2016 medicare advantage ppo overview - affordable …€¦ · · 2018-03-10welcome uaw trust...

Welcome UAW Trust Members

2016 Medicare Advantage PPO overview

H9572_O_UAWTrustppt FVNR 0715

Agenda

• What is Medicare Advantage?

• Who is eligible for Medicare Advantage?

• Plan benefits

- Deductible, copayments and coinsurance

- Out-of-pocket maximum

- Covered services

• Plan extras

• How to enroll

Why you should choose Medicare Advantage PPO 2

What is Medicare Advantage?

The 2003 Medicare Modernization Act let private companies contract with the federal government to administer Original Medicare benefits.

These plans are called Medicare Advantage plans. You still have all the benefits, rights and

protections of Original Medicare.

Medicare Advantage plans combine Medicare Parts A and B and may offer additional benefits not covered under Original Medicare.

Medicare

Advantage

plans provide:

+ Enhanced and additional benefits (supplemental coverage)

Why you should choose Medicare Advantage PPO

Original Medicare

Part A

Original Medicare

Part B

&

One comprehensive health care plan

3

Where am I covered?

Blue Cross Blue Shield of Michigan gives you access to providers anywhere in the United States.

Your benefits travel with you anywhere in the United States and its territories.

You’re covered for emergency and urgent care worldwide.

When traveling outside of the United States, in some cases, you’ll have

to pay for your emergency and urgent care and get a refund from us.


Who can join?

You’re eligible for the Medicare Advantage PPO if the following conditions are met:

NOTE: You can only

be enrolled in one

Medicare Advantage

plan at a time

• You are enrolled in Medicare Part A and Part B. (You must continue to pay Part B premium.)

• Your permanent address must be in any of the 15 states where the plan is offered through the Trust.

Although your

permanent address

must be in one of

the 15 blue states,

you are covered for

services in all 50

states.


Medicare Advantage PPO providers

• PPO, or Preferred Provider Organization, in-network or out-of-network benefits

• In-network – a provider who has a contractual

agreement to be a part of the Blue Cross Blue Shield Medicare Advantage PPO network

• Out-of-network – a provider who is not contracted to be a part of the Blue Cross Blue Shield Medicare Advantage PPO network

• Freedom to choose any doctor, specialist or hospital

- Your out-of-pocket costs are less when medical care is provided by an in-network PPO provider

- Referrals are not required


Are my providers in the Blue Cross Medicare Advantage PPO network?

Click www.bcbsm.com

Call 1-877-336-0377

Monday through Friday,

8:30 a.m. to 8 p.m. Eastern time

TTY users, call 711

or

You can also call your provider’s office and speak to the billing department. You can ask,

“Do you participate with the Medicare Advantage PPO plan offered by Blue Cross Blue Shield?”


Special provision for Florida We are still enhancing our provider network in some communities (shaded in blue). We encourage you to seek network doctors,

hospitals and other facilities. However, if you receive care from a non-network provider that accepts Original Medicare in one of the counties listed below, your care will be treated as if it were provided in-network.

These counties include: Baker, Brevard, Calhoun, Dixie, Gadsden, Gilchrist, Glades, Hamilton, Holmes, Jefferson, Lafayette, Liberty, Madison, Monroe, Nassau, Okeechobee, Putnam, Taylor, Union, Wakulla, and Washington.

Note: Residents of all other Florida counties should see in-network providers for their lowest cost share.

2016 Plan Year


Special provision for Massachusetts We are still enhancing our provider network in some communities (shaded in blue). We encourage you to seek

network doctors, hospitals and other facilities. However, if you receive care from a non-network provider that accepts Original Medicare in one of the counties listed below, your

care will be treated as if it were provided in-network.

These counties include: Berkshire, Dukes and Nantucket.

Note: Residents of all other Massachusetts counties should see in-network providers for their lowest cost share.

2016 Plan Year


Special provision for North Carolina

We are still enhancing our provider network in some communities (shaded in blue). We encourage you to seek network doctors,

hospitals and other facilities. However, if you receive care from a non-network provider that accepts Original Medicare in one of the counties listed below, your care will be treated as if it were

provided in-network.

