Eligible for Medicare and Medicaid? Be treated like the VIP you are - Y0093_PRE_591342_M - AmeriHealth Caritas VIP ...
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Eligible for Medicare and Medicaid? Be treated like the VIP you are. Y0093_PRE_591342_M
Introduction • AmeriHealth Caritas VIP Care (HMO-SNP) is a Medicare Advantage health maintenance organization (HMO), special needs program (SNP) for individuals enrolled in both Medicare and Medicaid. AmeriHealth Caritas VIP Care is a health plan with a Medicare contract. • AmeriHealth Caritas VIP Care sales agents are not employed by Medicare or state Medicaid. The representative is a licensed insurance agent. • A commission may be paid to each sales agent who enroll individuals into a AmeriHealth Caritas VIP Care Medicare Advantage Plan. • You are under no obligation to join a Medicare Advantage Plan. • You have given us permission to discuss our Medicare Advantage Plan with you. AmeriHealth Caritas VIP Care 2
AmeriHealth Caritas VIP Care
Marketing Information
The AmeriHealth Caritas VIP Care agent
will present and make available the
following documents:
• Enrollment application.
• Summary of Benefits.
• Formulary (List of Covered
Drugs).
• Provider and Pharmacy Directory.
• Multi-language insert.
• Scope of Appointment Form.
• Star Ratings document.
About AmeriHealth Caritas VIP Care
• Contracted with the Centers for Medicare & Medicaid Services (CMS) and the state Medicaid agency.
• AmeriHealth Caritas VIP Care is funded by the federal government to manage Medicare benefits for our
members.
• AmeriHealth Caritas VIP Care covers all Medicare benefits.
• Our benefits include:
- Prescription drug coverage.
- Dental, hearing, and vision coverage.
- Transportation, health club membership, meal benefit, and over-the-counter (OTC) medications.
AmeriHealth Caritas VIP Care 4
Medicare Basics
Part A Part B Part C Part D
Hospital insurance Medical insurance Medicare Advantage Plans Medicare prescription drug
(like HMOs and preferred coverage.
provider organizations
[PPOs]). Includes Parts A
and B and sometimes Part
D coverage.
AmeriHealth Caritas VIP Care 5
Medicare Basics
• Your initial enrollment period lasts seven months.
- Begins three months before your 65th birthday.
- Includes the month you turn 65.
- Ends three months after you turn 65.
• Enrollment is automatic if you get Social Security or
Railroad Retirement Board (RRB) benefits; it is not
automatic if you are still actively working.
• To enroll with Social Security, visit a local office. Call
1-800-772-1213 or visit www.socialsecurity.gov.
• If you retired from the railroad, enroll with the RRB. You
can visit the local office, call 1-877-772-5772, or visit
www.rrb.gov.
• There are other times you may enroll, but you may pay
a penalty if you delay enrollment to the Part B and
Part D programs.
AmeriHealth Caritas VIP Care 6
Medicaid Basics
• Federal-state health insurance program
- Is for people with limited income and resources.
- Is for certain people with disabilities.
- Covers most health care costs.
• Eligibility determined by the state.
• Application processes and benefits vary
by state.
• State office names vary.
• Apply if you think you might qualify.
AmeriHealth Caritas VIP Care 7
Medicare Savings Program and
Low-Income Subsidy
Medicare Savings Program (MSP) Low-income subsidy (LIS) — “Extra Help”
• Help from Medicaid paying Medicare costs. • Help paying prescription drug costs.
- Pays Medicare premiums. • Social Security or state determines eligibility.
- May pay Medicare deductibles and • Some groups automatically qualify:
coinsurance. - People with Medicare and Medicaid.
• Income limits change each year. - People with Supplemental Security Income (SSI)
• Some states offer their own programs. only.
- People in Medicare Savings Programs.
• You or someone on your behalf can apply. Visit:
- Your local Social Security Office.
- Your local County Assistance Office.
