2019 medicare product upmc for life hmo plans training...−details the 2019 benefit changes to the...

UPMC for Life HMO Plans2019 Medicare Product Training

2019 Medicare Product Training Agenda

Copyright 2012 UPMC Health Plan. All Rights Reserved2

• 2019 UPMC for Life Plans− Service Area Expansion/ Reduction− Details the 2019 benefit changes to the UPMC for Life HMO and

PPO plans.− Details the new plans being offered

• Medicare Advantage and Prescription Drug Coverage Overview − Provides an overview of 2019 Medicare Advantage program

changes and overview of the 2019 UPMC for Life changes that impact all of our Medicare plans.

• 2019 Member Document Changes

2019 Service Area Expansion

2019 UPMC for Life – HMO/PPO Service Area Expansion


UPMC for Life service area for 2019:

PA: Adams, Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Northampton, Perry, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, and York.

OH: Harrison and Jefferson

Service Area Expansion: Bradford, Juniata, Lackawanna, Luzerne, Mifflin, Northampton, Susquehanna, Wayne and Wyoming.

2019 UPMC for Life – HMO/PPO Service Area Expansion

UPMC for Life service area for 2019:


2019 Service Area Crosswalk

2019 Service Area CrosswalkWhat is a crosswalk?

Put simply, when a plan is terminating, members can be automatically moved to another equivalent, identical or similar planPut another way, when you crosswalk a plan you are moving a member from their existing plan into another similar plan.

2019 Service Area Crosswalk

• Why is a plan being crosswalked?– There can be many reasons why a plan is being crosswalked. It

could be due to low enrollment or not meeting access requirements.

2019 Crosswalked plans• 2 Medicare plans will be terming the end of this year (2018): HMO Deductible with

Rx in Lehigh Cap area (H3907 PBP 039) and the HMO Rx in Lehigh Cap area (H3907 PBP 040).

• The Lehigh Cap plans include: Adams, Cumberland, Dauphin, Fulton, Lancaster, Lebanon, Lehigh, Perry, and York counties

• The members in these plans will be crosswalked into an existing plan.

• The members ANOC will explain the consolidation. The reason for consolidation is the membership is too low in the Lehigh Cap plans.


HMO Deductible with RX Lehigh Cap

(H3907 039)

HMO Deductible with Rx WPA (H3907 037)

HMO with RX Lehigh Cap (H3907

040)

HMO with Rx WPA (H3907 029)

Non-Renewal and Service Area Reduction

• The UPMC for Life Options (ISNP) will be terminated as of 1/1/19.

• Sales is attempting to outreach to current members to move to the DSNP if they meet the full dual status or another UPMC Medicare plan if they don’t meet the criteria.


2019 General Plan Updates

General Plan Updates for Medicare Plans

• New fitness vendor- SilverSneakers

– Also added 1 Personal Training Session per calendar year

• Increased ER copayments to either a $90 copayment or $120 copayment, depending on the Maximum out of pocket.

• Added new supplemental benefits: Bathroom Safety Items, In-Home Safety Assessment, and Counseling Services.

• New Flexible Benefit- The meal benefit will be provided one time annually upon discharge from an inpatient stay, observation stay or a SNF stay for members that have all three diagnoses of COPD, CHF and Diabetes. The member will receive 2 meals a day for 28 days (56 meals total).



Removed Prior Authorization:

• Outpatient Mental Health/ Outpatient

• Partial Hospitalization

Added Prior Authorization:

• Pain management and sleep specialists

• Outpatient Rehab services (PT, OT, ST)

• Prosthetic Devices

• Chiropractic Services (Medicare-covered)

* Authorization for these services is the responsibility of the provider



Drug Management Program• Drug management programs will be integrated with CMS’s existing

Overutilization Monitoring System (OMS). The clinical guidelines used to determine if a beneficiary is potentially at-risk, which are based on using opioids from multiple prescribers and/or multiple pharmacies, will be expanded from those used in OMS currently. Sponsors will be allowed to limit an at-risk beneficiary’s access to frequently abused drugs to a selected prescriber(s) and/or pharmacy(ies) (“lock-in”), and through the use of beneficiary-specific point-of-sale (POS) claim edits, which are already permitted under the current policy. Part D sponsors may not implement such limitations unless they have engaged in case management with the prescribers of these drugs, and beneficiaries can submit prescriber and pharmacy preferences.

*More information to come from the Pharmacy Team



Election Periods: • Removing the Medicare Advantage Disenrollment Period

(MADP) and replacing it with a new Medicare Advantage open enrollment period (OEP) that will take place from January 1st through March 31st annually. The new OEP allows individuals enrolled in an MA plan, including newly MA-eligible individuals, to make a one-time election to go to another MA plan or Original Medicare. Individuals using the OEP to make a change may make a coordinating change to add or drop Part D coverage.

• OEP election is only for members enrolled in a MA or a MAPD plan. It cannot be used for those on Original Medicare or in a stand-alone Part D plan.


General Plan Updates for Medicare PlansElection Periods: • Revised SEP for Duals and other LIS-eligible beneficiaries –

CMS revised the Special Election Period (SEP) for dual-eligible and LIS beneficiaries from an open-ended monthly SEP to one that may be used only once per calendar quarter during the first nine months of the year. Separate SEPs can be used in the following circumstances: 1) within a certain period of time after a CMS or state-initiated enrollment; and 2) within a certain period of time after a change to an individual’s LIS or Medicaid status.


New Supplemental Benefits

• Bathroom Safety Items- The plan will cover up to 3 bathroom safety items as defined by the plan. Member must contact member services to order the bathroom safety items. Member services can then order the items through the online portal.


UPMC Bath Kit ItemsBath MatRaised toilet seatHandheld shower

Transfer chair w/backBath Chair w/ back

Grab Bar‐Side of the Tub (Adjustable)


In-Home Safety Assessment- The plan will cover one in-home safety assessment per calendar year. The in-home assessment will be done by a licensed healthcare professional, such as an occupational therapist and will evaluate the home to identify potential hazards. The member can contact member services to schedule the in-home assessment. This can be scheduled with a participating home health agency closest to the member’s home.



• Counseling Services- Licensed, Master's-level trained clinicians will provide member with up to 6 counseling sessions which would include: caregiving support; family and relationship concerns; stress, grief and other emotional issues; healthy lifestyle changes.

• The counseling services will be provided through Resources for Life


2019 UPMC for Life – Travel Concierge Program

Travel Concierge Program- included for all UPMC for LifeHMO Individual and some Group plans

• New for 2019: The Travel Concierge Program is expanding to North Carolina, South Carolina, Georgia, and Tennessee.

• The Travel Concierge Program will still be available in Florida

• 6-month limit for travel coverage

• Members are encouraged to contact the Health Plan prior to services being rendered, however, it Is not required.

• Must provide all plan-covered services (including supplemental benefits) at in-network member cost sharing levels.

• Contracted providers will be reimbursed at contracted rates - non-contracted providers will be reimbursed the local Medicare FFS rates.

• Providers cannot balance bill members.

• Services that currently require an authorization will also require an authorization under the Travel Concierge Program

• PPO members will not be affected and will still continue to be liable for out-of-network cost sharing amounts.


UPMC Networks• Network names are:

– UPMC Medicare Network

• The UPMC Medicare Network is the main HMO/PPO Network

• Adams, Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Montgomery, Northampton, Perry, Philadelphia, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, and York.

– UPMC Premier Medicare Network (PSP 1 Network)

• PSP network in Allegheny, Beaver, Bedford, Blair, Butler, Erie, Lawrence, Lycoming, Tioga, and Venango counties

– UPMC/Tower Medicare Network (PSP 2 Network)

• PSPs in Berks county

– UPMC/Excela Medicare Network (PSP 3 Network)

• PSP in Westmoreland county


New 2019 UPMC for Life Individual Plans

New Plans for 2019• HMO Rx Choice (H3907 049)

• Service Area: Erie, Lawrence, Mercer and Venango counties• Provider Network: UPMC Medicare Network

• HMO Premier RX (H3907 050)• Service Area: Erie, Lawrence, Mercer and Venango counties• Provider Network: UPMC PSP 1 Network

• HMO Premier RX (H3907 051)• Service Area: Westmoreland County• Provider Network: UPMC PSP 3 Network (Westmoreland/ Excela)

• HMO Premier RX (H3907 052)• Service Area: Cumberland and Dauphin counties• Provider Network: UPMC Medicare Network

*More information will be provided in later slides.


2019 Provider Specific Plans (PSP)

Provider Specific Plans (PSP)

• What is a Provider Specific Plan?– A Provider Specific Plan is designed to include a select

network of providers. Typically the network is a more narrow, smaller provider network.

