Addendum to '2001 Guide to Health Insurance for People with Medicare'

[LOGO] JANE SWIFT GOVERNOR COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation DIVISION OF INSURANCE One South Station • Boston, MA 02110-2208 (617) 521-7794 • FAX (617) 521-7773 TTY/TDD (617) 521-7490 http://www.state.ma.us/doi JENNIFER DAVIS CAREY DIRECTOR, CONSUMER AFFAIRS AND BUSINESS REGULATION LINDA RUTHARDT COMMISSIONER OF INSURANCE # BULLETIN 01-09 To: Commercial Insurers, Blue Cross and Blue Shield of Massachusetts (BCBSMA) and Health Maintenance Organizations (HMOs) From: Linda Ruthardt, Commissioner of Insurance Re: Addendum to "2001 Guide to Health Insurance for People with Medicare" Date: August 10, 2001 Enclosed please find a copy of the Massachusetts Addendum to the "2001 Guide to Health Insurance for People with Medicare." The Massachusetts Addendum must be provided along with the "2001 Guide to Health Insurance for People with Medicare" to those people eligible for Medicare pursuant to Massachusetts regulations 211 CMR 42.09(4) and 211 CMR 71.13(2)(d)4. Please note that the Massachusetts Addendum is in 14-point type. Please do not inadvertently include this bulletin cover memo with the Addendum when it is given to consumers. Questions regarding this bulletin by licensed carriers may be directed to Kevin Beagan, Director, Health Unit of the State Rating Bureau at the Division of Insurance at (617) 521-7347. [LOGO] JANE SWIFT GOVERNOR LILLIAN GLICKMAN SECRETARY The Commonwealth of Massachusetts Executive Office of Elder Affairs One Ashburton Place, Boston, MA 02108 Phone (617) 727-7750 Fax (617) 727-9368 TTY/TTD 1-800-872-0166 ## Massachusetts Bulletin for People with Medicare Currently, Medicare beneficiaries have several options available to them for receiving medical coverage. These include: - Medicare Parts A and B only; - Medicare supplemental insurance-known as Medigap; - Health Maintenance Organizations (HMOs) with Medicare contracts; - coverage through the employer of yourself or a spouse; - retiree health plans from past employers; - MassHealth programs that pay some or all of Medicare's deductibles, co-payments and premiums - free care from hospitals and neighborhood health plans; and - the Massachusetts Pharmacy Programs for elders and adults with disabilities. This bulletin provides basic information regarding the Medicare Supplemental (Medigap) insurance, Medicare managed care plans (HMOs), MassHealth, Medicare Savings programs and Pharmacy Programs available in Massachusetts. If you have an employer group health plan for active workers or retirees, then contact your employer or the group insurer for information about the benefits under your group health plan. If you are a veteran, contact your local veteran's agent for information about health care services available to veterans. Included at the end of this Bulletin are: - charts showing Medicare benefits; - the 3 types of non-group Medigap policies; - charts listing the Medigap and Medicare managed care companies offering insurance with monthly premium costs and company phone numbers; and - a sheet explaining when you can buy a Medigap policy or enroll in an HMO. ## Medicare Medicare is also referred to as "original Medicare" or "fee-for-service" Medicare. The Original Medicare Plan consists of two parts, Part A (Hospital Insurance) and Part B (Medical Insurance). In the Original Medicare Plan, you may go to any doctor, specialist, or hospital that accepts Medicare. See the two Medicare charts that list Medicare's benefits under Part A and Part B. Or, read your Medicare & You Handbook for more details about the Medicare program. Or, call 1-800-MEDICARE (1-800-633-4227 or TTY/TDD: 1-877-486-2048) for information or to order special free publications. ## Additional Insurance Once you have Medicare, like most people you will probably want additional health coverage that helps pay for what is not covered by Medicare. Keep in mind, no system of enhancing Medicare coverage is right for everyone. All plans have benefits and limitations that must be evaluated relative to your lifestyle and personal preferences. As a Medicare beneficiary you can choose to receive your Medicare benefits either through the fee-for-service system by supplementing Medicare with a Medigap policy or through a managed care plan such as a Health Maintenance Organization (HMO). ## Medicare Supplements ("Medigap Insurance") Medicare supplemental