| Coverage | |
| Summary of Coverage and Disclosure of Information | |
| Platinum Blue | |
| Benefits | |
| 2010 Medicare Benefits | |
| Monthly Rate Chart (effective Jan. 1, 2010) | |
| Monthly Rates for 2010 | |
| Dental Benefits and Rates |
About Medicare Medicare is a federal program that began in 1965 to provide health insurance for older Americans. Today, Medicare is the nation’s largest health insurance program, covering more than 44 million people age 65 and over and those with certain disabilities. Medicare has traditionally provided coverage for health care services such as hospital stays, skilled nursing facilities and doctors’ visits. As a result of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Medicare also provides prescription drug coverage and additional health plan options. This booklet is your guide to understanding Medicare, prescription drug coverage and your health plan options. You’ll learn more about Original Medicare (Part A and Part B), Medigap (Medicare supplement) plans, Medicare Cost plans, Medicare Advantage plans and Medicare Prescription Drug Plans. Original Medicare Original Medicare has two parts — Medicare Part A and Medicare Part B. Medicare Part A helps pay for inpatient care in hospitals and skilled nursing facilities. It is available at no cost to most everyone eligible for Medicare. Medicare Part B helps pay for doctor visits, physician services, lab tests, durable medical equipment and outpatient hospital treatment. Part B is available, for a monthly premium, to most people who are eligible for Medicare. The Centers for Medicare & Medicaid Services (CMS) is the administrator of Original Medicare. The Social Security Administration automatically enrolls most people in Original Medicare when they request Social Security benefits. You do not have to be retired to enroll in Original Medicare, and you can enroll in Original Medicare up to three months before you reach age 65. Contact the Social Security Administration at 1-800-772-1213 (TTY 1-800-325-0778) from 7 a.m. to 7 p.m., Monday through Friday, or go online to www.ssa.gov. Part A: Hospital Medicare Part A pays for inpatient hospital stays, skilled nursing facility care and hospice care after you pay deductibles and coinsurance. Hospital services Part A covers a semiprivate room, meals and eligible services for up to 90 days per benefit period. In 2010: Skilled nursing facility care Part A covers up to 100 days for eligible services in a Medicare-certified skilled nursing facility after a hospital stay of at least three covered days. In 2010: Hospice care Hospice services are paid by Medicare. Terminally ill patients may receive drugs for symptom control and pain relief, short-term respite care and home health services. Care must be provided by a Medicare certified hospice program. Home health care visits Unlimited visits for home health care are paid at 100 percent when ordered by a doctor and provided by a nurse and/or therapist from a Medicare-certified home health agency. Part B: Medical Medicare Part B covers doctors’ services, outpatient hospital care, durable medical equipment and some medical services and supplies not covered by Medicare Part A. For Part B, in 2010 you pay: for eligible services considered medically necessary *2010 Part B premium will be higher if an individual beneficiary’s income exceeds $85,000 (or a married couple’s income exceeds $170,000) Part B eligible services of your treatment but are not covered under Part A oxygen, ventilator-assist devices and durable medical equipment used in your home; prosthetic devices and portable X-ray services home health care facilities or rehabilitation facilities and ambulance transportation procedures performed at a Medicare certified ambulatory surgical center furnished by a certified comprehensive outpatient rehabilitation facility - Drugs received in a hospital’s outpatient department (in limited circumstances) - Certain cancer drugs taken by mouth - Drugs used with some types of medical equipment (such as a nebulizer or infusion pump) What Original Medicare doesn’t cover Original Medicare doesn’t cover all medical costs. You must pay deductibles and coinsurance when you receive health care services. Original Medicare also does not cover routine physicals, eye exams or outpatient prescription drugs. Your out-of-pocket expenses (the costs you pay) for these “coverage gaps” can add up quickly. Fortunately, you can enroll in several private health plan options to help cover services that Original Medicare does not cover. Some of these plan options include: Medigap (Medicare supplement) plans Medigap plans are sold by private health insurance companies and help pay for some of the health care costs or “gaps” that Medicare doesn’t cover. In most cases, you must have both Medicare Part A and Part B to buy a Medigap policy. In Iowa, Montana, Nebraska, North Dakota, South Dakota and Wyoming, there are 12 standardized Medigap policies, called Plans “A” through “L.” Each plan has a different set of benefits and different premiums, but not all companies offer all 12 policies. In Minnesota, there are three Medigap plans called Basic, Extended Basic and Medicare Select. Each plan has a different set of benefits and premiums. Many of these plans will have optional riders through which you can purchase more benefits for an additional monthly premium. If you have Medicare and also want drug coverage with your Medigap plan, you’ll need to purchase a separate stand-alone prescription drug plan. Buying a Medigap policy You don’t have to buy a Medigap health plan. However, you can choose to enroll in a plan to help pay for some of the health care costs not covered by Medicare. Your Medigap initial enrollment period starts on the first day of the month in which your Medicare Part B coverage becomes effective and ends six months later. If you don’t buy a Medigap plan when you’re first eligible, you may not be able to enroll at a later date. Other Medicare health plans In some states, other Medicare health plans, such as Cost plans, may be available. Cost plans offer additional benefits to help pay for expenses that Medicare doesn’t cover. Cost plans are regulated by both federal