new 86-100633-21 emblemhealth vip part b saver 000 anoc · 2020. 9. 28. · employer coverage, and...

EmblemHealth VIP Part B Saver (HMO) offered by HealthInsurance Plan of Greater New York (HIP)EmblemHealth Annual Notice of Changes for 2021 You are currently enrolled as a member of EmblemHealth VIP Part B Saver (HMO) Next yearthere will be some changes to the planrsquos costs and benefits This booklet tells about the changes

You have from October 15 until December 7 to make changes to your Medicarecoverage for next year

What to do now 1 ASK Which changes apply to you Check the changes to our benefits and costs to see if they affect you

Itrsquos important to review your coverage now to make sure it will meet your needs next year

Do the changes affect the services you use

Look in Sections 15 and 2 for information about benefit and cost changes for our plan Check the changes in the booklet to our prescription drug coverage to see if they affect you

Will your drugs be covered

Are your drugs in a different tier with different cost sharing

Do any of your drugs have new restrictions such as needing approval from us before you fillyour prescription

Can you keep using the same pharmacies Are there changes to the cost of using this

pharmacy

Review the 2021 Drug List and look in Section 16 for information about changes to ourdrug coverage

Your drug costs may have risen since last year Talk to your doctor about lower cost

alternatives that may be available for you this may save you in annual out-of-pocket coststhroughout the year To get additional information on drug prices visit gomedicaregovdrugprices These dashboards highlight which manufacturers have been increasing theirprices and also show other year-to-year drug price information Keep in mind that your planbenefits will determine exactly how much your own drug costs may change

OMB Approval 0938-1051 (Expires December 31 2021)

Check to see if your doctors and other providers will be in our network next year

Are your doctors including specialists you see regularly in our network

What about the hospitals or other providers you use

Look in Section 13 for information about our Provider Directory Think about your overall health care costs

How much will you spend out-of-pocket for the services and prescription drugs youuse regularly

How much will you spend on your premium and deductibles

How do your total plan costs compare to other Medicare coverage options

Think about whether you are happy with our plan 2 COMPARE Learn about other plan choices Check coverage and costs of plans in your area

Use the personalized search feature on the Medicare Plan Finder at wwwmedicaregovplan-compare website

Review the list in the back of your Medicare amp You handbook

Look in Section 32 to learn more about your choices

Once you narrow your choice to a preferred plan confirm your costs and coverage on the planrsquos

website 3 CHOOSE Decide whether you want to change your plan

If you dont join another plan by December 7 2020 you will be enrolled in EmblemHealthVIP Part B Saver (HMO)

To change to a different plan that may better meet your needs you can switch plans

between October 15 and December 7 4 ENROLL To change plans join a plan between October 15 and December 7 2020

If you donrsquot join another plan by December 7 2020 you will be enrolled in EmblemHealthVIP Part B Saver (HMO)

If you join another plan by December 7 2020 your new coverage will start on January 1

2021 You will be automatically disenrolled from your current plan

Additional Resources

This document is available for free in Spanish

Please contact our Customer Service number at 1-877-344-7364 for additional information(TTY users should call 711) Hours are 8 am to 8 pm 7 days a week

We can also provide information in a way that works for you (information in large print or

other alternate formats) Please call Customer Service at the number listed above if you needplan information in another format or language

Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies

the Patient Protection and Affordable Care Actrsquos (ACA) individual shared responsibilityrequirement Please visit the Internal Revenue Service (IRS) website at wwwirsgovAffordable-Care-ActIndividuals-and-Families for more information

About EmblemHealth VIP Part B Saver (HMO)

Health Insurance Plan of Greater New York (HIP) is an HMOHMO-POSHMO D-SNPplan with a Medicare contract and a Coordination of Benefits Agreement with the NewYork State Department of Health Enrollment in HIP depends on contract renewal HIP is anEmblemHealth company

When this booklet says ldquowerdquo ldquousrdquo or ldquoourrdquo it means HIPEmblemHealth When it says

ldquoplanrdquo or ldquoour planrdquo it means EmblemHealth VIP Part B Saver (HMO)

