Transcript WelcomeExcellus BlueCross BlueShield Medicare Plans Workshop Excellus BlueCross BlueShield contracts with the Federal government and is a Medicare Advantage Organization with a Medicare.

Welcome
2010
Excellus BlueCross BlueShield
Medicare Plans Workshop
Excellus BlueCross BlueShield contracts with the Federal government and is a
Medicare Advantage Organization with a Medicare contract.
(Sales Rep’s Name)
A nonprofit independent licensee of the Blue Cross Blue Shield Association
Medicare Sales Consultant
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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Agenda
 Medicare Basics
 Plan Options & Benefits
 Valuable Extras
 Enhanced Web Tools
 Questions
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Medicare Basics
There are two parts to Original Medicare: Part A and Part B
Part A
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Helps cover inpatient care in hospitals.
Helps cover skilled nursing facility, hospice and home health
care.
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You pay deductibles, coinsurance and copays.
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You usually don’t pay a monthly premium for Part A coverage
if you or your spouse paid Medicare taxes while working.
Medicare Basics
Part B
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Helps cover doctor’s services and outpatient care.
Helps cover some preventive care.
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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:
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•
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Vision Exam
Hearing Exam
Health and Wellness
Preventive Services
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
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.
Annual Enrollment Period (AEP)
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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)
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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
Medicare Advantage Plan Enrollment
Periods
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 Plan
Enrollment changes take effect on the first day of your birth month
Special Enrollment Period (SEP)
Change of residence into or out of the service area
Loss of employer coverage
Qualify 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.
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HMO vs. PPO
HMO
PPO
Health Maintenance Organization
Preferred 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
Can use In-Network & Out-of-Network
providers*
(You must use plan providers except in cases such as
emergency care, urgently needed care, or out-of-area
renal dialysis.)
(Out-of-pocket costs may be higher when you use an Outof-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
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Medicare
Medicare
Medicare
Medicare
Blue
Blue
Blue
Blue
Choice
Choice
Choice
Choice
ValueSM (HMO)
Value PlusSM (HMO)
OptimumSM (HMO)
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)
$500 copay for each Medicare-covered stay at a network hospital;
Maximum 3 copays per year;
4th and subsequent hospitalizations are covered in full
Inpatient Hospital Care
(unlimited days each benefit period)
Primary Care Physician
$20 copay per visit
Specialist
$40 copay per visit
Outpatient Hospital Services
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$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 supply
you pay:
$5 for Tier 1 generic drugs
$30 for Tier 2 preferred brand drugs
$75 for Tier 3 non-preferred drugs
25% coinsurance for Tier 4 specialty drugs
1
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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 nonsurgical. 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.
Medicare Blue Choice Value PlusSM (HMO)
$411
Benefit
Inpatient Hospital Care
(unlimited days each benefit period)
Medicare Blue Choice Value Plus (HM0)
$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 supply
you pay:
$5 for Tier 1 generic drugs
$30 for Tier 2 preferred brand drugs
$75 for Tier 3 non-preferred brand drugs
25% coinsurance for Tier 4 specialty drugs
1You
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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 nonsurgical. 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.
Medicare Blue Choice OptimumSM (HMO)
$1011
Benefit
Inpatient Hospital Care
(unlimited days each benefit period)
Medicare Blue Choice Optimum (HM0)
$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 supply
you pay:
$5 for Tier 1 generic drugs
$30 for Tier 2 preferred brand drugs
$75 for Tier 3 non-preferred brand drugs
33% 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
19 greater). Copays based on getting 30-day supply; call us about reduced copays for mail order or a
90-day supply.
Medicare Blue Choice PlatinumSM (HMO)
$611
Benefit
Inpatient Hospital Care
(unlimited days each benefit period)
Medicare Blue Choice Platinum (HM0)
$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
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.
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Medicare Blue PPOSM Plan 201 (PPO)
$361
In Network
Benefit
Out of Network
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
30% coinsurance
per 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% coinsurance
per 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 day
supply you pay:
$5 for Tier 1 generic drugs
$30 for Tier 2 preferred brand drugs
$75 for Tier 3 non-preferred brand drugs
25% 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
21 $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.
Medicare Prescription Drug Plan (Part D)
2 ways to get Medicare Prescription Drug Coverage:
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Join a stand-alone Medicare Prescription Drug Plan (PDP)
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Join a Medicare Advantage Prescription Drug Plan (MA-PD)
Medicare Prescription Drug Plan (Part D)
Formulary
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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
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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 1-800-4211220 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 BlueShield
PO Box 546
Buffalo, 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.
Medicare Prescription Drug Plan (Part D)
4 Coverage Phases
Catastrophic 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
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2 Benefits,
Catastrophic Coverage
You pay $2.50 for
generics and
$6.30 for brand
name drugs, or
5% of the price
(whichever is
greater)
Excellus BlueCross BlueShield
pays the balance
Coverage Gap
All costs are out-of-pocket
You Pay
Initial Coverage Period
Your copays/coinsurance
Excellus BlueCross BlueShield
pays the balance
Deductible is out-of-pocket
$0 or $1502
Out Of Pocket
Medicare Drug Benefit
limits for all phases of the Part D benefit change annually.
formulary, pharmacy network, premium, copayment/coinsurance may
change on January 1, 2011. Contact Excellus BlueCross BlueShield for details.
Medicare Prescription Drug Plan (Part D)
Some prescription drugs may have additional requirements or limits.
 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.
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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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Medicare Prescription Drug Plan (Part D)
People with limited incomes may qualify for Extra Help to pay for their
prescription drug costs. If eligible, Medicare could pay for:
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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.
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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.
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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Coverage While Traveling
Medicare Blue Choice:
 Emergency: Nationwide and Worldwide
 Urgent Care: Nationwide
 Routine Care: Covered under the Travel Benefit on
Medicare Blue Choice Optimum (HMO) and
Platinum (HMO) plans.
Medicare Blue PPO:
 Emergency: Nationwide and Worldwide
 Urgent Care: Nationwide
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Health and Wellness
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.
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Valuable Extras
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 TruHearing
The 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®
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Valuable Extras
 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.
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Enhanced Web Tools
Our Enhanced Web site
Allows members and prospective members to:
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Estimate annual costs
Compare our plans
Learn more about cost-cutting options
Enroll online*
…and more!
www.excellusbcbs.com/medicare
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*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.
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
•
•
•
•
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Social Security Administration:1-800-772-1213
TTY/TDD 1-800-325-0778
Monday – Friday 7:00 am – 7:00 pm
www.ssa.gov
Questions ?
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Thank You!
H3351, H3335
1774_0
(10/2009)