and state governments. That means benefits, level of coverage and provider networks may be different from Medigap plans. Cost plans also accept members who have only Part B coverage. Part D: Prescription drug plans Medicare works with health plans and other private companies to offer prescription drug plans. These Medicare-approved drug plans are also known as stand-alone Part D plans. Medicare Prescription Drug Plans provide insurance coverage for generic and brand-name prescription drugs. If you join a plan, you will likely pay a monthly premium, plus a share of the cost of your prescriptions. There are different drug plans available that vary by types of drugs covered, how much you have to pay and the pharmacies you can use. All drug plans must provide at least a standard level of coverage. Generally, the standard Medicare prescription drug coverage works like this:  It is important to keep in mind that many private Medicare prescription drug plans do not look like this standard design. Many plans offer enhanced prescription drug coverage for a higher premium and provide more coverage than the standard level of coverage. Extra help is available If you have limited income and resources (including savings, stocks and bonds, but not including a home and car), you may be able to get extra help to pay for your prescription drug coverage premiums and costs. To see if you qualify for getting extra help, call one of the following: TTY users should call 1-800-325-0778; or Medicare Advantage plans Medicare Advantage plans offer additional health plan choices for people with Medicare. With a Medicare Advantage plan, you can get Medicare Part A and Part B benefits, additional benefits and prescription drug coverage all from one plan. Benefits, premiums and copayments may change annually. Medicare works with health plans and other private companies to offer Medicare Advantage plans. Types of Medicare Advantage plans Health Maintenance Organization (HMO) plans have doctors and hospitals that are in the plan’s network. You will need to get most of your care and services from this network. You may need a referral for some services and to see providers who are not part of the network. You may pay more or may not be covered for services outside of the plan’s network. Preferred Provider Organization (PPO) plans also have doctors and hospitals that are in the plan’s network. In a PPO, however, referrals are not necessary to see a doctor, specialist or out-of-network provider. You may pay more if you go to doctors, hospitals or other providers that aren’t part of the PPO network. Private Fee-for-Service (PFFS) plans are similar to regular fee-for-service Medicare plans except that a private company, rather than Medicare, decides how much it will pay and how much you will pay for services. These plans are not required to have a provider network. If there is no network, you can go to any doctor or hospital. However, the provider must accept the plan’s payment terms before you can receive services. Medicare Advantage prescription drug coverage When you join a Medicare Advantage plan, you can receive Medicare-approved prescription drug coverage (Part D) through that plan’s Medicare Advantage prescription drug plan option. You’ll get all of your benefits (hospital, medical and prescription drugs) from one plan. If the Medicare Advantage plan you join offers prescription drug coverage, you can only get prescription drug coverage from that plan. That means if you have a Medicare Advantage plan that offers prescription drug coverage, you cannot enroll in a stand-alone prescription drug plan. Eligibility Original Medicare You are eligible for Medicare if you are a U.S. citizen or have been a permanent legal resident for five continuous years and: for at least two years, or Medigap (Medicare supplement) plans To enroll in a Medigap plan you must: under Medicaid or by another third party Medicare Prescription Drug Plans To enroll in a Medicare Prescription Drug Plan, you must: under Medicaid or by another third party You can join a stand-alone prescription drug plan if you have Original Medicare or Original Medicare and a Medigap or other supplemental insurance plan. Medicare Advantage plans To enroll in a Medicare Advantage plan, you must: When to enroll Original Medicare: Part A You are usually enrolled automatically in Medicare Part A starting the first day of the month you turn 65. If you don’t receive an enrollment notice, call Social Security at 1-800-772-1213 (railroad retirees should call 1-800-808-0772). If you are disabled, there is a 24-month waiting period for Medicare after you become disabled. In the meantime, you may qualify for Medicaid/Medical Assistance, COBRA coverage or services from state-specific programs. Original Medicare: Part B There are three opportunities to sign up for Part B: the Initial Enrollment Period, the Special Enrollment Period and the General Enrollment Period. Part B Initial Enrollment Period During the Part B Initial Enrollment Period, you can enroll three (3) months prior to the month of, or three (3) months after, your 65th birthday. Or, if you are disabled, after your 24th month of receiving disability benefits. If you want to decline Part B enrollment during the Initial Enrollment Period, you must return your Part B notice to Social Security. If you do not sign up, a 10 percent penalty is typically added to the Part B premium for each 12-month period you could have had Part B but didn’t enroll, unless you qualify for the Part B Special Enrollment Period. The penalty continues for as long as you have Part B. Part B Special Enrollment Period If you or your spouse has medical coverage through full-time employment with a union or an employer with more than 20 employees, or you cancelled Part B coverage because you went back to work and had group medical coverage, you can use the Part B Special Enrollment Period to enroll. The Special Enrollment Period lasts for eight months and begins when your employer or union coverage ends, or when employment ends, whichever is first. To use the Part B Special Enrollment Period, contact Social Security four months before you retire or when your employer or union