AmeriHealth Caritas VIP Care 8
Medicare Savings Program Eligibility Categories
for AmeriHealth Caritas VIP Care D-SNP
Enrollment
STATE QMB QMB+ SLMB SLMB+ QI FBDE QDWI
PA X X X
Dual Eligible Levels
Qualified Medicare Beneficiary (QMB Plus) Program:
Medicaid pays Part A (if any) and Part B premiums, and may pay deductibles, coinsurance,
and copayments consistent with the Medicaid State Plan.
Full Medicaid coverage.
Full Medicaid (only) (FBDE)
Full Medicaid coverage either through mandatory coverage groups (for example,
Supplemental Security Income [SSI] recipients) or optional coverage groups such as the
“special income level” group for institutionalized individuals or home and community-based
waiver participants and medically needy individuals.
Medicaid may pay Part A (if any) and Part B premiums and cost-sharing for Medicare services
furnished by Medicare providers to the extent consistent with the Medicaid State Plan.
Specified Low-Income Medicare Beneficiary Plus (SLMB Plus) Program:
Medicaid pays Part B premiums
Full Medicaid coverage
AmeriHealth Caritas VIP Care 9
Medicare Savings Program Income Limits
Individual Married Couple
Medicare Savings Program Monthly Income Monthly Income Qualification
Limit Limit
• Income may be up to 100% of the FPL.
• States determine resources criteria.
• To qualify as a QMB Plus, the individual
Qualified Medicare must be enrolled in Part A (or if
Beneficiary with uninsured for Part A, have filed for
$1,061 $1,430
Comprehensive Medicaid premium Part A on a conditional basis).
Benefits (QMB+) • To qualify for full Medicaid benefits, an
individual must meet financial and other
criteria.
• States determine income and resources
criteria.
Full-Benefit Dual Eligible • No required enrollment in Medicare
(FBDE) $1,404 $1,894 Parts A and B.
• State Medicaid eligibility may factor in
the individual’s institutional status or
clinical need in some cases.
• Income must be more than 100% but
less than 120% of the FPL.
• States determine resources criteria.
Specified Low-Income • To qualify as a SLMB Plus, individuals
Medicare Beneficiary with must be enrolled in Part A. Part A
$1,269 $1,711
Comprehensive Medicaid coverage is not a factor for full Medicaid
Benefits (SLMB+) eligibility.
• To qualify for full Medicaid benefits, an
individual must meet financial and other
criteria.
*Income limit effective January 1, 2019 and are subject to change effective January 1, 2020.
AmeriHealth Caritas VIP Care 10A Brief Overview of Special Needs Plans (SNPs) Three different types of special needs plans are authorized by CMS. 1. Dual Eligible SNP (D-SNP) Beneficiaries who qualify for both Medicare and Medicaid. Approximately 75 percent of all members enrolled in SNPs are members of D-SNPs. 2. Chronic (C-SNP) This sort of plan is available only to people with Medicare Parts A and B who are diagnosed with at least one of 15 chronic conditions. C-SNPs may only enroll people “who have one or more co-morbid and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes, and require specialized delivery systems across domains of care.” 3. Institutional (I-SNP) People who live in residential facilities, such as nursing homes, may be part of an I-SNP. I-SNPs may also choose to serve people living at home but only if they meet the residential setting level of care criteria. AmeriHealth Caritas VIP Care 11
Medicare Advantage (MA) Enrollment Process
and Dates
Date Description Action
Plans can start sharing new benefits so that beneficiaries
October 1 Marketing for upcoming contract year begins
can review plan information before making a decision
MA eligible individuals may enroll in or disenroll from an
October 15 – December 7 Annual Enrollment Period (AEP)
MA plan
Medicare beneficiaries enrolled in a Medicare Advantage
Medicare Advantage Open Enrollment Period Plan (except an MSA plan) can switch plans or return to
January 1 – March 31
(MA OEP) Original Medicare (and join a stand-alone Medicare
Prescription Drug Plan).
There are various types of SEPs, including SEPs for dual
eligibles. Note: SEP for dual-eligible individuals can be
used once during each of the following time periods:
• January – March,
January 1 – December 31 Special Enrollment Period (SEP)
• April – June, and
• July – September.
