Napa County. Medicare Advantage Plans. (Medicare Part C Plans) Compliments of HICAP. (Health Insurance Counseling and Advocacy Program)

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Rev. 10/14/2014 1

2015

Napa County

Medicare Advantage Plans

(Medicare Part C Plans)

HICAP Volunteer Counselors are available to help compare health plans in an

objective and unbiased manner. They can help consumers understand the advantages

and disadvantages of joining a Medicare Advantage Plan. In addition, the Volunteer

Counselors have information on Medicare benefits, Medicare Supplement Plans, and

other health insurance options.

HICAP counseling appointments are free of charge and can be scheduled at

locations throughout Lake, Marin, Mendocino, Napa, Solano, and Sonoma counties.

HICAP is a non-profit program administered by Senior Advocacy Services

and is funded by the California Department of Aging in partnership with the Area

Agency on Aging (AAA).

Compliments of

HICAP

(Health Insurance Counseling and Advocacy Program)

A program of

Senior Advocacy Services

1304 Southpoint Blvd. Suite 280 – Petaluma, Ca. 94954

1-800-434-0222 * (707) 526-4108

Fax #: (707) 526-5118

www.SeniorAdvocacyServices.org

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Rev. 10/14/2014 ² The rules to join, switch, or drop a Medicare Advantage (MA¹) Part C Plan are as follows:

You must have Medicare Parts A and B to join a Medicare Advantage (MA¹) plan. Based on the enrollment opportunities listed below, your effective date will be the first day of the month following the date of your request.

1. Initial Coverage Election Period (ICEP):

a. When you first become eligible for Medicare (usually first of the month of your 65^th birthday), you have the three months before eligibility, the month of eligibility, and three months after eligibility in Medicare (total of seven months) to choose a MA¹ plan.

b. If you get Medicare due to a disability, you can join during the 7-month period that begins 3 months before your 25^th month of disability and ends 3 months after your 25^th month of disability.

2. Annual Election Period (AEP) October 15 to December 7 Each Year:

a. If you request enrollment during this time, your effective date will be January 1.

b. In most cases, when you enroll in a new MA¹ plan, your membership in your current plan will automatically be cancelled.

c. If you enroll in a MA¹ HMO plan without a PDP², you cannot enroll in a stand-alone PDP² plan. d. If you enroll in a MA¹ PFFS plan without a PDP², you can enroll in a stand-alone PDP².

3. Annual Disenrollment Period (ADP) January 1 to February 14:

a. You can disenroll from a MA¹ plan and return to Original Medicare (Medicare Parts A and B). b. If you switch to Original Medicare during this period, you will have until February 14 to enroll in a

Medicare Prescription Drug (PDP) plan for your drug coverage.

c. Your effective date will be the first day of the month following the date of your request. d. You cannot switch to another MA¹ plan nor can people in Original Medicare join an MA¹ plan.

4. Special Election Periods (SEPs) may allow You to Change MA¹ Plans during the Year:

a. If your MA plan terminates on December 31, you have a SEP from October 1 to January 31 to enroll in a different MA or PDP plan or return to Original Medicare. Changes made before December 31 will be effective January 1; changes made before January 31 will be effective February 1.

b. If you move out of the service area of the MA¹ plan, you have a 2-month SEP to enroll in a new plan offered in your new county.

c. If your creditable prescription drug coverage through your employer health plan ends, you have a 2-month SEP starting the day you lose coverage.

d. If you have full Medi-Cal benefits, you have an ongoing SEP to enroll in or change MA¹ plans. e. If you lose your full Medi-Cal benefits, you have a 3-month SEP to change MA¹ plans.

f. If you are eligible for “Extra Help”, Low-Income Subsidy (LIS), you have an ongoing SEP.

g. If you lose the “Extra Help” (LIS), you have a 2-month SEP to change to another MA or PDP plan. h. If you live in, or move into or out of an institution (like a nursing home).

