Embed Size (px)
Citation preview
Open Enrollment
Medicare Retirees
October 20 - November 10, 2008
Benefits Choices 2009
What Should I Have Received in the Mail?
Packet including: Annual Open Enrollment Booklet (2009)
Open Enrollment Change Form
Medical Plans Comparison Chart Self-addressed envelope
Presentation Topics
What’s New for 20092009 Medical Plans Overview2009 Prescription Drugs Overview Choosing a Medical PlanHow Medicare Works with Sandia’s
Plans2009 Dental Care Plan OverviewOpen Enrollment InformationQuestions
Plan eliminated: CIGNA Senior Premier PPO
Plan design changes (e.g., copays and coinsurance as described under each plan)
Waiver of prescription drug coverage no longer an option
New Dental Care Plan replaces Dental Expense Plan
Class I eligibility rules modified New Class IIs no longer eligible
What’s New for 2009?
2009Medical Plans
Overview
Medical Plan Options
For details, review your 2009 Open Enrollment Booklet
UnitedHealthcareSenior Premier PPO
Presbyterian MediCare PPO
Lovelace Senior Plan
PresbyterianUNMH
Independent Providers
Presbyterian
Lovelace Health SystemUNMH
ABQ Health Partners
NM only
NM Only
UHC Senior Premier Plan Changes
2008 2009
Chiropractic/Acupuncture $1500 combined max/CY
$1000 each max/CY
Hypnotherapy, Biofeedback
20% No coverage
Out-of-Pocket Maximums (UHC Senior Premier PPO)
Prescription drug payments do NOT apply to the out-of-pocket maximums Coinsurance (e.g., 20%) does apply to the out-of-pocket maximum (with some exceptions)One annual out-of-pocket maximum for both in- and out-of-network services
Out-of-Pocket Maximum (UHC Senior Premier PPO)
Example of how the out-of-pocket maximum works for hospital care (2009 costs):
Cost You Pay Sandia Pays
Days 1 – 60 Medicare deductible
$1068
$1000 OOP maximum per calendar year
$68
Days 61 – 90 $267 per day $0 $267 per day
UHC Senior Premier PPO Rx Plan Changes
2008 2009
Mail Order Rx Drugs (maximum of 90 day supply)
Generic $18 copay 20% with $12 min and $24 max.
Preferred Brand $65 copay 30% with $50 min. and $80 max.
Non-preferred Brand
$100 copay 40% with $80 min. and $120 max.
Catalyst Rx forUHC Senior Premier PPO
Mandatory Specialty Drug Program through mail order from Walgreens/MedMark (limited to 30 day supply)
Drugs delivered via mail order through Walgreen/MedMark Specialty Team
Making contact by December 15 Available Monday to Friday (6 a.m. to 5 p.m. MST) at 1-866-823-2712
Specialty Drugs Treatment for cancer, multiple sclerosis, HIV, hemophilia, etc. Tend to be very expensive and require special monitoring
Catalyst Rx Info
Welcome Kit mailed in mid-December (for new UHC Senior Premier PPO members)
Letter with general info ID cards (1/single; 2/family) Preferred drug listing (condensed version) Pharmacies (major) listing Registration and prescription form
Present your new Catalyst ID card when getting a new prescription beginning January 1, 2009
Pharmacy Help Desk 1-866-854-8851 (available 24/7) Website www.catalystrx.com – Username: SNL Password: SNL Sandia external website at www.sandia.gov, Resources for…,
Employees and Retirees, Summary Plan Descriptions, Catalyst Rx Info
Catalyst reps available in lobby
Catalyst Mail Order Form
Medicare Advantage Plans
Overview
Medicare Advantage Plan Changes
Presbyterian MediCare PPO
Lovelace Senior Plan
In-network 2008 2009 2008 2009
PCP Office Visit $10 copay No change $5 copay $10 copay
Presbyterian MediCare PPO
Out-of-Network 2008 2009
PCP Office Visit $30 copay $35 copay
Outpatient Rehabilitation $30 copay $35 copay
Durable Medical Supplies $40 copay $50 copay
Prosthetics $25 copay $50 copay
Eye glass or contact lenses after cataract surgery
$25 copay $50 copay
Medicare Advantage Plans Summarized Comparison
Employer Group PlansPresbyterian MediCare
PPOLovelace Senior Plan
HMO
Annual CY deductible N/A N/A
Annual CY out-of-pocket N/A N/A
In- and out-of-network coverage
Both In-network only
Referrals to specialist required
No No
Payment via Copays (in-network) Copays
Prescription drug coverage administrator
Presbyterian Lovelace
Prescription drug mail order
Walgreens Mail Service Pharmacare Direct
Medicare Advantage PlansRx Comparison
Plan Features Presbyterian MediCare
PPO
Lovelace Senior Plan
Retail Rx Drugs (maximum of 30 day supply)
Generic $5 $5
Preferred Brand $35 $32
Non-preferred Brand $55 $62
Mail Order Rx Drugs (maximum of 90 day supply)
Generic $10 $15
Preferred Brand $87.50 $96
Non-preferred Brand $165 $186