insurance, also known as Medigap insurance, is designed to help fill in some of the gaps in coverage left by Original Medicare. A Medigap policy is an indemnity or fee-for-service policy. This means you may choose any doctor, specialist, or hospital you wish. When you buy a Medigap policy, you must have both Medicare A & B. You must pay monthly insurance premiums and may still have to pay for some Medicare deductibles and co-payments. If you see a non-participating Medicare provider, you may have to fill out paperwork and claims forms. All Medigap policies are clearly marked "Medicare Supplemental Insurance." There are three standard Medigap plans that can be sold in Massachusetts. They are titled: - Medicare Supplement Core - Medicare Supplement 1 (no outpatient prescription drug coverage) - Medicare Supplement 2 (outpatient prescription drug coverage: ($35 deductible per calendar quarter; 100% coverage for generic drugs, 80% coverage for brand-name drugs and no maximum limit for drug benefit) All companies must use consistent labeling of their plans. The benefits are virtually identical for each "type" of plan. For example, Supplement 1 offered by one company has the same coverage and benefits as Supplement 1 offered by another company. This makes comparing plans easier. It's the company's premiums and customer service that vary! An insurer is not allowed to sell a duplicate Medicare Supplement policy to an individual who already has a privately purchased Medicare Supplement policy. But, it is permissible for an insurer to sell a Medigap policy to someone who has an employer- sponsored retiree plan. If you choose to replace a current Medigap policy, you must sign a statement indicating you are replacing a Medigap policy and will not keep both policies. See the attached chart Three Standard Medigap Plans Offered in Massachusetts to compare the basic benefits of each plan. See the Medicare Supplement Policies Company Chart for monthly premium levels for policies approved by the Massachusetts Division of Insurance for sale to residents of Massachusetts. ## Who Can Buy Medigap Insurance? Medigap companies in Massachusetts cannot deny coverage, limit coverage or impose a waiting period based on pre-existing health conditions to any person, except to individuals under age 65 who are eligible for Medicare solely due to End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant). Medigap companies do not have to sell to individuals with End Stage Renal Disease until they reach the age of 65. ## When Can you Buy Medigap Insurance? You can buy a Medigap policy sold by an insurer in Massachusetts providing the insurer receives the application during an enrollment period. Enrollment periods occur each winter as well as several times during your lifetime. a. An annual open enrollment period for Medigap plans starts February 1st and ends March 31st. Benefits for people who enroll during the annual open enrollment period, begin June 1st. b. A six month open enrollment period belongs to any person who: - Enrolls in Medicare Part B for the first time, or - Becomes a resident of Massachusetts, or - Moves out of the service area of HMO plan, or - Loses employer-sponsored health plan because the job ended, the employer stopped providing coverage to its active employees, or the employer went bankrupt. - Turns 65 after they became eligible for Medicare Part B benefits due to disability before age 65. If one of these events just happened to you, you have 6-months to buy a policy starting from the date the event occurred. Your new Medigap policy will begin almost immediately. c. In addition, there are several other events that trigger a right to buy Medigap insurance at other times of your life. See the attached fact sheet titled When Can You Buy Medigap Policy in Massachusetts for other situations that can trigger an open enrollment/guarantee issue right to buy Medigap. # Is Your Medigap Policy Too Costly? If you now have a Medigap policy and the premium is becoming too costly, be aware that you may: - contact your company to see if you can downgrade to a lower cost plan with your current insurance company (for example, if you cannot join a closed plan); - during open enrollment, switch to another company offering a similar Medigap policy with a lower premium; - compare the benefits and costs of Medicare HMOs in your area; - contact your local MassHealth Enrollment Center or SHINE to