Monday, October 14, 2013

MEDICARE (Last Update: September 3, 2015)













Medicare Hotline Complaints Detailed at this website (Sept. 3, 2015): Click Here.

Total Retiree Advantage Illinois (TRAIL) Program 

The 2014 TRAIL Open Enrollment Period will be held October 15th through November 15th with coverage elections and changes effective January 1, 2015.
 
Members of the following group insurance programs must be enrolled in Medicare Parts A and B in order to be eligible for the Total Retiree Advantage Illinois (TRAIL) Program. In addition, any covered dependent must also be enrolled in Medicare Parts A and B in order to be eligible for TRAIL coverage. If either the member or any dependent on the member’s insurance through the State is not enrolled in Medicare Parts A and B, neither will be eligible for TRAIL Medicare Advantage plans. Members and dependents of non-Medicare households must seek benefits under the non-Medicare programs offered by the State, which are described on the Benefits website at www.benefitschoice.il.gov.

2014 TRAIL Seminar Schedule

September 19th:

Medicare Advantage Program

Since the Open Enrollment for the 2015 Medicare Advantage program (TRAIL) is October 15 through November 15, I have been getting many questions about the 2015 program – who is eligible, when will I get my packet, what options do I have, etc.

CMS has told us that during the first full week in October (hopefully October 6), CMS will be posting information on their web site about the 2015 Medicare Advantage Program. In addition, CMS will be holding informational seminars in October explaining the 2015 Medicare Advantage program. Attached is a listing of these seminars.

Remember, check out the CMS web site after October 6 -- http://www2.illinois.gov/cms/Employees/benefits/trail/Pages/default.aspx

Rich Frankenfeld, TRS Director of Outreach, 2815 W. Washington St., PO Box 19253, Springfield, IL 62794-9253 (217-753-0973)



for 2014 CMS Trail Seminar Schedule as of September 16, 2014:



Updated June 24th:

You may be tempted by prescription plans offered by various pharmacies (Walgreens, CVS, Osco, etc.) with lower co-pays.  BEWARE.  If you sign up for one of these plans, you are signing up for another plan D.  Since you already have a plan D, the pharmacy will notify Medicare, which will notify United Healthcare that you are signing up for another plan D, and your entire policy will be canceled.  DO NOT SIGN UP FOR ANY OTHER PRESCRIPTION PLANS!

There has been a change in the catastrophic prescription coverage with United Healthcare.  This level is reached when a total of $4500.00 has been spent on prescriptions.  Some members reached this level very quickly and were being charged very high prices for some of their medications.  The policy was changed so that the highest copay for any approved medication is $50.00. This is retroactive to the start of the program.  Everyone should have received a letter explaining this.  If you have paid more than $50.00 for any covered medication and have not been reimbursed, call United Healthcare to see if you are eligible for a refund -- from the IRTA
Updated June 17th:

“…A year-long investigation by the Center for Public Integrity has revealed that health insurers may have fleeced taxpayers out of $70 billion in just five years. You would think members of Congress in both parties would be so outraged they’d be launching their own investigation and railing against the ‘fraud and abuse’ they decry on the campaign trail…” 



Updated June 12th:

The Department of Central Management Services has amended its contract with United Healthcare to change the co-pay of the prescription drug plan when you reach the catastrophic level. This change will only affect a small group of people that are enrolled in the United Healthcare Medicare Advantage Plan. If you reach the catastrophic stage (out-of-pocket costs total $4,550 or more) your co-pay will now not exceed $50. The chart below is provided by the CMS. This amendment is retroactive to the beginning of the plan year; United Healthcare in the upcoming months will be contacting the individuals affected prior to this change to determine reimbursement. To find out more information concerning your Medicare Advantage Prescription Drug Coverage go to the IRTA website, www.irtaonline.org

STAGE 4

Catastrophic Coverage Stage - You enter this stage when your true out-of-pocket costs total $4,550.  You stay in this stage until the end of the plan year.

In this stage you no longer pay the plan's standard copayment; instead, how much you pay depends on which State-sponsored MA-PD plan you have enrolled in.  The table below provides the benefit offered by each MA-PD plan in 2014 and by a standard Part D plan.  The benefit for a standard Part D plan has been established by the federal government for 2014.


Coventry MA-PD HMO
Humana MA-PD HMO Plan
UnitedHealthcare MA-PD PPO Plan
Standard Part D Plan
You pay:
Generic: $2.55 copayment per 30-day supply

Nongeneric: $6.35 copayment per 30-day supply
Generic: Greater of 5% of the retail cost or $2.55 copayment, not to exceed amounts below:

Nongeneric: Greater of 5% of the retail cost or $6.35 copayment, not to exceed amounts below:

1-30 day supply:  $40
31-60 day supply:  $80
61-90 day supply:  $120
(90-day supply:  $80 if purchased through Mail Order)
Generic (up to 90-day supply): Greater of 5% of the retail cost or $2.55 copayment, not to exceed $50

Nongeneric (up to 90-day supply): Greater of 5% of the retail cost or $6.35 copayment, not to exceed $50
Generic (up to 90-day supply): Greater of 5% of the retail cost or $2.55 copayment

Nongeneric (up to 90-day supply): Greater of 5% of the retail cost or $6.35 copayment

Updated June 4th: 
TRAIL: As of June 1, United Healthcare (PPO) will have a dedicated office to handle TRAIL phone calls.  The call centers will be trained on TRAIL.  The issue in the past has been our members would be routed to call centers throughout the country and their representatives would not be up to speed on TRAIL and would often give conflicting answers to questions posed by members.

