GETTING
THE MOST
OUT OF YOUR
MEDICARE
1
GETTING THE MOST OUT OF
YOUR MEDICARE IS EASY.
Congratulations! We’re providing you with the information
you need to make the right Medicare decisions.
Now that Medicare is going through so many changes, it’s more important than ever to be sure
of your medical care and coverage. And peace of mind starts with clear, reliable information. At
EmblemHealth, we believe it should be easy for you to get all of the answers you need so you
feel comfortable and secure with your Medicare coverage decisions. It doesn’t have to be difficult
— if you have the right facts. We promise to help you find the coverage that best fits your
needs and gives you the care you deserve. With this guide, you’re well on your way to making
the right choices.
Whether you’re just aging into Medicare, still insured through work and contemplating retirement,
or thinking about a change in Medicare coverage, you’ve got help right here in this guide. We’ve
designed it to make it easier to navigate your options — no matter what your situation.
EmblemHealth is here to help you for the long run. For 75 years, New Yorkers have trusted us to
provide them with quality plans for different needs and budgets. We’re constantly looking for ways
to improve and better respond to your needs. We now serve some 2.8 million people with access to
our large network of physicians and hospitals across the tristate region. And with EmblemHealth
Medicare experts on staff, we’re always available by phone to answer your questions or even coordinate a personal meeting for you.
To learn more, call toll free 1-800-447-1162 seven days a week, from 8 am to
8 pm. (Those with a TDD machine, please call 1-877-444-2786.) Or visit us
online at www.emblemhealth.com/medicare to find out which plan is right
for you.
1
CONTENTS
4
WHO ARE YOU?
Just starting Medicare, or are you already enrolled?
8
A COVERAGE OVERVIEW
Understanding what each part of Medicare does for you
10
COST COMPARISON — LET’S RUN THE NUMBERS
Looking at your Medicare cost options
12
THE RIGHT COVERAGE FOR YOU
Getting the most out of your Medicare choices
16
MAKE SURE YOUR PRIORITIES ARE COVERED
Taking a look at Medicare Advantage
19
PERSONAL NOTES
Making notes on your plan choices or jotting down questions
WATCH FOR QUICK CHECKS
We’ve included Quick Checks in your guide to help you understand your choices and
easily make a decision you feel good about. When you see a “Quick Check” box, take
a minute to fill it out. It will keep you moving on your way to a better Medicare plan.
Quick Check
If you need to, just pick up the phone
and call us, or explore our new Web
site at www.emblemhealth.com/
medicare. You’ll be surprised to see
how easy it is to get the coverage
you’re looking for when you have help
from your friends at EmblemHealth.
2
THE MOST BASIC QUESTION:
WHO ARE YOU?
It may seem like a simple question, but just a few moments spent
thinking about your needs can help you pinpoint better Medicare
coverage options.
JUST STARTING WITH MEDICARE?
Enrolling at Age 65
If you’re approaching age 65 and ready to retire, you’ll probably be enrolling in Medicare for the
first time. There’s a limited time in which you may do so, called the Initial Coverage Election
Period (ICEP), from three months before the month of your 65th birthday to three months after.
During those seven months, you may enroll in any Medicare plan you’re eligible for. But if you
miss that window, you’ll have to wait for the next Annual Enrollment Period (AEP), which will
begin October 15 and continue through December 7.
Quick Check
Your Medicare Enrollment Window When Turning 65:
Write in your 65th birthday: ___________________________________________________
Enrollment Period Begins:
Write in three months before your 65th birthday: _________________________________
Enrollment Period Ends:
Write in three months after your 65th birthday: __________________________________
3
Enrolling at a later retirement age
If you’re over 65 and still working or covered under your employer’s plan, you have eight
months to enroll in Part B after your employment ends. You then have two months prior to the
start of your Part B coverage to choose a new plan. This is called a Special Election Period. If
you do not elect coverage during this window, you will not be eligible to enroll again until the
next AEP.