It may not be used in the 4th quarter of the year
(October – December).
The ICEP is the period during which an individual newly
eligible for MA may make an initial enrollment request to
enroll in an MA plan. This period begins three months
immediately before the individual’s first entitlement to
both Medicare Part A and Part B and ends on the later
January 1st – December 31 Initial Coverage Election Period (ICEP)
of:
1. The last day of the month preceding entitlement to
both Part A and Part B, or;
2. The last day of the individual’s Part B initial enrollment
period.
AmeriHealth Caritas VIP Care 12Special Election Period (SEP)
SEP SEP situations:
• An SEP is a period outside the usual AEP, IEP, or • Loss of creditable coverage
MAPD when an individual may elect a plan or (insurance through an employer).
change his or her current plan election. • Moving into or out of a plan service area.
• Typically, you must remain enrolled in a Medicare • Becoming eligible for Medicaid (dual eligibility).
Advantage Plan for the calendar year starting the
date your coverage begins (sometimes referred to • Loss of Medicaid eligibility.
as lock-in.) • Qualifying for or having a change to your low
• You may be able to join, switch from, or disenroll income subsidy (LIS).
from a Medicare Advantage Plan at other times. • Living in a long-term care facility.
• Qualifying for an SNP.
AmeriHealth Caritas VIP Care 13Understanding Late Enrollment
Penalty and Disenrollment
Late enrollment penalty Voluntary and involuntary disenrollment
• Certain individuals are subject to a late enrollment • Dual eligible beneficiaries can voluntarily disenroll
penalty if they do not enroll in a Part D prescription at any time.
drug program. • Involuntary disenrollment from AmeriHealth
• Individuals enrolled in AmeriHealth Caritas VIP Care Caritas VIP Care may apply if the member:
are typically not subject to the late enrollment • Moves out of the service area.
penalty because, due to income level, they are
likely to qualify for Extra Help. • Loses Medicare Part A or B coverage.
• A late enrollment penalty on individuals who do • Changes their eligibility status with Medicaid.
not receive Extra Help would apply. • Disruptive behavior.
• Unlawful presence.
AmeriHealth Caritas VIP Care 14Understanding AmeriHealth Caritas VIP Care
Understanding AmeriHealth Caritas VIP Care:
Service Area and Eligibility Criteria
• Enrolled in Medicare Part A and Part B.
• Lives in our service area.
• Enrolled in the Pennsylvania Medicaid program (Medical Assistance).
• Does not have end-stage renal disease (ESRD) (except for limited circumstances such as enrollment before illness
developed).
AmeriHealth Caritas VIP Care 16Understanding AmeriHealth Caritas VIP Care: Your Premium and Understanding Cost-Sharing Premium • $0 premium. Cost-sharing (sometimes referred to as copay or coinsurance) • Cost share is an amount that you pay when you visit a provider, hospital, or specialist. • You pay no cost-sharing or deductibles for medical services. • If Medicaid eligibility status changes, you could be subject to cost-sharing or premiums. AmeriHealth Caritas VIP Care 17
Understanding AmeriHealth Caritas VIP Care: Using Your HMO Network • AmeriHealth Caritas VIP Care is an HMO-SNP plan which requires you to have a primary care provider (PCP). We ask you to select a PCP to assist with coordinating your health care needs. We will assign you a PCP if you do not select one. • You must use network doctors, specialists, and hospitals. You may be required to pay out of pocket to use providers who are not included in our network. • We will provide you our most up-to-date provider directory in print, on our website, or by calling Member Services as we add additional providers in your area. • Our network of providers is updated in the online provider directory daily. • Emergency services are not subject to out-of-network costs. • Your PCP will refer you to AmeriHealth Caritas VIP Care specialist, home health , durable medical equipment (DME), hospital, and any other health care providers. • AmeriHealth Caritas VIP Care will reimburse PCPs, specialists, hospitals, and other providers who give you care. AmeriHealth Caritas VIP Care 18
Understanding AmeriHealth Caritas VIP Care: Using Your HMO Network Let’s now discuss your current providers. This may include your family, heart, and pain management doctors. AmeriHealth Caritas VIP Care 19
Understanding AmeriHealth Caritas VIP Care:
How Your Benefits Work
Hospital benefits Doctor benefits
• No deductible. Provider office visits:
• 90 days per benefit period covered by the plan. • PCP: $0 copay.
