UPMC for Life HMO Plans2019 Medicare Product Training
2019 Medicare Product Training Agenda
Copyright 2012 UPMC Health Plan. All Rights Reserved2
• 2019 UPMC for Life Plans− Service Area Expansion/ Reduction− Details the 2019 benefit changes to the UPMC for Life HMO and
PPO plans.− Details the new plans being offered
• Medicare Advantage and Prescription Drug Coverage Overview − Provides an overview of 2019 Medicare Advantage program
changes and overview of the 2019 UPMC for Life changes that impact all of our Medicare plans.
• 2019 Member Document Changes
2019 Service Area Expansion
2019 UPMC for Life – HMO/PPO Service Area Expansion
Copyright 2012 UPMC Health Plan. All Rights Reserved4
UPMC for Life service area for 2019:
PA: Adams, Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Northampton, Perry, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, and York.
OH: Harrison and Jefferson
Service Area Expansion: Bradford, Juniata, Lackawanna, Luzerne, Mifflin, Northampton, Susquehanna, Wayne and Wyoming.
2019 UPMC for Life – HMO/PPO Service Area Expansion
UPMC for Life service area for 2019:
Copyright 2012 UPMC Health Plan. All Rights Reserved5
2019 Service Area Crosswalk
2019 Service Area CrosswalkWhat is a crosswalk?
Put simply, when a plan is terminating, members can be automatically moved to another equivalent, identical or similar planPut another way, when you crosswalk a plan you are moving a member from their existing plan into another similar plan.
2019 Service Area Crosswalk
• Why is a plan being crosswalked?– There can be many reasons why a plan is being crosswalked. It
could be due to low enrollment or not meeting access requirements.
2019 Crosswalked plans• 2 Medicare plans will be terming the end of this year (2018): HMO Deductible with
Rx in Lehigh Cap area (H3907 PBP 039) and the HMO Rx in Lehigh Cap area (H3907 PBP 040).
• The Lehigh Cap plans include: Adams, Cumberland, Dauphin, Fulton, Lancaster, Lebanon, Lehigh, Perry, and York counties
• The members in these plans will be crosswalked into an existing plan.
• The members ANOC will explain the consolidation. The reason for consolidation is the membership is too low in the Lehigh Cap plans.
Copyright 2012 UPMC Health Plan. All Rights Reserved9
HMO Deductible with RX Lehigh Cap
(H3907 039)
HMO Deductible with Rx WPA (H3907 037)
HMO with RX Lehigh Cap (H3907
040)
HMO with Rx WPA (H3907 029)
Non-Renewal and Service Area Reduction
• The UPMC for Life Options (ISNP) will be terminated as of 1/1/19.
• Sales is attempting to outreach to current members to move to the DSNP if they meet the full dual status or another UPMC Medicare plan if they don’t meet the criteria.
Copyright 2012 UPMC Health Plan. All Rights Reserved10
2019 General Plan Updates
General Plan Updates for Medicare Plans
• New fitness vendor- SilverSneakers
– Also added 1 Personal Training Session per calendar year
• Increased ER copayments to either a $90 copayment or $120 copayment, depending on the Maximum out of pocket.
• Added new supplemental benefits: Bathroom Safety Items, In-Home Safety Assessment, and Counseling Services.
• New Flexible Benefit- The meal benefit will be provided one time annually upon discharge from an inpatient stay, observation stay or a SNF stay for members that have all three diagnoses of COPD, CHF and Diabetes. The member will receive 2 meals a day for 28 days (56 meals total).
Copyright 2012 UPMC Health Plan. All Rights Reserved12
General Plan Updates for Medicare Plans
Removed Prior Authorization:
• Outpatient Mental Health/ Outpatient
• Partial Hospitalization
Added Prior Authorization:
• Pain management and sleep specialists
• Outpatient Rehab services (PT, OT, ST)
• Prosthetic Devices
• Chiropractic Services (Medicare-covered)
* Authorization for these services is the responsibility of the provider
Copyright 2012 UPMC Health Plan. All Rights Reserved13
General Plan Updates for Medicare Plans
Drug Management Program• Drug management programs will be integrated with CMS’s existing
Overutilization Monitoring System (OMS). The clinical guidelines used to determine if a beneficiary is potentially at-risk, which are based on using opioids from multiple prescribers and/or multiple pharmacies, will be expanded from those used in OMS currently. Sponsors will be allowed to limit an at-risk beneficiary’s access to frequently abused drugs to a selected prescriber(s) and/or pharmacy(ies) (“lock-in”), and through the use of beneficiary-specific point-of-sale (POS) claim edits, which are already permitted under the current policy. Part D sponsors may not implement such limitations unless they have engaged in case management with the prescribers of these drugs, and beneficiaries can submit prescriber and pharmacy preferences.
*More information to come from the Pharmacy Team
Copyright 2012 UPMC Health Plan. All Rights Reserved14
General Plan Updates for Medicare Plans
Election Periods: • Removing the Medicare Advantage Disenrollment Period
(MADP) and replacing it with a new Medicare Advantage open enrollment period (OEP) that will take place from January 1st through March 31st annually. The new OEP allows individuals enrolled in an MA plan, including newly MA-eligible individuals, to make a one-time election to go to another MA plan or Original Medicare. Individuals using the OEP to make a change may make a coordinating change to add or drop Part D coverage.
• OEP election is only for members enrolled in a MA or a MAPD plan. It cannot be used for those on Original Medicare or in a stand-alone Part D plan.
Copyright 2012 UPMC Health Plan. All Rights Reserved15
General Plan Updates for Medicare PlansElection Periods: • Revised SEP for Duals and other LIS-eligible beneficiaries –
CMS revised the Special Election Period (SEP) for dual-eligible and LIS beneficiaries from an open-ended monthly SEP to one that may be used only once per calendar quarter during the first nine months of the year. Separate SEPs can be used in the following circumstances: 1) within a certain period of time after a CMS or state-initiated enrollment; and 2) within a certain period of time after a change to an individual’s LIS or Medicaid status.
Copyright 2012 UPMC Health Plan. All Rights Reserved16
New Supplemental Benefits
• Bathroom Safety Items- The plan will cover up to 3 bathroom safety items as defined by the plan. Member must contact member services to order the bathroom safety items. Member services can then order the items through the online portal.
Copyright 2012 UPMC Health Plan. All Rights Reserved17
UPMC Bath Kit ItemsBath MatRaised toilet seatHandheld shower
Transfer chair w/backBath Chair w/ back
Grab Bar‐Side of the Tub (Adjustable)
New Supplemental Benefits
In-Home Safety Assessment- The plan will cover one in-home safety assessment per calendar year. The in-home assessment will be done by a licensed healthcare professional, such as an occupational therapist and will evaluate the home to identify potential hazards. The member can contact member services to schedule the in-home assessment. This can be scheduled with a participating home health agency closest to the member’s home.
Copyright 2012 UPMC Health Plan. All Rights Reserved18
New Supplemental Benefits
• Counseling Services- Licensed, Master's-level trained clinicians will provide member with up to 6 counseling sessions which would include: caregiving support; family and relationship concerns; stress, grief and other emotional issues; healthy lifestyle changes.
• The counseling services will be provided through Resources for Life
Copyright 2012 UPMC Health Plan. All Rights Reserved19
2019 UPMC for Life – Travel Concierge Program
Travel Concierge Program- included for all UPMC for LifeHMO Individual and some Group plans
• New for 2019: The Travel Concierge Program is expanding to North Carolina, South Carolina, Georgia, and Tennessee.
• The Travel Concierge Program will still be available in Florida
• 6-month limit for travel coverage
• Members are encouraged to contact the Health Plan prior to services being rendered, however, it Is not required.
• Must provide all plan-covered services (including supplemental benefits) at in-network member cost sharing levels.
• Contracted providers will be reimbursed at contracted rates - non-contracted providers will be reimbursed the local Medicare FFS rates.
• Providers cannot balance bill members.
• Services that currently require an authorization will also require an authorization under the Travel Concierge Program
• PPO members will not be affected and will still continue to be liable for out-of-network cost sharing amounts.
Copyright 2012 UPMC Health Plan. All Rights Reserved20
UPMC Networks• Network names are:
– UPMC Medicare Network
• The UPMC Medicare Network is the main HMO/PPO Network
• Adams, Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Montgomery, Northampton, Perry, Philadelphia, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, and York.
– UPMC Premier Medicare Network (PSP 1 Network)
• PSP network in Allegheny, Beaver, Bedford, Blair, Butler, Erie, Lawrence, Lycoming, Tioga, and Venango counties
– UPMC/Tower Medicare Network (PSP 2 Network)
• PSPs in Berks county
– UPMC/Excela Medicare Network (PSP 3 Network)
• PSP in Westmoreland county
Copyright 2012 UPMC Health Plan. All Rights Reserved21
New 2019 UPMC for Life Individual Plans
New Plans for 2019• HMO Rx Choice (H3907 049)
• Service Area: Erie, Lawrence, Mercer and Venango counties• Provider Network: UPMC Medicare Network
• HMO Premier RX (H3907 050)• Service Area: Erie, Lawrence, Mercer and Venango counties• Provider Network: UPMC PSP 1 Network
• HMO Premier RX (H3907 051)• Service Area: Westmoreland County• Provider Network: UPMC PSP 3 Network (Westmoreland/ Excela)
• HMO Premier RX (H3907 052)• Service Area: Cumberland and Dauphin counties• Provider Network: UPMC Medicare Network
*More information will be provided in later slides.
Copyright 2012 UPMC Health Plan. All Rights Reserved22
2019 Provider Specific Plans (PSP)
Provider Specific Plans (PSP)
• What is a Provider Specific Plan?– A Provider Specific Plan is designed to include a select
network of providers. Typically the network is a more narrow, smaller provider network.