H3330_201428_M File amp Use

EmblemHealth VIP Part B Saver (HMO) Annual Notice of Changes for 2021 1

Summary of Important Costs for 2021 The table below compares the 2020 costs and 2021 costs for EmblemHealth VIP Part B Saver(HMO) in several important areas Please note this is only a summary of changes A copy of theEvidence of Coverage is located on our website at emblemhealthcommedicare You may also callCustomer Service to ask us to mail you an Evidence of Coverage

Cost 2020 (this year) 2021 (next year)

Monthly plan premium Your premium may be higheror lower than this amount (See Section 11 for details)

$0 $0

Deductible $1000 $1000

Maximum out-of-pocketamount This is the most you willpay out-of-pocket for yourcovered Part A and Part B services (See Section 12 fordetails)

$6700 $7550

Doctor office visits Primary care visits$25 copay per visit Specialist visits$50 copay per visit Referral required forspecialist visits

Primary care visits$25 copay per visit Specialist visits$50 copay per visit No Referral Required

Inpatient hospital stays Includes inpatient acuteinpatient rehabilitation long-term care hospitals and othertypes of inpatient hospitalservices Inpatient hospital carestarts the day you are formallyadmitted to the hospital with adoctorrsquos order The day beforeyou are discharged is your lastinpatient day

Days 1-3 $495 copay perday $0 copay per day foreach additional day for eachinpatient stay Unlimited days Prior authorization isrequired




Part D prescription drugcoverage (See Section 16 for details)

Deductible $435 CopaymentCoinsuranceduring the Initial CoverageStage Drug Tier 1Standard cost sharing You pay $4 per prescriptionPreferred cost sharingYou pay $0 per prescription Drug Tier 2Standard cost sharing You pay $20 per prescriptionPreferred cost sharingYou pay $18 per prescription Drug Tier 3Standard cost sharing You pay $47 per prescriptionPreferred cost sharingYou pay $45 per prescription Drug Tier 4Standard cost sharing You pay $100 perprescriptionPreferred cost sharingYou pay $95 per prescription Drug Tier 5Standard cost sharing You pay 25 of the totalcostPreferred cost sharingYou pay 25 of the totalcost

Deductible $445 CopaymentCoinsurance during the Initial CoverageStage Drug Tier 1Standard cost sharing You pay $7 per prescriptionPreferred cost sharingYou pay $2 per prescription Drug Tier 2Standard cost sharing You pay $20 per prescriptionPreferred cost sharingYou pay $15 per prescription Drug Tier 3Standard cost sharing You pay $47 per prescriptionPreferred cost sharingYou pay $42 per prescription Drug Tier 4Standard cost sharing You pay $100 perprescriptionPreferred cost sharingYou pay $95 per prescription Drug Tier 5Standard cost sharing You pay 25 of the totalcostPreferred cost sharingYou pay 25 of the totalcost


Annual Notice of Changes for 2021Table of Contents

Summary of Important Costs for 2021 1 SECTION 1 Changes to Benefits and Costs for Next Year 4

Section 11 ndash Changes to the Monthly Premium4

Section 12 ndash Changes to Your Maximum Out-of-Pocket Amount 4

Section 13 ndash Changes to the Provider Network 5

Section 14 ndash Changes to the Pharmacy Network 5

Section 15 ndash Changes to Benefits and Costs for Medical Services 6

Section 16 ndash Changes to Part D Prescription Drug Coverage 10 SECTION 2 Administrative Changes13 SECTION 3 Deciding Which Plan to Choose 13

Section 31 ndash If you want to stay in EmblemHealth VIP Part B Saver (HMO)13

Section 32 ndash If you want to change plans 13 SECTION 4 Deadline for Changing Plans14 SECTION 5 Programs That Offer Free Counseling about Medicare15 SECTION 6 Programs That Help Pay for Prescription Drugs 15 SECTION 7 Questions 16

Section 71 ndash Getting Help from EmblemHealth VIP Part B Saver (HMO) 16

Section 72 ndash Getting Help from Medicare16


SECTION 1 Changes to Benefits and Costs for Next Year Section 11 ndash Changes to the Monthly Premium