Prescription Drugs: There is no doughnut hole in this program.  Members will pay their normal copays up to $4,550.  When a member reaches the $4,550 amount, they will then be capped at the highest of the following for generic drugs: $2.55 or 5% of the cost of the drug, but not to exceed $50 for a 90 supply.  For preferred and non-preferred drugs: $6.35 or 5% of the cost of the drug, but not to exceed $50 for a 90 day supply.  It looks like they will make this retroactive for members that may have paid a different amount already.  (THIS IS STILL BEING WORKED OUT WITH UNITED HEALTHCARE)

Possible New Providers: Currently, 48 counties do not have an HMO coverage option for our members.  These counties tend to be in the central and southern part of the state.  There currently is a Request for Proposal (RFP) being conducted and the Department of CMS hopes to have a number of bidders to review for consideration.

TRAIL Medicare Advantage Enrollment Period: They plan on conducting the choice period between October 15th and November 15th.  Members will be able to make modifications to their benefits during this time. Any changes would become effective January 1, 2015.

Membership Info: TRAIL currently has 36,000 lives enrolled in the plan.  Of that number 93% enrolled in in the PPO and 7% enrolled in the HMOs.  In counties that had the HMO option, members still chose the PPO 87% of the time.  They expect an estimated 3,000 members to become eligible to participate in TRAIL this year.  --Will Lovett


Updated May 5th:

Please see the following explanation from United Health Care and the State of Illinois Department of Central Management Services regarding the cost of prescriptions once a member enters the "coverage gap" and "catastrophic" coverage.

When a member enters the prescription Medicare Part D 'coverage gap' (the amount between $2,850 and $4,550), the amounts that the member pays for their prescriptions is still the copayment amount; however, the amount the member pays (i.e., the copayment) is added to any manufacturer's discount given to the plan for brand name drugs the member filled.  



The manufacturer's discount is usually 50% of the drug's retail value and is given to the plan (UHC/OptumRX) for the cost of the drug.  It is this discount that is also added to the member's copayment that can throw them over the $4,550 amount into the 'catastrophic' coverage.  Once in the catastrophic level, the member will usually end up paying 5% of the cost of the drug.  



All of these costs are indicated on the Explanation of Benefits (EOB) from UHC.  The member will get two separate EOBs, one for medical services and one for prescriptions.  Members will only receive an EOB if they had medical or prescription expenses during the month.  The prescription EOB will list the name of the drug, the date it was filled, the pharmacy that filled the prescription, the tier the drug is in, what the plan paid for the drug, what the member paid for the drug (copayment) and 'other' payments, which are the manufacturer's discounts.  Please see the following example:

Humera (brand name drug was discounted 50%; total cost of the drug is not on the EOB, but in this case was $5,130.36); Plan Paid - $2,735.09; Member Paid - $50.00 (copayment); Discount - $2,345.27.

The Department of Central Management Services continues to work with United Health Care (UHC) to negotiate a fair alternative.  IRTA will continue to keep our members updated on any future changes.
 

Updated April 24, 2015:

This email only pertains to those members who are on Medicare.

Some members have experienced a premium increase in their Medicare Part B and Part D. Those parts of Medicare are dependent on your adjusted gross income.  The guideline booklet is attached to this email as a pdf file.  The income guidelines are on pages 8 and 9 of the booklet --Ed Wollet.

http://www.ssa.gov/pubs/EN-05-10536.pdf


Updated November 21st: 

IRTA Executive Director Jim Bachman spoke to the North Lake Shore Retired Teachers in Des Plaines this afternoon.  Pensions and healthcare were addressed.  Bachman reiterated the recommendation of IRTA that retirees remain with one of the State of Illinois plans (United Healthcare or Humana) at least through 2014.  He addressed the anxiety that the State of Illinois United Healthcare Advantage plan would not offer the same services as Medicare or that the plan would deny claims that Medicare would approve - Bachman strongly rejected both premises.

Bachman also stressed that unlike all other Advantage Plans which have negotiated reduced fees with providers, the State of IL plan pays doctors and institutions the same exact amount as Medicare.  He also explained that providers need to understand how the State of IL plans work; thus, retirees are urged to contact United Healthcare (UHC) and ask that they contact their doctor or hospital to provide them with plan information:  888-223-1092 (Group #12809).  

