welcome 2010 univera healthcare medicare plans workshop (sales rep’s name) medicare sales...

WelcomeWelcome20102010

Univera HealthcareUnivera Healthcare

Medicare Plans WorkshopMedicare Plans Workshop

(Sales Rep’s Name)

Medicare Sales Consultant

Univera Healthcare contracts with the Federal Government and is a Medicare Advantage Organization with a Medicare contract.

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Our VisionOur Vision

“…“…to be a best in class Medicare Program, to be a best in class Medicare Program, providing Medicare beneficiaries with a providing Medicare beneficiaries with a

range of products and services that meet range of products and services that meet their needs for health coverage at an their needs for health coverage at an

affordable price.”affordable price.”

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AgendaAgenda

• Medicare Basics

• Plan Options & Benefits

• Valuable Extras

• Enhanced Web Tools

• Questions

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Medicare BasicsMedicare BasicsThere are two parts to Original Medicare: Part A and Part B

Part A

• Helps cover inpatient care in hospitals.• Helps cover skilled nursing facility, hospice and home health

care.

• You pay deductibles, coinsurance, and copays.

• You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working.

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Medicare BasicsMedicare Basics

Part B

• Helps cover doctor’s services and outpatient care.• Helps cover some preventive care.

• With Part B you pay premium, deductible, coinsurance, and copays.• $96.40 monthly standard Medicare Part B premium generally

deducted from Social Security check• $135 Part B annual deductible• 20% coinsurance on most services

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Medicare BasicsMedicare Basics

Part C: Medicare Advantage Plans

Part D: Prescription Drug Plans

Medicare Supplement: Medigap Plans

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Your Plan OptionsYour Plan Options

• Medicare Supplement Plans (Medigap)• Secondary payer to Original Medicare

• Do not include Part D Drug Coverage• Can purchase Part D separately

• Medicare Advantage Plans • Medical Coverage with Part D Drug Coverage (MA-PD)

• Medical Coverage without Part D Drug Coverage (MA)

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What is a Medicare Supplement Plan? (Medigap)What is a Medicare Supplement Plan? (Medigap)

• A Medicare Supplement (Medigap) policy is designed to supplement the Original Medicare Plan

• Fills gaps in Original Medicare

• Medicare Part D drug coverage not included

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Medicare Supplement Plans (Medigap)Medicare Supplement Plans (Medigap)Plan A• Basic benefits only

Plan B • Basic benefits • Part A deductible under Original Medicare Plan

Plan C• Basic benefits • Parts A & B deductibles under Original Medicare Plan• Foreign travel emergency • Skilled Nursing Facility (SNF) coinsurance

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Medicare Supplement Plans (Medigap)Medicare Supplement Plans (Medigap)

Plan F / High Deductible F+ • Basic benefits • Part A & B deductibles under the Original Medicare Plan• Foreign travel emergency• Part B excess charges • Skilled Nursing Facility (SNF) coinsurance• F+ has $2,000 deductible (deductible subject to change

annually)Plan H • Basic benefits • Part A deductible under Original Medicare Plan• Skilled Nursing Facility (SNF) coinsurance• Foreign travel emergency

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How Do Medicare Advantage Plans Work?How Do Medicare Advantage Plans Work?• Provides Part A (Hospital) and Part B (Medical) Benefits

• You pay affordable copays/coinsurance

• Offers extra benefits such as:• Vision Exam• Hearing Exam• Health and Wellness• Preventive Services

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Eligibility and Service AreaEligibility and Service Area

You are eligible to join one of our Medicare Advantage HMO or PPOplans if:

• You have Medicare Part A (Hospital) and are enrolled in Medicare Part B (Medical)

• You are a legal resident in the service area of the plan (includes: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, and Wyoming counties, NY)

• You do not have End-Stage Renal Disease (ESRD)

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Medicare Advantage Plan Enrollment PeriodsMedicare Advantage Plan Enrollment Periods There are only certain times during the year when you may change or voluntarily end

your membership in a Medicare Advantage or stand-alone Prescription Drug Plan.

Annual Enrollment Period (AEP)• Runs from November 15 – December 31, each year• Can change Medicare Advantage or stand-alone Prescription Drug Plans• Can add or drop prescription drug coverage• Can return to Original Medicare• Enrollment changes take effect on January 1

Open Enrollment Period (OEP)• Runs from January 1 – March 31, each year• Can change Medicare Advantage Plans• Cannot add or drop prescription drug coverage• One opportunity to change to a similar plan

(no-drug plan to no-drug plan - OR - drug plan to drug plan)• Enrollment or disenrollment becomes effective the month after the

application is received

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Medicare Advantage Plan Enrollment PeriodsMedicare Advantage Plan Enrollment Periods

Initial Enrollment Period (IEP)•3 months before you turn age 65 to 3 months after the month you turn age 65 •If you get Medicare due to a disability, you can join during the 3 months before to 3 months after your 25th month of disability •Can join a Medicare Advantage or stand-alone Prescription Drug Plan.•Enrollment changes take effect on the first day of your birth month.