Quick Check
Your special enrollment period when retiring:
Write in the month you are retiring: ____________________________________________
Enrollment Period Begins:
Write in the month after you retire: ____________________________________________
Enrollment Period Ends:
Write in eight months after the start of your enrollment period: ____________________
To learn more, call toll free 1-800-447-1162 seven days a week, from 8 am to
8 pm. (Those with a TDD machine, please call 1-877-444-2786.) Or visit us
online at www.emblemhealth.com/medicare to find out which plan is right
for you.
4
ALREADY ENROLLED IN MEDICARE?
Add or switch coverage when you have the most options
available to you.
If you’re over 65 and would like to switch Medicare plans, or if you did not sign up during your
initial enrollment period, you may change or add plans during the Annual Enrollment Period.
This period will run from October 15 through December 7, and, with few exceptions, is the
only time you may add or switch Medicare Advantage Plans for coverage effective January 1 of
the next calendar year. It’s ideal to choose your plan during this time because it gives you the
most options available.
SOME EXCEPTIONS ALLOW YOU TO
ENROLL THROUGHOUT THE YEAR.
Special Election Period (SEP).
For a variety of reasons, you may qualify to enroll in Medicare coverage at any time of the year.
Below are situations that might qualify you for an SEP:
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service area.
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through no action of your own.
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Drug Plan or a Medicare Advantage Plan
whose contract is terminated.
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is made retroactively.
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Medicaid (a “dual eligible”).
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Plan (SNP) but lose the special needs
qualification required to be in that plan.
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for extra help paying for prescription drugs.
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program provided by the State.
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sponsored Prescription Drug Plan to a
Medicare Prescription Drug Plan.
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caused by an error by a Federal employee
or a contractor hired by the Federal
government.
5
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Prescription Drug Plan because it was
reprimanded by the Federal government
or the Federal government has determined
the plan violated a material provision of its
Medicare contract in relation to services
provided to you.
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renewing its contract with Medicare. This
SEP begins 90 calendar days prior to the
end of the contract year (i.e., October 1)
and ends on December 31 of the same year.
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Inclusive Care for the Elderly — PACE —
to a Medicare Advantage Prescription Drug
Plan — MA-PD.
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a skilled nursing facility, a nursing facility,
an intermediate care facility for the mentally retarded, a psychiatric hospital or unit,
a rehabilitation hospital or unit, a longterm care hospital or a swing-bed hospital.
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A and enroll in Medicare Part B during the
Part B General Enrollment Period.
If you have any questions, or have a unique situation that is not on this list, call EmblemHealth
immediately. An EmblemHealth Medicare specialist can assist you in determining whether
you qualify.
To learn more, call toll free 1-800-447-1162 seven days a week, from 8 am to
8 pm. (Those with a TDD machine, please call 1-877-444-2786.) Or visit us
online at www.emblemhealth.com/medicare to find out which plan is right
for you.
6
A COVERAGE OVERVIEW
Let’s take a look at what’s covered by Medicare’s different parts. Here’s a
quick overview of what each plan type does for you.
HOSPITAL COVERAGE
(PART A)
MEDICAL COVERAGE
(PART B)
PRESCRIPTION DRUG
COVERAGE (PART D)
Most people get Part A coverage
from the Federal government
automatically when they turn
65 if they have worked 40
quarters paying into Medicare.
Part A doesn’t charge any
premiums for most people.
Also provided by the Federal
government, Medical insurance,
or Part B, is optional and
combines with Part A. If you
choose to enroll in Part B, you’ll
pay a premium of up to $99.90*
a month and get coverage for
some services that don’t require a
hospital stay. (See page 9 for more
on costs.)
If you take prescription drugs
and you’re enrolled in Original
Medicare, you’ll need to choose
a Part D Prescription Drug
Plan. Original Medicare Parts
A and B do not cover your prescription drugs. When choosing
a Prescription Drug Plan, you’ll
want to pay special attention to
the list of medications it covers,
called the “formulary.”
Part A covers medically
necessary care requiring an
overnight stay in the hospital.
It also covers follow-up nursing
care after a hospital stay,
hospice care and some home
health care for the homebound.
