First Look: Plan Benefit Filings

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1 July 30, 2014 First Look: Plan Filings Maryland and Washington, D.C. 1

2 Disclaimers MedStar does not currently have a contract with CMS for the State of MD nor any special needs plans in Washington, D.C. plans represented herein are as filed with CMS, they may be changed, without notice, and are subject to CMS approval No benefit plan information may be shared with any beneficiary or other person for the purpose of selling a plan represented herein. MedStar will terminate any agents and report those agents to CMS upon learning that an agent shared this information with a beneficiary or other person for the purposes of selling a plan represented herein. Agents should continue to sell only plans that are approved by CMS and on the market for the 2014 plan year. MedStar will not pay agents/brokers who have not been trained and tested. MedStar will not pay compensation to agents/brokers not meeting licensure/appointment requirements or those that have been terminated for cause. 2

3 2015 Proposed Service Area State Service Area Products Maryland Anne Arundel Baltimore Baltimore City Charles Howard Prince George s St. Mary s Washington, D.C. Washington, D.C. Medicare Advantage (HMO) Dual Advantage (HMO DSNP) Care Advantage (HMO CSNP) 3

4 Proposed Product Descriptions Product Medicare Advantage (HMO) Description Medicare Advantage Part D Plan 1 Dual Advantage (HMO DSNP) Care Advantage (HMO CSNP) Medicare Advantage Part D Plan that is specialized for full benefit dual eligible beneficiaries 1 Medicare Advantage Part D Plan that is specialized for beneficiaries that have either one or both of the following 1 : Congestive Heart Failure Diabetes 4 1. Beneficiaries must be eligible to enroll in Medicare Advantage.

5 (HMO) s

6 HMO Plan Medical s (HMO) (HMO) Monthly Plan Premium $0 in addition to your Medicare Part B premium $0 in addition to your Medicare Part B premium Annual Out-of-Pocket Maximum (your total yearly out-of-pocket costs) $6,700 for all Medicare-covered benefits $6,700 for all Medicare-covered benefits Inpatient Hospital Care and Inpatient Mental Health Care $210 copay per day (days 1-7) / Acute $210 copay per day (days 1-7) / Mental Health $250 copay per day (days 1-7) / Acute $200 copay per day (days 1-7) / Mental Health Skilled Nursing Facility (SNF) $0 copay per day (days 1-20) $150 copay per day (days 21-00) $0 copay per day (days 1-20) $150 copay per day (days ) Doctor Office Visits Primary Care Physician (PCP) and Specialist $10 copay for each PCP visit $40 copay for each specialist visit $10 copay for each PCP visit $40 copay for each specialist visit 6

7 HMO Plan Medical s (HMO) (HMO) Outpatient Rehabilitation (e.g., occupational, physical, speech and language therapy) $40 copay per therapy visit $40 copay per therapy visit Outpatient Surgery Outpatient Hospital Facility - $200 copay per surgical procedure Ambulatory Surgical Center (ASC) - $175 copay per visit Outpatient Hospital Facility - $250 copay per surgical procedure Ambulatory Surgical Center (ASC) - $200 copay per visit Emergency Care $65 copay per visit $65 copay per visit Urgent Care $40 copay per visit $40 copay per visit Durable Medical Equipment 20% of the cost per item 20% of the cost per item Diabetic Supplies 20% of the cost per item 20% of the cost per item 7

8 HMO Medical s Care Advantage (HMO SNP) Care Advantage (HMO SNP) Lab Services, X-rays and Advanced Imaging Radiology Services (e.g., CT scans, MRI, MRA, PET scans, Nuclear Medicine and Stress tests) $0 copay for lab services $20 copay for general X-rays or ultrasound 20% of the cost for each advanced radiology imaging service $0 copay for lab services $20 copay for general X-rays or ultrasound 20% of the cost for each advanced radiology imaging service Preventive Services $0 copay for annual wellness exam, routine physical exam, immunizations (e.g., flu and pneumonia) and preventive screenings, including mammograms, Pap, pelvic, prostate, colorectal exams and bone mass measurement $0 copay for annual wellness exam, routine physical exam, immunizations (e.g., flu and pneumonia) and preventive screenings, including mammograms, Pap, pelvic, prostate, colorectal exams and bone mass measurement 8

9 Outpatient Prescription Drug s Prescription Drugs One Month Supply (30-days) Three Month Supply (90-days) Preferred Generic Drugs $4 copay $12 copay Non-preferred Generic Drugs $10 copay $30 copay Preferred Brand-Name Drugs $45 copay $135 copay Non-preferred Brand-Name Drugs $95 copay $285 copay Specialty Drugs (one month supply only) Coverage Gap Catastrophic Coverage 33% of the cost N/A After your total yearly drug costs reach $2,960 you will pay 65% of the costs for generic drugs. You will receive a discount on brand-name drugs and generally pay no more than 45% (plus dispensing fee) of the plan s cost. After your yearly out-of-pocket drug costs reach $4,700, you pay the greater of: 5% of the cost, or $2.65 for generic and $6.60 for all other drugs 9

