blueshieldca.com
Why choose Blue Shield?
Solutions for Medicare-eligible retirees
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You’ve got Medicare-eligible
retirees. We’ve got solutions.
Affordable and flexible product designs.
Coverage and quality you want.
The network strength you look for.
The cost controls you need.
Blue Shield
Flexible product designs.
Competitive price.
Superior service.
Why does Blue Shield make sense for your Medicare-eligible retirees?
Blue Shield offers a range of affordable health plans coupled with large provider networks, health and wellness programs, and outstanding service, including prescription drug coverage. We are committed to offering access to high-quality health care at affordable prices, helping to keep members healthy and happy, and making it easy for you to offer coverage for your Medicare-eligible retirees.
Blue Shield has the reputation and stability you can trust
The National Committee for Quality Assurance (NCQA) has awarded Blue Shield of California a status of “Commendable” – for its Medicare HMO products. The accreditation period extends from August 17, 2011 through August 17, 2014.
NCQA plan accreditations are based on three major components: Corporate standards; HEDIS1
clinical quality and care measures; and CAHPS2 patient satisfaction scores. HEDIS is the measurement
tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and CAHPS for customer service. A “Commendable” accreditation status is awarded only to plans that meet or exceed these rigorous standards.
On October 29, 2012, the Centers for Medicare & Medicaid Services announced that Blue Shield’s Medicare Star Ratings for its Medicare Advantage and Part D plans is 4 stars.3 Our Medicare Star
Ratings reflect Blue Shield’s excellence in healthcare, customer service, and compliance quality.
To access comparative NCQA accreditation statuses and other information on healthcare quality, or for more information about the National Committee for Quality Assurance, visit their website at www.ncqa.org.
Financial strength ratings (as of August 2012)4
• “A” rating from Standard and Poor’s • “A” (excellent) rating from A.M. Best
• “A” (excellent) rating by TheStreet.com Ratings
1 Healthcare Effectiveness Data and Information Set (HEDIS)
2 Consumer Assessment of Healthcare Providers and Systems (CAHPS)
3 Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
products
We help you make an informed decision.
Blue Shield provides affordable solutions for all your Medicare-eligible retiree health benefits needs and gives you greater control over your business’s health coverage. We have the plans and products to provide comprehensive, competitive benefits for your Medicare-eligible retirees and savings for your company.
• Blue Shield 65 PlusSM (HMO) includes both medical and prescription drug coverage
• Blue Shield of California Medicare Rx Plan (PDP) is a standalone plan offering prescription drug coverage
• Blue Shield Access+ HMO Medicare Coordination of Benefits (COB) Plan and Blue Shield of California Medicare Rx Plan
• Blue Shield Spectrum PPO Medicare Coordination of Benefits (COB) Plan and Blue Shield of California Medicare Rx Plan
Blue Shield 65 Plus
Blue Shield 65 Plus is an employer/union group sponsored Medicare Advantage Prescription Drug Plan (GMA-PD). Each member has one primary care physician (PCP) who manages the member’s care and refers the member to specialists within the physician’s medical group. When members choose their PCP, they are also choosing the medical group and hospital that are affiliated with their PCP.
Why it makes sense
Blue Shield knows the needs of Medicare-eligible retirees, and our Blue Shield 65 Plus plan has the quality coverage they require. This plan provides rich benefits, easy 24-hour access to health
experts, and valuable programs to support better health and more effective care.
We know your needs, too. So Blue Shield 65 Plus makes it easy for you to offer your Medicare-eligible retirees comprehensive coverage,
at a more affordable cost to you. Also, a more affordable plan can help reduce your Governmental Accounting Standards Board (GASB) or Financial Accounting Standards Board (FASB) liability.
Plan eligibility
Blue Shield 65 Plus is open to all your Medicare-eligible retirees who live in the plan service area, have both Medicare Parts A and B, and are retired. They can not have end-stage renal
We know Medicare
Over 170,000* Medicare beneficiaries in California have trusted their healthcare
coverage to Blue Shield of California. We know California, and we continue to deliver high-quality healthcare coverage at an affordable price, a tradition we have been building on for more than 70 years.
* Blue Shield Medicare Advantage HMO and Medicare Supplement plan membership reporting as of March 2013.
disease (ESRD) or kidney failure at the time of enrollment in Blue Shield 65 Plus, unless they are current Blue Shield commercial plan members. Also, they must meet the employer group’s/labor trust’s eligibility criteria for an “eligible” retiree. To offer this plan, the employer group/labor trust must have a minimum of 50 Medicare-eligible retirees who reside in the plan service area. More ways to customize coverage
We have the capability to customize benefits for Blue Shield 65 Plus by adding coverage for non-Medicare covered services in the
following areas:
• Non-Medicare covered chiropractic services, vision care, and podiatry care
• Acupuncture services • Coverage for hearing aids
Additional riders and custom benefits are available, including the SilverSneakers Fitness Program.