Part B covers medically
necessary services that don’t
require an overnight hospital
stay, such as doctor’s office
visits, hospital or clinical care
that doesn’t include an overnight stay, lab tests and some
screenings. You cannot be
refused Part B coverage.
ORIGINAL MEDICARE
* Amount is for 2012 and may change in 2013.
Source: www.medicare.gov
7
You can enroll in a Part D
Prescription Drug Plan from a
private insurance company to
get Prescription Drug coverage
along with Part A and/or Part
B coverage or to complement a
Medicare Supplement Plan. If
you do, you’ll pay an additional
premium as well as copayments
and deductibles. This is called a
“stand-alone” Part D Plan.
MEDICARE SUPPLEMENT
(MEDIGAP)
Medicare Parts A and B don’t
cover everything. They leave
gaps for things like deductibles,
copayments and coinsurance.
If you like, you may choose
from the long list of Medicare
Supplement Plans offered
by insurance companies to
Medicare beneficiaries. There are
12 plan options (they vary by
state), each offering a different
combination of benefits with
different levels of coverage.
All are tightly regulated by the
Federal government.
Please note: Medicare
Supplement Plans don’t include
Prescription Drug coverage (Part
D). If you choose a Medigap
Plan and want Prescription
Drug coverage, you’ll need to
pay extra for a Part D Plan.
MEDICARE ADVANTAGE
(PART C or PARTS C & D)
Coordinate all of your Medicare benefits through a single Medicare
Advantage Plan.
Medicare Advantage Plans often include the benefits of all of the
other plans available — and then some — for no additional cost.
If you already have Part A and you’re paying your monthly Part B
premium, Medicare Advantage Plans coordinate all of your Part A
(Hospital) and B (Medical), and often Part D (Prescription Drug),
benefits, plus extra benefits not covered by Original Medicare, into
a single plan. Some Medicare Advantage providers even offer all of
this at no additional premium cost beyond your Part B (Medical
insurance) premium.
Coordinated coverage under one, stable plan.
Medicare Advantage Plans can offer you reliable coverage featured
under one single plan without all of the confusion of multiple plans
with uncoordinated billing, administrators and networks. In addition,
Medicare Advantage Plans often offer additional value through extra
benefits not featured in any stand-alone plan option and without
charging additional premiums beyond Part B.
To learn more, call toll free 1-800-447-1162 seven days a week, from 8 am to
8 pm. (Those with a TDD machine, please call 1-877-444-2786.) Or visit us online
at www.emblemhealth.com/medicare to find out which plan is right for you.
8
COST COMPARISON —
LET’S RUN THE NUMBERS
A Quick Summary of Your Medicare Cost Options.
HOSPITAL COVERAGE
(PART A)
MONTHLY PREMIUM
ANNUAL DEDUCTIBLE
COPAYMENT COSTS
COINSURANCE PERCENTAGE
MEDICAL COVERAGE
(PART B)
FREE for most people.
Up to $99.90/month* for
2012 for most individuals
making less than $85,000
per year.
$1,156 per benefit period*
for 2012.
$140 per year* in 2012.
$289 per-day copayment*
begins after a certain number of
days in the hospital per benefit
period.
Copayments are required for
outpatient services.
Only for certain services.
You pay 20%; Part B pays
80%.
ORIGINAL MEDICARE
* Amounts are for 2012 and may change in 2013.
Source: www.medicare.gov
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QUICK CHECK
WHAT ARE YOUR MONTHLY MEDICAL BILLS?
Coverage Premiums: $
Coinsurance: $
Doctor Visit Copayments: $
Drug Costs: $
Total: $
PRESCRIPTION DRUG
COVERAGE (PART D)
MEDICARE SUPPLEMENT
(MEDIGAP)
MEDICARE ADVANTAGE
(PART C or PARTS C & D)
As low as $15.10.* It depends
on the plan. Many Medicare
Advantage Plans include Part D
coverage.
From $55 to $417 per month.*
Premiums vary depending on
which plan and which insurer
you choose.
As low as $0.
From $0 up. Lower deductibles
usually mean higher premiums.
Varies significantly from
plan to plan.
As low as $0.