—Robert Zahniser

A few members, who believe they qualify for the new Medicare Advantage plans, have personally told me that they had not received the Medicare Advantage Enrollment kit from CMS. If they don’t receive it by next Monday, November 25, please call TRS 800-877-7896 and request a form.
 While they may also print one from the CMS web site, we ask that they wait a few days to see if the official one arrives. The official one has a bar code which would make it easier for processing.

http://www2.illinois.gov/cms/Employees/benefits/trail/trip/Documents/TRIP_Form.pdf

Also, any member who believes they are qualified for the new Medicare Advantage program and has not previously enrolled in TRIP can contact our office and ask that an Enrollment Form and materials be sent.

If members need help completing the Enrollment form, please watch our enrollment video, posted on the TRS home page at trs.illinois.gov.

—Rich Frankenfeld, TRS Director of Outreach


Updated November 19th:

For those who have not attended an Illinois CMS Advantage Seminar, it is now available online:  http://www2.illinois.gov/cms/Employees/benefits/trail/Pages/TRAILSeminar.aspx

From TRS web site – a short PowerPoint presentation about how to complete the Medicare Advantage Enrollment Form – www.trs.illinois.gov


Updated November 18th:

“…For those who are concerned about the insurance companies drastically raising their fees next year, that has not been where their profits have been gained. But as recent news stories have shown, the Federal government hopes to reduce their costs for Medicare going forward.   These companies make their profits not only from the amount they collect from the government, but also from what they can keep of those funds.   We should all understand that insurance companies are in business to make money. For example: United Health Group Incorporated is a diversified managed healthcare company headquartered in Minnetonka, Minnesota. It is No. 17 on Fortune magazine’s top 500 companies in the United States.   They are doing well.” 
 
–Bob Lyons


 
 
Updated November 17th:

CMS is pleading with retirees to help them reach out to those who have infirmities and/or live out of state.  The fear is that some elderly will not attend to their mail or understand the necessity of returning the CMS form in order to continue insurance coverage.

TRS will accept and provide certification for CMS forms hand delivered to their offices.  They will also sign for registered mail delivery.  Retirees are reminded to use the CMS form received in the mail with an imprinted barcode.  Forms sent through regular mail require extra postage:  two stamps, not one.  The application form can be downloaded from the CMS Website if necessary, but using the form with the barcode will expedite processing.

CMS reports it continues to experience great success in having hospitals/doctors accept the IL Advantage PPO plan.  Again, retirees are urged to request United Healthcare or CMS to contact any doctor who requires information about the plan.  By law, all hospitals and doctors who accept Medicare can be used by participants of the IL Advantage PPO plan.  It is reported that in only very rare instances will it be necessary for retirees to pay at time of service for medical fees and submit the insurance form to United Healthcare for rapid reimbursement - this procedure is necessary only when a doctor or institution refuses to bill United Healthcare directly.    

--Robert Zahniser


Updated November 16th:

From Capitolfax:

http://capitolfax.com/2013/10/24/something-just-doesnt-seem-right-here/

* Insurance giant Health Alliance claims it seriously under bid all of its competitors to provide Medicare Advantage for thousands of Downstate public employee retirees

* So, why was the company disqualified? State experience requirements

Health Alliance spokeswoman Jane Hayes said the contract selections are puzzling, “because we’re often seen as too expensive.”

“Of course, they probably didn’t even look at the pricing, because we were thrown out on a technicality that the (state) chief procurement officer could have waived,” Hayes said.

The technical requirement Health Alliance didn’t meet pertained to experience administering large-member Medicare Advantage contracts.

The state required insurance vendors seeking the Medicare Advantage contracts to show they have at least five years’ experience administering Medicare Advantage plans — plus at least three years’ experience administering Medicare Advantage plans for at least one employer with a minimum 1,000 participants enrolled. Bidders also needed to show they had at least one year’s experience administering a Medicare Advantage plan for a government employer with at least 500 participants.


Updated November 13th:

Send Your Application early by Registered Mail:

1)  A single stamp on the return envelope to TRS containing the Medicare Advantage application is insufficient, and it is suggested that you might wish to send the application by Registered Mail to provide proof of delivery. Use at least two stamps.

2) It is strongly suggested that retirees DO NOT WAIT until midnight on December 13 to postmark your Medicare Advantage application envelopes, because otherwise TRS will likely be overwhelmed with the mail received.  –Robert Zahniser

On Tuesday, Nov. 12, you received an email alert from Teachers' Retirement System regarding a new Illinois Medicare Advantage program that most TRIP members in Medicare will have to participate in under state law. This message is a clarification of that email. Eligible TRIP members must enroll in the new Medicare Advantage unless they decide voluntarily to drop their participation in TRIP. If you drop TRIP, you will not have to participate in the state's new Medicare Advantage program. If you decide to end your participation in TRIP, you must complete and sign that section of the Medicare Advantage enrollment form and return the form to TRS.