Monthly premium (You must also continue to payyour Medicare Part B premium) As a member of EmblemHealthVIP Part B Saver (HMO) youreceive up to $500 a year ($4170per month) back on your MedicarePart B premium payments

$0 $0

Optional Supplemental Benefits Comprehensive Dental Benefit SilverSneakersreg Fitness Benefit

$1250

$15

$1250

$1250

Your monthly plan premium will be more if you are required to pay a lifetime Part D late

enrollment penalty for going without other drug coverage that is at least as good as Medicaredrug coverage (also referred to as ldquocreditable coveragerdquo) for 63 days or more

If you have a higher income you may have to pay an additional amount each month directly

to the government for your Medicare prescription drug coverage

Your monthly premium will be less if you are receiving ldquoExtra Helprdquo with your prescriptiondrug costs Please see Section 6 regarding ldquoExtra Helprdquo from Medicare

Section 12 ndash Changes to Your Maximum Out-of-Pocket Amount

To protect you Medicare requires all health plans to limit how much you pay ldquoout-of-pocketrdquoduring the year This limit is called the ldquomaximum out-of-pocket amountrdquo Once you reach thisamount you generally pay nothing for covered Part A and Part B services for the rest of the year


Maximum out-of-pocket amount Your costs for covered medicalservices (such as copays anddeductibles) count towardyour maximum out-of-pocketamount Your plan premium andyour costs for prescription drugs donot count toward your maximumout-of-pocket amount

$6700

$7550

Once you have paid $7550out-of-pocket for coveredPart A and Part B servicesyou will pay nothing foryour covered Part A andPart B services for the restof the calendar year


Section 13 ndash Changes to the Provider Network Our network has changed more than usual for 2021 An updated Provider Directory is located onour website at emblemhealthcommedicare You may also call Customer Service for updatedprovider information or to ask us to mail you a Provider Directory We strongly suggest thatyou review our current Provider Directory to see if your providers (primary care providerspecialists hospitals etc) are still in our network It is important that you know that we may make changes to the hospitals doctors and specialists(providers) that are part of your plan during the year There are a number of reasons why your provider might leave your plan but if your doctor or specialist does leave your plan you havecertain rights and protections summarized below

Even though our network of providers may change during the year we must furnish you withuninterrupted access to qualified doctors and specialists

We will make a good faith effort to provide you with at least 30 daysrsquo notice that your

provider is leaving our plan so that you have time to select a new provider

We will assist you in selecting a new qualified provider to continue managing your healthcare needs

If you are undergoing medical treatment you have the right to request and we will work with

you to ensure that the medically necessary treatment you are receiving is not interrupted

If you believe we have not furnished you with a qualified provider to replace your previousprovider or that your care is not being appropriately managed you have the right to file anappeal of our decision

If you find out your doctor or specialist is leaving your plan please contact us so we can

assist you in finding a new provider to manage your care Section 14 ndash Changes to the Pharmacy Network Amounts you pay for your prescription drugs may depend on which pharmacy you use Medicaredrug plans have a network of pharmacies In most cases your prescriptions are covered only if theyare filled at one of our network pharmacies Our network includes pharmacies with preferred costsharing which may offer you lower cost sharing than the standard cost sharing offered by othernetwork pharmacies for some drugs Our network has changed more than usual for 2021 An updated Pharmacy Directory is locatedon our website at emblemhealthcommedicare You may also call Customer Service for updatedprovider information or to ask us to mail you a Pharmacy Directory We strongly suggest that youreview our current Pharmacy Directory to see if your pharmacy is still in our network


Section 15 ndash Changes to Benefits and Costs for Medical Services We are changing our coverage for certain medical services next year The information belowdescribes these changes For details about the coverage and costs for these services see Chapter 4Medical Benefits Chart (what is covered and what you pay) in your 2021 Evidence of Coverage


Acupuncture You pay a $30 copay foreach Medicare-coveredAcupuncture visit No more than 20 acupuncturetreatments may beadministered annually Prior Authorization requiredafter visit 12

You pay a $10 copay foreach Medicare-coveredAcupuncture visit No more than 20 acupuncturetreatments may beadministered annually Prior Authorization requiredafter visit 12