From $0 to $95.* Generic
drugs generally have lower
copayments.
No copayments — however,
you still have copayments for
Parts A and B.
Copayments are generally low but
can vary widely. Many plans offer low
copayments for basic services like office
and hospital visits.
As low as 0% or as high
as 100%.
You pay 0% — but you still pay
applicable coinsurance for services
covered by Parts A and B.
You pay 0% in most cases — but
you may still pay any applicable
coinsurance for Part D-covered
drugs and out-of-network services.
To learn more, call toll free 1-800-447-1162 seven days a week, from 8 am to
8 pm. (Those with a TDD machine, please call 1-877-444-2786.) Or visit us online
at www.emblemhealth.com/medicare to find out which plan is right for you.
10
THE RIGHT COVERAGE IS
ALL ABOUT THE RIGHT CHOICES!
EmblemHealth has a variety of great plans to choose from.
Choosing What Type of Medicare Advantage Plan Best Suits
Your Needs Can Be Challenging.
Reliability is everything — you have to find a stable health plan you can count on.
Plan choice is essential — you have to make sure that the plan design and benefits offered meet
your needs.
EmblemHealth offers the flexibility of both Medicare Advantage HMOs AND Medicare
Advantage PPOs so you get the best of both worlds: reliability AND plan options.
EMBLEMHEALTH MEDICARE HMO
An excellent choice for affordable coverage that gives you
coordinated care from one of New York’s largest networks.
All In One Plan
All of our Medicare Advantage HMO Plans give you all of the benefits of Medicare Parts A
(Hospital insurance) and B (Medical insurance) PLUS Medicare Part D (Prescription Drug
coverage) — for little or no additional cost above your Medicare Part B premium.
Benefits Beyond Medicare
In addition to getting all of these parts in one plan, our Medicare Advantage HMO includes
additional benefits beyond Original Medicare — like Vision, Hearing and Dental.
Coordinated Care
With our Medicare Advantage HMO, you get to choose an in-network primary care physician
(PCP) whose job it is to refer you to the specialists and facilities you need. This makes your care
more efficient, and you don’t have to worry about finding your own specialists.
The goal of coordinated care is to make accessing your medical services as easy as possible, often
under one roof.
11
Save Money
You can get all of this for low or, depending on where you live, $0 plan premiums, a substantial
savings over plans that have you pay much higher premiums.
You will also save with low copayments because you are getting in-network care. That means with
an EmblemHealth Medicare Advantage HMO, your out-of-pocket costs can be lower.
Your HMO Coverage
You’re in control. EmblemHealth offers the following Medicare Advantage HMO Plans with a
diversity in plan design so you can cover all of your needs. Choose a plan based on network and
copayment levels.
VIP ESSENTIAL
(HMO)
VIP
(HMO)
VIP HIGH OPTION
(HMO)
All of the benefits of Original Medicare, plus low copayments and
a Prescription Drug Plan. Members of this plan choose a PCP from
a select group of health care providers who are part of our large
network. You must use these selected providers to be covered. For
2013, we have added 500 new PCPs to the Essential network,
making this plan more attractive than ever before.
All of the benefits of Original Medicare. Features low copays for
PCPs, specialists and inpatient hospital stays, plus Prescription
Drug coverage. You have access to any of the providers within
our extensive provider network.
This is a plan like VIP (HMO). For one monthly premium, you
get all of the benefits of Original Medicare and more, including
Prescription Drug coverage, and the resources of our expansive
HMO network, with no copays for Medical benefits.
To learn more, call toll free 1-800-447-1162 seven days a week, from 8 am to
8 pm. (Those with a TDD machine, please call 1-877-444-2786.) Or visit us
online at www.emblemhealth.com/medicare to find out which plan is right
for you.
12
EMBLEMHEALTH MEDICARE PPO
Quality coverage with great benefits and freedom in
provider choice.
The Flexibility to Choose Doctors In or Out of Network
Our Medicare Advantage PPO Plans provide all of the benefits of Original Medicare Part A
(Hospital insurance) and Medicare Part B (Medical insurance) PLUS the option to include Part D
Prescription Drug coverage in one plan.
