards the annual out-of-pocket maximum. - All plans require Members to continue to pay their monthly Medicare Part B premium, and live in the service area. - Medicare beneficiaries with ESRD are generally not eligible to join Medicare Advantage Plans unless they were a plan Member prior to developing ESRD. More information is available at www.medicare.gov. - Refer to Provider Service Center at www.thehealthplan.com to verify benefits and cost-sharing.
Refer to Provider Service Center at www.thehealthplan.com to verify benefits and cost-sharing. Classic 100 Plus (HMO POS) - 2013 Point-of-Service HMO Plan with the flexibility to see providers in or out-of-network Classic 100 In-network Classic 100 Out-of-network General Provisions Deductible $0 $0 Out of Pocket Maximum (a) $6,700 $10,000 Hospital Inpatient Acute Care $75 per day, days 1-10 25% Mental Health $75 per day, days 1-10 25% SNF $50 per day, days 11-20 25% Home Health Care $0 25% Outpatient Emergency Room (worldwide) $65 (d) $65 (d) Ambulatory Surgical Center $125 25% Outpatient Hospital Surgery $125 25% Radiology - General (X-rays) $20 25% Radiology - MRI/CAT/PET 20% 25% Therapeutic Radiology 20% 25% Laboratory Tests $5 25% Physical, Occupational, Speech Therapy $25 per day 25% Physician PCP Visits $10 $15 Annual Routine Physical Exam $10 $15 Specialist Visits $25 $30 Urgent Care $25 (d) $25 (d) Chiropractor $20 25% Podiatrist $25 $30 Psych Services (Ind/Grp) $25/$10 25% Substance Abuse (Ind/Grp) $25/$10 25% Other Medicare Part B Covered Drugs 20% 25% Ambulance (Waived if admitted) $100 25% DME/Supplies/Diabetic Monitoring (b) 20% 25% Prosthetics 20% 25% Medicare Part B Covered Immunizations $0 $30 Vision Exams (medical/routine) $25/$25 1/yr $30/$30 1/yr Routine Vision Hardware (c) $200 allowance every 2 years $200 allowance every 2 years Hearing Exams (diagnostic/routine) $25 $30 Hearing Aids (c) $1,000 allowance every 3 years $1,000 allowance every 3 years Annual Wellness Visit (1/year) $0 $30 Medicare Preventive Services $0 $30 Routine Foot Care (4 times/year) $0 $30 Fitness Center $0 25% Preventive Dental (c) $0 Exam, Cleaning every 6mos.; 20% $0 Dental X-rays once a year Part D No Rx coverage or $0 deductible Rx coverage Notes: (a) Coinsurance and copays apply toward out-of-pocket maximum. (b) $0 copay for preferred brand glucometer every 2 years. Prior authorization required for non-preferred supplies and/or higher quantities (c) Does not apply to the plan level OOP Max (d) Copay waived if admitted to hospital within 3 days of visit PCP selection is required. In-network PCP is encouraged but not required; PCP may be out-of-network provider. PCP referrals for specialty care are encouraged, but not required for payment of claim.