Ambulance Services You pay a $375 copay forcovered one-way groundambulance trip after you meetyour $1000 deductible Prior authorization is requiredfor Medicare-covered non-emergency services

You pay a $425 copay forcovered one-way groundambulance trip after you meetyour $1000 deductible Prior authorization is requiredfor Medicare-covered non-emergency services

Ambulatory Surgical Centers You pay a $300 copay forMedicare-covered ambulatorysurgical centers after youmeet your $1000 deductible Prior authorization is required

You pay a $325 copay forMedicare-covered ambulatorysurgical centers after youmeet your $1000 deductible Prior authorization isrequired



Hearing Services You pay a $10 copay for onecovered routine hearing examevery calendar year You pay a $40 copay forMedicare-covered diagnostichearing exams You pay a $10 copayfor Evaluation and fitting ofhearing aids every calendaryear Referral Required

You pay a $10 copay for onecovered routine hearing examevery calendar year You pay a $40 copay forMedicare-covered diagnostichearing exams You pay a $10 copayfor Evaluation and fitting ofhearing aids every calendaryear No Referral Required

Inpatient Mental HealthCare (Psychiatric Facility)

You pay a $1763 copay peradmission for each Medicare-covered inpatient stay Noadditional days covered Prior authorization is required

You pay a $1871 copay peradmission for each Medicare-covered inpatient stay Noadditional days covered Prior authorization isrequired

Medicare Part B PrescriptionDrugs

You pay 10 of the total costfor Part B drugs in the home You pay 20 of the totalcost for all other Part Bdrugs dispensed at a retailpharmacy mail orderpharmacy physician officeand outpatient facility Part B drugs are not subject toStep Therapy requirements Prior authorization is requiredfor some drugs

You pay 10 of the total costfor Part B drugs in the home You pay 20 of the totalcost for all other Part Bdrugs dispensed at a retailpharmacy mail orderpharmacy physician officeand outpatient facility Part B drugs may be subjectto Step Therapy requirements Prior authorization is requiredfor some drugs



Outpatient Mental HealthCare

You pay a $40 copay for eachMedicare-covered outpatientmental health care visit Certain Telehealth Servicesare not covered

You pay a $40 copay for eachMedicare-covered outpatientmental health care visit You pay a $40 copay for eachMedicare-covered IndividualMental Health care visitYou pay a $40 copay for eachMedicare-covered IndividualPsychiatric care visit(You have the option ofgetting these servicesthrough an in-person visitor by telehealth with anetwork provider who offersthe service by telehealth)

Outpatient RehabilitationServices

You pay a $40 copay forMedicare-covered outpatientrehabilitation services Prior authorization is required Referral Required

You pay a $40 copay forMedicare-covered outpatientrehabilitation services Prior authorization isrequired No Referral Required

Outpatient Substance AbuseServices

You pay a $40 copay for eachMedicare-covered individualor group visit Certain Telehealth Servicesare not covered

You pay a $40 copay for eachMedicare-covered individualor group visit You pay a $40 copayfor each Medicare-covered Individualoutpatient substanceabuse care visit (You havethe option of getting thisservice through an in-personvisit or by telehealth with anetwork provider who offersthe service by telehealth)



PhysicianPractitionerservices including doctorrsquosoffice visits

You pay a $25 copay for eachMedicare-covered primarycare office visit You pay a $50 copay for eachMedicare-covered specialistoffice visit Certain Telehealth Servicesare not covered Referral Required

You pay a $25 copay for eachMedicare-covered primarycare office visit You pay a $50 copay for eachMedicare-covered specialistoffice visit You have the option ofgetting these servicesthrough an in-person visitor by telehealth with anetwork provider who offersthe service by telehealth No Referral Required

Podiatry Services You pay a $40 copay forMedicare-covered podiatryservices

You pay a $40 copay foreach supplemental routinepodiatry visit (up to 4 routinevisits per calendar year) Referral Required

You pay a $40 copay forMedicare-covered podiatryservices You pay a $40 copay foreach supplemental routinepodiatry visit (up to 4 routinevisits per calendar year) No Referral Required

Services to Treat KidneyDisease

You pay a $0 copay forMedicare-covered KidneyDisease Education services Referral Required