What makes an EmblemHealth PPO flexible is that it offers you the freedom to select any
provider in or out of network within the plan service area.
No Referrals
With a PPO, you manage your own care. You do not need referrals from your primary care
provider. So you are free to see any specialist without a referral.
Coverage Through the Gap
While the coverage gap will be closing over time and will be completely eliminated by 2020, you
still need to worry about affording the cost of your prescription drugs when you hit the coverage
gap. We have PPO options that include coverage through the gap on generic drugs.
Benefits Beyond Medicare
An EmblemHealth Medicare Advantage PPO also includes benefits beyond Original Medicare
— like Vision, Hearing and Dental.
Save Money
You can get all of this for low, or depending on where you live, $0 plan premiums, a substantial
savings over plans that have you pay much higher premiums. If you make use of in-network
providers, you can save with low copayments and lower out-of-pocket costs.
Your PPO Coverage
You’re in control. EmblemHealth offers the following Medicare Advantage PPO Plans with a diverse
plan design so you can tailor your coverage by selecting the plan that best suits your needs. Choose
from plans with or without Prescription Drug coverage, and even those that include coverage
through the gap. Determine the network and copayment options that suit you best.
To learn more, call toll free 1-800-447-1162 seven days a week, from 8 am to
8 pm. (Those with a TDD machine, please call 1-877-444-2786.) Or visit us online
at www.emblemhealth.com/medicare to find out which plan is right for you.
13
PPO I
All of the benefits of Original Medicare, plus benefits for
in- and out-of-network coverage, with no referrals needed.
Prescription Drug coverage is not included in this plan.
PPO II
All of the benefits of Original Medicare, plus benefits for in- and
out-of-network coverage, with no referrals needed. Prescription
Drug coverage is included in this plan.
PPO III
All of the benefits of PPO II, plus coverage for preferred generic
drugs through the coverage gap.
PPO HIGH OPTION
All of the benefits of PPO III, with no copayments for in-network
doctor and hospital visits.
EMBLEMHEALTH MEDICARE SNP
Special Coverage for those Receiving Assistance from the State.
EmblemHealth has Special Needs Plans (SNP) designed to cover individuals who are dual eligible
(for both Medicare and Medicaid) and who receive care from Medicare and Medicaid or other
assistance from the State. We offer efficient, coordinated care to control costs and best deliver
specialized health services. Our Care Management staff can even develop an individual care plan to
ensure your needs are met.
If you receive full Medicaid benefits from the State, you can apply to receive Medicaid Advantage
benefits within the Dual-Eligible Plans.
PPO: Get these benefits with a Dual-Eligible
(PPO SNP) Plan:
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debit card
HMO: Get these benefits with a Dual-Eligible
(HMO SNP) Plan:
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debit card
DUAL-ELIGIBLE
(PPO SNP)
A plan like PPO II with $0 copays for in- and out-of-network
benefits and Presciption Drug coverage. For your over-the-counter
(OTC) medicine purchases, this plan also includes a debit card
with an annual benefit of $600.
DUAL-ELIGIBLE
(HMO SNP)
A plan like VIP (HMO) with $0 copays, access to our large HMO
provider network and Presciption Drug coverage. For your overthe-counter (OTC) medicine purchases, this plan also includes
a debit card with an annual benefit of $600.
14
MAKE SURE YOUR PRIORITIES
ARE COVERED.
Our priority is to promise every man, woman and child
a relationship they can count on to help them stay healthy,
get well and live better.
YOU SHOULD CHOOSE A PLAN THAT HAS YOUR BEST INTERESTS IN
MIND — AND WE CAN HELP. WE’RE MEDICARE EXPERTS. AND WE CARE.
To determine which Medicare plan is right for you, think about your needs in these areas.
HOW MUCH YOU PAY IN MONTHLY PREMIUMS.
Generally, the higher your monthly premiums, the lower your copayments and deductibles will be.
Consider how often you need to see your doctor and which would be a better value for you.
SELECTING YOUR OWN DOCTOR.