Refer to Provider Service Center at www.thehealthplan.com to verify benefits and cost-sharing. Classic 300 (HMO) - 2013 PCP selection, referrals for specialty care, and use of network providers required Classic 300 General Provisions Deductible $0 OOP Maximum (a) $6,700 Hospital Inpatient Acute Care $285 per day, days 1-5 Mental Health $285 per day, days 1-5 SNF $50 per day, days 1-20, $100 per day, days 21-55, $0 days 56-100 Home Health Care $0 Outpatient Emergency Room (worldwide) $65 (d) Ambulatory Surgical Center $250 Outpatient Hospital Surgery $250 Radiology - General (X-rays) $25 Radiology - MRI/CAT/PET 20% Therapeutic Radiology 20% Laboratory Tests $15 Physical, Occupational, Speech Therapy $20 per day Physician PCP Visits $0 Annual Routine Physical Exam $0 Specialist Visits $10 Urgent Care $35 (d) Chiropractor $20 Podiatrist $10 Psych Services (Ind/Grp) 35% Substance Abuse (Ind/Grp) 35% Other Medicare Part B Covered Drugs 20% Ambulance (Waived if admitted) $200 DME/Supplies/Diabetic Monitoring (b) 20% Prosthetics 20% Medicare Part B Covered Immunizations $0 (Flu, Pneumonia, Hep B) Vision Exams (medical/routine) $20/$20 1/yr Routine Vision Hardware (c) $200 allowance every 2 years Hearing Exams (diagnostic/routine) 20/$20 1/yr Hearing Aids (c) $ 1,000 allowance every 3 years Annual Wellness Visit (1/year) $0 Medicare Preventive Services $0 Routine Foot Care (4 times/year) $0 Fitness Center $0 Preventive Dental (c) $0 Cleanings and Exams every 6 months; $0 X-rays once per year Part D $0 deductible Rx coverage Notes: (a) Coinsurance and copays apply toward out-of-pocket maximum. (b) $0 copay for preferred brand glucometer every 2 years. Prior authorization required for non-preferred supplies and/or higher quantities (c) Does not apply to the plan level OOP Max (d) Copay waived if admitted to hospital within 3 days of visit
Refer to Provider Service Center at www.thehealthplan.com to verify benefits and cost-sharing. Preferred 100 & 200 (PPO) - 2013 PCP selection, referrals for specialty care, and use of network providers not required Preferred 100 Preferred 200 In-Network Out-of-Network In-Network Out-of- Network General Provisions Deductible $0 $0 $0 $0 OOP Maximum (a) $4,000 $10,000 $5,000 $10,000 Hospital Inpatient Acute Care $150/day, days 1-6 20% $200/day, days 1-8 25% Mental Health $150/day, days 1-6 20% $200/day, days 1-8 25% SNF $35/day, days 8-21, 20% $50/day, days 1-20 25% $100/day, days 22-100 $100/day, days 21-100 Home Health Care $0 20% $0 25% Outpatient Emergency Room (worldwide) $65 $65 Ambulatory Surgical Center $125 20% $200 25% Outpatient Hospital Surgery $125 20% $200 25% Radiology - General (X-rays) $15 20% $25 25% Radiology - MRI/CAT/PET $125 20% 20% 25% Therapeutic Radiology 20% 20% 20% 25% Laboratory Tests $5 20% $10 25% Physical, Occupational, Speech Therapy $25 20% $25 25% Physician PCP Visits $10 $15 $10 $15 Annual Routine Physical Exam $10 $15 $10 $15 Specialist Visits $20 $25 $25 $30 Urgent Care $25 $40 Chiropractor $20 20% $20 25% Podiatrist $20 $25 $25 $30 Psych Services (Ind/Grp) $25/$10 20% $25/$10 25% Substance Abuse (Ind/Grp) $25/$10 20% $25/$10 25% Other Medicare Part B Covered Drugs 20% 20% 20% 25% Ambulance (Waived if admitted) $150 20% $200 25% DME/Supplies/Diabetic Monitoring (d) 20% 20% 20% 25% Prosthetics 20% 20% 20% 25% Medicare Part B Covered $0 $25 $0 $30 Immunizations Vision Exams (medical/routine) $20/ $20 1/yr $25/ $25 1/yr $25/ $25 1/yr $30/$30 1/yr Routine Vision Hardware (e) $200 allowance every 2 years $200 allowance every 2 years Hearing Exams (diagnostic/routine) $20/ $20 1/yr $25/ $25 1/yr $25/ $25 1/yr $30/$30 1/yr Hearing Aids (e) $1,000 allowance every 3 years $1,000 allowance every 3 years Annual Wellness Visit (1/year) $0 $25 $0 $30 Medicare Preventive Services $0 $25 $0 $30 Routine Foot Care (4 times/year) $0 $25 $0 $30 Fitness Center $0 20% $0 25% Preventive Dental (e) $0 Clean Exam/6 mo. $0 X-rays 1/yr 20% $0 Clean Exam/6 mo. $0 X-rays 1/yr Part D No Rx coverage or $0 deductible Rx coverage No Rx coverage or $0 deductible Rx coverage (a) Deductible, coinsurance, copays apply to out-of-pocket max (c) Does not apply to the plan level OOP Max (b) Combined in- and out-of-network (d) Copay waived if admitted to hospital within 3 days *Annual Plan Deductible must be met before coverage begins. (e) Prior Auth for non-preferred brand or higher quantity 20%