These counties include: Burke, Camden, Cherokee, Clay, Craven, Currituck, Dare, Graham, Jackson,

Lenoir, Macon, Moore, Pasquotank, Rutherford, and Swain. Note: Residents of all other North

Carolina counties should see in-network providers for their lowest cost share.

2016 Plan Year


Special provision for Virginia

We are still enhancing our provider network in some communities (shaded in blue). We encourage you to seek network

doctors, hospitals and other facilities. However, if you receive care from a non-network provider that accepts Original Medicare in one of the counties listed below, your care will be treated as if it were provided in-network.

Note: Residents of all other Virginia counties should see in-network providers for their lowest cost share.

These counties include: Accomack, Alleghany, Amherst, Arlington, Augusta, Bath, Bland, Brunswick, Buchanan, Buckingham, Campbell, Carroll, Clarke, Dickenson, Essex, Fairfax, Fauquier, Frederick, Grayson, Greene, Halifax, Henry, Highland, Isle of Wight, King

George, King William, Lee, Loudoun, Mecklenburg, Nelson, Nottoway, Patrick, Pittsylvania, Prince Edward, Prince William, Rappahannock, Rockingham, Russell, Scott, Smyth, Southampton, Spotsylvania, Stafford , Sussex, Tazewell, Washington, Westmoreland, Wise and Wythe.

2016 Plan Year


• You use only your Medicare Plus Blue Group PPO card when you need medical care.*

• All your medical claims will be processed through Medicare Plus Blue Group PPO.

• Put your Medicare card and your old medical insurance card in a safe place.

*(Express Scripts provides

a separate prescription

drug card.)

Plan name

Medicare Advantage

Confidence comes with every card®.

Confidence comes in carrying one of the most recognized cards.


• Deductible – the amount you pay before your plan begins to pay

• Coinsurance – the percentage you pay for covered services after you have met your

deductible

• Copay – fixed amount you pay to receive a medical service, usually at the time of service (office visits, emergency room, urgent care)

• In network – a provider who has a contractual agreement to be a part of the Medicare

Advantage PPO network from Blue Cross Blue Shield

• Out of network – a provider who is not contracted to be a part of the Medicare Advantage PPO network from Blue Cross Blue Shield

• Coinsurance out-of-pocket maximum – the most you will pay in deductible and coinsurance during the year

• Copay out-of-pocket maximum – the most you will pay in copays during the year

Understanding important terms


In network Out of network

Office visits

(Primary care doctor)

Covered – $20 copay Covered – 50%

coinsurance after

deductible

Specialist visits

(No referral required)

Covered – $25 copay Covered – 50%

coinsurance after

deductible

Chiropractic manipulations Covered – $20 copay Covered – 50%

coinsurance after

deductible

Emergency care Covered – $50 copay (copay waived if admitted)

Urgent care Covered – $25 copay

Ambulance services (if medically necessary) Covered – 10% coinsurance

This information is not a complete description of benefits.

Contact the plan for more information. Limitations,

copayments and restrictions may apply. Benefits, provider

network, premium and/or copayments/coinsurance may

change on January 1 of each year.


Plan benefits

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Annual deductible per member per year $245 $490

In network and

out of network combined

Coinsurance 10% coinsurance

30% coinsurance

Out-of-pocket maximum for deductible and

coinsurance amounts for Medicare-covered

medical services, per member per year

$630 $1,395

In network and

out of network combined

Out-of-pocket maximum for copay-based

services

This is a safety net to ensure you do not pay more

than $3,000 in copays in one year

After the deductible is met, your plan has a coinsurance for

services, such as:

• Inpatient hospital services

• Skilled nursing facility

• Outpatient services

• Radiology services

• Surgical services

• Outpatient audiology, cardiac, physical, respiratory,

speech and occupational therapy

Deductible, coinsurance

and dollar maximums

Deductible and

coinsurance applies

to the out-of-pocket

maximum.



Welcome to Medicare exam Covered at 100% Covered at 100%

Routine physical Covered at 100% Covered at 100%

Pap smear and prostate cancer screening Covered at 100% Covered at 100%

Cardiovascular, diabetes and HIV screening Covered at 100% Covered at 100%

Immunizations Covered at 100% Covered at 100%

Mammography Covered at 100% Covered at 100%

Bone mass measurement Covered at 100% Covered at 70%

Colorectal cancer screening Covered at 100% Covered at 70%


Preventive services

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Hearing aids

We pay up to our

allowed amount, not to

exceed the benefit limit

of $2,000.