– They are also called “PSP” Plans
Copyright 2012 UPMC Health Plan. All Rights Reserved24
Provider Specific Plans (PSP)
• UPMC for Life offers 6 Provider Specific Plans• UPMC for Life HMO Premier Rx (H3907 045)
• UPMC for Life HMO Premier Rx (H3907 046)
• UPMC for Life HMO Rx (Berks County H3907 047)
• UPMC for Life HMO Premier Rx (H3907 050) * New plan for 2019• UPMC for Life HMO Premier Rx (H3907 051) * New plan for 2019• UPMC for Life PPO RX Enhanced (H5533 007)
Copyright 2012 UPMC Health Plan. All Rights Reserved25
Provider Specific Plans (PSP)
• We group these provider specific plans into 3 “Provider Networks”
Copyright 2012 UPMC Health Plan. All Rights Reserved26
PSP 1 Network PSP 2 Network PSP 3 Network
UPMC for Life HMO Premier Rx (H3907 046)
UPMC for Life HMO Premier Rx (H3907 050)
UPMC for Life HMO Premier Rx (H3907 045)
UPMC for Life HMO Rx (H3907 047)
UPMC for Life PPO RX Enhanced (H5533 007)
UPMC for Life HMO Premier Rx (H3907 051)
Provider Specific Plans (PSP)
PSP 1 Network• UPMC for Life HMO Premier
Rx (H3907 046)- The service area is Allegheny, Beaver, Bedford, Blair, Butler, Lycoming, Tioga- Partnership with Heritage Valley Health System (HVHS) and Butler Health System
• UPMC for Life HMO Premier Rx (H3907 050)
- The service area is Erie, Lawrence, Mercer, and Venango
Network consists of:• All UPMC-owned providers
and facilities• All HVHS providers, Primary
Health Network, and Integrated Care Network
• All Butler Health System providers, Primary Health Network, and Integrated Care Network
• Ancillaries, as appropriate
Copyright 2012 UPMC Health Plan. All Rights Reserved27
Provider Specific Plans (PSP)
• Things to know about PSP 1 Network– These plans are nicknamed “PSP 1”
– There is no cobranding
– The member services phone number is the main member services phone number (877-539-3080).
– The PSP 1 Network has it’s own Provider Directory
Copyright 2012 UPMC Health Plan. All Rights Reserved28
Provider Specific Plans (PSP)PSP 2 Network
• UPMC for Life HMO Premier Rx (H3907 045)
- The service area is Berks County
- Cobranding with Tower Health System
• UPMC for Life HMO Rx (H3907 047)
- The service area is Berks County
- Cobranding with Tower Health System
• UPMC for Life PPO Rx Enhanced (H5533 007)
- The service area is Berks County
- Cobranding with Tower Health System
Network consists of:
• Tower Health System and Berkshire Health System
• UPMC-owned providers
• Thomas Jefferson Health System
• Ancillaries, as appropriate
• UPMC and Tower Health System-owned rehabs
Copyright 2012 UPMC Health Plan. All Rights Reserved29
Provider Specific Plans (PSP)
• Things to know about PSP 2 Network– These plans are nicknamed “PSP 2”
– There is cobranding with Tower Health System
– The member services phone number is different. It is: 1-844-870-2231
– There is a separate Provider Directory for these plans
Copyright 2012 UPMC Health Plan. All Rights Reserved30
Provider Specific Plans (PSP)
PSP 3 Network• UPMC for Life HMO Premier Rx (H3907 051)
- The service area is Westmoreland County
- Cobranding with Excela Health
Network consists of:• Excela Health System Providers
• UPMC-owned providers
• Ancillaries, as appropriate
• UPMC and Excela Health System-owned rehabs
Copyright 2012 UPMC Health Plan. All Rights Reserved31
Things to know about PSP 3 Network
• There will be a separate Provider Directory for this plan
• This plan will have a tiering for inpatient stays. Tier 1 is for Excela and UPMC facilities
(excluding UPMC East and UPMC McKeesport). Tier 2 is for UPMC East and
McKeesport.
• The member services phone number is 877-539-3080.
2019 UPMC for Life Individual Plans
Please note: This is just a summary, not a full description of benefits. Please refer to the
Evidence of Coverage.
2019 HMO no Rx
Please note: This is just a summary, not a full description of benefits. Please refer to the
Evidence of Coverage.
2019 UPMC for Life Individual Plans
HMO (No Rx) Plan offering for 2019: Western Pennsylvania, Ohio, and Susquehanna (H3907 002)
Copyright 2012 UPMC Health Plan. All Rights Reserved34
Plan Design HMO (no Rx)
Contract ID H3907
PBP(s) 002
Service Area
Pennsylvania (Western & Central): Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Clinton, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, Lycoming, McKean, Mercer, Potter, Snyder, Somerset, Sullivan, Tioga, Union, Venango, Warren, Washington, and Westmoreland
Ohio: Harrison and Jefferson
Provider Network UPMC Medicare Network (HMO/PPO network)
Formulary Plan does not offer Part D prescription drugs.
2019 UPMC for Life Individual Plans
HMO (No Rx) Plan offering for 2019: Western Pennsylvania, Ohio, and Susquehanna (H3907 002)• Monthly Premium $0
List of Cost-Share Changes:
• Diagnostic Tests/Procedures/ Lab services was $0-$5, now $5 copay
• ER - $120 copay (CMS threshold increase from $100)
Copyright 2012 UPMC Health Plan. All Rights Reserved35
2019 HMO Rx
Please note: This is just a summary, not a full description of benefits. Please refer to the
Evidence of Coverage.
2019 UPMC for Life Individual Plans
The HMO Rx Plan offering for 2019: Western Pennsylvania & Ohio (H3907 029)
Copyright 2012 UPMC Health Plan. All Rights Reserved37
Plan Design HMO Rx
Contract ID H3907
PBP(s) 029
Service Area
Pennsylvania (Western, Central, Northeastern, and Lehigh Cap): Adams, Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Butler, Cambria, Cameron, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Northampton, Perry, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Wayne, Washington, Westmoreland, Wyoming, and York counties
Ohio: Harrison and Jefferson
Provider Network UPMC Medicare Network (HMO/PPO network)
Formulary Medicare HMO/PPO Formulary (00019208)
2019 UPMC for Life Individual PlansThe HMO Rx Plan offering for 2019: Western Pennsylvania & Ohio (H3907 029)
Monthly Premium: $81
List of Cost-Share Changes:• Inpatient Hospital/ Mental Health: $425 copay per stay (was $350)• Skilled Nursing: Days 1-20: $20 copay per day, days 21-100: $100 copay per day • Specialist visits : $35 copay (was $30)• Rehabilitation Services: $35 copay (was $30)• Mental Health/ Psychiatric/ Substance abuse: $35 copay (was $30)• Emergency Room: $120 copay (was $100)• Advanced Imaging: $275 copay (was $200)• Diagnostic Tests/ Procedures/ Lab Services: $5 copay (was $0-$5)• Ambulance Services (Ground & Air): $300 copay (was $200)• Dental Services (Medicare-covered): $35 copay (was $30)• Routine Dental Oral Exam, Routine Comprehensive Oral Exam, and Routine Bitewing X-rays: $0
copay• Comprehensive Dental Allowance: $150 allowance • Hearing Services (Medicare-covered): $35 copay (was $30)• Remote Technologies- eDerm: $35 copay (was $30)
Copyright 2012 UPMC Health Plan. All Rights Reserved38
2019 UPMC for Life Individual Plans
The HMO Rx Plan offering for 2019: SEPA and Delaware (H3907 042 and 048)
Copyright 2012 UPMC Health Plan. All Rights Reserved39
Plan Design HMO Rx
Contract ID H3907
PBP(s) 042 048
Service Area
Pennsylvania (Southeast/SEPA): Bucks, Chester, Montgomery, and Philadelphia counties
Pennsylvania (Delaware): Delaware county
Provider Network UPMC Medicare Network (HMO/PPO network)
Formulary Medicare HMO/PPO Formulary (00019208)
2019 UPMC for Life Individual Plans
The HMO Rx Plan offering for 2019: SEPA and Delaware (H3907 042 and 048)
Monthly Premium 042 (SEPA): $55Monthly Premium 048 (Delaware): $81
List of Cost-Share Changes:• Emergency Room: $90 copay (was $80)• Advanced Imaging: $275 copay (was $200) • Diagnostic Tests/ Procedures/ Lab Services: $5 copay (was $0-$5)• Ambulance Services (Ground & Air): $300 copay (was $200)• Routine Dental Oral Exam, Routine Comprehensive Oral Exam, and Routine Bitewing
X-rays: $0 copay (was $15)• Comprehensive Dental Allowance: $150 allowance
Copyright 2012 UPMC Health Plan. All Rights Reserved40
2019 UPMC for Life Individual Plans
The HMO Rx Plan offering for 2019: Berks County (H3907 047)
Copyright 2012 UPMC Health Plan. All Rights Reserved41
Plan Design HMO Rx
Contract ID H3907
PBP(s) 047
Service Area
Pennsylvania (Berks/Tower Health): Berks county
*Provider Specific Plan (PSP)
Provider Network UPMC PSP 2 Network (Berks/Tower Health)
Formulary Medicare HMO/PPO Formulary (00019208)
2019 UPMC for Life Individual PlansThe HMO Rx Plan offering for 2019: Berks (H3907 047)
Monthly Premium: $81
List of Cost-Share Changes:• Out-of-pocket maximum increased to $4,500 (was $3,400)• Inpatient Hospital/ Inpatient Mental Health: $500 copay per stay (was $350)• Skilled Nursing: $0 copay for days 1-20, $167.50 copay per day for days 21- 100
(Decreased copay $20 for days 1-20, Increased copay $87.50 for days 21-100)• Specialist Visits/ Outpatient Rehab: $35 copay (was $30)• Emergency Room: $90 copay (was $80)• Advanced Imaging: $275 copay (was $200)• Diagnostic Tests/ Procedures/ Lab Services: $5 copay ( was $0-$5)• Ambulance Services (Ground & Air): $300 copay (was $200)• Dental Services (Medicare-covered): $35 copay (was $30)• Routine Dental Oral Exam, Routine Comprehensive Oral Exam, and Routine Bitewing X-
rays: $0 copay (was $15)• Comprehensive Dental Allowance: $150 allowance • Hearing Services (Medicare- covered) and Vision Services (Medicare- covered): $35 copay
(was $30)• Remote Technologies- eDerm: $35 copay (was $30)
Copyright 2012 UPMC Health Plan. All Rights Reserved42
2019 HMO Deductible Rx
Please note: This is just a summary, not a full description of benefits. Please refer to the
Evidence of Coverage.
