Optima Medicare (PPO) Plans CY 2010. Medicare Medicare is a Federal health insurance program for those age 65 or older or individuals at any age who have.

Optima Medicare (PPO) Plans

CY 2010

Medicare• Medicare is a Federal health insurance program

for those age 65 or older or individuals at any age who have certain disabilities, or who have End Stage Renal Disease (permanent kidney failure)

• The Centers for Medicare and Medicaid Services (CMS) is the Federal agency which regulates Medicare.

• The Social Security Administration performs administrative functions for the Medicare program and provides general information.

Medicare• Medicare Part A (hospital

insurance) mainly covers inpatient care in a hospital, skilled nursing facility, home health care or hospice program.

• Most beneficiaries do not pay for Part A.

• Medicare Part B (medical insurance) covers outpatient care, including physician services, diagnostic services, ambulance, certain limited drugs, and durable medical equipment.

• Beneficiaries will pay $96.40 for Part B in 2009. Upper income beneficiaries will pay more.

Medicare• Medicare Part C (Medicare Advantage) plans

cover Part A and B benefits.

• Private plans contract with CMS to administer Part C plans under contract.

• CMS pays private plans to provide these benefits.

• Medicare Advantage plans have uniform premium and cost-sharing amounts, except for limited income subsidy beneficiaries under Part D.

• Medicare Advantage plans may include Part D benefits (MA-PD).

Medicare Part D Plans• Part D plans include

– Prescription Drug Plans (PDPs), – Medicare Advantage – Prescription Drug (MA-

PD) plans, – Cost Plans that offer Part D prescription drug

coverage, and – Program of All-Inclusive Care for the Elderly

(PACE) plans.

Enrolling In Medicare Advantage and Part D Plans

Election Periods

• Initial Election Period (IEP)

– Beneficiary Dependent

• Annual Election Period (AEP)

– November 15 to December 31

• Open Enrollment Period (OEP)

– January 1 to March 31

• Special Enrollment Period (SEP)

– Beneficiary Dependent

Annual Election Period (AEP)• November 15, 2009 – December 31, 2009.• Beneficiaries may add or drop MA and/or drug coverage.• Beneficiaries may switch to a different plan offering drug

coverage:– From a PDP to a different PDP,– From MA-PD to a different MA-PD,– From a PDP to an MA-PD or vice versa, or– To a Cost Plan offering Part D

• Beneficiaries have one AEP to use; once the enrollment is effective, the AEP has been used.

Open Enrollment Period (OEP)

• From January 1, 2010 through March 31, 2010 beneficiaries may make one change to how they receive their Medicare health benefits, but they may not add or drop drug coverage.

How Part D Works• Stage 1

– Premium• A premium is your

monthly cost to maintain coverage. If you choose a Medicare Advantage plan with prescription drug coverage, your Part D premium will be included in the overall premium.

• Stage 2– Deductible

• The amount you must pay for covered prescriptions before your Part D begins to pay. You pay the yearly deductible. Some plans like Optima Medicare (PPO) offer no deductible so you get coverage immediately.

How Part D Works - continued

• Stage 3

– Coinsurance

• You and your plan share the cost of your yearly prescription drugs until these costs reach $2,830.

• Stage 4

– The “Coverage Gap”

• When the total prescription costs reach $2,830, your drug benefit stops temporarily until you have paid $4,550 in total out-of-pocket expenses.

How Part D Works - continued

• Stage 5

– More than $4,550

• Once you have paid $4,550, you pay either $2.50 per prescription for generic drugs and $6.30 per prescription for all other drugs or 5% coinsurance for the rest of the calendar year. Your plan pays the rest.

Medicare Health Care Plan Premium Payment

Members can pay their premiums by:

Monthly bill Automatic bank withdrawal Withholding from Social Security Administration

The SSA Withholding option has created problems for many beneficiaries due to inter-agency coordination issues – we do not recommend it.

Marketing Notification by BrokersAn organization must require that the person performing marketing make the following disclosure, prior to enrollment or at the time of enrollment, in writing, to a potential enrollee*:

“The person that is discussing plan options with you is either employed by or contracted with Optima Health. The person may be compensated based on your enrollment in an Optima Medicare plan.”

*Source: CMS Managed Care Manual, Medicare Marketing Guidelines

Optima Medicare (PPO)

Plans and Benefits

Optima Medicare (PPO) Plans

• Optima’s plans are Medicare Advantage Preferred Provider Organization plans.

• Members can receive benefits in or out-of-network.

• Optima Medicare plans provide benefits equivalent to Original Medicare, plus additional benefits.

• Optima Medicare plans are filed annually with CMS, and become effective on January 1 of each year - they are calendar year plans.

Optima Medicare (PPO) Plans

Optima Medicare is a PPO Plan:• Members can choose providers in or out of

network. Out of Network providers are just like any provider - they may choose to participate in Medicare or not. Optima pays out of network providers the Medicare allowable fee schedule, just like Original Medicare or Medicare Supplement plans.

• With an Optima Medicare plan, members have freedom to travel, thanks to out of network coverage.