Medicare Advantage Plans (Lovelace Senior Plan and
Presbyterian MediCare)Must be continuously enrolled in Medicare Part A and B
Required to assign your Medicare benefits to the plan
Cannot be enrolled in one of these plans and another Medicare Advantage plan or another Medicare Part D plan at same time
Release of Medicare assignment if switching out of these plans (e.g., moving out of state) requires notification to Sandia Benefits at least six weeks prior or as soon as reasonably possible to avoid delays in release of your Medicare Assignment
Must select PCP although referrals to specialists are not required
Must inform health plan before moving or leaving the state for more than six months
Important: if you enroll in one of these plans you must complete the application form sent by Lovelace or Presbyterian and return it to them prior to December 31, 2008
Your plan benefits are described by the “Evidence of Coverage” document which is mailed to members in January ( Lovelace or Presbyterian)
Presbyterian MediCare Mail Order Form
Choosing a Medical Plan
Open Enrollment Coverage Options
Non-Medicare Member Plans Medicare-Member Plans
UHC Premier PPO UHC Senior Premier PPO
No corresponding plan Presbyterian MediCare PPO
CIGNA In-Network Plan Lovelace Senior Plan
What to Consider When Choosing a Medical Plan
Provider networks (e.g. doctors, hospitals)Benefits coverageIn-network and out-of-network coverageCopay vs. coinsurance payment for servicesFiling claims or notPrescription drug formulary under the planCoverage while on travelDependent coveragePremiums, if applicableDeductibleOut-of-pocket maximum
Emergencies, Urgent Care, Follow-up Care
If you are traveling and covered by UHC Senior Premier PPO:Emergencies, urgent care, and follow-up care are covered worldwide
– If you are traveling and covered by the Presbyterian MediCare or Lovelace Senior Plan
Emergencies and urgent care are covered worldwide
Follow-up care under Lovelace Senior Plan is not covered (need to return to NM)
Follow-up care under Presbyterian MediCare PPO Plan
Follow up care (outside USA) is covered out-of-network
Follow-up care (within USA) is covered out-of-network
Medicare does not cover services outside of the USA Call 911 if your require immediate medical or surgical care Call member services within 48 hours or as soon as reasonable
possible if admitted
What Do I Do When I Turn 65?Retirees in New Mexico
Within a few months before reaching age 65… Enroll in Medicare Parts A and B
Approximately 2-3 months before age 65, you should receive information from Sandia Benefits and Medicare
Retiree Medical Plan Options:UHC Senior Premier PPO (complete Medicare crossover form)
Lovelace Senior Plan (Sandia employer group)
Presbyterian MediCare PPO (enollment only during Open Enrollment and/or if other family members are already in the Plan)
Coverage takes effect the first day of the month in which you reach age 65
Contact Medicare or your local Social Security office for Medicare Parts A and B information
What Do I Do When I Turn 65? Retirees in CA and Other
Within a few months before reaching age 65…
Must enroll in Medicare Parts A and B (even if you are not taking your Social Security)
Approximately 2-3 months before you turn 65, you should receive information from Sandia Benefits and MedicareKaiser HMO members will receive a solicitation for Kaiser Senior Advantage Plan
• Once you reach age 65, the Retiree Medical Plan Option is available for transition as follows:
– UHC Senior Premier PPO for aging-in UHC Premier PPO members – CIGNA In-Network members must move to the UHC Senior Premier PPO
Plan (non-Medicare members must also move to UHC Premier PPO Plan) – Kaiser Senior Advantage Plan (must complete Kaiser enrollment paperwork
to assign Medicare)
Coverage takes effect the first day of the month in which you reach age 65
Contact Medicare or your local Social Security office for Medicare Parts A and B information
Continuation of Coverage for Surviving Spouse
Medical Coverage
Coverage for surviving spouse and/or eligible dependents is provided for six months, after retiree’s death, at the same premium-share rate that retiree paid
To continue coverage after six months, surviving spouse and/or dependents must elect continuation prior to the end of this six-months period
Continued coverage (7th month and beyond) cost is 50% of the full medical premium (see pg 34 of OE booklet).