2019 UPMC for Life Individual Plans
The HMO Deductible with Rx Plan offering for 2019: WPA , Lehigh Cap, and Ohio (H3907 037)
Copyright 2012 UPMC Health Plan. All Rights Reserved44
Plan Design HMO Deductible with Rx
Contract ID H3907
PBP(s) 037
Service Area
Pennsylvania (Western, Central, Northeastern, and Lehigh Cap): Adams, Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Butler, Cambria, Cameron, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Northampton, Perry, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Wayne, Washington, Westmoreland, Wyoming, and York counties
Ohio: Harrison and Jefferson
Provider Network UPMC Medicare Network (HMO/PPO network)
Formulary Medicare HMO/PPO Formulary (00019208)
2019 UPMC for Life Individual PlansThe HMO Deductible with Rx Plan offering for 2019: WPA , Lehigh Cap, and Ohio (H3907 037)
Monthly Premium: $22List of Cost-Share Changes:• Skilled Nursing: $0 copay for days 1-20, $172 copay per day for days 21- 100
(Increased copay $12 for days 21-100)• Specialist Visits: $35 copay (excluded from the deductible) (was $50)• Podiatry Services (Medicare-covered): $35 copay after the deductible (was $50)• Emergency Room: $90 copay (was $80)• Durable Medical Equipment/Oxygen/ Prosthetic Devices: $0 copay excluded from the
deductible• Advanced Imaging: $200 copay after the deductible (was $100)• Diagnostic Tests/ Procedures/ Lab Services: $10 copay per day/ excluded from the
deductible (was $0-$10)• Dental Services (Medicare-covered), Hearing Services (Medicare- covered) and Vision
Services (Medicare- covered): $35 copay excluded from the deductible (was $50)• Dental Cleaning (two every year): $0 copay• Remote Technologies- eDerm: $35 copay (was $38)
Copyright 2012 UPMC Health Plan. All Rights Reserved45
2019 UPMC for Life Individual Plans
The HMO Deductible with Rx Plan offering for 2019: SEPA and Delaware County(H3907 043 and 044)
Copyright 2012 UPMC Health Plan. All Rights Reserved46
Plan Design HMO Deductible with Rx
Contract ID H3907
PBP(s) 043 044
Service Area
Pennsylvania (Southeast/SEPA): Bucks, Chester, Montgomery, and Philadelphia counties
Pennsylvania (Delaware): Delaware county
Provider Network UPMC Medicare Network (HMO/PPO network)
Formulary Medicare HMO/PPO Formulary (00019208)
2019 UPMC for Life Individual PlansThe HMO Deductible with Rx Plan offering for 2019: SEPA and Delaware County(H3907 043 and 044)
Monthly Premium 043 (SEPA): $15Monthly Premium 044 (Delaware): $0
List of Cost-Share Changes:• Skilled Nursing: $0 copay for days 1-20, $172 copay per day for days 21- 100
(Increased copay $12 for days 21-100)• Specialist Visits: $35 copay (excluded from the deductible)(Decreased copay $15 in
SEPA (PBP 043) & Decreased copay $10 in Delaware (PBP 044)) • Podiatry Services (Medicare-covered): $35 copay after the deductible (was $50)• Emergency Room: $90 copay (was $80)• Durable Medical Equipment/Oxygen/ Prosthetic Devices: $0 copay excluded from the
deductible• Advanced Imaging: $200 copay after the deductible (was $100)• Diagnostic Tests/ Procedures/ Lab Services: $10 copay per day/ excluded from the
deductible (was $0-$10)• Dental Services (Medicare-covered), Hearing Services (Medicare- covered) and Vision
Services (Medicare- covered): $35 copay excluded from the deductible (was $50)• Remote Technologies- eDerm: $35 copay (was $38)
Copyright 2012 UPMC Health Plan. All Rights Reserved47
2019 HMO Plans
All HMO Deductible with Rx Plan offerings for 2019: Western Pennsylvania, Ohio, Susquehanna, and Southeast PA
Medical Services Excluded from the Deductible
Copyright 2012 UPMC Health Plan. All Rights Reserved48
• Chiropractic Services • Preventive Services
• Dental Services (Medicare‐covered and Routine Services) • Primary Care Doctor Visits
• Diabetes Training • Remote Technologies (eVisits & eDerm)
• Emergency Care • Skilled Nursing Facility
• Health and Wellness (Includes Fitness) • Specialist Visits
• Hearing Services (Medicare‐covered) • Urgently Needed Care (Clinics)
• Kidney Disease Training • Vision Services (Medicare‐covered and Routine Services)
• Lab Services and Diagnostic Procedures/Tests • Worldwide Emergency Coverage
• Part B Drugs
2019 HMO Rx Enhanced
Please note: This is just a summary, not a full description of benefits. Please refer to the
Evidence of Coverage.
2019 UPMC for Life Individual Plans
HMO Rx Enhanced Plan offering for 2019: WPA and Ohio (H3907 006)
Copyright 2012 UPMC Health Plan. All Rights Reserved50
Plan Design HMO Rx Enhanced
Contract ID H3907
PBP(s) 006
Service Area
Pennsylvania (Western & Central): Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Clinton, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, Lycoming, McKean, Mercer, Potter, Snyder, Somerset, Sullivan, Tioga, Union, Venango, Warren, Washington, and Westmoreland
Ohio: Harrison and Jefferson
Provider Network UPMC Medicare Network (HMO/PPO network)
Formulary Medicare HMO/PPO Formulary (00019208)
2019 UPMC for Life Individual Plans
HMO Rx Enhanced Plan offering for 2019: WPA and Ohio (H3907 006)
Monthly Premium: $290
List of Cost-Share Changes:• Emergency Room: $120 copayment (was $100)• Routine Hearing Exam: $0 copay every year (was $25)• Routine Hearing Aid Fitting: $0 copay once every 3 years (was $25)
Copyright 2012 UPMC Health Plan. All Rights Reserved51
2019 HMO Premier Rx
Please note: This is just a summary, not a full description of benefits. Please refer to the
Evidence of Coverage.
2019 UPMC for Life Individual Plans
The HMO Premier Rx Plan offering for 2019: Berks County (H3907 045)
Copyright 2012 UPMC Health Plan. All Rights Reserved53
Plan Design HMO Premier Rx
Contract ID H3907
PBP(s) 045
Service Area
Pennsylvania (Berks/Tower Health): Berks county
*Provider Specific Plan (PSP)
Provider Network UPMC PSP 2 Network (Berks/Tower Health)
Formulary Medicare HMO Premier Rx Formulary (00019213)
2019 UPMC for Life Individual Plans
The HMO Premier Rx Plan offering for 2019: Berks County (H3907 045)
Monthly Premium: $0List of Cost- Share Changes:• Out-of-Pocket Maximum: $6,700 (was $6,000)• Inpatient Hospital/ Mental Health: $250 copay per day for days 1-5, $0 copay per
day for days 6-90 (Increased copay $50 for days 1-5 )• Skilled Nursing: $0 copay for days 1-20, $167.50 copay per day for days 21- 100
(Increased copay $7.50 for days 21-100)• PCP Visits: $5 copay (was $0)• Specialist Visits: $40 copay (was $45)• Podiatry Services (Medicare-covered): $40 copay (was $50)• Emergency Room: $90 copay (was $80)• Diagnostic Tests/ Procedures/ Lab Services: $15 copay per day (was $0-$15)• X-Ray Services (Basic Imaging): $40 copay (was $30)
Copyright 2012 UPMC Health Plan. All Rights Reserved54
2019 UPMC for Life Individual Plans
Continued: HMO Premier Rx Plan offering for 2019: Berks (H3907 045)List of Cost-Share Changes:• Dental Services (Medicare-covered), Hearing Services (Medicare- covered) and Vision
Services (Medicare- covered): $40 copay (was $50)• Routine Dental Oral Exam, Routine Comprehensive Oral Exam, and Routine Bitewing
X-rays: $0 copay (was $15)• Comprehensive Dental Allowance: $150 allowance • Routine Hearing Exam (every year): $0 copay• Routine Hearing Aid Fitting (every 3 years): $0 copay• Routine Hearing Aids: $1,500 allowance every 3 years• Routine Vision Exam: $0 copay every year• Routine Vision Allowance: $150 allowance every year (was $100 every 2 years)• Remote Technologies- eVisits: $5 copay (was $0)
Copyright 2012 UPMC Health Plan. All Rights Reserved55
2019 UPMC for Life Individual Plans
The HMO Premier Rx Plan offering for 2019: Allegheny, Beaver, Bedford, Blair, Butler Lycoming and Tioga counties (H3907 046)
Copyright 2012 UPMC Health Plan. All Rights Reserved56
Plan Design HMO Premier Rx
Contract ID H3907
PBP(s) 046
Service Area
Pennsylvania (PSP 1 Allegheny): Allegheny, Beaver, Bedford, Blair, Butler, Lycoming, and Tioga counties
*Provider Specific Plan (PSP)
Provider Network UPMC PSP 1 Network (XXX)
Formulary Medicare HMO Premier Rx Formulary (00019213)
2019 UPMC for Life Individual PlansThe HMO Premier Rx Plan offering for 2019: Allegheny, Beaver, Bedford, Blair, Butler Lycoming and Tioga counties (H3907 046)
Monthly Premium: $0List of Cost-Share Changes:• Out-of-Pocket Maximum: $6,000 ($6,700)• Inpatient Hospital/ Mental Health: $275 copay per stay (Decreased copay $25 and
changed from per day to per stay)• Specialist Visits/ Outpatient Rehab: $35 copay (was $45) • Podiatry Services (Medicare-covered): $35 copay (was $50)• Ambulance Services (Ground & Air): $250 copay per one way trip (was $300)• Emergency Room: $90 copay (was $80)• Diagnostic Tests/ Procedures/ Lab Services: $10 copay per day ($0-$10 copay per
day)• Diagnostic Advanced Imaging: $140 copay (was $250)• Dental Services (Medicare-covered), Hearing Services (Medicare- covered) and Vision
Services (Medicare- covered): $35 copay (was $50)
Copyright 2012 UPMC Health Plan. All Rights Reserved57
2019 UPMC for Life Individual Plans
Continued: HMO Premier Rx Plan offering for 2019: Allegheny, Beaver, Bedford, Blair, Butler Lycoming and Tioga counties (H3907 046)
List of Changes:• Routine Dental Oral Exam, Routine Comprehensive Oral Exam, and Routine
Bitewing X-rays: $0 copay (was $15)• Comprehensive Dental Allowance: $325 allowance • Routine Hearing Exam (every year): $0 copay• Routine Hearing Aid Fitting (every 3 years): $0 copay• Routine Hearing Aids: $1,500 allowance every 3 years• Routine Vision Exam: $0 copay every year• Routine Vision Allowance: $150 allowance every year (was $100 ever 2 years)• Remote Technologies- eDerm: $35 copay (was $38)
Copyright 2012 UPMC Health Plan. All Rights Reserved58
2019 PPO High Deductible
Please note: This is just a summary, not a full description of benefits. Please refer to the
Evidence of Coverage.
