Welcome! An Introduction to the Health Options Program and Medicare for PSERS Retirees Turning Age 65

12/17/2019

Medicare/Health Options Program Video

Perhaps you had an opportunity to review

the introductory video available on

www.HOPbenefits.com prior to this meeting.

Let’s review the important points of this information so you can make the best decision

to meet your health care needs.

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http:www.HOPbenefits.com

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Good Summary Shown on Decision Tree

What Is Medicare?

Medicare is a federal government program to help seniors & disabled citizens with medical costs.

• Eligibility for Medicare generally begins at age 65.

• It is possible to become eligible for Medicare before age 65 if you qualify for Social Security disability benefits.

• Medicare coverage begins the 1st day of the month of 65th birthday (unless born on first day of month)

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Original Medicare

Medicare does not cover all medical expenses. Part A covers many Part B covers a portion of hospital expenses medical/surgical/doctor costs

Medicare Pays

Individual (or other insurance) pays

Deductible $0 $1,408

Days 1-60 100% $0

Days 61-90 100% less $552/day

$552/day

Days 91-150 100% less $704/day

$704/day

Medicare Individual Pays (or other

insurance) pays

Deductible $0 $198

Costs 80% 20%

Part B premium usually deducted from Social Security benefit

2020 Monthly Part B Premium is $144.60 for most new enrollees

No current Part A premium

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• Part C – Medicare Advantage Combines Original Medicare benefits with managed care benefits and may cover benefits not provided by Medicare; Requires payment of Part B premium

• Part C premium paid to Medicare Advantage plan

• Part D – Provides 3 stages of prescription drug coverage; member pays part of drug costs

• Premium paid to Medicare Part D plan

Benefits are administered through insurance plans licensed by the

federal government.

Newer Parts of Medicare

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Becoming Enrolled in Original Medicare

• If you ARE currently receiving Social Security benefits, Medicare enrollment is automatic; your Medicare card will be sent to you about three months prior to your 65th birthday and you will be automatically enrolled into Medicare Parts A & B

• If you ARE NOT receiving Social Security benefits, Medicare enrollment at age 65 requires you to contact the Social Security Office or register online at www.medicare.gov

• Must be enrolled in Medicare Parts A & B to purchase additional insurance coverage to fill gaps

• Late enrollment into Part B will result in permanently higher (penalty) premium unless eligible for exception

Part B Exception

If currently covered by employer health plan due to active employment of you or your spouse, enrollment in Part B may be deferred without future

penalty until that employer coverage is no longer available.

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How a Medicare Part D Plan Works

You Move to the Next Coverage Stage What You Pay

Stage When…

Initial Coverage

A portion of the cost depending on the plan

A portion of the cost (portion usually different from Initial Coverage Stage )

5% of the cost ($3.60 minimum for generics; $8.95 minimum for brands)

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Total drug spending (member & plan) reaches $4,020 in 2020

Member’s costs (not the plan’s payment) reaches $6,350 in 2020

Final stage

STOP

Move to Coverage

Gap

Coverage Gap Move to

Catastrophic

Catastrophic Coverage

Two Types of Additional Insurance to Help Pay for Gaps in Medicare Benefits

Medicare Supplement Plan • Helps to fill the coverage gaps of “Original”

Medicare benefits

• Medicare is primary coverage and supplement is secondary coverage

Medicare Advantage Plan • Combines “Original” Medicare benefits with

managed care benefits and may provide added benefits not available through Medicare; sometimes called “replacing Original Medicare”

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You must be enrolled in both Medicare Parts A and B to purchase a Medicare Supplement or a Medicare Advantage plan.