• Up to 190 days of inpatient psychiatric hospital care • Specialist: $0 copay.
for lifetime (same as Original Medicare). • Podiatrist (in-network only and as medically
• In-network ambulatory surgical center and necessary): $0 copay.
outpatient hospital facility visits with $0 copay . • Outpatient mental health care (in-network only):
$0 copay for individual therapy or group visits for
therapy or psychiatry.
AmeriHealth Caritas VIP Care 20Understanding AmeriHealth Caritas VIP Care: Emergency and Urgent Care Benefits Emergency care Urgent care • Coverage for a medical emergency when you • Urgently needed care is a non-emergency, believe your health is in serious danger. unforeseen medical illness, injury, or condition that • Examples include severe pain, sudden illness, or a requires immediate medical care. medical emergency without improvement in your • Due to the nature of your condition, it may not be condition. possible for you to obtain care from your PCP or a • Call 911 or go to your nearest emergency room. network provider. • Covered anywhere in the United States or • $0 copay for urgent care visits. its territories. • $0 copay for emergency room visits. AmeriHealth Caritas VIP Care 21
Understanding AmeriHealth Caritas VIP Care: Referrals PCPs are involved in the total management of medical care. They assist members with selecting network specialists to obtain services. Referrals are not required for in-network PCP and specialist visits. AmeriHealth Caritas VIP Care 22
Understanding AmeriHealth Caritas VIP Care: Prior Authorizations Prior authorization is advance approval from your provider before you receive services. Your provider must request prior authorization for the following services: • Inpatient hospital. • Inpatient psychiatric hospital. • Home health. • Cardiac and pulmonary rehabilitation. • Skilled nursing facility. • Outpatient hospital services. • Partial hospitalization. • Ambulatory surgical center (ASC) services. • Occupational therapy. • Physical therapy. • Diabetes services and supplies. • DME and prosthetic devices. • Certain diagnostic tests (for example, magnetic resonance imaging [MRI] and radiology services). AmeriHealth Caritas VIP Care 23
Understanding AmeriHealth Caritas VIP Care:
Your Prescription Drug Plan
Our plan provides low-cost prescription drug coverage through Part D and Part B.
Part D coverage: Part B coverage:
• Drugs are listed in the formulary. • Certain medications are covered under Part B:
• Drugs are classified in two tiers: - Oral anti-cancer drugs or an injectable drug
-Tier 1 (generic). administered by your provider.
-Tier 2 (brand). - There is $0 cost share for Part B chemotherapy
drugs and other Part B drugs.
• There is no annual deductible for Part D drugs.
• Copays will vary between $0.00 and $8.95 depending
upon the drug and subsidy level.
• Most Medicare plans apply three coverage periods to
prescription drug coverage: initial coverage limit,
coverage gap, and catastrophic coverage.
• These coverage periods may not apply to you due to
the low copays you incur as a member.
AmeriHealth Caritas VIP Care 24Understanding AmeriHealth Caritas VIP Care:
Your Prescription Drug Plan
Standard retail cost-sharing
One-month supply
Tier Two-month supply
Three-month supply
• Tier 1 (generic). For generic drugs:
• Tier 2 (brand). • $0 copay.
• $1.30 copay.
• $3.60 copay.
For brand drugs:
• $0 copay.
• $3.90 copay.
• $8.95 copay.