Coverage is for two

standard (analog or

digital) hearing aids

every 36 months.

We pay up to our

allowed amount, not to

exceed the benefit limit

of $2,000.

Coverage is for two

standard (analog or

digital) hearing aids

every 36 months.

Routine hearing test, fitting and evaluation $25 copay 30% coinsurance


Hearing

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*These services are covered in accordance with Medicare

guidelines. This is not an all-inclusive list of items available;

these are just some of the most commonly used items.



Durable medical equipment*

• Respirator equipment

• Compression stockings

• Wheelchairs

• Walkers and canes

• Neuromuscular stimulators

• Hospital beds

• Oxygen and CPAP

Covered at 100% Covered at 100%

Prosthetics and orthotics*

• Orthotic shoes

• Post-mastectomy bras

• Artificial limbs


Diabetic supplies*

• Self-testing monitor

• Test strips

• Lancet devices


DME and diabetic supplies

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Once you’re enrolled, you will receive an optional health assessment

• Quick and to the point

• Identifies potential health risks

• Gives you a lifestyle score and a plan for improvement

• Provides personalized feedback from wellness professionals

• Available online as well as on paper

• Secure and completely confidential


Help through life’s toughest moments

You may receive a telephone call or letters.

Additional programs we offer:

• 24/7 phone access to Blue Cross nurses.

• In-home health assessments.

• Assistance when you transition from hospital to home.

• Support during cancer treatment.

• In-home monitoring devices for COPD and heart failure.

• Nurse-driven coordination of care for complex medical situations.

• Tobacco cessation program, including access to a health coach.

• Welvie – an internet-based program that walks you through the surgery decision

process. It provides a unique, step-by step approach from diagnosis to recovery.


SilverSneakers® Fitness program

Included in coverage for Medicare Advantage members:

• Membership in a network of health clubs and exercise classes.

• More than 14,000 participating U.S. locations (no restrictions on days and times).

• Program AdvisorsSM at each location.

• SilverSneakers classes at many locations, appropriate for all fitness levels.

• Learn how exercise can improve your body, mind and spirit.

• Exercise at your own pace and have fun with people in your age group.

SilverSneakers® is a registered mark of Healthways, Inc. Healthways is an independent corporation retained by

Blue Cross Blue Shield of Michigan to provide fitness services to its Medicare Plus Blue Group PPO members.


Your prescription drug coverage is not covered by Blue Cross Blue Shield of Michigan. Your drug coverage is with Express Scripts®, which is a separate company from Blue Cross.

Prescription drug benefit


For information about prescription drug coverage, contact Express Scripts Medicare Customer Service at 1-866-662-0274. At the prompt, press 1. Customer Service is available

24 hours a day, seven days a week.

22

ID cards Explanation of benefits

Traditional Care Network

Medicare Advantage PPO

What are the differences?


Monthly

contribution✓

Deductible Out-of-pocket

maximum

Traditional Care Network $17 a month

($204 per year†)

$385

In network

$755

In network

Medicare Advantage PPO $0 per person $245

In network

$630

In network

Savings $17 per month

($204 per year*) $140* $125*



Deductible, copayments,

coinsurance and dollar maximums

24

✓You must continue to pay your Part B premium. †Amounts are based on a single-person contract.

*Savings may vary based on when you enroll and how much you

use your coverage.


Primary Care

Office visit

Specialist

Office visit


You pay 20%

of covered charges after

your Medicare Part B

annual deductible is met†

You pay 20%

of covered charges after

your Medicare Part B annual

deductible is met†

Medicare Advantage PPO

$20 per visit

In network

(not subject to Part B

deductible)

$25 per visit

In network


deductible)

Savings $20 copay vs. 20%

after your Part B

deductible*

$25 copay vs. 20% after your Part B deductible*

†Covered under Original Medicare


use your coverage.


Physician office services

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Emergency care visit Urgent care visit

Traditional Care Network $125 copay $50 copay

Medicare Advantage PPO $50 copay $25 copay

Savings $75

per visit*

$25 per visit*


use your coverage.