5. 5-Star Special Enrollment Period December 8, 2012 to November 30, 2013:

a. Starting December 8, 2012, you can switch to a 5-star MA¹ Plan at any time up to November 30, 2013. b. Your effective date will be first of the month following the date you enroll in the 5-Star plan.

c. You can only join a 5-star MA¹ plan if one is available and only once each year.

1 End Stage Renal Disease (ESRD): You can be denied enrollment in a MA plan if you have End Stage Renal Disease (ESRD), also known as kidney failure. If you develop ESRD while enrolled in a MA plan, the MA plan cannot disenroll you.

2 PDP = Prescription Drug Plan (PDP) and is referring to the stand-alone Medicare Part D prescription drug plans.

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Rev. 10/14/20143 ³

Napa County 2015 Medicare Advantage Plans

Company Name: Plan Name: Plan Type: Phone Numbers: Website:

Kaiser Permanente Senior Advantage *****

HMO (H0524-008) Non-Members: 1-800-777-1238

Members: 1-800-443-0815 www.kp.org

Kaiser Permanente Senior Advantage *****

HMO SNP (H0524-030) Non-Members: 1-800-777-1238

Members: 1-800-443-0815 www.kp.org

You Pay… You Pay…

1. Monthly Premium: $73 (+ Medicare Part B premium) $0 (You must have full Medi-Cal) 2. Doctor and Hospital Choice: Plan Doctors Only Plan Doctors only

3. Calendar Year Deductible: $0 $0

4. Out-of-Pocket Limit: $4,400 $3,400

5. PART A:

Inpatient Hospital Stays:

Days 1-7:$255 copay per day;

$0 copay for additional hospital days

$0 copay with unlimited days each benefit period

6. Skilled Nursing Facility Care:

Days 1-10: $25 copay per day Days 11-100:$50 copay per day

Days 1-100: $0 copay

7. Home Health Care: $0 copay for Medicare-covered visit $0 copay for Medicare-covered visit 8. Hospice Care: Medicare-certified hospice only Medicare-certified hospice only 9. PART B:

Calendar Year Deductible:

See appropriate copayments/ coinsurance amounts below.

10. Ambulance Services: $200 copay $0 copay

11. Chiropractic Care: $20 copay for Medicare-covered visit $0 copay for Medicare-covered visit 12. Diagnostic Tests, X-Rays,

Lab, Radiology Services:

$45-$45-$170 copay $0 copay

13. Doctor’s Office Visits: ²PCP: $25 copay per visit Specialist: $25 copay per visit

$0 copay 14. Durable Medical

Equipment (DME):

20% for Medicare-covered items $0 copay 15. Emergency Room (E.R.): $65 copay for Medicare-covered visit $0 copay 16. Urgent Care Services: $25-$65 copay for Medicare-covered

visit

$0 copay

17. Worldwide Services: Worldwide coverage Worldwide coverage 18. Outpatient Mental

Health Care Per Visit:

$25 copay individual therapy visit;

$12 copay for group therapy visit

$0 copay 19. Outpatient Services/

Surgery:

$250 ambulatory surgical center visit;

$0-$250 for outpatient hospital visit

$0 copay

20. Preventive Care Services: See Summary of Benefits or call plan See Summary of Benefits or call plan 21. Routine Hearing Exams: See Summary of Benefits or call plan See Summary of Benefits or call plan 22. Routine Vision Exams: See Summary of Benefits or call plan See Summary of Benefits or call plan 23. PART D:

Medicare Rx Prescription Drug Coverage:

www.kp.org/seniormedrx

Annual Deductible: $0

Initial Coverage: $5-$15-$45-$95- 33% to $2,850 for formulary drugs. Coverage Gap: $5-$10 generic drugs; 47.5% brand drugs until your out-of-pocket costs reach $4,700. Catastrophic Cov.: $5-$12 copay

Initial Coverage: Based on your copays agreed to by the “Extra Help” program to $2,850 for formulary drugs.