Continued coverage is available until surviving spouse remarries, dependent children become ineligible and/or coverage is terminated with Sandia
Continuation of Coverage for Surviving Spouse
Dental Coverage
Dental coverage for surviving spouse and/or eligible dependents is discontinued at the end of the month of retiree’s death
Coverage may be temporarily continued (COBRA process), for up to thirty-six months, by paying the monthly, COBRA surviving spouse group rate (2009 single rate - $38.00/month + 2% administrative fee)
Medicare and Sandia
Employer Group Plans
Medicare Part D
Part D is Medicare’s Prescription Drug Plan
Sandia’s Retiree Medical Plan Option includes prescription drug coverage – NO NEED to enroll in an individual Part D plan
Individual Part D Plan
Use your Part D plan first for prescription drug coverage
Submit your claim to Catalyst Rx (for UHC Senior Premier PPO members) for consideration of secondary coverage
Ex: If you pay $10 for a drug through your Part D plan, you would submit a paper claim to either Catalyst Rx (UHC Senior Premier PPO members) and if an eligible drug, you would be reimbursed 50% of the copay so you would receive $5 payment
Individual Part D members must disenroll from their individual plan to be eligible for the Employer Group Medicare Advantage plans (Lovelace
Senior Plan or Presbyterian MediCare) by December 31, 2008.
Medicare Part D
UHC members – your Notice of Creditable Coverage for Part D starts on page 54 of the OE Booklet
This Notice ensures that you can enroll, without penalty, in an individual Part D plan if you lose coverage with Sandia (the Medicare Advantage plans may require this notice)
Medicare does not allow double coverage by Medicare plans; therefore, your coverage through Presbyterian MediCare or the Lovelace Senior Plan will be dropped altogether if you enroll in an individual plan
Note: The vast majority of Sandia retirees elected to participate in a Sandia Retiree Medical Plan Option with prescription drug coverage and chose not to purchase an individual Medicare Part D prescription drug plan.
Medicare Coordination of Benefits with UHC Senior Premier PPO
Medicare is always the primary payer of benefitsThe UHC Senior Premier PPO Plan is secondary coverage After Medicare pays, then UHC Senior Premier PPO Plan calculates what it would have paid if not for Medicare, and then subtracts what Medicare has paid and pays the differenceOnce a retiree has met the out-of-pocket maximum for the calendar year, your UHC plan will pay the remaining balance of Medicare-eligible expenses that are not paid by Medicare and are eligible for benefits under this Plan (up to $150,000 lifetime maximum)
COB: In-Network Example Specialist Office Visit with UHC
coverage
Total Charge
Medicare Allowable
Medicare Deductible
(Part B in 2009)
Balance After
Deductible
Medicare Pays 80%
After Deductible
Balance Due
$325.00 $300.00 $135.00 $165.00 $132.00 $168.00
Total Charge
Medicare Allowable
Balance After
Medicare
UHC Pays Member Pays
Accumulated Annual
Maximum
$325.00 $300.00 $168.00 $108.00 $60.00 $60.00
Medicare
UHC Senior Premier Benefit
$300.00 x .8 = $240 - $132
$300.00-$240.00
COB: In-Network ExampleEmergency Room Visit with UHC
coverage
Total Charge
Medicare Allowable
Medicare Deductible
Balance After
Deductible
Medicare Pays 80%
After Deductible
Balance Due
$600 $450 Satisfied $450 $360 $90
Total Charge
Medicare Allowable
Balance After
Medicare
UHC Pays
Member Pays
Accumulated Annual
Maximum
$600 $450 $90 $0 $90 $150
Medicare
UHC Senior Premier Benefit
$60 (from last claim) + $90.
COB: In-Network ExampleHospital Care with UHC
coverage
Total Charge
Medicare Allowable
Medicare Deductible (Part A in
2008)
Balance After Deductible
Medicare Coverage
Balance Due
$0 Days 1-60 $1,068 $0 Full $1,068
Total Charge
Medicare Allowable
Balance After Medicare
UHC Pays Member Pays Accumulated Annual
Maximum
$0 Days 1-60 $1,068 $218 $850 $1,000
$267 per day
Days 61-90 $8,010 $8,010 $0 Met
Medicare
UHC Senior Premier Benefit
Medicare Advantage Plans
Lovelace Senior Plan and the Presbyterian MediCare PPO Plan
Fully insured employer group plans
Assign your Medicare to them
Provide all your medical and prescription drug coverage
No coordination of benefits with Medicare
Dental Care PlanOverview
2009 Dental Overview
Delta Dental remains the claims administrator New Dental Care Plan replaces Dental Expense Plan
Coinsurance coverage based on a percentage of the maximum approved fee: 100% for preventive 80% for basic and restorative services 50% for major and orthodontic
Annual deductible $50 per person/$150 family Annual maximum benefit $1500 (non-orthodontic) Lifetime maximum benefit $1800 for orthodontic
Monthly Premium-sharing for retirement after 12/31/2008 $8.00 for retiree $15.00 for retiree + 1 $20.00 for retiree + 2
2009 Dental Overview
The Dental Care Plan includes coverage enhancements:Sealants covered for all dependent children under age 14Benefits for specified (Endosteal) implant services
You can see any dentist in the Delta Dental PPO or the Delta Dental Premier or an out-of network dentist.
