humana medicare advantage and prescription drug plans y0040_spm_spre_mapd_13 cms approved...
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Humana Medicare Advantage and Prescription Drug Plans
Y0040_SPM_SPRE_MAPD_13 CMS ApprovedGNHH31KHH_13
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Medicare/Medicaid Coverage (Dual-Eligible):
• Do you qualify?
• If so, contact your state Medicaid agency and your doctor to see if a dual-eligible Special Needs Plan (SNP) is a good option for you.
• If you choose a dual-eligible SNP, you may be protected from cost sharing by the state and will not have to pay deductibles, copays, coinsurances associated with the Dual-Eligible SNP plan’s services. This will depend on the level of Medicaid coverage for which you are eligible.
Getting started…
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Are you eligible for a Medicare Advantage Plan?
• Enrolled in Medicare Part A and Part B?
• Permanent resident in service area?
• Have End-Stage Renal Disease (ESRD)?
End Stage Renal Disease is permanent kidney failure usually requiring dialysis or a kidney transplant. People with ESRD stay with Original Medicare. If you have ESRD, see me later about Special Needs Programs and other information.
Federal law won’t let us accept anyone with End-Stage Renal Disease – often called kidney failure – unless you:1. Have another health plan from the same organization within the same state, or
2. Were enrolled in a Medicare Advantage plan that was terminated or discontinued after Dec. 31, 1998, and this is your first election since that happened.
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2013 Plan Year Medicare Timeline
Compare plans so you’ll be ready to enroll by Oct. 15.
Pre-Enrollment: Oct. 1 – Oct. 14, 2012
Annual Election: Oct. 15 – Dec. 7, 2012
Annual Disenrollment: Jan. 1 – Feb. 14, 2013 Feb. 15 – Oct. 14, 2013
Note: This information doesn’t apply to Medicare Supplement Plans
If you’re eligible, you can enroll in Medicare health benefits, such as a Medicare Advantage plan with or without prescription drug coverage. Or you may choose to enroll in a stand-alone prescription drug plan.
Medicare Advantage plan members may disenroll from their MA plan and return to Original Medicare. They may also elect enrollment in a stand-alone drug plan.
You can't make a plan change without special circumstances (e.g., you move, you qualify for or lose eligibility for Medicaid).
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• Choosing the right Humana plan for you
• Your Medicare coverage options
• Humana’s plans and extras
• How to enroll
Let’s talk about . . .
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Humana offers a wide range of products and services that incorporate an integrated approach to lifelong well-being.
Dedication to the community• More than 50 years of helping people of all ages
Financial stability• Fortune 100 company
National coverage• Providing Medicare plans in 50 states, Puerto Rico, and the District of Columbia
Experience behind the coverage
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• What type of plan do you have now?
• What do you like about your coverage?
• What would you add to your current coverage to make it ideal for you?
• Who helps you make decisions about your healthcare?
The right Humana plan for you
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Medicare Today
Original Medicare ID Card
Medicare Supplement ID Card
Medicare Part D ID Card
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You receive a service, you pay a fee
• Usually pay a monthly premium for Part B
• You will have access to any doctor or provider that accepts Medicare
• Out-of-pocket costs include hospital and medical deductible and coinsurance
• May want to purchase separate Medicare Supplement insurance and Prescription Drug Plan to cover gaps
Original Medicare
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Medicare Supplement Insurance (also referred to as a Medigap policy)
• Purchased from private insurance companies
• Supplements Original Medicare coverage
• Covers some costs Original Medicare doesn’t pay
• Original Medicare pays before the Medicare Supplement plan provides payment
• Plans are standardized and can be purchased with varying coverage options
• Medicare Supplement plans have no provider networks
Original Medicare + Medicare Supplement Insurance
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• Private insurance companies approved by Medicare provide this coverage
• Provides Medicare beneficiaries a choice in how they receive Medicare coverage
• MA plans are not Medicare Supplement insurance plans
• These plans must offer all benefits of Original Medicare and can include Part D prescription drug coverage
• All plans offer maximum out-of-pocket protections
• MA plans include emergency coverage when traveling outside the US
What are Medicare Advantage (MA) health plans?
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Why Medicare Advantage?