AmeriHealth Caritas VIP Care 25Understanding AmeriHealth Caritas VIP Care: Prescription Drug Plan Benefits • Let’s now discuss your current medications. • The Formulary will show what tier your medication is in, which will help explain how your medications are covered. • Remember, your low-income subsidy or Extra Help level will lower the cost of your prescription copays. AmeriHealth Caritas VIP Care 26
Understanding AmeriHealth Caritas VIP Care:
Prescription Drug Plan Coverage Rules
Prior authorization Quantity limits Step therapy Transition process
• Certain drugs require • These are limits on • You must try certain less • In certain circumstances,
prior authorization. the amounts of expensive drugs that you are entitled to a
• You or your provider prescription drugs have been proven transition supply of
must contact you can obtain at effective for most prescription medications if
AmeriHealth Caritas VIP one time. people with your there is a change in your
Care before you can fill condition. status. You can have a one-
certain prescriptions • If your provider believes time temporary supply of a
because we must a coverage rule should non-formulary Part D
ensure that such drugs not apply, contact drug filled.
are medically necessary AmeriHealth Caritas VIP • Examples: A change in
for your condition. Care for an exception. treatment setting, moving
from an acute care hospital
to a long-term care facility,
or enrolling in a new
Medicare Advantage Plan.
AmeriHealth Caritas VIP Care 27Extra Benefits From AmeriHealth Caritas VIP Care
• We provide extra benefits not provided
by Original Medicare, including:
• Health club or fitness club
membership.
• Transportation.
• 24/7 Nurse Call Line, which gives
you telephone access to nurses to
answer your health care questions.
• Meal benefit - Covers meals after
Inpatient and Skilled Nursing Facility
discharge for qualified homebound
members
• There is no additional charge for extra
benefits.
AmeriHealth Caritas VIP Care 28Extra Benefits
Vision Preventive dental Comprehensive dental Hearing
• $0 copay for Medicare- • Oral exams: One every six • $2,000 plan coverage • $0 copay for Medicare-
covered diagnosis and months. $0 copay. limit for comprehensive covered diagnostic
treatment for diseases and • Cleaning: One every six dental benefits every hearing exams.
conditions of the eye. months. $0 copay. year, which includes • $0 copay for up to one
• $0 copay for up to one routine coverage for minor supplemental routine
• Fluoride treatment: One restorations (such as
vision exam every year. every six months. $0 hearing exam every
fillings), simple year.
• One pair of Medicare-covered copay. extractions, dentures,
eyeglasses or contact lenses • Dental X-rays: One every and denture repair, • $0 copay for one fitting
after cataract surgery. year. $0 copay. surgical extractions, evaluation for a hearing
• In addition to the cataract oral surgery, aid every two years.
• $1,000 plan coverage limit
surgery benefit, coverage for periodontics, and • $0 copay for up to one
for preventive dental
up to $200 every year towards endodontics. hearing aid every two
benefits every year.
eyeglasses or contact lenses. Crowns, bridges, and years.
implants are not
• $1,000 allowance every
covered services.
two years for hearing
• Authorization is aids for both ears
required for dentures, combined.
periodontics, and
endodontics.
AmeriHealth Caritas VIP Care 29Extra Benefits
Transportation OTC pharmacy Additional programs
• $0 copay for up to 80 • Typically includes medicines or • Health club or fitness club
one-way trips per year to plan- products that alleviate or treat membership and fitness classes:
approved locations. injuries or illness. o Attend a health club or
• Car, shuttle, and van services. • No statement from a medical fitness class at a plan-
• Scheduling rules apply. provider or documentation of a approved location.
diagnosis required to use the o $0 for the cost of a
benefit. membership for plan
• $150 every three months for items members. The benefit is
like aspirin, vitamins, and cold and limited to coverage of the
flu treatments. membership fee.
• Benefit does not carry over quarter o Start date is effective on the
to quarter. date of enrollment into the
fitness facility.
o The goal of the benefit is to
encourage a healthy lifestyle,
improve your health status,
and help manage chronic
conditions.
• 24/7 Nurse Call Line.
• Smoking and tobacco use cessation
programs.
• Meal benefit - Covers meals after IP
and SNF discharge for qualified
homebound members.