Special Enrollment Period (SEP)•Change of residence into or out of the service area•Loss of employer coverage•Qualify for Low Income Subsidy

To obtain information regarding Medicare Advantage Plan Enrollment Periods you can call our Customer Service Department at 1-800-558-4320. TTY/TDD 1-800-421-1220, Monday – Friday, 8:00 a.m. – 8:00 p.m., From November 15 – March 1, representatives are also available weekends from 8:00 a.m. – 8:00 p.m.

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HMO vs. PPOHMO vs. PPO

HMOHealth Maintenance Organization

PPOPreferred Provider Organization

Primary Care Physician (PCP) is required

Primary Care Physician (PCP) not required

Referral required to see a specialist

No referral required to see a specialist

Must use In-Network providers(You must use plan providers except in cases such as emergency care, urgently needed care, or out-of-area renal dialysis))

Can use In-Network & Out-of-Network providers*

(Out-of-pocket costs may be higher when you use an Out-of-Network provider, except in cases such as emergency care, urgently needed care, or out-of-area renal dialysis)

*Univera Healthcare provides reimbursement for all covered benefits regardless of whether they are received in-network, as long as they are medically necessary.

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Medicare Advantage Plan OptionsMedicare Advantage Plan Options

• HMO Plans• SeniorChoice® Value (HMO)• SeniorChoice® Value Plus (HMO)• SeniorChoice® Secure (HMO)• SeniorChoice® Select (HMO)

• PPO Plan• Univera Medicare PPOSM Plan 102 (PPO)

For full information on our SeniorChoice and/or our Univera Medicare PPO benefits, call our Customer Service Department at 1-800-558-4320, TTY/TDD 1-800-421-1220 Monday – Friday 8:00 a.m. – 8:00 p.m. From November 15 – March 1, representatives are also available weekends from 8:00 a.m. – 8:00 p.m.

Our contract with CMS is renewed annually and the availability of coverage beyond the current contract year is not guaranteed. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2011. Please contact Univera Healthcare for details.

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Benefit SeniorChoice®® Value (HMO)

Inpatient Hospital Care(unlimited days each benefitperiod)

$500 copay for each Medicare-covered stay at a network hospital;

Maximum 3 copays per year; 4th and subsequent hospitalizations are covered in full

Primary Care Physician $20 copay per visit

Specialist $40 copay per visit

Outpatient Hospital Services 2 $0 - $125 copay per visit

Radiology 20% coinsurance

Outpatient Prescription Drugs3

(Part D)

Part D with $150 annual deductible; Before total annual drug costs reach $2,830, for each 30 day supply you pay:$5 for Tier 1 generic drugs$30 for Tier 2 preferred brand drugs $75 for Tier 3 non-preferred brand drugs25% coinsurance for Tier 4 specialty drugs

SeniorChoiceSeniorChoice®® Value (HMO) Value (HMO) $16$1611

1 You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another 3rd party. 2 Your cost share will be higher when the service performed is of a surgical nature or observation and the lower cost share is applicable when the service is non-surgical. 3 See Summary of Benefits for more details. When your total Part D drug costs reach $2,830, you then pay 100% of the cost of your drugs. Once you or others on your behalf spend $4,550 in out-of-pocket costs, you then pay $2.50 for generics, and $6.30 for brand drugs or 5% of the price (whichever is greater). Copays based on getting 30-day supply; call us about reduced copays for mail order or a 90-day supply.

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Benefit SeniorChoice®® Value Plus (HMO)

Inpatient Hospital Care(unlimited days each benefitperiod)

$350 copay for each Medicare-covered stay at a network hospital; Maximum 3 copays per year; 4th and subsequent hospitalizations are covered in full




Radiology 10% coinsurance


(Part D)

Part D with $150 annual deductible;Before total annual drug costs reach $2,830, for each 30 day supply you pay:$5 for Tier 1 generic drugs$30 for Tier 2 preferred brand drugs $75 for Tier 3 non-preferred brand drugs25% coinsurance for Tier 4 specialty drugs

SeniorChoiceSeniorChoice®® Value Plus (HMO) Value Plus (HMO) $46 $4611


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Benefit SeniorChoice®® Secure (HMO)