determine if you qualify for Medicaid, QMB, SLMB, or QI; or - explore other free and discounted health care programs available for seniors in Massachusetts. Keep in mind that the plan you now have may no longer be approved for sale in Massachusetts. Therefore, if you cancel it and switch to another insurer, and then change your mind, you may not be able to return. ## Medicare Health Maintenance Organizations (HMOs) Managed care combines the functions of both health insurance and health services in one organization. It offers, on a pre-paid basis, medical and preventive services through a network of designated hospitals, doctors and other providers. An HMO is a managed care plan. Health Maintenance Organizations (HMO's) premiums and benefits stay in effect for one calendar year. ### How Do Medicare HMOs Work? When you enroll in a Medicare HMO, you are signing up to receive all your Medicare services through the HMO. Medicare prepays a monthly fixed amount to the plan. In return, the HMO is required to provide all of the services you would be entitled to under Original Medicare. Additional benefits such as periodic checkups, health screenings, vision services, prescription drugs, dental visits, hearing exams, eyeglasses and/or wellness programs may also be covered. You must continue to be enrolled in Medicare Part A and Part B and continue to pay the Part B premium while enrolled in a Medicare managed care plan. ### Medicare Contracts with HMOs to Provide Medicare Covered Services Under an HMO plan there is a "lock in" provision, which means members are required to use only the plan's network of providers and facilities. If you choose to receive services outside the plan's network, neither the plan nor Medicare will pay. You will be responsible for all of the charges for the out-of-network provider. The only exceptions are for emergencies, urgently needed care while temporarily outside the plan's service area, or when you receive prior approval from your primary care physician or HMO to see a specific medical provider outside the HMO's network. If you do join a Medicare HMO plan, you do have rights during your first year of coverage to switch out of the HMO plan and to a Medicare Supplement plan as explained in the 2001 Guide to Health Insurance for People with Medicare. ## Do HMOs Cover Emergency Care? All HMO plans with Medicare contracts must cover emergency care as part of the basic benefit package. HMO plans will pay if you have a medical emergency or an urgent need for care while you are temporarily out of the HMO's service area. However, they will not pay for routine care, or care you could have planned in advance. ## When Can You Enroll in a Medicare Managed Care Plan? Generally, Medicare Managed Care Plans in Massachusetts enroll eligible applicants continuously throughout the year. Medicare managed care plans cannot exclude or limit coverage for any applicant due to poor health or current health care condition (except individuals who have End-Stage Renal Disease – see note below about opportunity to convert into a Medicare HMO plan if previously covered by an employer group health plan by the same HMO.) ## To be eligible to enroll: - You must be enrolled in both Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) - You must live in the HMO's service area. In general, if you move out of the plan's service area you cannot stay in the plan. You must disenroll and join another Medicare managed plan in the new area or revert to the Original Medicare Plan. - You cannot have End-Stage Renal Disease. However, if you are already in a HMO plan and have End-Stage Renal Disease, you may be able to convert to your HMO's Medicare contract if they operate one. Check with your HMO to see if they have a Medicare contract. To learn more or get an application, contact the HMOs serving your county or town and request an enrollment packet including a benefits booklet and a provider directory. # MassHealth and Medicare Savings Programs - Programs That Help to Pay Medical Expenses Several Massachusetts health insurance programs may be tremendously helpful, as they will pay for medical costs for low-income Medicare beneficiaries. ## MassHealth Standard Health Insurance Coverage MassHealth Standard Health Insurance wraps around your Medicare coverage to pay for many of the gaps in Medicare, such as premiums, deductibles, co-payments, and extras like prescription drugs and eyeglasses. You