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Choose One or the Other—Not Both

Medicare Supplement

Part A Part B OR + Hospital Medical

Insurance Insurance

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Part D Part D Medicare Prescription Medicare Prescription Drug Coverage

Drug Coverage Usually part of the combined plan

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Medicare Supplement Insurance

Also known as Medigap

Medicare Advantage Plan

Part C (such as an HMO or PPO) Combines Parts A & B, may include Part D,

into a single plan, the benefits of which must equal or exceed the benefits provided

by Original Medicare

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Coverage selection complete If you buy a Medicare Advantage Plan, you

don’t need and can’t be sold a Medicare Supplement

Coverage selection complete 10

Health Options Program Offers Both

Premium Assistance: Unique Advantage

Up to $100/month to reimburse basic health insurance premiums for qualifying retirees

Available only if purchasing coverage in the Health Options Program or an approved school employer plan

Non-taxable reimbursement added to your monthly retirement benefit

Premium Assistance is not payable to spouses, surviving spouses or

dependents even if the retiree qualifies.

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Eligibility for Premium Assistance

24-1/2 years of service

OR

15 years of service with termination of employment & retirement at or after age 62,

OR

PSERS disability

PLUS

Out of-Pocket Premium Cost for an approved Medical Plan:

• Former school employer’s group insurance approved for Premium Assistance

• Any option under the PSERS Health Options Program

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Health Options Program Eligibility

A PSERS retiree, survivor annuitant, their spouses and dependent children may enroll in the PSERS Health Options Program and select either one of the Medicare Supplement

plans or one of the Medicare Advantage plans

• Spouse and dependent(s) must select same carrier/similar coverage as retiree

• If both spouses are school retirees, different carrier/coverage may be selected

Pre-65 coverage is available with the Health Options Program for

spouses and/or dependent(s) not

yet eligible for Medicare.

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More Advantages of Health Options Program

Benefits with no exclusions for pre-existing conditions or benefit waiting period for PSERS retirees and dependents

Flexibility to change coverage options as needs change at time of Qualifying Events and during Annual Option Selection Period

Choices of Coverage to fit individual needs and resources

Competitive Premium Rates for comparable benefits

Premiums deducted from retiree’s monthly retirement benefit

Access to Free Resources

• Frequent Health Options Program newsletter

• Toll-free customer phone service 1-800-773-7725

• Website www.HOPbenefits.com

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http:www.HOPbenefits.com

Qualifying Events (QE)

• Qualifying Events are the only times individuals may enroll in Health Options Program.

• Enrollment must be done within the 180 days after experiencing a Qualifying Event.

• A Qualifying Event may provide an opportunity for all eligible family members to enroll.

• Initial eligibility for Medicare at age 65 is a common Qualifying Event when retirees enroll in Health Options Program.

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Qualifying Events

• A member retires or loses health care coverage under a school employer’s health plan

• An individual involuntarily loses health care coverage under a non-school employer’s health plan (including coverage under COBRA)

• An individual (including a spouse) attains age 65 and/or becomes eligible for Medicare

• A member’s status changes (including marriage, divorce, the addition of a dependent through birth/adoption, or the loss of a dependent’s eligibility for coverage)

• A retiree becomes eligible for Premium Assistance due to a change in legislation

• A plan approved for Premium Assistance terminates, or an individual moves out of an approved plan’s service area

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Personalized Statement

• Sent to current retirees 3-9 months before 65th birthday along with an invitation to Health Options Program group meeting

• Includes benefit highlights for HOP Medicare Supplement (including prescription drug options) and Medicare Advantage Plans

• Shows your personal coverage options available and monthly premiums

Don’t forget the $100 Premium Assistance non-taxable reimbursement you may be eligible to receive in your

monthly PSERS benefit payment!

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Options for Medicare-Eligible Retirees

Supplements to Original Medicare HOP Medical Plan & Value Medical Plan

May add:

• Medicare Part D Rx coverage Enhanced, Basic & Value Medicare Rx Options

• Voluntary dental benefits plan

Medicare Advantage Plans Various Medicare Part C Plans available in specific geographic areas; include Part D Rx Coverage; some include vision and dental

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The HOP Medical Plan

• A separate insurance that supplements “Original” Medicare

• Medicare remains your primary coverage; HOP Medical Plan is secondary coverage paying deductibles and coinsurance

• No annual out-of-pocket maximum, except for Major Medical benefits

• Can use any doctors/hospitals anywhere that accept Medicare; no “in” or “out” of network providers or restricted service area

