Eligible for Medicare and Medicaid? Be treated like …...state Medicaid. The representative is a licensed insurance agent. • A commission may be paid to each sales agent who enroll

Eligible for Medicare and Medicaid?Be treated like the VIP you are.

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Sticky Note

Introduction

Keystone First VIP Choice 2

• Keystone First VIP Choice (HMO-SNP) is a Medicare Advantage health maintenance organization (HMO), special needs program (SNP) for individuals enrolled in both Medicare and Medicaid. Keystone First VIP Choice is a separate health insurance plan from any other health plan that uses the “Keystone” name.

• Keystone First VIP Choice is a health plan with a Medicare contract.

• Keystone First VIP Choice 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 Keystone First VIP Choice 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.

Keystone First VIP Choice Marketing Information

The Keystone First VIP Choice 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 Keystone First VIP Choice


• Contracted with the Centers for Medicare & Medicaid Services (CMS) and the state Medicaid agency.

• Keystone First VIP Choice is funded by the federal government to manage Medicare benefits for our members.

• Keystone First VIP Choice 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.

Medicare Basics


Part A Part B Part C Part D

Hospital insurance Medical insurance Medicare Advantage Plans (like HMOs and preferred provider organizations [PPOs]). Includes Parts A and B and sometimes Part D coverage.

Medicare prescription drug coverage.

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.

http://www.socialsecurity.gov/

http://www.rrb.gov/

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 varyby state.

• State office names vary.

• Apply if you think you might qualify.

Medicare Savings Program and Low-Income Subsidy


Medicare Savings Program (MSP) Low-income subsidy (LIS) — “Extra Help”

• Help from Medicaid paying Medicare costs.

- Pays Medicare premiums.

- May pay Medicare deductibles and coinsurance.

• Income limits change each year.

• Some states offer their own programs.

• Help paying prescription drug costs.

• Social Security or state determines eligibility.

• Some groups automatically qualify:

- People with Medicare and Medicaid.

- People with Supplemental Security Income (SSI) 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.

Medicare Savings Program Eligibility Categories for Keystone First VIP Choice 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

Medicare Savings Program Income Limits


*Income limit effective January 1, 2019 and are subject to change effective January 1, 2020.

Medicare Savings ProgramIndividual Monthly Income Limit

Married Couple Monthly Income Limit

Qualification

Qualified Medicare Beneficiary with Comprehensive Medicaid Benefits (QMB+)

$1,061 $1,430

• Income may be up to 100% of the FPL.• States determine resources criteria.• To qualify as a QMB Plus, the individual

must be enrolled in Part A (or ifuninsured for Part A, have filed for premium Part A on a conditional basis).

• To qualify for full Medicaid benefits, an individual must meet financial and other criteria.

Full-Benefit Dual Eligible (FBDE) $1,404 $1,894

• States determine income and resources criteria.

• No required enrollment in Medicare Parts A and B.

• State Medicaid eligibility may factor in the individual’s institutional status orclinical need in some cases.

Specified Low-Income Medicare Beneficiary with Comprehensive Medicaid Benefits (SLMB+)

$1,269 $1,711

• Income must be more than 100% but less than 120% of the FPL.

• States determine resources criteria.• To qualify as a SLMB Plus, individuals

must be enrolled in Part A. Part Acoverage is not a factor for full Medicaid eligibility.

• To qualify for full Medicaid benefits, an individual must meet financial and other criteria.

A 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.

Medicare Advantage (MA) Enrollment Process and Dates


Date Description Action

October 1 Marketing for upcoming contract year begins Plans can start sharing new benefits so that beneficiaries can review plan information before making a decision

October 15 – December 7 Annual Enrollment Period (AEP) MA eligible individuals may enroll in or disenroll from an MA plan

January 1 – March 31 Medicare Advantage Open Enrollment Period (MA OEP)

Medicare beneficiaries enrolled in a Medicare Advantage Plan (except an MSA plan) can switch plans or return to Original Medicare (and join a stand-alone Medicare Prescription Drug Plan).

January 1 – December 31 Special Enrollment Period (SEP)

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,• April – June, and• July – September.It may not be used in the 4th quarter of the year (October – December).

January 1st – December 31 Initial Coverage Election Period (ICEP)

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 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.

Special Election Period (SEP)


SEP SEP situations:

• An SEP is a period outside the usual AEP, IEP, or MAPD when an individual may elect a plan or change his or her current plan election.

• Typically, you must remain enrolled in a Medicare Advantage Plan for the calendar year starting the date your coverage begins (sometimes referred to as lock-in.)