Member Services Division
Teachers' Retirement System of the State of Illinois


“…received my enrollment forms from CMS.  Not complicated, but the daunting part is the unspoken part.  United Healthcare manages your Medicare A and B, but nowhere announces that it is actually acting as a supplemental... (previously known as C in some groups).  It will offer drug, but again the lack of a specific note that it will pick up what A and B doesn't is NOT clearly stated.  I will need to check now with my own medical people to see if they take or are considering taking United Healthcare and the new program, then make a call to CMS for clarifications.  Not a lot of time...”  --John Dillon


Updated November 12th:


from TRS

On or before Dec. 13, 2013, all TRIP members covered by Medicare will be required by the Department of Central Management Services to enroll in a state-sponsored Medicare Advantage health insurance plan. Click here for a direct link to information from CMS on this change.

Click here for a link to seminar dates and locations. Click here to read the letter from CMS dated October 21, 2013. CMS began mailing the Medicare Advantage enrollment kit, which includes the official enrollment form, on November 7. The insurance companies administering the coverage options for Medicare Advantage will be mailing detailed information about each of the plans separately.


Click here for a TRS audiovisual presentation available in three formats. [Expect extremely slow connections. It took several minutes to download for me]:


The presentation is designed to help TRIP members fill out the new Medicare Advantage enrollment form. Please make sure your audio (speakers) are on. Thank you.

Member Services Division
Teachers' Retirement System of the State of Illinois
                                                                     ******

from Ed Wollet:


The enclosed questions were raised at yesterday's Tazewell Co RTA meeting.  The answers came from the insurance providers. 

Can prescriptions be written for 90 days instead of just 30 days?  Is there a price savings for a 90 day prescription over a 30 or 60 day prescription? 

Prescriptions can be written for 90 days.  The cost savings are available only through the mail order companies associated with each Medicare Advantage plan. Using the mail order company will give you a 90 day supply for the 60 day price.  No discount exists for a brick-and-mortar pharmacy (i.e., CVS, Walgreen). 

Do the deductibles and co-pays for medical treatment begin fresh on February 1, 2014? 

Yes.  From February 1, 2014-December 31, 2014 the $250 deductible and the $1000 total out-of-pocket will apply.  The following benefit period will begin January 1, 2015 and run through December 31, 2015. 

If I sign up for one of the state MA plans and it doesn't work for me, can I get my traditional Medicare back and buy my own supplement? 

Yes, you never lose your traditional Medicare.  However, you would only be able to switch back during the Medicare enrollment period each year (Oct 15-Dec 6). 



Please remember that these answers should not take the place of attending one of the CMS insurance seminars set up during this month.


“A strong suggestion I heard at the TRS meeting at Andrew High School (Tinley Park) last Wednesday night: USE THE BAR-CODED ENROLLMENT FORM from the packet you receive this week, NOT a down-loaded form you print yourself.  These enrollment forms will need to go from TRS to UHC to Medicare and back to UHC in a very short window of time, and using the bar-coded form will expedite the process.  Also SEND IT BY MAIL, not fax” (Nancy Rode).
 

Updated November 11th:


TOTAL RETIREE ADVANTAGE ILLINOIS Health Insurance Plan


Roger Sanders attended Monday’s (11/11/13) informational meeting at Rock Island High School for the roll out of the new state health insurance program.  There were about 375 attendees, most of whom were members of the Teacher Retirement System (TRS).  The meeting lasted about 90 minutes.  

The following are Sanders’ observations, recognizing that over the next few weeks more information is likely to be forthcoming based upon questions that others will bring forward… 

Janice Bonneville, Deputy Director of Benefits for Illinois’ Central Management Services (CMS), presented the information.  Accompanying Ms. Bonneville were Leslie Booth, CMS Medicare Unit, and Dan Riewder from CMS.

          Total Retiree Advantage Illinois (TRAIL) is the new state healthcare program (www.cms.illinois.gov/thetrail).

TRIP-THE TRAIL, as it is called on the CMS web site, provides the “latest news” for TRS members:


An introductory decision guide for TRS members can be found online at the CMS web site:



It is recommended that you read this guide before attending your local informational meeting.  It will give you good background information to formulate your own questions.

          You must be Medicare eligible to qualify for the new TRIP-THE TRAIL program.  You must be age 65 and enrolled in Medicare Part A and Part B before September 30, 2013.  If you are not Medicare eligible, then your current state health insurance plan stays in effect with no change.  There will be another open enrollment time in the fall of 2014 for those turning age 65 after Sept. 30, 2013.



          There are three options within TRAIL.  All three are Medicare Advantage plans with Prescription Drug coverage (MA-PD) that fall within the approved national Medicare Part C program, i.e., a private insurance plan that meets federal Medicare coverage standards.  MA-PD plans are private insurance plans not administered by the federal government.  Plan benefits and claims processing are determined by the contract between Illinois and the private insurance company.  Claims for services are not submitted to Medicare.



Medicare Part A (hospital insurance) + Part B (medical insurance) + Part D (prescription drug coverage) = Medicare Advantage-Prescription Drug (MA-PD) 



The three MA-PD options available are



1)         A Preferred Provider Organization (PPO) administered by United Healthcare (UHC) that is available to members nationwide.