2019 UPMC for Life Individual Plans
PPO High Deductible with RxWestern PA (H5533 003)
Copyright 2012 UPMC Health Plan. All Rights Reserved60
Benefits PPO High Deductible with Rx
Contract ID H5533
PBP(s) 003
Service Area
Pennsylvania (Western): Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, and Westmoreland
Provider Network UPMC Medicare Network (HMO/PPO network)
Formulary Medicare HMO/PPO Formulary (00019208)
2019 UPMC for Life Individual Plans
PPO High Deductible with RxWestern PA (H5533 003)
Monthly Premium: $35
List of Cost-Share Changes:• Emergency Room: $90 copay (was $80) • DME/ Oxygen/ Prosthetic Devices and Medical Supplies: In-network 18%
coinsurance, out-of-network 50% coinsurance excluded from the deductible (Decreased coinsurance 2%, Updated to be excluded from plan deductible)
• Diagnostic Tests/ Procedures/ Lab Services: In-network $10 copay per day excluded from the deductible (was $0-$10)
Copyright 2012 UPMC Health Plan. All Rights Reserved61
2019 PPO Plans
The PPO High Deductible with Rx Plan offering for 2019: Western Pennsylvania$1,250 combined IN/OON deductible
Medical Services Excluded from the Deductible
Copyright 2012 UPMC Health Plan. All Rights Reserved62
In‐Network Services∙ Chiropractic Services (Medicare‐covered & Routine Services) ∙ Preventive Services (All zero cost‐share)∙ Dental Services (Medicare‐covered and Routine Services) ∙ Primary Care Physician Visits∙ Diabetic Training, Supplies, Shoes or Inserts ∙ Prosthetic Devices & Medical Supplies∙ Durable Medical Equipment/Oxygen ∙ Remote Technologies∙ Emergency Care ∙ Routine Podiatry Visits∙ Health and Wellness (includes Fitness) ∙ Skilled Nursing Facility Stays∙ Hearing Services (Medicare‐covered) ∙ Specialist Visits∙ Home Health Care ∙ Urgently Needed Care (Clinics)∙ Kidney Dialysis Training ∙ Vision Exam & Eyewear (Medicare‐covered & Routine Services)∙ Lab Services and Diagnostic Procedures/Tests ∙ Worldwide Emergency Coverage∙ Part B Drugs
Out‐of‐Network Services∙ Dental Services (routine services only) ∙ Routine Chiropractic Services∙ Emergency Care ∙ Routine Podiatry Visits∙ Health and Wellness (includes Fitness) ∙ Routine Vision Exam & Eyewear∙ Preventive Services ∙ Urgently Needed Care (Clinics)∙ Remote Technologies ∙ Worldwide Emergency Coverage
2019 PPO Rx Enhanced
Please note: This is just a summary, not a full description of benefits. Please refer to the
Evidence of Coverage.
2019 UPMC for Life Individual Plans
PPO Rx Enhanced WPA and Lehigh Cap (H5533 005 and 008)
Copyright 2012 UPMC Health Plan. All Rights Reserved64
Benefits PPO Rx EnhancedContract ID H5533PBP(s) 005 008
Service Area
Pennsylvania (Western): Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, and Westmoreland
Pennsylvania (Lehigh Cap): Adams, Bradford, Cumberland, Dauphin, Fulton, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Mifflin, Northampton, Perry, Susquehanna, Wayne, Wyoming, and York counties
Provider Network UPMC Medicare Network (HMO/PPO network)Formulary Medicare HMO/PPO Formulary (00019208)
2019 UPMC for Life Individual Plans
PPO Rx Enhanced WPA and Lehigh Cap (H5533 005 and 008)
Monthly Premium 005 (WPA): $135Monthly Premium 008 (Lehigh Cap): $45
List of Changes:• Emergency Room: $90 copay excluded from the deductible (was $80)• DME/ Oxygen/ Prosthetic Devices and Medical Supplies: In-network 18%
coinsurance, out-of-network 50% coinsurance excluded from the deductible (Decreased coinsurance 2%, Updated OON to be excluded from plan deductible)
• Diagnostic Tests/ Procedures/ Lab Services: In-network $5 copay per day (was $0-$5)
Copyright 2012 UPMC Health Plan. All Rights Reserved65
2019 PPO Plans
PPO Rx Enhanced Plan offerings for 2019:Western Pennsylvania, Lehigh Cap
No Annual Deductible for In Network Services$500 Annual Deductible Applies to Out of Network Services ONLY
Medical Services Excluded from the Deductible
Copyright 2012 UPMC Health Plan. All Rights Reserved66
Out‐of‐Network Services
∙ Chiropractic Services (Routine) ∙ Preventive Services
∙ Dental Services (Routine Services Only) ∙ Remote Technologies
∙ Emergency Care ∙ Urgently Needed Care (Clinics)
∙ Health and Wellness (Includes Fitness) ∙ Vision Exam (Routine)
∙ Hearing Services (Routine) ∙ Worldwide Emergency Coverage
∙ Podiatry Services (Routine)
2019 UPMC for Life Individual Plans
PPO Rx Enhanced Berks (H5533 007)
Copyright 2012 UPMC Health Plan. All Rights Reserved67
Benefits PPO Rx Enhanced
Contract ID H5533
PBP(s) 007
Service Area
Pennsylvania (Berks/Tower Health): Berks county
*Provider Specific Plan (PSP)
Provider Network UPMC PSP 2 Network (Berks/Tower Health)
Formulary Medicare HMO/PPO Formulary (00019208)
2019 UPMC for Life Individual Plans
PPO Rx Enhanced Berks (H5533 007)
Monthly Premium: $60
List of Cost-Share Changes:• Out-of-network deductible: $750 (was $500)• Emergency Room: $90 copay excluded from the deductible (was $80)• DME/ Oxygen/ Prosthetic Devices and Medical Supplies: In-network 18%
coinsurance, out-of-network 50% coinsurance excluded from the deductible (Decreased coinsurance 2%, Updated OON to be excluded from plan deductible)
• Diagnostic Tests/ Procedures/ Lab Services: In-network $5 copay per day (was $0-$5)
Copyright 2012 UPMC Health Plan. All Rights Reserved68
2019 PPO Plans
PPO Rx Enhanced Plan offerings for 2019:Berks County
No Annual Deductible for In Network Services$750 Annual Deductible Applies to Out of Network Services ONLY
Medical Services Excluded from the Deductible
Copyright 2012 UPMC Health Plan. All Rights Reserved69
Out‐of‐Network Services
∙ Chiropractic Services (Routine) ∙ Preventive Services
∙ Dental Services (Routine Services Only) ∙ Remote Technologies
∙ Emergency Care ∙ Urgently Needed Care (Clinics)
∙ Health and Wellness (Includes Fitness) ∙ Vision Exam (Routine)
∙ Hearing Services (Routine) ∙ Worldwide Emergency Coverage
∙ Podiatry Services (Routine)
2019 New Plan Offerings
2019 UPMC for Life Individual Plans
New Plans for 2019• HMO Rx Choice (H3907 049)
• Service Area: Erie, Lawrence, Mercer and Venango counties• Provider Network: UPMC Medicare Network
• HMO Premier RX (H3907 050)• Service Area: Erie, Lawrence, Mercer and Venango counties• Provider Network: UPMC PSP 1 Network
• HMO Premier RX (H3907 051)• Service Area: Westmoreland County• Provider Network: UPMC PSP 3 Network (Westmoreland/ Excela)
• HMO Premier RX (H3907 052)• Service Area: Cumberland and Dauphin counties• Provider Network: UPMC Medicare Network
Copyright 2012 UPMC Health Plan. All Rights Reserved71
2019 HMO Rx Choice (H3907 049)
Please note: This is just a summary, not a full description of benefits. Please refer to the
Evidence of Coverage.
2019 UPMC for Life Individual Plans
HMO Rx Choice (H3907 049)Monthly Premium: $40
• Service Area: Erie, Lawrence, Mercer and Venango counties• Provider Network: UPMC Medicare Network
• Out-of-Pocket Maximum- $3,400 • Inpatient Hospital/ Inpatient Mental Health Care- $400 copay per stay • Skilled Nursing Facility- $20 copay per day- days 1-20, $80 copay per day -days 21-100
• Primary Care Physician (PCP) Visits- $0 copay• Specialist Visits- $30 copay• Chiropractic Services (Medicare-covered)- $20 copay• Chiropractic Services (Routine)- No routine coverage• Podiatry Services (Medicare-covered)- $30 copay• Podiatry Services (Routine)- No routine coverage
Copyright 2012 UPMC Health Plan. All Rights Reserved73
2019 UPMC for Life Individual Plans
HMO Rx Choice (H3907 049)• Outpatient Surgery and Ambulatory Surgical Center (ASC) - $200 copay • Observation Stay- $200 copay • Ambulance Services (Ground & Air)- $100 copay per one way trip• Emergency Care(waived if admitted within 3 days)- $120 copay• Urgently Needed Care (Clinics) (out-of-area; urgent care clinics)- $50 copay• Outpatient Rehab Services (PT, OT, ST)- $0 copay• Cardiac/Pulmonary Rehab- $0 copay• Durable Medical Equipment (DME)/Oxygen- 20% coinsurance• Prosthetic Devices and Medical Supplies- 20% coinsurance• Lab Services(single copay per day per facility)- $10 copay per day• Diagnostic Procedures/Tests (single copay per day per facility)- $10 copay per day• X-Ray Services (Basic Imaging)(single copay per service)- $10 copay• Diagnostic Radiological Services (Advanced Imaging)(single copay per service- $100
copay • Therapeutic Radiological Services (Radiation)- $0 copay
Copyright 2012 UPMC Health Plan. All Rights Reserved74
2019 UPMC for Life Individual Plans
HMO Rx Choice (H3907 049)• Dental Services (Medicare-covered)- $30 copay• Dental Cleaning(two every year)- $0 copay • Dental Oral Exam - Routine(two every year)- $0 copay • Dental Oral Exam - Comprehensive(one every 36 months)-$0 copay • Dental X-rays - Bitewing(one every year)- $0 copay • Comprehensive Dental Allowance(one every year)- $325 allowance• Hearing Services (Medicare-covered)- $30 copay• Routine Hearing Exam(one every year)- $0 copay • Routine Hearing Aid Fitting(one every 3 years)- $0 copay • Routine Hearing Aids(one every 3 years)- $1,500 allowance• Vision Services (Medicare-covered)- $30 copay• Medicare-covered Glaucoma Screening/Diabetic Retinal Eye Exam- $0 copay• Medicare-covered Eyewear Cataract Glasses/Lenses- $0 copay• Routine Vision Exam(one every year)- $0 copay• Routine Vision Eyewear(one every year)- $200 allowance
Copyright 2012 UPMC Health Plan. All Rights Reserved75
HMO Premier RX (H3907 050)
Please note: This is just a summary, not a full description of benefits. Please refer to the
Evidence of Coverage.
