welcome 2010 excellus bluecross blueshield medicare plans workshop a nonprofit independent licensee...
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Welcome
2010Excellus BlueCross
BlueShield Medicare Plans Workshop
A nonprofit independent licensee of the Blue Cross Blue Shield Association
(Sales Rep’s Name)
Medicare Sales Consultant
Excellus BlueCross BlueShield contracts with the Federal government and is a Medicare Advantage Organization with a Medicare contract.
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Our Vision
“…to be a best in class Medicare Program, providing Medicare
beneficiaries with a range of products and services that meet their needs for
health coverage at an affordable price.”
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Medicare Basics
There are two parts to Original Medicare: Part A and Part B
Part A
Helps cover inpatient care in hospitals. Helps cover skilled nursing facility, hospice and home
health care.
You pay deductibles, coinsurance and copays.
You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working.
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Medicare Basics
Part B
Helps cover doctor’s services and outpatient care. Helps cover some preventive care.
With Part B you pay premium, deductible, coinsurance and copays. $96.40 monthly standard Medicare Part B premium generally
deducted from Social Security check $135 Part B annual deductible 20% coinsurance on most services
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Medicare Basics
Part C: Medicare Advantage Plans
Part D: Prescription Drug Plans
Medicare Supplement: Medigap Plans
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Your Plan Options
Medicare Supplement Plans (Medigap) Secondary payer to Original Medicare Do not include Part D Drug Coverage
• Can purchase Part D separately
Medicare Advantage Plans Medical Coverage with Part D Drug Coverage
(MA-PD) Medical Coverage without Part D Drug Coverage
(MA)
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What is a Medicare Supplement Plan? (Medigap)
A Medicare Supplement (Medigap) policy is designed to supplement the Original Medicare Plan
Fills gaps in Original Medicare
Medicare Part D drug coverage not included
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Medicare Supplement Plans (Medigap)
Plan A Basic benefits only
Plan B
Basic benefits
Part A deductible under Original Medicare Plan
Plan C
Basic benefits
Parts A & B deductibles under Original Medicare Plan
Foreign travel emergency
Skilled Nursing Facility (SNF) coinsurance
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Medicare Supplement Plans (Medigap)
Plan F / High Deductible F+
Basic benefits
Parts A & B deductibles under the Original Medicare Plan
Foreign travel emergency
Part B excess charges
Skilled Nursing Facility (SNF) coinsurance
F+ has $2,000 deductible (deductible subject to change annually)
Plan H
Basic benefits
Part A deductible under Original Medicare Plan
Skilled Nursing Facility (SNF) coinsurance
Foreign travel emergency
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How Do Medicare Advantage Plans Work?
Provides Part A (Hospital) and Part B (Medical) Benefits
You pay affordable copays/coinsurance
Offers extra benefits such as:• Vision Exam• Hearing Exam• Health and Wellness• Preventive Services
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Eligibility and Service Area
You are eligible to join one of our Medicare Advantage
HMO or PPO Plans if:
You have Medicare Part A (Hospital) and are enrolled in Medicare Part B (Medical)
You are a legal resident in the service area of the plan (includes: Livingston, Monroe, Ontario, Seneca, Wayne and Yates counties, NY)
You do not have End-Stage Renal Disease (ESRD)
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Medicare Advantage Plan Enrollment Periods
Annual Enrollment Period (AEP) Runs from November 15 – December 31, each year Can change Medicare Advantage or stand-alone Prescription Drug
Plans Can add or drop prescription drug coverage Can return to Original Medicare Enrollment changes take effect on January 1
Open Enrollment Period (OEP) Runs from January 1 – March 31, each year Can change Medicare Advantage Plans Cannot add or drop prescription drug coverage One opportunity to change to a similar plan
(No-drug plan to no-drug plan – OR – drug plan to drug plan) Enrollment or disenrollment becomes effective the month after the
application is received
There are only certain times during the year when you may change or voluntarily end your membership in a Medicare Advantage or stand-alone Prescription Drug Plan.