may enroll into MassHealth Medicaid if: - for an individual, your income is $716 or less per month and your assets are $2,000 or less. - for a married couple, your income is $958 or less per month and your assets are $3,000 or less. (Different asset and income rules are used when a married person needs Medicaid for nursing home care.) ## Qualified Medicare Beneficiary Program (QMB) QMB pays the Medicare premiums, deductibles, and co-payments. No extra medical benefits are covered, but QMB would pay the cost of a Hospital Deductible ($776 in 2000), the Part B annual $100 deductible, and all the 20% co-payments for Part B services like doctors' bills. You can enroll in QMB if: - for an individual, your income is $716 or less per month and your assets are $4,000 or less; or - for a married couple, you income is $958 or less per month and your assets are $6,000 or less. ## Specified Low-Income Medicare Beneficiary Program (SLMB) and Qualifying Individuals - 1 (QI-1) Programs The SLMB and the QI-1 Programs are both programs that will pay for your monthly Medicare Part B premium. This single benefit is significant! You will save $546 each year in Medicare premiums alone if you enroll. You may be eligible if: - for an individual, your income is $960 or less per month and your assets are $4,000 or less; or - for a married couple, your income is $1,286 or less per month and your assets are $6,000 or less. Call the MassHealth Enrollment Center at 1-888-665-9993 (TTY: 800-596-1272) for information about MassHealth Standard Health Insurance and the Medicare Savings Programs. # Other Programs That Can Help Pay Health Care Costs 1. The PHARMACY Program provides up to $1250 per year to help pay for prescription drugs. For eligibility you must be a (1) Massachusetts resident (2) age 65 or older or under age 65 with a disability (3) work less than 40 hours per month (4) gross annual income less than $15,708(individual) or $21,156 (married couple). The PHARMACY Program Plus program provides an unlimited prescription benefit for elders and younger people with disabilities who incur high prescription costs relative to their incomes. Call 1-800-AGE-INFO (1-800-243-4636) (TTY: 1-800-813-7787 for the hearing and speech impaired) for information and an application for the pharmacy program. 2. The MassHealth Program: MassHealth insurance is also available for long term unemployed adults and disabled working adults under the age of 65. Call the MassHealth Enrollment Center at 1-888-665-9993 (TTY: 800-596-1272) for information. 3. Hospital Free Care: Hospitals and community health centers provide free care to uninsured or underinsured Massachusetts residents. Contact your local hospital's billing office, community health center or the Division of Health Care Finance and Policy at (617) 988-3100 for information and eligibility. 4. Veterans' Affairs Medical Centers: To receive health care, most veterans must be enrolled. You can apply for enrollment at any VA health care facility or Veterans Agent office at any time of year. Application forms may also be obtained by calling toll-free to 1-877-222-VETS (1-877-222-8387) or accessing information on the Internet at www.va.gov/health/elig. Also, your local Veterans Agent will have information about other assistance available for veterans. ## Help Directory 1. For free health insurance information, counseling and assistance contact the Executive Office of Elder Affairs' SHINE (Serving the Health Information Needs of Elders) Program at 1-800-AGE-INFO(1-800-243-4636) (TTY/TDD 1-800-872-0166). The phone number for calls made from out-of-state is 617-727-7750. Or, contact your local Council on Aging to meet in person with a SHINE Counselor. 2. If you have a problem concerning your insurance or with buying insurance, or you believe that an agent, broker or company has treated you unfairly, please call the Division of Insurance, Consumer Services, 1-617-521-7777 (TTY/TDD 617-521- 7490). The telephone number in the Springfield area is 1-413-785-5526. The Division of Insurance web site is www.state.ma.us/doi. 3. For information about Medicare, local Medicare HMO's and to order free Medicare publications, including the "Medicare & You 2001 Handbook" call the Medicare Hotline 1-800-638-6833 (TTY/TDD 1-800-820-1200). 4. Call Medicare Part B: 1-800-882-1228 (TTY: 1-800-559-0443) for information about Medicare Part B claims and benefits. 