Coverage Gap: Same as above. Catastrophic Cov.: Same as above. 24. Optional Supplemental

Benefits:

Dental & Vision coverage available; contact plan for details and cost.

Dental & Vision coverage available; contact plan for details and cost. NOTE: This is a brief description of benefits. Please contact plan for details and Summary of Benefits.

1PCP = Primary Care Provider

*****Member Satisfaction Rating (1 Star=Poor; 2 Stars=Below Average; 3 Stars=Average; 4 Stars=Above Average; 5 Stars=Excellent)

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Rev. 10/14/14 ₄

SCAN – Heart First HMO - SNP (H5425-053) Non-Members: 1-877-807-7226

www.scanhealthplan.com

SCAN - Balance HMO - SNP (H5425-054) Non-Members: 1-877-807-7226

You Pay… You Pay…

1. Monthly Premium: $20 (+ Medicare Part B premium) $20 (+ Medicare Part B premium) 2. Doctor and Hospital Choice: Plan Doctors Only Plan Doctors Only

3. Calendar Year Deductible: $0 $0

4. Out-of-Pocket Limit: $3,400 $3,400

5. PART A:

Days 1-5:$195 copay per day

$0 copay for additional hospital days

$0 copay for additional hospital days 6. Skilled Nursing Facility

Care:

Days 1-20: $0 copay per day Days 21-100 $50 copay per day

7. Home Health Care: $0 for copay $ 0 for copay

8. Hospice Care: Medicare-certified hospice only Medicare-certified hospice only 9. PART B:

See appropriate copayments/ coinsurance amounts below:

See appropriate copayments/ coinsurance amounts below: 10. Ambulance Services: $300 copay one way $300 copay one way

11. Chiropractic Care: $15 copay (10 visits) $15 copay (10 visits) 12. Diagnostic Tests, X-Rays,

$0 copay; see Summary of Benefits or call plan

13. Doctor’s Office Visits: ³PCP: $5 copay per visit Specialist: $15 copay per visit

3PCP: $5 copay per visit Specialist: $15 copay per visit 14. Durable Medical

Equipment (DME):

20% for Medicare-covered items $0 for Medicare-covered items 15. Emergency Room (E.R.): $65 copay for Medicare-covered

visit $0 if admitted

$65 copay for Medicare-covered visit $0 if admitted

16. Urgent Care Services: $35 copay US Only $35 copay US Only 17. Worldwide Services: Worldwide coverage Worldwide Coverage 18. Outpatient Mental

Health Care Per Visit:

$25 for copay $25 for copay

19. Outpatient Services/ Surgery:

$100-22550 copay for ambulatory surgical visit

$100-225 copay for ambulatory surgical visit

20. Preventive Care Services: $0 copay for Medicare-covered $0 copay for Medicare-covered 21. Routine Hearing Exams: $0 copay (1 per year) $500 Aids $0 copay (1 per year) $500 Aids 22. Routine Vision Exams: $0 copay (1 per year) $25-175 lens/fr $0 copay (1 per year) $0-175 lens/fr 23. PART D:

Medicare Rx Prescription Drug Coverage (Part D):

Initial Coverage: $5-95-33% & $10 to $2,960 for formulary drugs. Catastrophic Cov.: $2.55/5% out- of-pocket costs reach $4,700. See Plan

24. Optional Supplemental Benefits:

Transport, Dental & Vision coverage available; contact plan for details and cost.

NOTE: This is a brief description of benefits. For more details, please contact plan for Summary of Benefits.