– They are also called “PSP” Plans



• UPMC for Life offers 6 Provider Specific Plans• UPMC for Life HMO Premier Rx (H3907 045)

• UPMC for Life HMO Premier Rx (H3907 046)

• UPMC for Life HMO Rx (Berks County H3907 047)

• UPMC for Life HMO Premier Rx (H3907 050) * New plan for 2019• UPMC for Life HMO Premier Rx (H3907 051) * New plan for 2019• UPMC for Life PPO RX Enhanced (H5533 007)



• We group these provider specific plans into 3 “Provider Networks”


PSP 1 Network PSP 2 Network PSP 3 Network

UPMC for Life HMO Premier Rx (H3907 046)



UPMC for Life HMO Rx (H3907 047)

UPMC for Life PPO RX Enhanced (H5533 007)



PSP 1 Network• UPMC for Life HMO Premier

Rx (H3907 046)- The service area is Allegheny, Beaver, Bedford, Blair, Butler, Lycoming, Tioga- Partnership with Heritage Valley Health System (HVHS) and Butler Health System


- The service area is Erie, Lawrence, Mercer, and Venango

Network consists of:• All UPMC-owned providers

and facilities• All HVHS providers, Primary

Health Network, and Integrated Care Network

• All Butler Health System providers, Primary Health Network, and Integrated Care Network

• Ancillaries, as appropriate



• Things to know about PSP 1 Network– These plans are nicknamed “PSP 1”

– There is no cobranding

– The member services phone number is the main member services phone number (877-539-3080).

– The PSP 1 Network has it’s own Provider Directory


Provider Specific Plans (PSP)PSP 2 Network


- The service area is Berks County

- Cobranding with Tower Health System

• UPMC for Life HMO Rx (H3907 047)



• UPMC for Life PPO Rx Enhanced (H5533 007)



Network consists of:

• Tower Health System and Berkshire Health System

• UPMC-owned providers

• Thomas Jefferson Health System


• UPMC and Tower Health System-owned rehabs



• Things to know about PSP 2 Network– These plans are nicknamed “PSP 2”

– There is cobranding with Tower Health System

– The member services phone number is different. It is: 1-844-870-2231

– There is a separate Provider Directory for these plans



PSP 3 Network• UPMC for Life HMO Premier Rx (H3907 051)

- The service area is Westmoreland County

- Cobranding with Excela Health

Network consists of:• Excela Health System Providers

• UPMC-owned providers


• UPMC and Excela Health System-owned rehabs


Things to know about PSP 3 Network

• There will be a separate Provider Directory for this plan

• This plan will have a tiering for inpatient stays. Tier 1 is for Excela and UPMC facilities

(excluding UPMC East and UPMC McKeesport). Tier 2 is for UPMC East and

McKeesport.

• The member services phone number is 877-539-3080.

2019 UPMC for Life Individual Plans

Please note: This is just a summary, not a full description of benefits. Please refer to the

Evidence of Coverage.

2019 HMO no Rx




HMO (No Rx) Plan offering for 2019: Western Pennsylvania, Ohio, and Susquehanna (H3907 002)


Plan Design HMO (no Rx)

Contract ID H3907

PBP(s) 002

Service Area

Pennsylvania (Western & Central): Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Clinton, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, Lycoming, McKean, Mercer, Potter, Snyder, Somerset, Sullivan, Tioga, Union, Venango, Warren, Washington, and Westmoreland

Ohio: Harrison and Jefferson

Provider Network UPMC Medicare Network (HMO/PPO network)

Formulary Plan does not offer Part D prescription drugs.


HMO (No Rx) Plan offering for 2019: Western Pennsylvania, Ohio, and Susquehanna (H3907 002)• Monthly Premium $0

List of Cost-Share Changes:

• Diagnostic Tests/Procedures/ Lab services was $0-$5, now $5 copay

• ER - $120 copay (CMS threshold increase from $100)


2019 HMO Rx




The HMO Rx Plan offering for 2019: Western Pennsylvania & Ohio (H3907 029)


Plan Design HMO Rx

Contract ID H3907

PBP(s) 029

Service Area

Pennsylvania (Western, Central, Northeastern, and Lehigh Cap): Adams, Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Butler, Cambria, Cameron, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Northampton, Perry, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Wayne, Washington, Westmoreland, Wyoming, and York counties



Formulary Medicare HMO/PPO Formulary (00019208)

2019 UPMC for Life Individual PlansThe HMO Rx Plan offering for 2019: Western Pennsylvania & Ohio (H3907 029)

Monthly Premium: $81

List of Cost-Share Changes:• Inpatient Hospital/ Mental Health: $425 copay per stay (was $350)• Skilled Nursing: Days 1-20: $20 copay per day, days 21-100: $100 copay per day • Specialist visits : $35 copay (was $30)• Rehabilitation Services: $35 copay (was $30)• Mental Health/ Psychiatric/ Substance abuse: $35 copay (was $30)• Emergency Room: $120 copay (was $100)• Advanced Imaging: $275 copay (was $200)• Diagnostic Tests/ Procedures/ Lab Services: $5 copay (was $0-$5)• Ambulance Services (Ground & Air): $300 copay (was $200)• Dental Services (Medicare-covered): $35 copay (was $30)• Routine Dental Oral Exam, Routine Comprehensive Oral Exam, and Routine Bitewing X-rays: $0

copay• Comprehensive Dental Allowance: $150 allowance • Hearing Services (Medicare-covered): $35 copay (was $30)• Remote Technologies- eDerm: $35 copay (was $30)



The HMO Rx Plan offering for 2019: SEPA and Delaware (H3907 042 and 048)


Plan Design HMO Rx

Contract ID H3907

PBP(s) 042 048

Service Area

Pennsylvania (Southeast/SEPA): Bucks, Chester, Montgomery, and Philadelphia counties

Pennsylvania (Delaware): Delaware county




The HMO Rx Plan offering for 2019: SEPA and Delaware (H3907 042 and 048)

Monthly Premium 042 (SEPA): $55Monthly Premium 048 (Delaware): $81

List of Cost-Share Changes:• Emergency Room: $90 copay (was $80)• Advanced Imaging: $275 copay (was $200) • Diagnostic Tests/ Procedures/ Lab Services: $5 copay (was $0-$5)• Ambulance Services (Ground & Air): $300 copay (was $200)• Routine Dental Oral Exam, Routine Comprehensive Oral Exam, and Routine Bitewing

X-rays: $0 copay (was $15)• Comprehensive Dental Allowance: $150 allowance



The HMO Rx Plan offering for 2019: Berks County (H3907 047)


Plan Design HMO Rx

Contract ID H3907

PBP(s) 047

Service Area

Pennsylvania (Berks/Tower Health): Berks county

*Provider Specific Plan (PSP)

Provider Network UPMC PSP 2 Network (Berks/Tower Health)


2019 UPMC for Life Individual PlansThe HMO Rx Plan offering for 2019: Berks (H3907 047)


List of Cost-Share Changes:• Out-of-pocket maximum increased to $4,500 (was $3,400)• Inpatient Hospital/ Inpatient Mental Health: $500 copay per stay (was $350)• Skilled Nursing: $0 copay for days 1-20, $167.50 copay per day for days 21- 100

(Decreased copay $20 for days 1-20, Increased copay $87.50 for days 21-100)• Specialist Visits/ Outpatient Rehab: $35 copay (was $30)• Emergency Room: $90 copay (was $80)• Advanced Imaging: $275 copay (was $200)• Diagnostic Tests/ Procedures/ Lab Services: $5 copay ( was $0-$5)• Ambulance Services (Ground & Air): $300 copay (was $200)• Dental Services (Medicare-covered): $35 copay (was $30)• Routine Dental Oral Exam, Routine Comprehensive Oral Exam, and Routine Bitewing X-

rays: $0 copay (was $15)• Comprehensive Dental Allowance: $150 allowance • Hearing Services (Medicare- covered) and Vision Services (Medicare- covered): $35 copay

(was $30)• Remote Technologies- eDerm: $35 copay (was $30)


2019 HMO Deductible Rx




The HMO Deductible with Rx Plan offering for 2019: WPA , Lehigh Cap, and Ohio (H3907 037)


Plan Design HMO Deductible with Rx

Contract ID H3907

PBP(s) 037

Service Area

Pennsylvania (Western, Central, Northeastern, and Lehigh Cap): Adams, Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Butler, Cambria, Cameron, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Northampton, Perry, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Wayne, Washington, Westmoreland, Wyoming, and York counties




2019 UPMC for Life Individual PlansThe HMO Deductible with Rx Plan offering for 2019: WPA , Lehigh Cap, and Ohio (H3907 037)

Monthly Premium: $22List of Cost-Share Changes:• Skilled Nursing: $0 copay for days 1-20, $172 copay per day for days 21- 100

(Increased copay $12 for days 21-100)• Specialist Visits: $35 copay (excluded from the deductible) (was $50)• Podiatry Services (Medicare-covered): $35 copay after the deductible (was $50)• Emergency Room: $90 copay (was $80)• Durable Medical Equipment/Oxygen/ Prosthetic Devices: $0 copay excluded from the

deductible• Advanced Imaging: $200 copay after the deductible (was $100)• Diagnostic Tests/ Procedures/ Lab Services: $10 copay per day/ excluded from the

deductible (was $0-$10)• Dental Services (Medicare-covered), Hearing Services (Medicare- covered) and Vision

Services (Medicare- covered): $35 copay excluded from the deductible (was $50)• Dental Cleaning (two every year): $0 copay• Remote Technologies- eDerm: $35 copay (was $38)



The HMO Deductible with Rx Plan offering for 2019: SEPA and Delaware County(H3907 043 and 044)