You pay a $0 copay forMedicare-covered KidneyDisease Education services No Referral Required

Skilled Nursing Facility(SNF) care

You pay a $0 copay per dayfor Medicare-covered days1-20 $178 copay per day forMedicare-covered days 21-100 each benefitperiod Prior authorization is required

You pay a $0 copay per dayfor Medicare-covered days1-20 $184 copay per day forMedicare-covered days 21-100 each benefitperiod Prior authorization isrequired


Section 16 ndash Changes to Part D Prescription Drug Coverage Changes to Our Drug List Our list of covered drugs is called a Formulary or ldquoDrug Listrdquo A copy of our Drug List is providedelectronically We made changes to our Drug List including changes to the drugs we cover and changes to therestrictions that apply to our coverage for certain drugs Review the Drug List to make sure yourdrugs will be covered next year and to see if there will be any restrictions If you are affected by a change in drug coverage you can

Work with your doctor (or other prescriber) and ask the plan to make an exception tocover the drug

To learn what you must do to ask for an exception see Chapter 9 of your Evidence

of Coverage (What to do if you have a problem or complaint (coverage decisionsappeals complaints)) or call Customer Service

Work with your doctor (or other prescriber) to find a different drug that we cover

You can call Customer Service to ask for a list of covered drugs that treat the same medicalcondition

In some situations we are required to cover a temporary supply of a non-formulary drug in the first90 days of the plan year or the first 90 days of membership to avoid a gap in therapy (To learn moreabout when you can get a temporary supply and how to ask for one see Chapter 5 Section 52 ofthe Evidence of Coverage) During the time when you are getting a temporary supply of a drug youshould talk with your doctor to decide what to do when your temporary supply runs out You caneither switch to a different drug covered by the plan or ask the plan to make an exception for youand cover your current drug If you have a current formulary exception for 2020 you need to submit a new request for anexception for 2021 You may submit your request for a formulary exception for 2021 in advance of2021 and if approved your formulary exception will be effective in 2021 Most of the changes in the Drug List are new for the beginning of each year However during theyear we might make other changes that are allowed by Medicare rules When we make these changes to the Drug List during the year you can still work with your doctor(or other prescriber) and ask us to make an exception to cover the drug We will also continue toupdate our online Drug List as scheduled and provide other required information to reflect drugchanges (To learn more about changes we may make to the Drug List see Chapter 5 Section 6 ofthe Evidence of Coverage)


Changes to Prescription Drug Costs Note If you are in a program that helps pay for your drugs (ldquoExtra Helprdquo) the informationabout costs for Part D prescription drugs may not apply to you We sent you a separate insertcalled the ldquoEvidence of Coverage Rider for People Who Get Extra Help Paying for PrescriptionDrugsrdquo (also called the ldquoLow Income Subsidy Riderrdquo or the ldquoLIS Riderrdquo) which tells you aboutyour drug costs If you receive ldquoExtra Helprdquo and havenrsquot received this insert by September 30 2020please call Customer Service and ask for the ldquoLIS Riderrdquo There are four ldquodrug payment stagesrdquo How much you pay for a Part D drug depends on which drugpayment stage you are in (You can look in Chapter 6 Section 2 of your Evidence of Coverage formore information about the stages) The information below shows the changes for next year to the first two stages ndash the YearlyDeductible Stage and the Initial Coverage Stage (Most members do not reach the other two stages ndashthe Coverage Gap Stage or the Catastrophic Coverage Stage To get information about your costs inthese stages look at Chapter 6 Sections 6 and 7 in the Evidence of Coverage which is located onour website at emblemhealthcommedicare You may also call Customer Service to ask us to mailyou an Evidence of Coverage) Changes to the Deductible Stage

Stage 2020 (this year) 2021 (next year)

Stage 1 Yearly DeductibleStageDuring this stage you paythe full cost of your Tier 2(Generic) Tier 3 (PreferredBrand) Tier 4 (Non-Preferred Drug) and Tier 5(Specialty Tier) drugs untilyou have reached the yearlydeductible