5. Call Medicare Part A: 1-888-896-4997 (TTY: 1-800-559-0443) for information about Medicare Part A claims and benefits. 6. Visit the Medicare web site at www.medicare.gov. It has web sites that will help you compare HMO plans, compare Medigap policies, and learn all about your Medicare benefits. 7. For free legal advice and help with a Medicare appeal for all Medicare beneficiaries, contact the Massachusetts Medicare Advocacy Project at 1-800-323-3205 or 617-371-1234 (TTY: 617-371-1228). 8. For individuals without Medicare under age 65 needing assistance in understanding HMO patient's rights and the grievance process available to HMO members contact the Office of Patient Protection, at 1-800-436-7757 or visit the web site at www.state.ma.us/opp. 9. Call the Social Security Administration at 1-800-772-1213 to enroll in Medicare, replace a lost Medicare card or to report a change in address. # 2000 Medicare Part A Benefits and Gaps (Chart outlines gaps in Medicare coverage. Refer to Medicare Handbook For complete list of Medicare benefits.) | Coverage | Beneficiary Pays | Medicare Pays | | --- | --- | --- | | Medicare Part A | | | | Inpatient Hospital Care* | | | | Days 1-60 | $776 deductible | Balance | | Days 61-90 | $194 per day | Balance | | Days 91-150 (lifetime reserve days) | $388 per day | Balance | | All additional days | All costs | Nothing | | Semiprivate room and board, general nursing and other hospital services and supplies. | | | | Skilled Nursing Facility Care* | | | | Days 1-20 | Nothing | All costs | | Days 21-100 | $97.00 per day | Balance | | All additional days | All costs | Nothing | | After three-day hospitalization and admitted to a skilled nursing facility approved by Medicare within 30 days of discharge. | | | | Home Health Care** | Nothing | Up to 35 hours per week | | Part-time or intermittent skilled care, home health aide services, and | | | | Durable Medical Equipment and Supplies | 20% of approved amount | 80% of approved amount | | Hospice Care | Small co-payments for inpatient respite and drugs | Balance | | Pain relief, symptom management and support services for the terminally ill. | | | | Blood | For first 3 pints | All but first 3 pints per calendar year | *A benefit period provides 90 days of hospital care, if needed. A new benefit period begins each time the beneficiary is out of the hospital or has not received skilled nursing care from any other facility for 60 consecutive days. Part A Premiums for Voluntary Enrollee (individuals who must purchase Part A): 30-39 work quarters $166/month in 2000 0-29 work quarters $301/month in 2000 Refer to Medicare & You 2000 Handbook for more information about Medicare benefits. Or call Medicare Part A at 1-888-896-4997 (TTY: 1-800-559-0443). # 2000 Medicare Part B Benefits and Gaps (This chart outlines gaps in Medicare coverage. Please refer to the Medicare & You 2000 Handbook for more information about Medicare benefits or call 1-800-882-1228 about Medicare Part B benefits - TTY: 1-800-559-0443) | Coverage | Beneficiary Pays | Medicare Pays | | --- | --- | --- | | Medicare Part B | | | | Medical Expenses | | | | • Doctors' services | $100 deductible* plus 20% ** of Medicare's approved amount. | 80% of Medicare's approved amount after $100 deductible has been met. | | • Inpatient and outpatient medical services and supplies | | | | • Physical and speech therapy | Limited charges above the approved amount may apply for some Part B providers. | Reduced to 50% for most outpatient mental health services. | | • Diagnostic tests | | | | • Ambulance services | | | | Medicare also pays for other medically necessary services, see Medicare Handbook. | | | | Clinical Lab Tests | Nothing for tests if medically necessary. | Generally 100% of approved amount. | | Blood tests, urinalysis, and more. | | | | Home Health Care | Nothing | Up to 35 hours per week | | Part-time or intermittent skilled care, home health aide services, and | | | | Durable Medical Equipment and Supplies | 20% of approved amount | 80% of approved amount | | Outpatient Hospital Treatment | After $100 deductible, 20% of the hospital charges (not limited to approved amount). | Medicare payment to hospital based on hospital cost. | | Blood | For first 3 pints, plus 20% of approved amount (after $100 deductible). | 80% of approved amount (after $100 deductible and starting with the 4th pint). | * Once you have incurred $100 of expenses for Medicare-covered services