Plan Design HMO Deductible with Rx

Contract ID H3907

PBP(s) 043 044

Service Area

Pennsylvania (Southeast/SEPA): Bucks, Chester, Montgomery, and Philadelphia counties

Pennsylvania (Delaware): Delaware county



2019 UPMC for Life Individual PlansThe HMO Deductible with Rx Plan offering for 2019: SEPA and Delaware County(H3907 043 and 044)

Monthly Premium 043 (SEPA): $15Monthly Premium 044 (Delaware): $0

List of Cost-Share Changes:• Skilled Nursing: $0 copay for days 1-20, $172 copay per day for days 21- 100

(Increased copay $12 for days 21-100)• Specialist Visits: $35 copay (excluded from the deductible)(Decreased copay $15 in

SEPA (PBP 043) & Decreased copay $10 in Delaware (PBP 044)) • Podiatry Services (Medicare-covered): $35 copay after the deductible (was $50)• Emergency Room: $90 copay (was $80)• Durable Medical Equipment/Oxygen/ Prosthetic Devices: $0 copay excluded from the

deductible• Advanced Imaging: $200 copay after the deductible (was $100)• Diagnostic Tests/ Procedures/ Lab Services: $10 copay per day/ excluded from the

deductible (was $0-$10)• Dental Services (Medicare-covered), Hearing Services (Medicare- covered) and Vision

Services (Medicare- covered): $35 copay excluded from the deductible (was $50)• Remote Technologies- eDerm: $35 copay (was $38)


2019 HMO Plans

All HMO Deductible with Rx Plan offerings for 2019: Western Pennsylvania, Ohio, Susquehanna, and Southeast PA

Medical Services Excluded from the Deductible


• Chiropractic Services • Preventive Services

• Dental Services (Medicare‐covered and Routine Services) • Primary Care Doctor Visits

• Diabetes Training • Remote Technologies (eVisits & eDerm)

• Emergency Care • Skilled Nursing Facility

• Health and Wellness (Includes Fitness) • Specialist Visits

• Hearing Services (Medicare‐covered) • Urgently Needed Care (Clinics)

• Kidney Disease Training • Vision Services (Medicare‐covered and Routine Services)

• Lab Services and Diagnostic Procedures/Tests • Worldwide Emergency Coverage

• Part B Drugs

2019 HMO Rx Enhanced




HMO Rx Enhanced Plan offering for 2019: WPA and Ohio (H3907 006)


Plan Design HMO Rx Enhanced

Contract ID H3907

PBP(s) 006

Service Area

Pennsylvania (Western & Central): Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Clinton, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, Lycoming, McKean, Mercer, Potter, Snyder, Somerset, Sullivan, Tioga, Union, Venango, Warren, Washington, and Westmoreland





HMO Rx Enhanced Plan offering for 2019: WPA and Ohio (H3907 006)


List of Cost-Share Changes:• Emergency Room: $120 copayment (was $100)• Routine Hearing Exam: $0 copay every year (was $25)• Routine Hearing Aid Fitting: $0 copay once every 3 years (was $25)


2019 HMO Premier Rx




The HMO Premier Rx Plan offering for 2019: Berks County (H3907 045)


Plan Design HMO Premier Rx

Contract ID H3907

PBP(s) 045

Service Area




Formulary Medicare HMO Premier Rx Formulary (00019213)


The HMO Premier Rx Plan offering for 2019: Berks County (H3907 045)

Monthly Premium: $0List of Cost- Share Changes:• Out-of-Pocket Maximum: $6,700 (was $6,000)• Inpatient Hospital/ Mental Health: $250 copay per day for days 1-5, $0 copay per

day for days 6-90 (Increased copay $50 for days 1-5 )• Skilled Nursing: $0 copay for days 1-20, $167.50 copay per day for days 21- 100

(Increased copay $7.50 for days 21-100)• PCP Visits: $5 copay (was $0)• Specialist Visits: $40 copay (was $45)• Podiatry Services (Medicare-covered): $40 copay (was $50)• Emergency Room: $90 copay (was $80)• Diagnostic Tests/ Procedures/ Lab Services: $15 copay per day (was $0-$15)• X-Ray Services (Basic Imaging): $40 copay (was $30)



Continued: HMO Premier Rx Plan offering for 2019: Berks (H3907 045)List of Cost-Share Changes:• Dental Services (Medicare-covered), Hearing Services (Medicare- covered) and Vision

Services (Medicare- covered): $40 copay (was $50)• Routine Dental Oral Exam, Routine Comprehensive Oral Exam, and Routine Bitewing

X-rays: $0 copay (was $15)• Comprehensive Dental Allowance: $150 allowance • Routine Hearing Exam (every year): $0 copay• Routine Hearing Aid Fitting (every 3 years): $0 copay• Routine Hearing Aids: $1,500 allowance every 3 years• Routine Vision Exam: $0 copay every year• Routine Vision Allowance: $150 allowance every year (was $100 every 2 years)• Remote Technologies- eVisits: $5 copay (was $0)



The HMO Premier Rx Plan offering for 2019: Allegheny, Beaver, Bedford, Blair, Butler Lycoming and Tioga counties (H3907 046)


Plan Design HMO Premier Rx

Contract ID H3907

PBP(s) 046

Service Area

Pennsylvania (PSP 1 Allegheny): Allegheny, Beaver, Bedford, Blair, Butler, Lycoming, and Tioga counties


Provider Network UPMC PSP 1 Network (XXX)

Formulary Medicare HMO Premier Rx Formulary (00019213)

2019 UPMC for Life Individual PlansThe HMO Premier Rx Plan offering for 2019: Allegheny, Beaver, Bedford, Blair, Butler Lycoming and Tioga counties (H3907 046)

Monthly Premium: $0List of Cost-Share Changes:• Out-of-Pocket Maximum: $6,000 ($6,700)• Inpatient Hospital/ Mental Health: $275 copay per stay (Decreased copay $25 and

changed from per day to per stay)• Specialist Visits/ Outpatient Rehab: $35 copay (was $45) • Podiatry Services (Medicare-covered): $35 copay (was $50)• Ambulance Services (Ground & Air): $250 copay per one way trip (was $300)• Emergency Room: $90 copay (was $80)• Diagnostic Tests/ Procedures/ Lab Services: $10 copay per day ($0-$10 copay per

day)• Diagnostic Advanced Imaging: $140 copay (was $250)• Dental Services (Medicare-covered), Hearing Services (Medicare- covered) and Vision

Services (Medicare- covered): $35 copay (was $50)



Continued: HMO Premier Rx Plan offering for 2019: Allegheny, Beaver, Bedford, Blair, Butler Lycoming and Tioga counties (H3907 046)

List of Changes:• Routine Dental Oral Exam, Routine Comprehensive Oral Exam, and Routine

Bitewing X-rays: $0 copay (was $15)• Comprehensive Dental Allowance: $325 allowance • Routine Hearing Exam (every year): $0 copay• Routine Hearing Aid Fitting (every 3 years): $0 copay• Routine Hearing Aids: $1,500 allowance every 3 years• Routine Vision Exam: $0 copay every year• Routine Vision Allowance: $150 allowance every year (was $100 ever 2 years)• Remote Technologies- eDerm: $35 copay (was $38)


2019 PPO High Deductible




PPO High Deductible with RxWestern PA (H5533 003)


Benefits PPO High Deductible with Rx

Contract ID H5533

PBP(s) 003

Service Area

Pennsylvania (Western): Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, and Westmoreland




PPO High Deductible with RxWestern PA (H5533 003)


List of Cost-Share Changes:• Emergency Room: $90 copay (was $80) • DME/ Oxygen/ Prosthetic Devices and Medical Supplies: In-network 18%

coinsurance, out-of-network 50% coinsurance excluded from the deductible (Decreased coinsurance 2%, Updated to be excluded from plan deductible)

• Diagnostic Tests/ Procedures/ Lab Services: In-network $10 copay per day excluded from the deductible (was $0-$10)


2019 PPO Plans

The PPO High Deductible with Rx Plan offering for 2019: Western Pennsylvania$1,250 combined IN/OON deductible



In‐Network Services∙ Chiropractic Services (Medicare‐covered & Routine Services) ∙ Preventive Services (All zero cost‐share)∙ Dental Services (Medicare‐covered and Routine Services) ∙ Primary Care Physician Visits∙ Diabetic Training, Supplies, Shoes or Inserts ∙ Prosthetic Devices & Medical Supplies∙ Durable Medical Equipment/Oxygen ∙ Remote Technologies∙ Emergency Care ∙ Routine Podiatry Visits∙ Health and Wellness (includes Fitness) ∙ Skilled Nursing Facility Stays∙ Hearing Services (Medicare‐covered) ∙ Specialist Visits∙ Home Health Care ∙ Urgently Needed Care (Clinics)∙ Kidney Dialysis Training ∙ Vision Exam & Eyewear (Medicare‐covered & Routine Services)∙ Lab Services and Diagnostic Procedures/Tests ∙ Worldwide Emergency Coverage∙ Part B Drugs

Out‐of‐Network Services∙ Dental Services (routine services only) ∙ Routine Chiropractic Services∙ Emergency Care ∙ Routine Podiatry Visits∙ Health and Wellness (includes Fitness) ∙ Routine Vision Exam & Eyewear∙ Preventive Services ∙ Urgently Needed Care (Clinics)∙ Remote Technologies ∙ Worldwide Emergency Coverage