2019 UPMC for Life Individual PlansHMO Premier RX (H3907 050)Monthly Premium: $0
• Service Area: Erie, Lawrence, Mercer and Venango counties• Provider Network: UPMC PSP 1 Network
• Out-of-Pocket Maximum: $6,000• Inpatient Hospital/ Mental Health: $375 copay per stay• Skilled Nursing: $0 copay for days 1-20, $160 copay per day for days 21-
100• PCP Visits: $0 copay• Specialist Visits: $35 copay • Podiatry Services (Medicare-covered): $35 copay• Observation Stay/ ASC: $350 copay• Ambulance Services (Ground & Air): $250 copay per one way trip• Emergency Room: $90• Urgent Care: $50 copay• Diagnostic Tests/ Procedures/ Lab Services: $10 copay per day• X-Ray Services (Basic Imaging): $50 copay
Copyright 2012 UPMC Health Plan. All Rights Reserved77
2019 UPMC for Life Individual Plans
HMO Premier RX (H3907 050)• Dental Services (Medicare-covered)- $35 copay• Dental Cleaning(two every year)- $0 copay • Dental Oral Exam - Routine(two every year)- $0 copay • Dental Oral Exam - Comprehensive(one every 36 months)-$0 copay • Dental X-rays - Bitewing(one every year)- $0 copay • Comprehensive Dental Allowance(one every year)- $325 allowance• Hearing Services (Medicare-covered)- $35 copay• Routine Hearing Exam(one every year)- $0 copay • Routine Hearing Aid Fitting(one every 3 years)- $0 copay • Routine Hearing Aids(one every 3 years)- $1,500 allowance• Vision Services (Medicare-covered)- $35 copay• Medicare-covered Glaucoma Screening/Diabetic Retinal Eye Exam- $0 copay• Medicare-covered Eyewear Cataract Glasses/Lenses- $0 copay• Routine Vision Exam(one every year)- $0 copay• Routine Vision Eyewear(one every year)- $200 allowance
Copyright 2012 UPMC Health Plan. All Rights Reserved78
HMO Premier RX (H3907 051)
Please note: This is just a summary, not a full description of benefits. Please refer to the
Evidence of Coverage.
2019 UPMC for Life Individual PlansHMO Premier RX (H3907 051)Monthly Premium: $0
• Service Area: Westmoreland County• Provider Network: UPMC PSP 3 Network (Westmoreland/ Excela)
• Out-of-Pocket Maximum: $6,000• Inpatient Hospital/ Mental Health: Tier 1:$375 copay per stay Tier 2:$80 copay
per day-days 1-5 $0 copay per day - days 6-90• Skilled Nursing: $0 copay for days 1-20, $160 copay per day for days 21- 100• PCP Visits: $0 copay• Specialist Visits: $35 copay • Podiatry Services (Medicare-covered): $35 copay• Observation Stay/ ASC: $350 copay• Ambulance Services (Ground & Air): $250 copay per one way trip• Emergency Room: $90• Urgent Care: $50 copay• Diagnostic Tests/ Procedures/ Lab Services: $10 copay per day• X-Ray Services (Basic Imaging): $50 copay
Copyright 2012 UPMC Health Plan. All Rights Reserved80
2019 UPMC for Life Individual Plans
HMO Premier RX (H3907 051)• Dental Services (Medicare-covered)- $35 copay• Dental Cleaning(two every year)- $0 copay • Dental Oral Exam - Routine(two every year)- $0 copay • Dental Oral Exam - Comprehensive(one every 36 months)-$0 copay • Dental X-rays - Bitewing(one every year)- $0 copay • Comprehensive Dental Allowance(one every year)- $325 allowance• Hearing Services (Medicare-covered) - $35 copay• Routine Hearing Exam(one every year)- $0 copay • Routine Hearing Aid Fitting(one every 3 years)- $0 copay • Routine Hearing Aids(one every 3 years)- $1,500 allowance• Vision Services (Medicare-covered)- $35 copay• Medicare-covered Glaucoma Screening/Diabetic Retinal Eye Exam- $0
copay• Medicare-covered Eyewear Cataract Glasses/Lenses- $0 copay• Routine Vision Exam(one every year)- $0 copay• Routine Vision Eyewear(one every year)- $200 allowance
Copyright 2012 UPMC Health Plan. All Rights Reserved81
HMO Premier RX (H3907 052)
Please note: This is just a summary, not a full description of benefits. Please refer to the
Evidence of Coverage.
2019 UPMC for Life Individual PlansHMO Premier RX (H3907 052)Monthly Premium: $0
• Service Area: Cumberland and Dauphin counties• Provider Network: UPMC Medicare Network
• Out-of-Pocket Maximum: $6,700• Inpatient Hospital/ Mental Health: $200 copay per day for days 1-5, $0 copay
per day for days 6-90• Skilled Nursing: $0 copay for days 1-20, $160 copay per day for days 21-
100• PCP Visits: $0 copay• Specialist Visits: $40 copay • Podiatry Services (Medicare-covered): $40 copay • Emergency Room: $90• Diagnostic Tests/ Procedures/ Lab Services: $10 copay per day• X-Ray Services (Basic Imaging): $50 copay
Copyright 2012 UPMC Health Plan. All Rights Reserved83
2019 UPMC for Life Individual Plans
HMO Premier RX (H3907 052)• Dental Services (Medicare-covered)- $40 copay• Dental Cleaning(two every year)- $0 copay • Dental Oral Exam - Routine(two every year)- $0 copay • Dental Oral Exam - Comprehensive(one every 36 months)-$0 copay • Dental X-rays - Bitewing(one every year)- $0 copay • Comprehensive Dental Allowance(one every year)- $325 allowance• Hearing Services (Medicare-covered)- $40 copay• Routine Hearing Exam(one every year)- $0 copay • Routine Hearing Aid Fitting(one every 3 years)- $0 copay • Routine Hearing Aids(one every 3 years)- $1,500 allowance• Vision Services (Medicare-covered)- $40 copay• Medicare-covered Glaucoma Screening/Diabetic Retinal Eye Exam- $0 copay• Medicare-covered Eyewear Cataract Glasses/Lenses- $0 copay• Routine Vision Exam(one every year)- $0 copay• Routine Vision Eyewear(one every year)- $200 allowance
Copyright 2012 UPMC Health Plan. All Rights Reserved84
Medicare Advantage and Prescription Drug Coverage Overview
Prescription Drug Overview
2019 Medicare “Standard” Prescription Drug Benefit• The following chart depicts the CMS Medicare Standard Part D benefit for 2019. A
prescription drug plan’s benefit must be actuarially equivalent or better than the standard Medicare option listed below:
Copyright 2012 UPMC Health Plan. All Rights Reserved86
Deductible
75% Coverage
25% Co‐insurance
Donut Hole
Member responsible for 37% of generic drug costs and 25% plus dispensing fee for brand name drugs once the Initial Coverage
limit is met.
Catastrophic Coverage
After $5,100 in member out of pocket costs.
Greater of 5% Co‐insurance or $3.40 / $8.50 Copay
$415 $3,820 Initial Coverage Limit
$5,100
TrOOP
Prescription Drug Overview
• Medicare Prescription Drug Coverage Stages and Changes for 2019:
− Deductible Stage (The 2019 deductible amount is set at $415 by CMS.)
• UPMC for Life non-SNP Plans do not have Part D deductibles.
− Initial Coverage Limit Stage
• The Initial Coverage Limit is a CMS defined annual limit. For 2019, the amount is $3,820
• Both the beneficiary’s cost-sharing and what the plan pays accumulates towards this limit.
Copyright 2012 UPMC Health Plan. All Rights Reserved87
Prescription Drug Overview
• Medicare Prescription Drug Coverage Stages and Changes for 2019:
− Coverage Gap Stage
• Both the member cost-sharing and drug manufacturer cost-sharing count toward TrOOP, the plans cost-sharing does not apply to the TrOOP.
• Members receive a discount on generic and brand name drugs in the coverage gap. The following is the 2019 beneficiary cost-sharing in the coverage gap stage:
− Generic Drugs: Once the $3,820 Initial Coverage Limit is met an individual will pay 37% for generic drugs while they are in the coverage gap.
− Brand Name Drugs: During the coverage gap stage, the beneficiary will pay 25% plus the dispensing fee.
Copyright 2012 UPMC Health Plan. All Rights Reserved88
Prescription Drug Overview
• Medicare Prescription Drug Coverage Stages and Changes for 2019:
− Catastrophic Coverage Stage• TrOOP is defined as the true out-of-pocket costs (e.g., $5,100) that an individual must
accumulate before catastrophic drug coverage is reached. The amount paid by the plan does NOT apply to the members’ TrOOP limit. TrOOP includes the following drug costs:
- Deductible - Copays/coinsurance- Coverage gap costs - Out-of-network prescription costs- Coverage gap costs paid by the drug manufacturer
• For 2019, the TrOOP increased to $5,100.
• The member’s cost-sharing for prescription drugs will decrease drastically when they reach this limit. The cost-sharing for 2019 is:− The larger of 5% of the cost of the drug; OR− $3.40 for generic drugs or a drug treated like a generic − $8.50 for all other drugs
Copyright 2012 UPMC Health Plan. All Rights Reserved89
Prescription Drug Overview
Medicare Prescription Drug Coverage Tiers and Changes for 2019
• The 5 tiers have remained the same for 2019
Copyright 2012 UPMC Health Plan. All Rights Reserved90
Tier 2018 2019
1 Preferred Generic Drugs Preferred Generic Drugs
2 Generic Drugs Generic Drugs
3 Preferred Brand Drugs Preferred Brand Drugs
4 Non‐Preferred Drugs Non‐Preferred Drugs
5 Specialty Drugs Specialty Drugs
2019 UPMC for Life – Preferred Network for Part D Prescription Drugs
Copyright 2012 UPMC Health Plan. All Rights Reserved91
HMO Deductible w/Rx HMO Rx
HMO Rx EnhancedHMO Choice Rx(All counties)
PPO HD w/RxPPO Rx Enhanced(All counties)
HMO Premier Rx (PSP)(All Counties)
Tier 1: Preferred Generic Drugs
$0 copay ‐ 30 day supply (retail)$0 copay ‐ 90 day supply (retail)
Tier 2: Generic Drugs
$10 copay ‐ 30 day supply (retail)$20 copay ‐ 90 day supply (retail)
Tier 3: Preferred Brand Drugs
$42 copay ‐ 30 day supply (retail)$105 copay ‐ 90 day supply (retail)
Tier 4: Non‐Preferred Drugs
$95 copay ‐ 30 day supply (retail)$285 copay ‐ 90 day supply (retail)
45% coinsurance‐ 30 day supply (retail) 45% coinsurance ‐ 90 day supply (retail)
Tier 5: Specialty Drugs 33% coinsurance – 30 day supply only
2019 UPMC for Life – Standard Network for Part D Prescription Drugs
Copyright 2012 UPMC Health Plan. All Rights Reserved92
HMO Deductible w/Rx HMO Rx
HMO Rx EnhancedHMO Choice Rx(All counties)
PPO HD w/RxPPO Rx Enhanced(All counties)
HMO Premier Rx (PSP)(All Counties)
Tier 1: Preferred Generic Drugs
$9 copay ‐ 30 day supply (retail)$27 copay ‐ 90 day supply (retail)
$0 copay ‐ 90 day supply (mail‐order)
Tier 2: Generic Drugs
$16 copay ‐ 30 day supply (retail)$48 copay ‐ 90 day supply (retail)
$20 copay ‐ 90‐day supply (mail‐order)
Tier 3: Preferred Brand Drugs
$47 copay ‐ 30 day supply (retail)$141 copay ‐ 90 day supply (retail)
$105 copay ‐ 90 day supply (mail‐order)
Tier 4: Non‐Preferred Drugs
$100 copay ‐ 30 day supply (retail)$300 copay ‐ 90 day supply (retail)
$300 copay ‐ 90 day supply (mail‐order)
50% coinsurance ‐ 30 day supply (retail) 50% coinsurance ‐ 90 day supply (retail)
45% coinsurance ‐ 90 day supply (mail‐order)
Tier 5: Specialty Drugs 33% coinsurance – 30 day supply only
2019 UPMC for LifeMember Document Changes
UPMC Networks• Network names are:
– UPMC Medicare Network
• The UPMC Medicare Network is the main HMO/PPO Network
• Adams, Allegheny, Armstrong, Beaver, Bedford, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Montgomery, Northampton, Perry, Philadelphia, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, and York.