*****Member Satisfaction Rating(1 Star=Poor; 2 Stars=Below Average; 3 Stars=Average; 4 Stars=Above Average; 5 Stars=Excellent)

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Rev. 10/14/2014 5

Napa County 2015 Medicare Advantage Plans

SCAN - Classic HMO (H5425-052) Non-Members: 1-877-807-7226

Intentionally Blank

You Pay… 1. Monthly Premium: $0 (+ Medicare Part B premium) 2. Doctor and Hospital Choice: Plan Doctors Only

3. Calendar Year Deductible: $0 4. Out-of-Pocket Limit: $3,400 5. PART A:

$0 copay for additional hospital days 6. Skilled Nursing Facility Care: Days 1-10: $0 copay per day

Days 11-20:$25 Days 21-100 $50 copay per day

7. Home Health Care: $0 for copay

8. Hospice Care: Medicare-certified hospice only 9. PART B:

See appropriate copayments/ coinsurance amounts below: 10. Ambulance Services: $200 copay

11. Chiropractic Care: $15 copay (10 visits) 12. Diagnostic Tests, X-Rays,

$0 copay; see Summary of Benefits or call plan

13. Doctor’s Office Visits: ³PCP: $5 copay per visit Specialist: $15 copay per visit 14. Durable Medical Equipment

(DME):

20% for Medicare-covered items

15. Emergency Room (E.R.): $65 copay for Medicare-covered visit $0 if admitted

16. Urgent Care Services: $35 for Medicare-covered visit 17. Worldwide Services: Worldwide coverage

18. Outpatient Mental Health Care Per Visit:

$25 for copay 19. Outpatient Services/

Surgery:

$75 copay for ambulatory surgical visit 20. Preventive Care Services: $0 copay for Medicare-covered

21. Routine Hearing Exams: $0 copay (1 per year) $500 Aids 22. Routine Vision Exams: $0 copay (1 per year) $25-175 lens/fr 23. PART D:

Medicare Rx Prescription Drug Coverage (Part D):

Initial Coverage: $3-$7-$45-$75-33%

& $10 to $2,850 for formulary drugs. Catastrophic Cov.: $2.55/5% out-of- pocket costs reach $4,940. See Plan

24. Optional Supplemental Benefits:

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Rev. 10/14/2014 6

Definitions of Medicare Advantage (MA) Plans:

Beginning January 1, 2014, is (one) Medicare Advantage plans available. When you sign up for a Medicare Advantage plan, you assign your Medicare Part A and Part B over to the plan. Your plan determines what is covered and what is not covered. The definition for each of these plans is below:

1. Health Maintenance Organization (HMO) plan: HMO Plans must cover all Medicare Part A and Part B health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Your costs may be lower than in the Original Medicare Plan.

2. Private Fee for Service (PFFS) Plan: A type of Medicare Advantage plan (Part C) in which you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan, rather than the Medicare program, decides how much it pays and what you pay for the services you will receive. You may pay more or less for Medicare-covered benefits and may have extra benefits than in the Original Medicare Plan. If your PFFS plan doesn’t offer a Part D drug benefit, you can join a stand-alone Prescription Drug Plan (PDP).

3. Special Needs Plan (SNP): Medicare Special Needs Plans’ (SNP) are specially designed for people with certain chronic diseases and other specialized health needs. These plans are only available for specific groups of people, such as people living in certain long-term care facilities (like a nursing home), people eligible for Medicare and Medicaid (Medi-Cal in California), or people with certain chronic or disabling conditions. All Medicare SNPs provide Medicare Part D prescription drug coverage.

About this Chart:

All Medicare Advantage (MA) plans must adhere to the guidelines established by the Centers for Medicare & Medicaid Services (CMS) and must provide all of the benefits covered under Original Medicare. This Comparison Chart is a summary only and highlights the areas where these plans may differ in benefits. For more specific information, please contact each plan directly.

MA plans are Individual Plans for people who do not qualify for an Employer Group Health Plan (EGHP). An EGHP may be very different from the plans listed in this chart. Converting an EGHP from actively working to a retiree plan, and going on Medicare may change your benefits and premiums. HICAP provides one-on-one counseling to help you compare your current EGHP plan with individual Medicare Advantage plans (HMO and PPO) and Medicare Supplement (Medigap) plans.