2019 PPO Rx Enhanced




PPO Rx Enhanced WPA and Lehigh Cap (H5533 005 and 008)


Benefits PPO Rx EnhancedContract ID H5533PBP(s) 005 008

Service Area

Pennsylvania (Western): Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, and Westmoreland

Pennsylvania (Lehigh Cap): Adams, Bradford, Cumberland, Dauphin, Fulton, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Mifflin, Northampton, Perry, Susquehanna, Wayne, Wyoming, and York counties

Provider Network UPMC Medicare Network (HMO/PPO network)Formulary Medicare HMO/PPO Formulary (00019208)


PPO Rx Enhanced WPA and Lehigh Cap (H5533 005 and 008)

Monthly Premium 005 (WPA): $135Monthly Premium 008 (Lehigh Cap): $45

List of Changes:• Emergency Room: $90 copay excluded from the deductible (was $80)• DME/ Oxygen/ Prosthetic Devices and Medical Supplies: In-network 18%

coinsurance, out-of-network 50% coinsurance excluded from the deductible (Decreased coinsurance 2%, Updated OON to be excluded from plan deductible)

• Diagnostic Tests/ Procedures/ Lab Services: In-network $5 copay per day (was $0-$5)


2019 PPO Plans

PPO Rx Enhanced Plan offerings for 2019:Western Pennsylvania, Lehigh Cap

No Annual Deductible for In Network Services$500 Annual Deductible Applies to Out of Network Services ONLY



Out‐of‐Network Services

∙ Chiropractic Services (Routine) ∙ Preventive Services

∙ Dental Services (Routine Services Only) ∙ Remote Technologies

∙ Emergency Care ∙ Urgently Needed Care (Clinics)

∙ Health and Wellness (Includes Fitness) ∙ Vision Exam (Routine)

∙ Hearing Services (Routine) ∙ Worldwide Emergency Coverage

∙ Podiatry Services (Routine)


PPO Rx Enhanced Berks (H5533 007)


Benefits PPO Rx Enhanced

Contract ID H5533

PBP(s) 007

Service Area






PPO Rx Enhanced Berks (H5533 007)


List of Cost-Share Changes:• Out-of-network deductible: $750 (was $500)• Emergency Room: $90 copay excluded from the deductible (was $80)• DME/ Oxygen/ Prosthetic Devices and Medical Supplies: In-network 18%

coinsurance, out-of-network 50% coinsurance excluded from the deductible (Decreased coinsurance 2%, Updated OON to be excluded from plan deductible)

• Diagnostic Tests/ Procedures/ Lab Services: In-network $5 copay per day (was $0-$5)


2019 PPO Plans

PPO Rx Enhanced Plan offerings for 2019:Berks County

No Annual Deductible for In Network Services$750 Annual Deductible Applies to Out of Network Services ONLY



Out‐of‐Network Services

∙ Chiropractic Services (Routine) ∙ Preventive Services

∙ Dental Services (Routine Services Only) ∙ Remote Technologies

∙ Emergency Care ∙ Urgently Needed Care (Clinics)

∙ Health and Wellness (Includes Fitness) ∙ Vision Exam (Routine)

∙ Hearing Services (Routine) ∙ Worldwide Emergency Coverage

∙ Podiatry Services (Routine)

2019 New Plan Offerings


New Plans for 2019• HMO Rx Choice (H3907 049)


• HMO Premier RX (H3907 050)• Service Area: Erie, Lawrence, Mercer and Venango counties• Provider Network: UPMC PSP 1 Network

• HMO Premier RX (H3907 051)• Service Area: Westmoreland County• Provider Network: UPMC PSP 3 Network (Westmoreland/ Excela)

• HMO Premier RX (H3907 052)• Service Area: Cumberland and Dauphin counties• Provider Network: UPMC Medicare Network


2019 HMO Rx Choice (H3907 049)




HMO Rx Choice (H3907 049)Monthly Premium: $40


• Out-of-Pocket Maximum- $3,400 • Inpatient Hospital/ Inpatient Mental Health Care- $400 copay per stay • Skilled Nursing Facility- $20 copay per day- days 1-20, $80 copay per day -days 21-100

• Primary Care Physician (PCP) Visits- $0 copay• Specialist Visits- $30 copay• Chiropractic Services (Medicare-covered)- $20 copay• Chiropractic Services (Routine)- No routine coverage• Podiatry Services (Medicare-covered)- $30 copay• Podiatry Services (Routine)- No routine coverage



HMO Rx Choice (H3907 049)• Outpatient Surgery and Ambulatory Surgical Center (ASC) - $200 copay • Observation Stay- $200 copay • Ambulance Services (Ground & Air)- $100 copay per one way trip• Emergency Care(waived if admitted within 3 days)- $120 copay• Urgently Needed Care (Clinics) (out-of-area; urgent care clinics)- $50 copay• Outpatient Rehab Services (PT, OT, ST)- $0 copay• Cardiac/Pulmonary Rehab- $0 copay• Durable Medical Equipment (DME)/Oxygen- 20% coinsurance• Prosthetic Devices and Medical Supplies- 20% coinsurance• Lab Services(single copay per day per facility)- $10 copay per day• Diagnostic Procedures/Tests (single copay per day per facility)- $10 copay per day• X-Ray Services (Basic Imaging)(single copay per service)- $10 copay• Diagnostic Radiological Services (Advanced Imaging)(single copay per service- $100

copay • Therapeutic Radiological Services (Radiation)- $0 copay



HMO Rx Choice (H3907 049)• Dental Services (Medicare-covered)- $30 copay• Dental Cleaning(two every year)- $0 copay • Dental Oral Exam - Routine(two every year)- $0 copay • Dental Oral Exam - Comprehensive(one every 36 months)-$0 copay • Dental X-rays - Bitewing(one every year)- $0 copay • Comprehensive Dental Allowance(one every year)- $325 allowance• Hearing Services (Medicare-covered)- $30 copay• Routine Hearing Exam(one every year)- $0 copay • Routine Hearing Aid Fitting(one every 3 years)- $0 copay • Routine Hearing Aids(one every 3 years)- $1,500 allowance• Vision Services (Medicare-covered)- $30 copay• Medicare-covered Glaucoma Screening/Diabetic Retinal Eye Exam- $0 copay• Medicare-covered Eyewear Cataract Glasses/Lenses- $0 copay• Routine Vision Exam(one every year)- $0 copay• Routine Vision Eyewear(one every year)- $200 allowance


HMO Premier RX (H3907 050)



2019 UPMC for Life Individual PlansHMO Premier RX (H3907 050)Monthly Premium: $0

• Service Area: Erie, Lawrence, Mercer and Venango counties• Provider Network: UPMC PSP 1 Network

• Out-of-Pocket Maximum: $6,000• Inpatient Hospital/ Mental Health: $375 copay per stay• Skilled Nursing: $0 copay for days 1-20, $160 copay per day for days 21-

100• PCP Visits: $0 copay• Specialist Visits: $35 copay • Podiatry Services (Medicare-covered): $35 copay• Observation Stay/ ASC: $350 copay• Ambulance Services (Ground & Air): $250 copay per one way trip• Emergency Room: $90• Urgent Care: $50 copay• Diagnostic Tests/ Procedures/ Lab Services: $10 copay per day• X-Ray Services (Basic Imaging): $50 copay



HMO Premier RX (H3907 050)• Dental Services (Medicare-covered)- $35 copay• Dental Cleaning(two every year)- $0 copay • Dental Oral Exam - Routine(two every year)- $0 copay • Dental Oral Exam - Comprehensive(one every 36 months)-$0 copay • Dental X-rays - Bitewing(one every year)- $0 copay • Comprehensive Dental Allowance(one every year)- $325 allowance• Hearing Services (Medicare-covered)- $35 copay• Routine Hearing Exam(one every year)- $0 copay • Routine Hearing Aid Fitting(one every 3 years)- $0 copay • Routine Hearing Aids(one every 3 years)- $1,500 allowance• Vision Services (Medicare-covered)- $35 copay• Medicare-covered Glaucoma Screening/Diabetic Retinal Eye Exam- $0 copay• Medicare-covered Eyewear Cataract Glasses/Lenses- $0 copay• Routine Vision Exam(one every year)- $0 copay• Routine Vision Eyewear(one every year)- $200 allowance



• Service Area: Westmoreland County• Provider Network: UPMC PSP 3 Network (Westmoreland/ Excela)

• Out-of-Pocket Maximum: $6,000• Inpatient Hospital/ Mental Health: Tier 1:$375 copay per stay Tier 2:$80 copay

per day-days 1-5 $0 copay per day - days 6-90• Skilled Nursing: $0 copay for days 1-20, $160 copay per day for days 21- 100• PCP Visits: $0 copay• Specialist Visits: $35 copay • Podiatry Services (Medicare-covered): $35 copay• Observation Stay/ ASC: $350 copay• Ambulance Services (Ground & Air): $250 copay per one way trip• Emergency Room: $90• Urgent Care: $50 copay• Diagnostic Tests/ Procedures/ Lab Services: $10 copay per day• X-Ray Services (Basic Imaging): $50 copay