• You may be able to join, switch from, or disenrollfrom a Medicare Advantage Plan at other times.

• Loss of creditable coverage (insurance through an employer).

• Moving into or out of a plan service area.

• Becoming eligible for Medicaid (dual eligibility).

• Loss of Medicaid eligibility.

• Qualifying for or having a change to your lowincome subsidy (LIS).

• Living in a long-term care facility.

• Qualifying for an SNP.

Understanding Late Enrollment Penalty and Disenrollment


Late enrollment penalty Voluntary and involuntary disenrollment

• Certain individuals are subject to a late enrollment penalty if they do not enroll in a Part D prescription drug program.

• Individuals enrolled in Keystone First VIP Choice are typically not subject to the late enrollment penalty because, due to income level, they are likely to qualify for Extra Help.

• A late enrollment penalty on individuals who do not receive Extra Help would apply.

• Dual eligible beneficiaries can voluntarily disenroll at any time.

• Involuntary disenrollment from Keystone First VIP Choice may apply if the member:

• Moves out of the service area.

• Loses Medicare Part A or B coverage.

• Changes their eligibility status with Medicaid.

• Disruptive behavior.

• Unlawful presence.

UnderstandingKeystone First VIP Choice

Understanding Keystone First VIP Choice: Service Area and Eligibility Criteria


Five counties:BucksChesterDelawareMontgomeryPhiladelphia

• 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).

• Keystone First VIP Choice is a separate health insurance plan from any other health plan that uses the “Keystone” name.

Understanding Keystone First VIP Choice: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.

Understanding Keystone First VIP Choice:Using Your HMO Network


• Keystone First VIP Choice 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 Keystone First VIP Choice specialist, home health , durable medical equipment (DME), hospital, and any other health care providers.

• Keystone First VIP Choice will reimburse PCPs, specialists, hospitals, and other providers who give you care.

Understanding Keystone First VIP Choice: Using Your HMO Network


Let’s now discuss your current providers. This may include your family, heart, and pain management doctors.

Understanding Keystone First VIP Choice: How Your Benefits Work


Hospital benefits Doctor benefits

• No deductible.

• 90 days per benefit period covered by the plan.

• Up to 190 days of inpatient psychiatric hospital care for lifetime (same as Original Medicare).

• In-network ambulatory surgical center and outpatient hospital facility visits with $0 copay .

Provider office visits:

• PCP: $0 copay.

• Specialist: $0 copay.

• Podiatrist (in-network only and as medicallynecessary): $0 copay.

• Outpatient mental health care (in-network only): $0 copay for individual therapy or group visits for therapy or psychiatry.

Understanding Keystone First VIP Choice: Emergency and Urgent Care Benefits


Emergency care Urgent care

• Coverage for a medical emergency when you believe your health is in serious danger.

• Examples include severe pain, sudden illness, or a medical emergency without improvement in your condition.

• Call 911 or go to your nearest emergency room.

• Covered anywhere in the United States or its territories.

• $0 copay for emergency room visits.

• Urgently needed care is a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care.

• Due to the nature of your condition, it may not be possible for you to obtain care from your PCP or a network provider.

• $0 copay for urgent care visits.

Understanding Keystone First VIP Choice: 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.

Understanding Keystone First VIP Choice: 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).

Understanding Keystone First VIP Choice: 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.

• Drugs are classified in two tiers:

-Tier 1 (generic).

-Tier 2 (brand).

• 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.

• Certain medications are covered under Part B:

- Oral anti-cancer drugs or an injectable drug administered by your provider.

- There is $0 cost share for Part B chemotherapy drugs and other Part B drugs.

Understanding Keystone First VIP Choice: Your Prescription Drug Plan


Standard retail cost-sharing

TierOne-month supplyTwo-month supplyThree-month supply

• Tier 1 (generic).

• Tier 2 (brand).

For generic drugs:

• $0 copay.

• $1.30 copay.

• $3.60 copay.

For brand drugs:

• $0 copay.

• $3.90 copay.

• $8.95 copay.

Understanding Keystone First VIP Choice: 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.

Understanding Keystone First VIP Choice: Prescription Drug Plan Coverage Rules


Prior authorization Quantity limits Step therapy Transition process

• Certain drugs require prior authorization.

• You or your provider must contact Keystone First VIP Choice before you can fill certain prescriptions because we must ensure that such drugs are medically necessary for your condition.

• These are limits on the amounts of prescription drugs you can obtain at one time.

• You must try certain less expensive drugs that have been proven effective for most people with your condition.