2)         Coventry Advantra HMO (available to residents of certain Illinois counties)

3)         Humana HMO (available to residents of certain Illinois counties)



HMO plans are for state coverage only unless there is a medical emergency when you are out-of-state.



A map of Illinois showing available plans by county is included in the CMS decision guide.

The MA-PD program consolidates Medicare Part A, B and D into one private insured plan with one ID card.  However, DO NOT THROW AWAY YOUR MEDICARE RED/WHITE/BLUE CARD.

Healthcare providers must be a provider under Medicare in order to qualify for each of the three programs (PPO or HMO).  For example, if a doctor does not accept Medicare, then they do not qualify under the state plan.



          Current TRIP members who are Medicare eligible have until December 13 to enroll in one of the new MA-PD plans.  There is no default coverage.  If you are Medicare eligible and don’t submit an enrollment form by the Dec. 13 deadline, your state health insurance coverage will terminate on Feb. 1, 2014.  ALL individuals covered MUST sign the enrollment form.  Your enrollment form must be returned to TRS and postmarked by Dec. 13, 2013.



For TRS members, if you opt out you cannot enroll in the state MA-PD plan in the future.  This is governed by Illinois statute.  You do not have to enroll in this new program.  If you opt out, you can join the original federal Medicare program and purchase Medicare supplement insurance if you wish. 

If you enroll in the TRAIL program and decide that it is not a good plan for you, then you can drop the plan at the next Medicare open enrollment period and enroll in the “original” Medicare program administered by the federal government.



          Plan benefits and premium amounts are described in the retiree healthcare decision guide.  Your premium cost is the amount you pay for Medicare Part A and Part B, plus the premium for the state plan.  There is no additional cost for Medicare Part D (prescription drug) because it is included in your state plan premium.  If you enroll in the state MA-PD plan, you do not need nor can you have an additional Medicare supplement plan.  Premiums for the PPO are substantially less than under the current TRIP plan.  Also, the deductible and out-of-pocket maximum are less under this MA-PD PPO plan compared to the current TRIP PPO plan.




Most of the information presented at the Rock Island meeting dealt with the United HealthCare MA-PD (PPO) since there are no approved HMO providers in that immediate area.


One confusing point relative to the United HealthCare MA-PD deals with approved providers.  There is a United HealthCare network of doctors and hospitals.  However, any doctor or hospital that accepts Medicare patients qualifies as an approved provider by United HealthCare.  However, health care providers that do not have a contract directly with United HealthCare have the choice to accept the PPO plan or not, except in the case of emergency treatment.  So, it is advisable to check with your own doctor and/or hospital to make sure they will bill United HealthCare for services if they are not a part of the United HealthCare network.  If they will not, you can pay for medical services received and request reimbursement from United HealthCare yourself.  

Obviously, this could be a problem.  You can also ask United HealthCare and CMS to reach out to your doctor or hospital to become a network member and/or to ensure that they will bill United HealthCare directly.  You can search for United HealthCare network providers on their web site at www.UHCRetiree.com/soi.

United HealthCare has a national network of pharmacies as well as a mail order program.  You should check to see if your pharmacy is in the network and check on the actual cost of your prescriptions.  For example, you may be only able to get a 30 day supply from a retail pharmacy under this plan when you have been able to get a 60 day supply under the existing TRIP plan; thus, your prescription costs could increase substantially.

ONLINE SITES WITH VALUABLE INFORMATION

United HealthCare site specifically for the Illinois TRAIL program
1-888-223-1092 United Healthcare Customer Service

Illinois Central Management Services
1-800-442-1300 CMS Bureau of Benefits

Your Retiree Health Care Decision Guide:

 
Updated November 9th:


The enrollment forms were mailed on Thursday. Retirees in the Teachers’ Program should begin receiving the TRAIL Enrollment Kits soon. The forms will also be available online Tuesday morning.  The form can be printed, filled out, and sent to the Teachers’ Retirement System.


Will all prescriptions and billing information, i.e., credit card information, be transferred to the new plan, or will express scripts continue to administer the plan?  Or will we have to get all new prescriptions? This answer came from a United Healthcare-PPO advisor:

Members will continue on their current pharmacy plan until February 1, 2014.  The member will take their new insurance card (i.e., United Healthcare) to their pharmacy.  All information including prescriptions and billing information will transfer to the new insurance plan.  There will be no need to get new prescriptions.

If members want to use mail order, those members will have to obtain new prescriptions that will be sent to the mail order company, Optum Rx.  There will be instructions and mailing envelops available to complete this process.  –Ed Wollet


Updated November 7th:


This information is from Ed Wollet:


These questions were asked at a meeting by DeWitt-Logan RTA members.  The answers came from United Healthcare, TRS, CMS, or IRTA.  The following answers apply only to the teachers' insurance plan and do not address the other state retiree plans.  These answers are not exhaustive and should not take the place of attending one of the CMS scheduled meetings.