HMO Premier RX (H3907 051)• Dental Services (Medicare-covered)- $35 copay• Dental Cleaning(two every year)- $0 copay • Dental Oral Exam - Routine(two every year)- $0 copay • Dental Oral Exam - Comprehensive(one every 36 months)-$0 copay • Dental X-rays - Bitewing(one every year)- $0 copay • Comprehensive Dental Allowance(one every year)- $325 allowance• Hearing Services (Medicare-covered) - $35 copay• Routine Hearing Exam(one every year)- $0 copay • Routine Hearing Aid Fitting(one every 3 years)- $0 copay • Routine Hearing Aids(one every 3 years)- $1,500 allowance• Vision Services (Medicare-covered)- $35 copay• Medicare-covered Glaucoma Screening/Diabetic Retinal Eye Exam- $0

copay• Medicare-covered Eyewear Cataract Glasses/Lenses- $0 copay• Routine Vision Exam(one every year)- $0 copay• Routine Vision Eyewear(one every year)- $200 allowance



• Service Area: Cumberland and Dauphin counties• Provider Network: UPMC Medicare Network

• Out-of-Pocket Maximum: $6,700• Inpatient Hospital/ Mental Health: $200 copay per day for days 1-5, $0 copay

per day for days 6-90• Skilled Nursing: $0 copay for days 1-20, $160 copay per day for days 21-

100• PCP Visits: $0 copay• Specialist Visits: $40 copay • Podiatry Services (Medicare-covered): $40 copay • Emergency Room: $90• Diagnostic Tests/ Procedures/ Lab Services: $10 copay per day• X-Ray Services (Basic Imaging): $50 copay



HMO Premier RX (H3907 052)• Dental Services (Medicare-covered)- $40 copay• Dental Cleaning(two every year)- $0 copay • Dental Oral Exam - Routine(two every year)- $0 copay • Dental Oral Exam - Comprehensive(one every 36 months)-$0 copay • Dental X-rays - Bitewing(one every year)- $0 copay • Comprehensive Dental Allowance(one every year)- $325 allowance• Hearing Services (Medicare-covered)- $40 copay• Routine Hearing Exam(one every year)- $0 copay • Routine Hearing Aid Fitting(one every 3 years)- $0 copay • Routine Hearing Aids(one every 3 years)- $1,500 allowance• Vision Services (Medicare-covered)- $40 copay• Medicare-covered Glaucoma Screening/Diabetic Retinal Eye Exam- $0 copay• Medicare-covered Eyewear Cataract Glasses/Lenses- $0 copay• Routine Vision Exam(one every year)- $0 copay• Routine Vision Eyewear(one every year)- $200 allowance


Medicare Advantage and Prescription Drug Coverage Overview

Prescription Drug Overview

2019 Medicare “Standard” Prescription Drug Benefit• The following chart depicts the CMS Medicare Standard Part D benefit for 2019. A

prescription drug plan’s benefit must be actuarially equivalent or better than the standard Medicare option listed below:


Deductible

75% Coverage

25% Co‐insurance

Donut Hole

Member responsible for 37% of generic drug costs and 25% plus dispensing fee for brand name drugs once the Initial Coverage

limit is met.

Catastrophic Coverage

After $5,100 in member out of pocket costs.

Greater of 5% Co‐insurance or $3.40 / $8.50 Copay

$415 $3,820 Initial Coverage Limit

$5,100

TrOOP


• Medicare Prescription Drug Coverage Stages and Changes for 2019:

− Deductible Stage (The 2019 deductible amount is set at $415 by CMS.)

• UPMC for Life non-SNP Plans do not have Part D deductibles.

− Initial Coverage Limit Stage

• The Initial Coverage Limit is a CMS defined annual limit. For 2019, the amount is $3,820

• Both the beneficiary’s cost-sharing and what the plan pays accumulates towards this limit.




− Coverage Gap Stage

• Both the member cost-sharing and drug manufacturer cost-sharing count toward TrOOP, the plans cost-sharing does not apply to the TrOOP.

• Members receive a discount on generic and brand name drugs in the coverage gap. The following is the 2019 beneficiary cost-sharing in the coverage gap stage:

− Generic Drugs: Once the $3,820 Initial Coverage Limit is met an individual will pay 37% for generic drugs while they are in the coverage gap.

− Brand Name Drugs: During the coverage gap stage, the beneficiary will pay 25% plus the dispensing fee.




− Catastrophic Coverage Stage• TrOOP is defined as the true out-of-pocket costs (e.g., $5,100) that an individual must

accumulate before catastrophic drug coverage is reached. The amount paid by the plan does NOT apply to the members’ TrOOP limit. TrOOP includes the following drug costs:

- Deductible - Copays/coinsurance- Coverage gap costs - Out-of-network prescription costs- Coverage gap costs paid by the drug manufacturer

• For 2019, the TrOOP increased to $5,100.

• The member’s cost-sharing for prescription drugs will decrease drastically when they reach this limit. The cost-sharing for 2019 is:− The larger of 5% of the cost of the drug; OR− $3.40 for generic drugs or a drug treated like a generic − $8.50 for all other drugs



Medicare Prescription Drug Coverage Tiers and Changes for 2019

• The 5 tiers have remained the same for 2019


Tier 2018 2019

1 Preferred Generic Drugs Preferred Generic Drugs

2 Generic Drugs Generic Drugs

3 Preferred Brand Drugs Preferred Brand Drugs

4 Non‐Preferred Drugs Non‐Preferred Drugs

5 Specialty Drugs Specialty Drugs

2019 UPMC for Life – Preferred Network for Part D Prescription Drugs


HMO Deductible w/Rx HMO Rx

HMO Rx EnhancedHMO Choice Rx(All counties)

PPO HD w/RxPPO Rx Enhanced(All counties)

HMO Premier Rx (PSP)(All Counties)

Tier 1: Preferred Generic Drugs

$0 copay ‐ 30 day supply (retail)$0 copay ‐ 90 day supply (retail)

Tier 2: Generic Drugs


Tier 3: Preferred Brand Drugs


Tier 4: Non‐Preferred Drugs


45% coinsurance‐ 30 day supply (retail) 45% coinsurance ‐ 90 day supply (retail)

Tier 5: Specialty Drugs 33% coinsurance – 30 day supply only

2019 UPMC for Life – Standard Network for Part D Prescription Drugs


HMO Deductible w/Rx HMO Rx

HMO Rx EnhancedHMO Choice Rx(All counties)

PPO HD w/RxPPO Rx Enhanced(All counties)

HMO Premier Rx (PSP)(All Counties)

Tier 1: Preferred Generic Drugs


$0 copay ‐ 90 day supply (mail‐order)

Tier 2: Generic Drugs


$20 copay ‐ 90‐day supply (mail‐order)

Tier 3: Preferred Brand Drugs



Tier 4: Non‐Preferred Drugs



50% coinsurance ‐ 30 day supply (retail) 50% coinsurance ‐ 90 day supply (retail)

45% coinsurance ‐ 90 day supply (mail‐order)

Tier 5: Specialty Drugs 33% coinsurance – 30 day supply only

2019 UPMC for LifeMember Document Changes

UPMC Networks• Network names are:

– UPMC Medicare Network

• The UPMC Medicare Network is the main HMO/PPO Network

• Adams, Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Montgomery, Northampton, Perry, Philadelphia, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, and York.

– UPMC Premier Medicare Network

• PSP network in Allegheny, Beaver, Bedford, Blair, Butler, Crawford, Erie, Lawrence, Lycoming, Tioga, and Venango counties

– UPMC/Tower Medicare Network

• PSPs in Berks county

– UPMC/Excela Medicare Network

• PSP in Westmoreland county


New addition to ID cards

• 2019 ID Cards will list a network name for the Medicare HMO and PPO plans– This is to assist providers in determining what network the member is in due to

the new PSP plans

• Network names are:– Non-PSP plans: UPMC Medicare Network

• PSP network in Allegheny, Beaver, Bedford, Blair, Butler, Erie, Lawrence, Lycoming, Tioga, and Venango counties: UPMC Premier Medicare Network

– PSPs in Berks county: UPMC/Tower Medicare Network

– PSP in Westmoreland County: UPMC/Excela Medicare Network

• The SNP ID cards will not contain the network names


New addition to ID cards


Sample ID Card:

2019 UPMC for Life - Provider Directories

2019 Provider Directories• Full Provider/Pharmacy Directory - (1 combined directory divided into two books)

– Full Provider/Pharmacy Directories will be a combined directory that will contain medical providers, pharmacy providers, and all applicable ancillary providers (dental, vision, and fitness.)

• Radius/Partial Directory (monthly)

– Radius/Partial Directory – is not a full provider directory. It will contain a subset of providers located within a specified fixed range of miles from a members’ home address.

• Stand Alone Pharmacy Directory

• Standalone PSP Provider Directories

• Provider Directories are no longer going to be mailed in any kit, but can be sent via by request only. Members are encouraged to use the website search.