• Non-profit self-insured plan for the sole benefit of participants; 100% of premiums go to pay claims & administrative expenses

• Discounted premium for this option when enrolling at age 65 or within 180 days of retirement occurring between ages 65-69

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Major Medical Benefits

A “$1 million safety net” that provides an additional level of coverage in the HOP Medical Plan to cover

some medical costs after Medicare benefits are exhausted

After you meet $250 annual deductible, benefits paid at 80%

Some examples of what’s covered: • Home intravenous (IV) therapy

• OB-GYN exams when not covered by Medicare every other year

• Medical expenses incurred while traveling outside of the United States (Medicare does not cover medical expenses incurred outside the United States)

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SilverSneakers® Fitness Program

SilverSneakers® is available to participants in the HOP Medical Plan & Pre-65 Medical Plan at no added cost

• Membership amenities include treadmills, weights, heated pools, fitness classes designed exclusively for seniors

• Special classes for SilverSneakers® members often available at participating fitness centers, now including most Curves and Snap locations

• Lists of participating fitness centers are maintained on the SilverSneakers® website www.silversneakers.com

• Use SilverSneakers® ID card sent to you after you enroll in either of these two medical plans each time you go to a participating facility

• Check with Medicare Advantage Plans to see what fitness benefits are provided by their coverage; benefits may differ by plan

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http:www.silversneakers.com

The Value Medical Plan

• Another separate insurance that supplements “Original” Medicare

• Medicare remains your primary coverage and the Value Medical Plan is your secondary coverage

• Can use any doctors/hospitals anywhere that accepts Medicare; No “in” or “out” of network providers or restricted service area

• Member pays first $300 of the Medicare Part A deductible and then the Plan pays all other Medicare eligible hospital expenses

• Member pays the Medicare Part B deductible and the Plan limits coverage for medical expenses partially paid by Part B

• Member’s annual out-of-pocket Medicare expenses capped at $5,000

• Does not include Major Medical benefits; no coverage for medical expenses incurred out of the United States

• SilverSneakers® not included

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Exclusions to Supplemental Plans

Costs Not Covered by Medicare, the HOP Medical Plan or the Value Medical Plan:

• Long-Term/Custodial Nursing Home Care

• Routine hearing (exams/hearing aids)

• Routine eye care (exams, prescription lenses, frames)

• All dental care (exams, cleanings, x-rays, fillings)

*MetLife Dental coverage can be added to either Plan

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Can be added to the HOP Medical or Value Medical Plans

The MetLife Dental Plan

• Offers in-network preventive care at no cost

• Provides up to $1,350/year in dental benefits, excludes preventative services

• In-network discounts apply after limit is reached

• No pre-existing condition restrictions

• TMJ & orthodontics are not covered

• Current HOP members may add during Fall 2019 Option Selection Period

• Opportunity to add dental at Age 65 Qualifying Event or upon initial HOP enrollment occurring after age 65

Member Pays In Network Out of Network

2 exams/cleanings +1 bite-wing x-rays $0 20%

Deductible-Basic & Major Services $0 $100

Basic services (fillings) 30% 50%

Major services (crowns) 40% 50%

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Prescription Drugs (Medicare Part D)

Rx = Prescription Drug

• Enhanced Medicare Rx Option

• Basic Medicare Rx Option

• Value Medicare Rx Option

Enhanced Medicare Rx Option

Basic Medicare Rx Option

Value Medicare Rx Option

Uses the Enhanced & Basic Formulary Uses the Gold5 Formulary

Covers more prescriptions

Lower out-of-pocket costs

Covers all of Meets Medicare’s Medicare’s required minimum coverage prescriptions requirements

Cost sharing Cost sharing and deductible

All Options have Catastrophic Stage coverage for extreme Rx expenses

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Abridged Prescription Drug Formularies

• Two separate formularies showlist of drugs covered—alphabetically and by medicalcondition• Purple – Enhanced & Basic Rx• Blue – Value Rx (Gold5)