Your out-of-pocket costs will be lower if you see a Delta Dental PPO network dentist because those dentists have agreed to a lower maximum approved fee thus making your percentage portion lower.
If you see an out-of-network dentist, those dentists can balance bill you for any amount above the maximum approved fee for the Delta Dental Premier network.
Maximum approved fee is contracted fee between Delta Dental and the network providers.
Eligibility Changes
Refer to IRS Code Section 152 or Publication 502, or consult your tax advisor for “qualifying child or qualifying relative”
for health care coverage.
“Financially dependent on you” has been eliminated and changed to “unmarried child under age 24”Although dependent may be eligible for our plans, your are required to report to Sandia any dependents who do not meet the tax requirements as we will need to impute income on the premiums
Imputed income means that the full premium rate for your dependent shall be reported as taxable
Stepchildren of the primary covered member who lives with the primary covered member at least 50% of the calendar year, or if ages 19 through 23, is a full-time student.
Ineligible Dependents
You must disenroll ineligible dependents within 31 calendar day of the event causing ineligibility
Consequence of failing to disenroll ineligible dependents:
Ineligible dependent’s coverage retroactively terminatedYou will be held liable to refund to Sandia the health care plan claims or monthly premiumsYour dependent could lose any rights to temporary continued health care coverage (COBRA)Sandia shall not be required to refund any premiums to the subscriber
Open Enrollment Information
Open Enrollment Process Tips
Review “Medical Plans Comparison Chart” Review Open Enrollment Booklet for more
information Complete “Open Enrollment Change Form
2009” (especially important for CIGNA Senior Premier PPO members)Must be postmarked by Nov. 10th
Complete Presbyterian MediCare or Lovelace Senior Plan form (if applicable)
Confirmations will be sent to only those who make changes
Do I Need to Take Action?
Action No Action
MedicalCoverage
If currently enrolled in the CIGNA Senior Premier PPO
To enroll if not currently enrolled
To change your current medical plan
To add or disenroll a dependent
To continue current medical plan coverage (except CIGNA Senior Premier PPO members)
If you waived coverage previously and wish to remain in this status
DentalCoverage
To enroll if not currently enrolled
To add or disenroll a dependent
To continue Dental Care Plan coverage
If you waived coverage previously and wish to remain in this status
To make a change… (postmarked by November 10th)
Follow the instructions below to make changes to your 2009 medical coverage.
STEP 1: Are you making any changes to your medical coverage for next year?
No No action is necessary. DO NOT RETURN THIS FORM. Yes Continue to Step 2
STEP 2: Do you need or want to change your medical plan for next year? Note: CIGNA Premier/Senior Premier and High Deductible Health Plan are no longer medical plan options. All members enrolled in these plans MUST select another medical plan option.
No Yes
NON-MEDICARE Member Plans MEDICARE Member Plans
UHC Premier PPO UHC Senior Premier PPO
Presbyterian MediCare PPO (No corresponding non-Medicare Plan is available)
Must be Medicare Part A & B eligible in January 2009 to enroll in this plan.
CIGNA In-Network
Lovelace Senior Plan Must be Medicare Part A & B eligible in January
2009 to enroll in this plan.
Kaiser Permanente Traditional HMO
Kaiser Permanente Senior Advantage
Must be Medicare Part A & B eligible in January 2009 to enroll in this plan.
STEP 3: Do you want to add or drop dependents for medical or dental for next year?
No Continue to Step 4. Yes Use the table below to add or drop your dependents.
Add/Drop Name Relat ionship Bir th Date/Age Medica l Denta l
A d d J o h n S m i th S o n 7 /1 6 /8 5 /6 5 y e a rs Y e s Y e s
STEP 4: Please print your name and phone number below:
Name (print) Age: Phone Number Social Security Number:
STEP 5: Sign and mail this form to the address below postmarked by November 10, 2008.
Signature
Date:e
Mail to: Sandia National Laboratories, Attn: Open Enrollment, MS1463 P. O. Box 5800 Albuquerque, NM 87185-1463
O P E N E N R O L L M E N T C H A N G E F O R M 2 0 0 9
Member Resources
OE website…
Sandia Benefit Contacts
Sandia Open Enrollment website www.sandia.gov– Resources for…
– Employees and Retirees– Retiree Open Enrollment
Benefits Customer Service Center (505) 844-HBES (4237) or (800) 417-2634, ext. 844-HBES (4237)Fax #: (505) 844-7535
If you have questions you can…• Send an email to [email protected] OR• Go to www.sandia.gov
– click on Employees & Retirees– click on HBE Weekly Update
– click on ? Get answers
Open Enrollment Period
October 20 – November 10th, 2008
No changes to any of your open enrollment
elections will be allowedafter November 10th
Questions ?