SilverSneakers Fitness Program – Better health, greater independence for your retirees
Blue Shield 65 Plus members can participate in SilverSneakers or SilverSneakers Steps at no additional cost to the member.
SilverSneakers
• Includes a basic fitness membership with access to amenities such as treadmills, weights, pools, and SilverSneakers classes, available at more than 10,000 locations nationwide
• Helps remove barriers to exercise such as affordability, fear and intimidation, motivation, health concerns, and safety
• Provides a non-intimidating environment where members can meet others who share their health goals
• Offers a Senior AdvisorSM at each participating
location to provide information and assistance
SilverSneakers Steps
• Offers a personalized fitness program to members who live 15 miles or more from a
participating SilverSneakers location and includes one of four available kits to use at home or on the go: general fitness, strength, walking, or yoga.
Blue Shield 65 Plus offers your retirees the opportunity to experience a healthy, active lifestyle with the SilverSneakers Fitness Program and SilverSneakers Steps. Learn more at
www.silversneakers.com.
Medicare Coordination
of Benefits (COB)
The Blue Shield plan that coordinates with Original Medicare
For Medicare retirees who reside outside of the Blue Shield 65 Plus service area, we can offer them the same HMO and/or PPO benefit plan offered to active employees. The only difference with these plans is that they coordinate with Original Medicare (Medicare pays primary, Blue Shield pays secondary). The advantages of offering these plans include:
• Retirees can use any doctor in their Blue Shield commercial HMO or PPO plan’s network
• A variety of services is available to help keep retirees healthy and well
• Works with retirees’ existing Medicare benefits Plan eligibility
In order to qualify for enrollment in this plan, prospective members must have Medicare Part A and/or Part B and must meet the employer group’s/labor trust’s eligibility criteria for an
“eligible” retiree. Access+ HMO
Access+ HMO plans offer your retirees a wide range of benefits, including preventive care, inpatient and outpatient hospital services, and emergency care. These plans also feature Access+ SpecialistSM – which allows members to
go directly to an Access+ network specialist in the same medical group or IPA as their primary care physician without a referral for a higher office visit copayment.
Shield Spectrum PPOSM
Our preferred provider organization (PPO) plans give your employees direct access to the physicians and specialists in our preferred provider network. Additional advantages include:
• One of the largest provider networks in California • Choice of 14 PPO plans • $0 deductible option • Two-tier provider network (preferred and non-preferred) • Predictable copayments, deductibles, and copayment maximums • The option to see providers outside of our PPO network
More ways to customize coverage
We have the capability to customize benefits for Medicare-coordinated benefit plans by adding coverage for routine care in the following areas: • Non-Medicare covered chiropractic services,
vision care, and podiatry care • Acupuncture services
• Coverage for hearing aids Prescription drug coverage
Currently, employers who want to offer retirees drug coverage as part of the Access+ HMO or Shield Spectrum PPO have two options:
• Combine with a group Medicare Prescription Drug Plan (GPDP)
OPTION 1
Blue Shield of California
Medicare Rx Plan
An employer/union group sponsored Medicare Prescription Drug Plan
Blue Shield of California Medicare Rx Plan (PDP) is a standalone Medicare Prescription Drug Plan offered to employer groups/unions. Blue Shield of California Medicare Rx Plan is a combination of the prescription drug coverage offered through an employer group/union health plan, plus the prescription drug coverage offered by Medicare. It’s a pharmacy benefit that works much like the prescription coverage for active members but with some differences:
• The plan is regulated by the Centers for Medicare & Medicaid Services (CMS).
• CMS requires tracking of total drug costs and member drug usage based on four different coverage stages: deductible, initial coverage limit (ICL), coverage gap, and catastrophic coverage.
• Members pay the cost-sharing amounts chosen by their employer group/union for covered prescription drugs through the coverage gap stage, then pay less once they are in the catastrophic coverage stage.
• There is a separate Medicare-approved formulary.
• There is a separate member ID card and separate, dedicated Member Services department.
Group PDP is designed for employer groups/ unions that currently offer prescription benefits to their Medicare-eligible retirees enrolled in a Blue Shield Coordination of Benefits (COB) Plan or another carrier’s medical plan.
Plan eligibility
In order to qualify for enrollment in the Blue Shield of California Medicare Rx Plan, prospective
members must reside in the plan service area, have Medicare Part A and/or Part B, and meet the employer group’s/labor trust’s eligibility criteria for an “eligible” retiree.
OPTION 2
Retiree drug subsidy (RDS)
• Employer receives RDS to reimburse part of retiree drug costs if benefits provided are at least as rich as standard Part D benefit; RDS became taxable effective 1/1/2013 as an incentive for employers to offer a GPDP.