Please note: When a member calls into member services to request a directory, they will automatically receive a Radius/Partial Directory unless they specifically state they would like the full directory. (The full directories are almost 1,700 pages)


2019 UPMC for Life Documents

2019 EOC, ANOC, and Formularies• The EOC and the abridged formulary will not be mailed with the

ANOC. There will be a form to request these the EOC and comprehensive formulary either via electronically or to mail a hard copy, or to access the website.

• We will just be creating the comprehensive formulary. We will not be creating an abridged formulary.



• New fitness vendor- SilverSneakers

– Also added 1 Personal Training Session per calendar year

• Increased ER copayments to either a $90 copayment or $120 copayment, depending on the Maximum out of pocket.

• Added new supplemental benefits: Bathroom Safety Items, In-Home Safety Assessment, and Counseling Services.

• New Flexible Benefit- The meal benefit will be provided one time annually upon discharge from an inpatient stay, observation stay or a SNF stay for members that have all three diagnoses of COPD, CHF and Diabetes. The member will receive 2 meals a day for 28 days (56 meals total).



Removed Prior Authorization:

• Outpatient Mental Health/ Outpatient Psychiatric

• Partial Hospitalization

Added Prior Authorization:

• Pain management and sleep specialists

• Outpatient Rehab services (PT, OT, ST)

• Prosthetic Devices

• Chiropractic Services (Medicare-covered)

* Authorization for these services is the responsibility of the provider



• Bathroom Safety Items- The plan will cover up to 3 bathroom safety items as defined by the plan. Member must contact member services to order the bathroom safety items. Member services can then order the items through the online portal.


UPMC Bath Kit ItemsBath MatRaised toilet seatHandheld shower

Transfer chair w/backBath Chair w/ back

Grab Bar‐Side of the Tub (Adjustable)


In-Home Safety Assessment- The plan will cover one in-home safety assessment per calendar year. The in-home assessment will be done by a licensed healthcare professional, such as an occupational therapist and will evaluate the home to identify potential hazards. The member can contact member services to schedule the in-home assessment. This can be scheduled with a participating home health agency closest to the member’s home.



• Counseling Services- Licensed, Master's-level trained clinicians will provide member with up to 6 counseling sessions which would include: caregiving support; family and relationship concerns; stress, grief and other emotional issues; healthy lifestyle changes.

• The counseling services will be provided through Resources for Life


Questions?

2019 SNP Product TrainingUPMC for Life Dual (HMO SNP)

Objectives

• After today’s overview you will have a better understanding of the following topics:– What is Medicare?– What is a Special Needs Plan?−Who is eligible?− 2019 Benefits & Prescription Drug Coverage

What is Medicare?

Objectives

What is Medicare?• Medicare is a health insurance

program which began in 1965 for:– People 65 years of age or older.– People with disabilities under age 65,

after 24 months.– People diagnosed with End‐Stage Renal

Disease (ESRD).• ESRD – Generally 3 months after a course

of regular dialysis begins or after a kidney transplant

– People diagnosed with amyotrophic lateral sclerosis (ALS).

• ALS – Immediately upon collecting Social Security Disability benefits, which occurs five months after being classified as “disabled”.

Medicare Part A

• Part A – Hospital Insurance helps cover the following services:• Inpatient hospital• Hospice care• Inpatient psychiatric hospital• Blood (after 3 pints)• Skilled nursing• Home health care

• Approximately 98% of beneficiaries DO NOT have to pay a Part A premium if a member or their spouse has paid into Medicare Taxes for at least 10 years.

Medicare Part B

• Part B – Medical Insurance helps cover the following services:

• Doctor visits• Outpatient hospital services• Outpatient surgery• Clinical laboratory• X‐Ray services• Durable medical equipment• Ambulance services• Prosthetics & supplies• Home health care• Outpatient rehabilitation therapy services (PT, OT, ST)• There is a Part B Medicare premium that may change annually.

Medicare Part C

• Medicare Advantage plans are offered by private insurance plans (e.g., UPMC Health Plan) that work with Medicare, plans include:– HMOs (Health Maintenance Organization)– PPOs (Preferred Provider Organization)– PFFS Plans (Private Fee‐for‐Service)– MSA Plans (Medical Saving Account)

• Medicare Advantage plans offer all benefits covered by Medicare Part A and B. Medicare Advantage plans can also have coverage for routine Vision and Dental coverage if the plan filed these additional supplemental benefits with CMS.

• In order to have Part C the beneficiary must have Medicare A, and B.

Medicare Part D

Part D – Medicare Advantage Prescription Drug Coverage.• Part D plans are offered by private

insurance plans (e.g., UPMC Health Plan) that work with Medicare.

• A beneficiary can select Original Medicare and also enroll into an individual prescription drug plan.

OR• A beneficiary can select a Medicare

Advantage plan with prescription drug coverage.

What is a Special Needs Plan?

What is a Special Needs Plan?

What is a Special Needs Plan?• Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or

PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.

Who is eligible?

Who is eligible?

Who is eligible to enroll?• Individuals who qualify for a Special Needs Plan must meet one of the

guidelines established by the Centers for Medicare & Medicaid Services (CMS):

– Institutionalized Medicare beneficiaries– Individuals with severe or disabling chronic conditions– Dual eligible beneficiaries

UPMC Offerings

The SNP Plan that UPMC offers is: –UPMC for Life Dual (HMO SNP)

•Dual‐eligible SNP–UPMC for Life Options (HMO SNP)

• Institutional SNP: This plan is terming for 2019

UPMC for Life Dual Enrollment Requirements

• An individual can join UPMC for Life Dual if they are entitled to Medicare Part A, enrolled in Medicare Part B, and receive full Medical Assistance.

• An individual must live in the service area.

• Individuals with end stage renal disease are not eligible to enroll in UPMC for Life Dual unless they are members of our organization and have been since their dialysis began.

UPMC for Life Dual Updates

Drug Management Program• Drug management programs will be integrated with CMS’s existing Overutilization

Monitoring System (OMS). The clinical guidelines used to determine if a beneficiary is potentially at‐risk, which are based on using opioids from multiple prescribers and/or multiple pharmacies, will be expanded from those used in OMS currently. Sponsors will be allowed to limit an at‐risk beneficiary’s access to frequently abused drugs to a selected prescriber(s) and/or pharmacy(ies) (“lock‐in”), and through the use of beneficiary‐specific point‐of‐sale (POS) claim edits, which are already permitted under the current policy. Part D sponsors may not implement such limitations unless they have engaged in case management with the prescribers of these drugs, and beneficiaries can submit prescriber and pharmacy preferences.

*The Pharmacy Department will be able to provide more information

UPMC for Life Dual Updates

Election Periods: • Starting Jan. 1, 2019, beneficiaries with Medicare and Medical

Assistance (Medicaid) will only be able to make ONE Medicare plan change per calendar year quarter from Jan. 1 – Sept. 30.

• That means you can make ONE plan change during the timeframes below:

• Jan. 1 – Mar. 31• Apr. 1 – Jun. 30• Jul. 1 – Sept.30• Your coverage will be effective the first of the next month.• There are some exceptions to this when certain events happen in your

life such as losing Medical Assistance coverage. There are rules about when you can make changes and the type of changes you can make based on your circumstances.

Plan Overview

Quick Plan Overview• UPMC for Life Dual

– Operates under the current contract number of H4279 – UPMC for You, Inc. license

– Has one Plan Benefit Package (PBP), 001, available in the following PA counties for 2019:

• Existing: 28 WPA, Berks, Bucks, Chester, Clinton, Dauphin, Delaware, Fulton, Lehigh, Lycoming, Montgomery, Perry, Philadelphia, Snyder, Sullivan, Tioga, Union

• New counties for 2019: Bradford, Cumberland, Juniata, Lackawanna, Lancaster, Lebanon, Luzerne, Mifflin, Northampton, Susquehanna, Wayne, Wyoming, York

Quick Plan Overview

Removed Prior Authorization:• Outpatient Mental Health/

Outpatient Psychiatric• Partial Hospitalization

Added Prior Authorization: • Pain management and sleep

specialists• Outpatient Rehab services (PT,

OT, ST) • Prosthetic Devices• Chiropractic Services

(Medicare‐ covered)* Authorization for these services is the responsibility of the provider

2019 DSNP Expansion Counties

• Set to expand to multiple PA counties with CHC launch – Rest of PA 2020

2019 Group/Plan Codes

Plan Name Group Subgroups Plan Code Contract PBP Rx Rider

Vision Rider

Dental Rider

UPMC for Life Dual

MCSND1 500‐508 GYA H4279 001 A267 MSV3 12Y

UPMC for Life Dual ‐Deemed

MCSNDG 500‐508 GYD H4279 001 A268 MSV3 12Y

2019 Benefit Information

• The SNP Plans provide the beneficiary with all the usual services covered by original Medicare and some additional enhanced benefits.

• Members must use the established network of doctors, specialists, and hospitals to receive covered care services.

• If member has UPMC CHC and UPMC for Life Dual, they will receive only one ID card and it will contain two member ID numbers. The first ID # will be listed as Primary which will be their DSNP member number; the second ID # will be listed as Secondary which will be their CHC number.

• UPMC for Life Dual members that have not enrolled with UPMC CHC must also show their Access or Community Health Choices card along with their UPMC for Life Dual card. – These members will only receive a UPMC for Life card

• Note: The Medicare coverage through UPMC for Life Dual pays as primary and Medical Assistance (Medicaid) whether the member has coverage through UPMC CHC, another CHC or ACCESS pays as secondary.