10 Supplemental s and Services Routine Vision Dental Services Fitness $0 copay for one routine eye exam per year $100 allowance toward the cost of one pair of glasses (frames and lenses) or contact lenses every year Routine Preventive Dental Services $0 copay for routine oral exam and cleaning every six months $0 copay for one fluoride treatment per year $0 copay for one dental X-ray per year $0 copay for fitness benefit when using a network fitness center or gym. $0 copay for one routine eye exam per year $100 allowance toward the cost of one pair of glasses (frames and lenses) or contact lenses every year Routine Preventive Dental Services $0 copay for routine oral exam and cleaning every six months $0 copay for one fluoride treatment per year $0 copay or one dental X-ray per year $0 copay for fitness benefit when using a network fitness center or gym. Silver&Fit is a fitness and healthy aging program designed to help enrollees achieve better health through regular exercise. The Silver&Fit Program includes access to fitness facility membership through a local network of participating fitness facilities, home exercise kits, health and wellness educational materials and support. Silver&Fit is a fitness and healthy aging program designed to help enrollees achieve better health through regular exercise. The Silver&Fit Program includes access to fitness facility membership through a local network of participating fitness facilities, home exercise kits, health and wellness educational materials and support. 10

11 Supplemental s and Services Nurse Advice Hotline Enrollees have access 24 hours a day, seven days a week to general and specific healthcare advice and information from experienced registered nurses. Enrollees have access 24 hours a day, seven days a week to general and specific healthcare advice and information from experienced registered nurses. 11

12 Full Dual Eligible Special Needs Plan

13 HMO DSNP Plan Medical s Monthly Plan Premium Annual Out-of-Pocket Maximum (your total yearly out-of-pocket costs) Inpatient Hospital Care and Inpatient Mental Health Care $0 in addition to your Medicare Part B premium $0 in addition to your Medicare Part B premium $6,700 for all Medicare-covered benefits $6,700 for all Medicare-covered benefits In 2014, the amounts for each benefit period were $0 or: Days 1-60: <$1,216> deductible Days 61-90: <$304> per day 60 Lifetime Reserve Days: <$608> per day (Lifetime reserve days can only be used once.) In 2014 the amounts for each benefit period were $0 or: Days 1-60: <$1,216> deductible Days 61-90: <$304> per day 60 Lifetime Reserve Days: <$608> per day (Lifetime reserve days can only be used once.) Skilled Nursing Facility (SNF) Note: The above amounts are subject to change for 2015 based on CMS guidance. In 2014, the amounts for each benefit period were $0 or: Days 1-20: <$0> for each benefit period Days : <$152> per day 100 days for each benefit period Note: The above amounts are subject to change for 2015 based on CMS guidance. In 2014, the amounts for each benefit period were $0 or: Days 1-20: <$0> for each benefit period Days : <$152> per day 100 days for each benefit period Note: The above amounts are subject to change for 2015 based on CMS guidance. Note: The above amounts are subject to change for 2015 based on CMS guidance. 13

14 HMO DSNP Plan Medical s Doctor Office Visits Primary Care Physician (PCP) and Specialist Outpatient Rehabilitation (e.g., occupational, physical, speech and language therapy) Outpatient Surgery 0% or 20% of the cost for PCP visits 0% or 20% of the cost for specialist visits 0% or 20% of the cost for PCP visits 0% or 20% of the cost for specialist visits 0% or 20% of the cost per therapy visit 0% or 20% of the cost per therapy visit Outpatient Hospital Facility 0% or 20% of the cost per surgical procedure Outpatient Hospital Facility 0% or 20% of the cost per surgical procedure Ambulatory Surgical Center (ASC) 0% or 20% of the cost per visit Ambulatory Surgical Center (ASC) 0% or 20% of the cost per visit Emergency Care 0% or 20% of the cost per visit 0% or 20% of the cost per visit Urgent Care 0% or 20% of the cost per visit 0% or 20% of the cost per visit Durable Medical Equipment 0% or 20% of the cost per item 0% or 20% of the cost per item Diabetic Supplies 0% or 20% of the cost per item 0% or 20% of the cost per item 14