1. What is the Medicare Advantage (MA) deductible?  A: $250 annually.

2. What is the total out-of-pocket?  $1000 annually.  From IRTA: the $250 annual deductible is included in the $1000 annual out-of-pocket. Out-of-pocket expenses are for medical expenses only and do not include prescription co-pays.
3. If I take dependent coverage, will there be an annual deductible and out-of-pocket for each of us?  Yes.  Each person in the household will have an individual card with the same group number but different participant number.

4. Do the MA plans cover such procedures as hips, knees, joints, pacemakers...?  The MA plans pay for procedures that are covered by Medicare.  Procedures like elective cosmetic surgery would not be covered, but the procedures listed above are covered as long as they are medically necessary and are covered by Medicare.

5. Are there any meds that are not covered?  If the drug is in the formulary, it is covered.  If the drug is not in the formulary but the doctor believes it is medically necessary, then a pre-authorization can be made with the insurer.  It is up to the insurer to then accept or deny coverage for that drug.  Co-pays for drugs range from $2 for UHC-PPO designated generic drugs, to Tier 1 drugs $10, Tier 2 $25, Tier 3 &4 $50.  Some non-medically necessary drugs, such as Viagra, are not covered and would have to be purchased out-of-pocket.  The drug formulary will be available on the insurer's website.

6. Does MA pay excess charges?  Your responsibility is the cost of the annual deductible and annual out-of-pocket expenses.  Once you have met those costs, there will be no further costs to you other than the drug co-pays.

7. Medicare Supplement (Medigap) plans are from a private insurer.  Does Medigap Plan F pay if Medicare does not pay?  No.  Medigap only pays after Medicare Primary has paid, so those policies only cover the remainder of Medicare eligible expenses. This answer came from an agent who specializes in Medigap insurance. Medigap insurance does not have a drug benefit.  Participants in Medigap insurance policies would have to pick up Medicare Part D to be covered. State insurance through United Healthcare will cost about $47/month.

8. What's the difference between the UHC-PPO and one of the HMOs?  HMOs limit access to Illinois in-network participants unless it is an emergency.  The UHC-PPO is nationwide.  All medical providers who participate in Medicare and are willing to accept you as a patient are treated as though they were in-network, anywhere in the United States.  If the provider will not bill UHC and you want to stay with that provider, you can pay the provider out-of-pocket and then submit the bills to UHC for reimbursement.  UHC should also be notified so their provider team can contact the provider to explain the benefits of him/her becoming a UHC listed participant.

Updated November 2nd:


FROM NORTH LAKE SHORE RETIRED TEACHERS’ ASSOCIATION:   

IRTA is advising that members stay with the state program for this year and evaluate it. On first inspection, it appears to be a good program, with premiums lower than what we have had in the past and a number of extra promised benefits. Until we know how it will work, it is not advisable to sever the connection to TRIP and be in the position of having to obtain insurance privately.


Updated October 31st:

Which doctors are in the plan?


“CMS stated that once members receive their enrollment kits and know what plans are available to them, they can then contact the carrier on their dedicated Medicare Advantage number.  Our understanding is that the HMO plans will provide a directory of their physicians and hospitals, but United Healthcare still states that any doctor that accepts Medicare will accept their plan.  If a doctor or hospital states they will not accept the United Healthcare Medicare Advantage PPO, retirees should contact United Healthcare on their dedicated line. However, they are asking retirees to wait until they have the enrollment kits before making these calls” –Susan Goetz (IRTA).

Updated October 30th:
“Both Representative Drury and Senator Morrison’s office have been MOST HELPFUL relative to pending retiree healthcare issues.  Please see the following response from Joe Piasecki, Chief of Staff for Senator Morrison” –Robert Zahniser


Q: If a doctor accepts Medicare, is he required to accept the Medicare Advantage PPO?

No, but approximately 98% of providers nationwide do accept MA PPOs


Q: Do all retirees in Illinois have access to providers, facilities and services in their counties?

CMS: Yes, the rule under the PPO plan is the provider must be a Medicare provider. They can access the provider regardless of whether they are in the PPO network. If they are not in the PPO network, the provider can bill United Healthcare. If the medical provider does not want to bill United Healthcare, a member can pay the cost upfront and receive reimbursement from United Healthcare.


Q: If their provider is not interested in billing United Healthcare are members responsible for all the expenses and then reimbursed?

CMS: That is correct. Members will be told to reach out to United Healthcare and they will reach out to their providers. If a provider will not accept payment from United Healthcare, then United Healthcare will reach out to the provider and figure out the problem.


Q: How quickly would reimbursements be made to members paying expenses out of pocket?

CMS: United Healthcare has indicated members will be reimbursed within 10 days.


Q: If you leave traditional Medicare for an advantage plan, can you go back to traditional Medicare at any point? If someone accepts the Advantage PPO Plan, but after two months is dissatisfied, can they leave the State plan and purchase a Medigap policy and Drug plan without penalty from the State OR penalty in purchasing the alternative healthcare and drug plans?