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Initial Enrollment Period (IEP)3 months before you turn age 65 to 3 months after the month you turn age 65 If you get Medicare due to a disability, you can join during the 3 months before to 3 months after your 25th month of disability Can join a Medicare Advantage or stand-alone Prescription Drug PlanEnrollment changes take effect on the first day of your birth month
Special Enrollment Period (SEP)Change of residence into or out of the service areaLoss of employer coverageQualify for Low Income Subsidy
To obtain more information regarding Medicare Advantage Enrollment Periods you can contact our Customer Service Department at 1-877-883-9577. TTY/TDD 1-800-421-1220. Monday – Friday 8:00 a.m. – 8:00 p.m. From November 15 – March 1, representatives are available weekends from 8:00 a.m. – 8:00 p.m.
Medicare Advantage Plan Enrollment Periods
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HMO vs. PPO
HMOHealth Maintenance Organization
PPOPreferred Provider Organization
Primary Care Physician (PCP) is required
Primary Care Physician (PCP) not required
Referral required to see a specialist No referral required to see a specialist
Must use In-Network providers(You must use plan providers except in cases such as emergency care, urgently needed care, or out-
of-area renal dialysis.)
Can use In-Network & Out-of-Network providers*
(Out-of-pocket costs may be higher when you use an Out-of-Network provider, except in cases such as emergency care, urgently needed care, or out-of-
area renal dialysis)
*Excellus BlueCross BlueShield provides reimbursement for all covered benefits regardless of whether they are received in-network, as long as they are medically necessary.
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Medicare Advantage Plan Options
HMO Plans Medicare Blue Choice ValueSM (HMO) Medicare Blue Choice Value PlusSM (HMO) Medicare Blue Choice OptimumSM (HMO) Medicare Blue Choice PlatinumSM (HMO)
PPO Plan Medicare Blue PPOSM Plan 201 (PPO)
For full information on our Medicare Blue Choice and/or our Medicare Blue PPO Plan benefits, call our Customer Service Department at 1-877-883-9577 or TTY/TDD 1-800-421-1220 Monday – Friday 8:00 a.m. – 8:00 p.m. From November 15 – March 1, representatives are also available weekends from 8:00 a.m. – 8:00 p.m.
Our contract with CMS is renewed annually and the availability of coverage beyond the current contract year is not guaranteed. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2011. Please contact Excellus BlueCross BlueShield for details.
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Medicare Blue Choice ValueSM (HMO) $5.501
Benefit Medicare Blue Choice Value (HM0)
Inpatient Hospital Care(unlimited days each benefit period)
$500 copay for each Medicare-covered stay at a network hospital;
Maximum 3 copays per year; 4th and subsequent hospitalizations are covered in full
Primary Care Physician $20 copay per visit
Specialist $40 copay per visit
Outpatient Hospital Services 2 $0 - $125 copay per visit
Radiology 20% coinsurance
Outpatient Prescription Drugs3
(Part D)
Part D with $150 annual deductible; Before total annual drug costs reach $2,830, for each 30 day
supplyyou pay:$5 for Tier 1 generic drugs$30 for Tier 2 preferred brand drugs $75 for Tier 3 non-preferred drugs25% coinsurance for Tier 4 specialty drugs
1 You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another 3rd party. 2 Your cost share will be higher when the service performed is of a surgical nature or observation and the lower cost share is applicable when the service is non-surgical. 3 See Summary of Benefits for more details. When your total Part D drug costs reach $2,830, you pay 100% of the cost of your drugs. Once you or others on your behalf spend $4,550 in out-of-pocket costs, you then pay $2.50 for generics, and $6.30 for brand drugs or 5% of the price (whichever is greater). Copays based on getting 30-day supply; call us about reduced copays for mail order or a 90-day supply.