15 HMO DSNP Plan Medical s Lab Services, X-rays and Advanced Imaging Radiology Services (e.g., CT scans, MRI, MRA, PET scans, Nuclear Medicine and Stress tests) 0% or 20% of the cost for lab services 0% or 20% of the cost for X-rays or ultrasound 0% or 20% of the cost for each advanced imaging radiology service 0% or 20% of the cost for lab services 0% or 20% of the cost for X-rays or ultrasound 0% or 20% of the cost for each advanced imaging radiology service Preventive Services $0 copay for annual wellness exam, routine physical exam, immunizations (e.g., flu and pneumonia) and preventive screenings, including mammograms, Pap, pelvic, prostate, colorectal exams and bone mass measurement $0 copay for annual wellness exam, routine physical exam, immunizations (e.g., flu and pneumonia) and preventive screenings, including mammograms, Pap, pelvic, prostate, colorectal exams and bone mass measurement 15

16 Outpatient Prescription Drug s Prescription Drugs Part D Deductible $320 Member Cost Share After the Part D deductible is met, member pays 25% coinsurance up to the Initial Coverage Limit Initial Coverage Limit (ICL) $2,960 Coverage Gap Out-of-Pocket Threshold $4,700 After the member s total yearly drug costs reach $2,960, the member will receive a discount on brand-name drugs and generally pay no more than 45% (plus dispensing fee) of the plan s cost for brand drugs and 65% of the plan s cost for generic drugs until the yearly out-of-pocket drug costs reach $4,700. Low-income Subsidy (LIS) Catastrophic Coverage Medicare beneficiaries with limited income and resources may qualify for extra help to pay for prescription drugs costs referred to as low-income subsidy (LIS) assistance. After the member s yearly out-of-pocket drug costs reach $4,700, the member pays based on income and institutional status: Generic drugs (including brand drugs treated as generic), either: $0 copay, or $1.20 copay, or $2.65 copay For all other drugs, either: $0 copay, or $3.60 copay, or $6.60 copay 16

17 Supplemental s and Services Routine Vision Dental Services $0 copay for one routine eye exam per year $100 allowance toward the cost of one pair of glasses (frames and lenses) or contact lenses every year Routine Preventive Dental Services $0 copay for routine oral exam and cleaning every six months $0 copay for one fluoride treatment per year $0 copay for one dental X-ray per year $0 copay for one routine eye exam per year $100 allowance toward the cost of one pair of glasses (frames and lenses) or contact lenses every year Routine Preventive Dental Services $0 for routine oral exam and cleaning every six months $0 copay for one fluoride treatment per year $0 copay for one dental X-ray per year Comprehensive Dental Services coverage amount of $1,000 a year Includes: non-routine, diagnostic, restorative, endodontics, periodontics, extractions, prosthodontics, and other oral/maxillofacial surgery Comprehensive Dental Services coverage amount of $800 a year Includes: non-routine, diagnostic, restorative, endodontics, periodontics, extractions, prosthodontics, and other oral/maxillofacial surgery 17

18 Supplemental s and Services Transportation Services $0 copay / per trip Maximum trips - 24-one way trips per year Transportation services are available for valid health-related purposes only Member must notify the plan at least 48 hours in advance to access and arrange for transportation. $0 copay / per trip Maximum trips - 24-one way trips per year Transportation services are available for valid health-related purposes only Member must notify the plan at least 48 hours in advance to access and arrange for transportation. Note: This notification requirement does not apply to emergency services. Note: This notification requirement does not apply to emergency services. Over-the-Counter (OTC) Items coverage amount - $25/per month Note: coverage amount can only be used to purchase OTC items for the enrollee coverage amount - $15/per month Note: coverage amount can only be used to purchase OTC items for the enrollee Examples of OTC items: first aid products, allergy, cold and pain relievers, eye and ear care products, and vitamins and supplements. Examples of OTC items: first aid products, allergy, cold and pain relievers, eye and ear care products, and vitamins and supplements. Unused Coverage Amount - any unused amount does NOT carry forward to next month within the benefit period Unused Coverage Amount - any unused amount does NOT carry forward to next month within the benefit period Nurse Advice Hotline Enrollees have access 24 hours a day, seven days a week to general and specific healthcare advice and information from experienced registered nurses. Enrollees have access 24 hours a day, seven days a week to general and specific healthcare advice and information from experienced registered nurses. 18

19 Care Advantage (HMO SNP) Chronic or Disabling Condition Special Needs Plan (Chronic Heart Failure and/or Diabetes)

20 HMO CSNP Plan Medical s Care Advantage (HMO SNP) Care Advantage (HMO SNP) Monthly Plan Premium $0 in addition to your Medicare Part B premium $0 in addition to your Medicare Part B premium Annual Out-of-Pocket Maximum (your total yearly out-of-pocket costs) $6,700 for all Medicare-covered benefits $6,700 for all Medicare-covered benefits Inpatient Hospital Care and Inpatient Mental Health Care $210 copay per day (days 1-7) / Acute $210 copay per day (days 1-7) / Mental Health $250 copay per day (days 1-7) / Acute $200 copay per day (days 1-7) / Mental Health Skilled Nursing Facility (SNF) $0 copay per day (days 1-20) $150 copay per day (days ) $0 copay per day (days 1-20) $150 copay per day (days ) Doctor Office Visits Primary Care Physician (PCP) and Specialist $10 copay for each PCP visit $40 copay for each specialist visit $10 copay for each PCP visit $40 copay for each specialist visit 20