CMS:  Members can go back to traditional Medicare during any subsequent Medicare Open Enrollment period. Enrollment in Medigap policies vary by the company offering the policy.  We do not place any restrictions on the member’s ability to leave the State plan. There is no financial penalty with the State, although members in the Teachers’ and College plans have no automatic right of return if they leave those plans. 

Final Thoughts: enrollees who are considering leaving the State plan for either a Medigap or another Medicare Advantage are encourage to contact federal Medicare directly and ask specific questions regarding their enrollment rights. CMS is strongly recommending that members stay in the State plan, at least for this first year.  They have low premiums and, more importantly, no gap in coverage under Part D.   If at the end of the first 11 months they find it does not work for them, they can make a change during open enrollment in the fall of 2014.

The original deadline for the State enrollment period was December 6th.  However, CMS were asked to extend that period to give impacted members a full month to make a decision.  Thus, CMS moved the deadline to December 13th

Additionally, CMS has posted the Decision Guide, which gives a high level overview of the plans to our new website, www.cms.illinois.gov/thetrail.  Members can review that guide to understand the plan design of the State programs and compare them to other plans they may be considering.  

Lastly, CMS will be running an audio/video presentation at each seminar as well as responding to questions.  The AV presentation and FAQs will be posted to the CMS website for individuals who cannot attend the seminars to access.


For 2014 Medicare Rates: 2014 Medicare Costs  

CMS website for Medicare Advantage: Click Here.

“Under the Illinois UHC-PPO, you can continue to use your Medicare-approved out-of-state primary-care physicians whether they accept payment from United Healthcare PPO or not.  If that primary care physician will not bill UHC-PPO, you can pay the doctor’s bill and submit the claim directly to UHC-PPO. You will be reimbursed just as the doctor would have been under the PPO plan.  All doctors who accept Medicare are considered in-network for purposes of reimbursement. The portion of the bill that is residual (the part of the bill not reimbursed) will be applied to your annual deductible and your out-of-pocket maximum (reported to be $1250). This is the same information you should find in the benefit sign-up packets being mailed out from CMS” (Ed Wollet).


Updated October 29th:

IEA members that are Medicare eligible now have access to a full overview of their insurance (deductibles, co-pays, premiums and insurance plans) via the new CMS website. Click Here: Total Retiree Advantage Illinois “TRAIL” website.


Benefit packets will be mailed to members’ homes and will arrive the week of November 11th, but the information is available now on the CMS website at the link above.

CMS will be holding insurance seminars around the state.  DOWNLOAD THE SCHEDULE HERE.
 

Updated October 28th:

“All hospitals do not accept Medicare Advantage! Call your medical provider before you choose” –Al Popowits.
“I spoke to my Internist’s Business Manager today.  I was informed that the office does not accept Medicare Advantage Plans.  I explained that Illinois Public Employees and Retirees have been told that any doctor that accepts Medicare MUST accept the Illinois Advantage PPO Plan on an out-of-network basis.  I was told that the doctor’s office has attempted to get information about the plan, but they have been told that it will likely be mid-December before they have anything for their legal team to review.  

THIS IS UNACCEPTABLE!  Retirees must make a decision about insurance by December 13 (or December 7 in the event you opt to take a private drug plan), but this is not possible if the information is not to doctors until mid-December” –Robert Zahniser.


MEDICARE ADVANTAGE PLAN ADMINISTRATORS 


Plan Component
Administrator's Name
 Customer Service Phone Numbers

UnitedHealthcare Group Medicare Advantage PPO
 UnitedHealthcare
 (888) 223-1092


Coventry Advantra HMO
Coventry Advantra
 (855) 223-4807

Humana Medicare 
Employer HMO
The Humana Benefit Plan HMO and
the Humana Health Plan HMO
 Humana
 (800) 951-0125

 


Updates on October 25th:


  


United Healthcare:
1-877-596-3258


“A state benefits official Friday urged retirees to carefully review Illinois’ new Medicare Advantage plans before making a decision about how to handle their Medicare coverage. Janice Bonneville,  deputy director of benefits for the Department of Central Management Services, said many retirees will find their costs are lower and coverage better with the new insurance plans than what they are getting under their current coverage…”

A REMINDER: you must prove dependency to CMS before December 6th.  To get a Return Transcript, go to www.irs.gov.  Look for the link to Return Transcript and fill out the form.
For Fax: 1-877-223-8478. You only need the first page.  Make a copy of it for yourself; then black out all the financial data (Marge Sucansky).  


Updated October 24th:

A REMINDER: all professional insurance brokers have cautioned about leaving the State Healthcare Insurance Program until the terms of the new plan are known. You cannot go back to TRIP once you leave it. Professional advice on the healthcare matter is to not make decisions as of yet. Attend insurance meetings and gather information for now.
 
 
Updated October 23rd: 
 
This insurance only applies to those individuals who, PRIOR TO OCTOBER 1, 2013, have Medicare Primary insurance and whose dependents are also Medicare Primary prior to that date.