– UPMC Premier Medicare Network
• PSP network in Allegheny, Beaver, Bedford, Blair, Butler, Crawford, Erie, Lawrence, Lycoming, Tioga, and Venango counties
– UPMC/Tower Medicare Network
• PSPs in Berks county
– UPMC/Excela Medicare Network
• PSP in Westmoreland county
Copyright 2012 UPMC Health Plan. All Rights Reserved94
New addition to ID cards
• 2019 ID Cards will list a network name for the Medicare HMO and PPO plans– This is to assist providers in determining what network the member is in due to
the new PSP plans
• Network names are:– Non-PSP plans: UPMC Medicare Network
• PSP network in Allegheny, Beaver, Bedford, Blair, Butler, Erie, Lawrence, Lycoming, Tioga, and Venango counties: UPMC Premier Medicare Network
– PSPs in Berks county: UPMC/Tower Medicare Network
– PSP in Westmoreland County: UPMC/Excela Medicare Network
• The SNP ID cards will not contain the network names
Copyright 2012 UPMC Health Plan. All Rights Reserved95
New addition to ID cards
Copyright 2012 UPMC Health Plan. All Rights Reserved96
Sample ID Card:
2019 UPMC for Life - Provider Directories
2019 Provider Directories• Full Provider/Pharmacy Directory - (1 combined directory divided into two books)
– Full Provider/Pharmacy Directories will be a combined directory that will contain medical providers, pharmacy providers, and all applicable ancillary providers (dental, vision, and fitness.)
• Radius/Partial Directory (monthly)
– Radius/Partial Directory – is not a full provider directory. It will contain a subset of providers located within a specified fixed range of miles from a members’ home address.
• Stand Alone Pharmacy Directory
• Standalone PSP Provider Directories
• Provider Directories are no longer going to be mailed in any kit, but can be sent via by request only. Members are encouraged to use the website search.
Please note: When a member calls into member services to request a directory, they will automatically receive a Radius/Partial Directory unless they specifically state they would like the full directory. (The full directories are almost 1,700 pages)
Copyright 2012 UPMC Health Plan. All Rights Reserved97
2019 UPMC for Life Documents
2019 EOC, ANOC, and Formularies• The EOC and the abridged formulary will not be mailed with the
ANOC. There will be a form to request these the EOC and comprehensive formulary either via electronically or to mail a hard copy, or to access the website.
• We will just be creating the comprehensive formulary. We will not be creating an abridged formulary.
Copyright 2012 UPMC Health Plan. All Rights Reserved98
Recap
General Plan Updates for Medicare Plans
• New fitness vendor- SilverSneakers
– Also added 1 Personal Training Session per calendar year
• Increased ER copayments to either a $90 copayment or $120 copayment, depending on the Maximum out of pocket.
• Added new supplemental benefits: Bathroom Safety Items, In-Home Safety Assessment, and Counseling Services.
• New Flexible Benefit- The meal benefit will be provided one time annually upon discharge from an inpatient stay, observation stay or a SNF stay for members that have all three diagnoses of COPD, CHF and Diabetes. The member will receive 2 meals a day for 28 days (56 meals total).
Copyright 2012 UPMC Health Plan. All Rights Reserved100
General Plan Updates for Medicare Plans
Removed Prior Authorization:
• Outpatient Mental Health/ Outpatient Psychiatric
• Partial Hospitalization
Added Prior Authorization:
• Pain management and sleep specialists
• Outpatient Rehab services (PT, OT, ST)
• Prosthetic Devices
• Chiropractic Services (Medicare-covered)
* Authorization for these services is the responsibility of the provider
Copyright 2012 UPMC Health Plan. All Rights Reserved101
New Supplemental Benefits
• Bathroom Safety Items- The plan will cover up to 3 bathroom safety items as defined by the plan. Member must contact member services to order the bathroom safety items. Member services can then order the items through the online portal.
Copyright 2012 UPMC Health Plan. All Rights Reserved102
UPMC Bath Kit ItemsBath MatRaised toilet seatHandheld shower
Transfer chair w/backBath Chair w/ back
Grab Bar‐Side of the Tub (Adjustable)
New Supplemental Benefits
In-Home Safety Assessment- The plan will cover one in-home safety assessment per calendar year. The in-home assessment will be done by a licensed healthcare professional, such as an occupational therapist and will evaluate the home to identify potential hazards. The member can contact member services to schedule the in-home assessment. This can be scheduled with a participating home health agency closest to the member’s home.
Copyright 2012 UPMC Health Plan. All Rights Reserved103
New Supplemental Benefits
• Counseling Services- Licensed, Master's-level trained clinicians will provide member with up to 6 counseling sessions which would include: caregiving support; family and relationship concerns; stress, grief and other emotional issues; healthy lifestyle changes.
• The counseling services will be provided through Resources for Life
Copyright 2012 UPMC Health Plan. All Rights Reserved104
Questions?
2019 SNP Product TrainingUPMC for Life Dual (HMO SNP)
Objectives
• After today’s overview you will have a better understanding of the following topics:– What is Medicare?– What is a Special Needs Plan?−Who is eligible?− 2019 Benefits & Prescription Drug Coverage
What is Medicare?
Objectives
What is Medicare?• Medicare is a health insurance
program which began in 1965 for:– People 65 years of age or older.– People with disabilities under age 65,
after 24 months.– People diagnosed with End‐Stage Renal
Disease (ESRD).• ESRD – Generally 3 months after a course
of regular dialysis begins or after a kidney transplant
– People diagnosed with amyotrophic lateral sclerosis (ALS).
• ALS – Immediately upon collecting Social Security Disability benefits, which occurs five months after being classified as “disabled”.
Medicare Part A
• Part A – Hospital Insurance helps cover the following services:• Inpatient hospital• Hospice care• Inpatient psychiatric hospital• Blood (after 3 pints)• Skilled nursing• Home health care
• Approximately 98% of beneficiaries DO NOT have to pay a Part A premium if a member or their spouse has paid into Medicare Taxes for at least 10 years.
Medicare Part B
• Part B – Medical Insurance helps cover the following services:
• Doctor visits• Outpatient hospital services• Outpatient surgery• Clinical laboratory• X‐Ray services• Durable medical equipment• Ambulance services• Prosthetics & supplies• Home health care• Outpatient rehabilitation therapy services (PT, OT, ST)• There is a Part B Medicare premium that may change annually.
Medicare Part C
• Medicare Advantage plans are offered by private insurance plans (e.g., UPMC Health Plan) that work with Medicare, plans include:– HMOs (Health Maintenance Organization)– PPOs (Preferred Provider Organization)– PFFS Plans (Private Fee‐for‐Service)– MSA Plans (Medical Saving Account)
• Medicare Advantage plans offer all benefits covered by Medicare Part A and B. Medicare Advantage plans can also have coverage for routine Vision and Dental coverage if the plan filed these additional supplemental benefits with CMS.
• In order to have Part C the beneficiary must have Medicare A, and B.
Medicare Part D
Part D – Medicare Advantage Prescription Drug Coverage.• Part D plans are offered by private
insurance plans (e.g., UPMC Health Plan) that work with Medicare.
• A beneficiary can select Original Medicare and also enroll into an individual prescription drug plan.
OR• A beneficiary can select a Medicare
Advantage plan with prescription drug coverage.
What is a Special Needs Plan?
What is a Special Needs Plan?
What is a Special Needs Plan?• Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or
PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.
Who is eligible?
Who is eligible?
Who is eligible to enroll?• Individuals who qualify for a Special Needs Plan must meet one of the
guidelines established by the Centers for Medicare & Medicaid Services (CMS):
– Institutionalized Medicare beneficiaries– Individuals with severe or disabling chronic conditions– Dual eligible beneficiaries
UPMC Offerings
The SNP Plan that UPMC offers is: –UPMC for Life Dual (HMO SNP)
•Dual‐eligible SNP–UPMC for Life Options (HMO SNP)
• Institutional SNP: This plan is terming for 2019
UPMC for Life Dual Enrollment Requirements
• An individual can join UPMC for Life Dual if they are entitled to Medicare Part A, enrolled in Medicare Part B, and receive full Medical Assistance.
• An individual must live in the service area.
• Individuals with end stage renal disease are not eligible to enroll in UPMC for Life Dual unless they are members of our organization and have been since their dialysis began.
UPMC for Life Dual Updates
Drug Management Program• Drug management programs will be integrated with CMS’s existing Overutilization
Monitoring System (OMS). The clinical guidelines used to determine if a beneficiary is potentially at‐risk, which are based on using opioids from multiple prescribers and/or multiple pharmacies, will be expanded from those used in OMS currently. Sponsors will be allowed to limit an at‐risk beneficiary’s access to frequently abused drugs to a selected prescriber(s) and/or pharmacy(ies) (“lock‐in”), and through the use of beneficiary‐specific point‐of‐sale (POS) claim edits, which are already permitted under the current policy. Part D sponsors may not implement such limitations unless they have engaged in case management with the prescribers of these drugs, and beneficiaries can submit prescriber and pharmacy preferences.
*The Pharmacy Department will be able to provide more information
UPMC for Life Dual Updates
Election Periods: • Starting Jan. 1, 2019, beneficiaries with Medicare and Medical
Assistance (Medicaid) will only be able to make ONE Medicare plan change per calendar year quarter from Jan. 1 – Sept. 30.