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Medicare Blue Choice Value PlusSM (HMO)
$411
Benefit Medicare Blue Choice Value Plus (HM0)
Inpatient Hospital Care(unlimited days each benefit period)
$350 copay for each Medicare-covered stay at a network hospital;
Maximum 3 copays per year; 4th and subsequent hospitalizations are covered in full
Primary Care Physician $20 copay per visit
Specialist $35 copay per visit
Outpatient Hospital Services2 $0 - $100 copay per visit
Radiology 10% coinsurance
Outpatient Prescription Drugs3
(Part D)
Part D with $150 annual deductible; Before total annual drug costs reach $2,830, for each 30 day
supplyyou pay:$5 for Tier 1 generic drugs$30 for Tier 2 preferred brand drugs $75 for Tier 3 non-preferred brand drugs25% coinsurance for Tier 4 specialty drugs
1You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another 3rd party. 2 Your cost share will be higher when the service performed is of a surgical nature or observation and the lower cost share is applicable when the service is non-surgical. 3 See Summary of Benefits for more details. When your total Part D drug costs reach $2,830, you pay 100% of the cost of your drugs. Once you or others on your behalf spend $4,550 in out-of-pocket costs, you then pay $2.50 for generics, and $6.30 for brand drugs or 5% of the price (whichever is greater). Copays based on getting 30-day supply; call us about reduced copays for mail order or a 90-day supply.
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Medicare Blue Choice OptimumSM (HMO) $1011
Benefit Medicare Blue Choice Optimum (HM0)
Inpatient Hospital Care(unlimited days each benefit period)
$250 copay for each Medicare-covered stay at a network hospital;
Maximum 3 copays per year;4th and subsequent hospitalizations are covered in full
Primary Care Physician $15 copay per visit
Specialist $30 copay per visit
Outpatient Hospital Services2 $0 - $50 copay per visit
Radiology $30 copay
Outpatient Prescription Drugs3
(Part D)
Part D with $0 annual deductible; Before total annual drug costs reach $2,830, for each 30 day
supplyyou pay: $5 for Tier 1 generic drugs$30 for Tier 2 preferred brand drugs $75 for Tier 3 non-preferred brand drugs33% coinsurance for Tier 4 specialty drugs
1You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another 3rd party. 2 Your cost share will be higher when the service performed is of a surgical nature or observation and the lower cost share is applicable when the service is non-surgical. 3See Summary of Benefits for more details. When your total Part D drug costs reach $2,830, you pay 100% of the cost of your drugs. Once you or others on your behalf spend $4,550 in out-of-pocket costs, you then pay $2.50 for generics, and $6.30 for brand drugs or 5% of the price (whichever is greater). Copays based on getting 30-day supply; call us about reduced copays for mail order or a 90-day supply.
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Medicare Blue Choice PlatinumSM (HMO) $611
1You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another 3rd party. 2Your cost share will be higher when the service performed is of a surgical nature or observation and the lower cost share is applicable when the service is non-surgical. See Summary of Benefits for more details.
Benefit Medicare Blue Choice Platinum (HM0)
Inpatient Hospital Care(unlimited days each benefit period)
$100 copay for each Medicare-covered stay at a network hospital;
Maximum 3 copays per year; 4th and subsequent hospitalizations are covered in full
Primary Care Physician $10 copay per visit
Specialist $25 copay per visit
Outpatient Hospital Services2 $0 - $35 copay per visit
Radiology $25 copay
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Medicare Blue PPOSM Plan 201 (PPO)
$361
Benefit In Network Out of Network
Inpatient Hospital Care
(unlimited days eachbenefit period)
$500 copay for each Medicare-covered stay at a network
hospital; Maximum 3 copays per year;4th and subsequent hospitalizations are covered in full
30% coinsuranceper visit
Primary Care Physician
$20 copay per visit $25 copay per visit
Specialist $40 copay per visit $45 copay per visit
Outpatient Hospital Services2 $0 - $125 copay per visit
30% coinsuranceper visit
Radiology 20% coinsurance 30% coinsurance
Outpatient Prescription
Drugs3
(Part D)
Part D with $150 annual deductible;Before total annual drug costs reach $2,830, for each
30 daysupply you pay:$5 for Tier 1 generic drugs$30 for Tier 2 preferred brand drugs $75 for Tier 3 non-preferred brand drugs25% coinsurance for Tier 4 specialty drugs
Emergency Benefit Only
1You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another 3rd party. 2Your cost share will be higher when the service performed is of a surgical nature or observation and the lower cost share is applicable when the service is non-surgical. 3 See Summary of Benefits for more details. When your total Part D drug costs reach $2,830, you pay 100% of the cost of your drugs. Once you or others on your behalf spend $4,550 in out-of-pocket costs, you then pay $2.50 for generics, and $6.30 for brand drugs or 5% of the price (whichever is greater). Copays based on getting 30-day supply; call us about reduced copays for mail order or a 90-day supply.