21 HMO CSNP Plan Medical s Care Advantage (HMO SNP) Care Advantage (HMO SNP) Outpatient Rehabilitation (e.g., occupational, physical, speech and language therapy) $40 copay per therapy visit $40 copay per therapy visit Outpatient Surgery Outpatient Hospital Facility - $200 copay per surgical procedure Ambulatory Surgical Center (ASC) - $175 copay per visit Outpatient Hospital Facility - $250 copay per surgical procedure Ambulatory Surgical Center (ASC) - $200 copay per visit Emergency Care $65 copay per visit $65 copay per visit Urgent Care $40 copay per visit $40 copay per visit Durable Medical Equipment 20% of the cost per item 20% of the cost per item Diabetic Supplies $0 copay for diabetic supplies $0 copay for diabetic supplies 21

22 HMO CSNP Plan Medical s Care Advantage (HMO SNP) Care Advantage (HMO SNP) Lab Services, X-rays and Advanced Imaging Radiology Services (e.g., CT scans, MRI, MRA, PET scans, Nuclear Medicine and Stress tests) $0 copay for lab services $20 copay for general X-rays or ultrasound 20% of the cost for each advanced radiology imaging service $0 copay for lab services $20 copay for general X-rays or ultrasound 20% of the cost for each advanced radiology imaging service Preventive Services $0 copay for annual wellness exam, routine physical exam, immunizations (e.g., flu and pneumonia) and preventive screenings, including mammograms, Pap, pelvic, prostate, colorectal exams and bone mass measurement $0 copay for annual wellness exam, routine physical exam, immunizations (e.g., flu and pneumonia) and preventive screenings, including mammograms, Pap, pelvic, prostate, colorectal exams and bone mass measurement 22

23 Outpatient Prescription Drug s Prescription Drugs One Month Supply (30 days) Three Month Supply (90 days) Preferred Generic Drugs $4 copay $12 copay Non-preferred Generic Drugs $10 copay $30 copay Preferred Brand-Name Drugs $45 copay $135 copay Non-preferred Brand-Name Drugs Specialty Drugs (one month supply only) $95 copay $285 copay 33% of the cost N/A Preferred Diabetic Drugs $10 copay $30 copay Coverage Gap Catastrophic Coverage After your total yearly drug costs reach $2,960 you will pay 65% of the costs for generic drugs. You will receive a discount on brand-name drugs and generally pay no more than 45% (plus dispensing fee) of the plan s cost. After your yearly out-of-pocket drug costs reach $4,700, you pay the greater of: 5% of the cost, or $2.65 for generic and $6.60 for all other drugs 23

24 Supplemental s and Services Routine Vision Dental Services Fitness $0 copay for one routine eye exam per year $100 allowance toward the cost of one pair of glasses (frames and lenses) or contact lenses every year Routine Preventive Dental Services $0 copay for routine oral exam and cleaning every six months $0 copay for one fluoride treatment per year $0 copay for one dental X-ray per year $0 copay for fitness benefit when using a network fitness center or gym. $0 copay for one routine eye exam per year $100 allowance toward the cost of one pair of glasses (frames and lenses) or contact lenses every year Routine Preventive Dental Services $0 copay for routine oral exam and cleaning every six months $0 copay for one fluoride treatment per year $0 fcopay or one dental X-ray per year $0 copay for fitness benefit when using a network fitness center or gym. Silver&Fit is a fitness and healthy aging program designed to help enrollees achieve better health through regular exercise. The Silver&Fit Program includes access to fitness facility membership through a local network of participating fitness facilities, home exercise kits, health and wellness educational materials and support. Silver&Fit is a fitness and healthy aging program designed to help enrollees achieve better health through regular exercise. The Silver&Fit Program includes access to fitness facility membership through a local network of participating fitness facilities, home exercise kits, health and wellness educational materials and support. 24

25 Supplemental s and Services Transportation Services Nurse Advice Hotline $0 copay / per trip Maximum trips - 10-one way trips per year Transportation services are available for valid health-related purposes only Member must notify the plan at least 48 hours in advance to access and arrange for transportation. Note: This notification requirement does not apply to emergency services. Enrollees have access 24 hours a day, seven days a week to general and specific healthcare advice and information from experienced registered nurses. $0 copay / per trip Maximum trips - 10-one way trips per year Transportation services are available for valid health-related purposes only Member must notify the plan at least 48 hours in advance to access and arrange for transportation. Note: This notification requirement does not apply to emergency services. Enrollees have access 24 hours a day, seven days a week to general and specific healthcare advice and information from experienced registered nurses. 25

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