The deductible is $435 During this stage you pay $4standard cost sharing and $0preferred cost sharing for drugson Tier 1 (Preferred Generic) and the full cost of drugson Tier 2 (Generic) Tier 3(Preferred Brand) Tier 4 (Non-Preferred Drug) and Tier 5(Specialty Tier) until you havereached the yearly deductible



Changes to Your Cost Sharing in the Initial Coverage Stage To learn how copayments and coinsurance work look at Chapter 6 Section 12 Types of out-of-pocket costs you may pay for covered drugs in your Evidence of Coverage


Stage 2 Initial CoverageStageOnce you pay the yearlydeductible you move tothe Initial Coverage StageDuring this stage the planpays its share of the costof your drugs and you payyour share of the cost The costs in this row arefor a one-month (30-day) supply when youfill your prescription at anetwork pharmacy For information aboutthe costs for a long-termsupply or for mail-orderprescriptions look inChapter 6 Section 5 of yourEvidence of Coverage We changed the tier for someof the drugs on our DrugList To see if your drugswill be in a different tierlook them up on the DrugList

Your cost for a one-monthsupply at a networkpharmacy Tier 1 (Preferred Generic)Standard cost sharing You pay $4 per prescriptionPreferred cost sharingYou pay $0 per prescription Tier 2 (Generic)Standard cost sharing You pay $20 per prescriptionPreferred cost sharingYou pay $18 per prescription Tier 3 (Preferred Brand)Standard cost sharing You pay $47 per prescriptionPreferred cost sharingYou pay $45 per prescription Tier 4 (Non-Preferred Drug)Standard cost sharing You pay $100 per prescriptionPreferred cost sharingYou pay $95 per prescription Tier 5 (Specialty Tier)Standard cost sharing You pay 25 of the total costPreferred cost sharingYou pay 25 of the total cost____________Once your total drug costshave reached $4020 youwill move to the next stage(the Coverage Gap Stage)

Your cost for a one-monthsupply at a networkpharmacy Tier 1 (Preferred Generic)Standard cost sharing You pay $7 per prescriptionPreferred cost sharingYou pay $2 per prescription Tier 2 (Generic)Standard cost sharing You pay $20 per prescriptionPreferred cost sharingYou pay $15 per prescription Tier 3 (Preferred Brand)Standard cost sharing You pay $47 per prescriptionPreferred cost sharingYou pay $42 per prescription Tier 4 (Non-Preferred Drug)Standard cost sharing You pay $100 per prescriptionPreferred cost sharingYou pay $95 per prescription Tier 5 (Specialty Tier)Standard cost sharing You pay 25 of the total costPreferred cost sharingYou pay 25 of the total cost______________Once your total drug costshave reached $4130 youwill move to the next stage(the Coverage Gap Stage)


Changes to the Coverage Gap and Catastrophic Coverage Stages The other two drug coverage stages ndash the Coverage Gap Stage and the Catastrophic Coverage Stagendash are for people with high drug costs Most members do not reach the Coverage Gap Stageor the Catastrophic Coverage Stage For information about your costs in these stages look atChapter 6 Sections 6 and 7 in your Evidence of Coverage

SECTION 2 Administrative Changes

Description 2020 (this year) 2021 (next year)

Provider Network Medical Provider Network You have access to providersin the EmblemHealth VIPPrime Network and can getmost services from providersin the ConnectiCare ChoiceNetwork in Connecticut

Medical Provider Network You have access to providersin the EmblemHealth VIPBold Network and can getmost services from providersin the ConnectiCare ChoiceNetwork in Connecticut

SECTION 3 Deciding Which Plan to Choose

Section 31 ndash If you want to stay in EmblemHealth VIP Part BSaver (HMO) To stay in our plan you donrsquot need to do anything If you do not sign up for a differentplan or change to Original Medicare by December 7 you will automatically be enrolled inour EmblemHealth VIP Part B Saver (HMO) Section 32 ndash If you want to change plans We hope to keep you as a member next year but if you want to change for 2021 follow these steps Step 1 Learn about and compare your choices

You can join a different Medicare health plan timely

OR-- You can change to Original Medicare If you change to Original Medicare you willneed to decide whether to join a Medicare drug plan If you do not enroll in a Medicare drugplan please see Section 11 regarding a potential Part D late enrollment penalty