• Explains limitations/exceptions

• Comprehensive & AbridgedFormularies available online

• Enhanced Rx Option coversmedications not covered at allunder other plans—seeComprehensive Formulary fordetails

• Drugs available by mail order orat local pharmacies

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How Much You Pay for Prescription Drugs

Cost you pay depends on the tier of drug purchased and in what coverage stage you are at time of purchase

Different Benefits for Different Drug Types

Preferred Generic (Tier 1)

Drug chemically equivalent to name brand; not under patent; usually least costly

Non-Preferred Generic (Tier 2)

Drug chemically equivalent to name brand; not under patent

Preferred Brand (Tier 3)

Patented name brand drug for which a generic equivalent is not available

Non-Preferred Brand (Tier 4)

Name brand drug for which a generic equivalent is available (patent expired)

Specialty (Tier 5) High cost oral or injectable drugs used to treat complex conditions

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- -

Enhanced Rx Option - 2020

You Pay Retail Pharmacy Mail Order

$0 Annual Deductible

Initial Coverage Stage up to a total drug cost of $4,020

Tier 1

Tier 2

Tier 3

Tier 4

Tier 5

30 day supply 31-90 day supply Up to 90 day supply

$4 maximum $12 $12

$11 maximum $33 $33

25% to maximum of $150

25% to maximum of $300

25% to a maximum of $280

35% to maximum of $200

35% to maximum of $400

35% to a maximum of $380

33% no maximum (30 days only)

Coverage Gap Stage up to TrOOP (True Out of Pocket) Maximum of $6,350

All Tiers 25% (70% manufacturer discount also applies to TrOOP)

Catastrophic Coverage Stage after reaching TrOOP (True Out-of-Pocket) Maximum of $6,350

Generic

Name Brand

Greater of 5% or $3.60 to maximum of $100

Greater of 5% or $8.95 to maximum of $100

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- -

You Pay

Basic Rx Option - 2020

Retail Pharmacy Mail Order

$100 (excludes generics) Annual Deductible

Initial Coverage Stage up to a total drug cost of $4,020

Tier 1

Tier 2

Tier 3

Tier 4

Tier 5

30 day supply 31-90 day supply Up to 90 day supply

$5 maximum $15 $15

$12 maximum $36 $36

30% to maximum of $200

30% to maximum of $500

30% to a maximum of $450

40% no maximum

30% no maximum (30 days only)

Coverage Gap Stage up to TrOOP (True Out of Pocket) Maximum of $6,350

All Tiers 25% (70% manufacturer discount also applies to TrOOP)

Catastrophic Coverage Stage after reaching TrOOP (True Out-of-Pocket) Maximum of $6,350

Generic

Name Brand

Greater of 5% or $3.60 to maximum of $250

Greater of 5% or $8.95 to maximum of $250

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- -

Value Rx Option - 2020

You Pay

Uses the OptumRx Gold5 Formulary

Retail Pharmacy & Mail Order

$435 Annual Deductible

Initial Coverage Stage up to a total drug cost of $4,020

Tier 1

Tier 2/3/4/5

$2 for 30 day supply; $6 for 31-90-day supply (not subject to annual deductible)

25% no maximum

Coverage Gap Stage up to TrOOP (True Out of Pocket) Maximum of $6,350

All Tiers 25% no maximum

(70% manufacturer discount also applies to TrOOP)

Catastrophic Coverage Stage after reaching TrOOP (True Out-of-Pocket) Maximum of $6,350

Generic

Name Brand

Greater of 5% or $3.60

Greater of 5% or $8.95

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Medicare Rx Options

Enhanced Basic Value Medicare Rx Medicare Rx Medicare Rx

Option Option Option

Single $128 $69 $23

Rates shown in Personalized Statement include the Rx premium Premium Assistance not payable for enrollment in a Rx plan only Prior Authorization & Step Therapy requirement for some medications On-line tool for prescription drugs covered through OptumRx:

Access www.HOPbenefits.com Click on “Find a Drug” Select “Formulary Lookup Tool” Enter the name of your medication in the “Drug name” box Click search button