• Most plans offer health and drug coverage
• Extra benefits, discounts and value added services
• Most plans have lower out-of-pocket costs than Original Medicare
• Very little paperwork
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Medicare Advantage (MA) plans
• Health Maintenance Organization (HMO) FIND OUT MORE
• Preferred Provider Organization (PPO) FIND OUT MORE
• Private-Fee-for-Service (PFFS) FIND OUT MORE
Part D Medicare Prescription Drug coverage
•May be purchased as a stand-alone plan; or
•As part of a Medicare Advantage Prescription Drug Plan (MAPD)
All plans must meet minimum coverage level set by Medicare
More plan choices with Medicare Advantage
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Health Maintenance Organization (HMO)
• Defined network of providers
• Primary Care Physician (PCP) coordinates all of your care
• You may have to receive a referral from your PCP to see a specialist
• In most cases, you must use network providers for all scheduled care. There is no coverage for out-of-network care, except for emergency or urgent care
• Out-of-pocket costs may be significantly lower than Original Medicare
Go to: Is a Stand-Alone drug plan right for you?
Is an HMO right for you?
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Dual Eligible Special Needs Plan (SNP)
• Additional benefits over Medicaid
• Enhanced Care Management Services
• Defined network of providers
• Primary Care Physician (PCP) coordinates all of your care
• Individualized care plan that caters to your needs
• In most cases, you must use network providers for all scheduled care. No coverage for out-of-network care, except for emergency or urgent care
• Out-of-pocket costs may be significantly lower
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Chronic Condition Special Needs Plan (SNP)
• Additional benefits tailored to members with certain chronic conditions
• Enhanced Care Management Services
• Defined network of providers
• Primary Care Physician (PCP) coordinates all of your care
• Individualized care plan that caters to your needs
• In most cases, you must use network providers for all scheduled care. No coverage for out-of-network care, except for emergency or urgent care
• Out-of-pocket costs may be significantly lower
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Preferred Provider Organization (PPO)
• Defined network of providers
• No referral needed to see any doctor
• Flexibility to use providers who aren’t part of the network
• Out-of-pocket costs may increase significantly when you use out-of-network providers, facilities or labs, except for emergency care*
• You may save more when you use network providers because the plan pays a larger share of the cost
Go to: Is a Stand-Alone drug plan right for you?
Is a PPO right for you?
* In some cases, the costs are the same in and out of network
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Private-Fee-for-Service (PFFS)
• No referral needed to see any doctor
• Most plans include provider networks, but any provider can participate except under the following conditions:
— Your doctor must agree to accept the Private-Fee-for-Service plan’s payment terms and conditions
— For plans with Rx you must use network pharmacies to obtain prescription drugs, except in emergencies or urgent situations
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Is a PFFS right for you?
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PFFS plan review
Private-Fee-for-Service (PFFS)
• Before seeing a provider, you should consider . . .
—A Private Fee-for-Service plan is not a Medicare supplement plan. Providers who do not contract with our plan are not required to see you except in an emergency.
— If they choose to provide services, they must bill the Private-Fee-for-Service plan for your covered healthcare services. They may not bill you.
— If your PFFS plan has a network, you can still receive services from non-network providers, but you may pay more to see a doctor or other healthcare professional who isn’t in our network.
—Private-Fee-for-Service plans do not pay after Medicare pays its share.
—You’re required to pay the appropriate deductibles, copayments, and coinsurance.
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PFFS plan review
• We have network providers – providers who have signed contracts with our plan – for all services covered under Original Medicare in our fully networked plans.
• For partial network plans, contracted providers are limited to certain Durable Medical Equipment providers, home health providers, and some freestanding labs. These providers have agreed to see members of our plan.
• Providers can find the plan’s terms and conditions of payment on our website.
www.humana-medicare.com/medicare-advantage-plans/humana-gold-choice-terms-conditions.asp
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Is a stand-alone drug plan right for you?
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Medicare Part D Prescription Drug Plans (PDP)
• Plans offered by private companies under contract with Medicare
• Companies may offer plans with different levels of coverage
• Check your prescription drug needs with the plan's coverage and drug list as well as with your cost for those drugs
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The basic plan (defined by Medicare). All Part D plans are required by law to offer benefits equal to or better than:
Basic Prescription Benefit
* See Coverage in the Gap on following slide** Annual Out-of-Pocket Amount doesn’t include monthly premiums.