To learn more about Original Medicare and the different types of Medicare plans read Medicareamp You 2021 call your State Health Insurance Assistance Program (see Section 5) or call Medicare(see Section 72) You can also find information about plans in your area by using the Medicare Plan Finder on theMedicare website Go to wwwmedicaregovplan-compare Here you can find information aboutcosts coverage and quality ratings for Medicare plans As a reminder HIPEmblemHealth offers other Medicare health plans and Medicare prescriptiondrug plans These other plans may differ in coverage monthly premiums and cost-sharing amounts Step 2 Change your coverage

To change to a different Medicare health plan enroll in the new plan You willautomatically be disenrolled from EmblemHealth VIP Part B Saver (HMO)

To change to Original Medicare with a prescription drug plan enroll in the new drug

plan You will automatically be disenrolled from EmblemHealth VIP Part B Saver (HMO)

To change to Original Medicare without a prescription drug plan you must either

Send us a written request to disenroll Contact Customer Service if you need moreinformation on how to do this (phone numbers are in Section 71 of this booklet)

ndash or ndash Contact Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day

7 days a week and ask to be disenrolled TTY users should call 1-877-486-2048

SECTION 4 Deadline for Changing Plans If you want to change to a different plan or to Original Medicare for next year you can do it fromOctober 15 until December 7 The change will take effect on January 1 2021 Are there other times of the year to make a change In certain situations changes are also allowed at other times of the year For example peoplewith Medicaid those who get ldquoExtra Helprdquo paying for their drugs those who have or are leavingemployer coverage and those who move out of the service area may be allowed to make a changeat other times of the year For more information see Chapter 10 Section 23 of the Evidence ofCoverage If you enrolled in a Medicare Advantage plan for January 1 2021 and donrsquot like your plan choiceyou can switch to another Medicare health plan (either with or without Medicare prescriptiondrug coverage) or switch to Original Medicare (either with or without Medicare prescription drugcoverage) between January 1 and March 31 2021 For more information see Chapter 10 Section22 of the Evidence of Coverage


SECTION 5 Programs That Offer Free Counseling about Medicare The State Health Insurance Assistance Program (SHIP) is a government program with trainedcounselors in every state In New York State the SHIP is called Health Insurance InformationCounseling and Assistance Program (HIICAP) HIICAP is independent (not connected with any insurance company or health plan) It is astate program that gets money from the Federal government to give free local health insurancecounseling to people with Medicare HIICAP counselors can help you with your Medicare questionsor problems They can help you understand your Medicare plan choices and answer questions aboutswitching plans You can call HIICAP at 1-800-701-0501You can learn more about HIICAP byvisiting their website at wwwagingnygov

SECTION 6 Programs That Help Pay for Prescription Drugs You may qualify for help paying for prescription drugs Below we list different kinds of help

ldquoExtra Helprdquo from Medicare People with limited incomes may qualify for ldquoExtra Helprdquo topay for their prescription drug costs If you qualify Medicare could pay up to 75 or moreof your drug costs including monthly prescription drug premiums annual deductibles andcoinsurance Additionally those who qualify will not have a coverage gap or late enrollmentpenalty Many people are eligible and donrsquot even know it To see if you qualify call

1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048 24

hours a day7 days a week

The Social Security Office at 1-800-772-1213 between 7 am and 7 pm Mondaythrough Friday TTY users should call 1-800-325-0778 (applications) or

Your State Medicaid Office (applications)

Help from your statersquos pharmaceutical assistance program New York State has a

program called Elderly Pharmaceutical Insurance Coverage (EPIC) that helps people payfor prescription drugs based on their financial need age or medical conditionTo learn moreabout the program check with your State Health Insurance Assistance Program (the nameand phone numbers for this organization are in Section 5 of this booklet)

Prescription Cost-sharing Assistance for Persons with HIVAIDS The AIDS Drug

Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with HIVAIDS have access to life-saving HIV medications Individuals must meet certain criteriaincluding proof of State residence and HIV status low income as defined by the State anduninsuredunder-insured status Medicare Part D prescription drugs that are also coveredby ADAP qualify for prescription cost-sharing assistance through the New York State HIVUninsured Care Program For information on eligibility criteria covered drugs or how toenroll in the program please call 1-800-542-2437