Inpatient Hospital Care (unlimited days each benefitperiod)





Radiology $30 copay


(Part D)

Part D with $0 annual deductible; Before total annual drug costs reach $2,830, for each 30 day supply you pay:$5 for Tier 1 generic drugs$30 for Tier 2 preferred brand drugs $75 for Tier 3 non-preferred brand drugs33% coinsurance for Tier 4 specialty drugs

SeniorChoiceSeniorChoice®® Secure (HMO) Secure (HMO) $86 $8611


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SeniorChoiceSeniorChoice®® Select (HMO) Select (HMO)

$55$5511

Benefit SeniorChoice®® Select (HMO)

Inpatient Hospital Care (unlimited days each benefitperiod)





Radiology $25 copay

1 You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another 3rd party.

2 Your cost share will be higher when the service performed is of a surgical nature or observation and the lower cost share is applicable when the service is non-surgical. See Summary of Benefits for more details.

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Univera Medicare PPOUnivera Medicare PPOSMSM 102 (PPO) 102 (PPO) $36 $3611

Benefit In Network Out of Network

Inpatient Hospital Care (unlimited days eachbenefit period)

$500 copay for each Medicare-covered stay at a network hospital; Maximum 3 copays per year4th and subsequent hospitalizations are covered in full

30% coinsurance per visit

Primary Care Physician $20 copay per visit $25 copay per visit

Specialist $40 copay per visit $45 copay per visit

Outpatient HospitalServices 2

$0 - $125 copay per visit 30% coinsurance per visit

Radiology 20% coinsurance 30% coinsurance

Outpatient PrescriptionDrugs3

(Part D)

Part D with $150 annual deductible;Before total annual drug costs reach $2,830, for each 30 day supply you pay: $5 for Tier 1 generic drugs$30 for Tier 2 preferred brand drugs $75 for Tier 3 non-preferred brand drugs25% coinsurance for Tier 4 specialty drugs

Emergency Benefit Only


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Medicare Prescription Drug Plan (Part D)Medicare Prescription Drug Plan (Part D)

2 ways to get Medicare Prescription Drug Coverage:

• Join a stand-alone Medicare Prescription Drug Plan (PDP)

• Join a Medicare Advantage Prescription Drug Plan (MA-PD)

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Formulary• List of drugs that are covered under your Part D drug plan• To obtain a copy of our formulary go to our Web site at

www.univerahealthcare.com/medicare

Network• About 60,000 pharmacies nationwide• Retail, mail order, long term care, home infusion, Indian/Tribal/Urban

pharmacies included• For additional information regarding our pharmacy network, quantity limits,

and mail order prescription drug service call: 1-800-659-1986 TTY/TDD 1-800-421-1220 Monday – Friday 8:00 a.m. –

8:00 p.m. From November 15 – March 1 representatives are also available weekends from 8:00 a.m. – 8:00 p.m.

• You may write us at: Univera Healthcare, PO Box 546, Buffalo, NY 14201

You must use network pharmacies to access your prescription drug benefit, except undernon-routine circumstances when you cannot reasonably use network pharmacies.

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You pay $2.50 for generics and $6.30

for brand name drugs, or 5% of the price (whichever is

greater)

Catastrophic Coverage

Univera Healthcare

pays the balance

Coverage Gap

All costs are out-of-pocket

You Pay

Your copays/coinsurance

Initial Coverage Period

Univera Healthcare pays the balance

Deductible is out-of-pocket

$0 or $1502

Medicare Drug BenefitOut Of Pocket

4 Coverage PhasesCatastrophic Coverage begins when you or others on your behalf have spent $4,5501.

No coverage when total drug spend exceeds $2,8301 until your true out of pocket spending reaches $4,5501.

Initial Coverage starts after you have met your deductible, if applicable, and continues until your total drug costs reach $2,8301.

You must pay your deductible, if applicable, before you start getting your prescription drug coverage.


1 Coverage limits for all phases of the Part D benefit change annually.

2 Benefits, formulary, pharmacy network, premium, copayment/coinsurance may change on January 1, 2011. Contact Univera Healthcare for details.

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Medicare Prescription Drug Plan (Part D)Medicare Prescription Drug Plan (Part D)Some prescription drugs may have additional requirements or limits.Some prescription drugs may have additional requirements or limits.

• Prior Authorization• In some cases, we require you to obtain prior approval

from us before you fill your prescription.

• Step Therapy• In some cases, we require you to first try certain drugs to

treat your medical condition before we will cover another drug for that condition.

• Quantity Limits • For certain drugs, we limit the amount of the drug that we

will cover per prescription.