2013 Medicare Prescription Drug Plan Basic Coverage
2013 Basic Benefits You Pay
Deductible $325 100% of first $325
Initial Coverage Limit $2,970 25% of the next $2,645 ($661.25)
Coverage Gap* $3,763.7547.5% of covered brand name and 79% of generic drugs of the next $3,763.75 until the cumulative out-of-pocket costs reach $4,750
Annual Out-of-Pocket Amount $4,750**
Catastrophic Coverage Medicare and Plan 95%$2.65 for generic/multiple-source drug and $6.60 for all other drugs; or 5% coinsurance, whichever is greater
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• It’s also called the “donut hole.” • The “coverage gap” happens when you have to pay part of your drug costs. • In 2013, you’ll generally pay no more than 47.5 percent on applicable brand-name drugs. • Generally, you’ll pay no more than 79 percent for generic drugs until your annual
out-of-pocket costs reach $4,750.
Here’s How it Works1. Plans pay part of your costs until the total drug costs add up to $2,970
2. Once the total drug costs reach $2,970, you’ll enter the coverage gap, where you’ll pay 47.5 percent on applicable brand name drugs, and 79 percent for generic drugs, until your annual out-of-pocket costs reach $4,750
3. When your annual out-of-pocket costs reach $4,750, your plan returns to paying a larger share of your drug costs
Get to Know the Coverage Gap
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Find out about your Humana benefits
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In Network Providers
Like Medicare, Humana cannot guarantee that your provider is in or will remain part of a plan network. Here are two ways you can determine whether your provider accepts your Humana Medicare Advantage Plan:• Use Humana’s online provider look-up, Physician Finder• Call your provider’s billing department and ask if the
provider accepts the specific Humana plan you are considering
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You have unique needs for staying healthy. That’s why Humana offers optional supplemental benefits* (OSBs).
OSBs are extra benefits not included in Original Medicare that:•Provide choices that make it easier for you to get coverage you want •Control costs and personalize your benefit needs•Can be added when you enroll in Medicare Advantage or any time during the year
These benefits have an extra premium, which is combined with your Medicare Advantage plan premium.
*may not be available on all plans
Add optional benefits
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• Mail-order pharmacies*
• Fitness program*
• 24-hour nurse hot line*
• SmartSummary®
• Humana Active Outlook® (HAO)*
• Personal Health Coaching*
• Online tools on Humana.com and m.humana.com
*may not be available with all plans
Value and Well-being
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Complete an application
In the next two weeks:
Humana processes your application and confirms your eligibility
You’ll receive a verification call for each enrollee in the household
Medicare confirms your enrollment
Receive your ID card
Member Benefit Package arrives in your mailbox
Health Assessment We’ll contact you about completing a health questionnaire
What happens now?
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In the months to come:• Member Kickoff Meeting
• Your Humana agent calls you
• Evidence of Coverage
• SmartSummary®
• Annual Wellness Visit
• Use your Preventive benefits
What happens next?
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• If you wonder if you can afford your prescription medicines
• Call to see if you may qualify for money the Federal government has set aside to help people with their drug expenses
— 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, seven days a week;
— The Social Security office at 1-800-772-1213 TTY users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.; or
— Your state Medicaid office
Extra Help
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Thanks for your time and attention. Any questions?
Where to find information:
• “Medicare and You 2013” handbook (available in October or November 2012)
• www.medicare.gov
• Your local State Health Insurance Program (SHIP)
• Humana-Medicare.com
• Humana offers Member Kickoff Meetings
- Bring the Humana Guide from your Member Benefit Package
Questions?
Humana is a Medicare Advantage organization and a stand-alone prescription drug plan with a Medicare contract. Medicare beneficiaries, except for Group Medicare or Special Needs Plans, may enroll in the plan only during specific times of the year. Contact Humana for more details.
You must use network pharmacies, except under non-routine circumstances. Quantity limitations and restrictions may apply. If you are a member of a qualified State Pharmaceutical Assistance Program, please contact the Program to verify that the mail order pharmacy will coordinate with that Program.
This information is available for free in other languages. Please contact our Customer Care number at 1-800-457-4708 (TTY: 711) for additional information. Hours are 8 a.m. to 8 p.m., seven days a week through Feb. 15, 2013 and 8 a.m. to 8 p.m. Monday – Friday the rest of the year.
Esta información está disponible gratuitamente en otros lenguajes. Póngase en contacto con nuestro Departamento de Atención al Cliente al 1-800-457-4708 (TTY: 711) si desea mayores informes. El horario es de 8 a.m. a 8 p.m., los siete días de la semana hasta el 15 de febrero de 2013 y de 8 a.m. a 8 p.m. de lunes a viernes por el resto del año.
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