Refer to Provider Service Center at www.thehealthplan.com to verify benefits and cost-sharing. Secure 200 (HMO SNP) - 2013 PCP selection, referrals for specialty care, and network providers required Secure 200 Chronic SNP for Beneficiaries with Type 1 or Type 2 Diabetes General Provisions Deductible $0 OOP Maximum (b) $3,400 Hospital Inpatient Acute Care $100 per day, days 1-5 Mental Health $100 per day, days 1-5 SNF $60 per day, days 7-34 Home Health Care $0 Outpatient Emergency Room (worldwide) $65 Ambulatory Surgical Center $100 Outpatient Hospital Surgery $100 Radiology - General (X-rays) $15 Radiology - MRI/CAT/PET $75 per day Therapeutic Radiology $45 per day Laboratory Tests $5 Physical, Occupational, Speech Therapy $10 Physician PCP Visits $5 Annual Routine Physical Exam $5 Specialist Visits $30 Urgent Care $30 Chiropractor $20 Podiatrist $30 Psych Services (Ind/Grp) $25/$10 Substance Abuse (Ind/Grp) $25/$10 Other Medicare Part B Covered Drugs 10% Ambulance (Waived if admitted) $100 DME 20% Prosthetics 20% Diabetic Monitoring/Supplies (d) $0 Preferred Meter, Strips, Lancets, 20% for Non-preferred brand Medicare Part B Covered Immunizations $0 Vision Exams (medical/routine) $20/ $20 1/yr Routine Vision Hardware $200 allowance each year Hearing Exams (diagnostic/routine) $20/ $20 1/yr Hearing Aids $800 allowance every three years Annual Wellness Visit (1/year) $0 Medicare Preventive Services $0 Routine Foot Care (4 times/year) $0 Fitness Center $0 OTC Drugs Not Covered Preventive Dental (e) $20 Cleanings and Exams every 6 months; $20 -$30 X-rays once per year Part D $0 deductible Rx coverage (a) Coinsurance and copays apply to out-of-pocket maximum (b) Prior authorization required for non-preferred brand supplies and/or higher quantities (c) Does not apply to the plan level OOP Max (d) Copay waived if admitted to hospital within 3 days
Refer to Provider Service Center at www.thehealthplan.com to verify benefits and cost-sharing. Reserve 100 MSA - 2013 PCP selection, referrals for specialty care, and use of network providers not required General Provisions Annual Plan Deductible $3,000 Fund Contribution $1,500 OOP Maximum (a) $3,000 Hospital Inpatient Acute Care Mental Health SNF Home Health Care Outpatient Emergency Room (worldwide) Ambulatory Surgical Center Outpatient Hospital Surgery Radiology - General (X-rays) Radiology - MRI/CAT/PET Therapeutic Radiology Laboratory Tests Physical, Occupational, or Speech Therapy Physician PCP Visits Specialist Visits Urgent Care Chiropractor Podiatrist Psych Services (Ind/Grp) Substance Abuse (Ind/Grp) Other Medicare Part B Covered Drugs Ambulance (Waived if admitted) DME/Supplies/Diabetic Monitoring (b) Prosthetics Medicare Part B Covered Immunizations Vision Exams (medical/routine) for Medicare-covered eye exams. Routine eye exams are not covered. Post-Cataract Surgery Eyeglasses or Contacts for Medicare-covered eyewear. Routine Eyewear Not Covered Hearing Exams (diagnostic) for Medicare-covered hearing exams. Routine hearing exams are not covered Hearing Aids Not Covered Annual Wellness Visit (1/year) Medicare Preventive Services Routine Foot Care (4 times/year) Not Covered Fitness Center Not Covered Preventive Dental (e) Not Covered Part D Rx N/A Notes: (a) Deductible, coinsurance and copays