• The Secondary ID will be the member’s recipient ID number

ID Card

• Sample ID Cards

2019 Supplemental Benefits for UPMC for Life Dual

Benefit UPMC for Life Dual

Dental $0 copay for:Exam/cleaning/x‐rays every six monthsUpdated for 2019‐ $3,000 annual allowance for comprehensive dental (includes fillings & simple extractions)

Hearing $0 copay for:1 routine hearing exam and fitting per yearHearing aid allowance of $1,500 every three years

Vision $0 copay for:Routine eye exam every year$250 allowance for eyeglasses or contact lenses every year

2019 Supplemental Benefits for UPMC for Life Dual(Continued)


Health and Wellness • Nursing Hotline• Additional nutritional counseling available for

the following conditions: Alzheimer’s, cancer, multiple sclerosis, and stroke

• UPMC Anywhere Care• New for 2019‐ SilverSneakers is the new fitness

vendor. Gym membership as well as at‐home DVDs and one personal training session per calendar year

Transportation • $0 copay for:• 50 one‐way trips per calendar year

Podiatry • New for 2019‐ 4 routine visits every year

2019 Supplemental Benefits for UPMC for Life Dual(Continued)


Meal Benefit(only post discharge from Inpatient Hospital, Observation or SNF stay)

14 meals will be delivered to the member’s homeover a one week period – 2 meals a day for 7 days

Bathroom Safety Devices $0 copayThe member can choose up to 6 bathroom safetyitems per year

PERS (Personal Emergency Response System)

$0 copayOne per lifetime

OTC Allowance $125/quarter Allowance can accrue for a maximum benefit of $500/yearMust go to a participating locations and must only purchase eligible itemsWill receive a reloadable OTC card

2019 Medicare Premiums, Deductibles, & FFS Rates

Medicare FFS Rates

2018 2019 (TBA)

Part B Premiums $134.00 $134.00

Part B Deductible (annual)* $183.00 $183.00

Applies to Inpatie

nt

Acute and Inpatie

ntMen

tal H

ealth

Part A Hospital Deductible (days 1‐60) $1,340.00 $1,340.00

Hospital Days 61‐90 $335.00 $335.00

Lifetime Reserve Days (days 91 – 150) $670.00 $670.00

SNF (days 1 – 20) $0 copay $0 copay

SNF (days 21 – 100) $167.50 $167.50

Part D Premium (Drug) $37.10 $37.10

• The Medicare premiums, deductibles, and coinsurance amounts for a member who remains entitled to Medicare Part A, enrolled in Part B, and maintains full Medical Assistance coverage are fully subsidized (e.g. no member responsibility).

• The UPMC for Life Dual Summary of Benefits will show that members have a 0% cost‐sharing responsibility

* Applies only to Medicare‐covered outpatient services; excludes Labs, Emergency Care, Home Health, Pap Smears, Medicare covered preventive services, and non Medicare covered vision, dental, & hearing

Maximum Out‐of‐Pocket Costs for Medical Services

• The out‐of‐pocket maximum is the maximum amount that a member would pay out of their pocket during the calendar year for covered Part A (hospital insurance) and Part B (medical insurance) services. Part D copays are not applied to this out of pocket.

− In 2019, UPMC for Life Dual members have a $3,400 maximum out‐of‐pocket amount for covered Part A and Part B services

− This applies only when the member falls into the grace period (lost Medical Assistance).

• Medical Assistance picks up the balances after the Medicare payment for dual eligible members and the out‐of‐pocket is not applicable.

• Members will remain responsible for any Medical Assistance copays.

UPMC for Life Dual Grace Period

• UPMC for Life Dual members will be provided with a 150‐180 day grace period, when they lose their Medical Assistance coverage.

• During the grace period, UPMC for Life Dual members are encouraged to contact their County Assistance Office to regain full Medical Assistance.

• UPMC for Life Dual members who are unable to regain full Medical Assistance coverage will be disenrolled after the grace period ends.

• Once the member is disenrolled, they will return to Original Medicare unless they enroll in another Medicare Advantage plan.

UPMC for Life Dual Grace Period (Continued)

• While in the grace period:– Members will not be responsible for copayments or coinsurance

for covered services, except for Part D prescription drug copayments.

– Members will remain responsible for the Part B premium at all times, unless this amount is paid on their behalf.

– If a member receives a balance bill from a provider, they are encouraged to call Member Services, as members are not responsible for balance bills.

– UPMC for Life Dual providers are not allowed to balance bill our members.

(Once members are in the Grace Period, the out of pocket accumulates, the part B deductible is not taken. Part B drugs are also paid at 100% once the member is in the Grace Period. If a member is trying to get a part B drug during the time they lost their full Medical Assistance and when they are in the Grace Period, the claim will need to be adjusted to pay at 100%.)

UPMC for Life Dual2019 Pharmacy Coverage• UPMC for Life Dual has a 5‐tier drug list:

– Tier 1 – Preferred Generic Drugs– Tier 2 – Generic Drugs– Tier 3 – Preferred Brand Drugs– Tier 4 – Non‐Preferred Drugs– Tier 5 – Specialty Drugs

• Part D Rx’s are dispensed as a 30‐day supply (except for long‐term care facility residents).

• Temporary transition supply is dispensed in a 30‐day supply for non‐formulary drugs. – For long‐term care facility residents, the transition drug supply

remains at 31‐days• There will now be Preferred and Standard Pharmacy locations. The cost

share will remain the same for the members because they will continue to pay their LIS copays.

Low Income Subsidy (LIS)

• Medicare beneficiaries with limited income and resources may qualify for extra help to pay for prescription drugs costs. This low‐income subsidy (LIS) assistance will help pay for monthly premiums, yearly deductibles, and copayments.

• Full benefit dual eligibles, such as those in the UPMC for Life Dual, are automatically eligible for the low‐income subsidy.

• Low Income Subsidy Rider – Needs to be in member’s hands by September 30th. This will be mailed with the ANOC.

Low Income Subsidy (LIS)

2018 2019

SNP Part D Premium $37.10 $37

Generic Copays $0; $1.25; $3.35 $0, $1.25, $3.40

Brand Copays $0; $3.70; $8.35 $0, $3.80, $8.50

Initial Coverage Limit $3,750.00 $3,820.00

Catastrophic Coverage Limit $5,000.00 $5,100.00

Questions?

• Any questions?

Thank you!

Chapter 2 ‐Medicare Managed Care ManualChapter 3 – Medicare Prescription Drug Benefit Manual

Updated 7/31/18

Why is this Training Important to You?

• CMS holds UPMC accountable to the guidance in:– MA Chapter 2, MAPD Chapter 3

Enrollment and Disenrollment• CMS performs audits to determine if we are following their

regulations.• We are required to follow the guidelines as listed in the

Chapter unless otherwise stated by CMS.• You are at least partially responsible for executing these

regulations so we are in compliance with CMS.

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Processing the Enrollment RequestSection 40.2

• The Plan may ask to see the individual’s Medicare card to verify the spelling of the name, and to confirm the correct recording of Medicare Number, and entitlement dates for Medicare Part A and Part B.

• The individual does not have to show or provide the Medicare card or other evidence when submitting the request.

• Other forms of evidence are only requested when the enrollment request doesn’t include the Medicare Number and the plan is unable to locate the individual in CMS systems.

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Entitlement Information and Medicare Number Section 40.2B

• CMS systems are updated within two business days of SSA processing new or changed Part A or Part B entitlement for a Medicare beneficiary. The CMS systems are the most up‐to‐date data regarding Medicare entitlement for the beneficiary.

• The Medicare Number will be assigned at the time CMS first receives entitlement information for a new beneficiary. If the enrollment request does not include the Medicare Number and the plan is unable to locate the individual in the BEQ or MARx online query, the organization should consider the enrollment request incomplete.

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Entitlement Information and Medicare NumberSection 40.2 B

The individual may provide the Medicare Number to the plan verbally or in writing.

Examples of documents the beneficiary may send to the plan which display the Medicare Number (and entitlement information) include:• Medicare card• Medicare Award notice from SSA (shows Medicare entitlement dates only)• Benefit Verification notice from SSA (includes Medicare number and entitlement

start dates)• Medicare card information from the individual’s MyMedicare.gov account• A notice from CMS regarding change in Medicare Number

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Entitlement Information and Medicare NumberSection 40.2 B

NOTE: • If the beneficiary provides any of the notices listed on the previous slide,

the date on the letter should be no more than two months before the enrollment request was received by the plan.

• If there is a discrepancy between the entitlement information in a document and the information in CMS’s systems, use the data in CMS’s systems to determine eligibility for enrollment.

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Restoration of the MA Open Enrollment Period Section 30.5

CMS has discontinued the Medicare Advantage Disenrollment Period (MADP) (January 1 – February 14th) and established the:

Medicare Advantage Open Enrollment Period (MA OEP) effective January 1, 2019.

MA plan enrollees may enroll in another MA plan or disenroll from their MA plan and return to Original Medicare.