• That means you can make ONE plan change during the timeframes below:
• Jan. 1 – Mar. 31• Apr. 1 – Jun. 30• Jul. 1 – Sept.30• Your coverage will be effective the first of the next month.• There are some exceptions to this when certain events happen in your
life such as losing Medical Assistance coverage. There are rules about when you can make changes and the type of changes you can make based on your circumstances.
Plan Overview
Quick Plan Overview• UPMC for Life Dual
– Operates under the current contract number of H4279 – UPMC for You, Inc. license
– Has one Plan Benefit Package (PBP), 001, available in the following PA counties for 2019:
• Existing: 28 WPA, Berks, Bucks, Chester, Clinton, Dauphin, Delaware, Fulton, Lehigh, Lycoming, Montgomery, Perry, Philadelphia, Snyder, Sullivan, Tioga, Union
• New counties for 2019: Bradford, Cumberland, Juniata, Lackawanna, Lancaster, Lebanon, Luzerne, Mifflin, Northampton, Susquehanna, Wayne, Wyoming, York
Quick Plan Overview
Removed Prior Authorization:• Outpatient Mental Health/
Outpatient Psychiatric• Partial Hospitalization
Added Prior Authorization: • Pain management and sleep
specialists• Outpatient Rehab services (PT,
OT, ST) • Prosthetic Devices• Chiropractic Services
(Medicare‐ covered)* Authorization for these services is the responsibility of the provider
2019 DSNP Expansion Counties
• Set to expand to multiple PA counties with CHC launch – Rest of PA 2020
2019 Group/Plan Codes
Plan Name Group Subgroups Plan Code Contract PBP Rx Rider
Vision Rider
Dental Rider
UPMC for Life Dual
MCSND1 500‐508 GYA H4279 001 A267 MSV3 12Y
UPMC for Life Dual ‐Deemed
MCSNDG 500‐508 GYD H4279 001 A268 MSV3 12Y
2019 Benefit Information
• The SNP Plans provide the beneficiary with all the usual services covered by original Medicare and some additional enhanced benefits.
• Members must use the established network of doctors, specialists, and hospitals to receive covered care services.
• If member has UPMC CHC and UPMC for Life Dual, they will receive only one ID card and it will contain two member ID numbers. The first ID # will be listed as Primary which will be their DSNP member number; the second ID # will be listed as Secondary which will be their CHC number.
• UPMC for Life Dual members that have not enrolled with UPMC CHC must also show their Access or Community Health Choices card along with their UPMC for Life Dual card. – These members will only receive a UPMC for Life card
• Note: The Medicare coverage through UPMC for Life Dual pays as primary and Medical Assistance (Medicaid) whether the member has coverage through UPMC CHC, another CHC or ACCESS pays as secondary.
• The Secondary ID will be the member’s recipient ID number
ID Card
• Sample ID Cards
2019 Supplemental Benefits for UPMC for Life Dual
Benefit UPMC for Life Dual
Dental $0 copay for:Exam/cleaning/x‐rays every six monthsUpdated for 2019‐ $3,000 annual allowance for comprehensive dental (includes fillings & simple extractions)
Hearing $0 copay for:1 routine hearing exam and fitting per yearHearing aid allowance of $1,500 every three years
Vision $0 copay for:Routine eye exam every year$250 allowance for eyeglasses or contact lenses every year
2019 Supplemental Benefits for UPMC for Life Dual(Continued)
Benefit UPMC for Life Dual
Health and Wellness • Nursing Hotline• Additional nutritional counseling available for
the following conditions: Alzheimer’s, cancer, multiple sclerosis, and stroke
• UPMC Anywhere Care• New for 2019‐ SilverSneakers is the new fitness
vendor. Gym membership as well as at‐home DVDs and one personal training session per calendar year
Transportation • $0 copay for:• 50 one‐way trips per calendar year
Podiatry • New for 2019‐ 4 routine visits every year
2019 Supplemental Benefits for UPMC for Life Dual(Continued)
Benefit UPMC for Life Dual
Meal Benefit(only post discharge from Inpatient Hospital, Observation or SNF stay)
14 meals will be delivered to the member’s homeover a one week period – 2 meals a day for 7 days
Bathroom Safety Devices $0 copayThe member can choose up to 6 bathroom safetyitems per year
PERS (Personal Emergency Response System)
$0 copayOne per lifetime
OTC Allowance $125/quarter Allowance can accrue for a maximum benefit of $500/yearMust go to a participating locations and must only purchase eligible itemsWill receive a reloadable OTC card
2019 Medicare Premiums, Deductibles, & FFS Rates
Medicare FFS Rates
2018 2019 (TBA)
Part B Premiums $134.00 $134.00
Part B Deductible (annual)* $183.00 $183.00
Applies to Inpatie
nt
Acute and Inpatie
ntMen
tal H
ealth
Part A Hospital Deductible (days 1‐60) $1,340.00 $1,340.00
Hospital Days 61‐90 $335.00 $335.00
Lifetime Reserve Days (days 91 – 150) $670.00 $670.00
SNF (days 1 – 20) $0 copay $0 copay
SNF (days 21 – 100) $167.50 $167.50
Part D Premium (Drug) $37.10 $37.10
• The Medicare premiums, deductibles, and coinsurance amounts for a member who remains entitled to Medicare Part A, enrolled in Part B, and maintains full Medical Assistance coverage are fully subsidized (e.g. no member responsibility).
• The UPMC for Life Dual Summary of Benefits will show that members have a 0% cost‐sharing responsibility
* Applies only to Medicare‐covered outpatient services; excludes Labs, Emergency Care, Home Health, Pap Smears, Medicare covered preventive services, and non Medicare covered vision, dental, & hearing
Maximum Out‐of‐Pocket Costs for Medical Services
• The out‐of‐pocket maximum is the maximum amount that a member would pay out of their pocket during the calendar year for covered Part A (hospital insurance) and Part B (medical insurance) services. Part D copays are not applied to this out of pocket.
− In 2019, UPMC for Life Dual members have a $3,400 maximum out‐of‐pocket amount for covered Part A and Part B services
− This applies only when the member falls into the grace period (lost Medical Assistance).
• Medical Assistance picks up the balances after the Medicare payment for dual eligible members and the out‐of‐pocket is not applicable.
• Members will remain responsible for any Medical Assistance copays.
UPMC for Life Dual Grace Period
• UPMC for Life Dual members will be provided with a 150‐180 day grace period, when they lose their Medical Assistance coverage.
• During the grace period, UPMC for Life Dual members are encouraged to contact their County Assistance Office to regain full Medical Assistance.
• UPMC for Life Dual members who are unable to regain full Medical Assistance coverage will be disenrolled after the grace period ends.
• Once the member is disenrolled, they will return to Original Medicare unless they enroll in another Medicare Advantage plan.
UPMC for Life Dual Grace Period (Continued)
• While in the grace period:– Members will not be responsible for copayments or coinsurance
for covered services, except for Part D prescription drug copayments.
– Members will remain responsible for the Part B premium at all times, unless this amount is paid on their behalf.
– If a member receives a balance bill from a provider, they are encouraged to call Member Services, as members are not responsible for balance bills.
– UPMC for Life Dual providers are not allowed to balance bill our members.
(Once members are in the Grace Period, the out of pocket accumulates, the part B deductible is not taken. Part B drugs are also paid at 100% once the member is in the Grace Period. If a member is trying to get a part B drug during the time they lost their full Medical Assistance and when they are in the Grace Period, the claim will need to be adjusted to pay at 100%.)
UPMC for Life Dual2019 Pharmacy Coverage• UPMC for Life Dual has a 5‐tier drug list:
– Tier 1 – Preferred Generic Drugs– Tier 2 – Generic Drugs– Tier 3 – Preferred Brand Drugs– Tier 4 – Non‐Preferred Drugs– Tier 5 – Specialty Drugs
• Part D Rx’s are dispensed as a 30‐day supply (except for long‐term care facility residents).
• Temporary transition supply is dispensed in a 30‐day supply for non‐formulary drugs. – For long‐term care facility residents, the transition drug supply
remains at 31‐days• There will now be Preferred and Standard Pharmacy locations. The cost
share will remain the same for the members because they will continue to pay their LIS copays.
Low Income Subsidy (LIS)
• Medicare beneficiaries with limited income and resources may qualify for extra help to pay for prescription drugs costs. This low‐income subsidy (LIS) assistance will help pay for monthly premiums, yearly deductibles, and copayments.
• Full benefit dual eligibles, such as those in the UPMC for Life Dual, are automatically eligible for the low‐income subsidy.
• Low Income Subsidy Rider – Needs to be in member’s hands by September 30th. This will be mailed with the ANOC.
Low Income Subsidy (LIS)
2018 2019
SNP Part D Premium $37.10 $37
Generic Copays $0; $1.25; $3.35 $0, $1.25, $3.40
Brand Copays $0; $3.70; $8.35 $0, $3.80, $8.50
Initial Coverage Limit $3,750.00 $3,820.00
Catastrophic Coverage Limit $5,000.00 $5,100.00
Questions?
• Any questions?
Thank you!
Chapter 2 ‐Medicare Managed Care ManualChapter 3 – Medicare Prescription Drug Benefit Manual
Updated 7/31/18
Why is this Training Important to You?
• CMS holds UPMC accountable to the guidance in:– MA Chapter 2, MAPD Chapter 3
Enrollment and Disenrollment• CMS performs audits to determine if we are following their
regulations.• We are required to follow the guidelines as listed in the
Chapter unless otherwise stated by CMS.• You are at least partially responsible for executing these
regulations so we are in compliance with CMS.
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Processing the Enrollment RequestSection 40.2
• The Plan may ask to see the individual’s Medicare card to verify the spelling of the name, and to confirm the correct recording of Medicare Number, and entitlement dates for Medicare Part A and Part B.
• The individual does not have to show or provide the Medicare card or other evidence when submitting the request.
• Other forms of evidence are only requested when the enrollment request doesn’t include the Medicare Number and the plan is unable to locate the individual in CMS systems.
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Entitlement Information and Medicare Number Section 40.2B
• CMS systems are updated within two business days of SSA processing new or changed Part A or Part B entitlement for a Medicare beneficiary. The CMS systems are the most up‐to‐date data regarding Medicare entitlement for the beneficiary.
• The Medicare Number will be assigned at the time CMS first receives entitlement information for a new beneficiary. If the enrollment request does not include the Medicare Number and the plan is unable to locate the individual in the BEQ or MARx online query, the organization should consider the enrollment request incomplete.
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Entitlement Information and Medicare NumberSection 40.2 B
The individual may provide the Medicare Number to the plan verbally or in writing.