in any year, the Part B deductible does not apply to any further covered services you receive for the rest of the year. ** Part B Coinsurance is paid after you have met the annual Part B deductible of $100 for covered services in 2000. A 20% coinsurance amount applies to most physician services. A 50% coinsurance applies to most outpatient mental health services. Monthly Part B Premium is $45.50 per month for 2000. Services Not Covered by Medicare (partial list only): Private Duty Nursing, Experimental Procedures, Care Outside of the U.S., Custodial Care at Home, Custodial Care in Nursing Home, Outpatient Prescription Drugs, Hearing Aids, Eyeglasses (generally), Most Chiropractic Services, Dental Care, Acupuncture, Routine Physicals, or Private Hospital Room. # When Can You Buy Medigap Insurance in Massachusetts? When Can You Enroll in a Medicare HMO? ## Medigap Policies ✓ Some Medigap companies sell throughout the year to all Medicare beneficiaries or to members of an association. See SHINE's Medigap Chart for details. ✓ All Medicare beneficiaries* can buy any Medigap policy during the state's annual open enrollment period of February and March (policies then take effect June 1st). Generally, downgrading or upgrading your Medigap policy or buying from some companies is limited to this annual open enrollment period. *(Medicare beneficiaries who have ESRD and are under age 65 do not have these same protections. Upon turning 65, however, Medicare beneficiaries with ESRD cannot be excluded by Medigap companies.) ✓ However, after February and March, if a company is not voluntarily selling all its policies throughout the year, you can only buy a Medigap policy if you are someone who... 1. Just enrolled in Medicare Part B, either at age 65 or due to disability. You have 6 months to buy a Medigap policy and companies must offer all 3 types of Medigap policies (Core, Supplement #1 and Supplement #2) for sale. 2. Just moved into Massachusetts. You have 6 months to buy a Medigap policy and companies must offer all 3 types of Medigap policies (Core, Supplement #1 and Supplement #2) for sale. 3. Just moved out of your Medicare HMO's service area. You have 6 months to buy a Medigap policy and companies must offer all 3 types of Medigap policies (Core, Supplement #1 and Supplement #2) for sale. 4. Was enrolled in a Medicare HMO Plan or PACE Program that announced it would close and no longer provide services in your area after December 31st. You have 75 days (starting with the receipt of the HMO's October 2nd notification letter and ending December 15th) to buy a Medigap policy and companies must sell all 3 types of Medigap policies (Core, Supplement #1 and Supplement #2). If you decide to stay in the HMO plan through December 31st, then you will also have an additional 63 days (starting on January 1) to buy a Medigap policy and companies must offer the Core and Supplement #1 type of policies. 5. Lost or is about to lose employer coverage (because your active job ends or the employer stops coverage for active employees). You have 6 months to buy a Medigap policy and companies must offer all 3 types of Medigap policies (Core, Supplement #1 and Supplement #2) for sale. (End of COBRA coverage does not trigger Medigap protection). 6. Had an employer's health plan that offers benefits that supplement Medicare (Medicare pays first and private insurance plan pays second) but the plan was or is about to be terminated or the plan ceased to provide all such supplemental health benefits to the individual. For example, most retiree policies supplement Medicare. For disabled Medicare beneficiaries, the Employer Group Health Plan (EGHP) is the secondary (supplemental) payer if the employer group has less than 100 employees. You have 63 days (starting with termination or disenrollment) to buy a Medigap policy and companies must offer the Core and Supplement #1 type of policies. 7. Had cancelled a Medigap policy voluntarily, enrolled into a Medicare HMO plan or PACE program plan, and no more than 12 months have gone by since joining the Medicare HMO plan and now you want to disenroll or have already voluntarily disenrolled from the Medicare HMO. You have 63 days (starting with terminating your HMO membership) to buy the Medigap policy you had before, if it is still offered for sale, or to buy a Core or Supplement #1 policy from any company. 