Emergency medical care

26



Inpatient hospital

services

Outpatient surgery

Skilled nursing

Physical therapy

Laboratory and

pathology tests

Traditional Care Network 10% coinsurance after plan

deductible is met

10% coinsurance after plan

deductible is met

Medicare Advantage PPO 10% coinsurance after plan

deductible is met 100% covered

Savings Lower deductible*

saves you money

100% covered vs. 10% after your Traditional Care

Network deductible is met*


use your coverage.

Hospital and

other services

27

Outpatient

diagnostic

services



Chiropractic spinal manipulations

SilverSneakers® Fitness club membership


You pay 20% of covered

charges after your

Medicare Part B annual

deductible is met

Not a benefit

Medicare Advantage PPO $20 per visit in-network


deductible)

Free — included at no cost

with your coverage

$20 copay vs. 20% after your Part B deductible

Free fitness membership

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How to enroll

• Call Retiree Health Care Connect at 1-866-637-7555

8:30 a.m. to 4:30 p.m. Eastern time, Monday through Friday.

TTY users call 711.

• To enroll for a January 1 effective date, you must call

between November 2 and 25.

• If you choose to enroll after November 25, your effective date

will vary based on when you enroll.

• Coverage is effective the first day of the second month

after you enroll (for example, if you enroll in December

2015, your coverage will start on February 1, 2016).


If you enroll during Your coverage will start on

October 2015 January 1, 2016

November 2015 January 1, 2016

December 2015 February 1, 2016

January 2016 March 1, 2016

February 2016 April 1, 2016

March 2016 May 1, 2016

April 2016 June 1, 2016

May 2016 July 1, 2016

June 2016 August 1, 2016

July 2016 September 1, 2016

August 2016 October 1, 2016

September 2016 November 1, 2016


Don’t leave your money behind When a Traditional Care Network member transfers to Medicare Advantage PPO during the

calendar year, you get credit for what you’ve already paid toward your TCN Plan*:


*This applies only to members transferring from the TCN plan to Medicare Advantage PPO.

31

• Deductible up to $245 per person

• Out-of-pocket maximum up to $630 per person

TCN MA

• View your claims.

• View and print your EOBs.

• Check to see if your doctor or hospital is in the network.

• Check current out-of-pocket totals for:

- Deductible

- Out-of-pocket maximum

Easy to use tools

You can save yourself a phone call with our easy-to-use website, www.bcbsm.com. After you create your member

account, you can:


http://www.bcbsm.com

• If you choose the Medicare Advantage plan, the Trust will waive your monthly contribution for 2016.

(Your monthly contribution is the part that comes out of your pension check.)

You must continue to pay your Medicare Part B premium.

• You can enroll at any time.

• You are always free to disenroll and switch back to TCN coverage.

• Over 63,000 UAW Trust members have already enrolled in

the Medicare Advantage plan from Blue Cross Blue Shield of Michigan.

• Free SilverSneakers Fitness membership.

Reasons to join


Ready to join? Here’s what happens next


1

2

3

4

5

We’ll confirm your eligibility.

(Two to three weeks before the start date of your coverage)

Look for your Blue Cross Blue Shield of Michigan member ID card.

(One to two weeks before the start date of your coverage)

Review your welcome packet.

(One to two weeks before the start date of your coverage)

Start using your plan.

Start using SilverSneakers participating facilities.

Questions before enrolling? Call:

1-877-336-0377

8:30 a.m. to 8 p.m. Eastern time

Monday through Friday, TTY users, call 711

Or visit our website www.bcbsm.com/UAWTrust

Contact information

SilverSneakers

1-866-584-7352

TTY users call 711

www.silversneakers.com*

Prescription drug Express Scripts®

1-866-662-0274

24 hours a day, 7 days a week

To enroll call Retiree Health Care Connect 1-866-637-7555 8:30 a.m. to 4:30 p.m. Eastern time

Monday through Friday, TTY users call 711

Why you should choose Medicare Advantage PPO 35 R040913

*Blue Cross Blue Shield of Michigan does not control

this website or endorse its general content.

2016 medicare advantage ppo overview - affordable …€¦ · · 2018-03-10welcome uaw trust...

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