Examples of documents the beneficiary may send to the plan which display the Medicare Number (and entitlement information) include:• Medicare card• Medicare Award notice from SSA (shows Medicare entitlement dates only)• Benefit Verification notice from SSA (includes Medicare number and entitlement
start dates)• Medicare card information from the individual’s MyMedicare.gov account• A notice from CMS regarding change in Medicare Number
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Entitlement Information and Medicare NumberSection 40.2 B
NOTE: • If the beneficiary provides any of the notices listed on the previous slide,
the date on the letter should be no more than two months before the enrollment request was received by the plan.
• If there is a discrepancy between the entitlement information in a document and the information in CMS’s systems, use the data in CMS’s systems to determine eligibility for enrollment.
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Restoration of the MA Open Enrollment Period Section 30.5
CMS has discontinued the Medicare Advantage Disenrollment Period (MADP) (January 1 – February 14th) and established the:
Medicare Advantage Open Enrollment Period (MA OEP) effective January 1, 2019.
MA plan enrollees may enroll in another MA plan or disenroll from their MA plan and return to Original Medicare.
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Restoration of the MA Open Enrollment Period Chapter 2, Section 30.5
This chart outlines who can use the MA OEP and when:
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Who can use the MA OEP: MA OEP occurs:
Individuals enrolled in MA plans as of January 1 January 1 – March 31
New Medicare beneficiaries who are enrolled in an MA plan during their ICEP
The month of entitlement to Part A and Part B – the last day of the 3rd month of entitlement.
ICEP Example
Mr. Smith will turn 65 on July 13, 2019. He will become eligible for Medicare Part A and Part B beginning on July 1 and has decided to enroll in Part B for an effective date of July 1. Mr. Smith’s ICEP begins April 1, 2019 and ends on October 31, 2019.
Mr. Smith can use his MA OEP election from July 1‐ September 30, 2019 to make an election into another plan. September is the end of the 3rd month of entitlement.
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Restoration of the MA Open Enrollment Period
Individuals may add or drop Part D coverage during the MA OEP.
Individuals enrolled in either MA‐PD or MA‐only plans can switch to:
– MA‐PD– MA‐only– Original Medicare (with or without a stand‐alone Part D plan).
The effective date for an MA OEP election is the first of the month following receipt of the enrollment request.
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Restoration of the MA Open Enrollment Period Chapter 2, Section 30.5
NOTE: • The MA OEP does not provide an opportunity for an
individual enrolled in Original Medicare to join a MA plan. • It also does not allow for Part D changes for individuals
enrolled in Original Medicare, including those enrolled in stand‐alone Part D plans.
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Ranking of Election Periods
1. ICEP/IEP‐D – Initial Coverage Election Period/ Initial Enrollment
Period for Part D
2. MA OEP – Medicare Advantage Open Enrollment Period
3. SEP – Special Election Period
4. AEP – Annual Election Period
5. OEPI – Open Enrollment Period for Institutionalized Individuals
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SEP (Modified)Dual‐Eligible Individuals and Other LIS‐Eligible Individuals
Dual‐Eligible Individuals and Other LIS‐Eligible Individuals: This SEP is for individuals who have Medicare Part A and Part B and receive any type of assistance from Medicaid. This includes:
– Full benefit dual eligible– Partial duals (eligible to receive cost sharing)– LIS (but do not receive Medicaid benefits)
This SEP begins the month the individual becomes dually‐eligible and exists as long as he/she receives Medicaid benefits.
However, there are limits on how often it can be used.
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SEP (Modified)Dual‐Eligible Individuals and Other LIS‐Eligible Individuals
Use of this SEP is separate from and in addition to:
• SEP for Individuals who Lose or Have a Change in the Dual or LIS Eligibility Status
And• SEP for Individuals Who Have Been Enrolled into a Plan by
CMS or the State
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SEP (Modified)Dual‐Eligible Individuals and Other LIS‐Eligible Individuals
This SEP allows an individual to enroll in, or disenroll from a Part D plan once per calendar quarter from January through September. This SEP can be used once during each of the following time periods:
• January – March• April – June• July – September
It may not be used in the 4th quarter of the year (October – December)
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SEP (Modified)Dual‐Eligible Individuals and Other LIS‐Eligible Individuals
This SEP is considered “used” based on the date the application is received by the Plan.
If the plan receives an application in March (which would be effective April 1st), this counts as “using” the SEP for the 1stquarter, not the 2nd quarter.
CMS will reject enrollment transactions for individuals who have already used this SEP in the calendar quarter.
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SEP (Modified)Dual‐Eligible Individuals and Other LIS‐Eligible Individuals LIMITATION
This SEP has a limitation for “At‐Risk” and “Potential At‐Risk” Beneficiaries
• At‐Risk: Part D eligible individual who is determined to be at‐risk for misuse or abuse of a frequently abused drug in accordance with the requirements for drug management programs at § 423.153(f).
• Potential At‐Risk: A Part D eligible individual who is identified as being potentially at‐risk for misuse or abuse of a frequently abused drug in accordance with the requirements for drug management programs at § 423.153(f).
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SEP (Modified)Dual‐Eligible Individuals and Other LIS‐Eligible Individuals LIMITATION
Once a member is identified (by the Plan) as a “potential at‐risk” or “at risk” beneficiary and we have sent written notice to the member, he/she cannot use this SEP to change plans while this designation is in place. The notice to the individual explains that this SEP is no longer available.
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SEP (Modified)Dual‐Eligible Individuals and Other LIS‐Eligible Individuals LIMITATION
Duration of the Limitation – This limitation starts as of the date on the initial notice sent to the “potential at‐risk” beneficiary.
NOTE: • The limitation ends based on whichever situation occurs first. • The enrollment limitation for a “potential at‐risk” or an “at‐
risk” individual will not apply to other Part D enrollment periods, including the AEP or other SEPs.
The chart on the next page outlines when the limitation ends.
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Situation SEP limitation ends
Plan decides not to identify the “potential at‐risk” beneficiary as an “at‐risk” beneficiary.
60 days from the date on the initial notice or the date the beneficiary receives notice of the plan’s decision, if earlier.
The “potential at‐risk” or “at‐risk” identification is subsequently removed by plan or through beneficiary’s favorable appeal of an “at‐risk” determination
The date that the designation is removed by the plan or upon effectuation of a favorable appeal
The plan determines the beneficiary is “at‐risk” 12 months from the date the individual is determined to be “at‐risk”
The plan extends the “at‐risk” designation beyond the initial 12 months
24 months from the date the individual is determined to be “at‐risk” NOTE: This is the maximum consecutive time the SEP limitation can be imposed for each “at‐risk” limitation a sponsor implements.
159
SEP (Expanded)Individuals who Gain, Lose, or Have a Change in their Dual or LIS‐Eligible Status
Individuals who Gain, Lose, or Have a Change in their Dual or LIS‐Eligible Status:SEP provided for individuals who receive “Extra Help”. It includes those who:
• Become eligible for any type of assistance including “partial duals” who receive cost sharing assistance under Medicaid and individuals who qualify for LIS (but do not receive Medicaid benefits);
• Lose eligibility for any type of assistance; and• Have a change in the level of assistance they receive (e.g., stop receiving
Medicaid benefits, but still qualify for LIS, those who have a change in cost sharing).
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SEP (Expanded)Individuals who Gain, Lose, or Have a Change in their Dual or LIS‐Eligible Status
• The SEP allows the individual one opportunity to make an election within three months of any of the changes noted above, or notification of such a change, whichever is later.
• The effective date for enrollments under this SEP is the first day of the month following receipt of the enrollment request by the plan.
• NOTE: Use of this SEP does not count towards the once per calendar quarter limitation outlined in SEP for Dual‐eligible Individuals and Other LIS‐Eligible Individuals.
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SEP for Providing Individuals who Requested Materials in Accessible Formats Equal Time to Make Enrollment Decisions
• Plans are required to provide materials in accessible formats to its members. This generally includes Braille, Data CD, Audio CD, or other formats accepted by the member in place of the original print material.
• CMS will grant an SEP in situations where the organization or CMS is unable to provide required notices or information in an accessible format, as requested by an individual, within the same timeframe that it was able to provide the same information to individuals who did not request an accessible format.
• This limited SEP ensures that beneficiaries who have requested information in accessible formats are not disadvantaged by any additional time necessary to fulfil their request, including missing an election period deadline.
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SEP for Providing Individuals who Requested Materials in Accessible Formats Equal Time to Make Enrollment Decisions
• The SEP begins at the end of the election period during which the beneficiary was seeking to make an election. The start and length of the SEP, as well as the effective date, is dependent upon the situation, and are at least as long as the time it took for the information to be provided to the individual in an accessible format.
• Plans may provide this SEP when the conditions described in this section are met, ensuring adequate documentation of the situation (such as records indicating the amount of time taken to provide accessible versions of materials) is maintained. Individuals seeking assistance for this SEP may also contact 1‐800‐MEDICARE.
163
SEP for Individuals Affected by a FEMA‐Declared Weather Related Emergency or Major Disaster
A SEP exists for individuals affected by a weather‐related emergency or major disaster who were unable to, and did not make an election during another valid election period. This includes both enrollment and disenrollment elections. Individuals will be considered “affected” and eligible for this SEP if they:
• Reside, or resided at the start of the incident period, in an area for which FEMA has declared an emergency or a major disaster and has designated affected counties as being eligible to apply for individual or public level assistance;
• Had another valid election period at the time of incident period; and • Did not make an election during that other valid election period.
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SEP for Individuals Affected by a FEMA‐Declared Weather Related Emergency or Major Disaster
• In addition, the SEP is available to those individuals who don’t live in the affected areas but rely on help making healthcare decisions from friends or family members who live in the affected areas. The SEP is available from the start of the incident period and for four full calendar months thereafter.
165
SEP for CMS and State‐Initiated Enrollments
• Individuals who are enrolled into a plan by CMS or a State (i.e., through passive enrollment, auto‐enrollment, facilitated enrollment, and reassignment) have an SEP to disenroll from their new plan or enroll into a different plan.
• The SEP permits a onetime election within three months of the effective date of the assignment, or notification of the assignment, whichever is later. It allows the individual to make an election before the enrollment is effective in the receiving plan or after the coverage in the receiving plan starts.
166
SEP for CMS and State‐Initiated Enrollments
• This SEP must be used within three months of the start of coverage in the receiving plan. In the case where the notice is sent after the coverage in the receiving plan starts, the SEP ends three months after the date of the notice. This SEP is provided so that an individual may exercise any mandatory “opt‐out” right provided to the enrollee as part of the CMS or State‐initiated enrollment.
• The effective date for enrollments under this SEP is the first day of the month following receipt of the enrollment request by the plan.
• Individuals passively enrolled due to a plan’s non‐renewal or termination may also be eligible for an additional SEP.
167