8. When you first became eligible for Medicare Part B, you enrolled in a Medicare HMO plan or PACE program and you want to disenroll within the first 12 months of enrolling in the HMO plan and buy a Medigap policy. You have 63 days to buy a Medigap policy and companies must offer all 3 types of Medigap policies (Core, Supplement #1 and Supplement #2) for sale. 9. Was insured by a Medigap company that became insolvent or bankrupt. You have 63 days to buy a Medigap policy and companies must offer the Core and Supplement #1 type of policies. 10. Was insured by a Medigap policy but the policy ended due to an "involuntary termination of policy." You have 63 days to buy a Medigap policy and companies must offer the Core and Supplement #1 type of policies. 11. Was insured by a Medigap company or Medicare HMO that substantially violated a provision of its policy or contract. You have 63 days to buy a Medigap policy and companies must offer the Core and Supplement #1 type of policies. 12. Was insured by a Medigap policy or Medicare HMO and the company or its agent materially misrepresented the policy's terms and conditions during marketing. You have 63 days to buy a Medigap policy and companies must offer the Core and Supplement #1 type of policies. 13. Note: If you had MassHealth insurance that has ended or is about to end, there is no special Medigap protection for you. If you want to buy a Medigap policy, you must wait until the annual open enrollment period, unless a company is voluntarily open throughout the year. See the SHINE Medigap chart for company details. ## Medicare HMO Plans During 2000 and 2001, all Medicare HMOs in Massachusetts enroll new members continuously. If you submit your application before the 10th of the month, then your new HMO coverage will begin on the 1st of the following month. If you submit your application after the 10th of the month, then your new coverage will not begin until the 1st of the second month. The date that the completed enrollment form is received by the HMO will determine its effective date. Beneficiaries should call the HMO for a confirmed effective date. The HMO must also send a letter to the beneficiary that will state the effective date. Example: If the Medicare HMO receives your application by July 8th, your new coverage will begin August 1st. If the Medicare HMO receives your application on July 11th, then the new coverage would begin on September 1. However, read the next 2 rules carefully! ✓ If you are about to get Medicare A and B for the first time, then you must complete the HMO's enrollment forms in the 3 months prior to the month you actually get Medicare in order for your health insurance to begin the same month of your Medicare health insurance. ✓ Each November, the HMOs start to enroll for coverage to begin on January 1st. However, if you need your coverage to begin on December 1st, you must complete your enrollment forms and send them into the HMO no later than November 10th. For more information, contact the Serving the Health Information Needs of Elders (SHINE) Counseling Program at 1-800-AGE-INFO (1-800-243-4636 - TTY: 1-800-872-0166). SHINE Counselors provide free and unbiased information, counseling and assistance to elders and Medicare beneficiaries on all their health care options. ### Three Standard Medigap Plans Offered in Massachusetts Comparison of Plan Types | Basic Benefits In All Plans: | Medicare Supplement Core | Medicare Supplement 1 | Medicare Supplement 2 | | --- | --- | --- | --- | | **Medicare Part A/ Hospital Stay:** Coinsurance for 61^{st}-90^{th} day in each benefit period; coinsurance for 60 Medicare lifetime hospital reserve days; additional 365 lifetime days covered in full. **Medicare Part B/ Medical Expenses:** Coinsurance - generally 20% of Medicare approved expenses **Blood:** First 3 pints of blood each year. | | | | | **Additional Benefits:** | | | | | Medicare Part A Hospital Stay Deductible $776 per benefit period in 2000 | No | Yes | Yes | | Medicare Part A Nursing Facility Coinsurance $97 per day for 21^{st}-100^{th} day in 2000 | No | Yes | Yes | | Medicare Part B Annual Deductible-$100 | No | Yes | Yes | | Foreign Travel Medicare-covered services while abroad | No | Yes | Yes | | Mental Health Hospital Stays | 60 days per calendar year | 120 days per benefit period | 120 days per benefit period | | Outpatient Prescription Drugs $35 deductible each calendar quarter, then 100% coverage for generic drugs 80% coverage for brand-name