Optima Medicare (PPO) Plans 2010 Plans and Benefits

In 2010, Optima will offer four plan designs:

2010 Medicare Plan Choices

Optima Medicare Preferred

Optima Medicare Preferred

Plus

Optima Medicare

Value

Optima Medicare

Value Plus

Monthly Premium

$90.00 $148.00 $0.00 $0.00

Inpatient Benefits2010 Medicare Plan Choices

Optima Medicare Preferred 

Optima Medicare Preferred Plus

Optima Medicare Value

Optima Medicare Value Plus

Benefits NetworkNon-Network Network

Non-Network Network 

Non-Network Network 

Non-Network

Inpatient Benefits                

Inpatient Hospital Care

$100 Copay per day, days 1-5

$100 Copay per day, days 1-5

$100 Copay per day, days 1-5

$100 Copay per day, days 1-5

$200 copay per day, days 1 - 5

$200 copay per day, days 1 - 5

$200 copay per day, days 1 - 6

$200 copay per day, days 1 - 6

Inpatient Mental Health

$100 Copay per day, days 1-5

$100 Copay per day, days 1-5

$100 Copay per day, days 1-5

$100 Copay per day, days 1-5

$200 copay per day, days 1 - 5

$200 copay per day, days 1 - 5

$200 copay per day, days 1 - 6

$200 copay per day, days 1 - 6

Skilled Nursing Facility

$60 copay per day, days 4-100

$60 copay per day, days 4-100

$60 copay per day, days 4-100

$60 copay per day, days 4-100

$120 copay days 4 - 100

$120 copay days 4 - 100

$120 copay days 4 - 100

$120 copay days 4 - 100

Home Health Care $0 $15 $0 $15 $0 $15 $0 $15

Outpatient Benefits2010 Medicare Plan Choices

Optima Medicare Preferred 

Optima Medicare Preferred Plus

Optima Medicare Value

Optima Medicare Value Plus

Benefits NetworkNon-Network Network

Non-Network Network 

Non-Network Network 

Non-Network

Outpatient Services                Outpatient

Surgery/services $0 $250 per admit $0

$250 per admit 20% 30% 20% 30%

Ambulance Services$50 per trip

$50 per trip

$50 per trip

$50 per trip 20% 30% 20% 30%

Emergency Care$50 per visit

$50 per visit

$50 per visit

$50 per visit

$50 per trip

$50 per trip

$50 per trip

$50 per trip

Urgently Needed Care$10 per visit.

$10 per visit

$10 per visit.

$10 per visit

$10 per visit

$10 per visit

$10 per visit

$10 per visit

Outpatient Rehabilitation Services $0

$15 per visit $0

$15 per visit

20% copay

30% copay

20% copay

30% copay

Durable Medical Equipment & Prosthetics $0

20% copay $0

20% copay

20% copay

30% copay

20% copay 30%

Diagnostic Tests, X-Rays, and Lab Services

$0 per visit, $50 for MRI, CT and PET scans.

$15 per visit, $100 for MRI, CT and PET scans

$0 per visit, $50 for MRI, CT and PET scans.

$15 per visit, $100 for MRI, CT and PET scans

20% copay

30% copay

20% copay

30% copay

Physician Benefits2010 Medicare Plan Choices

Optima Medicare Preferred 

Optima Medicare Preferred Plus

Optima Medicare Value

Optima Medicare Value Plus

Benefits NetworkNon-Network Network

Non-Network Network 

Non-Network Network 

Non-Network

Physician Services                Doctor Office Visits $10 $15 $10 $15 $10 30% $10 30%

Chiropractic Services $10 $15 $10 $15 $10 30% $10 30%Podiatry Services $10 $15 $10 $15 $10 30% $10 30%

Physical Exams$0 annual exam

$15 per annual exam

$0 annual exam

$15 per annual exam

Vision Services

$10 per visit for routine eye exam. $25 for post-cataract eyewear.

20% for post-cataract eyeware. 20% for Medicare-covered eye exams.

$10 per visit for routine eye exam. $25 for post-cataract eyewear.

20% for post-cataract eyeware. 20% for Medicare-covered eye exams.

$25 for post-cataract eyewear, $30 per Medicare-covered eye exam

30% for post-cataract eyeware. 30% for Medicare-covered eye exams.

$25 for post-cataract eyewear, $30 per Medicare-covered eye exam

30% for post-cataract eyeware. 30% for Medicare-covered eye exams.

Preventive Services2010 Medicare Plan Choices

Optima Medicare Preferred 

Optima Medicare Preferred Plus

Optima Medicare Value

Optima Medicare Value Plus

Benefits NetworkNon-Network Network

Non-Network Network 

Non-Network Network 

Non-Network

Preventive Tests and Services                

Bone Mass Measurement $0 $0 $0 $0 $0 $0 $0 $0 Colorectal Screening

Exams $0 $0 $0 $0 $0 $0 $0 $0 Immunizations $0 $0 $0 $0 $0 $0 $0 $0 Mammograms $0 $0 $0 $0 $0 $0 $0 $0

Pap Smears and Pelvic Exams $0 $0 $0 $0 $0 $0 $0 $0

Prostate Cancer Screening Exams $0 $0 $0 $0 $0 $0 $0 $0

Part B and Part D Drug Coverage2010 Medicare Plan Choices

Optima Medicare Preferred 

Optima Medicare Preferred Plus

Optima Medicare Value

Optima Medicare Value Plus

Benefits NetworkNon-Network Network

Non-Network Network 

Non-Network Network 

Non-Network

Prescription Drug Coverage                

Part B Prescription Drugs10% copay

20% copay

10% copay

20% copay

20% copay

30% copay

20% copay

30% copay

Part D Prescription Drugsnot covered 

not covered

not covered 

not covered$4/$30/$60/30% $4/$30/$60/30%

Thank you

We look forward to serving

your healthcare needs.

"We Improve Health Every Day"