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You may be able to get Extra Help to pay for your prescription drug premiums and costs.

To see if you qualify for getting Extra Help, call:1) 1-800-MEDICARE (1-800-633-4227), TTY/TDD

users should call 1-877-486-2048, 24 hours a day/7 days a week

2) The Social Security Office at1-800-772-1213 between 7:00 a.m. – 7:00 p.m., Monday through Friday, TTY/TDD users should call 1-800-325-0778; or

3) Your State Medicaid office

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People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for:

• seventy-five percent of drug costs including monthly prescription drug premiums,

• annual deductibles, and• coinsurance.

Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty.

• Many people are eligible for these savings and don’t even know it. • For more information about this Extra Help, contact your local

Social Security Office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.


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Other Government InsuranceOther Government Insurance

EPIC - Elderly Pharmaceutical Insurance Coverage • New York State residents that are 65 or older, and have an

annual income of $35,000 or less if single, or $50,000 or less if married

• New York State Department of Health:

• www.health.state.ny.us/health_care/epic

• 1-800-332-3742

Department of Veterans Affairs• Provides coverage to veterans

• Call the VA in your area if you believe that you may be eligible

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Coverage While TravelingCoverage While Traveling

SeniorChoice (HMO):• Emergency: Nationwide and Worldwide• Urgent Care: Nationwide• Routine Care: Covered under the Travel Benefit on

SeniorChoice® Secure (HMO) and Select (HMO) plans.

Univera Medicare PPO:• Emergency: Nationwide and Worldwide• Urgent Care: Nationwide

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Health and WellnessHealth and Wellness

Active Anytime® Flexible Fitness Benefit• Up to $650 per calendar year* • Qualified fitness facility membership fees • Qualified weight management program membership fees• Included in SeniorChoice (HMO) and Univera Medicare

PPO plans

* This benefit does not cover any ancillary services or items that are not part of a membership fee.

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Valuable ExtrasValuable Extras

• 24-hour Personal Health Coaching Line• Provides education and programs on nutrition, weight

management and much more.

• Disease & Case Management• Clinical staff work with you to make informed choices

on your health care and prescriptions.

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Enhanced Web ToolsEnhanced Web Tools

Our Enhanced Web site

Allows members and prospective members to:

• Estimate annual costs• Compare our plans• Learn more about cost-cutting options• Enroll online*

…and more!

www.univerahealthcare.com/www.univerahealthcare.com/medicaremedicare

*Medicare beneficiaries may enroll in Univera Healthcare Medicare Advantage Plans through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at www.medicare.gov. For more information, contact Univera Healthcare at 1-800-659-1986, TTY/TDD 1-800-421-1220, Monday – Friday, 8:00 a.m. – 8:00 p.m. From November 15 – March 1, 8:00 a.m. – 8:00 p.m., 7 days a week.

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How to EnrollHow to Enroll

• Complete application form• One application per person• You must continue to pay your Medicare Part B

premium• You may need to cancel your other insurance

carrier• Effective date of coverage is determined by

enrollment period and when application is signed and received

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Why Univera Healthcare?

• More than 3,000 Participating Providers

• In business for over 30 years

• Offering plans that fit your needs and budget

• Commitment to our local community

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How To Contact UsHow To Contact UsCall us:Medicare Sales Representative:

•1-800-659-1986 TTY/TDD 1-800-421-1220•Monday – Friday 8:00 a.m. – 8:00 p.m.From November 15 – March 1, representatives are also available weekends from 8:00 a.m. – 8:00 p.m.

For full information on our Medicare benefits call a Medicare Customer Service Representative:

•1-800-558-4320 TTY/TDD 1-800-421-1220•Monday – Friday 8:00 a.m. – 8:00 p.m.From November 15 – March 1, representatives are also available weekends from 8:00 a.m. – 8:00 p.m.

Write us:Univera HealthcareP.O. Box 546Buffalo, NY 14201

Visit us on the web at: www.univerahealthcare.com/medicare

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Important NumbersImportant Numbers

Centers for Medicare & Medicaid Services (CMS)• 1-800-633-4227 • TTY/TDD 1-877-486-2048• 24 hours a day, 7 days a week• www.medicare.gov

To apply for Low Income Subsidy• Social Security Administration:1-800-772-1213 • TTY/TDD 1-800-325-0778• Monday – Friday 7:00 am – 7:00 pm• www.ssa.gov

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Questions ?Questions ?

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Thank You!Thank You!

H3351, H3335 1775_0 (10/2009) H3351, H3335 1775_0 (10/2009)

welcome 2010 univera healthcare medicare plans workshop (sales rep’s name) medicare sales...

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