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http:www.HOPbenefits.com

Tips for Selecting a Medicare Rx Plan

Some General “Rules of Thumb”

Adequate Rx coverage at the lowest overall cost to you (considering the deductible, co-pays and premiums you pay) may be provided by:

• The Value Rx Plan - if you are taking a very minimal number of low-cost drugs and primarily want coverage for the unexpected

• The Basic Rx Plan - if your total drug costs remain within the Initial Stage of Part D benefits

• The Enhanced Rx Plan - if your total drug costs cause you to reach the Coverage Gap Stage and remain there for the balance of the year

• The Enhanced or Basic Rx Plan - if you reach the Catastrophic Stage, depending on the maximum out-of-pocket for your high cost medications

Individual circumstances may vary these general guidelines as to which plan best suits your needs.

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More Tips for Choosing a Medicare Rx Plan

Individual circumstances (numbers of drug taken, costs of those drugs) may vary the general guidelines as to which plan best suits your needs.

Enhanced Rx Option does not have an annual deductible.

Basic Medicare Rx Option has a $100 deductible for Brand & Specialty drugs.

Value Rx Option: • requires you to pay an up-front, out-of-pocket deductible ($435 annually for

2020, excluding Preferred Generics) for prescription drug costs before the coverage begins to pay a portion of your costs.

• uses a different formulary than the Enhanced & Basic Rx Options.

In selecting an Rx option, be sure to consider your total out-of-pocket costs (deductibles plus co-payments/co-insurance) plus the cost of the

monthly premiums to determine your best overall option.

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Combines “Original” Medicare and

managed care benefits • Enrollee must continue to pay Medicare Part B premium

• Must be enrolled in Health Options Program group Medicare Advantage plan to receive Premium Assistance

Medicare Advantage Plans

• Receive the highest level of benefits when using network or participating providers (doctors & hospitals)

• Emergency benefits covered for medical services received when traveling outside service area of any Medicare Advantage plan

• Medicare Advantage plans may provide some vision, hearing and dental allowances not available through Medicare/HOP Medical Plan

• Most Medical Advantage Plans include fitness and wellness benefits

See Personalized Statement for details about benefits and premium costs of various Medicare Advantage plan(s) available where you live

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Medicare Advantage Plans

Different Types of Coverage

Health Maintenance Organization (HMO)

Preferred Provider Organization (PPO)

Require use of network providers and referrals

No referrals required

No non-emergency coverage for out-of-network services

Fixed co-pays when using in-network providers

Provides both in-network and out-of-network

services after deductibles & coinsurance

Plans have limited geographic service areas

Call the HOP Administration Unit at 1-800-773-7725 to request

detailed materials for the Medicare Advantage plan(s) available

where you live.

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Aetna Service Area

Aetna Medicare VO2 PPO Erie

Crawford

Mercer

Law-rence

Beaver

Washington

Greene

Warren

Venango

Forest

Butler

Clarion

Arm-strong

Allegheny

Westmoreland

Fayette Somerset

Bedford

Cambria Indiana

Elk

Jeffer-son

Clearfield

McKean

Hunting -don

Fulton

Franklin

Blair

Centre

Cameron

Clinton

Mifflin

Potter

Perry

Adams

Juniata

Lycoming

Snyder

Tioga

Sullivan

Col-umbia

Montour

Bradford

Dauphin

Lebanon

Lancaster

North-umberland

York

Wyom -ing

Luzerne

Carbon

Susque-hanna

Schuylkill

Berks

Chester

Lehigh

Wayne

Pike

Monroe

Lacka-wanna

Northampton

Delaware Philadelphia

Bucks

Available in all of Pennsylvania & New Jersey and parts of Florida, Maryland and New York

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Capital BlueCross Service Area

Capital BlueCross BlueJourney PPO

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Available in Pennsylvania + all other states except DE & MD Erie