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Restoration of the MA Open Enrollment Period Chapter 2, Section 30.5

This chart outlines who can use the MA OEP and when:

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Who can use the MA OEP: MA OEP occurs:

Individuals enrolled in MA plans as of January 1 January 1 – March 31

New Medicare beneficiaries who are enrolled in an MA plan during their ICEP

The month of entitlement to Part A and Part B – the last day of the 3rd month of entitlement.

ICEP Example

Mr. Smith will turn 65 on July 13, 2019. He will become eligible for Medicare Part A and Part B beginning on July 1 and has decided to enroll in Part B for an effective date of July 1. Mr. Smith’s ICEP begins April 1, 2019 and ends on October 31, 2019.

Mr. Smith can use his MA OEP election from July 1‐ September 30, 2019 to make an election into another plan. September is the end of the 3rd month of entitlement.

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Restoration of the MA Open Enrollment Period

Individuals may add or drop Part D coverage during the MA OEP.

Individuals enrolled in either MA‐PD or MA‐only plans can switch to:

– MA‐PD– MA‐only– Original Medicare (with or without a stand‐alone Part D plan).

The effective date for an MA OEP election is the first of the month following receipt of the enrollment request.

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Restoration of the MA Open Enrollment Period Chapter 2, Section 30.5

NOTE: • The MA OEP does not provide an opportunity for an

individual enrolled in Original Medicare to join a MA plan. • It also does not allow for Part D changes for individuals

enrolled in Original Medicare, including those enrolled in stand‐alone Part D plans.

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Ranking of Election Periods

1. ICEP/IEP‐D – Initial Coverage Election Period/ Initial Enrollment

Period for Part D

2. MA OEP – Medicare Advantage Open Enrollment Period

3. SEP – Special Election Period

4. AEP – Annual Election Period

5. OEPI – Open Enrollment Period for Institutionalized Individuals

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SEP (Modified)Dual‐Eligible Individuals and Other LIS‐Eligible Individuals

Dual‐Eligible Individuals and Other LIS‐Eligible Individuals: This SEP is for individuals who have Medicare Part A and Part B and receive any type of assistance from Medicaid. This includes:

– Full benefit dual eligible– Partial duals (eligible to receive cost sharing)– LIS (but do not receive Medicaid benefits)

This SEP begins the month the individual becomes dually‐eligible and exists as long as he/she receives Medicaid benefits.

However, there are limits on how often it can be used.

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Use of this SEP is separate from and in addition to:

• SEP for Individuals who Lose or Have a Change in the Dual or LIS Eligibility Status

And• SEP for Individuals Who Have Been Enrolled into a Plan by

CMS or the State

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This SEP allows an individual to enroll in, or disenroll from a Part D plan once per calendar quarter from January through September. This SEP can be used once during each of the following time periods:

• January – March• April – June• July – September

It may not be used in the 4th quarter of the year (October – December)

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This SEP is considered “used” based on the date the application is received by the Plan.

If the plan receives an application in March (which would be effective April 1st), this counts as “using” the SEP for the 1stquarter, not the 2nd quarter.

CMS will reject enrollment transactions for individuals who have already used this SEP in the calendar quarter.

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SEP (Modified)Dual‐Eligible Individuals and Other LIS‐Eligible Individuals LIMITATION

This SEP has a limitation for “At‐Risk” and “Potential At‐Risk” Beneficiaries

• At‐Risk: Part D eligible individual who is determined to be at‐risk for misuse or abuse of a frequently abused drug in accordance with the requirements for drug management programs at § 423.153(f).

• Potential At‐Risk: A Part D eligible individual who is identified as being potentially at‐risk for misuse or abuse of a frequently abused drug in accordance with the requirements for drug management programs at § 423.153(f).

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Once a member is identified (by the Plan) as a “potential at‐risk” or “at risk” beneficiary and we have sent written notice to the member, he/she cannot use this SEP to change plans while this designation is in place. The notice to the individual explains that this SEP is no longer available.

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Duration of the Limitation – This limitation starts as of the date on the initial notice sent to the “potential at‐risk” beneficiary.

NOTE: • The limitation ends based on whichever situation occurs first. • The enrollment limitation for a “potential at‐risk” or an “at‐

risk” individual will not apply to other Part D enrollment periods, including the AEP or other SEPs.

The chart on the next page outlines when the limitation ends.

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Situation SEP limitation ends

Plan decides not to identify the “potential at‐risk” beneficiary as an “at‐risk” beneficiary.

60 days from the date on the initial notice or the date the beneficiary receives notice of the plan’s decision, if earlier.

The “potential at‐risk” or “at‐risk” identification is subsequently removed by plan or through beneficiary’s favorable appeal of an “at‐risk” determination

The date that the designation is removed by the plan or upon effectuation of a favorable appeal

The plan determines the beneficiary is “at‐risk” 12 months from the date the individual is determined to be “at‐risk”

The plan extends the “at‐risk” designation beyond the initial 12 months

24 months from the date the individual is determined to be “at‐risk” NOTE: This is the maximum consecutive time the SEP limitation can be imposed for each “at‐risk” limitation a sponsor implements.

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SEP (Expanded)Individuals who Gain, Lose, or Have a Change in their Dual or LIS‐Eligible Status

Individuals who Gain, Lose, or Have a Change in their Dual or LIS‐Eligible Status:SEP provided for individuals who receive “Extra Help”. It includes those who:

• Become eligible for any type of assistance including “partial duals” who receive cost sharing assistance under Medicaid and individuals who qualify for LIS (but do not receive Medicaid benefits);

• Lose eligibility for any type of assistance; and• Have a change in the level of assistance they receive (e.g., stop receiving

Medicaid benefits, but still qualify for LIS, those who have a change in cost sharing).

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SEP (Expanded)Individuals who Gain, Lose, or Have a Change in their Dual or LIS‐Eligible Status

• The SEP allows the individual one opportunity to make an election within three months of any of the changes noted above, or notification of such a change, whichever is later.

• The effective date for enrollments under this SEP is the first day of the month following receipt of the enrollment request by the plan.

• NOTE: Use of this SEP does not count towards the once per calendar quarter limitation outlined in SEP for Dual‐eligible Individuals and Other LIS‐Eligible Individuals.

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SEP for Providing Individuals who Requested Materials in Accessible Formats Equal Time to Make Enrollment Decisions

• Plans are required to provide materials in accessible formats to its members. This generally includes Braille, Data CD, Audio CD, or other formats accepted by the member in place of the original print material.

• CMS will grant an SEP in situations where the organization or CMS is unable to provide required notices or information in an accessible format, as requested by an individual, within the same timeframe that it was able to provide the same information to individuals who did not request an accessible format.

• This limited SEP ensures that beneficiaries who have requested information in accessible formats are not disadvantaged by any additional time necessary to fulfil their request, including missing an election period deadline.

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SEP for Providing Individuals who Requested Materials in Accessible Formats Equal Time to Make Enrollment Decisions

• The SEP begins at the end of the election period during which the beneficiary was seeking to make an election. The start and length of the SEP, as well as the effective date, is dependent upon the situation, and are at least as long as the time it took for the information to be provided to the individual in an accessible format.

• Plans may provide this SEP when the conditions described in this section are met, ensuring adequate documentation of the situation (such as records indicating the amount of time taken to provide accessible versions of materials) is maintained. Individuals seeking assistance for this SEP may also contact 1‐800‐MEDICARE.

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SEP for Individuals Affected by a FEMA‐Declared Weather Related Emergency or Major Disaster

A SEP exists for individuals affected by a weather‐related emergency or major disaster who were unable to, and did not make an election during another valid election period. This includes both enrollment and disenrollment elections. Individuals will be considered “affected” and eligible for this SEP if they:

• Reside, or resided at the start of the incident period, in an area for which FEMA has declared an emergency or a major disaster and has designated affected counties as being eligible to apply for individual or public level assistance;

• Had another valid election period at the time of incident period; and • Did not make an election during that other valid election period.

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SEP for Individuals Affected by a FEMA‐Declared Weather Related Emergency or Major Disaster

• In addition, the SEP is available to those individuals who don’t live in the affected areas but rely on help making healthcare decisions from friends or family members who live in the affected areas. The SEP is available from the start of the incident period and for four full calendar months thereafter.

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SEP for CMS and State‐Initiated Enrollments

• Individuals who are enrolled into a plan by CMS or a State (i.e., through passive enrollment, auto‐enrollment, facilitated enrollment, and reassignment) have an SEP to disenroll from their new plan or enroll into a different plan.

• The SEP permits a onetime election within three months of the effective date of the assignment, or notification of the assignment, whichever is later. It allows the individual to make an election before the enrollment is effective in the receiving plan or after the coverage in the receiving plan starts.

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SEP for CMS and State‐Initiated Enrollments

• This SEP must be used within three months of the start of coverage in the receiving plan. In the case where the notice is sent after the coverage in the receiving plan starts, the SEP ends three months after the date of the notice. This SEP is provided so that an individual may exercise any mandatory “opt‐out” right provided to the enrollee as part of the CMS or State‐initiated enrollment.

• The effective date for enrollments under this SEP is the first day of the month following receipt of the enrollment request by the plan.

• Individuals passively enrolled due to a plan’s non‐renewal or termination may also be eligible for an additional SEP.

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