AmeriHealth Caritas VIP Care 30Using AmeriHealth Caritas VIP Care’s Health Care Services • Present your AmeriHealth Caritas VIP Care ID card and your state Medicaid ID card when you receive medical services or fill prescriptions. • You do not need to use your red, white, and blue Medicare card. • If you have AmeriHealth Caritas Community Health Choices as your Medicaid plan, you will receive one ID card with both plans’ logo that you can use to see your doctors • Store your red, white, and blue Medicare card in a safe place. AmeriHealth Caritas VIP Care 31
Key Points to Remember • Our history and mission demonstrate that we care about your health care needs. • We will provide high-quality customer service and care management services. • We will advocate for your care. AmeriHealth Caritas VIP Care 32
Key Points to Remember As a AmeriHealth Caritas VIP Care member: • You will not lose Medicare coverage by joining AmeriHealth Caritas VIP Care. • You will receive Medicare benefits from AmeriHealth Caritas VIP Care rather than directly from the federal government. We provide the following benefits: • Extra benefits to help pay for dentures and denture repairs. • Your choice of a PCP in our network. • No monthly plan premium. • Drug coverage with low or no cost-sharing. • Comprehensive Formulary (list of covered drugs). • No copayments for provider visits. AmeriHealth Caritas VIP Care 33
Easy Enrollment Process
Easy enrollment process What happens next
• Complete the enrollment application. • You will receive an outbound eligibility verification (OEV)
• Sign the application. letter from AmeriHealth Caritas VIP Care within 15 days
of the application date to verify your enrollment. You will
• Keep a copy of the online application/telephonic also receive the following:
application or enrollment confirmation number for
your records. • Enrollment acknowledgement and confirmation
letter.
• We will forward the enrollment application
to Medicare. • Welcome kit with enrollment materials and
information on your benefits.
• Member ID card.
• Health Risk Assessment — complete and return to
help us plan how to meet your health care needs.
AmeriHealth Caritas VIP Care 34Other Resources • Medicare & You Handbook. • www.medicare.gov. • www.cms.gov. • www.medicaid.gov. • www.healthcare.gov. • 1-800-MEDICARE (633-4227) (TTY 1-877-486-2048). AmeriHealth Caritas VIP Care 35
Thank You www.amerihealthcaritasvipcare.com Call toll free at 1-855-241-3648 (TTY 711). Seven days a week from 8 a.m. to 8 p.m. AmeriHealth Caritas VIP Care is an HMO-SNP with a Medicare contract and a contract with the Pennsylvania Medicaid program. Enrollment in AmeriHealth Caritas VIP Care depends on contract renewal. The plan is available to anyone who has both Medical Assistance from the state and Medicare. This information is not a complete description of benefits. Call Member Services at 1-866-533-5490 (TTY 711), seven days a week, 8 a.m. to 8 p.m., for more information. The Formulary, pharmacy network, and provider network may change at any time. You will receive notice when necessary. Out-of-network/noncontracted providers are under no obligation to treat AmeriHealth Caritas VIP Care members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. AmeriHealth Caritas VIP Care 36
Discrimination is Against the Law
AmeriHealth Caritas VIP Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national
origin, age, disability, or sex. AmeriHealth Caritas VIP Care does not exclude people or treat them differently because of race, color, national origin,
age, disability, or sex.
AmeriHealth Caritas VIP Care :
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
○ Qualified sign language interpreters
○ Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
○ Qualified interpreters
○ Information written in other languages
If you need these services, contact AmeriHealth Caritas VIP Care Member Services at 1-866-533-5490 (TDD/TTY 711). We are available from 8 a.m.
to 8 p.m., seven days a week.
If you believe that AmeriHealth Caritas VIP Care has failed to provide these services or discriminated in another way on the basis of race, color,
national origin, age, disability, or sex, you can file a grievance with: AmeriHealth Caritas VIP Care Appeals & Grievances Department, PO Box
80109, London, KY 40742-0109, Phone: 1-866-533-5490 (TDD/TTY 711), Fax: 1-855-221-0046. You can file a grievance by mail, fax, or phone. If
you need help filing a grievance, AmeriHealth Caritas VIP Care Member Services is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
AmeriHealth Caritas VIP Care 37Multi-language Interpreter Services H4227_001_MLI_2014_Accepted_08282016
Multi-language Interpreter Services AmeriHealth Caritas VIP Care 39
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