SECTION 7 Questions

Section 71 ndash Getting Help from EmblemHealth VIP Part B Saver (HMO) Questions Wersquore here to help Please call Customer Service at 1-877-344-7364 (TTY only call711) We are available for phone calls 8 am to 8 pm 7 days a week Calls to these numbers are free Read your 2021 Evidence of Coverage (it has details about next years benefits andcosts) This Annual Notice of Changes gives you a summary of changes in your benefits and costsfor 2021 For details look in the 2021 Evidence of Coverage for EmblemHealth VIP Part BSaver (HMO) The Evidence of Coverage is the legal detailed description of your plan benefits Itexplains your rights and the rules you need to follow to get covered services and prescription drugsA copy of the Evidence of Coverage is located on our website at emblemhealthcommedicareYou may also call Customer Service to ask us to mail you an Evidence of Coverage Visit our Website You can also visit our website at emblemhealthcommedicare As a reminder our website has themost up-to-date information about our provider network (Provider Directory) and our list of covereddrugs (FormularyDrug List) Section 72 ndash Getting Help from Medicare To get information directly from Medicare Call 1-800-MEDICARE (1-800-633-4227) You can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day 7 days a week TTY usersshould call 1-877-486-2048 Visit the Medicare Website You can visit the Medicare website (wwwmedicaregov) It has information about cost coverageand quality ratings to help you compare Medicare health plans You can find information aboutplans available in your area by using the Medicare Plan Finder on the Medicare website (To viewthe information about plans go to wwwmedicaregovplan-compare) Read Medicare amp You 2021 You can read the Medicare amp You 2021 Handbook Every year in the fall this booklet is mailed topeople with Medicare It has a summary of Medicare benefits rights and protections and answersto the most frequently asked questions about Medicare If you donrsquot have a copy of this booklet


you can get it at the Medicare website (wwwmedicaregov) or by calling 1-800-MEDICARE(1-800-633-4227) 24 hours a day 7 days a week TTY users should call 1-877-486-2048

86-100633-21

Annual Notice of Changes

Check to see if your doctors and other providers will be in our network next year

Are your doctors including specialists you see regularly in our network

What about the hospitals or other providers you use

Look in Section 13 for information about our Provider Directory Think about your overall health care costs

How much will you spend out-of-pocket for the services and prescription drugs youuse regularly

How much will you spend on your premium and deductibles

How do your total plan costs compare to other Medicare coverage options

Think about whether you are happy with our plan 2 COMPARE Learn about other plan choices Check coverage and costs of plans in your area

Use the personalized search feature on the Medicare Plan Finder at wwwmedicaregovplan-compare website

Review the list in the back of your Medicare amp You handbook

Look in Section 32 to learn more about your choices

Once you narrow your choice to a preferred plan confirm your costs and coverage on the planrsquos

website 3 CHOOSE Decide whether you want to change your plan

If you dont join another plan by December 7 2020 you will be enrolled in EmblemHealthVIP Part B Saver (HMO)

To change to a different plan that may better meet your needs you can switch plans

between October 15 and December 7 4 ENROLL To change plans join a plan between October 15 and December 7 2020

If you donrsquot join another plan by December 7 2020 you will be enrolled in EmblemHealthVIP Part B Saver (HMO)

If you join another plan by December 7 2020 your new coverage will start on January 1

2021 You will be automatically disenrolled from your current plan

















$0 $0



$6700 $7550




























$0 $0


$1250

$15

$1250

$1250










$6700

$7550














































































































SECTION 7 Questions




86-100633-21


















$0 $0



$6700 $7550




























$0 $0


$1250

$15

$1250

$1250










$6700

$7550














































































































SECTION 7 Questions




86-100633-21
























$0 $0


$1250

$15

$1250

$1250










$6700

$7550














































































































SECTION 7 Questions




86-100633-21














































































































SECTION 7 Questions




86-100633-21




86-100633-21


new 86-100633-21 emblemhealth vip part b saver 000 anoc · 2020. 9. 28. · employer coverage, and...

Documents