apply toward out-of-pocket maximum. (b) Original Medicare limits apply Medicare participation is required to treat and accept reimbursement for Reserve MSA Members. Reimbursement will equal Medicare current rates for Medicare Part A and Medicare Part B covered services. Medicare does not allow plan coverage of any benefit until deductible has been met, including preventive services. Members are liable for the cost of services not covered by Medicare; payment for these services will not count towards the Member s deductible. Members may not be balanced billed; any balance after Geisinger GOLD payment is not the liability of the Member.
Things you should know for 2013 Medicare rules have changed for Medicare Advantage coverage of Preventive Services for 2013. Medicare Advantage Plans are no longer allowed to cover extra sessions or more frequent sessions for Medicare-covered Preventive Screening Services than Original Medicare covers. Exceptions were made for a few services; Plans were allowed to continue to cover Cervical and Vaginal Cancer Screening (Pap & Pelvic Exams) once a year for all female beneficiaries during 2013. Coverage of other Medicare preventive screenings such as Cardiovascular Disease Screening (Screening Cholesterol Test) and Screening Colonoscopy are limited to the same frequency of testing as Original Medicare. Due to demand, Medicare has decided to once again to allow Medicare Advantage Plans to cover an annual routine physical examination as an extra non-medicare benefit for 2013: The Annual Routine Physical Examination benefit is a comprehensive hands-on physical examination of the entire body, performed by the Member s Primary Care Provider once each calendar year. The Annual Routine Physical exam is meant to compliment the Medicare Annual Wellness Visit, and should not be used as a substitute for an Annual Wellness Visit. The Annual Routine Physical Examination may be performed during the same visit as an Annual Wellness Visit or they may be done separately on different dates of service. Annual Wellness Visits have no cost to the Member; Annual Routine Physical Examinations have a PCP copayment. Medicare has changed deductible rules for Local PPO plans like Geisinger Gold Preferred to match Medicare s regional PPO plan requirements. Local PPO plans that charge a plan deductible must now charge deductible on all Part A and Part B services that are obtained out-of-network. Medicarecovered preventive screening services and non-medicare benefits covered by the plan are exempt from this rule. PPO plans that charge a plan deductible are required to have one single combined plan deductible starting in 2013. Covered services subject to plan deductible obtained either in-network or out-of-network will count toward meeting the plan s annual deductible. Coverage of eyeglasses or contact lenses after cataract surgery is a Medicare-covered benefit and is subject to Medicare benefit rules: Only basic frames and lenses are covered. If Members purchase any additional add-on features such as deluxe frames or no-line bifocal lenses, they must pay for these extra features themselves; only the cost of the basic frames and lenses are covered. Eyewear suppliers should submit a detailed itemized bill to allow calculation of the cost of the covered eyewear separate from any non-covered extra features. Please note: Geisinger Gold also offers a non-medicare routine eyewear benefit (eyeglasses or contact lenses) for many of our plans. This supplemental benefit provides a $200 allowance toward routine eyewear every two years. This is a separate benefit from the Medicare-covered post-cataract surgery eyewear benefit. There are no restrictions on lens or frame type for non- Medicare-covered routine eyewear; however routine eyewear payment is limited to the $200 allowance every two years.