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Medicare Prescription Drug Plan (Part D)
2 ways to get Medicare Prescription Drug Coverage:
Join a stand-alone Medicare Prescription Drug Plan (PDP)
Join a Medicare Advantage Prescription Drug Plan (MA-PD)
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Medicare Prescription Drug Plan (Part D)Formulary List of drugs that are covered under your Part D drug plan To obtain a copy of our formulary go to our
Web site at www.excellusbcbs.com/medicare
Network About 60,000 pharmacies nationwide Retail, mail order, long term care, home infusion, Indian/Tribal/Urban
pharmacies included For additional information regarding our pharmacy network, quantity
limits or mail order prescription drug service call 1-800-659-1986. TTY/TDD 1-800-421-1220 Monday – Friday 8:00 a.m. – 8:00 p.m. From November 15 – March 1, representatives are also available weekends from 8:00 a.m. – 8:00 p.m.
You may write to us at: Excellus BlueCross BlueShieldPO Box 546Buffalo, NY 14201
You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances when you cannot reasonably use network pharmacies.
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Medicare Prescription Drug Plan (Part D)
You pay $2.50 for generics and $6.30 for brand name drugs, or 5% of the price (whichever is
greater)
Catastrophic Coverage
Excellus BlueCross BlueShield pays the balance
Coverage GapAll costs are out-of-pocket
You PayYour
copays/coinsurance
Initial Coverage PeriodExcellus BlueCross BlueShield pays the
balanceDeductible is out-of-pocket
$0 or $1502
Medicare Drug BenefitOut Of Pocket
4 Coverage PhasesCatastrophic Coverage begins when you or others on your behalf have spent $4,5501.
No coverage when total drug spend exceeds $2,8301 until your true out of pocket spending reaches $4,5501.
Initial Coverage starts after you have met your deductible, if applicable, and continues until your total drug costs reach $2,8301.
You must pay your deductible, if applicable, before you start getting your prescription drug coverage.
1 Coverage limits for all phases of the Part D benefit change annually.
2 Benefits, formulary, pharmacy network, premium, copayment/coinsurance may change on January 1, 2011. Contact Excellus BlueCross BlueShield for details.
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Prior Authorization In some cases, we require you to obtain prior
approval from us before you fill your prescription.
Step Therapy In some cases, we require you to first try certain
drugs to treat your medical condition before we will cover another drug for that condition.
Quantity Limits For certain drugs, we limit the amount of the drug
that we will cover per prescription.
Medicare Prescription Drug Plan (Part D)
Some prescription drugs may have additional requirements or limits.
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Medicare Prescription Drug Plan (Part D)
You may be able to get Extra Help to pay for your prescription drug premiums and costs.
To see if you qualify for getting Extra Help, call:1. 1-800-MEDICARE (1-800-633-4227), TTY/TDD users
should call 1-877-486-2048, 24 hours a day/7 days a week
2. The Social Security Office at 1-800-772-1213 between 7:00 a.m. – 7:00 p.m., Monday through Friday, TTY/TDD users should call 1-800-325-0778
3. Your State Medicaid office
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People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for:
seventy-five percent of drug costs including monthly prescription drug premiums,
annual deductibles, and co-insurance.
Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty.
Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social
Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.
Medicare Prescription Drug Plan (Part D)
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Other Government Insurance
EPIC - Elderly Pharmaceutical Insurance Coverage
• New York State residents that are 65 or older, and have an annual income of $35,000 or less if single, or $50,000 or less if married
• New York State Department of Health:• www.health.state.ny.us/health_care/epic• 1-800-332-3742
Department of Veterans Affairs• Provides coverage to veterans• Call the VA in your area if you believe that you
may be eligible
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Medicare Blue Choice: Emergency: Nationwide and Worldwide Urgent Care: Nationwide Routine Care: Covered under the Travel Benefit
on Medicare Blue Choice Optimum (HMO) andPlatinum (HMO) plans.