coverage ends, and request a form that your employer will need to complete to activate your Special Enrollment Period. Then send the employer paperwork along with your Part B enrollment form to Social Security. If you are 65 and continue your employer coverage through COBRA, you should enroll in Part B — you will not get a Special Enrollment Period when COBRA ends. You must sign up for Part B during the first eight months you have COBRA coverage to avoid the late enrollment penalty in the General Enrollment Period. Part B General Enrollment Period If you do not enroll in Part B during the Initial or Special Enrollment Periods, you can enroll during the General Enrollment Period from January 1 through March 31 of each year, with coverage starting July 1 of the year you enroll. For each year you delay enrolling, you are charged a 10 percent Part B penalty. This charge increases annually as Medicare premiums increase and will continue for your lifetime or as long as you are on Part B. Medigap (Medicare supplement) plans The Medigap Open Enrollment Period lasts for six months starting on the first day of the month in which your Medicare Part B coverage becomes effective. If you enroll during this time, you won’t need to provide a health history to your health plan. If you delay buying Medigap coverage, you may need to complete a health history application and could be denied coverage. Note: If you want to enroll in a Medigap plan and a stand-alone prescription drug plan, be sure to do so within the valid enrollment periods outlined here. Prescription drug plans, Medicare Advantage plans and Medicare Advantage plans with prescription drug coverage Initial Enrollment Period If you are newly eligible for Medicare, you most likely qualify for the Initial Enrollment Period. During the Initial Enrollment Period, you can enroll in a stand-alone prescription drug plan, a Medicare Advantage plan or a Medicare Advantage plan with prescription drug coverage three (3) months prior to the month of, or three (3) months after, your 65th birthday, or after your 24th month of receiving disability benefits. Annual Enrollment Period If you are currently a Medicare beneficiary, you can make one “election” during the Annual Enrollment Period between November 15 and December 31 of each year. This includes enrolling in or changing to a stand-alone prescription drug plan, a Medicare Advantage plan or a Medicare Advantage plan with prescription drugs for an effective date of January 1 of the following year. Open Enrollment Period The Open Enrollment Period from January 1 through March 31 of each year can be used only for these situations: 1) a different Medicare Advantage plan or 2) Original Medicare* only 1) a different Medicare Advantage plan with prescription drugs or 2) Original Medicare* and a prescription drug plan with prescription drugs * Beneficiaries with Original Medicare may also be enrolled in a Medigap plan Special Election Period A Special Election Period allows you to enroll in a prescription drug plan or Medicare Advantage plan after an Initial or Annual Enrollment Period has ended. Some reasons you might qualify for a Special Election Period are: as good as (“creditable”) the standard Medicare benefit A glossary of Medicare-related terms Benefit period – A benefit period begins on the first day of an inpatient hospital stay and ends when you have been out of the hospital or skilled nursing facility for 60 consecutive days. Centers for Medicare & Medicaid Services (CMS) – The federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid program. CMS makes sure that beneficiaries in both programs are able to get access to high-quality health care. Cost-sharing – The percentage (coinsurance) or flat amount (copayment) you must pay, up to a certain amount or limit. Coinsurance – The percentage of the Medicareapproved amount that you pay for a medical service. With some plans, you do not pay coinsurance until you have first paid a deductible. Copayment – A set amount you pay for a medical service, such as a doctor’s visit. Copayments are also used for some hospital outpatient services in the Original Medicare plan. Deductible – A set amount of money you must pay before receiving coverage for benefits. Generally, deductibles apply to Medicare Part A, Part B and Part D. Deductibles may also apply to Medicare Advantage and Medigap plans. Lifetime reserve days – These are additional days that Medicare will pay for when you are in a hospital for more than 90 days. You have a total of 60 lifetime reserve days that can be used once during your lifetime. With Original Medicare, you have a per day copay when you use lifetime reserve days. Medicare Advantage – A Medicare health plan option under which a private health plan arranges for all Medicare-covered services. With a Medicare Advantage plan, Medicare pays a set amount of money for your care every month to a private health plan that manages Medicare benefits for its members. The most common types of Medicare Advantage plans are HMO, PPO and PFFS plans. Some Medicare Advantage plans may also offer Medicare prescription drug (MA-PD) benefits to their enrollees. Medicare Cost plan – This is a type of Medicare plan available in certain areas of the country. You can join a Cost plan even if you have only Medicare Part B. Generally, a Cost plan pays in-network benefits only; if you go to a non-network provider, Original Medicare benefits and cost-sharing apply. Some Cost plans also include travel benefits. Medigap (Medicare supplement) plan – Health insurance policies that typically have standardized benefits and are sold by private insurance companies. Medigap policies work in tandem with your Medicare Part A and Part B coverage. They generally allow you to use any doctor or hospital that accepts Medicare. Part D (prescription drug plan) – A Medicare Part D prescription drug plan may be either a stand-alone prescription drug plan that you can enroll in if you have Original Medicare or a Medigap plan, or a Medicare Advantage plan that includes Medicare prescription drug benefit coverage. Premium – The payment you make to a health plan for medical or drug benefits purchased, usually paid each month. |