Presentation on theme: "Optima Medicare (PPO) Plans CY 2010. Medicare Medicare is a Federal health insurance program for those age 65 or older or individuals at any age who have."— Presentation transcript:
Optima Medicare (PPO) Plans CY 2010
Medicare Medicare is a Federal health insurance program for those age 65 or older or individuals at any age who have certain disabilities, or who have End Stage Renal Disease (permanent kidney failure) The Centers for Medicare and Medicaid Services (CMS) is the Federal agency which regulates Medicare. The Social Security Administration performs administrative functions for the Medicare program and provides general information.
Medicare Medicare Part A (hospital insurance) mainly covers inpatient care in a hospital, skilled nursing facility, home health care or hospice program. Most beneficiaries do not pay for Part A. Medicare Part B (medical insurance) covers outpatient care, including physician services, diagnostic services, ambulance, certain limited drugs, and durable medical equipment. Beneficiaries will pay $96.40 for Part B in Upper income beneficiaries will pay more.
Medicare Medicare Part C (Medicare Advantage) plans cover Part A and B benefits. Private plans contract with CMS to administer Part C plans under contract. CMS pays private plans to provide these benefits. Medicare Advantage plans have uniform premium and cost-sharing amounts, except for limited income subsidy beneficiaries under Part D. Medicare Advantage plans may include Part D benefits (MA-PD).
Medicare Part D Plans Part D plans include –Prescription Drug Plans (PDPs), –Medicare Advantage – Prescription Drug (MA- PD) plans, –Cost Plans that offer Part D prescription drug coverage, and –Program of All-Inclusive Care for the Elderly (PACE) plans.
Enrolling In Medicare Advantage and Part D Plans
Election Periods Initial Election Period (IEP) –Beneficiary Dependent Annual Election Period (AEP) –November 15 to December 31 Open Enrollment Period (OEP) –January 1 to March 31 Special Enrollment Period (SEP) –Beneficiary Dependent
Annual Election Period (AEP) November 15, 2009 – December 31, Beneficiaries may add or drop MA and/or drug coverage. Beneficiaries may switch to a different plan offering drug coverage: –From a PDP to a different PDP, –From MA-PD to a different MA-PD, –From a PDP to an MA-PD or vice versa, or –To a Cost Plan offering Part D Beneficiaries have one AEP to use; once the enrollment is effective, the AEP has been used.
Open Enrollment Period (OEP) From January 1, 2010 through March 31, 2010 beneficiaries may make one change to how they receive their Medicare health benefits, but they may not add or drop drug coverage.
How Part D Works Stage 1 –Premium A premium is your monthly cost to maintain coverage. If you choose a Medicare Advantage plan with prescription drug coverage, your Part D premium will be included in the overall premium. Stage 2 –Deductible The amount you must pay for covered prescriptions before your Part D begins to pay. You pay the yearly deductible. Some plans like Optima Medicare (PPO) offer no deductible so you get coverage immediately.
How Part D Works - continued Stage 3 –Coinsurance You and your plan share the cost of your yearly prescription drugs until these costs reach $2,830. Stage 4 –The Coverage Gap When the total prescription costs reach $2,830, your drug benefit stops temporarily until you have paid $4,550 in total out-of-pocket expenses.
How Part D Works - continued Stage 5 –More than $4,550 Once you have paid $4,550, you pay either $2.50 per prescription for generic drugs and $6.30 per prescription for all other drugs or 5% coinsurance for the rest of the calendar year. Your plan pays the rest.
Medicare Health Care Plan Premium Payment Members can pay their premiums by: Monthly bill Automatic bank withdrawal Withholding from Social Security Administration The SSA Withholding option has created problems for many beneficiaries due to inter-agency coordination issues – we do not recommend it.
Marketing Notification by Brokers An organization must require that the person performing marketing make the following disclosure, prior to enrollment or at the time of enrollment, in writing, to a potential enrollee*: The person that is discussing plan options with you is either employed by or contracted with Optima Health. The person may be compensated based on your enrollment in an Optima Medicare plan. *Source: CMS Managed Care Manual, Medicare Marketing Guidelines
Optima Medicare (PPO) Plans and Benefits
Optima Medicare (PPO) Plans Optimas plans are Medicare Advantage Preferred Provider Organization plans. Members can receive benefits in or out-of- network. Optima Medicare plans provide benefits equivalent to Original Medicare, plus additional benefits. Optima Medicare plans are filed annually with CMS, and become effective on January 1 of each year - they are calendar year plans.
Optima Medicare (PPO) Plans Optima Medicare is a PPO Plan: Members can choose providers in or out of network. Out of Network providers are just like any provider - they may choose to participate in Medicare or not. Optima pays out of network providers the Medicare allowable fee schedule, just like Original Medicare or Medicare Supplement plans. With an Optima Medicare plan, members have freedom to travel, thanks to out of network coverage.
Optima Medicare (PPO) Plans 2010 Plans and Benefits In 2010, Optima will offer four plan designs: 2010 Medicare Plan Choices Optima Medicare Preferred Optima Medicare Preferred Plus Optima Medicare Value Optima Medicare Value Plus Monthly Premium $90.00$148.00$0.00
Part B and Part D Drug Coverage
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