• An actuary must attest that the plan is at least as rich as the standard Part D benefit.
• Employer bears administrative burden for compliance and collection of RDS payment. • No reinsurance (catastrophic coverage) provided. • Blue Shield of California will support the actuarial
and reporting requirements.
• Employers must submit a subsidy request to CMS no later than 90 days prior to plan effective date.
networks
regional coverage
Blue Shield 65 Plus
By choosing Blue Shield 65 Plus, you give your Medicare-eligible retirees easy access to a large network of physicians, specialists, and hospitals. Our providers must meet our credentialing standards and
include some of the most prestigious physicians and hospitals in the state.
service area
The Blue Shield 65 Plus service area includes these counties: • Fresno* • Imperial* • Kern* • Madera* • Nevada* • Los Angeles • Riverside* • San Bernardino* • Orange • San Diego • San Luis Obispo • San Diego • San Joaquin • Sacramento • San Francisco • Contra Costa • Santa Cruz • San Mateo • Santa Clara
Medicare Coordination of
Benefits (COB)
The Blue Shield plan that coordinates with Original Medicare
For Medicare retirees who reside outside of the Blue Shield 65 Plus service area, we can offer them the same HMO and/or PPO benefit plan offered to active employees. Members can use any doctor in Blue Shield’s commercial HMO and PPO plan networks.
Blue Shield of California
Medicare Rx Plan
Blue Shield is approved to offer group PDP to eligible Medicare beneficiaries throughout the United States, as long as the employer group/ union is headquartered in California. Members must use network pharmacies in order to access their Part D prescription medications under routine circumstances. This network is not limited to California and members have access to prescriptions through network pharmacies all over the country. This includes more than 5,600 California pharmacies, with access to 24-hour pharmacies in some locations. Our preferred network pharmacies, Sav-On, Safeway/Vons, and CVS, allow members to obtain a 90-day supply of covered drugs for the cost of two 30-day copayments.
Other large chain network pharmacies include Costco, Kmart, Raley’s, Ralphs, Rite Aid, Target, Walgreens, and Wal-Mart.
Kern* (partial county) Ventura San Bernardino* (partial county) Riverside* (partial county) Imperial* (partial county) Orange Los Angeles San Luis Obispo
Fresno* (partial county) Madera* (partial county) Nevada* (partial county) San Francisco San Joaquin (partial county)
healthcare services
Healthy solutions for a healthier bottom line.
Blue Shield is leading the way to reduce costs and improve care with a comprehensive approach to healthcare management and a caring, personal touch. People with chronic diseases and those at high risk benefit from a wide range of programs for disease and case management with the goal of delivering appropriate support in the most cost-efficient manner. These programs are also good for your client’s business. They are very cost-effective and return more in healthcare savings than the cost of the programs themselves.
Health and wellness support
Many Medicare-eligible retirees can benefit from a wide range of health and wellness programs that help them manage their health. At no extra cost to the member, Blue Shield offers these programs: • NurseHelp 24/7SM – Round-the-clock access to
registered nurses
• LifeReferrals 24/7SM – Expert assistance on
personal, financial, and legal issues
• Health Coach – Personal assistance to help members reach health goals
• Health Advocate – Helps members navigate the healthcare system
• Disease management programs – Help members manage chronic conditions like diabetes
client services
We make your job easier.
You can trust Blue Shield to provide responsive, flexible, and creative solutions to meet your company’s unique needs. Our Account Service Team uses an integrated, full-service team approach to better accommodate your specific needs, including sales, underwriting, and account service. We have dedicated Medicare sales expertise to help understand options for your Medicare-eligible retirees. Our knowledgeable professionals make switching to Blue Shield easy with attentive, personal assistance and a host of services, including product training, presentations, open enrollment support, and more.
You can also count on our knowledgeable and courteous Member Services representatives to deliver the service you and your Medicare-eligible retirees expect and deserve. They will know your plan benefits inside and out, and are empowered to respond quickly and solve most issues on the first phone call.
the bottom line
A n in d ep en d en t m em b er o f t h e B lu e S h ie ld A ssoc ia tio n A 4 35 29 -R EV 1 ( 5/ 13 )You know what your Medicare-eligible retirees deserve.
You know what your business needs.
Let us show you what Blue Shield can deliver …
… accessible, high-quality healthcare coverage
at an affordable price.
SilverSneakers is a registered mark of Healthways, Inc., an independent company that does not provide Blue Shield of California products or services. Blue Shield and the Shield symbol are registered marks of the BlueCross BlueShield Association, an association of independent Blue Cross and Blue Shield plans.
Blue Shield 65 Plus
Blue Shield of California is an HMO plan with a Medicare contract. Enrollment in Blue Shield of California depends on contract renewal.
Blue Shield of California Medicare Rx Plan