Crawford

Mercer

Law-rence

Beaver

Washington

Greene

Warren

Venango

Forest

Butler

Clarion

Arm-strong

Allegheny

Westmoreland

Fayette Somerset

Bedford

Cambria Indiana

Elk

Jeffer-son

Clearfield

McKean

Hunting -don

Fulton

Franklin

Blair

Centre

Cameron

Clinton

Mifflin

Potter

Perry

Adams

Juniata

Lycoming

Snyder

Tioga

Sullivan

Col-umbia

Montour

Bradford

Dauphin

Lebanon

Lancaster

North-umberland

York

Wyom -ing

Luzerne

Carbon

Susque-hanna

Schuylkill

Berks

Chester

Lehigh

Wayne

Pike

Monroe

Lacka-wanna

Northampton

Delaware

Philadelphia

Bucks

Highmark Service Area

Freedom Blue Highmark PPO offered in 61 counties of PA and in all other states

Security Blue HMO Point-of-Service offered in Allegheny, Fayette, Greene, Indiana, Washington & Westmoreland Counties

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Available in PA + all other states Erie

Crawford

Mercer

Law-rence

Beaver

Clearfield

Washington Bedford Lancaster

Greene

Warren

Franklin

Venango

Forest

Butler Arm-

Elk

Clarion Col-

strong

Allegheny Indiana Dauphin

Westmore-land

Fayette Fulton Philadelphia Somerset

Cambria

Jeffer

Lehigh

Delaware

-son

McKean

Hunting -don

Blair

Centre

Lebanon

Cameron Sullivan -ing

Clinton

Mifflin

Potter

Perry

Adams

Juniata

Lycoming

York

Snyder

Tioga

umbia Montour

Bradford

North-umberland

Wayne

Wyom

Luzerne

Carbon

Susque-hanna

Schuylkill

Berks

Chester

Pike

Monroe

Lacka-wanna

Northampton

Bucks

Independence Blue Cross Service Area

Independence Blue Cross Keystone 65 Select ($5/$40) HMO

Chester

Delaware

Philadelphia

Bucks

Available in Southeastern

Pennsylvania only

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UPMC Service Area

UPMC for Life HMO (University of Pittsburgh Medical Center)

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Available in parts of Pennsylvania only Erie

Crawford

Mercer

Lawr-ence

Beaver

Washington

Greene

Warren

Venango Forest

Butler

Clarion

Arm-strong

Allegheny

Westmoreland

Fayette Somerset

Bedford

Cambria Indiana

Elk

Jeffer -son Clearfield

McKean

Hunting -don

Fulton

Blair

Cameron

Clinton

Mifflin

Potter

Perry

Juniata

Lycoming

Snyder

Tioga

Sullivan

Bradford

Dauphin

Lebanon

Lancaster

York

Wyom -ing

Susque-hanna

Berks

Chester

Lehigh

Wayne

Lacka-wanna

Northampton

Delaware

Philadelphia

Bucks

HOP Pre-65 Medical Plan • Fee-for-service companion to HOP Medical Plan

and Value Medical Plan

• Details available in separate booklet

HOP Pre-65 Companion Plans

Managed Care Pre-65 Companion Plans • Aetna Premier Open Choice PPO

• Capital Blue Cross PPO

• Highmark PPO Blue (80-70 Plan)

• Independence Blue Cross – POS $20-$40/$250

• UPMC Health Plan EPO

Call the HOP Administration Unit (1-800-773-7725) if you want detailed materials for any Pre-65 Plan(s) available where you live.

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Follow These Steps to Enroll

• Review your Personalized Statement, comparing the different benefits and premiums for the options available to you

• Use enrollment application enclosed with Personalized Statement if you want to enroll in HOP Medical Plan, Value Medical Plan or HOP Pre-65 Medical Plan, one of the prescription drug options and/or dental coverage

• Call 1-800-773-7725 to request a packet if you want more details about any of the group Medicare Advantage (Part C) plans.

• Complete/submit the appropriate application about six weeks prior to your desired effective date; cannot submit more than 90 days in advance

• If you submit your application with fewer than 6 weeks before you want coverage to become effective, please include a check (payable to HOP) for the first month’s full premium

• Mail all enrollments to: HOP Administration Unit P.O. Box 1764 Lancaster, PA 17608-1764

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Questions?

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