• If your provider believes a coverage rule should not apply, contact Keystone First VIP Choice for an exception.

• In certain circumstances, you are entitled to a transition supply of prescription medications if there is a change in your status. You can have a one-time temporary supply of a non-formulary Part D drug filled.

• Examples: A change in treatment setting, moving from an acute care hospital to a long-term care facility, or enrolling in a new Medicare Advantage Plan.

Extra Benefits From Keystone First VIP Choice


• 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.

Extra Benefits


Vision Preventive dental Comprehensive dental Hearing

• $0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye.

• $0 copay for up to one routine vision exam every year.

• One pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.

• In addition to the cataract surgery benefit, coverage for up to $200 every year towards eyeglasses or contact lenses.

• Oral exams: One every six months. $0 copay.

• Cleaning: One every six months. $0 copay.

• Fluoride treatment: One every six months. $0 copay.

• Dental X-rays: One every year. $0 copay.

• $1,000 plan coverage limit for preventive dental benefits every year.

• $2,000 plan coverage limit for comprehensive dental benefits every year, which includes coverage for minor restorations (such as fillings), simple extractions, dentures, and denture repair, surgical extractions, oral surgery, periodontics, and endodontics. Crowns, bridges, and implants are not covered services.

• Authorization is required for dentures, periodontics, and endodontics.

• $0 copay for Medicare-covered diagnostic hearing exams.

• $0 copay for up to one supplemental routine hearing exam every year.

• $0 copay for one fitting evaluation for a hearing aid every two years.

• $0 copay for up to one hearing aid every two years.

• $1,000 allowance every two years for hearing aids for both ears combined.

Extra Benefits


Transportation OTC pharmacy Additional programs

• $0 copay for up to 80 one-way trips per year to plan-approved locations.

• Car, shuttle, and van services.

• Scheduling rules apply.

• Typically includes medicines or products that alleviate or treat injuries or illness.

• No statement from a medical provider or documentation of a diagnosis required to use the benefit.

• $150 every three months for items like aspirin, vitamins, and cold and flu treatments.

• Benefit does not carry over quarter to quarter.

• Health club or fitness club membership and fitness classes:

o Attend a health club or fitness class at a plan-approved location.

o $0 for the cost of a membership for plan members. The benefit is limited to coverage of the membership fee.

o Start date is effective on the 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.

Using Keystone First VIP Choice’s Health Care Services


• Present your Keystone First VIP Choice 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 Keystone First 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.

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.

Key Points to Remember


As a Keystone First VIP Choice member:

• You will not lose Medicare coverage by joining Keystone First VIP Choice.

• You will receive Medicare benefits from Keystone First VIP Choice 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.

As a reminder, Keystone First VIP Choice is a separate health insurance plan from any other health plan that uses the “Keystone” name.

Easy Enrollment Process


Easy enrollment process What happens next

• Complete the enrollment application.

• Sign the application.

• Keep a copy of the online application/telephonic application or enrollment confirmation number for your records.

• We will forward the enrollment application to Medicare.

• You will receive an outbound eligibility verification (OEV) letter from Keystone First VIP Choice within 15 days of the application date to verify your enrollment. You will also receive the following:

• Enrollment acknowledgement and confirmation letter.

• 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.

Other 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).

Thank You


www.keystonefirstvipchoice.com

Call toll free at 1-855-241-3648 (TTY 711).

Seven days a week from 8 a.m. to 8 p.m.

Keystone First VIP Choice is an HMO-SNP with a Medicare contract and a contract with the Pennsylvania Medicaid program. Enrollment in Keystone First VIP Choice 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 1-800-450-1166 (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/non- contracted providers are under no obligation to treat Keystone First VIP Choicemembers, 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.


Discrimination is Against the Law

Keystone First VIP Choice complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Keystone First VIP Choice does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Keystone First VIP Choice :• 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 Keystone First VIP Choice Member Services at 1-800-450-1166 (TDD/TTY 711). We are available from 8 a.m. to 8 p.m., seven days a week.

If you believe that Keystone First VIP Choice 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: Keystone First VIP Choice Appeals & Grievances Department, PO Box 80109, London, KY 40742-0109, Phone: 1-800-450-1166 (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, Keystone First VIP Choice 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 Services200 Independence Avenue, SW

Room 509F, HHH BuildingWashington, 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.

http://www.hhs.gov/ocr/office/file/index.html

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Documents

Eligible for Medicare and Medicaid? Be treated like …...state Medicaid. The representative is a licensed insurance agent. • A commission may be paid to each sales agent who enroll