Some plans are more flexible than others. If you have a primary care physician or a specialist
you would like to see, making sure they are accepted under your plan is a good idea.
EXTRA BENEFITS.
Benefits like Dental, Vision and Hearing are included in some plans at no extra charge.
Determine how much you’re paying out of pocket for these costs. You may save money
with these benefits included.
PRESCRIPTION DRUG COVERAGE.
Some plans include Prescription Drug coverage. Consider totaling your prescription drug costs
before selecting a plan. If you have high prescription drug costs, it may make sense to choose a
plan that provides Prescription Drug coverage.
15
PRIMARY CARE PHYSICIAN.
Some plans use your primary care physician to manage your health care. If you like the convenience
of having your care in the hands of one doctor, a plan like this may fit your needs.
These are some of the considerations you’ll discuss when you speak to an EmblemHealth Medicare
expert. If you know which of the above benefits are important to you, then finding the right plan
is that much easier. You can rest easy knowing your priorities are covered with EmblemHealth.
To learn more, call toll free 1-800-447-1162 seven days a week, from 8 am to
8 pm. (Those with a TDD machine, please call 1-877-444-2786.) Or visit us
online at www.emblemhealth.com/medicare to find out which plan is right
for you.
16
UNANSWERED QUESTIONS
At EmblemHealth, it’s our goal to help you find Medicare
coverage in which you can be confident. And to do that, you
need to consider all of your options carefully. Here are some
areas you may want to ask questions about:
QUICK CHECK
1. QUESTIONS ABOUT YOUR ENROLLMENT OPPORTUNITIES (pages 3-6):
2. QUESTIONS ABOUT THE DIFFERENT PARTS OF MEDICARE (pages 7-8):
3. QUESTIONS ABOUT THE COSTS OF MEDICARE PLANS (pages 9-10):
4. QUESTIONS ABOUT MEDICARE ADVANTAGE HMO, PPO AND SNP
(pages 11–14):
5. QUESTIONS ABOUT MEDICARE ADVANTAGE PLANS (pages 15-16):
17
PERSONAL NOTES
Use this section to make notes on your plan choices or jot down
questions you’d like to ask an EmblemHealth Medicare expert.
To learn more, call toll free 1-800-447-1162 seven days a week, from 8 am to
8 pm. (Those with a TDD machine, please call 1-877-444-2786.) Or visit us
online at www.emblemhealth.com/medicare to find out which plan is right
for you.
18
WE’RE HERE FOR ALL OF YOUR
MEDICARE NEEDS
1
PHONE: Call toll free 1-800-447-1162, seven days a week, from 8 am to 8 pm.
(Those with a TDD machine, please call 1-877-444-2786.)
2
WEB: Visit us online at
www.emblemhealth.com/medicare,
24 hours a day, seven days a week. Our
Web site makes it easy to find the right
plan for you with:
• Videos — we will walk you through your
Medicare options step by step
• Easy-to-use Plan Finder
• Prescription Drug Cost Calculator
• Quick Doctor Finder
3
IN PERSON: Call now to schedule a one-on-one consultation with an EmblemHealth
Medicare expert.
To learn more, call toll free 1-800-447-1162 seven days a week, from 8 am to 8 pm.
(Those with a TDD machine, please call 1-877-444-2786.) Or visit us online at
www.emblemhealth.com/medicare to find out which plan is right for you.
Resources: 1-800-MEDICARE (1-800-633-4227), www.medicare.gov
Group Health Incorporated (GHI) and HIP Health Plan of New York (HIP) are Medicare
Advantage organizations with Medicare contracts. GHI and HIP are EmblemHealth companies.
Plans vary by county. Limitations, copayments, and restrictions may apply. Benefits, formulary,
pharmacy network, premium and/or copayments/coinsurance may change on January 1 of
each year. A Special Needs Plan is available to anyone who has both Medical Assistance from
the State and Medicare. You must continue to pay your Medicare Part B premium. The benefit
information provided is a brief summary, not a complete description of benefits. Premiums,
copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive.
Please contact the plan for further details.
Y0026_123161 Accepted 09/12/2012
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