Medicare Blue PPO: Emergency: Nationwide and Worldwide Urgent Care: Nationwide
Coverage While Traveling
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GoGetters® Flexible Fitness Benefit• Up to $650 per calendar year* • Qualified fitness facility membership fees • Qualified weight management program
membership fees• Included in Medicare Blue Choice (HMO) and Medicare Blue PPO plans
* This benefit does not cover any ancillary services or items that are not part of a membership fee.
Health and Wellness
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Blue365 offers access to savings and discounts on items that members may purchase directly from independent vendors. Blue365 may also be used in conjunction with the GoGetters® Benefit.
Fitness- save on membership, monthly fees and other services at Gold’s Gym®, Curves®, Snap FitnessTM and Global FitTM
Nutrition- Save on programs, products and consultations at eDiets®, Kronos Optimal Health® and Jenny Craig®
Elective procedures- Save on vision products and services at Davis Vision®, QualSight LASIK ®, LasikPlus® and TruVisionTM
Hearing aids- Save on products from BeltoneTM and TruHearingThe products and services described above are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the Excellus BlueCross BlueShield grievance process.Note: Not all vendors that have provided discounts for Blue365 are
qualified fitness facilities or weight management programs for purposes of our GoGetters®benefit.
Valuable Extras
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24-hour Personal Health Coaching Line Provides education and programs on
nutrition, weight management and much more.
Disease & Case Management Clinical staff work with you to make informed
choices on your health care and prescriptions.
Valuable Extras
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Our Enhanced Web site
Allows members and prospective members to:
Estimate annual costs Compare our plans Learn more about cost-cutting options Enroll online*
Enhanced Web Tools
www.excellusbcbs.com/www.excellusbcbs.com/medicaremedicare
…and more!
*Medicare beneficiaries may enroll in Excellus BlueCross BlueShield Medicare Advantage Plans through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at www.medicare.gov. For more information, contact Excellus BlueCross BlueShield at 1-800-659-1986, TTY/TDD 1-800-421-1220, 8:00 a.m. – 8:00 p.m., Monday – Friday. From November 15 – March 1, 8:00 a.m. – 8:00 p.m., 7 days a week.
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How to Enroll
Complete application form One application per person You must continue to pay your Medicare
Part B premium You may need to cancel your other
insurance carrier Effective date of coverage is determined
by enrollment period and when application is signed and received
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Why Excellus BlueCross BlueShield?
Power of Blue- One of the most recognized healthcare insurers
More than 3,000 Participating Providers
In business for over 70 years
Offering plans that fit your needs and budget
Commitment to our local community
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How to Contact us
Call us:Medicare Sales Representative:
• 1-800-659-1986 TTY/TDD 1-800-421-1220• Monday – Friday 8:00 a.m. – 8:00 p.m.
From November 15 – March 1, representatives are also available weekends from 8:00 a.m. – 8:00 p.m.
For full information on our Medicare benefits call a Medicare Customer
Service Representative:• 1-877-883-9577 TTY/TDD 1-800-421-1220• Monday – Friday 8:00 a.m. – 8:00 p.m.
From November 15 – March 1, representatives are also available weekends from 8:00 a.m. – 8:00 p.m.
Write us:• Excellus BlueCross BlueShield P.O. Box 546
Buffalo, NY 14201
Visit us on the Web at www.excellusbcbs.com/medicare
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Important Numbers
Centers for Medicare & Medicaid Services (CMS)• 1-800-633-4227 • TTY/TDD 1-877-486-2048• 24 hours a day, 7 days a week• www.medicare.gov
To apply for Low Income Subsidy• Social Security Administration:1-800-772-1213 • TTY/TDD 1-800-325-0778• Monday – Friday 7:00 am – 7:00 pm• www.ssa.gov
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