drugs | No | No | Yes | # Medicare Supplement Plans Offered in Massachusetts | Medigap Carriers Please note that rates may change in 2001 | Monthly Premiums for Policies | | | | --- | --- | --- | --- | | | Medicare Supplement Core | Medicare Supplement 1 | Medicare Supplement 2 | | Allianz Life Insurance Company of N.A. Only for members of Air Force Sergeants Assn 1-800-882-5541 Only for members of Fleet Reserve Assn 1-800-424-1120 Only for members of Marine Corps Assn 1-800-424-5181 Only for members of Nat Assn of Retired Fed Emp 1-800-233-5764 Only for members of National Rifle Assn 1-877-672-3006 Only for members of Reserve Officers Assn of USA 1-800-247-7988 (open enrollment: Feb-Mar; at initial eligibility) | $62.83 | $119.00 | $268.67 | | Blue Cross & Blue Shield of MA (Medex) 1-800-258-2226 (open enrollment: Feb-Mar; at initial eligibility^{1}) | $65.58 | $121.95 | $345.73 | | Hartford Life Insurance Company Only for members of The Retired Officers Assn 1-800-247-2192 (open enrollment: continuous) | $44.90 | $102.35 | $286.26 | | Lincoln National Life Insurance Company Only for members of Military Benefit Assn 1-800-336-0100 (open enrollment: continuous) | $53.09 | $ 78.19 | $116.30 | | United HealthCare Insurance Company Only for members of Amer Assn of Retired Persons 1-800-523-5800 (open enrollment: Feb-Mar^{2}; at initial eligibility^{1}) | $86.25 | $128.75 | $345.50 | 1. Plan offers discounted rates to certain members joining when initially eligible. 2. Plan adds surcharge for enrollment after initial eligibility period. # Medicare HMO Plans Offered in Massachusetts ## For Coverage in 2001 (continued) | Medicare HMO (continued) | Monthly Premium | Office Copay | Prescription Drug Benefit | Service Area by County | | --- | --- | --- | --- | --- | | Harvard Pilgrim Health Care, Inc. 1-800-779-7723 (continuous enrollment) | First Seniority $35 | $5 | $150 per calendar quarter at retail price ($600 total per year) Copayments (30-day): $ 5 for Generic $10 for Preferred Brand $25 for Non-preferred Mail Order (90-day): $ 8 for Generic $15 for Preferred Brand $75 for Non-preferred | Essex, Middlesex Norfolk, Suffolk $35 | | HMO Blue Blue Cross Blue Shield 1-800-678-2265 (continuous enrollment) | Blue Care 65 $85 to $105 See Service Area by County | Prim Care Physician $5 Specialist $15 | $150 per calendar quarter at discounted price ($600 total per year) Retail Copay (34-day): $ 8 for Generic $15 for Brand Mail Order (90-day): $10 for Generic $20 for Brand | Barnstable, Bristol, Franklin, Hampden, part of Hampshire $105 Essex, Plymouth, Worcester $95 Middlesex, Norfolk, Suffolk $85 | | Tufts Associated Health Plan 1-800-246-2400 (continuous enrollment) | Secure Horizons $25 to $45 See Service Area by County | $5 | $150 per calendar quarter at negotiated price ($600 total per year) Retail Copay (30-day): $ 5 for Generic $15 for Preferred Brand $35 for Non-preferred Mail Order (90-day): $10 for Generic $30 for Preferred Brand $70 for Non-preferred | Hampden $45 Barnstable, Bristol Essex, Plymouth $40 Worcester $35 Middlesex, Norfolk, Suffolk $25 | # Medicare HMO Plans Offered in Massachusetts ## For Coverage in 2001 Please note that the following rates for Medicare HMO plans, offered through a contract with the federal government, must be reviewed by the Massachusetts Division of Insurance. Contact the company for information about products only being offered in parts of counties. | Medicare HMO | Monthly Premium | Office Copay | Prescription Drug Benefit | Service Area by County | | --- | --- | --- | --- | --- | | Fallon Community Health Plan, Inc. 1-800-868-5200 (continuous enrollment) | Fallon Premium Rx $5 Office Visit $30 | $5 | $175 per calendar quarter at discounted price ($700 total per year) Copayment (up to 90-day): $ 8 for Generic $ 15 for Brand-name | Worcester; Parts of Hampden, Hampshire, and Norfolk $30 | | | Fallon Premium Saver $5 Office Visit $4 | $5 | NONE | Worcester; Parts of Hampden, Hampshire, and Norfolk $4 | | | Fallon Premium Saver $10 Office Visit $0 | $10 | NONE | Worcester; Parts of Hampden, Hampshire, and Norfolk $0 | | | Fallon Premium Rx $10 Office Visit $60 | $10 | $175 per calendar quarter at discounted price ($700 total per year) Copayment (up to 90-day): $ 8 for Generic $ 15 for Brand-name | Parts of Franklin and Middlesex $60 | | | Fallon Premium Saver $10 Office Visit $8.50 | $10 | NONE | Parts of Franklin and Middlesex $8.50 |