1. United Healthcare PPO (UHC) gives nationwide coverage and appears to offer better benefits at a lower premium than either of the alternative HMO products.
2. UHC PPO maximum out-of-pocket is $1250 applied annually as $250 deductible + $1000 out-of-pocket co-pays.
3. The UHC PPO policy is specifically designed for eligible state of Illinois retirees; it is not available to the general public.
4. You can choose any doctor anywhere in the United State who accepts Medicare. 
5. The drug plan is similar to the current one (tier 1 drugs have a $10 co-pay, tier 2 drugs $20, tier 3 drugs $40); however, if the drug is a generic and is on the UHC preferred drug list, the co-pay is only $2.
6. This is nationwide insurance protection with the only requirement being that you go to a doctor who accepts Medicare.
7. The premium for members is $47.56/month. This is well below current coverage costs. Dependent coverage is $142.67.
8. Participants will carry one card that will act for both Medicare and the supplemental policy.
A lot of information and sign-up forms will be mailed out to you in the next few days.  Check your mail and be sure to attend one of the statewide meetings being offered by CMS.  Also, information will be available on the CMS, TRS, and IRTA websites --Ed Wollet.

Our understanding right now is that you will still pay for Medicare, and that premium will be deducted as usual from your Social Security check if you receive SS.  The UHC premium will deduct from your pension. The Medicare Advantage plan pays both the Medicare portion of a medical bill and then pays the residual amount based on the MA contract (in other words, there is an 80-20 split between UHC and insured). Any applicable deductibles and co-pays come first for the insured to pay up to a maximum out-of-pocket of $1250 annually. You can drop out of the plan if you don't like it and return to traditional Medicare and purchase your own supplement. 

If you have met your TCHP deductible, it will not roll over into the new plan.  On February 1, you will be rolled into the new plan if you elect to take it.  If you are not 65 yet, you will stay in CIGNA until you turn 65.  Then at the next enrollment period in October, you can make the change.  Forty-three counties will not have HMO's.    



Updated October 21st: 

CMS has posted on its web site the initial letter that gives more information, including rates, about the new Medicare Advantage plans that are being offered to members enrolled in Medicare Parts A and B will be mailed the week of October 21, 2013. 

Continue to check the CMS web site for more information.
The letter includes the following rates:
TRIP Medicare Advantage Plan Monthly Rates

·        Coventry Advantra HMO -- $35.36 (member)/106.08 (dependent)
·        Humana HMOs -- $55.34/166.01
·        United Healthcare PPO -- $47.56/142.67
  
The cost of premiums are available here.
Individual premiums will be 75% subsidized.
Dependent coverage will be 25% subsidized.
Any doctor that accepts Medicare will accept users of Medicare Advantage.
All Medicare benefits that are currently provided will continue to be provided.
The deductible is reduced from the current Cigna plan from $500 to $250.
Out-of-pocket is reduced from $1250 to $1000.

A drug plan is included.

 
Updated October 18th:

Currently, CMS is waiting for approval of the letter which will be sent to all qualifying participants. To receive the letter members must meet BOTH of the following criteria:

The member must be enrolled in Medicare Parts A and B, AND
If the member has dependents on his/her coverage, ALL of the covered dependents must also be enrolled in both Medicare Part A and B.

CMS is expecting final approval of the letter today therefore the letter should be mailed by the beginning of next week. The letter will be delivered in a CMS envelope. The letter should be printed on yellow paper. Included in the letter will be general information about the plans, enrollment period dates, and premium rates.

You should receive a postcard shortly after the initial letter reminding you of the enrollment dates. A third mailing will be sent to you including an enrollment kit, a map of coverage area, dates and locations of seminars. You will also receive informational kits from the vendors.


4 comments:

  1. Please forgive my ignorance, but will all hospitals that accept Regular Medicare A & B also accept the new UHC plan also? Thanks.

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  2. The answer to your question is yes: "If the provider accepts Medicare, the costs will be covered by the UHC plan" (Rich Frankenfeld, TRS).

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  3. Glen, an outstanding job of compiling this information. THANK YOU!!! Such a great job of trying to keep us all informed. I do feel so bad for those retirees that fall into the digital divide. I fear that so many of our fellow retired educators may be left by the wayside due to their lack of computer literacy or circumstances that they have little or no control of.

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  4. Thank you for helping us understand these plans. I get confused and do not know how to handle them because It is hard to understand insurance. I have had medical issues this year and one of my doctors which I like very much does not accept medicare- period. I involved UHC to help but to no avail. I had to pay him out of my pocket which was over a $1,000 and on a fix income. I tried to get reimbursed from UHC but they told me that since he does not accepts medicare they could not reimburse me. Whist is your reaction yo this? And, am getting nervous with the new enrollment period because it is hard to determine which is the best plan for one in terms of dollars and cents that is not an HMO. Is there any one that can help me determine a good medical plan? Would appreciate that.

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